Periodontitis as a risk factor for cerebrovascular accident: a case-control study in the Indian population

Vitamin D levels and oral health in stroke patients during inpatient rehabilitation

BACKGROUND

Stroke is a severe that restricts the individual's functions, effects the oral health.

OBJECTIVES

The aim of this study was to investigate the relationship between oral health and vitamin D levels in stroke patients in rehabilitation units.

METHODS

Participants with stroke, and age- and sex-matched healthy controls were recruited for the study. Oral Health Impact Scale-14 (OHIP-14), Decayed, Missing, Filled Teeth (DMFT) Index, Community Periodontal Index of Treatment Needs (CPITN), Gingival Index (GI) and Plaque Index (PI) were assessed for all participants. Barthel Index (BI), Brunnstrom Recovery Scale (BRS) and Modified Ashworth Scale (MAS) assessed for the stroke patients. Vitamin D levels of each participant were recorded.

RESULTS

The stroke patients' DMFT index and OHIP-14 values were higher than those of the healthy controls (p < .05). However, no significant differences were observed in terms of CPTIN, PI, or GI scores (p > .05). No statistically significant difference was determined in the DMFT index, OHIP-14 scores, Community Periodontal Index of Treatment Needs (CPITN), PI (Plaque Index) and GI (Gingival Index) scores according to vitamin D levels among the stroke patients (p > .05). Stroke patients' functional scores (BRS, MAS and BI), vitamin D levels and oral health status (OHIP-14, DMFT, CPITN, PI and GI) were subjected to correlation analysis. This revealed significant negative correlation between BRS (arm, hand and leg), and BI and OHIP-14 scores (p < .05).

CONCLUSION

Although the DMFT index and oral health-related quality of life were adversely affected in stroke patients, no relationship was found between vitamin D and oral health status.

The oral microbiome of patients with ischemic stroke predicts their severity and prognosis

Background and objectives

Stroke is a common group of cerebrovascular diseases that can lead to brain damage or death. Several studies have shown a close link between oral health and stroke. However, the oral microbiome profiling of ischemic stroke (IS) and its potential clinical implication are unclear. This study aimed to describe the oral microbiota composition of IS, the high risk of IS, and healthy individuals and to profile the relationship between microbiota and IS prognosis.

Methods

This observational study recruited three groups: IS, high-risk IS (HRIS), and healthy control (HC) individuals. Clinical data and saliva were collected from participants. The modified Rankin scale score after 90 days was used to assess the prognosis of stroke. Extracted DNA from saliva and performed 16S ribosomal ribonucleic acid (rRNA) gene amplicon sequencing. Sequence data were analyzed using QIIME2 and R packages to evaluate the association between the oral microbiome and stroke.

Results

A total of 146 subjects were enrolled in this study according to the inclusion criteria. Compared with HC, HRIS and IS demonstrated a progressive increase trend in Chao1, observed species richness, and Shannon and Simpson diversity index. On the basis of permutational multivariate analysis of variance, the data indicate a great variation in the saliva microbiota composition between HC and HRIS (F = 2.40, P < 0.001), HC and IS (F = 5.07, P < 0.001), and HRIS and IS (F = 2.79, P < 0.001). The relative abundance of g_Streptococcus, g_Prevotella, g_Veillonella, g_Fusobacterium, and g_Treponema was higher in HRIS and IS compared with that in HC. Furthermore, we constructed the predictive model by differential genera to effectively distinguish patients with IS with poor 90-day prognoses from those with good (area under the curve = 79.7%; 95% CI, 64.41%-94.97%; p < 0.01).

Discussion

In summary, the oral salivary microbiome of HRIS and IS subjects have a higher diversity, and the differential bacteria have some predictive value for the severity and prognosis of IS. Oral microbiota may be used as potential biomarkers in patients with IS.

Periodontitis is a potential risk factor for transient ischemic attack and minor ischemic stroke in young adults: A nationwide population-based cohort study

BACKGROUND

This study aims to determine whether periodontitis is a risk factor for transient ischemic attack (TIA) in young adults.

METHODS

The National Health Insurance (NHI) Research Database in Taiwan was the source of the data used in this retrospective cohort study. Individuals aged 20 to 53 years with periodontitis in 2001 and 2002 (n = 792,426) and an age- and sex-matched control group (n = 792,426) were selected. All participants were followed up until TIA diagnosis, 55 years of age, removal from the NHI program, death, or December 31, 2016. The incidence density and hazard ratio (HR) of new-onset TIA were compared between individuals with periodontitis and controls. Periodontitis was defined by dentists according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 523.3-5 with concurrent antibiotic prescription or periodontal treatment excluding scaling performed by certified dentists. TIA was defined according to the ICD-9-CM code 435.x at hospital discharge.

RESULTS

After adjustment for confounding factors, the risk of developing TIA/minor ischemic stroke was calculated to be higher in participants with periodontitis (HR, 1.24; 95% confidence interval, 1.15-1.32; P <0.001) than in those without. The HR was slightly higher among people aged 20 to 40 years than among those aged 40 to 53 years.

CONCLUSION

Periodontitis is associated with an increased risk of developing TIA/minor ischemic stroke. Periodontitis might be a modifiable risk factor for stroke in young adults. Clinicians must devote greater attention to this potential association to develop new preventive and therapeutic strategies for stroke in young adults.

Association between the interval of worksite dental check-ups and dental and medical expenditures: a single-site, 12-year follow-up study in Japan

OBJECTIVES

The purpose of this study was to identify the effective intervals of worksite dental check-ups to reduce cumulative dental expenditures (CDEs) and cumulative medical expenditures (CMEs), based on 12 years of follow-up dental check-ups.

SETTING, DESIGN AND PARTICIPANTS

A longitudinal study was conducted between 2002 and 2014 fiscal years. A total of 2691 full-time employees (2099 males and 592 females) aged 20-59 years in a manufacturing company in Japan were recruited.

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on the follow-up of 12-year dental check-ups, the interval of dental check-ups visits was classified into the following categories: 'Once per year' as the regular group, 'At least once per 2 years' as the subregular group and others as the irregular group. CDEs and CMEs per capita were examined by the three groups of dental check-ups interval after adjustment for sex, age, occupation and total CMEs at baseline. For sensitivity analysis, decayed teeth, missing teeth and Community Periodontal Index were added as adjustment factors.

