Relation of Periodontitis to Risk of Cardiovascular and All-Cause Mortality (from a Danish Nationwide Cohort Study)

The Association Between Periodontal Disease and Cardiovascular Disease: Insights From Imaging, Observational, and Genetic Data

Background

Periodontal disease is the sixth most common disease worldwide and may be a contributory risk factor for cardiovascular disease (CVD).

Objectives

This study utilizes noninvasive cardiac imaging and longitudinal and genetic data to characterize the association between periodontal disease and both cardiovascular magnetic resonance (CMR) imaging biomarkers of remodeling and incident coronary artery disease (CAD).

Methods

From the UK Biobank, 481,915 individuals were included, 91,022 (18.9%) of whom had self-reported periodontal disease. For imaging analysis, 59,019 had paired CMR data. Multivariable linear regression models were constructed to examine the association of periodontal disease on CMR outcomes. The endpoints for the CMR analyses were left ventricle (LV) end-diastolic volume, LV ejection fraction, LV mass, LV mass:volume ratio, LV global longitudinal strain, and native T1 values. The relationship between periodontal disease and CVD was assessed using Cox proportional hazards regression models, with incident CAD as the endpoint. To examine the relationship of genetically determined periodontal disease on CAD, a genome-wide polygenic risk score was constructed.

Results

Periodontal disease was associated with a significantly higher LV mass:volume ratio (effect size: 0.00233; 95% CI: 0.0006-0.004) and significantly lower T1 values (effect size: -0.86 ms; 95% CI: -1.63 to -0.09). Periodontal disease was independently associated with an increased hazard of incident CAD (HR: 1.09; 95% CI: 1.07-1.13) at a median follow-up time of 13.8 years. Each SD increase in the periodontal disease polygenic risk score was associated with increased odds of CAD (OR: 1.03; 95% CI: 1.02-1.05).

Conclusions

Using an integrated approach across imaging, observational, and genomic data, periodontal disease is associated with biomarkers of subclinical remodeling as well as incident CAD. These findings highlight the potential importance of periodontal disease in the broader context of CVD prevention.

Could the periodontal therapy improve the cardiologic patient health? A narrative review

BACKGROUND

Cardiovascular diseases (CVD) is the major cause of mortality globally, with increasing evidence suggesting a link between periodontitis, and CVD. This study aims to explore the association between periodontitis and CVD, and the impact of periodontal therapy on cardiovascular health.

METHODS

This review synthesized findings from preclinical and clinical studies, without publication year restrictions, examining periodontitis and CVD through various lenses. Scientific databases were inspected with keywords related to periodontitis and CVD.

RESULTS

The review identifies a substantial association between periodontitis and an increased risk of several CVD, supported by both epidemiological and interventional studies. Results suggest the complexity of the relationship, influenced by factors like the severity of periodontitis and the presence of other systemic conditions. Clinical data indicates that periodontal therapy, particularly non-surgical periodontal therapy, may reduce systemic inflammatory markers and thus may play a role in the primary and secondary prevention of CVD events, highlighting the potential of periodontal therapy to not only maintain oral health but also to modulate cardiovascular risk factors.

CONCLUSIONS

Current evidence supports a significant association between periodontitis and increased cardiovascular risk, promoting integrated healthcare approaches that consider oral health as a key-component of cardiovascular care and wellbeing.

Chronic periodontitis and risk of cerebro-cardiovascular diseases among older Koreans

BACKGROUND AND OBJECTIVE

There is a relative lack of evidence from observational studies of older populations investigating the association between chronic periodontitis and cerebro-cardiovascular diseases. Accordingly, we investigated the risk of cerebro-cardiovascular diseases according to the severity of chronic periodontitis among older adults.

METHODS

Data on older adults with chronic periodontitis were extracted from the Korea National Health Insurance Service-Senior Cohort Database using diagnosis codes and dental procedures. Participants were divided into two exposure groups. Among 46 737 participants eligible for inclusion, 21 905 (46.9%) had newly diagnosed mild chronic periodontitis, and 24 832 (53.1%) had newly diagnosed severe chronic periodontitis. To determine the risk of cerebro-cardiovascular diseases, including ischemic stroke, haemorrhagic stroke, and myocardial infarction, multivariable-adjusted Cox proportional hazards modelling was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) in this retrospective follow-up study.

RESULTS

A total of 3453 (7.4%) outcomes were identified during a mean follow-up of 6.1 years. Kaplan-Meier analysis revealed that disease-free probability was lower in the severe group than in the mild group (log-rank P < .001). In the multivariable-adjusted model, the HR for cerebro-cardiovascular diseases in the severe group (relative to the mild group) was 1.16 (95% CI: 1.09-1.25). In individual outcome analysis, ischemic stroke and myocardial infarction were associated with chronic periodontitis severity, but haemorrhagic stroke was not.

CONCLUSION

The severity of chronic periodontitis could be associated with the risk of cerebro-cardiovascular diseases in older adults.

Association between gingivitis, tooth loss and cardiovascular risk: Insights from a 10-year nationwide cohort study of 3.7 million Koreans

BACKGROUND

While studies have suggested an association between periodontal disease and an increased risk of cardiovascular disease, the strength of this association and its specific links to various types of cardiovascular disease have not been thoroughly investigated. This study aimed to examine how gingivitis and tooth loss affect cardiovascular diseases, probing their individual impacts.

METHODS

A retrospective cohort study was conducted, encompassing 3,779,490 individuals with no history of cardiovascular disease, utilizing data from the National Health Examination and the Korean National Health Insurance database from 2006 to 2019. Cox proportional hazards models were applied to estimate the association between tooth loss, gingivitis, and cardiovascular disease.

RESULTS

Following a median follow-up of 10.38 years, 17,942 new cardiovascular disease cases were identified, comprising 10,224 cases of angina pectoris, 6,182 cases of acute myocardial infarction, and 9,536 cases of stroke. It was observed that the risk of stroke was significantly higher in the tooth loss group compared to the control group (adjusted hazard ratio [aHR]: 1.09, 95% confidence interval [CI]: 1.04-1.15). In the group with gingivitis and tooth loss, the risk of stroke and cardiovascular disease was significantly higher than in the control group (aHR: 1.12, 95% CI: 1.04-1.20; aHR: 1.08, 95% CI: 1.03-1.14). The gingivitis group exhibited a higher risk associated with stroke (aHR: 1.05, 95% CI: 1.01-1.10) among individuals aged 50 and above. However, statistically significant associations between periodontal disease and angina pectoris were not observed, nor between periodontal disease and acute myocardial infarction except among those aged above 50. Furthermore, the association between periodontal disease and cardiovascular disease was found to be stronger among individuals over the age of 50, males, those with obesity, and smokers compared to the control group.

CONCLUSIONS

Our results emphasize the association of tooth loss and gingivitis with cardiovascular disease, specifically stroke, underlining the critical need for preventive oral healthcare. Tailored interventions are necessary to reduce the heightened risk of cardiovascular disease events, especially stroke, among older, obese individuals and smokers.

Evaluation of oral health in 148 patients with systemic sclerosis-data from a prospective interdisciplinary monocentric cohort

In daily rheumatology practice, systemic sclerosis is primarily regarded as a potentially life-threatening disease characterized by fibrosis of various organs. Therefore, other manifestations, such as orofacial involvement, are often not of primary concern. Furthermore, due to its rarity, the disease might not be well known by dentists, which contrasts with the increased risk of various problems in the oral cavity. Periodontitis in particular is a known risk factor for morbidity and mortality and is associated with various systemic diseases. The risk of periodontitis appears to be increased in patients with systemic sclerosis, but little is known about the gender-specific differences. This study aims to elucidate the health-conscious behaviour of patients, their dental care and the risk of periodontitis with regard to gender-specific differences. This descriptive study of the Interdisciplinary Centre of Rheumatic Diseases (INDIRA) in collaboration with the Department of Orthodontics at the University Hospital of Tuebingen, Germany, examined the data of 148 patients with systemic sclerosis with regard to their oral health using a questionnaire and evaluating the risk of periodontitis with the DG Paro self-assessment score in this cohort. Among the participating patients, 90% reported regular visits to the dentist and good dental care. Nevertheless, more than half of the patients had missing teeth and problems opening their mouths. Sicca symptoms in the oral cavity were also common (40%). The risk of periodontitis among female participants was high (around 60%), and even higher among male study participants (around 80%). Gingival bleeding as a surrogate parameter for periodontitis was associated with salivary flow and the modified Rodnan skin score (mRSS). Despite a high awareness of dental health, we observed a high risk of periodontitis, especially in male patients with systemic sclerosis. In addition, the association between xerostomia and missing teeth as well as gingival bleeding and mRSS may indicate an increased risk in patients with a more progressive disease. We would therefore recommend regular dental consultations and careful oral hygiene for patients with systemic sclerosis in addition to the-more organ-focused-regular examinations of patients.

