Can a chronic dental infection be considered a cause of cardiovascular disease? A review of the literature

Presence and consequence of tooth periapical radiolucency in patients with cirrhosis

Background

Periapical radiolucency is the radiographic sign of inflammatory bone lesions around the apex of the tooth. We determined the prevalence and predictors of periapical radiolucency in patients with cirrhosis and the association with systemic inflammation status and cirrhosis-related complications.

Methods

A total of 110 cirrhosis patients were consecutively enrolled. Periapical radiolucency was defined as the presence of radiolucency or widening of the periapical periodontal ligament space to more than twice the normal width. Predictors of periapical radiolucency and the association with systemic inflammation markers and cirrhosis-related complications were explored by univariable and multivariable logistic regression analyses.

Results

Periapical radiolucency was present in one or more teeth in 46% of the patients. Strong predictors were gross caries (odds ratio [OR] 3.12, 95% confidence interval [CI] 1.43–6.79) and severe periodontitis (OR 3.98, 95% CI 1.04–15.20). Also old age (OR 1.10, 95% CI 1.01–1.19) and smoking (OR 3.24, 95% CI 1.02–17.62) were predictors. However, cirrhosis etiology (alcoholic vs nonalcoholic) or severity (Model of End-Stage Liver Disease score) were not predictors. The patients with periapical radiolucency had higher C-reactive protein (15.8 mg/L vs 8.1 mg/L, P=0.02) and lower albumin contents (25 g/L vs 28 g/L, P=0.04) than those without. Furthermore, the patients with periapical radiolucency had a higher prevalence of cirrhosis-related complications such as ascites, hepatic encephalopathy, and/or variceal bleeding (46% vs 27%, P=0.05).

Conclusion

Periapical radiolucency is often present as an element of poor oral health status and likely has an adverse clinical significance, which should motivate diagnostic and clinical attention to the findings.

Dental Calculus Links Statistically to Angina Pectoris: 26-Year Observational Study

Objectives

Dental infections, such as periodontitis, associate with atherosclerosis and its complications. We studied a cohort followed-up since 1985 for incidence of angina pectoris with the hypothesis that calculus accumulation, proxy for poor oral hygiene, links to this symptom.

Methods

In our Swedish prospective cohort study of 1676 randomly selected subjects followed-up for 26 years. In 1985 all subjects underwent clinical oral examination and answered a questionnaire assessing background variables such as socio-economic status and pack-years of smoking. By using data from the Center of Epidemiology, Swedish National Board of Health and Welfare, Sweden we analyzed the association of oral health parameters with the prevalence of in-hospital verified angina pectoris classified according to the WHO International Classification of Diseases, using descriptive statistics and logistic regression analysis.

Results

Of the 1676 subjects, 51 (28 women/23 men) had been diagnosed with angina pectoris at a mean age of 59.8 ± 2.9 years. No difference was observed in age and gender between patients with angina pectoris and subjects without. Neither was there any difference in education level and smoking habits (in pack years), Gingival index and Plaque index between the groups. Angina pectoris patients had significantly more often their first maxillary molar tooth extracted (d. 16) than the other subjects (p = 0.02). Patients also showed significantly higher dental calculus index values than the subjects without angina pectoris (p = 0.01). Multiple regression analysis showed odds ratio 2.21 (95% confidence interval 1.17–4.17) in the association between high calculus index and angina pectoris (p = 0.015).

Conclusion

Our study hypothesis was confirmed by showing for the first time that high dental calculus score indeed associated with the incidence of angina pectoris in this cohort study.

Decreased circulating neopterin is associated with increased arterial elasticity: a beneficial role of periodontal treatment

BACKGROUND

The aim of this study was to evaluate the effect of periodontal treatment on arterial elasticity and circulating neopterin in patients with moderate to severe periodontitis in a Chinese population.

METHODS

One hundred and eight patients with moderate to severe periodontitis were eligible to take part in the study and were randomized into two groups. The treatment group received intensive periodontal treatment, while the control group received control periodontal treatment. All parameters, including brachial-ankle pulse wave velocity (baPWV), ankle brachial index (ABI), serum neopterin (NP), high-sensitivity C-reactive protein (hs-CRP), Interleukin-6 (IL-6), were evaluated before treatment and 1 month after treatment.

