Faculty Bibliography

CONTEXT: The effect of periodontal therapy on diabetes outcomes has not been established. OBJECTIVE: This update examines the effect of periodontal treatment on diabetes outcomes. DATA SOURCES: Literature since October 2009 using MEDLINE. STUDY ELIGIBILITY CRITERIA: Published RCTs including periodontal therapy for diabetic subjects, a metabolic outcome, an untreated control group, and follow-up of 3 months. DATA EXTRACTION: Pre-defined data fields, including study quality indicators were used. DATA SYNTHESIS: A search revealed 56 publications of which 9 met inclusion criteria. Mean change of HbA1c from baseline was compared across treatment groups. Pooled analysis was based on random effects models. RESULTS: A meta-analysis indicated a mean treatment effect of -0.36% HbA1c (CI -0.54, -0.19) compared to no treatment after periodontal therapy (p < 0.0001). Heterogeneity tests revealed only minimal evidence of publication bias (I(2 ) = 9%). LIMITATIONS: Small sample size and high risk of bias remain problematic for studies of this type. Periodontal therapy varied considerably. CONCLUSION: The modest reduction in HbA1c observed as a result of periodontal therapy in subjects with type 2 diabetes is consistent with previous systematic reviews. Despite this finding, there is limited confidence in the conclusion due to a lack of multi-centre trials of sufficient sample size are lacking.

Abstract Context: The effect of periodontal therapy on diabetes outcomes has not been established. Objective: This update examines the effect of periodontal treatment on diabetes outcomes. Data sources: Literature since October 2009 using MEDLINE. Study eligibility criteria: Published RCTs including periodontal therapy for diabetic subjects, a metabolic outcome, an untreated control group, and follow-up of 3 months. Data extraction: Pre-defined data fields, including study quality indicators were used. Data synthesis: A search revealed 56 publications of which 9 met inclusion criteria. Mean change of HbA1c from baseline was compared across treatment groups. Pooled analysis was based on random effects models. Results: A meta-analysis indicated a mean treatment effect of _0.36% HbA1c (CI _0.54, _0.19) compared to no treatment after periodontal therapy (p < 0.0001). Heterogeneity tests revealed only minimal evidence of publication bias (I2 = 9%). Limitations: Small sample size and high risk of bias remain problematic for studies of this type. Periodontal therapy varied considerably. Conclusion: The modest reduction in HbA1c observed as a result of periodontal therapy in subjects with type 2 diabetes is consistent with previous systematic reviews. Despite this finding, there is limited confidence in the conclusion due to a lack of multi-centre trials of sufficient sample size are lacking.

BACKGROUND:Diabetes and periodontitis are complex chronic diseases with an established bidirectional relationship. There is long-established evidence that hyperglycaemia in diabetes is associated with adverse periodontal outcomes. However, given the ubiquity of periodontal diseases and the emerging global diabetes epidemic, the complications of which contribute to significant morbidity and premature mortality, it is timely to review the role of periodontitis in diabetes. AIMS/OBJECTIVE:To report the epidemiological evidence from cross-sectional, prospective and intervention studies for the impact of periodontal disease on diabetes incidence, control and complications and to identify potential underpinning mechanisms. EPIDEMIOLOGY/BACKGROUND:Over the last 20 years, consistent and robust evidence has emerged that severe periodontitis adversely affects glycaemic control in diabetes and glycaemia in non-diabetes subjects. In diabetes patients, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence supports an increased risk for diabetes onset in patients with severe periodontitis. Biological mechanisms: Type 2 diabetes is preceded by systemic inflammation, leading to reduced pancreatic b-cell function, apoptosis and insulin resistance.Increasing evidence supports elevated systemic inflammation (acute-phase and oxidative stress biomarkers) resulting from the entry of periodontal organisms and their virulence factors into the circulation, providing biological plausibility for the effects of periodontitis on diabetes. AGE (Advanced Glycation Endproducts)-RAGE (Receptor for AGEs) interactions and oxidative-stress-mediated pathways provide plausible mechanistic links in the diabetes to periodontitis direction. INTERVENTIONS/METHODS:Randomized controlled trials (RCTs) consistently demonstrate that mechanical periodontal therapy associates with approximately a 0.4% reduction in HbA1C at 3 months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes. RCTs are needed with larger numbers of subjects and longer term follow-up, and if results are substantiated, adjunctive periodontal therapies subsequently need to be evaluated. There is no current evidence to support adjunctive use of antimicrobials for periodontal management of diabetes patients. GUIDELINES/CONCLUSIONS:Given the current evidence, it is timely to provide guidelines for periodontal care in diabetes patients for medical and dental professionals and recommendations for patients/the public.

Chronic periodontitis is a destructive chronic inflammatory disease of bacterial etiology. Mounting evidence confirms that not all patients are susceptible to inflammatory periodontal disease, and further, that the extent and severity of its clinical manifestation varies as a function of individual risk. Risk assessment models are needed to target treatment effectively. Contemporary risk assessment, as applied to periodontal disease, represents an innovative approach to managing periodontitis. The central intent of this paper is to review the current view of risk assessment as it relates to the diagnosis and management of chronic periodontitis, as well as to consider a number of such applications that can be incorporated into daily practice.

