1. Preventive Measures Infection & Delayed Wound Healing Frequent dental visits to assess plaque control Risk assessment profiles to identify risk factors Address risk factors of –periodontal disease –caries –candidiasis Post-operative antibiotic therapy if necessary Avoidance of smoking

2. Infections and Diabetes Bacterial infections  insulin-mediated glucose uptake by skeletal muscle whole-body insulin resistance –Chronic systemic inflammation leads to increased insulin resistance Acute endotoxemia and cytokine production (TNF- , IL-1 , IL-6) induce insulin resistance and  insulin action –Reduced glucose tolerance –Increased risk of diabetic complications

5. Periodontitis and Diabetes May increase insulin resistance May aggravate glycemic control –Taylor et al., 1996 - Type 2 subjects with periodontitis had worse glycemic control –Thorstensson et al., 1996 N=39 / group Diabetics with severe vs mild or gingivitis, 1-11 year follow-up Severe periodontitis: > prevalence of proteinuria > number of cardiovascular complications: stroke, TIA, angina, MI, heart failure, intermittent claudication

6. Periodontal Disease Predicts Mortality in Diabetics Periodontal disease is strongly predictive of mortality from ischemic heart disease and diabetic nephropathy in Pima Indians with Type 2 diabetes 60% of subjects had severe periodontitis 204/628 subjects >35 years of age died in an 11 year follow up –44/54 CVD related deaths were attributed to ischemic heart disease –28/35 diabetes-related deaths were attributed to nephropathy The age and sex-adjusted death rates were –3.7 for no or mild periodontitis –19.6 for moderate periodontitis –28.4 for severe periodontitis Diabetes Care 2005;28:27-32

7. Effect of Periodontitis on Overt Nephropathy and End-Stage Renal Disease in Type 2 Diabetes Periodontitis predicts development of overt nephropathy and ESRD in individuals with type 2 diabetes. During up to a 22 year follow-up of 529 subjects –193 developed macroalbuminuria –68 developed ESRD Whether treatment of periodontitis will reduce the risk of diabetic kidney disease remains to be determined. Diabetes Care 2007;30:306-311

8. Moderate Periodontitis Severe Periodontitis Edentulous Macro Albuminuria (p=.01) 2.02.12.6 ESRD (p=.02) 2.33.54.9 Effect of Periodontitis on Overt Nephropathy and End-Stage Renal Disease in Type 2 Diabetes