Association between obstructive sleep apnoea and chronic periodontitis: a population-based study

Exploring the links between periodontal diseases and obstructive sleep apnoea: An overview for clinicians

Both periodontal diseases (PDs) and obstructive sleep apnoea (OSA) are highly prevalent disorders with global impact, associated with a large burden at individual patient and health system levels. These disorders often co-exist, but there is growing evidence that the association between the disorders goes beyond an overlap between two highly prevalent diseases that have shared risk factors. Evidence suggests a potential causal relationship, although further research is required to verify this. Regardless of any causal relationship, the co-existence of these disorders is important to recognize since they may act in combination to heighten health risks, particularly cardiovascular risk. Thus, dentists have an important role in screening for OSA in patients presenting with PDs, and similarly, they need to evaluate periodontal health in patients requiring treatment for OSA. Here we provide a narrative review of the association between PDs and OSA to raise awareness among clinicians and promote multidisciplinary collaborations that aim at an evidence-based and effective management of such patients.

Association between sleep and periodontitis: NHANES 2009-2014 and Mendelian randomization study

OBJECTIVE

We assessed association between periodontitis and sleep patterns.

METHODS

Our study included 7289 participants based on a large-scale study in NHANES. Periodontitis was defined through an oral examination. We used logistic regression to explore association between sleep status and risk of periodontitis. Further, stratified analysis was conducted. We performed a Mendelian randomization (MR) analysis using publicly available genetic data from corresponding studies.

RESULTS

Odds Ratio (OR) of periodontitis was 1.25 (1.07-1.46) in individuals with < 7 hours/per night. Stratification analysis showed individuals under 45 years old (OR: 1.28, 95% CI: 1.07-1.54), women (1.28(1.07-1.54)), education levels below high school (1.45(1.03-2.05)) and higher family income (-1.28(1.06-1.56)) were more likely to deteriorate to periodontitis if sleep time less than 7 hours. IVW-MR showed periodontitis risk was not associated with genetically increased levels of sleep time (0.22 (0.02-3.05)) or insomnia (0.83(0.55-1.24)).

CONCLUSION

There was no indication that sleep status was associated with periodontitis.

Sleep and periodontal health

Sleep is fundamental for health and well-being. An adequate amount and quality of sleep is a cardinal component of a healthy lifestyle at the basis of the prevention of many non-communicable chronic diseases. Recent evidence suggests that sleep disorders, particularly obstructive sleep apnea, represent an emerging risk factor for periodontal health. This review article provides a critical appraisal of the existing literature concerning the association between sleep duration, sleep quality, sleep disorders in general, and obstructive sleep apnea with periodontal diseases, including gingivitis and periodontitis. The putative mechanisms underlying these associations are described as well as the potential clinical implications for diagnosis and treatment.

Correlations between Obstructive Sleep Apnea Syndrome and Periodontitis: A Systematic Review and Meta-Analysis

The focus of this article was to evaluate the link between obstructive sleep apnea syndrome (OSAS) and periodontitis, considering various hypotheses supporting the relationship between respiratory disorders and periodontitis. The literature review for this study was performed using the PubMed, Google Scholar, Cochrane library, and Proquest databases. The review process was guided by the PRISMA guidelines. The PECOS protocol (Population, Exposure, Control, Outcome, Study) was followed in developing the search strategy to ensure consistent and accurate selection of articles. To evaluate quality, cross-sectional studies were reviewed using the Joanna Briggs Institute (JBI) critical appraisal tool. Case-control studies were assessed with the Newcastle-Ottawa Scale (NOS). The research included a total of 10 studies, encompassing 88,040 participants. The meta-analysis observed a statistically significant association between OSAS and periodontitis, with an odds ratio OR = 2.4620 (95%-CI: 1.7345-3.4946 p ≤ 0.0001). The results suggest a potential association between OSA and periodontitis. Further investigations are warranted to confirm this association and elucidate its underlying mechanism.

Oral Health Implications of Obstructive Sleep Apnea: A Literature Review

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep. While the systemic implications of OSA are well documented, the dental consequences are less frequently discussed yet equally significant. This review aims to elucidate the oral health impacts of OSA, emphasizing the importance of interdisciplinary care.

METHODS

A comprehensive literature search was conducted across several databases to identify studies examining the relationship between OSA and various oral health parameters. The review included observational studies, clinical trials, and systematic reviews published in English up to January 2024.

