Periodontitis and cardiovascular diseases: Consensus report

Comparison of periodontal parameters between patients with ischemic and dilative cardiomyopathy

Background

This cross-sectional study aimed in the comparison of periodontal parameters, number of remaining teeth and oral behaviour between patients with ischemic- (ICM) and non-ischemic dilative cardiomyopathy (DCM).

Methods

Patients with HF from the Department for Cardiac Surgery at the Heart Center Leipzig were included. The two groups (ICM and DCM) were composed by matching according to age, gender and smoking habits. All participants received a comprehensive periodontal examination, including a periodontal probing on six measurement points of each tooth.

Results

A total of 226 patients (n = 113 each group) was included. Patients in DCM group used interdental cleaning significantly more often than ICM (23.9% vs. 12.5%, p = 0.04). The majority of patients in both groups (ICM: 83.6%, DCM: 84.6%, p = 0.23) were diagnosed with stage III–IV periodontitis. Periodontal parameters were comparable between groups (p > 0.05). Variance analysis revealed no influence of the group (ICM vs. DCM) on the number of remaining teeth (p = 0.16), periodontitis stage (p = 0.27) or the periodontal inflamed surface area (p = 0.62).

Conclusions

Patients with severe HF show high periodontal burden, without any differences between ICM and DCM group. Therefore, increased attention should be payed to periodontal health of patients with severe heart disease, irrespective of their underlying disease.

Treg: A Promising Immunotherapeutic Target in Oral Diseases

With the pandemic of COVID-19, maintenance of oral health has increasingly become the main challenge of global health. Various common oral diseases, such as periodontitis and oral cancer, are closely associated with immune disorders in the oral mucosa. Regulatory T cells (Treg) are essential for maintaining self-tolerance and immunosuppression. During the process of periodontitis and apical periodontitis, two typical chronic immune-inflammatory diseases, Treg contributes to maintain host immune homeostasis and minimize tissue damage. In contrast, in the development of oral precancerous lesions and oral cancer, Treg is expected to be depleted or down-regulated to enhance the anti-tumor immune response. Therefore, a deeper understanding of the distribution, function, and regulatory mechanisms of Treg cells may provide a prospect for the immunotherapy of oral diseases. In this review, we summarize the distribution and multiple roles of Treg in different oral diseases and discuss the possible mechanisms involved in Treg cell regulation, hope to provide a reference for future Treg-targeted immunotherapy in the treatment of oral diseases.

Infections as Novel Risk Factors of Atherosclerotic Cardiovascular Diseases: Pathophysiological Links and Therapeutic Implications

Atherosclerotic cardiovascular diseases (ASCVD) are the major cause of mortality worldwide. Despite the continuous progress in ASCVD therapy, the residual risk persists beyond the management of traditional risk factors. Several infections including Helicobacter pylori infection, periodontal disease, and viral infections are associated with the increased risk of ASCVD, both directly by damage to the heart muscle and vasculature, and indirectly by triggering a systemic proinflammatory state. Hence, beyond the optimal management of the traditional ASCVD risk factors, infections should be considered as an important non-classical risk factor to enable early diagnosis and appropriate treatment. Here, we summarized the currently available evidence regarding the role of inflammation in ASCVD and the association between the particular infections and pathogens (Helicobacter pylori, periodontal disease, pneumonia, Cytomegalovirus, Human immunodeficiency virus, Herpes simplex virus, and severe acute respiratory syndrome coronavirus 2) on the development and progression of ASCVD. We also speculated about the potential therapeutic implications of the anti-inflammatory and anti-infective drugs on ASCVD outcomes, including drugs routinely administered in patients with ASCVD (statins, P2Y12 receptor inhibitors, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers) and novel strategies aiming at residual risk reduction (colchicine, anti-cytokine drugs, and methotrexate). Considering the emerging association between infections and ASCVD, it is crucial to determine the possible advantages of infection prevention and treatment in patients with ASCVD.

Economic burden of periodontitis in the United States and Europe - an updated estimation

BACKGROUND

The aim of this study is to estimate the direct and indirect economic burdens of periodontal disease in the US and in Europe.

METHODS

We used the most recent data available for the US and for Europe (32 European countries) to estimate the cost of periodontal disease. Global health, dental and periodontal expenditures were estimated. We tried to estimate the direct and the indirect costs of periodontitis. Indirect costs, those related to productivity losses, are a consequence of periodontal disease proper, plus edentulism and caries because of periodontal disease.

RESULTS

In 2018, the aggregate cost in the US was estimated at $3.49B and €2.52B in Europe. Indirect costs because of periodontal disease amounted to $150.57B (95% confidence interval [CI]: 103.32-189.87) in the US countries and €156.12B (95% CI: 123.72-221.86) in Europe. The majority of the projected indirect costs were because of edentulism related to periodontal disease and periodontal disease. Indirect costs were the majority of the estimated economic impact with an average of 0.73% (95% CI: 0.50%-0.93%) of annual gross domestic product in the US and 0.99% (95% CI: 0.78%-1.40%) in Europe.

CONCLUSIONS

Periodontal disease caused an estimated loss of $154.06B in the US and €158.64B in Europe, in 2018. These results show that the economic burden of periodontal disease is significant and its indirect costs are impactful.

Oral Microbiome in Relation to Periodontitis Severity and Systemic Inflammation

Systemic inflammation induced by periodontitis is suggested to be the link between periodontitis and cardiovascular disease. The aim of this work was to explore the oral microbiome in periodontitis in relation to disease severity and systemic inflammation. The saliva and subgingival microbiome from periodontal pocket samples of patients with severe (n = 12) and mild periodontitis (n = 13) were analyzed using metagenomic shotgun sequencing. The taxa and pathways abundances were quantified. The diversity was assessed and the abundances to phenotype associations were performed using ANCOM and linear regression. A panel of inflammatory markers was measured in blood and was associated with taxa abundance. The microbial diversity and species richness did not differ between severe and mild periodontitis in either saliva or periodontal pockets. However, there were significant differences in the microbial composition between severe and mild periodontitis in the subgingival microbiome (i.e., pocket samples) and, in a lower grade, in saliva, and this is positively associated with systemic inflammatory markers. The “red complex” and “cluster B” abundances in periodontal pockets were strongly associated with inflammatory markers interleukin-6 and the white blood cell count. Our data suggest that systemic inflammation in severe periodontitis may be driven by the oral microbiome and may support the indirect (inflammatory) mechanism for the association between periodontitis and cardiovascular disease.

Biofilm inhibition in oral pathogens by nanodiamonds

Complex microbial communities, e.g., biofilms residing in our oral cavity, have recognized clinical significance, as they are typically the main cause for infections. Particularly, they show high resistance to conventional antibiotics, and alternatives including nanotechnology are being intensively explored nowadays to provide more efficient therapeutics. Diamond nanoparticles, namely, nanodiamonds (NDs) with many promising physico-chemical properties, have been demonstrated to work as an effective antibacterial agent against planktonic cells (free-floating state). However, little is known about the behaviors of NDs against biofilms (sessile state). In this study, we uncovered their role in inhibiting biofilm formation and their disrupting effect on preformed biofilms in several selected orally and systemically important organisms. The current findings will advance the mechanistic understanding of NDs on oral pathogens and might accelerate corresponding clinical translation.

The effect of bariatric surgery on periodontal health: systematic review and meta-analyses

INTRODUCTION

We aimed to determine whether periodontal health deteriorates after bariatric surgery (BS).

METHODS

A search was performed in Medline and Embase, for prospective cohort studies with data on change in periodontal parameters after BS. Meta-analysis was performed with available data.

RESULTS

The results of 4 included studies consistently show significant (p < 0.05) worsening of bleeding on probing (4.21% (95% CI: 0.32, 8.11)), clinical attachment loss (0.16 mm (95% CI: 0.05, 0.27)), periodontal pocket depth (PPD) (0.14 mm (95% CI: 0.06, 0.23)) and percentage of PPD 4-5 mm: 1.72% (95% CI: 0.11, 3.34) 6 months after BS, but no change after 12 months.

CONCLUSIONS

BS may have a transient negative effect on periodontal health.