RESULTS

Compared with the irregular group, the pooled CDEs (including dental check-ups fee) per capita in the subregular group (OR 0.91, 95% CI 0.85 to 0.98) and regular group (OR 0.87, 95% CI 0.81 to 0.93) were significantly lower overall. The younger adults in the subregular group and younger-aged and middle-aged adults in the regular group had significantly lower CDEs. Sensitivity analysis confirmed these findings.

CONCLUSIONS

Our findings suggest that regular and subregular worksite dental check-ups were related to reduction of CDEs. It is important to promote a yearly interval between dental check-ups.

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

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

Evaluation of Oral Hygiene Status in Patients with Hemorrhagic and Ischemic Stroke

Background:

Stroke can broadly be categorized into ischemic or hemorrhagic. Ischemic stroke accounts for 85% of cerebrovascular accidents (CVAs), whereas hemorrhagic stroke accounts for 15% of CVAs. Stroke is broadly associated with loss of sensation or unilateral paralysis of orofacial structures.

Objectives:

The present study was conducted to evaluate the prevalence of various oral features in patients with ischemic and hemorrhagic stroke.

Materials and Methods:

One hundred patients diagnosed with stroke admitted in the intensive care unit were included in the study. The evaluation of oral manifestations and their prevalence was done by a well-experienced oral medicine expert deputed in the dental department of the hospital. A single examiner performed all oral evaluations.

Results:

The mean and median for the age were 60.8 and 59. Sixty of 100 patients were male, whereas 38 were female. Forty patients had hemorrhagic stroke, whereas 60 had ischemic stroke. Senenty-eight patients of 100 had features of periodontitis, 90 of 100 patients presented with halitosis, 79 presented with caries, 83 patients had positive signs of tongue hypermobility, and 75 patients had dysphagia.

Conclusion:

Oral hygiene is the most neglected aspect during rehabilitation in stroke patients. It is critical for stroke patients to receive thorough oral care, as it can prevent other systemic ailments and potentially life-threatening complications like aspiration pneumonia.

Evaluating the Effectiveness of Medical-Dental Integration to Close Preventive and Disease Management Care Gaps

Background

The integration of medical care into the dental setting has been shown to facilitate the closure of care gaps among patients with unmet needs. However, little is known about whether program effectiveness varies depending on whether the care gap is related to preventive care or disease management.

Materials and Methods

We used a matched cohort study design to compare closure of care gaps between patients aged 65+ who received care at a Kaiser Permanente Northwest (KPNW) Medical-Dental Integration (MDI) clinic or a non-MDI dental clinic between June 1, 2018, and December 31, 2019. The KPNW MDI program focuses on closing 12 preventive (e.g., flu vaccines) and 11 disease management care gaps (e.g., HbA1c testing) within the dental setting. Using the multivariable logistic regression, we separately analyzed care gap closure rates (yes vs. no) for patients who were overdue for: (1) preventive services only (n = 1,611), (2) disease management services only (n = 538), or (3) both types of services (n = 429), analyzing closure of each care gap type separately. All data were obtained through the electronic health record of KPNW.

Results

The MDI patients had significantly higher odds of closing preventive care gaps (OR = 1.51, 95% CI = 1.30-1.75) and disease management care gaps (OR = 1.65, 95% CI = 1.27-2.15) than the non-MDI patients when they only had care gaps of one type or the other. However, no significant association was found between MDI and care gap closure when patients were overdue for both care gap types.

Conclusions

Patients with care gaps related to either preventive care or disease management who received dental care in an MDI clinic had higher odds of closing these care gaps, but we found no evidence that MDI was helpful for those with both types of care gaps.

Practical Implications

MDI may be an effective model for facilitating the delivery of preventive and disease management services, mainly when patients are overdue for one type of these services. Future research should examine the impact of MDI on long-term health outcomes.

Serum High-Sensitive C-reactive Protein May Reflect Periodontitis in Patients With Stroke

BACKGROUND/AIM

Chronic infectious diseases are believed to increase the risk of stroke. We aimed to evaluate the prevalence of periodontal disease and its association with systemic inflammatory processes in patients suffering an acute stroke/transient ischemic attack (TIA).

PATIENTS AND METHODS

Altogether 36 acute stroke/TIA patients underwent clinical, laboratory and radiological examinations. The level of systemic inflammation was analyzed both with routine measurements of plasma C-reactive protein (p-CRP) and serum high-sensitivity CRP (s-hsCRP) to analyze their associations with periodontitis. The diagnostic criteria for periodontitis included increased probing depth (>4 mm) measured from four different sites, bleeding on probing, and horizontal (>1 mm), vertical (>1 mm) or apical bone loss observed on orthopantomography.

RESULTS

Twenty-six (72.2%) patients were diagnosed with periodontitis. Only five of the patients with periodontitis (19.2%) had elevated p-CRP values whereas the majority, (17/26; 65.4%) had elevated s-hsCRP values (p<0.01). Absolute s-hsCRP values in patients with periodontitis (8.9±12.5 mg/l) were significantly higher than in patients without periodontitis (2.3±3.0 mg/l; p<0.05). Absolute p-CRP concentrations did not differ (2.3±5.8 vs. 2.4±5.1 mg/l; p=not significant). The total number of periodontitis findings was significantly associated with s-hsCRP values (r=1.83) but not with p-CRP values. Conversely, seventeen of the nineteen patients with elevated s-hsCRP (89.5%) indicative of systemic inflammation had periodontitis.

CONCLUSION

Periodontitis is a common finding among patients with acute stroke/TIA as over 80% of patients with cryptogenic stroke/TIA had periodontitis. S-hsCRP is a useful tool for detecting subclinical systemic inflammation.

Dental Care Use, Edentulism, and Systemic Health among Older Adults

Past research suggests there are systematic associations between oral health and chronic illness among older adults. Although causality has not yet been credibly established, periodontitis has been found to be associated with higher risk of both heart disease and stroke. We advance this literature by estimating the direct association between dental care use and systemic health using multiple waves of the 1992 to 2016 Health and Retirement Study. Through the inclusion of individual fixed effects in our regression models, we account for unobservable time-invariant characteristics of individuals that might otherwise bias estimates of the association between dental care use and health. We find statistically significant negative associations between dental care use and the number of health conditions, self-reported overall health, the incidence of heart disease, and the incidence of stroke. In particular, the use of dental care within the past 2 y is associated with a 2.7% reduction in the likelihood of being diagnosed with a heart condition and a reduction in the likelihood of a stroke diagnosis of between 5.3% and 11.6%. We also find large positive correlations between edentulism and the measures of chronic illness. Associations from models estimated separately for men and women are qualitatively similar to one another. These findings provide additional motivation for the consideration of a Medicare dental benefit.