RESULTS

The parameters including NP, hs-CRP, IL-6 and baPWV decreased significantly after 1 month in the treatment group (p < 0.05 for all comparisons) but not in the control group (p > 0.05). There was no significant difference in the change of ABI between the two groups (p = 0.231). A positive correlation was found between the decreased circulating NP and increased arterial elasticity in the treatment group (r = 0.947, p < 0.001).

CONCLUSIONS

This study demonstrates for the first time that the fall in circulating NP induced by periodontal treatment contributes to increased arterial elasticity in patients with moderate and severe periodontitis.

Relationship of Edentulism, Sleep Disordered Breathing and Cardiovascular Disease: NHANES, 2007-2008

BACKGROUND

Edentulism, though declining in younger adults, remains prevalent in the U.S. older adult population. Poorer health outcomes, including cardiovascular outcomes have been associated with edentulism. Sleep disorders are also common in older adults and have been associated with cardiovascular disease. The purpose of this study is to determine if edentulism is associated with cardiovascular disease when sleep disorders are included in the analyses.

METHODS

Data from the National Health and Nutrition Examination Survey, 2007-2008 were used in this study. Adjusted logistic regression analyses were performed with cardiovascular disease as the dependent variable and dental status (edentulism, dentate) as the key independent variable and sleep variables introduced as potential confounders.

RESULTS

In multivariable analyses, edentulism was independently associated with cardiovascular disease with an adjusted odds ratio of 2.15 (95% CI: 1.54, 3.00). The model included a sleep summary variable, race, sex, education, smoking status, and drinking status, physical activity, body mass index, conditions or disease count, family poverty index, and insurance status.

CONCLUSIONS

Edentulism was associated with cardiovascular disease independent of sleep disordered breathing.

Apical periodontitis and incident cardiovascular events in the Baltimore Longitudinal Study of Ageing

AIM

To evaluate whether the presence of apical periodontitis (AP), root canal treatment (RCT) and endodontic burden (EB) - as the sum of AP and RCT sites - were associated with long-term risk of incident cardiovascular events (CVE), including cardiovascular-related mortality, using data on participants in the Baltimore Longitudinal Study of Ageing (BLSA).

METHODOLOGY

This retrospective cohort included 278 dentate participants in the BLSA with complete medical and dental examinations. Periodontal disease (PD) and missing teeth were recorded. The total number of AP and RCT sites was determined from panoramic radiographs. EB was calculated as the sum of AP and RCT sites. Oral inflammatory burden (OIB) was calculated combining PD and EB. The main outcome was incident CVE including angina, myocardial infarction and cardiovascular-related death. Participants were monitored for up to 44 years (mean = 17.4± 11.1 years) following dental examination. Relative risks (RRs) were calculated through Poisson regression models, estimating the relationship between AP, RCT, EB, PD, OIB and incident CVE.

RESULTS

Mean age at baseline was 55.0 ±16.8 years and 51.4% were men. Sixty-two participants (22.3%) developed CVE. Bivariate analysis showed that PD, EB, number of teeth and OIB were associated with incident CVE. Multivariate models, adjusted for socio-demographic and medical variables, showed that age ≥60 years (RR = 3.07, 95% CI =1.68-5.62), hypertension (RR = 2.0, 95% CI = 1.16-3.46) and EB ≥3 (RR = 1.77, 95% CI = 1.04-3.02) were independently associated with incident CVE. The association between OIB and incident CVE was reduced to nonsignificance after adjustments (RR = 1.97, 95% CI = 0.83-4.70).

CONCLUSIONS

EB in midlife was an independent predictor of CVE amongst community-dwelling participants in the BLSA. Prospective studies are required to evaluate cardiovascular risk reduction with the treatment of AP.

