Oral health knowledge and habits in children with type 1 diabetes mellitus
Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disease and periodontal disease: relationship to different clinical variables. 1 Department of Periodontology, Faculty of Dental Sciences, Chhatrapati of periodontal diseases among individuals with type I and type II diabetes in north The association between diabetes and periodontal diseases has been the association of this condition with behavioral and clinical variables. Type 1 diabetes mellitus (T1DM) is a chronic systemic metabolic disease . diabetes mellitus and periodontal diseaee: relationship to different clinical variables.
Nevertheless, some significant differences have been detected, such as the greater prevalence of Porphyromonas gingivalis  and Prevotella intermedia   in diabetic subjects.
These studies indicate that there are probably subtle differences between diabetics and non-diabetics, although the clinical relevance of these differences is not clear. The origins of these differences could lie in the previously observed effects on periodontal tissues that could favor the growth of more pathogenic species.
Relationship between Periodontal Disease and Type 1 Diabetes in Adolescents
Figure 3 illustrates schematically the mechanisms of interaction between DM and periodontitis. Researchers have attempted to demonstrate the effect of periodontal treatment on the metabolic control in DM, and there would appear to be good evidence in support of this hypothesis as the treatment of periodontal diseases has been seen to improve not only the clinical and immunological parameters of periodontitis but also long-term glycemic control in DM  - .
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Subjects were randomly assigned into two groups: In addition, HbA1c levels in the treatment group decreased significantly from 7. These authors performed a controlled 6-month clinical study of 20 patients divided into two groups type 2 diabetes and non-diabeticswith moderate generalized chronic periodontitis.
Conven- tional periodontal scaling and root planing were performed, and the response to this treatment was compared between the groups at 3 and 6 months. An improvement in all clinical variables was observed, with no statistically significant differences between the groups, with the exception of probing depth. The improvement observed in blood HbA1c levels confirmed a positive metabolic response to periodontal treatment, with a lower value for this variable at 3 and 6 months after periodontal treatment.
InSingh et al. Patients were divided into three groups of Group A received treatment with full mouth scaling and root planing only; Group B received treatment with full mouth scaling and root planing followed by systemic doxycycline mg daily for 14 days ; and Group C received no treatment control group.
They found that Groups A and B showed a mean difference of 0. In spite of the promising results of these studies, it should be noted that few rando- mized clinical studies have been conducted, and the results are variable and at times contradictory. They vary in terms of both the type of treatment and the type of DM, although most have studied patients with type 2 DM.
Generally, the results indicate that periodontal treatment, including root scaling and planning improves glycemic control in type 2 DM   although some do not report any improvement .
Fewer studies have been conducted among type 1 DM patients and the results are contra- dictory  .
Systematic literature reviews with meta-analysis have also established that an improvement in DM metabolic control occurs after periodontal treatment. The first of these analyzed 10 studies involving periodontal intervention.
A total of type 1 and type 2 diabetic patients were included in this analysis, with periodontal treatment as predictor and the change in HbA1c level as outcome . The results showed a mean reduction in HbA1c levels of 0.
InTeeuw et al. In a transversal study by Spangler et al.
Type 1 diabetes mellitus and periodontal disease: relationship to different clinical variables.
InGurav made a systematic review to determine the effect of periodontal treatment on metabolic control in type 2 DM patients . It was concluded that perio- dontal therapy might be an adjuvant procedure in anti-diabetic treatment for these patients, although glycemic control did not improve in isolation.
He also stressed the need for randomized controlled multi-centre clinical studies to verify the hypothesis. More recently, a systematic review with meta-analysis by the Cochrane Collaboration included 35 studies, with a total of 2, participants with type 1 or type 2 DM, diagnosed with periodontitis  ; they concluded that there was low quality evidence that the treatment of periodontal disease improves glycemic control in DM patients, with a mean HbA1c reduction of 0.
They point out that larger, well-conducted and clearly reported studies are needed in order to understand the potential of periodontal treatment for improving glycemic control among DM patients. Taken together, the meta-analyses and other available evidence indicate that HbA1c reductions of around 0. The mechanisms that produce this effect remain unclear, but it is probably due to a reduction in systemic inflammation for example, reduction of serum levels of mediators such as TNF-a and IL-6 after treatment and resolution of periodontal inflammation.
These findings are important because reductions in HbA1c are associated with a lower risk of diabetic complications.
