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Component of
Hyperinflammation:
Treating Periodontitis in
Obese Diabetic Patients
Abstract
Roger B Johnson, DDS, PhD Increasitig evidence points to periodontal disease as a significatii risk factor in the eti-
Professor [)f Anatomy ology o other diseases with inflammatory components, such as cardiovascular disease
Professor of Periodontics
Department of Periodontics and type 2 diabetes mellitus. Thus, it may be possible to reduce the risk for other dis-
& Preventive Sciences eases with an inflammatory cotnponent by maintaining a healthy periodontium. In
University ol Mississippi Medical Center addition to plaque and calculus, other factors such as diet, body weight, lifestyle, and
Jackson, Mississippi
enNironmental stress complicate the maintenance of a healthy periodontium. It is
becoming more important for the general dentist to address these additional risk fac-
tors in addition to providing conventional treatment for periodontai disease. This
review addresses a multifactorlal approach to the treatment of periodontal disease and
suggests that the "focal theory" of infection may still be relevant for oral inflammation.
Learning Objectives
After reading this article, the reader should be abk to:
explain ihc role of systemic hypcr- describe the role of tumor necrosis
inflammaiion in [he etiology of peri- factor-a in the etiology of both peri-
odontitis, obesity, and type 2 diabetes odoniitis and type 2 diabetes
mellitus. mellitus.
discuss the lifestyle risk factors in the
etiology of periodontitis.
D
uring the past decade, nutner- ment (26%).' A new paradigm for treat-
ous published research studies nicni ol the diabetic dental patient with
and reviews have promoted a periodontitis has emerged lliat provides
re-evaluation of the relatiotiship between a more active role for the dentist in the
the oral and the systetnic health of an overall management of these patients. In
individual.'"' In addition, new risk fac- this paradigm, lifestyle risk factors in-
tors for periodontal diseases have been cluding weight control, exercise, diet,
reported, which expands (and possibly and stress management are added to the
confounds) treattneni options for the conventional treatment of periodontitis.
health professional team. The obese dia-
betic dental patient with periodontitLs is The Focal Theory of
an example oi an individual requiring a Infection Revisited
broad scope of treatment by both med- In 1912, Billings published ihc
ical and dental health professionals, first scientific paper using "focal infec-
based on the results of these recent stud- tion" in the title. This paper described
ies. However, a survey of general den- a theor)' of "focal infection," which was
tists reveals that a very low percentage of supported for many years by both
them either screen for diabetes (7%) or medical and dental health profession-
take an active role in diabetes manage- als. This theory proposed that foci of
I
Recent studies report that diabetic patients with
severe periodontitis had a 6-fold worsening of glycmie A new paradigm for treatment
control during a 2-year period/" In addition, diabetic pa- of the diabetic dental patient with
tients wilh severe periodontitis have an increased risk for
periodontitis has emerged that provides
other complications of type 2 diahetes, including vascu-
lar, kidney, and retinal diseases. In an 11-year study, 82% a more active role for the dentist in
of diabetie patients with severe periodontitis experienced the overall management of these patients.
one or more major circulatory diseases, including heart
attack, siroke, or peripheral vascular diseases, compared Treatment of the Obese Diabetic Dental Patient
with 21% of the diahelic patients without periodontitis.^^*" with Periodontal Disease
These severe diabetic complications occurred despite sim- Because bO% of tbe US population is either over-
I ilar HbAi,. levels between the groups.
Obesity also has been established as a risk factor for
weight or obese, ihe chances of treating an obese diabetic
patieni are good."^ Because ihe common risk factors for
both periodontitis and type 2 diahetes. Obese persons obesity, periodoniiiis, and type 2 diahcies include systemic
I
The distrihution of body fat has heen reported to have a glucose levels, communicating with ihe patient's physi-
crucial role in the association between obesity and peri- cian, and adjusting ihe frequency of dental visiis, for treat-
odontitis, with upper lx)dy olx-sity, waist-to-bip ratio (WHR), tiient of diabetic dental patients'^"; however, recent stud-
and body mass index (BMl) being the most important ies suggest that the rates of proactive patient management
risk factors,'"" acliviiies by tlcntists arc quite low.' In addition, smoking
i
synergistically. b. 6-fold
b. the liver produces additional Interleukin (lL)-6. c. 8-fold
c. nutnerous cytokines are released into the d. 10-fold
systetnic circulation.
d. periodontal disease becomes chronic. 9. Oral health researchers recommend proactive
diabetic dental patieni management, such as:
4. Which of the following statements is true a. monitoring blood glucose levels.
regarding ohesity? b. comtnunication with the patient's physician.
a. Obese individuals arc unlikely to experience c. adjusting the frequency of dental visits.
periodontitis. d. all of the above
b. Obesity enhances the synthesis and release of
Tumor necrosis factor (TNF)-a and IL-6. 10. The combination of whicb ofthe following has
c. Distribution of adipose tissue is not a risk been reported lo improve periodonlitis and
factor for periodontitis. glycmie control?
d. Adipose tissue contains low concentrations of a. mechanical debridement atid systemic antibiotics
proinflammatory cytokines. b. mechanical debridement and increased
physical activity
5. Which of the following is an etiologic factor c. systemic antibiotics and increased physical
for periodontitis and also blocks the insulin activity
receptor, contributing to insulin resistance and d. mechanical debridement and chlorhexidine
type 2 diabetes? rinses
a. IL-6
b. IL-l
e. TNF-a
d. IL-4