The association of tooth scaling and decreased cardiovascular disease: a nationwide population-based study

Periodontitis and Outer Retinal Thickness: a Cross-Sectional Analysis of the United Kingdom Biobank Cohort

Purpose

Periodontitis, a ubiquitous severe gum disease affecting the teeth and surrounding alveolar bone, can heighten systemic inflammation. We investigated the association between very severe periodontitis and early biomarkers of age-related macular degeneration (AMD), in individuals with no eye disease.

Design

Cross-sectional analysis of the prospective community-based cohort United Kingdom (UK) Biobank.

Participants

Sixty-seven thousand three hundred eleven UK residents aged 40 to 70 years recruited between 2006 and 2010 underwent retinal imaging.

Methods

Macular-centered OCT images acquired at the baseline visit were segmented for retinal sublayer thicknesses. Very severe periodontitis was ascertained through a touchscreen questionnaire. Linear mixed effects regression modeled the association between very severe periodontitis and retinal sublayer thicknesses, adjusting for age, sex, ethnicity, socioeconomic status, alcohol consumption, smoking status, diabetes mellitus, hypertension, refractive error, and previous cataract surgery.

Main Outcome Measures

Photoreceptor layer (PRL) and retinal pigment epithelium-Bruch's membrane (RPE-BM) thicknesses.

Results

Among 36 897 participants included in the analysis, 1571 (4.3%) reported very severe periodontitis. Affected individuals were older, lived in areas of greater socioeconomic deprivation, and were more likely to be hypertensive, diabetic, and current smokers (all P < 0.001). On average, those with very severe periodontitis were hyperopic (0.05 ± 2.27 diopters) while those unaffected were myopic (-0.29 ± 2.40 diopters, P < 0.001). Following adjusted analysis, very severe periodontitis was associated with thinner PRL (-0.55 μm, 95% confidence interval [CI], -0.97 to -0.12; P = 0.022) but there was no difference in RPE-BM thickness (0.00 μm, 95% CI, -0.12 to 0.13; P = 0.97). The association between PRL thickness and very severe periodontitis was modified by age (P < 0.001). Stratifying individuals by age, thinner PRL was seen among those aged 60 to 69 years with disease (-1.19 μm, 95% CI, -1.85 to -0.53; P < 0.001) but not among those aged < 60 years.

Conclusions

Among those with no known eye disease, very severe periodontitis is statistically associated with a thinner PRL, consistent with incipient AMD. Optimizing oral hygiene may hold additional relevance for people at risk of degenerative retinal disease.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The association between periodontitis and cerebrovascular disease, and dementia. Scientific report of the working group of the Spanish Society of Periodontology and the Spanish Society of Neurology

OBJECTIVE

This article reviews the scientific evidence on the relationship between periodontitis and neurological disease, and particularly cerebrovascular disease and dementia. We also issue a series of recommendations regarding the prevention and management of periodontitis and these neurological diseases at dental clinics and neurology units.

DEVELOPMENT

In response to a series of questions proposed by the SEPA-SEN working group, a literature search was performed, with no restrictions on study design, to identify the most relevant articles on the association between periodontitis and cerebrovascular disease and dementia from the perspectives of epidemiology, treatment, and the biological mechanisms involved in these associations.

CONCLUSIONS

Periodontitis increases the risk of ischaemic stroke and Alzheimer dementia. Recurrent bacterial infections and increased low-grade systemic inflammation seem to be possible biological mechanisms underlying this association. Limited evidence suggests that various oral health interventions can reduce the future risk of cerebrovascular disease and dementia.

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.

Dental scaling and lower risk of spontaneous intracranial hemorrhage

Background

-Spontaneous intracranial hemorrhage (ICH) has high fatality while has few proven treatments. We aim at investigating the association between dental scaling (DS) and the risk of ICH.

Methods

-In this cohort study, two cohorts were matched by propensity score based on potential confounders. Data from ICH between January 2008 and December 2014 in Taiwan were analyzed. The subjects underwent DS at least 6 times between January 1, 2002, and December 31, 2007, while the matched controls did not undergo any DS during the same period. Cumulative incidences and hazard ratios (HRs) were calculated after adjusting for competing confounders.

Results

-Each cohort consisted of 681,126 subjects. Compared with the non-DS cohort, the regular-DS cohort had a significantly lower incidence of ICH (0.8% vs 1.2%; P < 0.0001), and the adjusted hazards ratio (aHR) of 7-year ICH was 0.61 (95% confidence interval, CI, 0.59-0.63; P < 0.0001). The 30-39-year age group of the regular-DS cohort had the lowest HR (0.57; 95% CI, 0.52-0.61; P < 0.0001) of 7-year ICH when compared with similar controls. Compared with the controls, the regular-DS cohort also had significantly lower HR (0.82; 95% CI, 0.81-0.82; P < 0.0001) of 7-year hypertension. Compared with those without DS, the lowest risk of intracerebral hemorrhage was observed in the male participants with regular DS (0.43; 95% CI, 0.40-0.47; P < 0.0001).

Conclusions

-Regular DS was consistently associated with lower ICH risk in subjects aged 30-59 years, which may benefit from the decreased HBP risk. DS had a potential role in the prophylaxis for ICH, a condition with a high disability or mortality.

