Evidence that periodontal treatment improves biomarkers and CVD outcomes

Periodontitis and Cardiovascular Diseases. Consensus Report

Background

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

Material and Methods

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

Results and Conclusions

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Treating periodontal disease in patients with myocardial infarction: A randomized clinical trial

BACKGROUND

Periodontitis has been associated with coronary artery disease, but the impact of a periodontal treatment on the endothelial function of patients with a recent ST-segment elevation myocardial infarction (STEMI) was not investigated.

METHODS

Randomized controlled trial (NCT02543502). Patients admitted between August 2012 and January 2015 were included. Patients were screened during the index hospitalization for STEMI, and those with severe periodontal disease were randomized 2 weeks later to periodontal treatment or to control. The primary endpoint of this trial was the between group difference in the variation of flow-mediated vasodilation (FMD) in the brachial artery assessed by ultrasound from baseline to the 6-month follow-up. Secondary outcomes were cardiovascular events, adverse effects of periodontal treatment and inflammatory markers.

RESULTS

Baseline characteristics were balanced between patients in the intervention (n = 24) and control groups (n = 24). There was a significant FMD improvement in the intervention group (3.05%; p = .01), but not in the control group (-0.29%; p = .79) (p = .03 for the intergroup comparison). Periodontal treatment was not associated with any adverse events and the inflammatory profile and cardiovascular events were not significantly different between both groups.

CONCLUSIONS

Treatment of periodontal disease improves the endothelial function of patients with a recent myocardial infarction, without adverse clinical events. Larger trials are needed to assess the benefit of periodontal treatment on clinical outcomes.

CLINICAL TRIAL REGISTRATION

NCT02543502 (https://clinicaltrials.gov/ct2/show/NCT02543502?term=NCT02543502&rank=1).

Factors affecting decision making at reassessment of periodontitis. Part 2: interpretation of clinical findings - systemic factors

This paper is the second in a four-part series outlining treatment planning at periodontal reassessment. The first article focussed on the information that should be gathered at the reassessment appointment. Treatment can involve a range of non-surgical and surgical approaches. A variety of general, practical and local site factors can affect the choice of one option over another in choosing the most predictable treatment option. Residual periodontal probing depths can be associated with both systemic and local factors. This article (part 2) outlines systemic factors that need to be assessed when faced with residual periodontal probing depths.

A review of the influence of periodontal treatment in systemic diseases

The effects and consequences of periodontal diseases might not be confined to the oral cavity. A great body of evidence has arisen supporting the claim demonstrating an association with several systemic conditions and diseases. With different levels of evidence, an association between periodontal disease and cardiovascular disease, diabetes, psoriasis, rheumatoid arthritis, pregnancy outcomes and respiratory diseases has been established. However, the true nature of this association, if it is causal, still remains elusive. For a better understanding of the complex relationships linking different conditions, interventional studies now begin to focus on the possible outcomes of periodontal treatment in relation to the events, symptoms and biomarkers of several systemic disorders, assessing if periodontal treatment has any impact on them, hopefully reducing their severity or prevalence. Therefore, we proceeded to review the recent literature on the subject, attempting to present a brief explanation of the systemic condition or disease, what proposed mechanisms might give biological plausibility to its association with periodontal disease, and finally and more importantly, what data are currently available pertaining to the effects periodontal treatment may have. Raising awareness and discussing the possible benefits of periodontal treatment on overall systemic health is important, in order to change the perception that periodontal diseases are only limited to the oral cavity, and ultimately providing better and comprehensive care to patients.

Current Knowledge on Correlations Between Highly Prevalent Dental Conditions and Chronic Diseases: An Umbrella Review

INTRODUCTION

Studies have investigated the relationships between chronic systemic and dental conditions, but it remains unclear how such knowledge can be used in clinical practice. In this article, we provide an overview of existing systematic reviews, identifying and evaluating the most frequently reported dental-chronic disease correlations and common risk factors.

METHODS

We conducted a systematic review of existing systematic reviews (umbrella review) published between 1995 and 2017 and indexed in 4 databases. We focused on the 3 most prevalent dental conditions and 10 chronic systemic diseases with the highest burden of disease in Germany. Two independent reviewers assessed all articles for eligibility and methodologic quality using the AMSTAR criteria and extracted data from the included studies.

RESULTS

Of the initially identified 1,249 systematic reviews, 32 were included for qualitative synthesis. The dental condition with most frequently observed correlations to chronic systemic diseases was periodontitis. The chronic systemic disease with the most frequently observed correlations with a dental condition was type 2 diabetes mellitus (T2DM). Most dental-chronic disease correlations were found between periodontitis and T2DM and periodontitis and cardiovascular disease. Frequently reported common risk factors were smoking, age, sex, and overweight. Using the AMSTAR criteria, 2 studies were assessed as low quality, 26 studies as moderate quality, and 4 studies as high quality.

CONCLUSION

The quality of included systematic reviews was heterogeneous. The most frequently reported correlations were found for periodontitis with T2DM and for periodontitis with cardiovascular disease. However, the strength of evidence for these and other disease correlations is limited, and the evidence to assess the causality of these disease correlations remains unclear. Future research should focus on the causality of disease links in order to provide more decisive evidence with respect to the design of intersectoral care processes.

Mediators between oral dysbiosis and cardiovascular diseases

Clinical periodontitis is associated with an increased risk for cardiovascular diseases (CVDs) through systemic inflammation as the etiopathogenic link. Whether the oral microbiota, especially its quality, quantity, serology, and virulence factors, plays a role in atherogenesis is not clarified. Patients with periodontitis are exposed to bacteria and their products, which have access to the circulation directly through inflamed oral tissues and indirectly (via saliva) through the gastrointestinal tract, resulting in systemic inflammatory and immunologic responses. Periodontitis is associated with persistent endotoxemia, which has been identified as a notable cardiometabolic risk factor. The serology of bacterial biomarkers for oral dysbiosis is associated with an increased risk for subclinical atherosclerosis, prevalent and future coronary artery disease, and incident and recurrent stroke. In addition to species-specific antibodies, the immunologic response includes persistent, cross-reactive, proatherogenic antibodies against host-derived antigens. Periodontitis may affect lipoprotein metabolism at all levels, and all lipoprotein classes are affected. Periodontitis or its bacterial signatures may be involved not only in increased storage of proatherogenic lipids but also in attenuation of the anti-atherogenic processes, thereby putatively increasing the net risk of atherosclerosis. In this review we summarize possible molecular mediators between the dysbiotic oral microbiota and atherosclerotic processes.

Periodontal Disease Is Associated With Increased Risk of Hypertension: A Cross-Sectional Study

Objective: Published evidence showed that periodontal disease is associated with hypertension. However, relevant findings remain controversial, with few evidences focusing on Chinese population. Therefore, the aim of this study was to investigate the association between periodontal disease and hypertension in Chinese population.

Methods: A total of 4,930 participants from an available health examination that was carried out in 2017 were selected for this retrospective study. The correlations between periodontal disease and hypertension were investigated using univariate and multiple logistic regression analyses and propensity score adjusted analysis. Interaction and subgroup analyses were also used to detect variable factors.