RESULTS

OSA was significantly associated with heightened risks of bruxism, dry mouth, periodontal disease, temporomandibular joint disorders, palatal and dental changes, and alterations in taste sensation. Mouth breathing associated with OSA was a critical factor in exacerbating xerostomia and dental caries. Furthermore, the systemic inflammation induced by OSA appeared to correlate with the severity of periodontal disease. Patients using oral appliance therapy for OSA also showed notable changes in dental occlusion and required ongoing dental monitoring.

CONCLUSIONS

The findings underscore the bidirectional relationship between OSA and oral health, highlighting the need for dental professionals to be integral participants in the management of OSA. Early dental evaluation and intervention can contribute to the overall health and quality of life of individuals with OSA. The review advocates for the development of clinical guidelines to facilitate the early identification and management of OSA-related oral health issues within dental practice and encourages a collaborative approach to patient care.

Sleep Duration and Risk of Periodontitis-A Systematic Review and Meta-Analysis

Periodontitis, with a high prevalence in the whole population, is the main cause of tooth loss. Some studies have revealed that sleep duration may be related to periodontitis, however, the opinions are not consistent. This meta-analysis was carried out to study the potential relationship between sleep duration and periodontitis. A search of relevant articles was conducted on Embase, PubMed, Cochrane Library, and Web of Science. Papers published until the end of November 2022 reporting associations between sleep duration and periodontitis were considered. The pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated to assess the association. Software STATA 14.0 was employed to conduct this analysis. A total of 11 cross-sectional studies were included. Our study showed neither short sleep duration (SSD) nor long sleep duration (LSD) were associated with periodontitis (SSD: OR = 1.04, 95% CI: 0.83, 1.29; LSD: OR = 1.12, 95% CI: 0.94, 1.23), while higher prevalence was observed when sleep duration ≤5 h (OR = 1.41, 95% CI: 1.33, 1.51). In addition, both SSD and LSD were not associated with severe periodontitis (SSD: OR = 0.94, 95% CI: 0.75, 1.16; LSD: OR = 1.19, 95% CI: 0.80, 1.76). In conclusion, the present review indicated that too little sleep duration (≤5 h) significantly increased the risk of periodontitis. However, the evidence is limited due to cross-sectional design of most studies, Hence longitudinal studies should be conducted to support this finding.

Influence of Obstructive Sleep Apnea on the Risk of Dental Caries: Insights from a 13-Year Population-Based Retrospective Study

KNOWLEDGE TRANSFER STATEMENT

Obstructive sleep apnea has been proven to have a great negative impact on patients, and the relationship between sleep apnea and dental caries is still inconclusive. Our study shows that patients with sleep apnea and those older than 45 y have a significant risk of dental caries.

Effect of mandibular advancement appliance use on oral and periodontal health in patients with OSA: a systematic review

STUDY OBJECTIVES

Use of a mandibular advancement appliance (MAA) is an effective treatment option for mild-to-moderate obstructive sleep apnea (OSA). MAA is well-tolerated but undesirable effects may be observed over time. The present systematic review aimed to assess the effect of MAA use on oral and periodontal health in patients with OSA.

METHODS

MEDLINE (PubMed), Cochrane, and Scopus were searched for randomized and non-randomized controlled trials (RCTs, NRCTs), cohorts, and case-control studies reporting on side effects of MAA treatment in OSA patients during a follow-up of at least 6 months.

RESULTS

From a total of 169 articles screened, 28 were selected. The most frequently reported MAA-related effects on oral health were: hypersalivation (weighted mean prevalence, 33.3%), occlusal changes (30.2%), muscle pain (22.9%), tooth discomfort or pain (20.2%), and xerostomia (18.3%). No MAA-related periodontal effect was reported. The periodontal status prior to MAA treatment was rarely assessed and described, but 5 studies (17.8%) stated that periodontitis was an exclusion criterion for MAA. Only one retrospective study specifically evaluated periodontal parameters and reported no significant changes in periodontally healthy patients with OSA using MAA for over 7 years.

CONCLUSION

MAA use is associated with a number of clinical consequences on oral health, but there is no evidence to conclude whether or not MAA affects periodontal health in patients with OSA. This aspect appears to be under-evaluated and should be further investigated in relation to the type of MAA, the duration of treatment, and prior history of periodontitis.

