![Page 1: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/1.jpg)
Diabetes & Periodontal Health:
A Two-way relationship.
Francesco D’AiutoDMD, MClinDent, PhD, MRD RCS(Eng) RCPS (Glasg)
HEFCE Senior Clinical Lecturer/ Hon Consultant Periodontology Unit
![Page 2: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/2.jpg)
Endothelial damage,
platelet aggregation
HSP 60,
molecular mimicry
Oral Cavity – Systemic Exposure
![Page 3: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/3.jpg)
Periodontitis
Questions:
• Does Diabetes Mellitus affects Periodontal Health?
• Does Periodontal Health affects Diabetes Mellitus and its complications?
• Does periodontitis treatment improves metabolic control in people with Diabetes?
![Page 4: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/4.jpg)
I. Type 1 diabetes* - previously known asjuvenile diabetes insulin-dependent diabetes
mellitus (IDDM)II. Type 2 diabetes* - previously known as
adult-onset diabetes non-insulin-dependent diabetes mellitus (NIDDM)
III. Other specific types (includes Secondary Diabetes)
IV. Gestational diabetes mellitus (GDM)American Diabetes Association: http://care.diabetesjournals.org/
![Page 5: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/5.jpg)
IDF Atlas 2006
46.5
80.3
73%
67.0
99.4
48%10.4
18.7
80%
24.5
44.5
81%
53.2
64.1
21%28.3
40.5
43%
16.2
32.7
102%
World
2007 = 246 million
2025 = 380 million
Increase 55%Diabetes Atlas, 3rd edition, IDF 2006
![Page 6: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/6.jpg)
Weyer C, et al. J Clin Invest. 1999;104:787-794.
Insulin resistance
Hyperinsulinemia
Compensated insulin resistanceNormal glucose tolerance
Impaired glucose tolerance
ß-cell “failure”
Type 2 diabetes
Genetic Factors
Genetic Factors
Acquired:•Obesity
•Sedentary lifestyle•Aging
ß-cell decompensation
Glucose and/or fat toxicity
![Page 7: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/7.jpg)
![Page 8: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/8.jpg)
DCCT Research Group.. 1993;329:977
![Page 9: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/9.jpg)
EVERY 1% reduction in HbA1C
REDUCED RISK*
1%
Deaths from diabetes
Heart attacks
Microvascular complications
Peripheral vascular disorders
*p<0.0001Stratton IM, et al 2000
![Page 10: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/10.jpg)
DIABETES
Periodontal Diseases- Gingivitis- Periodontitis
Oral Lichen Planus
Caries
Xerostomia
Candidiasis
![Page 11: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/11.jpg)
• Case/Control (N=350/group)
Lalla et al 2006
![Page 12: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/12.jpg)
![Page 13: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/13.jpg)
From Cianciola et al JADA1982
![Page 14: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/14.jpg)
• Experimental Gingivitis (N=9/arm)
Salvi et al 2005
![Page 15: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/15.jpg)
From G. Taylor 1996
![Page 16: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/16.jpg)
From Graves et al Periodontol 2000 2007
![Page 17: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/17.jpg)
Type 2 Diabetes
Hypertension
DyslipidemiaCentral obesityInsulinResistance
![Page 18: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/18.jpg)
TG
GlucoseDiabetes
BP
HDL
AbdominalObesity
Apo BLittle LDL PAI-1
Adipo-nectin
InsulinResistance
CRP
Microalb
Cardio- vascularDisease
Type 2Diabetes
Metabolic syndrome
![Page 19: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/19.jpg)
• 28 Zucker rats diabetes – Ligature induced periodontitis (P) versus control (C).
• High (HF) vs Low (LF) Fat Diet
Watanabe et al 2008
![Page 20: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/20.jpg)
Variable% or mean (95%CI)
Mild or no Periodontitis
(N=11758)
Moderate Periodontitis
(N=1582)
Severe Periodontitis
(N=337)
D’Aiuto F et al 2008
![Page 21: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/21.jpg)
Nibali Let al 2013
![Page 22: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/22.jpg)
• NHANES I Follow-up study (7,168 dentate) • 47% had periodontal index 0 (periodontally healthy); the
remaining periodontal index quintiles.
