Radmand Simon
Fifth year, group 13
Effect of non-surgical periodontal treatment on glycemic control and periodontal status in diabetes mellitus type 2 patient with chronic periodontitis.
A systematic review
Master’s Thesis
Supervisor
Assoc.Prof. I.Pacauskienė Kaunas, 2018
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY DEPARTMENT OF PERIODONTOLOGY
Effect of non-surgical periodontal treatment on glycemic control and periodontal status in diabetes mellitus type 2 patient with chronic periodontitis.
A systematic review
Master’s Thesis
The thesis was done By student ... Supervisor ... (signature) (signature) ... ...
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EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE Evaluation: ... Reviewer: ...
(scientific degree. name and surname)
Reviewing date: ...
No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially No 1 Summary (0.5 point)
Is summary informative and in compliance with the
thesis content and requirements? 0.3 0.1 0
2 Are keywords in compliance with the thesis essence? 0.2 0.1 0 3 Introduc-
tion, aim and tasks (1 point)
Are the novelty, relevance and significance of the
work justified in the introduction of the thesis? 0.4 0.2 0 4 Are the problem, hypothesis, aim and tasks formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0
7 Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language,
publication condition, etc.) 0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening,
eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11 Is the data extraction method from the articles (types of investigations, participants, interventions,
analysed factors, indexes) described? 0.4 0.2 0
12 Are all the variables (for which data were sought and any assumptions and simplifications made)
listed and defined? 0.4 0.2 0
13 Are the methods, which were used to evaluate the risk of bias of individual studies and how this 0.2 0.1 0 22
information is to be used in data synthesis, described?
14 Were the principal summary measures (risk ratio, difference in means) stated? 0.4 0.2 0 15 Systemiza- tion and analysis of data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving
the reasons in each stage of exclusion presented? 0.6 0.3 0 16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18 Are the extracted and systemized data from studies presented in the tables according to individual
tasks? 0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations review discussed? of the performed systemic 0.4 0.2 0 21 Does author present the interpretation of the results? 0.4 0.2 0 22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and tasks
of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and precisely?
0.2 0.1 0
27 Is the scientific level of references suitable for Master’s thesis? 0.2 0.1 0 28 Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than
5 years – at least 40%? 0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the analysed topic? +0.2 +0.1 0
30 recommen- Practical dations
Are the practical recommendations suggested and
are they related to the received results? +0.4 +0.2 0
31
Were additional methods of data analysis and their results used and described (sensitivity analyses,
32
Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysis presented?
+2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General require- ments
Is the thesis volume sufficient (excluding
annexes)? 15-20 pages (-2 points) (-5 points) <15 pages 34 Is the thesis volume increased artificially? -2 points -1 point
35 Does the thesis structure satisfy the requirements of Master’s thesis? -1 point -2 points 36 Is the thesis written in correct language, scientifically, logically and laconically? -0.5 point -1 points 37 Are there any grammatical, style or computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral, and are the volumes of its structural parts balanced? -0.2 point -0.5 points
39 Amount of plagiarism in the thesis. (not evaluated) >20%
40
Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key terms
and abbreviations (if needed)? -0.2 point -0.5 points
43 Is the quality of the thesis typography (quality of printing, visual aids, binding)
good? -0.2 point -0.5 points
*In total (maximum 10 points): *Remark: the amount of collected points may exceed 10 points.
TABLE OF CONTENT 1. SUMMARY 2. ABBREVIATIONS 2.1 Periodontal abbreviations 2.2 Metabolic Abbreviations 3. INTRODUCTION
4. SELECTION CRITERIA OF THE STUDIES, SEARCH METHODS AND STRATEGY
4.1 Comprehensive selection path of review 4.2 Search terms and criteria
4.3 Inclusion criteria 4.4 Exclusion criteria
4.5 Research strategy and bias 4.6 Full text for data extraction
5. SYSTEMATIZATION AND ANALYSIS OF DATA 5.1 Characteristics and type of studies
5.1.1 Number of participant, mean age, and gender 5.1.2 Country and publishing date of included studies 5.1.3 Bias of included studies
5.2 Protocol of included studies
5.2.1 Periodontal protocol 5.2.2 Periodontal calibration
5.2.3 Periodontal examination and indexes 5.2.4 Metabolic protocol 5.2.5 Intervention of studies 5.2.6 Outcomes 5.2.6.1 Periodontal outcomes 5.2.6.2 Metabolic outcomes 5.2.7 Influence of covariates
6. DISCUSSION
6.1 Limitations of included studies
6.2 Periodontal health maintenance recommendations for Diabetic patients
7. CONCLUSIONS 8. PRACTICAL RECOMMENDATION 9. CONFLICT OF INTEREST 10. FUNDING 11. ACKNOWLEDGEMENT 12. REFERENCES ANNEXES
Annex 1. Individual development plan for the master thesis Annex 2. Title page 1
Annex 3. Title page 2
Annex 4. Evaluation table of systematic review type of master thesis Annex 5. Descriptive results for the included studies
Annex 6. Bias of included studies
TABLES
Table 1. Search terms and keywords Table 2. Characteristics of included studies
Table 3.1 Criterias used to describe periodontal status
Table 3.2 Periodontal instruments used for periodontal examination Table 3.3 List of periodontal examiners
Table 4. Periodontal evaluation and periodontal outcomes
GRAPH
Graph 1. Number of participants, mean age and gender
FIGURE
Figure 1. “Oral compilation of diabetes mellitus” Figure 2. Flow diagram
1. SUMMARY Background:
The Effect of Diabetes on the periodontal tissues have been scientifically accepted. In order to reduce not only the oral effects of Diabetes Mellitus Type 2 but also the system impact the disease implicates, the importance of a well controlled glycemic levels is of vast significance. A reduction and maintenance of the HbA1c level within the desired value is the main goal for diabetic patients.
Aim: To systematically review the influence of non-surgical periodontal treatment on glycemic
control and periodontal status in DMT2 patients with chronic periodontitis.
Tasks: 1. To evaluate the effect of non-surgical periodontal treatment on the glycated
hemoglobin(HbA1c) level in DMT2 patients with chronic periodontitis. 2. To investigate whether non-surgical periodontal treatment improves the periodontal status in DMT2 patients with chronic periodontitis.
Methods:
This review used LSMU ezproxy to gain access to databases(database used for this study: PubMed), for the purpose of article screening. 243 total publications identified, post search term
acknowledgements 30 full-text articles were assessed for eligibility, the inclusion and exclusion criteria reduced the selection of suitable articles to 22, mainly consisting of randomized clinical trials. Finally 15 studies were chosen to be used for full data analysis, after qualitative synthesis.
