Arterial stiffness in periodontitis patients and controls. A case–control and pilot intervention study

Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients

Objectives

This narrative review aims to update the current evidence and offer insight into the new non-invasive ultrasound techniques used to early identify degenerative vascular changes in subjects with periodontitis and to investigate if these methodologies could be useful to identify subclinical cardiovascular disease (CVD) dysfunction in periodontitis patients and to monitor changes in CVD risk after periodontal treatment.

Methods

Studies examining the assessment of vascular endothelial function through the latest methodologies were analyzed. Systematic reviews, observational studies, and clinical trials in the English language were identified using PubMed, Web of Science, and Google Scholar databases with key search terms such as "periodontitis," "endothelial dysfunction (ED)," "arterial stiffness," and "periodontal therapy."

Results

Several mechanisms are involved in the association between periodontitis and CVD. The key players are periodontal bacteria and their toxins, which can enter the circulation and infiltrate blood vessel walls. The increase in proinflammatory molecules such as interleukins and chemokines, c-reactive protein, fibrinogen, and oxidative stress also plays a decisive role. In addition, an increase in parameters of ED, arterial stiffness, and atherosclerosis, such as carotid intima-media thickness, pulse wave velocity, and flow-mediated dilatation, has been shown in periodontal patients.

Conclusions

The literature today agrees on the association of periodontitis and CVD and the positive role of periodontal therapy on systemic inflammatory indices and cardiovascular outcomes. Hopefully, these non-invasive methodologies could be extended to periodontal patients to provide a comprehensive understanding of the CVD-periodontitis link from the perspective of a personalized medicine approach in periodontology.

Can oral health care be a gateway to improve cardiovascular disease? A scoping review

Background

Cardiovascular diseases (CVDs) are a significant cause of morbidity and mortality worldwide, resulting in a high socioeconomic burden. Growing evidence has shown a link between oral diseases and several chronic conditions including CVDs. The focus of this review is to investigate and summaries the evidence surrounding oral health interventions and their potential impact on reducing both the risk and/or severity of CVDs.

Methods

A scoping review was conducted to examine oral health interventions for managing CVD outcomes and risks. The review adhered to the Joanna Briggs Institute (JBI) framework for evidence synthesis and followed the reporting standards outlined by the Preferred Reporting Items for Systematic Reviews and Meta-analysis- extension to Scoping Review (PRISMA-ScR). A systematic search across EBSCOhost, PubMed, and Scopus databases from 2012 to 2024 was utilized to identify relevant studies. Inclusion criteria focused on English language articles with a sample size of at least 50, evaluating the impact of oral health interventions on CVD outcomes.

Results

Out of the initial 2,154 studies identified in the search, 12 studies met the inclusion and exclusion criteria and were included in the final analysis. Overall, the studies revealed that along with surgical and non-surgical periodontal therapy, regular oral hygiene care practices, including toothbrushing, tongue brushing, and flossing, significantly reduced the risk of cardiovascular events and mortality. These interventions in patients with or without CVD baseline have shown a decrease in CVD risk markers as well as a reduction in bacterial colonization. Similarly, consistent oral hygiene routines, combined with regular dental visits, were associated with a lower risk of heart failure and CVD risk mortality.

Conclusion

The evidence extracted from this review suggests that periodontal therapy, regular dental cleaning, and re-enforcing of oral health regimes can stabilize oral health conditions and subsequently improve CVD progression/risks. However, limited to no evidence exists regarding the therapeutic effects of oral health promotion in managing CVD markers and its direct impact on disease outcomes, warranting further investigation.

Oral health as a modifiable risk factor for cardiovascular diseases

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide with a high socioeconomic burden. Increasing evidence supports a convincing connection with increased cardiovascular risk of periodontal diseases (PD), a group of widespread, debilitating, and costly dysbiotic relapsing-remitting inflammatory diseases of the tissues supporting the teeth. Herein, we ensembled the best available evidence on the connection between CVDs and PD to review the recently emerging concept of the latter as a non-traditional risk factor for CVDs. We focused on oral dysbiosis, inflammation-associated molecular and cellular mechanisms, and epigenetic changes as potential causative links between PD and CVDs. The available evidence on the effects of periodontal treatment on cardiovascular risk factors and diseases was also described.