Periodontitis and systemic inflammation as independent and interacting risk factors for mortality: evidence from a prospective cohort study

BACKGROUND

Recent studies have highlighted the role of low-grade systemic inflammation in linking periodontitis to cardiovascular disease (CVD) outcomes, but many aspects remain unclear. This study examines the independent and reciprocal associations of periodontitis and low-grade systemic inflammation with all-cause and CVD mortality in a large-scale cohort.

METHODS

A total of 3047 participants from the prospective, population-based Study of Health in Pomerania (SHIP-START) were followed for a period of 13.0 ± 2.4 years. For the association between various inflammation/periodontitis measures and mortality, hazard ratios (HRs) were obtained from covariate-adjusted Cox proportional hazards models. Interactions were analysed in joint models: on the multiplicative scale, HRs were reported and on the additive scale, relative excess risks due to interaction (RERI) were calculated. Subject and variable-specific interval records were used to account for time-varying exposures and covariates.

RESULTS

During the observation period, 380 (12.5%) individuals died from CVD (n = 125) or other causes (n = 255). All markers of periodontitis and inflammation showed apparent associations with all-cause mortality (HRs per SD-increase: mean PPD: 1.068 (95% confidence interval (CI): 0.988-1.155), mean CAL: 1.205 (95% CI: 1.097-1.323), missing teeth: 1.180 (95% CI: 1.065-1.307), periodontitis score: 1.394 (95% CI: 1.202-1.616), leukocytes: 1.264 (95% CI: 1.163-1.374), fibrinogen: 1.120 (95% CI: 1.030-1.218), CRP: 1.231 (95% CI: 1.109-1.366), inflammation score: 1.358 (95% CI: 1.210-1.523)). For CVD mortality, all PPD related variables showed significant associations. Interaction modelling revealed some variation with respect to mortality type and exposure combinations. On the additive scale, RERIs for periodontitis score and inflammation score implied 18.9% and 27.8% excess mortality risk for all-cause and CVD mortality, respectively. On the multiplicative scale, the HRs for interaction were marginal.

CONCLUSIONS

Both periodontitis and inflammation were significantly associated with all-cause mortality and CVD mortality. On the additive scale, a substantial excess risk was observed due to the interaction of periodontitis and inflammation, suggesting that the greatest treatment benefit may be achieved in patients with both periodontitis and high systemic inflammation. As periodontal therapy has been reported to also reduce systemic inflammation, the possibility of a reduction in CVD mortality risk by anti-inflammatory treatments, including periodontal interventions, seems worthy of further investigation.

Treated periodontitis and recurrent events after first-time myocardial infarction: A Danish nationwide cohort study

AIM

To investigate the association between previous periodontal treatment and recurrent events after first-time myocardial infarction (MI).

MATERIALS AND METHODS

From the Danish nationwide registries, patients with first-time MI between 2000 and 2015 were divided into three groups according to oral health care within 1 year prior to first-time MI. A multiple logistic regression model provided adjusted odds ratios (ORs) with 95% confidence intervals (CIs) to assess the 3-year risk of major adverse cardiovascular events (MACE).

RESULTS

A total of 103,949 patients were included. Patients with treated periodontitis (PD) prior to first-time MI had an adjusted 3-year risk of MACE similar to patients presumed periodontally healthy (OR 0.97 [95% CI 0.92-1.03]). Patients with no prior dental visits were significantly older, had more comorbidities and showed significantly increased adjusted 3-year risks of MACE (OR 1.47 [95% CI 1.42-1.52]), cardiovascular death (OR 1.71 [95% CI 1.64-1.78]) and heart failure (OR 1.13 [95% CI 1.07-1.20]) compared with patients presumed periodontally healthy.

CONCLUSIONS

Patients with treated PD 1 year prior to first-time MI had a similar risk of recurrent cardiovascular events as patients presumed periodontally healthy. No dental visit prior to first-time MI was an independent risk factor for recurrent events.

Periodontal disease and subsequent risk of cardiovascular outcome and all-cause mortality: A meta-analysis of prospective studies

Studies reported periodontal disease (PD) periodontal disease is associated with many systemic diseases, including cardiovascular outcomes and all-cause mortality. However, the precise mechanistic link for these relationship remained unclear. We therefore performed a meta-analysis of cohort studies to investigate the association of PD with the risk of cardiovascular outcomes and all-cause mortality. We systematically searched the databases of PubMed, EmBase, and the Cochrane library to identify eligible studies until April 2023. The investigated outcomes included major adverse cardiovascular events (MACEs), coronary heart disease (CHD), myocardial infarction (MI), stroke, cardiac death, and all-cause mortality. The summary relative risk (RR) with 95% confidence interval (CI) were calculated using the random-effects model. Thirty-nine cohort studies with 4,389,263 individuals were selected for final meta-analysis. We noted PD were associated with elevated risk of MACEs (RR: 1.24; 95%CI: 1.15-1.34; P<0.001), CHD (RR: 1.20; 95%CI: 1.12-1.29; P<0.001), MI (RR: 1.14; 95%CI: 1.06-1.22; P = 0.001), stroke (RR: 1.26; 95%CI: 1.15-1.37; P<0.001), cardiac death (RR: 1.42; 95%CI: 1.10-1.84; P = 0.007), and all-cause mortality (RR: 1.31; 95%CI: 1.07-1.61; P = 0.010). Sensitivity analyses indicated the pooled conclusions for cardiovascular outcomes and all-cause mortality are robustness. The associations of PD with the risk of ardiovascular outcomes and all-cause mortality could affected by region, study design, PD definition, follow-up duration, and study quality. This study found the risk of cardiovascular outcomes and all-cause mortality were elevated in PD patients, and the intervention for PD should be applied to prevent the risk of cardiovascular outcomes.

Social Isolation/Loneliness and Tooth Loss in Community-Dwelling Older Adults: The Sukagawa Study

Background and Objectives

The relationship between social isolation/loneliness and oral health is unclear. This study investigated the association between social isolation/loneliness and tooth loss in older Japanese adults.

Research Design and Methods

This was a cross-sectional study of a population-based cohort (the Sukagawa Study); 5,490 cohort study participants aged ≥75 years and who were independent answered a self-administered questionnaire in 2018. Social isolation was defined based on the 6-item Japanese version of the Lubben Social Network Scale. Loneliness was measured by the 3-item Japanese version of the University of California, Los Angeles (UCLA) Loneliness Scale version 3. The primary outcome was tooth loss, defined as having fewer than 20 teeth. The secondary outcomes were decreased toothbrushing frequency and diminished ability to chew food. Prevalence ratios (PRs) were estimated using a modified Poisson regression analysis in 2 models-Model 1, which adjusted for age, gender, smoking status, alcohol consumption, low annual income, and short education period, and Model 2, which added history of depression, history of diabetes mellitus, history of stroke, and cognitive impairment to Model 1.

Results

The primary analysis included 4,645 participants. Adjusted PRs of social isolation and loneliness for tooth loss (Model 1) were 0.97 (95% confidence interval [CI] 0.92-1.01) and 1.06 (95% CI 1.01-1.12), respectively; those for decreased toothbrushing frequency were 1.13 (95% CI 0.95-1.36) and 1.56 (95% CI 1.26-1.92), respectively; and those for chewing difficulty were 1.61 (95% CI 1.06-2.43) and 2.94 (95% CI 1.91-4.53), respectively. The adjusted PRs in Model 2 demonstrated results similar to that of Model 1.

Discussion and Implications

Loneliness is associated with tooth loss among older adults, whereas social isolation is not. Our findings can inform plans for policymakers, professionals, and organizations to identify lonely older adults and provide social prescriptions to improve their access to oral health care services.

Association between periodontal disease and pericardial adipose tissue in patients with cardiovascular disease

Background

Periodontal disease (PD) is associated with an increased risk of cardiovascular disease (CVD). Pericardial adipose tissue (PAT) is known as a marker of progressive CVD. This study sought to assess the association between PD and PAT in patients with CVD.

Methods

We retrospectively investigated 135 patients admitted for CVD who underwent computed tomography coronary angiography (CTCA) and periodontal examinations. Periodontal assessment using the community periodontal index (CPI) was based on the probing pocket depth around teeth. Patients with CPI ≥3 were categorized as having PD. PAT volume was measured with a quantitative semi-automated procedure using CTCA images. Patients were divided into tertiles according to PAT volume. Baseline characteristics and PD findings were compared among the tertiles.