Host-derived biomarkers in gingival crevicular fluid for complementary diagnosis of apical periodontitis

Apical periodontitis (AP) develops as a result of the host’s immune inflammatory response to pulpal infection of the dental root canals that leads to the generation of an apical lesion of endodontic origin (ALEO) and potentially to systemic metabolic alterations. Misdiagnosed ALEO is not infrequent due to the lack of diagnostic tools to differentiate apical lesions of different natures. Despite the conservative endodontic treatment shows a high success rate, there are refractory cases that can not be identified early enough during follow up. This evidences the need to develop complementary diagnostic tools, such as oral fluid biomarker analysis. Gingival crevicular fluid (GCF) is a serum transudate that becomes an exudate under inflammatory conditions, carrying molecules from local periodontal tissues and general circulation than can be harvested non-invasively. We aimed to review the available literature analyzing GCF composition in AP patients to evaluate whether GCF has any potential for complementary diagnosis. To the date, only few studies addressing changes of GCF components in AP are available. Most studies support GCF modifications in specific components in AP-affected teeth, suggesting that it might reflect periapical inflammation. GCF has potential for diagnostic tool, treatment follow-up and eventually to assess systemic comprise.

Pro-inflammatory genetic markers of atherosclerosis

Atherosclerosis (AS) is a chronic, progressive, multifactorial disease mostly affecting large and medium-sized elastic and muscular arteries. It has formerly been considered a bland lipid storage disease. Currently, multiple independent pathways of evidence suggest this pathological condition is a peculiar form of inflammation, triggered by cholesterol-rich lipoproteins and influenced both by environmental and genetic factors. The Human Genome Project opened up the opportunity to dissect complex human traits and to understand basic pathways of multifactorial diseases such as AS. Population-based association studies have emerged as powerful tools for examining genes with a role in common multifactorial diseases that have a strong environmental component. These association studies often estimate the risk of developing a certain disease in carriers and non-carriers of a particular genetic polymorphism. Dissecting out the influence of pro-inflammatory genes within the complex pathophysiology of AS and its complications will help to provide a more complete risk assessment and complement known classical cardiovascular risk factors. The detection of a risk profile will potentially allow both the early identification of individuals susceptible to disease and the possible discovery of potential targets for drug or lifestyle modification; i.e. it will open the door to personalized medicine.

Does Oral Hygiene Trigger Carotid Artery Intima-Media Thickness?

<p><b>Background and Purpose:</b> The aim of this study was to evaluate whether poor oral hygiene is associated with the intima-media thickness of the carotid arteries, which is one of the predictors of future progression of subclinical atherosclerosis.</p><p><b>Methods:</b> We selected 108 patients during periodontal examinations according to their oral hygiene. The patients had no history of atherosclerotic disease. The results of carotid artery B-mode ultrasonography examinations were analyzed at baseline and after a mean of 7.8 months. Patients were scored on the DMFT index for the number of decayed (D), missing (M), and filled (F) teeth (T). We also used the Silness-Loe plaque index (SLI) to evaluate oral hygiene and dental plaque. The patients were divided into 2 groups according to DMFT and SLI criteria. Group I had a DMFT index of 0 to 3 and an SLI score of 0 or 1; group II had a DMFT index of 4 to 28 and an SLI score of 2 or 3.</p><p><b>Results:</b> Dental status and oral hygiene were significantly associated with carotid artery intima-media thickness. Patients with increasing DMFT and SLI indices were correlated with intima-media thickness of the carotid artery.</p><p><b>Conclusions:</b> Chronic poor oral hygiene and tooth loss are related to subclinical atherosclerotic changes in the carotid arteries and might be indicative of future progression of atherosclerosis.</p>

Carotid and popliteal artery intima-media thickness in patients with poor oral hygiene and the association with acute-phase reactants

Purpose

The aim of this study was to evaluate whether poor oral hygiene is associated with carotid and popliteal arterial intima–media thickness, which is one of the predictors of future progression of sub-clinical atherosclerosis, and high-sensitivity C-reactive protein (hsCRP) and fibrinogen levels.

Methods

A specialised dentist checked the patients and selected 550 patients during periodontal examinations, according to their oral hygiene. The patients had no history of atherosclerotic disease. Carotid and popliteal artery B-mode ultrasonographic examinations and hsCRP and fibrinogen levels were analysed at baseline and after a mean of 6.2 months. The patients were scored on the DMFT index for the number of decayed (D), missing (M), and filled (F) teeth (T). We also used the Silness-Loe plaque index (SLI) to evaluate oral hygiene and dental plaque. The patients were divided into two groups using the DMFT and SLI criteria. Group I had a DMFT index score from 0 to 3 and SLI index score of 0 or 1. Group II had a DMFT index score from 4 to 28 and SLI index score of 2 or 3.