Mechanical biofilm disruption causes microbial and immunological shifts in periodontitis patients

Periodontitis is characterized by subgingival biofilm dysbiosis, inflammation and tissue destruction. Current treatment involves mechanical biofilm disruption known as non-surgical periodontal therapy (NSPT). This study sought to characterise the impact of treatment on microbial diversity and overall community, and the parallel impact on host inflammation in the oral cavity. Fourty-two periodontitis patients were included in this study, with periodontal clinical parameters, subgingival plaque and saliva samples collected at baseline and 90 days after treatment. Salivary cytokines were quantified, and subgingival plaque was analysed using 16S rRNA sequencing. After treatment, there were marked health-associated alterations in microbial composition and diversity, including differential abundance of 42 genera and 61 species. These changes were accompanied by substantial clinical improvement (pockets ≥ 5 mm, 27.50% to 9.00%, p < 0.001) and a decrease in salivary IL-1β (p < 0.001)-a putative marker of periodontal inflammation. Despite significant reductions in disease associated anaerobes, several genera (Fusobacterium, Prevotella, Tanenerella, Treponema) remained present and formed a distinct subnetwork associated with residual disease. Collectively, this study shows that current periodontal treatment results in partial restoration of a healthy microbial ecosystem, but features of biofilm dysbiosis and host inflammation remain in some patients, which were surprisingly independent of clinical response.

Lower Number of Teeth Is Related to Higher Risks for ACVD and Death-Systematic Review and Meta-Analyses of Survival Data

Tooth loss reflects the endpoint of two major dental diseases: dental caries and periodontitis. These comprise 2% of the global burden of human diseases. A lower number of teeth has been associated with various systemic diseases, in particular, atherosclerotic cardiovascular diseases (ACVD). The aim was to summarize the evidence of tooth loss related to the risk for ACVD or death. Cohort studies with prospective follow-up data were retrieved from Medline-PubMed and EMBASE. Following the PRISMA guidelines, two reviewers independently selected articles, assessed the risk of bias, and extracted data on the number of teeth (tooth loss; exposure) and ACVD-related events and all-cause mortality (ACM) (outcome). A total of 75 articles were included of which 44 were qualified for meta-analysis. A lower number of teeth was related to a higher outcome risk; the pooled risk ratio (RR) for the cumulative incidence of ACVD ranged from 1.69 to 2.93, and for the cumulative incidence of ACM, the RR ranged from 1.76 to 2.27. The pooled multiple adjusted hazard ratio (HR) for the incidence density of ACVD ranged from 1.02 to 1.21, and for the incidence density of ACM, the HR ranged from 1.02 to 1.30. This systematic review and meta-analyses of survival data show that a lower number of teeth is a risk factor for both ACVD and death. Health care professionals should use this information to inform their patients and increase awareness on the importance of good dental health and increase efforts to prevent tooth loss.

Salvadora persica: Nature's Gift for Periodontal Health

Salvadora persica (SP) extract, displays very valuable biotherapeutic capacities such as antimicrobial, antioxidant, antiparasitic and anti-inflammatory effects. Numerous investigations have studied the pharmacologic actions of SP in oral disease therapies but its promising outcomes in periodontal health and treatment are not yet entirely described. The current study has been planned to analyze the reported effects of SP as a support to periodontal therapy to indorse regeneration and healing. In consort with clinical trials, in vitro investigations show the advantageous outcomes of SP adjunctive to periodontal treatment. Yet, comprehensive supplementary preclinical and clinical investigations at molecular and cellular levels are indispensable to reveal the exact therapeutic mechanisms of SP and its elements for periodontal health and therapy.

Making a complex dental care tailored to the person: population health in focus of predictive, preventive and personalised (3P) medical approach

An evident underestimation of the targeted prevention of dental diseases is strongly supported by alarming epidemiologic statistics globally. For example, epidemiologists demonstrated 100% prevalence of dental caries in the Russian population followed by clinical manifestation of periodontal diseases. Inadequately provided oral health services in populations are caused by multi-factorial deficits including but not limited to low socio-economic status of affected individuals, lack of insurance in sub-populations, insufficient density of dedicated medical units. Another important aspect is the “participatory” medicine based on the active participation of population in maintaining oral health: healthcare will remain insufficient as long as the patient is not motivated and does not feel responsible for their oral health. To this end, nearly half of chronically diseased people do not comply with adequate medical services suffering from severely progressing pathologies. Noteworthy, the prominent risk factors and comorbidities linked to the severe disease course and poor outcomes in COVID-19-infected individuals, such as elderly, diabetes mellitus, hypertension and cardiovascular disease, are frequently associated with significantly altered oral microbiome profiles, systemic inflammatory processes and poor oral health. Suggested pathomechanisms consider potential preferences in the interaction between the viral particles and the host microbiota including oral cavity, the respiratory and gastrointestinal tracts. Since an aspiration of periodontopathic bacteria induces the expression of angiotensin-converting enzyme 2, the receptor for SARS-CoV-2, and production of inflammatory cytokines in the lower respiratory tract, poor oral hygiene and periodontal disease have been proposed as leading to COVID-19 aggravation. Consequently, the issue-dedicated expert recommendations are focused on the optimal oral hygiene as being crucial for improved individual outcomes and reduced morbidity under the COVID-19 pandemic condition. Current study demonstrated that age, gender, socio-economic status, quality of environment and life-style, oral hygiene quality, regularity of dental services requested, level of motivation and responsibility for own health status and corresponding behavioural patterns are the key parameters for the patient stratification considering person-tailored approach in a complex dental care in the population. Consequently, innovative screening programmes and adapted treatment schemes are crucial for the complex person-tailored dental care to improve individual outcomes and healthcare provided to the population.

Microbiological Profiles of Dental Implants in Metabolic Syndrome Patients: A Case-Control Study

There is a lack of knowledge on the possible influence of systemic conditions on peri-implantitis. The aim of this case-control study is to evaluate the difference in terms of oral pathogens' concentrations in the peri-implant sulcus of a group of patients affected by metabolic syndrome (Mets) compared to healthy subjects. For each patient, peri-implant sulcular biofilm samples were obtained by inserting two sterile endodontic paper points in the deepest aspect of the peri-implant sulcus for 30 s. The quantitative real-time polymerase chain reaction was performed to evaluate total bacterial counts of six pathogens. Patients were screened for peri-implant diseases and clinical and radiographic parameters were recorded. A total of 50 patients was enrolled in the study, 25 affected by Mets and 25 healthy. Significantly higher bacterial counts were discovered for Aggregatibacter actinomycetemcomitans (p = 0.0008), Prevotella intermedia (p = 0.0477) and Staphylococcus aureus (p = 0.034) in MetS patients compared to healthy subjects. Performing a sub-group analysis, considering peri-implant status and dividing patients by MetS diagnosis, no statistically significant (p < 0.05) differences were found. For the first time, a correlation between MetS presence and a greater prevalence of some bacterial species in the peri-implant sulcus was reported, irrespectively from peri-implant status (health vs. disease).

An aMMP-8 Point-of-Care and Questionnaire Based Real-Time Diagnostic Toolkit for Medical Practitioners

The aim of this cross-sectional study is to propose an efficient strategy based on biomarkers adjunct with an interview/questionnaire covering risk factors for periodontitis for the identification of undiagnosed periodontitis by medical professionals. Active matrix metalloproteinase (aMMP)-8 levels in mouthrinse were analyzed by a point-of-care (PoC)/chairside lateral-flow immunotest, and salivary total MMP-8, total MMP-9 and calprotectin levels were analyzed by enzyme-linked immunosorbent assays (ELISAs) and active MMP-9 by gelatin zymography for 149 Greek patients. Patients underwent a full-mouth oral health examination for diagnosis according to the 2018 classification system of periodontal diseases. In addition, patient characteristics (risk factors: age, gender, education level, smoking and body mass index) were recorded. Receiver operating curve (ROC) analysis indicated better diagnostic precision to identify undiagnosed periodontitis for oral fluid biomarkers in adjunct with an interview/questionnaire compared with a plain questionnaire (i.e., risk factors): aMMP-8 AUC (95% confidence interval) = 0.834 (0.761-0.906), total MMP-8 = 0.800 (0.722-0.878), active MMP-9 = 0.787 (0.704-0.870), total MMP-9 = 0.773 (0.687-0.858) and calprotectin = 0.773 (0.687-0.858) vs. questionnaire = 0.764 (0.676-0.851). The findings of this study suggest that oral fluid biomarker analysis, such as a rapid aMMP-8 PoC immunotest, could be used as an adjunct to an interview/questionnaire to improve the precision of timely identification of asymptomatic, undiagnosed periodontitis patients by medical professionals. This strategy appears to be viable for referring patients to a dentist for diagnosis and treatment need assessment.

Food restriction reduces hepatic alterations associated with experimental periodontitis

BACKGROUND

Periodontitis is a chronic inflammatory and multifactorial disease that affects the periodontal structures and can cause alterations in the hepatic tissue. The aim of the present study was to evaluate whether a diet with food restriction can decrease oral and liver alterations associated with ligature-induced periodontitis.