The effects of regular dental scaling on the complications and mortality after stroke: a retrospective cohort study based on a real-world database

BACKGROUND

Previous observational studies have shown that people with dental scaling (DS) had decreased risk of stroke. However, limited information is available on the association between DS and poststroke outcomes. The present study aimed to evaluate the effects of regular DS on the complications and mortality after stroke.

METHODS

We conducted a retrospective cohort study of 49,547 hospitalized stroke patients who received regular DS using 2010-2017 claims data of Taiwan's National Health Insurance. Using a propensity-score matching procedure, we selected 49,547 women without DS for comparison. Multiple logistic regressions were used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of poststroke complications and in-hospital mortality associated with regular DS.

RESULTS

Stroke patients with regular DS had significantly lower risks of poststroke pneumonia (OR 0.58, 95% CI 0.54-0.63), septicemia (OR 0.58, 95% CI 0.54-0.63), urinary tract infection (OR 0.68, 95% CI 0.66-0.71), intensive care (OR 0.81, 95% CI 0.78-0.84), and in-hospital mortality (OR 0.66, 95% CI 0.62-0.71) compared with non-DS stroke patients. Stroke patients with regular DS also had shorter hospital stays (p < 0.0001) and less medical expenditures (p < 0.0001) during stroke admission than the control group. Lower rates of poststroke adverse events in patients with regular DS were noted in both sexes, all age groups, and people with various types of stroke.

CONCLUSION

Stroke patients with regular DS showed fewer complications and lower mortality compared with patients had no DS. These findings suggest the urgent need to promote regular DS for this susceptible population of stroke patients.

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.

Periodontopathic Microbiota and Atherosclerosis: Roles of TLR-Mediated Inflammation Response

Atherosclerosis is a chronic inflammatory disease with a high prevalence worldwide, contributing to a series of adverse cardiovascular and cerebrovascular diseases. Periodontal disease induced by pathogenic periodontal microbiota has been well established as an independent factor of atherosclerosis. Periodontal microorganisms have been detected in atherosclerotic plaques. The high-risk microbiota dwelling in the subgingival pocket can stimulate local and systematic host immune responses and inflammatory cascade reactions through various signaling pathways, resulting in the development and progression of atherosclerosis. One often-discussed pathway is the Toll-like receptor-nuclear factor-κB (TLR-NF-κB) signaling pathway that plays a central role in the transduction of inflammatory mediators and the release of proinflammatory cytokines. This narrative review is aimed at summarizing and updating the latest literature on the association between periodontopathic microbiota and atherosclerosis and providing possible therapeutic ideas for clinicians regarding atherosclerosis prevention and treatment.

Effect of Dental Screening on Cardiovascular Risk: A Nationwide Cohort Study

AIM

To evaluate the effect of dental screening on the risk of cardiovascular disease (CVD) using data from a nationwide population-based cohort.

MATERIALS AND METHODS

This retrospective cohort study extracted data of 478,245 individuals aged 40-79 years who participated in a health screening programme in 2002-2003 from the National Health Insurance Service-National Health Screening Cohort. Based on screening experience, participants were classified into the non-screening, general screening only, and dental screening groups. Using Cox proportional hazard models, hazard ratios (HRs) were determined for major adverse cardiovascular events (MACE) during each group's 11-year follow-up period.

RESULTS

The risk of MACE in the dental screening group was 10% lower than that in the non-screening group (adjusted HR, 0.90; 95% confidence interval [CI], 0.87-0.93; P<0.001) and 9% lower than that in the general screening only group (adjusted HR, 0.91; 95% CI, 0.89-0.94; P<0.001).

CONCLUSIONS

Dental screening was associated with a lower MACE risk; however, decreases in CVD-related healthcare utilisation and costs were not clinically significant. The association could be attributed to healthy habits of participants in the dental screening group; nevertheless, it is conceivable that the improvement of oral health through dental screening influenced CVD prevention.

Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review

Background

Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. However, it is unclear how observational studies most commonly define MACE in the literature when using administrative data.

Methods

We identified peer-reviewed articles published in MEDLINE and EMBASE between January 1, 2010 to October 9, 2020. Studies utilizing administrative data to assess the MACE composite outcome using International Classification of Diseases 9th or 10th Revision diagnosis codes were included. Reviews, abstracts, and studies not providing outcome code definitions were excluded. Data extracted included data source, timeframe, MACE components, code definitions, code positions, and outcome validation.

Results

A total of 920 articles were screened, 412 were retained for full-text review, and 58 were included. Only 8.6% (n = 5/58) matched the traditional three-point MACE RCT definition of acute myocardial infarction (AMI), stroke, or cardiovascular death. None matched four-point (+unstable angina) or five-point MACE (+unstable angina and heart failure). The most common MACE components were: AMI and stroke, 15.5% (n = 9/58); AMI, stroke, and all-cause death, 13.8% (n = 8/58); and AMI, stroke and cardiovascular death 8.6% (n = 5/58). Further, 67% (n = 39/58) did not validate outcomes or cite validation studies. Additionally, 70.7% (n = 41/58) did not report code positions of endpoints, 20.7% (n = 12/58) used the primary position, and 8.6% (n = 5/58) used any position.

