Poor oral health and coronary heart disease

A profile of state-level differences in the oral health of people with and without disabilities, in the U.S., in 2004

OBJECTIVES

The aim of this study was to provide state-level surveillance data assess the oral health of people with disabilities.

METHODS

Data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS)--a state-based, random-digit-dialed telephone survey of the U.S. civilian noninstitutionalized population 18 years of age and older--were used to estimate disability prevalence and state-level differences in oral health among people with and those without disabilities.

RESULTS

Nationally, people with disabilities were less likely than people without disabilities to visit a dentist or dental clinic in the past year. The percentage of people with disabilities who reported they had visited a dentist in the past year was lowest in Mississippi (48.9%) and highest in Connecticut (74.5%). Among people without disabilities reporting they had visited a dentist or dental clinic in the past year, the percentage was lowest in Mississippi (60.7%) and highest in Minnesota (80.7%). Edentulism was higher among people with disabilities compared with those without disabilities. Among people with disabilities, edentulism was lowest in the District of Columbia (4.1%) and highest in Kentucky (18.7%). Among people without disabilities, edentulism was lowest in California (2.7%) and highest in Kentucky (11.3%).

CONCLUSIONS

Despite numerous studies and reports documenting the unmet oral health needs of people with disabilities, there has been no systematic national surveillance of oral health among people with disabilities in the United States. This article provides much-needed state-by-state and national epidemiologic data regarding the oral health of people with disabilities.

Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease

BACKGROUND

Several epidemiological studies have suggested periodontitis as a risk factor for coronary heart disease (CHD), but results have been inconsistent.

METHODS AND RESULTS

We evaluated the association between clinical and radiographic measures of periodontitis, edentulism, and incident CHD (angina, myocardial infarction, or fatal CHD) among 1203 men in the VA Normative Aging and Dental Longitudinal Studies who were followed up with triennial comprehensive medical and dental examinations up to 35 years (median 24 years). Cox proportional hazards models with time-varying effects of exposure and potential confounders were fit. We found a significant dose-dependent association between periodontitis and CHD incidence among men < 60 years of age (hazard ratio 2.12, 95% confidence interval 1.26 to 3.60 comparing highest versus lowest category of radiographic bone loss, P for trend=0.02), independent of age, body mass index, smoking, alcohol intake, diabetes mellitus, fasting glucose, total cholesterol, high-density lipoprotein cholesterol, triglycerides, hypertension, systolic and diastolic blood pressure, education, marital status, income, and occupation. No association was found among men > 60 years of age. Similar results were found when the sum of probing pocket depths was used as a measure of periodontitis. Among men > or = 60 years of age, edentulous men tended to have a higher risk of CHD than dentate men in the lowest bone loss (hazard ratio 1.61, 95% confidence interval 0.95 to 2.73) and lowest pocket depth (hazard ratio 1.72, 95% confidence interval 1.03 to 2.85) categories, independent of confounders.

CONCLUSIONS

Chronic periodontitis is associated with incidence of CHD among younger men, independent of established cardiovascular risk factors.

The Periodontitis and Vascular Events (PAVE) pilot study: recruitment, retention, and community care controls

BACKGROUND

Population-based clinical and laboratory studies have reported findings providing support for a possible relationship between periodontal disease and cardiovascular disease. The Periodontitis and Vascular Events (PAVE) pilot study was conducted to investigate the feasibility of a randomized secondary prevention trial to test whether treatment of periodontal disease reduces the risk for cardiovascular disease.

METHODS

Five clinical centers recruited participants who had documented coronary heart disease and met study criteria for periodontal disease. Eligible participants were randomized to receive periodontal therapy provided by the study or community dental care. Follow-up telephone calls and clinic visits were planned to alternate at 3-month intervals after randomization, with all participants followed until at least the 6-month clinic visit. Participants were followed for adverse events and periodontal and cardiovascular outcomes.

RESULTS

A total of 303 participants were randomized. Recruitment that involved active participation of a cardiologist with responsibility for the patients worked best among the strategies used. Of those who had not withdrawn, 93% completed the 6-month contact. During follow-up, 11% of the 152 subjects in the community dental care group reported receiving periodontal therapy outside of the study.

CONCLUSIONS

If appropriate recruitment strategies are used, this pilot study demonstrated that it is feasible to conduct a secondary prevention trial of periodontal therapy in patients who have had coronary heart disease. If a community dental care group is used, sample size estimation needs to take into account that a non-trivial proportion of participants in this group may receive periodontal therapy outside of the study.

The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis

BACKGROUND

Previous studies have shown conflicting results as to whether periodontitis (PD) is associated with increased risk of coronary heart disease (CHD). The aim of the current study was to evaluate whether such an association exists.

METHODS

A systematic review of the literature revealed 5 prospective cohort studies (follow-up >6 years), 5 case-control studies, and 5 cross-sectional studies that were eligible for meta-analysis. Individual studies were adjusted for confounding factors such as age, sex, diabetes mellitus, and smoking. The 3 study categories were analyzed separately. Heterogeneity of the studies was assessed by Cochran Q test. The studies were homogeneous; therefore, the Mantel-Haenszel fixed-effect model was used to compute common relative risk and odds ratio (OR).

RESULTS

Meta-analysis of the 5 prospective cohort studies (86092 patients) indicated that individuals with PD had a 1.14 times higher risk of developing CHD than the controls (relative risk 1.14, 95% CI 1.074-1.213, P < .001). The case-control studies (1423 patients) showed an even greater risk of developing CHD (OR 2.22, 95% CI 1.59-3.117, P < .001). The prevalence of CHD in the cross-sectional studies (17724 patients) was significantly greater among individuals with PD than in those without PD (OR 1.59, 95% CI 1.329-1.907, P < .001). When the relationship between number of teeth and incidence of CHD was analyzed, cohort studies showed 1.24 times increased risk (95% CI 1.14-1.36, P < .0001) of development of CHD in patients with <10 teeth.

CONCLUSIONS

This meta-analysis indicates that both the prevalence and incidence of CHD are significantly increased in PD. Therefore, PD may be a risk factor for CHD. Prospective studies are required to prove this assumption and evaluate risk reduction with the treatment of PD.

Associations between periodontal diseases and systemic diseases: a review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular diseases and osteoporosis

The aim of this review article is to examine the associations between periodontal diseases and common systemic diseases, namely diabetes, respiratory diseases, cardiovascular diseases and osteoporosis. A substantial number of review articles have been published to elucidate the relationships between these diseases; however, none provide a complete overview on this topic from the aspects of definition, classification, clinical characteristics and manifestations, inter-relationships and interactions, proposed schematic mechanisms, clinical implications and management of periodontal patients with these systemic diseases. The aim of this article is to provide an overall understanding and general concepts of these issues in a concise and inter-related manner.

