Periodontal infections and cardiovascular disease--how strong is the association?

Changes in Oral Health and Dental Esthetic in Smokers Switching to Combustion-Free Nicotine Alternatives: Protocol for a Multicenter and Prospective Randomized Controlled Trial

BACKGROUND

Although the detrimental effects of conventional combustible cigarettes on oral health and dental esthetics are well known, there is limited information about the long-term impact of combustion-free nicotine alternatives (C-F NA) such as e-cigarettes or heated tobacco products.

OBJECTIVE

This multicenter, prospective, 3-parallel-arm randomized controlled trial will investigate whether switching from combustible cigarettes to C-F NA will lead to measurable improvements in oral health parameters and dental esthetics over 18 months in adult smokers with limited gum disease.

METHODS

Regular smokers not intending to quit and without clinical signs of periodontitis will be randomly assigned (1:4 ratio) to either standard of care with brief cessation advice (control group; arm A) or C-F NA use (intervention group; arm B). The study will also include a reference group of never smokers (reference group; arm C). The primary end point is the change in the Modified Gingival Index (MGI) score from baseline between the control arm (arm A) and the intervention arm (arm B) at the 18-month follow-up. In addition, the study will analyze the within- and between-group (arms A, B, and C) changes in MGI assessment, plaque imaging, dental shade quantitation, tooth stain scores, and oral health-related quality of life questionnaires measured at each study time point. All participants will attend a total of 7 clinic visits: screening, enrollment, and randomization (visit 0); baseline visit-day 14 (visit 1); day 90 (visit 2); day 180 (visit 3); day 360 (visit 4); and day 540 (visit 5). This multicenter study will be conducted in 4 dental clinics in 4 countries. The statistical analysis will involve descriptive statistics for continuous and categorical data. Primary end points will undergo tests for normality and, based on distribution, either a 2-sided t test or Mann-Whitney U test. Linear mixed model with random factors center and study arms by center will also be applied. Secondary end points, including MGI assessment and quality of life, will be subjected to similar tests and comparisons. Only if one value of the parameter MGI is missing after day 1, the last available observation will be carried forward. The analysis will be performed on the substituted data. Secondary parameters will not have missing value replacement.

RESULTS

Participant recruitment began in October 2021, and enrollment was completed in June 2023. Results will be reported in 2025.

CONCLUSIONS

This will be the first study to provide key insights into oral health benefits or risks associated with using C-F NA in smokers who are seeking alternatives to cigarette smoking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04649645; https://clinicaltrials.gov/ct2/show/NCT04649645.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53222.

Congenital Heart Diseases and Periodontal Diseases—Is There a Link?

An understanding in the field of periodontal medicine explains the fact that the oral cavity serves as a niche for numerous pathogenic microorganisms. When these microorganisms or their by-products disseminate to the various parts of the body, they are capable of triggering diseases characterized by an altered host immune-inflammatory response in the anatomically distinct organ. This mechanism is reported in the propagation of cardiovascular diseases with respect to periodontal medicine. Abundant amount of literature suggests an association between atherosclerotic cardiovascular disease and periodontal diseases. However, there is very less data available to highlight the association between periodontal disease and non-atherosclerotic cardiovascular disease, such as congenital anomalies of the heart. This review outlines the relationship between periodontal diseases and congenital heart diseases and also helps us understand whether the presence of periodontal disease can worsen the preexisting congenital cardiac disease.

The evidence for a role of bacteria and viruses in cardiovascular disease

Inflammation plays a critical role in atherosclerosis and cardiovascular disease. Bacteria and viruses are major causative agents of inflammation in the body which normally develops as a response to infection. It is a logical extention, therefore, to believe bacterial and viral infections may be involved in a variety of presentations of cardiovascular diseases. The purpose of this review is to describe the data and conclusions to date on the involvement of these infectious agents in the induction of cardiovascular disease. The review also discusses the various specific bacteria and viruses that have been implicated in cardiovascular disease and the mechanisms, if known, that these agents induce cardiovascular disease.

Oral Microbiota: Microbial Biomarkers of Metabolic Syndrome Independent of Host Genetic Factors

The oral microbiota plays a critical role in both local and systemic inflammation. Metabolic syndrome (MetS) is characterized by low-grade inflammation, and many studies have been conducted on the gut microbiota from stool specimens. However, the etiological role of the oral microbiota in the development of MetS is unclear. In this study, we analyzed the oral and gut microbiome from 228 subgingival plaque and fecal samples from a Korean twin-family cohort with and without MetS. Significant differences in microbial diversity and composition were observed in both anatomical niches. However, a host genetic effect on the oral microbiota was not observed. A co-occurrence network analysis showed distinct microbiota clusters that were dependent on the MetS status. A comprehensive analysis of the oral microbiome identified Granulicatella and Neisseria as bacteria enriched in subjects with MetS and Peptococcus as bacteria abundant in healthy controls. Validation of the identified oral bacteria by quantitative PCR (qPCR) showed that healthy controls possessed significantly lower levels of G. adiacens (p = 0.023) and a higher ratio of Peptococcus to Granulicatella (p < 0.05) than MetS subjects. Our results support that local oral microbiota can be associated with systemic disorders. The microbial biomarkers identified in this study would aid in determination of which individuals develop chronic diseases from their MetS and contribute to strategic disease management.

The Epidemiologic and Clinical Findings of Patients with Buerger Disease

BACKGROUND

Buerger disease is a nonatherosclerotic peripheral arterial disease, which is mostly observed in young male smokers. Buerger disease is characterized by the observation of peripheral arterial occlusion by angiography. The condition may be caused by microembolization in the small-sized arteries of the distal extremities. Buerger disease is diagnosed based on the Shionoya's clinical diagnostic criteria, which include: (1) a history of smoking, (2) onset before the age of 50 years, (3) the presence of infrapopliteal arterial occlusions, (4) either upper limb involvement or phlebitis migrans, and (5) the absence of atherosclerotic risk factors other than smoking. Several studies have reported that oral bacterial infections (periodontitis) could activate the onset of Buerger disease. In this study, we report the epidemiologic and clinical manifestations of patients with Buerger disease.

