PAPER

THE CORRELATION BETWEEN DIABETES AND THE PERIODONTAL DISEASES

IN THE PATIENTS WITH DIABETES AT NORTH JAKARTA ON 2008

By:

LUZELIA M.S SALDANHA

030.10.163

MEDICAL FACULTY OF TRISAKTI UNIVERSITY

JAKARTA
JULY 4, 2011

1
 PREFACE

I Gratitude to the Almighty God's mercy and blessings so that I can finish this paper with well.

I also do not forget to thank all those who have helped complete this paper.

I hope this paper can be beneficial to all those who use it and can provide additional knowledge

for the readers.

In order to improve the quality of this paper, I expect criticism and suggestions, which build

up from all parties

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 CONTENTS

Preface 2
Contents 3
Chapter I Introduction 5
Background 5
Problems 5
Limitation of Problems 7
Objective 7
Method of writing 7
Frame of writing
Chapter II Diabetes 8
Definition 8
Symptoms 8
Causes 9
Risk factors 10
Complications 12
Test and diagnosis 15
Treatments and drugs 17
Prevention 22
Chapter III Periodontal diseases 23
Definition 23
Symptoms 23
Causes 24
Risk factors 26
Complications 31
Diagnosis 32

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 Treatments 33
Prevention 37
Chapter IV The correlation between diabetes and periodontal diseases in the patients with
diabetes at North Jakarta on 2008 42
Periodontal Disease as a Complication of Diabetes 42
The Effect of Periodontitis on Diabetes 44
Diabetes increases the risk of periodontitis and severity of 44

Periodontitis and the promotion of diabetes susceptibility factors 45

The interaction mechanism of periodontitis and diabetes 46

Chapter V Conclusion 48

References 49

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 CHAPTER I

INTRODUCTION

1.1 Background

Diabetes is a systemic chronic metabolic disease related with genetic and environmental
factors and autoimmune. Periodontal disease is a destructive disease in gum support
organizations (gum, periodontal membrane, alveolar bone). A lot of Research shows the diabetes
and periodontal disease is two -way relationship concerning periodontal disease and diabetes.
Diabetes increases the risk of periodontitis, and severity of diabetes is susceptible and promoting
factors. Diabetes patients not only have a high incidence rate, but also are characteristic of fast
disease Development speed, severe damage, and poor treatment effect. The association between
diabetes and periodontal diseases has been studied extensively for more than 50 years. At
present, the relationship between periodontal disease and diabetes has basically established, but
the internal mechanism of the interaction between them has not been entirely clear. In this paper,
the correlation and the interactive mechanism between periodontal disease and diabetes will be
reviewed.

1.2 Problems

1.2.1 Diabetes :

1. What is diabetes?
2. What is the symptoms of diabetes?
3. What are the causes of diabetes?
4. What are risk factors of diabetes?
5. What are the complications of diabetes?
6. How to tests and diagnose diabetes?
7. What are the treatments and drugs for diabetes?
8. How to prevent diabetes?
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1.2.2 Periodontal diseases:

1. What is periodontal (gum) disease?

2. What are the symptoms of periodontal (gum) disease?
3. What causes periodontal diseases?
4. What are the risk factors of periodontal diseases?
5. What are the complications of periodontal diseases?
6. How to diagnose periodontal diseases?

7. How is periodontal diseases treated?

8. How can I prevent periodontal (gum) disease?

1.2.3 The correlation between diabetes and periodontal disease

1. Does periodontitis as a complication of Diabetes?

2. What is The Effect of Periodontitis on Diabetes?

3. How cans diabetes increases the risk of periodontitis and severity of?

4. What is the promotion of diabetes susceptibility factors and periodontitis?

5. How the interaction mechanism of periodontitis and diabetes?

1.3 Limitation of Problems

In order to this study is not very extensive and clearly demarcated, the authors limit the
study problem as follows:

a. This study uses correlation analysis with the use of intervening variables, the data
analysis this study uses regression analysis intervening / regression line.

b. Variables examined in this study is to determine the mechanisms and magnitude of the
effect relationship between diabetes and periodontal diseases to patients with diabetes

c. Study was conducted in North Jakarta

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1.4 Objectives

At present, the relationship between periodontal disease and diabetes has basically
established, but the internal mechanism of the interaction between them has not been entirely
clear. In this paper, the correlation and the interactive mechanism between periodontal disease
and diabetes will be reviewed to help identify high risk patients, to promote new
drug development and the development of targeted preventive measures in patient with diabetes
at North Jakarta.

1.5 Method of writing

The methods applied include a literature search strategy, inclusion and exclusion criteria
for selecting the studies, characteristics of the studies, quality assessment and meta-analysis.

1.6 Frame of writing

Data sources included PubMed, EMBASE, SciELO, Jaoa, Nejm and LILACS. Selected
papers were articles relating to human studies investigating whether or not diabetes is a risk
factor for periodontitis and if it influences the response to periodontal therapy. Those papers that
were published between January 2000 and June 2007 were retrieved.

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 CHAPTER II

DIABETES

2.1 Definition

The term diabetes refers to a group of diseases that affect how your body uses blood
glucose, commonly called blood sugar. Glucose is vital to your health because it's an important
source of energy for the cells that make up your muscles and tissues. It's your brain's main source
of fuel [1].

If you have diabetes, no matter what type, it means you have too much glucose in your blood,
although the reasons may differ. Too much glucose can lead to serious health problems [2]. There
are four type of diabetes, diabetes type 1, diabetes type 2, prediabetes, and gestational diabetes.

Chronic diabetes conditions include type 1 diabetes and type 2 diabetes. Potentially reversible
diabetes conditions include prediabetes when your blood sugar levels are higher than normal,
but not high enough to be classified as diabetes and gestational diabetes, which occurs during
pregnancy [3].

2.2 Symptoms

Diabetes symptoms vary depending on how high your blood sugar is elevated. Some people,
especially those with prediabetes or type 2 diabetes, may not experience symptoms initially. In
type 1 diabetes, however, symptoms tend to come on quickly and be more severe. Some of the
signs and symptoms of type 1 and type 2 diabetes include [4-8]:

Increased thirst
Frequent urination
Extreme hunger
Unexplained weight loss
Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and
fat that happens when there's not enough insulin)

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 Fatigue
Blurred vision
Slow-healing sores
Mild high blood pressure
Frequent infections, such as gum or skin infections and vaginal or bladder infections

Although type 1 diabetes can develop at any age, it typically appears during childhood or
adolescence. Type 2 diabetes, the most common type, can develop at any age and is often
preventable [9].

2.3 Causes
To understand diabetes, first you must understand how glucose is normally processed in
the body.

How glucose nomally works

Glucose is a main source of energy for the cells that make up your muscles and other tissues.
Glucose comes from two major sources: the food you eat and your liver. During digestion, sugar
is absorbed into the bloodstream. Normally, sugar then enters cells, with the help of insulin.

The hormone insulin comes from the pancreas, a gland located just behind the stomach. When
you eat, your pancreas secretes insulin into your bloodstream. As insulin circulates, it acts like a
key, unlocking microscopic doors that allow sugar to enter your cells. Insulin lowers the amount
of sugar in your bloodstream. As your blood sugar level drops, so does the secretion of insulin
from your pancreas [10-13].

Your liver acts as a glucose storage and manufacturing center. When you haven't eaten in a while
your liver releases stored glucose to keep your glucose level within a normal range.

Causes of type 1 diabetes

In type 1 diabetes, your immune system which normally fights harmful bacteria or viruses
attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or
no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.
Type 1 is thought to be caused by a combination of genetic susceptibility and environmental

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factors, though exactly what those factors are is still unclear [14].

Causes of prediabetes and type 2 diabetes

In prediabetes which can lead to type 2 diabetes and in type 2 diabetes, your cells become
resistant to the action of insulin, and your pancreas is unable to make enough insulin to
overcome this resistance. Instead of moving into your cells, sugar builds up in your bloodstream
[15]. Exactly why this happens is uncertain, although as in type 1 diabetes, it's believed that
genetic and environmental factors play a role in the development of type 2. Being overweight is
strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight
[16,17].

Causes of gestational diabetes

During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones
make your cells more resistant to insulin. As your placenta grows larger in the second and third
trimesters, it secretes more of these hormones making it even harder for insulin to do its job
[18].

Normally, your pancreas responds by producing enough extra insulin to overcome this resistance.
But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your
cells and too much stays in your blood. This is gestational diabetes [19].

2.4 Risk factors

Risk factors for diabetes depend on the type of diabetes [20].

Risk factors for type 1 diabetes

Although the exact cause of type 1 diabetes is unknown, genetic factors likely play a role. Your
risk of developing type 1 diabetes increases if you have a parent or sibling who has type 1
diabetes. Environmental factors, such as exposure to a viral illness, also likely play some role in
type 1 diabetes. Other factors that may increase your risk include: [20-23]

The presence of damaging immune system cells (autoantibodies). Sometimes family

members of people with type 1 diabetes are tested for the presence of diabetes
autoantibodies. If you have these autoantibodies, you have an increased risk of

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 developing type 1 diabetes. But, not everyone who has these autoantibodies develops type
1.
Dietary factors. A number of dietary factors have been linked to an increased risk of type
1 diabetes, such as low vitamin D consumption; early exposure to cow's milk or cow's
milk formula; or exposure to cereals before 4 months of age or after 7 months of age.
However, none of these factors has been shown to cause type 1 diabetes.
Race. Type 1 diabetes is more common in whites than in other races.
Geography. Certain countries, such as Finland and Sweden, have higher rates of type 1
diabetes.

Risk factors for prediabetes and type 2 diabetes

Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and
others don't. It's clear that certain factors increase the risk, however, including: [24]

Weight. The more fatty tissue you have, the more resistant your cells become to insulin.
Inactivity. The less active you are, the greater your risk. Physical activity helps you
control your weight, uses up glucose as energy and makes your cells more sensitive to
insulin. Exercising less than three times a week may increase your risk of type 2 diabetes.
Family history. Your risk increases if a parent or sibling has type 2 diabetes.
Race. Although it's unclear why, people of certain races including blacks, Hispanics,
American Indians and Asians are at higher risk.
Age. Your risk increases as you get older. This may be because you tend to exercise less,
lose muscle mass and gain weight as you age. But type 2 diabetes is increasing
dramatically among children, adolescents and younger adults.
Gestational diabetes. If you developed gestational diabetes when you were pregnant,
your risk of developing prediabetes and type 2 diabetes later increases. If you gave birth
to a baby weighing more than 9 pounds (4 kilograms), you're also at risk of type 2
diabetes.
Polycystic ovary syndrome. For women, having polycystic ovary syndrome a
common condition characterized by irregular menstrual periods, excess hair growth and
obesity increases the risk of diabetes.
High blood pressure. Having blood pressure over 140/90mm Hg is linked to an

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 increased risk of type 2 diabetes.
Abnormal cholesterol levels. If you have low levels of high-density lipoprotein (HDL),
or "good," cholesterol, your risk of type 2 diabetes is higher. Low levels of HDL are
defined as below 35 mg/dL.
High levels of triglycerides. Triglycerides are a fat carried in the blood. If your
triglyceride levels are above 250 mg/dL, your risk of diabetes increases.

Risk factors for gestational diabetes

Any pregnant woman can develop gestational diabetes, but some women are at greater risk than
are others. Risk factors for gestational diabetes include:

Age. Women older than age 25 are at increased risk.

Family or personal history. Your risk increases if you have prediabetes a precursor to
type 2 diabetes or if a close family member, such as a parent or sibling, has type 2
diabetes. You're also at greater risk if you had gestational diabetes during a previous
pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.
Weight. Being overweight before pregnancy increases your risk.
Race. For reasons that aren't clear, women who are black, Hispanic, American Indian or
Asian are more likely to develop gestational diabetes.

