Poor oral health and coronary heart disease

Alterations in diversity of the oral microbiome in pediatric inflammatory bowel disease

BACKGROUND

Oral pathology is a commonly reported extraintestinal manifestation of Crohn's disease (CD). The host-microbe interaction has been implicated in the pathogenesis of inflammatory bowel disease (IBD) in genetically susceptible hosts, yet limited information exists about oral microbes in IBD. We hypothesize that the microbiology of the oral cavity may differ in patients with IBD. Our laboratory has developed a 16S rRNA-based technique known as the Human Oral Microbe Identification Microarray (HOMIM) to study the oral microbiome of children and young adults with IBD.

METHODS

Tongue and buccal mucosal brushings from healthy controls, CD, and ulcerative colitis (UC) patients were analyzed using HOMIM. Shannon Diversity Index (SDI) and Principal Component Analysis (PCA) were employed to compare population and phylum-level changes among our study groups.

RESULTS

In all, 114 unique subjects from the Children's Hospital Boston were enrolled. Tongue samples from patients with CD showed a significant decrease in overall microbial diversity as compared with the same location in healthy controls (P = 0.015) with significant changes seen in Fusobacteria (P < 0.0002) and Firmicutes (P = 0.022). Tongue samples from patients with UC did not show a significant change in overall microbial diversity as compared with healthy controls (P = 0.418).

CONCLUSIONS

As detected by HOMIM, we found a significant decrease in overall diversity in the oral microbiome of pediatric CD. Considering the proposed microbe-host interaction in IBD, the ease of visualization and direct oral mucosal sampling of the oral cavity, further study of the oral microbiome in IBD is of potential diagnostic and prognostic value.

Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association

A link between oral health and cardiovascular disease has been proposed for more than a century. Recently, concern about possible links between periodontal disease (PD) and atherosclerotic vascular disease (ASVD) has intensified and is driving an active field of investigation into possible association and causality. The 2 disorders share several common risk factors, including cigarette smoking, age, and diabetes mellitus. Patients and providers are increasingly presented with claims that PD treatment strategies offer ASVD protection; these claims are often endorsed by professional and industrial stakeholders. The focus of this review is to assess whether available data support an independent association between ASVD and PD and whether PD treatment might modify ASVD risks or outcomes. It also presents mechanistic details of both PD and ASVD relevant to this topic. The correlation of PD with ASVD outcomes and surrogate markers is discussed, as well as the correlation of response to PD therapy with ASVD event rates. Methodological issues that complicate studies of this association are outlined, with an emphasis on the terms and metrics that would be applicable in future studies. Observational studies to date support an association between PD and ASVD independent of known confounders. They do not, however, support a causative relationship. Although periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction in short-term studies, there is no evidence that they prevent ASVD or modify its outcomes.

Poor oral health and coronary artery disease: a case-control study

BACKGROUND

There is insufficient research on the relationship of oral health and coronary artery disease (CAD) from developing countries, such as Pakistan. This study observes the status of oral health in the CAD population.

METHODS

A case-control study was conducted on 145 cases and 145 controls. Otherwise healthy patients with CAD (cases) and individuals free from previous/current history of CAD (controls), having ≥14 remaining teeth, were examined for oral health status through missing teeth, plaque index (PI), and community periodontal index (CPI). Student t test, χ2 test, and multivariate regression analysis were applied at significance level of 95% (P ≤ 0.05) to compare study parameters between cases and controls.

RESULTS

A significant difference between cases and controls was observed in this study sample with respect to missing teeth (P = 0.027) and periodontal parameters of PI and CPI (P < 0.001). Cases were observed with significantly higher scores of PI (2 and 3) and CPI (3 and 4) compared with controls. Prevalence of periodontal parameters was observed to be higher in cases than controls at subgroup-level (sex and age group) analysis. A significant odds ratio (OR), unadjusted, between CAD and periodontal indicators of PI (mild to severe plaque/no plaque: OR = 5.04, 95% confidence interval [95% CI] = 2.24 to 11.36) and CPI (healthy/poor periodontal status: OR = 4.59, 95% CI = 1.81 to 11.61) scores was noted; cases were at odds of 1.20 (95% CI = 0.93 to 15.68, P = 0.017) for having poor oral health after adjusting age, sex, and education.

CONCLUSION

Poor oral health was significantly associated with CAD in this study sample matched for sociodemographic characteristics.

Treatment of periodontal diseases reduces chronic systemic inflammation in maintenance hemodialysis patients

BACKGROUND

Evidences suggest that chronic systemic inflammation is associated with increasing mortality in maintenance hemodialysis patients due to atherosclerosis and malnutrition. Periodontal diseases are treatable sources of systemic inflammation in hemodialysis patients. We therefore evaluated the effect of periodontal treatment in maintenance hemodialysis patients.

METHOD

Periodontal diseases were evaluated in 30 stable maintenance hemodialysis patients by using clinical periodontal status by plaque index (PI) and periodontal disease index (PDI). Hematologic, biochemical, nutritional, and dialysis-related parameters as well as highly sensitive C-reactive protein (hs-CRP), a sensitive systemic inflammatory marker, were analyzed before and after periodontal therapy.