METHODS

Fifty-eight patients who were surgically treated between July 1989 and June 2014 at Tokyo Medical and Dental University Hospital were enrolled in this study. All of the patients clinically diagnosed with Buerger disease based on Shionoya's clinical diagnostic criteria. Fifty-five male and 3 female patients were treated. The mean age of the patients was 48 years (range, 21-73 years).

RESULTS

All of the patients were either smokers or had a history of smoking. The mean Brinkman index score was 780 (range, 150-1,640). Their mean age at the onset of Buerger disease was 38 years (range, 21-50). The arterial lesions extended to the femoral arteries in 25% of cases, to the iliac arteries in 8% and to the abdominal aorta and/or visceral arteries in 6% of cases. Upper limb involvement, including cyanosis, paleness, and gangrene, was obvious in 84% of patients, and phlebitis migrans was recognized in 34%. The lower extremities symptoms involved intermittent claudication in 23% of the patients, rest pain in 13% of the patients, and ulceration or gangrene in 64% of the patients. Fifteen patients had undergone surgical arterial reconstruction, 4 patients had received endovascular therapy, 33 patients had undergone lumbar sympathectomy and 8 patients had undergone thoracic sympathectomy. Twenty percent of the patients needed minor limb amputations, and 4% required major limb amputations. In the patients who were examined for their oral conditions, periodontitis corresponding to grades B (moderate periodontitis), C (severe periodontitis), and D (edentulous patients) was revealed in 31%, 56%, and 13% of the patients, respectively.

CONCLUSIONS

More than half of the Buerger disease patients in this study were suffering from severe periodontitis. It is possible that not only the cessation of smoking, but also the improvement of periodontal care could improve the clinical symptoms related to Buerger disease.

The Two-Way Association of Periodontal Infection with Systemic Disorders: An Overview

Oral cavity that harbors diverse bacterial populations could also act as a site of origin for spread of pathogenic microorganisms to different body sites, particularly in immunocompromised hosts, patients, the elderly, or the underprivileged. A number of recent publications have advocated that patients with periodontal diseases are more susceptible to metabolic endotoxemia, inflammation, obesity, type 2 diabetes, and other related systemic complications, concluding that periodontal diseases could be a potential contributing risk factor for a wide array of clinically important systemic diseases. However, despite a significant increase in the prevalence of periodontal infections and systemic diseases in the past few decades, the fundamental biological mechanisms of connection between these ailments are still not fully explicated. Consequently, the mechanisms by which this bidirectional damage occurs are being explored with a concentric vision to develop strategies that could prevent or control the complications of these ailments. This paper attempts to summarize and hypothesize the diverse mechanisms that hint to a certain connection between the two prevalent chronic situations.

Periodontitis as a risk factor of atherosclerosis

Over the last two decades, the amount of evidence corroborating an association between dental plaque bacteria and coronary diseases that develop as a result of atherosclerosis has increased. These findings have brought a new aspect to the etiology of the disease. There are several mechanisms by which dental plaque bacteria may initiate or worsen atherosclerotic processes: activation of innate immunity, bacteremia related to dental treatment, and direct involvement of mediators activated by dental plaque and involvement of cytokines and heat shock proteins from dental plaque bacteria. There are common predisposing factors which influence both periodontitis and atherosclerosis. Both diseases can be initiated in early childhood, although the first symptoms may not appear until adulthood. The formation of lipid stripes has been reported in 10-year-old children and the increased prevalence of obesity in children and adolescents is a risk factor contributing to lipid stripes development. Endothelium damage caused by the formation of lipid stripes in early childhood may lead to bacteria penetrating into blood circulation after oral cavity procedures for children as well as for patients with aggressive and chronic periodontitis.

Advances in immune-modulating therapies to treat atherosclerotic cardiovascular diseases

In addition to hypercholesterolemia, innate and adaptive immune mechanisms play a critical role in atherogenesis, thus making immune-modulation therapy a potentially attractive way of managing atherosclerotic cardiovascular disease. These immune-modulation strategies include both active and passive immunization and confer beneficial reduction in atherosclerosis. Preclinical studies have demonstrated promising results and we review current knowledge on the complex role of the immune system and the potential for immunization as an immune-modulation therapy for atherosclerosis.

Relationship between periodontal disease and subclinical atherosclerosis: the Dong-gu study

AIM

We assessed the association of periodontal disease and number of missing teeth with subclinical atherosclerosis in an adult Korean population.

MATERIALS AND METHODS

Cross-sectional data from 5404 individuals aged ≥50 years were obtained from the 2008-2010 Dong-gu study. Periodontal examinations were conducted to determine the number of missing teeth, pocket depth (PD), clinical attachment loss (CAL), and bleeding on probing (BOP). The percentages of sites with PD ≥ 4 mm (PD 4%), CAL ≥ 4 mm (CAL 4%), and BOP (BOP%) were recorded for each participant. B-mode ultrasound was performed to determine common carotid artery intima-media thickness (CCA IMT) and the presence of carotid plaques. Multivariate linear regression models were used to assess the associations between periodontal parameters and CCA IMT and carotid plaque.

RESULTS

Number of missing teeth was associated with increased CCA IMT, and BOP% was associated with increased CCA IMT in females only. This association was robust in never smokers.

CONCLUSIONS

The number of missing teeth was associated with CCA IMT, and BOP% was associated with CCA IMT in females only. These associations were robust in never smokers. Our results suggest that tooth loss due to oral disease may play a role in subclinical carotid atherosclerosis.

Effects of tobacco on cytokine expression from human endothelial cells

OBJECTIVE

To investigate the effects of nicotine and cigarette smoke condensate (CSC) exposure on cytokine expression from human endothelial cells in order to identify one possible mechanism that smoking plays in the pathogenesis of both periodontal disease (PDD) and cardiovascular disease (CVD).

METHODS

Human endothelial cells (HUVECs) were exposed to different concentrations of nicotine and CSC to examine the effects that they have on cell proliferation and cytotoxicity. Non-toxic levels were then used to examine cytokine expression using cytokine protein arrays.

RESULTS

Exposure to nicotine caused significant down-regulation in the expression of IL-10 (P = 0.046), growth-regulated oncogene (GRO)α (P = 0.036), MCP-1 (P = 0.046), and GMCSF (P = 0.004) compared with the control untreated HUVECs. Exposure to CSC caused significant down-regulation in the expression of GRO (P = 0.04), GROα (P = 0.01), IL-6 (P = 0.03), and MCP-1 (P = 0.04) compared with the control untreated HUVECs.