Impact of Nonsurgical Periodontal Treatment on Blood Pressure: A Prospective Cohort Study

OBJECTIVES

 Arterial hypertension and periodontitis are two of the most common diseases worldwide and recent evidence supports a causal relationship between them. Despite all antihypertensive strategies, an important number of patients are undiagnosed and a large number of the diagnosed fail to achieve optimal blood pressure (BP) measurements. Some studies point out that periodontal treatment could have positive effects on BP levels. The aim of this study is to determine if nonsurgical periodontal treatment can help BP level control in prehypertensive patients with periodontitis.

MATERIALS AND METHODS

 Thirty-five patients were included in the study and received nonsurgical periodontal treatment according to necessity. Clinical data, periodontal data, and BP measurements were taken at baseline, periodontal re-evaluation visit (4-6 weeks after treatment), and 6-month follow-up.

RESULTS

 Periodontal treatment caused a statistically significant reduction (p < 0.05) of systolic blood pressure (SBP) and diastolic blood pressure (DBP) at re-evaluation visit of 4.7 (p = 0.016) and 3.4 mm Hg (p = 0.015), respectively. The effect was maintained at 6-month follow-up visit with a reduction in SBP and DBP of 5.2 (p = 0.007) and 3.7 (p = 0.003) mm Hg, respectively.

CONCLUSION

 Despite the limitations of this study, it suggests that nonsurgical periodontal treatment can be effective in lowering BP levels in patients with prehypertension and periodontitis. Moreover, it highlights the importance of dentists in prevention, detection, and control of this important cardiovascular risk factor.

The effects of severe periodontitis on arterial stiffness using cardio-ankle vascular index in patients with type 2 diabetes

BACKGROUND AND OBJECTIVE

Arterial stiffness, which is a measure of the elasticity of the arteries, is also a risk factor for the development of cardiovascular diseases and its measurement is important for evaluating the atherosclerosis process. The purpose of this cross-sectional study to investigate whether severe periodontitis in short-term type 2 diabetes may be associated with increased cardio-ankle vascular index (CAVI) values specified for subclinical atherosclerosis risk.

METHODS

A total of 136 subjects, including 69 subjects with short-term type 2 diabetes (35 with severe periodontitis and 34 with periodontally healthy) and 67 systemically healthy subjects (32 with severe periodontitis and 35 with periodontally healthy) were enrolled to this study. Assessment of all participants included in this study in terms of arterial stiffness was determined by CAVI. Serum fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), triglyceride (TRG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC) and C-reactive protein (CRP) levels were calculated using standard methods. Full mouth periodontal measurements were recorded. Multiple linear regression analysis was performed to evaluate the relationship between periodontal parameters and mean CAVI values of the groups.

RESULTS

Mean CAVI levels were significantly higher in diabetic and periodontitis group compared to the other study groups (p < .05). In diabetes and periodontitis group, CAVI was showed positive correlations with CRP (r = .337, p = .048) and HbA1c (r = .442, p = .008). Also, positive significant correlations were found with probing depth (PD) and clinical attachment level (CAL) in the periodontitis groups. Multiple regression analysis revealed that CAL independently predicted CAVI levels in periodontitis groups (β = .433, p = .019 in diabetes and periodontitis groups and β = .57, p = .001 in systemically healthy and periodontitis group respectively).

CONCLUSION

This is the first study investigating the association between severe periodontitis and CAVI in patients with short-term diabetes. Our findings suggest that severe periodontitis may be an intermediate factor in the pathway between type 2 diabetes and cardiovascular disease by increasing the arterial stiffness.

Association between Periodontal Disease and Arteriosclerosis-Related Diseases

Periodontitis, a major inflammatory disease of the oral cavity that can cause low-grade systemic inflammation, has been suggested to influence the development of comorbidities. Multiple systemic inflammatory mechanisms are common in the development of periodontal disease and atherosclerosis. Observational studies conducted worldwide have reported that periodontal disease may independently influence the progression of atherosclerotic disease. However, there is still insufficient evidence to demonstrate the causal relationship. This review describes the association between periodontal disease and arteriosclerosis-related diseases with the latest findings.