RESULT

Maintenance hemodialysis patients had high prevalence of periodontal disease (63%). At baseline, hs-CRP positively correlated with clinical periodontal status (PI, r = 0.74, p < 0.001; PDI, r = 0.66, p < 0.001), but negatively correlated with hemoglobin (r = -0.51, p < 0.001), serum albumin (r = -0.61, p = 0.002), and normalized protein catabolic rate (r = -0.42, p = 0.043). After completion of periodontal therapy (duration 6 ± 2 weeks), the PI and PDI significantly declined from 2.13 to 1.48 (p = 0.001) and 3.53 to 2.52 (p = 0.001), respectively, while hs-CRP significantly declined from 3.8 to 0.6 mg/L (p < 0.001). Moreover, erythropoietin dosage could be reduced from 8000 to 6000 unit/week (p = 0.03) after treatment. Pre-dialysis blood urea nitrogen increased from 66.18 to 79.54 mg/dL (p = 0.003) and serum albumin level increased from 3.15 to 3.38 mg/dL (p = 0.003), reflecting improved nutritional status of the patients after periodontal treatment.

CONCLUSION

Periodontitis is an important source of chronic inflammation. Treatment of periodontal diseases can improve systemic inflammation, nutritional status, and erythropoietin responsiveness in the hemodialysis population.

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: a new factor associated with the presence of multiple complex coronary lesions

BACKGROUND AND AIM

Periodontal disease, including bone loss, is thought to be involved in coronary artery disease. Multiple complex coronary lesions relate to multifocal destabilization of coronary plaques. We investigated whether bone loss could be associated with the presence of multiple complex coronary lesions.

METHODS

This cross-sectional study included 150 patients with recent myocardial infarction (<1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss >50% was performed. Patients with no or simple complex lesions were compared to patients with multiple complex lesions.

RESULTS

Over 20% of patients had multiple complex coronary lesions. Patients with multiple complex lesion were less likely to be women and more likely to have multivessel disease or elevated C-reactive protein (CRP) than patients with no or single complex lesion. Bone loss >50% tended to be more frequent in patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion. Bone loss >50% increased the risk of multiple complex lesion.

CONCLUSION

Bone loss was associated with complex multiple coronary lesions, beyond systemic inflammation. These findings may bear important clinical implications for the prevention and treatment of coronary artery disease.

Prospective association of periodontal disease with cardiovascular and all-cause mortality: NHANES III follow-up study

BACKGROUND

It has been suggested that periodontal disease (PD) was associated with an increased risk for cardiovascular diseases (CVD), although evidence is inconclusive.

PURPOSE

We first sought to prospectively evaluate the relationship of PD to CVD and all-cause mortality using a national representative sample in the United States.

METHODS

The study population consisted of 10,849 participants who were 30 years or older and received a periodontal examination from NHANES III mortality follow-up sample (1988-2006). CVD and all-cause deaths were ascertained from the National Death Index records. The causes of death were defined using the International Classification of Disease coding (ICD-10). The severity of PD was categorized as non-PD, modest and severe PD based on clinical attachment loss and pocket depth.

RESULTS

Of the study sample, 3105 and 561 participants were identified as modest and severe PD cases, respectively. After up to 18 years of follow-up, there were total 2894 deaths, of which 1225 were from CVD. The levels of inflammation markers (high sensitivity C-reactive protein, white cell count and fibrinogen) were significantly higher in men with severe PD compared to men without PD (p<0.05). The prospective associations were evaluated using multivariable Cox proportional-hazards models. After adjusting for age, gender, race, household income and traditional risk factors of CVD, severe PD was associated with an increase risk of CVD mortality and all-cause mortality in men aged 30-64 years (HR=2.13 with 95% confidence interval of 1.37-3.31 for CVD mortality; HR=1.64 with 95% confidence interval of 1.25-2.15 for all-cause mortality). In addition, significant linear trends were found in CVD and all-cause mortality across the severity of PD (p<0.001). However, no significant associations were found in men aged ≥65 and in women.

CONCLUSIONS

There appears to be prospective associations between PD and CVD and all-cause mortality in men aged 30-64 years. Inflammation may be one possible pathway to link PD with CVD.

Mechanisms involved in the association between periodontal diseases and cardiovascular disease

It is now well accepted that besides the cholesterol associated mechanisms of atherogenesis, inflammation plays a crucial role in all stages of the development of the atherosclerotic lesion. This 'inflammation hypothesis' raises the possibility that through systemic elevations of pro-inflammatory cytokines, periodontal diseases might also contribute to systemic inflammation and, therefore, to atherogenesis. In fact, there is evidence that periodontal diseases are associated with higher systemic levels of high-sensitivity C-reactive protein and a low grade systemic inflammation. This phenomenon has been explained based on mechanisms associated with either the infectious or the inflammatory nature of periodontal diseases. The purposes of this article were to review (1) the evidence suggesting a role for oral bacterial species, particularly periodontal pathogens, in atherogenesis; (2) the potential mechanisms explaining an etiological role for oral bacteria in atherosclerosis; (3) the evidence suggesting that periodontal infections are accompanied by a heightened state of systemic inflammation; (4) the potential sources of systemic inflammatory biomarkers associated with periodontal diseases; and (5) the effects of periodontal therapy on systemic inflammatory biomarkers and cardiovascular risk.

Is periodontal inflammation associated with raised blood pressure? Evidence from a National US survey

There is incomplete and inconclusive evidence for the association between periodontal disease markers and arterial blood pressure, particularly from large national epidemiological studies. This study assessed the relationship between different markers of periodontal inflammation and disease with arterial blood pressure in people aged 17 years and over in USA. We analysed data from the Third National Health and Nutrition Examination Survey on 6617 men and 7377 women who received a periodontal examination. Blood pressure was analysed in both a continuous format and a binary variable for case definition of hypertension. Periodontal disease markers (extent of gingival bleeding, pocket depth, and loss of attachment, and a case definition of periodontitis) were associated on the arterial blood pressure outcomes through a series of regression models, incrementally adjusting for confounders (demographic, inflammation markers, chronic conditions, smoking, BMI, socio-economic status). All periodontal measures had significant crude associations with SBP and hypertension. Gingival bleeding, a marker of current periodontal inflammation, was the only measure consistently and significantly associated with raised SBP and an increased odds of hypertension in the US adult population throughout the adjustment process. For a 10% greater extent of gingival bleeding, the average SBP was higher by 0.5 (0.3, 0.6) mmHg in the fully adjusted model. By referring to the general population and the whole distribution of blood pressure, not only to those at higher risk for hypertension, this association might have some important implications for clinical practice and public health strategies.