Results

A significant association was observed between dental status, oral hygiene, carotid and popliteal artery intima–media thickness and hsCRP level. Patients with increasing DMFT and SLI scores correlated with increasing carotid artery intima–media thickness.

Conclusions

The results clearly showed that chronic poor oral hygiene and tooth loss are related to sub-clinical atherosclerotic changes in the carotid arteries and may be indicative of future progression of atherosclerosis.

Periodontal disease immunology: 'double indemnity' in protecting the host

During the last two to three decades our understanding of the immunobiology of periodontal disease has increased exponentially, both with respect to the microbial agents triggering the disease process and the molecular mechanisms of the host engagement maintaining homeostasis or leading to collateral tissue damage. These foundational scientific findings have laid the groundwork for translating cell phenotype, receptor engagement, intracellular signaling pathways and effector functions into a 'picture' of the periodontium as the host responds to the 'danger signals' of the microbial ecology to maintain homeostasis or succumb to a disease process. These findings implicate the chronicity of the local response in attempting to manage the microbial challenge, creating a 'Double Indemnity' in some patients that does not 'insure' health for the periodontium. As importantly, in reflecting the title of this volume of Periodontology 2000, this review attempts to inform the community of how the science of periodontal immunology gestated, how continual probing of the biology of the disease has led to an evolution in our knowledge base and how more recent studies in the postgenomic era are revolutionizing our understanding of disease initiation, progression and resolution. Thus, there has been substantial progress in our understanding of the molecular mechanisms of host-bacteria interactions that result in the clinical presentation and outcomes of destructive periodontitis. The science has embarked from observations of variations in responses related to disease expression with a focus for utilization of the responses in diagnosis and therapeutic outcomes, to current investigations using cutting-edge fundamental biological processes to attempt to model the initiation and progression of soft- and hard-tissue destruction of the periodontium. As importantly, the next era in the immunobiology of periodontal disease will need to engage more sophisticated experimental designs for clinical studies to enable robust translation of basic biologic processes that are in action early in the transition from health to disease, those which stimulate microenvironmental changes that select for a more pathogenic microbial ecology and those that represent a rebalancing of the complex host responses and a resolution of inflammatory tissue destruction.

Social Relationships and Dental Care Service Utilization Among Older Adults

Objectives: This study described the association between dental care service utilization and two domains of social relationships (social integration and social support) among older adults. Methods: The study employed data from the 2008 Health and Retirement Study, examining regression models for whether a person visited a dentist in the past 2 years, including adjustments for demographic, socioeconomic, and health characteristics. Results: Social interaction, social participation, neighborhood cohesion, and marital status were related to an increased likelihood of having visited a dentist. Older persons exhibiting loneliness and having received financial aid from network members demonstrated a decreased likelihood of visiting a dentist. The increased likelihood of visiting a dentist when a child lives nearby only occurred after introducing health covariates. Discussion: The article discusses the implications of the study findings as they relate to social relationships and oral health and recommends some additional research directions to explore the etiology of dental care use.

Association between self-reported oral health, tooth loss and atherosclerotic burden

Previous studies have suggested that oral diseases may influence the development of atherosclerosis. The aim of this study was to test the hypothesis that poor self-reported oral health (SROH) and tooth loss are positively associated with coronary atherosclerotic burden (CAB). 382 consecutive subjects undergoing coronary angiography were included. Socio-demographic characteristics, cardiovascular risk factors and oral health status were collected using a standardized questionnaire, including data on SROH and use of dental prosthesis. Number of teeth and anthropometric measures were collected through clinical examinations. CAB at coronary angiography was quantified using the Friesinger score (FS). Prevalence ratios (PR) were calculated with Poisson regression analyses. Mean age was 60.3 ± 10.8 years, with 63.2% males. In the bivariate analysis, there was a significant association (p < 0.05) between CAB and age (> 60y) (PR = 1.01, 95%CI = 1.02-1.16), male gender (PR = 1.11, 95%CI = 1.03-1.19), smoking (PR = 1.08, 95%CI = 1.01- 1.16), hypertension (PR = 1.12, 95%CI = 1.03-1.22), diabetes (PR = 1.17, 95%CI = 1.05-1.21), poor SROH (PR = 1.22, 95%CI = 1.02-1.46) and tooth loss (< 20 teeth present) (PR = 1.10, 95%CI = 1.02-1.19). The use of dental prosthesis was not associated with CAB. The multivariate models, adjusted for age, gender, smoking, hypertension, diabetes and dyslipidemia showed that poor SROH (p = 0.03) and tooth loss (p = 0.02) were independently associated with CAB, confirming the study hypothesis.