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

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

Severe periodontitis is associated with the serum levels of hypersensitive C reactive protein and lipoprotein-associated phospholipase A2 in the patients of acute ischemic stroke

BACKGROUND

Periodontitis is associated with the pathogenesis of atherosclerotic plaque, and hypersensitive C reactive protein (hs-CRP) and lipoprotein-associated phospholipase A2 (Lp-PLA2) are the serum biomarkers of the stability of atherosclerotic plaque. Whether periodontitis is associated with the serum level of hs-CRP and Lp-PLA2 of acute ischemic stroke remains unclear.

MATERIAL AND METHODS

We recruited 103 cases with acute ischemic stroke within 7 days after stroke onset. Pocket depth and clinical attachment loss were assessed by oral examination to define the severe periodontitis. Demographic information including gender, age and body weight index, income level, education level, past medical history include smoking history, drinking history, ischemic stroke history, coronary heart disease, hypertension, diabetes and hyperlipidemia were collected, and serum biomarkers including white blood cell (WBC), fibrinogen, total cholesterol (TC), triglyceride (TG), lower density lipoprotein (LDL-C), high density lipoprotein (HDL-C), hs-CRP, HemoglobinA1c (HbAlc), Homocysteine (HCY) and Lp-PLA2 were tested.

RESULTS

65 (63.1%) cases were diagnosed as severe periodontitis. Severe periodontitis group showed more male, age, drinking history, higher levels of hs-CRP and Lp-PLA2. Multivariate logistic regression showed that severe periodontitis was were significantly associated with hs-CRP (OR = 2.367, 95%CI: 1.182-4.738; P = .015) and Lp-PLA2 (OR = 2.577, 95% CI: 1.010-6.574; P = .048).

CONCLUSIONS

Severe periodontitis is independently associated with the serum Level of hs-CRP and Lp-PLA2 in patients with acute ischemic stroke. Whether the improvement of periodontitis could decrease the occurrence and re-occurrence of ischemic stroke by stablizating atherosclerotic plaque need be further studied in future.

Periodontal Pathogens and Neuropsychiatric Health

Increasing evidence incriminates low-grade inflammation in cardiovascular, metabolic diseases, and neuropsychiatric clinical conditions, all important causes of morbidity and mortality. One of the upstream and modifiable precipitants and perpetrators of inflammation is chronic periodontitis, a polymicrobial infection with Porphyromonas gingivalis (P. gingivalis) playing a central role in the disease pathogenesis. We review the association between P. gingivalis and cardiovascular, metabolic, and neuropsychiatric illness, and the molecular mechanisms potentially implicated in immune upregulation as well as downregulation induced by the pathogen. In addition to inflammation, translocation of the pathogens to the coronary and peripheral arteries, including brain vasculature, and gut and liver vasculature has important pathophysiological consequences. Distant effects via translocation rely on virulence factors of P. gingivalis such as gingipains, on its synergistic interactions with other pathogens, and on its capability to manipulate the immune system via several mechanisms, including its capacity to induce production of immune-downregulating micro-RNAs. Possible targets for intervention and drug development to manage distal consequences of infection with P. gingivalis are also reviewed.

Oral Bacterial Signatures in Cerebral Thrombi of Patients With Acute Ischemic Stroke Treated With Thrombectomy

Background

Chronic infections have been reported to be risk factors for both coronary heart disease and ischemic stroke. DNA of oral bacteria, mainly from the viridans streptococci group, has been detected in coronary thrombus aspirates of myocardial infarction and cerebral aneurysms. Viridans streptococci are known to cause infective endocarditis and possess thrombogenic properties. We studied the presence of oral bacterial DNA in thrombus aspirates of patients with acute ischemic stroke treated with mechanical thrombectomy.

Methods and Results

Thrombus aspirates and arterial blood were taken from 75 patients (69% men; mean age, 67 years) with acute ischemic stroke. The presence of Streptococcus species, mainly the Streptococcus mitis group, belonging to viridans streptococci as well as Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans in samples were determined using a quantitative polymerase chain reaction with specific primers and probes. The relative amount of bacterial DNA in a sample was determined with the comparative threshold cycle method. Bacterial DNA was detected in 84% (n=63) of aspired thrombi, and 16% (n=12) of samples were considered bacterial DNA negative. DNA of Streptococcus species, mainly the S mitis group, was found in 79% (n=59) of samples. The median relative amount of Streptococcus species DNA was 5.10‐fold higher compared with the control blood samples from the same patients. All thrombi were negative for both P gingivalis and A actinomycetemcomitans.

Conclusions

This is the first study showing the common presence of bacterial DNA from viridans streptococci in aspired thrombi of patients with acute ischemic stroke. Streptococcal bacteria, mostly of oral origin, may contribute to the progression and thrombotic events of cerebrovascular diseases.

Association between Periodontal Health and Stroke: Results from the 2013-2015 Korea National Health and Nutrition Examination Survey (KNHANES)

Background/purpose

As the population ages, the prevalence of stroke increases, and as such there has been increasing interest in the risk factors associated with stroke. Although an association between periodontitis and stroke has been suggested, there has been no study of this association among the Korean population. Therefore, we investigated the association between periodontal health and stroke among Korean adults.

Materials and methods

A total of 9497 adults aged ≥40 years representing the Korean population were included in this cross-sectional study from the Korea National Health and Nutrition Examination Survey (KNHANES) VI (2013–2015). Periodontitis was diagnosed by dentists based on the Community Periodontal Index (CPI). Also, participants filled out a questionnaire regarding their experience of doctor-diagnosed stroke. Hypertension, diabetes, body mass index (BMI), and oral hygiene behavior covariates were adjusted in logistic regression analysis.