Characterization of the Porphyromonas gingivalis conjugative transposon CTnPg1: determination of the integration site and the genes essential for conjugal transfer

In our previous study, extensive genomic rearrangements were found in two strains of the Gram-negative anaerobic bacterium Porphyromonas (Por.) gingivalis, and most of these rearrangements were associated with mobile genetic elements such as insertion sequences and conjugative transposons (CTns). CTnPg1, identified in Por. gingivalis strain ATCC 33277, was the first complete CTn reported for the genus Porphyromonas. In the present study, we found that CTnPg1 can be transferred from strain ATCC 33277 to another Por. gingivalis strain, W83, at a frequency of 10(-7) to 10(-6). The excision of CTnPg1 from the chromosome in a donor cell depends on an integrase (Int; PGN_0094) encoded in CTnPg1, whereas CTnPg1 excision is independent of PGN_0084 (a DNA topoisomerase I homologue; Exc) encoded within CTnPg1 and recA (PGN_1057) on the donor chromosome. Intriguingly, however, the transfer of CTnPg1 between Por. gingivalis strains requires RecA function in the recipient. Sequencing analysis of CTnPg1-integrated sites on the chromosomes of transconjugants revealed that the consensus attachment (att) sequence is a 13 bp sequence, TTTTCNNNNAAAA. We further report that CTnPg1 is able to transfer to two other bacterial species, Bacteroides thetaiotaomicron and Prevotella oralis. In addition, CTnPg1-like CTns are located in the genomes of other oral anaerobic bacteria, Porphyromonas endodontalis, Prevotella buccae and Prevotella intermedia, with the same consensus att sequence. These results suggest that CTns in the CTnPg1 family are widely distributed among oral anaerobic Gram-negative bacteria found in humans and play important roles in horizontal gene transfer among these bacteria.

Effect of phase I periodontal therapy on anti-cardiolipin antibodies in patients with acute myocardial infarction associated with chronic periodontitis

BACKGROUND

Serum anti-cardiolipin (aCL) antibodies are prevalent in patients with periodontal diseases. These increased aCL concentrations were identified to play a modulating role in cardiovascular diseases. The present study aims to explore the effect of phase I periodontal therapy on immunoglobulin (Ig)M and IgG aCL antibodies in patients with acute myocardial infarction (AMI) associated with chronic periodontitis.

METHODS

A cross-sectional randomized clinical study was conducted within two groups comprising a sample size of 72 patients (n = 36 each). Group 1 had clinical features of AMI, and group 2 had clinical features of AMI associated with chronic periodontitis. After a thorough clinical and oral examination, the plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (AL) were recorded. Serum sample collection by venipuncture was done for estimation of serum IgM and IgG aCL concentration by using an enzyme-linked immunosorbent assay method. In group 2, phase I periodontal therapy was performed, and clinical and biochemical parameters were reanalyzed after 1 month.

RESULTS

In group 2, the mean PI, GI, PD, clinical AL, and serum IgM and IgG aCL antibody levels were significantly higher than in group 1 patients. In addition, study results showed significant alterations in concentrations of serum IgM (P = 0.008) and IgG (P <0.001) aCL along with periodontal parameters after phase I periodontal therapy.

CONCLUSION

The phase I periodontal therapy altered levels of serum IgG and IgM aCL antibodies in patients with AMI associated with chronic periodontitis.

Alterations of Serum Lipid and Inflammatory Cytokine Profiles in Patients with Coronary Heart Disease and Chronic Periodontitis: A Pilot Study

Serum lipid and inflammatory cytokine profiles were assessed in 124 in-patients with coronary heart disease (CHD) (CHD group) and 43 inpatients with no evidence of CHD (control group). In all patients, research questionnaires and examinations of periodontal health were conducted and venous blood samples were analysed. Both groups were divided into two subgroups according to the presence or absence of chronic periodontitis in individual patients. The prevalence of chronic periodontitis was higher in patients from the CHD group than in the control group. Levels of total cholesterol, triglycerides, low-density lipoprotein, oxidized low-density lipoprotein, high-sensitivity C-reactive protein, interleukin-6 and tumour necrosis factor-a were significantly higher in CHD patients with chronic periodontitis than in those without periodontitis. In conclusion, chronic periodontitis may be associated with CHD.

Cardiovascular disease and the role of oral bacteria

In terms of the pathogenesis of cardiovascular disease (CVD) the focus has traditionally been on dyslipidemia. Over the decades our understanding of the pathogenesis of CVD has increased, and infections, including those caused by oral bacteria, are more likely involved in CVD progression than previously thought. While many studies have now shown an association between periodontal disease and CVD, the mechanisms underpinning this relationship remain unclear. This review gives a brief overview of the host-bacterial interactions in periodontal disease and virulence factors of oral bacteria before discussing the proposed mechanisms by which oral bacterial may facilitate the progression of CVD.