Genetically predicted obstructive sleep apnea is causally associated with an increased risk for periodontitis

BACKGROUND

Although obstructive sleep apnea (OSA) and periodontitis are associated, whether this association is causative is uncertain.

METHODS

We conducted a bidirectional Mendelian randomization (MR) analysis using data from publically accessible genome-wide association studies. The single-nucleotide polymorphisms (SNPs) for OSA were derived from 16,761 cases and 201,194 controls. The pooled data of periodontitis association involved up to 17,353 individuals. Disease-associated single-nucleotide polymorphisms were selected as an instrumental variable at the genome-wide significance level (p < 5.0 × 10- 6). Subsequently, the causal effects were estimated using three different methods: inverse variance weighting (IVW), MR-Egger, and weighted median. Then, these causal estimates were expressed as dominance ratios [odds ratio (OR)].

RESULTS

The MR analysis revealed that genetically determined OSA promotes the development of periodontitis [ IVW OR = 1.117, 95% confidence interval (CI) = 1.001-1.246, p = 0.048). Furthermore, no causal effect of genetically predicted periodontitis on OSA was noted in the reverse MR analysis (IVW OR = 1, 95% CI: 0.95-1.06, p = 0.87). The trend in results from the MR-Egger regression and weighted median (WM) was consistent with that in results from the IVW method. The robustness of the results was confirmed by the sensitivity analysis.

CONCLUSIONS

In summary, the results of our MR investigation suggest an association between OSA and periodontitis, proposing that early screening and treatment of OSA is beneficial for the prevention and prognosis of periodontitis.

Implications of sleep disorders for periodontitis

PURPOSE

Periodontitis is a chronic inflammatory disease caused by multi-factors. Sleep is a natural physiologic process, and the sleep duration, quality, and patterns might be associated with periodontitis. Meanwhile, periodontitis might in turn induce systemic inflammation and thus impact sleep in different ways as well.

METHODS

To investigate the bidirectional relationship between sleep disorder and periodontitis, a literature search was conducted to reveal the interaction and possible mechanism between these two diseases.

RESULTS

The results show that sleep disorders can affect the progression of periodontitis via some pathomechanisms, and periodontitis also has a reverse impact on sleep.

CONCLUSION

Although the epidemiologic and clinical trials found the possible associations between sleep disorder and periodontitis, their relationship is still not that explicit. Further studies are warranted to shed light on them, to improve preventive health care.

Oral microbiota in obstructive sleep apnea patients: a systematic review

PURPOSE

Evidence suggests that patients with obstructive sleep apnea (OSA) are at increased risk of suffering from periodontitis, a chronic inflammatory disease of the tooth-supporting tissues associated with a dysbiotic oral microbiota. This systematic review aims to explore the current literature about the composition of the oral microbiota in patients with OSA compared to those without OSA.

METHODS

Medline, Embase, and Cochrane Library were searched in May 2022 to identify original articles investigating the oral microbiota composition and/or oral microbiome (any microbiological technique) of patients with OSA (adults or children) vs. controls. Case report, reviews, and animal studies were excluded.

RESULTS

Of over 279 articles initially identified, 8 were selected, of which 3 dealt with pediatric patients. Overall, 344 patients with OSA and 131 controls were included. Five studies used salivary samples, 2 oral mucosal swabs, and 1 subgingival plaque sample. With different methods to characterize oral microbiota, 6/8 studies observed significant differences between patients with OSA patients and controls in the composition and relative abundance of several bacteria species/genera linked to periodontitis.

CONCLUSION

Within the limitations of the available literature, the present systematic review indicates that OSA and related conditions (e.g., mouth breathing) are associated with different oral microbiota compositions, which may underlie the association between OSA and periodontitis.

The association between respiratory diseases and periodontitis: A systematic review and meta-analysis

AIM

To evaluate (1) whether periodontitis has an influence on the prevalence/incidence of respiratory diseases (chronic obstructive pulmonary disease [COPD], asthma, community-acquired pneumonia [CAP], obstructive sleep apnoea [OSA] and COVID-19), and (2) what is the impact of periodontal therapy on the onset or progression of respiratory diseases.

MATERIALS AND METHODS

An electronic search was performed on Pubmed, Cochrane Library and Scopus databases up to October 2021, to identify studies answering the PECOS and PICOS questions.

