The sex paradox in the interplay between periodontitis, obesity, and serum C-reactive protein: Data from a general population

Sex differences in the association between dual-energy x-ray absorptiometry-measured body composition and periodontitis

BACKGROUND

A positive association between obesity based on body mass index (BMI) and periodontitis has been reported. Fat tissue-related systemic inflammation acts as the link to periodontal comorbidities of obesity. However, the BMI is unable to distinguish fat and fat-free tissues. More precise measures are required to evaluate body composition, including fat and fat-free tissues. This study aimed to determine the sex differences in the association between dual-energy x-ray absorptiometry (DXA)-measured body composition (i.e., fat mass and muscle mass) and phenotypes with periodontitis.

METHODS

Cross-sectional data of 3892 participants from the National Health and Nutrition Examination Survey (NHANES) study 2011‒2014 were analyzed. Adiposity indices (fat mass index [FMI] and percentage body fat [%BF]) and muscle mass index (MMI) were calculated. The participants were categorized by the quintiles of FMI, MMI, and %BF. Body composition phenotypes were categorized as: low adiposity-low muscle (LA-LM), low adiposity-high muscle (LA-HM), high adiposity-low muscle (HA-LM), or high adiposity-high muscle (HA-HM), respectively. Periodontitis was defined by the CDC/AAP (Centers for Disease Control and Prevention/American Academy of Periodontology) criteria. Multivariable logistic regression analysis was conducted, stratified by sex. We further adjusted for white blood cell (WBC) counts in the sensitivity analysis.

RESULTS

Restricted cubic splines revealed non-linear associations between body composition indices and periodontitis risk. Women with a higher FMI (odds ratio for Q5 vs. Q1 [ORQ5vs1] = 1.787, 95% confidence interval: 1.209-2.640) or %BF (ORQ5vs1 = 2.221, 1.509-3.268) had increased odds of periodontitis. In addition, women with HA-LM phenotype were more likely to develop periodontitis (OR = 1.528, 1.037-2.252). Interestingly, the WBC count, a systemic inflammatory biomarker, attenuated these associations. No statistically significant associations were found in men.

CONCLUSIONS

The association between DXA-measured body composition and phenotypes with periodontitis differs per sex. Only in women higher adiposity indices and HA-LM phenotype were associated with an increased risk of periodontitis.

Sex effects on gingival transcriptomic patterns during initiation, progression, and resolution of periodontitis

BACKGROUND

The prevalence and severity of periodontitis demonstrates altered population distribution with age, sex, and race and ethnicity. While males exhibit greater frequency of disease, particularly with aging, the underlying basis for this observation remains obscure.

OBJECTIVE

This study used a nonhuman primate (Macaca mulatta) model of experimental ligature-induced periodontitis in adult animals to evaluate gingival transcriptomic differences stratified based upon sex of the animal.

METHODS

The 18 animals represented humans ages 40-80 years, with gingival tissue samples obtained at baseline, 0.5 months (initiation), 1 and 3 months (progression), and at 5 months that were 60 days after ligature removal for clinical disease resolution. Microarray analysis was used to quantify gene expression profiles in the gingival tissues.

RESULTS

The results demonstrated clear gene expression differences in healthy (baseline) tissues between the sexes, with elevations in females associated with immune responses and elevation in males related to tissue structural genes. With disease initiation, fewer genes differed between the sexes, while these differences were significantly increased in progressing disease and resolution, particularly in male animals. Overexpressed biological processes showed tissue structural/functional genes at initiation, with host response pathways altered during disease progression. Resolution samples generally demonstrated biological processes of cellular metabolism that differed from baseline healthy samples.

CONCLUSION

The transcriptomic findings support sex as a biological variable in periodontitis using a nonhuman primate model of experimental periodontitis.

Association between C-Reactive protein and periodontitis in an obese population from the NHANES 2009-2010

BACKGROUND

Various data have been obtained on the relationship between body mass index (BMI) and C-reactive protein (CRP) and periodontitis. The aim of this study was to determine whether CRP/BMI are associated with periodontitis using data from the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

A cross-sectional analysis of data from 3602 participants in the 2009-2010 NHANES cycle was performed. The definition of periodontitis was used to divide participants into four groups according to the criteria of Eke. Correlations between CRP/BMI and periodontitis were tested for statistical significance by means of descriptive statistics, multivariate regression, and subgroup-stratified analyses, with and without adjustments for confounders (such as age and sex).