METHODS

Twenty-four female Wistar rats were used in this study, randomized into three groups (n = 8 for each group): control (regular food); periodontitis (regular food + periodontitis induced with ligatures); and food restriction (diet with food restriction and periodontitis induction). The following periodontium parameters were analyzed tooth mobility (TM), probing pocket depth (PPD), gingival bleeding index (GBI), and alveolar bone height (ABH). In the liver, the levels of oxidative stress markers-malondialdehyde (MDA), glutathione (GSH), total cholesterol, and levels of myeloperoxidase (MPO) activity were measured. Liver samples were analyzed for histopathological score. In the blood tissue, the levels of enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), glucose, total cholesterol, and the high-density lipoprotein (HDL) were also evaluated.

RESULTS

The animals that received a diet with food restriction + periodontitis showed a decrease in hepatic histopathological score (P < 0.05) when compared with the periodontitis group, the same for glucose, total cholesterol, ALT, AST, and ABH data. The group with food restriction + periodontitis showed a decrease in the histopathological liver score (P < 0.05) compared with the group with periodontitis.

CONCLUSION

This study revealed that food restriction reduced oral damages, as well as hepatic, blood and alveolar bone alterations associated with ligature-induced periodontitis in rats.

Cardiovascular risks of periodontitis and oral hygiene indicators in patients with diabetes mellitus

AIM

Periodontitis is a common chronic inflammatory disease prevalent in diabetes. The aim of this study was to evaluate periodontitis and poor oral hygiene as independent risk factors for either cerebral or myocardial infarction in the diabetes population.

METHODS

This retrospective cohort study included 17,009 patients with diabetes who had participated in a nationwide health-screening programme, including oral health examination, during 2002-2003 in South Korea. Presence of periodontitis, tooth loss and carious teeth were assessed by professional dentists, and the number of tooth brushings per day was evaluated through self-reported questionnaires. The primary study outcome was the development of cerebral or myocardial infarction, based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes, up to 31 December 2015.

RESULTS

The study enrolled 17,009 patients with diabetes. Over the mean 11.64 years of follow-up, 1341 patients presented with either cerebral or myocardial infarction. On multivariable Cox proportional hazards regression analysis, presence of periodontitis was an independent risk factor for either cerebral or myocardial infarction [adjusted hazard ratio (HR): 1.17, 95% confidence interval (CI): 1.02-1.34; P = 0.030]. An increased number of carious teeth (≥5) was also associated with risk of cerebral or myocardial infarction (adjusted HR: 1.67, 95% CI: 1.20-2.32; P = 0.002), whereas frequent tooth brushing (≥2 times/day) was negatively associated with risk of cerebral or myocardial infarction (adjusted HR: 0.79, 95% CI: 0.70-0.90; P < 0.001) compared with tooth brushing ≤1 time/day.

CONCLUSION

Early identification and intervention of periodontal disease may be effective in reducing cardiovascular complications in the diabetes population, and improved oral hygiene would probably be associated with lower cardiovascular risk in diabetes.

The potential impact of salivary peptides in periodontitis

Periodontitis is a complex immune-inflammatory condition characterized by the disruption of the periodontal ligament and subsequent formation of periodontal pockets, and by alveolar bone loss, often resulting in tooth loss. A myriad of factors, namely, genetic, metabolic, immunological, and inflammatory, is associated with progression of periodontitis. Periodontitis is also associated with systemic conditions such as neoplastic disorders, obesity, and diabetes. The current diagnosis of this disease relies on clinical measurements such as clinical attachment loss and probing depth, which have poor precision due to patient, operator and probe-related factors. Thus, there is a need to develop reliable, objective, and reproducible biomarkers for early diagnosis of periodontitis. In this regard, saliva, with contributions from the gingival crevicular fluid, holds great potential. However, most of the information on biomarkers of periodontium-related salivary proteins has come from studies on the molecular pathogenesis of periodontitis. In periodontitis, a more holistic approach, such as the use of -omics technologies, for biomarker discovery, is needed. Herein, we review the biomarkers proposed to date for the assessment of periodontitis, with emphasis on the role of salivary peptides in periodontitis and their assessment by high-throughput saliva proteomics. We also discuss the challenges pertaining to the identification of new periodontitis biomarkers in saliva.

The Impact of Oral Health on Respiratory Viral Infection

Influenza virus and severe acute respiratory syndrome coronavirus (SARS-CoV-2) have caused respiratory diseases worldwide. Coronavirus disease 2019 (COVID-19) is now a global health concern requiring emergent measures. These viruses enter the human body through the oral cavity and infect respiratory cells. Since the oral cavity has a complex microbiota, influence of oral bacteria on respiratory virus infection is considered. Saliva has immune molecules which work as the front line in the biophylactic mechanism and has considerable influence on the incidence and progression of respiratory viral infection. Salivary scavenger molecules, such as gp340 and sialic acid, have been reported to exert anti-influenza virus activity. Salivary secretory immunoglobulin A (SIgA) has potential to acquire immunity against these viruses. Biological features of the oral cavity are thought to affect viral infection in respiratory organs in various ways. In this review, we reviewed the literature addressing the impact of oral conditions on respiratory infectious diseases caused by viruses.

Periodontal disease and myocardial infarction risk: A meta-analysis of cohort studies

INTRODUCTION

The objective of this meta-analysis was to systematically assess the association between periodontal disease (PD) and myocardial infarction (MI).

METHODS

We searched the EMBASE, PubMed, and Cochrane Library databases for eligible cohort studies from inception to August 31st, 2020 that reported the association between PD and MI. Data extraction was conducted after screening the literature. The risk of bias of the included studies was evaluated by using the Newcastle-Ottawa Scale (NOS). The combined OR value and 95% confidence interval (CI) were calculated by using STATA 11.0 software, and the source of any heterogeneity was determined by performing subgroup analysis and sensitivity analysis.

RESULTS

A total of 10 cohort studies involving 5,369,235 participants fulfilled the inclusion criteria. The meta-analysis showed an increased risk for MI in patients with PD [RR = 1.13, 95% CI (1.04, 1.21), P = 0.004], and this result was robust according to sensitivity analysis. Subgroup analyses indicated that the results were affected by sex, effect value, study quality, survey form and investigation type.

DISCUSSION

This meta-analysis suggests that PD is modestly associated with MI, especially in women, which is similar to the conclusions of earlier meta-analyses of case-control or observational studies. PD may be an untraditional risk factor for cardiovascular diseases, including MI; thus, maintaining periodontal health may be an effective measure to prevent MI. More cohort studies are still needed to further explore the relationship between the incidence of MI and PD.

Association between Dietary Inflammatory Index and Periodontitis: A Cross-Sectional and Mediation Analysis

Inflammation-modulating elements are recognized periodontitis (PD) risk factors, nevertheless, the association between dietary inflammatory index (DII) and PD has never been appraised. We aimed to assess the association between DII and PD and the mediation effect of DII in the association of PD with systemic inflammation. Using the National Health and Nutrition Examination Survey 2009–2010, 2011–2012 and 2013–2014, participants who received periodontal exam and provided dietary recall data were included. The inflammatory potential of diet was calculated via DII. PD was defined according to the 2012 case definition. White blood cells (WBC), segmented neutrophils and C-reactive protein (CRP) were used as proxies for systemic inflammation. The periodontal measures were regressed across DII values using adjusted multivariate linear regression and adjusted mediation analysis. Overall, 10,178 participants were included. DII was significantly correlated with mean periodontal probing depth (PPD), mean clinical attachment loss (CAL), thresholds of PPD and CAL, WBC, segmented neutrophils and DII (p < 0.01). A linear regression logistic adjusted for multiple confounding variables confirmed the association between DII and mean PPD (B = 0.02, Standard Error [SE]: 0.02, p < 0.001) and CAL (B = −0.02, SE: 0.01, p < 0.001). The association of mean PPD and mean CAL with both WBC and segmented neutrophils were mediated by DII (from 2.1 to 3.5%, p < 0.001). In the 2009–2010 subset, the association of mean CAL with serum CRP was mediated by DII (52.0%, p < 0.01). Inflammatory diet and PD may be associated. Also, the inflammatory diet significantly mediated the association of leukocyte counts and systemic inflammation with PD.

How strong is the link between periodontitis and stroke?