Results

Eighty-six patients were diagnosed with PD (63.7 %). Mean PAT volume was 181.4 ml, and patients were categorized as small-PAT (PAT <148.9 ml), intermediate-PAT (148.9 ml ≤ PAT ≤204.6 ml), and large-PAT (PAT >204.6 ml). The prevalence of PD was significantly higher in large-PAT (38/46, 82.6 %) than in small-PAT (18/45, 40.0 %) and intermediate-PAT (30/44, 68.2 %) patients. Multivariate logistic regression analysis showed that body weight, history of hypertension, and the presence of PD were independent predictors for large-PAT (odds ratio [OR]: 1.12, P < 0.001, OR: 3.97, P = 0.017, and OR: 4.18, P = 0.0078, respectively).

Conclusion

The presence and severity of PD were significantly correlated with PAT volume, which has been associated with progressive CVD. Further prospective studies are warranted to assess the impact of PD on the onset and outcomes of CVD.

Free Radicals and Obesity-Related Chronic Inflammation Contrasted by Antioxidants: A New Perspective in Coronary Artery Disease

We are surrounded by factors called free radicals (FR), which attach to the molecules our body is made of, first among them the endothelium. Even though FR are to a certain extent a normal factor, nowadays we face an escalating increase in these biologically aggressive molecules. The escalating formation of FR is linked to the increased usage of man-made chemicals for personal care (toothpaste, shampoo, bubble bath, etc.), domestic laundry and dish-washer detergents, and also an ever wider usage of drugs (both prescription and over the counter), especially if they are to be used long-term (years). In addition, tobacco smoking, processed foods, pesticides, various chronic infectious microbes, nutritional deficiencies, lack of sun exposure, and, finally, with a markedly increasing impact, electromagnetic pollution (a terribly destructive factor), can increase the risk of cancer, as well as endothelial dysfunction, owing to the increased production of FR that they cause. All these factors create endothelial damage, but the organism may be able to repair such damage thanks to the intervention of the immune system supported by antioxidants. However, one other factor can perpetuate the state of inflammation, namely obesity and metabolic syndrome with associated hyperinsulinemia. In this review, the role of FR, with a special emphasis on their origin, and of antioxidants, is explored from the perspective of their role in causing atherosclerosis, in particular at the coronary level.

Current knowledge on the association between cardiovascular and periodontal disease: an umbrella review

INTRODUCTION

Periodontal disease (PD) and cardiovascular diseases (CVD) are among the most common pathologies in the world and their relationship has long been studied. Both conditions lead to a chronic inflammatory process with degenerative characteristics and their biunivocal correlation is now well established. The aim of this umbrella review on cardiovascular and periodontal disease was to evaluate the real degree of association between these two pathological conditions.

EVIDENCE ACQUISITION

We conducted a comprehensive literature search on PubMed/Medline and in the Cochrane Library for systematic reviews focused on clinical evidence regarding the relationship between PD and CVD. The internal validity of systematic reviews and meta-analyses was formally analyzed using the Overview Quality Assessment Questionnaire (OQAQ) Tool. The umbrella review was planned in accordance with current international recommendations and was described as specified by the PRISMA Guidelines.

EVIDENCE SYNTHESIS

Thirty-one systematic reviews, including 8 meta-analyses for a total of 507 clinical studies and over 3,549,966 patients were included. PD resulted to be associated with a higher risk of developing CVD (acute coronary syndrome, acute myocardial infarction) and cerebrovascular diseases (ischemic stroke); however, if the treatment of periodontitis reduces the risk of CVD events related is yet to be investigated.

CONCLUSIONS

To date, the relationship between CVD and PD provides heterogeneous data. There is an association between PD and CVD, but a causal relationship cannot be established. Further research with properly designed long-term follow-up studies are needed in order to examine various physiopathological aspects of their association.

Periodontal disease is associated with the risk of cardiovascular disease independent of sex: A meta-analysis

Objectives

Studies have established a link between periodontal disease and cardiovascular disease (CVD), but it is unclear whether there is a sex difference in their association.

Methods

The PubMed, Embase, and Cochrane databases were searched until June, 21 2022. Cardiovascular outcomes included any CVD, myocardial infarction (MI), coronary heart disease (CHD), or stroke. Studies reported the prevalence of CVD in patients with periodontal disease and the relationship between periodontal disease and CVD. The study is registered with PROSPERO (CRD42022333663). The level of evidence and recommendations is assessed by the Grading of Recommendations for Assessment, Development and Evaluation (GRADE).

Results

Twenty-six studies were included. In patients with periodontal disease, the prevalence of CVD was 7.2% [9 studies; 95% confidence interval (CI): 2.7-13.6%], and prevalence for CHD, hypertension, stroke, and heart failure was 6.6, 25.3, 1, and 1.1%, respectively. There was a significant association between periodontal disease and CVD in men [odds ratio (OR) = 1.22; 95% CI: 1.12-1.34] and women (OR = 1.11; 95% CI: 1.05-1.17), with no significant sex difference (P > 0.05).

Conclusion

Cardiovascular disease is relatively common in patients with periodontal disease, and an increased risk of CVD is associated with periodontal disease independent of sex. Interventions targeting periodontal disease may be beneficial for CVD.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333663.

Hypotheses on Atherogenesis Triggering: Does the Infectious Nature of Atherosclerosis Development Have a Substruction?

Since the end of the 20th century, it has been clear that atherosclerosis is an inflammatory disease. However, the main triggering mechanism of the inflammatory process in the vascular walls is still unclear. To date, many different hypotheses have been put forward to explain the causes of atherogenesis, and all of them are supported by strong evidence. Among the main causes of atherosclerosis, which underlies these hypotheses, the following can be mentioned: lipoprotein modification, oxidative transformation, shear stress, endothelial dysfunction, free radicals' action, homocysteinemia, diabetes mellitus, and decreased nitric oxide level. One of the latest hypotheses concerns the infectious nature of atherogenesis. The currently available data indicate that pathogen-associated molecular patterns from bacteria or viruses may be an etiological factor in atherosclerosis. This paper is devoted to the analysis of existing hypotheses for atherogenesis triggering, and special attention is paid to the contribution of bacterial and viral infections to the pathogenesis of atherosclerosis and cardiovascular disease.

Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years

AIM

To evaluate the association between periodontal disease and all-cause mortality in a longitudinal cohort study over 50 years.

MATERIALS AND METHODS

Participants (N = 1156) in the Veterans Affairs Dental Longitudinal Study, aged 25-85 years at enrollment in 1968, received comprehensive medical and oral exams approximately every 3 years through 2007. Periodontal status was defined using person-level, mean whole-mouth radiographic alveolar bone loss (ABL) scores using a five-point Schei ruler, each unit representing 20% increments of ABL. Time-varying Cox regression models estimated hazard ratios (HRs) for the association between continuous and categorical ABL and mortality, adjusting for covariates.

RESULTS

Each one-unit increase in mean ABL score was associated with a 14% increase in the hazard of mortality (adjusted HR = 1.14, 95% confidence interval [CI] 1.02, 1.27). When assessed categorically, HRs for average scores of 2 to <3 and 3 to ≤5 showed increasing associations with hazard of mortality, relative to 0 to <1 (adjusted HR = 1.17, 95% CI 0.94, 1.46; and HR = 1.65, 95% CI 0.94, 2.85, respectively). By contrast, we observed null associations for average scores of 1 to <2 relative to 0 to <1 (adjusted HR = 1.00, 95% CI 0.86, 1.17).

CONCLUSIONS

Time-varying periodontal status assessed using radiographic ABL was positively associated with all-cause mortality even after confounder adjustment.

Periodontal disease as a non-traditional risk factor for acute coronary syndrome: a systematic review and meta-analysis

OBJECTIVES

Previous observational studies have suggested an association between periodontal disease (PD) and cardiovascular and cerebrovascular diseases. Nonetheless, evidence linking PD with coronary heart disease (CHD) and acute coronary syndrome (ACS) is still contradictory. We aim to systematically review the role of PD as a risk factor for ACS (myocardial infarction and unstable angina).

METHODS

The protocol was registered in PROSPERO (CRD42021286278) and we followed the recommendations of the PRISMA and AMSTAR 2 guidelines. We systematically searched for 7 databases and electronic thesis repositories from inception to February 2022. We included articles without language restriction following the PECO strategy (population: "adult participants"; exposure: "periodontal disease"; comparator: "no periodontal disease"; outcome: "acute coronary syndrome" OR "acute myocardial infarction" OR "unstable angina"). Odds ratios (OR) with 95% confidence intervals (95% CI) were pooled using random effects and heterogeneity was quantified by Cochran's Q and Higgins' I² statistics. Subgroup analyses were carried out according to the participants' sex, type of diagnosis of PD, type of study, and continent of origin of studies.