2.5 Complications

Long-term complications of diabetes develop gradually. The longer you have diabetes
and the less controlled your blood sugar the higher the risk of complications. Eventually,
diabetes complications may be disabling or even life-threatening. Possible complications
include: [25-27]

Cardiovascular disease. Diabetes dramatically increases the risk of various

cardiovascular problems, including coronary artery disease with chest pain (angina), heart
attack, stroke and narrowing of arteries (atherosclerosis). If you have diabetes, you are
more likely to have heart disease or stroke.
Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels
(capillaries) that nourish your nerves, especially in the legs. This can cause tingling,

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 numbness, burning or pain that usually begins at the tips of the toes or fingers and
gradually spreads upward. Left untreated, you could lose all sense of feeling in the
affected limbs. Damage to the nerves related to digestion can cause problems with
nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.
Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel
clusters (glomeruli) that filter waste from your blood. Diabetes can damage this delicate
filtering system. Severe damage can lead to kidney failure or irreversible end-stage
kidney disease, requiring dialysis or a kidney transplant. The rates of serious kidney
disease have dropped significantly in recent years, likely due to improvements in diabetes
management.
Eye damage (retinopathy). Diabetes can damage the blood vessels of the retina (diabetic
retinopathy), potentially leading to blindness. As many 25 percent of people with diabetes
have some form of diabetic retinopathy. And, about 4 percent of people with diabetes
have diabetic retinopathy that's so advanced that it may affect their ability to see.
Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk
of various foot complications. Left untreated, cuts and blisters can become serious
infections. Severe damage might require toe, foot or even leg amputation.
Skin and mouth conditions. Diabetes may leave you more susceptible to skin problems,
including bacterial and fungal infections. Gum infections also may be a concern,
especially if you have a history of poor dental hygiene.
Brain problems. Recent research suggests that high blood sugar levels may increase the
risk of Alzheimer's disease in people who have type 2 diabetes and a certain gene linked
to the development of Alzheimer's disease. Further research is needed to confirm this
link.
Cancer. People with diabetes have a higher risk of some cancers. But the reasons aren't
clear. It may be that the factors that increase the risk of type 2 diabetes also increase the
risk of type 2 diabetes, or it may be a factor of the disease or its treatment. This is an
active area of research, but in the meantime, no changes in treatment are recommended.

Complications of gestational diabetes

Most women who have gestational diabetes deliver healthy babies. However, untreated or
uncontrolled blood sugar levels can cause problems for you and your baby.

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Complications in your baby can occur as a result of gestational diabetes:

Excess growth. Extra glucose can cross the placenta, which triggers your baby's pancreas
to make extra insulin. This can cause your baby to grow too large (macrosomia). Very
large babies are more likely to require a C-section birth.
Low blood sugar. Sometimes babies of mothers with gestational diabetes develop low
blood sugar (hypoglycemia) shortly after birth because their own insulin production is
high. Prompt feedings and sometimes an intravenous glucose solution can return the
baby's blood sugar level to normal.
Respiratory distress syndrome. If your baby is delivered early, respiratory distress
syndrome a condition that makes breathing difficult is possible. Babies who have
respiratory distress syndrome may need help breathing until their lungs become stronger.
Jaundice. This yellowish discoloration of the skin and the whites of the eyes may occur
if a baby's liver isn't mature enough to break down a substance called bilirubin, which
normally forms when the body recycles old or damaged red blood cells. Although
jaundice usually isn't a cause for concern, careful monitoring is important.
Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a
higher risk of developing obesity and type 2 diabetes later in life.
Death. Untreated gestational diabetes can result in a baby's death either before or shortly
after birth.

Complications in you can also occur as a result of gestational diabetes:

Preeclampsia. This condition is characterized by high blood pressure and excess protein
in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even
life-threatening complications for both mother and baby.
Subsequent gestational diabetes. Once you've had gestational diabetes in one
pregnancy, you're more likely to have it again with the next pregnancy. You're also more
likely to develop diabetes typically type 2 diabetes as you get older.

Complications of prediabetes
Prediabetes may develop into type 2 diabetes.

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2.6 Tests and diagnosis

Symptoms of type 1 diabetes often appear suddenly and are usually the reason that blood
sugar levels are checked. Because symptoms of other types of diabetes and prediabetes come on
more gradually, the American Diabetes Association (ADA) has recommended screening
guidelines [28]. The ADA recommends that the following people be screened for diabetes:

Anyone with a body mass index over 25, regardless of age, who has additional risk
factors, such as high blood pressure, a sedentary lifestyle, a history of polycystic ovary
syndrome, having delivered a baby who weighed more than 9 pounds, a history of
diabetes in pregnancy, high cholesterol levels, a history of heart disease, or having a close
relative with diabetes.
Anyone over the age of 45 is advised to receive an initial blood sugar screening, and
then, if the results are normal, to be screened every three years thereafter.

Tests for type 1 and type 2 diabetes

Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar
level for the past two to three months. It measures the percentage of blood sugar attached
to hemoglobin, the oxygen-carrying protein in red blood cells. The higher your blood
sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5
percent or higher on two separate tests indicates that you have diabetes.

If the A1C test results aren't consistent, the test isn't available, or if you have certain conditions
that can make the A1C test inaccurate such as if you're pregnant or have an uncommon form
of hemoglobin (known as a hemoglobin variant) your doctor may use the following tests to
diagnose diabetes:

Random blood sugar test. A blood sample will be taken at a random time. Regardless of
when you last ate, a random blood sugar level of 200 milligrams per deciliter (mg/dL)
11.1 millimoles per liter (mmol/L) or higher suggests diabetes.
Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting
blood sugar level between 100 and 125 mg/dL (5.6 and 6.9 mmol/L) is considered
prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you'll be
diagnosed with diabetes.

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If type 1 diabetes is suspected, you'll also likely have a blood test to look for diabetes antibodies.
In addition, your urine will be tested to look for the presence of ketones, a byproduct produced
when muscle and fat tissue are used for energy when the body doesn't have enough insulin to use
the available glucose.

Tests for gestational diabetes

Medical experts haven't established a single set of screening guidelines for gestational diabetes.
Some question whether gestational diabetes screening is needed if you're younger than 25 and
have no risk factors. Others say that screening all pregnant women no matter their age is
the best way to catch all cases of gestational diabetes.

Your doctor will likely evaluate your risk factors for gestational diabetes early in your pregnancy.

If you're at high risk of gestational diabetes for example, your body mass index
(BMI) before pregnancy was 30 or higher or you have a mother, father, sibling or child
with diabetes your doctor may test for diabetes at your first prenatal visit.
If you're at average risk of gestational diabetes, you'll likely have a screening test for
gestational diabetes sometime during your second trimester between 24 and 28 weeks
of pregnancy.

Your doctor may use the following screening tests:

Initial glucose challenge test. You'll begin the glucose challenge test by drinking a
syrupy glucose solution. One hour later, you'll have a blood test to measure your blood
sugar level. A blood sugar level below 130 to 140 milligrams per deciliter (mg/dL), or 7.2
to 7.8 millimoles per liter (mmol/L), is usually considered normal on a glucose challenge
test, although this may vary at specific clinics or labs. If your blood sugar level is higher
than normal, it only means you have a higher risk of gestational diabetes. Your doctor will
diagnose you after giving you a follow-up test.
Follow-up glucose tolerance testing. For the follow-up test, you'll be asked to fast
overnight and then have your fasting blood sugar level measured. Then you'll drink
another sweet solution this one containing a higher concentration of glucose and
your blood sugar level will be checked every hour for a period of three hours. If at least
two of the blood sugar readings are higher than normal, you'll be diagnosed with
gestational diabetes.
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Tests for prediabetes
The primary test to screen for prediabetes is:

The glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar
level for the past two to three months. It works by measuring the percentage of blood
sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher
your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C
level between 5.7 and 6.4 percent suggests you have prediabetes. Normal levels are below
5.7 percent.

If the A1C test isn't available, or if you have certain conditions that can make the A1C test
inaccurate such as if you're pregnant or have an uncommon form of hemoglobin (known as a
hemoglobin variant) your doctor may use the following tests to diagnose diabetes:

Fasting blood sugar test. A blood sample will be taken after an overnight fast. A blood
sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. Normal
is below 100 mg/dL.
Oral glucose tolerance test. A blood sample will be taken after you fast for at least eight
hours or overnight. Then you'll drink a sugary solution, and your blood sugar level will be
measured again after two hours. A blood sugar level less than 140 mg/dL (7.8 mmol/L) is
normal. A blood sugar level from 140 to 199 mg/dL (7.8 to 11 mmol/L) is considered
prediabetes. This is sometimes referred to as impaired glucose tolerance (IGT).

2.7 Treatments and drugs

Depending on what type of diabetes you have, blood sugar monitoring, insulin and oral
medications may play a role in your treatment. A pancreas transplant may be an option for people
with diabetes that is difficult to control [29].

But no matter what type of diabetes you have, eating a healthy diet, maintaining a healthy weight
and keeping an eye on your blood sugar levels are all keys to managing your diabetes.

Treatments for all types of diabetes

An important part of managing all types of diabetes is maintaining a healthy weight through a

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healthy diet and exercise plan:

Healthy eating. Contrary to popular perception, there's no diabetes diet. You won't be
restricted to boring, bland foods. Instead, you'll need plenty of fruits, vegetables and
whole grains foods that are high in nutrition and low in fat and calories and fewer
animal products and sweets. In fact, it's the best eating plan for the entire family. Even
sugary foods are OK once in a while, as long as they're included in your meal plan.

Yet understanding what and how much to eat can be a challenge. A registered dietitian
can help you create a meal plan that fits your health goals, food preferences and lifestyle.
This may include carbohydrate counting, especially if you have type 1 diabetes.

Physical activity. Everyone needs regular aerobic exercise, and people who have
diabetes are no exception. Exercise lowers your blood sugar level by transporting sugar to
your cells, where it's used for energy. Exercise also increases your sensitivity to insulin,
which means your body needs less insulin to transport sugar to your cells. Get your
doctor's OK to exercise. Then choose activities you enjoy, such as walking, swimming or
biking. What's most important is making physical activity part of your daily routine. Aim
for at least 30 minutes or more of aerobic exercise most days of the week. If you haven't
been active for a while, start slowly and build up gradually.

Treatments for type 1 and type 2 diabetes

Treatment for type 1 diabetes involves insulin injections or the use of an insulin pump, frequent
blood sugar checks and carbohydrate counting. Treatment of type 2 diabetes primarily involves
monitoring of your blood sugar, along with diabetes medications, insulin or both.

Monitoring your blood sugar. Depending on your treatment plan, you may check and
record your blood sugar level several times a week to three or more times a day. Careful
monitoring is the only way to make sure that your blood sugar level remains within your
target range. People who receive insulin therapy may also choose to monitor their blood
sugar levels with a continuous glucose monitor. Although this technology doesn't yet
replace the glucose meter, it can provide important information about trends in blood
sugar levels.

Even if you eat on a rigid schedule, the amount of sugar in your blood can change

18
 unpredictably. With help from your diabetes treatment team, you'll learn how your blood
sugar level changes in response to things like food, physical activity, medications, illness,
alcohol, stress and for women fluctuations in hormone levels.

In addition to daily blood sugar monitoring, your doctor may recommend regular A1C
testing to measure your average blood sugar level for the past two to three months.
Compared with repeated daily blood sugar tests, A1C testing better indicates how well
your diabetes treatment plan is working overall. An elevated A1C level may signal the
need for a change in your insulin regimen or meal plan. Your target A1C goal may vary
depending on your age and various other factors. However, for most people, the
American Diabetes Association recommends an A1C of below 7 percent. Ask your doctor
what your A1C target is.

Insulin. Anyone who has type 1 diabetes needs insulin therapy to survive. Some people
with type 2 diabetes also need insulin therapy. Because stomach enzymes interfere with
insulin taken by mouth, oral insulin isn't an option for lowering blood sugar. Often insulin
is injected using a fine needle and syringe or an insulin pen a device that looks like an
ink pen, except the cartridge is filled with insulin.

