Association between periodontal pockets and elevated cholesterol and low density lipoprotein cholesterol levels

Association between periodontal disease and metabolic syndrome

OBJECTIVES

Metabolic syndrome is a complex medical disorder characterized by visceral fat-type obesity involving hypertension, and abnormal glucose and lipid metabolism. The objective of this study was to investigate the relationship between periodontal disease and components of metabolic syndrome (obesity, lipid abnormality, hypertension, and hyperglycemia) in industrial workers of a single company in Tokyo, Japan.

METHODS

The study subjects consisted of 2478 adult employees (2028 men and 450 women; mean age: 43.3 years). The association between the presence of periodontal pockets and components of metabolic syndrome was investigated cross-sectionally using multiple logistic regression analysis, odds ratios (ORs), and 95 percent confidence intervals (CIs).

RESULTS

Body mass index, blood pressure, triglycerides, fasting blood glucose, and hemoglobin A1c (HbA1c) were significantly elevated (P < 0.05) in patients with periodontal pockets of 4 mm or more. We found that the OR of the presence of periodontal pockets adjusted for age, gender, and smoking habit was 1.8 (96 percent CI = 1.4-2.3) when the subjects with two positive components and without positive component were compared. And it was 2.4 (96 percent CI = 1.7-2.7) when the subjects with three or four positive components and without positive component were compared.

CONCLUSIONS

Our findings suggest an association between periodontal disease and metabolic syndrome in Japanese workers between the ages of 20 and 60 years.

Regulation of high-density lipoprotein by inflammatory cytokines: establishing links between immune dysfunction and cardiovascular disease

Coronary artery disease is a primary co-morbidity in metabolic diseases such as metabolic syndrome, diabetes and obesity. One contributing risk factor for coronary artery disease is low high-density lipoprotein-cholesterol (HDLc). Several factors influence steady-state HDLc levels, including diet, genetics and environment. Perhaps more important to coronary artery disease is factors that attribute to the dynamics of reverse cholesterol transport, storage, and excretion of excess cholesterol. HDLc biogenesis, clearance and innate ability to serve as a cholesterol acceptor and transporter all contribute to HDLc's function as a negative regulator of cardiovascular disease. With the recent failure of torcetrapid, focus is being placed on HDLc biology and its role in various metabolic diseases. Low HDLc levels are often associated with an increased state of background inflammation. Recently, several syndromes with clear pro-inflammatory components have been shown to be inversely correlated with low HDLc levels in the absence of obesity, diabetes and metabolic syndrome. Early studies with HDLc during the acute-phase response suggest that HDLc is substantially physically modified during acute infection and sepsis, and recent studies show that HDLc is physically modified by chronic pro-inflammatory disease. In this review, several of these connections are described and cytokine signalling related to HDLc is examined.

Is gum disease killing your patient?

There is considerable epidemiological evidence to support the concept that poor oral health, especially the extent and severity of periodontal disease, may put patients at a significant risk for a variety of systemic conditions. This association raises the question that if patients or members of the dental profession ignore oral health, is there an increased risk of morbidity and mortality? In this presentation, the relationship between periodontal disease and many systemic conditions will be explored further. In addition, if periodontal disease does increase the risk of various systemic diseases, it raises the issue as to what the impact of treating periodontal disease is in reducing the magnitude of the risk. There is increasing evidence that reducing the inflammatory component in the periodontal tissues does have potential systemic effects. This has been shown to improve hyperglycaemic control in diabetics, reduce the prevalence of adverse pregnancy outcomes and improve surrogate markers that may be of benefit in patients suffering from coronary heart disease.

Increased levels of circulating endothelial progenitor cells in subjects with moderate to severe chronic periodontitis

AIM

Emerging evidence shows that periodontal disease is associated with endothelial dysfunction. The purpose of this study was to determine the association between chronic periodontitis (CP) and circulating endothelial progenitor cells (EPC).

MATERIALS AND METHODS

Eighty-six non-smoking subjects (36 males and 50 females, aged 35-80 years) were recruited, including 23 subjects with no or mild CP and 63 subjects with moderate to severe CP. The levels of circulating EPC were quantitatively determined by fluorescence-activated cell analysis, including CD34+/kinase insert domain-containing receptor (KDR)+ (more mature EPC) and CD133+/KDR+ (less mature EPC). Periodontal conditions, the intima-media thickness of carotid arteries and circulating biomarkers were examined.

RESULTS

Subjects with moderate to severe CP exhibited an increased risk of high EPC count, compared with those with no or mild CP: CD34+/KDR+ EPC [odds ratio (OR)=9.5, 95% confidence interval (95% CI) 1.5-61.0, p=0.018; CD133+/KDR+ EPC, OR=4.6, 95% CI 1.1-19.5, p=0.039]. C-reactive protein was significantly associated with high CD34+/KDR+ EPC count and age was inversely related with high EPC count. Age, gender and CD34+/KDR+ EPC were independent variables of increased carotid intima-media thickness (p<0.05).

CONCLUSION

This study shows for the first time that moderate to severe CP is associated with an increased level of circulating EPC.

Cardiovascular disease parameters in periodontitis

BACKGROUND

Recently, there has been an increasing in the impact of oral health on atherosclerosis and subsequent cardiovascular disease. The aim of this study is to investigate the association between chronic periodontitis and cardiovascular risk markers.

METHODS

Forty patients with periodontitis and 40 healthy gender-, body mass index-, and age-matched individuals were compared by measuring total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, levels of cytokines, antibodies against oxidized low-density lipoprotein, thiobarbituric acid reactive substances, total and differential white blood cell counts, and the non-linear index of refraction.