Results: Finally, a total of 3,952 participants aged 30–68 years were eligible for this study. The results showed that hypertension risk was statistically significant associated with periodontal disease either in unadjusted (OR = 1.28, 95%CI = 1.14–1.47) or in adjusted (OR = 1.34, 95%CI = 1.14–1.58) model. Result from propensity score adjusted analysis also demonstrated a similar association (OR = 1.23, 95%CI = 1.06–1.42).

Conclusion: Periodontal disease is significantly and positively correlated with increased risk of hypertension in Chinese population, and exact mechanisms of this association should be explored in future.

Evaluation of Effect of Surgical and Nonsurgical Periodontal Therapy on Serum C-Reactive Protein, Triglyceride, Cholesterol, Serum Lipoproteins and Fasting Blood Sugar in Patients with Severe Chronic Periodontitis

Background:

Cardiovascular disease has been associated with multiple risk factors such as dyslipidemia. However, the focus has recently shifted towards some novel risk factorsi.e. infection from periodontitis.

Given this background, we aimed to assess the effect of periodontal therapy on some CVD risk factors including Total Cholesterol (TC), Low-Density Lipoprotein(LDL), High-Density Lipoprotein(HDL), Triglycerides(TG) and C-Reactive Protein (CRP). Fasting Blood Sugar (FBS) level has also been measured.

Methods:

Thirty patients (12 male and 18 female) who had severe periodontitis were tested for different blood parameters; namely Total Cholesterol (TC), Low-Density Lipoprotein (LDL), High-Density Lipoprotein(HDL), Triglycerides (TGs), C-Reactive Protein (CRP) and Fasting Blood Sugar (FBS). Enzymatic colorimetric methods were applied to measure all the parameters’ values except for CRP. The first stage of periodontal treatment comprised oral hygiene instruction as well as scaling and root planing. After 1 month, at the next stage, open flap debridement surgery was performed on all 4 quadrants of the mouth. The blood parameters were reassessed and compared with the baseline values after 3 months. Two patients (female) failed to participate in the follow-ups. The Pearson's and Spearman's correlation coefficients were calculated to determine whether changes in laboratory variables are associated with age and average probing depth or not.

Results:

All the assessed parameters related to 28 patients showed mean reduction which proved to be significant for CRP (p=0.011) and cholesterol (p=0.035). Among all parameters, only CRP level was found to have a significant positive correlation with pocket depth. Other blood parameters' relationship with age and probing depth proved to be insignificant.

Conclusion:

Considering the results, periodontal treatment may significantly lower lipid profile serum levels and some inflammatory factors.

Evaluating All Potential Oral Complications of Diabetes Mellitus

Diabetes mellitus (DM) is associated with several microvascular and macrovascular complications, such as retinopathy, nephropathy, neuropathy, and cardiovascular diseases. The pathogenesis of these complications is complex, and involves metabolic and hemodynamic disturbances, including hyperglycemia, insulin resistance, dyslipidemia, hypertension, and immune dysfunction. These disturbances initiate several damaging processes, such as increased reactive oxygen species (ROS) production, inflammation, and ischemia. These processes mainly exert their damaging effect on endothelial and nerve cells, hence the susceptibility of densely vascularized and innervated sites, such as the eyes, kidneys, and nerves. Since the oral cavity is also highly vascularized and innervated, oral complications can be expected as well. The relationship between DM and oral diseases has received considerable attention in the past few decades. However, most studies only focus on periodontitis, and still approach DM from the limited perspective of elevated blood glucose levels only. In this review, we will assess other potential oral complications as well, including: dental caries, dry mouth, oral mucosal lesions, oral cancer, taste disturbances, temporomandibular disorders, burning mouth syndrome, apical periodontitis, and peri-implant diseases. Each oral complication will be briefly introduced, followed by an assessment of the literature studying epidemiological associations with DM. We will also elaborate on pathogenic mechanisms that might explain associations between DM and oral complications. To do so, we aim to expand our perspective of DM by not only considering elevated blood glucose levels, but also including literature about the other important pathogenic mechanisms, such as insulin resistance, dyslipidemia, hypertension, and immune dysfunction.

Erythritol Functional Roles in Oral-Systemic Health

Erythritol belongs chemically to the family of polyols (or sugar alcohols), yet it is metabolized by animals and humans very differently compared to all other polyols. While polyols have been used traditionally (for about 80 y) to replace sugar in sweet foods to reduce demineralization of tooth enamel and to reduce postprandial blood glucose levels, benefits achieved merely through the absence of sugar, emerging evidence shows that erythritol can play a number of functional roles to actively support maintenance of oral and systemic health. Oral health studies revealed that erythritol can reduce dental plaque weight, reduce dental plaque acids, reduce counts of mutans streptococci in saliva and dental plaque, and reduce the risk for dental caries better than sorbitol and xylitol, resulting in fewer tooth restorations by dentist intervention. Systemic health studies have shown that erythritol, unlike other polyols, is readily absorbed from the small intestine, not systemically metabolized, and excreted unchanged within the urine. This metabolic profile renders erythritol to be noncaloric, to have a high gastrointestinal tolerance, and not to increase blood glucose or insulin levels. Published evidence also shows that erythritol can act as an antioxidant and that it may improve endothelial function in people with type 2 diabetes. This article reviews the key research demonstrating erythritol's oral and systemic health functionalities and underlying mechanisms.

Nonsurgical and surgical treatment of periodontitis: how many options for one disease?

Treatment of periodontitis aims at preventing further disease progression with the intentions to reduce the risk of tooth loss, minimize symptoms and perception of the disease, possibly restore lost periodontal tissue and provide information on maintaining a healthy periodontium. Therapeutic intervention includes introduction of techniques to change behavior, such as: individually tailored oral-hygiene instructions; a smoking-cessation program; dietary adjustment; subgingival instrumentation to remove plaque and calculus; local and systemic pharmacotherapy; and various types of surgery. No single treatment option has shown superiority, and virtually all types of mechanical periodontal treatment benefit from adjunctive antimicrobial chemotherapy. Periodontal treatment, because of the chronic nature of periodontitis, is a lifelong commitment to intricate oral-hygiene techniques, which, when properly implemented, will minimize the risk of disease initiation and progression.