RESULTS

We included 46 papers (17 cohort, 25 case-control, and 4 cross-sectional studies) that met the inclusion criteria. This meta-analysis includes a total of 6,806,286 participants and at least 68,932 ACS events, mainly myocardial infarction (MI). In accordance with our results, PD is associated with a higher risk of ACS (OR 1.35; 95% CI 1.25-1.45). However, clinical and methodological heterogeneity was significant (I²=86%, p<0.05). In the sensitivity analysis, the exclusion of some studies with "extreme" results (outliers) did not significantly affect the overall estimate or heterogeneity. In subgroup analysis, we found no statistically significant differences between men and women according to subgroup difference tests (I²=0%, p=0.67). Conversely, there were differences according to the type of diagnosis of PD (clinical or self-reported diagnosis), type of study (cohort, case-control, or cross-sectional study), and the continent of origin (North America, South America, Asia, or Europe) of the studies (I²=79%-96%, p<0.10). Of the 46 studies, only 4 had a high risk of bias. Additionally, the funnel plot suggested publication bias.

CONCLUSION

PD may be an important non-traditional risk factor for ACS. Although, this meta-analysis brings together more studies, and therefore more evidence, than any other previous similar study, its results should be interpreted with caution due to the great heterogeneity and the potential presence of bias.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the third update of a review originally published in 2014, and most recently updated in 2019. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

An information specialist searched five bibliographic databases up to 17 November 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There are no new completed RCTs on this topic since we published our last update in 2019. We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Gradual Drug Release Membranes and Films Used for the Treatment of Periodontal Disease

Periodontitis is an inflammatory disease that, if not treated, can cause a lot of harm to the oral cavity, to the patients' quality of life, and to the entire community. There is no predictable standardized treatment for periodontitis, but there have been many attempts, using antibiotics, tissue regeneration techniques, dental scaling, or root planning. Due to the limits of the above-mentioned treatment, the future seems to be local drug delivery systems, which could gradually release antibiotics and tissue regeneration inducers at the same time. Local gradual release of antibiotics proved to be more efficient than systemic administration. In this review, we have made a literature search to identify the articles related to this topic and to find out which carriers have been tested for drug release as an adjuvant in the treatment of periodontitis. Considering the inclusion and exclusion criteria, 12 articles were chosen to be part of this review. The selected articles indicated that the drug-releasing carriers in periodontitis treatment were membranes and films fabricated from different types of materials and through various methods. Some of the drugs released by the films and membranes in the selected articles include doxycycline, tetracycline, metronidazole, levofloxacin, and minocycline, all used with good outcome regarding their bactericide effect; BMP-2, Zinc-hydroxyapatite nanoparticles with regenerative effect. The conclusion derived from the selected studies was that gradual drug release in the periodontal pockets is a promising strategy as an adjuvant for the treatment of periodontal disease.

Policies Supporting Oral Health in Ageing Populations Are Needed Worldwide

This literature review examines the need to develop appropriate policies specific to the oral health needs of older people that are individualised, cost-effective, and sustainable. Poor oral health and impaired oral function negatively affect the health and quality of life of older adults. Developing care systems that aim to meet patients' normative needs as well as their perceived needs and expectations is one factor in successful delivery of appropriate dental care. Cost is another significant driver of utilisation, and many older adults worldwide lack adequate resources for dental care. Failure to address these issues results in poor outcomes and increased costs of dental and medical care. Disease prevention and control at early stages can preserve public and private financial resources as well as quality of life and well-being for older adults at any stage of life.

Cardiovascular Diseases and Periodontitis

Periodontitis is a chronic inflammatory disease of the tooth-supporting connective tissue and alveolar bone that is initiated by a bacterial biofilm in periodontal pockets. It affects about half of adults in the Western world, and is associated with a range of systemic comorbidities, e.g., cardiovascular disease (CVD), diabetes and rheumatoid arthritis, and these diseases share overlapping systemic and target tissue inflammatory mechanisms. Indeed, mounting evidence has indicated that their association is causal and built on the presence of systemic low-grade inflammation (LGI). Prior research linking periodontitis to CVD has mainly been derived from experimental studies, observational data, and small interventional trials with surrogate markers of CVD, e.g., endothelial dysfunction. However, recent data from randomised studies have demonstrated that intensive treatment of periodontitis can reduce blood pressure in patients with hypertension in conjunction with reduction of systemic inflammatory markers. Furthermore, targeted anti-inflammatory therapy has been shown to reduce recurrent events in patients with established CVD and LGI. Along this line, the concept of residual inflammatory risk has emerged as an independent new risk factor for atherothrombotic CVD. The present review summarizes translational evidence indicating that periodontitis is a risk factor for CVD dependent on LGI, and we conclude that treatment of periodontitis is likely to contribute importantly to reduction of residual inflammatory risk.

Periodontal care attendance in Denmark in 2012-2016 - a nationwide register-based study

OBJECTIVE

Planning and evaluation of oral healthcare systems rely on monitoring of care patterns. Monitoring periodontal care patterns provide information on the burden and occurrence of periodontitis in the population and on the direct financial cost. The aims of the study were to describe patterns in periodontal care among dental care attenders that might incite subsequent investigation and revised treatment guidelines. Secondly, to estimate the direct societal costs of periodontal care.

MATERIAL AND METHODS

A retrospective register-based study utilising data from the Danish Public Health Insurance which includes all dental care attenders in 2012-2016, three years before and one year after a national risk-based recall maintenance program was rolled out in Denmark.

RESULTS

The 2.7 million yearly dental care attenders corresponded to ∼60% of the eligible population and in the range of 20-24% received periodontal care. Total expenditure for periodontal care in Denmark increased by 13% from 2012 to 2016, from €78 to €88 million. The proportion of total healthcare funding spent on periodontal care was 0.61% in 2016.

CONCLUSIONS

Patients with periodontitis have large out-of-pocket yearly expenses for periodontal care. Despite small changes in periodontal clinical practice that may indicate improved targeting of patients in need of periodontal care, challenges of reaching non-attenders and non-adherence to care are unsolved. More research into outcomes from periodontal therapy in daily practice, seen from both normative and patient perspectives, would help establish knowledge of the efficiency of existing periodontal care systems and help identify barriers and facilitators for attending care in Denmark.

Maladaptive trained immunity and clonal hematopoiesis as potential mechanistic links between periodontitis and inflammatory comorbidities

Periodontitis is bidirectionally associated with systemic inflammatory disorders. The prevalence and severity of this oral disease and linked comorbidities increases with aging. Here, we review two newly emerged concepts, trained innate immunity (TII) and clonal hematopoiesis of indeterminate potential (CHIP), which together support a potential hypothesis on how periodontitis affects and is affected by comorbidities and why the susceptibility to periodontitis and comorbidities increases with aging. Given that chronic diseases are largely triggered by the action of inflammatory immune cells, modulation of their bone marrow precursors, the hematopoietic stem and progenitor cells (HSPCs), may affect multiple disorders that emerge as comorbidities. Such alterations in HSPCs can be mediated by TII and/or CHIP, two non-mutually exclusive processes sharing a bias for enhanced myelopoiesis and production of innate immune cells with heightened proinflammatory potential. TII is a state of elevated immune responsiveness based on innate immune (epigenetic) memory. Systemic inflammation can initiate TII in the bone marrow via sustained rewiring of HSPCs, which thereby display a skewing toward the myeloid lineage, resulting in generation of hyper-reactive or "trained" myeloid cells. CHIP arises from aging-related somatic mutations in HSPCs, which confer a survival and proliferation advantage to the mutant HSPCs and give rise to an outsized fraction of hyper-inflammatory mutant myeloid cells in the circulation and tissues. This review discusses emerging evidence that supports the notion that TII and CHIP may underlie a causal and age-related association between periodontitis and comorbidities. A holistic mechanistic understanding of the periodontitis-systemic disease connection may offer novel diagnostic and therapeutic targets for treating inflammatory comorbidities.

