Influence of body mass index and obesity upon the association between periodontitis and sleep apnea-hypopnea syndrome.

OBJECTIVES: We aimed to explore the association between periodontitis and sleep apnea-hypopnea syndrome (SAHS) and the possible influence of body mass index (BMI) and obesity upon this association. MATERIALS AND METHODS: A case-control study was made involving 114 subjects (60 patients with SAHS and 54 controls). A thorough periodontal evaluation was carried out, and demographic and clinical data were collected. RESULTS: Periodontitis was more prevalent in SAHS (80%) than in the controls (48.1%). The recorded statistically significant association (OR = 4.31; p = 0.001) was seen to weaken in the multivariate model (OR = 2.03; p = 0.204), with BMI adopting a more influential role. The apnea-hypopnea index (AHI) was correlated to probing depth (PD) (r = 0.40; p = 0.002) and clinical attachment level (CAL) (r = 0.41; p = 0.001). The periodontal parameters were seen to be higher in obese SAHS patients (BMI ≥ 30 kg/m2) than in non-obese SAHS patients (BMI < 30 kg/m2). CONCLUSIONS: The greater prevalence and severity of periodontitis in patients with SAHS were fundamentally influenced by BMI. On the other hand, periodontitis was more severe in patients with severe SAHS. CLINICAL RELEVANCE: Patients with SAHS have a greater prevalence of periodontitis, fundamentally related to increased obesity. Therefore, obese subjects with SAHS should be screened for periodontal disease.

Relationship Between Surgical Difficulty of Third Molar Extraction Under Local Anesthesia and the Postoperative Evolution of Clinical and Blood Parameters.

PURPOSE: To determine whether the Pederson scale is a good predictor of the surgical difficulty of third molar extraction and establish whether such surgical difficulty is directly related to the postoperative course as assessed from clinical (pain, inflammation, and trismus) and blood (C-reactive protein, interleukin-6 [IL-6], and fibrinogen) parameters. MATERIALS AND METHODS: A prospective observational study was conducted of 2 groups of patients who underwent simple or surgical third molar extraction under local anesthesia. Clinical and blood parameters and possible complications were recorded for 1 week after extraction. RESULTS: A total of 118 patients were studied. Surgical difficulty as predicted by the Pederson scale showed significant differences (P < .001) for osteotomy, sectioning of the crown, root sectioning, duration of intervention, type of closure, and number of sutures. Under conditions of equal surgical difficulty, the evolution of the groups was similar for pain and inflammation, although trismus was greater for patients subjected to surgical extraction. After the operation, marked increments were recorded in serum C-reactive protein, IL-6, and fibrinogen, although without differences among different levels of surgical difficulty. The probability of complications was similar in the routine and surgical extraction groups. The appearance of complications was the principal cause of alterations in clinical and blood parameters. CONCLUSIONS: The Pederson scale is a good predictor of the surgical difficulty of third molar removal as assessed from different clinical and blood parameters. C-reactive protein, IL-6, and fibrinogen concentrations varied considerably after the operation but were not influenced by the degree of surgical difficulty. The presence of postoperative complications was associated with a poorer evolution of clinical and blood parameters.

Changes in oral health-related quality of life after three different strategies of implant therapy: a clinical trial.

This research aims to evaluate changes in Oral Health-related Quality of Life (OHQoL) by means of the Oral Impacts on Daily Performances (OIDP) of patients treated with three distinct implant strategies. This clinical trial consisted of an oral examination and a questionnaire-based interview carried out before and after the definitive prosthetic rehabilitation in a consecutive sample of patients requiring dental implants. According to the clinical diagnosis and patient preference, patients were assigned to the one of the following groups: the conventional group (CGCL; n = 40), where implants were inserted without guiding and conventionally loaded; to the guided surgery but conventional loading group (GSCL; n = 35); or to the guided surgery and immediate loading group (GSIL; n = 29). At baseline, the OHQoL was significantly greater among those assigned to CGCL (2.4 ± 1.3) than those assigned to GSCL (3.3 ± 1.3), which were both greater than those patients assigned to GSIL (4.6 ± 2.0). After implant therapy, the oral well-being was significantly better than at baseline, and patient satisfaction was greater when the implants were loaded immediately (8.7 ± 1.1) than if the prosthetic rehabilitation was delayed (8.3 ± 1.1). In the GSIL group, the effect size of the OIDP exceeded the threshold value of 0.8 for all of the OIDP domains and for the total OIDP score and patient satisfaction. A global improvement in the OHQoL scores and patient satisfaction was observed after implant therapy, but the change was markedly greater in the GSIL group.

