Vascular diseases and oral infections

Exploring the presence of oral bacteria in non-oral sites of patients with cardiovascular diseases using whole metagenomic data

Cardiovascular diseases (CVDs) encompass various conditions affecting the heart and its blood vessels and are often linked with oral microbes. Our data analysis aimed to identify oral bacteria from other non-oral sites (i.e., gut, arterial plaque and cultured blood) that could be linked with CVDs. Taxonomic profiling identified bacteria to the species level and compared with the Human Oral Microbiome Database (HOMD). The oral bacteria in the gut, cultured blood and arterial plaque samples were catalogued, with their average frequency calculated for each sample. Additionally, data were filtered by comparison with the Human Microbiome Project (HMP) database. We identified 17,243 microbial species, of which 410 were present in the HOMD database and further denominated as "oral", and were found in at least one gut sample, but only 221 and 169 species were identified in the cultured blood and plaque samples, respectively. Of the 410 species, 153 were present solely in oral-associated environments after comparison with the HMP database, irrespective of their presence in other body sites. Our results suggest a potential connection between the presence of specific species of oral bacterial and occurrence of CVDs. Detecting these oral bacterial species in non-oral sites of patients with CVDs could help uncover the link between oral health and general health, including cardiovascular conditions via bacterial translocation.

The systemic oral health connection: Biofilms

Frequently, periodontal health and it's associated oral biofilm has not been addressed in those patients who have systemic health issues, especially those who are not responding to medical treatment via their physician. Oral biofilm may be present in the periodontal sulcus in the absence of clinical disease of periodontal disease (bleeding on probing, gingival inflammation) and periodontal reaction is dependent on the patient's immune response to the associated bacterial and their byproducts. Increasing evidence has been emerging the past decade connecting oral biofilm with systemic conditions, either initiating them or complicating those medical conditions. The patient's health needs to be thought of as a whole-body system with connections that may originate in the oral cavity and have distant affects throughout the body. To maximize total health, a coordination in healthcare needs to be a symbiosis between the physician and dentist to eliminate the oral biofilm and aid in prevention of systemic disease or minimize those effects to improve the patient's overall health and quality of life. Various areas of systemic health have been associated with the bacteria and their byproducts in the oral biofilm. Those include cardiovascular disease, chronic kidney disease, diabetes, pulmonary disease, prostate cancer, colon cancer, pancreatic cancer, pre-term pregnancy, erectile dysfunction Alzheimer's disease and Rheumatoid arthritis. This article will discuss oral biofilm, its affects systemically and review the medical conditions associated with the oral systemic connection with an extensive review of the literature.

Effect of per Capita Income on the Relationship between Periodontal Disease during Pregnancy and the Risk of Preterm Birth and Low Birth Weight Newborn. Systematic Review and Meta-Analysis

This work analyzed the available evidence in the scientific literature about the risk of preterm birth and/or giving birth to low birth weight newborns in pregnant women with periodontal disease. A systematic search was carried out in three databases for observational cohort studies that related periodontal disease in pregnant women with the risk of preterm delivery and/or low birth weight, and that gave their results in relative risk (RR) values. Eleven articles were found, meeting the inclusion criteria. Statistically significant values were obtained regarding the risk of preterm birth in pregnant women with periodontitis (RR = 1.67 (1.17–2.38), 95% confidence interval (CI)), and low birth weight (RR = 2.53 (1.61–3.98) 95% CI). When a meta-regression was carried out to relate these results to the income level of each country, statistically significant results were also obtained; on the one hand, for preterm birth, a RR = 1.8 (1.43–2.27) 95% CI was obtained and, on the other hand, for low birth weight, RR = 2.9 (1.98–4.26) 95% CI. A statistically significant association of periodontitis, and the two childbirth complications studied was found, when studying the association between these results and the country’s per capita income level. However, more studies and clinical trials are needed in this regard to confirm the conclusions obtained.

Comparative evaluation of C-reactive protein and complete blood count in chronic periodontitis patients following Phase I therapy: A serological and hematological study

Background

Periodontitis is an example of persistent low-grade disease. The primary cause for the disease is anaerobic gram-negative bacteria thriving in a protective biofilm in subgingival periodontal pockets. The treatment of this infection is removal of these deposits by mechanical instrumentation (Phase I therapy). This can help achieve reduction of the bacterial load thus suppressing localized inflammation. Phase I therapy or mechanical debridement of the subgingival area causes a severe transient bacteremia along with some damage to the surrounding soft tissue, resulting in a systemic inflammatory response being elicited. The objective of the current study was to comparatively assess periodontal parameters, serum C-reactive protein (CRP) levels, and transitory alterations in hematological parameters; in 30-systemically healthy patients having chronic periodontitis, before and after Phase I therapy.

Materials and Method

The individuals underwent an intensive session of mechanotherapy with ultrasonic scalers. Blood samples were taken before treatment and at 1, 7, and 30 days after treatment to assess the parameters.