Dietary carbohydrate intake is associated with the subgingival plaque oral microbiome abundance and diversity in a cohort of postmenopausal women

Limited research exists on carbohydrate intake and oral microbiome diversity and composition assessed with next-generation sequencing. We aimed to better understand the association between habitual carbohydrate intake and the oral microbiome, as the oral microbiome has been associated with caries, periodontal disease, and systemic diseases. We investigated if total carbohydrates, starch, monosaccharides, disaccharides, fiber, or glycemic load (GL) were associated with the diversity and composition of oral bacteria in subgingival plaque samples of 1204 post-menopausal women. Carbohydrate intake and GL were assessed from a food frequency questionnaire, and adjusted for energy intake. The V3-V4 region of the 16S rRNA gene from subgingival plaque samples were sequenced to identify the relative abundance of microbiome compositional data expressed as operational taxonomic units (OTUs). The abundance of OTUs were centered log(2)-ratio transformed to account for the compositional data structure. Associations between carbohydrate/GL intake and microbiome alpha-diversity measures were examined using linear regression. PERMANOVA analyses were conducted to examine microbiome beta-diversity measures across quartiles of carbohydrate/GL intake. Associations between intake of carbohydrates and GL and the abundance of the 245 identified OTUs were examined by using linear regression. Total carbohydrates, GL, starch, lactose, and sucrose intake were inversely associated with alpha-diversity measures. Beta-diversity across quartiles of total carbohydrates, fiber, GL, sucrose, and galactose, were all statistically significant (p for PERMANOVA p < 0.05). Positive associations were observed between total carbohydrates, GL, sucrose and Streptococcus mutans; GL and both Sphingomonas HOT 006 and Scardovia wiggsiae; and sucrose and Streptococcus lactarius. A negative association was observed between lactose and Aggregatibacter segnis, and between sucrose and both TM7_[G-1] HOT 346 and Leptotrichia HOT 223. Intake of total carbohydrate, GL, and sucrose were inversely associated with subgingival bacteria alpha-diversity, the microbial beta-diversity varied by their intake, and they were associated with the relative abundance of specific OTUs. Higher intake of sucrose, or high GL foods, may influence poor oral health outcomes (and perhaps systemic health outcomes) in older women via their influence on the oral microbiome.

BigMouth: development and maintenance of a successful dental data repository

Few clinical datasets exist in dentistry to conduct secondary research. Hence, a novel dental data repository called BigMouth was developed, which has grown to include 11 academic institutions contributing Electronic Health Record data on over 4.5 million patients. The primary purpose for BigMouth is to serve as a high-quality resource for rapidly conducting oral health-related research. BigMouth allows for assessing the oral health status of a diverse US patient population; provides rationale and evidence for new oral health care delivery modes; and embraces the specific oral health research education mission. A data governance framework that encouraged data sharing while controlling contributed data was initially developed. This transformed over time into a mature framework, including a fee schedule for data requests and allowing access to researchers from noncontributing institutions. Adoption of BigMouth helps to foster new collaborations between clinical, epidemiological, statistical, and informatics experts and provides an additional venue for professional development.

Patients with periodontitis and erectile dysfunction suffer a greater incidence of major adverse cardiovascular events: a prospective study in Spanish population

BACKGROUND

Periodontitis and erectile dysfunction have been linked with cardiovascular disease. The association of periodontitis and erectile dysfunction with the occurrence of major adverse cardiovascular events has not been previously assessed. The aim of this study was to determine if the presence of periodontitis and erectile dysfunction has any effect on the incidence of major adverse cardiovascular events.

METHODS

Male patients that attended the Urology service were enrolled in a prospective study. Erectile dysfunction was diagnosed according to the International Index of Erectile Function. Sociodemographic data and periodontal clinical parameters were gathered (pocket probing depth, clinical attachment loss, bleeding on probing, plaque index and number of teeth) at baseline. Major adverse cardiovascular events occurred both before and during the follow-up time were registered. Bivariate analyses, as well as a multivariate analysis were performed, adjusting for potential confounders.

RESULTS

158 patients were included, with a mean follow-up of 4.2 years. A greater number of major adverse cardiovascular events occurred in the group that presented periodontitis and erectile dysfunction (p = 0.038). After adjusting by age and previous cardiovascular disease in the multivariate analysis, the annual major adverse cardiovascular event rate was estimated to be 3.7 times higher in the same group (p = 0.049). Other periodontal clinical variables together with erectile dysfunction supported these results and were close to statistical significance.

CONCLUSIONS

Patients with periodontitis and erectile dysfunction, adjusted by age and a cardiovascular disease, showed 3.7 times more risk of suffering major adverse cardiovascular events after mean follow-up of 4.2 years.

ONE-SENTENCE SUMMARY

Patients with periodontitis and erectile dysfunction showed a risk 3.7 times higher of suffering major adverse cardiovascular events after a mean follow-up of 4.2 years. This article is protected by copyright. All rights reserved.

Atherosclerosis pathogenesis from the perspective of microvascular dysfunction

The article discusses different points of view on atherosclerosis development. The facts confirming the lipid hypothesis are presented. Attention is drawn to the possible participation of vasa vasorum in the development of atherosclerosis.

Implication of thyroid function in periodontitis: a nationwide population-based study

Possible links between periodontitis and various cardiometabolic and autoimmune diseases have been advocated on the basis of chronic inflammation or oxidative stress. However, the association between periodontitis and thyroid dysfunction is under-researched. Participants without previous thyroid disease or ongoing thyroid-related medication were included from a nationwide population-level survey. Participants were categorized into tertiles of thyroid stimulating hormone (TSH) levels (first tertile < 1.76 mIU/L; second tertile 1.76-2.83 mIU/L; third tertile > 2.83 mIU/L), and periodontal condition was assessed using the Community Periodontal Index. Of the total of 5468 participants, 1423 had periodontitis (26%). A significant difference in the weighted prevalence of periodontitis according to TSH tertiles was observed, with the highest prevalence in the first tertile (26.5%) and the lowest prevalence in the third tertile (20.9%, p = 0.003). Subjects in the first TSH tertile had higher odds for periodontitis than those in the third tertile (OR 1.36, 95% CI 1.10-1.68; p for trend = 0.005) after adjusting for covariates. This association was consistent across subgroups and within sensitivity analyses among subjects without specific factors affecting thyroid function or diseases reported to be related to periodontitis. The present study demonstrated that low TSH levels were associated with significantly higher odds for periodontitis.

Associations of periodontal disease and tooth loss with all-cause and cause-specific mortality in the Sister Study

AIM

Studies have found that periodontal disease and tooth loss are associated with increased mortality; however, associations with cause-specific mortality and all-cause mortality within specific subgroups have not been thoroughly investigated.

MATERIALS AND METHODS

We examined the association of self-reported periodontal disease and disease/decay-related tooth loss with subsequent all-cause and cause-specific mortality in the Sister Study, a prospective cohort study of 50,884 women aged 35-74 years at baseline, whose sister was diagnosed with breast cancer. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the associations were calculated with adjustment for relevant confounders.

RESULTS

With a mean follow-up of 10.9 years (range 0.1-14.3), 2058 women died. Participants with periodontal disease had a slightly higher rate of all-cause mortality (HR = 1.08, 95% CI 0.98-1.19), while participants with tooth loss had an increased rate of all-cause mortality (HR = 1.15, 95% CI 1.05-1.26). For cause-specific mortality, women with tooth loss had increased rates of death from circulatory system diseases, respiratory system diseases, and endocrine/metabolic diseases. Results varied in stratified models, but no heterogeneity across strata was found.

CONCLUSIONS

In this large prospective study, periodontal disease and tooth loss were associated with all-cause and certain specific cause-specific mortality outcomes.

Number of teeth is independently associated with ischemic stroke: A case-control study

Poor oral health has been suggested as a potential risk factor for the occurrence of cardiovascular events. The present study aimed to test the hypothesis that the number of permanent natural teeth (NT) is independently associated with the occurrence of ischemic stroke (IS) or transient ischemic attack (TIA) in a southern Brazilian population. This case-control study enrolled 458 subjects, 229 hospital patients diagnosed with IS or TIA (cases) and 229 patients with no history of cardiovascular disease (controls). NT was assessed through a head and neck multidetector computed tomography angiography (MDCTA) and panoramic radiographs. The participants were matched by age and sex. Sociodemographic and medical confounding variables were obtained from the hospital charts and through a structured questionnaire. Multivariate logistic regression analysis were carried out to estimate the association between NT and the occurrence of IS or TIA. The mean age was 58.37 ± 10.75 years, with 46.7% males. Adjusted analyses showed an independent association between IS or TIA and hypertension (OR = 6.34, 95%CI = 3.93-10.24), smoking (OR = 4.70, 95%CI = 2.76-7.99) and NT (lower quartile: ≤7 teeth) (OR = 5.59, 95%CI = 2.88-10.86). The number of permanent natural teeth was inversely and independently associated with the occurrence of IS or TIA in this population. Present findings suggest a gradient effect on the association between oral health and IS.

Periodontitis related to cardiovascular events and mortality: a long-time longitudinal study

OBJECTIVE

The present study assessed if individuals ≥ 60 years of age with periodontitis are more likely to develop stroke or ischemic heart diseases, or at a higher risk of death for 17 years.

MATERIAL AND METHODS

At baseline individuals ≥ 60 received a dental examination including a panoramic radiograph. Periodontitis was defined as having ≥ 30% sites with ≥ 5-mm distance from the cementoenamel junction to the marginal bone level. Medical records were annually reviewed from 2001 to 2018. Findings from the medical records identifying an ICD-10 code of stroke and ischemic heart diseases or death were registered.