Low dose of propranolol down-modulates bone resorption by inhibiting inflammation and osteoclast differentiation

BACKGROUND AND PURPOSE

Bones are widely innervated, suggesting an important role for the sympathetic regulation of bone metabolism, although there are controversial studies. We investigated the effects of propranolol in a model of experimental periodontal disease.

EXPERIMENTAL APPROACH

Rats were assigned as follows: animals without ligature; ligated animals receiving vehicle and ligated animals receiving 0.1, 5 or 20 mg·kg(-1) propranolol. After 30 days, haemodynamic parameters were measured by cardiac catheterization. Gingival tissues were removed and assessed for IL-1β, TNF-α and cross-linked carboxyterminal telopeptides of type I collagen (CTX) by elisa, or intercellular adhesion molecule 1 (ICAM-1), receptor activator of NF-κ B ligand (RANKL) and osteoprotegerin (OPG) by Western blot analysis. Sections from the mandibles were evaluated for bone resorption. Also, we analysed the ability of propranolol to inhibit osteoclastogenesis in vitro.

RESULTS

Propranolol at 0.1 and 5 mg·kg(-1) reduced the bone resorption as well as ICAM-1 and RANKL expression. However, only 0.1 mg·kg(-1) reduced IL-1β, TNF-α and CTX levels as well as increased the expression of OPG, but did not alter any of the haemodynamic parameters. Propranolol also suppressed in vitro osteoclast differentiation and resorptive activity by inhibiting the nuclear factor of activated T cells (NFATc)1 pathway and the expression of tartrate-resistant acid phosphatase (TRAP), cathepsin K and MMP-9.

CONCLUSIONS AND IMPLICATIONS

Low doses of propranolol suppress bone resorption by inhibiting RANKL-mediated osteoclastogenesis as well as inflammatory markers without affecting haemodynamic parameters.

Missing, unreplaced teeth and risk of all-cause and cardiovascular mortality

BACKGROUND

A dentition of at least 20 teeth is associated with sufficient masticatory efficiency and is a stated health goal of the World Health Organisation. We examined whether subjects with missing, unreplaced teeth had an increased mortality risk.

METHODS

We used data prospectively collected from those participants in the population-based Study of Health in Pomerania who had fewer than 20 remaining teeth, resulting in a sample of 1803 participants with a median age of 64 years. Of those, 188 subjects had 9 or more unreplaced teeth. During a median follow-up period of 9.9 years, 362 subjects died, 128 of whom of cardiovascular causes.

RESULTS

We found that having 9 or more unreplaced teeth was related to all-cause mortality (rate ratio 1.53, 95% CI: 1.11-2.10; adjusted for variables according to causal diagrams: remaining teeth, age, sex, education, income, marital status, partnership, and oral health behaviour) and cardiovascular mortality (rate ratio 1.94, 95% CI: 1.15-3.25). When adjusting not only for the variables according to causal diagrams but also for smoking, alcohol consumption, physical activity, obesity, hypertension, diabetes, and dyslipidemia, the rate ratio was 1.43 (95% CI: 1.05-1.96) for all-cause mortality and 1.88 (95% CI: 1.10-3.21) for cardiovascular mortality.

CONCLUSIONS

A reduced, unrestored dentition is associated with increased mortality risk. Thus, clinicians and dietitians have a responsibility to consider individual chewing ability in nutritional recommendations.

Clarithromycin suppresses the periodontal bacteria-accelerated abdominal aortic aneurysms in mice

BACKGROUND AND OBJECTIVE

Although clarithromycin (CAM) has many biological functions, including regulation of MMPs, little is known about its effect on abdominal aortic aneurysms. Periodontopathic bacteria have been reported to be associated with several kinds of circulatory diseases. The purpose of this study was therefore to clarify the effect of CAM on periodontopathic bacteria-accelerated abdominal aortic aneurysms.