RESULTS

The levels of triglycerides and high-density lipoprotein in periodontitis patients were significantly higher and lower, respectively (P = 0.002 and P = 0.0126), compared to controls. Total cholesterol, low-density lipoprotein, and lipid peroxide levels were the same in both groups (P = 0.2943, P = 0.1284, and P = 0.067, respectively). Interleukin (IL)-6 and -8, antibodies against oxidized low-density lipoprotein, and leukocyte and neutrophil counts were significantly higher in periodontitis patients (P <0.05). The value of the non-linear index of refraction of low-density lipoprotein solutions was higher in the controls (P = 0.015) compared to individuals with periodontitis.

CONCLUSION

Our results confirmed and further strengthened the suggested association between coronary artery disease and periodontitis.

Metabolic syndrome and periodontitis: is oxidative stress a common link?

A review of pathological mechanisms that can explain the relationship between periodontitis and cardiovascular disease (CVD) is necessary to improve the management of both conditions. Metabolic syndrome is a combination of obesity, hypertension, impaired glucose tolerance or diabetes, hyperinsulinemia, and dyslipidemia. All these have been examined in recent years in terms of their relationship to periodontitis. Reviewed data indicate an association between some of them (body mass index, high-density lipoprotein-cholesterol [HDL-C], triglycerides, high blood pressure, among others) and periodontitis. Oxidative stress may act as a potential common link to explain relationships between each component of metabolic syndrome and periodontitis. Both conditions show increased serum levels of products derived from oxidative damage, with a pro-inflammatory state likely influencing each other bidirectionally. Adipocytokines might modulate the oxidant/anti-oxidant balance in this relationship.

Periodontal disease: a modifiable risk factor for cardiovascular disease in ESRD patients?

Accumulating evidence suggests that periodontal disease is associated with increased risk of cardiovascular disease (CVD). Several mechanisms have been proposed to explain this association. To date, however, a causal relation has not been firmly established. In addition, the extent to which treatment of periodontal disease might result in lower incidence of CVD has not been addressed in any study to date. Further research is needed before recommendations are made regarding monitoring and therapy of periodontal disease.

Periodontal status in subjects with hyperlipidemia

BACKGROUND

Hyperlipidemia is a major risk factor for cardiovascular disease. Recent reports showed a possible association between periodontal disease and an increased risk for cardiovascular disease. The aim of this study was to evaluate whether hyperlipidemia has any influence on periodontal status.

METHODS

Fifty-one subjects with hyperlipidemia and 47 normolipidemic subjects participated in this study. Biochemical parameters, including plasma triglyceride, total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels, and periodontal parameters, including plaque index (PI), probing depth (PD), clinical attachment level (CAL), and percentage of sites with bleeding on probing (BOP [%]), were evaluated.

RESULTS

The mean values of PI, PD, CAL, and BOP (%) for the hyperlipidemic group were significantly higher than those for the control group. Plasma triglyceride, total cholesterol, and LDL-C levels were significantly and positively associated with PI, PD, BOP (%), and CAL. HDL-C was significantly, but negatively, associated with CAL. Plasma triglyceride level was significantly associated with PD and BOP (%) after further analyses.

CONCLUSIONS

The results of our study showed that patients with mild or moderate hyperlipidemia manifested higher values of periodontal parameters compared to normolipidemic individuals. Further studies are needed to determine the effect of hyperlipidemia on periodontal disease.

Endotoxin levels are associated with high-density lipoprotein, triglycerides, and troponin in patients with acute coronary syndrome and angina: possible contributions from periodontal sources

BACKGROUND

Recent studies have reported an association between poor dental health and acute coronary syndrome (ACS). The purpose of this study was to correlate the presence of periodontitis with serum endotoxin/lipopolysaccharides (LPS), lipid profiles, troponin, and immunoglobulin G (IgG) antibody to Porphyromonas gingivalis in control patients or patients with ACS or angina at the time of hospital admission.

METHODS

Blood samples from 194 subjects presenting with ACS, angina, or non-cardiac chest pain were analyzed for endotoxin/LPS (Limulus amebocyte lysate assay), lipid profile, troponin, and IgG antibody to P. gingivalis. Data were collected from hospital charts and dental records, and health questionnaire responses.

RESULTS

Subjects with ACS or angina were more likely to have poor oral care, fewer remaining teeth, and increased alveolar radiographic bone loss compared to subjects with chest pain. In all subjects, endotoxin/LPS and IgG antibody to P. gingivalis tended to increase in association with increased radiographic bone loss. Endotoxin/LPS increased directly with triglyceride and troponin levels (P = 0.04 and P = 0.006, respectively) and inversely with high-density lipoprotein (HDL) levels (P = 0.002). IgG antibody to P. gingivalis levels was directly correlated with very low-density lipoprotein (P = 0.03) and triglycerides (P = 0.06) and inversely with low-density lipoprotein (P = 0.01).

CONCLUSIONS

Results showed more alveolar bone loss in patients with cardiac disease than in patients without cardiac disease, but there was no difference between the groups in the serum levels of endotoxin/LPS or IgG antibody to P. gingivalis. However, there were associations between endotoxin/LPS and levels of serum triglycerides, troponin, and HDL.

Cardiovascular disease and periodontitis: an update on the associations and risk

BACKGROUND

Associations between periodontitis and cardiovascular diseases have been recognized.

MATERIAL AND METHODS

New literature since the last European Workshop on Periodontology has been reviewed.

RESULTS

The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1-2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear.

CONCLUSIONS

Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case-control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

Steroid 5alpha-reductase activity of Treponema denticola

INTRODUCTION

Previously we have shown that reference and freshly isolated Treponema denticola cultures possess 5alpha-reductase (5alpha-R) and 3beta- and 17beta-hydroxysteroid dehydrogenase activity. A gene matching the 3-oxo-5alpha-steroid 4-dehydrogenase family protein (gene ID: 2739284; locus tag: TDE2697) has been identified in T. denticola ATCC 35405. The aim of the work presented here was to optimize assay conditions and determine steroid substrate specificities for the 5alpha-R activity of T. denticola ATCC 33520.