RESULTS

There were no statistically significant differences (p > 0.05) regarding BMI and the development of periodontitis. After adjustment for age, sex, race, marital status, annual family income, alcohol consumption, hypertension, smoking, chronic pulmonary disease, cardiovascular disease, diabetes, flossing, and arthritis, CRP correlated significantly with the development of periodontitis in the subgroups stratified by obesity, with an odds ratio (OR) of 1.2 (95% CI, 1.0 to 1.5).

CONCLUSION

Through data analysis, we found an association between CRP levels and periodontitis prevalence in the American population, although this association was only present in the obese population. While there are several hypotheses about the underlying mechanism, further studies are needed to validate these findings.

Correlation of salivary visfatin levels in obese and NON-OBESE population with periodontal status

Background

Visfatin is an inflammatory adipokine that has been linked to obesity and plays a key function in immune response modulation. It's also been proposed that it's a pro-inflammatory marker for periodontitis. Hence, the aim of the present study was to assess the salivary Visfatin levels in obese and non-obese population and correlate with the periodontal status.

Materials and methods

A total of 40 individuals aged between 21 and 35 years (Group 1: n = 20, non-obese and Group 2: n = 20, obese) were enrolled in this case-control study. Clinical parameters such as periodontal probing depth (PPD) and clinical attachment level (CAL) were recorded. Body Mass Index (BMI) was recorded. Unstimulated salivary samples were collected and the samples were assayed for Visfatin using human Visfatin ELISA kit. The results were analysed using SPSS Software, Version 23.0. Unpaired t-test and Mann-Whitney U test was used to compare the clinical parameters and salivary Visfatin level between both the groups. Also, Spearman's rank correlation test was done for correlation of BMI with salivary Visfatin levels and clinical parameters.

Results

The salivary Visfatin level was higher in group 2 (33.1070 ± 0.81 ng/mL) as compared to group 1 (22.2310 ± 1.33 ng/mL). Moderate positive statistically significant association was found between BMI and Visfatin (r = 0.738, p = 0.000). Also when Visfatin and PPD and CAL were correlated, moderate positive statistically significant association was found (r = 0.625, p = 0.000 and r = 0.630, p = 0.000).

Conclusion

The present study suggests that there exists a positive correlation between BMI and salivary Visfatin and BMI and periodontal parameters including probing depth and clinical attachment level. This illustrates that salivary Visfatin may be a potential marker for periodontal inflammation in obese population.

Periodontal disease could be a potential risk factor for non-alcoholic fatty liver disease: An 11-year retrospective follow-up study

OBJECTIVE

This study aimed to evaluate the association of periodontal disease with non-alcoholic fatty liver disease (NAFLD).

MATERIALS AND METHODS

A retrospective follow-up study using the National Health Insurance Service-National Sample Cohort was performed from 2002 to 2015 in the Korean population. A total of 165,032 subjects were followed up for incident NAFLD during 11 years. Periodontal disease and NAFLD were defined by a diagnosis using the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes. Periodontal status was used as the severity of periodontal status and the number of dental visit due to PD.

RESULTS

Periodontitis was associated with a 4% increase in risk for NAFLD after adjusting for socio-demographic factor, health behaviors, and systemic diseases (adjusted hazard ratio [aHR] = 1.04, 95% CI = 1.01 to 1.07). Between the number of dental visit due to PD and the risk for NAFLD was observed a dose-effect association (aHR = 1.02, 95% CI = 0.99 to 1.05 for once; aHR = 1.10, 95% CI = 1.06 to 1.15 for two times; aHR = 1.14, 95% CI = 1.06 to 1.24 for three times).

CONCLUSIONS

Our data confirmed that periodontitis showed an association with a higher incidence of NAFLD.

CLINICAL RELEVANCE

Prevention and management of periodontal disease could be beneficial for reducing the risk of NAFLD.