Salivary flow and xerostomia in patients with type 2 diabetes.

BACKGROUND: Saliva is secreted by the major and minor salivary glands. There are a number of physiological factors that can reduce this secretion such as age, sex, body weight, number of teeth present in the mouth or time of day. This decrease may also be caused by the use of certain drugs, radiotherapy for head and neck cancer, chronic rheumatic diseases such as Sjögren's syndrome and other systemic disorders such as diabetes mellitus (DM). Objective of this study was to investigate the effect of type 2 DM on salivary secretion and its relation to the sensation of xerostomia. METHODS: Forty-seven patients with type 2 DM and 46 healthy individuals, aged 40-80, participated in the study. Samples of saliva were collected, at rest and after stimulation, at baseline and after the administration of a meal. A questionnaire of 10 items was used to define the patients' sensations of xerostomia. For statistical analysis, the Mann-Whitney test was used to assess the difference in salivary flow between the two groups and the relationship between the response to each of the questions and salivary flow levels. The degree of the patients' sensation of xerostomia was analysed by the Fisher test. RESULTS AND CONCLUSIONS: There was a significant decrease in total saliva levels at rest in patients with type 2 DM compared to the control group. The study group also experienced higher levels of dryness at night and on waking as well as a greater sensation of lingual burning compared to the control group.

Chronic periodontitis impairs polymorphonuclear leucocyte-endothelium cell interactions and oxidative stress in humans.

AIM: To evaluate the relationship between oxidative stress parameters in polymorphonuclear leucocytes (PMNs) and PMN-endothelial cell interactions in patients with chronic periodontitis (CP) according to different degrees of severity of the disease. MATERIALS AND METHODS: For this cross-sectional study, 182 subjects were divided into four groups according to degree of CP: without CP (n = 37), mild CP (n = 59), moderate CP (n = 51), and severe CP (n = 35). We determined anthropometric and biochemical variables, periodontal parameters, inflammatory markers, oxidative stress parameters (superoxide and mitochondrial membrane potential), and PMN-endothelium cell interactions (rolling flux, velocity, and adhesion). RESULTS: Systemic inflammatory markers-C-reactive protein, leucocyte count, TNFα, and retinol-binding protein 4-were altered in the group with CP. Total superoxide was augmented in patients with moderate and severe periodontitis, whereas mitochondrial membrane potential did not change. Furthermore, PMNs adhesion and rolling flux were increased in subjects with CP. CONCLUSION: In a systemic proinflammatory environment, PMNs from patients with CP exhibit hyperactivity and produce higher amounts of superoxide. In parallel with this, an increase in PMNs rolling flux and cell adhesion to the endothelium suggests the presence of alterations of PMN-endothelium interactions in patients with CP that can lead to atherosclerosis and cardiovascular complications.

Dietary therapy and non-surgical periodontal treatment in obese patients with chronic periodontitis.

AIM: The effect of dietary weight loss intervention on periodontal therapy is unknown. Therefore, we aimed to evaluate whether weight loss improves the response of obese subjects to non-surgical periodontal treatment. MATERIALS AND METHODS: This interventional study in obese patients was conducted at the University Hospital Dr. Peset (Valencia, Spain). Patients were divided into two groups with and without dietary therapy. All participants received non-surgical periodontal treatment. Periodontal, anthropometric and biochemical parameters were assessed at baseline and 12 weeks. RESULTS: A total of 78 patients were re-evaluated after intervention. All periodontal parameters improved in both groups after periodontal treatment, but the reductions in mean probing depth (PD) (0.23 mm vs. 0.12 mm) and in percentage of sites with PD 4-5 mm (10.4% vs. 5.89%) were significantly higher in the dietary group. Additionally, complement component 3 (C3) and tumour necrosis factor alpha (TNFα) decreased in the dietary group after intervention. Percentage of change in mean PD correlated with change in C3 (r = 0.233, p = 0.043), and percentage of change in sites with PD 4-5 mm correlated with change in TNFα (r = 0.414, p = 0.012). CONCLUSIONS: This study suggests that dietary weight loss intervention causes a greater reduction in systemic inflammation, which may enhance the response to periodontal treatment.

