Article Type : Short commentary
Authors : Sakamoto D and Bando H
Keywords : Chronic periodontitis; Type 2 diabetes mellitus (T2DM); Low carbohydrate diet (LCD); International Diabetes Federation (IDF); European Federation of Periodontology (EFP)
Chronic
periodontitis and type 2 diabetes mellitus (T2DM) have been recently prevalent
and crucial diseases. Both diseases show mutual vicious cycle as influencing
each other. A systematic review revealed that T2DM cases with periodontitis
have elevated odds ratio for retinopathy (2.8-8.7), neuropathy (3.2-6.6),
nephropathy (1.9-8.5), cardiovascular complications (1.3-17.7) and mortality
(2.3-8.5) compared to those without periodontitis. Adequate therapy for chronic
periodontitis a few months would bring 0.27-0.48% decrease in HbA1c by
meta-analyses. For patients with both diseases, low carbohydrate diet (LCD)
seems to be effective associated with reduced HbA1c, body weight, Advanced
Glycation End Products (AGEs) and inflammatory process.
In usual medical
practice, type 2 diabetes mellitus (T2DM) and chronic periodontitis have been
recently prevalent and crucial diseases worldwide [1]. These diseases are
common in the departments of internal medicine and dentistry [2]. According to
previous reports, both of these diseases may cause various complications as
mutual vicious cycle [3]. A systematic review was conducted concerning the
association of chronic periodontitis PD and diabetic complications [4]. It
included 14 studies and analyzed diabetic macro- and microvascular
complications and death with periodontitis. Compared to diabetes without
periodontitis, higher risks were found in diabetic cases with periodontitis.
The odds ratio revealed 2.8-8.7 in retinopathy, 3.2-6.6 in neuropathy, 1.9-8.5
in nephropathy, 1.3-17.7 in cardiovascular complications and 2.3-8.5 in
mortality.
Regarding the problems of
diabetes and periodontitis, dentists conducted clinical research of chairside
screening for undiagnosed diabetes mellitus (UDM) for 7343 cases [5]. UDM was
defined as no past diabetic history, or not fasting glucose >126 mg/dL,
postprandial glucose > 200mg/dL. Periodontitis was defined for positive
medical history. As a result, the ratio of UCD was 5.6%, while obesity and
edentulous (no teeth, toothless jaw) showed 12.6% and obesity and periodontitis
showed 12.2%. In recent study, meta-analysis was reported concerning the
association among nephropathy, retinopathy and periodontitis [1]. T2DM patients
were included from 8 articles, in which 1207 cases with microvascular
complications, and 1734 cases with periodontitis as well. As a result, odds
ratio (OR) was 1.96 for periodontitis with microvascular complications. From
subgroup analysis, the relationship existed among nephropathy, retinopathy and periodontitis
for Asian rase (OR 2.33) and North American populations (OR 1.42).
For current therapy of
T2DM and chronic periodontitis, authors and colleagues have continued adequate
medical practice with internal medicine and dentistry departments for years
[2,6]. The guideline for T2DM is based on American Diabetes Association (ADA)
and the European Association for the Study of Diabetes (EASD), and others [7].
On the other hand, the guideline for T2DM and periodontitis is based on
International Diabetes Federation (IDF) and European Federation of
Periodontology (EFP) [8,9].
As to the basic therapy
for diabetes, nutritional treatment would be important [10]. The standard
method was formerly Calorie Restriction (CR), but recent tendency was changed.
Low Carbohydrate Diet (LCD) was started in the medical regions by Drs. Atkins
and Bernstein [11]. After that, LCD has been well-known in North American and
European areas. For recent decade, clinical benefit of LCD has been prevalent
to medical staffs and patients, which are also beneficial for glucose, lipid
profile and arteriosclerotic cardiovascular disease (ASCVD) [12]).
Our medical team have
treated many patients with diabetes, obesity and chronic periodontitis [13,14].
Our group has initiated LCD at first in Japan, and developed LCD movement
medically and socially through the activity of Japan LCD Promotion Association
(JLCDPA) [15]. For practical use, three types of LCD have been recommended,
which are super-LCD, standard-LCD, petite-LCD methods including carbohydrate
12%, 26%, 40%, respectively [16]. As any food includes a certain percentage of
carbohydrate, and then minimum intake of carbohydrate becomes 12%. LCD has been
applied to lots of cases with significant results. About 2900 cases showed 10% <
weight reduction for 25%, and 5% < weight reduction for 59% [17].
Furthermore, LCD has brought hyperketonemia, which has been effective for not
only protection of hyperglycemia, obesity, hyperlipidemia, but also reduction
of Advanced Glycation End Products (AGEs) [18], inflammatory process and
oxidation by reactive oxygen species (ROS) [19].
Among our clinical
practice, a case with diabetes and chronic periapical periodontitis showed
impressive course. He was 57-year-old man who suffered from impaired mastication
and limited number of teeth [20]. By dental treatment and LCD for 3 months,
general status was relieved satisfactory, in which weight decreased 100 kg to
90 kg and HbA1c improved 7.8% to 5.4%. Due to the standard guideline from EFP
and IDF, the treatment for chronic periodontitis reveals clinical efficacy for
diabetic patients [8]. By proper therapy for a few months, the reduction of
HbA1c was reported to be about 0.27-0.48% by meta-analyses [21].
In the light of basic
science, periodontal microbiome studies showed that the association between
altered periodontal microbiome and changed glucose metabolism may be present
[22]. Associated to this process, elevated glucose values will enhance the
expression of pathogen receptors leading to stimulate response of the host.
Hyperglycemia may also enhance pro-inflammatory response for the pathway of
AGEs [22]. As periodontal pathogens product some cytokines for acute phase
proteins, the insulin action and sensitivity may be impaired [23]. Discussion
on the clinical efficacy has been continued concerning treatment of chronic
periodontal disease only and/or combined therapy of periodontitis and diabetes.
A recent study presented the comparison of HbA1c changes for patients with both
diseases. They were treated and followed by the treatment of full-mouth scaling
associated with scaling root planing (SRP) for three months. The results showed
that periodontal treatment had brought decreased inflammatory markers,
indicating clinical efficacy of decreased HbA1c levels [23].
A recent study showed the correlation between
glucose control and chronic periodontitis for T2DM patients [24]. The subjects
included 182 cases with chronic periodontitis. As the protocol, several
biomarkers were included such as fasting plasma glucose, HbA1c, remaining tooth
number, probing depth (PD), bleeding on probing (BoP), clinical attachment
level (CAL), and others. As a result, two groups (HbA1c is ?7% vs HbA1c <7%)
revealed the significant difference as mean PD (3.78 vs. 3.42 mm, p<0.01), mean CAL (4.5 vs. 4.1 mm, p=0.02), mean remaining teeth (18.5 vs 20.4, p<0.01). Consequently,
extension of chronic periodontitis was found more prevalent in T2DM cases with
poor glycemic variability than those with good control [24].
In conclusion,
periodontal therapy can reduce HbA1c value. Diabetic patients have to check
oral status and receive adequate periodontal treatment. Especially, when
diabetic patient is hospitalized, to manage dental examination is required,
because it is not included for the routine check [25]. Thus, physicians and
medical staffs always have to keep dental evaluation in mind for diabetic
patients.
None.
Funding
There was no funding
received for this paper.
Conflicts of Interest
The authors declare no
conflict of interest.
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