An insulin pump also may be an option. The pump is a device about the size of a cell
phone worn on the outside of your body. A tube connects the reservoir of insulin to a
catheter that's inserted under the skin of your abdomen. A tubeless pump that works
wirelessly is also now available. You program an insulin pump to dispense specific
amounts of insulin. It can be adjusted to deliver more or less insulin depending on meals,
activity level and blood sugar level.

Many types of insulin are available, including rapid-acting insulin, long-acting insulin
and intermediate options. Depending on your needs, your doctor may prescribe a mixture
of insulin types to use throughout the day and night.

Oral or other medications. Sometimes other oral or injected medications are prescribed
as well. Some diabetes medications stimulate your pancreas to produce and release more
insulin. Others inhibit the production and release of glucose from your liver, which means
you need less insulin to transport sugar into your cells. Still others block the action of
stomach enzymes that break down carbohydrates or make your tissues more sensitive to

19
 insulin.
Transplantation. In some people who have type 1 diabetes, a pancreas transplant may be
an option. Islet transplants are being studied as well. With a successful pancreas
transplant, you would no longer need insulin therapy. But transplants aren't always
successful and these procedures pose serious risks. You need a lifetime of immune-
suppressing drugs to prevent organ rejection. These drugs can have serious side effects,
including a high risk of infection, organ injury and cancer. Because the side effects can be
more dangerous than the diabetes, transplants are usually reserved for people whose
diabetes can't be controlled or those who have serious complications.
Bariatric surgery. Although it is not specifically considered a treatment for type 2
diabetes, people with type 2 who also have a body mass index over 35 may benefit from
this type of surgery. People who've undergone gastric bypass have seen significant
improvements in their blood sugar levels. However, this procedure's long-terms risks and
benefits for type 2 diabetes aren't yet known.

Treatment for gestational diabetes

Controlling your blood sugar level is essential to keeping your baby healthy and avoiding
complications during delivery. In addition to maintaining a healthy diet and exercising, your
treatment plan may include monitoring your blood sugar and, in some cases, using insulin.

Your health care provider will also monitor your blood sugar level during labor. If your blood
sugar rises, your baby may release high levels of insulin which can lead to low blood sugar
right after birth.

Treatment for prediabetes

If you have prediabetes, healthy lifestyle choices can help you bring your blood sugar level back
to normal or at least keep it from rising toward the levels seen in type 2 diabetes. Maintaining a
healthy weight through exercise and healthy eating can help. Exercising at least 150 minutes a
week and losing 5 to 10 percent of your body weight may prevent or delay type 2 diabetes.

Sometimes medications such as the oral diabetes drugs metformin (Glucophage) and acarbose
(Precose) also are an option if you're at high risk of diabetes, including when your prediabetes
is worsening or you have cardiovascular disease, fatty liver disease or polycystic ovary
syndrome.

20
In other cases, medications to control cholesterol statins, in particular and high blood
pressure medications are needed. Your doctor might prescribe low-dose aspirin therapy to help
prevent cardiovascular disease if you are at high risk. Healthy lifestyle choices remain key,
however.

Signs of trouble in any type of diabetes

Because so many factors can affect your blood sugar, problems sometimes arise. These
conditions require immediate care, because if left untreated, seizures and loss of consciousness
(coma) can occur [30].

High blood sugar (hyperglycemia). Your blood sugar level can rise for many reasons,
including eating too much, being sick or not taking enough glucose-lowering medication.
Check your blood sugar level often, and watch for signs and symptoms of high blood
sugar frequent urination, increased thirst, dry mouth, blurred vision, fatigue and
nausea. If you have hyperglycemia, you'll need to adjust your meal plan, medications or
both.
Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for
energy, your body may begin to break down fat. This produces toxic acids known as
ketones. Watch for loss of appetite, weakness, vomiting, fever, stomach pain and a sweet,
fruity smell on your breath. You can check your urine for excess ketones with an over-
the-counter ketones test kit. If you have excess ketones in your urine, consult your doctor
right away or seek emergency care. This condition is more common in people with type 1
diabetes.
Hyperosmolar hyperglycemic nonketotic syndrome. Signs and symptoms of this life-
threatening condition include a blood sugar reading over 600 mg/dL, dry mouth, extreme
thirst, fever, drowsiness, confusion, vision loss and hallucinations. Hyperosmolar
syndrome is caused by sky-high blood sugar that turns blood thick and syrupy. It tends to
be more common in people with type 2 diabetes, and it's often preceded by an illness.
Call your doctor or seek immediate medical care if you have signs or symptoms of this
condition.
Low blood sugar (hypoglycemia). If your blood sugar level drops below your target
range, it's known as low blood sugar. Your blood sugar level can drop for many reasons,

21
 including skipping a meal and getting more physical activity than normal. However, low
blood sugar is most likely if you take glucose-lowering medications that promote the
secretion of insulin or if you're receiving insulin therapy. Check your blood sugar level
regularly, and watch for signs and symptoms of low blood sugar sweating, shakiness,
weakness, hunger, dizziness, headache, blurred vision, heart palpitations, irritability,
slurred speech, drowsiness, confusion, fainting and seizures. Low blood sugar is treated
with quickly absorbed carbohydrates, such as fruit juice or glucose tablets.

2.8 Prevention

Type 1 diabetes can't be prevented. However, the same healthy lifestyle choices that help
treat prediabetes, type 2 diabetes and gestational diabetes can help prevent them.

Eat healthy foods. Choose foods low in fat and calories. Focus on fruits, vegetables and
whole grains. Strive for variety to prevent boredom.
Get more physical activity. Aim for 30 minutes of moderate physical activity a day. Take
a brisk daily walk. Ride your bike. Swim laps. If you can't fit in a long workout, break it
up into smaller sessions spread throughout the day.
Lose excess pounds. If you're overweight, losing even 5 percent of your body weight
for example, 10 pounds (4.5 kilograms) if you weigh 200 pounds (90.7 kilograms) can
reduce the risk of diabetes. To keep your weight in a healthy range, focus on permanent
changes to your eating and exercise habits. Motivate yourself by remembering the
benefits of losing weight, such as a healthier heart, more energy and improved self-
esteem.

Sometimes medication is an option as well. Oral diabetes drugs such as metformin (Glucophage)
may reduce the risk of type 2 diabetes but healthy lifestyle choices remain essential.

22
 CHAPTER III

PERIODONTAL DISEASES

3.1 Definition

The word periodontal literally means "around the tooth." Periodontal diseases, also called
gum diseases, are serious bacterial infections that destroy the gums and the surrounding tissues
of the mouth. If the inflammation is left untreated, the disease will continue and the underlying
bones around the teeth will dissolve, and will no longer be able to hold the teeth in place [31].
Chronic inflammation, resulting from a periodontal disease, is responsible for 70 percent of all
adult tooth losses, and affects 75 percent of people at some point in their lives. Gum, or
periodontal, disease is a major infection of gum tissue that surrounds the teeth which, if not
treated early, can result in not only destroyed oral connective tissue, but also bone structure
destruction. The different types of periodontal disease are often classified by the stage the
disease has advanced to at the time of evaluation, including [32.33]:

gingivitis
With gingivitis, the mildest form of periodontal disease, the gums are likely to become red,
swollen, and tender, causing them to bleed easily during daily cleanings and flossing.
Treatment by a dentist and proper, consistent care at home help to resolve the problems
associated with gingivitis.

mild periodontitis
Untreated gingivitis leads to mild periodontitis. This stage of gum disease shows evidence of
the bone around the tooth starting to erode. Prompt medical attention is necessary to prevent
further erosion and damage.

moderate to advanced periodontitis

This most advance stage of gum disease shows significant bone and tissue loss surrounding
the teeth.

3.2 Symptoms

Gum disease may progress painlessly, producing few obvious signs, even in the late stages of the
disease. Although the symptoms of periodontal disease often are subtle, the condition is not
entirely without warning signs. Certain symptoms may point to some form of the disease. The

23
following are the most common symptoms of gum disease. However, each individual may
experience symptoms differently. In general, symptoms progress over time and include [33,34]:

Red, Swollen Gums, and tender gums

Gum Bleeding. Bleeding of the gums, even during brushing, is a sign of inflammation and the
major marker of periodontal disease. One exception is juvenile periodontitis, in which
symptoms are mild or even absent. It should be noted that the gums of smokers with
periodontal disease tend to bleed less than nonsmokers.
Bad Breath. Debris and bacteria can cause a bad taste in the mouth and persistent bad breath.
Gum Recession and Loose Teeth. As the disease advances the gums recede, and supporting
structure of bone is lost. Teeth loosen, sometimes causing a change in the way the upper and
lower teeth fit together when biting down or how partial dentures fit.
Abscesses. Deepening periodontal pockets between the gums and bone can become blocked
by tartar or food particles. Infection-fighting white blood cells become trapped and die. Pus
forms, and an abscess develops. Abscesses can destroy both gum and tooth tissue, cause
nearby teeth to become loose and painful, and may cause fever and swollen lymph nodes.

Other symptoms of periodontal diseases include [35]:

bleeding while brushing and/or flossing

receding gums
loose or separating teeth
persistent odorous breath
dentures no longer fit
pus between the teeth and gums
a change in bite and jaw alignment

The symptoms of gum disease may resemble other conditions or medical problems. Consult a
dentist or other oral health specialist for a diagnosis.

3.3 Causes

Periodontal disease is marked by bacterial overgrowth. However, a persistent immune

response to chronic infections in the mouth is believed to play a major role in gum destruction.

24
Bacterial Culprits
Researchers have found more than 350 species of microorganisms in the typical healthy mouth.
Periodontal infections are linked to fewer than 5% of these species. Healthy and disease-causing
bacteria can generally be grouped into two categories:

The harmless or helpful bacteria are usually known as gram positive aerobic bacteria.
In periodontal disease, the bacterial balance shifts over to gram negative anaerobic bacteria.
Inflammatory disease and injury cannot develop without these bacteria.

Following are some of the bacteria most implicated in periodontal disease and bone loss [36]:

Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. These two bacteria

appear to be particularly likely to cause aggressive periodontal disease. Both P.
gingivalis and A. actinomycetemcomitans, along with multiple deep pockets in the gum, are
associated with resistance to standard treatments for gum disease. P. gingivalis may double
the risk for serious gum disease. P. gingivalis produces enzymes, such as one called arginine-
specific cysteine proteinase, that may disrupt the immune system and lead to subsequent
periodontal connective tissue destruction.
Bacteroides forsythus is also strongly linked to periodontal disease.
Other bacteria associated with periodontal disease are Treponema denticola, T.
socranskii, and P. intermedia. These bacteria, together with P. gingivalis, are frequently
present at the same sites, and are associated with deep periodontal pockets.

Some bacteria are related to gingivitis, but not plaque development. They include various
streptococcal species.

The Autoimmune and Inflammatory Response

Evidence indicates that periodontal disease is an autoimmune disorder, in which immune factors
in the body attack the person's own cells and tissue -- in this case, those in the gum. It appears to
work like this [37]:

The bacteria that form plaque and tartar release toxins that stimulate the immune system to
overproduce powerful infection-fighting factors called cytokines.
Ordinarily, cytokines are important for healing. In excess, however, they can cause
inflammation and severe damage.
In addition, white blood cells produced by the immune response to bacteria also release a
family of enzymes called matrix metalloproteinases (MMPs), which break down connective
tissue.

25
Studies suggest that this inflammatory response may have damaging effects not only in the gums
but also in organs throughout the body, including the heart.

Viral Causes
Certain herpes viruses (herpes simplex and varicella-zoster virus, the cause of chickenpox and
shingles) are known causes of gingivitis. Other herpes viruses (cytomegalovirus and Epstein-
Barr) may also play a role in the onset or progression of some types of periodontal disease,
including aggressive and severe chronic periodontal disease. All herpes viruses go through an
active phase followed by a latent phase and possibly reactivation [38].

These viruses may cause periodontal disease in different ways, including release of tissue-
destructive cytokines, overgrowth of periodontal bacteria, suppressing immune factors, and
initiation of other disease processes that lead to cell death.