Results:
Out of the 15 different included studies, 11 found a HbA1c level reduction with a statistical significance(p≤0.05). Even though the other 4 studies observed a reduction of the HbA1c level, it was not of statistical significance. But all periodontal parameters used by the various studies, being; PPD, CAL, BOP, GI, PI, REC, PESA, PISA, CPI had a improved (with p≤0.05) in correlation with the periodontal therapy carries out. Other metabolic parameters evaluated also showed a significant improvement post-treatment.
Conclusions:
Non surgical periodontal treatment may have a beneficial effect on the glycemic control(HbA1c level) for Diabetes Mellitus Type 2 patients, by assessing the results of the included studies(11 of 15 indicating a statistically significant(p≤0.05) reduction of HbA1c level). On the contrary the
periodontal parameters showed a significant improvement after non-surgical periodontal treatment for DMT2 patients. But in order to confirm this conclusion with certainty additional well structured studies regarding this subject with a large amount of participants, should be made.
2. ABBREVIATIONS
2.1 Periodontal abbreviations
● AAP: American Academy of Periodontology
● AL : Attachment Loss
● BOP: Bleeding On Probing
● CAL: Clinical Attachment Loss
● CPI: Community Periodontal Index
● GI: Gingival Index
● NSPT: Non-Surgical Periodontal Treatment
● PD: Pocket Depth
● PESA: Periodontal Epithelial Surface Area
● PISA: Periodontal Inflamed Surface Area
● PI: Plaque Index
● PPD: Periodontal Pocket Depth ● REC: Gingival Recession
● SRP: Scaling and Root Planing
2.2 Metabolic abbreviations
● Aa: Aggregatibacter actinomycetemcomitans
● DMT2: Diabetes Mellitus Type 2 ● FPG: Fasting Plasma Glucose ● HbA1c: Glycemic Hemoglobin
● HDL: High Density Lipoprotein Cholesterol ● LDL: Low Density Lipoprotein cholesterol ● TC: Total Cholesterol
● Tf : Tannerella forsythia
● TG: TriGlycerides
● Pg: Porphyromonas gingivalis
3. INTRODUCTION
Diabetes mellitus type 2 is a disease that affects the body's glycemic control, and can with time have high repercussions on the organs and their function. Nowadays diabetes type 2 is considered as a worldwide epidemic, that will keep rising during the upcoming years. The new estimations, predicts that in the year 2030, 366 millions people will suffer from the disease world wide. [27]
Diabetes mellitus type 2 is a metabolic disease that comes from a defect on the insulin production by the kidney or a defect in the insulin activity, or a combination of both. Treatments are since a number of year available for the disease, the main one being the glycemic control and is also the most important one for any patient suffering from the disease [28]. This control can prevent complications that will occur with time if the glycemic control could not be maintained on a healthy level. The main indications for glycemic control is HbA1c which is the serum glucose level during the 120 day lifespan of the red blood cells, and is one of the best indicator of glycemic control [27]. Periodontitis is one of the most common disease of the oral cavity, this disease appears most of the times with no symptoms for the patient. Thus the patient doesn’t realize he is sick until a random consultation is made, or he is consulting for something else. In case a patient suffers from
periodontitis [31]. The periodontal anatomy, is attacked and multiple changes occurs, for a dentist the best mean to recognize the disease will be when they see an increase in the probing depth, in the clinical attachment level and eventually severe mobility [31]. If left untreated periodontitis will result in loss of a tooth or multiple teeth. Periodontitis is a disease has a number of important risk factor such as: age, smoking, oral hygiene, genetics, and now diabetes mellitus is also classified as one of the risk factor for periodontitis [31].
In the past few years, relationship between diabetes mellitus and chronic periodontitis has been an important matter researched all over the world. Many studies have suggested two different way by which the relationship between diabetes mellitus and periodontitis could occur. One of them being that a poor glycemic control could induce an increased risk of periodontal disease for a patient suffering from diabetes mellitus type 2, in the other way a better glycemic control could decrease the pathological development of periodontal disease. It seem as if there is a 2 way relationship between the 2 diseases [29].
A lot of studies also focused on how the treatment of periodontal disease could affect the glycemic control, on patient already suffering from both those diseases (periodontitis and diabetes mellitus type 2). Some systematic review and meta-analysis already observed a positive correlation between non surgical periodontal treatment and diabetes mellitus. Seeing this, the author aimed to
research the latest literature to confirm whether or not, non surgical periodontal therapy could have a positive impact on the glycemic control especially by evaluating and analysing the HbA1c levels. So in order to validitate a non-surgical periodontal treatment for DMT2 patients with periodontitis, a initial overview and understanding of the relationship and effect the two conditions should be
investigated. The complications that diabetes implies on the oral cavity and periodontal tissues should be acknowledged not only by the patient in the purpose of maintaining a proper oral hygiene, but also by the clinicians in their approach, OH-I and treatment considerations.
A greater susceptibility to oral tissue trauma and infections as well as having a delayed healing time, all indicate that more invasive surgical periodontal treatment are not recommended for these type of patients. Oral complications of diabetes mellitus was nicely presented by Debora C. Matthews in the article update by the “Royal College of Dental Surgeons of Ontario” in the Canadian Dental Association[26]. The table made by the stated author was table #1 in the article named; “The Two-Way relationship Between Diabetes and Periodontal Disease”.
Figure 1. “Oral compilation of diabetes mellitus”
Aim of study: To systematically review the influence of non-surgical periodontal treatment on
glycemic control and periodontal status in DMT2 patients with chronic periodontitis.
Tasks: 1. To evaluate the effect of non-surgical periodontal treatment on the glycated
hemoglobin(HbA1c) level in DMT2 patients with chronic periodontitis.
2. To investigate whether non-surgical periodontal treatment improves the periodontal status in DMT2 patients with chronic periodontitis.
4. SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY
4.1 Comprehensive selection path of review
This research was made using online databases by gaining access though Lithuanian university of health and science own online library, in order to find articles from websites like: PubMed, wiley online library and Journal of periodontology. In this systematic review the initial search objective was to obtain clinical trials(preferably randomized) regarding the effects of NSPT on DMT2 patients with periodontal disease. In addition to clinical trials, other studies were selected for reference use in introduction and discussion.