Data sources PubMed, Scopus, Web of Science, The Cochrane Library, LILACS, OpenGrey and Google Scholar. No language restriction applied; studies conducted until September 2018.Study selection Observational studies in humans exposed and not exposed to periodontitis, in which the primary outcome was the risk of cerebrovascular accident, including haemorrhagic and ischaemic attacks (transient ischaemic attack and ischaemic stroke).Data extraction and synthesis Three examiners conducted a literature search. Duplicates, opinion articles, technical articles, guides and animal studies were excluded. Quality assessment was carried out followed by assessment of risk of bias. The extracted data were analysed using RevMan software. The meta-analysis looked for odds ratio (OR) in case-control studies and risk ratio (RR) in cohort studies as well as their 95% confidence intervals.Results Ten studies were included, all showing low risk of bias. The number of patients ranged from 80 to 15,792 with follow-up duration from 0 to 15 years. The studies showed variable heterogeneity. For stroke in case-control studies (seven studies), the overall heterogeneity was considerable (I2 = 77%). For ischaemic stroke in case-control studies (five studies), the overall heterogeneity was considerable (I2 = 72%), but after an outlying study was removed (I2 = 78%), it reduced significantly (I2 = 4%). For stroke in cohort studies (three studies), null heterogeneity was observed (I2 = 0%). The meta-analysis informed the three main outcomes: 1) individuals with periodontitis were twice as likely to suffer stroke (OR 2.31 [1.39, 3.84], p = 0.001, I2 = 77%); 2) individuals with periodontitis were twice as likely to suffer ischaemic stroke (OR 2.72 [2.00, 3.71], p <0.00001, I2 = 4%); and 3) individuals with periodontitis had a higher risk of experiencing stroke (RR 1.88 [1.55, 2.28], p <0.00001). Overall, the authors found that stroke events were associated with periodontitis.Conclusions The meta-analysis suggests an association between risk of stroke and periodontal disease. However, there is a need for prospective studies to ascertain the relationship between periodontal disease severity and stroke severity; whether there is an impact of periodontal treatment and to review whether periodontal disease impacts on stroke survival.

Periodontal disease and risk of mortality and kidney function decline in advanced chronic kidney disease: a nationwide population-based cohort study

OBJECTIVES

Periodontal disease is prevalent in patients with chronic kidney disease (CKD) and potentially associated with kidney function decline. However, it is uncertain whether periodontal disease affects the risk of mortality and morbidity in patients with advanced CKD.

MATERIALS AND METHODS

Taiwan's National Health Insurance Research Database was used to conduct a nationwide population-based cohort study. Propensity score matching procedures were performed to select people with stage 5 CKD and to compare the long-term risk of mortality, end-stage renal disease, and major adverse cardiovascular events (MACE) between people with and without periodontal disease. Multivariable Cox regression analyses were conducted to calculate the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for the outcome of interest.

RESULTS

A total of 8119 subjects with stage 5 CKD were initially included. After matching to demographic and clinical covariates, 1254 subjects with 7099 person-years of follow-up were selected for analyses. Periodontal disease was not associated with long-term risks of all-cause mortality (aHR: 0.77, 95% CI: 0.49-1.22), progression to end-stage renal disease (aHR: 0.91, 95% CI: 0.75-1.10), or MACE (aHR: 1.18, 95% CI: 0.91-1.53). These findings were generally consistent across subgroups of age, sex, comorbid diabetes, uses of systemic antibiotic, and different dental procedures.

CONCLUSIONS

Periodontal disease is not a predictor for long-term mortality or morbidity in patients with advanced CKD.

CLINICAL RELEVANCE

These results provide important evidence to elucidate the relationship between periodontitis and critical clinical outcomes of advanced CKD.

Can treatment of severe periodontitis in patients with ST-segment elevation myocardial infarction improve endothelial function?

Design This is a parallel-group, unicentric, randomised, assessor-blinded, superiority trial with equal allocation ratio to evaluate and compare the effects of periodontal treatment on endothelial function, measured by a flow-mediated dilation of brachial artery, in patients with a recent ST-segment elevation myocardial infarction (STEMI).Study population The study population included a total of 48 patients who were recruited from a hospital in Brazil. Patients who had a recent episode of acute STEMI and also exhibited severe periodontal disease were included, while exclusion criteria included factors like patients who were <30 years old, HIV-positive, had chronic inflammatory or neoplastic diseases, pregnant, significant dental loss (<8 teeth remaining) etc. After seeking consent, patients were randomised to two groups: patients in the intervention group were provided with periodontal treatment while no treatment was given to patients in the control group. Patients were assessed for the primary outcome (flow-mediated dilation [FMD] in the brachial artery), secondary outcomes (periodontal health and inflammatory markers) and other safety outcomes after six months of intervention.Data analysis Data was analysed using the intention-to-treat principle, wherein t-tests and chi-square tests were used to compare baseline variables between groups, while dependent t-test was used for within-group comparisons. The Mann-Whitney test was used to compare cytokine levels from baseline to six-month follow-up. Effect sizes were presented along with their respective p values and confidence intervals. Lastly, a sensitivity analysis was also carried out by taking stringent p values for establishing significance (p = 0.025).Results Statistically significant improvement was seen in FMD values among patients who received periodontal treatment (from 9.0 ± 4.4% at baseline to 12.1 ± 5.6% at follow-up; p = 0.01), while the patients in the control group exhibited a non-significant change in FMD values (from 12.2 ± 7.2% at baseline to 11.9 ± 4.0% at follow-up; p = 0.79). Group difference for observed 'FMD variation' was initially found to be significant (3.4%, CI = 0.6-5.8% and using generalised estimating equation p = 0.03). However, on repeating the analysis by taking stringent p values for establishing significance (p = 0.025), non-significant difference in FMD variation was seen. In the intervention group, all periodontal health parameters significantly improved over a period of six months (p <0.001, for all parameters) while inflammatory markers in both groups exhibited non-significant differences for the study period. No adverse outcomes were reported.Conclusions Treatment of periodontitis among patients with a recent episode of STEMI significantly improves the endothelial function as shown by improved FMD.

Rheumatoid arthritis associated with the occurrence, severity and extension of periodontitis: A case-control study

Background

Emerging evidence pointed to a potential association between periodontitis (PE) and rheumatoid arthritis (RA), based on shared characteristics and similarities in risk factors, immunogenetics and pathways of tissue destruction. The aim of this study was to evaluate the potential association between RA and PE, as well as the influence of risk variables in this association.

Material and Methods

The present case-control study comprised 471 individuals (157 cases with RA and 314 controls) that underwent a full-mouth periodontal examination. The association between risk variables and the occurrence of AR and PE were evaluated through univariate and multivariate logistic analysis.

Results

Higher frequency (p<0.001), severity (p=0.006) and extension (p=0.018) of PE was observed among the cases when compared to controls. Variables retained in the final multivariate models for the occurrence of PE were: lower number of teeth, smoking, no use of dental floss, ≥4 daily toothbrushing and RA; for the occurrence of RA were: higher age, female gender, smoking, alcohol use and PE. It is important to stress that RA (OR=2.53; 95%CI 1.24-3.86; p<0.001) was retained in the model for PE, and PE (OR=3.12; 95%CI 1.47-4.26; p<0.001) was retained in the model for RA.

Conclusions

The present study demonstrated a high frequency of PE among individuals with RA and an important association among the occurrence, severity and extension of PE and RA and smoking. Key words:Case-control study, risk factors, periodontitis, rheumatoid arthritis.

Association between periodontitis and severity of COVID-19 infection: A case-control study

AIM

COVID-19 is associated with an exacerbated inflammatory response that can result in fatal outcomes. Systemic inflammation is also a main characteristic of periodontitis. Therefore, we investigated the association of periodontitis with COVID-19 complications.

MATERIALS AND METHODS

A case-control study was performed using the national electronic health records of the State of Qatar between February and July 2020. Cases were defined as patients who suffered COVID-19 complications (death, ICU admissions or assisted ventilation), and controls were COVID-19 patients discharged without major complications. Periodontal conditions were assessed using dental radiographs from the same database. Associations between periodontitis and COVID 19 complications were analysed using logistic regression models adjusted for demographic, medical and behaviour factors.

RESULTS

In total, 568 patients were included. After adjusting for potential confounders, periodontitis was associated with COVID-19 complication including death (OR = 8.81, 95% CI 1.00-77.7), ICU admission (OR = 3.54, 95% CI 1.39-9.05) and need for assisted ventilation (OR = 4.57, 95% CI 1.19-17.4). Similarly, blood levels of white blood cells, D-dimer and C Reactive Protein were significantly higher in COVID-19 patients with periodontitis.

CONCLUSION

Periodontitis was associated with higher risk of ICU admission, need for assisted ventilation and death of COVID-19 patients, and with increased blood levels of biomarkers linked to worse disease outcomes.

