The objective of this article was to conduct a systematic review of the literature to contrast the existing evidence regarding the relationship between periodontal disease (PD) and diabetes mellitus (DM) with the possibly increased risk of SARS-CoV-2 infection, as well as to establish a hypothesis that explains the ways in which this interaction could take place. A literature search up from 1 January 2020 to 21 March 2021 was conducted in three electronic databases, namely, PubMed, Web of Science, and Scopus, in order to identify studies on periodontal disease alone or in conjunction with diabetes mellitus, reporting any relation with SARS-CoV-2 infection as a primary outcome. Only articles published in the English language were included. Due to the lack of studies, we decided to collect all the theoretical and clinical evidence suggesting a possible biological pathway evidencing the relationship among PD, DM, and SARS-CoV-2 infection. From a total of 29 articles, 12 were included for final review studies (five reviews, two hypotheses, one Special Issue, one perspective, one commentary, one case–control study, and one case report). In addition, this systematic review article hypothesizes the correlation between PD and type 2 diabetes mellitus (T2DM) by expression of angiotensin-converting enzyme 2 (ACE2) in periodontal tissue and the risk of SARS-CoV-2 infection. T2DM is a metabolic disorder characterized by high blood glucose levels resulting from altered insulin secretion or action. Likewise, periodontitis and T2DM are inflammatory disorders with a bidirectional association, and both diseases have a similar immunomodulatory cascade and cytokine profile. ACE2 is a crucial component of the renin–angiotensin system (RAS) and the key factor of entry in the cells by the new SARS-CoV-2. ACE2 is widely distributed in the lung and kidneys, and interestingly has a great distribution in the oral cavity, principally in the tongue and periodontal tissue. ACE2 in periodontal tissue plays a crucial role between health and disease. Moreover, the ACE2/Ang-(1-7)/MasR axis is downregulated in the dysbiotic and inflammatory periodontal environment. Nevertheless, the balance of ACE2 activity is modified in the context of concurrent diabetes, increasing the expression of ACE2 by the uncontrolled glycemia chronic in T2DM. Therefore, the uncontrolled hyperglycemia possibly increases the risk of developing periodontitis and triggering overexpression of ACE2 in periodontal tissue of T2DM patients, with these events potentially being essential to SARS-CoV-2 infection and the development of mild-to-severe form of COVID-19. In this sense, we would like to point out that the need for randomized controlled trials is imperative to support this association.
Introducción: La periodontitis es una de las principales complicaciones de la diabetes mellitus tipo 2 (DMT2), ambas enfermedades presentan una relación bidireccional donde el descontrol glucémico es un factor determinante para el desarrollo de la periodontitis. Sin embargo, el grado de severidad del descontrol glucémico y de la periodontitis no han sido evaluados a fondo. Objetivo: Evaluar la relación que existe entre el descontrol glucémico en DMT2 y la severidad de la periodontitis. Material y métodos: Hombres y mujeres con DMT2 con y sin periodontitis crónica generalizada del Hospital «Dr. Donato G Alarcón» fueron incluidos en el estudio. Tras firma de consentimiento informado se realizó una exploración periodontal registrando: enrojecimiento gingival, sangrado, supuración, profundidad de sondeo y nivel de inserción clínica. Asimismo, se obtuvieron muestras de sangre venosa periférica para determinar niveles de hemoglobina glicosilada (HbA1c), colesterol, triglicéridos, lipoproteína de alta densidad (HDL), lipoproteína de baja densidad (LDL), creatinina y recuento de granulocitos. Resultados: Se incluyeron 158 casos con DMT2, la población presentó 42 (26%) con salud periodontal, 36 (22%) periodontitis leve, 26 (16%) periodontitis moderada y 54 (34%) con periodontitis severa. Con respecto a la HbA1c, se encontró con buen control 26 (16%), mal control 56 (35%) y con alto riesgo de complicaciones 46 (48%). Se encontró una disminución significativa en el enrojecimiento gingival y un aumento en los niveles de pérdida de inserción clínica en pacientes con alto riesgo de complicaciones. Asimismo, se encontró un aumento significativo de granulocitos en el grupo de casos con alto riesgo de complicaciones. Discusión: El aumento descontrolado y prolongado de los niveles de glucosa en sangre se ha correlacionado con el desarrollo de diversas complicaciones. En el periodonto los eventos generados por este desbalance se han relacionado con el desarrollo de la periodontitis. Sin embargo, no se ha evaluado la relación entre el grado de severidad y el descontrol glucémico. Conclusión: Se encontró una relación positiva entre niveles altos de HbA1c y la severidad de la periodontitis crónica generalizada.
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