4.2 Search terms and criteria:
At first titles which contained key words of relevance were selected, according to the search terms used. After retrieving a primary search result (of 243 articles) , the electronic search (on PubMed) was restricted to clinical trials with a publishing span of 10 years. Out of the search results, 30 articles had been chosen for the abstract to be read based on relevance for this particular study. Removal of duplicate studies form different sites was not necessary do to the use of one search engine, PubMed.
Table 1. Search terms and keywords Search terms
1. Periodontitis
2. Diabetes mellitus type 2 3. Periodontal therapy
4. Non-surgical periodontal treatment 5. HbA1c
6. hyperglycemia 7. periodontal disease
8. Periodont* (Used in pubmed for all terms that start with periodont) 9. Diabet* (Used in pubmed for all terms that start with diabet) 10. Periodontal surgery
11. Overweight 12. Obesity
13. Glycemic control
4.3 Inclusion criteria:
Studies were decided to be included when mentioning Non-surgical conventional treatment of periodontal tissues in Diabetes Mellitus type II patients with periodontitis. Cohort studies, randomized clinical trial and cross-sectional studies included. All of the studies must have been conducted in a period of 10 years(2008-2018). The study must have a cohort number (n) equal to or superior to 40 patients, patients should be at least 18 years old, no sex predilection. Only humans(vivo studies), nationality irrelevant. Other systemic diseases should not be present. The articles must have a relevant confidence interval(p) (p<0.05) to be included.
4.4 Exclusion criteria:
Studies done in vitro or other species were excluded. Literature review, mini-review or previous systematic review was excluded(but may be used as reference only for introduction). Studies that required additional access in order to download the proper full text version. Studies that weren’t written in english were not used for this particular systematic review.
4.5 Research strategy and bias
This research was made by the author of the systematic review according to the terms and regulations provided as well as PRISMA recommendations. Every article which was selected as being suitable for the systematic review by the author, was prior to inclusion submitted to the Master thesis supervisor for confirmation. A mutual agreement had to be reached between the supervisor and the student in order to use the article.
4.6 Full text for data extraction
Then 22 trials were chosen for full text analysis, then filtered according to the inclusion- and exclusion criteria(2.3 & 2.4). Finally 15 articles were selected for full data extraction and included in the study.
Figure 2. Flow diagram
Table 2. Characteristics of included studies Author, year,
country
Study design, duration of study
Number of participants, Mean age, Gender
Effect on glycemic control: Positive or negative 1. Mauri- Obradors et al., 2017, Spain Single-blind, clinical randomized trial. Duration: 6 months n=90 Mean age: ≈ 61 Male: n=37 // Female: n=53
HbA1c levels: Positive*
2. Koromantzos et al., 2011 Greece Randomized controlled clinical trial. Duration: 6 months n=60 Mean age: 59,52 Male: n=33 // Female: n=27
HbA1c levels: Positive
3. Mizuno et al., 2017
Japan
Singel masked, single center, randomized clinical trial.
Duration: 6 months
n=40
Mean age: ≈ 62 (pat.≥30 years)
Male: n=28 // Female: n=9
HbA1c levels: Negative**
4. Gay et al., 2014 USA Randomized controlled clinical trial. Duration: 4 months n=154 Mean age: ≈ 52,7 Male: n=55 // female: n= 71
HbA1c levels: Negative
5. Moeintaghavi et al., 2012 Iran Randomized controlled clinical trial. Duration: 3 months n=40 Mean age: 50.29 Male: n=20 // female: n=20
HbA1c levels: Positive
6. Botero et al., 2013
Colombia
3-group double blind randomized clinical trial. Duration: 9 months
n=105 Mean age: 57
Male: n=31 // Female: n=74
HbA1c levels: Positive
7. Kapellas et al., 2017 Australia Randomized subgroup analysis (PerioCardio study) Duration: 3 months n=62 Mean age: 45,9 Male: n=35 // female: n=27
HbA1c levels: Negative
8. Vandita Mishra et al., 2016 India
Inter group comparison study
Duration: 1 month
n=42
Mean age: 40.74
Male: n=18 // Female: n=24
HbA1c levels: Positive
9. Al-Nowaiser et al., 2014
Saudi arabia
Multi-center, randomized, parallel, single blind study. Duration: 9 months
n=76
Mean age: 42
Male: n=47 // Female: n=29
HbA1c levels: Positive
10. Soorya K V et al., 2014 India Interventional clinicobiochemical study Duration: 6 months n=45
Mean age: N/A but age range 35- 70
Gender : both included, N/A
HbA1c levels: Positive
11. Engebretson et al., 2013 USA Single-masked, randomized, multi-center clinical trial Duration: 6 months n=514 Mean age: ≈ 57,3 Male: n= 277 // female: n=237
HbA1c levels: Negative
12. Kaur et al., 2015, India
Randomized control trial duration: 6 months
n=100
Mean age: ≈ 52,38 Male: n=48 // Female: n=52
HbA1c levels: Positive
13. Wang et al., 2017, China
Blind randomized clinical trial
Duration: 3 months
n=44
Mean age: ≈ 61,76 Male: n= 26 // female: n=13
HbA1c levels: Positive
14. Raman et al., 2014, Malaysia
A randomized clinical trial Duration: 3 months
n=40
Mean age: ≈ 56
Male: n=20 // Female: n=12
HbA1c levels: Positive
15. Goel et al., 2017, Nepal Open-label comparative clinical trial. Duration: 3 months n=82 Mean age: ≈ 52,23 Male: n=56 // Female: n= 26
HbA1c levels: Positive
Table 2. specifications
*Positive is define here as any study having a statistical significance (p<0.05) toward HbA1c value. ** Negative is define here as any study having no statistical significance (p>0.05) toward HbA1c value
5. SYSTEMIZATION AND ANALYSIS OF DATA
5.1 Characteristics and type of studies:
The data of 15 articles were extracted and included in the study based on the inclusion criteria and quality of study(as seen on table 2). From the included studies:
● 11 were fundamentally randomized clinical trials, although some of them were “modified” according to to the specific article.
● 1 interventional clinicobiochemical study. ● 1 openlabel comparative clinical trial. ● 1 intergroup comparison study.
● 1 randomized subgroup analysis(perioCardio study).
5.1.2 Number of participants, mean age and gender:
As stated in the inclusion criteria the studies with 40 participants or more that are above the age of 18 were chosen. The highest amount of participants was in the study by Engebretson et al.,2013, USA, with 514 participants. The lowest amount of patients was seen in 3 different randomized clinical trial consisting of 40 participants each (Raman et al., 2014, Malaysia, Moeintaghavi et al.