The Relationship between Hypertension and Periodontitis: A Cross-Sectional Study

Recent evidence suggests an association between hypertension and periodontitis, although the pathways and implications underlying both chronic conditions are still poorly understood. Therefore, the aim of this study was to evaluate the relationship between hypertension and periodontitis through an observational clinical study using periodontal, physical, and biochemical analyses in hypertensive and non-hypertensive individuals with periodontitis. A total of one hundred patients were divided into two groups. The first group was hypertensive patients with periodontitis. The second group was non-hypertensive patients with periodontitis. Periodontal parameters of probing depth, bleeding on probing, and clinical attachment level were evaluated. The systolic, diastolic, mean, and differential blood pressure were measured in the physical examination. In addition, body mass index and waist-hip ratio were verified. Biochemical tests for glycated hemoglobin, fasting blood glucose, estimated blood glucose, total cholesterol, high-density lipoprotein, creatinine, glutamate pyruvate transaminase, glutamic oxaloacetic transaminase, and C-reactive protein were evaluated. The data were submitted for statistical analysis (α = 0.05%). The results of this study demonstrated that patients with cardiovascular disease did not present with worse periodontal clinical parameters in the conditions studied. However, it is important to bear in mind that this cross-sectional study has some inherent limitations to its design; therefore, to study the relationship between hypertension and periodontitis further, an interventional randomized clinical trial should be conducted.

Association between cardiovascular diseases and periodontal disease: more than what meets the eye

Cardiovascular diseases (CVDs) are inflammatory diseases of coronary arteries accompanying atheroma formation that can spawn impairment and, in severe cases, death. CVDs are the leading cause of death in the world. In recent decades, investigators have focused their impact on CVD by periodontal disease (PD). PD is a risk factor that can trigger the formation, maturation, and instability of atheroma in the arteries. Two mechanisms have been proposed to explain this relationship: periodontopathic pathogens explicitly invade the circulation or indirectly increase systemic levels of inflammatory mediators. It has been suggested that improvement in disease state has a positive effect on others. This review summarizes evidence from epidemiological studies as well as researches focusing on potential causation channels to deliver a comprehensive representation of the relationship between PD and CVD.

Periodontal and systemic health of morbidly obese patients eligible for bariatric surgery: a cross-sectional study

Background

In obese patients, periodontitis might be associated with deprived systemic health. Edmonton obesity staging system (EOSS) is a new tool for classification of obesity that considers the metabolic, physical, and psychological health. The cross-sectional study aimed to evaluate the periodontal status of morbidly obese patients eligible for bariatric surgery and the association between periodontitis, obesity-related comorbidities, and EOSS.

Methods

Morbidly obese patients eligible for bariatric surgery underwent detailed periodontal examination and were divided into the periodontitis group (PG) and the non-periodontitis group (NPG). The medical and demographic data were obtained from medical files, while behavioural data were obtained by the interview. Descriptive statistics and simple statistical tests were used to summarise the characteristics of the sample and the differences between PG and NPG. The logistic regression models were used to calculate the association (odds ratio (OR)) between periodontitis and obesity-related diseases and EOSS.

Results

The study included 79 patients, with an average BMI of 44.6 kg/m² (SD = 7.2). The prevalence of periodontitis was 65% (CI 95% 53%-75%). PG patients (n = 51) were older, more often smokers and were more often hypertensive than NPG patients (n = 28) (p < 0.05). Hypertension was positively associated with periodontitis with adjusted OR 3.98 (95% CI 1.23–12.8; p = 0.021)) and age with adjusted OR 1.06, (95% CI 1.01–1.13; p = 0.038)), while other tested conditions (diabetes, dyslipidaemia, and smoking habits) did not show significant association with periodontitis. Periodontitis did not correlate with EOSS or other obesity-related comorbidities (p > 0.05).

Conclusion

The morbidly obese patients eligible for bariatric surgery show a high prevalence of periodontitis and, therefore, are advised to be examined by a dentist before undergoing surgery. They have higher odds of hypertension but not of other obesity-related diseases or higher stages of EOSS. The medical personnel should raise awareness among obese patients on the potential association of poor periodontal health with hypertension.

Trial registration

NCT04653714.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02207-0.

Role of mechanosensitive channels/receptors in atherosclerosis

Mechanical forces are critical physical cues that can affect numerous cellular processes regulating the development, tissue maintenance, and functionality of cells. The contribution of mechanical forces is especially crucial in the vascular system where it is required for embryogenesis and for maintenance of physiological function in vascular cells including aortic endothelial cells, resident macrophages, and smooth muscle cells. Emerging evidence has also identified a role of these mechanical cues in pathological conditions of the vascular system such as atherosclerosis and associated diseases like hypertension. Of the different mechanotransducers, mechanosensitive ion channels/receptors are gaining prominence due to their involvement in numerous physiological and pathological conditions. However, only a handful of potential mechanosensory ion channels/receptors have been shown to be involved in atherosclerosis, and their precise role in disease development and progression remains poorly understood. Here, we provide a comprehensive account of recent studies investigating the role of mechanosensitive ion channels/receptors in atherosclerosis. We discuss the different groups of mechanosensitive proteins and their specific roles in inflammation, endothelial dysfunction, macrophage foam cell formation, and lesion development, which are crucial for the development and progression of atherosclerosis. Results of the studies discussed here will help in developing an understanding of the current state of mechanobiology in vascular diseases, specifically in atherosclerosis, which may be important for the development of innovative and targeted therapeutics for this disease.