Body mass index and self‐rated oral health in Korean adults in 2017

OBJECTIVE

To investigate the association between obesity and self-rated oral health (SROH). This study examined the cross-sectional associations between body mass index (BMI) and SROH in Korean adults.

MATERIALS AND METHODS

This study used data from 217 304 adults (100 110 men and 117 194 women aged > 19 years) from the 2017 Korean Community Health Survey. Participants were categorised into six ordinal groups based on BMI: underweight (<18.5 kg/m² ), normal weight (18.5-22.9 kg/m² ), overweight (23.0-24.9 kg/m² ), obese-I (25.0-27.4 kg/m² ), obese-II (27.5-29.9 kg/m² ) or obese-III (≥30.0 kg/m² ). SROH was assessed using responses to the question, "How do you rate your oral health, including your teeth and gums?" rated on a 5-point scale. SROH was categorised as "good" (reported as "fair," "good" or "very good") or "poor" or "very poor." Age- and sex-stratified associations between BMI categories and poor SROH were assessed using ordinal logistic regression analysis with sampling weights.

RESULTS

The age-adjusted odds ratio (OR) for poor SROH according to BMI levels was lowest in the overweight group in both men and women. In men, the OR for poor SROH was 2.03 (99% confidence interval [CI], 1.72-2.39) in the underweight group, 1.17 (99% CI, 1.17-1.25) in the normal group, 1.05 (99% CI, 0.98-1.13) in the obese-I group, 1.08 (99% CI, 0.98-1.18) in the obese-II group and 1.36 (99% CI, 1.20-1.55) in the obese-III group. In women, the OR was 1.18 (99% CI, 1.07-1.31) in the underweight group, 1.01 (99% CI, 0.95-1.07) in the normal group, 1.07(99% CI, 0.99-1.16) in the obese-I group, 1.16 (99% CI, 1.04-1.30) in the obese-II group and 1.39 (99% CI, 1.20-1.62) in the obese-III group. From the restricted cubic spline models in both sexes, BMI showed a J-shaped association with poor and very poor SROH in men and women. In a stratified analysis by age group and sex, men and older women in the underweight group had poorer SROH than those in overweight group.

CONCLUSION

In a nationally representative sample of Korean adults, there was a J-shaped association between BMI and poor SROH, with the highest risk in the underweight group amongst men and in the obese-III group amongst women. Furthermore, in men and women over 65 years of age, underweight and obesity were associated with poorer SROH.

Waistline to the gumline: Relationship between obesity and periodontal disease-biological and management considerations

Obesity is a pandemic and periodontitis is the sixth most prevalent disease in the world. These two noncommunicable diseases share several risk determinants. Epidemiologic evidence from the last 2 decades has established an increase in periodontitis prevalence in obese and overweight individuals. Biologic mechanisms potentially linking obesity and periodontal disease are adiposity-associated hyperinflammation, microbial dysbiosis, altered immune response, specific genetic polymorphisms, and increased stress. However, because of the lack of longitudinal interventional studies and randomized clinical trials, there is insufficient evidence to determine the cause-effect relationship between these two diseases. Despite this, the negative impact of obesity on oral health is well established. Several logistic and physiologic complications are associated with treating obese patients in a dental setting, and it requires an interprofessional team approach. Oral health care professionals need to be aware of the specific management considerations while rendering for this cohort, including modified practice facility and equipment, tailored supportive periodontal therapy, and heightened precaution during conscious sedation and surgical procedures.

Sex-specific genetic factors affect the risk of early-onset periodontitis in Europeans

AIMS

Various studies have reported that young European women are more likely to develop early-onset periodontitis compared to men. A potential explanation for the observed variations in sex and age of disease onset is the natural genetic variation within the autosomal genomes. We hypothesized that genotype-by-sex (G × S) interactions contribute to the increased prevalence and severity.

MATERIALS AND METHODS

Using the case-only design, we tested for differences in genetic effects between men and women in 896 North-West European early-onset cases, using imputed genotypes from the OmniExpress genotyping array. Population-representative 6823 controls were used to verify that the interacting variables G and S were uncorrelated in the general population.