Type 1 diabetes mellitus and periodontal disease: relationship to different clinical variables.
In light of the above, it is now considered that there is sufficient evidence to justify further research into the contribution of periodontal treatment to metabolic control in diabetic patients. As several authors have pointed out, the prevention and management of periodontal disease must be considered an integral part of DM management .
Implications for Health-Care Professionals Clearly, oral and periodontal healthcare must form an integral part of DM management . In this context, improved understanding of the relationship between DM and periodontal disease must be disseminated not only among healthcare professionals but also among DM patients. Many DM patients remain unaware of the complications involved in the disease they suffer including those of the oral cavity and they often receive scant information about these from healthcare professionals.
It is necessary to train professionals and inform patients about the benefits of oral healthcare in relation to DM. This has clear clinical implications as stated by Watanabe pointing to the need for direct collaboration between the endocrinologist and the dentist in the treatment of diabetics with periodontal disease.
In fact, oral healthcare professionals have a valuable opportunity to identify undiag- nosed DM or pre-diabetes among dental patients, and refer these patients to the GP or endocrinologist  - . On this basis, the International Diabetes Federation has established a series of recom- mendations for periodontal care of diabetic patients : Conclusions As the literature reviewed in this paper makes clear, the association between DM and periodontal diseases is an established fact; it is clear that glycemic control improves periodontal conditions, while the management of periodontal infection improves the metabolic status of diabetic patients.
In this context, the clinical implications of this two-relationship should be a focus for further research. Furthermore, the possibility that both diseases have several pathogenic features in common should make it possible to guarantee the early diagnosis of both.
Healthcare pro- fessionals should also remember that disordered glucose metabolism can affect the development and severity of periodontal diseases. Further clinical, microbiological, biochemical and epidemiological studies are needed with large patient samples, including both type 1 and type 2 DM patients, well-designed randomized, controlled trials that compare different treatment modalities with the ultimate objective of establishing a clear strategy for multidisciplinary treatment of diabetic patients with periodontal disease.
Conflict of Interest None declared. Cite this paper Molina, C.
An Established Two-Way Relation- ship. Journal of Diabetes Mellitus, 6, The qualitative variables were described as frequencies and proportions, and the quantitative variables as the mean and standard deviation SD.
The Student t-test was used in the bivariate analysis to compare the means. Logistic regression analysis was done using the forward stepwise method for selecting variables according to the statistic likelihood ratio, in order to assess the association of the independent variables with the probability of being a diabetic patient. The mean age was The time elapsed from the diagnosis was 4 - 15 years and they were diagnosed around the mean age of 11 years [ Table 1 ].
The two groups were matched for age, physical build, and oral hygiene. There was no significant difference in the plaque index, as the oral hygiene was similar in the two groups.
Significant differences were recorded in the bleeding index, pocket depth, and attachment loss [ Table 2 ]. The diabetic group presented with a mean pocket depth of 6.
The gingival bleeding index was 2. The CAL was greater in the diabetics 4. Table 2 Open in a separate window The mean glycosylated hemoglobin HbA1c value among the diabetic patients was 8.
Type 2 diabetes was determined in individuals with previous medical diagnosis of diabetes, ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance. Questionnaire The self-administered questionnaire included demographic i. Medical examination Subjects undertook a routine medical examination, including a blood chemical analysis for hemoglobin A1c HbA1c level.
The following criteria were used to diagnose diabetes: Dental examination Clinical examinations were performed by a single examiner in the dental office, using a reflector for illumination and a triple syringe to dry teeth. Biosafety norms were followed. All faces of the teeth were examined. The CPI index  was used for the periodental assessment, in which the dentition was divided into sextants.
The highest CPI code was recorded in each segment code 0: No signs of periodontal disease, code 1: Gingival bleeding after gentle probing, code 2: Supragingival or subgingival calculus, code 3: Periodontal status was divided into three categories according to the CPI code: The other parameters considered in the diagnosis were: Gingivitis, individuals who exhibited at least one site of bleeding on probing based on the criteria of the American Academy of Periodontology  ; and periodontitis, individuals who exhibited clinical attachment loss CAL 3 mm in two or more non-adjacent teeth or those who exhibited CAL 5 mm in Results The average age of the study population was Average duration of diabetes was 5.
The sample comprised mostly of women Univariate analysis of the independent variables and risk of periodontitis in north Indian adults Click here to view A total of 6.