Association between metabolic syndrome and periodontitis: The role of lipids, inflammatory cytokines, altered host response, and the microbiome

Periodontitis has been associated with many systemic diseases and conditions, including metabolic syndrome. Metabolic syndrome is a cluster of conditions that occur concomitantly and together they increase the risk of cardiovascular disease and double the risk of type 2 diabetes. In this review, we focus on the association between metabolic syndrome and periodontitis; however, we also include information on diabetes mellitus and cardiovascular disease, since these two conditions are significantly intertwined with metabolic syndrome. With regard to periodontitis and metabolic syndrome, to date, the vast majority of studies point to an association between these two conditions and also demonstrate that periodontitis can contribute to the development of, or can worsen, metabolic syndrome. Evaluating the effect of metabolic syndrome on the salivary microbiome, data presented herein support the hypothesis that the salivary bacterial profile is altered in metabolic syndrome patients compared with healthy patients. Considering periodontitis and these three conditions, the vast majority of human and animal studies point to an association between periodontitis and metabolic syndrome, diabetes, and cardiovascular disease. Moreover, there is evidence to suggest that metabolic syndrome and diabetes can alter the oral microbiome. However, more studies are needed to fully understand the influence these conditions have on each other.

Modelling the Validity of Periodontal Disease Screening Questions in a Nondental Clinical Setting

OBJECTIVE

Periodontal examinations are time-consuming and potentially uncomfortable for recipients. We modelled if self-reported questions alone, or combined with objective evidence of periodontal bone loss observable from radiographs, are accurate predictors of periodontitis.

METHODS

Self-reported data from the Australian National Survey of Adult Oral Heath 2004-06 were compared with clinical periodontal examinations to assess the validity of 8 periodontitis screening questions in predicting moderate/severe periodontitis. To model alveolar bone loss, a proxy variable simulating radiographic clinical attachment level (rCAL) was created. Three multivariable binary logistic regression models were constructed: responses to 8 screening questions alone (Model 1), screening questions combined with 5 classic periodontitis risk indicators (age, sex, smoking status, country of birth, and diabetes status) (Model 2), and the addition of rCAL (Model 3). Predictive validity was determined via sensitivity (Se) and specificity (Sp) scores and graphically represented using area under the receiver operator characteristic curves (AUROC).

RESULTS

Data from 3630 participants periodontally examined determined that 32.4% exhibited periodontitis. Periodontitis risk indicators were all significantly associated with periodontitis case status. Six of 8 screening questions (Model 1) were weak periodontitis predictors (Se = 0.28; Sp = 0.89; AUROC = 0.61). Combining 13 variables for (Model 2) improved prediction (Se = 0.55; Sp = 0.81; AUROC = 0.77). The addition of rCAL (Model 3) improved diagnostic capacity considerably (AUROC = 0.86).

CONCLUSIONS

Self-reported questions combined with classic risk indicators are "useful" for periodontitis screening. Addition of radiographs markedly improved diagnostic validity. Based on modelling, nondental health care professionals may provisionally screen for periodontitis with minimal training.

Periodontitis, Blood Pressure, and the Risk and Control of Arterial Hypertension: Epidemiological, Clinical, and Pathophysiological Aspects-Review of the Literature and Clinical Trials

Purpose of Review

Arterial hypertension is an important risk factor for cardiovascular disease. In the world, about 45% of people suffer from arterial hypertension, while good blood pressure control is achieved by only approximately 50% of all hypertensive patients treated. The reason for the high prevalence of arterial hypertension and its poor control is low knowledge of hypertensinogenic factors. One such factor is periodontitis, which is a disease of social importance.

Recent Findings

It has been shown that the occurrence of periodontitis leads to an increase in blood pressure, increasing the risk of arterial hypertension. Periodontitis can also lead to ineffectiveness of antihypertensive treatment. Some interventional studies have shown that treatment of periodontitis reduced blood pressure in patients with arterial hypertension. The pathogenesis of arterial hypertension in periodontitis is complex and concerns mainly the impairment of the vasodilatation properties of the endothelium.