RESULTS

Seventy-five articles were selected. Meta-analyses identified statistically significant associations of periodontitis with COPD (nstudies  = 12, odds ratio [OR] = 1.28, 95% confidence interval [CI] [1.16; 1.42], p < .001), and OSA (ns  = 6, OR = 1.65, 95% CI [1.21; 2.25], p = .001), but not for asthma (ns  = 9, OR = 1.53, 95% CI [0.82; 2.86], p = .181). For acute conditions, two studies were found for CAP, while for COVID-19, significant associations were found for the need of assisted ventilation (ns  = 2, OR = 6.24, 95% CI [2.78; 13.99], p < .001) and COVID-related mortality (ns  = 3, OR = 2.26, 95% CI [1.36, 3.77], p = .002). Only four intervention studies were found, showing positive effects of periodontal treatment on COPD, asthma and CAP.

CONCLUSIONS

A positive association between periodontitis and COPD, OSA and COVID-19 complications has been found, while there is a lack of intervention studies.

Relationship of obstructive sleep apnea with periodontal condition and its local and systemic risk factors

OBJECTIVE

Obstructive sleep apnea (OSA) and periodontitis share risk factors, such as age, obesity, stress, and cardiovascular events, which have a bidirectional cause-effect relationship through systemic inflammation. Our objective was to determine the relationship between OSA and the periodontal condition and its associated local and systemic risk factors.

MATERIAL AND METHODS

This was an observational case-control study involving 60 patients. Local oral risk factors and the systemic condition of each patient were evaluated. All patients underwent polysomnography for the diagnosis of OSA. Chi-squared, one-way ANOVA, and Bonferroni's tests were performed.

RESULTS

A higher percentage of patients with periodontitis had severe OSA (66.66%); however, no statistically significant association was found between the two pathologies (p = 0.290). In terms of systemic risk factors, an association was found between arterial hypertension and severe OSA (p = 0.038), and in terms of local factors, an association was found between the use of removable prostheses and severe OSA (p = 0.0273).

CONCLUSION

In the general population, patients with periodontitis showed a higher prevalence of severe OSA. Obesity and hypothyroidism were the most prevalent systemic findings in patients with OSA and periodontitis. Arterial hypertension and osteoarthritis were found to be associated with severe OSA. The local risk factors associated with periodontitis and severe OSA were removable partial dentures and misfit resins.

CLINICAL RELEVANCE

To study the factors that can facilitate the progression of OSA and periodontitis, physicians and dentists should be advised to provide comprehensive care for patients with both pathologies.

Patients with obstructive sleep apnea can favor the predisposing factors of periodontitis by the presence of P. melaninogenica and C. albicans, increasing the severity of the periodontal disease

Objective

The aim of this study was to analyze the cultivable oral microbiota of patients with obstructive sleep apnea (OSA) and its association with the periodontal condition.

Methods

The epidemiology profile of patients and their clinical oral characteristics were determined. The microbiota was collected from saliva, subgingival plaque, and gingival sulcus of 93 patients classified into four groups according to the periodontal and clinical diagnosis: Group 1 (n = 25), healthy patients; Group 2 (n = 17), patients with periodontitis and without OSA; Group 3 (n = 19), patients with OSA and without periodontitis; and Group 4 (n = 32), patients with periodontitis and OSA. Microbiological samples were cultured, classified, characterized macroscopically and microscopically, and identified by MALDI-TOF-MS. The distribution of complexes and categories of microorganisms and correlations were established for inter- and intra-group of patients and statistically evaluated using the Spearman r test (p-value <0.5) and a multidimensional grouping analysis.

Result

There was no evidence between the severity of OSA and periodontitis (p = 0.2813). However, there is a relationship between the stage of periodontitis and OSA (p = 0.0157), with stage III periodontitis being the one with the highest presence in patients with severe OSA (prevalence of 75%; p = 0.0157), with more cases in men. The greatest distribution of the complexes and categories was found in oral samples of patients with periodontitis and OSA (Group 4 P-OSA); even Candida spp. were more prevalent in these patients. Periodontitis and OSA are associated with comorbidities and oral conditions, and the microorganisms of the orange and red complexes participate in this association. The formation of the dysbiotic biofilm was mainly related to the presence of these complexes in association with Candida spp.

