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Diabetes mellitus can promote susceptibility to severe periodontitis by contributing to (1) microbiome factors; (2) host immune factors include neutrophil dysfunction, M1/M2 macrophage imbalance, and Th17/Treg imbalance; (3) enhanced inflammatory response to the bacterial challenge via cytokines, adipokines, miRNAs, and AGEs/RAGE; (4) oxidative stress and ROS; (5) alveolar bone resorption damage via RANKL/OPG ratio; and (6) epigenetic changes.