RESULTS

Associations between periodontitis and incidence of ischemic heart disease were found in this 17-year follow-up study in all individuals 60-93 years (HR: 1.5, CI: 1.1-2.1, p = 0.017), in women (HR: 2.1, CI: 1.3-3.4, p = 0.002), and in individuals 78-96 years (HR: 1.7, CI: 1.0-2.6, p = 0.033). Periodontitis was associated with mortality in all individuals (HR: 1.4, CI: 1.2-1.8, p = 0.002), specifically in men (HR: 1.5, CI: 1.1-1.9, p = 0.006) or in ages 60-72 years (HR: 2.2, CI: 1.5-3.2, p = 0.000). Periodontitis was more prevalent among men (OR: 1.8, CI: 1.3-2.4, p = 0.000).

CONCLUSIONS

Individuals with periodontitis have an increased risk for future events of ischemic heart diseases and death.

CLINICAL RELEVANCE

Improving periodontal health in older individuals may reduce overall mortality and ischemic heart diseases. Both dental and medical professionals should be aware of the associations and ultimately cooperate.

Age at first childbirth in relation to oral health later in life

OBJECTIVE

This study aimed to examine the relationship between age at first childbirth and oral health. The mediation effect of body mass index (BMI) on this relationship was also determined.

METHODS

This study analyzed data of 2,506 parous postmenopausal women aged 50 or older from the Korea National Health and Nutrition Examination Survey 2013-2015. Chewing inconvenience was investigated by an oral interview. Periodontitis and dental caries were determined through dental examinations. Multivariable logistic regression analysis was performed to examine the relationship between age at first childbirth and oral health, and mediation analysis was performed to examine the contribution of BMI on the relationship between age at first childbirth and oral health.

RESULTS

Women who underwent their first delivery between the age of 26 and 46 years had significantly decreased odds of chewing inconvenience (odds ratio [OR] = 0.72, 95% confidence interval [95% CI] = 0.56-0.93, P = 0.010) compared with the odds of those women whose first delivery was between at the age of 15 and 22 years. We also found a significant linear relationships between age at first childbirth and odds of chewing inconvenience (OR = 0.83, 95% CI = 0.74-0.95, P = 0.017) and dental caries (OR = 0.84, 95% CI = 0.74-0.96, P = 0.025). BMI accounted for 12.9% of the relationship between age at first childbirth and dental caries. Age at first childbirth was only indirectly associated with periodontitis through BMI (OR = 0.98, 95% CI = 0.96-0.99, P = 0.003).

CONCLUSIONS

Women whose first delivery occurred at a young age had significantly increased odds of chewing inconvenience and dental caries. BMI mediated the relationships between age at first childbirth and periodontitis and dental caries.

Periodontal disease and myocardial infarction risk: A meta-analysis of cohort studies

INTRODUCTION

The objective of this meta-analysis was to systematically assess the association between periodontal disease (PD) and myocardial infarction (MI).

METHODS

We searched the EMBASE, PubMed, and Cochrane Library databases for eligible cohort studies from inception to August 31st, 2020 that reported the association between PD and MI. Data extraction was conducted after screening the literature. The risk of bias of the included studies was evaluated by using the Newcastle-Ottawa Scale (NOS). The combined OR value and 95% confidence interval (CI) were calculated by using STATA 11.0 software, and the source of any heterogeneity was determined by performing subgroup analysis and sensitivity analysis.

RESULTS

A total of 10 cohort studies involving 5,369,235 participants fulfilled the inclusion criteria. The meta-analysis showed an increased risk for MI in patients with PD [RR = 1.13, 95% CI (1.04, 1.21), P = 0.004], and this result was robust according to sensitivity analysis. Subgroup analyses indicated that the results were affected by sex, effect value, study quality, survey form and investigation type.

DISCUSSION

This meta-analysis suggests that PD is modestly associated with MI, especially in women, which is similar to the conclusions of earlier meta-analyses of case-control or observational studies. PD may be an untraditional risk factor for cardiovascular diseases, including MI; thus, maintaining periodontal health may be an effective measure to prevent MI. More cohort studies are still needed to further explore the relationship between the incidence of MI and PD.

Risk of incident cardiovascular disease in people with periodontal disease: A systematic review and meta-analysis

OBJECTIVES

Cardiovascular disease (CVD) is a major cause of mortality; periodontal disease (PD) affects up to 50% of the world's population. Observational evidence has demonstrated association between CVD and PD. Absent from the literature is a systematic review and meta-analysis of longitudinal cohort studies quantifying CVD risk in PD populations compared to non-PD populations. To examine the risk of incident CVD in people with PD in randomised controlled trials and longitudinal cohort studies.

MATERIAL AND METHODS

We searched Medline, EMBASE and Cochrane databases up to 9th Oct 2019 using keywords and MeSH headings using the following concepts: PD, CVD, longitudinal and RCT study design. CVD outcomes included but were not restricted to any CVD, myocardial infarction, coronary heart disease (CHD) and stroke. Diagnosis method and severity of PD were measured either clinically or by self-report. Studies comparing incident CVD in PD and non-PD populations were included. Meta-analysis and meta-regression was performed to determine risk of CVD in PD populations and examine the effects of PD diagnosis method, PD severity, gender and study region.

RESULTS

Thirty-two longitudinal cohort studies were included after full text screening; 30 were eligible for meta-analysis. The risk of CVD was significantly higher in PD compared to non-PD (relative risk [RR]: 1.20, 95% CI: 1.14-1.26). CVD risk did not differ between clinical or self-reported PD diagnosis (RR = 0.97, 95% CI: 0.87-1.07,). CVD risk was higher in men (RR: 1.16, 95% CI: 1.08-1.25) and severe PD (RR: 1.25, 95% CI: 1.15-1.35). Among all types of CVD, the risk of stroke was highest (RR = 1.24; 95% CI:1.12-1.38), the risk of CHD was also increased (RR = 1.14; 95% CI:1.08-1.21).

CONCLUSION

This study demonstrated modest but consistently increased risk of CVD in PD populations. Higher CVD risk in men and people with severe PD suggests population-targeted interventions could be beneficial.

Severe Periodontal Disease Increases Acute Myocardial Infarction and Stroke: A 10-Year Retrospective Follow-up Study

This study aimed to evaluate the causal association of periodontal disease with acute myocardial infarction (AMI) and stroke, after controlling for various confounders among the Korean population. A retrospective cohort study using the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) was performed during 2002 to 2015 (baseline: 2002 to 2005; follow-up: 2006 to 2015) in the Republic of Korea. A total of 298,128 participants with no history of AMI or stroke were followed up for 10 y. AMI and stroke were defined by a diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) guideline. Periodontal condition was classified into 3 groups (healthy, moderate periodontal disease, severe periodontal disease [SPD]) using the combination of ICD codes, treatment codes in the NHIS, and recommendation of periodontal treatment by the dentists in HEALS. Various confounders, such as sociodemographic, behavioral, systemic, and oral health factors, including hypercholesterolemia, were considered. Multivariable Cox regression analysis was applied to estimate adjusted incidence rate ratio (adjusted hazard ratio [aHR]) based on person-year of periodontal condition for AMI, stroke, and nonfatal major adverse cardiovascular events (MACEs) encompassing AMI or stroke controlling for various confounders. Stratified analyses according to age group, sex, and toothbrushing frequency were also performed. After controlling for various confounders, participants with SPD compared with non-SPD participants had a higher incidence by 11% for AMI (aHR, 1.11; 95% confidence interval [CI], 1.02-1.20), by 3.5% for stroke (aHR, 1.035; 95% CI, 1.01-1.07), and by 4.1% for MACEs (aHR, 1.04; 95% CI, 1.01-1.07). The association of SPD with AMI and MACE was highly modified in females and adults aged 40 to 59 y. In the total Korean population, SPD increased total AMI events by 4.3%, total stroke events by 1.4%, and the total MACEs by 1.6%. Our data confirmed that SPD was causally associated with the new events of AMI and stroke.

Association Between Periodontal Disease and Atherosclerotic Cardiovascular Diseases: Revisited

Atherosclerotic cardiovascular disease (ACVD) is an inflammatory disease of the coronary arteries associated with atheroma formation, which can cause disability and often death. Periodontitis is ranked as the sixth most prevalent disease affecting humans affecting 740 million people worldwide. In the last few decades, researchers have focused on the effect of periodontal disease (PD) on cardiovascular disease. The aim of this review was to investigate the association between these two diseases. PD is a potential risk factor that may initiate the development, maturation, and instability of atheroma in the arteries. Two mechanisms were proposed to explain such association, either periodontal pathogens directly invade bloodstream or indirectly by increasing systemic level of inflammatory mediators. Interestingly, it has been suggested that improvement in the condition of one disease positively impact the condition of the other one. Highlighting the association between these two diseases, the importance of early diagnosis and treatment of PD and its impact on cardiovascular status may be of great value in reducing the complications associated with ACVDs. Further in vitro and in vivo studies with longer follow up are necessary to confirm the causal relationship between PD and ACVDs.