MATERIAL AND METHODS

Abdominal aortic aneurysm was produced in mice by the peri-aortic application of 0.25 m CaCl(2). The mice were inoculated once per week with live Porphyromonas gingivalis, which is one of the major periodontopathic bacteria. Test mice (n=8) were given a daily oral dose of CAM, while control mice (n=13) were not.

RESULTS

Four weeks after the operation, the P. gingivalis-injected and CAM-treated mice showed a significant decrease in the aortic diameter in comparison with the mice only injected with P. gingivalis. Histopathologically, the samples obtained from the P. gingivalis-injected and CAM-treated mice showed less elastic degradation. Moreover, the plasma MMP-2 concentration of the CAM-treated mice decreased significantly.

CONCLUSION

These findings suggest that CAM administration is useful to suppress periodontal bacteria-accelerated abdominal aortic aneurysms via MMP regulation.

The association of tooth loss with all-cause and circulatory mortality. Is there a benefit of replaced teeth? A systematic review and meta-analysis

We systematically reviewed whether the number of teeth is related to all-cause or circulatory mortality and whether replaced teeth are protective against all-cause or circulatory mortality. The search was based on the PubMed database. All cohort studies published in peer-reviewed journals were selected. Studies on periodontal disease and mortality were excluded if they did not provide information on the number of teeth. Risk estimates from studies with appropriate exposure definition, confounder adjustment and sample size were included in a meta-analysis. Three high-quality studies found a relationship between the number of teeth and circulatory mortality, whereas a moderate study did not. Two out of four moderate- to high-quality studies reported a relationship between the number of teeth and all-cause mortality. No study has investigated whether replaced teeth are protective against mortality. Therefore, denture use was taken as proxy. The methodological quality of studies on denture use and mortality was generally low to moderate. The findings of two moderate studies indicated an effect of prosthodontic replacements on all-cause mortality, which was supported in bias analysis. It is open whether competing risks of cause-specific death other than circulatory mortality reduce an effect of the number of teeth on all-cause mortality. An effect of denture use on circulatory mortality remains to be established, as well as whether the number of replaced teeth affects mortality. Specifying the role of potential pathways by which tooth loss-related mortality is mediated will possibly increase the value of dental treatment for general health.

Periodontal disease as a risk factor for cardiovascular disease: suggestion of a further link in systemic lupus erythematosus

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Due to either infection or disease activity, elevated levels of inflammatory markers and up-regulation of the autoimmune process can contribute to the development of atherosclerosis in SLE patients. Periodontal diseases are among the most prevalent chronic infections in humans and are characterized by pathogen-induced oral inflammatory disease affecting the supporting tissues of teeth. Several cytokines capable of inducing systemic effects are produced during the course of this infection. The presence of these cytokines can be verified by changes in the levels of C-reactive protein (CRP). Periodontal disease is a well-known risk factor for atherosclerosis. The potential for beneficial prevention of CVD events through the use of periodontal treatment has been previously recommended. This review reinforces the hypothesis that periodontal infection could be a risk factor for CVD in patients diagnosed with SLE, and suggests that by reducing the progression of this oral infection, levels of inflammatory markers common to both diseases (SLE and periodontal disease) would likely decrease.

Paraoxonases as potential antibiofilm agents: their relationship with quorum-sensing signals in Gram-negative bacteria

The property of many bacteria to form biofilms constitutes a major health problem. Bacteria living in biofilms have a very high resistance to antibiotics. Biofilms may develop at a certain locations with the participation of secreted molecules, termed quorum-sensing signals, when a sufficient density of bacterial growth occurs. In Gram-negative bacteria, acyl homoserine lactones (AHL) have been identified as major quorum-sensing signals. The paraoxonases (PONs) constitute a family of enzymes comprising 3 members (PON1, PON2, and PON3) that have lactonase activity and are able to hydrolyze AHL. In this minireview, we summarize some existing basic knowledge on PON genetics, biochemistry, and function and describe recent research that reports evidence of the important roles that they may play in the organism's defense against biofilm formation. Finally, we propose some lines of future research that could be very productive.