Is systemic inflammation a missing link between periodontitis and hypertension? Results from two large population-based surveys

OBJECTIVE

The primary objective was to investigate the relationship between periodontitis and hypertension in two independent large surveys. The secondary objective was to ascertain whether systemic inflammation had a mediation effect in the association.

METHODS

This cross-sectional study analysed representative samples of the US (n = 3460; NHANES 2009/10) and Korean (n = 4539; 2015 KNHANES VI-3) populations. The association between periodontitis (exposure), hypertension (outcome) and inflammatory markers [C-reactive protein (CRP) and white blood cell counts (WBC)] (mediators) was assessed using multivariate linear and logistic regression models and mediation analysis.

RESULTS

Participants with periodontitis were more likely to have hypertension (NHANES: OR = 1.3, 95% CI: 1.0-1.6, P = 0.025; KNHANES: OR = 1.2, 95% CI: 1.0-1.4, P = 0.041) and actual systolic blood pressure ≥ 140 mmHg (NHANES: OR = 1.6, 95% CI: 1.1-2.3, P < 0.001; KNHANES: OR = 1.3, 95% CI :1.0-1.6, P < 0.031) than those without the disease. These associations were independent of age, gender, BMI, education level, smoking, alcohol consumption, creatinine, physical activity, presence of other comorbidities and confirmed in participants not taking antihypertensive medications. Diagnosis of periodontitis was directly associated with WBC (in both surveys: NHANES: β ± SE = 0.3 ± 0.1, P < 0.004; KNHANES: β ± SE = 0.3 ± 0.1, P < 0.001) and with CRP levels (in one survey: NHANES: β ± SE = 0.1 ± 0.03, P < 0.007; KNHANES: β ± SE = 0.1 ± 0.04, P > 0.213). Mediation analyses confirmed that CRP acted as a mediator in the association between periodontitis and hypertension in both populations (mediated effect: NHANES: β ± SE = 0.010 ± 0.003, P < 0.001; KNHANES: β ± SE = 0.003 ± 0.001, P = 0.015). WBC acted as a mediator in the KNHANES (mediated effect: β ± SE = 0.004 ± 0.001, P = 0.004) whilst in the NHANES, its effect was dependent of CRP inclusion in the model (mediated effect WBC + CRP: β ± SE = 0.002 ± 0.001, P = 0.001).

CONCLUSIONS

These findings suggest that periodontitis is closely linked to hypertension and systemic inflammation is, in part, a mediator of this association.

Association Between Periodontitis and Blood Pressure Highlighted in Systemically Healthy Individuals: Results From a Nested Case-Control Study

[Figure: see text].

Comparative Analysis of Cytokine Expression in Oral Keratinocytes and THP-1 Macrophages in Response to the Most Prevalent Serotypes of Aggregatibacter actinomycetemcomitans

BACKGROUND

Periodontitis is a chronic inflammatory disease associated with a dysbiotic biofilm. Many pathogens have been related with its progression and severity, one of which is Aggregatibacter actinomycetemcomitans, a Gram-negative bacteria with seven serotypes (a-g) according with the structure of its LPS, with serotype b defined as the most virulent compared with the other serotypes. The aim of this study was to evaluate the response of oral keratinocytes and macrophages to A. actinomycetemcomitans.

METHODS

Oral keratinocytes (OKF6/TERT2) and macrophages (THP-1) were infected with A. actinomycetemcomitans serotypes a, b and c. The expression of IL-1β, IL-6, IL-8, IL-18, TNF-α, MMP-9, RANKL, TLR-2, TLR-4, TLR-6, thymic stromal lymphopoietin (TSLP), and ICAM-1 was evaluated by qPCR at 2 and 24 h after infection.

RESULTS

An increase in the expression of these molecules was induced by all serotypes at both times of infection, with macrophages showing higher levels of expression at 24 h compared to epithelial cells in which the highest levels were observed in the first hours after infection.

CONCLUSIONS

Keratinocytes and macrophages contribute to the inflammation in periodontitis from the early stages of infection, producing the first waves of cytokines, acting as the first signal for professional immune cell recruitment and modulation of more specific immune responses.

Endpoints of active periodontal therapy

Aim

Position paper on endpoints of active periodontal therapy for designing treatment guidelines. The question was as follows: How are, for an individual patient, commonly applied periodontal probing measures—recorded after active periodontal therapy—related to (a) stability of clinical attachment level, (b) tooth survival, (c) need for re‐treatment or (d) oral health‐related quality of life.

Methods

A literature search was conducted in Ovid MEDLINE(R) and Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations and Daily <1946 to 07 June 2019>.

Results

A total of 94 papers were retrieved. From the literature search, it was found that periodontitis patients with a low proportion of deep residual pockets after active periodontal therapy are more likely to have stability of clinical attachment level over a follow‐up time of ≥1 year. Other supporting literature confirms this finding and additionally reports, at the patient level, that probing pocket depths ≥6 mm and bleeding on probing scores ≥30% are risks for tooth loss. There is lack of evidence that periodontal probing measures after completion of active periodontal treatment are tangible to the patient.

Conclusions

Based on literature and biological plausibility, it is reasonable to state that periodontitis patients with a low proportion of residual periodontal pockets and little inflammation are more likely to have stability of clinical attachment levels and less tooth loss over time. Guidelines for periodontal therapy should take into consideration (a) long‐term tangible patient outcomes, (b) that shallow pockets (≤4 mm) without bleeding on probing in patients with <30% bleeding sites are the best guarantee for the patient for stability of his/her periodontal attachment, (c) patient heterogeneity and patient changes in immune response over time, and (d) that treatment strategies include lifestyle changes of the patient. Long‐term large population‐based and practice‐based studies on the efficacy of periodontal therapies including both clinical and patient‐reported outcomes (PROs) need to be initiated, which include the understanding that periodontitis is a complex disease with variation of inflammatory responses due to environment, (epi)genetics, lifestyle and ageing. Involving people living with periodontitis as co‐researchers in the design of these studies would also help to improve their relevance.

Effects of periodontal management for patients with type 2 diabetes on healthcare expenditure, hospitalization and worsening of diabetes: an observational study using medical, dental and pharmacy claims data in Japan

AIMS

To investigate the effects of regular periodontal management for people with type 2 diabetes on total healthcare expenditure, hospitalization and the introduction of insulin.

MATERIALS AND METHODS

We collected data of individuals who were prescribed diabetes medications during the fiscal year 2015 from the claims database of a prefecture in Japan. We fitted generalized linear models that had sex, age, comorbidities and the status of periodontal management during the previous two years as predictors.

RESULTS

A total of 16,583 individuals were enrolled. The annual healthcare expenditure in the third year was 4% less (adjusted multiplier 0.96, 95% confidence interval [CI] 0.92-1.00) in the group receiving periodontal management every year. The adjusted odds ratio (aOR) for all-cause hospitalization was 0.90 (95% CI: 0.82-0.98). The aOR of introducing insulin in the third year for those who had not been prescribed insulin during the previous two years (n = 13,222) was 0.77 (95% CI: 0.64-0.92) in the group receiving periodontal management every year.

CONCLUSION

Regular periodontal management for diabetic people was associated with reduced healthcare expenditure, all-cause hospitalization and the introduction of insulin therapy.

Lipid, fatty acid, carnitine- and choline derivative profiles in rheumatoid arthritis outpatients with different degrees of periodontal inflammation

Rheumatoid arthritis (RA) and periodontitis are chronic inflammatory diseases with several pathogenic pathways in common. Evidence supports an association between the diseases, but the exact underlying mechanisms behind the connection are still under investigation. Lipid, fatty acid (FA) and metabolic profile alterations have been associated with several chronic inflammatory diseases, including RA and periodontitis. Mitochondria have a central role in regulating cellular bioenergetic and whole-body metabolic homeostasis, and mitochondrial dysfunction has been proposed as a possible link between the two disorders. The aim of this cross-sectional study was to explore whole-blood FA, serum lipid composition, and carnitine- and choline derivatives in 78 RA outpatients with different degrees of periodontal inflammation. The main findings were alterations in lipid, FA, and carnitine- and choline derivative profiles. More specifically, higher total FA and total cholesterol concentrations were found in active RA. Elevated phospholipid concentrations with concomitant lower choline, elevated medium-chain acylcarnitines (MC-AC), and decreased ratios of MC-AC and long-chain (LC)-AC were associated with prednisolone medication. This may indicate an altered mitochondrial function in relation to the increased inflammatory status in RA disease. Our findings may support the need for interdisciplinary collaboration within the field of medicine and dentistry in patient stratification to improve personalized treatment. Longitudinal studies should be conducted to further assess the potential impact of mitochondrial dysfunction on RA and periodontitis.