Levels of serum retinol-binding protein 4 before and after non-surgical periodontal treatment in lean and obese subjects: An interventional study.

AIM: We aimed to evaluate serum RBP4 levels before and after periodontal therapy in lean and obese subjects with chronic periodontitis (CP) in order to determine its possible association with periodontitis. MATERIALS AND METHODS: This is an interventional study for which a total of 112 lean and 119 obese subjects were recruited. Patients with CP were evaluated before and after three months of non-surgical periodontal treatment. Periodontal, anthropometric, biochemical parameters and serum levels of TNF-α, IL-6, hs-CRP and RBP4 were assessed. RESULTS: Serum RBP4 levels were associated with an increased probability of periodontitis (OR = 1.60; 95% CI: 1.02-2.50), showing patients with CP to have higher RBP4 levels than those without CP in both lean and obese populations (3.35 vs 3.06 and 3.74 vs 3.21, respectively). Following periodontal treatment, RBP4 and TNF-α decreased, and all periodontal parameters improved to the same extent in both groups, except for number of teeth with probing depth (PD) ≥4 mm, which improved to a less extent in obese than in lean subjects. In the multivariable regression model, the number of teeth with PD ≥4 mm was independently associated with RBP4 (ß = 0.192). CONCLUSION: RBP4 was associated with chronic periodontitis before and after non-surgical periodontal treatment.

Tooth agenesis code (TAC) in complete unilateral and bilateral cleft lip and palate patients.

The objective of this study is to characterize and compare tooth agenesis codes and their prevalence in a population of Spanish patients with unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP), and to determine if the extent of the cleft (BCLP or UCLP) was associated with the number of absent teeth. This retrospective cross-sectional human study included 118 patients with complete BCLP (29) or UCLP (89) and permanent dentition from first molar to first molar. Congenitally missing teeth were identified on panoramic radiographs using the tooth agenesis code (TAC) to identify agenesis codes. Agenesis prevalence was 50.6 and 51.7% for UCLP and BCLP patients, respectively. The lateral upper incisor was the most frequently absent tooth, especially in the cleft quadrant. Numbers of absent teeth ranged from 1 to 6. This study represents a different approach from previous agenesis investigations in cleft patients. These Spanish patients showed a high number of ageneses, presenting nineteen different tooth agenesis codes. A total of five TACs were unique, in other words, observed in a single patient in the sample. No statistically significant relationship was found between the extent of the cleft and the number of absent teeth. The TAC system makes it possible to identify agenesis codes with simultaneous absence of teeth not detected in general prevalence studies.

Post-extraction mesio-distal gap reduction assessment by confocal laser scanning microscopy - a clinical 3-month follow-up study.

AIM: The aim of this 3-month follow-up study is to quantify the reduction in the mesio-distal gap dimension (MDGD) that occurs after tooth extraction through image analysis of three-dimensional images obtained with the confocal laser scanning microscopy (CLSM) technique. MATERIALS AND METHODS: Following tooth extraction, impressions of 79 patients 1 month and 72 patients 3 months after tooth extraction were obtained. Cast models were processed by CLSM, and MDGD changes between time points were measured. RESULTS: The mean mesio-distal gap reduction 1 month after tooth extraction was 343.4 µm and 3 months after tooth extraction was 672.3 µm. The daily mean gap reduction rate during the first term (between baseline and 1 month post-extraction measurements) was 10.3 µm/day and during the second term (between 1 and 3 months) was 5.4 µm/day. CONCLUSIONS: The mesio-distal gap reduction is higher during the first month following the extraction and continues in time, but to a lesser extent. When the inter-dental contacts were absent, the mesio-distal gap reduction is lower. When a molar tooth is extracted or the distal tooth to the edentulous space does not occlude with an antagonist, the mesio-distal gap reduction is larger. The consideration of mesio-distal gap dimension changes can help improve dental treatment planning.

Involvement of insulin resistance in normoglycaemic obese patients with periodontitis: A cross-sectional study.

