Inflammatory bowel disease as a risk factor for periodontitis under Taiwanese National Health Insurance Research database

Unravelling the Oral-Gut Axis: Interconnection Between Periodontitis and Inflammatory Bowel Disease, Current Challenges, and Future Perspective

As the opposite ends of the orodigestive tract, the oral cavity and the intestine share anatomical, microbial, and immunological ties that have bidirectional health implications. A growing body of evidence suggests an interconnection between oral pathologies and inflammatory bowel disease [IBD], implying a shift from the traditional concept of independent diseases to a complex, reciprocal cycle. This review outlines the evidence supporting an 'oral-gut' axis, marked by a higher prevalence of periodontitis and other oral conditions in IBD patients and vice versa. We present an in-depth examination of the interconnection between oral pathologies and IBD, highlighting the shared microbiological and immunological pathways, and proposing a 'multi-hit' hypothesis in the pathogenesis of periodontitis-mediated intestinal inflammation. Furthermore, the review underscores the critical need for a collaborative approach between dentists and gastroenterologists to provide holistic oral-systemic healthcare.

Key periodontal pathogens may mediate potential pathogenic relationships between periodontitis and crohn's disease

BACKGROUND

Crohn's disease (CD)-associated periodontitis is common. However, the role of periodontal pathogens in the Coexistence of CD and periodontal disease remains unclear.

METHODS

To investigate the potential relationship mediated by periodontal pathogens between periodontitis and CD, we collected salivary samples from healthy participants (H group, n = 12), patients with CD (Ch group, n = 10), patients with periodontitis (Ps group, n = 12), and patients with Coexistence of CD and periodontal disease (Cp group, n = 12) and analyzed them by 16 S rRNA sequencing.

RESULTS

Patients with Coexistence of CD and periodontal disease had increased levels of Fusobacterium, Actinomyces, Leptotrichia, and Prevotella, which correlated with the severity of periodontitis. Conversely, the levels of Streptococcus, Neisseria, Haemophilus, and Gemella, which decreased in Coexistence of CD and periodontal disease, were negatively correlated with the severity of periodontitis. To further investigate the role of periodontal pathogens in CD development, representative periodontal pathogens causing periodontitis, Porphyromonas gingivalis and Fusobacterium nucleatum, were administered to mice. These pathogens migrate to, and colonize, the gut, accelerating CD progression and aggravating colitis, and even systemic inflammation. In vitro experiments using a Caco-2/periodontal pathogen coculture revealed that P. gingivalis and F. nucleatum increased intestinal permeability by directly disrupting the tight junctions of intestinal epithelial cells.

CONCLUSION

Our findings strongly suggest that periodontal pathogens play a role in the relationship between periodontitis and CD. These results provide a basis for understanding the pathogenesis of Coexistence of CD and periodontal disease and may lead to the development of novel therapeutic strategies.

Bidirectional associations between periodontitis and inflammatory bowel disease: A systematic review of longitudinal studies with meta-analysis and trial sequential analysis

The bidirectional associations between periodontitis and inflammatory bowel disease (IBD) with temporal directionality remain inconclusive. This study aims to evaluate the bidirectional associations between periodontitis and IBD through a systematic review and meta-analysis. Five databases (PubMed, Embase, Web of Science, Scopus and Cochrane Library) were systematically searched from inception to 27 February 2024. Two independent reviewers performed a review of the retrieved studies. Longitudinal studies, including cohort and nested case-control studies, were considered eligible for the study design. The pooled risk ratio (RR) and hazard ratio (HR) derived from the meta-analysis were used to assess whether periodontitis (or IBD) was a risk factor for IBD (or periodontitis). Trial sequential analysis (TSA) was performed to evaluate the reliability of the results. Four studies (n = 10 270 912) on the risk of IBD in patients with periodontitis and two (n = 33 420) on the risk of periodontitis in patients with IBD were included. The result suggested that periodontitis did not increase the risk of IBD (pooled RR = 1.04, 95% confidence interval [CI]: 0.99-1.09; p = .164; I-squared statistic [I2] = 27%). For subtypes of IBD, periodontitis was associated with the occurrence of ulcerative colitis (UC) (pooled RR = 1.12, 95% CI: 1.04-1.21; p = .003; I2 = 38%), but not with Crohn's disease (CD) (pooled RR = 0.98, 95% CI: 0.92-1.04; p = .475; I2 = 0%). Specifically, the risk of UC was higher among men (pooled HR = 1.11, 95% CI: 1.01-1.22; p = .025; I2 = 0%) and smokers (pooled HR = 1.23, 95% CI: 1.07-1.42; p = .004; I2 = 0%) with periodontitis than their counterparts without periodontitis. Patients with IBD may have a higher risk of developing periodontitis (pooled HR = 1.37, 95% CI: 1.26-1.49; p < .001; I2 = 18%); however, whether IBD subtypes increased the occurrence of periodontitis remained uncertain. The TSA results confirmed the reliability of the primary findings. Based on limited longitudinal evidence, patients with periodontitis do not exhibit an increased risk of developing IBD overall, but they are at increased risk of UC (not CD). On the contrary, patients with IBD have a higher risk of developing periodontitis over time. More high-quality longitudinal studies are needed to determine the effect of specific subtypes of IBD on periodontitis.