Conclusion

Periodontopathogenic bacteria of the orange complex, such as Prevotella melaninogenica, and the yeast Candida albicans, altered the cultivable oral microbiota of patients with periodontitis and OSA in terms of diversity, possibly increasing the severity of periodontal disease. The link between yeasts and periodontopathogenic bacteria could help explain why people with severe OSA have such a high risk of stage III periodontitis. Antimicrobial approaches for treating periodontitis in individuals with OSA could be investigated in vitro using polymicrobial biofilms, according to our findings.

Association between sleep-disordered breathing and periodontal diseases: A systematic review protocol

Background

Sleep-disordered breathing (SDB) is a chronic sleep-related breathing disorder, considered associated with increased risk of cardiovascular disorders, metabolic disorders, cognitive dysfunction and behavior changes. Periodontal diseases are chronic infectious diseases that are also believed to be associated with cardiovascular diseases, metabolic syndrome and cognitive dysfunction. Several studies have indicated that SDB may be associated with periodontal diseases through certain mechanisms such as inflammation response, oxidative stress and oral dryness. The aim of this systematic review is to explore the association between SDB and periodontal diseases in an integrated approach.

Materials and Methods

This systematic review will include cohort studies, cross-sectional studies and case-control studies that are identified by electronic and manual searches. Electronic searches will be conducted in the following databases: PubMed, Embase, Scopus and Web of Science. Our search will cover articles published from inception of databases to March 2022 without restrictions in language and settings. Pre-determined eligibility criteria include: participants (participants without a history of respiratory diseases, history of periodontal treatment within the past 6 months and history of medication that is known to influence SDB or periodontal diseases); exposure (participants who have been diagnosed with SDB or at high-risk for SDB); comparison (participants without SDB); and outcome (periodontal parameters, such as probing depth, clinical attachment level, bleeding on probing, radiographic bone loss). Two authors will perform study screening and data extraction independently and in duplicate. All discrepancies will be solved by discussion. The methodological quality of included studies will be assessed using the Newcastle-Ottawa Scale.

Discussion

This systematic review will summarize the existing evidence on the association between SDB and periodontal diseases, a topic of controversy and clinical significance. Its findings can provide evidence for the development of relevant prevention and treatment strategies. The results will be disseminated through peer-reviewed journals.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022313024. Registered on March 28th 2022.

Incidence and risk of periodontitis in obstructive sleep apnea: A meta-analysis

Introduction

At present, the possible relationship between obstructive sleep apnea and periodontitis has been reported. The link remains ambiguous and unclear. The objective of this study is to assess the association between OSA and periodontitis.

Methods

Three databases, including Pubmed, Embase, and the Web of Science, were systematically searched to identify eligible studies that from their establishment to February 2022 for relevant studies. Subsequently, a meta-analysis was conducted to determine the relationship of pooled-effects more accurately.

Results

A summary analysis of the 9 results from the studies covering 43,414 individuals showed a statistical association results of the between OSA and the incidence rate of periodontitis(OR = 0.52; 95% CI: 0.49–0.55; I² = 98.43%; P = 0.000). In addition, OSA patients and the risk of the population were statistically significantly associated with an increased risk of periodontitis.(OR = 1.56; 95% CI: 1.06–2.06; P = 0.00).

Conclusions

Our results indicated that OSA may be associated with an increased risk of periodontitis. Further studies are required to confirm the link and explore the underlying mechanism of the link.

Association between obstructive sleep apnea and periodontitis in Chinese male adults: A cross-sectional study

STATEMENT OF PROBLEM

An association between obstructive sleep apnea and periodontitis has been suggested, but supporting data are lacking.

PURPOSE

The purpose of this cross-sectional study was to investigate any association between obstructive sleep apnea and periodontitis in Chinese male adults.

MATERIAL AND METHODS

Ninety-three male adults (aged between 24 and 35 years) were recruited and examined between June and September 2019. Obstructive sleep apnea was diagnosed by using portable, overnight polysomnography, and all participants were classified into study and control groups based on the apnea-hypopnea index. Periodontal examinations were conducted before polysomnography measuring probing depth, clinical attachment level, and bleeding on probing. An objective nasal airway resistance assessment was also performed before polysomnography to quantify mouth breathing during sleep.