Results

The mean age of the study population was 55.71 ± 0.17 years and 52.7% of them were female. Also, 248 people had a history of having a stroke. Results of the logistic regression analysis after adjusting for age and sex showed a significant relationship between oral health behavior, periodontal health, and stroke even after adjusting for age, sex, education, household income, national health insurance, employment status, alcohol, smoking, diabetes, hypertension, BMI, and oral health behaviors (odds ratio [OR], 1.71; 95% confidence interval [CI] = 1.03–2.85).

Conclusion

Our findings suggest that periodontitis is associated with stroke in Korean adults.

Periodontitis As A Risk Factor For Stroke: A Systematic Review And Meta-Analysis

This systematic review and meta-analysis investigate the association between periodontitis and stroke. This review followed the methods established by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Searches were conducted in five databases and two sources of grey literature. After the selection of the articles, a risk of bias evaluation was performed. Three meta-analyzes were performed: Assessing the overall association between stroke and periodontitis in case–control studies; Ischemic stroke and periodontitis in case–control studies; The association between stroke and periodontitis in cohort studies. Heterogeneity was assessed using the I² index and the odds ratio was also calculated (p < 0.05). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate the level of evidence. 2193 potentially relevant studies were identified, with 10 studies included in qualitative and quantitative analysis. All the articles were considered with low risk of bias and a low level of certainty. The results demonstrated a positive association between both disorders and increased risk for stroke among cohort studies (RR 1.88 [1.55, 2.29], p<0.00001, I²=0%) and for ischemic stroke events in case–control studies (RR 2.72 [2.00, 3.71], p<0.00001, I²= 4%). Periodontitis may represent a risk factor for stroke, especially in ischemic events. However, new studies with a robust design are necessary for a reliable conclusion.

Oral health in patients with stroke: a meta-analysis of comparative studies

Objective: This meta-analysis systematically analyzed and compared oral health between stroke patients and controls.Data source: The electronic databases of PubMed, EMBASE, PsycINFO, Medline and Web of Science were independently searched by two authors from their inception to 14 June 2018.Study selection: Eleven studies comparing oral health between stroke patients (n = 1,742) and controls (n = 1,193) were analyzed.Data extraction: The full texts of the 11 studies were independently reviewed. Data on oral health were independently extracted by two authors.Data synthesis: Mean differences (MD) and 95% confidence intervals (CI) were calculated and synthesized using fixed or random-effects models, as appropriate. Compared to controls, stroke patients had poorer oral health: they had more Dental Caries (5 studies; MD = 2.89, 95% CI: 0.91-4.88, p= .04), but less Remaining Teeth scores (6 studies; MD = -2.93, 95% CI: -3.91, -1.95; p < .00001). Both the Plaque Index (3 studies; MD = 0.21, 95% CI: 0.14, 0.28; p < .00001) and Gingival Index scores (4 studies; MD = 0.22, 95% CI: 0.14, 0.30; p < .00001) were significantly higher in stroke patients, indicating worse periodontal status.Conclusions: Stroke patients had poorer overall oral health status compared to controls. Given the importance of oral health to overall health, further research on screening for oral health problems after stroke should be conducted and effective management strategies should be devised and implemented.

The Possible Causal Link of Periodontitis to Neuropsychiatric Disorders: More Than Psychosocial Mechanisms

Increasing evidence implies a possible causal link between periodontitis and neuropsychiatric disorders, such as Alzheimer's disease (AD) and major depression (MD). A possible mechanism underlying such a link can be explained by neuroinflammation induced by chronic systemic inflammation. This review article focuses on an overview of the biological and epidemiological evidence for a feasible causal link of periodontitis to neuropsychiatric disorders, including AD, MD, Parkinson's disease, and schizophrenia, as well as the neurological event, ischemic stroke. If there is such a link, a broad spectrum of neuropsychiatric disorders associated with neuroinflammation could be preventable and modifiable by simple daily dealings for oral hygiene. However, the notion that periodontitis is a risk factor for neuropsychiatric disorders remains to be effectively substantiated.

Oral Health and Brain Injury: Causal or Casual Relation?

Background

To systematically review the current literature investigating the association between oral health and acquired brain injury.

Methods

A structured search strategy was applied to PubMed, Embase, Web of Science, and CENTRAL electronic databases until March 2017 by 2 independent reviewers. The preferred reporting items for systematic review and meta-analysis guidelines were used for systematic review.

Results

Even though the objective was to assess the association between oral health and acquired brain injury, eligible studies focused solely on different forms of stroke and stroke subtypes. Stroke prediction was associated with various factors such as number of teeth, periodontal conditions (even after controlling for confounding factors), clinical attachment loss, antibody levels to Aggregatibacter actinomycetemcomitans and Prevotella intermedia. The literature showed no consensus on the possible association between gingivitis and stroke. Patients with stroke generally had poorer oral hygiene practices and oral health. Dental prophylaxis and professional intervention reduced the incidence of stroke.

Conclusions

Overall, oral health and stroke were related. Periodontitis and tooth loss were independently associated with stroke. However, prevention and timely intervention may reduce the risk of stroke. Stroke was the main cerebral lesion studied in the literature, with almost no publications on other brain lesions.

Oral health status in patients with acquired brain injury: a systematic review

OBJECTIVE

To undertake a systematic review of the current knowledge and future perspectives regarding the status of various oral health factors, including social and behavioral aspects, in patients with acquired brain injury (ABI).

STUDY DESIGN

A structured search strategy was applied to PubMed, Embase, and Scopus electronic databases until January 2016 to identify studies presenting assessments of the oral health status of patients afflicted with any kind of ABI. The search strategy was restricted to English-language publications that enrolled patients aged more than 18 years. Studies on the association of oral health conditions and brain injury were excluded. No study was excluded based on its qualitative analysis.

RESULTS

A total of 27 studies were reviewed. Stroke was the most commonly studied ABI. Stroke patients had a higher number of missing teeth, poorer plaque and gingival index scores, and higher colonization of Candida albicans in saliva, all of which were significantly reduced after intervention. Oral health-related quality of life was poorer in patients compared to the general population.

CONCLUSION

Stroke was the most predominant brain injury condition studied in the literature, with few publications focusing on other forms of brain injury. Overall, oral health has been noted to be poor in patients with ABI, but oral hygiene and oral health-related quality of life have been found to improve when oral hygiene interventions are provided to patients.