CONCLUSIONS

Exposure of HUVECs to nicotine or CSC affects the levels of cytokine expression including reduction in anti-inflammatory and chemoattractant cytokines. This may subsequently affect the host defensive mechanisms of the tissues. The action of toxic chemicals in tobacco smoke on endothelial cells is a potential pathogenic mechanism that may in part explain the association between tobacco, PDD, and CVD.

Poor oral health as a chronic, potentially modifiable dementia risk factor: review of the literature

Poor oral health, including caries, tooth loss, and periodontitis, is ubiquitous worldwide, and is potentially treatable and preventable. Like adverse oral health conditions, Alzheimer disease and related disorders are also very common among aging populations. Established risk factors for Alzheimer disease include cerebrovascular disease and its vascular risk factors, many of which share associations with evidence of systemic inflammation also identified in periodontitis and other poor oral health states. In this review, we present epidemiologic evidence of links between poor oral health and both prevalent and incident cognitive impairment, and review plausible mechanisms linking these conditions, including evidence from compelling animal models. Considering that a large etiologic fraction of dementia remains unexplained, these studies argue for further multidisciplinary research between oral health conditions, including translational, epidemiologic, and possibly clinical treatment studies.

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.

Increased levels of Porphyromonas gingivalis are associated with ischemic and hemorrhagic cerebrovascular disease in humans: an in vivo study

Objective:

This study investigated the role of periodontal disease in the development of stroke or cerebral infarction in patients by evaluating the clinical periodontal conditions and the subgingival levels of periodontopathogens.

Material and Methods:

Twenty patients with ischemic (I-CVA) or hemorrhagic (H-CVA) cerebrovascular episodes (test group) and 60 systemically healthy patients (control group) were evaluated for: probing depth, clinical attachment level, bleeding on probing and plaque index. Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans were both identified and quantified in subgingival plaque samples by conventional and real-time PCR, respectively.

Results:

The test group showed a significant increase in each of the following parameters: pocket depth, clinical attachment loss, bleeding on probing, plaque index and number of missing teeth when compared to control values (p<0.05, unpaired t-test). Likewise, the test group had increased numbers of sites that were contaminated with P. gingivalis (60%x10%; p<0.001; chi-squared test) and displayed greater prevalence of periodontal disease, with an odds ratio of 48.06 (95% CI: 5.96-387.72; p<0.001). Notably, a positive correlation between probing depth and the levels of P. gingivalis in ischemic stroke was found (r=0.60; p=0.03; Spearman's rank correlation coefficient test). A. actinomycetemcomitans DNA was not detected in any of the groups by conventional or real-time PCR.

Conclusions:

Stroke patients had deeper pockets, more severe attachment loss, increased bleeding on probing, increased plaque indexes, and in their pockets harbored increased levels of P. gingivalis. These findings suggest that periodontal disease is a risk factor for the development of cerebral hemorrhage or infarction. Early treatment of periodontitis may counteract the development of cerebrovascular episodes.

Macrophage activation associated with chronic murine cytomegalovirus infection results in more severe experimental choroidal neovascularization

The neovascular (wet) form of age-related macular degeneration (AMD) leads to vision loss due to choroidal neovascularization (CNV). Since macrophages are important in CNV development, and cytomegalovirus (CMV)-specific IgG serum titers in patients with wet AMD are elevated, we hypothesized that chronic CMV infection contributes to wet AMD, possibly by pro-angiogenic macrophage activation. This hypothesis was tested using an established mouse model of experimental CNV. At 6 days, 6 weeks, or 12 weeks after infection with murine CMV (MCMV), laser-induced CNV was performed, and CNV severity was determined 4 weeks later by analysis of choroidal flatmounts. Although all MCMV-infected mice exhibited more severe CNV when compared with control mice, the most severe CNV developed in mice with chronic infection, a time when MCMV-specific gene sequences could not be detected within choroidal tissues. Splenic macrophages collected from mice with chronic MCMV infection, however, expressed significantly greater levels of TNF-α, COX-2, MMP-9, and, most significantly, VEGF transcripts by quantitative RT-PCR assay when compared to splenic macrophages from control mice. Direct MCMV infection of monolayers of IC-21 mouse macrophages confirmed significant stimulation of VEGF mRNA and VEGF protein as determined by quantitative RT-PCR assay, ELISA, and immunostaining. Stimulation of VEGF production in vivo and in vitro was sensitive to the antiviral ganciclovir. These studies suggest that chronic CMV infection may serve as a heretofore unrecognized risk factor in the pathogenesis of wet AMD. One mechanism by which chronic CMV infection might promote increased CNV severity is via stimulation of macrophages to make pro-angiogenic factors (VEGF), an outcome that requires active virus replication.

Effect of periodontal treatment on lipoproteins levels in plasma in patients with periodontitis

OBJECTIVES

Recent epidemiological studies have shown that individuals with periodontitis have a significantly increased risk of developing coronary heart disease. In addition to conventional risk factors, dyslipidemia may be associated with this increased risk.

METHODS

We measured concentration of lipids in patients with moderate to severe periodontitis before and 3, 6 and 12 months after local periodontal treatment. A total of 50 participants with periodontitis and 25 participants without periodontitis were included in the analyses. Lipoproteins were measured by using serological analyses of the Central Biochemical Laboratory in Clinical Center in Nis. Periodontal health indicators included the plaque index, gingival bleeding index, and periodontal disease status (defined by pocket depth and attachment loss). Patients were non-surgically treated with mechanical debridement of calculus once a week for 1 month.

RESULTS

The results show a significant relation between indicators of poor periodontal status and serum level lipoproteins. Periodontal therapy resulted in a significant reduction of local inflammation and tissue destruction as reflected in reduced pocket depth and reduced bleeding indices. The levels of lipoproteins after therapy seemed to be lower than those reported before treatment in patients with periodontitis compared with healthy ones. Lipoproteins were significantly decreased after treatment (P < 0.005) except high-density lipoprotein cholesterol which was not significantly reduced (P > 0.05).

CONCLUSION

This pilot study shows that periodontal disease significantly affects the serum levels of lipoproteins and suggests that following successful periodontal treatment decreases serum lipid concentration. This study suggests also that lipoproteins are possible intermediate factors that may link periodontal disease to elevated cardiovascular risk.