RESULTS

Overall, 40 (43.0%) participants had periodontitis, and 19 (20.4%) had obstructive sleep apnea; in those diagnosed with periodontitis, 13 of 40 (32.5%) also had obstructive sleep apnea. Obstructive sleep apnea was positively associated with periodontitis (odds ratio =3.719, 95% CI=1.234 to 11.209, P=.020). The obstructive sleep apnea group showed significantly higher bleeding on probing (P=.034) and clinical attachment level (P=.046). Correlation analysis showed a weak but positive correlation between the severity of obstructive sleep apnea and that of periodontitis. The regression analysis identified the lowest oxygen saturation (odds ratio=0.894, 95% CI=0.842 to 0.949, P=.002) to be significantly associated with the prevalence of periodontitis.

CONCLUSIONS

A significant association was observed between obstructive sleep apnea and periodontitis. Low oxygen saturation might be a predictive index for periodontitis, suggesting that hypoxia caused by obstructive sleep apnea might be related to the symptoms of periodontitis.

Periodontitis severity in obstructive sleep apnea patients

OBJECTIVES

This cross-sectional study investigated the stages of periodontitis in obstructive sleep apnea (OSA) patients and risk factors associated with periodontitis severity among them.

MATERIALS AND METHODS

A total of 194 patients underwent a polysomnography/polygraphy and were referred to periodontal examination. According to apnea-hypopnea index (AHI), patients were classified as mild OSA (AHI < 15) and moderate to severe OSA (AHI ≥ 15), whereas periodontitis severity was determined by the clinical attachment level (CAL) according to the recent Classification of Periodontal Diseases and Conditions. Patients were grouped into two categories: stages 1 and 2, and stages 3 and 4.

RESULTS

Higher AHI values were reported in OSA patients exhibiting periodontitis stages 3 and 4 compared to OSA patients with periodontitis stages 1 and 2 (p = 0.043) and the non-periodontitis group (p = 0.044). A positive correlation was found between AHI and mean CAL (r = 0.215; p = 0.004), and between AHI and plaque scores (r = 0.292; p < 0.001). Following a multivariable regression analysis, AHI was a significant predictor of mean CAL (β = 0.169; p = 0.031), explaining 16.4% of variability in mean CAL (adjusted R² = 0.164; p < 0.001). Older patients had higher odds for an increased mean CAL (β = 0.266; p = 0.001), as well as patients smoking or formerly smoking (β = 0.305; p < 0.001) whereas visiting a dental medicine doctor once a year or more often was associated with a decreased mean CAL (β =  - 0.182; p = 0.02).

CONCLUSIONS

OSA was associated with severe stages of periodontitis along with increased age, smoking, low frequency of dental visits, and poor oral hygiene.

CLINICAL RELEVANCE

Screening for periodontitis is recommended for patients with more severe forms of OSA.

Obstructive Sleep Apnea and Periodontal Disease: A Systematic Review

Background and Objectives: The objective of this study was to evaluate the association between periodontal disease and obstructive sleep apnea syndrome (OSAS). Materials and Methods: Electronic search using PubMed, Scopus, LILACS, and Cochrane library was carried out for randomized controlled trials, cohort, case-control, longitudinal and epidemiological studies on humans published from January 2009 until September 2020. The participants had to be male and female adults who were diagnosed with OSAS either by overnight polysomnography (carried out at a sleep laboratory or at home) or by a home sleep testing monitor (Apnea Risk Evaluation System). Methodological quality assessment was carried out using the Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies while an adapted form of NOS was used for cross-sectional studies. Results: Ten studies fulfilled the inclusion criteria of our review, 5 were case-control studies, and 5 cross-sectional. Sample size ranged from 50 to 29,284 subjects, for a total of 43,122 subjects, 56% of them were male, their age ranged from 18 to 85 years old. The heterogeneity among the studies regarding the classification of periodontal disease, and the different methods for OSAS severity assessment, complicated the comparison among the studies. Conclusions: There is low evidence of a possible association between OSAS and periodontitis. The pathophysiological mechanism, cause-effect, or dose-response relationship are still unclear. Further studies are needed and should use a precise classification of OSAS subjects, while the new classification of periodontitis from the World Workshop of Chicago 2017 should be used for the periodontal assessment.

Influence of body mass index and obesity upon the association between periodontitis and sleep apnea-hypopnea syndrome

OBJECTIVES

We aimed to explore the association between periodontitis and sleep apnea-hypopnea syndrome (SAHS) and the possible influence of body mass index (BMI) and obesity upon this association.