Results

There was a clear recuperation in periodontal parameters as well as marked improvement in the values of CRP and complete blood count (CBC) by 30 days after transient alterations occurring initially.

Conclusion

Phase I (mechanotherapy) - the first step in treatment of periodontitis leads to transient bacteremia by systemic dispersal of bacteria harbored in dental plaque. This produces an acute-phase response resulting in variations in the levels of CRP and the CBC counts. After a month, both periodontal and hematological parameters show marked improvement, thus establishing periodontal health and decreasing the risk of inadvertent cardiovascular or thromboembolic episode.

Latest Concepts in the Endodontic Management of Patients with Cardiovascular Disorders

There are several cardiovascular interventions that need special considerations in the provision of treatments within the scope of endodontics. If these interventions are not carefully identified, diagnosed, and considered in the overall treatment plan for the patient, they may result in fatal conditions. These include hypertension that causes fatal cardiac disorders, such as angina pectoris, ischemic heart diseases, and myocardial infarction, and also cerebrovascular diseases; congestive heart failure; infective endocarditis, valvular diseases, and carrying pacemakers; and the use of antiplatelet and anticoagulant drugs that are commonly prescribed for patients who have experienced heart stroke. The aim of this article is to review the newest recommendations for patients with these disorders who require endodontic treatments.

Dental Infection and Resistance-Global Health Consequences

Antibiotics are widely used in dental caries and another dental related issues, both for therapeutic and prophylactic reasons. Unfortunately, in recent years the use of antibiotics has been accompanied by the rapid emergence antimicrobial resistance. Dental caries and periodontal diseases are historically known as the top oral health burden in both developing and developed nations affecting around 20⁻50% of the population of this planet and the uppermost reason for tooth loss. Dental surgeons and family practitioners frequently prescribed antimicrobials for their patients as outpatient care. Several studies reported that antibiotics are often irrationally- and overprescribed in dental diseases which is the basis of antimicrobial resistance. The aim of this review is to evaluate the use of antibiotics in dental diseases. Almost certainly the promotion of primary oral health care (POHC) in primary health care program especially among the least and middle-income countries (LMIC) may be the answer to ensure and promote rational dental care.

A practical guide to the oral microbiome and its relation to health and disease

The oral microbiome is incredibly complex with the average adult harboring about 50-100 billion bacteria in the oral cavity, which represent about 200 predominant bacterial species. Collectively, there are approximately 700 predominant taxa of which less than one-third still have not yet been grown in vitro. Compared to other body sites, the oral microbiome is unique and readily accessible. There is extensive literature available describing the oral microbiome and discussing the roles that bacteria may play in oral health and disease. However, the purpose of this review is not to rehash these detailed studies but rather to educate the reader with understanding the essence of the oral microbiome, namely that there are abundant bacteria in numbers and types, that there are molecular methods to rapidly determine bacterial associations, that there is site specificity for colonization of the host, that there are specific associations with oral health and disease, that oral bacteria may serve as biomarkers for non-oral diseases, and that oral microbial profiles may have potential use to assess disease risk.

Periodontitis as risk factor for acute myocardial infarction: A case control study

OBJECTIVES

To assess the periodontal status among the patients suffering from acute myocardial infarction (AMI) and to investigate whether periodontitis is a risk factor for AMI or not.

MATERIALS AND METHODS

A cross-sectional study of 60 subjects, 30 subjects in each AMI group and control group was conducted. Details of risk factors like age, sex, smoking, and alcohol consumption were obtained through a personal interview. Medical history was retrieved from the medical file. The oral hygiene status was assessed by using a simplified oral hygiene index (OHI-S) and the periodontal status was assessed by community periodontal index (CPI) and loss of attachment (LOA) as per World Health Organization (WHO) methodology 1997. Chi-square test was used to analyze qualitative data whereas t-test and one way analysis of variance (ANOVA) test was used for quantitative data. Multiple regression model was applied to check the risk factors for AMI.

RESULTS

The mean OHI-S score for case and control group was 3.98 ± 0.70 and 3.11 ± 0.68, respectively, which was statistically highly significant ( P < 0.001). There was high severity of periodontitis (for both in terms of CPI and LOA) in the case group as compared with control group, that was found to be statistically highly significant ( P < 0.001). There was a significant result for OHI-S and LOA score with odds ratio of 0.13 and 0.79, respectively, when the multiple logistic regression model was applied.

CONCLUSION

The results of the present study show evidence that those patients who have experienced myocardial infarction exhibit poor periodontal conditions in comparison to healthy subjects and suggest an association between chronic oral infections and myocardial infarction.