Effects of periodontal treatment on carotid intima-media thickness in patients with lifestyle-related diseases: Japanese prospective multicentre observational study

Atherosclerosis, a chronic inflammatory disease in arterial blood vessels, is one of the major causes of death in worldwide. Meanwhile, periodontal disease is a chronic inflammatory disease caused by infection with periodontal pathogens such as P. gingivalis (Porphyromonas gingivalis). Several studies have reported association between periodontal infection and atherosclerosis, but direct investigation about the effects of periodontal treatment on atherosclerosis has not been reported. We have planned Japanese local clinics to determine the relationship between periodontal disease and atherosclerosis under collaborative with medical and dental care. A prospective, multicentre, observational study was conducted including 38 medical patients with lifestyle-related diseases in the stable period under consultation at participating medical clinics and 92 periodontal patients not undergoing medical treatment but who were consulting at participating dental clinics. Systemic and periodontal examinations were performed before and after periodontal treatment. At baseline, LDL-C (low-density lipoprotein cholesterol) levels and percentage (%) of mobile teeth were positively related to plasma IgG (immunoglobulin) antibody titer against P. gingivalis with multivariate analysis. Corresponding to improvements in periodontal clinical parameters after treatment, right and left max IMT (maximum intima-media thickness) levels were decreased significantly after treatment (SPT-S: start of supportive periodontal therapy, SPT-1y: at 1 year under SPT, and SPT-3y: at 3 years under SPT). The present study has clarified our previous univariate analysis results, wherein P. gingivalis infection was positively associated with progression of atherosclerosis. Thus, routine screening using plasma IgG antibody titer against P. gingivalis and periodontal treatment under collaborative with medical and dental care may prevent cardiovascular accidents caused by atherosclerosis.

Oral health and cardiovascular care: Perceptions of people with cardiovascular disease

MAIN OBJECTIVE

The aim of this study was to explore the perception of patients with cardiovascular disease towards oral health and the potential for cardiac care clinicians to promote oral health.

METHOD

A needs assessment was undertaken with twelve patients with cardiovascular disease attending cardiac rehabilitation between 2015 and 2016, in three metropolitan hospitals in Sydney, Australia. These patients participated in face-to-face semi-structured interviews. Data was analysed using thematic analysis.

RESULTS

Results suggested that while oral health was considered relevant there was high prevalence of poor oral health among participants, especially those from socioeconomic disadvantaged background. Awareness regarding the importance of oral health care its impact on cardiovascular outcomes was poor among participants. Oral health issues were rarely discussed in the cardiac setting. Main barriers deterring participants from seeking oral health care included lack of awareness, high cost of dental care and difficulties in accessing the public dental service. Findings also revealed that participants were interested in receiving further information about oral health and suggested various mediums for information delivery. The concept of cardiac care clinicians, especially nurses providing education, assessment and referrals to ongoing dental care was well received by participants who felt the post-acute period was the most appropriate time to receive oral health care advice. The issues of oral health training for non-dental clinicians and how to address existing barriers were highlighted by participants.

RELEVANCE TO CLINICAL PRACTICE

The lack of oral health education being provided to patients with cardiovascular disease offers an opportunity to improve care and potentially, outcomes. In view of the evidence linking poor oral health with cardiovascular disease, cardiac care clinicians, especially nurses, should be appropriately trained to promote oral health in their practice. Affordable and accessible dental care services for people with cardiovascular disease should be considered and offered by health services in Australia.

Effect of periodontal therapy with systemic antimicrobials on parameters of metabolic syndrome: A randomized clinical trial

Aim

To investigate the effect of basic periodontal therapy (BPT) with antimicrobials (AM) on the parameters of metabolic syndrome (MetS) (waist circumference, systolic/diastolic blood pressure [BP], HDL‐cholesterol, triglycerides, glucose).

Methods

One hundred and ten periodontitis patients without known comorbidities and unaware of possible MetS were randomly assigned to BPT (n = 56) or BPT+AM (n = 54) and followed for 12 months post‐therapy. Number of patients with undiagnosed MetS was also determined.

Results

In all patients, the periodontal condition improved; however, the BTP+AM group showed greater pocket depth reduction than the BPT group. Post‐therapy, systolic BP (p < .05) and triglycerides (p < .05) reduced significantly during the follow‐up period. No significant differences could be assessed between the BPT+AM and BPT group. Despite the absence of self‐reported comorbidities, 27.2% (n = 30) periodontitis patients fulfilled the criteria of MetS at baseline. After therapy, this proportion changed to 14.5% at 3 months (p = .007), to 17.3% at 6 months (p = .017) and to 21.8% at 12‐month follow‐up (p = .383).

Conclusion

Although a reduction in systolic BP and triglycerides and a temporarily improvement in the whole metabolic status were observed, the use of antimicrobials in conjunction with BTP does not yield any additional improvement in the parameters of MetS.

Serum lipids modify periodontal infection - interleukin-6 association

AIM

The aim of this study was to investigate whether the systemic response against a local inflammatory process in periodontium is dependent on the individual's serum lipid composition.

MATERIAL AND METHODS

This study was based on a subpopulation of the Health 2000 Survey that included 878 subjects who were aged between 45 and 64 years, dentate, non-diabetic and non-rheumatic. The inflammatory condition of periodontium was measured by means of the number of teeth with deepened (4 mm or deeper) periodontal pockets. Systemic inflammation was assessed by means of the serum levels of interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α). The association between an inflammatory condition in the periodontium and the systemic inflammatory response was analysed using linear regression models.

RESULTS

The number of teeth with deepened periodontal pockets was associated with elevated serum IL-6 levels among subjects with an unfavourable lipid composition (low-density lipoprotein cholesterol ≥3.7 mmol/l or high-density lipoprotein cholesterol <1.3 mmol/l). There was no association between serum TNF-α levels and the number of teeth with deepened periodontal pockets in these data.

CONCLUSION

The systemic response against the inflammatory condition of periodontium varied between individuals. The variation appeared to be dependent on the serum lipid composition or related factors.

Salivary and serum procalcitonin and C-reactive protein as biomarkers of periodontitis in United States veterans with osteoarthritis or rheumatoid arthritis

Serum procalcitonin (ProCT) is elevated in response to bacterial infections, whereas high sensitivity C-reactive protein (hsCRP) is a nonspecific inflammatory marker that is increased by excess adipose tissue. We examined the efficacy of ProCT and hsCRP as biomarkers of periodontitis in the saliva and serum of patients with arthritis, which is characterized by variable levels of systemic inflammation that potentially can confound the interpretation of inflammatory biomarkers. Blood and unstimulated whole saliva were collected from 33 patients with rheumatoid arthritis (RA) and 50 with osteoarthritis (OA). Periodontal status was assessed by full mouth examination and patients were categorized as having no/mild, moderate or severe periodontitis by standard parameters. Salivary and serum ProCT and hsCRP concentrations were compared. BMI, diabetes, anti-inflammatory medications and smoking status were ascertained from the patient records. Differences between OA and RA in proportionate numbers of patients were compared for race, gender, diabetes, adiposity and smoking status. Serum ProCT was significantly higher in arthritis patients with moderate to severe and severe periodontitis compared with no/mild periodontitis patients. There were no significant differences in salivary ProCT or salivary or serum hsCRP in RA patients related to periodontitis category. Most of the OA and RA patients were middle aged or older, 28.9% were diabetic, 78.3% were overweight or obese, and slightly more than half were either current or past smokers. The OA and RA groups differed by race, but not gender; blacks and males were predominant in both groups. The OA and RA groups did not differ in terms of controlled or uncontrolled diabetes, smoking status or BMI. The RA patients had been prescribed more anti-inflammatory medication than the OA patients. Our results demonstrate that circulating ProCT is a more discriminative biomarker for periodontitis than serum hsCRP in patients with underlying arthritis. Any elevation in salivary and serum hsCRP due to periodontitis apparently was overshadowed by differences among these patients in factors that influence CRP, such as the extent of inflammation between RA and OA, the extent of adipose tissue, the use of anti- inflammatory medications and smoking status. Although our study showed no differences in salivary ProCT related to severity of periodontitis, this biomarker also may be useful with further refinement.