Risk of acute and chronic coronary syndrome in a population with periodontitis: A cohort study

OBJECTIVE

To investigate the role of periodontitis in the risk of acute and chronic coronary syndrome with compounding factors, including sociodemographic factors and medication use.

METHODS

This retrospective cohort study used nationwide, population-based data from the Korean National Health Insurance Service-Health Screening Cohort database (514,866 individuals, 40-79 years). Propensity score matching was used for analysis. Information of subjects for 12 years was included. Socioeconomic and clinical factors were recorded and analysed.

RESULTS

The periodontitis group had a greater risk of overall acute coronary syndrome (hazard ratio [95% confidence interval] =1.25 [1.15, 1.35], p < .001) and non-fatal acute coronary syndrome (1.26 [1.16, 1.37], p < .001). The hazard ratio for chronic coronary syndrome was higher in patients with periodontitis (1.35 [1.25, 1.46], p < .001). The cumulative incidence of both acute and chronic coronary syndrome gradually increased, and the hazard ratios reached 1.25 and 1.35 at the 12-year follow-up, respectively. Subgroup analysis revealed that periodontitis had a significantly greater link with acute coronary syndrome incidence in males, younger adults, smokers and subjects without hypertension (p < .01) and with chronic coronary syndrome incidence in smokers, subjects without hypertension and subjects without dyslipidaemia (p < .05).

CONCLUSIONS

Periodontitis is associated with an increased risk of acute and chronic coronary syndrome.

Resveratrol and Its Analogs as Functional Foods in Periodontal Disease Management

Periodontitis is a common chronic inflammatory disease driven by the interaction between a dysbiotic oral microbiome and the dysregulated host immune-inflammatory response. Naturally derived nutraceuticals, such as resveratrol and its analogs, are potential adjunctive therapies in periodontal treatment due to their antimicrobial and anti-inflammatory properties. Furthermore, different analogs of resveratrol and the choice of solvents used may lead to varying effects on therapeutic properties. This review presents the current findings and gaps in our understanding on the potential utility of resveratrol and its analogs in periodontal treatment.

Estimation of the Periodontal Inflamed Surface Area by Simple Oral Examination

The periodontal inflamed surface area (PISA) is a useful index for clinical and epidemiological assessments, since it can represent the inflammation status of patients in one contentious variable. However, calculation of the PISA is difficult, requiring six point probing depth measurements with or without bleeding on probing on 28 teeth, followed by data input in a calculation program. More simple methods are essential for screening periodontal disease or in epidemiological studies. In this study, we tried to establish a convenient partial examination method to estimate PISA. Cross-sectional data of 254 subjects who completed active periodontal therapy were analyzed. Teeth that represent the PISA value were selected by an item response theory approach. The maxillary second molar, first premolar, and lateral incisor and the mandibular second molar and lateral incisor were selected. The sum of the PISAs of these teeth was significantly correlated with the patient’s PISA (R² = 0.938). More simply, the sum of the maximum values of probing pocket depth with bleeding for these teeth were also significantly correlated with the patient’s PISA (R² = 0.6457). The simple model presented in this study may be useful to estimate PISA.

The Subgingival Plaque Microbiome, Systemic Antibodies Against Bacteria and Citrullinated Proteins Following Periodontal Therapy

Periodontitis (PD) shows an association with rheumatoid arthritis (RA) and systemic inflammation. Periodontal pathogens, namely Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, are proposed to be capable of inducing citrullination of peptides in the gingiva, inducing the formation of anti-citrullinated protein antibodies (ACPAs) within susceptible hosts. Here, we sought to investigate whether periodontal treatment influenced systemic inflammation and antibody titres to P. gingivalis, A. actinomycetemcomitans, Prevotella intermedia and ACPA in 42 systemically health patients with periodontal disease. Subgingival plaque and serum samples were collected from study participants before (baseline) and 90 days after treatment to analyse the abundance of specific bacteria and evaluate anti-bacterial antibodies, C-reactive protein (CRP), tumour necrosis factor α (TNF-α), interleukin 6 (IL-6) and ACPA in serum. Following treatment, all patients showed reduced periodontal inflammation. Despite observing a weak positive correlation between CRP and IL-6 with periodontal inflammation at baseline, we observed no significant reductions in any indicators of systemic inflammation 90 days after treatment. In contrast, anti-P. gingivalis IgG significantly reduced post-treatment (p < 0.001, Wilcoxon signed rank test), although no changes were observed for other antibody titres. Patients who had detectable P. gingivalis in subgingival plaques had significantly higher anti-P. gingivalis IgG and ACPA titres, suggesting a potential association between P. gingivalis colonisation and systemic antibody titres.

Act Locally, Act Globally-Microbiota, Barriers, and Cytokines in Atherosclerosis

Atherosclerosis is a lipid-driven chronic inflammatory disease that is characterized by the formation and progressive growth of atherosclerotic plaques in the wall of arteries. Atherosclerosis is a major predisposing factor for stroke and heart attack. Various immune-mediated mechanisms are implicated in the disease initiation and progression. Cytokines are key mediators of the crosstalk between innate and adaptive immune cells as well as non-hematopoietic cells in the aortic wall and are emerging players in the regulation of atherosclerosis. Progression of atherosclerosis is always associated with increased local and systemic levels of pro-inflammatory cytokines. The role of cytokines within atherosclerotic plaque has been extensively investigated; however, the cell-specific role of cytokine signaling, particularly the role of cytokines in the regulation of barrier tissues tightly associated with microbiota in the context of cardiovascular diseases has only recently come to light. Here, we summarize the knowledge about the function of cytokines at mucosal barriers and the interplay between cytokines, barriers, and microbiota and discuss their known and potential implications for atherosclerosis development.

Prolonged multimodal fasting modulates periodontal inflammation in female patients with metabolic syndrome: A prospective cohort study

AIM

To determine the potential anti-inflammatory effect of a multimodal periodic fasting programme on surrogate parameters of periodontal inflammation in hospitalized patients diagnosed for metabolic syndrome (MetS).

MATERIAL AND METHODS

A total of 47 patients were recruited and hospitalized in an integrative ward for an intensified two-week multimodal fasting, diet and lifestyle programme. Patients were periodontally examined at baseline (t1), after the 2-week fasting protocol (t2) and, subsequently, 4 months after fasting (t3). The following parameters were determined: periodontal screening index (PSI), bleeding on probing (BOP), gingival crevicular fluid volume (GCF), plaque index (PI), C-reactive protein (CRP), blood pressure (BP), waist circumference (WC), fasting glucose (FGLU), triglycerides (TRG), high-density lipoprotein (HDL) and HbA1c.

RESULTS

A total of 28 female and 8 male patients fulfilled the defined criteria for MetS and were analysed separately by gender. At t2, BOP and GCF were reduced when compared to t1 (median: t2 = 39; t1 = 33.1%; p < .001 and t2 = 73.9; t1 = 59.3 Periotron units p = .02, respectively). BOP reduction correlated to FGLU (R = .37, p = .049) and weight reduction (R = .4, p = .04).

CONCLUSION

This study showed for the first time that clinically supervised periodic fasting in female patients with MetS may facilitate the reduction of periodontal inflammation.

Severe Periodontal Disease Increases Acute Myocardial Infarction and Stroke: A 10-Year Retrospective Follow-up Study

This study aimed to evaluate the causal association of periodontal disease with acute myocardial infarction (AMI) and stroke, after controlling for various confounders among the Korean population. A retrospective cohort study using the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) was performed during 2002 to 2015 (baseline: 2002 to 2005; follow-up: 2006 to 2015) in the Republic of Korea. A total of 298,128 participants with no history of AMI or stroke were followed up for 10 y. AMI and stroke were defined by a diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) guideline. Periodontal condition was classified into 3 groups (healthy, moderate periodontal disease, severe periodontal disease [SPD]) using the combination of ICD codes, treatment codes in the NHIS, and recommendation of periodontal treatment by the dentists in HEALS. Various confounders, such as sociodemographic, behavioral, systemic, and oral health factors, including hypercholesterolemia, were considered. Multivariable Cox regression analysis was applied to estimate adjusted incidence rate ratio (adjusted hazard ratio [aHR]) based on person-year of periodontal condition for AMI, stroke, and nonfatal major adverse cardiovascular events (MACEs) encompassing AMI or stroke controlling for various confounders. Stratified analyses according to age group, sex, and toothbrushing frequency were also performed. After controlling for various confounders, participants with SPD compared with non-SPD participants had a higher incidence by 11% for AMI (aHR, 1.11; 95% confidence interval [CI], 1.02-1.20), by 3.5% for stroke (aHR, 1.035; 95% CI, 1.01-1.07), and by 4.1% for MACEs (aHR, 1.04; 95% CI, 1.01-1.07). The association of SPD with AMI and MACE was highly modified in females and adults aged 40 to 59 y. In the total Korean population, SPD increased total AMI events by 4.3%, total stroke events by 1.4%, and the total MACEs by 1.6%. Our data confirmed that SPD was causally associated with the new events of AMI and stroke.