Chronic periodontitis is associated with lacunar infarct: a case-control study

BACKGROUND AND PURPOSE

Chronic periodontitis (ChP) and lacunar infarct (LI) are two common diseases amongst the elderly. Although several studies have shown an association between ischaemic stroke and ChP, little is known about the relationship between ChP and LI. The study aims to investigate whether ChP is associated with the presence of lacunar stroke.

METHODS

An age- and gender-matched case-control study of 62 cases (subjects diagnosed with LI) and 60 controls is reported. Clinical periodontal measures (probing pocket depth, recession, clinical attachment level, full mouth plaque score and full mouth gingival bleeding on probing score) were assessed, and associated risk factors for periodontitis and lacunar stroke were ascertained by means of a structured questionnaire.

RESULTS

Chronic periodontitis showed a strong association with LI after adjusting for common vascular risk factors (odds ratio 4.20; 95% confidence interval 1.81-10.20; P = 0.001). Likewise, severe ChP and LI also tended to be significantly associated, independent of other vascular covariates (odds ratio 3.53; 95% confidence interval 1.07-12.77; P = 0.04).

CONCLUSIONS

Chronic periodontitis was independently associated with the presence of LI after adjusting for well-known vascular risk factors for lacunar stroke. Further observational studies are necessary to investigate the pathophysiological mechanisms that can explain this relationship.

Association between periodontitis and ischemic stroke: a systematic review and meta-analysis

Several observational studies have suggested an association between periodontitis and cerebral ischemia. This meta-analysis aimed to investigate whether this link exists, and if so, the degree to which it is significant. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline for systematic review was used. The search strategy included using electronic databases and hand searching works published up to March 2015. MEDLINE via PubMed, EMBASE, Proceedings Web of Science and Current Contents Connect were searched by two independent reviewers. Case-control, cross-sectional or cohort studies including patients with measures of periodontitis and ischemic stroke were eligible to be included in the analysis. Quality assessments of selected studies were performed. From a total of 414 titles and abstracts, 57 potentially relevant full text papers were identified. After inclusion criteria were applied, 8 studies were included in the present systematic review (5 case-control and 3 cohort studies). Although it was not the intention, cross-sectional studies were excluded due to eligibility criteria were not accomplished. Therefore, meta-analyses were conducted with data retrieved from the 8 studies included. These meta-analyses showed statistically significant association between periodontitis and ischemic stroke in both cohort pooled relative risks at 2.52 (1.77-3.58), and case-control studies pooled relative risks at 3.04 (1.10-8.43). In conclusion, the present meta-analysis demonstrated an association between periodontitis and ischemic stroke. However, well-designed prospective studies should be carried out to provide robust evidence of the link between both diseases. In regards to ischemic stroke subtypes, further case-control studies should be carried out to investigate whether there is any association between the different subtypes of cerebral infarcts and periodontitis.

Comprehensive oral-health assessment of individuals with acquired brain-injury in neuro-rehabilitation setting

PRIMARY OBJECTIVE

To perform a detailed clinical oral health assessment and oral-health-related social and behavioural aspect assessment in individuals with acquired brain injury (ABI).

RESEARCH DESIGN

Prospective observational study.

METHODS AND PROCEDURES

Thirteen individuals with ABI were recruited. Individual's social and behavioural history, bed-side oral examination score (BOE), tooth condition and periodontal status (bleeding, plaque and clinical attachment loss) were thoroughly examined. The entire examination took up to 60 minutes, using proper dental armamentarium.

MAIN OUTCOMES AND RESULTS

All evaluated individuals were diagnosed with chronic generalized periodontitis. A relationship between active periodontal disease and severe BOE score was observed (p = 0.01). Significant interaction between severe BOE scores (≥ 15 or ≥ 14) and periodontal disease severity of ≥ 2 mm (p = 0.01) was observed. The same interaction was seen between severe BOE scores and the combination of 75% extent and 2 mm severity (p = 0.01). Severity and activity of periodontitis showed dependence on individual brushing frequency (p = 0.03 and p = 0.05, respectively).

CONCLUSIONS

Individuals with ABI had a poor status across a range of oral-, dental- and periodontal-related parameters. Further structured studies are required to define evidence-based assessment approaches for such clinical reality.

The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease

OBJECTIVES

The objective of this study was to systematically review the epidemiological evidence for an association between periodontitis (PD) and incident atherosclerotic cardiovascular disease (ACVD), including coronary heart disease (CHD), cerebrovascular disease and peripheral arterial disease.

METHODS

Systematic review of cohort and case-control studies on the association of clinically or radiographically diagnosed PD and ACVD.

RESULTS

Overall, 12 studies were included in this study (six studies on CHD, three studies on cerebrovascular disease, two studies on both coronary heart and cerebrovascular disease mortality and one study on peripheral arterial disease).All but one study reported positive associations between various periodontal disease measures and the incidence of ACVD, at least in specific subgroups. The association was stronger in younger adults and there was no evidence for an association between PD and incident CHD in subjects older than 65 years. Only one study evaluated the association between PD and secondary cardiovascular events.

CONCLUSIONS

There is evidence for an increased risk of ACVD in patients with PD compared to patients without. However, this may not apply to all groups of the population. There is insufficient evidence for an association between PD and the incidence of secondary cardiovascular events.

The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease

OBJECTIVES

The objective of this study was to systematically review the epidemiological evidence for an association between periodontitis (PD) and incident atherosclerotic cardiovascular disease (ACVD), including coronary heart disease (CHD), cerebrovascular disease and peripheral arterial disease.

METHODS

Systematic review of cohort and case-control studies on the association of clinically or radiographically diagnosed PD and ACVD.

RESULTS

Overall, 12 studies were included in this study (six studies on CHD, three studies on cerebrovascular disease, two studies on both coronary heart and cerebrovascular disease mortality and one study on peripheral arterial disease). All but one study reported positive associations between various periodontal disease measures and the incidence of ACVD, at least in specific subgroups. The association was stronger in younger adults and there was no evidence for an association between PD and incident CHD in subjects older than 65 years. Only one study evaluated the association between PD and secondary cardiovascular events.

CONCLUSIONS

There is evidence for an increased risk of ACVD in patients with PD compared to patients without. However, this may not apply to all groups of the population. There is insufficient evidence for an association between PD and the incidence of secondary cardiovascular events.