Periodontitis and Inflammatory Bowel Disease: A Review

The complex relationship between periodontitis (PD) and inflammatory bowel disease (IBD) has received significant attention in recent studies. Emerging evidence suggests that the oral-gut axis plays a pivotal role in their interaction. This review provides a comprehensive, up-to-date analysis of original research from 2003 to 2023 on the PD-IBD relationship and aims to be a reference for future research. Relevant literature was sourced from the PubMed database using the keywords "periodontitis" and "inflammatory bowel disease". Additionally, a manual library search and a review of bibliographies were conducted. Of the 297 articles retrieved, 27 studies were chosen for final review. Out of these, 21 studies (78%), including both in vitro and in vivo research, indicated an association between PD and IBD. While many studies confirm a bi-directional relationship, others refute it or deem it clinically irrelevant. There is a need for more accessible studies, such as randomized trials, which also investigate the factors that could influence the outcomes to clarify the exact molecular mechanisms and clinical implications of this complex relationship.

Dental visits and colon-rectum cancer: A nationwide population-based nested case-control study in Taiwan

Background/purpose

Although oral health and systemic diseases are closely associated, little is known about the utilization of ambulatory dental visits in patients prior to diagnosis of colon-rectum cancer (CRC). In this study, a nested case-control study based on the population-based health claim database was conducted to clarify the relationship between dental visits and CRC in Taiwan.

Materials and methods

From the Longitudinal Health Insurance Research Database 2010 (LHIRD 2010), we identified 4787 patients who were newly diagnosed with CRC from 2005 to 2013. We also recruited 19,148 control subjects matched in a 1:4 ratio based on sex and age at the index date from LHIRD 2010. Both groups were retrospectively traced back to 1997 to obtain any records of ambulatory dental visits that occurred within 8 years prior to the index date. ICD-9 codes 520-529 for diseases of oral cavity, salivary glands, and jaw were defined as dental visits.

Results

The mean frequency of dental visits within 8 years prior to index date among patients with CRC were significantly higher than the control group (P = 0.005). Patients with CRC had significantly higher proportions of certain co-morbidities than control group. However, periodontal treatment, caries filling, and tooth extraction were borderline and not significantly related to CRC after adjustment.

Conclusion

Our results indicate that the utilization of ambulatory dental visits is significantly increased in patients with CRC prior to its diagnosis. Certain co-morbidities may also affect the frequency of dental visits and the occurrence of CRC.

Unraveling the Link between Periodontitis and Inflammatory Bowel Disease: Challenges and Outlook

Periodontitis and Inflammatory Bowel Disease (IBD) are chronic inflammatory conditions, characterized by microbial dysbiosis and hyper-immunoinflammatory responses. Growing evidence suggest an interconnection between periodontitis and IBD, implying a shift from the traditional concept of independent diseases to a complex, reciprocal cycle. This review outlines the evidence supporting an "Oral-Gut" axis, marked by a higher prevalence of periodontitis in IBD patients and vice versa. The specific mechanisms linking periodontitis and IBD remain to be fully elucidated, but emerging evidence points to the ectopic colonization of the gut by oral bacteria, which promote intestinal inflammation by activating host immune responses. This review presents an in-depth examination of the interconnection between periodontitis and IBD, highlighting the shared microbiological and immunological pathways, and proposing a "multi-hit" hypothesis in the pathogenesis of periodontitis-mediated intestinal inflammation. Furthermore, the review underscores the critical need for a collaborative approach between dentists and gastroenterologists to provide holistic oral-systemic healthcare.

