Diabetes and Periodontal disease A two way relationship

Contentsbull Diabetes overview

bull Periodontal disease overview

bull Relation between Diabetes and

Periodontal disease

bull effect of diabetes on periodontal disease

and its mechanism

bull Effect of periodontal disease on diabetes

and its mechanism

bull references

Introduction

bull Its widely thought that any diseases associated with each other

then one caused the other

bull But many of these diseases interrelationship mechanisms is

obscure

bull A better understanding of this relationship provides more

appropriate treatment for these patients

bull So in this seminar we will figure out the relation between

diabetes and periodontal disease and its bidirectional

mechanisms

DiabetesAmong many systemic diseases diabetes have been a nightmare

to researches doctors and patients due to its difficult control and

diverse complications

Classification

according to

its patho-

physiology

DM

Type I

IDDM

due to destruction of beta cells of

pancreas

Type II

NIDDM

due to insulin

resistance

Gestational

temporary condition

occurs during

pregnancy

others

Drug- or chemical-

induced

Diseases of the

exocrine pancreas

Genetic defects in

β-cell function insulin action

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Contentsbull Diabetes overview

bull Periodontal disease overview

bull Relation between Diabetes and

Periodontal disease

bull effect of diabetes on periodontal disease

and its mechanism

bull Effect of periodontal disease on diabetes

and its mechanism

bull references

Introduction

bull Its widely thought that any diseases associated with each other

then one caused the other

bull But many of these diseases interrelationship mechanisms is

obscure

bull A better understanding of this relationship provides more

appropriate treatment for these patients

bull So in this seminar we will figure out the relation between

diabetes and periodontal disease and its bidirectional

mechanisms

DiabetesAmong many systemic diseases diabetes have been a nightmare

to researches doctors and patients due to its difficult control and

diverse complications

Classification

according to

its patho-

physiology

DM

Type I

IDDM

due to destruction of beta cells of

pancreas

Type II

NIDDM

due to insulin

resistance

Gestational

temporary condition

occurs during

pregnancy

others

Drug- or chemical-

induced

Diseases of the

exocrine pancreas

Genetic defects in

β-cell function insulin action

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Introduction

bull Its widely thought that any diseases associated with each other

then one caused the other

bull But many of these diseases interrelationship mechanisms is

obscure

bull A better understanding of this relationship provides more

appropriate treatment for these patients

bull So in this seminar we will figure out the relation between

diabetes and periodontal disease and its bidirectional

mechanisms

DiabetesAmong many systemic diseases diabetes have been a nightmare

to researches doctors and patients due to its difficult control and

diverse complications

Classification

according to

its patho-

physiology

DM

Type I

IDDM

due to destruction of beta cells of

pancreas

Type II

NIDDM

due to insulin

resistance

Gestational

temporary condition

occurs during

pregnancy

others

Drug- or chemical-

induced

Diseases of the

exocrine pancreas

Genetic defects in

β-cell function insulin action

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

DiabetesAmong many systemic diseases diabetes have been a nightmare

to researches doctors and patients due to its difficult control and

diverse complications

Classification

according to

its patho-

physiology

DM

Type I

IDDM

due to destruction of beta cells of

pancreas

Type II

NIDDM

due to insulin

resistance

Gestational

temporary condition

occurs during

pregnancy

others

Drug- or chemical-

induced

Diseases of the

exocrine pancreas

Genetic defects in

β-cell function insulin action

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Classification

according to

its patho-

physiology

DM

Type I

IDDM

due to destruction of beta cells of

pancreas

Type II

NIDDM

due to insulin

resistance

Gestational

temporary condition

occurs during

pregnancy

others

Drug- or chemical-

induced

Diseases of the

exocrine pancreas

Genetic defects in

β-cell function insulin action

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

bull Actually to understand diabetes its as simple as just

increase in glucose in blood whether its due to insulin

deficiency or resistance

bull But what will result from this increase

Why is it dangerous then

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

bull Deficiency of insulin secretion or insulin resistance results in

Inability to transport

glucose into cells

Glucose retained in the blood stream

Hyperglycemia Complications

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

bull microangiopathy

bull nephropathy

bull neuropathy

bull macro vascular disease

bull delayed wound healing

- All the forms of DM are associated with hyperglycemia

hyperlipidemia and associated complications

bull The five classic major complications of diabetes

include

bull Periodontitis has been recognized as the sixth

complication associated with diabetes-Diabetes-related complications can be very serious

and even life-threatening

-So medical management is necessary to

Prevent initiation or progression of

complications

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Medical management if

diabetic patients

Pharmacological

Insulin therapyOral

hypoglycemic agents

Non pharmacological

Exercise dietary control weight

loss

The best method to evaluate the glycemic control of patients is HBA1cWhere the ADA recommends a target of lt7 for individual with DM