Does the periodontal health of thalassemia major patients have an impact on the blood lipid profiles? A preliminary report

Cardiac symptoms and premature death from cardiac causes are still suggested to be a major problem in thalassemic patients. One of the main reasons for the cardiovascular events in thalassemia major (TM) patients has suggested having iron overload, in addition to other reasons such as hypoxia, abnormal lipoproteins levels, atherosclerotic conditions, etc. This study aims to investigate whether the periodontal health has an impact on the blood lipid levels. Twenty-four TM patients and sex-matched controls (C) enrolled to this study. The measurements of the periodontal parameters (gingival index, plaque index, bleeding on probing, probing depth, and clinical attachment level) were recorded. Besides, in venous blood samples the lipid profile was investigated. All of the periodontal parameters were significantly higher in TM group than in C group (P<0.05). Triglyceride and cholesterol/high density lipoprotein ratio had significant positive correlations with the periodontal parameters (P<0.05). Multiple regression analyses present significant associations between gingival index, plaque index scores, and the cholesterol/high density lipoprotein ratio (P<0.001). Our study results showed that the lipid profile of TM patients might be affected by their periodontal health. Further studies are needed to determine the lipid profile involvement magnitude and the cardiovascular disease risk caused by the periodontal health of TM patients.

Dental caries and periodontitis: contrasting two infections that have medical implications

Both dental decay and periodontal disease are diagnosable and treatable bacterial infections. They are distinctly different infections, with dental decay occurring on the supragingival surfaces of the teeth and periodontal infections occurring in the gingival tissue approximating the subgingival plaque. The bacteria involved and the pathophysiology of these infections are distinctly different.

Periodontal disease and risk of myocardial infarction: the role of gender and smoking

BACKGROUND

Studies examining the association between periodontal disease and coronary heart disease have shown a consistent but weak to moderate relationship. Limited data have been reported in women and the role of smoking has not been fully clarified.

METHODS/RESULTS

A population-based case-control study examining the association between periodontal disease (PD) and acute non-fatal myocardial infarction (MI) was conducted in Erie and Niagara counties in Western New York State. Cases (574) were discharged alive from local hospitals with MI diagnosis. Controls (887) were county residents randomly selected from the NY State Department of Motor Vehicles rolls and Health Care Financing Administration files. Periodontal disease was assessed using clinical attachment loss (CAL). Among men (415 cases), the odds ratio (OR) of the association between mean CAL (mm) and MI, adjusting for the effects of age, body mass index (BMI), physical activity, hypertension, cholesterol, diabetes, and total pack-years of cigarette smoking was 1.34 (1.15-1.57). In women (120 cases), the corresponding OR was 2.08 (1.47-2.94). The estimate of this association among non-smokers, also adjusting for age, gender, BMI, physical activity, hypertension, cholesterol, diabetes, and total pack-years of cigarette smoking, was 1.40 (1.06-1.86), while it was 1.49 (1.26-1.77) among smokers.

CONCLUSIONS

This study provides evidence of an association between PD and incident MI in both genders. This association appears to be independent from the possible confounding effect of smoking.

Associations between tooth loss and mortality patterns in the Glasgow Alumni Cohort

OBJECTIVE

To use data from the Glasgow Alumni Cohort to investigate whether oral health in young adulthood is independently associated with later life cardiovascular disease (CVD) and cancer mortality.

METHODS AND RESULTS

Of the original cohort (n = 15 322), 12 631 subjects were traced through the National Health Service Central Register. Of these, 9569 men and 2654 women were 30 years or younger at baseline. During up to 57 years of follow-up, 1432 deaths occurred among subjects with complete data, including 509 deaths from CVD and 549 from cancer. After adjusting for potential confounders, no substantial association was found between the number of missing teeth (as a continuous variable) and all-cause mortality (hazard ratio (HR) for each extra missing tooth = 1.01; 95% confidence interval (CI) 1.00 to 1.02), CVD mortality (HR = 1.01; 95% CI 0.99 to 1.03) or cancer mortality (HR = 1.00; 95% CI 0.98 to 1.02). When the number of missing teeth was treated as a categorical variable, there was evidence that students with nine or more missing teeth at baseline had an increased risk of CVD (HR = 1.35; 95% CI 1.03 to 1.77) compared with those with fewer than five missing teeth. When the number of missing teeth was transformed using fractional polynomials, there seemed to be a non-linear relation between missing teeth and CVD mortality.

CONCLUSIONS

Although some evidence was found to support the relation between tooth loss and CVD mortality, causal mechanisms underlying this association remain uncertain.

Prediction of Periodontal Disease From Multiple Self-Reported Items in a German Practice-Based Sample

BACKGROUND

Ascertainment of periodontal disease using self-reported measures would be useful for large epidemiologic studies. This study evaluates whether a combination of self-reported items with established risk factors in a predictive model can assess periodontal disease accurately.

METHODS

Responses of 246 subjects to a detailed questionnaire were compared to their periodontal disease history as assessed from radiographs. Multiple regression modeling was used to construct predictive models using self-reported items and established risk factors.

RESULTS

Depending on the definition of gold-standard periodontal disease, two or three self-reported items were selected for the predictive models, in addition to age, gender, and smoking. Self-reported tooth mobility was associated strongly with periodontal disease independent of other risk factors and was selected in all models. For dichotomous definitions of periodontal disease, discrimination of predictive logistic regression models was good with areas under the receiver operating characteristic curve >0.80. Assessment of periodontal disease history based on extreme quantiles of model-predicted values yielded high sensitivity and specificity.

CONCLUSION

The combination of several self-reported items may be useful for ascertainment of periodontal disease in epidemiologic studies.

Periodontal disease as a risk factor for acute myocardial infarction. A case-control study in Goans highlighting a review of the literature

OBJECTIVES

The aim of the present study was to investigate the possible association between periodontal health and acute myocardial infarction (AMI) in a case-control design.

MATERIALS AND METHODS

A total of 500 patients, 250 with AMI and 250 with coronary heart disease (CHD) were included in this study. The patients in the AMI group were admitted in the department of Medicine, Goa Medical College and Hospital, Bambolim-Goa because of AMI. The patients in the CHD group had no documented history of recent acute coronary events. Medical history was taken and data on serum lipid values, decayed teeth, missing teeth, filled teeth, probing depth (PD), simplified oral hygiene index (OHI-S) and bleeding on probing (BOP) were recorded. Sample proportions were compared by Pearson's chi-square test and quantitative variables with Student's t-test. The relation of clinical parameters and conventional risk factors with AMI was assessed with multivariate logistic regression analysis.

RESULTS

All the serum lipids and dental parameters were statistically different between AMI and CHD groups (p <0.05). Logistic regression analysis showed that serum lipids, number of decayed teeth, mean PD, percentage of sites with BOP, and oral hygiene were significantly associated with AMI (p <0.05).

CONCLUSION

The results of this study indicate that periodontal disease may be associated with AMI. We propose that prospective randomised studies are needed to determine whether periodontal disease is a risk factor in the occurrence of AMI.

Periodontal Destruction Is Associated With Coronary Artery Disease and Periodontal Infection With Acute Coronary Syndrome

BACKGROUND

Coronary artery disease (CAD) is a highly prevalent disease with significant morbidity and mortality. Periodontal disease has been suggested to influence this disease and has been associated with CAD in some epidemiologic studies. However, this relation is still controversial. This study aimed to determine the relationship between periodontal disease measures and CAD and acute coronary syndromes (ACSs).

METHODS

Two hundred one patients presenting with stable angina or ACS referred for coronary angiography underwent a periodontal assessment including evaluation of periodontal pathogens. Severity of CAD was determined by the number of obstructed coronary arteries.