Efficacy of a chairside diagnostic test kit for estimation of C-reactive protein levels in periodontal disease

Background:

C-reactive protein [CRP] levels increase to hundreds of mg/mL within hours following infection. Studies have shown that serum CRP levels were elevated in periodontal disease. However, in all the previous studies, CRP levels were measured by using high-sensitivity CRP assay kits with minimal detection limits of 0.1 to 3 mg/L, which was much below the normal value of 10 mg/L. These high-sensitivity CRP assays need a proper laboratory setup, and these methods cannot be used as a routine chair-side test in the dental office.

Aim:

The purpose of this study was to investigate the serum CRP levels in subjects with periodontal disease by using a rapid chair-side diagnostic test kit with a lower detection limit of 6 mg/L and to compare the CRP levels before and after periodontal therapy.

Materials and Methods:

A total of 45 systemically healthy subjects were selected for the study. Subjects were divided into three groups: group A: healthy controls, group B: gingivitis, group C: periodontitis. Serum levels of CRP were determined by using a latex slide agglutination method with commercially available kit with lower detection limit of 6 mg/L.

Results:

CRP was negative in all the 15 subjects in groups A and B at baseline, 7th and 30th day. CRP was positive only in 2 subjects in Group C at baseline and 7th day.

Conclusion:

Estimation of serum CRP by using a rapid chair-side diagnostic test kit is not of any significance in subjects with periodontitis.

Molecular survey of atheromatous plaques for the presence of DNA from periodontal bacterial pathogens, archaea and fungi

BACKGROUND AND OBJECTIVE

Chronic infections, such as periodontitis, have been associated with the development and progression of atherosclerosis. The mechanisms through which this occurs have yet to be elucidated. This study was carried out to detect periodontopathic bacteria as well as archaea and fungi in atheromatous plaques and search for factors associated with their occurrence in atheromas.

MATERIAL AND METHODS

  A cross-sectional study was carried out including 30 patients diagnosed with atherosclerosis in the carotid, coronary or femoral arteries. Plaques were collected during surgery and analysed using PCR to detect Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola and members of the Synergistetes group. Samples were also surveyed with universal primers for bacterial, archaeal and fungal DNA. Patients responded to a questionnaire to determine factors associated with PCR results.

RESULTS

All dentate individuals (66.7%) had periodontal disease, 95% of which was severe and 65% extensive. None of the targeted periodontopathic bacteria was found in the atheromas. No sample yielded positive results for fungal and archaeal DNA. Four samples (13%) were positive for the presence of bacterial DNA. Of these, three participants were dentate (two with severely chronic generalized periodontitis and one with severely chronic localized periodontitis).

CONCLUSION

This study did not confirm previous findings of periodontal pathogens in atheromas, making it impossible to establish factors associated with their presence in plaques. Presence of bacterial DNA in some samples indicates that periodontal or nonoral bacterial species other than the ones targeted in this study may be involved with some cases of atherosclerosis.

The history of dentistry and medicine relationship: could the mouth finally return to the body?

The relationship between dentistry and medicine has been acknowledged throughout the history of humanity. This relationship was documented in ancient medicine accounts, and has survived until the present day, accompanied by the evolution of molecular technologies. Although we have had very important researchers' contributions in this interdisciplinary area, mainly after the 18th century, the knowledge on oral infections is still ignored by or unknown to the majority of clinical dentists and physicians. These circumstances could be changed through a broader divulgation of this complex relationship, both in the dentistry and in the medicine areas, which in turn would have a significant impact in systemic health worldwide. This movement has already started, as was observed in a World Health Assembly resolution which called for oral health to be integrated into chronic disease prevention programs in 2007. This was a significant indicator of changing perceptions of oral health over the past several decades. This brief review reports the evolution through time of the knowledge on the association between dental infections and systemic diseases, as well as the paths which we could take to consolidate this historical trend.

Treatment of periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid intima-media thickness

Several cohort studies reported a relation of cardiovascular events and periodontal disease. In particular, Porphyromonas gingivalis is associated with the development of atherosclerotic plaques. We verified in a longitudinal study whether inflammation biomarkers, endothelial adhesion molecules, leukocyte activation markers, and intima-media thickness could be beneficially modified by periodontal treatment alone. Thirty-five otherwise healthy individuals affected by mild to moderate parodontopathy were enrolled in the study. Echo-Doppler cardiography of the carotid artery, fluorescence-activated cell sorting analyses on lymphocytes and monocytes, and plasma inflammatory indices were evaluated at baseline and at multiple time points after the periodontal treatment. Results showed that inflammation biomarkers were abnormally increased at baseline. Periodontal treatment resulted in a significant reduction of the total oral bacterial load that was associated with a significant amelioration of inflammation biomarkers and of adhesion and activation proteins. Notably, intima-media thickness was significantly diminished after treatment. Inflammatory alterations associated with the genesis of atherosclerotic plaques are detected in otherwise healthy individuals affected by parodontopathy and are positively influenced by periodontal treatment. Reduction of oral bacterial load results in a modification of an anatomical parameter directly responsible for atherosclerosis. These results shed light on the pathogenesis of atherosclerosis and could have practical implications for public health.

Microbial risk factors of cardiovascular and cerebrovascular diseases: potential therapeutical options

Infection and inflammation may have a crucial role in the pathogenesis of atherosclerosis. This hypothesis is supported by an increasing number of reports on the interaction between chronic infection, inflammation, and atherogenesis. Assessment of serological and inflammatory markers of infection may be useful adjuncts in identifying those patients who are at a higher risk of developing vascular events, and in whom more aggressive treatments might be warranted.

Correlation between atherosclerosis and periodontal putative pathogenic bacterial infections in coronary and internal mammary arteries

BACKGROUND

Chronic infections, such as periodontitis, have been associated with an increased risk for atherosclerosis and coronary artery disease. The aim of this study was to investigate biopsy samples of coronary and internal mammary arteries for the presence of putative pathogenic bacteria (Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Tannerella forsythensis), Chlamydia pneumoniae, and human cytomegalovirus (CMV).