Other potential causes of periodontal (gum) disease include [38,39]:

genetics
lifestyle choices
a diet low in nutrients
smoking / the use of smokeless tobacco
autoimmune or systemic diseases
diabetes
hormonal changes in the body
bruxism (incessant clenching of the teeth)
certain medications

3.4 Risk Factors

More than 75% of Indonesian adults have some form of gum disease, but according to a
major survey, only 60% have any significant knowledge about the problem. Gum inflammation
and ulcers are common, and not all people with these problems develop periodontal disease.
Still, about 30% of people are genetically susceptible to periodontal disease. Other factors also
put individuals at higher risk.

Oral Environment
Lack of Oral Hygiene. Lack of oral hygiene encourages bacterial buildup and plaque formation.

26
Sugar and Acid. The bacteria that cause periodontal disease thrive in acidic environments.
Therefore, eating sugars and other foods that increase the acidity in the mouth increase bacterial
counts.

Poorly Contoured Restorations. Poorly contoured restorations (fillings or crowns) that provide
traps for debris and plaque can also contribute to its formation.

Anatomical Tooth Abnormalities. Abnormal tooth structure can increase the risk.

Wisdom Teeth. Wisdom teeth, also called third molars, can be a major breeding ground for the
bacteria that cause periodontal disease. In fact, for patients in their 20s, periodontal disease is
most likely to occur around the wisdom teeth. Periodontitis can occur in wisdom teeth that have
broken through the gum as well as teeth that are impacted (buried). Periodontal disease can also
be present even in patients with wisdom teeth who do not have any symptoms. Adolescents and
young adults with wisdom teeth should have a dentist check for signs of periodontal disease.

Age
Children and Adolescents. Gingivitis, in varying degrees, is nearly a universal finding in children
and adolescents. In rare genetic cases, children and adolescents are subject to destructive forms
of the disease. Researchers have also observed some of the organisms seen in periodontal disease
in young children without signs of gum problems. Healthy children, however, do not generally
harbor two primary periodontal bacteria, P. gingivalis and T. denticola. The disease is also
uncommon in teenagers.

Adults. As people age, the risk for periodontal disease increases. Over half of American adults
have gingivitis surrounding 3 - 4 teeth, and 30% have significant periodontal disease surrounding
3 - 4 teeth. In a study of people over 70 years old, 86% had at least moderate periodontitis, and
over a quarter of them had lost their teeth.

Female Hormones
About three-quarters of periodontal office visits are made by women, even though women tend
to take better care of their teeth than men. Female hormones affect the gums, and women are
particularly susceptible to periodontal problems. Hormone-influenced gingivitis appears in some
adolescents, in some pregnant women, and is occasionally a side effect of birth control
medication [40].

Before Menstruation. Gingivitis may flare up in some women a few days before they menstruate,
when progesterone levels are high. Gum inflammation may also occur during ovulation.
Progesterone dilates blood vessels causing inflammation, and blocks the repair of collagen, the
structural protein that supports the gums.

27
Pregnancy. Hormonal changes during pregnancy can aggravate existing gingivitis, which
typically worsens around the second month and reaches a peak in the eighth month. Pregnancy
does not cause gum disease, and simple preventive oral hygiene can help maintain healthy gums.
Any pregnancy-related gingivitis usually resolves within a few months of delivery. Because
periodontal disease can increase the risk for low-weight infants and cause other complications, it
is important for pregnant women to see a dentist.

Oral Contraceptives. Some studies report that oral contraceptives containing the synthetic
progesterone desogestrel (but not dienogest, another common progesterone) increase the risk for
periodontal disease.

Menopause. Estrogen deficiency after menopause reduces bone mineral density, which can lead
to bone loss. Bone loss is associated with both periodontal disease and osteoporosis. Bone loss in
the alveolar bone (which holds the tooth in place) may be a major predictor of tooth loss in
postmenopausal women. Periodontal disease is the main cause of alveolar bone loss. During
menopause, some women may also develop a rare condition called menopausal
gingivostomatitis, in which the gums are dry, shiny, and bleed easily. Women may also
experience abnormal tastes and sensations (such as salty, spicy, acidic, and burning) in the
mouth.

Family Factors
Periodontal disease often occurs in members of the same family. Genetics, intimacy, hygiene, or
a mixture of factors may be responsible. Studies have found that children of parents with
periodontitis are 12 times more likely to have the bacteria thought to be responsible for causing
plaque and, eventually, periodontal disease.

Genetic Factors. Genetic factors may play the critical role in half the cases of periodontal
disease. Up to 30% of the population may have some genetic susceptibility to periodontal
disease.

Intimacy. Intimate partners and spouses of people with periodontal disease may also be at risk.
Researchers have found that the bacteria P. gingivalis may be contagious after exposure to an
infected person over a long period of time. There is no risk from short exposure, such as after a
fast kiss or when sharing an eating utensil.

Smoking and Nicotine

Smoking is the single major preventable risk factor for periodontal disease. The habit can cause
bone loss and gum recession even in the absence of periodontal disease. A number of studies
indicate that smoking and nicotine increase inflammation by reducing oxygen in gum tissue and

28
triggering an over-production of immune factors called cytokines (specifically ones called
interleukins). In excess, cytokines are harmful to cells and tissue.

Furthermore, when nicotine combines with oral bacteria, such as P. gingivalis, the effect
produces even greater levels of cytokines and eventually leads to periodontal connective tissue
breakdown. Smokers may be more than 10 times more likely than nonsmokers to harbor the
bacteria that cause periodontal disease and are also more likely to have advanced periodontal
disease.

The risk of periodontal disease increases with the number of cigarettes smoked per day. Smoking
cigars and pipes carries the same risks as smoking cigarettes. Exposure to secondhand smoke
may also be associated with an increased risk for developing periodontal disease, according to
one study. Fortunately, when smokers quit, their periodontal health gradually recovers to a state
comparable to that of nonsmokers.

Some research also indicates that regular cannabis (marijuana) smoking also increases the risk of
periodontal disease.

Diseases Associated with Periodontal Disease

Diabetes. Much evidence exists on the link between type 1 and 2 diabetes and periodontal
disease. Diabetes causes changes in blood vessels, and high levels of specific inflammatory
chemicals such as interleukins, that significantly increase the chances of periodontal disease.
High levels of triglycerides (which are common in type 2 diabetes) also appear to impair
periodontal health. Obesity, common in people with type 2 diabetes, may also predispose a
person to gum disease. Controlling both type 1 and 2 diabetes may help reduce periodontal
problems [51]. For children with diabetes, good oral hygiene should begin at a young age.

Osteoporosis and Osteonecrosis. Osteoporosis (loss of bone density) has been associated with
periodontal disease in postmenopausal women [52].

There have been a few reports of osteonecrosis (bone decay) of the jaw in patients who take oral
bisphosphonate drugs such as alendronate (Fosamax). However, almost all cases of osteonecrosis
of the jaw associated with bisphosphonate drugs occur during or after the use of intravenous
bisphosphonates, usually given as part of treatment for bone cancer or other cancers that have
spread to the bone. Symptoms of osteonecrosis of the jaw include loose teeth, exposed jawbone,
pain or swelling in the jaw, gum infections, and poor healing of the gums.
Osteoporosis is a condition marked by progressive loss of bone density, thinning of bone tissue,
and increased risk of fractures. Osteoporosis may result from disease, dietary or hormonal
deficiency, or advanced age. Regular exercise and vitamin and mineral supplements can reduce
and may even reverse loss of bone density.

29
As a precaution, the American Dental Association (ADA) [53] recommends that patients who are
prescribed or are to receive bisphosphonate drugs get a thorough dental exam before beginning
drug therapy, or as soon as possible after beginning therapy. The ADA also recommends that
patients who take oral bisphosphonate drugs should discuss with their dentists any potential risks
from dental procedures (such as extractions and implants) that involve the jawbone. In any case,
be sure to inform your dentist if you are taking a bisphosphonate drug. Your dentist or oral
surgeon may need to take special precautions when performing dental surgery.

Herpes-Related Gingivitis. Herpes virus is a common cause of gingivitis in children and has
become increasingly common in adults. It typically starts out with a purplish color and "boggy"
sensation in the gums. Multiple blisters may form across the mucus membranes in the mouth and
gums, followed by ulcers. They usually resolve in 7 - 14 days.

HIV-Associated Gingivitis. HIV-associated gingivitis has been reported in 15 - 50% of patients

with HIV or AIDS. HIV-positive individuals harbor larger numbers of periodontal bacteria
(candida albicans, P. gingivalis, black-pigmented anaerobic rods, and A.
actinomycetemcomitans) than people without HIV. Severe pain is characteristic, along with odor,
spontaneous bleeding, ulcers, and swollen, bright red gums. The inflammation never recedes, but
halitosis and acute episodes can be managed by conventional cleaning treatments. Its severest
form, known as necrotizing stomatitis, can be diagnostic for AIDS. In addition to bleeding, the
gums in the front of the mouth are a yellowish-gray color, and bone thrusts out.

Autoimmune Diseases. Autoimmune conditions (Crohn's disease, multiple sclerosis, rheumatoid

arthritis, lupus erythematosus, CREST syndrome) have been associated with a higher incidence
of periodontal disease. Some research suggests that periodontal disease may even play some
causal role. Still, more research is needed to determine a definitive association between these
diseases.

Other Diseases. People with tuberculosis, syphilis, Wegener's granulomatosis, amyloidosis, and
many genetic disorders are also at higher risk for periodontitis.

Vitamin C Deficiencies
Vitamin C helps the body repair and maintain connective tissue, and its antioxidant effects are
important in the presence of tissue-destroying oxidants in periodontal disease. Research indicates
that vitamin C deficiency contributes to periodontal disease. Vitamin C levels are especially
depleted in smokers. Eating citrus fruits high in vitamin C (such as grapefruit) may be helpful for
patients with periodontitis.

30
Ethnic, Socioeconomic, and Geographic Factors
Dental disease is most likely to affect the poor. Children and the elderly suffer the worst oral
care, and ethnic minorities follow. In the United States, the lack of access to dental insurance is a
contributing factor.

Drug-Induced Gingivitis
Gingival overgrowth can be a side effect of nearly 20 different drugs, most commonly phenytoin
(Dilantin), cyclosporine (Sandimmune), and a short-acting form of the calcium channel blocker
nifedipine (Procardia).

3.5 Complications

The ultimate outcome of uncontrolled periodontal disease is tooth loss. As the destructive
factors cause the breakdown of bone and connective tissue, teeth lose their anchor.

Bad Breath
A much less severe but nevertheless distressing problem caused by periodontal disease is bad
breath, although coatings on the tongue may contribute more to bad breath than periodontal
disease.

Heart Disease and Stroke

Studies have reported that people who have heart disease have a 1.5 - 4 times increased risk for
periodontal disease. (The risk is highest for patients with extensive gum disease, bleeding from
every tooth.) Acute coronary syndrome, high blood pressure (hypertension), and high cholesterol
have also been associated with periodontal disease.

Periodontal disease has also been linked to stroke and coronary artery disease (CAD). The more
severe the periodontitis, the greater the risk for heart problems. However, it is still not clear
whether periodontal disease is a risk factor for stroke or a marker that reflects various risk factors
common to both conditions.

An inflammatory response may be the common element. This is an over-reaction of the immune
system that causes injury to tissues in the body. Patients with heart conditions and periodontal
disease may have elevated levels of C-reactive protein (CRP), which indicates inflammation is
present. Some research indicates that this inflammatory response can also cause injury in the
arteries supplying blood to the heart [54].

Other evidence suggests that the periodontal disease bacteria themselves -- particularly P.
gingivalis, T. denticola, T. forsythia, and streptococci species -- may be associated with thicker

31
carotid arteries (a predictor of heart attack and stroke), regardless of C-reactive protein levels. It
is still not clear if periodontal disease actually causes heart disease.

It is also not clear if treating gum disease can reduce the risks of heart disease and improve
health outcomes for patients with periodontal disease and vascular heart problems. Studies have
been mixed, but research is ongoing.