Comparative analysis of oral microbiome from Zang and Han populations living at different altitudes

OBJECTIVES

The aim of this study was to obtain greater insight into the environmental and genetic factors affecting the oral microbiome.

DESIGN

To this end, we investigated the oral microbiome composition in Han and Zang populations living at different altitudes. The saliva microbiome in 115 individuals from Zang and Han populations living at different altitudes was analyzed using the 16 s rRNA gene sequencing method on the Illumina MiSeq platform. The dominant species in the oral microbiome were verified by quantitative real-time polymerase chain reaction (qPCR) analysis.

RESULTS

The Han population, living at an altitude of 500 m, had higher microbiome diversity than the Zang population living at altitudes of 3000-4000 m. People living at 3000 m had a higher relative abundance of Leptothrix genus, but people living at 500 m had a higher relative abundance of Capnocytophaga genus according to Lefse difference analysis (P < 0.05). Compared to the Zang population, the Han population had higher relative abundances of Porphyromonas and Treponema genus organisms, especially Porphyromonas (P < 0.001). qPCR analysis confirmed that people living at high altitudes had the highest relative abundance of Porphyromonas gingivalis (P < 0.01).

CONCLUSIONS

This study showed that both genetics and the environment had significant influences on the oral microbiome composition. The study proposed a meaningful research direction to explore the relationship between different ethnic and altitude groups and oral diseases, such as periodontal diseases.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis

AIM

To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis.

MATERIALS AND METHODS

NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%.

RESULTS

The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group.

CONCLUSIONS

Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

Association of Periodontitis with Atherosclerotic Cardiovascular Diseases: A Nationwide Population-based Retrospective Matched Cohort Study

We investigated the association between periodontitis and atherosclerotic cardiovascular disease (ACVD) development using the National Health Insurance Service-National Sample Cohort 2.0 (NHIS-NSC2) database, which contains data for approximately 1 million nationally representative random participants. We selected 52,425 participants aged 20+ years and diagnosed with periodontitis from January to December 2003 and used propensity score matching to select an equivalent number of participants who were never diagnosed with periodontitis in the period covered by the NHIS-NSC2 database (2002-2015). The propensity scores were based on sex, age group, type of national health insurance, household income, diabetes status, and hypertension status and were used for 1:1 matching of individuals with similar propensities. A total of 104,850 participants were selected for the study. A multivariable Cox proportional hazard regression model was used to investigate the risk of ACVD development due to periodontitis from 2003 to 2015 after adjusting for sex, age, type of national health insurance, household income, hypertension status, and diabetes status. Participants with periodontitis had a higher risk of ACVD (adjusted hazard ratio: 1.09, 95% confidence interval: 1.05-1.13) than those without periodontitis. Thus, periodontitis can increase the risk of ACVD, and prevention of periodontitis may help reduce the risk of cardiovascular disease.

Antimicrobial effect of nanostructured membranes for guided tissue regeneration: an in vitro study

OBJECTIVE

The purpose of this in vitro study was to evaluate the antibacterial effect of a novel non-resorbable, bioactive polymeric nanostructured membrane (NMs), when doped with zinc, calcium and doxycycline.

METHODS

A validated in vitro subgingival biofilm model with six bacterial species (Streptococcus oralis, Actinomyces naeslundii, Veillonela parvula, Fusobacterium nucleatum, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans) was used. The experimental NMs, with and without being doped with doxycycline, calcium and zinc, were placed on hydroxyapatite (HA) discs. As positive control membranes, commercially available dense polytetrafluoroethylene (d-PTFE) membranes were used and, as negative controls, the HA discs without any membrane. The experimental, positive and negative control discs were exposed to a mixed bacterial suspension, at 37 °C under anaerobic conditions, during 12, 24, 48 and 72 h. The resulting biofilms were analyzed through scanning electron microscopy (SEM), to study their structure, and by quantitative polymerase chain reaction (qPCR), to assess the bacterial load, expressed as colony forming units (CFU) per mL. Differences between experimental and control groups were evaluated with the general linear model and the Bonferroni adjustment.

RESULTS

As shown by SEM, all membrane groups, except the NMs with doxycycline, resulted in structured biofilms from 12-72 hours. Similarly, only the membranes loaded with doxycycline demonstrated a significant reduction in bacterial load during biofilm development, when compared with the control groups (p < 0.001).

SIGNIFICANCE

Doxycycline-doped nanostructured membranes have an impact on biofilm growth dynamics by significant reducing the bacterial load.

Autoantibodies against M5-muscarinic and beta1-adrenergic receptors in periodontitis patients

Autoantibodies against muscarinic and beta₁-adrenergic receptors are considered a potential cause and/or risk factor for chronic heart failure. Association of periodontitis with such autoantibodies and with impaired heart function has been observed in patients exposed to endemic Chagas' disease, which triggers by itself cardiomyopathy and receptor immunization.Here we studied the association between periodontitis, markers of cardiac injury and receptor autoimmunization in periodontitis patients (n = 147) not exposed to Chagas' disease. The autoantibodies were determined by IgG binding to native intact muscarinic and beta₁-adrenergic receptors or to a cyclic peptide mimicking the disease-relevant conformational autoepitope presented by the active beta₁-adrenergic receptor. Possible cardiac injury and inflammatory status were judged by serum levels of proBNP/Troponin I and CRP/IL-6, respectively. These parameters were analysed in healthy and periodontally diseased individuals as well as before and after periodontal therapy.Patients with periodontitis had significantly (p < 0.001) higher levels of autoantibodies against M₅-muscarinic and beta₁-adrenergic receptors, which further increased following periodontal therapy. Receptor autoantibodies were associated with increased inflammatory status but not with increased markers of cardiac injury. Thus, our data indicate that periodontitis triggers systemic inflammation, which is associated with receptor autoimmunization, and, independently thereof, with cardiac injury.

Periodontal diseases and association with atherosclerotic disease

Cardiovascular diseases still account for the majority of deaths worldwide, although significant improvements in survival, after being affected by cardiovascular disease, have been achieved in the last decades. Periodontal diseases are also a common global burden. Several studies have shown a link between cardiovascular disease and periodontitis, although evidence is still lacking regarding the direct cause-effect relation. During the 2012 "Periodontitis and systemic diseases" workshop, the available evidence on the association between cardiovascular and periodontal diseases was discussed, covering biologic plausibility and clinical studies. The objective of the present narrative review was to update the previous reviews presented at the 2012 workshop, following similar methodological approaches, aiming to critically assess the available evidence. With regard to biologic plausibility, two aspects were reviewed: (a) for microbiologic mechanisms, assessing periodontal bacteria as a contributing factor to atherosclerosis based on seven "proofs," substantial evidence was found for Proofs 1 through 6, but not for Proof 7 (periodontal bacteria obtained from human atheromas can cause atherosclerosis in animal models), concluding that periodontal pathogens can contribute to atherosclerosis; (b) mechanistic studies, addressing five different inflammatory pathways that could explain the links between periodontitis and cardiovascular disease with the addition of some extra pathways , suggest an association between both entities, based on the presence of higher levels of these inflammatory markers in patients with periodontitis and cardiovascular disease, vs healthy controls, as well as on the evidence that periodontal treatment reduces serum levels of these mediators. When evidence from clinical studies was analyzed, two aspects were covered: (a) epidemiologic studies support the estimation that the incidence of atherosclerotic disease is higher in individuals with periodontitis than in individuals with no reported periodontitis, irrespective of many common risk factors, but with a substantial variability in the definitions used in reporting of exposure to periodontal diseases in different studies; (b) intervention trials have shown that periodontal therapy can reduce serum inflammatory mediators, improve the lipids profile, and induce positive changes in other cardiovascular disease surrogate measures, but no evidence is available to support that adequate periodontal therapy is able to reduce the risk for cardiovascular diseases, or the incidence of cardiovascular disease events in periodontitis patients.

Influence of Chronic Periodontitis on the Long-Term Mortality and Cardiovascular Events in Kidney Transplant Recipients

Chronic periodontitis (CP) is associated with cardiovascular disease and mortality in different populations. The aim of this study was to examine an association of CP with hard endpoints in patients after kidney transplantation during a 15-year follow-up period. Study group consist of 117 patients (77M/40F, median age 44 years) divided into two subgroups: those with initially advanced CP (CPITN 3-4) and those with no or moderate CP (CPITN 0-2). All cardiovascular events, graft losses, and re-transplantations were recorded. All deaths were noted and verified, including those occurred after the return to dialysis therapy, the causes of death were identified. Cox regression with Firth's penalized maximum likelihood models were used for data analysis. During the observation period, 49 deaths occurred. Advanced CP (n = 35) was not associated with overall mortality but was associated with increased risk of death with functioning graft (DWFG) [HR 3.54 (1.20-10.45); p < 0.05]. Risk of graft loss was not associated with CP status. In conclusion, an advanced CP was independently associated with increased risk of DWFG, but not all-cause or cardiovascular mortality after renal transplantation.