The role of microbiome in the pathogenesis of oral-gut-liver axis between periodontitis and nonalcoholic fatty liver disease

Periodontitis and nonalcoholic fatty liver disease (NAFLD) are two prevalent non-communicable diseases affecting people worldwide. The delicate interplay between oral microbiome, intestinal barrier, immune system, and liver is susceptible to disruption by environmental and genetic factors which could result in the onset of systemic diseases. The oral-liver and liver-gut axes have been proposed as the possible mechanisms to explain the links among these factors. Many evidences are mounting to support the role of imbalanced interactions between microbiota and immune system in the development of immune-mediated diseases. The emerging concept of the oral-gut-liver axis is gaining recognition as a means to explore the interconnections among NAFLD, periodontitis, and gut dysbiosis. There is substantial evidence indicating that oral and gut dysbiosis are the significant risk factors for liver disease. Therefore, the role of inflammatory mediators in linking these organs cannot be overlooked. Understanding these complex relationships is crucial in the development of effective strategies for the prevention and management of liver diseases.

Association between inflammatory bowel disease and periodontitis: A bidirectional two-sample Mendelian randomization study

AIM

This Mendelian randomization (MR) study was performed to explore the potential bidirectional causal association between inflammatory bowel disease (IBD) and periodontitis.

MATERIALS AND METHODS

We used genetic instruments from the genome-wide association study summary statistics of European descent for IBD (12,882 cases and 21,770 controls) to investigate the association with periodontitis (3046 cases and 195,395 controls) and vice versa. The radial inverse-variance weighted method was carried out to obtain the primary causal estimates, and the robustness of the results was assessed by a series of sensitivity analyses. Due to multiple testing, associations with p values <.008 were considered as statistically significant, and p values ≥.008 and <.05 were considered as suggestively significant.

RESULTS

In the primary causal estimates, IBD as a whole was associated with an increased risk of periodontitis (odds ratio [OR], 1.060; 95% confidence interval [CI], 1.017; 1.105; p = .006). Subtype analyses showed that ulcerative colitis (UC) was associated with periodontitis (OR, 1.074; 95% CI 1.029; 1.122; p = .001), while Crohn's disease (CD) was not. Regarding the reverse direction, periodontitis showed a suggestive association with IBD as a whole (OR, 1.065; 95% CI 1.013; 1.119; p = .014). Subtype analyses revealed that periodontitis was associated with CD (OR, 1.100; 95% CI 1.038; 1.167; p = .001) but not UC. The final models after outlier removal showed no obvious pleiotropy, indicating that our primary analysis results were reliable.

CONCLUSIONS

The present MR study provides moderate evidence on the bidirectional causal relationship between IBD and periodontitis. The bidirectional increased risk found in our study was marginal and, possibly, of limited clinical relevance. More studies are needed to support the findings of our current study.

Patients with inflammatory bowel disease have a higher chance of developing periodontitis: A systematic review and meta-analysis

Background and objective

Periodontitis affects up to one billion people worldwide, and has been proven to be associated with several systemic inflammatory conditions. This study investigates the specific relationship between two multifactorial diseases: Inflammatory bowel disease (IBD) and periodontitis. To thoroughly explore this issue, we investigated separately whether IBD patients have a higher chance of developing periodontitis, and equally, whether patients with periodontitis have a higher chance of developing IBD.

Methods

The systematic search was performed in three databases: MEDLINE, Cochrane Trials, and Embase, up to 26 October 2021. The protocol was registered in PROSPERO. All eligible studies investigating the association between IBD and periodontitis from either direction were included. The Newcastle-Ottawa Scale was used to assess the risk of bias. As a primary outcome, we investigated the prevalence of IBD and periodontitis, and calculated the odds ratio (OR). Our secondary outcomes involved comparing the clinical periodontal outcomes of IBD patients to those of IBD-free patients.