METHODS

5alpha-R activity of cell-free preparations was assayed with radioactive steroid substrates. 5alpha-R-reduced products were identified using thin-layer chromatography and a radioisotope scanner. Assay conditions were optimized for co-factor, buffer and pH requirements. Apparent substrate specificities were determined for progesterone, 4-androstenedione, testosterone and corticosterone. The time-course for metabolism of radiolabelled progesterone and cholesterol substrates was investigated with anaerobic cultures.

RESULTS

The optimum pH for 5alpha-R was 5.5 and the preferred co-factor was NADPH. The order of the steroids with respect to their 5alpha-R substrate specificities was (in descending order): progesterone, 4-androstenedione, testosterone and corticosterone. There are at least two intermediates in the synthesis of 5alpha-dihydrocholesterol from cholesterol.

CONCLUSION

These results suggest that the 3-oxo-5alpha-steroid 4-dehydrogenase family protein gene of T. denticola codes for a functional protein that resembles mammalian 5alpha-R isoenzyme 2 with regard to co-factor requirement and pH optimum.

Anaerobic dental flora and the acute coronary syndrome

OBJECTIVE

Evidence exists that coronary heart disease is influenced by anaerobic bacterial flora and gingival inflammation. We assessed the association of periodontal bacteria, coronary artery disease, and acute coronary events.

METHODS

The benzoyl-DL-arginine naphthylamide test, which detects several periodontal pathogens, and the papillary bleeding score were used to quantify gingival health. Participants with coronary heart disease (n=245) presenting with (n=92) and without an acute coronary syndrome were compared with persons seeking dental treatment (University dental, n=195) and a healthy cohort (Healthy dental, n=156).

RESULTS

An 'infection', defined by a positive benzoyl-DL-arginine naphthylamide test score in>or=50% of sampled sites, was present in 408 participants. Compared with Healthy dental, the odds ratio for coronary heart disease having an infection was 8.6 (95% confidence interval, 4.0-18.4) and for University dental odds ratio=16 (95% confidence interval, 6.5-39.5). Patients with an acute coronary syndrome at the time of benzoyl-DL-arginine naphthylamide sampling were 3.95 times more likely to have an infection compared with coronary heart disease patients with no history of acute coronary syndrome (P=0.003), a finding independent of other covariates.

CONCLUSIONS

Persons with coronary heart disease, particularly associated with an acute coronary syndrome, have anaerobic bacterial dental flora similar to individuals seeking periodontal dental care, and unlike periodontally healthy individuals.

Severe periodontitis is associated with systemic inflammation and a dysmetabolic status: a case–control study

BACKGROUND AND AIM

A cluster of metabolic factors defines a syndrome that predisposes to diabetes and cardiovascular disease. Chronic infections such as periodontitis might alter these individual metabolic factors and the systemic inflammatory burden. The aim of this study was to investigate the association between severe periodontitis and increase in inflammatory and metabolic risk factors for cardiovascular disease.

MATERIALS AND METHODS

We examined 302 patients with severe periodontitis and 183 healthy controls, and we collected a blood sample from each subject in order to investigate differences in inflammatory (leukocyte numbers and differential counts) and metabolic markers (lipids and glucose).

RESULTS

After correcting for differences in age, gender, smoking and ethnicity, periodontitis subjects exhibited a low-grade systemic inflammation (increased white cell counts, 1.10+/-1.02 x 10(9)/l, 95%CI 1.05-1.15, p=0.0001), dyslipidemia [lower high-density lipoprotein cholesterol, 1.14+/-1.03 mmol/l, 95%CI 1.08-1.20, p<0.0001 and higher low-density lipoprotein cholesterol, 1.12+/-1.03, 95%CI 1.05-1.19, p<0.0001) and increased non-fasting serum glucose levels (1.04+/-1.01 mmol/l, 95%CI 1.02-1.06, p=0.01) when compared with controls. The associations were confirmed in a subpopulation of Caucasian non-smokers. A trend for a dose dependent effect of the number of periodontal pockets on the tested inflammatory and metabolic markers was observed.

CONCLUSIONS

These data suggest a possible link between severe generalized periodontitis, systemic inflammation and a dysmetabolic state in otherwise healthy individuals.

Relationship of periodontal infection to serum antibody levels to periodontopathic bacteria and inflammatory markers in periodontitis patients with coronary heart disease

Several reports have demonstrated a possible association of periodontal infections with coronary heart disease (CHD) by elevated antibody titre to periodontopathic bacteria in CHD patients compared with non-diseased controls. Although each periodontopathic bacterium may vary in virulence for periodontitis and atherosclerosis, antibody response to multiple bacteria in CHD patients has not been understood fully. Therefore, serum levels of antibody to 12 periodontopathic bacteria together with other atherosclerotic risk markers were compared among 51 patients with CHD, 55 patients with moderate to severe chronic periodontitis and 37 healthy individuals. The antibody response was the most prevalent for Porphyromonas gingivalis, a major causative organism, in CHD as well as periodontitis patients. However, antibody positivity was different between CHD and periodontitis if the response was analysed for two different strains of P. gingivalis, namely FDC381 and Su63. While periodontitis patients were positive for both P. gingivalis FDC381 and Su63, a high frequency of antibody positivity for P. gingivalis Su63 but not for FDC381 was observed in CHD patients. The results indicate that the presence of particular periodontopathic bacteria with high virulence may affect atherogenesis. Identifying the virulence factors of P. gingivalis Su63 may gain insight into the new therapeutic modality for infection-induced deterioration of atherosclerosis.