Influence of periodontal disease on risk of dementia: a systematic literature review and a meta-analysis

Periodontal disease (PD) is common and increases cardiovascular diseases. However, it is unclear whether PD is associated with increased risk of dementia. We carried out a systematic review and meta-analysis to investigate the influence of PD on dementia. We projected the number of dementia cases to be saved by reducing PD prevalence in the world. We searched cohort and case-control studies reporting the association of PD with all dementia (or any specific type of dementia) through PubMed, MEDLINE, PsycINFO, SocINDEX, CINHAL, and CNKI until 7th November 2018. Five cohorts and seven case-control studies were identified for review. We pooled eligible data to calculate relative risk (RR) of dementia in relation to PD and computed the number of dementia cases saved through reducing PD prevalence. Of 12 studies, six were undertaken in Asia, four in Europe and two in America. Eleven studies showed a positive association between PD and the risk of dementia, of which 10 were significant, and one reported a non-significant inverse association. Overall their quality was good. Pooled RR of dementia in relation to PD from all high quality studies was 1.38 (95%CI 1.01-1.90); in the five cohorts was 1.18 (1.06-1.31) and in the two case-control studies 2.25 (1.48-3.42). A 50% reduction in the current prevalence of 20% of PD in the population could save 850,000 (630,000-1,420,000) patients with dementia in the world. PD could increase the risk of incident dementia. Preventing and treating PD could contribute to controlling the global epidemic of dementia.

Association between periodontitis and all-cause and cancer mortality: retrospective elderly community cohort study

BACKGROUND

Periodontal infection induces inflammation, which may increase the risk of tumor-promoting effects. The aim of this study was to assess the association between periodontitis and all-cause mortality, and all-cancer and specific cancers' mortality in a health examination cohort of the elderly in the communities.

METHODS

A dataset of health examinations for the elderly with cause of death from 2005 to 2012 was obtained from the Department of Health, Taipei City Government. We enrolled 82,548 study participants with 262,035 visits. A Cox proportional hazards model and Cox frailty model were used for calculating the hazard ratios under different periodontal status by using SAS and Rstudio.

RESULTS

Being male, elderly, having a low education level, and smoking were risk factors for mortality in this retrospective elderly community cohort study. Participants with periodontitis followed across time had significantly higher hazard ratios (HRs) for all-cause mortality and all-cancer mortality (HR = 1.092, 95% confidence interval (CI):1.038 to 1.149, HR = 1.114, 95% CI:1.032 to 1.203, respectively) in the Cox frailty models after adjusting for age, marital status, education level, sex, and smoking status. After adjusting for age and sex, the hazard ratio was 1.185 (95% CI: 1.027 to 1.368) for lung cancer mortality, and 1.340 (95% CI: 1.019 to 1.762) for prostate cancer mortality in the periodontitis group with each visit.

CONCLUSIONS

The findings indicated that being male, having a low education level, and daily smoking were risk factors for mortality, and showed mixed evidence that periodontal disease is associated with all-cause, all-cancer and specific-cancer mortality including lung and prostate cancer. We suggest the importance of regular health screening in order to achieve early disease detection and lower mortality risk.

Association between Periodontitis, Genetic Polymorphisms and Presence of Coronary Artery Disease in Southern Brazil

Background

Periodontitis and coronary artery disease (CAD) share an inflammatory etiology; there is a recent concern regarding the investigation of an association between these two conditions. Current theories indicate that cytokines and proteins have an important role in this process. C-reactive protein and interleukin-6 are inflammatory derivatives produced in the presence of periodontitis and in the pathophysiology of coronary disease. The polymorphisms of CRP + 1444 C > T and IL6-174 G > C are recognized in the literature as being related to CAD.

Objective

This study investigates the association between periodontitis and coronary artery disease, through the presence of PCR and IL-6 polymorphisms.

Methods

We selected 80 patients who underwent diagnostic catheterization in the HU of UFSM. The presence of periodontitis was determined by the Community Periodontal Index, whereas the CAD was established by the medical report. DNA was collected from a saliva sample and the presence of polymorphism was determined by PCR and restriction enzymes. A significance level of 5% was adopted.

Results

The mean age of all participants (p = 0.035, OR 2.65; 95%CI: (1.02-6.87) male gender (p = 0.012, OR 3.37; 95% CI: (1.28- (p = 0.013, OR 3.66; 95% CI: (1.27-10.5)), PCR polymorphism + 1444C > T (p = 0.001, OR 6.37; 95% CI:, (2.25-17.9)) and IL6 -174 G > C polymorphism (p = 0.025, OR 2.87, 95% CI: (1.09-7.55)) were statistically associated with the presence of CAD. Age > 60 years and presence of the PCR +1444 C > T polymorphism remained independently associated with CAD after adjustment by logistic regression.

Conclusions

The presence of the PCR + 1444 C > T polymorphism in this study was independently associated with the presence of coronary artery disease.

Number of functional teeth more strongly predicts all-cause mortality than number of present teeth in Japanese older adults

Aim

Previous studies on the association between intraoral conditions and mortality in community‐dwelling older individuals reported that fewer present teeth (PT) are significant risk factors for mortality. However, how the number of PT relative to the number of functional teeth (FT), including both present and rehabilitated teeth, influences mortality has not been investigated fully. This study examined the impact of the number of FT on mortality among community‐dwelling Japanese older adults.

Methods

This study was a retrospective, observational and population‐based follow‐up study, which examined 1188 older individuals who participated in an annual geriatric health examination from 2009 to 2015. The average follow‐up period was 1697.0 ± 774.5 days. The primary outcome was all‐cause mortality at follow‐up. The numbers of PT and FT of each participant were counted during an oral examination. In addition, demographics, clinical variables, blood nutrient markers, physical functions and perceived masticatory function were measured.

Results

Kaplan–Meier analysis, followed by a log‐rank test, revealed that fewer PT (P < 0.001) and FT (P = 0.002) were significantly associated with a reduced survival rate. Cox's proportional hazard analysis indicated that the number of FT, but not the number of PT, was a significant independent mortality risk factor after adjusting for demographics, clinical variables, nutrient markers and physical functioning (P = 0.036, hazard ratio: 2.089).

Conclusions

Current results suggest that the number of FT more strongly predicts all‐cause mortality than the number of PT among community‐dwelling older adults. Further studies are necessary to consider the confounding of socioeconomic status and disability status. Geriatr Gerontol Int 2020; ••: ••–••.

Low levels of antibodies for the oral bacterium Tannerella forsythia predict cardiovascular disease mortality in men with myocardial infarction: A prospective cohort study

Antibody levels to periodontal pathogens in prediction of cardiovascular disease (CVD) mortality were explored using data from a health survey in Oslo in 2000 (Oslo II-study) with 12 1/2 years follow-up. IgG antibodies to four common periodontal pathogens; Tannerella forsythia (TF), Porphyromonas gingivalis (PG), and Treponema denticola (TD) all termed collectively the "red complex", and Aggregatibacter actinomycetemcomitans(AA) were analysed. The study sample consisted of 1172 men drawn from a cohort of 6,530 men who participated in the Oslo II-study, where they provided information on medical and dental history. Of the study sample, 548 men had reported prior myocardial infarction (MI) at baseline whereas the remaining 624 men were randomly drawn from the ostensibly healthy participants for comparative analyses. Dental anamnestic information included tooth extractions and oral infections. An inverse relation was found for trend by the quartile risk level of TF predicting CVD mortality, p-value for trend = 0.017. Comparison of the first to fourth quartile of TF antibodies resulted in hazard ratio (HR) = 1.82, 95% confidence interval 1.12-2.94, p = 0.015, adjusted for age, education, diabetes, daily smoking, and systolic blood pressure. Specificity comparing decile 1 to deciles 2-10 of TF predicting mortality was 92.3%. We found an increased HR by low levels of antibodies to the bacterium T. forsythia predicting CVD mortality in a 12 ½ years follow-up in persons who had experienced an MI but not among non-MI men. This novel finding constitutes a plausible causal link between oral infections and CVD mortality.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the second update of a review originally published in 2014, and first updated in 2017. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, two trials registries, and the grey literature to September 2019. We placed no restrictions on the language or date of publication. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to August 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.