AIM: We explored the association between obesity and periodontitis with the aim of determining the possible role of insulin resistance (IR) in this relationship. MATERIALS AND METHODS: A total of 212 subjects-110 obese and 102 lean individuals-were evaluated for periodontal disease and divided according to IR: a lean group without IR (LWIR), an obese group without IR (OWIR), and an obese group with IR (OIR). Anthropometric, metabolic, inflammatory and periodontal parameters were evaluated. RESULTS: Periodontitis was more prevalent in obese (80.9%) than in lean subjects (41.2%), with the former group showing a risk of periodontitis sixfold that of the latter. Obese subjects as a whole displayed higher diastolic blood pressure, TNFα and hsCRP and lower HDL cholesterol than lean subjects. OIR had higher systolic blood pressure, glucose, insulin, HOMA-IR, A1c, triglycerides and number of teeth with PD ≥ 4 mm than OWIR, while other periodontal variables remained unaltered. The multivariable regression model showed that probing depth, bleeding on probing and HOMA-IR were independent predictors of number of teeth with PD ≥ 4 mm. CONCLUSION: Our data support an association between obesity and periodontitis, and point to a central role of IR. Periodontitis tends to be more extensive in obese patients with IR.

Oral manifestations of rheumatoid arthritis. A cross-sectional study of 73 patients.

OBJECTIVE: A study is made of the main oral manifestations of patients with rheumatoid arthritis (RA), particularly salivary flow, and of its possible association to periodontal disease. MATERIAL AND METHODS: A prospective comparative study was made of 146 patients (73 with RA and 73 controls), recording pocket depth, clinical attachment loss, bleeding index, plaque index, and the DMFT index to assess periodontal and dental alterations. Sialometric measurements were also made to determine resting, stimulated, and parotid salivary flow. RESULTS: The patients with RA had greater periodontal pocket depths (with moderate depths in most cases), as well as greater attachment loss and more bacterial plaque. The resting whole saliva and stimulated parotid saliva rates were also clearly decreased in the RA group compared with the controls. CONCLUSIONS: Patients with RA are more likely to present periodontal disease, poorer oral hygiene manifesting as an increased accumulation of bacterial plaque, and decreased salivary flow rates. CLINICAL RELEVANCE: Vulnerability to periodontitis is confirmed in one of the largest samples ever studied of patients with rheumatoid arthritis (RA). Also, there is evidence of hyposialia (decrease in salivary rate) in RA patients without Sjögren's syndrome.

Sleep quality in patients with xerostomia: a prospective and randomized case-control study.

Objectives To investigate sleep quality, anxiety/depression and quality-of-life in patients with xerostomia. Materials and methods This prospective, observational, cross-sectional study was conducted among a group of xerostomia patients (n = 30) compared with 30 matched control subjects. The following evaluation scales were used to assess the psychological profile of each patient: the Hospital Anxiety and Depression Scale, the Oral Health Impact Profile-14 (OHIP-14), the Xerostomia Inventory, the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS). Results The PSQI obtained 5.3 3 ± 1.78 for patients with xerostomia compared with 4.26 ± 1.01 for control subjects (p = 0.006); ESS obtained 5.7 ± 2.1 for test patients vs 4.4 0 ± 1 for control subjects (p = 0.010). Statistical regression analysis showed that xerostomia was significantly associated with depression (p = 0.027). Conclusions Patients with xerostomia exhibited significant decreases in sleep quality compared with control subjects.

[Dental management in patients with cirrhosis]. / Manejo odontológico en el paciente cirrótico.

The present article makes a brief review about dental management of the patients with cirrhosis. It focus on problems related with infections, haemorrhagic events and treatment with drugs of common use in odontology.

Oral health in a group of patients with Rett syndrome in the regions of Valencia and Murcia (Spain): a case-control study.