Summary

Hygiene and periodontitis treatment should be a method of preventing arterial hypertension and a method of increasing the effectiveness of antihypertensive treatment.

Does Periodontal Treatment Help in Arterial Hypertension Control? A Systematic Review of Literature

Arterial hypertension and periodontal diseases are two of the pathologies with more prevalence worldwide. In the last few years, several scientific evidences have demonstrated the relationship between both diseases. Besides the etiopathogenic and causal relationship, some recent publications have pointed out that the therapeutic approach of periodontitis could have positive effects on the control of arterial hypertension.The aim of this systematic review is to determine whether there is a decrease in or better control of blood pressure after performing nonsurgical periodontal treatment in patients with periodontitis.A thorough search in PubMed, Scopus, and ISI Web of Science databases with the keywords "'periodontal disease' OR 'periodontitis' OR 'periodontal' AND 'blood pressure' OR 'hypertension' OR 'arterial hypertension'" was conducted. The quality of the reported information was assessed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for systematic reviews.Eight articles were considered for this systematic review. Five of the studies showed statistically significant reduction in systolic blood pressure (SBP) values.Despite the limitations of the review, nonsurgical treatment of periodontal disease seems to reduce SBP values. Further research with larger and longer-term clinical trials are needed to demonstrate this potential positive effect.

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.

Association between periodontitis and pulse wave velocity: a systematic review and meta-analysis

OBJECTIVES

Severe periodontitis has been associated with endothelial dysfunction and arterial stiffness. The present study aimed to provide a critical appraisal and a meta-analysis of the literature investigating pulse wave velocity (PWV) in patients with and without severe periodontitis and to assess whether treatments influence PWV.

MATERIALS AND METHODS

English literature was searched on multiple databases up to April 2020 by two independent reviewers. Studies comparing PWV between patients with and without severe periodontitis or assessing the impact of periodontal treatments on PWV were searched and retrieved. Pool data analyses with random effect models were performed. The risk of bias was assessed using Newcastle-Ottawa Scale and RoB2 tools.

RESULTS

Seventeen studies were selected. Of these, 10 were used for the meta-analysis. Twelve were cross-sectional studies and 5 interventional studies, including 3176 patients, of whom 1894 had severe periodontitis and 1282 were considered as the controls (without severe periodontitis). Based on carotid-femoral PWV measurement, patients with severe periodontitis (n = 309) have a significantly higher PVW than patients with non-severe periodontitis (n = 213), with a mean difference of 0.84 m/s (95% CI 0.50-1.18; p < 0.0001; I² = 5%). Similarly, carotid-radial or brachial-ankle PWV values were significantly higher in patients with severe periodontitis. Results concerning the effect of non-surgical periodontal therapy were not conclusive. Overall, 9 studies (53%) were classified at a low risk of bias.

CONCLUSIONS

The present study demonstrates that patients with severe periodontitis have higher PWV compared to patients with non-severe periodontitis.

CLINICAL SIGNIFICANCE

Severe periodontitis is associated with arterial stiffness, supporting the mutual involvement of dentists and physicians.

The severity and extent of periodontitis is associated with cardio-ankle vascular index, a novel arterial stiffness parameter

OBJECTIVES

To evaluate the association between the severity and extent of periodontitis and arterial stiffness using the cardio-ankle vascular index (CAVI).

MATERIALS AND METHODS

A cross-sectional study of 2888 Electricity Generation Authority of Thailand (EGAT) employees aged 44-78 years was conducted. The severity of periodontitis was evaluated based on mean clinical attachment level (CAL). The percentage of sites with CAL ≥ 5 mm was used to divide the extent of periodontitis into healthy (0%), localized (> 0-< 30%), and generalized (≥ 30%). The CAVI value, a novel blood pressure-independent arterial stiffness parameter, was analyzed as both continuous and categorical data (low: < 9 or high: ≥ 9). Regression analysis was used to estimate the level of association.

RESULTS

The participants demonstrated a mean CAL, % sites with CAL ≥ 5 mm, and a CAVI value of 3.2 ± 1.2 mm, 16.0 ± 20.8%, and 8.24 ± 1.12, respectively. Higher mean CAVI was observed with greater mean CAL and % sites with CAL ≥ 5 mm. The mean CAVI of the healthy, localized, and generalized periodontitis groups were 8.01 ± 1.11, 8.22 ± 1.12, and 8.51 ± 1.04, respectively (p < 0.01). Linear and logistic regression analysis demonstrated a significant relationship between CAVI and all periodontal variables with β = 0.004-0.17 and OR = 1.01-1.58, respectively.