Conclusions

Components of MACE endpoints and diagnostic codes used varied widely across observational studies. Variability in the MACE definitions used and information reported across observational studies prohibit the comparison, replication, and aggregation of findings. Studies should transparently report the administrative codes used and code positions, as well as utilize validated outcome definitions when possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01440-5.

Association of Tooth Scaling with Acute Myocardial Infarction and Analysis of the Corresponding Medical Expenditure: A Nationwide Population-Based Study

Accumulating evidence has shown a significant correlation between periodontal diseases and systemic diseases. In this study, we investigated the association between the frequency of tooth scaling and acute myocardial infarction (AMI). Here, a group of 7164 participants who underwent tooth scaling was compared with another group of 7164 participants without tooth scaling through propensity score matching to assess AMI risk by Cox’s proportional hazard regression. The results show that the hazard ratio of AMI from the tooth scaling group was 0.543 (0.441, 0.670) and the average expenses of AMI in the follow up period was USD 265.76, while the average expenses of AMI in follow up period for control group was USD 292.47. The tooth scaling group was further divided into two subgroups, namely A and B, to check the influence of tooth scaling frequency on AMI risk. We observed that (1) the incidence rate of AMI in the group without any tooth scaling was 3.5%, which is significantly higher than the incidence of 1.9% in the group with tooth scaling; (2) the tooth scaling group had lower total medical expenditures than those of the other group because of the high medical expenditure associated with AMI; and (3) participants who underwent tooth scaling had a lower AMI risk than those who never underwent tooth scaling had. Therefore, the results of this study demonstrate the importance of preventive medicine.

Oral Health and Cardiovascular Disease: Mapping Clinical Heterogeneity and Methodological Gaps

BACKGROUND

Numerous studies have examined the associations between poor oral health and the incidence of cardiovascular disease (CVD) over the past 25 y. This long history of research has resulted in a broad and heterogenous epidemiological field whose implications are difficult to understand and whose methodological gaps are hard to track.

OBJECTIVES

This systematic mapping review aims to systematically map clinical heterogeneity and methodological gaps in assessing the relationship between poor oral health and CVD outcomes.

METHODS

Medline, Embase, and Cochrane Library were searched to identify longitudinal studies that examined the relationship between any oral health indicator and CVD outcomes. Each database was searched from its inception date and June 27, 2018. Extracted data assess the clinical heterogeneity (participants' characteristics, exposure and outcome measures, length of follow-up) and methodological gaps (availability of randomized controlled trials, utilization of time-varying exposures, propensity methods, mediation analysis, and competing risks analysis).

RESULTS

Eighty-five studies met the inclusion criteria. Clinical heterogeneity is evident in participants' characteristics (age, clinical status, and occupation) and in the definitions of oral health indicators and CVD outcomes. More important, a significant proportion of studies reported unclear definitions for CVD outcomes. The search strategy did not reveal any randomized controlled trials. Time-varying exposures, propensity methods, mediation analysis, and competing risks analysis are used infrequently in the identified studies.

CONCLUSION

There is a need for a universally accepted conceptual framework on the association between oral health and CVD to derive more consistent definitions for oral health and CVD outcomes that are aligned with the investigated research questions. There is also a need to use emerging research methods to maximize the impact of research in this area.

KNOWLEDGE TRANSFER STATEMENT

Clinical heterogeneity is evident in the definitions of oral health indicators and cardiovascular disease outcomes. Propensity methods, mediation analysis, and competing risks analysis are used infrequently in the identified studies. The identified clinical heterogeneity and methodological gaps interfere with summarizing existing evidence and understanding their practical implications. Advancing the current understanding of the associations between oral health and cardiovascular disease goes hand in hand with minimizing clinical heterogeneity and closing the identified methodological gaps.

Serum IgG titers to periodontal pathogens predict 3-month outcome in ischemic stroke patients

Several cohort studies have shown that periodontal disease is associated with an increased risk for stroke. However, it remains unclear whether serum antibody titers for a specific periodontal pathogen are associated with outcome after ischemic stroke, and which kinds of pathogens are associated with ischemic stroke. We examined the relationship between serum IgG titers to periodontal pathogens and outcome in ischemic stroke patients. A total of 445 patients with acute ischemic stroke (194 female [44.0%], mean age 71.9±12.3 years) were registered in this study. Serum IgG titers to 9 periodontal pathogens (Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Prevotella nigrescens, Fusobacterium nucleatum, Treponema denticola, Tannerella forsythensis, Campylobacter rectus, Eikenella corrodens) were evaluated using the enzyme-linked immunosorbent assay (ELISA) method. An unfavorable outcome was defined as a 3 or higher on the modified Rankin Scale. The proportion of patients with unfavorable outcome was 25.4% (113 patients). Based on multivariate logistic regression analysis, numbers of IgG antibodies positive for periodontal pathogens (odds ratio 1.20, 95% CI 1.02-1.41, p = 0.03) were independent predictors of unfavorable outcome in ischemic stroke patients.

Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea

AIMS

Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associations with cardiovascular disease. This study aimed to evaluate whether oral hygiene behaviour can alleviate cardiovascular risk associated with oral health status using a nationwide population-based cohort.

METHODS AND RESULTS

The data of 247 696 healthy adults aged 40 years or older who underwent an oral health screening programme and had no history of major cardiovascular events were extracted from the National Health Insurance System-National Health Screening Cohort. After a median follow-up of 9.5 years, 14 893 major cardiovascular events occurred including cardiac death, myocardial infarction, stroke, and heart failure. The risk of cardiovascular events was higher when a subject had periodontal disease, a higher number of dental caries, or more tooth loss. Performing one more tooth brushing a day was associated with a 9% significantly lower risk of cardiovascular events after multivariable adjustment. Regular dental visits (once a year or more) for professional cleaning were also shown to reduce cardiovascular risk by 14%. Improved oral hygiene behaviours were shown to attenuate the cardiovascular risk originating from periodontal disease, dental caries, and tooth loss.

CONCLUSION

Oral hygiene care such as frequent tooth brushing and regular dental visits for professional cleaning reduced the risk of future cardiovascular events in healthy adults. This study also suggests that improved oral hygiene behaviour may modify the association between oral health and cardiovascular diseases.

Improved oral hygiene care is associated with decreased risk of occurrence for atrial fibrillation and heart failure: A nationwide population-based cohort study

AIMS

Poor oral hygiene can provoke transient bacteremia and systemic inflammation, a mediator of atrial fibrillation and heart failure. This study aims to investigate association of oral hygiene indicators with atrial fibrillation and heart failure risk in Korea.

METHODS

We included 161,286 subjects from the National Health Insurance System-Health Screening Cohort who had no missing data for demographics, past history, or laboratory findings. They had no history of atrial fibrillation, heart failure, or cardiac valvular diseases. For oral hygiene indicators, presence of periodontal disease, number of tooth brushings, any reasons of dental visit, professional dental cleaning, and number of missing teeth were investigated.

RESULTS

During median follow-up of 10.5 years, 4911 (3.0%) cases of atrial fibrillation and 7971 (4.9%) cases of heart failure occurred. In multivariate analysis after adjusting age, sex, socioeconomic status, regular exercise, alcohol consumption, body mass index, hypertension, diabetes, dyslipidemia, current smoking, renal disease, history of cancer, systolic blood pressure, blood and urine laboratory findings, frequent tooth brushing (≥3 times/day) was significantly associated with attenuated risk of atrial fibrillation (hazard ratio: 0.90, 95% confidence interval (0.83-0.98)) and heart failure (0.88, (0.82-0.94)). Professional dental cleaning was negatively (0.93, (0.88-0.99)), while number of missing teeth ≥22 was positively (1.32, (1.11-1.56)) associated with risk of heart failure.

CONCLUSION

Improved oral hygiene care was associated with decreased risk of atrial fibrillation and heart failure. Healthier oral hygiene by frequent tooth brushing and professional dental cleaning may reduce risk of atrial fibrillation and heart failure.

Methodological approaches for investigating links between dental and chronic diseases with claims data: A scoping study

OBJECTIVES

The purpose of this study was to provide an overview of methodological approaches to assess the relationship between dental diseases and other noncommunicable diseases on the basis of claims data.

METHODS

Based on the methodological framework of Arksey and O'Malley, a scoping study was conducted. By searching electronic databases (PubMed, Web of Science, and LILACS), appropriate articles were identified. After extracting relevant information and entering it into a data-charting form, the study characteristics and the methodological approaches were summarized descriptively.

RESULTS

Fifty-one articles were identified for inclusion in the analysis. Most of the selected studies (78 percent) originated from Taiwan and employed a cohort design. The majority of studies considered dental diseases, particularly periodontal disease (PD) measures, but no common standard was identified for the definition of PD. Unmeasured confounding, misclassification, and surveillance bias were reported to be the main limitations of the claims data analyses.

CONCLUSIONS

Claims data provide a very useful information source to further delineate the relationship between PDs and other noncommunicable diseases. If diagnostic codes are available, they seem to be the most suitable tool to assess PD in claims-based studies. In databases that do not contain dental diagnostic codes, e.g., databases in Germany and the United States, the identification of PD is a particular challenge. The inclusion of dental diagnostic codes in all claims databases is strongly recommended. Due to the public health relevance of PD, there is a need for more comprehensive documentation of dental parameters within claims data.

Periodontal Disease: A Risk Factor for Diabetes and Cardiovascular Disease

Periodontitis is a chronic inflammatory disease, initiated by the presence of a bacterial biofilm, called dental plaque, which affects both the periodontal ligaments and bone surrounding teeth. In the last decades, several lines of evidence have supported the existence of a relationship between periodontitis and systemic health. For instance, as periodontitis acts within the same chronic inflammatory model seen in cardiovascular disease (CVD), or other disorders, such as diabetes, several studies have suggested the existence of a bi-directional link between periodontal health and these pathologies. For instance, people with diabetes are more susceptible to infections and are more likely to suffer from periodontitis than people without this syndrome. Analogously, it is now evident that cardiac disorders are worsened by periodontitis, both experimentally and in humans. For all these reasons, it is very plausible that preventing periodontitis has an impact on the onset or progression of CVD and diabetes. On these grounds, in this review, we have provided an updated account on the current knowledge concerning periodontal disease and the adverse effects exerted on the cardiovascular system health and diabetes, informing readers on the most recent preclinical studies and epidemiological evidence.