METHODS

Patients with a diagnosis of coronary artery disease were included in the study. Fifteen coronary arteries with atherosclerosis and 15 internal mammary arteries without clinically assessable atherosclerotic degeneration were investigated. Both groups of specimens were obtained during coronary artery bypass grafting surgery. In all cases, the coronary and mammary artery specimens were taken from the same patient. The detection of periodontal pathogens, C. pneumoniae, and CMV was done by polymerase chain reaction analysis.

RESULTS

Bacterial DNA was found in nine of 15 (60%) coronary artery biopsy samples: P. gingivalis in eight (53.33%), A. actinomycetemcomitans in four (26.67%), P. intermedia in five (33.33%), and T. forsythensis in two (13.33%) samples; CMV was detected in 10 (66.67%) samples, and C. pneumoniae was detected in five (33.33%) samples. Some of the samples contained more than one type of bacteria. Periodontal pathogens were not detected in internal mammary artery biopsies, whereas CMV was present in seven (46.67%) samples and C. pneumoniae was present in six (40%) samples.

CONCLUSION

The absence of putative pathogenic bacteria in internal mammary arteries, which are known to be affected rarely by atherosclerotic changes, and their presence in a high percentage of atherosclerotic coronary arteries support the concept that periodontal organisms are associated with the development and progression of atherosclerosis.

Gingivitis, dental caries and tooth loss: risk factors for cardiovascular diseases or indicators of elevated health risks

OBJECTIVES

The results of earlier studies connecting dental diseases to cardiovascular diseases are inconsistent. Our aim in this cross-sectional study was to investigate whether there are associations of dental diseases and diagnosed angina pectoris among the 1966 Northern Finland Birth Cohort.

MATERIALS AND METHODS

A postal questionnaire was sent to all cohort members in 1997-1998. The number of replies totalled 8690. Angina pectoris was determined by asking whether the respondent had been diagnosed with angina pectoris. Gingivitis, dental caries and tooth loss were determined on the basis of self-reported gingival bleeding, presence of dental caries and six or more missing teeth.

RESULTS

We found overall associations of gingivitis (odds ratio (OR) 1.52, confidence interval (CI) 1.04-2.22), dental caries (OR 1.50, CI 1.04-2.18) and tooth loss (OR 1.53, CI 0.69-3.42) with the presence of angina pectoris. The associations were modified by gender and socioeconomic status. In addition, gingivitis, dental caries and tooth loss were also associated with several cardiovascular risk factors.

CONCLUSION

There were associations of self-reported gingivitis, dental caries and tooth loss with angina pectoris. However, the associations between dental diseases and cardiovascular risk factors suggest that the associations may be because of confounding.

Isolation and identification of hydroxyl-platelet-activating factor from natural sources

Platelet-activating factor (PAF), a potent inflammatory mediator that has previously been detected in elevated levels in inflamed gingival tissues, in gingival crevicular fluid (GCF) and in saliva, is implicated in periodontal disease. The biologically active phospholipid detected in gingival crevicular fluid is a hydroxyl-PAF analogue. In a preliminary study this bioactive molecule was detected for the first time in human blood derived from volunteers with chronic periodontitis as well as from periodontally healthy volunteers. Compounds isolated from natural sources as well as synthetic ones have been reported as biologically active lipids with physiological importance based on the fact that they induce platelet aggregation with EC50 values ranging from 100 to 0.01 microM through interaction with G-protein-coupled receptors like the PAF receptor, leading to altered signal transduction. In this study, the existence of hydroxyl-PAF analogue in human blood was further studied as well as its distribution in plasma and in blood components. The existence of hydroxyl-PAF analogue was also investigated in samples from rabbit blood hen's egg yolk. The hydroxyl-PAF analogue was purified by high-performance liquid chromatography, detected by biological assays and identified by electrospray MS analysis. Quantitative determination of PAF and hydroxyl-PAF analogue (expressed as PAF-like activity) showed a statistically significant increase in the ratio of plasma hydroxyl-PAF analogue levels to plasma PAF levels in volunteers with periodontitis. Moreover, hydroxyl-PAF analogue was also detected in rabbit blood and hen's egg yolk samples. These data support that this bioactive lipid may play a role in oral inflammation and suggest PAF as a member of a lipid molecule family with different structures and from different sources which share the same or similar biological activities, apparently with different physiological roles in human and animals.

(A2) Oral health and general health

The interactions between oral and systemic health are bi-directional and complex, involving many pathways. Regarding health as not merely the absence of disease, but as a state of total well-being, these interactions profoundly influence the progress of many diseases, and the quality of life and economic performance of HIV-infected individuals and populations. The evidence base for specific interactions is currently weak, partly because few good-quality studies have been published, partly because of the naïveté of the instruments currently available for recording these interactions and their inherent complexity. Recording quality of life should be a fundamental aspect of all future studies. The most significant conclusion of this Workshop is the need for all involved in oral health research and oral health care to be seen as, and to act as, essential partners in comprehensive care for whole patients and communities.

Risk factors and prevalence of periodontitis in community-dwelling elders in Mexico

AIM

The objective of this study was to determine whether an association existed between chronic systemic diseases/conditions, risk factors common in old age, and the extent and severity of chronic periodontal disease.

MATERIALS AND METHODS

Sociodemographic and lifestyle characteristics were examined by contrasting rural, urban-marginal, and urban social environments in Central Mexico. Data were analysed with Analysis of Variance, chi2 tests, and multivariable logistic regression.

RESULTS

A total of 473 adults 60 years old and over were interviewed; 315 were also examined and underwent laboratory assays (participation rate, 66%); women, 62%; mean age 73+/-8 years; 23% edentulous. The distribution of periodontitis by sociodemographic variables showed differences across locales (73% low-urban, 57% middle-urban, 29% rural). The regression model indicated that periodontitis was more frequently associated with low-urban locale, higher systolic blood pressure, higher body mass index, and worse calculus readings, with an interaction whereby being obese and having a high calculus index was associated with a high probability of having periodontitis.

CONCLUSIONS

Overall periodontal conditions were fair. While we identified oral, systemic, and social variables that modulated the experience of periodontitis, it would appear that urban, low social class elders appeared to have worse periodontal conditions.

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.