Association of periodontal and cardiovascular diseases: South-Asian studies 2001-2012

Large proportion of Asian populations have moderate to severe periodontal disease and a substantial number are anticipated to be at high risk of cardiovascular diseases (CVD). This study reviews epidemiology and association of periodontal and CVDs from the South-Asian region. Observational studies and clinical trials published during January 2001-December 2012 focusing association between periodontitis and CVDs in South-Asian countries were retrieved from various databases and studied. Current evidence suggests that both periodontal and CVDs are globally prevalent and show an increasing trend in developing countries. Global data on epidemiology and association of periodontal and CVDs are predominantly from the developed world; whereas Asia with 60% of the world's population lacks substantial scientific data on the link between periodontal and CVDs. During the search period, 14 studies (5 clinical trials, 9 case-controls) were reported in literature from South-Asia; 100% of clinical trials and 77% case-control studies have reported a significant association between the oral/periodontal parameters and CVD. Epidemiological and clinical studies from South-Asia validate the global evidence on association of periodontal disease with CVDs. However, there is a need for meticulous research for public health and scientific perspective of the Periodontal and CVDs from South-Asia.

A cross-sectional study of the associations between periodontitis and carotid arterial calcifications in an elderly population

OBJECTIVE

To evaluate if the presence of periodontitis is associated with carotid arterial calcifications diagnosed on panoramic radiographs in an elderly population.

MATERIALS AND METHODS

Study individuals were randomly selected from the Swedish civil registration database representing the aging population (60-96 years) in Karlskrona, Sweden. Bleeding on probing (BOP) and the deepest probing measurement at each tooth were registered. The proportions of teeth with a probing depth ≥ 5 mm and the proportion of teeth with bleeding on probing were calculated. Analog panoramic radiographs were taken and the proportion of sites with a distance ≥ 5 mm between the alveolar bone level and the cement-enamel junction (CEJ) were assessed. A diagnosis of periodontitis was declared if a distance between the alveolar bone level and the CEJ ≥ 5 mm could be identified from the panoramic radiographs at > 10% of sites, probing depth of ≥ 5 mm at one tooth or more and with BOP at > 20% of teeth.

RESULTS

Readable radiographs were obtained from 499 individuals. Carotid calcification was identified in 39.1%. Individuals were diagnosed with periodontitis in 18.4%. Data analysis demonstrated that individuals with periodontitis had a higher prevalence of carotid calcifications (Pearson χ(2) = 4.05 p < 0.05) and with a likelihood of 1.5 (95% CI = 1.0, 2.3, p < 0.05).

CONCLUSIONS

Data analysis demonstrated a significant association between periodontitis and carotid calcification.

Association between periodontal disease and non-fatal ischemic stroke: a case-control study

OBJECTIVE

This study aimed to investigate the association between clinical and radiological markers of periodontal disease and ischemic stroke and to assess the potential influence of inflammatory response on the observed associations.

METHODS

A prospective case-control study including a series of 48 cases with a minor ischemic stroke and 47 controls was conducted at the University Hospital of Dijon. Vascular risk factors, clinical dental examination (plaque index, gingival index, percentage of pockets >5 mm, percentage of bleeding on probing (BOP) sites), dental panoramic (bone loss) and biological parameters (CRP, total cholesterol, HDL, LDL, fasting glucose) were collected. Conditional regression analyses were performed to identify factors associated with ischemic stroke.

RESULTS

The prevalence of hypertension, high CRP and glucose levels and overall odontological variables was higher in stroke patients. In multivariable analyses, hypertension (OR = 12.56; 95% CI = 2.29-69.96, p = 0.004), CRP levels >5 mg/L (OR = 18.54; 95% CI = 2.01-171.17, p = 0.010), BOP (OR = 1.049; 95% CI = 1.012-1.88, p = 0.009) and bone loss >20% (OR = 1.053; 95% CI = 1.017-1.091, p = 0.004) were associated with ischemic stroke. Among stroke patients, there was a non-significant trend towards higher CRP levels in patients with bone loss >20% compared with those with bone loss <20% (8.1 ± 1.27 mg/L vs 3.12 ± 3.14 mg/L, p = 0.25), whereas other biological parameters were very similar between the two groups.

CONCLUSION

This case-control study demonstrates that periodontal disease, especially markers such as BOP and bone loss, is independently associated with ischemic stroke.

Organisation, practice and experiences of mouth hygiene in stroke unit care: a mixed-methods study

AIMS AND OBJECTIVES

To (1) investigate the organisation, provision and practice of oral care in typical UK stroke units; (2) explore stroke survivors', carers' and healthcare professionals' experiences and perceptions about the barriers and facilitators to receiving and undertaking oral care in stroke units.

BACKGROUND

Cerebrovascular disease and oral health are major global health concerns. Little is known about the provision, challenges and practice of oral care in the stroke unit setting, and there are currently no evidence-based practice guidelines.

DESIGN

Cross-sectional survey of 11 stroke units across Greater Manchester and descriptive qualitative study using focus groups and semi-structured interviews.

METHODS

A self-report questionnaire was used to survey 11 stroke units in Greater Manchester. Data were then collected through two focus groups (n = 10) with healthcare professionals and five semi-structured interviews with stroke survivors and carers. Focus group and interview data were recorded, transcribed verbatim and analysed using framework approach.

RESULTS

Eleven stroke units in Greater Manchester responded to the survey. Stroke survivors and carers identified a lack of oral care practice and enablement by healthcare professionals. Healthcare professionals identified a lack of formal training to conduct oral care for stroke patients, inconsistency in the delivery of oral care and no set protocols or use of formal oral assessment tools.

CONCLUSION

Oral care post-stroke could be improved by increasing healthcare professionals' awareness, understanding and knowledge of the potential health benefits of oral care post-stroke. Further research is required to develop and evaluate the provision of oral care in stroke care to inform evidence-based education and practice.

RELEVANCE TO CLINICAL PRACTICE

Development of staff training and education, and evidence-based oral care protocols may potentially benefit patient care and outcomes and be implemented widely across stroke care.

Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions

BACKGROUND

Treatment of periodontal (gum) disease may lessen the adverse consequences of some chronic systemic conditions.