Geographical variations and influential factors in prevalence of cardiometabolic diseases in South Korea

Geographical variations and influential factors of disease prevalence are crucial information enabling optimal allocation of limited medical resources and prioritization of appropriate treatments for each regional unit. The purpose of this study was to explore the geographical variations and influential factors of cardiometabolic disease prevalence with respect to 230 administrative districts in South Korea. Global Moran’s I was calculated to determine whether the standardized prevalences of cardiometabolic diseases (hypertension, stroke, and diabetes mellitus) were spatially clustered. The CART algorithm was then applied to generate decision tree models that could extract the diseases’ regional influential factors from among 101 demographic, economic, and public health data variables. Finally, the accuracies of the resulting model–hypertension (67.4%), stroke (62.2%), and diabetes mellitus (56.5%)–were assessed by ten-fold cross-validation. Marriage rate was the main determinant of geographic variation in hypertension and stroke prevalence, which has the possibility that married life could have positive effects in lowering disease risks. Additionally, stress-related variables were extracted as factors positively associated with hypertension and stroke. In the opposite way, the wealth status of a region was found to have an influence on the prevalences of stroke and diabetes mellitus. This study suggested a framework for provision of novel insights into the regional characteristics of diseases and the corresponding influential factors. The results of the study are anticipated to provide valuable information for public health practitioners’ cost-effective disease management and to facilitate primary intervention and mitigation efforts in response to regional disease outbreaks.

Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke

BACKGROUND AND PURPOSE

Periodontal disease is independently associated with cardiovascular disease. Identification of periodontal disease as a risk factor for incident ischemic stroke raises the possibility that regular dental care utilization may reduce the stroke risk.

METHODS

In the ARIC (Atherosclerosis Risk in Communities) study, pattern of dental visits were classified as regular or episodic dental care users. In the ancillary dental ARIC study, selected subjects from ARIC underwent fullmouth periodontal measurements collected at 6 sites per tooth and classified into 7 periodontal profile classes (PPCs).

RESULTS

In the ARIC study 10 362 stroke-free participants, 584 participants had incident ischemic strokes over a 15-year period. In the dental ARIC study, 6736 dentate subjects were assessed for periodontal disease status using PPC with a total of 299 incident ischemic strokes over the 15-year period. The 7 levels of PPC showed a trend toward an increased stroke risk (χ² trend P<0.0001); the incidence rate for ischemic stroke/1000-person years was 1.29 for PPC-A (health), 2.82 for PPC-B, 4.80 for PPC-C, 3.81 for PPC-D, 3.50 for PPC-E, 4.78 for PPC-F, and 5.03 for PPC-G (severe periodontal disease). Periodontal disease was significantly associated with cardioembolic (hazard ratio, 2.6; 95% confidence interval, 1.2-5.6) and thrombotic (hazard ratio, 2.2; 95% confidence interval, 1.3-3.8) stroke subtypes. Regular dental care utilization was associated with lower adjusted stroke risk (hazard ratio, 0.77; 95% confidence interval, 0.63-0.94).

CONCLUSIONS

We confirm an independent association between periodontal disease and incident stroke risk, particularly cardioembolic and thrombotic stroke subtype. Further, we report that regular dental care utilization may lower this risk for stroke.

Comorbidity of periodontal disease: two sides of the same coin? An introduction for the clinician

Increasing evidence has suggested an independent association between periodontitis and a range of comorbidities, for example cardiovascular disease, type 2 diabetes, rheumatoid arthritis, osteoporosis, Parkinson’s disease, Alzheimer’s disease, psoriasis, and respiratory infections. Shared inflammatory pathways are likely to contribute to this association, but distinct causal mechanisms remain to be defined. Some of these comorbid conditions may improve by periodontal treatment, and a bidirectional relationship may exist, where, for example, treatment of diabetes can improve periodontal status. The present article presents an overview of the evidence linking periodontitis with selected systemic diseases and calls for increased cooperation between dentists and medical doctors to provide optimal screening, treatment, and prevention of both periodontitis and its comorbidities.

Periodontal Treatment and the Risks of Cardiovascular Disease in Patients with Type 2 Diabetes: A Retrospective Cohort Study