In vitro and animal studies suggest a possible role for the tetracycline class of drugs in the inhibition of non-enzymatic protein glycation. We conducted a 3-month, randomized placebo-controlled pilot clinical trial of conventional sub-gingival debridement (periodontal therapy), combined with either a three month regimen of sub-antimicrobial-dose doxycycline (SDD), a two week regimen of antimicrobial-dose doxycycline (ADD), or placebo in 45 patients with long-standing type 2 diabetes (mean duration 9 years) and untreated chronic periodontitis. Subjects were taking stable doses of oral hypoglycemic medications and/or insulin. Treatment response was assessed by measuring hemoglobin A1c (HbA1c), plasma glucose, and clinical periodontal disease measures. At one-month and three-month follow-up, clinical measures of periodontitis were decreased in all groups (data to be presented elsewhere). At three months, mean HbA1c levels in the SDD group were reduced 0.9% units from 7.2% units+/-2.2 (+/-SD), to 6.3% units+/-1.1, which represents a 12.5% improvement. In contrast, there was no significant change in HbA1c in the ADD (7.5%+/-2.0 to 7.8%+/-2.1) or placebo (8.5%+/-2.0 to 8.5%+/-2.6) groups. Mean HbA1c change from baseline was significantly greater in the SDD group compared with the ADD group (p=0.04) but not placebo (p=0.22). Moreover, a larger proportion of subjects in the SDD group experienced improvement (p<0.05) compared to the ADD or placebo groups. Mean plasma glucose levels were not significantly different between or within the groups. The results of this pilot study suggest that the treatment of periodontitis with sub-gingival debridement and 3-months of daily sub-antimicrobial-dose doxycycline may decrease HbA1c in patients with type 2 diabetes taking normally prescribed hypoglycemic agents.

The aim of this study was to test whether performance on a range of manual dexterity haptic simulator exercises was associated with preclinical operative dentistry examination and Perceptual Ability Test (PAT) scores. Thirty-nine first-year dental students were tested with three haptic exercises--straight line, circle, and mirror line--each performed twice. Haptic exercise outcomes for accuracy, time, and success rate were measured using commercially available computer software. Spearman correlation coefficients and Student's t-test were used to assess the results. PAT and exam scores were not significantly correlated. Significant correlations were observed between exam scores and both time and accuracy scores for the circle and mirror exams. These results suggest that haptic devices have a potential role in predicting performance in preclinical dental education. Further studies are warranted to develop and validate diagnostic testing strategies for dental students and to evaluate implementation of haptics in the dental teaching environment.

We tested whether a computerized dental simulator (CDS) pre-test could predict preclinical operative dentistry examination scores. Thirty-eight first-year students completed cavity preparations during a single four-hour CDS pre-test prior to the operative dentistry course and during subsequent practical examinations. Masked, calibrated faculty members scored the preparations in both settings. Pass rates for the CDS pre-test, Exam 1, and Exam 2 were 50 percent, 66 percent, and 86 percent, respectively. Students who passed the CDS pre-test were more likely to pass Exam 1 (95 percent vs. 37 percent, p=0.0004) but not Exam 2 (89 percent vs. 83 percent, p=0.66) and had better mean scores on Exam 1 (73.4 vs. 68.3, p<0.0001), but not Exam 2 (76.2 vs. 74.7, p=0.35). As a diagnostic, success on the CDS pre-test predicted success on Exam 1 with 72 percent sensitivity and 92 percent specificity (positive predictive value 95 percent, negative predictive value 63 percent). As a diagnostic for Exam 2 performance, the CDS pre-test was a weaker predictor and not statistically significant. These findings suggest that a pre-course CDS test may help to identify students in need of early instructional intervention. Future studies are warranted to further define and implement the use of simulation technology in the assessment of students' psychomotor learning potential.

BACKGROUND: Major challenges in periodontology include understanding the pathophysiology, the interplay between various components of the host response, parallels with other diseases and identifying biomarkers of the disease. OBJECTIVES: Four reviews were compiled with the aim of better understanding: (1) the role of polymorphic nuclear leucocytes (PMNs), i.e. neutrophils; (2) the function of cytokine networks in the host response; (3) whether parallels exist with rheumatoid arthritis (RA); and (4) whether useful biomarkers currently exist to help in the management of periodontal disease. MATERIAL AND METHODS: Based on the focused questions, electronic and manual searches were conducted for human, animal and cellular studies on the above topics. RESULTS: Papers fulfilling the inclusion criteria were selected and reviews were written and reviewed and corrected before the academy meeting to produce consensus statements. CONCLUSION: The following consensus statements were produced. PMNs are important in the pathophysiology of periodontal disease but there is limited evidence on their much quoted destructive potential. Cytokine networks are enormously complex and we are really at the beginning of understanding their role in the disease process. RA has both similarities and marked differences to periodontal disease although the existing utilization of anti-cytokine therapies and other molecules in its treatment may have importance in periodontal disease therapy. Biomarkers for periodontal disease have yet to be completely defined but the ratio of receptor activator of NF-kappaB ligand to osteoprotegerin appears to be a biomarker test with utility for detecting bone destruction.