The flavonoids luteolin and quercetagetin inhibit lipoteichoic acid actions on H9c2 cardiomyocytes

Dental focal infections are infections in the mouth that cause subsequent infection and symptoms in other parts of the body. Dental conditions such as periodontitis have been associated with coronary heart disease. In this study, we investigated the effect of flavonoids on activation of mitogen-activated protein kinase (MAPK) family members, protein kinase B (AKT), and IL-1 beta expression by rat heart embryonic (H9c2) cells upon stimulation with LTA. Pretreatment with four flavonoids, including quercetin, genistein, quercetagetin, and luteolin diminished LTA-induced ERK1/2, JNK, p38, and AKT phosphorylation and IL-1 beta gene expression. Our findings indicate that flavonoids interfere with LTA signal transduction.

Infection After Acute Ischemic Stroke

Background and Purpose— Infection after experimental focal ischemia may result from brain-induced immunodepression, but it is unsettled whether a similar syndrome occurs in human stroke.

Summary of Review— Many patients develop infections shortly after acute stroke regardless of optimal management. Mortality is higher in these patients and the severity of stroke is the strongest determinant of the infectious risk. However, it is controversial whether infections promote neurological worsening or alternatively represent a marker of severe disease. The brain and the immune system are functionally linked through neural and humoral pathways, and decreased immune competence with higher incidence of infections has been demonstrated in several acute neurological conditions. In experimental brain ischemia, infections are associated with the activation of the autonomous nervous system and neuroendocrine pathways, which increase the strength of anti-inflammatory signals. A strong cytokine-mediated anti-inflammatory response was recently observed in stroke patients at higher risk of infection, although infection could not demonstrate an independent association with the progression of the symptoms.

Conclusions— The appearance of infection in patients with acute stroke obeys in part to immunological mechanisms triggered by acute brain injury. An excessive anti-inflammatory response is a key facilitating factor for the development of infection, and it is likely that this immunological response represents an adaptive mechanism to brain ischemia. Contrarily, it is unclear whether infection contributes independently to poor outcome in human stroke. Overall, a better understanding of the cross-talk between the brain and the immune system might lead to more effective therapies in patients with acute stroke.

Periodontitis as risk factor for acute myocardial infarction. A case control study of Spanish adults

OBJECTIVE

The present study was designed to determine, in a case-control study of a Spanish population, whether periodontitis is a risk factor for acute myocardial infarction.

BACKGROUND

Although part of cardiovascular risk could be explained by periodontal disease, available meta-analyses find significant heterogeneity and recommend the need for further observational and intervention studies.

METHODS

A case-control study was conducted of 149 Spanish patients aged between 40 and 75 years, with 72 cases (acute myocardial infarction) and 77 controls (trauma patients). Periodontitis was measured as the percentage of sites with clinical attachment loss greater than 3 mm. A multivariate logistic regression model was constructed to estimate the adjusted effect of periodontitis on acute myocardial infarction, after considering the potential confounding effect of a large pool of risk factors.

RESULTS

In a bivariate analysis, males, older patients, smokers, and those with hypertension, diabetes or hypercholesterolemia, showed an increased risk of acute myocardial infarction. The cases, compared to controls, showed worse results for all periodontal variables studied: gingival retraction, pocket depth, and periodontitis. The final multiple logistic model included sex, age, tobacco habit, hypertension, diabetes, hypercholesterolemia, regular exercise, and periodontitis. The association between periodontitis (dichotomized) and acute myocardial infarction was high and significant in both the unadjusted (odds ratio = 4.42, p < 0.001) and adjusted analyses (odds ratio = 3.31, p = 0.005).

CONCLUSION

There is evidence of an association between periodontitis and acute myocardial infarction after adjusting for well-known risk factors for acute myocardial infarction.

Further evidence of the association between periodontal conditions and coronary artery disease

BACKGROUND

There is increasing evidence that chronic infections, such as periodontal diseases, could play a role in the initiation and development of coronary artery disease (CAD). The present study was intended to test for a possible association between presence and severity of periodontitis and coronary artery disease in a Belgian population.

METHODS

A total of 108 CAD patients (mean age 59.2 +/- 11 years) and 62 presumably healthy controls (mean age 57.7 +/- 9 years) were enrolled in the study. Probing depth, periodontal pocket bleeding index (PPBI), plaque index, furcation involvements, and tooth mobility were evaluated to compare periodontal health in both groups. The subjects were also ranked according to a novel index of periodontitis severity, the periodontal index for risk of infectiousness (PIRI), aimed at quantifying the risk of release of proinflammatory mediators from the periodontal sites.

RESULTS

Periodontitis was significantly more frequent in CAD patients than in controls (CAD patients: 91%; controls: 66%). The mean number of pockets was 18 +/- 17.1 in cardiac patients versus 7.6 +/- 12.7 in controls (P < 0.0001), despite the fact that the mean number of missing teeth was significantly greater in cases than in controls (14 +/- 7.1 versus 9 +/- 5.2; P < 0.0001). Furthermore, proportions of mobile teeth, bleeding sites, periodontal pockets, and involved furcations were significantly higher in CAD patients than in controls. In addition, the extent of the periodontal disease present was also greater in cases than in controls. A logistic model, adjusted for known cardiovascular risk factors, showed a strong association between CAD and periodontitis (odds ratio [OR] = 6.5). Moreover, there was a significant dose-response relationship between increasing scores of the periodontal risk of infectiousness and the presence of CAD (adjusted OR = 1.3 per PIRI unit).

