Periodontal improvement with intensive diabetes care

Research Topic:

Background + Aims

Periodontal disease is commonly seen in individuals with diabetes, particularly with Type 2 diabetes mellitus (T2DM). The chronic inflammation associated with periodontal disease can exacerbate glycaemic control issues and contribute to the progression of diabetes. There is increased evidence regarding the bidirectional relationship between periodontitis and diabetes. Poor glycaemic control can worsen periodontal health, while periodontitis can further impair glycaemic control, creating a vicious cycle.
Effective management of diabetes typically involves strict glycaemic control through lifestyle modifications, medication, and regular monitoring. Intensive diabetes care aims to maintain blood glucose levels within target ranges to prevent or mitigate diabetes-related complications. Improving glycaemic control has been shown to have beneficial effects on periodontal health, as reduced blood glucose levels can decrease the inflammatory response in periodontal tissues.
This study aims to investigate the effectiveness of diabetic intervention in improving periodontal health in patients with poorly controlled T2DM.

Materials + Methods

This prospective cohort study included adult participants who were aged ≥20 years old, diagnosed with T2DM and with periodontal disease at baseline. Participants were excluded if they had severe renal impairment (estimated glomerular filtration rate of <15 mL/min/1.73 m2 or undergoing renal replacement therapy, and those with a severe infection or serious trauma), were edentulous (i.e. had no teeth) or needed acute dental care.
Participants received comprehensive diabetes management, which included 2 weeks of hospitalisation and continuous outpatient follow-ups, lifestyle interventions including caloric restriction (daily caloric intake to <25–30 kcal/kg of ideal body weight) and regular exercise (30 mins or more at least 3 times per week). Post-discharge participants received medical therapy and advice as outpatients.
Brief oral hygiene instruction and dental prophylaxis without subgingival professional mechanical plaque removal (PMPR) were provided for all participants. Any subgingival PMPR was postponed to the post-observation period.
Dental and periodontal examinations (tooth mobility, periodontal pocket depth (PPD), clinical attachment level (CAL) and bleeding on probing (BOP) were recorded by a periodontist and calibrated at baseline and specific follow-up periods.
Statistical tests were used to compare changes in periodontal parameters before and after the intervention. The analysis accounted for potential confounders and assessed the impact of the combined intervention on periodontal health.
The primary outcomes included improvements in PPD, CAL, and reduction in gingival inflammation.

Results

A total of 33 Japanese participants with T2DM were included in the study. The mean age of participants was 58.7 years, and 82% were diagnosed with Stage III or IV periodontitis at baseline.
Glycaemic Control Improvement: The mean HbA1c level decreased significantly from 9.6 ± 1.8% at baseline to 7.4 ± 1.3% at the 6-month follow-up, indicating improved glycaemic control.
Significant improvements were observed in several periodontal parameters were demonstrated:
- The ratio of PPD ≥4 mm significantly decreased.
- There was a notable reduction in BOP.
- Improvements were noted to the full-mouth plaque control record (PCR), although plaque control remained unsatisfactory overall.
- Both the periodontal epithelial surface area (PESA) and periodontal inflamed surface area (PISA) showed significant improvement
The study found that the reduction in PPD and PESA was significantly associated with changes in both HbA1c and fasting plasma glucose (FPG) levels. Additionally, the reduction in PISA was significantly associated with improvements in FPG after adjusting for confounding factors such as smoking status and changes in body mass index.

Limitations

Despite adjusting for various factors that could influence periodontal parameters, there may still be unmeasured confounding factors, such as socio-economic status, that could affect the results.
The study did not conduct a prior sample size calculation due to its exploratory nature, which may limit the generalisability of the findings.
The study limited participants to Japanese with poorly controlled T2DM, so other races/ ethnicities were not accounted for, limiting the generalisability of the findings.
The absence of a comparative control group makes it difficult to determine the specific effects of intensive diabetes care on periodontal health, as improvements could be influenced by other factors.
Cause-related periodontal treatments were postponed until after the observation period, which may have influenced the periodontal outcomes observed during the study.
The study excluded participants with acute inflammation or those requiring early therapeutic intervention, resulting in a low percentage of severely advanced periodontal pockets in the participants.
14 participants were managed with insulin therapy during the observation period, which may have contributed to effective glycaemic control and also improved periodontal inflammation.
Future research will require larger-scale studies with comparative control groups to validate their findings and further explore the therapeutic effects of diabetes care on periodontal health.

Conclusion

Intensive diabetes care, without the need for subgingival cause-related periodontal therapy, resulted in statistically significant reductions in PPD and BOP in patients with poorly controlled T2DM.
The improvements in periodontal parameters were significantly associated with enhancements in glycaemic control, as evidenced by reductions in HbA1c and fasting plasma glucose (FPG) levels. This suggests that better management of diabetes can lead to reduced periodontal inflammation. The findings support the hypothesis that hyperglycaemia-induced periodontal inflammation can be alleviated through intensive diabetes management, even in the absence of traditional periodontal treatments like subgingival PMPR. While the study demonstrated significant improvements, the authors cautioned that diabetes treatment does not completely eliminate periodontal disease. Therefore, careful interpretation of the results is necessary, as periodontal disease may still persist despite improvements in certain parameters.
Highlighting the importance of glycaemic control in managing oral health encourages the integration of dental assessments into diabetes care plans, fostering interdisciplinary collaboration among healthcare providers.

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