2012, Iran and Mizuno et al. 2017, Japan).
All of the studies included both male and female participants, but one study did not include the male to female predilection (Soorya K V et al. 2014, India). Combining all studies together will result in
a total number of male and female participants to 731 and 674 respectively, this according to the
values given. Some studies did not mention the male/female n of the participants but only the gender predilection of the patients that completed the study. Numbers more precisely seen on the previous page.
Graph 1. Number of participants, mean age and gender
The mean age of the participants was mentioned in every study except for one study with only stated the age range 35-70 y(Soorya K V et al., 2014, India).The mean age can more specifically be seen in the 3.1 table above. The highest mean age in a single study was 62 years (Mizuno et al., 2017 Japan) and the lowest was in the study by Vandita Mishra et al., 2016, India being 40.74 years.
5.1.3 Country and publishing date of included studies:
Three of the studies used for this study were from India, and two studies from USA. Then one study form each of these countries were selected for inclusion: Australia, China, Colombia, Greece, Iran, Japan, Malaysia, Nepal, Saudi Arabia, Spain. The publishing date of the included studies were restricted to 10 years of age for the purpose of relevance. The oldest study was actually from the year 2011, while 5 of the studies was published in 2017.
5.1.4 Bias of included studies: See [Annex 6.]
There where some limitations present in not only this review but also in the studies selected for inclusion, which can possibly alter the outcomes. There were some studies that used multiple examiners to measure periodontal parameters, this may influence the measurements recorded, due to clinical differences in “pressure applied” and technique between examiners. Even the amount and types of parameters evaluated and recorded differed in the studies. Some studies did not present a clear methodical layout, and provided inadequate information necessary for full sectional assessment. this study may also lack important information, due to inclusion of english studies only.
5.2 Protocol of included studies
5.2.1 Periodontal protocol:
Multiple indexes were used in the determination and assessment of periodontal disease as well as being used for changes in periodontal parameters(explained in 3.2.2). The majority of studies checked the indexes on 6 sites of the teeth included for measurement. 11 of the included studies recorded measurements on 6 sites/teeth, more specifically on the; mesio- buccal, mid-buccal, distobuccal, mesio-lingual, mid-lingual, and disto-lingual areas. One of the studies recorded only 4 surfaces of the teeth excluding 3rd molars[7]. One of the studies did not provide information regarding sites measured(N/A)[8]. Another study had a similar mishap they only mentioned that measurements were taken for each tooth[5]. One study stated that they were;”Utilizing Kappa statistics, good agreements (>0.8) were obtained for reproducibility of all recorded clinical parameters”[14]. These measurements were recorded at baseline then post treatment(at final visit), if the if the study extended to 6 or more months then additional benchmark examinations were made, were the parameters above were taken again. This in order to clinically see the progression in stages.
5.2.2 Periodontal calibration:
The definition of periodontitis differs in some studies but mentioned to an extent in all studies included. 4 of the included studies used the American Academy of periodontology`s case definition, as a classification tool in order to assess the periodontal diseases
status[1][5][7][8]. The parameters used in order to classify the type and severity of periodontitis was the Periodontal pocket depth/pocket depth(PPD/PD) and Clinical attachment loss/attachment loss(CAL/AL), or a combination of both of them. One of the studies used only CAL in order to assess the periodontal characteristics[1]. Three of the studies used only PPD/PD for defining the Periodontitis severity [5][10][15], one of these studies in addition used the CP-index as a classification of Periodontitis. 10 of the studies used both of the parameters in order to check the periodontal status, while one of the studies did not provide information about parameters used for determination of periodontitis
Table 3:
TABLE 3.1 CRITERIAS USED TO DESCRIBE PERIODONTAL STATUS
STUDY 1 CAL > 4mm, generalized chronic periodontitis* (Armitage 1999)
STUDY 2 Moderate to severe, at least 8 sites PPD>6mm and 4 site CAL > 5mm
STUDY 3 Mild to advanced, 2 interproximal sites with CAL>3mm or one with PPD 5mm
STUDY 4 PD: Mild: 1-3mm, Moderate: 4-6mm , severe > 7mm
CAL: Mild1-2 mm, moderate 3-4 mm, severe≥ 5mm
STUDY 5** Mild to moderate with PPD>5mm
STUDY 6 Moderate periodontitis: CAL>4mm, PD>5mm for 2 or more interproximal site on different teeth
STUDY 7** Moderate/Severe: PPD > 4mm and CAL> 3mm
STUDY 8** 1999 criteria
STUDY 9 PPD and CAL> 5mm in at least 8 different sites
STUDY 10 Periodontitis: PD>4mm, CPI of 3 or more
STUDY 11 Moderate to advanced periodontitis CAL and PD <5mm
STUDY 12 Moderate: CAL ≥4 mm; PD ≥5 mm
Severe: CAL ≥ 6 mm; PD≥5 mm
STUDY 13 <30% of the teeth with PPD > 5mm or 5 sites and CAL > 4mm or, <60% of teeth with PD> 4mm; CAL>3mm
STUDY 14 Moderate to advanced periodontitis: PPD >5mm in 5 sites and CAL > 4mm in 2 different quadrants with BOP
STUDY 15 Moderate to severe on tooth with PD > 5-7mm in each quadrant
*Periodontitis here is always considered as generalized only the degree of severity can variates. **According American Academy of Periodontology
TABLE 3.2 PERIODONTAL INSTRUMENTS USED FOR PERIODONTAL EXAMINATION STUDY 1 Manual periodontal probe with the diameter of 1,5 mm
STUDY 2 Manual periodontal probe
STUDY 3 CP-11 Color-Coded Probe, Hu-Friedy
STUDY 4 North Carolina probe Hu-Friedy, Chicago IL
STUDY 5 Williams’ periodontal probe Hu-Friedy, Chicago, IL, USA
STUDY 6 UNC-15 probe
STUDY 7 PCP2 periodontal probe
STUDY 8 PCP-UNC 15 probe
STUDY 9 Manual periodontal probe, Florida Probe Corporation, Gainesville, FL, USA
STUDY 10 UNC-15 probe
STUDY 11 N/A
STUDY 12 Manual calibrated periodontal probe, Williams Probe, Hu-Friedy Manufacturing Co., Chicago, IL, USA
STUDY 13 Williams periodontal probe
STUDY 14 Electronic constant- force probe Florida Probe
STUDY 15 University of North Carolina-15, Hu-Friedy, Chicago, IL, USA
5.2.3 Periodontal examination and indexes: TABLE 3.3 LIST OF PERIODONTAL EXAMINERS
STUDY 1 Single examiner, dentist.