RESULTS

Patients with severe CAD defined by multiple vessel disease had significantly more periodontal destruction than those with mild CAD, as shown by mean clinical attachment level, a measure of chronic periodontal disease (CAL; 5.43 +/- 1.8 versus 4.85 +/- 1.6; P = 0.02), percentage of teeth with CAL >or=5 mm (82.1 +/- 23.4 versus 70.4 +/- 26.9; P = 0.002), and number of missing teeth (8.75 +/- 6.6 versus 6.76 +/- 6.6; P = 0.03). Logistic regression analysis showed that percentage of teeth with CAL >or=5 mm was significantly associated with CAD severity. Patients with ACS had significantly higher plaque scores, gingival index, and Porphyromonas gingivalis counts than stable patients. Logistic regression analysis showed that either plaque score or percentage of P. gingivalis was significantly associated with ACS.

CONCLUSION

Periodontal destruction measures are significantly correlated with CAD severity, whereas periodontal infectious measures are significantly associated with clinical cardiac status.

The Relationship Between Cardiovascular Xerogenic Medication Intake and the Incidence of Crown/Root Restorations

OBJECTIVES

This retrospective, longitudinal cohort study quantified the strength of the association between xerogenic cardiovascular medication use and dental restorations, using the latter as a proxy measure for dental caries experience.

METHODS

Study data were collected from 11 years of electronic clinical/pharmacy records in two large dental group practices associated with managed care organizations (MCO). Records were extracted for all members who were at least 55 years old at the end of the 11 year window, and had at least 48 months of concurrent dental, medical, and pharmacy coverage. The authors identified 4448 individuals whose only xerogenic medication exposure was to drugs treating a cardiovascular condition. This group was compared to a group not taking any medications (n=1183), and a group taking medications with no known xerostomic side effect (n=5622). Poisson regression compared restoration incidence and mean restoration rates among the three groups.

RESULTS

MCO members taking cardiovascular or nonxerogenic medications had higher restoration incidence and mean restoration rates than individuals taking no medications. A small difference in mean restoration rate between the non-xerogenic medication group and the cardiovascular drug group was observed; no significant difference in restoration incidence was seen between these two groups.

CONCLUSIONS

This study provides objective quantification of cardiovascular medication's long-term effects on increased restorations in older adults. When grouped under a single category labeled "cardiovascular", drugs with effects targeting the cardiovascular system did not appear to unequivocally lead to higher restorative experiences.

Periodontal infections and cardiovascular disease: the heart of the matter

BACKGROUND

Oral infection models have emerged as useful tools to study the hypothesis that infection is a cardiovascular disease (CVD) risk factor. Periodontal infections are a leading culprit, with studies reporting associations between periodontal disease and CVD. The results, however, have varied, and it often is unclear what conclusions can be drawn from these data.

SUMMARY

An association exists between periodontal disease and CVD. It is unknown, however, whether this relationship is causal or coincidental. Early studies predominantly used nonspecific clinical and radiographic definitions of periodontal disease as surrogates for infectious exposure. While most studies demonstrated positive associations between periodontal disease and CVD, not all studies were positive, and substantial variations in results were evident. More recent studies have enhanced the specificity of infectious exposure definitions by measuring systemic antibodies to selected periodontal pathogens or by directly measuring and quantifying oral microbiota from subgingival dental plaque. Results from these studies have shown positive associations between periodontal disease and CVD.

CONCLUSIONS

Evidence continues to support an association among periodontal infections, atherosclerosis and vascular disease. Ongoing observational and focused pilot intervention studies may inform the design of large-scale clinical intervention studies. Recommending periodontal treatment for the prevention of atherosclerotic CVD is not warranted based on scientific evidence. Periodontal treatment must be recommended on the basis of the value of its benefits for the oral health of patients, recognizing that patients are not healthy without good oral health. However, the emergence of periodontal infections as a potential risk factor for CVD is leading to a convergence in oral and medical care that can only benefit the patients and public health.

Relationship between survival rates and numbers of natural teeth in an elderly Japanese population

OBJECTIVES

The objective of this study was to assess whether elderly people with 20 or more natural teeth were more likely to live longer than a cohort with less than 20 teeth.

MATERIALS AND METHODS

Groups of elderly people over 80 years of age (24 males and 35 females) with 20 or more teeth (>or=20 group) were compared with elderly people (24 males and 35 females) with less than 20 teeth (<20 group). Follow-up studies were conducted at regular intervals for 10 years from July 1992 to July 2002. The cumulative survival rate of the >or=20 group (average +/- SE tooth number of teeth - males, 23.9 +/- 0.6; females, 23.8 +/- 0.4) was compared with the <20 group (average number of teeth - males, 3.8 +/- 1.1; females, 2.6 +/- 0.8). The multivariate Cox proportional hazard models with the number of teeth in a group (>or=20 group or <20 group). Smoking status and alcohol intake as covariates were used to adjust the cumulative survival rate.

RESULTS

The male participants in the >or=20 group had a significantly higher cumulative survival rates (p < 0.05) than the <20 group at 18 and 21 months from baseline. There were no significant differences in survival rates between the female groups. Adjusted cumulative survival rate was significantly different at 72, 75 and 78 months between the >or=20 group and <20 group for males but not for females.

CONCLUSION

Having 20 or more natural teeth was associated with increased survival rate in elderly males, but not among the elderly females.

Antibodies to Periodontal Organisms Are Associated with Decreased Kidney Function

BACKGROUND/AIMS

Increasing evidence suggests that clinical signs of periodontal disease are independently associated with renal impairment. However, no studies have examined the possible linkage of kidney disease with serum antibody to oral pathogens.

METHODS

The periodontal disease status was assessed in an older community-dwelling population (Dental Atherosclerosis Risk in Communities) to include: clinical measurements; oral biofilm microbial composition by DNA checkerboard, and serum antibody immunoglobulin-gamma (IgG) titers to specific bacteria by immunocheckerboard. Baseline characteristics were used to compute estimated glomerular filtration rate defining eGFR <60 ml/min/1.73 m(2) as impaired renal function in 103 of 5,032 subjects. Levels of serum IgG to specific oral bacteria were categorized by quartiles (comparing upper vs. lower three) as high titer and GFR <60 as the dependent variable in logistic regression models, adjusting for multiple comparisons (Hotelling T(2)) and traditional risk factors including age, race, smoking, diabetes, hypertension, body mass, waist-to-hip ratio, serum triglycerides, HDL, and LDL cholesterol.

RESULTS

High levels of serum IgG to selected periodontal pathogens including Porphyromonas gingivalis, Treponema denticola and Aggregobacter actinomycetemcomitans were associated with an increased odds for GFR <60 ml/min/1.73 m(2), adjusted odds ratio ranging from 1.6 to 1.8 and p < 0.05.

CONCLUSIONS

Elevated IgG to periodontal pathogens is significantly associated with impaired kidney function, independent of traditional risk factors. Prospective studies are necessary to confirm these findings.