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Oral complications of DM

XEROSTOMIA

Candidiasis

Burning mouth

syndrome

Dental caries

Periodontal disease

Oral mucosal diseases

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Periodontal disease

bull Definition

PD is a chronic bacterial

infection that affects both the

gingiva and the bone that

supports the teeth and is

caused by anaerobic Gram-

negative microorganisms that

are present in the bacterial

plaque that adheres to the

teeth

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

bull Periodontal diseases include

- gingivitis (in which the inflammation is confined to

the gingiva and is reversible with good oral hygiene)

- periodontitis (in which the inflammation extends and

results in tissue destruction and alveolar bone

resorption)

bull As a whole periodontal diseases can be found in over

90 of people

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Risk factors of periodontal diseaseNon Genetic

-Smoking is a major risk factor

- Diabetes

-Conditions associated with compromised immune responses (eg HIV)

- Nutritional defects

-Osteoporosis

-Medications that cause drug induced gingival overgrowth (eg some calcium channel blockers phenytoin cyclosporine)

- Local factors (eg anatomical deficiencies in the alveolar bone)

Genetic factors (as yet poorly defined)

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Epidemiologybull severe periodontitis that threatens tooth retention affecting 10ndash

15 of adults

bull Moderate periodontitis is even more common affecting 40ndash

60 of adults

bull Periodontitis is therefore a highly prevalent but largely hidden

chronic inflammatory disease Furthermore it has negative and

profound impacts on many aspects of daily living and quality of

life affecting confidence social interactions and food choices

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

PathogenesisMicrobial plaque

Microbial enzymes waste products bacterial antigens

Release of pro-inflammatory cytokines and other chemical mediators by epithelial and dendritic cells

Inflammatory response in gingival tissue

Gingival edema due to fluid accumulation and cell infiltration

Production of degrading enzymes (MMP-8) by inflammatory cells causing CT destruction

Breakdown of junctional epithelium contact tooth is lost pocket is formed

Pocket favors more colonization of facultative and anaerobic micro-organisms

More immune response tissue destruction bone resorption

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Early stages

bull the condition is typically asymptomatic

bull it is not usually painful

bull many patients are unaware until the condition has

progressed enough to result in tooth mobility

bull The pockets deepen as a result of the further

destruction of fibers of the periodontal ligament and

the resorption of the alveolar bone that occurs in

parallel with the progressing attachment loss

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Advanced periodontitis

bull Characterized by

- gingival erythema and edema

- gingival bleeding

- gingival recession

- tooth mobility drifting of teeth

- suppuration from periodontal pockets

- tooth loss

bull The pocket is the space between the root surface and the gingiva

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Relation to Diabetesbull Its Considered the sixth complication of

diabetes

bull More likely to occur in diabetic patients

bull Poorly controlled diabetics are more likely to develop periodontal disease than well-controlled diabetics

bull bull Poorly controlled diabetics had three foldincreases in risk of having periodontitis compared to non-diabetics

bull The duration of having diabetes is an important factor to evaluate the risk for development of periodontal disease

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Effect of diabetes on periodontium

bull The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time

bull This is due to change in

Micro-organisms

Host response

Blood vessels

Wound healing

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

1-Change in oral Microorganisms

So increase the susceptibility of diabetics to periodontal disease

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

2-Change in Host Response differences in the immunoinflammatory response to bacteria

between people with diabetes and those without diabetes

1 The function of cells including neutrophils monocytes and

macrophages is altered in many people with diabetes

The adherence chemotaxis and phagocytosis of neutrophils are often impaired so it prevents destruction of

bacteria in the periodontal pocket thereby increasing periodontal

destruction

2-Other immune inflammatory responses are up regulated in people with diabetes

For example macrophages and monocytes often exhibit elevated production of pro -inflammatory cytokines and mediators

such as (TNF-α) in the blood and gingival crevicular fluid in response to PDL

pathogens which may increase host tissue destruction suggesting both a local and

systemic hyper responsiveness of this immune cell line

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

a)The primary reparative cell in the periodontium the fibroblast does not function properly in high-glucose environments

b)Furthermore the collagen that is produced by these fibroblasts is susceptible to rapid degradation by matrix metalloproteinase enzymes which are elevated in diabetes

Thus periodontal wound healing responses to chronic microbial insult may be altered in those with sustained hyperglycemia resulting in increased bone loss and attachment loss