PURPOSE

To estimate the effects of periodontal therapy on medical costs and hospitalizations among individuals with diagnosed type 2 diabetes (T2D); coronary artery disease (CAD); cerebral vascular disease (CVD); rheumatoid arthritis (RA); and pregnancy in a retrospective observational cohort study.

METHODS

Insurance claims data from 338,891 individuals with both medical and dental insurance coverage were analyzed in 2011-2013. Inclusion criteria were (1) a diagnosis of at least one of the five specified systemic conditions and (2) evidence of periodontal disease. Subjects were categorized according to whether they had completed treatment for periodontal disease in the baseline year, 2005. Outcomes were (1) total allowed medical costs and (2) number of hospitalizations, per subscriber per year, in 2005-2009. Except in the case of pregnancy, outcomes were aggregated without regard to reported cause. Individuals who were treated and untreated for periodontal disease were compared independently for the two outcomes and five systemic conditions using ANCOVA; age, gender, and T2D status were covariates.

RESULTS

Statistically significant reductions in both outcomes (p<0.05) were found for T2D, CVD, CAD, and pregnancy, for which costs were lower by 40.2%, 40.9%, 10.7%, and 73.7%, respectively; results for hospital admissions were comparable. No treatment effect was observed in the RA cohorts.

CONCLUSIONS

These cost-based results provide new, independent, and potentially valuable evidence that simple, noninvasive periodontal therapy may improve health outcomes in pregnancy and other systemic conditions.

A systematic review and meta-analysis of clinical, microbiological, and behavioural aspects of oral health among patients with stroke

OBJECTIVE

The objective of this study was to review clinical, microbiological, and immunological aspects of oral health, as well as oral health related behaviours among patients following stroke.

DATA SOURCES

A structured search strategy was applied to three electronic databases to identify relevant papers.

STUDY SELECTION

The initial search yielded 19,927 papers, 60 potentially relevant studies (Kappa: 0.974) and 23 relevant papers (Kappa: 0.965) in accordance with the inclusion criteria. Outcomes regarding tooth condition, periodontal condition, oral hygiene status, and dental attendance were pooled for seven meta-analyses. Narrative summaries were provided for those outcomes which could not be pooled for meta-analysis.

RESULTS

The standardized differences in mean values of the parameters (fixed effect, random effect model) for patients with stroke compared to control groups were: number of teeth (-0.325, -0.271), DMFT (0.246, 0.246), oral hygiene status - plaque index (0.305, 0.356) and gingival index (0.716, 0.653), periodontal health status - clinical attachment loss (0.437, 0.490) and probing depth (0.470, 0.579). In addition, a lower chance of dental attendance was observed among patients with stroke (odds ratio: 0.493, 0.480). For those outcomes which could not be pooled for meta-analysis, it was not possible to draw any qualitative conclusion due to the equivocal results of these studies.

CONCLUSIONS

There is an increasing interest in oral health of patients with stroke. Patients with stroke had a poorer clinical oral health status across a range of parameters (tooth loss, dental caries experience, and periodontal status). Coupled with this, their dental attendance was less frequent. Further studies employing standardized assessments of oral health/oral health behaviour can confirm these oral health disparities.

CLINICAL SIGNIFICANCE

With comprehensive literature search, this systematic review and meta-analysis indicated a poorer oral health status and less frequent dental attendance behaviour among patients with stroke.

Periodontal disease and stroke: a meta-analysis of cohort studies

This review aimed to determine the association between periodontal disease and stroke incidence by a meta-analysis of cohort studies. Cohort studies that evaluated the incidence of stroke (fatal or non-fatal, ischaemic or haemorrhagic) and baseline periodontal status and calculated relative risk values were included. The quality of the included studies was assessed using an evaluation grid. The analyses were conducted separately for three outcomes: periodontitis, gingivitis and loss of teeth. Adjusted values of relative risk or of hazard ratio were used to assess risk values in each study. Random effects meta-analyses were conducted when data could be pooled. From the 743 references retrieved, only nine cohort studies were suitable for inclusion in this review. Quality scores of the studies varied greatly. Three prospective studies, which used reliable indicators of periodontal disease, obtained the highest scores. Conversely, three studies that used a subjective evaluation of stroke incidence or diagnosed stroke without imaging obtained the lowest score. The results of the meta-analyses varied depending on the outcome considered and the type of stroke. The risk of stroke was significantly increased by the presence of periodontitis [relative risk 1.63 (1.25, 2.00)]. Tooth loss was also a risk factor for stroke [relative risk 1.39 (1.13, 1.65)]. The risk of stroke did not vary significantly with the presence of gingivitis. This review shows that periodontitis and tooth loss are associated with the occurrence of stroke.

Periodontitis in patients with coronary artery disease: an 8-year follow-up

BACKGROUND

This study examines whether preceding assessment of periodontal status in patients with established coronary artery disease (CAD) can predict future CAD endpoints (myocardial infarction, new revascularization procedure, or CAD-related death) during 8-year follow-up and whether the changes in periodontal status over time differ in patients with CAD compared with healthy controls.

METHODS

In 2003, periodontal status was examined in 161 patients with CAD who underwent percutaneous coronary intervention or coronary artery bypass graft due to significant stenosis in the coronary arteries and 162 controls without CAD. Eight years later, 126 patients with CAD (102 males and 24 females, mean age: 68 ± 8.9 years) and 121 controls (101 males and 20 females, mean age: 69 ± 9.0 years) were reexamined periodontally. A standard classification of periodontal disease in three groups (mild, moderate, and severe) was used. CAD endpoints during follow-up were obtained by review of medical records. CAD as cause of death was confirmed from the Swedish Cause of Death Register.

RESULTS

No significant differences were found among patients with CAD, with or without CAD-related endpoints at 8-year follow-up, and severity of periodontitis at baseline (P = 0.7). CAD did not influence the incidence or severity of periodontitis. Significant differences were found at the final examination in periodontitis prevalence and severity (P = 0.001), number of teeth (P = 0.006), probing depth 4 to 6 mm (P = 0.016), bleeding on probing (P = 0.001), and radiographic bone level (P = 0.042) between CAD patients and controls, all in favor of controls.