Beneficial Effects of Periodontal Treatment on Metabolic Control of Hypercholesterolemia

BACKGROUND

The authors aimed to evaluate whether local periodontal therapy may influence plasma lipid levels in patients with periodontitis.

METHODS

Fifty patients (31 females and 19 males, age 36-66 yr) were randomly assigned to the treatment and control groups. Lipid profile and dental variables were measured at baseline and at the end of the study in both groups.

RESULTS

In the third month, there was a significant decrease in total and low density lipoprotein (LDL) cholesterol levels of the treatment group compared with baseline values. Also, the reduction in bleeding on probing, pocket depth, attachment loss, plaque index and gingival index were statistically significant in the treatment group.

CONCLUSIONS

The present study indicates that periodontitis causes changes in total and LDL cholesterol levels and local periodontal treatment resulted in a significant decrease in these markers. These results suggest a potential effect of periodontitis-driven systemic inflammation on lipid metabolism.

Influence of periodontal therapy on the regulation of soluble cell adhesion molecule expression in aggressive periodontitis patients

BACKGROUND

Inflammatory periodontal disease is associated with an increased risk of cardiovascular disease. Circulating cell adhesion molecules (CAM) (intercellular adhesion molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1], and E-selectin) have been suggested as potential candidate markers of endothelial dysfunction, which contribute to the pathogenesis of cardiovascular diseases. The regulation of CAM in subjects with severe periodontitis and the influence of periodontal intervention on systemic CAM levels are not clear. The aim of this study was to determine whether intensive periodontal therapy reduces serum levels of CAM in patients with generalized aggressive periodontitis.

METHODS

Blood samples were collected at six treatment time points from 21 patients with previously untreated generalized aggressive periodontitis (mean age: 34.6 +/- 4.3 years). Patients received subgingival scaling and root planing and antibiotic therapy and were monitored over a 6-month recall period. Serum levels of soluble ICAM-1 (sICAM-1), VCAM-1 (sVCAM-1), and E-selectin (sE-selectin) were measured by enzyme-linked immunosorbent assay.

RESULTS

sE-selectin plasma levels decreased significantly (P <0.01) during periodontal therapy. Mean plasma levels were 65.95 ng/ml before treatment and 44.71 ng/ml 6 months after antibiotic therapy. sICAM-1 and sVCAM-2 serum levels were unaffected by therapeutic intervention.

CONCLUSIONS

Periodontal therapy reduces plasma sE-selectin levels. Whether this leads to a reduction in risk of future cardiovascular events in patients with aggressive periodontal disease warrants further studies.

Effects of a high-cholesterol diet on cell behavior in rat periodontitis

Studies have shown an association between periodontitis and serum cholesterol levels. We hypothesized that high dietary cholesterol could influence periodontitis as a result of proliferation of the junctional epithelium. Rats were divided into 4 groups. Two groups were fed a regular diet, and 2 groups were fed a high-cholesterol diet. One of each dietary group was treated with periodontitis-inducing agents (lipopolysaccharide and proteases), while the other was treated with pyrogen-free water. Feeding rats with a high-cholesterol diet induced an increase in blood total cholesterol and a decrease in high-density lipoprotein cholesterol. Proliferation of the junctional epithelium with increasing bone resorption was promoted by the consumption of a high-cholesterol diet. High dietary cholesterol further increased the cell-proliferative activity of the junctional epithelium induced by lipopolysaccharide and proteases. These results suggest that high dietary cholesterol can initiate and augment periodontitis in the rat periodontitis model.

Overexpression of lysosomal acid lipase and other proteins in atherosclerosis

Atherosclerosis is one of the major causes of morbidity and mortality in the western world. The existing data of elevated expression levels of proteins like DNA damage and DNA repair enzymes in human atherosclerotic plaques are reviewed. From the literature, the effect of overexpression of different proteins using adenoviral vectors or the model of transgenic mice on the development of atherosclerosis will be discussed. Special focus is placed on the lysosomal acid lipase (LAL), because LAL connects extra-cellular with intra-cellular lipid metabolism and is the only hydrolase for cleavage of cholesteryl esters delivered to the lysosomes. Patients with a deficiency of LAL show an accumulation of lipids in the cells and develop pre-mature atherosclerosis. To answer the question of the influence of LAL in atherosclerosis if overexpressed, we show for the first time data of transgenic mice overexpressing LAL and the effect on the lipid level.

Periodontal disease and coronary heart disease

BACKGROUND

Several epidemiological studies have demonstrated an association between periodontal disease and coronary heart disease (CHD). The association could be a result of confounding by mutual risk factors. The present study was undertaken in a Danish population to reveal the significance of common risk factors.

METHODS

The investigation was conducted as a case-control study comprising 250 individuals: 110 individuals with verified CHD from a Department of Cardiovascular Medicine and 140 control individuals without CHD from the Copenhagen City Heart Study. Information on diabetic status, smoking habits, alcohol consumption, physical activity, school attendance, household income, body weight and height, triglyceride, and serum cholesterol was obtained. Full-mouth probing depth (PD), clinical attachment loss (CAL), bleeding on probing (BOP), and alveolar bone level (ABL) on radiographs were registered. ABL was stratified into ABL1=ABL<or=2 mm; ABL2=ABL>2 to <or=4 mm; and ABL3=ABL>4 mm. Multiple logistic regression models with stepwise backward elimination were used allowing variables with P<0.15 to enter the multivariate analysis.

RESULTS

The CHD group had a significantly lower outcome with respect to PD, BOP, CAL, and ABL. For participants<60 years old, only risk factors such as smoking and diabetic status entered the multivariate analysis. For the ABL3 group, there was a significant association with CHD for participants<60 years old, the odds ratio being 6.6 (1.69 to 25.6). For participants>or=60 years old, there was no association.

CONCLUSIONS

The present study showed a positive association between periodontal disease and CHD in agreement with several other studies. The association was highly age dependent and could only be attributed to diabetes and smoking to some extent.

