C-reactive protein in relation to early atherosclerosis and periodontitis

The long-term effect of periodontitis treatment on changes in blood inflammatory markers in patients with generalized aggressive periodontitis

BACKGROUND

Periodontitis is characterized by local inflammatory conditions in the periodontium, its severe form has been associated with elevated systemic inflammatory markers. However, the long-term effects of periodontal inflammation control on systemic inflammatory markers are unclear.

OBJECTIVE

This study aimed to investigate the long-term effects of periodontal therapy on the levels of peripheral venous blood inflammatory markers in patients with generalized aggressive periodontitis (GAgP), all of whom were now diagnosed as Stage III or IV Grade C periodontitis.

METHODS

Patients with GAgP were consecutively recruited from April 2013 to August 2014 (T0). Active periodontal treatment (APT) was provided, and follow-ups were conducted over a 3- to 5-year period (T1). Clinical parameters were assessed and fasting venous blood was collected at T0 and T1. Complete blood cell counts were obtained, and biochemical analyses were performed to evaluate the levels of serum components. The correlations between probing depth (PD) and hematological parameters were analyzed.

RESULTS

A total of 49 patients with GAgP completed APT and follow-ups. Probing depth (PD) reduced from 5.10 ± 1.07 mm at T0 to 3.15 ± 0.65 mm at T1. For every 1-mm reduction in PD after treatment, the neutrophil count, neutrophil-lymphocyte ratio, and total protein concentration were reduced by 0.33 × 109/L, 0.26, and 1.18 g/L, respectively. In contrast, the albumin/globulin ratio increased by 0.10.

CONCLUSION

This study indicated that periodontal therapy may have beneficial effects on peripheral venous blood inflammatory markers in patients with GAgP during long-term observation.

More than just teeth: How oral health can affect the heart

Epidemiological evidence has revealed a potential relationship between periodontal disease and cardiovascular disease (CVD). Consensus regarding a link between these pathologies remains elusive, however, largely secondary to the considerable overlap between risk factors and comorbidities common to both disease processes. This review article aims to update the evidence for an association by summarizing the evidence for causality between periodontitis and comorbidities linked to CVD, including endocarditis, hypertension (HTN), atrial fibrillation (AF), coronary artery disease (CAD), diabetes mellitus (DM) and hyperlipidemia (HLD). This article additionally discusses the role for periodontal therapy to improved management of the comorbidities, with the larger goal of examining the value of periodontal therapy on reduction of CVD risk. In doing so, we endeavor to further the understanding of the commonality between periodontitis, and CVD.

Analysis of the Effects of IL-6 -572 C/G, CRP -757 A/G, and CRP -717 T/C Gene Polymorphisms; IL-6 Levels; and CRP Levels on Chronic Periodontitis in Coronary Artery Disease in Indonesia

Interleukin 6 (IL-6) and C-Reactive Protein (CRP) play an important role in chronic periodontitis with coronary artery disease (CAD). Genetic factors can affect a person's risk of CAD, which affects one-third of the population. This study investigated the role of IL-6 -572 C/G, CRP -757 A/G, and CRP -717 T/C gene polymorphisms. IL-6 and CRP levels on the severity of periodontitis in CAD in Indonesia were also evaluated. This case-control study was conducted with mild and moderate-severe chronic periodontitis groups. A path analysis test was conducted with Smart PLS with a 95% confidence interval to determine the significant variable for chronic periodontitis. Our study revealed that the effects of IL-6 -572 C/G, CRP -757 A/G, and CRP -717 T/C gene polymorphisms on IL-6 levels and CRP levels were not significant. IL-6 and CRP levels were not significantly different between the two groups. We found that IL-6 levels had a significant effect on CRP levels in periodontitis patients with CAD (path coefficient 0.322, p = 0.003). IL-6 -572 C/G, CRP -757 A/G, and CRP -717 T/C gene polymorphisms had no effect on the severity of chronic periodontitis in CAD patients in the Indonesian population. We also observed no apparent effects of the influence of gene polymorphisms in IL-6 -572 C/G, CRP -757 A/G, and CRP -717 T/C genes. Although the IL-6 and CRP levels were not significantly different between the two groups, IL-6 levels affected CRP levels in periodontitis patients with CAD.

The Stockholm Study: Over 30 years’ Observation of the Effect of Oral Infections on Systemic Health

The Stockholm Studies are a series of investigations started in 1985 and still ongoing. Out of 105,798 inhabitants, aged 30 and 40 years and living in the greater Stockholm area in Sweden, 3273 subjects were randomly selected. Of them, 1676 were clinically examined focusing on oral health. The subjects were then followed up using national population and health registers in order to study associations between oral health parameters and systemic health outcomes and finally death. The 35 years of observation provides unique possibilities to analyze, for example, how periodontitis links to a number of systemic health issues. The results have consequently provided numerous new associations and confirmed earlier observations on how poor oral health is associated with heart diseases and cancer.