Objective Periodontal disease may predispose individuals to cardiovascular disease (CVD). Diabetes mellitus, especially in patients with severe periodontitis, increases the risk of CVD mortality. However, the outcomes of periodontal therapy vary among the different treatment modalities. We aim to investigate whether periodontal treatment could influence the occurrence of CVD in patients with type 2 diabetes and periodontal problems. Methods A retrospective cohort study was conducted based on a dataset released by Taiwan National Health Insurance (NHI). The dataset was composed of randomly sampled, newly diagnosed diabetic patients who received insurance benefits from 1999 to 2001; patients who were younger than 18 years of age or who already had CVD before 1999 were excluded. The NHI code was used to identify the treatments, including subgingival curettage and flap operations. The patients' demographic variables were matched using a 1:4 propensity score. All of the subjects were followed up until the onset of CVD, or December 31, 2011. A Cox proportional hazards regression analysis was performed to evaluate the effects of periodontal treatment on the rates of myocardial infarction, heart failure and stroke. Results Three thousand thirty-nine and 12,156 diabetic subjects were classified into the advanced periodontal treatment group and the non-advanced periodontal treatment group, respectively. The Cox proportional hazards analysis revealed that although the overall incidence of CVD was not significantly improved (Hazard ratio, HR 0.95; 95% CI 0.90-1.01), advanced periodontal treatment reduced the rates of myocardial infarction (HR 0.92; 95% CI 0.85-0.99) and heart failure (HR 0.60; 95% CI 0.45-0.80). There was no significance difference in the incidence of stroke (HR 0.95; 95% CI 0.85-1.06). Conclusion Advanced periodontal therapy lowers the rate of CVD, especially myocardial infarction and heart failure. Dental management has a beneficial effect on the health of patients with type 2 diabetes.

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

Periodontitis and atherosclerosis are highly prevalent chronic inflammatory diseases, and it has been suggested that periodontitis is an independent risk factor of cardiovascular disease (CVD) and that a causal link may exist between the 2 diseases. Using Danish national registers, we identified a nationwide cohort of 17,691 patients who received a hospital diagnosis of periodontitis within a 15-year period and matched them with 83,003 controls from the general population. We performed Poisson regression analysis to determine crude and adjusted incidence rate ratios of myocardial infarction, ischemic stroke, cardiovascular death, major adverse cardiovascular events, and all-cause mortality. The results showed that patients with periodontitis were at higher risk of all examined end points. The findings remained significant after adjustment for increased baseline co-morbidity in periodontitis patients compared with controls, for example, with adjusted incidence rate ratio 2.02 (95% CI 1.87 to 2.18) for cardiovascular death and 2.70 (95% CI 2.60 to 2.81) for all-cause mortality. Patients with a hospital diagnosis of periodontitis have a high burden of co-morbidity and an increased risk of CVD and all-cause mortality. In conclusion, our results support that periodontitis may be an independent risk factor for CVD.

The Association Between Insomnia and Increased Future Cardiovascular Events: A Nationwide Population-Based Study

OBJECTIVES

Insomnia may increase the risk of cardiovascular disease (CVD), but the reported magnitude of the associations between sleep characteristics and CVD is inconsistent. We investigated the association between insomnia and the risk of developing acute myocardial infarction (AMI) and/or stroke by using a nationwide, population-based cohort database in Taiwan.

METHODS

The analyses were conducted using information from a random sample of 1 million people enrolled in the nationally representative Taiwan National Health Insurance Research Database. A total of 44,080 individuals who were 20 years or older, including 22,040 people who had diagnosis of insomnia during the study period and an age-, sex-, comorbidity-matched group of 22,040 people without insomnia, were enrolled in our study. The study end points were the occurrence of cardiovascular events including AMI or stroke during follow-up.

RESULTS

During a 10-year follow-up, 302 AMI events and 1049 stroke events were identified. The insomnia group had a higher incidence of AMI (2.25 versus 1.08 per 1000 person-years) and stroke (8.01 versus 3.69 per 1000 person-years, p < .001). Cox proportional hazard regression model analysis showed that insomnia was independently associated with a higher risk of future AMI (hazard ratio [HR] = 1.68, 95% confidence interval [CI] = 1.31-2.16, p < .001), stroke (HR = 1.85, 95% CI = 1.62-2.12, p < .001), and the composite event index (HR = 1.81, 95% CI = 1.61-2.05, p < .001), after adjusting for age, sex, and comorbidities.

CONCLUSIONS

Insomnia is associated with an increased risk of future cardiovascular events.

Association between periodontal disease and osteoporosis by gender: a nationwide population-based cohort study

Periodontitis and osteoporosis are primary concerns in public health and clinical management. The aim of this study was to investigate the association between periodontitis and osteoporosis by gender.Data were retrieved from the National Health Insurance Research Database, Taiwan. A diagnosis of periodontitis was defined on the basis of subgingival curettage, periodontal flap operation, and gingivectomy (excluding those with restorative or aesthetic indications). Multiple logistic regression was used for analysis. After adjusting for age, sex, income, and geographical region, there was a significant association between periodontitis and osteoporosis among women (odds ratio: 1.96; 95% confidence interval 1.17-3.26). The association between periodontitis and osteoporosis was significant among women.

Dental prophylaxis decreases the risk of acute myocardial infarction: a nationwide population-based study in Taiwan

Purpose

To investigate the association between periodontal disease (PD) and acute myocardial infarction (AMI), and evaluate the effect of dental prophylaxis on the incidence rate (IR) of AMI.

Methods

The Longitudinal Health Insurance Database 2000 from the National Health Insurance program was used to identify 511,630 patients with PD and 208,713 without PD during 2000–2010. Subjects with PD were grouped according to treatment (dental prophylaxis, intensive treatment, and PD without treatment). The IRs of AMI during the 10-year follow-up period were compared among groups. Cox regression analysis adjusted for age, sex, socioeconomic status, residential urbanicity, and comorbidities was used to evaluate the effect of PD treatment on the incidence of AMI.