The influence of cholesterol, progesterone, 4-androstenedione and testosterone on the growth of Treponema denticola ATCC 33520 in batch cultures

Previously, we have shown that reference and freshly isolated Treponema denticola cultures are capable of metabolising cholesterol, progesterone, 4-androstenedione and testosterone by means of 5alpha-reductase, 3beta-and 17beta-hydroxysteroid dehydrogenase activity [Clark DT, Soory M. The metabolism of cholesterol and certain hormonal steroids by Treponema denticola. Steroids. 2006;71:352-63. ]. The aim of the work presented in this paper was to investigate the modulation of T. denticola growth in batch cultures by these steroids, using T. denticola ATCC 33520 as a model system. Growth curves were summarised using statistics based on optical density and protein yield. Cholesterol was found to stimulate growth at concentrations of 10 and 25microg/mL. Certain hormonal steroids inhibited the maximum achievable optical density at concentrations of 1 and 10microg/mL while the minimum concentration shown to inhibit protein yield was 0.001microg/mL of progesterone. The potential of the hormonal steroids to inhibit growth was in the order of progesterone, 4-androstenedione and testosterone.

Serum antibody response to periodontal pathogens and herpes simplex virus in relation to classic risk factors of cardiovascular disease

BACKGROUND

Increasing evidence links chronic infections, especially burden of several infections, with increased risk for cardiovascular diseases (CVD). We studied joint immune response against two major periodontal pathogens and herpes simplex virus (HSV) in relation to established risk factors of CVD.

METHODS

Serum antibody levels to HSV, Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis were determined by ELISA. The study included 1107 subjects, 734 from Finland and 373 from Russia.

RESULTS

Combined antibody response to periodontal pathogens was associated inversely (OR, 95% CI) with high-density lipoprotein (HDL) cholesterol concentration (beta = 0.35; 0.20, 0.60; P < 0.001) and directly with HSV antibody quartiles: compared with the first quartile, ORs (95% CI) for quartiles 2-4 were 1.43 (0.88-2.32), 1.74 (1.07-2.82), and 1.89 (1.18-3.02), respectively (P for trend <0.001), after adjusting for age, gender, area, education, smoking, BMI, alcohol, triglycerides, and number of teeth. In linear regression analysis, the 3-pathogen antibody score (comprising antibody levels against periodontal pathogens and HSV) was inversely associated with HDL cholesterol concentration (beta = -0.067/1 mmol/l; -0.235, -0.018; P < 0.05).

CONCLUSIONS

HSV infection may promote infection by periodontal pathogens. Furthermore, the infectious burden comprising HSV and periodontitis may increase the risk for CVD by clearly decreasing HDL cholesterol concentrations.

Oxidative damage of periodontal tissue in the rat periodontitis model: effects of a high-cholesterol diet

Studies suggest an association between consumption of a high-cholesterol diet and periodontitis. We addressed the mechanism by which high dietary cholesterol could be detrimental to periodontal health in a rat model. Feeding a high-cholesterol diet augmented the effects of bacterial pathogens and their products (e.g., lipopolysaccharide and proteases) on production of pro-inflammatory cytokines in fibroblasts. High dietary cholesterol also increased mitochondrial 8-hydroxydeoxyguanosine in the periodontal tissues. These results suggest that excessive tissue oxidative damage induced by high dietary cholesterol could potentiate pro-inflammatory cytokine production by fibroblasts stimulated with bacterial pathogens.

The metabolism of cholesterol and certain hormonal steroids by Treponema denticola

The aim was to investigate whether reference cultures and fresh isolates of Treponema denticola are able to 5alpha-reduce and further metabolise testosterone, 4-androstenedione, progesterone, corticosterone, cortisol or cholesterol. Two reference and five freshly isolated cultures of T. denticola were incubated with either radiolabeled or unlabeled steroid substrates; in the first case products were identified by thin layer chromatography and in the latter by gas chromatography-mass spectroscopy. All the substrates were 5alpha-reduced. Both reference cultures and fresh isolates of T. denticola presented 3beta- and 17beta-hydroxy steroid dehydrogenase activity. It was concluded that T. denticola was capable of steroid metabolism and hypotheses are discussed regarding the in vivo function of this metabolism including, T. denticola utilising host supplied steroids as growth factors and T. denticola steroid metabolism acting as a virulence factor.

Risk factors and prevalence of periodontitis in community-dwelling elders in Mexico

AIM

The objective of this study was to determine whether an association existed between chronic systemic diseases/conditions, risk factors common in old age, and the extent and severity of chronic periodontal disease.

MATERIALS AND METHODS

Sociodemographic and lifestyle characteristics were examined by contrasting rural, urban-marginal, and urban social environments in Central Mexico. Data were analysed with Analysis of Variance, chi2 tests, and multivariable logistic regression.

RESULTS

A total of 473 adults 60 years old and over were interviewed; 315 were also examined and underwent laboratory assays (participation rate, 66%); women, 62%; mean age 73+/-8 years; 23% edentulous. The distribution of periodontitis by sociodemographic variables showed differences across locales (73% low-urban, 57% middle-urban, 29% rural). The regression model indicated that periodontitis was more frequently associated with low-urban locale, higher systolic blood pressure, higher body mass index, and worse calculus readings, with an interaction whereby being obese and having a high calculus index was associated with a high probability of having periodontitis.

CONCLUSIONS

Overall periodontal conditions were fair. While we identified oral, systemic, and social variables that modulated the experience of periodontitis, it would appear that urban, low social class elders appeared to have worse periodontal conditions.

