Glycaemic control is a key component in diabetes mellitus (diabetes) management. Periodontitis is the inflammation and destruction of the underlying supporting tissues of the teeth. Some studies have suggested a bidirectional relationship between glycaemic control and periodontitis. Treatment for periodontitis involves subgingival instrumentation, which is the professional removal of plaque, calculus and debris from below the gumline using hand or ultrasonic instruments. This is known variously as scaling and root planing, mechanical debridement or non-surgical periodontal treatment. Subgingival instrumentation is sometimes accompanied by local or systemic antimicrobials, and occasionally by surgical intervention to cut away gum tissue when periodontitis is severe.
This review is part one of an update of a review published in 2010 and first updated in 2015, and evaluates periodontal treatment versus no intervention or usual care.
To investigate the effects of periodontal treatment on glycaemic control in people with diabetes mellitus and periodontitis.
An information specialist searched six bibliographic databases up to 7 September 2021 and additional search methods were used to identify published, unpublished and ongoing studies.
We searched for randomised controlled trials (RCTs) of people with type 1 or type 2 diabetes mellitus and a diagnosis of periodontitis that compared subgingival instrumentation (sometimes with surgical treatment and/or adjunctive antimicrobial therapy) compared to no active intervention or "usual care" (oral hygiene instruction, education or support interventions, and/or supragingival scaling (also known as PMPR, professional mechanical plaque removal)). To be included, the RCTs had to have lasted at least three months and have measured HbA1c.
Data collection and analysis
At least two review authors independently examined the titles and abstracts retrieved by the search, selected the included trials, extracted data from included trials and assessed included trials for risk of bias. Where necessary and possible, we attempted to contact study authors.
Our primary outcome was blood glucose levels measured as glycated (glycosylated) haemoglobin assay (HbA1c), which can be reported as a percentage of total haemoglobin or as millimoles per mole (mmol/mol).
Our secondary outcomes included adverse effects, periodontal indices (bleeding on probing, clinical attachment level, gingival index, plaque index and probing pocket depth), quality of life, cost implications and diabetic complications.
We included 35 studies, which randomised 3249 participants to periodontal treatment or control. All studies used a parallel RCT design and followed up participants for between 3 and 12 months. The studies focused on people with type 2 DM, other than one study that included participants with type 1 or type 2 diabetes. Most studies were mixed in terms of whether metabolic control of participants at baseline was good, fair or poor. Most of the studies were carried out in secondary care.
We assessed two studies as being at low risk of bias, 14 studies at high risk of bias and the risk of bias in 19 studies was unclear. We undertook a sensitivity analysis for our primary outcome based on studies at low risk of bias and this supported the main findings.
Moderate-certainty evidence from 30 studies (2443 analysed participants) showed an absolute reduction in HbA1c of 0.43% (4.7 mmol/mol) 3 to 4 months after treatment of periodontitis (95% confidence interval (CI) -0.59 % to -0.28 %; -6.4 mmol/mol to -3.0 mmol/mol). Similarly, after 6 months, we found an absolute reduction in HbA1c of 0.30% (3.3 mmol/mol) (95% CI -0.52 to-0.08; -5.7 mmol/mol to -0.9 mmol/mol; 12 studies, 1457 participants), and after 12 months, an absolute reduction of 0.50% (5.4 mmol/mol) (95% CI -0.55 to -0.45%; -6.0 to -4.9 mmol/mol; one study, 264 participants). Studies that measured adverse effects generally reported that no or only mild harms occurred, and any serious adverse events were similar in intervention and control arms. However, this is very low certainty evidence as the adverse effects of periodontal treatments were not evaluated in most studies.
Our 2022 update of this review has doubled the number of included studies and participants, which has led to a change in our conclusions about the primary outcome of glycaemic control and in our level of certainty in this conclusion. We now have moderate-certainty evidence that periodontal treatment using subgingival instrumentation improves glycaemic control in people with both periodontitis and diabetes by a clinically significant amount when compared to no treatment or usual care. Further trials evaluating periodontal treatment versus no treatment/usual care are unlikely to change the overall conclusion reached in
Bibliographical noteA C K N O W L E D G E M E N T S
For this updated review (2022), we thank Cochrane Oral Health,particularly Anne Littlewood (who devised search strategies andran the searches), Luisa M Fernandez Mauleffinch, and Anne-Marie Glenny; peer reviewers Professor Philip Preshaw (Schoolof Dentistry, University of Dundee, UK) and Pia-Merete Jervøe-Storm (Department of Periodontology, Operative and PreventiveDentistry, Center for Dental and Oral Medicine, University HospitalBonn, Germany); translator Sinval A Rodrigues Junior; and trialauthors who provided additional information about their studies,P Kaur Khanuja (Kaur 2015), E Mauri and J López (Mauri-Obradors2018).Cochrane Oral Health supported the authors in the development ofthis review update. The following people conducted the editorialprocess for this article.• Sign-off Editor (final editorial decision) and Editor (providedfeedback on submitted draN to prepare for peer review): Anne-Marie Glenny, Co-ordinating Editor, Cochrane Oral Health, TheUniversity of Manchester, UK.• Managing Editor (selected peer reviewers, collated peer-reviewer comments, provided editorial guidance to authors,conducted editorial policy checks) and Copy Editor (copyedited final draN according to Cochrane style manual): Luisa MFernandez Mauleffinch, Managing Editor, Cochrane Oral Health,The University of Manchester, UK.• Information Specialist (checked accuracy of search sections ofthe review): Anne Littlewood, Information Specialist, CochraneOral Health, The University of Manchester, UK.For earlier versions of this review, we thank Cochrane OralHealth, specifically, Anne Littlewood, Laura MacDonald, Luisa MFernandez Mauleffinch, and Anne-Marie Glenny; Cochrane OralHealth translators Chunjie Li, Andreas Neudecker, and FarhadShokraneh; and peer reviewers Rahul Alam, Deborah Matthews,Didac Mauricio, and Hugo Pinto. We thank the trial authors whoprovided unpublished information that allowed more thoroughappraisal of studies: Elena Firkova (Yun 2007), Judith Jones (Jones2007), Sayaka Katagiri (Katagiri 2009), Panagiotis Koromantzos(Koromantzos 2011), Shaila Patil Kothiwale (Kothiwale 2013), ElifUnsal (Kiran 2005), and Jean-Noel Vergnes (Calbacho 2004; Vergnes2018).We gratefully acknowledge the contributions of Brian Stevenson,Susan Furness, David Moles, and Edward Mills as authors on earlierversions of this review.Particular thanks are expressed by Terry Simpson to RichardIbbetson for his personal support and guidance during this review'sinitial conception.