Selective proteolysis of apolipoprotein B-100 by Arg-gingipain mediates atherosclerosis progression accelerated by bacterial exposure

Epidemiological studies suggest the association of periodontal infections with atherosclerosis, however, the mechanism underlying this association remains poorly understood. Porphyromonas gingivalis is the primary etiologic agent of adult periodontitis and produces a unique class of cysteine proteinases consisting of Arg-gingipain (Rgp) and Lys-gingipain (Kgp). To elucidate key mechanisms for progression of atherosclerosis by P. gingivalis infection, we tested the effects of the disruption of genes encoding Rgp and/or Kgp and inhibitors specific for the respective enzymes on atherosclerosis progression in apolipoprotein E-knockout mice. Repeated intravenous injection of wild-type P. gingivalis resulted in an increase in atherosclerotic lesions as well as an increase in the serum LDL cholesterol and a decrease of HDL cholesterol in these animals. LDL particles in P. gingivalis-injected animals were modified as a result of selective proteolysis of apoB-100 in LDL particles. This modification of LDL by P. gingivalis resulted in an increase in LDL uptake by macrophages and consequent foam cell formation in vitro. The atherosclerotic changes induced by P. gingivalis infection were attenuated by disruption of Rgp-encoding genes or by an Rgp-specific inhibitor. Our results indicate that degradation of apoB-100 by Rgp plays a crucial role in the promotion of atherosclerosis by P. gingivalis infection.

The use of different measurements and definitions of periodontal disease in the study of the association between periodontal disease and risk of myocardial infarction

BACKGROUND

The role of periodontal disease as an independent risk factor for cardiovascular disease (CVD) has been under debate because of the inconsistency of findings across studies. One of the major issues is the method used to assess or define periodontal disease. The present study assesses if the observed association between periodontal disease and incident myocardial infarction (MI) depends on the measurements and/or criteria used to define periodontal disease.

METHODS

A population-based case-control study to evaluate the association between PD and risk of MI was conducted between 1997 and 2001 in Western New York with 537 cases and 800 controls, aged 35 to 69 years. Cases were survivors of incident MI from local hospitals in Erie and Niagara counties. Controls were randomly selected from residents of the same counties. Periodontal disease was assessed using interproximal clinical attachment loss (CAL), probing depth (PD), alveolar crest height (ACH), and number of missing teeth. From these measurements, four different case definitions of periodontal disease were created.

RESULTS

Using the continuous forms of periodontal measurements, the odds ratios (ORs) (95% confidence interval) of the association with incident MI were 1.46 (1.26 to 1.69), 2.19 (1.66 to 2.89), 1.30 (1.14 to 1.49), and 1.04 (1.02 to 1.07) for mean CAL, PD, ACH, and number of missing teeth, respectively. Regardless of the case definition of periodontal disease, the estimates of the association with incident MI were statistically significant.

CONCLUSIONS

The observed association between periodontal disease and incident MI was consistent across different measurements and/or case definitions of periodontal disease used. The magnitude of the association varies depending on the measurements or the criteria used to define periodontal disease.

Dental and periodontal status and risk for progression of carotid atherosclerosis: the inflammation and carotid artery risk for atherosclerosis study dental substudy

BACKGROUND AND PURPOSE

Dental and periodontal disease are potentially involved in the pathogenesis of atherosclerosis. We investigated whether dental and periodontal status is associated with the presence and future progression of carotid stenosis.

METHODS

We randomly selected 411 of 1268 participants from the prospective Inflammation and Carotid Artery Risk for Atherosclerosis Study and evaluated dental and periodontal status and oral hygiene at baseline measuring three World Health Organization-validated indices: DMFT (decayed, missing, filled teeth), SLI (Silness-Löe Index), and CPITN (community periodontal index for treatment needs), respectively. The degree of carotid stenosis was measured by duplex ultrasound at baseline and after median 7.5 months (range=6 to 9 months) to identify patients with progressive carotid stenosis.

RESULTS

DMFT (P<0.01), SLI (P=0.048), CPITN (P=0.007), and edentulousness (P=0.007) were associated with the baseline degree of carotid stenosis. Atherosclerosis progression was observed in 48 of 411 patients (11.7%). DMFT (adjusted odds ratio [OR]=1.11, 95% CI=1.01 to 1.22, P=0.032) and SLI (adjusted OR=1.77, 95% CI=1.09 to 2.79, P=0.021), but not CPITN (adjusted OR=1.51, 95% CI=0.89 to 2.45, P=0.16) were significant predictors of disease progression, irrespective of traditional cardiovascular risk factors and the baseline degree of stenosis. Edentulous patients had a significantly increased risk for disease progression as compared with patients with teeth (adjusted OR=2.10, 95% CI=1.06 to 4.16, P=0.33).

CONCLUSIONS

Dental status, oral hygiene, and particularly tooth loss are associated with the degree of carotid stenosis and predict future progression of the disease.

Periodontal disease and atherosclerosis from the viewpoint of the relationship between community periodontal index of treatment needs and brachial-ankle pulse wave velocity

BACKGROUND

It has been suggested that periodontal disease may be an independent risk factor for the development of atherosclerosis. However, the relationship between periodontal disease and atherosclerosis has not been fully elucidated. This study aimed to assess the effects of periodontal disease on atherosclerosis.

METHODS

The study design was a cross-sectional study. Subjects were 291 healthy male workers in Japan. We used the Community Periodontal Index of Treatment Needs (CPITN) score, average probing depth and gingival bleeding index (rate of bleeding gums) to assess the severity of periodontal disease. We also used the Brachial-Ankle Pulse Wave Velocity (baPWV) as the index for the development of atherosclerosis.

RESULTS

The unadjusted odds ratio (OR) of atherosclerosis in relation to the CPITN score was 1.41 [95% CI: 1.16-1.73]. However, after adjustment for age, systolic blood pressure and smoking, the CPITN score had no relationship with atherosclerosis (adjusted OR: 0.91 [0.68-1.20]).

CONCLUSION

Our results show no relationship between mild periodontal disease and atherosclerosis after appropriate adjustments.

Consequences of and strategies to deal with residual post-treatment root canal infection

Bacterial sampling of prepared root canals is used to determine the presence and character of the remaining microbiota. However, it is likely that current sampling techniques only identify organisms in the main branches of the root canal system whereas it is unlikely that they can sample areas beyond the apical end-point of preparation and filling, or in lateral canals, canal extensions, apical ramifications, isthmuses and within dentinal tubules. Thus, it may be impossible by current techniques to identify residual post-treatment root canal infection. In histologic observations of root apices, bacteria have been found in inaccessible inter-canal isthmuses and accessory canals often in the form of biofilms. There is no in vivo evidence to support the assumption that these bacteria can be entombed effectively in the canal system by the root filling and thus be rendered harmless. As a consequence of this residual root infection, post-treatment apical periodontitis, which may be radiographically undetectable, may persist or develop as a defence mechanism to prevent the systemic spread of bacteria and/or their byproducts to other sites of the body. Histologic observation of root apices with surrounding bone removed from either patients or human cadavers has demonstrated that post-treatment apical periodontitis is associated with 50-90% of root filled human teeth. Thus, if the objective of root canal treatment is to eliminate apical periodontitis at a histological level, current treatment procedures are inadequate. It is essential that our knowledge of the local and systemic consequences of both residual post-treatment root infection and post-treatment apical periodontitis be improved. The continued development of treatments that can effectively eliminate root infection is therefore a priority in clinical endodontic research. Post-treatment disease following root canal treatment is most often associated with poor quality procedures that do not remove intra-canal infection; this scenario can be corrected via a nonsurgical approach. However, infection remaining in the inaccessible apical areas, extraradicular infection including apically extruded dentine debris with bacteria present in dentinal tubules, true radicular cysts, and foreign body reactions require a surgical intervention.