Relation between chronic periodontal disease and plasmatic levels of triglycerides, total cholesterol and fractions

Many people in the world are affected by hyperlipidemia, which is a known risk factor for atherosclerotic disease. On the other hand, periodontitis, a prevalent oral disease, has been connected to several systemic health changes, including an altered lipid metabolism. Transient and recurrent bacteremias, which may be caused by periodontal infection, induce an intense local and systemic inflammatory response, leading to changes in the whole body. The aim of the present study was to verify the relationship between severe and moderate periodontal disease and blood lipid levels. Sixty individuals seen at the clinics of the University of Taubaté, São Paulo, over 20 years old, were divided into two groups, with and without periodontitis, and paired according to sex and age. Their levels of total cholesterol, tryglicerides and fractions were determined. Variables related to high cholesterol levels, including age, sex and body mass index, were evaluated. The values recommended by the Brazilian Society of Cardiology were considered to classify lipidemia. The results showed that mean levels of cholesterol (192.1 mg/dl +/- 40.9) and triglycerides (153.5 mg/dl +/- 105.6) in individuals with periodontitis were higher than, but not statistically different from, those of individuals without periodontitis (186.1 mg/dl +/- 35.4 and 117.5 mg/dl +/- 68, respectively). Therefore, this study has demonstrated that there is no significant relationship between periodontal disease, regardless of its intensity, and blood lipid levels in the studied population.

Dental infections and cardiovascular diseases: a review

Accumulating evidence suggests that chronic infections, such as periodontitis, are associated with increased risk for cardiovascular diseases (CVD). The mechanisms behind the association are not known. Like herpes viruses and Chlamydia pneumoniae, periodontal pathogens cause atherosclerosis in experimental animals and have been found in human atherosclerotic lesions. Higher concentrations of total and low density lipoprotein (LDL) cholesterol and triglycerides and lower concentrations of high density lipoprotein (HDL) cholesterol have been observed in individuals with periodontitis before periodontal treatment. Periodontitis also induces a peripheral inflammatory and immune response, reflected in elevated concentrations of C-reactive protein (CRP) and IgA-class antibodies to periodontal pathogens. The prevalence of CVD seems to be highest in those individuals in whom periodontitis coexists with elevated CRP levels. This may indicate that periodontitis is a CVD risk factor in individuals who react to the infection with a systemic inflammatory and immune response. This may be due to genetic reasons and may also apply to other chronic low-grade infections.

Systemic effects of periodontitis: epidemiology of periodontal disease and cardiovascular disease

There have been 42 published studies describing associations between oral conditions and cardiovascular diseases. In the absence of randomized controlled trials, the 16 longitudinal studies represent the highest level of evidence available. However, two databases produced eight of the 16 studies. There also is extensive variability in definitions of the oral exposure that include salivary flow, reported periodontal disease, number of teeth, oral organisms, antibodies to oral organisms, Total Dental Index, Community Periodontal Index of Treatment Needs, plaque scores, probing depth, attachment loss, and bone level. Variability also exists in the cardiovascular outcomes that include atherosclerosis measures and events, such as hospitalization for coronary heart disease (CHD), chronic CHD, fatal CHD, total stroke, ischemic stroke, and revascularization procedures. One of the criticisms of this research is that the exposure has not been represented by measures of infection. To begin to address this concern, we present new data showing that patterns of high and low levels of eight periodontal pathogens and antibody levels against those organisms are related to clinical periodontal disease as well as other characteristics of the individuals, such as age, race, gender, diabetic status, atherosclerosis, and CHD. As others before us, we conclude that the cumulative evidence presented above supports, but does not prove, a causal association between periodontal infection and atherosclerotic cardiovascular disease or its sequelae. A number of legitimate concerns have arisen about the nature of the relationship and, indeed, the appropriate definitions for periodontal disease when it is thought to be an exposure for systemic diseases. There is still much work needed to identify which aspects of the exposure are related to which aspects of the outcome. Principal component analyses illustrate the complexity of the interactions among risk factors, exposures, and outcomes. These analyses provide an initial clustering that describes and suggests the presence of specific syndromes.

Marginal periodontium as a potential reservoir of human papillomavirus in oral mucosa

BACKGROUND

Although human papillomaviruses (HPVs) are associated with a number of proliferative epithelial lesions including squamous cell malignancies, they can also be detected in the normal oral mucosa in 10% to 20% of the adult population. However, the point of entry and the site of replication of HPV in the oral cavity are not known. Since the gingival pocket is the only site in the oral mucosa where basal cells, known to be targets of HPV at other mucosal sites, are normally exposed to the environment, we hypothesized that this could be the site of latent HPV.

METHODS

Gingival biopsies taken from 38 individuals with clinically diagnosed periodontal disease were examined. The presence of HPV DNA was studied by using nested PCR (polymerase chain reaction with MY09/MY11 and GP05+/GP06+ primers targeting the L1 region of HPV), followed by subsequent hybridization with a cocktail of 12 high-risk HPV oligoprobes and in situ hybridization (ISH) with probes for HPV screening and the HPV subtype 16.

RESULTS

In the present study, high-risk HPV types were detected in 26% (8/31) of the gingival biopsies with PCR. By using in situ hybridization, the viral DNA was localized to the coronal part of the junctional epithelium in the gingival pocket.

CONCLUSIONS

The results suggest that the periodontal pocket might serve as a reservoir of HPVs in oral mucosa. While having important implications in understanding the HPV transmission, this observation does not rule out the possibility that HPV may be involved in the initiation of periodontal disease.

Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol

Severe periodontitis has been associated with increased systemic inflammation. In a three-arm preliminary randomized trial, we investigated the impact of standard (SPT) and intensive periodontal therapy (IPT) on serum inflammatory markers and cholesterol levels. Medical and periodontal parameters, C-reactive protein (CRP), interleukin-6 (IL-6), total cholesterol, and LDL cholesterol were evaluated in 65 systemically healthy subjects suffering from severe generalized periodontitis. Two months after treatment, both SPT and IPT resulted in significant reductions in serum CRP compared with the untreated control (0.5 +/- 0.2 mg/L for SPT, P = 0.030 and 0.8 +/- 0.2 mg/L for IPT, P = 0.001). Similar results were observed for IL-6. Changes in inflammation were independent of age, gender, body mass index, and ethnicity, but a significant interaction between cigarette smoking and treatment regimen was found. The IPT group also showed a decrease in total and LDL cholesterol after 2 months. Analysis of these data indicates that periodontitis causes moderate systemic inflammation in systemically healthy subjects.

Oral health, atherosclerosis, and cardiovascular disease

During the last two decades, there has been an increasing interest in the impact of oral health on atherosclerosis and subsequent cardiovascular disease (CVD). The advent of the inflammation paradigm in coronary pathogenesis stimulated research in chronic infections caused by a variety of micro-organisms-such as Chlamydia pneumoniae, Helicobacter pylori, and cytomegalovirus-as well as dental pathogens, since these chronic infections are thought to be involved in the etiopathogenesis of CVD by releasing cytokines and other pro-inflammatory mediators (e.g., C-reactive protein [CRP], tumor necrosis factor [TNF-alpha]) that may initiate a cascade of biochemical reactions and cause endothelial damage and facilitate cholesterol plaque attachment. Yet, due to the multi-factorial nature of dental infection and CVD, confirming a causal association is difficult, and the published results are conflicting. The main deficit in the majority of these studies has been the inadequate control of numerous confounding factors, leading to an overestimation and the imprecise measurement of the predictor or overadjustment of the confounding variables, resulting in underestimation of the risks. A meta-analysis of prospective and retrospective follow-up studies has shown that periodontal disease may increase the risk of CVD by approximately 20% (95% confidence interval [CI], 1.08-1.32). Similarly, the reported risk ratio between periodontal disease and stroke is even stronger, varying from 2.85 (CI 1.78-4.56) to 1.74 (CI 1.08-2.81). The association between peripheral vascular disease and oral health parameters has been explored in only two studies, and the resultant relative risks among individuals with periodontitis were 1.41 (CI 1.12-1.77) and 2.27 (CI 1.32-3.90), respectively. Overall, it appears that periodontal disease may indeed contribute to the pathogenesis of cardiovascular disease, although the statistical effect size is small.

Periodontal infections and atherosclerosis: mere associations?

PURPOSE OF REVIEW

Several lines of evidence from the last few decades suggest that periodontitis is an important risk factor for cardiovascular diseases. In this review we discuss the recent findings on the systemic effects of periodontitis, which may contribute to the pathogenesis of atherosclerosis, with a special emphasis on lipoproteins.

RECENT FINDINGS

In addition to the epidemiological studies exploring the direct or indirect relationship between clinical periodontitis and cardiovascular diseases, studies utilizing serology, animal models, cell cultures, and biochemistry of lipoproteins have been published. Local infection in the periodontal pockets triggers a systemic inflammatory response releasing inflammatory mediators and awakens a strong immune response against periodontal pathogens. Elevated systemic antibody levels especially to Porphyromonas gingivalis are associated with an increased risk for atherosclerosis. Periodontitis is also accompanied by proatherogenic changes in both low and high density lipoproteins, which lead to enhanced cholesteryl ester uptake by and reduced cholesterol efflux from macrophages. Vesicles and lipopolysaccharide isolated from P. gingivalis activate macrophages to convert into foam cells. Moreover, animal studies have demonstrated that infection by P. gingivalis enhances progression of atherosclerosis.

SUMMARY

Recent studies have clarified the mechanisms by which periodontitis may contribute to the development of atherosclerosis. Serological, animal, and cell culture studies provide evidence that infection by P. gingivalis may promote atherosclerosis. The influence of periodontitis on lipoprotein metabolism has emerged as a new, important factor. Recent studies provide experimental proof that periodontitis may predispose to atherosclerosis.

Antibodies to Periodontal Pathogens and Stroke Risk

Background and Purpose— The association between cerebrovascular events and periodontitis has been found in few studies based on clinical periodontal examinations. However, evidence on the association between periodontal pathogens and stroke is lacking. Therefore, the aim of the study was to investigate whether elevated levels of serum antibodies to major periodontal pathogens predict stroke in a case–control study.

Methods— The study population comprised 6950 subjects (aged 45 to 64 years) who participated in the Mobile Clinic Health Survey in 1973 to 1976 in Finland. During a follow-up of 13 years, a total of 173 subjects had a stroke. From these, 64 subjects had already experienced a stroke or had signs of coronary heart disease (CHD) at baseline, whereas 109 subjects were apparently healthy. Two controls per case were matched for age, gender, municipality, and disease status. Serum IgG and IgA class antibody levels to the periodontal pathogens, Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis , were determined by multiserotype enzyme-linked immunosorbent assay.

Results— The cases identified during the follow-up that were free of stroke or CHD at baseline were more often IgA-seropositive for A. actinomycetemcomitans than were their controls, 41.3% versus 29.3%. Compared with the seronegative, the seropositive subjects had a multivariate odds ratio of 1.6 (95% CI, 1.0 to 2.6) for stroke. The patients with a history of stroke or CHD at baseline were more often IgA-seropositive for P. gingivalis than were their controls, 79.7% versus 70.2%. When compared with the seronegative, the seropositive subjects had an odds ratio of 2.6 (1.0 to 7.0) for secondary stroke.

Conclusions— The present prospective study provides serological evidence that an infection caused by major periodontal pathogens is associated with future stroke.