Interferon gamma in the etiology of atherosclerosis and periodontitis

Clinical observations and a few research reports seem to suggest that intraoral infection as well as periodontal teeth could potentially lead to systemic infections including atherosclerosis. The aim of our investigations was to determine whether periodontal disease might aggravate atherosclerosis and whether interferon-gamma (IFNG), widely recognized as a potent multifunctional cytokine, might serve as a marker of the process. This is the first research based on tissue material such as atheromata and periodontal pocket granulation tissue. The study population consisted of 15 patients with periodontitis and atherosclerosis. Control group comprised 15 non-atherosclerotic patients with periodontitis. IFNG, IFNGR1 and IFNGR2 expression was analysed using qRT-PCR profiling in the inflammatory granulation tissue and atheroma. Granulation tissue samples obtained from non-atherosclerotic group showed a significant increase in IFNG and a decrease of IFNGR1, IFNGR2 expression whereas granulation tissue and atheromata of patients with systemic disease demonstrated lower IFNG and higher IFNGR1 and IFNGR2 expression.

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

Cardiovascular diseases (CVD) have a complex etiology determined by risk factors, which are in turn associated to a strong genetic component and to environmental factors. In the biological background for the development of CVD, low-grade chronic inflammation plays a role as a pathogenetic determinant of atherosclerosis. Dental infections have been associated with CVD. Periodontal disease is a chronic infection of the supporting tissues of the tooth that can lead to teeth loss. In recent years, a number of reports have demonstrated the possible relationship between periodontal disease and CVD. Apical periodontitis, on the other hand, is the late consequence of an endodontic infection, which is caused by the persistence of coronal caries and involves the root canal system of the tooth. Most of the time, it is a chronic infection. Some studies have found a correlation between a "composite status" of oral health (eg. caries, tooth loss, periodontal disease) and CVD, but only a few of them have addressed the association between apical periodontitis and CVD. This "state of the art" paper represents the first stage of an incoming study on the relationship between chronic endodontic infection and CVD.

Oral health and frailty in the medieval English cemetery of St Mary Graces

The analysis of oral pathologies is routinely a part of bioarcheological and paleopathological investigations. Oral health, while certainly interesting by itself, is also potentially informative about general or systemic health. Numerous studies within modern populations have shown associations between oral pathologies and other diseases, such as cardiovascular disease, certain types of cancer, and pulmonary infections. This article addresses the question of how oral health was associated with general health in past populations by examining the relationship between two oral pathologies (periodontal disease and dental caries) and the risk of mortality in a cemetery sample from medieval England. The effects of periodontitis and dental caries on risk of death were assessed using a sample of 190 individuals from the St Mary Graces cemetery, London, dating to approximately AD 1350-1538. The results suggest that the oral pathologies are associated with elevated risks of mortality in the St Mary Graces cemetery such that individuals with periodontitis and dental caries were more likely to die than their peers without such pathologies. The results shown here suggest that these oral pathologies can be used as informative indicators of general health in past populations.

The human oral microbiome

The human oral cavity contains a number of different habitats, including the teeth, gingival sulcus, tongue, cheeks, hard and soft palates, and tonsils, which are colonized by bacteria. The oral microbiome is comprised of over 600 prevalent taxa at the species level, with distinct subsets predominating at different habitats. The oral microbiome has been extensively characterized by cultivation and culture-independent molecular methods such as 16S rRNA cloning. Unfortunately, the vast majority of unnamed oral taxa are referenced by clone numbers or 16S rRNA GenBank accession numbers, often without taxonomic anchors. The first aim of this research was to collect 16S rRNA gene sequences into a curated phylogeny-based database, the Human Oral Microbiome Database (HOMD), and make it web accessible (www.homd.org). The HOMD includes 619 taxa in 13 phyla, as follows: Actinobacteria, Bacteroidetes, Chlamydiae, Chloroflexi, Euryarchaeota, Firmicutes, Fusobacteria, Proteobacteria, Spirochaetes, SR1, Synergistetes, Tenericutes, and TM7. The second aim was to analyze 36,043 16S rRNA gene clones isolated from studies of the oral microbiota to determine the relative abundance of taxa and identify novel candidate taxa. The analysis identified 1,179 taxa, of which 24% were named, 8% were cultivated but unnamed, and 68% were uncultivated phylotypes. Upon validation, 434 novel, nonsingleton taxa will be added to the HOMD. The number of taxa needed to account for 90%, 95%, or 99% of the clones examined is 259, 413, and 875, respectively. The HOMD is the first curated description of a human-associated microbiome and provides tools for use in understanding the role of the microbiome in health and disease.

"Gum bug, leave my heart alone!"--epidemiologic and mechanistic evidence linking periodontal infections and atherosclerosis

Evidence from epidemiologic studies suggests that periodontal infections are independently associated with subclinical and clinical atherosclerotic vascular disease. Although the strength of the reported associations is modest, the consistency of the data across diverse populations and a variety of exposure and outcome variables suggests that the findings are not spurious or attributable only to the effects of confounders. Analysis of limited data from interventional studies suggests that periodontal treatment generally results in favorable effects on subclinical markers of atherosclerosis, although such analysis also indicates considerable heterogeneity in responses. Experimental mechanistic in vitro and in vivo studies have established the plausibility of a link between periodontal infections and atherogenesis, and have identified biological pathways by which these effects may be mediated. However, the utilized models are mostly mono-infections of host cells by a limited number of 'model' periodontal pathogens, and therefore may not adequately portray human periodontitis as a polymicrobial, biofilm-mediated disease. Future research must identify in vivo pathways in humans that may (i) lead to periodontitis-induced atherogenesis, or (ii) result in treatment-induced reduction of atherosclerosis risk. Data from these studies will be essential for determining whether periodontal interventions have a role in the primary or secondary prevention of atherosclerosis.

The link between periodontal disease and cardiovascular disease: How far we have come in last two decades ?