Association of the OGG1 Ser326Cys polymorphism with tooth loss

Although tooth loss is a serious health problem for elderly people, little is known about the genetic basis for susceptibility to it. In the present study we aimed to find a single nucleotide polymorphism (SNP) associated with tooth loss. DNA samples from 119 outpatients (mean age=78.8 years) were genotyped on seven polymorphisms (tumor necrosis factor-alpha -1031T/C, interleukin-1beta -511C/T, interleukin-6 -634C/G, macrophage migration inhibitory factor -173G/C, interleukin-1 receptor antagonist variable number of tandem repeat in intron 2, matrix metalloproteinase-1 -16071G/2G, and oxoguanine glycosylase 1 (OGG1) Ser326Cys (1245C/G)), and the results were statistically evaluated. Of the seven polymorphisms tested, only OGG1 Ser326Cys was revealed to associate with tooth loss at a statistically significant level (P=0.0086). In addition, a multivariate logistic regression analysis in which age, gender, body mass index (BMI), and ischemic heart disease were included as independent variables indicated that Ser326Cys could be an independent factor affecting tooth loss (OR, 3.191; 95%CI, 1.174-8.672). The data suggest that the OGG1 Ser326Cys polymorphism may be associated with tooth loss.

The relationship between maternal periodontitis, adverse pregnancy outcome and miscarriage in never smokers

BACKGROUND

It has been postulated that associations between periodontal disease and systemic conditions may be because of the confounding effects of smoking. In addition, studies of this type rarely investigate the adverse pregnancy outcome of miscarriage.

AIM

The aim of this prospective study was to investigate a relationship between periodontal disease in pregnancy and subsequent adverse pregnancy outcomes in a population of never smokers.

MATERIALS AND METHODS

Pregnant women were recruited at 12 weeks gestation. Demographic, behavioural and medical data were collected. A periodontal examination was performed and data on each subjects' pregnancy outcome were collected.

RESULTS

A total of 1793 women reported never previously smoking. Of these, 7.3% had a pre-term birth and 0.9% a late miscarriage. As expected in this population, we found no associations between poorer periodontal health and either pre-term birth or low birth weight (LBW). In contrast, the subjects who experienced a late miscarriage had a higher mean probing depth at mesial sites compared with the subjects that gave birth at term (2.69 mm versus 2.41 mm, p=0.006).

CONCLUSIONS

There was an association between some measures of periodontal disease and late miscarriage; however, there was no association between periodontitis and pre-term birth or LBW in this 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.

Pharmacy practice, research, education, and advocacy for older adults

In the United States, older adults have become the fastest growing segment of the population and are expected to double in number to 70 million by 2030. As a whole, older adults have different health care needs than younger patients, and some of these needs should be met by pharmacists. Clinical pharmacy practice affecting older adults occurs in a variety of settings, including community, ambulatory care, primary care, hospital, assisted living, nursing home, home health care, hospice, and Alzheimer's disease units. Although specialty training in geriatrics or gerontology is not required for pharmacists to care for older adults, it is extremely helpful. Pharmacy education related to the care of older adults has improved slightly in the past several years but will need to increase even more to provide all pharmacists with the basic skills and knowledge to care for this unique group of patients. In addition, pharmacotherapy research targeting older adults needs to increase. Although it can be challenging, funding for this type of research is available. Patient and political advocacy is also important to support this growing population.

The effects of periodontal therapy on vascular endothelial function: a pilot trial

BACKGROUND

Chronic periodontal infection is associated with an increased risk of coronary heart disease. Although the mechanism responsible for the relationship between periodontal disease and cardiovascular events is not fully understood, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium.

METHODS

Twenty-two otherwise healthy adults with moderate to severe periodontitis who underwent complete mouth disinfection were evaluated to determine if periodontal therapy would result in improved endothelial function and a decrease in serum inflammatory markers. Subjects had measurements of periodontal disease severity, flow-mediated (endothelium-dependent), and nitroglycerin-mediated (endothelium-independent) dilation of the brachial artery, serum C-reactive protein (CRP) and interleukin 6 (IL-6), and serum total and high-density lipoprotein cholesterol levels on 2 baseline visits separated by 1 month and, again, 1 month after treatment.

RESULTS

There were no significant changes in clinical periodontal measures, flow-mediated dilation, nitroglycerin-mediated dilation, CRP, IL-6, total cholesterol, or high-density lipoprotein cholesterol between the repeated baseline measurements. Periodontal treatment, however, resulted in significant improvements in periodontal pocketing, flow-mediated dilation, and serum IL-6, as well as a trend toward reduction in serum CRP; there were no significant changes in nitroglycerin-mediated dilation or in cholesterol levels.

CONCLUSIONS

These results represent proof of concept that improvement in endothelial function, as measured by flow-mediated dilation of the brachial artery, may be possible through near-elimination of chronic oral infection and suggest that the conduct of a larger controlled trial is justified.

Porphyromonas gingivalis-induced platelet aggregation in plasma depends on Hgp44 adhesin but not Rgp proteinase

Evidence from recent epidemiological studies suggests a link between periodontal infections and increased risk of atherosclerosis and related cardiovascular and cerebrovascular events in human subjects. One of the major pathogens of periodontitis, Porphyromonas gingivalis, has the ability to aggregate human platelets in platelet-rich plasma (PRP). Mechanism of P. gingivalis-induced platelet aggregation in PRP was investigated. Proteinase inhibitors toward Arg-gingipain (Rgp) and Lys-gingipain (Kgp) did not suppress P. gingivalis-induced platelet aggregation in PRP, whereas the Rgp inhibitor markedly inhibited P. gingivalis-induced platelet aggregation using washed platelets. Mutant analysis revealed that P. gingivalis-induced platelet aggregation in PRP depended on Rgp-, Kgp- and haemagglutinin A (HagA)-encoding genes that intragenically coded for adhesins such as Hgp44. Hgp44 adhesin on the bacterial cell surface, which was processed by Rgp and Kgp proteinases, was essential for P. gingivalis-induced platelet aggregation in PRP. P. gingivalis cell-reactive IgG in plasma, and FcgammaRIIa receptor and to a lesser extent GPIbalpha receptor on platelets were found to be a prerequisite for P. gingivalis-induced platelet aggregation in PRP. These results reveal a novel mechanism of platelet aggregation by P. gingivalis.