Periodontitis, cardiovascular disease and pregnancy outcome--focal infection revisited?

Over the last two decades there has been a renewed interest around the possible effects of periodontal disease on both cardiovascular health and pregnancy outcome (among other diseases), a topic which has interested science for hundreds of years. These have led to a range of studies, workshops and consensus documents being published, with corresponding coverage in general and professional media. In this article the authors summarise the history and supporting theories behind such associations, whether clinical studies have been able to confirm these and what this might mean for general practitioners who are questioned on this topic by patients.

Relation of Periodontitis to Risk of Cardiovascular and All-Cause Mortality (from a Danish Nationwide Cohort Study)

Periodontitis and atherosclerosis are highly prevalent chronic inflammatory diseases, and it has been suggested that periodontitis is an independent risk factor of cardiovascular disease (CVD) and that a causal link may exist between the 2 diseases. Using Danish national registers, we identified a nationwide cohort of 17,691 patients who received a hospital diagnosis of periodontitis within a 15-year period and matched them with 83,003 controls from the general population. We performed Poisson regression analysis to determine crude and adjusted incidence rate ratios of myocardial infarction, ischemic stroke, cardiovascular death, major adverse cardiovascular events, and all-cause mortality. The results showed that patients with periodontitis were at higher risk of all examined end points. The findings remained significant after adjustment for increased baseline co-morbidity in periodontitis patients compared with controls, for example, with adjusted incidence rate ratio 2.02 (95% CI 1.87 to 2.18) for cardiovascular death and 2.70 (95% CI 2.60 to 2.81) for all-cause mortality. Patients with a hospital diagnosis of periodontitis have a high burden of co-morbidity and an increased risk of CVD and all-cause mortality. In conclusion, our results support that periodontitis may be an independent risk factor for CVD.

Periodontitis and systemic diseases: a record of discussions of working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

There has been an explosion in research into possible associations between periodontitis and various systemic diseases and conditions.

AIM

To review the evidence for associations between periodontitis and various systemic diseases and conditions, including chronic obstructive pulmonary disease (COPD), pneumonia, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and cancer, and to document headline discussions of the state of each field. Periodontal associations with diabetes, cardiovascular disease and adverse pregnancy outcomes were not discussed by working group 4.

RESULTS

Working group 4 recognized that the studies performed to date were largely cross-sectional or case-control with few prospective cohort studies and no randomized clinical trials. The best current evidence suggests that periodontitis is characterized by both infection and pro-inflammatory events, which variously manifest within the systemic diseases and disorders discussed. Diseases with at least minimal evidence of an association with periodontitis include COPD, pneumonia, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and cancer. The working group agreed that there is insufficient evidence to date to infer causal relationships with the exception that organisms originating in the oral microbiome can cause lung infections.

CONCLUSIONS

The group was unanimous in their opinion that the reported associations do not imply causality, and establishment of causality will require new studies that fulfil the Bradford Hill or equivalent criteria. Precise and community-agreed case definitions of periodontal disease states must be implemented systematically to enable consistent and clearer interpretations of studies of the relationship to systemic diseases. The members of the working group were unanimous in their opinion that to develop data that best inform clinicians, investigators and the public, studies should focus on robust disease outcomes and avoid surrogate endpoints. It was concluded that because of the relative immaturity of the body of evidence for each of the purported relationships, the field is wide open and the gaps in knowledge are large.

Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

This consensus report is concerned with the association between periodontitis and atherosclerotic cardiovascular disease (ACVD). Periodontitis is a chronic multifactorial inflammatory disease caused by microorganisms and characterized by progressive destruction of the tooth supporting apparatus leading to tooth loss; as such, it is a major public health issue.

AIMS

This report examined biological plausibility, epidemiology and early results from intervention trials. PLAUSIBILITY: Periodontitis leads to entry of bacteria in the blood stream. The bacteria activate the host inflammatory response by multiple mechanisms. The host immune response favors atheroma formation, maturation and exacerbation.

EPIDEMIOLOGY

In longitudinal studies assessing incident cardiovascular events, statistically significant excess risk for ACVD was reported in individuals with periodontitis. This was independent of established cardiovascular risk factors. The amount of the adjusted excess risk varies by type of cardiovascular outcome and across populations by age and gender. Given the high prevalence of periodontitis, even low to moderate excess risk is important from a public health perspective.

INTERVENTION

There is moderate evidence that periodontal treatment: (i) reduces systemic inflammation as evidenced by reduction in C-reactive protein (CRP) and improvement of both clinical and surrogate measures of endothelial function; but (ii) there is no effect on lipid profiles--supporting specificity. Limited evidence shows improvements in coagulation, biomarkers of endothelial cell activation, arterial blood pressure and subclinical atherosclerosis after periodontal therapy. The available evidence is consistent and speaks for a contributory role of periodontitis to ACVD. There are no periodontal intervention studies on primary ACVD prevention and there is only one feasibility study on secondary ACVD prevention.

CONCLUSIONS

It was concluded that: (i) there is consistent and strong epidemiologic evidence that periodontitis imparts increased risk for future cardiovascular disease; and (ii) while in vitro, animal and clinical studies do support the interaction and biological mechanism, intervention trials to date are not adequate to draw further conclusions. Well-designed intervention trials on the impact of periodontal treatment on prevention of ACVD hard clinical outcomes are needed.

Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

This consensus report is concerned with the association between periodontitis and atherosclerotic cardiovascular disease (ACVD). Periodontitis is a chronic multifactorial inflammatory disease caused by microorganisms and characterized by progressive destruction of the tooth supporting apparatus leading to tooth loss; as such, it is a major public health issue.

AIMS

This report examined biological plausibility, epidemiology and early results from intervention trials. PLAUSIBILITY: Periodontitis leads to entry of bacteria in the blood stream. The bacteria activate the host inflammatory response by multiple mechanisms. The host immune response favors atheroma formation, maturation and exacerbation.

EPIDEMIOLOGY

In longitudinal studies assessing incident cardiovascular events, statistically significant excess risk for ACVD was reported in individuals with periodontitis. This was independent of established cardiovascular risk factors. The amount of the adjusted excess risk varies by type of cardiovascular outcome and across populations by age and gender. Given the high prevalence of periodontitis, even low to moderate excess risk is important from a public health perspective.

INTERVENTION

There is moderate evidence that periodontal treatment: (i) reduces systemic inflammation as evidenced by reduction in C-reactive protein (CRP) and improvement of both clinical and surrogate measures of endothelial function; but (ii) there is no effect on lipid profiles - supporting specificity. Limited evidence shows improvements in coagulation, biomarkers of endothelial cell activation, arterial blood pressure and subclinical atherosclerosis after periodontal therapy. The available evidence is consistent and speaks for a contributory role of periodontitis to ACVD. There are no periodontal intervention studies on primary ACVD prevention and there is only one feasibility study on secondary ACVD prevention.