RESULTS

In total, 20 loci indicated G × S associations (P < 0.0005), 3 of which were previously suggested as risk genes for periodontitis (ABLIM2, CDH13, and NELL1). We also found independent G × S interactions of the related gene paralogs MACROD1/FLRT1 (chr11) and MACROD2/FLRT3 (chr20). G × S-associated SNPs at CPEB4, CDH13, MACROD1, and MECOM were genome-wide-associated with heel bone mineral density (CPEB4, MECOM), waist-to-hip ratio (CPEB4, MACROD1), and blood pressure (CPEB4, CDH13).

CONCLUSIONS

Our results indicate that natural genetic variation affects the different heritability of periodontitis among sexes and suggest genes that contribute to inter-sex phenotypic variation in early-onset periodontitis.

Assessment of Cardiovascular Risk in Women with Periodontal Diseases According to C-reactive Protein Levels

Cardiovascular diseases (CVD) are highly prevalent non-communicable diseases worldwide. Periodontitis may act as a non-traditional cardiovascular risk (CVR) factor, linked by a low-grade systemic inflammation mediated by C-reactive protein (CRP). Patients with periodontitis reported higher serum CRP levels; however, a CRP systemic and periodontal correlation in gingival crevicular fluid (GCF) and its CVR impact have been barely studied. We aimed to assess the association between periodontal diseases and CVR in a group of adult women, based on serum high-sensitivity CRP (hs-CRP) levels; and secondly, to determine the association between serum and GCF CRP levels. Gingival crevicular fluid and blood samples were obtained from women with periodontitis, gingivitis, and healthy controls. Serum and GCF CRP were determined by turbidimetric method and Luminex technology, respectively. Data were analyzed and adjusted by CVR factors. All women presented moderate CVR, without an evident association between serum hs-CRP levels and periodontal diseases. While serum hs-CRP concentrations did not significantly differ between groups, patients with gingivitis and periodontitis showed higher CRP levels in GCF, which positively correlated to CRP detection in serum.

Additive Effect of Periodontal Disease and Obesity on COVID-19 Outcomes

This study aims to examine the impact of periodontal disease in obesity on COVID-19 infection and associated outcomes. This retrospective longitudinal study included 58,897 UK Biobank participants tested for COVID-19 between March 2020 and February 2021. Self-reported oral health indicators (bleeding gums, painful gums, and loose teeth) were used as surrogates for periodontal disease. Body fat levels were quantified by body mass index (BMI) and categorized as normal weight (18.5 to 24.9 kg/m²), overweight (25 to 29.9 kg/m²), and obese (≥30 kg/m²). Multivariable logistic regression and Cox proportional hazard models were used to quantify risk of COVID-19 infection, hospital admission, and mortality, adjusted for participants’ demographics and covariates. Of 58,897 participants, 14,466 (24.6%) tested positive for COVID-19 infection. COVID-19 infection was higher for participants who were overweight (odds ratio, 1.18; 95% CI, 1.12 to 1.24) and obese (odds ratio, 1.33; 95% CI, 1.26 to 1.41) as compared with those of normal weight, but infection was not affected by periodontal disease. The hospital admission rate was 57% higher (hazard ratio, 1.57; 95% CI, 1.25 to 1.97) in the obese group with periodontal disease than without periodontal disease, and admission rates increased with BMI category (normal weight, 4.4%; overweight, 6.8%; obese, 10.1%). Mortality rates also increased with BMI category (normal weight, 1.9%; overweight, 3.17%; obese, 4.5%). In addition, for participants with obesity, the mortality rate was much higher (hazard ratio, 3.11; 95% CI, 1.91 to 5.06) in participants with periodontal disease than those without. Obesity is associated with higher hospitalization and mortality rates, and periodontal disease may exacerbate this impact. The results could inform health providers, policy makers, and the general public of the importance to maintain good oral health through seamless provision of dental services and public oral health prevention initiatives.

C-Reactive Protein Mediates the Effect of Serum Progesterone on Obesity for Men and Postmenopausal Women in Henan Rural Cohort Study

Purpose

Studies of progesterone with obesity have been lacking, and no prior studies have investigated progesterone and C-reactive protein in rural natural populations. This study aimed to investigate the association of serum progesterone with obesity based on anthropometric parameters in Henan Rural Cohort, then further to explore the potential role of C-reactive protein in this association.