Oral hygiene and oral symptoms among the elderly in long-term care

Dental teams examined 1910 elderly adults living in long-term care settings (1358 institutionalized, 552 homebound) from all 19 counties in Norway to document oral hygiene, oral symptoms and ability to receive dental treatment. The Mucosal-Plaque Score (MPS) was used to assess oral status. The MPS was significantly better in women than in men, in individuals with dentures than in those with any remaining teeth, and in people who were homebound rather than those who lived in institutions. The MPS did not differ between age groups or geographic regions. According to the Treatment Ability Index, nearly a quarter of the sample was able to receive comprehensive dental care. Reports of "any oral symptom" and "eating/chewing problems" decreased with age and were most prevalent for individuals who had dentures. The MPS had only slight impact on oral symptoms, chewing ability and dry mouth (p > 0.05). Dry mouth was found in 16.9% and was most prevalent in individuals with dentures.

Diagnosis of Helicobacter pylori infection and diseases associated with Helicobacter pylori by Helicobacter pylori outer membrane proteins

AIM: To examine the serological response of patients with upper gastrointestinal diseases and Helicobocter pylori (H pylori) infection to two H pylori outer membrane proteins (OMPs) (M_r18000 and M_r26000) acquired by gene recombinant technique, and to determine the diagnostic significance of serological tests derived from these OMPs.

METHODS: Recombinant vectors encoding the two H pylori OMPs were used to transform and express in BL21 (DE3) E.coli. After purification with Ni²⁺-NTA agarose resin, colloid gold kits were prepared with purified recombinant proteins to detect H pylori infection and H pylori-associated diseases by the immunity-marker technology. We selected 150 patients with H pylori infection and digestive symptoms without previous treatment, including chronic gastritis (n = 60), duodenal ulcer (n = 30), gastric ulcer (n = 30), and gastric cancer (n = 30). As controls, 33 H pylori-negative healthy volunteers were also recruited. Serum samples were collected from all subjects, and the antibodies to specific proteins of H pylori were tested with the colloid gold test kits. The sensitivity, specificity and accuracy of the colloid gold tests were evaluated, by using the combination of standard diagnostic methods (¹³C urea breath test and bacteria culture) and classic enzyme-linked immunosorbent assay (ELISA) as reference.

RESULTS: After purification with Ni²⁺-NTA agarose resin, the purity of recombinant fusion proteins was about 95%. The recombinant fusion proteins were recognized by the specific monoclonal antibodies against the two H pylori OMPs, as demonstrated by the ELISA. Of the 150 serum samples from patients infected with H pylori 141 (94.0%) responded positively to the recombinant protein with M_r26000, while the seropositive rates were 95.0%, 96.7%, 96.7% and 90.0% for patients with H pylori-associated chronic gastritis, duodenal ulcer, gastric ulcer, and gastric cancer respectively. The sensitivity, specificity, and accuracy of the colloid gold kit with M_r26000 protein were 94.0%, 97.0%, and 94.5%, respectively. Compared with the classic ELISA, bacteria culture and ¹³C urea breath test results in detecting H pylori-infection, there was no significant difference (P > 0.05). For the colloid gold kit with M_r18000, the seropositive rates were 52.0%, 40.0%, 40.0%, 53.3% and 86.7%, respectively, in H pylori-infected patients, and those with H pylori-associated chronic gastritis, duodenal ulcer, gastric ulcer, and gastric cancer. There was a significant difference (P < 0.05) in seropositivity between patient with gastric cancer (86.7%) and those with other diseases (43.3%).

CONCLUSION: The two colloid gold kits derived from the recombinant OMPs are useful tools either for detecting H pylori infection, or for, predicting H pylori-associated gastric malignancy.

Hydroxyl-platelet-activating factor exists in blood of healthy volunteers and periodontal patients

Periodontal diseases are localized chronic inflammatory conditions of the gingival and underlying bone and connective tissue. Platelet-activating factor (PAF), a potent inflammatory phospholipid mediator that has been previously detected in elevated levels in inflamed gingival tissues, in gingival crevicular fluid and in saliva, is implicated in periodontal disease. Our results from previous studies showed that the biologically active phospholipid detected in gingival crevicular fluid is a hydroxyl-PAF analogue. In this study, hydroxyl-PAF analogue was detected for the first time in human blood derived from patients with chronic periodontitis as well as from periodontally healthy volunteers. The hydroxyl-PAF analogue was purified by high-performance liquid chromatography, detected by biological assays and identified by electrospray analysis. In addition, the quantitative determination of PAF and hydroxyl-PAF analogue (expressed as PAF-like activity) showed a statistically significant increase in the ratio of hydroxyl-PAF analogue levels to PAF levels in periodontal patients, suggesting that this bioactive lipid may play a role in oral inflammation.

The Short-Term Effects of Treatment of Chronic Periodontitis on Circulating Levels of Endotoxin, C-Reactive Protein, Tumor Necrosis Factor-α, and Interleukin-6

BACKGROUND

The acute-phase response involves molecules including tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and C-reactive protein (CRP). This study aimed to determine whether subgingival scaling resulted in rapid changes in plasma concentrations of these molecules.

METHODS

Twenty-three non-smoking adults with chronic periodontitis received subgingival scaling for 60 minutes. Venous blood samples were taken at 0, 15, 30, 60, and 120 minutes. TNF-alpha and IL-6 were assayed from all samples and CRP from the baseline and final samples. Lipopolysaccharide (LPS) was assayed at 0, 15, and 30 minutes using limulus lysate assay (LAL) and EndoCAb Ig assays.

RESULTS

LPS assays were suggestive of a transient low-grade bacteremia, but changes in LPS approaching significance (P=0.061) were seen with LAL only. There was a significant increase in circulating TNF-alpha (P=0.0387) and IL-6 (P<0.0001), and the degree of change in TNF-alpha was correlated with the severity of periodontal breakdown (P=0.001). There was also a significant correlation between levels of IL-6 and TNF-alpha (P<0.001).

CONCLUSIONS

Chronic periodontitis patients undergoing an episode of subgingival scaling show a significant elevation in circulating TNF-alpha and IL-6. This may account for anecdotal reports of pyrexia following treatment and may be significant in terms of the relationship between periodontal disease, bacteremia, and cardiovascular disease.