Clustering by periodontitis-associated factors: A novel application to NHANES data

BACKGROUND

Unsupervised clustering is a method used to identify heterogeneity among groups and homogeneity within a group of patients. Without a prespecified outcome entry, the resulting model deciphers patterns that may not be disclosed using traditional methods. This is the first time such clustering analysis is applied in identifying unique subgroups at high risk for periodontitis in National Health and Nutrition Examination Surveys (NHANES 2009 to 2014 data sets using >500 variables.

METHODS

Questionnaire, examination, and laboratory data (33 tables) for >1,000 variables were merged from 14,072 respondents who underwent clinical periodontal examination. Participants with ≥6 teeth and available data for all selected categories were included (N = 1,222). Data wrangling produced 519 variables. k-means/modes clustering (k = 2:14) was deployed. The optimal k-value was determined through the elbow method, formula = ∑ (x_i ² ) - ((∑ x_i )2 /n). The 5-cluster model showing the highest variability (63.08%) was selected. The 2012 Centers for Disease Control and Prevention/American Academy of Periodontology (AAP) and 2018 European Federation of Periodontology/AAP periodontitis case definitions were applied.

RESULTS

Cluster 1 (n = 249) showed the highest prevalence of severe periodontitis (43%); 39% self-reported "fair" general health; 55% had household income <$35,000/year; and 48% were current smokers. Cluster 2 (n = 154) had one participant with periodontitis. Cluster 3 (n = 242) represented the greatest prevalence of moderate periodontitis (53%). In Cluster 4 (n = 35) only one participant had no periodontitis. Cluster 5 (n = 542) was the systemically healthiest with 77% having no/mild periodontitis.

CONCLUSION

Clustering of NHANES demographic, systemic health, and socioeconomic data effectively identifies characteristics that are statistically significantly related to periodontitis status and hence detects subpopulations at high risk for periodontitis without costly clinical examinations.

Association Between Periodontal Disease and Atherosclerotic Cardiovascular Diseases: Revisited

Atherosclerotic cardiovascular disease (ACVD) is an inflammatory disease of the coronary arteries associated with atheroma formation, which can cause disability and often death. Periodontitis is ranked as the sixth most prevalent disease affecting humans affecting 740 million people worldwide. In the last few decades, researchers have focused on the effect of periodontal disease (PD) on cardiovascular disease. The aim of this review was to investigate the association between these two diseases. PD is a potential risk factor that may initiate the development, maturation, and instability of atheroma in the arteries. Two mechanisms were proposed to explain such association, either periodontal pathogens directly invade bloodstream or indirectly by increasing systemic level of inflammatory mediators. Interestingly, it has been suggested that improvement in the condition of one disease positively impact the condition of the other one. Highlighting the association between these two diseases, the importance of early diagnosis and treatment of PD and its impact on cardiovascular status may be of great value in reducing the complications associated with ACVDs. Further in vitro and in vivo studies with longer follow up are necessary to confirm the causal relationship between PD and ACVDs.

Inflammation in Periodontal Disease: Possible Link to Vascular Disease

Inflammation is a well-organized protective response to pathogens and consists of immune cell recruitment into areas of infection. Inflammation either clears pathogens and gets resolved leading to tissue healing or remains predominantly unresolved triggering pathological processes in organs. Periodontal disease (PD) that is initiated by specific bacteria also triggers production of inflammatory mediators. These processes lead to loss of tissue structure and function. Reactive oxygen species and oxidative stress play a role in susceptibility to periodontal pathogenic bacterial infections. Periodontal inflammation is a risk factor for systemic inflammation and eventually cardiovascular disease (CVD). This review discusses the role of inflammation in PD and its two way association with other health conditions such as diabetes and CVD. Some of the mechanisms underpinning the links between inflammation, diabetes, CVD and PD are also discussed. Finally, we review available epidemiological data and other reports to assess possible links between oral health and CVD.

Oral health status and cardiovascular risk profile in Cameroonian military population

Background

Periodontal diseases (PD) seem to appear today as predictors of some cardiovascular diseases (CVD). There is a lack of data on the oral health among Cameroonian military population, and its relationship with CVD.

Purpose

Investigate on the link between oral health of Cameroonian military from the Ngaoundéré garrison and their cardiovascular risk profile.

Participants and methods

A cross-sectional study at the Fifth Military Sector Health Center in Ngaoundéré was conducted. General health parameters assessment was done according to the World Health Organization STEPS manual for surveillance of risk factors for non-communicable chronic diseases and the Alcohol Use Disorders Identification Test. The periodontal status was assessed using Dutch Periodontal Screening Index.

Results

Two hundred and five participants who were officers and non-commissioned officers (aged 47 ± 08 and 32 ± 08 years respectively), with 86.4% of men were included. Smoking was associated to periodontitis (OR = 4.44 [1.73–11.43], p = 0.0031). Quality of oral hygiene was associated to high cardiovascular risk profile, poor/good (OR = 3.96 [1.07–14.57], p = 0.0386) and medium/good (OR = 3.44 [1.11–10.66], p = 0.0322).

Conclusion

Lifestyle as tobacco consumption and poor oral hygiene were associated to CVD among military, and this call for change.

Does Last Year's Cost Predict the Present Cost? An Application of Machine Leaning for the Japanese Area-Basis Public Health Insurance Database

The increasing healthcare cost imposes a large economic burden for the Japanese government. Predicting the healthcare cost may be a useful tool for policy making. A database of the area-basis public health insurance of one city was analyzed to predict the medical healthcare cost by the dental healthcare cost with a machine learning strategy. The 30,340 subjects who had continued registration of the area-basis public health insurance of Ebina city during April 2017 to September 2018 were analyzed. The sum of the healthcare cost was JPY 13,548,831,930. The per capita healthcare cost was JPY 446,567. The proportion of medical healthcare cost, medication cost, and dental healthcare cost was 78%, 15%, and 7%, respectively. By the results of the neural network model, the medical healthcare cost proportionally depended on the medical healthcare cost of the previous year. The dental healthcare cost of the previous year had a reducing effect on the medical healthcare cost. However, the effect was very small. Oral health may be a risk for chronic diseases. However, when evaluated by the healthcare cost, its effect was very small during the observation period.

Association of Periodontal Status, Number of Teeth, and Obesity: A Cross-Sectional Study in Japan

Recent reports have shown an association between obesity and periodontitis, but the precise relationship between these conditions has yet to be clarified. The purpose of this study was to compare the status of periodontitis, tooth loss, and obesity. Participants comprised 235 patients at the Center for Medical and Dental Collaboration in Kanagawa Dental University Hospital between 2018 and 2020. Clinical examinations such as blood testing, body composition analysis, periodontal measurement, assessment of chewing ability, salivary testing, and oral malodor analysis were performed. Periodontal inflamed surface area (PISA) was significantly associated with the number of teeth and body mass index (BMI). The number of teeth was negatively associated with age, but positively with chewing ability. Chewing ability was associated negatively with age, and positively with high-sensitivity C-reactive protein (hsCRP). The level of methyl-mercaptan in breath and protein and leukocyte scores from salivary testing were positively associated with PISA. The rate of insufficient chewing ability was increased in subjects with hemoglobin (Hb)A1c ≥ 7%. The high PISA group showed increased hsCRP. BMI as an obesity marker was positively associated with PISA, indicating periodontal inflammation. Chewing ability was related to serum markers such as HbA1c and hsCRP.

Association between periodontitis and pulse wave velocity: a systematic review and meta-analysis

OBJECTIVES

Severe periodontitis has been associated with endothelial dysfunction and arterial stiffness. The present study aimed to provide a critical appraisal and a meta-analysis of the literature investigating pulse wave velocity (PWV) in patients with and without severe periodontitis and to assess whether treatments influence PWV.

MATERIALS AND METHODS

English literature was searched on multiple databases up to April 2020 by two independent reviewers. Studies comparing PWV between patients with and without severe periodontitis or assessing the impact of periodontal treatments on PWV were searched and retrieved. Pool data analyses with random effect models were performed. The risk of bias was assessed using Newcastle-Ottawa Scale and RoB2 tools.