CONCLUSIONS

There is a significant dose-dependent association between the severity and extent of periodontitis and arterial stiffness measured by CAVI in Thai adults.

CLINICAL RELEVANCE

Preventing arterial stiffness, an early sign of cardiovascular events, by controlling the emerging risk factors, such as periodontitis, might have a high impact on health promotion.

Periodontitis is associated with hypertension: a systematic review and meta-analysis

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10-1.35] and severe PD (OR = 1.49; 95% CI: 1.09-2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88-6.11] and DBP (2.03 mmHg; 95% CI: 1.25-2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

Periodontal therapy and cardiovascular risk

Cardiovascular diseases are the worldwide leading cause of mortality. Cardiovascular diseases are noncommunicable conditions with a complex pathogenesis, and their clinical manifestations include major cardiovascular events such as myocardial infarction and stroke. Epidemiologic evidence suggests a consistent association between periodontitis and increased risk of cardiovascular diseases. Some evidence supports a beneficial effect of the treatment of periodontitis on both surrogate and hard cardiovascular outcomes. This narrative review has been conducted as an update of the most recent evidence on the effects of periodontitis treatment on cardiovascular outcomes since the last commissioned review of the European Federation of Periodontology-American Academy of Periodontology World Workshop in 2012. Newer evidence originating from published randomized controlled trials confirms a positive effect of periodontal treatment on surrogate measures of cardiovascular diseases, whereas there have been no randomized controlled trials investigating the effect of periodontal treatment on the incidence of cardiovascular disease events such as myocardial infarction and stroke. In conclusion, there is sufficient evidence from observational and experimental studies on surrogate cardiovascular measures to justify the design and conduct of appropriately powered randomized controlled trials investigating the effect of effective periodontal interventions on cardiovascular disease outcomes (ie, myocardial infarction and stroke) with adequate control of traditional cardiovascular risk factors.

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.

Periodontitis and Hypertension: Is the Association Causal?

High blood pressure (BP) and periodontitis are two highly prevalent conditions worldwide with a significant impact on cardiovascular disease (CVD) complications. Poor periodontal health is associated with increased prevalence of hypertension and may have an influence on BP control. Risk factors such as older age, male gender, non-Caucasian ethnicity, smoking, overweight/obesity, diabetes, low socioeconomic status, and poor education have been considered the common denominators underpinning this relationship. However, recent evidence indicates that the association between periodontitis and hypertension is independent of common risk factors and may in fact be causal in nature. Low-grade systemic inflammation and redox imbalance, in particular, represent the major underlying mechanisms in this relationship. Neutrophil dysfunction, imbalance in T cell subtypes, oral-gut dysbiosis, hyperexpression of proinflammatory genes, and increased sympathetic outflow are some of the pathogenetic events involved. In addition, novel findings indicate that common genetic bases might shape the immune profile towards this clinical phenotype, offering a rationale for potential therapeutic and prevention strategies of public health interest. This review summarizes recent advances, knowledge gaps and possible future directions in the field.

Association between Periodontitis and High Blood Pressure: Results from the Study of Periodontal Health in Almada-Seixal (SoPHiAS)

Periodontitis is a common chronic inflammatory disease which could have an important impact on blood pressure (BP). This study aimed to explore (a) the association between periodontal health and BP in a large representative cohort, (b) the predictive value of diagnosis of periodontitis in undiagnosed raised BP and (c) whether age is a mediator of this relationship. In total, 1057 randomly recruited individuals (mean age, 60.9 ± 16.3 years, 57.7% women) underwent periodontal clinical assessment and one-single BP measurement using an automated sphygmomanometer device. Logistic and linear regression models were used to estimate the odds of hypertension based on periodontitis case definitions. Mediation analysis was performed to understand the effect of age on the association of periodontitis with hypertension. Adjusted logistic model for gender, smoking habits and body mass index confirmed the association between high BP and periodontitis (OR = 2.31, 95%CI: 1.75-3.04, p < 0.001). Among 168 participants with undiagnosed high BP (15.9% of the study sample), 62.5% had periodontitis (n = 105). In this study, the association between periodontitis with both systolic blood pressure (SBP) (77.6%, p < 0.001) and diastolic blood pressure (DBP) (66.0%, p < 0.001) was mediated by age. Periodontitis is closely linked to BP in a representative Portuguese population.