Many epidemiological studies have investigated the relationship between periodontal disease (PD) and cardiovascular disease (CVD), but their results are heterogeneous. This review article is designed to update the potential association, that forms the basis of understanding for a (causal) role for PD to cardiovascular events; as reported by various observational (case-control, cohort, cross-sectional) studies, epidemiological and interventional studies, not considering the other number of systemic health outcomes like cerebrovascular disease, pregnancy complications, chronic obstructive pulmonary disease, diabetes mellitus complications, osteoporosis, etc. A brief overview has been included for atherosclerosis (ATH), its pathophysiology and the association of periodontal infections as a risk factor for causing ATH, which seems to be a rational one; as development of ATH involves a chronic low-grade inflammation and moreover, it has long been set up prior to development of ischemic heart disease and thus provides potential contributing mechanisms that ATH may contribute singly or in concert with other risk factors to develop ischemic heart disease. This article goes on to discuss the correlation of evidence that is gathered from many scientific studies showing either strong, modest, weak or even no links along with their critical analyses. Finally, this article summarizes the present status of the links that possibly exist between PD and its role as a risk factor in triggering cardiovascular events, in the fairly long journey for the last two decades.

Increased prevalence of cardiovascular and autoimmune diseases in periodontitis patients: a cross-sectional study

BACKGROUND

Associations between periodontitis and cardiovascular and autoimmune diseases are most often assessed in patients with a particular cardiovascular or autoimmune disease. To prevent selection bias, this study assesses the existence of associations between periodontitis and cardiovascular and autoimmune diseases in patients attending a dental or periodontal clinic.

METHODS

Data were collected from 1,276 randomly selected dental records from patients attending a dental (n = 588) or periodontal (n = 688) clinic. Data on the prevalence of cardiovascular and autoimmune diseases were obtained from a validated health questionnaire. Data on the presence of periodontitis were taken from patients' dental records.

RESULTS

In uncontrolled analyses, the prevalence of hypertension, diabetes mellitus (DM), and rheumatoid arthritis (RA) is significantly increased in patients with periodontitis. Controlled for confounding, periodontitis was associated with DM, with an odds ratio of 4 (1.03 to 15.3), in the dental clinic. DM was not associated with periodontitis in periodontal clinics. Hypertension does not seem to be associated with periodontitis when controlling for confounders. Periodontitis may be associated with RA in both clinic types.

CONCLUSIONS

The increased prevalence of cardiovascular and autoimmune diseases among patients with periodontitis attending dental or periodontal clinics may, at least in part, be influenced by confounding. However, the increased prevalence of DM and RA in patients with periodontitis could not be explained by confounding.

Improving health for elderly people: an international health promotion and disease prevention agenda

Across the world, there are substantial but missed opportunities for promoting health of older persons and extending the healthy life span. Current approaches to health care rely on late detection and treatment of disease, and some of the most expensive systems of care have population health outcomes that are poor to mediocre. A majority of deaths and disability result from progression of preventable chronic diseases for which human behaviors are major contributing factors. An organized and aggressive agenda in health promotion and disease prevention emerges as an important part of the strategy to both promote health and control costs. After reviewing data on determinants of health and contribution of behavioral factors to morbidity and mortality, this paper presents the evidence for efficacy and effectiveness of specific behavioral and clinical interventions to reduce risk for many of the problems accounting for death and disability among elders. We address tobacco use, lack of exercise, inadequate nutrition, hypertension, delirium, obesity, falls, cancer screening, poor oral health, osteoporosis, immunizations and medication safety. Strategies for implementation of effective interventions present an international challenge.

Tooth loss, apolipoprotein E, and decline in delayed word recall

Our previous research suggests an association between a low number of teeth and increased risk of dementia. The aim of the present study was to determine if a low number of teeth is specifically related to memory decline as evidenced by low Delayed Word Recall scores. In addition, we examined the combined effect of a low number of teeth and the apolipoprotein E epsilon4 allele on Delayed Word Recall scores. We hypothesized that the scores of those who had the allele and a low number of teeth (0-9) would decline more rapidly over time than those participants with a greater number of teeth who lacked the allele. We found that individuals with both risk factors (the allele and fewer teeth) had lower Delayed Word Recall scores at the first examination and declined more quickly compared with participants with neither of these risk factors or with either risk factor alone.

Adrenomedullin is expressed during rodent dental tissue development and promotes cell growth and mineralization

BACKGROUND INFORMATION

ADM (adrenomedullin) has pleiotropic effects, including regulation of inflammation, infection, angiogenesis, mineralized-tissue formation and development. Recently, we demonstrated up-regulation of the ADM transcript in diseased pulpal tissue while the protein is sequestered within the dentine extracellular matrix during dentinogenesis. The present study aimed to characterize ADM localization during rodent dental tissue development and determine its potential effects on dental cells. Finally, we sought to profile ADM transcript levels in adult organs and tissues to compare its expression in teeth relative to other tissues.

RESULTS

Immunohistochemical analysis of developmental rat oral tissues indicated that, at E16 (embryonic day 16), ADM was present in dental epithelium and, by E18, ADM localized to the dental papilla and inner and outer dental epithelia. By E20, ADM was detected in secretory odontoblasts and ameloblasts and exhibited a similar expression profile to that of the key dentinogenesis signalling molecule, TGF-beta1 (transforming growth factor-beta1). Cell growth analysis in the dental MDPC-23, OD-21 and control 3T3 cell lines exposed to ADM (range 10(-15)-10(-7) M) together with EDTA-extracted DMPs (dentine matrix proteins) (range 0.00001-1000 mg/ml) containing comparable concentrations of ADM demonstrated that ADM stimulated a biphasic response in dental cell growth, comparable with that of DMPs, with peak stimulation observed at approximately 10(-11) M. For mineralization analysis, cell lines were exposed to combinations of 50 microg/ml ascorbic acid, 10 mM beta-G (beta-glycerophosphate), 10(-8) M DEX (dexamethasone) and ADM (range 10(-15)-10(-7) M). The results demonstrated that ADM could substitute for DEX to stimulate mineralization. Postnatally, multiple tissue expression profiling indicated abundant ADM levels in tongue and pulpal tissues.