3-Altered wound healing

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Diabetics with poor glycemic control have accumulated high levels of

irreversibly glycated proteins called advanced glycation end products

(AGEs) in the tissues including the periodontium

AGEs are a primary link between numerous diabetic complications because

a) they induce marked changes in cells and extracellular matrix

components including abnormal endothelial cell function capillary

growth and vessel proliferation also occur in the periodontium of some

people with diabetes

b) Interactions between AGEs and their receptors on inflammatory cells

result in the increased production of pro-inflammatory cytokines such as IL-

1 α and TNF- α seen in subjects with diabetes compared with those without

diabetes and it may contribute to the increased prevalence and severity of

periodontal diseases found in numerous studies of populations of people with

diabetes

4Change in microvascular integrity

HyperglycemiaNon enzymatic

glucose metabolism

Advance glycation end

products

(AGE`s)

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Effect of periodontitis on diabetes bull Inflammation is a common link between periodontal diseases and

diabetes

bull In patients with diabetes hyper inflammatory immune cells can

exacerbate the elevated production of proinflammatory cytokines This

has the potential to increase insulin resistance and make it more difficult

for the patient to control his or her diabetes

bull periodontal treatment that decreases inflammation may help diminish

insulin resistance

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

bull In a recent study of subjects with type 2 diabetes and periodontitis it

was found that periodontal treatment resulted in a significant reduction

in serum levels of TNF-α that was accompanied by a significant

reduction in mean HbA1c values (from 80 to 71 percent)

bull The improvement in HbA1c values was correlated strongly with the

reduction in serum TNF-α levels across the patient population This

suggests that a reduction in periodontal inflammation may help

decrease inflammatory mediators in the serum that are associated with

insulin resistance thereby improving glycemic control

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

CONCLUSION

The relationship between diabetes and periodontitis

bull The severity of periodontitis was significantly higher in

diabetic patients compared to non- diabetic patients

bull this bidirectional relationship between periodontal disease and

diabetes mellitus makes diabetes a disorder of importance to

dentists and dental hygienists and to patients seen in the dental

office

bull Diabetes is associated with an increased risk of developing

inflammatory periodontal diseases and glycemic control is

an important determinant in this relationship

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Any Questions

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Made by Lobna Muhammad Ihab Ghada AbdelMohsen Karma NabeelFatma Mahmoud Mayan Sayed

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

Resources-Paper on PubMed1ldquoTreating periodontal disease may improve metabolic control in diabeticsrdquo(2010)Vergnes JN11Department of Dentistry Toulouse University Hospital (CHU de Toulouse) and Toulouse Dental School Paul Sabatier University Toulouse FrancePaper link httpwwwncbinlmnihgovpubmed20938470

2- The effects of periodontal treatment on diabetes(Oct 2003)Taylor GW11Department of Cariology Restorative Sciences and Endodontics The University of Michigan School of Dentistry Ann Arbor 48109-1078 USA gwtumicheduPaper link httpwwwncbinlmnihgovpubmed18196672

3-Treatment of periodontal disease for glycemic control in people with diabetes( may 2010)Simpson TC1 Needleman I Wild SH Moles DR Mills EJ

1Edinburgh Dental Institute University of Edinburgh Lauriston Place Edinburgh Scotland UK EH3 8HAPaper link httpwwwncbinlmnihgovpubmed20464734

4- Oral DiseasesVolume 14 Issue 3 pages 191ndash203 April 2008by Taylor GW1 Borgnakke WS

1School of Dentistry University of Michigan Ann Arbor MI 48109 USA gwtumichedu

5 -Periodontal disease and diabetesA two-way streetBrian L Mealey DDS MSLink httpwwwadaorg~mediaADAMember20CenterFIlesPerio_diabetesashx

6 -Periodontitis and Diabetes Mellitus (Nov 2012)Michal Straka1 and Michaela Straka-Trapezanlidis2

1] Slovak Medical University Bratislava Slovakia[2] Private Practice Krizna 44 Bratislava SlovakiaLink httpwwwintechopencombookspathophysiology-and-complications-of-diabetes-mellitusperiodontitis-and-diabetes-mellitus

7 -Periodontal disease and systemic complications (2012)

Rui Vicente OppermannI Patricia WeidlichI Marta Liliana MusskopfII

department of Periodontology School of Dentistry Univ Federal do Rio Grande do Sul - UFRGS Porto Alegre RS Brazil IIGraduate Program in Dentistry School of Dentistry Univ Federal do Rio Grande do Sul - UFRGS Porto Alegre RS Link httpwwwscielobrscielophpscript=sci_arttextamppid=S1806-83242012000700007amplng=enampnrm=isoamptlng=en