TRPV4 is a regulator in P. gingivalis lipopolysaccharide-induced exacerbation of macrophage foam cell formation

Porphyromonas gingivalis (P.g), a major causative agent of periodontitis, has been linked to atherosclerosis, a chronic inflammatory vascular disease. Recent studies have suggested a link between periodontitis and arterial stiffness, a risk factor for atherosclerosis. However, the mechanisms by which P.g infection contributes to atherogenesis remain elusive. The formation of lipid-laden macrophage "foam cells" is critically important to development and progression of atherosclerosis. We have obtained evidence that TRPV4 (transient receptor potential channel of the vanilloid subfamily 4), a mechanosensitive channel, is a regulator of macrophage foam cell formation both in response to P.g-derived lipopolysaccharide (PgLPS) or to an increase in matrix stiffness. Importantly, we found that TRPV4 activity (Ca²⁺ influx) was increased in response to PgLPS. Genetic deletion or chemical antagonism of TRPV4 channels blocked PgLPS-triggered exacerbation of oxidized LDL (oxLDL)-mediated foam cell formation. Mechanistically, we found that (1) TRPV4 regulated oxLDL uptake but not its cell surface binding in macrophages; (2) reduced foam cell formation in TRPV4 null cells was independent of expression of CD36, a predominant receptor for oxLDL, and (3) co-localization of TRPV4 and CD36 on the macrophage plasma membrane was sensitive to the increased level of matrix stiffness occurring in the presence of PgLPS. Altogether, our results suggest that TRPV4 channels play an essential role in P.g-induced exacerbation of macrophage foam cell generation through a mechanism that modulates uptake of oxLDL.

Role of macrophage TRPV4 in inflammation

Transient receptor ion channels have emerged as immensely important channels/receptors in diverse physiological and pathological responses. Of particular interest is the transient receptor potential channel subfamily V member 4 (TRPV4), which is a polymodal, nonselective, calcium-permeant cation channel, and is activated by both endogenous and exogenous stimuli. Both neuronal and nonneuronal cells express functional TRPV4, which is responsive to a variety of biochemical and biomechanical stimuli. Emerging discoveries have advanced our understanding of the role of macrophage TRPV4 in numerous inflammatory diseases. In lung injury, TRPV4 mediates macrophage phagocytosis, secretion of pro-resolution cytokines, and generation of reactive oxygen species. TRPV4 regulates lipid-laden macrophage foam cell formation, the hallmark of atheroinflammatory conditions, in response to matrix stiffness and lipopolysaccharide stimulation. Accumulating data also point to a role of macrophage TRPV4 in the pathogenesis of the foreign body response, a chronic inflammatory condition, through the formation of foreign body giant cells. Deletion of TRPV4 in macrophages suppresses the allergic and nonallergic itch in a mouse model, suggesting a role of TRPV4 in skin disease. Here, we discuss the current understanding of the role of macrophage TRPV4 in various inflammatory conditions.

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.

Impact of anti-infective periodontal therapy on parameters of vascular health

AIM

This study assessed the impact of anti-infective periodontal therapy on the status of vascular health.

MATERIALS AND METHODS

Periodontal and vascular health of 55 patients with severe untreated chronic periodontitis was evaluated before and 12 months after anti-infective periodontal therapy. Observed parameters were bleeding on probing (BoP), pocket probing depth (PPD), periodontal inflamed surface area index (PISA), pulse wave velocity (PWV), augmentation index (AIx), central pulse pressure (PPao) and peripheral systolic pressure (RRsys).

RESULTS

ΔPISA (baseline-12 months) correlated with ΔPWV (τ 0.21; p < .03), ΔAIx (τ 0.29; p < .002) and ΔPPao (τ 0.23; p < .02). ΔBoP% (baseline-12 months) correlated with ΔPWV (τ 0.18; p < .05) and ΔAIx (τ 0.25; p < .01), while mean ΔPPD (baseline-12 months) correlated with ΔPWV (τ 0.24; p < .01) and ΔAIx (τ 0.21; p < .03). Grouping patients evenly into three groups based on tertiles of BoP resolution after 12 months revealed a significant decrease in the observed PWV median value by -0.6 m/s (p < .04) in the best response tertile (ΔBoP ≥ 88%). In the worst response tertile (ΔBoP ≤ 66%), by contrast, significant increase in PPao (+10.5 mmHg; p < .02) and AIx (+5.5; p < .02) was observed.