MATERIALS AND METHODS

A case-control study was made involving 114 subjects (60 patients with SAHS and 54 controls). A thorough periodontal evaluation was carried out, and demographic and clinical data were collected.

RESULTS

Periodontitis was more prevalent in SAHS (80%) than in the controls (48.1%). The recorded statistically significant association (OR = 4.31; p = 0.001) was seen to weaken in the multivariate model (OR = 2.03; p = 0.204), with BMI adopting a more influential role. The apnea-hypopnea index (AHI) was correlated to probing depth (PD) (r = 0.40; p = 0.002) and clinical attachment level (CAL) (r = 0.41; p = 0.001). The periodontal parameters were seen to be higher in obese SAHS patients (BMI ≥ 30 kg/m²) than in non-obese SAHS patients (BMI < 30 kg/m²).

CONCLUSIONS

The greater prevalence and severity of periodontitis in patients with SAHS were fundamentally influenced by BMI. On the other hand, periodontitis was more severe in patients with severe SAHS.

CLINICAL RELEVANCE

Patients with SAHS have a greater prevalence of periodontitis, fundamentally related to increased obesity. Therefore, obese subjects with SAHS should be screened for periodontal disease.

[Obstructive Sleep disordered breathing, sleep bruxism and periodontal diseases]

Sleep disordered breathing (SDB) may be associated with sleep bruxism and periodontal diseases. Through a review of the current literature, this article aims to describe the characteristics of sleep bruxism and its relationship with SDB as well as the current evidence supporting an association between periodontal diseases and SDB. Sleep bruxism is characterized by muscle clenching and tooth grinding during sleep, typically during N2 sleep stage and in association with micro-arousals. The probability of observing sleep bruxism is almost 4 times higher in the presence of SDB, with a close temporal relationship between the episode of upper airway obstruction or oxygen desaturation and the episode of bruxism, which most often occurs in the 0-10 seconds following the obstruction. These findings support the hypothesis that sleep bruxism is triggered by SDB and may have a "protective" role being a muscular activity that helps restore the permeability of the upper airways. On the other hand, SDB have been linked to periodontal diseases. Periodontal diseases are inflammatory and dysbiotic disorders that can have a negative impact on oral health (leading to the destruction of the periodontium and tooth loss) and on general health. Recently, it has been observed that SDB patients have a 1.6 to 4-fold higher risk of having or developing severe periodontitis, suggesting that SDB may be a new risk factor for periodontal diseases. Dentists, who are part of the team of sleep medicine specialists, have a key role in the detection, prevention and treatment of SDB and their relationship with sleep bruxism and periodontal diseases.

Auricular Acupressure Improves Habit Reversal Treatment for Nail Biting

OBJECTIVE

Nail biting leads to a variety of health issues. Habit reversal treatment is a major approach to cease nail biting, but is often ineffective since patients continue to suffer from anxiety, a major trigger. This study investigated whether the potential anxiety relief provided by auricular acupressure could improve the efficacy of habit reversal treatment, as evidenced by improved stomatological and other outcomes.

METHODS

In a pragmatic, randomized, crossover, pilot clinical trial, 83 nail biters (8-12 years old) received habit reversal treatment in combination with either auricular acupressure intended to reduce anxiety (Method A) or placebo auricular acupressure (Method B). The alternative protocol was employed after a two-month washout period. The primary outcome measured was the 41-item child self-reported version of the Screen for Child Anxiety Related Emotional Disorders, while the secondary outcomes were the nail growth status (NS), which represented the fingernail growth of each finger during habit reversal treatment, simplified plaque index (SPI), and the simplified gingival index (SGI) as measures of oral health. A paired sample t-test was used to assess the differences between Methods A and B, and the differences in the anxiety scores, NS, SGI, and SPI between the baseline and each time point.

RESULTS

Forty-one children successfully completed both arms of the treatments and attended all appointments. There were significant differences in the efficacy of habit reversal treatment, the anxiety score, the nail status, and the SGI in favor of Method A (p < 0.001).

CONCLUSION

Auricular acupressure appears to improve the efficacy of habit reversal treatment, likely by reducing anxiety.

Association between obstructive sleep apnea and comorbidities with periodontal disease in adults

Background:

Several studies have reported an association between periodontal disease and obstructive sleep apnea (OSA). However, heterogeneity of results suggests that there is insufficient evidence to support this association.

Aims:

The objective of this study was to identify the association between periodontal disease and OSA in adults with different comorbidities.