Patients and Methods

A total of 4687 participants (2474 men and 2213 postmenopausal women) from the Henan Rural Cohort study were included. Logistic regression analysis, linear regression analysis, and restricted cubic splines were performed to estimate the relationships between progesterone, C-reactive protein, obesity, and obesity-related parameters. Mediation analysis was carried out to assess the intermediary role of C-reactive protein played in the association between progesterone and obesity.

Results

After controlling for confounders, the odds ratios of obesity no matter how obesity was defined was associated with progesterone (P trend <0.05). Moreover, progesterone was related to obesity-related parameters. Also, C-reactive protein increased with the elevation of progesterone, and C-reactive protein was associated with obesity no matter how obesity was defined (P trend <0.001). Mediation analysis indicated that hsCRP had the mediating effects on the obesity, and the proportion of the effects were 15.35% and full mediating effect (defined by body mass index), 15.46% and 12.24% (defined by waist circumference), 19.14% and 12.12% (defined by waist-to-hip ratio), 23.81% and 15.09% (defined by waist-to-height ratio) for men and postmenopausal women, relatively.

Conclusion

In the Chinese rural men and postmenopausal women population, progesterone and C-reactive protein are related to obesity. We firstly found C-reactive protein partly mediates the effect of progesterone on obesity, indicating that systemic inflammation played a critical role in the association.

Individual predisposition and the intricate interplay between systemic biomarkers and periodontal risk in a general population

BACKGROUND

Increasing age is associated with systemic diseases as well as with periodontal diseases. We wondered whether a biological age score constructed exclusively from systemic biomarkers would reflect periodontal risk factors at baseline and tooth loss as well as periodontal outcome during 10 years follow-up.

METHODS

From the Study of Health in Pomerania (SHIP) 2256 participants (1072 male, 1184 female) were studied for the relationship of the systemic biomarkers glycated hemoglobin (HbA1c), low density lipoprotein cholesterol (LDL), fibrinogen, white blood cell count, blood pressure, and waist circumference to their age. Construction of a biological age (BA) score allowed its comparison with the participants' actual chronological age (CA) and their predisposition to periodontal disease.

RESULTS

Though nearly identical in CA, participants appearing younger than their true age had a significantly reduced burden of periodontal risk factors. If BA > CA, then risk factors were more frequent including smoking, oral hygiene, dental visits, education, and income. After 10 years, in participants with identical CA, tooth loss followed their BA calculated at baseline, that is, with BA > CA fewer teeth were preserved. Similarly, periodontal measures varied according to BA; sex differences were obvious. Most significant were BA-related differences in inflammatory and anthropometry parameters.

CONCLUSIONS

The results support the assumption that risk profiles aggregated in BA constitute a characteristic susceptibility pattern unique to each individual, common to both systemic and periodontal diseases. Although BA was constructed exclusively from systemic measures at baseline, BA reflects the oral conditions at follow-up.

Effectiveness of an individually tailored oral hygiene intervention in improving gingival health among community-dwelling adults with physical disabilities in Thailand

AIMS

Persons with physical disabilities require specific methods for sustaining good oral health. This study aimed to evaluate an individually tailored oral hygiene intervention program (IT-OHI) for improving gingival health among adults with disabilities.

METHODS AND RESULTS

A single group, quasi-experimental design with pre- and post-tests, conducted at a community club for disabled people in Thailand. This study included 145 adults with disabilities, aged 18-74 years. Trained caregivers provided IT-OHI program to all participants. Calibrated dentists assessed the gingival bleeding and dental plaque at baseline/pre-intervention (T0) and at 6 (T1) and 12 (T2) weeks post-intervention. The outcomes were analyzed using the Friedman test, Cochran's Q test, and Binary logistic regression. There were significant decreases in bleeding on probing scores (P < .001) and plaque control record scores (P < .001) throughout the study. However, considering the individual periods, values between T1 and T2 did not improve. Additionally, the IT-OHI program's protective effect was more substantial among the male participants at 12 weeks post-intervention (odds ratio = 0.094, P = .027) than among the females.