CONCLUSIONS

During oral and dental tissue development ADM initially localizes to epithelial tissue, whereas during later stages it is present in mineralized secreting cells, including odontoblasts. ADM may regulate proliferation and mineralization processes during development, whereas, in adulthood, it may be important for maintaining dental tissue homoeostasis.

The American Journal of Cardiology and Journal of Periodontology editors' consensus: periodontitis and atherosclerotic cardiovascular disease

ACKNOWLEDGMENT

This Editors' Consensus is supported by an educational grant from Colgate-Palmolive, Inc., New York, New York, and is based on a meeting of the authors held in Boston, Massachusetts, on January 9, 2009.

DISCLOSURE

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Kornman is a full-time employee and shareholder of Interleukin Genetics, Waltham, Massachusetts, which owns patents on genetic biomarkers for chronic inflammatory diseases. Dr. Genco is a consultant to Merck, Whitehouse Station, New Jersey. Dr. Ridker has received research support from AstraZeneca, Wilmington, Delaware; Novartis; Pfizer, New York, New York; Roche, Nutley, New Jersey; Sanofi-Aventis, Bridgewater, New Jersey; and Abbott Laboratories, Abbott Park, Illinois. Dr. Ridker has received non-financial research support from Amgen, Thousand Oaks, California. Dr. Ridker is a co-inventor on patents held by Brigham and Women's Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease. Dr. Ridker is a research consultant for Schering-Plough, Kenilworth, New Jersey; Sanofi-Aventis; AstraZeneca; Isis, Carlsbad, California; Novartis; and Vascular Biogenics, Tel Aviv, Israel. Dr. Van Dyke is a co-inventor on patents held by Boston University, Boston, Massachusetts, that relate to inflammation control, including consulting fees. Dr. Roberts has received honoraria for speaking from Merck, Schering-Plough, AstraZeneca, and Novartis. All other individuals in a position to control content disclosed no relevant financial relationships.

Do genetic factors explain the association between poor oral health and cardiovascular disease? A prospective study among Swedish twins

Epidemiologic studies suggest positive associations between poor oral health and cardiovascular disease. The authors undertook a prospective study among 15,273 Swedish twins (1963-2000) to examine whether genetic factors underlying the 2 diseases could explain previous associations. They estimated hazard ratios and 95% confidence intervals controlling for individual factors and stratifying on twin pairs to control for familial effects. Quantitative genetic analyses estimated genetic correlations between oral diseases and cardiovascular disease outcomes. Tooth loss (hazard ratio (HR) = 1.2, 95% confidence interval (CI): 1.1, 1.4) and periodontal disease (HR = 1.3, 95% CI: 1.0, 1.4) were associated with small excess risks of cardiovascular disease; periodontal disease was also associated with coronary heart disease (HR = 1.4, 95% CI: 1.1, 1.6). Adjustment for genetic factors in co-twin analyses did not appreciably change estimates. In contrast, tooth loss was more strongly associated with coronary heart disease in twin models (HR = 2.1, 95% CI: 1.2, 3.8) compared with adjusting for individual factors alone (HR = 1.3, 95% CI: 1.1, 1.4). There was evidence of shared genetic factors between cardiovascular disease and tooth loss (r(G) = 0.18) and periodontal disease (r(G) = 0.29). Oral disease was associated with excess cardiovascular disease risk, independent of genetic factors. There appear to be common pathogenetic mechanisms between poor oral health and cardiovascular disease.

Number of teeth and myocardial infarction and stroke among elderly never smokers

Background

In most previous studies the association between number of teeth and cardiovascular diseases has been found to be stronger among younger age groups than in older age groups, which indicates that age may modify the association between number of teeth and cardiovascular diseases.

We investigated the association between tooth loss and atherosclerotic vascular diseases such as myocardial infarction and stroke in a homogeneous elderly population.

The study population was comprised of a subpopulation of 392 community-living elderly people who participated in the population-based Kuopio 75+ study. The data were collected through an interview, a structured clinical health examination and from patient records. The main outcome measures were a history of diagnosed myocardial infarction and diagnosed ischemic stroke. Prevalence proportion ratios (PPR) were estimated using generalised linear models.

Results

Edentate subjects had a weakly, statistically non-significantly increased likelihood of a history of myocardial infarction and ischemic stroke compared with dentate subjects. Those with a large number of teeth had a slightly, but not statistically significantly increased likelihood of a history of myocardial infarction and ischemic stroke compared with those with a small number of teeth.

Conclusion

These data did not show evidence that total or partial tooth loss would be associated with atherosclerotic vascular diseases such as myocardial infarction and ischemic stroke among an elderly population aged 75 years or older.

Oral infection-inflammatory pathway, periodontitis, is a risk factor for endothelial dysfunction in patients with coronary artery disease

OBJECTIVE

Several studies have shown that periodontitis is a risk factor for cardiovascular diseases. There is an association between inflammation and endothelial dysfunction. The purpose of this study was to evaluate endothelial function in patients with coronary artery disease (CAD) who had periodontitis.