Results

The systematic search resulted in 1,715 records, 14 of which were eligible for qualitative synthesis and 8 for quantitative synthesis. On the basis of the results of the primary outcome, IBD diagnosis was associated with significantly higher odds of periodontitis: OR = 2.65 (CI: 2.09-3.36, I 2 = 0 (CI: 0-0.75)). For subgroup analysis, we investigated separately the odds in Crohn's disease (CD) patients: OR = 2.22 (CI: 1.49-3.31, I 2 = 0.05 (CI: 0-0.76)) and in ulcerative colitis (UC) patients: OR = 3.52 (CI: 2.56 to 4.83, I 2 = 0 (CI: 0-0.75)); the odds were significantly higher in all cases. Two studies investigated whether patients with periodontitis were more susceptible to IBD, and both found that periodontitis was significantly associated with the risk of subsequent UC, but not with subsequent CD. However, more studies are needed to prove an association.

Conclusion

Our analysis confirmed that IBD patients have a higher chance of developing periodontitis, and are a higher risk population in dentistry. Both dentists and gastroenterologists should be aware of this relationship and should emphasize the importance of prevention even more than in the healthy population.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021286161].

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.

Exosomes derived from 3D-cultured MSCs improve therapeutic effects in periodontitis and experimental colitis and restore the Th17 cell/Treg balance in inflamed periodontium

Although mesenchymal stem cell-derived exosomes (MSC-exos) have been shown to have therapeutic effects in experimental periodontitis, their drawbacks, such as low yield and limited efficacy, have hampered their clinical application. These drawbacks can be largely reduced by replacing the traditional 2D culture system with a 3D system. However, the potential function of MSC-exos produced by 3D culture (3D-exos) in periodontitis remains elusive. This study showed that compared with MSC-exos generated via 2D culture (2D-exos), 3D-exos showed enhanced anti-inflammatory effects in a ligature-induced model of periodontitis by restoring the reactive T helper 17 (Th17) cell/Treg balance in inflamed periodontal tissues. Mechanistically, 3D-exos exhibited greater enrichment of miR-1246, which can suppress the expression of Nfat5, a key factor that mediates Th17 cell polarization in a sequence-dependent manner. Furthermore, we found that recovery of the Th17 cell/Treg balance in the inflamed periodontium by the local injection of 3D-exos attenuated experimental colitis. Our study not only showed that by restoring the Th17 cell/Treg balance through the miR-1246/Nfat5 axis, the 3D culture system improved the function of MSC-exos in the treatment of periodontitis, but also it provided a basis for treating inflammatory bowel disease (IBD) by restoring immune responses in the inflamed periodontium.

Periodontal and dental health in inflammatory bowel diseases: a systematic review

Introduction: An increased risk of dental caries and periodontal diseases has been reported for inflammatory bowel disease (IBD) patients and are challenging conditions to manage.Areas covered: The authors searched international databases to find all studies assessing dental/periodontal outcomes in patients with IBD and other immune-mediated inflammatory disease (IMID), as well as the association between IMID medications and dental/periodontal status.Expert opinion: IBD are associated with a higher risk of both periodontitis and caries. Some evidence from rheumatoid arthritis suggests that periodontitis may be associated with a lower response to anti-TNF. There is no reliable evidence that IBD patients may be at greater risk of complications during routine dental care. On the basis of current data, guidelines can be proposed for the dental management focusing on the detection and eradication of infectious foci prior to the implementation of immunosuppressants/biologics and modified dental treatment protocol for invasive dental procedures that includes antibiotic prophylaxis.

Oral manifestations of inflammatory bowel disease: the neglected piece of the puzzle

Inflammatory bowel disease (IBD) is a chronic relapsing remitting autoimmune disease including Crohn's disease and ulcerative colitis. IBD is associated with various extra-intestinal manifestations including oral manifestation. To date, only limited studies addressing the characteristics of the oral manifestations are available. The aim of the present review is to report the oral manifestations and their characteristics in IBD. A Medline/PubMed and Embase databases search were conducted and all relevant studies were extracted and analyzed. Overall, the oral manifestations in IBD were mostly associated with Crohn's disease rather than Ulcerative colitis where their prevalence ranged from 8 to 50%. Specific lesions for Crohn's disease include mucosal tags, cobblestoning and deep linear ulcerations with vertical fissures, while for ulcerative colitis, pyostomatisis vegetans was more disease specific. Notably, most of the oral manifestations were unrelated to disease activity, however more data are needed to accurately assess this correlation. Oral manifestations among IBD patients are not uncommon as Crohn's disease account for most of them. More data are warranted to precisely characterize their prevalence and association to intestinal activity.