Results

The IR of AMI among subjects without PD was 0.19%/year. Among those with PD, the IR of AMI was lowest in the dental prophylaxis group (0.11%/year), followed by the intensive treatment (0.28%/year) and PD without treatment (0.31%/year; P<0.001) groups. Cox regression showed that the hazard ratio (HR) for AMI was significantly lower in the dental prophylaxis group (HR =0.90, 95% confidence interval =0.86–0.95) and higher in the intensive treatment (HR =1.09, 95% confidence interval =1.03–1.15) and PD without treatment (HR =1.23, 95% confidence interval =1.13–1.35) groups than in subjects without PD.

Conclusion

PD is associated with a higher risk of AMI, which can be reduced by dental prophylaxis to maintain periodontal health.

Acute myocardial infarction in patients with atrial fibrillation with a CHA2DS2-VASc score of 0 or 1: a nationwide cohort study

BACKGROUND

The risk of acute myocardial infarction (AMI) in patients with atrial fibrillation (AF) with a CHA2DS2-VASc score of 0 (for men) or 1 (for women) has not been previously investigated.

OBJECTIVE

The objective of the present study was to compare the risk of AMI in AF and non-AF subjects with a low (0 or 1) CHA2DS2-VASc score.

METHODS

By using the National Health Insurance Research Database in Taiwan, we identified 7254 men with AF (with a CHA2DS2-VASc score of 0) and 4860 women with AF (with a CHA2DS2-VASc score of 1). For each study patient, 1 age-, sex-, and CHA2DS2-VASc score-matched subject without AF was randomly selected to constitute the control group (n = 12,114). The clinical end point was the occurrence of AMI.

RESULTS

During a mean follow-up period of 5.7 ± 3.6 years, 258 patients (1.1%) suffered an AMI, with an annual incidence of 0.29% and 0.10% for patients with and without AF. AF was an independent risk factor of AMI, with an adjusted hazard ratio (HR) of 2.93 (95% confidence interval 2.21-3.87; P < .001). The risk of AMI was higher in men with AF than in women with AF, with a hazard ratio of 2.24 (95% confidence interval 1.61-3.11; P < .001) after adjustment for age and other comorbidities.

CONCLUSION

In patients with a CHA2DS2-VASc score of 0 or 1, AF was an independent risk factor of AMI. The risk of AMI was higher in men with AF than in women with AF. Cardiovascular risk prevention should be performed as part of the holistic management of AF to minimize the risks of AMI associated with AF.

Effect of an oral hygienic care program for stroke patients in the intensive care unit

PURPOSE

The effects of an oral hygienic care program (OHCP) have been reported in several diseases. However, no study exists investigating the influence of an OHCP on stroke patients or patients in the intensive care unit (ICU) has been reported, thus we sought to investigate the potential effect of an OHCP.

MATERIALS AND METHODS

Fifty-six consecutive stroke patients who were admitted to the ICU were randomly assigned to two groups: the intervention (29 patients) and control groups (27 patients). The OHCP included tooth brushing with an inter-dental brush and tongue cleaner and cleaning with chlorhexidine was administered to patients by one dentist once per day during admission in the ICU (mean, 2.2 weeks). The plague index, gingival index, clinical attachment loss, and colonization degree of candida albicans were assessed.

RESULTS

After OHCP, the plaque index, gingival index, and colonization degree of candida albicans in saliva showed a significant decrease in the intervention group compared to those of the control group (p<0.05). However, no significant difference was observed in clinical attachment loss and the colonization degree of candida albicans on the tongue (p>0.05).

CONCLUSION

Our OHCP was effective in improving the oral hygienic status and periodontal health of stroke patients during their stay in the ICU. Therefore, we recommend administration of the OHCP for stroke patients during their stay in the ICU.

Are dentists interested in the oral-systemic disease connection? A qualitative study of an online community of 450 practitioners

Background

Dentists in the US see an increasing number of patients with systemic conditions. These patients are challenging to care for when the relationship between oral and systemic disease is not well understood. The prevalence of professional isolation exacerbates the problem due to the difficulty in finding expert advice or peer support. This study aims to identify whether dentists discuss the oral-systemic connection and what aspects they discuss; to understand their perceptions of and attitudes toward the connection; and to determine what information they need to treat patients with systemic conditions.

Methods

We retrieved 14,576 messages posted to the Internet Dental Forum from April 2008 to May 2009. Using natural language processing and human classification, we identified substantive phrases and keywords and used them to retrieve 141messages on the oral-systemic connection. We then conducted coding and thematic analysis to identify recurring themes on the topic.

Results

Dentists discuss a variety of topics on oral diseases and systemic health, with the association between periodontal and systemic diseases, the effect of dental materials or procedures on general health, and the impact of oral-systemic connection on practice behaviors as the leading topics. They also disseminate and share research findings on oral and systemic health with colleagues online. However, dentists are very cautious about the nature of the oral-systemic linkage that may not be causal. Nonetheless, they embrace the positive association as a motivating point for patients in practice. When treating patients with systemic conditions, dentists enquire about the cause of less common dental diseases potentially in relation to medical conditions in one-third of the cases and in half of the cases seek clinical guidelines and evidence-based interventions on treating dental diseases with established association with systemic conditions.