METHODS AND RESULTS

We evaluated forearm blood flow (FBF) responses to acetylcholine (ACh), an endothelium-dependent vasodilator, and to sodium nitroprusside (SNP), an endothelium-independent vasodilator, in 101 CAD patients with periodontitis (37 men and 11 women, 63+/-12 yr) and without periodontitis (36 men and 17 women, 62+/-13 yr). FBF was measured by using strain-gauge plethysmography. Circulating levels of C-reactive protein and interleukin-6 were significantly higher in the periodontitis group than in the non-periodontitis group. FBF response to ACh was significantly smaller in the periodontitis group than in the non-periodontitis group. SNP-stimulated vasodilation was similar in the two groups. Periodontal therapy reduced serum concentrations of C-reactive protein from 2.7+/-1.9 to 1.8+/-0.9mg/L (P<0.05) and interleukin-6 from 2.6+/-3.4 to 1.6+/-2.6ng/L (P<0.05) and augmented ACh-induced vasodilation from 14.7+/-5.2 to 20.1+/-6.1mL/(min100mL) tissue (P<0.05) in patients with periodontitis. The SNP-stimulated vasodilation was similar before and after treatment. After administration of N(G)-monomethyl-l-arginine, a nitric oxide synthase inhibitor, FBF response to ACh was similar before and after treatment.

CONCLUSION

These findings suggest that periodontitis is associated with endothelial dysfunction in patients with CAD through a decrease in nitric oxide bioavailability. Systemic inflammation may be, at least in part, a cause and predictor of progression of endothelial dysfunction.

Longitudinal Evaluation of Multi-phasic, Odontological and Nutritional Associations in Dentists (LEMONADE Study): study design and profile of nationwide cohort participants at baseline

Background

To examine the association between oral health and general well-being, we are currently conducting a nationwide cohort study comprising members of the Japan Dental Association (JDA). Herein, we describe the study design and the profile of the participants at baseline.

Methods

From 2001 through 2006, the participants completed a baseline questionnaire that surveyed factors related to lifestyle, general health, and oral health. Morbidity and mortality have been monitored by using information from fraternal insurance programs operated by prefectural dental associations. All respondents provided written, informed consent for participation and the use of their insurance data.

Results

A total of 21 272 JDA members participated in the baseline survey (response rate, 36.2%). Their mean age ± SD was 52.3 ± 12.3 years; 8.0% were women. Among the respondents, 30.2% of men and 10.7% of women were current smokers; 73.5% of men and 44.8% of women were current drinkers. The cohort scored higher on oral health indices than did the general Japanese population: dentists were more likely to brush their teeth ≥3 times/day, to have ≥20 teeth, to have fewer lost teeth, to be free from periodontal diseases, and to have higher General Oral Health Assessment Index scores. There was, however, considerable inter-individual variation in scores on the indices.

Conclusions

More than one-third of JDA members participated in the study. Their oral average health status was better than that of the general population. Nevertheless, it will be possible to compare morbidity and mortality between those with better and worse scores on oral health indices.

Oral health, general health, and quality of life in older people

The purpose of this report is to review the interrelationship between poor oral health conditions of older people and general health. The impact of poor oral health on quality of life (QOL) is analyzed, and the implications for public health intervention and oral health care are discussed. Findings from the current research may lead to the following conclusions: The available scientific evidence is particularly strong for a direct relationship between diabetes and periodontal disease; the direct relationship between periodontal disease and cardiovascular disease is less convincing. General and associated oral health conditions have a direct influence on elder people's QOL and lifestyle. The growing number of elderly people challenges health authorities in most countries. The evidence on oral health-general health relationships is particularly important to WHO in its effort to strengthen integrated oral health promotion and disease prevention around the globe.

Association between periodontal disease and coronary artery disease

The etiology of coronary artery disease (CAD) is multifunctional. There is increasing evidence that dental infections could play a role in the initiation and development of CAD. In a case control double blind study, one hundred male and female (mean age 51 ± 9.4) angiographically documented CAD, compared with one hundred male and female patients (mean age 50.6 ± 9) with angiographically negative coronary artery. All the patients (cases and control) underwent dental examination for the presence and severity of periodontitis by a dentist who was oblivious the result of the angiography performed. The association between periodontal disease status and CAD was significant (P=0.011); periodontitis was apparently more frequent in CAD positive patients than in control (86% versus 61%). Adjustment of coronary risk factors (smoking, DM, hypertension and hyperlipidemia) in both cases and control groups suggests that the association between periodontitis and CAD in our study was independent of coronary risk factors. There is increasing evidence that dental infection, especially aerobic organisms which have capability of aggregation of platelets, is the most important cause. Dental infection would be an independent risk factor for CAD.

Salivary lysozyme and prevalent hypertension

Although the etiology of essential hypertension is not clearly understood, endothelial dysfunction from chronic infection and/or impaired glucose metabolism may be involved. We hypothesized that salivary lysozyme, a marker for oral infection and hyperglycemia, might display a significant relationship with hypertension, an early stage of cardiovascular disease. Logistic regression analyses of the Kuopio Oral Health and Heart Study demonstrated that persons with higher lysozyme levels were more likely to have hypertension, after adjustment for age, gender, smoking, BMI, diabetes, the ratio of total cholesterol to HDL cholesterol, and C-reactive protein. The exposure to increasing quartiles of lysozyme was associated with adjusted Odds Ratios for the outcome, hypertension, 1.00 (referent), 1.25, 1.42, and 2.56 (linear trend p < 0.003). When we restricted the sample to the individuals without heart disease (N = 250), we observed a non-significant trend for increasing odds. Our hypothesis--"high salivary lysozyme levels are associated with the odds of hypertension"--was confirmed.