Altered lipoprotein subclass distribution and PAF-AH activity in subjects with generalized aggressive periodontitis

In this study, we examined whether the documented increase of plasma triglycerides in patients with generalized aggressive periodontitis (GAgP) is associated with changes in lipoprotein subclass distribution and/or LDL-associated platelet-activating factor acetylhydrolase (PAF-AH) activity. Lipoprotein subclasses were analyzed in whole plasma samples using nuclear magnetic resonance methods. Compared with subjects without periodontitis (NP subjects; n = 12), GAgP subjects (n = 12) had higher plasma levels of large, medium, and small VLDL (35.0 +/- 6.7 vs. 63.1 +/- 9.6 nmol/l; P = 0.025), higher levels of intermediate density lipoprotein (24.8 +/- 11.6 vs. 87.2 +/- 16.6 nmol/l; P = 0.006), lower levels of large LDL (448.3 +/- 48.5 vs. 315.8 +/- 59.4 nmol/l; P = 0.098), and higher levels of small LDL (488.2 +/- 104.2 vs. 946.7 +/- 151.6 nmol/l; P = 0.021). The average size of LDL from NP and GAgP subjects was 21.4 +/- 0.2 and 20.6 +/- 0.3 nm, respectively (P = 0.031). Compared with NP subjects, GAgP subjects had a greater number of circulating LDL particles (961.3 +/- 105.3 vs. 1,349.0 +/- 133.2 nmol/l; P = 0.032). Differences in the plasma levels of large, medium, and small HDL were not statistically significant. NP and GAgP subjects had similar plasma levels of total LDL-associated PAF-AH activity; however, LDL of GAgP subjects contained less PAF-AH activity per microgram of LDL protein (1,458.0 +/- 171.0 and 865.2 +/- 134 pmol/min/microg; P = 0.014). These results indicate that, in general, GAgP subjects have a more atherogenic lipoprotein profile and lower LDL-associated PAF-AH activity than NP subjects. These differences may help explain the increased risk of GAgP subjects for cardiovascular disease.

Tooth loss and heart disease: findings from the Behavioral Risk Factor Surveillance System

BACKGROUND

The purpose of this study was to examine the association between tooth loss and heart disease.

METHODS

Data were analyzed from the 1999 to 2002 Behavioral Risk Factor Surveillance System, an ongoing telephone survey operated by state health agencies with assistance from the Centers for Disease Control and Prevention. The study was conducted based on 41,891 adults aged 40 to 79 years old in 22 states and the District of Columbia.

RESULTS

A significant association was observed between the extent of tooth loss and heart disease prevalence. After adjustment for age, gender, race/ethnicity, education, and marital status, respondents who had 1 to 5 missing teeth, 6 to 31 missing teeth, or were edentulous were significantly more likely than those without tooth loss to have heart disease (adjusted prevalence: 6.8%, 10.2%, and 11.5%, respectively, vs. 5.3%; p<0.001). These associations persisted after further adjustment for smoking status, diabetes, alcohol consumption, hypertension, hypercholesterolemia, and body mass index (5.7%, 7.5%, and 8.5%, respectively, vs. 4.7%; p<0.05); and after stratification by age group (40 to 59 years and 60 to 79 years) and smoking status (ever smoked and never smoked).

CONCLUSIONS

Tooth loss is associated in a consistent and graded fashion with the self-reported prevalence of heart disease. Health promotion counseling should include the prevention and control of cardiovascular disease risk factors and the maintenance of good oral health.

Tooth loss is independently associated with the risk of acquired aortic valve sclerosis

BACKGROUND

Several studies have shown that periodontal disease and atherosclerosis are associated. Aortic valve sclerosis (AVS) represents the sum of processes that are similar to the development of atherosclerosis. The present analysis was performed to investigate associations between periodontal disease, tooth loss, and AVS.

METHODS

The population-based SHIP was conducted in northeast Germany. A study population of 2341 individuals aged > or =45 years was available for the present analysis. Aortic valve sclerosis was determined by echocardiography. Periodontal status was assessed by attachment loss and tooth loss.

RESULTS

The prevalence of AVS was 29.9%. Logistic regression analyses did not reveal attachment loss as an independent risk factor for AVS. However, a reduced number of teeth was independently associated with AVS. Other risk factors for AVS were age, history of myocardial infarction, body mass index, pulse pressure, plasma fibrinogen and lipoprotein (a) levels, and the use of drugs that act on the renin-angiotensin system.

CONCLUSION

A reduced number of teeth was independently associated with the risk of AVS. This finding further strengthens the link between oral health and cardiovascular disorders.

Associations Between Periodontal Disease and Systemic Disease: Evaluating the Strength of the Evidence

Much work has been published on the association between periodontal disease and systemic disease, including original reports, narrative reviews, systematic reviews, and meta-analyses. Based on the existent work, one can assign an evidence level and grade, using standard evidence-based criteria, to the data available in the four major categories of medical outcomes studied: cardiovascular/cerebrovascular, pregnancy, pulmonary, and diabetes. We discuss methodologic and conceptual problems in the study of oral-systemic associations, focusing as an example on the association between periodontal disease and cardiovascular/cerebrovascular disease. We argue that the hierarchical ranking of studies by levels of evidence may be misleading. In particular, while randomized controlled trials (RCTs) are needed to determine the efficacy of periodontal treatment to reduce the risk of cardiovascular events, they may be of limited value in determining the etiologic role of periodontal disease on coronary heart disease and stroke. We discuss limitations of RCTs as well as the limitations of currently available data from epidemiologic studies, including study design and confounding and misclassification errors. We conclude that well-designed observational studies into the associations between periodontal disease and systemic disease need to remain an integral component of future research efforts in order to fully understand such associations.

Periodontal disease is associated with renal insufficiency in the Atherosclerosis Risk In Communities (ARIC) study

BACKGROUND

Periodontitis, a chronic bacterial infection of the oral cavity, is a novel risk factor for atherosclerotic cardiovascular disease (CVD). Given the numerous shared risk factors for CVD and chronic kidney disease (CKD), we hypothesized that periodontitis also is associated with renal insufficiency in the Dental Atherosclerosis Risk in Communities study.

METHODS

We conducted a cross-sectional study of 5,537 middle-aged black and white men and women. Periodontitis was determined by using an independent clinically derived definition and categorized as healthy/gingivitis, initial, and severe. Renal insufficiency is defined as glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 . Multivariable logistic regression models were used to estimate odds ratios and 95% confidence intervals for renal insufficiency using healthy/gingivitis as the referent group.

RESULTS

A total of 2,276 individuals had initial periodontitis, and 947 individuals had severe periodontal disease. One hundred ten individuals (2%) had a GFR less than 60 mL/min/1.73 m2 . Compared with healthy/gingivitis, initial and severe periodontal disease were associated with a GFR less than 60 mL/min/1.73 m2 (odds ratio, 2.00; 95% confidence interval, 1.23 to 3.24) for initial periodontal disease and an odds ratio of 2.14 for severe disease (95% confidence interval, 1.19 to 3.85) after adjustment for important risk factors for CVD and CKD. Sensitivity analysis showed that initial and severe periodontitis were each associated with an elevated serum creatinine level (men, >1.4 mg/dL [>124 micromol/L]; women, >1.2 mg/dL [>106 micromol/L]; odds ratio, 3.21; 95% confidence interval, 1.32 to 7.76 and odds ratio, 5.39; 95% confidence interval, 2.08 to 13.99, respectively).

CONCLUSION

This is the first study to show an association of periodontal disease with prevalent renal insufficiency. A prospective study is necessary to determine the exact nature of the observed relationship.

The association between tooth loss and the self-reported intake of selected CVD-related nutrients and foods among US women

OBJECTIVES

Many studies have reported associations between oral health and cardiovascular diseases; poor nutritional status due to impaired dentition status has been suggested as a mediator. Our objective is to evaluate the associations between tooth loss and the self-reported consumption of fruits and vegetables and selected CVD-related nutrients.

METHODS

A total of 83,104 US women who completed a food frequency questionnaire (FFQ) in 1990 and 1994 and reported number of natural teeth in 1992, were included in a cross-sectional analysis relating dietary intake to number of natural teeth. A longitudinal analysis was also conducted to evaluate whether tooth loss in 1990-1992 was associated with change in diet between 1990 and 1994.