Demmer et al 2008
![Page 23: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/23.jpg)
Collin et al 1998
Prospective study
![Page 24: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/24.jpg)
Prospective study (2y) Pima Indians
Reviewed in Taylor 2008
![Page 25: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/25.jpg)
• N=628 (>35 y) periodontal disease on CV mortality in Pima Indians with type 2 diabetes
• 11 years FU
Saremi et al 2005
![Page 26: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/26.jpg)
• 529 individuals, – 107 (20%) none/mild – 200 (38%) moderate – 117 (22%) severe – 105 (20%) edentulous
• Up to 22 years FU
Shultis et al 2007
![Page 27: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/27.jpg)
Janket et al 2005
![Page 28: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/28.jpg)
Teeuw et al 2010
Updated search to 2009
![Page 29: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/29.jpg)
Engrebretson & Kocher 2013
![Page 30: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/30.jpg)
Variable Control (N=49) Test (N=43) P value
Age 58.48±1.64 60.02±1.69 0.515Male Gender, N (%) 34 (77,3) 28(57,1) 0.049Smoking N (%):CurrentFormerNever
13 (29,5)12 (27,3)20 (40,8)
13 (26,5) 19 (43,2) 16 (32,7)
0.369
BMI 27.31±0.55 27.50±0.79 0.853Diabetes age, years 16.50±0.90 18.04±1.67 0.558HbA1c, % 8.03±0.22 7.64±0.16 0.166SES N (%):LowMediumHigh
21 (47,7)17 (38,6)6 (13,6)
34 (69,4)13 (26,5)
2 (4,1)
0.069
Calabrese N, D’Aiuto F et al 2011
![Page 31: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/31.jpg)
Baseline 4 Months 8 Months
HbA
1c %
0,0
7,2
7,5
7,8
8,1
8,4
TestCTRL
*=1.08%
95% CI 1.01 to 1.14, P=0.026
Calabrese N, D’Aiuto F et al 2011
![Page 32: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/32.jpg)
Variable Control (N=10) Test (N=10)Age, years 54.99±6.67 55.44±6.64Male Gender, N (%) 6 (60) 8(80)Smoking N (%):NeverCurrent
7 (70)3 (30)
8 (80) 2(20)
BMI, Kg/m2 28±2 26±1
HbA1c, % 8.30±0.16 8.13±0.19
CRP, mg\L 4.31±0.64 3.19±1.13
WBC, 109 cell 6.24±0.61 5.42±0.40
D’Aiuto F et al Unpublished
![Page 33: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/33.jpg)
D’Aiuto F et al Unpublished
=0.64%95%CI 0.18 to 1.26, P=0.044
![Page 34: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/34.jpg)
D’Aiuto F et al 2005
202124 202124N =
IPTSPTControl
CRP
[mg/
L]
8
6
4
2
0
BL
2M202124 202124N =
IPTSPTControl
IL-6
[pg/
ml]
5
4
3
2
1
0
BL
2M
Periodontal Therapy - Chronic Inflammation
![Page 35: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/35.jpg)
Correa et al 2010
• 23 T2-DM before and 3 months after non-surgical periodontal therapy.
![Page 36: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/36.jpg)
Baseline Day 1 Day 7 1 Month 2 Months 6 Months
FM
D %
0
1
4
5
6
7
8
9
10
IPT (N=61)
CPT (N=59)
=2.0%95% CI 1.2 to 2.8,
P<0.0001
Tonetti MS, D’Aiuto F et al 2007
Periodontal Therapy - Endothelial Function
![Page 37: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/37.jpg)
Experimental Design - RCT (N=250) UKCRN 5280
SCR
EEN
ING
BASELINE
Randomization
2m 12m1d 7d 9m6m
Test
Control
At October 2013: • N=285 recruited• N=250 reached 6 months fw-up• N=237 reached 12 months fw-up
![Page 38: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/38.jpg)
Future goals
• Large epidemiological studies to ascertain the impact of periodontal health/diseases on diabetes incidence and complications.
• Large RCTs on Metabolic/Vascular effects of Treatment of Oral inflammation in people with Diabetes
• Mechanistic studies to clarify the pathways involved • Oral health promotion becoming part of medical
management of people with diabetes
![Page 39: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/39.jpg)
![Page 40: Diabetes & PeriodontalHealth: A Two-way relationship. and PDL Health.pdf · Diabetes & PeriodontalHealth: A Two-way relationship. Francesco D’Aiuto DMD, MClinDent, PhD, MRD RCS(Eng)](https://reader031.vdocument.in/reader031/viewer/2022011809/5d44eb4f88c9931d568be856/html5/thumbnails/40.jpg)
AcknowledgementsProf John E DeanfieldDr Stefano MasiMrs Bhowruth, DevinaDr Marco OrlandiFrancis O’NeillMohamed Parkar
Eastman Clinical Investigation Centre Staff Mrs Jean SuvanNurses (Banbai Hirani, Kasia Niziolek, Tiffany Mellor) Dental hygienists (Alastair Lomax, Chiara Curra’)Heather FinchProf Nikos DonosDr Nikolaos Gkranias
Prof Aroon D Hingorani, UCLProf Liam Smeeth, LSHTMProf Raymond MacAllister, UCLProf Derek Yellon, UCLDr Derek Housenloy, UCLProf Steve E Humphries, UCLDr George Tsakos, UCL
Research Group Collaborators - UK
Collaborators - EUProf Pirkko Pussinen, HelsinkiProf Ulf Landmesser, Zurich