CONCLUSIONS

It was concluded that: (i) there is consistent and strong epidemiologic evidence that periodontitis imparts increased risk for future cardiovascular disease; and (ii) while in vitro, animal and clinical studies do support the interaction and biological mechanism, intervention trials to date are not adequate to draw further conclusions. Well-designed intervention trials on the impact of periodontal treatment on prevention of ACVD hard clinical outcomes are needed.

Clinical research activity in periodontal medicine: a systematic mapping of trial registers

AIM

The primary aim of the study was to systematically map registration records on periodontal medicine in clinical trial registers. The secondary aim was to assess the evolution of periodontal medicine in clinical periodontal research as a whole.

MATERIAL AND METHODS

We searched all registration records related to periodontology in the World Health Organization International Clinical Trials Registry Platform. For registration records classified in the field of periodontal medicine, we assigned the 2015 MeSH(®) term for the most precisely corresponding systemic condition.

RESULTS

Fifty-seven systemic conditions have been hypothesized to be linked with periodontal diseases, covering nearly 2% of the diseases indexed in MeSH. In addition to diabetes, cardiovascular disease or preterm birth, other systemic conditions have been the subject of registration records, such as anaemia, liver diseases, dyspepsia or ankylosing spondylitis. A trend towards increasing diversification of systemic conditions has appeared over time. About a third of registration records in clinical periodontal research deals with periodontal medicine.

CONCLUSIONS

Periodontal medicine now constitutes an important part of clinical periodontal research. Research activity in periodontal medicine has grown continuously since the early 2000s, and exploration of registers gives a useful up-to-date snapshot of this constantly evolving field of research.

Short-term changes on C-reactive protein (CRP) levels after non-surgical periodontal treatment in systemically healthy individuals

OBJECTIVES

The aim of the present study was to evaluate serum C-reactive protein (CRP) levels in chronic periodontitis patients and periodontally healthy individuals and to assess the effect of non-surgical periodontal treatment on the CRP levels.

MATERIALS AND METHODS

Twenty-two patients with chronic periodontitis (test group) and 22 periodontally healthy individuals (control group), both groups without any systemic disorder or potential confounding factors, were included in the study. At baseline, periodontal clinical variables and CRP levels were obtained in both groups. In the test group, oral hygiene instruction and scaling and root planning were carried out; then, after 60 days, periodontal clinical variables and CRP levels were reevaluated.

RESULTS

The baseline CRP level in the test group was significantly higher than the corresponding value in the control group (1.98 ± 1.55 vs. 1.26 ± 1.05 mg/L; p < 0.05). After periodontal treatment in the test group, there were improvements in all periodontal clinical variables (p < 0.05). The CRP level decreased significantly in those patients with higher baseline levels of CRP (>3 mg/L).

CONCLUSIONS

Chronic periodontitis seemed to promote elevated levels of CRP. Furthermore, non-surgical periodontal treatment significantly decreased the levels of CRP only in patients with high baseline levels of such pro-inflammatory cytokine.

CLINICAL RELEVANCE

Periodontitis may be a potential factor to change the risk of CVD. Thus, the control of periodontal infection performed by health professionals may improve cardiovascular health.

Absence of Bacteria on Coronary Angioplasty Balloons from Unselected Patients: Results with Use of a High Sensitivity Polymerase Chain Reaction Assay

Periodontitis is a chronic, bacterially-induced inflammatory disease of the tooth-supporting tissues, which may result in transient bacteremia and a systemic inflammatory response. Periodontitis is associated with coronary artery disease independently of established cardiovascular risk factors, and translocation of bacteria from the oral cavity to the coronary arteries may play a role in the development of coronary artery disease. Very few studies have used angioplasty balloons for in vivo sampling from diseased coronary arteries, and with varying results. Therefore, the aim of this study was to assess if bacterial DNA from primarily oral bacteria could be detected on coronary angioplasty balloons by use of an optimized sampling process combined with an internally validated sensitive polymerase chain reaction (PCR) assay. Coronary angioplasty balloons and control samples from a total of 45 unselected patients with stable angina, unstable angina/non-ST elevation myocardial infarction, and ST-elevation myocardial infarction (n = 15 in each group) were collected and analyzed using a PCR assay with high sensitivity and specificity for 16S rRNA genes of the oral microbiome. Despite elimination of extraction and purification steps, and demonstration of sensitivity levels of 25–125 colony forming units (CFU), we did not detect bacterial DNA from any of the coronary angioplasty balloons. A subsequent questionnaire indicated that the prevalence of periodontitis in the study cohort was at least 39.5%. Although coronary angioplasty balloons are unlikely to be useful for detection of bacteria with current PCR techniques in unselected patients with coronary artery disease, more studies are warranted to determine the extent to which bacteria contribute to atherosclerosis and its clinical manifestations and whether the presence of bacteria in the arteries is a transient phenomenon.

Systemic Biomarkers in 2-Phase Antibiotic Periodontal Treatment: A Randomized Clinical Trial

Accumulating evidence suggests that periodontal infections may have an impact on systemic health. In patients with untreated periodontitis, very high values for several inflammatory markers in serum are expressed simultaneously. We investigated to what extent these peak values change after nonsurgical and surgical periodontal treatment, with adjunctive antibiotics administered during the first or the second treatment phase. In a single-center, randomized, placebo-controlled, and double-masked clinical trial, 80 patients with chronic or aggressive periodontitis were randomized into 2 treatment groups: group A, receiving systemic amoxicillin and metronidazole during the first, nonsurgical phase of periodontal therapy (phase 1), and group B, receiving the antibiotics during the second, surgical phase (phase 2). Serum samples were obtained at baseline (BL), 3 mo after phase 1 (M3), and 6 and 12 mo after phase 2 (M6, M12). Samples were evaluated for 15 cytokines and 9 acute-phase proteins using the Bio-Plex bead array multianalyte detection system. For each analyte, peak values were defined as greater than mean +2 SD of measurements found in 40 periodontally healthy persons. Sixty-six patients showed a peak value of at least 1 analyte at BL. At M12, the number of these patients was only 36 (P = 0.0002). This decrease was stronger in group A (BL: 35, M12: 19, P = 0.0009) than in group B (BL: 31, M12: 17, P = 0.14). Twenty patients displayed peak values of at least 4 biomarkers at BL. The nonsurgical therapy delivered in the first phase reduced most of these peaks (group A, BL: 9, M3: 4, P = 0.17; group B, BL: 11, M3: 2, P = 0.01), irrespective of adjunctive antibiotics. The reductions obtained at M3 were maintained until M12 in both groups. Initial, nonsurgical periodontal therapy reduced the incidence of peak levels of inflammatory markers. Antibiotics and further surgical therapy did not enhance the effect (Clinicaltrials.gov NCT02197260).