Effect on Diabetes
Diabetes is not only a risk factor for periodontal disease -- periodontal disease itself can worsen
diabetes and make it more difficult to control blood sugar.

Effect on Respiratory Disease

Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs,
increasing the risks for respiratory diseases and worsening chronic lung conditions, such as
emphysema.

Effect on Pregnancy
Many studies strongly indicate that bacterial infections that cause moderate-to-severe periodontal
disease in pregnant women can increase the risk for premature delivery and low birth weight
infants. The more severe the infection, the greater the risk to the baby. Research indicates that
bacteria from gum disease and tooth decay may trigger the same factors in the immune system,
which can then cause premature dilation and contractions [55].

Women should have a periodontal examination before becoming pregnant or as soon as possible
thereafter. Because women with diabetes are at higher risk for periodontal disease, it is especially
important that they see a dentist early in pregnancy. Doctors are still not sure if treating
periodontal disease can improve birth outcomes. In any case, periodontal treatment is safe for
pregnant women.

3.6 Diagnosis

The dental practitioner typically performs a number of procedures to determine a

diagnosis of periodontal disease.

Medical History
The dentist will first take a medical history to reveal any past or present periodontal problems,
any underlying diseases that might be contributing to the problem, and any medications the
patient is taking. After noting the general state of oral hygiene, the dentist may ask about the
quality of home dental care.

32
Physical Examination
Inspection of the Gum Area. The dentist inspects the color and shape of gingival tissue on the
cheek (buccal) side and the tongue (lingual) side of every tooth and compares these qualities to
the healthy ideal. Redness, puffiness, and bleeding upon probing indicate inflammation. If the
gum formation between teeth is blunt and not pointed, acute necrotizing periodontal disease may
be indicated.

Periodontal Screening and Recording (PSR). PSR is a painless procedure used to measure and
determine the severity of periodontal disease [56]:

The dentist uses a mirror and a periodontal probe, a fine instrument calibrated in millimeters
(mm), which is used to measure pocket depth.
The probe is held along the length of the tooth with the tip placed in the pocket. The tip of
the probe will then touch the point where the connective tissue attaches to the tooth.
The dentist will "walk" the probe to six specified points on each tooth, three on the buccal
(cheek) and three on the lingual (tongue) sides. The dentist measures the depth of the probe
at each point.
Pocket depths greater than 3 mm indicate disease.

These measurements help determine the condition of the connective tissue and amount of
gingival overgrowth or recession.

Testing Tooth Movement. Tooth mobility is determined by pushing each tooth between two
instrument handles and observing any movement. Mobility is a strong indicator of bone support
loss.

X-rays. X-rays are taken to show any loss of bone structure supporting the teeth. Eighteen x-rays
make up the full mouth series necessary for diagnosis.

3.7 Treatment

Studies support the effectiveness of active treatment combined with a strict maintenance
program for patients with periodontal disease. In one study, for example, people with periodontal
disease who were inconsistent in caring for their gums after treatment had nearly six times the
risk for tooth loss as those who were very vigilant.

Some dentists have reported a success rate of 85% when professional treatment and good home
maintenance are combined. Treatment helps nonsmokers more than smokers, particularly when
pockets are deep and persistent. Some studies suggest that periodontal treatment in people with

33
type 2 diabetes helps improve blood sugar levels. Whether treatment will help reduce other
health risks, including heart attack and stroke, is unknown.

Treatment Goals. Once periodontal disease has been identified, the goals of treatment are:

To arrest and control the progress of the disease

To leave the periodontal tissues in an easily maintainable state
If possible, to restore the supporting structures, which include bone, gum tissue, and
ligaments

Treatment Phases. To achieve these goals, there are various approaches:

Initial cleaning, scaling, and curettage

Surgery -- if needed for reducing deep pockets that remain underneath the gum after
extensive cleaning sessions
Low-dose oral or topical antibiotics
Maintenance

After the active treatment is completed and the mouth is in a relative state of health, the patient
should have regular cleanings lasting 45 minutes to 1 hour, about every 3 months. These may be
done by the dental hygienist, the periodontist, or the general dentist. The patient may alternate
between them. Home care, of course, must be continued.

Antibiotics Before Treatment. In cases where the individual has a mitral valve prolapse or history
of rheumatic heart disease, pretreatment with an appropriate antibiotic is required before any
dental work, including cleaning. This is necessary to prevent the possibility of bacterial
endocarditis, which can be life threatening.

Deep Cleaning: Scaling and Root Planing

Scaling, polishing, and sometimes curettage are used to manage periodontal disease. They are
usually accomplished in a series of three to four visits spaced about a week apart. (Patients might
ask their dentist about the gas nitrous oxide, which is helpful for many patients and may reduce
the visits to a single one.) The dental hygienist or practitioner generally uses both ultrasonic and
manual instruments to remove calculus [57].

Calculus above the gum is easily seen. The dental professional usually detects calculus below
the gum by careful probing with an instrument.
The hygienist or dentist may use an ultrasonic instrument for removal of the more accessible
calculus. This probe-like device vibrates at a frequency range higher than is audible to the

34
 human ear. Some people with low tolerance for the ultrasonic probe may wish to request
nitrous oxide.
A spray of water is used with ultrasound to prevent overheating and to flush out the debris
that is dislodged.
The dental professional will scrape the plaque from above and below the gum line (called
scaling). When the probe contacts the rock-like calculus, deposits fracture off the tooth fairly
efficiently.
The hygienist or dentist will then smooth the rough spots on the tooth. Smoothing the surface
helps remove bacteria that collect there (root planing) and also helps the gums reattach.
Polishing is the finishing procedure. It uses a rubber cup with an abrasive paste to remove
plaque and stains on the crown portion of the tooth. It produces a smooth surface, making it
temporarily harder for plaque to adhere.

After the cleaning procedure, the dentist will check the pocket depths around the teeth after the
cleaning process has been completed. Further treatment needs are determined by the results of
these initial sessions:

If the cleaning processes have reduced inflammation, observation only is needed.

If an abscess is present, surgery may be required.

Finally, the dental hygienist or practitioner should offer thorough instructions on home care to
insure the removal of bacteria on a daily basis. This includes proper use of the toothbrush, paste,
mouth rinses, floss, floss threaders, and proxabrushes. Home care can effectively eliminate the
plaque above the gums and down to 2 mm below the gums.

Gingival Curettage
Gingival curettage removes the soft tissue lining of the periodontal pockets in order to
completely eliminate bacteria and diseased tissue. It may be used along with scaling and root
planing, but achieves a deeper and more complete cleaning. Evidence indicates, however, that it
does not contribute any additional benefits beyond simple scaling and planing.

Surgery (Open Flap Curettage)

Surgery allows access for deep cleaning of the root surface, removal of diseased tissue, and
repositioning and shaping of the bones, gum, and tissues supporting the teeth. Surgical
procedures vary depending on the individual diagnosis and needs of the patient. The basic
procedure is known as open flap curettage. It involves [57]:

The periodontal surgeon lifts, or flaps, the gums away from the tooth and surrounding bone.
The diseased root surfaces are cleaned and curetted (scraped) to remove deposits.

35
 Gum tissue is replaced into positions to minimize pocket depth.
The periodontist may also contour the remaining bone and attempt to regenerate lost bone
and gingival attachment through bone grafts and guided tissue regeneration or the use of
enamel matrix protein derivatives.

There is some debate about whether this procedure is any more effective in preventing disease
progression than non-surgical therapies, such as low-dose doxycycline, short-term antibiotics, or
antibiotic gels. Some studies have reported that although surgical treatment reduced pocket depth
more than non-surgical therapies for at least a year after the procedure, benefits from surgery do
not persist beyond 5 years, except in very deep pockets.

Postsurgery Pain and Discomfort. Post-surgery discomfort is usually managed easily with over-
the-counter medications such as ibuprofen. If discomfort is severe, stronger analgesics may be
prescribed. Some patients experience sensitivity to hot or cold temperatures from exposed roots.
These problems can be managed with topical fluoride treatments or, in severe cases, with dental
restoration.

Techniques and Materials for Restoring Gum Tissue and Bone

Guided Tissue Regeneration. A more advanced technique, called guided tissue regeneration, is
used to stimulate bone and gum tissue growth [58]:

First, the root surfaces and diseased bone are meticulously cleaned out. Preventing bacterial
contamination is very important. The more residual bacteria, the greater the chance that the
treatment will fail.
A specialized piece of fabric is sewn around the tooth to cover the crater in the bone left after
the cleaning. It is either absorbable or nonabsorbable.
The gum is then sewn over the fabric. The fabric prevents the gum tissue from growing down
into the bone defect and allows the bone and the attachment to the root to regenerate.
After 4 - 6 weeks, the nonabsorbable fabric must be removed using a minor surgical
procedure. The absorbable membrane may be left in. In general, there is little difference in
outcome between absorbable and nonabsorbable procedures. The absorbable fabric may not
be as effective as standard grafts if gum tissue is thin, although newer materials may prove to
produce better results.

Bone Grafting. In some cases of severe bone loss, the surgeon may attempt to encourage
regrowth and restoration of bone tissue that has been lost through the disease process. This
involves bone grafting:

The surgeon places bone graft material into the defect.

36
 The material may be either bone from the same patient or a substance called decalcified
freeze-dried bone allografts (DFDBA) which is obtained from a donor.
This material then stimulates new bone growth in the area.

Enamel Matrix Protein Derivative. Amelogenin is a derivative of a major protein in the structure
(the matrix) of enamel that helps stimulate gum tissue growth. A gel containing amelogenin
(Emdogain) is applied during surgery and forms a coat over the roots of the teeth. The gel itself
dissolves after 2 days, leaving the active substance behind. Studies report that it is safe and may
significantly reduce the effects of periodontal disease.

Cosmetic and Gum Grafting Treatments

Gum grafting techniques can also be very useful for improving the looks of the gum as well as
adding support to the teeth. During this procedure, the periodontist takes gum tissue from the
palate or another donor source to cover the exposed root in order to even the gum line and reduce
sensitivity. Other procedures are available to improve the look of the gums and teeth. The gum
line can be sculpted to improve uneven or excess gums and to cover exposed roots as gums
recede.

Implants
Periodontists report that they are achieving great success with tooth implants in patients who
have lost teeth due to periodontal disease. The average cost for a single implant is high, however,
and one implant requires 5 - 7 months for completion.

3.8 Prevention

Healthy habits and good oral hygiene are critical in preventing gum disease. Regular and
effective tooth brushing and mouth washing, however, are effective only above and slightly
below the gum line. Once periodontal disease develops, more intensive treatments are needed.

Dietary Changes
It is important to reduce both the quantity and, in particular, the frequencyof sugar intake. Avoid
snacks and drinks with sugar (other than natural sugars found in fruits and vegetables). Eat
sugar-containing foods with meals, ideally followed by brushing. Since fruit juices can also
cause tooth erosion in children, parents should emphasize milk and water.

Quitting Smoking
Smoking plays a significant role in many cases of chronic periodontal disease. For smokers,
quitting is one of the most important steps toward regaining periodontal health.

37
Fluoride Treatments
Fluoride treatment in children has helped to account for the decline in periodontal disease in
adults. Because fluoride prevents decay, back molars, which keep the teeth in place, are spared,
and are thus less vulnerable to bacteria. Even before teeth first erupt, babies' gums should be
wiped clean with a bit of gauze bearing a dab of fluoride toothpaste. Supplementation with
fluoride tablets or drops may be recommended for children 6 months or older who drink
unfluoridated water or who are at risk for dental problems. A prescription from the child's
pediatrician or dentist is required.

Some dentists recommend a fluoride gel for adult patients who are still at risk for tooth decay or
sensitivity, but extra fluoride is generally not necessary for adults who use fluoride toothpaste.

Dental Examinations
Periodontitis is a silent disease. People with the disease rarely experience pain and may not be
aware of the problem. A periodontal examination by a general dentist once or twice a year
should reveal any incipient or progressive problems. A full mouth series of x-rays is advised
every 2 - 3 years. This will alert the dentist to early bone loss and other disorders of the oral
cavity.