RESULTS

After adjusting for age, total calorie intake, smoking and physical activity, edentulous women appeared to have dietary intake associated with increased risk for CVD, including significantly higher intake of saturated fat, trans fat, cholesterol and vitamin B12, and lower intake of polyunsaturated fat, fiber, carotene, vitamin C, vitamin E, vitamin B6, folate, potassium, vegetables, fruits, and fruits excluding juices compared with women with 25-32 teeth. In the longitudinal analyses, women who lost more teeth were more likely to change their diet in ways that would potentially increase risk for development of CVD. They also tended to avoid hard foods, such as raw carrot, fresh apple or pear.

CONCLUSIONS

Women with fewer teeth have unhealthier diets such as decreased intake of fruits and vegetables, which could increase CVD risk. Diet may partially explain associations between oral health and cardiovascular disease.

Can the relation between tooth loss and chronic disease be explained by socio-economic status? A 24-year follow-up from the population study of women in Gothenburg, Sweden

The objective of this study was to evaluate the association between number of missing teeth and all cause, cardiovascular, and cancer mortality as well as morbidity and to explore whether socio-economic factors mediate this association. An ongoing prospective cohort study of 1462 Swedish women included a dental survey in 1968/69 with follow-up until 1992/93. The dental examination included a panoramic radiographic survey and a questionnaire. Number of missing teeth at baseline was analysed in a Cox proportional hazards model to estimate time to mortality and morbidity. Number of missing teeth, independently of socio-economic status variables (the husband's occupational category, combined income, and education) was associated with increased all cause mortality and cardiovascular disease mortality respectively (relative risk (RR): 1.36; 95% confidence interval (95% CI): 1.18-1.58) and (RR: 1.46; 95% CI: 1.15-1.85 per 10 missing teeth), but no associations were found for cancer mortality (RR: 1.18; 95% CI: 0.91-1.52). The relation between poor oral health and future cardiovascular disease could not be explained by measures of socio-economic status in this study.

The accuracy of individual self-reported items to determine periodontal disease history

The objective of this study was to evaluate the validity of self-reported periodontal disease and symptoms to predict periodontal disease history in a German population. We analysed data from 246 patients who answered a self-administered questionnaire on self-perceived periodontal disease and self-reported symptoms of periodontal disease. Actual periodontal status was assessed from panoramic radiographs and periodontal disease was defined as > or = 3 teeth with radiographic alveolar bone loss (ABL) > 5 mm (prevalence 39%). Sensitivity (SN) and specificity (SP) of self-reported items for diagnosis of periodontal disease history were calculated. The diagnostic accuracy of any individual item was generally low. For example, self-perceived periodontal disease had SN of 49% and SP of 67%. All self-reported items had low sensitivity, while self-reported professionally diagnosed bone loss, tooth loss caused by periodontal disease and mobility had SP > 90%. In conclusion, we did not identify a single individual question that can assess periodontal disease from self-reporting with satisfactory validity. Future studies will evaluate whether multivariate prediction rules using information from several self-reported variables are a valid means to ascertain periodontal disease history.

Systemic effects of periodontal diseases

A number of studies suggest an association between periodontal disease and cardiovascular disease, pulmonary disease, diabetes,and pregnancy complications. Presently, the data must be regarded as preliminary. Additional large-scale longitudinal epidemiologic and interventional studies are necessary to validate these associations and to determine whether the associations are causal. The goal of this article is to review the history of this concept, describe the biologically plausible circumstances that may underlie these potential associations, and provide a summary of the published literature that supports or refutes them.

Periodontal disease and coronary heart disease: a reappraisal of the exposure

BACKGROUND

Results from studies relating periodontal disease to cardiovascular disease have been mixed. Residual confounding by smoking and use of clinical measures of periodontal disease rather than measures of infection have been 2 major criticisms. The aims of this study were to investigate relationships between prevalent coronary heart disease (CHD) and 2 exposures, (1) clinical periodontal disease and (2) IgG antibodies to 17 oral organisms, and to evaluate the role of smoking in these relationships.

METHODS AND RESULTS

Our study is based on a subset of participants in the Atherosclerosis Risk in Communities (ARIC) Study, who received a complete periodontal examination during visit 4 (1996-1998). The exposures were periodontal status and serum IgG antibody levels against 17 periodontal organisms, and the outcome was prevalent CHD at visit 4. Multivariable analyses indicate that periodontal status is not significantly associated with CHD in either ever smokers or never smokers. Similar analyses evaluating antibodies indicate that high antibodies (above the median) to Treponema denticola (odds ratio [OR]=1.7; 95% CI, 1.2 to 2.3), Prevotella intermedia (OR=1.5; 95% CI, 1.1 to 2.0), Capnocytophaga ochracea (OR=1.5; 95% CI, 1.1 to 2.1), and Veillonella parvula (OR=1.7; 95% CI, 1.2 to 2.3) are significantly associated with CHD among ever smokers, whereas Prevotella nigrescens (OR=1.7; 95% CI, 1.1 to 2.6), Actinobacillus actinomycetemcomitans (OR=1.7; 95% CI, 1.2 to 2.7), and Capnocytophaga ochracea (OR=2.0; 95% CI, 1.3 to 3.0) were associated with CHD among never smokers.

CONCLUSIONS

Clinical signs of periodontal disease were not associated with CHD, whereas systemic antibody response was associated with CHD in ever smokers and never smokers. These findings indicate that the quality and quantity of the host response to oral bacteria may be an exposure more relevant to systemic atherothrombotic coronary events than clinical measures.

Periodontal treatment improves endothelial dysfunction in patients with severe periodontitis

BACKGROUND

Because epidemiological studies provide evidence that periodontal infections are associated with an increased risk of progression of cardiovascular and cerebrovascular disease, we postulated that endothelial dysfunction, a critical element in the pathogenesis of atherosclerosis, would be present in patients with periodontal disease.

METHODS

We tested endothelial function in 30 patients with severe periodontitis and 31 control subjects using flow-mediated dilation (FMD) of the brachial artery. The groups were matched for age, sex, and cardiovascular risk factors. Three months after periodontal treatment, including both mechanical and pharmacological therapy, endothelial function was reassessed by brachial artery FMD. Markers of systemic inflammation were measured at baseline and at follow up.

RESULTS

Flow-mediated dilation was significantly lower in patients with periodontitis than in control subjects (6.1% +/- 4.4% vs 8.5% +/- 3.4%, P = .002). Successful periodontal treatment resulted in a significant improvement in FMD (9.8% +/- 5.7%; P = .003 compared to baseline) accompanied by a significant decrease in C-reactive protein concentrations (1.1 +/- 1.9 vs 0.8 +/- 0.8 at baseline, P = .026). Endothelium-independent nitro-induced vasodilation did not differ between the study groups at baseline or after periodontal therapy.

CONCLUSION

These results indicate that treatment of severe periodontitis reverses endothelial dysfunction. Whether improved endothelial function will translate into a beneficial effect on atherogenesis and cardiovascular events needs further investigation.

Porphyromonas gingivalis bacteremia induces coronary and aortic atherosclerosis in normocholesterolemic and hypercholesterolemic pigs

OBJECTIVES

The aim of this study was to determine whether recurrent intravenous injections with Porphyromonas gingivalis (P gingivalis), mimicking periodontitis-associated bacteremia, promotes coronary artery and aortic atherosclerosis in pigs.