STUDY 2 Single examiner, periodontist
STUDY 3 2 calibrated dentist preformed all examinations.
STUDY 4 2 calibrated periodontists.
STUDY 5 periodontist was the single examiner.
STUDY 6 2 clinicians carried out the examination
STUDY 7 2 dental clinicians, one oral health therapist, one being a dentist
STUDY 8 N/A
STUDY 9 Precalibrated periodontists supported by trained dental assistants
STUDY 10 N/A(intervention done by one periodontist)
STUDY 11 Mentioned that the “periodontal examiners were calibrated”, statement suggest that there is a plural of examiners, but specifications N/A
STUDY 12 Single examiner
STUDY 13 Single periodontist
STUDY 14 One examiner
STUDY 15 Single examine
There was in total 7 studies which used one examiner for the periodontal parameters, which is preferable because of the lower risk of bias. 4 Studies used 2 examiners in order to conduct the clinical results. One study used 4 examiners with dental assistants[9]. one study just mentioned that there was more then one examiner[11] and N/A for 2 studies[8][10].
Periodontal indexes used in the various studies: PPD, CAL, BOP, GI, PI, REC, PESA,
PISA, CPI. The indexes used in all studies were: Periodontal pocket depth, and the same for clinical
attachment loss excluding Vandita Mishra et al. 2016, India. Bleeding on probing and plaque index/gingival index was also mentioned in almost all studies, 8(not in [1][5][8][10][12][13][15]) and 12(not in [4][10][13]) respectively. Gingival recession was measured in 2 studies[4][7].
CPI was calculated in one study (Soorya K V et al. 2014 India). One of the included studies also assessed the periodontal inflamed surface area (PISA) and periodontal epithelial surface area (PESA)[13].
5.2.4 Metabolic protocol:
All of the included studies had a mutual metabolic parameter which was measured, analyses and recorded, being the glycemic haemoglobin HbA1c(level) value. In addition to the assessment of glycemic control some studies included other parameters which were measured as well: 3 studies checked the FPG(Fasting plasma glucose)[1][5][6]. 2 studies mentioned the HDL(High density lipoprotein cholesterol) and TC(total cholesterol) level changes[5][7]. One of the studies used the Oxidative index as a metabolic parameter[3]. LDL(low density lipoprotein cholesterol) and TG(Triglycerides) levels were assessed in the same study[5]. Visfatin(an adipose hormone associated with diabetes mellitus) was measured and evaluated in one of the studies included[8]. The study by Al-Nowaiser et al. 2014, Saudi arabia, also added bacterial changes for evaluation, including; Aggregatibacter actinomycetemcomitans(Aa), Porphyromonas gingivalis (Pg), and
Prevotella intermedia(Pi) and Tannerella forsythia (Tf)[9]. Wang et al. 2017 China, assessed the
levels of TNF-α, IL-6, APN, and FGF21[13]. Systemic hs-CRP used in one study as well[14].
5.2.5 intervention of studies:
The main intervention performed was non-surgical periodontal therapy for at least one of the groups randomly selected in each study. Two studies added additional treatment alternative parallel to the periodontal therapy (Botero et al. 2013, Colombia and Al-Nowaiser et al. 2014, Saudi arabia), but one of them added a group which only received periodontal therapy that could be used as reference. Blood samples was taken from all participants to see the outcome of the metabolic changes in both intervention- and control-groups. The studies all had a concomitant parameter that they recorded in order to asses the glycemic control, this parameter being the HbA1c level, which is highly relevant in patients suffering for diabetes mellitus type 2.
5.2.6 Outcomes
5.2.6.1 Periodontal outcomes:
All the studies included showed a statistically significant improvement of all parameters recorded in
each individual study, being; PPD, CAL, BOP, GI, PI, REC, PESA, PISA, CPI. Most of the studies
that recorded those indexes measured them at 6 classical point: mesio-buccal, buccal, disto-buccal, mesio-lingual, lingual, and disto-lingual: Most of the examined clinical parameters had a reduction
with a p-value of p<0.01. For a more detailed view of the results for each study see “Annex 5.
Descriptive results for the included studies”.
Table 4. Periodontal evaluation and periodontal outcomes
Authors Periodontal evaluation Periodontal Outcomes
1. Mauri- Obradors et al., 2017
Spain
Periodontal records included: • PI • GI • PD • CAL
Patient underwent 3 periodontal examination • One at baseline • At 3 months • At 6 months Periodontitis: “when at least 9 teeth present, 30% of the probed gingiva with a depth and clinical attachment level ≥4 mm.” (Armitage, 1999) Average PD = 3,28mm TG had a reduction in PD: • −1.18mm (at 3 month) • −1.28 mm (at 6 month) 2. Koromantzos et al., 2011
Greece Patient underwent 3 periodontal examination: • One at baseline
• At 3 months • At 6 months
Periodontal record included : • PPD
• CAL • BOP • GI
Periodontitis define as 8 sites with PPD of >6mm and four sites with CAL of >5 mm, in at least two different quadrants.
Periodontal parameters change from baseline to 6 months: ( IG – intervention group//CG – control group) • BOP (%) p<0.01: o IG; 38.12 (22.53) o CG; 4.35 (16.1) • GI (%) p<0.01: o IG; 48.01 (27.33) o CG; 13.90 (18.03) • PPD 4–6mm (%) p<0.05: o IG;11.16 (15.34) o CG; 2.61(7.90) • PPD ≥7mm (%)p<0.01: o IG; 7.60 (10.10) o CG; 2.21 (3,5) • CAL 4–6mm (%) p<0.01: o IG; 6.23 (22.78) o CG; 0.91 (12.30) • CAL ≥7mm (%)p=0.05: o IG; 11.75 (13.01) o CG; 4.12 (8.74) 3. Mizuno et al., 2017 Japan
Periodontal record included : • PPD • CAL • BOP
• Plaque control with erythrosine staining
Periodontal parameters difference at baseline and 6 months:
• Mean PPD (mm): -0.40 mm (-0.68 to -0.13) Mild to advanced chronic periodontitis, p=0.006
defined as 2 interproximal sites with CAL 3 • Mean CAL (mm): -0.34 mm(-0.57 to -0.11) mm and 2 interproximal sites with PPD 4 mm p=0.005
(on different teeth) or one site with PPD 5 • Mean BOP (%):-13.10 % (-24.24 to -1.96)
4. Gay et al., 2014 USA
Examination made at baseline and 4-6 weeks after periodontal therapy.