Manifesto for a paradigm shift: periodontal health for a better life

This article outlines the European Federation of Periodontology's (EFP) manifesto Periodontal Health for a Better Life which was informed by the first joint EFP/American Academy of Periodontology workshop on periodontitis and systemic health. The EFP manifesto calls upon the dental profession to engage in screening and providing preventive advice to patients who are at risk of common chronic diseases and conditions such as cardiovascular disease, diabetes and cancer. In particular, the article emphasises the dental team's role in promoting behaviour change in their patients aimed at reducing smoking and obesity levels, by promoting healthy nutrition and exercise. The chairman of the National Association of Primary Care Medicine, Dr Charles Alessi, has strongly endorsed this model and highlighted the important opportunities offered by a capitation-based new contract for the dental team to engage fully in preventive medicine in support of medical colleagues and in the best interests of public health and patients across England.

The Epidemiologic and Clinical Findings of Patients with Buerger Disease

BACKGROUND

Buerger disease is a nonatherosclerotic peripheral arterial disease, which is mostly observed in young male smokers. Buerger disease is characterized by the observation of peripheral arterial occlusion by angiography. The condition may be caused by microembolization in the small-sized arteries of the distal extremities. Buerger disease is diagnosed based on the Shionoya's clinical diagnostic criteria, which include: (1) a history of smoking, (2) onset before the age of 50 years, (3) the presence of infrapopliteal arterial occlusions, (4) either upper limb involvement or phlebitis migrans, and (5) the absence of atherosclerotic risk factors other than smoking. Several studies have reported that oral bacterial infections (periodontitis) could activate the onset of Buerger disease. In this study, we report the epidemiologic and clinical manifestations of patients with Buerger disease.

METHODS

Fifty-eight patients who were surgically treated between July 1989 and June 2014 at Tokyo Medical and Dental University Hospital were enrolled in this study. All of the patients clinically diagnosed with Buerger disease based on Shionoya's clinical diagnostic criteria. Fifty-five male and 3 female patients were treated. The mean age of the patients was 48 years (range, 21-73 years).

RESULTS

All of the patients were either smokers or had a history of smoking. The mean Brinkman index score was 780 (range, 150-1,640). Their mean age at the onset of Buerger disease was 38 years (range, 21-50). The arterial lesions extended to the femoral arteries in 25% of cases, to the iliac arteries in 8% and to the abdominal aorta and/or visceral arteries in 6% of cases. Upper limb involvement, including cyanosis, paleness, and gangrene, was obvious in 84% of patients, and phlebitis migrans was recognized in 34%. The lower extremities symptoms involved intermittent claudication in 23% of the patients, rest pain in 13% of the patients, and ulceration or gangrene in 64% of the patients. Fifteen patients had undergone surgical arterial reconstruction, 4 patients had received endovascular therapy, 33 patients had undergone lumbar sympathectomy and 8 patients had undergone thoracic sympathectomy. Twenty percent of the patients needed minor limb amputations, and 4% required major limb amputations. In the patients who were examined for their oral conditions, periodontitis corresponding to grades B (moderate periodontitis), C (severe periodontitis), and D (edentulous patients) was revealed in 31%, 56%, and 13% of the patients, respectively.

CONCLUSIONS

More than half of the Buerger disease patients in this study were suffering from severe periodontitis. It is possible that not only the cessation of smoking, but also the improvement of periodontal care could improve the clinical symptoms related to Buerger disease.

Effect of Non-Surgical Periodontal Treatment on Clinical and Biochemical Risk Markers of Cardiovascular Disease: A Randomized Trial

BACKGROUND

Various studies have shown periodontal disease is one of the risk factors for coronary heart disease (CHD), and periodontal treatment of patients with CHD has also been correlated with reduction in systemic markers of CHD. The aim of this study is to evaluate the effect of non-surgical periodontal treatment (NSPT) on the cardiovascular clinical and biochemical status of patients with CHD.

METHODS

Seventy known patients with CHD were allocated randomly to either a control group (C; no periodontal therapy) (n = 35) or an experimental group (E; NSPT in the form of scaling and root planing [SRP]) (n = 35). Cardiovascular status was assessed using clinical parameters such as pulse, respiratory rate, blood pressure (BP), and biochemical parameters, such as high-sensitivity C-reactive protein (hsCRP), lipid profile, and white blood cell (WBC) count, at baseline and 1, 3, and 6 months. Intergroup and intragroup comparisons were performed using Student t test, and P <0.05 was considered statistically significant.

RESULTS

The complete data at the end of the study were provided by only 55 patients (group C, n = 25; group E, n = 30). Highly statistically significant reduction was observed in systolic BP (7.1 mm Hg) and very-low-density lipoproteins (VLDLs; 5.16 mg/dL) in group E. Changes were also observed in other cardiovascular biochemical and clinical parameters but were not statistically significant.

CONCLUSIONS

NSPT (in the form of SRP) positively affects limited cardiovascular (clinical and biochemical) status of patients with CHD. Reduction in triglyceride, VLDL, total WBC, lymphocyte, and neutrophil counts and increase in hsCRP, total cholesterol, high-density lipoprotein, and low-density lipoprotein levels were observed. Highly significant reduction in VLDL cholesterol levels and systolic BP was observed among the various parameters measured.

[The epidemiological relationship of periodontitis, intestinal dysbiosis, atherogenic dyslipidemia and metabolic syndrome]

The study of risk factors for cardio-vascular continuum (CVC), the influence of the digestive tract endobiosis on lipid-carbohydrate metabolism and clinical status, a retrospective analysis of 1000 medical records of patients, suffering from various diseases of internal organs (Gastrointestinal tract, coronary heart disease, type 2 diabetes, obesity) in combination with periodontitis of varying severity, aged 20 to 55 years. A statistically significant relationship is directly proportional to the severity of inflammation of periodontal tissues with body mass index (BMI), especially pronounced in patients with a BMI ≥225 kg/m2 which is the "calling card" of the metabolic syndrome - clinical model polymorbidity.

Periodontal therapy and systemic inflammation in type 2 diabetes mellitus: a meta-analysis

AIM

The aim of this systematic review was to assess the effect of periodontal therapy (PT) on serum levels of inflammatory markers in people with type 2 diabetes mellitus (T2DM).

METHODS OF STUDY SELECTION

A literature search was carried out using MEDLINE via Pubmed, EMBASE, LILACS and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Randomized-controlled trials (RCTs) and controlled clinical trials (CCTs) evaluating the effect of PT on systemic inflammatory markers were deemed eligible. Case series (CS), reports and pilot trials were excluded. Study quality was assessed using the Cochrane Collaboration's risk assessment tool. Meta-analysis was carried out using random effect methods.

RESULTS

The search strategy identified 3,164 potential studies of which 61 were assessed for eligibility and 9 (6 RCTs and 3 CCTs) were included in this systematic review. Three RCTs were classified by the authors as being at low risk of bias and three were "unclear" and classified as uncertain risk of bias. All CCTs were considered to be at a high risk of bias. The meta-analysis showed a statistically significant mean difference (MD) for TNF- α (-1.33 pg/ml, 95% CI: -2.10; -0.56, p<0.001) and CRP (-1.28 mg/l, 95% CI: -2.07; - 0.48, p<0.001) favoring periodontal intervention versus control.