CONCLUSION

In the present study, periodontitis was revealed to be a significant risk factor for CAD after adjusting for other confounding factors, with the level of association increasing with the individual extent of the periodontal lesions.

Associations of Periodontal Status with General Health Conditions and Serum Antibody Titers forPorphyromonas gingivalisandActinobacillus actinomycetemcomitans

BACKGROUND

The purpose of the present study was to evaluate associations of periodontal status with general health conditions and with serum antibody titers for Porphyromonas gingivalis (Pg) and Actinobacillus actinomycetemcomitans (Aa) in a Japanese population.

METHODS

Subjects (1,314) aged 40 years or older were recruited for the study. Their periodontal status was evaluated using the community periodontal index of treatment needs (CPITN). Records from general health examinations were used for the present analyses, including data on age, gender, body mass index, systolic and diastolic blood pressure (SBP/DBP); levels of serum alkaline phosphatase, total cholesterol, high-density lipoprotein cholesterol, triglyceride, fasting blood glucose, and C-reactive protein (CRP); counts of white blood cells (WBC) and platelets; smoking habit; and electrocardiogram recordings. Serum IgG antibody titers for Pg fimbrial antigens (IgG.Pg.Fim.), Pg whole-cell antigens (IgG.Pg.whol.), and Aa whole-cell antigens (IgG.Aa.whol.) were determined using enzyme-linked immunosorbent assay. The subjects were divided, according to their maximum CPITN codes, into four periodontal groups: max.CPITN-0/1/2, -3, -4, or -MS (missing sextant).

RESULTS

Multivariable logistic regression analyses revealed significant associations of the max.CPITN-4 subjects who were males (odds ratio, OR: 2.03) or smokers (OR: 1.73), or who had high diastolic blood pressure (OR: 1.27), high WBC (OR: 1.24), high serum CRP level (OR: 2.39) and high serum IgG.Pg.Fim. (OR: 1.17), IgG.Pg.whol. (OR:1.54), and IgG.Aa.whol. (OR: 1.19) titers.

CONCLUSION

Significant associations between periodontal status and several health conditions were found in the adult population examined, including gender, smoking habit, diastolic blood pressure, white blood cell counts, C-reactive protein, and serum IgG antibodies to P. gingivalis fimbriae, IgG P. gingivalis whole cell, and IgG A. actinomycetemcomitans whole cell titers.

Systemic release of endotoxins induced by gentle mastication: association with periodontitis severity

BACKGROUND

Periodontitis has recently been identified as a potential risk factor for systemic pathologies such as cardiovascular disease, the hypothesis being that periodontal pockets could release pro-inflammatory bacterial components, for instance endotoxins, into the bloodstream. It is known that the oral cavity can be a source of circulating bacteria, but this has never been shown for bacterial endotoxins, and no evidence exists so far that the risk of systemic injury is related to the severity of periodontitis. The aim of the present study was to test the influence of gentle mastication on the occurrence of endotoxemia in patients with or without periodontal disease.

METHODS

A total of 67 subjects were periodontally examined and grouped according to their periodontal status. This classification was based on an original index of severity of periodontal disease (periodontal index for risk of infectiousness, PIRI) aimed at reflecting the individual risk of systemic injury from the periodontal niches. Thus, the patients were classified into 3 risk groups: low, PIRI = 0; n = 25; moderate, 1 < or = PIRI < or = 5, n = 27; and high 6 < or = PIRI < or = 10, n = 15. Blood samples were collected before and 5 to 10 minutes after a standardized session of gentle mastication for detection of circulating endotoxins. Blood samples were tested with a chromogenic limulus amoebocyte lysate assay.

RESULTS

Overall, blood levels of endotoxin after mastication were found to be significantly higher than before mastication (0.89 +/- 3.3 pg/ml versus 3.0 +/- 5.8 pg/ml; P= 0.0002). Likewise, the incidence of positive endotoxemia rose from 6% before mastication to 24% after mastication (P = 0.001). When accounting for the PIRI index, endotoxin levels and positive endotoxemia proved to be significantly higher in patients with severe periodontal disease than in the subjects with low or moderate periodontitis.

CONCLUSIONS

Gentle mastication is able to induce the release of bacterial endotoxins from oral origin into the bloodstream, especially when patients have severe periodontal disease. This finding suggests that a diseased periodontium can be a major and underestimated source of chronic, or even permanent, release of bacterial pro-inflammatory components into the bloodstream.