Determination of the genome sequence of Porphyromonas gingivalis strain ATCC 33277 and genomic comparison with strain W83 revealed extensive genome rearrangements in P. gingivalis

The gram-negative anaerobic bacterium Porphyromonas gingivalis is a major causative agent of chronic periodontitis. Porphyromonas gingivalis strains have been classified into virulent and less-virulent strains by mouse subcutaneous soft tissue abscess model analysis. Here, we present the whole genome sequence of P. gingivalis ATCC 33277, which is classified as a less-virulent strain. We identified 2090 protein-coding sequences (CDSs), 4 RNA operons, and 53 tRNA genes in the ATCC 33277 genome. By genomic comparison with the virulent strain W83, we identified 461 ATCC 33277-specific and 415 W83-specific CDSs. Extensive genomic rearrangements were observed between the two strains: 175 regions in which genomic rearrangements have occurred were identified. Thirty-five of those genomic rearrangements were inversion or translocation and 140 were simple insertion, deletion, or replacement. Both strains contained large numbers of mobile elements, such as insertion sequences, miniature inverted-repeat transposable elements (MITEs), and conjugative transposons, which are frequently associated with genomic rearrangements. These findings indicate that the mobile genetic elements have been deeply involved in the extensive genome rearrangement of P. gingivalis and the occurrence of many of the strain-specific CDSs. We also describe here a very unique feature of MITE400, which we renamed MITEPgRS (MITE of P. gingivalis with Repeating Sequences).

Periodontal Disease Burden and Pathological Changes in Organs of Dogs

Bacterial plaque associated periodontal disease is the most common chronic infection in man and dogs. In man, there is an association between periodontal disease and myocardial infarction and stroke, while in dogs it has also been associated with changes in internal organs. Inflamed periodontal tissues present a ‘periodontal disease burden’ to the host and the extent of this inflammatory disease burden is likely to affect the degree of associated pathological change in distant organs. This hypothesis was investigated in dogs with naturally occurring periodontal disease. Post-mortem investigations including periodontal assessment, standard necropsy, and organ histology were performed on 44 mature toy and miniature Poodles (related, periodontitis predisposed breeds) that died naturally or were euthanized based on clinical disease. Animals with gross primary organ pathology were excluded. The periodontal disease burden was estimated from the total surface area of periodontal pocket epithelium using six measurements of probing depth for each tooth and the tooth circumferences. Ordinal logistic regression (OR) analysis established that for each square centimeter of periodontal disease burden there was a 1.4-times higher likelihood of greater changes being present in the left atrio-ventricular valves (OR = 1.43), plus 1.2 and 1.4 times higher likelihood for greater liver and kidney pathology (OR = 1.21; OR = 1.42), respectively. The results show that there is a link between the estimated ‘periodontal disease burden’ resulting from plaque-bacteria associated periodontal disease and the level of internal pathology in this population, implying that periodontitis might contribute to the development of systemic pathology in dogs.

Prevalence of edentulousness and related factors among elderly Finns

Edentulousness is a multifactor phenomenon. While its overall prevalence is diminishing, it is increasing in older age groups. The aim of this study was to assess the prevalence of edentulousness among the elderly in two municipalities in Finland and to estimate different factors related to it. All persons born in the years 1919, 1922, 1925, 1928, 1931, 1934 and 1937 living in two municipalities (Kirkkonummi in the southern part of Finland and Lakeus in the northern part of Finland) were invited to participate in the study in 1997. The target population consisted of 1733 subjects of whom 1191 were disposed to participate in a clinical examination performed by two dentists. Of the subjects, 624 were from the southern district (Kirkkonummi) and 566 were from the northern district (Lakeus). The participation rates were 62% and 78%, respectively. The subjects answered a questionnaire comprising sociodemographical data, questions on dental and general health and health behaviour. Logistic regression analysis was used to assess the associations between edentulousness and potential associating factors. The overall prevalence of edentulousness was 37%; being 53% in the northern region and 22% in the southern region. Edentulousness was positively associated with high age [odds ratio (OR = 1.09), confidence interval (CI = 1.06-1.12)], female gender (OR = 2.06, CI = 1.43-2.94), northern place of residence (OR = 2.01, CI = 1.45-2.78), low level of education (OR = 7.09, CI = 3.18-15.81), cardiovascular diseases (OR = 1.51, CI = 1.03-2.21) and current smoking versus never smoking (OR = 1.73, CI = 1.17-2.55). Social factors were more prominently associated with edentulousness than factors related to general health.

Refining exposure definitions for studies of periodontal disease and systemic disease associations

BACKGROUND

Substantial variation exists in reported associations between periodontal infections and cardiovascular disease. Imprecise periodontal exposure definitions are possible contributors to this variability. We studied appropriate exposure definitions for studying associations between clinical periodontal disease (PD) and systemic disease.

METHODS

Data originate from men and women aged 20-79 enrolled in the Study of Health in Pomerania (SHIP) from 1997-2001. Age and sex-adjusted correlation analysis identified PD definitions with the highest cross-sectional associations with three subclinical markers of systemic disease: plasma fibrinogen (n = 3481), serum hemoglobin A1c (HbA1c) (n = 3480), and common carotid artery intima-media thickness (c-IMT) (n = 1745, age > or = 45).

RESULTS

In men and women, percent of sites with attachment loss (AL) > or =6 mm and tooth loss both revealed the highest correlation with HbA1c (rho = 0.11; several other definitions related similarly), while the strongest fibrinogen correlation was observed with percent of sites with pocket depth > or =3 mm (rho = 0.19). Findings for c-IMT among men were strongest for percent of sites with AL > or =6 mm (rho = 0.14; several other definitions related similarly) while among women, percent of sites with pocket depth > or =5 or 6 mm had the highest observed correlation (rho = 0.13).

CONCLUSIONS

A range of near optimal definitions varied according to gender and whether the systemic disease marker reflected an acute or chronic situation. Pocket depth was more strongly correlated with the acute marker fibrinogen while attachment and tooth loss tended to be more strongly correlated with the chronic markers, HbA1c, and c-IMT. These findings can be useful in designing future studies investigating the association between PD and systemic disease.