Periodontal diseases cause alteration in the oral cavity and are related to systemic diseases such as DM2. The severity and progression of PD have been linked to increase in OS and the alteration of its regulation system. In the same way, it is considered that time of living with T2DM is a factor that influence in periodontal recovery.
The objective of this research was to evaluate the effects of NSPT plus Zn+ gluconate and Mg+ 2 oxide for 30 days in patients with PD associated with DM2.
To our knowledge, this is the first research to report the use of Zn+ gluconate and Mg+ 2 oxide plus NSPT in populations affected by PD-DM2.
The results showed that the group of patients with PD and DM2 have deficiencies in levels of Zn+ and Mg+ 2 at baseline. This information adds to what has been reported in other studies, where DM2 has been associated with low levels of Zn+ and Mg+ 2 and their influence on the development of complications such as nephropathies and PD15,16 .
The alterations in the levels of these elements refer to their participation in the pathophysiology of DM2 and its complications because of the dysregulation of cellular pathways where Zn+ and Mg+ 2 are co-factors28–30.
Nevertheless, the pathways related to the alteration in the levels of Zn+ and Mg+ 2 in patients with DM2 and its co-morbidities are still unclear. In patients with chronic kidney diseases associated with DM2, deficiencies of Zn+ have been described to be related to the decrease in intestinal zinc absorption, uremic toxicity, as well as its bioavailability related to tubular dysfunction and glomerular filtration31. Further research is required to evaluate how PD influences deficiencies of these elements when associated with DM2.
The results prove the reduction of DoP, CAL, BoP, PISA, and DBPI after periodontal intervention in both groups. Mailao et al.,2015 mention that NSPT, reduces dental biofilm, dental calculus, and endotoxins followed by a change in the periodontal clinical characteristics32, conditioning the root surfaces to be biologically acceptable and stopping the progression of PD33. This could suggest a positive change in the clinical response to treatment, resulting in the reduction of OS, antioxidant activity, and inflammation. More research is needed on the host response mechanisms to NSPT related to the observed clinical changes.
In this research, it was also identified that patients with DM2 and PD presented elevated levels of MDA. Research reports have linked deficiencies of Zn+ and Mg+ 2 to increased OS in periodontal tissues34,35. Lipid peroxidation is the main mechanism of damage caused by ROS, which generates an increase in MDA levels9. This is an oxidative state biomarker that is related to micro and macrovascular damage during PD. Its increase in patients with DM2 and PD could indicate greater severity and inflammatory state34,36 .
After 30 days of NSPT, a decrease in MDA levels was detected. This result contributes to the findings on the effects of NSPT on oxidative stress biomarkers. Several studies have reported that a reduction in these markers occurs 3 months after periodontal intervention 37,33. In this research, a reduction at 30 days after treatment is shown and clinical improvement of periodontal tissues that could be related to the decrease in MDA is identified, too. The correct execution of NSPT, proper adherence to patients’ instructions, and the response of periodontal tissue to the therapy are factors that support the reduction in treatment time reported in this study39.
On the other hand, research has shown that OS damage in periodontal disease is regulated and controlled by an endogenous system of antioxidant enzymes5. However, in patients with PD and DM2 with deficiencies in Zn+ and Mg+ 2, the expression of antioxidant enzymes is affected, reducing their concentration and activity40.
The results of this research demonstrate that patients presented low levels of enzymatic activity units for SOD and CAT, increasing their levels after 30 days of NSPT. Sukhtankar et al., 2013 suggest that during the inflammatory process in PD, SOD enzyme levels rise as a result of increased superoxide anion on periodontal tissues and decreases after 2 months of treatment41. This suggests that the antioxidants enzymes, in addition to acting on oxidative stress, could take part in recovery and wound healing processes on periodontal tissues.
Continuing with studies of NSPT and its effects in DM2 patients, Hass-Nogueira et al., 2021, proposed the use of supplements that support the remission of PD and promote periodontal stability18. The use of essential oils, ginger, melatonin, probiotics, vitamin C, among other has been highlighted42–46 .
In this regard, this work proposes the use of zinc gluconate and magnesium oxide as a co-adjuvant of NSPT in patients with PD associated with DM2. Other studies reported the use of co-supplementation with Zn+ and Mg+ 2 in women with gestational DM, as they show a reduction in biomarkers of OS and an increase in total antioxidant capacity (TAC) after 6 months of use 47. With this information, the benefits of Zn+ and Mg+ 2 supplementation for the management of other disease conditions are recognized.
As a result of the effects of NSPT plus the supplementation of Zn+ gluconate and Mg+ 2 oxide proposed in this research, it was possible to observe that, 30 days after the periodontal treatment, levels of enzymatic activity for SOD and CAT increased to a greater extent compared to the group that only received NSPT. These results add valuable information to all the research describing the participation of Zn+ and Mg+ 2 as co-factors in the synthesis of antioxidant enzymes and how supplementation increases their activity48,49. This research suggests that the increase in the levels of antioxidant enzymatic activity by SOD and CAT is one of the response mechanisms to protect and recover periodontal tissue affected by PD associated with DM2. The role of these enzymes in periodontal healing processes should be further evaluated.
Further research is necessary to describe the cellular biological pathways involved in the regulation of oxidative stress, the inflammatory process, and the subsequent antioxidant response following supplementation with Zn+ and Mg+ 2. It could be claimed that these elements reduce the expression of cellular nuclear factors such as NF-kB and Nrf2 in periodontal and immune cells.
In this research, it was expected that the epidemiological behavior of periodontal disease and diabetes mellitus would be similar in our groups with respect to gender. However, we were able to observe that more female patients were present. This consistent with previous research which reports that women are more susceptible to both conditions and exhibit a higher degree of severity50. As a result of the increase in levels of steroidal hormones, bone metabolism, and inflammation. Further research is needed on the supplementation of Zn+ and Mg+ 2 in women and its potential influence on metabolism and hormonal regulation.