Association between periodontal disease and acute myocardial infarction

BACKGROUND

Coronary heart disease is the leading cause of morbidity and mortality throughout the world. Well-known risk factors independently or combined participate in both myocardial infarction and atherosclerosis. Recent data have shown that viral and bacterial infections may also contribute to the acute thromboembolic events. The aim of the present study was to investigate the possible association between periodontal health and coronary heart disease in patients with acute myocardial infarction and chronic coronary heart disease.

METHODS

A total of 120 patients, 60 with acute myocardial infarction (AMI) and 60 with chronic coronary heart disease (CCHD) were included in this study. The patients in the AMI group (50 men and 10 women; mean age 53.8 +/- 9.5 years) were admitted to the Department of Cardiology, University Hospital of Ege because of AMI. The CCHD patients group (42 men and 18 women; mean age 58.5 +/- 11.6 years) had no documented history of recent acute coronary events. All patients were clinically examined and completed a medical questionnaire. Missing teeth, restorations, probing depth (PD) and bleeding on probing (BOP) were recorded. Blood samples were taken on admission for measurements of serum total cholesterol, triglycerides, high density lipoprotein cholesterol (HDL-cholesterol), low density lipoprotein cholesterol (LDL-cholesterol), and fasting blood glucose level. Sample proportions were compared by chi square test, quantitative variables with Student t test. The relation of clinical parameters and conventional risk factors to AMI was assessed with logistic regression analysis.

RESULTS

The number of sites with PD > or = 4 mm, the percentage of sites exhibiting BOP, smoking status, total cholesterol, LDL-cholesterol, and triglycerides were statistically different between AMI and CCHD groups (P <0.05). Logistic regression analysis showed that the percentage of sites exhibiting BOP, the number of sites with PD > or = 4, the number of restorations, smoking status, and triglycerides levels were significantly associated with AMI (P <0.05).

CONCLUSIONS

The results of this study indicate that periodontal disease may be associated with acute myocardial infarction. To our knowledge, this is the first study that reports the importance of periodontal health in the occurrence of acute myocardial infarction in a Turkish population. We propose that prospective randomized studies are needed to determine whether periodontal disease is a risk factor in the occurrence of acute myocardial infarction.

Systemic diseases caused by oral infection

Recently, it has been recognized that oral infection, especially periodontitis, may affect the course and pathogenesis of a number of systemic diseases, such as cardiovascular disease, bacterial pneumonia, diabetes mellitus, and low birth weight. The purpose of this review is to evaluate the current status of oral infections, especially periodontitis, as a causal factor for systemic diseases. Three mechanisms or pathways linking oral infections to secondary systemic effects have been proposed: (i) metastatic spread of infection from the oral cavity as a result of transient bacteremia, (ii) metastatic injury from the effects of circulating oral microbial toxins, and (iii) metastatic inflammation caused by immunological injury induced by oral microorganisms. Periodontitis as a major oral infection may affect the host's susceptibility to systemic disease in three ways: by shared risk factors; subgingival biofilms acting as reservoirs of gram-negative bacteria; and the periodontium acting as a reservoir of inflammatory mediators. Proposed evidence and mechanisms of the above odontogenic systemic diseases are given.

Systemic diseases caused by oral infection

Recently, it has been recognized that oral infection, especially periodontitis, may affect the course and pathogenesis of a number of systemic diseases, such as cardiovascular disease, bacterial pneumonia, diabetes mellitus, and low birth weight. The purpose of this review is to evaluate the current status of oral infections, especially periodontitis, as a causal factor for systemic diseases. Three mechanisms or pathways linking oral infections to secondary systemic effects have been proposed: (i) metastatic spread of infection from the oral cavity as a result of transient bacteremia, (ii) metastatic injury from the effects of circulating oral microbial toxins, and (iii) metastatic inflammation caused by immunological injury induced by oral microorganisms. Periodontitis as a major oral infection may affect the host's susceptibility to systemic disease in three ways: by shared risk factors; subgingival biofilms acting as reservoirs of gram-negative bacteria; and the periodontium acting as a reservoir of inflammatory mediators. Proposed evidence and mechanisms of the above odontogenic systemic diseases are given.

The antimicrobial treatment of periodontal disease: changing the treatment paradigm

Over the last 100 years, methods of surgical periodontal treatment have enjoyed a history of success in improving oral health. The paradigm of care is based on the "non-specific plaque hypothesis"--that is, the overgrowth of bacterial plaques cause periodontal disease, and the suppression of this overgrowth reduces disease risk. The central feature of this approach to care is the removal of inflamed gingival tissue around the teeth to reduce periodontal pocket depth, thereby facilitating plaque removal by the dentist and by the patient at home. Over the last 30 years, with the recognition that periodontal disease(s) is caused by specific bacteria and that specific antimicrobial agents can reduce or eliminate the infection, a second paradigm has developed. This new paradigm, the "specific plaque hypothesis", focuses on reducing the specific bacteria that cause periodontal attachment loss. The contrast between the two paradigms can be succinctly stated as follows: The antimicrobial therapy reduces the cause, while the surgical therapy reduces the result of the periodontal infection. The specific plaque hypothesis has two important implications. First, with the increasing attention to evidence-based models for prevention, treatment, outcome assessment, and reimbursement of care, increasing attention and financial effort will be channeled into effective preventive and treatment methods. Second, the recent observations that periodontal infections increase the risk of specific systemic health problems, such as cardiovascular disease, argue for the prevention and elimination of these periodontal infections. This review highlights some of the evidence for the specific plaque hypothesis, and the questions that should be addressed if antimicrobial agents are to be used responsively and effectively.