OBJECTIVES: Rett syndrome (RS) is a rare disease with oral manifestations that have not been described in detail or in a standardized manner in the literature. The present study describes the oral health of the population with RS in two Spanish regions, following the protocol of the World Health Organization for conducting common oral health surveys. STUDY DESIGN: A prospective, observational case-control study was carried out, involving a group of patients with RS (n1=41) and a mean age of 13.37±3.19 years, and an age- and gender-matched control group without RS (n0=82). The data referred to oral health and habits were recorded by means of a questionnaire and oral examination was used to document caries indicators (prevalence of caries, df(t), df(s), DMF(T), DMF(S) and indices referred to dental loss, morbidity, restoration), the Community Periodontal Index (CPI), and the most characteristic oral manifestations. RESULTS: The most frequent oral habit in the patients with RS was diurnal bruxism, followed by stereotyped tongue movements and oral breathing. The caries scores were lower in the RS population than in the control group, but patients with RS showed greater periodontal alterations and a greater prevalence of drooling, dental wear, high-arched palate and anterior open bite. CONCLUSIONS: The population with RS exhibits characteristic and early oral habits and alterations, and periodontal problems that are more notorious than caries disease, so that our efforts should focus on the diagnosis and early correction of the parafunctional habits, promoting restorative treatment, and providing instructions on correct oral hygiene.

Surgical difficulty and postoperative course of the third molar extraction under general anesthesia: An intervention trial.

BACKGROUND: Third molar extractions are one of the most common surgical procedures in the area of ​​stomatology. However, we know that even if they are minor surgeries, they can cause a postoperative period with local and systemic repercussions. Thus, the aim of this intervention trial is to determine the relationship between clinical parameters (pain, inflammation and trismus) and serum parameters (C-reactive protein (CRP), IL-6 and fibrinogen) that are modified in the first postoperative week, and the appearance of complications after extraction with general anesthesia, using the Pederson scale. METHODS: The research question was: Can postoperative discomfort after third molar extraction under general anesthesia be predicted using Pederson scale? An interventional trial was carried out of third molar extractions under general anesthesia in Dr. Peset University Hospital. Patient selection was performed randomized using MS Excel. Then were divided into two groups (n = 126): group A (2 complex extractions) and group B (4 extractions: 2 simple and 2 complex). All parameters were collected at the surgery and 7 days after surgery. RESULTS: The clinical postoperative parameters showed significant differences in relation to surgical difficulty. In summary, the degree of surgical difficulty can be predicted with the Pederson scale before extracting mandibular third molars. CRP and fibrinogen levels increase significantly with the degree of surgical difficulty. CONCLUSION: Significant differences (p < 0.001) were observed in all the intraoperative parameters according to surgical difficulty as assessed by the Pederson scale. Therefore, this scale was a good indicator to estimate the patient's postoperative period.

Could Periodontitis Increase the Risk of Suffering from Pancreatic Cancer?-A Systematic Review.

(1) Background: The relationship between periodontitis and systemic pathologies continues to grow. Recently, the presence of periodontal pathogens has been linked to an increased risk of pancreatic cancer (PC) and its mortality. Thus, a systematic review is needed to identify whether an association between the two diseases can be established. The objective of this review is to elucidate the mechanisms responsible for this association. (2) Methods: A systematic review was carried out using three databases (PubMed, Embase and Scopus) with the following keywords "Periodontitis AND pancreatic cancer". A total of 653 articles were retrieved; before selection and screening, the inclusion and exclusion criteria were defined, resulting in a total of 13 articles being included in the review. (3) Results: The increase in low-grade systemic inflammation, pH changes, and the cytotoxicity of certain periodontopathogenic bacteria were found in the scientific literature reviewed as mechanisms linking periodontitis with the risk of PC. (4) Conclusions: Through this systematic review, we have seen how periodontitis can be related to PC and how it worsens its prognosis. Knowing the behavior of periodontopathogenic bacteria and the influence they have on our immune and inflammatory system may help to achieve an interdisciplinary approach to both pathologies.

Pediatric morbidity after oral surgery procedures under general anaesthesia: A systematic review.

The aim of this study is to carry out a systematic review of the existing literature on postoperative morbidity after general anaesthesia (GA) in the dental care of paediatric patients, its frequency, characteristics and association with the intervention performed. MATERIAL AND METHODS: An exhaustive search of the literature published up to 23 February 2022 was carried out in PubMed, Web of Science, Cochrane and EBSCO, with the following strategy: (infant OR child OR adolescent) AND (Oral Surgical Procedures OR Dentistry, Operative) AND Anesthesia, General AND Postoperative Complications. RESULTS: The most frequent reason for the indication of general anaesthesia was dental caries and its complications (up to 91.0% of patients), followed by lack of cooperation/anxiety and/or fear for dental procedures in the office (between 39.8 and 47.9%). There is a higher prevalence for treatments in the special patient group reaching 87.7% compared to 63.3% in healthy patients. The main comorbidities recorded were: physical or mental disability, neurological, haematological, cardiac disorders, asthma, Down's syndrome; it was not possible to establish their association with the intervention performed. Regarding complications, complaints occurred between 43.0 and 98.9% of cases within the first 24 hours, the main reason being pain (between 14.0% and 95.0%). CONCLUSIONS: Pediatric dental procedures under GA carry a very low risk of major complications, but have a virtually universal incidence of minor complications.