Association between Periodontitis and Carotid Artery Calcification: A Systematic Review and Meta-Analysis

Recent studies have supported the relationship between periodontitis and carotid artery calcification (CAC), but still uncertain. This systematic review is aimed at evaluating the association between periodontitis and CAC. The search was conducted in four electronic databases: PubMed, EMBASE, Web of Science, and The Cochrane Library, supplemented by checking references of included articles and related review articles. Eligibility assessment and data extraction were conducted independently. The quality assessment and publication bias analysis were performed. The association between periodontitis and CAC was presented in odd ratio (OR) with 95% confidence interval (CI). Additional outcomes included the percentage of alveolar bone loss in CAC versus non-CAC. Twelve studies were included, and 10 were performed quantity analysis. Periodontitis with secure definition (OR = 2.02, 95%CI = 1.18 - 3.45) and insecure definition (OR = 10.78, 95%CI = 4.41 - 26.34) was associated with CAC. And a higher average percentage of alveolar bone loss (weighted mean difference = 10.84%; 95%CI = 6.40 - 15.48) was also observed in CAC patients compared to non-CAC patients. No significant publication bias was found. The results of this systematic review and meta-analysis revealed a significant relationship between periodontitis and CAC.

Mechanisms underlying the association between periodontitis and atherosclerotic disease

Atherosclerosis is central to the pathology of cardiovascular diseases, a group of diseases in which arteries become occluded with atheromas that may rupture, leading to different cardiovascular events, such as myocardial infarction or ischemic stroke. There is a large body of epidemiologic and animal model evidence associating periodontitis with atherosclerotic disease, and many potential mechanisms linking these diseases have been elucidated. This chapter will update knowledge on these mechanisms, which generally fall into 2 categories: microbial invasion and infection of atheromas; and inflammatory and immunologic. With respect to the invasion and infection of atheromas, it is well established that organisms from the subgingival biofilm can enter the circulation and lodge in most distant tissues. Bacteremias resulting from oral interventions, and even oral hygiene activities, are well documented. More recently, indirect routes of entry of oral organisms (via phagocytes or dendritic cells) have been described for many oral organisms, into many tissues. Such organisms include the periodontal pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Tannerella forsythia, and Fusobacterium nucleatum. Intracellular survival of these organisms with dissemination to distant sites (The Trojan Horse approach) has been described. Their relative contribution to atheroma formation and progression has been studied mainly in experimental research, with results demonstrating that these organisms can invade endothelial cells and phagocytic cells within the atheroma, leading to pathogenic changes and progression of the atheroma lesion. The second category of mechanisms potentially linking periodontitis to atherosclerosis includes the dumping of inflammatory mediators originating from periodontal lesions into the systemic circulation. These inflammatory mediators, such as C-reactive protein, matrix metalloproteinases, fibrinogen, and other hemostatic factors, would further accelerate atheroma formation and progression, mainly through oxidative stress and inflammatory dysfunction. Moreover, direct effects on lipid oxidation have also been described. In summary, the evidence supports the concept that periodontitis enhances the levels of systemic mediators of inflammation that are risk factors for atherosclerotic diseases.

Hypertension: Focus on autoimmunity and oxidative stress

Understanding the causal role of the immune and inflammatory responses in hypertension has led to questions regarding the links between hypertension and autoimmunity. Immune pathology in primary hypertension mimics several autoimmune mechanisms observed in the pathogenesis of systemic lupus erythematosus, psoriasis, systemic sclerosis, rheumatoid arthritis and periodontitis. More importantly, the prevalence of hypertension in patients with these autoimmune diseases is significantly increased, when compared to control populations. Clinical and epidemiological evidence is reviewed along with possible mechanisms linking hypertension and autoimmunity. Inflammation and oxidative stress are linked in a self-perpetuating cycle that significantly contributes to the vascular dysfunction and renal damage associated with hypertension. T cell, B cell, macrophage and NK cell infiltration into these organs is essential for this pathology. Effector cytokines such as IFN-γ, TNF-α and IL-17 affect Na⁺/H⁺ exchangers in the kidney. In blood vessels, they lead to endothelial dysfunction and loss of nitric oxide bioavailability and cause vasoconstriction. Both renal and vascular effects are, in part, mediated through induction of reactive oxygen species-producing enzymes such as superoxide anion generating NADPH oxidases and dysfunction of anti-oxidant systems. These mechanisms have recently become important therapeutic targets of novel therapies focused on scavenging oxidative (isolevuglandin) modification of neo-antigenic peptides. Effects of classical immune targeted therapies focused on immunosuppression and anti-cytokine treatments are also reviewed.