Root canal treatment and general health: a review of the literature

REVIEW

The focal infection theory was prominent in the medical literature during the early 1900s and curtailed the progress of endodontics. This theory proposed that microorganisms, or their toxins, arising from a focus of circumscribed infection within a tissue could disseminate systemically, resulting in the initiation or exacerbation of systemic illness or the damage of a distant tissue site. For example, during the focal infection era rheumatoid arthritis (RA) was identified as having a close relationship with dental health. The theory was eventually discredited because there was only anecdotal evidence to support its claims and few scientifically controlled studies. There has been a renewed interest in the influence that foci of infection within the oral tissues may have on general health. Some current research suggests a possible relationship between dental health and cardiovascular disease and published case reports have cited dental sources as causes for several systemic illnesses. Improved laboratory procedures employing sophisticated molecular biological techniques and enhanced culturing techniques have allowed researchers to confirm that bacteria recovered from the peripheral blood during root canal treatment originated in the root canal. It has been suggested that the bacteraemia, or the associated bacterial endotoxins, subsequent to root canal treatment, may cause potential systemic complications. Further research is required, however, using current sampling and laboratory methods from scientifically controlled population groups to determine if a significant relationship between general health and periradicular infection exists.

The prevalence of BANA-hydrolyzing periodontopathic bacteria in smokers

Smoking has been identified as a risk factor for development of periodontal disease and a strong indicator for treatment failure in periodontal patients. This study examined 172 patients categorized as current smokers (n=55), previous smokers (n=38) or individuals that had never smoked (n=79). A total of 670 interproximal plaques collected with a wooden toothpick were analyzed for hydrolysis of the synthetic trypsin substrate benzoyl-DL-arginine naphthylamide (BANA). About 95% of the BANA hydrolysis by plaque is due to the presence of one or more of the periodontopathogens, P. gingivalis, T. denticola or B. forsythus. Gingival health was measured using the papillary bleeding score (PBS). Current smokers had less gingival bleeding than previous smokers or those who had never smoked (20% versus 41% and 25%, respectively). Plaque removed from non-bleeding sites in current smokers were 11x more likely to have a positive BANA reaction when compared to plaque removed from non-bleeding sites in individuals who never smoked. A significant positive relationship exists between smoking and colonization by the BANA periodontopathogens. Smoking may select for these periodontopathic species in the plaque and may be one reason why smoking is a risk factor in periodontal disease development.

Anaerobic Periodontal Infections as Risk Factors for Medical Diseases

Advanced forms of periodontal disease are associated with the overgrowth of a limited number of gram-negative anaerobic species in plaques found in periodontal pockets. Double-blind clinical trials of metronidazole and doxycycline, combined with debriding of the tooth surfaces, have significantly reduced the need for periodontal surgery. Epidemiologic studies have indicated that untreated periodontal disease could be a risk factor for preterm delivery of low birth weight infants, coronary heart disease, and cerebral vascular accidents. This is because gram-negative anaerobic species implicated in periodontal disease, eg, Bacteroides forsythus, Porphyromonas gingivalis, and Treponema denticola, could introduce lipopolysaccharides, heat-shock proteins, and proinflammatory cytokines into the blood stream. If periodontal disease is a risk factor for cardiovascular disease, then it is a modifiable risk factor, as periodontal disease is treatable.

Periodontal findings in elderly patients with non-insulin dependent diabetes mellitus

The periodontal status of 25 patients with non-insulin dependent diabetes mellitus (NIDDM) (age range 58 to 76) was investigated and compared with 40 non-diabetic control subjects (age range 59 to 77). Surfaces with visible plaque and bleeding after probing, calculus, recessions, and pathological pockets were examined. The total attachment loss was calculated as a sum of recessions and pockets in millimeters. Mesial and distal bone loss was measured from panoramic radiographs and mean alveolar bone loss was calculated. Periodontal disease was considered advanced when mean alveolar bone loss was over 50%, or 2 or more teeth had pockets > or = 6 mm. Microbiological analysis comprised the detection of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Bacteroides forsythus by a polymerase chain reaction (PCR) method. Patients with NIDDM had significantly more often advanced periodontitis than control subjects, 40.0% and 12.5%, respectively. Diabetic patients did not harbor more pathogens than the control subjects. The HbA1C level deteriorated in patients with advanced periodontitis, but not in other patients with NIDDM, when compared to the situation 2 to 3 years earlier. Advanced periodontitis seems to be associated with the impairment of the metabolic control in patients with NIDDM, and a regular periodontal surveillance is therefore necessary.