Recovery of periodontopathogenic bacteria from embalmed human cadavers

There is recent interest in recovery of periodontopathogenic bacteria from arterial and bronchial tissues to identify a link between periodontal and cardiovascular or pulmonary diseases. This interest could provide a useful clinical correlation exercise for gross anatomy. Our objective was to perform a feasibility study to determine whether these bacteria could be recovered from two sites within eight (4 dentate, 4 edentulous) human embalmed cadavers from an anatomical dissection laboratory. Bacterial samples were collected from the right coronary artery and the right superior secondary bronchus and assayed for the presence and concentrations of the DNA of A. actinomycetemcomitans, E. corrodens, C. rectus, P. intermedia, P. gingivalis, B. forsythus, T. denticola, and F. nucleatum. Frequencies were compared using a Kruskal-Wallis H-test. Correlations between the presence of teeth, bacterial species, and site were determined by a Spearman's rho correlation test. A. actinomycetemcomitans and B. forsythus frequencies were different between the sites in edentulous subjects (P <0.05); the frequency of B. forsythus was different in dentate and edentulous subjects at the bronchus site (P <0.05). Numerous significant correlations were identified between strains of bacteria, site, and presence of teeth. Thus, it is possible for the DNA of periodontopathogenic bacteria to be recovered from human embalmed cadavers. Collection and identification of these bacteria from these cadavers could be a useful clinical correlation exercise for dental students in a gross anatomy class.

Dental infections and serum inflammatory markers in patients with and without severe heart disease

OBJECTIVE

The objective of this study was to investigate if patients with severe heart disease (CHD patients) present more signs of dental infections than patients without heart disease (non-CHD patients), if serum inflammatory markers differ between the groups, and if there is a link between these and the oral health parameters.

METHODS

We performed clinical and radiologic dental examinations and collected serum samples of 256 patients with New York Heart Association class II-IV heart disease (CHD patients) and 250 non-CHD controls. Serum samples were analysed using pertinent methods in the clinical laboratory of the hospital, and the differences in serum biomarkers between CHD patients and non-CHD patients were examined using various statistical methods. A modified dental index (MDI) was constructed and used in the analyses.

RESULTS

CHD patients were significantly more likely to be edentulous (34.8% vs. 14.8%) and retain less natural teeth than non-CHD patients (8.6 vs. 17) (P <.001). In CHD patients the remaining teeth and supporting tissues were more often diseased. High MDI scores were significantly associated with CHD status (OR 1.31, CI 1.16-1.48), as was gingivitis (OR 3.37, CI 1.66-6.86), while the presence of deep periodontal pockets was not. Serum C-reactive protein and fibrinogen concentrations and blood erythrocyte sedimentation rates were higher in the CHD group. Also, H. pylori and Chlamydia antibodies were significantly higher in the CHD group.

CONCLUSION

CHD patients presented with poorer oral health status than non-CHD patients. Serum inflammatory markers were significantly higher in the CHD patients compared to the non-CHD group. High MDI scores linked with risk of CHD.

Oral disorders and chronic systemic diseases in very old adults living in institutions

This study evaluated whether oral disorders were associated with chronic systemic diseases in 532 Canadian adults who are old and very old and living in institutions. A brief oral examination documented tooth retention, caries, and periodontal and gingival health. Medical records provided information about chronic systemic conditions. A history of stroke was associated with a higher experience of caries, a higher ratio of decayed-to-present teeth, and more gingival and periodontal problems. Participants with high blood pressure, osteoporosis, or diabetes were more likely to be edentulous or to have fewer teeth than participants who did not have these conditions. Participants who had arthritis retained more teeth with age. Participants who had more diseases also tended to have poorer gingival or periodontal conditions, fewer teeth, and higher risk of edentulousness. The associations between systemic diseases and more severe oral disorders may be direct or may be mediated by underlying factors such as health behaviors.

Construction and characterization of bivalent vaccine candidate expressing HspA and Mr18000 OMP from Helicobacter pylori

AIM: To construct a recombinant vector which can express outer membrane protein (OMP) with M_r18000 and heat shock protein A (HspA) from Helicobacter pylori (H. pylori) in E. coli BL21, and to exploit the possibility for obtaining the vaccine conferring protection from H. pylori infection.

METHODS: The target gene of HspA was amplified from H. pylori chromosome by PCR, and then inserted into the prokaryotic expression vector pET32a (+) by restrictive endonuclease enzyme kpn I, BamH I simultaneously. The recombinant vector was used to sequence, and then together with pET32a (+)/Omp₁₈, digested by restrictive endonuclease enzyme Hind III and BamH I simultaneously. pET32a(+)/ HspA and Omp₁₈ were recovered from 1% agarose gel by gel kit, and ligated with T₄ ligase by BamH I digested viscidity end. The recombinant plasmid of pET32a(+)/HspA/Omp₁₈ was transformed and expressed in E. coli BL21 (DE3) under induction of IPTG. After purification, its antigenicity of the fusion protein was detected by Western blot.

RESULTS: Enzyme digestion analysis and sequencing showed that the target genes were inserted into the recombinant vector, composed of 891 base pairs, encoded objective polypeptides of 297 amino acid residues. Compared with GenBank reported by Tomb et al there were 1.3% and 1.4% differences in obtained H. pylori nucleotide sequence and amino acid residues, respectively. SDS-PAGE analysis showed that relative molecule mass (M_r) of the expressed product was M_r 51000, M_r of protein expressed by pET32a (+) was about M_r 20000, and soluble expression product accounted for 18.96% of total bacterial protein. After purification with Ni⁺²-NTA agarose resins, the purification of recombinant fusion protein was about 95%. Western blot showed that recombinant fusion protein could be recognized by the patients’ serum infected with H. pylori and anti-Omp₁₈ monoclone, suggesting that this protein had good antigenicity.

CONCLUSION: The gene coding for H. pylori M_r18000 OMP and HspA was cloned and expressed successfully. The results obtained lay the foundation for development of H. pylori protein vaccine and a quick diagnostic kit.

Relationship of destructive periodontal disease to the acute-phase response

BACKGROUND

Destructive periodontal diseases have been associated with an increased risk of atherosclerotic complications; however, the potential mechanisms are yet to be defined. Inflammation plays a central role in atherosclerosis since C-reactive protein (CRP), an acute-phase protein monitored as a marker of inflammatory status, has been identified as a major risk factor for atherosclerotic complications. Recent reports that destructive periodontal diseases can increase CRP values present the possibility that the acute-phase response may link these 2 disease processes. The objective of the present investigation was to determine the effect of destructive periodontal disease status, severity, and progression on components of the acute-phase response in an urban minority population.