Application of a capsaicin rinse in the treatment of burning mouth syndrome.

OBJECTIVE: To examine the efficacy of a new topical capsaicin presentation as an oral rinse in improving the symptoms of burning mouth syndrome (BMS). STUDY DESIGN: A prospective, double-blind, cross-over study was made of 30 patients with BMS. There were 7 dropouts; the final study series thus comprised 23 individuals. The patients were randomized to two groups: (A) capsaicin rinse (0.02%) or (B) placebo rinse, administered during one week. After a one-week washout period, the patients were then assigned to the opposite group. Burning discomfort was scored using a visual analog scale (VAS): in the morning before starting the treatment, in the afternoon on the first day of treatment, and at the end of the week of treatment in the morning and in the afternoon. The same scoring sequence was again applied one week later with the opposite rinse. RESULTS: The mean patient age was 72.65 ± 12.10 years, and the duration of BMS was 5.43 ± 3.23 years on average. Significant differences in VAS score were recorded in the capsaicin group between baseline in the morning (AM1) or afternoon (AA1) and the end of the week of treatment (AA7)(p=0.003 and p=0.002, respectively). CONCLUSION: The topical application of capsaicin may be useful in treating the discomfort of BMS, but has some limitations.

Oral manifestations in a group of adults with autism spectrum disorder.

OBJECTIVE: A number of studies have evaluated the buccodental health of patients with autism spectrum disorder (ASD), though most have involved children, and no specific oral manifestations have been described. The present study describes the buccodental disorders and hygiene habits in a group of adults with ASD. STUDY DESIGN: A prospective case-control study was made of a group of patients with ASD (n=30), with a mean age of 27.7±5.69 years, and of a healthy age- and gender-matched control group (n=30). An evaluation was made of the medical history, medication, oral hygiene habits and oral diseases, with determination of the CAOD, CAOS and OHI-S oral hygiene scores. RESULTS: Most of the patients in the ASD group used two or more drugs and were assisted in brushing 2-3 times a day. The most frequent manifestations were bruxism, self-inflicted oral lesions and certain malocclusions. The CAOD and CAOS scores were significantly lower than in the controls. CONCLUSIONS: Adults with ASD and assisted dental hygiene presented fewer caries than the non-disabled population. However, bruxism, ogival palate and anterior open bite were frequent in the patients with ASD.

Efect of periodontal disease and non surgical periodontal treatment on C-reactive protein. Evaluation of type 1 diabetic patients.

OBJECTIVES: The purpose of this study was to analyze how anti-infectious periodontal treatment affects C reactive protein (CRP) values in patients with type 1 diabetes, and correlate baseline CRP levels with periodontal disease severity. STUDY DESIGN: A cohort of fifty three subjects with type 1 diabetes and moderate to severe periodontitis were recruited. Periodontal parameters were measured, and blood samples were obtained to evaluate high-sensitivity C-reactive protein (hs-CRP). Group 1 was treated with scaling, root planning, and systemic administration of doxycycline. Group 2 received only scaling and root planning. RESULTS: Hs-CRP was reduced after periodontal treatment in group 1 (-0.22 mg/l) and 2 (-0.21 mg/l ) but this reduction was not statistically significant, even in the patients with the best response to periodontal treatment. However, significant correlation appeared between hs-CRP and mean probing pocket depth (PPD) (p=0, 01) and mean clinical attachment level (CAL) (p=0,03). CONCLUSIONS: Non-surgical periodontal treatment couldn' t reduce hs-CRP values, however, it was found an association between advanced periodontitis and elevated blood hs-CRP levels in patients with type 1 diabetes. It can be speculated that periodontal disease increases production of pro-inflammatory mediators in patients with type 1 diabetes, but other producing sources of these pro-inflammatory substances may exist.