CONCLUSIONS

The study results did not show a significant association during 8 years among CAD endpoints and periodontal status at baseline. The progression of periodontitis was low in both groups, although the higher proportion of individuals with severe periodontitis among patients with CAD compared with controls remained unchanged over the 8-year follow-up. Further long-term prospective studies are needed to show whether periodontitis can be considered a risk or prognostic factor for CAD, in terms of endpoints including myocardial infarction, new revascularization procedure, and CAD-related death.

Randomized clinical trial of oral health promotion interventions among patients following stroke

OBJECTIVE

To evaluate the effectiveness of oral health promotion interventions on clinical oral health.

DESIGN

Single-blind randomized controlled trial conducted over 3 weeks of in-hospital rehabilitation.

SETTING

Stroke rehabilitation ward in Hong Kong.

PARTICIPANTS

Patients with stroke (N=102) admitted to the rehabilitation ward.

INTERVENTIONS

Patients were randomly assigned either: (1) oral hygiene instruction, (2) oral hygiene instruction and chlorhexidine mouthrinse, or (3) oral hygiene instruction, chlorhexidine mouthrinse, and assisted brushing.

MAIN OUTCOME MEASURES

Dental plaque, gingival bleeding, and oral functional status were assessed at baseline and review. Development of infectious complications were also monitored during the clinical trial.

RESULTS

Poor oral hygiene and an overall neglect of oral hygiene practices were observed at baseline. Reductions in dental plaque were significantly greater in the 2 groups receiving chlorhexidine compared with the group receiving oral hygiene instruction alone (P<.001). Reductions in gingival bleeding scores were 3- to 4-fold greater in groups receiving chlorhexidine. No cases of pneumonia were observed during the course of the clinical trial.

CONCLUSIONS

The oral health condition of patients may be safeguarded after acute stroke with the use of chlorhexidine mouthrinse in conjunction with a standard mechanical plaque removal tool, such as an electric toothbrush. These interventions are acceptable to the majority of patients, and their administration poses a minimal burden to rehabilitation ward staff.

Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association

A link between oral health and cardiovascular disease has been proposed for more than a century. Recently, concern about possible links between periodontal disease (PD) and atherosclerotic vascular disease (ASVD) has intensified and is driving an active field of investigation into possible association and causality. The 2 disorders share several common risk factors, including cigarette smoking, age, and diabetes mellitus. Patients and providers are increasingly presented with claims that PD treatment strategies offer ASVD protection; these claims are often endorsed by professional and industrial stakeholders. The focus of this review is to assess whether available data support an independent association between ASVD and PD and whether PD treatment might modify ASVD risks or outcomes. It also presents mechanistic details of both PD and ASVD relevant to this topic. The correlation of PD with ASVD outcomes and surrogate markers is discussed, as well as the correlation of response to PD therapy with ASVD event rates. Methodological issues that complicate studies of this association are outlined, with an emphasis on the terms and metrics that would be applicable in future studies. Observational studies to date support an association between PD and ASVD independent of known confounders. They do not, however, support a causative relationship. Although periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction in short-term studies, there is no evidence that they prevent ASVD or modify its outcomes.

[Relationship between periodontitis and systemic diseases]

Periodontitis is a biofilm-induced inflammatory disease affecting the periodontium with a high and even increasing prevalence in the German population. During recent years, there is emerging evidence for systemic effects of a periodontal infection, in particular in relation to diabetes and atherosclerosis. There is a bi-directional relationship between periodontitis and diabetes. Diabetes promotes the occurrence, the progression, and the severity of periodontitis. The periodontal infection complicates the glycemic control in diabetes, increases the risk of diabetes-associated complications and possibly even of its onset. As a consequence, the treatment of periodontal infections should become an integral part of the management of diabetes, whereas glycemic control is a prerequisite for successful periodontal therapy. Periodontal infections are considered as independent risk factor for atherosclerosis and their clinical sequelae, e.g., cerebro- and cardiovascular diseases. The positive association is only moderate, however remarkably consistent. Periodontal therapy can result in positive effects on subclinical markers of atherosclerosis.

Association between periodontal disease and stroke

OBJECTIVE

Periodontitis is a very common human infection. There is evidence that periodontitis is associated with cerebrovascular disease (CVD) and stroke. The aim of this study is to examine the relationship between periodontal disease and CVD in observational studies.

METHODS

An electronic search of the English literature using PubMed was conducted. A meta-analysis of the studies reporting on the risk of stroke in patients with periodontitis was performed.

RESULTS

Six prospective and seven retrospective studies met the inclusion criteria. Patients with both hemorrhagic and ischemic cerebrovascular events, fatal and nonfatal, were included. Definition of periodontitis was taken directly from included studies. Most studies have been adjusted for common cardiovascular risk factors. Separate statistical analysis was performed for prospective and retrospective studies. Overall adjusted risk of stroke in subjects with periodontitis was 1.47 times higher than in subjects without (95% confidence interval, 1.13-1.92;P = .0035) in prospective and 2.63 times (95% confidence interval, 1.59-4.33;P = .0002) in retrospective studies. The application of the trim and fill algorithm does not change the initial significant inference.

CONCLUSIONS

There is evidence that periodontitis is associated with increased risk of stroke. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity of the studies as well as the differences in periodontitis definition.

"Gum bug, leave my heart alone!"--epidemiologic and mechanistic evidence linking periodontal infections and atherosclerosis

Evidence from epidemiologic studies suggests that periodontal infections are independently associated with subclinical and clinical atherosclerotic vascular disease. Although the strength of the reported associations is modest, the consistency of the data across diverse populations and a variety of exposure and outcome variables suggests that the findings are not spurious or attributable only to the effects of confounders. Analysis of limited data from interventional studies suggests that periodontal treatment generally results in favorable effects on subclinical markers of atherosclerosis, although such analysis also indicates considerable heterogeneity in responses. Experimental mechanistic in vitro and in vivo studies have established the plausibility of a link between periodontal infections and atherogenesis, and have identified biological pathways by which these effects may be mediated. However, the utilized models are mostly mono-infections of host cells by a limited number of 'model' periodontal pathogens, and therefore may not adequately portray human periodontitis as a polymicrobial, biofilm-mediated disease. Future research must identify in vivo pathways in humans that may (i) lead to periodontitis-induced atherogenesis, or (ii) result in treatment-induced reduction of atherosclerosis risk. Data from these studies will be essential for determining whether periodontal interventions have a role in the primary or secondary prevention of atherosclerosis.