Periodontal parameters recorded: • PD • CAL • REC • BOP PD result: • Mild(1-3mm), • moderate(4-6mm) • severe(≥ 7mm).
Clinical attachment loss results; • Mild(1-2mm),
• moderate(3-4mm), • severe(≥ 5mm).
Periodontal parameters changes at baseline and 4 months:
• BOP p <0.05(%):
o Experiment (EG): −18.7% (−85% to 42.2%) o Control (CG): −8.7% (−100% to 35%) • PD changes (sites with initial PD 4–6 mm) p<0.001(mm): o EG: 4.8 ± 0.3 to 3.6 ± 0.6
o CG: 4.7 ± 0.3 to 4.2 ± 0.7 • PD changes (sites with initial PD ≥ 7 mm) p<0.001(mm): o EG: 7.4 ± 0.5 to 5.3 ± 1.2
o CG: 7.4 ± 0.6 to 5.8 ± 1.5 • CAL changes (sites with initial PD 4–6 mm) p<0.001 (mm): o EG: 5.1 ± 1.0 to 4.6 ± 1.0
o CG; 5.1 ± 1.2 to 4.9 ± 1.3 • CAL changes (sites with initial PD ≥ 7mm) p<0.001 (mm): o EG: 7.7 ± 1.4 to 6.9 ± 1.4 o CG: 8.1 ± 1.7 to 7.3 ± 1.6 5. Moeintaghavi et al., 2012 Iran
Periodontal parameters was checked at baseline and 3 months later, for both of the groups.
Periodontal parameters: • GI • PI • CAL • PPD
Chronic periodontitis periodontal requirement to be recruited.
Classification of periodontitis patient according the AAP. (PPD needs to be <5 mm).
Periodontal parameters changes at baseline and 3 months:
• PPD decreased from: 2.31 ± 1.3 to 2.21 ± 1.2 (mm) (p = 0.012)
• CAL decreased from: 3.14 to 2.8 (p = 0.00) • PI decreased from: 88.9% to 63.22% (p = 0.005) • GI decreased from: 1.86 ± 0.83 to 1.24 ± 1.03 (p = 0.00)
For control group increase in all the value with p < 0,05 for all parameters
6. Botero et al., 2013
Colombia
Periodontal parameters was checked at baseline and 3, 6 and 9 months Periodontal parameters: • BOP • PI • CAL • PPD Classification:
• Moderate periodontitis if on 2 or more interproximal sites on different teeth
• CAL ≥ 4 mm • PD ≥ 5 mm
Periodontal parameters changes;
• PD Baseline - 9 mo, median reduction ranged from; 0.71 mm in AZ-Sca, 0.39 for PB-sca and 0.20 in Az-prof. Az-Sca group had a p=0,036 • CAL Baseline - 9 mo, median attachment increase ranged from; 0.17 mm in AZ-Sca, 0.14 in PB-sca and 0.11 in Az-prof
7. Kapellas et al., 2017
Australia
Periodontal parameters was checked at baseline and at 3 months
Periodontal parameters: • BOP • GI • CAL • PPD • REC Classification based on AAP with • CAL ≥ 3mm • PPD ≥ 4mm
Periodontal parameters changes; p=0,01
• Mean extent CAL ≥3 mm %: o TG: 64.3 to 51.0
o CG: 61.8 to 58.4 • Mean gingival bleeding: o TG: 1.6 to 1.0
o CG: 1.6 to 1.5
8. Vandita Mishra et al., 2016 India
Periodontal parameters was checked at baseline and at 1 months
Periodontal parameters: • GI • PI • PPD
Classification and enrollment of periodontitis patient based on AAP
Correlation of visfatin with other clinical parameters including PI, GI, PPD and HbA1c(HbA1c correlation coefficient 0.587 <0.001),
9. Al-Nowaiser et al., 2014
Saudi arabia
Periodontal parameters was checked at baseline, post treatment, 1, 3 and 6 months after treatment
Periodontal parameters: • GI • PI
• PPD • CAL • BOP
Moderate to severe periodontitis if at least 8 sites with:
• PPD ≥ 5mm • CAL ≥ 5mm
Periodontal parameters outcome: p<0,05 • Mean PI : o Baseline 2.14±0.16
o Final visit 1.39±0.12 • Mean PPD: o Baseline 3.89±0.13 mm
o Final visit 2.39±0.21 mm, • CAL mean: o Baseline, 4.92±0.17 mm
o Final visit 4.18±0.19mm • Mean GI: o Baseline: 2.12±0.11
o Final visit: 1.36±0.21 • Mean BOP (%) o Baseline: 66±6.9
10. Soorya K V et al., 2014
India
Periodontal parameters was checked at baseline, and 3 months after treatment Periodontal parameters:
• CPI • PPD • CAL Considered as periodontitis
• PD ≥ 4mm • CPI score ≥ 3
Periodontal parameters outcome: p<0,05 • Mean CPI: o Baseline 3.62
o Final visit 2.38 • Mean PPD: o Baseline 2.04 mm
o Final visit 1.09mm, • CAL mean: o Baseline,0.95mm
o Final visit 0.75mm 11. Engebretson et al., 2013 USA Periodontal parameters: • PPD • CAL
• GI (from 6 index teeth) • PI (from 6 index teeth) Considered as periodontitis • CAL ≥ 5mm • PPD ≥ 5mm
Periodontal parameters difference between control and experimental group at 6 months: p<0.0001 • PD: 0.33mm (95% CI: 0.26, 0.39), • CAL: 0.31mm (95% CI: 0.23, 0.39), • BOP (%): 16.5%(95% CI: 12.9, 20.0) • GI (%): 0.28 (95% CI: 0.21, 0.35) 12. Kaur et al., 2015 India
Periodontal parameters were checked at baseline, 3 and 6 months after treatment Periodontal parameters: • PPD • CAL • GI • PI • PESA • PISA
Criteria generalized moderate to severe chronic periodontitis
Periodontal parameters differences at baseline and 6 months:
• BOP p <0.05 (%):
o Experiment (EG): − 34.71 ± 14.78 o Control (CG): -3.52 ± 4.43
• PD changes (sites with initial PD 4–6 mm)(%): o EG: 15.19 ± 7.99
o CG: 4.16 ± 5.62
• PD changes (sites with initial PD ≥ 7 mm) (%):
o EG: 6.29 ± 2.70 o CG: -3.16 ± 4.41
• CAL changes (sites with initial PD 4–6 mm) (mm): o EG: 0.71 ± 0.36 o CG; -0.07 ± 0.08 13. Wang et al., 2017 China
Periodontal parameters were checked at baseline and 3 month
Periodontal parameters: • PPD
• AL
Chronic periodontitis definition: • 30% of teeth with • 60% of teeth
Periodontal parameters differences at baseline and 3 months(p<0,001):
• PD changes (mm): o EG: 0.07 ± 0.28 o CG: -0.57 ± 0.30
• CAL changes (sites with initial PD 4–6 mm) (mm): o EG: 0.08 ± 0.32 o CG: -0.50 ± 0.37 o PD ≥ 5 mm o PD ≥ 4 mm o AL ≥ 4 mm o AL ≥ 3mm 14. Raman et al., 2014
Malaysia Periodontal parameters were checked at baseline, 2 and 3 months Periodontal parameters: • PPD • AL • GBI • PI • BOP
Chronic periodontitis definition:
Periodontal parameters outcome:
• PI: between NSPT and OHI groups significant difference at 2 months recall (p = 0.013) • Mean PPD within the NSPT: p = 0.003 o Baseline 2.56 ± 0.57 mm
o Final visit 1.94 ± 0.26 mm,