CONCLUSION

The results of this meta-analysis support the hypothesis that PT reduces serum levels of TNF- α and CRP in T2DM individuals. The decrease of inflammatory burden has important implications for metabolic control and can, in part, explain the mechanisms linking periodontitis and increased risk for complications in people with T2DM.

Local and serum levels of adipokines in patients with obesity after periodontal therapy: one-year follow-up

AIM

This study evaluated the effects of scaling and root planing (SRP) on gingival crevicular fluid (GCF) and serum levels of adipokines in patients with chronic periodontitis (CP) with or without obesity.

METHODS

Twenty patients with obesity and 20 patients without obesity, all with CP, received SRP. Serum and GCF levels of resistin, adiponectin, leptin, tumour necrosis factor [TNF]-α and interleukin [IL]-6 were evaluated by enzyme-linked immunosorbent assay at baseline, 3, 6 and 12 months post-therapy.

RESULTS

SRP reduced the amounts of TNF-α in deep sites and increased the concentration of adiponectin in shallow sites of non-obese patients (p < 0.05). SRP increased the concentrations of TNF-α and leptin in patients with obesity (p < 0.05). GCF levels of TNF-α were higher in patients with obesity than in patients without obesity at all time-points (p < 0.05). There were no changes in serum levels of any adipokines for any group after therapy (p > 0.05). Patients with obesity exhibited higher serum levels of leptin at all time-points and IL-6 at 3 months post-therapy (p < 0.05).

CONCLUSIONS

Obesity may modulate systemic and periodontal levels of adipokines in favour of pro-inflammation, independently of periodontal therapy. SRP did not affect the circulating levels of adipokines in patients with or without obesity.

Effect of non-surgical periodontal therapy on plasma homocysteine levels in Indian population with chronic periodontitis: a pilot study

AIM

Homocysteine (Hcy) is implicated in the development of cardiovascular diseases (CVD). The effect of periodontal disease and periodontal therapy on plasma Hcy remains controversial. Hence, in this pilot study we assessed the effect of periodontal disease and non-surgical periodontal therapy (NSPT) on plasma Hcy in systemically healthy Indian subjects.

MATERIALS AND METHODS

Forty participants (30 to 39 years) were enrolled in the study and were divided into two groups based on gingival index, probing depth, and clinical attachment level (CAL): Healthy (control group; n = 20) and Chronic Periodontitis (test group; n = 20). Plasma samples were collected and quantified at baseline and 12 weeks after scaling and root planing (SRP) for Hcy using High Performance Liquid Chromatography with fluorescent detection (HPLC-fld).

RESULTS

Plasma Hcy levels of chronic periodontitis (17.87 ± 1.21 μmol/l) subjects was significantly higher than healthy subjects (9.09 ± 2.11 μmol/l). Post-therapy, the plasma Hcy concentration reduced significantly (11.34 ± 1.87 μmol/l) (p < 0.05).

CONCLUSION

The rise and descent of plasma Hcy levels with periodontal inflammation and therapy, respectively, indicate a direct relationship of Hcy with chronic periodontitis. NSPT may be employed as an adjunctive Hcy Lowering Therapy, contributing towards primary prevention against CVD's.

Periodontal Disease and its Association with Angiographically Verified Coronary Artery Disease

PURPOSE

The aim of this research was to investigate the association of chronic and aggressive periodontitis with the severity of coronary artery disease which was angiographically verified.

MATERIAL AND METHODS

Subjects were selected among the hospitalized patients at the University Hospital Centre Zagreb who had coronary angiography done because of the chest pain. Thorough clinical examination included periodontal indices and clinical and socio-demographic characteristics of participants. Subjects were divided in two test groups, acute coronary syndrome (ACS) and stable coronary artery disease (CAD), and the control group with no significant CAD. Data were analyzed using Kruskal-Wallis and Pearson's Chi-Square test.

RESULTS

From 106 subjects, 66 (62.3%) were hospitalized for ACS, 22 (20.7%) had stable CAD and only 18 (17.0%) had no significant CAD. Only 26 (24.5%) out of 106 patients were never smokers (p<0.05). Chronic periodontitis was the most common finding with 68.2% in ACS group and 54.5% in stable CAD group, while healthy patients without periodontitis (72.6%) were dominant in the control group (p<0.001). Stable CAD group had the highest mean probing depth (PD) 3.92±1.16, gingival recession (GR) 1.34±0.78, clinical attachment level (CAL) 4.60±1.41 and bleeding on probing (BOP) 45.98±26.19 values, whereas ACS group had mean PD value of 3.77±0.91, GR 1.11±0.66, CAL 4.32±1.08 and BOP 41.30±22.09, and no significant CAD group had mean PD value of 3.27±0.97, GR 0.69±0.37, CAL 3.62±1.04 and BOP 26.39±13.92 (p<0.05).

CONCLUSION

Periodontitis was shown to be associated with angiographically verified coronary artery disease. Physical inactivity, poor oral hygiene and periodontal inflammation were observed in patients with ACS and stable CAD.

Associations between the number of natural teeth and metabolic syndrome in adults

AIM

To explore associations between the number of natural teeth and metabolic syndrome in adults.

MATERIAL AND METHODS

Cross-sectional data from the National Health and Nutrition Examination Survey 2005-2008 were used. Eligible adults (n = 5511) were classified into four groups by their number of natural teeth (excluding third molars): full dentition, 21-27 teeth, 1-20 teeth, or edentulous. Metabolic syndrome was defined by diagnostic guidelines from the American Heart Association and National Heart, Lung, and Blood Institute. Associations were analysed by survey logistic regression. Biometric and metabolic parameters in different dentition groups were compared.

RESULTS

Adjusting for age, gender, race/ethnicity, ratio of family income to poverty, physical activity, smoking, and energy intake, tooth loss was significantly associated with metabolic syndrome (p = 0.002). Compared to participants with full dentition, the odds were 32% higher in those with 21-27 teeth, 55% higher in those with 1-20 teeth and 79% higher in edentulous participants. The number of natural teeth was inversely associated with body mass index, waist circumference, blood pressure, fasting plasma glucose and insulin concentrations (p < 0.01 for all); it was positively associated with serum HDL cholesterol concentration (p = 0.003).

CONCLUSIONS

The number of natural teeth is inversely associated with the presence of metabolic syndrome in adults.

Cardiovascular risks associated with incident and prevalent periodontal disease

AIM

While prevalent periodontal disease associates with cardiovascular risk, little is known about how incident periodontal disease influences future vascular risk. We compared effects of incident versus prevalent periodontal disease in developing major cardiovascular diseases (CVD), myocardial infarction (MI), ischaemic stroke and total CVD.

MATERIAL AND METHODS

In a prospective cohort of 39,863 predominantly white women, age ≥45 years and free of cardiovascular disease at baseline were followed for an average of 15.7 years. Cox proportional hazard models with time-varying periodontal status [prevalent (18%), incident (7.3%) versus never (74.7%)] were used to assess future cardiovascular risks.