METHODS AND RESULTS

Pigs (n=36) fed low- or high-fat chow were divided into P gingivalis-sensitized and P gingivalis-challenged groups or P gingivalis-sensitized controls and saline-treated controls. Pigs were sensitized with 10(9) killed P gingivalis subcutaneously. Four weeks later all sensitized pigs in the group to be challenged started intravenous injections thrice weekly for 5 months with 10(6) to 10(7) colony forming units of P gingivalis while controls received saline. Anti-P gingivalis antibody, serum cholesterol, and complete blood counts were assayed monthly. Pigs were euthanized 2 weeks after the last injection, and coronary arteries and aortas were analyzed by histomorphometry and immunohistochemistry. Anti-P gingivalis antibody was increased by P gingivalis exposure. P gingivalis-challenged pigs developed a significantly greater amount of coronary and aortic atherosclerosis than controls in the normocholesterolemic group and nearly significant in the hypercholesterolemic group. P gingivalis was detected by polymerase chain reaction in arteries from most (94%, 16 of 17) P gingivalis-challenged pigs but not controls.

CONCLUSIONS

Recurrent P gingivalis bacteremia induces aortic and coronary lesions consistent with atherosclerosis in normocholesterolemic pigs and increases aortic and coronary atherosclerosis in hypercholesterolemic pigs.

Improving the oral health of older people: the approach of the WHO Global Oral Health Programme

The proportion of older people continues to grow worldwide, especially in developing countries. Non-communicable diseases are fast becoming the leading causes of disability and mortality, and in coming decades health and social policy-makers will face tremendous challenges posed by the rapidly changing burden of chronic diseases in old age. Chronic disease and most oral diseases share common risk factors. Globally, poor oral health amongst older people has been particularly evident in high levels of tooth loss, dental caries experience, and the prevalence rates of periodontal disease, xerostomia and oral precancer/cancer. The negative impact of poor oral conditions on the quality of life of older adults is an important public health issue, which must be addressed by policy-makers. The means for strengthening oral health programme implementation are available; the major challenge is therefore to translate knowledge into action programmes for the oral health of older people. The World Health Organization recommends that countries adopt certain strategies for improving the oral health of the elderly. National health authorities should develop policies and measurable goals and targets for oral health. National public health programmes should incorporate oral health promotion and disease prevention based on the common risk factors approach. Control of oral disease and illness in older adults should be strengthened through organization of affordable oral health services, which meet their needs. The needs for care are highest among disadvantaged, vulnerable groups in both developed and developing countries. In developing countries the challenges to provision of primary oral health care are particularly high because of a shortage of dental manpower. In developed countries reorientation of oral health services towards prevention should consider oral care needs of older people. Education and continuous training must ensure that oral health care providers have skills in and a profound understanding of the biomedical and psychosocial aspects of care for older people. Research for better oral health should not just focus on the biomedical and clinical aspects of oral health care; public health research needs to be strengthened particularly in developing countries. Operational research and efforts to translate science into practice are to be encouraged. WHO supports national capacity building in the oral health of older people through intercountry and interregional exchange of experiences.

Dental Caries, Periodontal Disease, and Cardiac Arrhythmias in Community-Dwelling Older Persons Aged 80 and Older: Is There a Link?

OBJECTIVES

To examine whether caries or periodontitis is associated with cardiac arrhythmias in community-dwelling people aged 80 and older.

SETTING

Urban, community-based population in Stockholm, Sweden.

DESIGN

Cross-sectional.

PARTICIPANTS

Eligible persons were identified through the Kungsholmen Project, which is an ongoing, longitudinal, population-based study of the oldest old. The present study included 125 dentate individuals.

MEASUREMENTS

Data from interviews, a medical examination, and an oral examination. The assessment of cardiac arrhythmia was based on a clinical examination by a physician or the Stockholm Inpatient Register. Active root caries, active coronal caries, and periodontitis were assessed using previously defined National Institute of Dental and Craniofacial Research diagnostic criteria.

RESULTS

The primary finding of the multivariate logistic regression analysis was that persons with three or more active root caries lesions had more than twice the odds of cardiac arrhythmias than persons without active root caries. The results did not notably change after adjusting for age, medications that reduce saliva, and number of teeth. Persons with one to two active coronal caries lesions had 2.8 times higher odds (95% confidence interval=1.1-7.0) of arrhythmia than persons without active coronal caries, but there was no greater risk for persons with three or more coronal caries lesions. There was no association between periodontal disease and arrhythmia.

CONCLUSION

The findings indicate that there may be a link between active root caries and cardiac arrhythmias in the oldest old. Nevertheless, although a biological pathway is not obvious, it is plausible that both are simply markers of declining general health. The results suggest the need for further study of these relationships.

Persistent infection and vascular disease: a systematic review

More than 150 epidemiological or clinical studies have reported on associations between vascular disease and the presence of certain persistent bacterial and viral agents, or of clinical conditions (e.g., periodontal disease) that are associated with persistent infection. This article provides a review of such studies, particularly in relation to Helicobacter pylori, Chlamydia pneumoniae, dental disease and cytomegalovirus (CMV), as well as references to possible mechanisms. The association between coronary heart disease and H. pylori or between heart disease and dental disease may be accounted for by residual confounding. Although markers of C. pneumoniae infection are around twenty times more common in atherosclerotic plaques than in disease-free blood vessels, the sequence of infection and disease is uncertain. For CMV, a limited number of patients with classic atherosclerotic coronary heart disease have been investigated in seroepidemiological studies. For all such agents, better and larger seroepidemiological and pathology-based studies are needed to resolve these uncertainties, as well as - at some stage - large-scale, randomised intervention studies.

Periodontitis as risk factor for acute myocardial infarction. A case control study of Spanish adults

OBJECTIVE

The present study was designed to determine, in a case-control study of a Spanish population, whether periodontitis is a risk factor for acute myocardial infarction.

BACKGROUND

Although part of cardiovascular risk could be explained by periodontal disease, available meta-analyses find significant heterogeneity and recommend the need for further observational and intervention studies.

METHODS

A case-control study was conducted of 149 Spanish patients aged between 40 and 75 years, with 72 cases (acute myocardial infarction) and 77 controls (trauma patients). Periodontitis was measured as the percentage of sites with clinical attachment loss greater than 3 mm. A multivariate logistic regression model was constructed to estimate the adjusted effect of periodontitis on acute myocardial infarction, after considering the potential confounding effect of a large pool of risk factors.

RESULTS

In a bivariate analysis, males, older patients, smokers, and those with hypertension, diabetes or hypercholesterolemia, showed an increased risk of acute myocardial infarction. The cases, compared to controls, showed worse results for all periodontal variables studied: gingival retraction, pocket depth, and periodontitis. The final multiple logistic model included sex, age, tobacco habit, hypertension, diabetes, hypercholesterolemia, regular exercise, and periodontitis. The association between periodontitis (dichotomized) and acute myocardial infarction was high and significant in both the unadjusted (odds ratio = 4.42, p < 0.001) and adjusted analyses (odds ratio = 3.31, p = 0.005).

CONCLUSION

There is evidence of an association between periodontitis and acute myocardial infarction after adjusting for well-known risk factors for acute myocardial infarction.