A rare case of pediatric Crohn's disease and alveolar bone loss: a report and review

Crohn's disease (CD) is a granulomatous inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal tract, but its etiology is still unclear. CD patients usually have extraintestinal manifestations including oral manifestations, and this can also occasionally appear in children. Oral manifestations, including aphthous stomatitis, typically develop on the mucocutaneous tissue. As pediatric CD is not common, there have been no reports concerning alveolar bone resorption for these kinds of patients. An 11-year-old Chinese girl was referred to our hospital because of reoccurring painful oral ulcers, with a 2.5-year history of CD and recurrent oral ulcers. Clinical examinations revealed intestinal lesions, oral ulcers, and alveolar bone loss. CD and its related periodontitis were diagnosed. After comprehensive therapy, including periodontal scaling and anti-inflammatory treatment, the oral ulcers gradually healed. One year later, follow-up visit showed the anterior alveolar bone to be stable and new alveolar bone regenerating around the mandibular anterior teeth at some sites. It is rare for CD children to have periodontitis, especially with severe alveolar bone loss. This case suggests that when treating periodontitis in children, the possibility of systemic disease, such as CD, should be considered and attended to. Early diagnosis and symptomatic treatment and care are crucial.

History of Inflammatory Bowel Disease and Self-Reported Oral Health: Women's Health Initiative Observational Study

Background and Objective: Both periodontal disease and inflammatory bowel disease (IBD), are chronic inflammatory conditions, which are mediated by a complex interplay among a dysbiotic microbiota, dysregulated host immune-inflammatory responses, and lifestyle factors. Despite substantial differences in physical and chemical environments, rather strong correlations have been detected between microbial compositions of the oral cavity and stool. In this study, we tested the hypothesis that oral health conditions are affected by the presence of IBD. Materials and Methods: We analyzed the data from 73,621 women who were enrolled in the Women's Health Initiative observational cohort study and completed a follow-up questionnaire that surveyed oral health status specifically at year 5. Among these, 880 reported IBD at the baseline, including 47% who were symptomatic cases and 27% who were on immunosuppressive treatment. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association of IBD and medication status for self-reported oral health outcomes, using logistic regression models, adjusted for selected covariates. Results: IBD was not associated with periodontal disease history itself in a multivariable model; however, poorer self-rated oral health was modestly associated with the presence of IBD (OR = 1.15, 95% CI: 1.01-1.30). Likewise, more frequent eating limitations due to teeth were associated with the presence of IBD history (OR = 1.22, 95% CI: 1.07-1.39). When IBD cases were limited to those who were symptomatic, the associations with these two self-rated oral health outcomes were more pronounced with ORs of 1.28 (95% CI: 1.07-1.54) and 1.36 (95% CI: 1.07-1.54), respectively. Immunosuppressive treatment had little effect on these risk estimates. Conclusions: Among this nation-wide cohort of women 50-79 years of age, history of IBD was associated with poorer perceived oral health status.

Time trend in the prevalence of oral lichen planus based on Taiwanese National Health Insurance Research Database 1996-2013

BACKGROUND/PURPOSE

Oral lichen planus (OLP) is a common chronic inflammatory disease characterized by a T cell-mediated immune response against epithelial cells. The epidemiological survey of OLP in Taiwanese population was scarce. In this study, we investigated the time trend of prevalence stratified by gender, age, urbanization, and income of OLP based on National Health Insurance Research Database (NHIRD).

MATERIALS AND METHODS

We studied the claims data of Taiwanese population from NHIRD 1996 to 2013. Patients with the diagnosis of OLP based on the International Classification of Diseases, Ninth Clinical Modification (ICD-9-CM) code: 697.0 were recruited in this study. Demographic characteristics were analyzed by multi-variate Poisson regression.

RESULTS

The prevalence of OLP increased significantly from 1.3 (per 105) in 1996 to 12.8 (per 105) in 2013 (p for trend < 0.001). The prevalence was higher among female than male (RR: 2.13; 95% CI: 2.07-2.18, p < 0.001). The subjects living in suburban area had a lower risk of OLP than those living in urban area (RR: 0.80; 95% CI: 0.78-0.82, p < 0.001). The higher income group had higher risk of OLP compared with the lower income group (RR, 2.27; 95% CI, 2.17-2.36, p < 0.001).

CONCLUSION

The prevalence of OLP in Taiwan significantly increased over the past 18 years. The mean age with OLP was shown in an increased pattern. In addition, OLP occurs more frequently in women than in men.