Association between periodontal disease and non-fatal ischemic stroke: a case-control study

OBJECTIVE

This study aimed to investigate the association between clinical and radiological markers of periodontal disease and ischemic stroke and to assess the potential influence of inflammatory response on the observed associations.

METHODS

A prospective case-control study including a series of 48 cases with a minor ischemic stroke and 47 controls was conducted at the University Hospital of Dijon. Vascular risk factors, clinical dental examination (plaque index, gingival index, percentage of pockets >5 mm, percentage of bleeding on probing (BOP) sites), dental panoramic (bone loss) and biological parameters (CRP, total cholesterol, HDL, LDL, fasting glucose) were collected. Conditional regression analyses were performed to identify factors associated with ischemic stroke.

RESULTS

The prevalence of hypertension, high CRP and glucose levels and overall odontological variables was higher in stroke patients. In multivariable analyses, hypertension (OR = 12.56; 95% CI = 2.29-69.96, p = 0.004), CRP levels >5 mg/L (OR = 18.54; 95% CI = 2.01-171.17, p = 0.010), BOP (OR = 1.049; 95% CI = 1.012-1.88, p = 0.009) and bone loss >20% (OR = 1.053; 95% CI = 1.017-1.091, p = 0.004) were associated with ischemic stroke. Among stroke patients, there was a non-significant trend towards higher CRP levels in patients with bone loss >20% compared with those with bone loss <20% (8.1 ± 1.27 mg/L vs 3.12 ± 3.14 mg/L, p = 0.25), whereas other biological parameters were very similar between the two groups.

CONCLUSION

This case-control study demonstrates that periodontal disease, especially markers such as BOP and bone loss, is independently associated with ischemic stroke.

Severity of periodontitis in patients with isolated coronary artery ectasia

The concept that coronary artery ectasia (CAE) is an inflammatory-related disease has been increasingly recognized. Periodontitis induced low-grade chronic systemic inflammation has been shown to be associated with cardiovascular diseases. The aim of the present study was to evaluate the association between periodontitis and CAE.Thirty-two patients with isolated CAE, and 28 age, sex and smoking status-matched subjects with normal coronary arteries (NCA) underwent full dental examinations. Periodontal disease was evaluated using the following clinical parameters; number of remaining teeth, plaque index (PI), gingival index (GI), bleeding on probing (BOP), and pocket depth (PD).Cases and controls did not differ according to their baseline characteristics and prevalence of traditional cardiovascular risk factors. Patients with isolated CAE had higher periodontal indices when compared to subjects with NCA (PD: 3.6 ± 1.26 mm versus 2.3 ± 0.79 mm; GI: 2.29 ± 0.86 versus 1.43 ± 1.19; BOP (%): 52.18 ± 20.1 versus 27.8 ± 10.9, P < 0.001, P < 0.05 and P < 0.05, respectively). Moreover, in multivariate analysis higher values for PD were found to be significant predictors for the likelihood of having coronary ectasia.The results of the present study demonstrate for the first time that there is an association between periodontitis and isolated CAE.

Periodontal disease and stroke: a meta-analysis of cohort studies

This review aimed to determine the association between periodontal disease and stroke incidence by a meta-analysis of cohort studies. Cohort studies that evaluated the incidence of stroke (fatal or non-fatal, ischaemic or haemorrhagic) and baseline periodontal status and calculated relative risk values were included. The quality of the included studies was assessed using an evaluation grid. The analyses were conducted separately for three outcomes: periodontitis, gingivitis and loss of teeth. Adjusted values of relative risk or of hazard ratio were used to assess risk values in each study. Random effects meta-analyses were conducted when data could be pooled. From the 743 references retrieved, only nine cohort studies were suitable for inclusion in this review. Quality scores of the studies varied greatly. Three prospective studies, which used reliable indicators of periodontal disease, obtained the highest scores. Conversely, three studies that used a subjective evaluation of stroke incidence or diagnosed stroke without imaging obtained the lowest score. The results of the meta-analyses varied depending on the outcome considered and the type of stroke. The risk of stroke was significantly increased by the presence of periodontitis [relative risk 1.63 (1.25, 2.00)]. Tooth loss was also a risk factor for stroke [relative risk 1.39 (1.13, 1.65)]. The risk of stroke did not vary significantly with the presence of gingivitis. This review shows that periodontitis and tooth loss are associated with the occurrence of stroke.