The relationship between dental disease and cerebral vascular accident in elderly United States veterans

We report here information obtained from a cross-sectional study of 401 veterans, who were at least 60 years of age, which showed that several dental/oral conditions can be significantly associated with the diagnosis of a cerebral vascular accident (CVA), when included in a multivariate logistic regression model with and without many of the known risk factors for a CVA. The dental findings relative to the prevalence of dental caries and periodontal disease were not distinctly different between the subjects with and without a CVA in the bivariate analysis. A higher stimulated salivary flow was negatively associated with a CVA in the multivariate models. The plaque index and oral hygiene habits relating to brushing, flossing, and frequency of having teeth cleaned by a dentist/hygienist were significantly associated with a CVA in the bivariate analysis. Among these oral hygiene parameters, *needing help in brushing one's teeth" and the reported annual visit to the dentist/hygienist for teeth cleaning remained significant in the multivariate models involving the dependent-living subjects. The need for help in brushing one's teeth could reflect the fact that many subjects had reduced manual dexterity as a result of the CVA and required this extra care. However, the finding that those dependent-living individuals who reported that they did not have their teeth cleaned at least once a year were 4.76 times more likely to have had a CVA, suggests that a pattern of oral neglect might be associated with developing a CVA. The implications of this in terms of an intervention strategy for CVA warrants further consideration. However, caution is recommended because the data were obtained from a convenience sampling of older veterans and may not be generalizable to other populations.

Assessing the relationship between dental disease and coronary heart disease in elderly U.S. veterans

Several recent studies have shown a link between dental disease and coronary heart disease. The authors studied 320 U.S. veterans in a convenience sample to assess the relationship between oral health and systemic diseases among older people. They present cross-sectional data confirming that a statistically significant association exists between a diagnosis of coronary heart disease and certain oral health parameters, such as the number of missing teeth, plaque benzoyl-DL-arginine-naphthylamide test scores, salivary levels of Streptococcus sanguis and complaints of xerostomia. The oral parameters in these subjects were independent of and more strongly associated with coronary heart disease than were recognized risk factors, such as serum cholesterol levels, body mass index, diabetes and smoking status. However, because of the convenience sample studied, these findings cannot be generalized to other populations.

Poor oral health and coronary heart disease

A few recent studies have shown associations between poor oral health and coronary heart disease (CHD). The objective of this study was to examine the incidence of CHD in relation to number of teeth present and periodontal disease, and to explore potential mediators of this association, in a prospective cohort study. This study is a part of the ongoing Health Professionals Follow-Up Study (HPFS). Participants included a US national sample of 44,119 male health professionals (58% of whom were dentists), from 40 to 75 years of age, who reported no diagnosed CHD, cancer, or diabetes at baseline. We recorded 757 incident cases of CHD, including fatal and non-fatal myocardial infarction and sudden death, in six years of follow-up. Among men who reported pre-existing periodontal disease, those with 10 or fewer teeth were at increased risk of CHD compared with men with 25 or more teeth (relative risk = 1.67; 95% confidence interval, 1.03 to 2.71), after adjustment for standard CHD risk factors. Among men without pre-existing periodontal disease, no relationship was found (relative risk = 1.11; 95% confidence interval, 0.74 to 1.68). The associations were only slightly attenuated after we controlled for dietary factors. No overall associations were found between periodontal disease and coronary heart disease. Tooth loss may be associated with increased risk of CHD, primarily among those with a positive periodontal disease history; diet was only a small mediator of this association.

Periodontal status among male industrial workers in southern Finland with or without access to subsidized dental care

The association between subsidized dental care and periodontal status was studied in male industrial workers in southern Finland in 1994. Clinical examinations and a multiple-choice questionnaire were completed for 325 workers (age, 38-65 years) with access to subsidized dental care and 174 controls without access. The CPITN scores based on full-mouth recordings were analyzed, using both the individual and sextant as units of analysis. Overall, 6% of the subsidized group and 2% of the control group had no periodontal treatment need (p < 0.05). Deep pockets > or = 6 mm were found in 5% of the subsidized workers and 11% of the controls (p < 0.05). In the logistic regression analyses the probability of calculus was negatively associated with access to subsidized dental care. Smoking was the strongest independent factor affecting periodontal status. Our findings show a positive relationship between access to subsidized dental care and periodontal status.

Seafaring: a risk for seamen's oral health?

Information about the oral status and dental health behavior and the working history of 369 Finnish seamen on different types of ships was gathered by means of a questionnaire. A control group of workers on shore was formed for sailors 35-44 years of age. Removable dentures were worn by 16% of the seamen. Oral disorders during the week before the study were reported by one-third. During the previous 2 years 14% of the sailors had had at least one episode of oral troubles, 15% twice and 9% three or even more times. One-third of seamen with oral trouble had needed pain-killing tablets or antibiotics. Sick leave days had been needed by 3% of respondents during the previous 2 years because of oral disorder (mean length of sick leave period was 1.4 days). The control group reported gum bleeding more often than the seafarers. Even though there were no signs of poorer dental condition in sailors than in the controls on shore, the possibility that the seafaring could constitute a risk for the oral health of seamen in other age groups cannot be excluded.