Dentists now often perform Periodontal Screening and Recording (PSR) using a probe to
measure gum pockets. Previously performed only by periodontists, this procedure is now
encouraged as part of a regular dental examination. The dentist will identify any areas where
deep pocketing has occurred, where the health of the gingiva appears compromised, and where
there is undue mobility of teeth. It is the general dentist's responsibility to identify periodontal
disease and inform the patient. If the condition is severe, the dentist may want to refer the patient
to a periodontist.

Daily Dental Care

Correct tooth brushing, mouth cleansing, and flossing should be everyone's defense against
periodontal disease. (However, good hygiene is probably not enough to prevent periodontal
disease in many people. Regular visits to a dentist are extremely important, especially for high-
risk individuals.)

Brushing Guidelines. The following are some recommendations for brushing:

Use a soft-bristled brush that fits the size and shape of your mouth. Place the brush where the
gum meets the tooth, with bristles resting along each tooth at a 45-degree angle.
Place the brush where the gum meets the tooth, with bristles resting along each tooth at a 45-
degree angle.
Move the brush back and forth gently. Use short (tooth-wide) strokes.

38
 Begin by brushing the outer tooth surfaces, followed by the inner tooth surfaces, and then the
chewing surfaces of the teeth.
For the inside surfaces of the front teeth, gently use the tip of the brush in an up-and-down
stroke.
Brush your tongue to help remove additional bacteria.
Flossing should finish the process. A mouthwash may also be used.

If brushing after each meal is not possible, rinsing the mouth with water after eating can reduce
bacteria by 30%.

Toothbrushes. A vast assortment of brushes of varying sizes and shapes are available, and each
manufacturer makes its claim for the benefits of a particular brush. Look for the American
Dental Association (ADA) seal on both electric and regular brushes.

In spite of the wide variety of nonelectric toothbrushes, both in shape and bristle design, a study
of eight brands found no significant differences in effectiveness among them.

Electric toothbrushes, particularly those with a stationary grip and revolving tufts of bristles, can
be advantageous for some people with physical disabilities. Electric toothbrushes with heads that
move back and forth up to thousands of times a minute remove significantly more plaque than
ordinary brushes. Even more high-tech brushes are now available that use sound waves to
remove plaque.

In general, studies have reported no differences between electric and manual toothbrushes in
their ability to remove plaque. However, if a regular toothbrush works, it isn't necessary to buy
an expensive electric one.

For individuals with average dexterity, a four- or five-rowed, soft, nylon-bristled toothbrush is
sufficient. The most important factor in buying any toothbrush, electric or manual, is to choose
one with a soft head. Soft bristles get into crevices easier and do not irritate the gums, thereby
reducing the risk of exposing teeth below the gum line compared to hard brushes.

Toothbrushes should be replaced every 1 - 3 months. Not only do they become breeding grounds
for bacteria, but the worn bristles are less effective at removing plaque.

Toothpaste. The objective of a good toothpaste is to reduce the development of plaque and
eliminate periodontal-causing microorganisms without destroying the organisms that are
important for a healthy mouth. All brands should show ADA approval. Even a good toothpaste,
however, cannot be delivered past 3 mm below the gum line, where periodontitis develops.

39
Toothpastes are a combination of abrasives, binders, colors, detergents, flavors, fluoride,
humectants, preservatives, and artificial sweeteners. Avoid highly abrasive toothpastes,
especially for individuals whose gums have receded.

Ingredients contained in toothpastes may include [59,60]:

Fluoride. Most commercial toothpastes contain fluoride, which both strengthens tooth enamel
against decay and enhances remineralization of the enamel. Fluoride also inhibits acid-loving
bacteria, especially after eating, when the mouth is more acidic. This antibacterial activity
may help control plaque.
Triclosan. Triclosan is an anti-bacterial substance that may help reduce mild gingivitis.
Metal salts. Metal salts, such as stannous and zinc, serve mostly as anti-bacterial substances
in toothpastes. Stannous fluoride gel toothpastes do not reduce plaque, however, even though
they have some effect against the bacteria that cause it, but slightly reduce gingivitis.
Peroxide and baking soda. Toothpastes with these ingredients claim to have a whitening
action, but while they may help remove stains there is little evidence they whiten the actual
color of the teeth. In addition, these substances appear to offer no benefits against gum
disease.
Antibacterial sugar substitutes (xylitol), and detergents (delmopinol)

Mouthwashes. The American Dental Association recommends (in addition to daily brushing and
flossing) antimicrobialmouthwash to help prevent and reduce plaque and gingivitis,
and fluoride mouthwashes to help provide additional protection against tooth decay.

Chlorhexidine (Peridex or PerioGard) is an antimicrobial mouthwash available by

prescription only. It reduces plaque by 55% and gingivitis by 30 - 45%. Patients should rinse
for 1 minute twice daily. They should wait at least 30 minutes (and preferably 2 hours)
between brushing and rinsing since chlorhexidine can be inactivated by certain compounds in
toothpastes. It has a bitter taste. It also binds to tannins, which are in tea, coffee, and red
wine, so it has tendency to stain teeth in people who drink these beverages. Studies are mixed
as to its effectiveness for preventing or reducing periodontal disease.
Listerine is another antimicrobial mouthwash. It is composed of essential oils and is available
over the counter. It reduces plaque and gingivitis, when used for 30 seconds twice a day. It
leaves a burning sensation in the mouth that most people better tolerate after a few days of
use. The usual regimen is to rinse twice a day. (Listerine PocketPaks, which are strips that
dissolve on the tongue, have no proven effects on plague and gingivitis.)
Mouthwashes containing cetylpyridinium (Scope, Cepacol) have moderate antimicrobial
effect on plaque, but only if they are used an hour after brushing. None are as effective as

40
 Listerine or chlorhexidine, but they may still have some value for people who cannot tolerate
the other mouthwashes.
Mouthwashes containing stannous fluoride and amine fluoride (Meridol) are moderately
effective, but are also not as effective as effective as Listerine or chlorhexidine.
Fluoride mouthwashes (Act) are helpful in preventing cavities.
Mouthwashes that contain alcohol are dangerous for children and should be kept away from
them.

Flossing. The use of dental floss, either waxed or unwaxed, is critical in cleaning between the
teeth where the toothbrush bristles cannot reach. In spite of this, nearly two-thirds of people do
not floss.

To floss correctly, the following steps may be helpful:

Break off about 18 inches of floss and wind most of it around the middle finger of one hand
and the rest around the other middle finger.
Hold the floss between the thumbs and forefingers and gently guide and rub it back and forth
between the teeth.
When it reaches the gum line, the floss should be curved around each tooth and slid gently
back and forth against the gum.
Finally, rub gently up and down against the tooth. Repeat with each tooth, including the
outside of the back teeth.
If, on repeated flossing attempts, the floss becomes shredded or cannot be removed easily
from between the teeth, a rough crown or overhanging filling may be the cause. In such
cases, the restoration should be redone. Such areas create spaces for the collection of food
debris, plaque, and calculus.

Here are some tips in choosing the right floss or flossing device:

Use a floss that does not shred or break.

Avoid a very thin floss, which can cut the gum if brought down with too much force or not
guided along the side of the tooth.
A floss threader is an invaluable aid for the person who has bridgework. Made of plastic, it
looks like a needle with a huge eye, or loop. A piece of floss is threaded into the loop, which
can then be inserted between the bridge and the gum. The floss that is carried through with it
can then be used to clean underneath the false tooth or teeth and along the sides of the
abutting teeth.

41
 Another handy device for cleaning under bridges is a Proxabrush, which is an interdental
cleaner. This is a tiny narrow brush that can be worked in between the natural teeth and
around the attached false tooth or teeth.
Special toothpicks such as Stim-U-Dent may be effective for wide spaces between teeth but
should never replace flossing. Standard toothpicks should never be used for regular hygiene.
Electronic products, such as water piks, are also helpful. These devices are expensive but
may improve flossing compliance.

Producing Saliva and Drinking Water. Saliva is important for diluting the toxins created by
plaque. Drinking at least 7 glasses of water a day helps reduce inflammation in the mouth by
producing more saliva. Increasing water intake is particularly important as one ages, when less
saliva is produced.

42
 CHAPTER IV
THE CORRELATION BETWEEN DIABETES AND THE PERIODONTAL DISEASES IN
THE PATIENTS WITH DIABETES AT NORTH JAKARTA, 2008

With lifestyle changes and the acceleration of the aging process, our country is the
prevalence of diabetes rose rapidly, but not with age-related periodontitis as a common and
frequently occurring oral, there trends in the incidence increased gradually. In recent years with
the study of periodontitis and diabetes gradual deepening of the relationship between the two has
been basically clear. Periodontitis has been considered the sixth complication of diabetes [61].

4.1 Periodontal Disease as a Complication of Diabetes [62]

Periodontitis has been referred to as the sixth complication of diabetes. A number of

studies found a higher prevalence of periodontal disease among diabetic patients than
among healthy controls. In a large cross-sectional study, showed that diabetic patients were twice
as likely as nondiabetic subjects to have attachment loss. Firatli followed type diabetic patients
and healthy controls for 5 years. The people with diabetes had significantly more clinical
attachment loss than controls. In another cross-sectional study, Bridges and others found that
diabetes affected all periodontal parameters, including bleeding scores, probing depths, loss of
attachment and missing teeth. In fact, one study has shown that diabetic patients are 5 times more
likely to be partially edentulous than nondiabetic subjects. People with type I and type 2 diabetes
appear equally susceptible to periodontal disease and tooth loss. Other factors are involved in the
high prevalence of periodontal diseases in association with diabetes. The relationship between
diabetes and periodontal disease appears to be very strong within certain populations, such as
Aboriginal peoples, which indicates a genetic component. A recent study found that smoking
increases the risk of periodontal disease by nearly 10 times in diabetic patients. According to
these results, the management of diabetic patients should include strong recommendations to
quit smoking. For both type 1 and type 2 diabetes, there does not appear to be any correlation
between the prevalence or the severity of periodontal disease and the duration of diabetes.

43
4.2 The Effect of Periodontitis on Diabetes
Recent investigations have attempted to determine if the presence of periodontal disease
influences the control of diabetes. There appears to be good evidence to support this hypothesis.
Grossi and others [63] have suggested that effective control of periodontal infection in diabetic
patients reduces the level of AGEs in the serum. The level of glycemic control seems to be the
key factor. Tervonen and Karjalainen [64] followed diabetic patients and nondiabetic controls for
3 years. They found that the level of periodontal health in diabetic patients with good or
moderate control of their condition was similar to that in the nondiabetic controls. Those with
poor control had more attachment loss and were more likely to exhibit recurrent disease. This
phenomenon has been pointed out by other researchers. [65-67] from this, we can conclude that
prevention and control of periodontal disease must be considered an integral part of diabetes
control. The principles of treatment of periodontitis in diabetic patients are the same as those for
nondiabetic patients and are consistent with our approach to all high-risk patients who already
have periodontal disease. Major efforts should be directed at preventing periodontitis in patients
who are at risk of diabetes .Diabetic patients with poor metabolic control should be seen more.

4.3 Diabetes increases the risk of periodontitis and severity of

Found in periodontitis clinical incidence of diabetic patients showed a trend of high
incidence, and this high incidence of periodontitis with age, sex and no relationship between
oral health statuses. Glycemic control in diabetic patients with periodontal disease severity level
was positively correlated. The longer the duration of diabetes is more frequent and more severe
periodontal disease occurs, as follows: gums repeated serious and difficult to control swelling,
bleeding, multiple periodontal abscesses, alveolar bone destruction, tooth mobility shift and fall
off. Emrich other than by horse to 1 342 Indians, and found that patients with type 2 diabetes
incidence of non-diabetic patients with periodontitis about 3 times, and that periodontitis is a
potential complication of diabetes. Periodontal conditions Comparative studies have shown that
type 1 diabetes clinical periodontal attachment loss was significantly higher than non-diabetics.
diabetic patients because of the relative or absolute insulin levels in the body becoming less
hormone secretion and calcium metabolism of calcium and phosphorus can lead to osteoporosis
bone decalcification , alveolar bone as part of the body, by the effect of diabetes, and other parts
of the bone tissue have the same reaction, due to bone loss in patients with type 2 diabetes than

44
non-diabetic patients significantly increased, and thus type 2 diabetes has been considered to be
tooth alveolar bone loss contributing factor. animal experimental studies: Zhang Wei-chen,
found: alveolar bone resorption activity in diabetic rats, cortical bone thinning, the surface and
reduce the number of osteoblasts was flat or star, a rare new bone formation. Mahamed, etc. The
results show that bone loss in diabetic mice compared with non-diabetic mice increased
significantly, and that the T cell-mediated immune response in diabetic periodontitis contributing
factor to bone loss. These results show that 1 diabetes and type 2 diabetes may increase the
incidence of periodontitis [68].