Periodontal disease and biomarkers related to cardiovascular disease

Periodontal disease is a chronic infection of the gums characterized by a loss of attachment between the tooth and bone, and by bone loss. We evaluated cross-sectionally the association between periodontal disease and C-reactive protein (CRP), fibrinogen, factor VII, tissue plasminogen activator (t-PA), LDL-C, von Willebrand factor, and soluble tumor necrosis factor receptors 1 and 2. The final sample consisted of 468 men (ages 47-80 yrs), participating in the Health Professional Follow-up Study, who provided blood and were free of CVD, diabetes, and cancer. In multivariate regression models controlling for age, cigarette smoking, alcohol intake, physical activity, and aspirin intake, self-reported periodontal disease was associated with significantly higher levels of CRP (30% higher among periodontal cases compared with non-cases), t-PA (11% higher), and LDL-C (11% higher). Based on our data, periodontal disease showed significant associations with biomarkers of endothelial dysfunction and dyslipidemia, which may potentially mediate the association between periodontal and cardiovascular disease.

Some characteristics of 50/55-year-old individuals with various experience of destructive periodontal disease: a cross-sectional study

OBJECTIVE

To analyze the association between subject characteristics and degree of destructive periodontal disease in a randomly selected sample of 50/55-year-old individuals.

METHODS

A randomized and geographically stratified (urban/rural districts) subject sample composed of dentate 50-year-old (n = 190) and 55-year-old individuals (n = 359) from the county of Varmland, Sweden were examined. Data were collected through full mouth clinical and radiographic examinations and by the use of questionnaires. Based on the cumulative distribution of the individuals with respect to mean probing attachment loss (PAL), subgroups of subjects with the lowest (L20%) and highest (H20%) experience of PAL were identified. Similar classifications were made for never-smokers and current smokers. Correlation analyses and forward stepwise logistic regression models were performed.

RESULTS

The subgroup with the most extensive PAL loss (H20%) included a significantly higher proportion of (i) males (60 vs 33%), (ii) subjects with low educational level (65 vs 41%), (iii) smokers (49 vs 15%), and had (iv) less favorable lifestyle characteristics than the subgroup with minimal experience of PAL loss (L20%). The same pattern of differences was observed when the analysis was restricted to never-smokers, with the addition of a significantly lower proportion of subjects living in urban areas (40 vs 69%) in the H20% compared to the L20% subgroup. The stepwise logistic regression analysis revealed that number of teeth and smoking habits were significant factors in the identification of individuals in the L20% subgroup. For the H20% subgroup, number of teeth, gender, number of cigarettes/day and lifestyle index were significant explanatory variables.

CONCLUSION

Number of remaining teeth and smoking habits were identified as the main discriminating factors for classification of subjects with regard to degree of destructive periodontal disease.

Periodontitis decreases the antiatherogenic potency of high density lipoprotein

Periodontitis, a consequence of persistent bacterial infection and chronic inflammation, has been suggested to predict coronary heart disease (CHD). The aim of this study was to investigate the impact of periodontitis on HDL structure and antiatherogenic function in cholesterol efflux in vitro. HDL was isolated from 30 patients (age 43.6 +/- 6.1 years, mean +/- SD) with periodontitis before and after (3.2 +/- 1.4 months) periodontal treatment. The capacity of HDL for cholesterol efflux from macrophages (RAW 264.7), HDL composition, and key proteins of HDL metabolism were determined. After periodontal treatment, phospholipid transfer protein (PLTP) activity was 6.2% (P<0.05) lower, and serum HDL cholesterol concentration, PLTP mass, and cholesteryl ester transfer protein activity were 10.7% (P<0.001), 7.1% (P=0.078), and 19.4% (P<0.001) higher, respectively. The mean HDL2/HDL3 ratio increased from 2.16 +/- 0.87 to 3.56 +/- 0.48 (P<0.05). HDL total phospholipid mass and sphingomyelin-phosphatidylcholine ratio were 7.4% (P<0.05) and 36.8% (P<0.001) higher, respectively. The HDL-mediated cholesterol efflux tended to be higher after periodontal treatment; interestingly, this increase was significant (P<0.05) among patients whose C-reactive protein decreased (53.7% reduction, P=0.015) and who were positive by PCR for Actinobacillus actinomycetemcomitans. These results suggest that periodontitis causes similar, but milder, changes in HDL metabolism than those that occur during the acute-phase response and that periodontitis may diminish the antiatherogenic potency of HDL, thus increasing the risk for CHD.

Association between periodontal disease and left ventricle mass in essential hypertension

Chronic periodontitis has been associated with an increased risk for cardiovascular disease. Left ventricular mass is an established independent predictor of cardiovascular disease. In the present cross-sectional study, we tested the association between periodontitis and left ventricular mass in subjects with essential hypertension. One hundred four untreated subjects with essential hypertension underwent clinical examinations, including echocardiographic study, laboratory tests, and assessment of periodontal status according to the community periodontal index of treatment needs (CPITN). With increasing severity of periodontitis, there was a progressive increase in left ventricle mass. Mean values (g/height2.7) were 39.0 (+/-2.7) in CPITN 0 (periodontal health), 40.2 (+/-6.4) in CPITN 1 (gingival bleeding), 42.7 (+/-6.8) in CPITN 2 (calculus), 51.4 (+/-11.7) in CPITN 3 (pockets 4 to 5 mm), and 76.7 (+/-11.3) in CPITN 4 (pockets > or =6 mm) (overall F 51.2; P<0.0001). Body surface area (P=0.04), systolic (P<0.0001) and diastolic (P<0.01) blood pressure, and left ventricular mass (P<0.0001) were determinants of a composite of CPITN 3 and 4. In a multivariate logistic analysis, left ventricular mass was the sole determinant (P<0.0001) of CPITN stages 3 and 4. Our findings suggest a direct association between severity of periodontitis and left ventricular mass in subjects with essential hypertension. Periodontal evaluation might contribute to refine cardiovascular risk assessment in hypertensive subjects.