• PAL within the NSPT group: p = 0.001 o Baseline, 3.35 ± 0.83 mm
o Final visit 2.92 ± 0.72 mm • Mean PPD OHI group: (p < 0.001). o Baseline: 2.29 ± 0.69 mm
o Final visit: 2.09 ± 0.72 mm • Mean PAL OHI group (p < 0.001). o Baseline: 2.79 ± 0.96 mm o final visit: 2.62 ± 0.97 mm (p < 0.001). • PD ≥ 5 mm at 5 sites • AL of ≥4 mm in at least 2 different quadrants • BOP 15. Goel et al., 2017 Nepal
Periodontal parameters were checked at baseline and 3 months
Periodontal parameters: • PPD
• GI • CAL
Chronic severe periodontitis definition:
Periodontal parameters outcome:
• PD: decreased by 0,9 mm in TG (p<0.001) • CAL: increase by 0,3mm compare compared to the control group increase of 0.05 mm (p<0.001).
5.2.6.2 Metabolic outcomes:
The HbA1c level had a reduction of statistical significance(p<0.05) in 11 of the studies. The remaining studies also had a decrease in HbA1c, but with a p-value above 0.05[3][4][7][11]. The outcome for fasting plasma glucose(FPG) levels which was evaluated in 3 studies[1][5][6] were, there was a statistical significance(p<0.05) in the reduction of this parameter level, with the most significant value being p=0,006[5].
Visfatin, which is a adipose hormone use as a metabolic parameter, had a mean reduction of 54,85 in the treatment groups at one month check-up, with a p value of p=0.00001[8]. In one of the studies[5] using the most combinations of metabolic measurements, with a positive HbA1c change in value(p = 0.003), but negative outcomes for the other parameters after treatment; TG, TC, LDL
and HDL(p = 0.49, p = 0.33, p = 0.30 and p = 0.08, respectively). The study including Oxidative
Index[3], had an improvement by observing a reduction of -1 unit at the 3 month follow-up with a p-value of 0.007.
5.2.7 Influence of covariates:
Due to previously mentioned values seen in outcomes a correlation can be observed between the periodontal and metabolic values in most cases. But it is of great value to weigh in the extent of covariant involvement. The covariants mentioned were BMI[7][8], smoking[1][2][7], tooth
brushing[1][3] and medicament[4] related which is important to assess, due to its ability to alter the outcomes. The numbers of participants which are in the group of covarients mentioned, will create a bias due to the role these covariates have on periodontitis, and its overall effect on the periodontium. There were addition metabolic measurements taken beside the main one focused on in this
systematic review(HbA1c), these where mentioned in articles[1][3][5][6][7][8][9][13][14](see 3.2.3 for the “metabolic measurements” used in each article).
6. DISCUSSION
This study evaluated the effectiveness of non-surgical periodontal treatment for patients with periodontitis that suffer from diabetes mellitus type 2. In order to assess the local and systemic changes periodontal and metabolic parameters were used to observe conditional changes, in association to periodontal therapy(SRP). The periodontal effect was expected to show a significant reduction, which it did. The main metabolic parameter focused on for this study was the HbA1c level, due to its use for diabetic patients specifically, by showing the glycemic control[22]. 11 of the included studies had a significant reduction of HbA1c levels, showing a more desirable diabetic control. Other metabolic parameters had a statistically significant reduced except HDL(with a p=0.08)[5], which can be seen in detail under 5.2.6.2. This showing that non surgical periodontal therapy not only helps the patients oral hygiene and periodontal condition, but may have systemic benefits for diabetic patients.
A systematic review and meta-analysis made by (Stefano) Corbella et al. Italy, in 2013, consisting of 15 studies regarding the effect of non periodontal treatment in diabetic patients(14/15 with DMT2). The outcomes showed that there was a significant reduction of the HbA1c level post periodontal treatment, -0,38% HbA1c level 3 month after non-surgical periodontal treatment and - 0,31% 6 months after treatment. In the same review, other systematic reviews was referred to, and concluded that most of those reviews provided data that, periodontal therapy had a significant improvement of glycemic control. Another meta-analyses by Li from 2015, found the same correlation between non-surgical periodontal therapy and metabolic effect of DMT2 patients, the results they received seemed to support the effect of non-surgical periodontal treatments
improvement of glycemic control[20].
Non-surgical periodontal treatment is of great importance for diabetic patients suffering from periodontitis due to; reduction of conditional side effects, improvement of a potential factor(HbA1c level) for impairing the glycemic control. While it preserves or improves periodontal health and oral status[32].
6.1 Limitations of included studies:
Regarding the gender ratio, some studies only mentioned the sex predilection of the participants which completed the study[3][4][13][14]. And one study just mentioned that both male and females were included, gender ratio N/A[10]. Thereby the overall included participants gender were not provided, which could alter the accuracy of the gender ratio. The provided information showed a
total of 731 males and 674 females included in the combined studies selected, as seen there is a slight male predilection(which is noteworthy). In total it amounts to 1405 participants divided into male/female, while the total amount of participants included in the all studies were 1494. consequently 89 participants were excluded from the gender selectioning taken place.