4.4 Periodontitis and the promotion of diabetes susceptibility factors

Since the 60 years since the 20th century, scholars have conducted a series of periodontal
treatment on glycemic control in diabetic patients affect the experimental research, covering the
subgingival scaling, subgingival scaling, root planing and other mechanical treatment and
antimicrobial agents therapy and combination of both. The complete periodontal treatment, the
symptoms of diabetes and improve the availability of appropriate controls, showed lower
glycated hemoglobin levels. Kiran order to study the periodontal health condition such as type 2
diabetes metabolic control of to 44 patients with type 2 diabetes subjects were randomly divided
into two groups, the treatment group received full-mouth periodontal scaling and root planing
treatment, the control group did not receive any periodontal treatment, again 3 months after
treatment detection of the corresponding index and found that periodontal treatment group, with
the glycated hemoglobin levels decreased significantly compared with that before treatment,
while the control group slightly increased compared with before treatment. This study suggests
that non-surgical periodontal therapy in patients with Type 2 diabetes metabolic control. closely
related to diabetes and periodontitis, diabetes associated with the risk of severe periodontitis than
non-diabetic patients with 2 to 3 times higher, a survey shows that diabetes incidence of
periodontitis 59.6%. The survey also diabetic patients showed older age, longer duration, higher
prevalence of periodontitis. but will also affect the blood glucose control of chronic periodontitis,
severe periodontitis may further cause the deterioration of glycemic control. Qin group of
experimental studies suggest that, through the periodontal based therapy can improve glucose
metabolism in diabetic patients with periodontitis and reduce the level of HbA1c levels, to
improve the periodontal condition. for periodontal treatment at the same time, active control of
diabetes, to correct metabolic disorders, more effective prevention and control of diabetes teeth
weeks of disease, improve the therapeutic effect of periodontal disease [69].

45
4.5 The interaction mechanism of periodontitis and diabetes

On the mechanism of interaction between periodontitis and diabetes, many years

of Researches focused on leukocyte chemotaxis and phagocytosis defects, vascular basement
membrane, collagen metabolic disorders and genetic factors are closely related. And get a
reasonable explanation, will not go into details in this . In recent years, a large number of studies
have shown that the accumulation of advanced glycation end products, hyperlipidemia and
insulin resistance, are also involved in the interaction between periodontitis and diabetes [70].

4.5.1 The accumulation of advanced glycation end products

Recent studies have found that glucose metabolism in patients with diabetes end products
(advanced glycation end praducts, AGEs) in the case of non-enzymatic, glucose, fructose and
glucose 6 - phosphate and other biological macromolecules, especially long-lived proteins, such
as collagen, matrix proteins such as glycosylation occurs to form the product. It can not be
enzymes break down proteins and lipids, blood glucose levels can accelerate the slow increase in
the formation and accumulation of AGEs. AGEs can stimulate phagocytic cells to release
inflammatory cytokines , inflammatory mediators can activate osteoclasts and collagenase,
causing bone and periodontal tissue destruction. AGEs may affect the accumulation of monocyte
and neutrophil emigration and phagocytic activity, cannot effectively kill the bacteria, so that
mature subgingival bacteria and transformed into G-, resulting in periodontal infection. AGEs
have been sugar and non-enzymatic protein, so that the body changes a variety of proteins and
affect the healing of periodontal infection.

4.5.2 Hyperlipidemia

Patients with diabetes (types 1 and 2) high glucose, is usually associated with high blood
lipids. Lipids usually presents with high plasma low-density lipoprotein cholesterol (low density
lipoproteincholesterol, LDL), triglycerides (triglycerides, TRG) and free fatty acid levels were
significantly increased. Fatty acid metabolism and high cholesterol can affect the function of a
variety of cells, causing diabetes complications. From diabetes blood mononuclear cells isolated
from inflammatory response to bacteria has a magnifying effect, the performance in
lipopolysaccharide stimulated monocytes from excessive inflammatory mediators such as and so
on. The single cells with high reactivity independent of high blood sugar, but may be related to
high blood cholesterol. Noack and other [71] studies have shown that impaired glucose tolerance
as a risk factor of diabetes is not a risk factor for periodontitis, but more like high blood lipid risk

46
factors for periodontitis. Suggest that diabetes may increase high blood lipids, another important
mechanism for the development of periodontitis.

4.5.3 Insulin resistance (IR)

On insulin sensitivity and resistance to a variety of mechanisms, adipocytokines, genetic factors,

environmental stress and inflammation and so may be in connection with transmitter. Recently
found that insulin resistance and inflammation in the classical pathway between the closely
linked. Pro-inflammatory cytokines and adipose tissue, endocrine interaction between the
immune system, causing IR and cell structure and dysfunction, eventually leading to type 2
diabetes. Periodontal inflammation in the periodontal tissue into the environment, thought to be
involved in the process. In the impact of periodontal disease on diabetes, may be crucial factors.
Has been confirmed that obese adipose tissue secretion of inflammatory cytokines induced
insulin resistance is an important factor, cancer and severe systemic infection associated with
insulin resistance is also considered. The success of periodontal treatment in diabetic patients
with periodontitis can improve blood sugar control, which may be in patients with periodontitis
by reducing circulating levels of increased sensitivity to insulin. At present, there is no study
confirmed that periodontal disease and a direct link between the IR. However, periodontal
disease may cause or make inflammatory neurotransmitter levels, periodontal infection to the
body's release of and the source of other inflammatory neurotransmitters. Which, the most
closely related to IR. That can prevent the insulin receptor autophosphorylation and to inhibition
by inhibiting the tyrosine kinase signal transduction 2, resulting in receptor levels caused by IR
[72].

47
 CHAPTER V

CONCLUSION

Diabetes is a systemic chronic metabolic disease related with genetic and environmental
factors and autoimmune. Periodontal disease is a destructive disease in gum support
organizations (gum, periodontal membrane, alveolar bone). A lot of Research shows the diabetes
and periodontal disease is two -way relationship concerning periodontal disease and diabetes.
Diabetes increases the risk of periodontitis, and severity of diabetes is susceptible and promoting
factors. Diabetes patients not only have a high incidence rate, but also are characteristic of fast
disease Development speed, severe damage, and poor treatment effect [73].
There is good evidence to support the claim that periodontitis may be more prevalent
among diabetic patients than nondiabetic people. Similarly, studies have shown that periodontal
therapy influences glycemic control in people with diabetes mellitus. Given that nearly 10% of
Canadians are affected by either type 1 or type 2 diabetes (including those in whom the disease is
undiagnosed), all dentists will encounter patients with diabetes. Dental practitioners must be
aware of the implications of this relationship and manage their patients periodontal care
accordingly [74].
In general, the evidence described in the present review supports a potential role for
careful management of periodontal disease in patients with diabetes mellitus as an adjunctive
treatment to help improve glycemic control. However, larger randomized controlled trials are
necessary to provide conclusive evidence. Physicians need to be mindful of poor periodontal
health as one of the possible reasons for a patient's poor control of diabetes mellitus. Thorough
examination by physicians of the mouth and teeth is important for all patientsespecially those
diagnosed as having diabetes mellitus. It is also appropriate for physicians to recommend that
patients avoid concentrated sweets, brush and floss after meals, and use topical antiseptics as an
oral rinse or a pulsed irrigation. Physicians should also strongly consider referring such patients
to dentists for mechanical treatment [75].

48
 REFERENCES

1. Masharani U. Diabetes mellitus & hypoglycemia. In: McPhee SJ, et al. Current Medical
Diagnosis & Treatment 2010. New York, N.Y.: McGraw Hill Medical; 2010.
http://www.accessmedicine.com/content.aspx?aID=15524. Accessed Nov. 19, 2010.
2. Standards of medical care in diabetes 2011. Diabetes Care. 2011;34(suppl):1.
3. Diabetes overview. National Institute of Diabetes and Digestive and Kidney Diseases.
http://diabetes.niddk.nih.gov/dm/pubs/overview/DiabetesOverview.pdf. Accessed Nov.
19, 2010.
4. Diabetes mellitus (DM). The Merck Manuals: The Merck Manual for Healthcare
Professionals.
http://www.merckmanuals.com/professional/sec12/ch158/ch158b.html#sec12-ch158-
ch158b-1105. Accessed Dec. 2, 2010.
5. Knip M, et al. Dietary intervention in infancy and later signs of beta-cell autoimmunity.
New England Journal of Medicine. 2010;363:1900.
6. Am I at risk for type 2 diabetes? National Institute of Diabetes and Digestive and Kidney
Diseases. http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/. Accessed Nov. 30, 2010.
7. Diabetes and pregnancy. American College of Obstetricians and Gynecologists.
http://www.acog.org/publications/patient_education/bp051.cfm?printerFriendly=yes.
Accessed Dec. 2, 2010.
8. Diagnosis and management of type 2 diabetes mellitus in adults. Bloomington, Minn.:
Institute for Clinical Systems Improvement.
http://www.icsi.org/diabetes_mellitus__type_2/management_of_type_2_diabetes_mellitu
s__9.html. Accessed Nov. 19, 2010.
9. Burrows NR, et al. Incidence of treatment for end-stage renal disease among individuals
with diabetes in the U.S. continues to decline. Diabetes Care. 2010;33:73.
10. Zhang X, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008.
Journal of the American Medical Association. 2010;304:649.
11. Matsuzaki T, et al. Insulin resistance is associated with the pathology of Alzheimer
disease. Neurology. 2010;75:764.
12. Giovanucci E, et al. Diabetes and cancer: A consensus report. CA: A Journal for Cancer
Clinicians. 2010;60:1.
13. Gestational diabetes. National Institute of Child Health and Human Development.
http://www.nichd.nih.gov/health/topics/gestational_diabetes.cfm. Accessed Dec. 2, 2010.
14. Stoner GD. Hyperosmolar hyperglycemic state. American Family Physician.
2005;71:1723.
15. Church TS, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in
patients with type 2 diabetes. Journal of the American Medical Association.
2010;304:2253.
16. McCulloch DK. Overview of medical care in adults with diabetes mellitus.
http://www.uptodate.com/home/index.html. Accessed Nov. 19, 2010.
49
17. Natural Medicines in the Clinical Management of Diabetes. Natural Medicines
Comprehensive Database. http://www.naturaldatabase.com. Accessed Dec. 2, 2010.
18. Standards of medical care in diabetes 2011. Diabetes Care. 2011;34(suppl):1.
19. Health care guideline: Routine prenatal Care. Bloomington, Minn.: Institute for Clinical
Systems Improvement. 2010.
http://www.icsi.org/prenatal_care_4/prenatal_care__routine__full_version__2.htm.
Accessed Feb. 1, 2011.
20. American College of Obstetricians and Gynecologists. Practice Bulletin. Clinical
management guidelines for obstetrician-gynecologists. Number 30, September 2001
(replaces Technical Bulletin Number 200, December 1994). Gestational diabetes.
Obstetrics and gynecology. 2001;98:525.
21. Diabetes Care, 2004. Who Has Diabetes? Retrieved
from http://www.lifescan.com/care/essentials/whohasdiabetes/ on August 19, 2004.