CONCLUSION

The IT-OHI program had partial effectiveness in improving gingival health and reducing dental plaque accumulation in a group of Thai people with physical disabilities; however, the long-term impact remains unclear.

Is periodontal disease a risk factor for severe COVID-19 illness?

Periodontal disease (PD) comprises a group of diseases involving inflammatory aspects of the host and dysbiotic events that affect periodontal tissues and could have systemic implications. Diverse factors and comorbidities have been closely associated with PD such as diabetes, obesity, aging, hypertension, and so on; although, underlying mechanisms or causal associations have not been established completely. Interestingly, these same factors have been widely associated with progression or severe coronavirus disease 2019 (COVID-19), an illness caused by coronavirus SARS-CoV-2. Since inflammatory and dysbiotic factors as well as comorbidities affect systemic health, it is possible that periodontal status indicates the risk of complication of COVID-19. However, assessment of oral health history including periodontal status in COVID-19 patients has not been reported. Knowing PD is associated with severe COVID-19 could help identify risk groups and establish pertinent recommendations.

Competing interplay between systemic and periodontal inflammation: obesity overrides the impact of oral periphery

Objectives

We aimed at investigating whether the interaction between the local inflammation, periodontitis, and obesity is independently associated with systemic inflammation.

Methods

From the population-based Study of Health in Pomerania, 3366 participants, without (2366) and with (1000) obesity, were studied for the association of periodontitis, measured as probing depth (PD) and plaque together with body mass index (BMI) on C-reactive protein (CRP). Quantile regression was used to evaluate the association between periodontal, anthropometric, and inflammatory variables (outcomes).

Results

The overall prevalence of obesity in this adult population was 31.4% in men and 28.1% in women. Both PD and plaque were positively associated with CRP, revealing an increasing impact across the CRP concentration distribution. Adjusting the regression of CRP or fibrinogen on PD for waist circumference attenuated but did not abolish the PD coefficients. Dental plaque was similarly associated with these interrelations. Association between PD and a dental plaque was different among participants with low-, medium-, or high-risk CRP concentrations.

Conclusion

Local and systemic sources of inflammation contribute to blood levels of inflammatory markers. The respective contributions depend on the relative rate in each of the inflammation-inducing risks and are dominated by adiposity.

Clinical relevance

Keeping systemic inflammation low in order to prevent age-related disease sequelae.

Electronic supplementary material

The online version of this article (10.1007/s00784-020-03514-y) contains supplementary material, which is available to authorized users.

Effect of periodontal therapy on adipokine biomarkers in overweight

AIM

The aim of this study was to evaluate the effect of non-surgical periodontal therapy on circulating levels of the systemic inflammation-associated biomarkers orosomucoid (ORM), high-sensitivity C-reactive protein (hsCRP), chemerin, and retinol-binding protein 4 (RBP4) in overweight or normal-weight patients with periodontitis at 27.5 months after therapy.

MATERIALS AND METHODS

This exploratory subanalysis includes patients from the ABPARO-trial (ClinicalTrials.gov NCT00707369). The per-protocol collective provided untreated periodontitis patients with high (≥28 kg/m² ) or moderate (21-24 kg/m² ) BMI. Out of the per-protocol collective, 80 patients were randomly selected and stratified for BMI group, sex, and treatment group (antibiotics/placebo), resulting in 40 overweight and normal-weight patients. Patients received non-surgical periodontal therapy and maintenance at 3-month intervals. Plasma samples from baseline and 27.5 months following initial treatment were used to measure the concentrations of ORM, hsCRP, chemerin, and RBP4.

RESULTS

At the 27.5-month examination, ORM and hsCRP decreased noticeably in the overweight group (ORM: p = .001, hsCRP: p = .004) and normal-weight patients (ORM: p = .007, hsCRP: p < .001). Chemerin decreased in the overweight group (p = .048), and RBP4 concentrations remained stable.

CONCLUSION

Non-surgical periodontal therapy reduced systemically elevated inflammation-associated biomarkers in periodontitis patients. These improvements were more pronounced in overweight patients than in normal-weight patients.