In this particular study a age range was not implemented, the only criteria regarding age were participants above 18 years. As observed in Table .2 the lowest mean age=40.74[7] and the highest respectively equaling approximately 62 years of age. Due to the mean age range, the effect and response to non-surgical periodontal therapy of the treatment groups may be distorted.
The type and amount of examiners should also be taken into account, by using a single experienced examiner(dentist or periodontist) for recording the periodontal parameters a more uniformed and accurate result can be expected, which was the case in most clinical trials included[1][2][5][12][13][14][15]. The highest amount of examiners was 4 periodontists, supported by dental assistants, which will increase the bias regarding this section[9]. The amount of pressure applied and accuracy whilst taking measurements and recording the data, differs in clinicians. Leading to a higher risk of errors the more clinicians combined in the examination section.
Covariants like smoking and BMI, which was mentioned in 4 studies[1][2][7][8], has a risk of altering the outcome and results. This due to the impact they have on periodontitis and periodontal health of the included patients involved in the studies stated. A bias will be created because of the participants categorized under these covatients, thereby it is of great importance to take note of the included covariates for single studies, for future outcome confirmation.
The studies selected were all published within the last 7 years, due to requirement of relevant clinical trials. The oldest study was published 2011[2], even though the inclusion criteria of this systematic review had a publishing range of 10 years from present.
The limitations of the various studies respectively lead to limitations of this systematic review, as well as particular studies not providing sufficient clarity in their methods and outcome. Although the main limitation for this systematic review was the lack of ability to access some really good randomized clinical trials, which had a large number of participants and relevancy in this field. This due to the restricted ezproxy access capabilities, so i needed to use and assess what was available for full text analyses.
Certain aspects like; “life style/destructive habits”, nutritional status and diet of the included participants in the various studies where not mentioned, which can also impact and alter the outcomes, during the duration of studies and/or prior to study inclusion.
Even though there way some limitations for the studies included as well as this particular study, all the articles chosen had scientific relevance and methodology. The main purpose of this study was to determine if non-surgical periodontal treatment had an effect on glycemic control for DMT2
patients. Other effects were also assessed, in order to see if there was a broader view of the beneficial implementations for periodontal therapy.
6.2 Periodontal health maintenance recommendations for Diabetic patients:
The oral manifestations that occur in diabetes patients needs to be taken in to consideration not only during treatment but also for the post treatment needs that they require. HbA1c has been used as a diagnióstic measurement for Diabetic patients because of its indication of the glucose blood level and thereby the glycemic control of diabetic patients[22].
A HbA1c level between 4%-6% is considered as reasonable diabetes control, <7% shows a manifestation of well/good control, 7%-8% indicates moderate control, and a value of >8% seen as poorly controlled diabetes[23].
The evaluation and records of the metabolic diabetes control is of great importance because, a reduced HbA1c value is associated with a reduction of the diabetes complications. For reference, a 1% HbA1c reduction is associated with a 21% decrease of any “endpoint”, related with diabetes. Not only for conditions in the oral cavity but also has an impact on the systemic conditions related with diabetes, for example: 1% reduction of HbA1c respectively leads to a procentual reduction of, 21% of deaths associated with diabetes, 14% for myocardial infarction and 37% for microvascular complications[24].
The type of periodontal disease in correlation with either well/poorly controlled Diabetes will alter the interval of revisitation and “check up periods”. But in case of chronic, mild to moderate periodontitis and advanced or aggressive periodontitis the type of diabetes control is irrelevant. The patient should visit the dentist every 3 months when OHI, monitoring of periodontal parameters should be made alongside deplaquing, and a annual record of these parameter should be made and stored in order to see the long term progression of the periodontal status. Periodontal therapy(SRP) should be made according to the individual needs of the patient in question [26].
The same author(Debora C. Matthews) that made the Table 1. mentioned in the introduction
regarding oral complications of diabetes also made another table, which has a clear layout and helps separate the treatment/visitation needs for patients with different type of controlled diabetes.
7. CONCLUSIONS
1. Non-surgical periodontal treatment had a statistically significant reduction of the HbA1c level in
11 out of 15 clinical studies. NSPT may have a beneficial effect on glycemic control for diabetes mellitus type 2 patients with chronic periodontitis
2. Non-surgical periodontal treatment had a statistically significant improvement on the periodontal
status and periodontal parameters, for DMT2 patients with CP.
Additional well structured studies with a large amount of participants should be made, regarding the glycemic control effect of non surgical periodontal treatment on DMT2 patients. In the purpose of confirming, and validating the findings in this study. Which is of importance not only for the patient, but clinician as well, in order to provide a proper treatment for enhancement of glycemic control in DMT2 patients.
8. PRACTICAL RECOMMENDATIONS
According to this systematic review, it can be recommended for dental practitioners to assess the glycemic control before and after periodontal treatment has be done. In this case, the role of the periodontal treatment could help the patient to reduce and maintain a better glycemic control. Dental practitioners could also ask their patient to have a blood test in order for them to assess which kind of treatment will be the best suitable for them, to have better healing and a beneficial impact on their metabolic control. A close relation with the general doctor of the diabetes mellitus type 2 patients is also very important. More indepth research is needed in order to investigate the link between the periodontal disease, non surgical periodontal treatment and its effect on glycemic control (HbA1c). So that a better understanding for the scientific community can be achieved. Also the effect of glycemic control (poor or good) on the periodontium should be evaluated.
Future research could focus on particular age group, ethnicities or sex group as well.
Researcher could also see how surgical periodontal treatment affects the glycemic control (HbA1c) so that dentist or periodontist will have an easier time choosing the treatment options.
It will also be importance that future researchers investigate the glycemic control effect of non surgical periodontal treatment for other kind of diabetes sufferers, such as diabetes mellitus type 1, gestational diabetes and pre diabetics, as those patient that have an increased risk of suffering from periodontitis.
9. CONFLICT OF INTEREST
No conflicts of interest hereby declared by the author.
10. FUNDING
This study received no funding.
11. ACKNOWLEDGEMENT
I would initially like to thank my supervisor, Assoc.Prof. I.Pacauskienė, for her patience,
consideration and guidance during the whole thesis period. Prof. Pacauskienė was a well needed mentor during this journey.
Thanks to the support of my family being the reason i have been able to make it this far in pursuing my goals.
Big thanks to Julien-Wassim Achard who has been there for me like a brother, and helped motivate and push me through thick and thin.
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