CONCLUSION

Efficacious resolution of periodontal inflammation may beneficially impact on vascular health.

Oxidative Stress in Oral Diseases: Understanding Its Relation with Other Systemic Diseases

Oxidative stress occurs in diabetes, various cancers, liver diseases, stroke, rheumatoid arthritis, chronic inflammation, and other degenerative diseases related to the nervous system. The free radicals have deleterious effect on various organs of the body. This is due to lipid peroxidation and irreversible protein modification that leads to cellular apoptosis or programmed cell death. During recent years, there is a rise in the oral diseases related to oxidative stress. Oxidative stress in oral disease is related to other systemic diseases in the body such as periodontitis, cardiovascular, pancreatic, gastric, and liver diseases. In the present review, we discuss the various pathways that mediate oxidative cellular damage. Numerous pathways mediate oxidative cellular damage and these include caspase pathway, PERK/NRF2 pathway, NADPH oxidase 4 pathways and JNK/mitogen-activated protein (MAP) kinase pathway. We also discuss the role of inflammatory markers, lipid peroxidation, and role of oxygen species linked to oxidative stress. Knowledge of different pathways, role of inflammatory markers, and importance of low-density lipoprotein, fibrinogen, creatinine, nitric oxide, nitrates, and highly sensitive C-reactive proteins may be helpful in understanding the pathogenesis and plan better treatment for oral diseases which involve oxidative stress.

Inflammatory Markers for Arterial Stiffness in Cardiovascular Diseases

Arterial stiffness predicts an increased risk of cardiovascular events. Inflammation plays a major role in large arteries stiffening, related to atherosclerosis, arteriosclerosis, endothelial dysfunction, smooth muscle cell migration, vascular calcification, increased activity of metalloproteinases, extracellular matrix degradation, oxidative stress, elastolysis, and degradation of collagen. The present paper reviews main mechanisms explaining the crosstalk between inflammation and arterial stiffness and the most common inflammatory markers associated with increased arterial stiffness, considering the most recent clinical and experimental studies. Diverse studies revealed significant correlations between the severity of arterial stiffness and inflammatory markers, such as white blood cell count, neutrophil/lymphocyte ratio, adhesion molecules, fibrinogen, C-reactive protein, cytokines, microRNAs, and cyclooxygenase-2, in patients with a broad variety of diseases, such as metabolic syndrome, diabetes, coronary heart disease, peripheral arterial disease, malignant and rheumatic disorders, polycystic kidney disease, renal transplant, familial Mediterranean fever, and oral infections, and in women with preeclampsia or after menopause. There is strong evidence that inflammation plays an important and, at least, partly reversible role in the development of arterial stiffness, and inflammatory markers may be useful additional tools in the assessment of the cardiovascular risk in clinical practice. Combined assessment of arterial stiffness and inflammatory markers may improve non-invasive assessment of cardiovascular risk, enabling selection of high-risk patients for prophylactic treatment or more regular medical examination. Development of future destiffening therapies may target pro-inflammatory mechanisms.

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.

Assessment of arterial stiffness in periodontitis using a novel pulse wave imaging methodology

AIM

We investigated the cross-sectional relationship between periodontal status and arterial stiffness, assessed through a novel Pulse Wave Imaging methodology.

METHODS

Eighty volunteers were enrolled (39% male, age range 24-78 years) and 33 pairs were formed of periodontitis patients/periodontally healthy controls, matched by age and gender. A full-mouth periodontal examination was performed and the degree of stiffness of the right and left carotid arteries was assessed by measuring pulse wave velocity (PWV) and the uniformity in pulse wave propagation (R² ). Wilcoxon signed-rank tests for paired observations were used to compare periodontitis patients and healthy controls. Univariate and multivariate analyses were performed to analyze the association between PWV and R² and potential explanatory variables.

RESULTS

Patients with periodontitis had a statistically significantly lower uniformity in wave propagation (R² ) than controls (p = .01), but PWV did not differ between the two groups. Univariate analysis showed a significant negative association between R² and periodontitis, body mass index and smoking; periodontitis remained statistically associated with R² in the multivariate analyses.

CONCLUSIONS

Patients with periodontitis and no established cardiovascular disease presented with lower degree of uniformity in the transmission of the pulse wave through the carotid arteries, suggesting an association between periodontitis and arterial stiffness/functional alterations.