METHODS

Clinical measurements recorded included probing depth, attachment level, gingival erythema, bleeding upon probing, suppuration, and plaque. Disease progression was defined as a >2 mm loss of attachment 2 months post-baseline. Serum antibody was measured by enzyme-linked immunosorbent assay. CRP was measured using a high-sensitivity CRP (hsCRP) assay. A commercial laboratory measured serum glucose (non-fasting), albumin, cholesterol, high-density lipoprotein (HDL), triglycerides, low-density lipoprotein (LDL), and iron.

RESULTS

Increased serum IgG antibody to Porphyromonas gingivalis, but not to 5 other species, was associated with periodontal disease status, increased severity, and progression as were age, male gender, and smoking. Cholesterol and LDL were increased in disease, and HDL and iron were increased in health. hsCRP, glucose, and cholesterol increased with disease progression. By regression analysis, IgG antibody to P. gingivalis correlated with age, probing depth, and hsCRP, and negatively correlated with albumin and iron. By logistic regression, subjects who experienced multiple sites of disease progression and elevated antibody to P. gingivalis increased the odds ratio of hsCRP>2.08 mg/l by 14.1 and 5.6, respectively.

CONCLUSION

These results suggest that destructive periodontal disease and disease progression are associated with changes in serum components consistent with an acute-phase response.

Effect of treatment of chronic periodontitis on levels of serum markers of acute-phase inflammatory and vascular responses

AIMS

Recent epidemiological work suggests an association between periodontal disease severity and cardiovascular disease risk. This study aimed to ascertain if circulating levels of cardiovascular and systemic inflammatory markers could be modified following treatment of periodontal disease.

METHOD

Adult subjects were recruited from those awaiting periodontal treatment and randomised to either immediate (test, n=24) or delayed treatment (control, n=15). Demographic and clinical data were collected and venous blood was taken before and either 6 weeks after completion of treatment or after an equivalent 3-month control period. Periodontal examination included probing depth, loss of attachment, plaque scores and bleeding scores. Blood was analysed to determine serum and plasma fibrinogen, C-reactive protein, sialic acid, tumour necrosis factor-alpha and interleukin -6 and -1beta. Effects of treatment were assessed by paired tests and analysis of variance by treatment group with baseline covariates.

RESULTS

Treatment improved plaque and bleeding scores and reduced probing depths (p<0.002). However, there were no statistically significant changes in levels of any of the systemic markers.

CONCLUSION

Improvement in periodontal health did not influence the levels of vascular markers.

Comparison of sample collection methods for the PCR detection of oral anaerobic pathogens

AIMS

To provide evidence that DNA-PCR diagnostics of oral pathogens based on standard sample collection by paper point insertion from the depth of the periodontal pocket can be replaced by a novel non-invasive collection method based on swab technique from the gingiva.

METHODS AND RESULTS

In this study we compared the results from two collection methods performed in 35 patients with chronic adult periodontitis. Statistical analysis showed a highly significant association of diagnostic results between both collection techniques.

CONCLUSIONS

The Pocket-out method represents a reliable alternative to the standard collection technique for PCR diagnosis of oral pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

Due to its simplicity and non-invasiveness, the Pocket-out collection could be performed in any physician office, or even by the patient himself. With respect to the putative association between periodontal disease and various systemic illnesses, this method could be integrated with various screening programs of oral pathogens.

Inflammatory status and insulin resistance

PURPOSE OF REVIEW

The inflammatory response is essential in the response to pathogens. TNF-alpha, IL-1 and IL-6 are key mediators of the response. They initiate metabolic changes to provide nutrients for the immune system, from host tissues. These changes include hyperlipidemia and increased gluconeogenesis. Insulin resistance and disordering of lipid metabolism occur in obesity, diabetes mellitus, atherosclerosis. This review examines recent research that links inflammation to insulin insensitivity.

RECENT FINDINGS

Population studies show a strong association between indices of inflammation, and abnormal lipid and carbohydrate metabolism, obesity and atherosclerosis. TNF-alpha is produced, by cells of the immune system and by adipocytes. It may provide the link between inflammation and insulin sensitivity. TNF-alpha results in insulin insensitivity, indirectly by stimulating stress hormone production and directly by sustained induction of SOCS-3 which decreases insulin-induced insulin receptor substrate 1 (IRS1) tyrosine phosphorylation and its association with the p85, regulatory subunit of phosphatidylinositol-3 kinase; and by negative regulation of PPAR gamma. Adipose tissue produces both TNF-alpha and leptin. Production of the latter relates positively to adipose tissue mass and through its actions on immune function exerts a pro-inflammatory influence.

SUMMARY

Recent studies on diseases which involve insulin insensitivity (e.g. obesity, type 2 diabetes and atherosclerosis) also show increased cytokine production and markers of inflammation. Evidence at present favours chronic inflammation as a trigger for chronic insulin insensitivity, rather than the reverse situation.

Screening for traditional risk factors for cardiovascular disease: a review for oral health care providers

BACKGROUND

Cardiovascular disease, or CVD, is associated with a very high rate of morbidity and mortality among people in the United States. Primary and secondary prevention measures will help reduce cardiovascular events and increase the overall health of the patient population.

METHODS

The author conducted MEDLINE and Internet searches and reviewed publications from professional organizations for the most up-to-date information on CVD and associated risk factors.

RESULTS

More than 450,000 articles and monographs on CVD were published in English between January 1990 and May 2001. Of these, approximately 45,000 discussed CVD and risk factors. The author selected and reviewed more than 550 publications on the basis of their relevance to epidemiology, etiology, and primary and secondary prevention of CVD.

CONCLUSIONS

Recent information regarding the pathogenesis and treatment of CVD suggests that oral health care providers can perform screening for risk factors and aid in monitoring of specific conditions that put people at an increased risk of developing and exacerbating existing CVD. Dentists need to take a proactive role in this endeavor.

CLINICAL IMPLICATIONS

As with most medical conditions, oral health care providers play an important function as it relates to the overall health of their patients. This article provides a timely update on CVD and the relationship between CVD and its risk factors, and offers suggestions for oral health care providers as to when they should interact with patients and patients' primary health care providers to possibly reduce the mortality and morbidity of CVD.