RESULTS

Incidence rates of all CVD outcomes were higher in women with prevalent or incident periodontal disease. For women with incident periodontal disease, risk factor adjusted hazard ratios (HRs) were 1.42 (95% CI, 1.14-1.77) for major CVD, 1.72 (1.25-2.38) for MI, 1.41 (1.02-1.95) for ischaemic stroke and 1.27 (1.06-1.52) for total CVD. For women with prevalent periodontal disease, adjusted HRs were 1.14 (1.00-1.31) for major CVD, 1.27 (1.04-1.56) for MI, 1.12 (0.91-1.37) for ischaemic stroke and 1.15 (1.03-1.28) for total CVD.

CONCLUSION

New cases of periodontal disease, not just those that are pre-existing, place women at significantly elevated risks for future cardiovascular events.

Effects of periodontal therapy on C-reactive protein and HDL in serum of subjects with periodontitis

Objective

To investigate the effects of nonsurgical periodontal therapy on levels of high-sensitivity C-reactive protein in the sera and its association with body mass index and high density lipoprotein in subjects with severe periodontitis.

Methods

Sera from 28 subjects (mean age: 34.36±6.24; 32% men) with severe periodontitis and 27 healthy controls (mean age: 33.18±6.42; 33% men) were collected prior to periodontal therapy. Blood samples were obtained from 23 subjects who completed therapy (9-12 months). Oral and systemic parameters such as the number of blood cells, glucose examination, lipid profile, and high-sensitivity C-reactive protein levels accessed by high-sensitivity immunonephelometry assay, were included.

Results

Before therapy, in the periodontitis group, the ratio of subjects with high-sensitivity C-reactive protein <0.3 mg/dL was statistically lower than in the control group (P<0.0216). After therapy, the ratio of subjects with high-sensitivity C-reactive protein <0.3 mg/dL was significantly higher (65.22%) (P<0.0339). The mean value for body mass index was statistically lower in subjects with high-sensitivity C-reactive protein <0.3 mg/dL (24.63±4.19), compared with those with high-sensitivity C-reactive protein >0.3 mg/dL (28.91±6.03) (P<0.0411). High density lipoprotein presented a mean value statistically higher after therapy (P<0.0027).

Conclusion

In systemically healthy subjects with periodontitis, periodontal therapy was associated with decreased levels of circulating high-sensitivity C-reactive protein and increase of high density lipoprotein in serum. The clinical trial was registered at http://www.clinicaltrials.gov.br/, No. RBR-24T799.

The Infection Hypothesis Revisited: Oral Infection and Cardiovascular Disease

Background. The pathophysiology of cardiovascular disease (CVD) includes inflammation in the development of atherosclerosis and thrombosis. Increasing evidence supports oral infections, and in particular the common periodontal disease, to be associated with CVD development. Periodontal infection is present in populations worldwide and in the moderate to mild form in about 35% of populations according to the World Health Organization. Objective. This review of the literature aims to present cross evidence from medical research disciplines that explore how oral infections can contribute to increase the risk for CVDs and how treatment of oral infections can reduce the risk for CVDs. Design. Review article. Results. Long-term exposure to active nontreated infections of the oral cavity presents an opportunity for bacteria, bacterial products, and viruses to enter the circulation. Toxic bacterial products enter the circulation, affecting atherosclerosis, causing platelet adhesiveness that results in clot formation, and establishing cardiac vegetation. Pathological observations have identified oral bacteria in heart valves, aortic aneurysms, and arterial walls. Clinical intervention studies on periodontal disease reduce the risk level of serological predictors for CVDs. Conclusions. This paper presents evidence across medical research disciplines for oral infections to be considered as one of the risk factors for CVDs.

Impact of scaling and root planing on C-reactive protein levels in gingival crevicular fluid and serum in chronic periodontitis patients with or without diabetes mellitus

Purpose

The present study was conducted to evaluate the impact of scaling and root planing (SRP) on the C-reactive protein (CRP) levels of gingival crevicular fluid (GCF) and serum in chronic periodontitis patients with type 2 diabetes mellitus (T2DM-CP) or without type 2 diabetes mellitus (NDM-CP).

Methods

Forty-eight human participants were divided into two groups: an experimental (T2DM-CP) group (group I, n=24) comprising chronic periodontitis patients with random blood sugar ≥200 mg/dL and type 2 diabetes mellitus, and control (NDM-CP) group (group II, n=24) of those with chronic periodontitis and random blood sugar <200 without T2DM for the study. All subjects underwent nonsurgical periodontal therapy (NSPT) including complete SRP and subgingival debridement. Periodontal health parameters, plaque index (PI), gingival index (GI), probing pocket depth (PPD), clinical attachment level (CAL), GCF volume (GCF vol), GCF-CRP, random blood glucose (RBS), glycated hemoglobin, and systemic inflammatory markers, serum CRP, total leukocyte count (TLC), neutrophil count (Neutr) and lymphocyte count (Lymph), were evaluated at baseline, 1 month, and 3 months after SRP.

Results

NSPT resulted in statistically significant improvement in periodontal health parameters (PI, GI, PPD, CAL, GCF vol), CRP levels in serum as well as GCF of both groups I and II. The mean improvement in periodontal health parameters (PI, GI, PPD, CAL, GCF vol), CRP levels in serum and GCF was greater in group I than group II after NSPT. There was nonsignificant increase in GCF-CRP, TLC, Lymph, and RBS, and a significant increase in Neutr and Serum CRP in group II at 1 month. The Serum CRP level of 20 out of 24 group II patients had also increased at 1 month.

Conclusions

The CRP levels in both GCF and serum were higher in T2DM-CP patients than in NDM-CP patients. Although there was a significant improvement in both the groups, greater improvement was observed in both GCF and serum samples of T2DM-CP patients.

Graphical Abstract

The effect of periodontal therapy on cardiovascular risk markers: a 6-month randomized clinical trial

AIM

To determine the influence of non-surgical mechanical periodontal treatment on inflammatory markers related to risk for cardiovascular disease.

MATERIAL AND METHODS

A total of 64 patients with severe chronic periodontitis was randomly subjected to immediately periodontal treatment (test group, n = 32) or delayed periodontal treatment, without treatment during the study period (control group, n = 32). Clinical periodontal and laboratory examinations were performed at baseline (T0), 2 months (T2), and 6 months (T6) after the initial examinations (Control group) or completion of periodontal treatment (Test group).

RESULTS

After 2 months of periodontal treatment there was a significant reduction of erythrocyte sedimentation rate (ESR) and triglycerides (p = 0.002, p = 0.004, respectively) in the test group. Median values of C-reactive protein, ESR, total cholesterol, and triglycerides were reduced after 6 month of periodontal treatment in the test group (p < 0.001, p < 0.001, p < 0.001, and p = 0.015, respectively).

CONCLUSIONS

The non-surgical periodontal treatment was effective in reducing the levels of systemic inflammation markers and improved the lipid profile in subjects with severe chronic periodontitis.