Conclusions

Dentists’ unmet information needs call for more research into the association between less studied dental conditions and systemic diseases, and more actionable clinical guidelines for well-researched disease connections. To improve dissemination and foster behavioral change, it is imperative to understand what information clinicians need and in which situations. Leveraging peer influence via social media could be a useful strategy to achieve the goal.

Periodontal disease and recurrent vascular events in stroke/transient ischemic attack patients

Periodontal disease (PD) has been shown to be associated with incident stroke. We investigated whether PD is independently associated with recurrent vascular events and certain inflammatory markers in stroke/transient ischemic attack (TIA) patients. In this prospective, longitudinal, hospital-based cohort study, PD was assessed in stroke/TIA patients. High periodontal disease (HPD) was defined as the highest tertile of extent (% of sites) with an attachment loss of 5 mm or more. Serum interleukin-6 (IL-6), high-sensitivity C-reactive protein, and soluble intracellular adhesion molecule 1 (s-ICAM) were measured. The patients were followed for recurrent vascular events-stroke, TIA, myocardial infarction, and vascular death. In the 106 patients who were evaluated, 40 (38%) showed HPD and 27 (26%) had recurrent vascular events over a median of 24 months (range, 12-24 months). HPD patients had higher levels of IL-6 (P=.01) and s-ICAM (P=.03). HPD was associated with recurrent vascular events before (log-rank P=.01; hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.2-5.7) and after adjustment for significant confounders-age and stroke status (HR, 2.5; 95% CI, 1.1-5.5; P=.03); adjustment for possible confounders-age, male, years of education, and cardioembolic strokes (HR, 2.8; 95% CI, 1.2-6.5; P=.02); and adjustment for propensity score that accounted for all potential measured confounders (HR, 2.8; 95% CI, 1.2-6.5; P=.02). There is an independent association between HPD and recurrent vascular events in stroke/TIA patients. HPD is also associated with higher serum levels of IL-6 and s-ICAM.

Metformin-inclusive therapy reduces the risk of stroke in patients with diabetes: a 4-year follow-up study

Metformin is a kind of oral hypoglycemic agents commonly prescribed to patients with diabetes mellitus. Although past studies had proven its protective effect on cardiovascular risk and related mortality, the evidence of metformin on stroke prevention was still insufficient and conflicting. Our study randomly selected 14,856 patients with diabetes from the database provided by the Taiwan National Health Research Institute, and 2 cohorts were formulated according to whether metformin was in the prescription record. All cases were followed up for 4 years to track their stroke incidence. As a result, 701 (17.5%) of 3999 diabetic patients had stroke without metformin use, whereas 994 (9.2%) of 10,857 patients had stroke with metformin use. Cox proportional hazard regressions showed that the stroke hazard ratio (HR) of metformin was .383. After adjustment for the patients' age, gender, hypertension, atrial fibrillation, hyperlipidemia, coronary artery disease, and medications including antiplatelets, coumadin, statin, and estrogen use, the HR was still .468. Further stratified analysis revealed that metformin had more protective effect in the patients with higher risk of stroke. Therefore, metformin should be placed in priority when prescribing oral hypoglycemic agents for diabetic patients when considering stroke prevention according to our study.

Dental Prophylaxis and Periodontal Treatment Are Protective Factors to Ischemic Stroke

Background and Purpose—

A correlation has been found between periodontal disease (PD) and stroke. This study was conducted to investigate whether dental prophylaxis and periodontal treatment reduce the incidence rate (IR) of ischemic stroke.

Methods—

We identified 510 762 PD cases and 208 674 non-PD subjects from January 1, 2000, to December 31, 2010. The PD cases were divided into dental prophylaxis, intensive treatment, and no treatment groups. The stroke IRs were assessed among groups during follow-up. Cox regression analysis was used after adjustment for age, sex, and comorbidities to determine the relationship between periodontal treatment and incidence of ischemic stroke.

Results—

The stroke IR of the non-PD subjects was 0.32%/year. In the PD group, subjects who received dental prophylaxis had the lowest stroke IR (0.14%/year); subjects with intensive treatment or tooth extraction had a higher stroke IR (0.39%/year); and subjects without PD treatment had the highest stroke IR (0.48%/year; P <0.001). After adjustment for confounders, the dental prophylaxis and intensive treatment groups had a significant lower hazard ratios for stroke than the non-PD group (hazard ratio=0.78 and 0.95; 95% confidence interval=0.75–0.81 and 0.91–0.99, respectively), whereas the PD without treatment group had a significant higher hazard ratio for stroke (1.15; 95% confidence interval=1.07–1.24), especially among the youngest (20–44) age group (hazard ratio=2.17; 95% confidence interval=1.64–2.87) after stratifying for age.

Conclusions—

Maintaining periodontal health by receiving dental prophylaxis and PD treatment can help reduce the incidence of ischemic stroke.