22. Sue K. Milchovich & Barbara Dunn-Long. (1999) Diabetes Mellitus - A Practical
Handbook. Palo Alto: Bull Publishing Company.

23. Carolyn Leontos. (2000) What to Eat When You Get Diabetes. New York: John Wiley
& Sons, Inc.

24. Richard S. Beaser. (1995) The Joslin Guide to Diabetes - Program for Managing Your
Treatment. New York: Simon & Schuster.

25. Elaine Magee. (1999) Tell me What to Eat if I have Diabetes. Franklin Lakes, NJ: Career
Press.

26. Knip M, et al. Dietary intervention in infancy and later signs of beta-cell autoimmunity.
New England Journal of Medicine. 2010;363:1900.

27. Mayoclinic. Diabetes. Available at http://www.mayoclinic.com/health/diabetes/DS01121.

accessed on june 30, 2011.

28. American diabetes association. Diabetes. Available at http://www.diabetes.org/diabetes-

basics/?utm_source=WWW&utm_medium=GlobalNavDB&utm_campaign=CON.
Accessed on june 30, 2011.

29. Tan M, Daneman D, Lau D, and others. Diabetes in Canada: strategies towards 2000. In:
Canadian Diabetes Advisory Board; 1997; Toronto; 1997. p. 3.

30. Tan MH, MacLean DR. Epidemiology of diabetes mellitus in Canada. Clin Invest Med
1995; 18(4):240-6.

50
31. Amaliya , Timmerman MF, Abbas F, Loos BG, Van der Weijden GA, Van Winkelhoff
AJ, et al. Java project on periodontal diseases: the relationship between vitamin C and the
severity of periodontitis. J Clin Periodontol. 2007 Apr;34(4):299-304.

32. Boggess KA; Society for Maternal-Fetal Medicine Publications Committee. Maternal
oral health in pregnancy. Obstet Gynecol. 2008 Apr;111(4):976-86.

33. de Oliveira RR, Schwartz-Filho HO, Novaes AB Jr, Taba M Jr. Antimicrobial
photodynamic therapy in the non-surgical treatment of aggressive periodontitis: a
preliminary randomized controlled clinical study. J Periodontol. 2007 Jun;78(6):965-73.

34. Eberhard J, Jepsen S, Jerve-Storm PM, Needleman I, Worthington HV. Full-mouth

disinfection for the treatment of adult chronic periodontitis. Cochrane Database Syst Rev.
2008 Jan 23;(1):CD004622.

35. Eberhard J, Jerve-Storm PM, Needleman I, Worthington H, Jepsen S. Full-mouth

treatment concepts for chronic periodontitis: a systematic review. J Clin Periodontol.
2008 Jul;35(7):591-604. Epub 2008 May 21.

36. Kolahi J, Soolari A. Rinsing with chlorhexidine gluconate solution after brushing and
flossing teeth: a systematic review of effectiveness. Quintessence Int. 2006
Sep;37(8):605-12.

37. Lamster IB, DePaola DP, Oppermann RV, Papapanou PN, Wilder RS. The relationship
of periodontal disease to diseases and disorders at distant sites: communication to health
care professionals and patients. J Am Dent Assoc. 2008 Oct;139(10):1389-97.

38. Lamster IB, Lalla E, Borgnakke WS, Taylor GW. The relationship between oral health
and diabetes mellitus. J Am Dent Assoc. 2008 Oct;139 Suppl:19S-24S.

39. Nguyen DH, Martin JT. Common dental infections in the primary care setting. Am Fam
Physician. 2008 Mar 15;77(6):797-802.

40. Paraskevas S, Huizinga JD, Loos BG. A systematic review and meta-analyses on C-
reactive protein in relation to periodontitis. J Clin Periodontol. 2008 Apr;35(4):277-90.
Epub 2008 Feb 20.

51
41. Persson GR, Yeates J, Persson RE, Hirschi-Imfeld R, Weibel M, Kiyak HA. The impact
of a low-frequency chlorhexidine rinsing schedule on the subgingival microbiota (the
TEETH clinical trial). J Periodontol. 2007 Sep;78(9):1751-8.

42. Staudte H, Sigusch BW, Glockmann E. Grapefruit consumption improves vitamin C

status in periodontitis patients. Br Dent J. 2005 Aug 27;199(4):213-7, discussion 210.

43. Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, glycemic
control and complications. Oral Dis. 2008 Apr;14(3):191-203.

44. Thomson WM, Poulton R, Broadbent JM, Moffitt TE, Caspi A, Beck JD, et al. Cannabis
smoking and periodontal disease among young adults. JAMA. 2008 Feb 6;299(5):525-31.

45. Lingen MW, Kumar V. Head and neck. In: Kumar V, Abbas AK, Fausto N, eds. Robbins
& Cotran Pathologic Basis of Disease. 7th ed. Philadelphia, Pa: Elsevier; 2004:773 .
46. Parks ET, Lancaster H. Oral manifestations of systemic disease. Dermatol Clin.2003;
21:171 182, viii.
47. Centers for Disease Control and Prevention. National diabetes fact sheet: United States,
2005. US Department of Health and Human Services, Centers for Disease Control and
Prevention Web site. Available at:http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf.
Accessed May 23, 2006.
48. Nishimura F, Iwamoto Y, Mineshiba J, Shimizu A, Soga Y, Murayama Y. Periodontal
disease and diabetes mellitus: the role of tumor necrosis factor-alpha in a 2-way
relationship. J Periodontol.2003; 74:97 102.
49. Amsterdam JT. Oral medicine. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's
Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: CV Mosby;
2002:892 .
50. Loesche WJ, Grossman NS. Periodontal disease as a specific, albeit chronic, infection:
diagnosis and treatment [review]. Clin Microbiol Rev. 2001;14:727752. Available
at: http://cmr.asm.org/cgi/content/full/14/4/727?view=long&pmid=11585783. Accessed
May 23, 2006.
51. Chow AW. Infections of the oral cavity, head, and neck. In: Mandell GL, Bennett JE,
Dolin R, eds. Principles and Practice of Infectious Disease. 5th ed. Philadelphia, Pa:
Churchill Livingstone;2000 : 689.

52
52. Slots J. Selection of antimicrobial agents in periodontal therapy [review]. J Periodontal
Res.2002; 37:389 398.
53. American Dental Association, American Academy of Orthopaedic Surgeons. Advisory
statementantibiotic prophylaxis for dental patients with total joint replacements.
September 4, 2003. American Academy of Orthopaedic Surgeons/American Association
of Orthopaedic Surgeons Web site. Available
at:http://www.aaos.org/wordhtml/papers/advistmt/1014.htm. Accessed June 30, 2011.
54. Preshaw PM, Hefti FA, Jepsen S, Etienne D, Walker C, Bradshaw MH. Subantimicrobial
dose doxycycline as adjunctive treatment for periodontitis. A review [review].J Clin
Periodontol.2004; 31:697 707.
55. Keskin M, Kurtoglu S, Kendirci M, Atabek ME, Yazici C. Homeostasis model
assessment is more reliable than fasting glucose/insulin ratio and quantitative insulin
sensitivity check index for assessing insulin resistance among obese children and
adolescents. Pediatrics. 2005;115:e500e503 [Epub March 1, 2005]. Available
at:http://pediatrics.aappublications.org/cgi/content/full/115/4/e500. Accessed May 23,
2006.
56. Iwamoto Y, Nishimura F, Nakagawa M, Sugimoto H, Shikata K, Makino H. The effect of
antimicrobial periodontal treatment on circulating tumor necrosis factor-alpha and
glycated hemoglobin level in patients with type 2 diabetes. J Periodontol.2001; 72:774
778.
57. Noma H, Sakamoto I, Mochizuki H, Tsukamoto H, Minamoto A, Funatsu H, et al.
Relationship between periodontal disease and diabetic retinopathy [letter].Diabetes Care.
2004;27:615. Available at: http://care.diabetesjournals.org/cgi/content/full/27/2/615.
Accessed May 23, 2006.
58. Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M, Knowler WC, et al. Severe
periodontitis and risk for poor glycemic control in patients with noninsulin-dependent
diabetes mellitus. J Periodontol.1996;67(10 suppl): 10581093.
59. Saito T, Shimazaki Y, Kiyohara Y, Kato I, Kubo M, Iida M, et al. The severity of
periodontal disease is associated with the development of glucose intolerance in non-
diabetics: the Hisayama study. J Dent Res. 2004;83:485490. Available
at: http://jdr.iadrjournals.org/cgi/content/full/83/6/485. Accessed May 23, 2006.

53
60. Stewart JE, Wager KA, Friedlander AH, Zadeh HH. The effect of periodontal treatment
on glycemic control in patients with type 2 diabetes mellitus. J Clin Periodontol.2001;
28:306 310.
61. Kiran M, Arpak N, Unsal E, Erdogan MF. The effect of improved periodontal health on
metabolic control in type 2 diabetes mellitus. J Clin Periodontol.2005; 32:266 272.
62. Al-Mubarak S, Ciancio S, Aljada A, Mohanty P, Ross C, Dandona P. Comparative
evaluation of adjunctive oral irrigation in diabetics. J Clin Periodontol.2002; 29:295
300.
63. Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, and others.
Assessment risk for periodontal disease. I. Risk indicators for attachment loss. J
Periodontol 1994; 65(3):260-7.
64. Tervonen T, Karjalainen K. Periodontal disease related to diabetic status. A pilot study of
the response to periodontal therapy in type 1 diabetes. J Clin Periodontol 1997;
24(7):505-10.
65. Christgau M, Palitzsch KD, Schmalz G, Kreiner U, Frenzel S. Healing response to non-
surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological,
and immunologic results. J Clin Periodontol 1998; 25(2):112-24.
66. Stewart JE, Wager KA, Friedlander AH, Zadeh HH. The effect of periodontal treatment
on glycemic control in patients with type 2 diabetes mellitus. J Clin Periodontol 2001;
28(4):306-10.
67. Westfelt E, Rylander H, Blohme G, Jonasson P, Lindhe J. The effect of periodontal
therapy in diabetics. Results after 5 years. J Clin Periodontol 1996; 23(2):92-100.
68. Christgau M, Palitzsch KD, Schmalz G, Kreiner U, Frenzel S. Healing response to non-
surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological,
and immunologic results. J Clin Periodontol. 1998;25:112 124.
69. Miller LS, Manwell MA, Newbold D, Reding ME, Rasheed A, Blodgett J, et al. The
relationship between reduction in periodontal inflammation and diabetes control: a report
of 9 cases. J Periodontol.1992; 63:843 848.
70. Promsudthi A, Pimapansri S, Deerochanawong C, Kanchanavasita W. The effect of
periodontal therapy on uncontrolled type 2 diabetes mellitus in older subjects.Oral
Dis.2005; 11:293 298.

54
71. Noack, Westfelt E, Rylander H, Blohme G, Jonasson P, Lindhe J. The effect of
periodontal therapy in diabetics. Results after 5 years. J Clin Periodontol 1996; 23(2):98-
100.
72. Rodrigues DC, Taba MJ, Novaes AB, Souza SL, Grisi MF. Effect of non-surgical
periodontal therapy on glycemic control in patients with type 2 diabetes mellitus
[published correction appears in J Periodontol. 2004;75:780]. J Periodontol.2003;
74:1361 1367.
73. Smith GT, Greenbaum CJ, Johnson BD, Persson GR. Short-term responses to
periodontal therapy in insulin-dependent diabetic patients [published correction appears
in J Periodontol. 1996;67:1368]. J Periodontol.1996; 67:794 802.
74. Aldridge JP, Lester V, Watts TL, Collins A, Viberti G, Wilson RF. Single-blind studies
on the effects of improved periodontal health on metabolic control in type 1 diabetes
mellitus. J Clin Periodontol. 1995;22:271 275.
75. Skaleric U, Schara R, Medvescek M, Hanlon A, Doherty F, Lessem J. Periodontal
treatment by Arestin and its effects on glycemic control in type I diabetes patients.J Int
Acad Periodontol.2004; 6(4 suppl):160 165.

55