Bacteremia in conjunction with endodontic therapy

This study characterizes oral microorganisms believed to have spread from the root canal into the blood stream during and after endodontic therapy of teeth with Asymptomatic apical periodontitis. Microbiological samples were taken under aseptic conditions from the root canal of 26 single-rooted teeth in 26 patients. In the endodontic treatment of 13 of the patients (Group 1), the first 3 reamers, sizes 15, 20 and 25, were used to a level 2 mm beyond the apical foramen. In the other 13 patients (Group 2), the instrumentation ended inside the root canal 1 mm short of the apical foramen. Blood samples were taken from the patients during the instrumentation and 10 min after the treatment was completed. Anaerobic microorganisms were isolated from all root canals. In 7 patients of Group 1, Propionibacterium acnes, Peptostreptococcus prevotii, Fusobacterium nucleatum, Prevotella intermedia and Saccharomyces cerevisiae were recovered from the blood. In 4 patients of Group 2, P. intermedia, Actinomyces israelii, Streptococcus intermedius and Streptococcus sanguis were isolated from the blood. Biochemical tests and antibiograms revealed that the isolates from the root canal and blood had identical profiles within the patients, strongly suggesting that the microorganisms isolated from the blood had the root canal as their source.

Systemic diseases caused by oral microorganisms

Human endodontic and periodontal infections are associated with complex microfloras in which approximately 150, (in apical periodontitis) and 350 (in marginal periodontitis) bacterial species have been encountered. These infections are predominantly anaerobic, with gram-negative rods being the most common isolates. The anatomic closeness of this microflora to the bloodstream can facilitate bacteremia and systemic spread of bacterial by-products and immunocomplexes. A variety of clinical procedures such as tooth extraction, periodontal and endodontic treatment, may cause translocation of microorganisms from the oral cavity to the bloodstream. The microorganisms that gain entrance to the blood circulate throughout the body, but are usually eliminated by the host (reticuloendothelial system) within minutes. However, in patients with ineffective heart valves or vascular diseases, bacteremia can be a potential danger, leading most commonly to infective endocarditis and myocardial or cerebral infarction. Other forms of systemic diseases such as brain abscesses, hematological infections and implant infections have also been related to oral microorganisms.

Profiling of Propionibacterium acnes recovered from root canal and blood during and after endodontic treatment

This report describes the first results of an ongoing study of bacteremia after endodontic treatment of teeth with Asymptomatic apical periodontitis. After access cavity preparation, microbiological samples were taken from the root canal under aseptic conditions in 4 single-rooted teeth in 4 patients. In treatment of 2 of the patients, the first 3 reamers (sizes 15-25) were deliberately used to a level 2 mm beyond the apical foramen. In 2 patients the instrumentation ended inside the root canal 1 mm short of the apical foramen. Blood samples were taken from the patients during the endodontic instrumentation and 10 min after the treatment was completed. Using lysis-filtration under anaerobic conditions, the blood was passed through a cellulose membrane filter. The filters as well as the root canal samples were incubated using an anaerobic technique. Anaerobic bacteria were isolated from all root canals. In the 2 patients where overinstrumentation had occurred, Propionibacterium acnes was recovered both from the root canals and from the blood samples taken during and after the treatment had been completed. Biochemical profiles, antibiotic susceptibility tests and electrophoresis of soluble proteins revealed that Propionibacterium acnes isolated from the root canal and blood samples were identical within patients, but varied between patients. Facultative anaerobic bacteria including Streptococcus sanguis were recovered from only one root canal sample and not from the blood samples.

New views on periodontal microbiota in special patient categories

The microorganisms in periodontitis of special patient categories have been only partially elucidated. The periodontitis microbiota of HIV-infected individuals, cancer patients on myelosuppressive therapy, and persons with other medical disorders includes common suspected periodontal pathogens as well as enteric rods, pseudomonads, staphylococci and yeasts. Failing implants also may be associated with classical periodontal pathogens as well as primarily nonoral potential pathogens. Refractory periodontitis in systemically healthy adults can show a great variety of oral and nonoral organisms. The frequent occurrence of unusual periodontal organisms in special patient categories may be due to a weakened host response and/or usage of various chemotherapeutic regimens. The unusual organisms may contribute to progressive periodontitis and in leukemia patients may even give rise to life-threatening systemic manifestations. The primary therapeutic goal in special periodontitis patients is control of pathogens and amid the wide range of pathogenic microfloras, an effective treatment strategy should include a comprehensive microbiological analysis, especially if systemic antimicrobial therapy is contemplated.