RESULTS

Seventeen studies were selected. Of these, 10 were used for the meta-analysis. Twelve were cross-sectional studies and 5 interventional studies, including 3176 patients, of whom 1894 had severe periodontitis and 1282 were considered as the controls (without severe periodontitis). Based on carotid-femoral PWV measurement, patients with severe periodontitis (n = 309) have a significantly higher PVW than patients with non-severe periodontitis (n = 213), with a mean difference of 0.84 m/s (95% CI 0.50-1.18; p < 0.0001; I² = 5%). Similarly, carotid-radial or brachial-ankle PWV values were significantly higher in patients with severe periodontitis. Results concerning the effect of non-surgical periodontal therapy were not conclusive. Overall, 9 studies (53%) were classified at a low risk of bias.

CONCLUSIONS

The present study demonstrates that patients with severe periodontitis have higher PWV compared to patients with non-severe periodontitis.

CLINICAL SIGNIFICANCE

Severe periodontitis is associated with arterial stiffness, supporting the mutual involvement of dentists and physicians.

Nutrition as a Key Modifiable Factor for Periodontitis and Main Chronic Diseases

Nutrition is recognized as an essential component in the prevention of a number of chronic diseases, including periodontal disease. Based on these considerations, a better understanding is required regarding how the diet, and more particularly the intake of macronutrients and micronutrients, could impact the potential relationship between nutrition and periodontal diseases, periodontal diseases and chronic diseases, nutrition and chronic diseases. To overcome this complexity, an up-to-date literature review on the nutriments related to periodontal and chronic diseases was performed. High-sugar, high-saturated fat, low-polyols, low-fiber and low-polyunsaturated-fat intake causes an increased risk of periodontal diseases. This pattern of nutrients is classically found in the Western diet, which is considered as an ‘unhealthy’ diet that causes cardiovascular diseases, diabetes and cancers. Conversely, low-sugar, high-fiber and high-omega-6-to-omega-3 fatty acid ratio intake reduces the risk of periodontal diseases. The Mediterranean, DASH, vegetarian and Okinawa diets that correspond to these nutritional intakes are considered as ‘healthy’ diets, reducing this risk of cardiovascular diseases, diabetes and cancers. The role of micronutrients, such as vitamin D, E, K and magnesium, remains unclear, while others, such as vitamin A, B, C, calcium, zinc and polyphenols have been shown to prevent PDs. Some evidence suggests that probiotics and prebiotics could promote periodontal health. Periodontal and chronic diseases share, with a time delay, nutrition as a risk factor. Thus, any change in periodontal health should be considered as a warning signal to control the dietary quality of patients and thus reduce the risk of developing chronic diseases later on.

The inflammation link between periodontal disease and coronary atherosclerosis in patients with acute coronary syndromes: case-control study

BACKGROUND

Coronary atherosclerosis and periodontal disease, due to their prevalence, are a serious epidemiological problem. Pathophysiological evidence points to their possible common inflammatory etiopathological background. The aim of the study was to analyze the relationship between the presence and severity of periodontitis, systemic inflammation and selected parameters of myocardial injury and heart function in patients with acute myocardial infarction.

METHODS

The study group consisted of 71 patients 54.22 (7.05)-year-old hospitalized due to acute myocardial infarction. The patients underwent a coronary angiographic examination and echocardiography. The following laboratory parameters were determined: blood morphology, high sensitivity C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), fibrinogen, troponin I, creatine kinase myocardial band (CK-MB), brain natriuretic peptide (BNP), lipidogram, glucose, creatinine, glomerular filtration rate (GFR), thyroid stymulating hormone (TSH), glycated hemoglobin (HbA1c). Dental assessment of the patients was performed and the following indicators were included: the number of teeth preserved, approximal plaque index (API), bleeding on probing (BoP), pocket depth (PD), the number of bleeding periodontal pockets ≥ 4 mm in depth (NoPD ≥ 4 mm), the percentage of bleeding periodontal pockets ≥ 4 mm in depth (%PD ≥ 4 mm), clinical attachment loss (CAL). The control consisted of 40 patients 52 (± 8.43)-year-old without a history of coronary heart disease. These patients were subjected to a periodontal examination using the above parameters and classification methods. The following statistical tests were implemented: Shapiro-Wilk test, Levene's test, Mann Whitney's U analysis, Univariate Analysis of Variance (ANOVA); the post-hoc analysis was performed with the use of Tukey's honest significant difference test (HSD), Kruskal-Wallis's non-parametric test, Spearman's rank correlation, logistic regression analysis, linear regression analysis and ROC analysis.

RESULTS

The BoP (bleeding on probing) significantly correlated with fibrynogen (R-0.36; p-0.006). All indices regarding the pocket depth correlated significantly with the number of leukocytes: PD (R-0.27; p-0.02), NoPD ≥ 4 mm (R-0.28, p-0.02), %PD ≥ 4 mm (R-0.27; p-0.02). PD (R-0.28; p-0.01) and NoPD ≥ 4 mm (R-0.24; p-0.04) were also associated significantly with the level of hsCRP. The BoP is correlated closely with the levels of BNP (R-0.29, p-0.02). The multifactorial analysis showed that significant predictors of myocardial infarction are API and BoP. The analysis showed that API and BoP are important predictors of troponin levels. Linear regression analysis showed that only CAL is a significant predictor of BNP.

CONCLUSIONS

Patients with acute myocardial infarction have worse periodontal status compared to people without coronary heart disease. Greater severity of periodontitis, plaque accumulation and bleeding on probing are associated with acute myocardial infarction. Periodontitis is a risk factor for myocardial infarction and also affects the degree of post-infarction left ventricular damage, which means that there is an inflammatory link between these two diseases.

Hypertension and Its Associations with Dental Status: Data from the Dental, Oral, Medical Epidemiological (DOME) Nationwide Records-Based Study

Conflicting results have been published regarding the associations between dental status and hypertension. This study aims to explore whether or not hypertension is associated with dental status among young to middle-aged adults. To that end, data from the Dental, Oral, Medical Epidemiological (DOME) study were analyzed. The DOME is a cross-sectional records-based study that combines comprehensive socio-demographic, medical, and dental databases of a nationally representative sample of military personnel. Included were 132,529 subjects aged 18–50 years who attended the military dental clinics for one year. The prevalence of hypertension in the study population was 2.5% (3363/132,529). Following multivariate analysis, the associations between hypertension and dental parameters were lost and hypertension retained a positive association with obesity (Odds ratio (OR) = 4.2 (3.7–4.9)), diabetes mellitus (OR = 4.0 (2.9–5.7)), birth country of Western Europe vs. Israeli birth country (OR = 1.9 (1.6–2.2)), male sex (OR = 1.9 (1.6–2.2)), cardiovascular disease (OR = 1.9 (1.6–2.3)), presence of fatty liver (OR = 1.8 (1.5–2.3)), the birth country Asia vs. Israeli birth country (OR = 1.6 (1.1–2.3)), smoking (OR = 1.2 (1.05–1.4)), and older age (OR = 1.05 (1.04–1.06)). Further analysis among an age-, smoking- and sex matched sub-population (N = 13,452) also revealed that the dental parameters lost their statistically significant association with hypertension following multivariate analysis, and hypertension retained a positive association with diabetes (OR = 4.08 (2.6–6.1)), obesity (OR = 2.7 (2.4–3.2)), birth country of Western Europe vs. Israel (OR = 1.9 (1.6–2.3)), cardiovascular disease (OR = 1.8 (1.5–2.2)), fatty liver (OR = 1.7 (1.3–2.3)), high school education vs. academic (OR = 1.5 (1.3–1.8)), and low socio-economic status (SES) vs. high (OR = 1.4 (1.03–1.8)). We analyzed the associations between C-reactive protein (CRP) and dental parameters and combined the statistically significant variables to create a dental inflammation score (DIS). This crated a final model with the appropriate weights written as follows: DIS = (periodontal disease × 14) + (the number of teeth that required crowns × 11) + (missing teeth × 75). The mean DIS was 10.106 ± 25.184, and it exhibited a weak positive association with hypertension in the univariate analysis (OR = 1.011 (1.010–1.012)). Receiver operating characteristic (ROC) analysis of the DIS against hypertension produced a failed area under the curve (AUC) result (0.57 (0.56–0.58)). Moreover, the DIS also lost its statistical significance association with hypertension following multivariate analysis. We conclude that hypertension had no statistically significant nor clinically significant association with dental status. The study established a profile of the “patient vulnerable to hypertension”, which retained well-known risk factors for hypertension such as older age, male sex, smoking, diabetes, obesity, and fatty liver but not dental parameters.