Settings and Design:

One hundred and ninety-nine individuals (107 women and 92 men) underwent polysomnography with a mean age of 49.9 years were recruited.

Materials and Methods:

The presence of OSA, comorbidities, and periodontal disease was evaluated in each individual. Student's t-tests or Chi-square and ANOVA tests were used to determine the differences between groups.

Results:

The prevalence of periodontal disease was 62.3% and 34.1% for gingivitis. The results showed no statistically significant association between all groups of patients with OSA and non-OSA patients for gingivitis (P = 0.27) and for periodontitis (P = 0.312). However, statistically significant association was shown between periodontitis and mild OSA compared with the periodontitis and non-OSA referent (P = 0.041; odds ratio: 1.37 and 95% confidence interval 1.11–2.68). The analysis between OSA and comorbidities showed a statistically significant difference for patients with OSA and hypertension (P < 0.001) and for patients with OSA and hypertensive cardiomyopathy (P < 0.001) compared with healthy individuals. Periodontitis was more likely in men with severe OSA and with any of two comorbidities such as hypertension or hypertensive cardiomyopathy. Women with hypertension or hypertensive cardiomyopathy were more likely to have mild OSA, and these associations were statistically significant (P < 0.05).

Conclusions:

This study identified association between periodontitis and mild OSA and this association was more frequent in women with hypertension or hypertensive cardiomyopathy. Periodontitis was associated with severe OSA in men who showed any of two comorbidities such as hypertension or hypertensive cardiomyopathy.

Expression of RUNX2 and MDM21 in rats with periodontitis under chronic intermittent hypoxia

OBJECTIVE

To discuss the expression of RUNX2 and MDM21 in rats with periodontitis under the chronic intermittent hypoxia.

METHODS

A total of 32 SD healthy rats were randomly divided into four groups, with 8 rats in each group. The molecular biological techniques of immunohistochemistry, RT-PCR and Western blotting were employed to detect the effect of different hypoxia time (0, 6, 12, 24 and 48 h) and different concentrations of hypoxia (0.000, 0.001, 0.010, 0.060 and 0.100 ppm) on the expression of RUNX2 and MDM21 in rats of four groups.

RESULTS

The expression of RUNX2 and MDM21 in each group was significantly higher than the one at other concentrations when the concentration was 0.010 ppm, with the statistical difference (P < 0.05). The expression of RUNX2 and MDM21 was that normoxic control group > normoxic periodontitis group > hypoxia control group > hypoxia periodontitis group under the action with the concentration of 0.010 ppm for 12 h, but there was no significant difference for the comparison among groups (P > 0.05).

CONCLUSIONS

The condition of chronic intermittent hypoxia can reduce the expression of RUNX2 and MDM21 in rats with periodontitis and aggravate the damage of periodontal bone.

Dysthymia increases the risk of temporomandibular disorder: A population-based cohort study (A STROBE-Compliant Article)

Numerous studies have investigated the relationship between depression and temporomandibular disorders (TMD), but the conclusions remain vague. The aim of this study was to examine the causal effect between depression and TMD.The reporting of this study conforms to the STROBE statement. In this retrospective cohort study, all samples were recruited from a representative subdataset of 1 million insured persons for the year 2005 Longitudinal Health Insurance Database, who were randomly selected from all beneficiaries enrolled in the National Health Insurance program of Taiwan. We used a propensity score and stratified 926,560 patients into 2 groups (propensity1 = 588,429 and propensity2 = 338,131) and 4 cohorts (propensity1 with depression = 18,038, propensity1 without depression = 570,391, propensity2 with depression = 38,656, propensity2 without depression = 299,475) to detect the development of TMD among the depressive and nondepressive patients between 2004 and 2013.The positive correlative factors of TMD included female, total number of times seeking medical advice (TTSMA) for anxiety state, TTSMA for generalized anxiety disorder, TTSMA for mandible fracture, and TTSMA for unspecified anomaly of jaw size. The propensity2 group was represented by elder and female-predominant patients who used more psychiatric health resources. Among 3 types of depression, only dysthymia (so-called chronic depression) had a causal impact on TMD in the propensity 2 group. In the propensity 2 group, the hazard ratio of dysthymia for TMD measured by Cox's regression was 1.64 (95% confidence interval 1.28-2.09), after adjusting for demographic factors, psychiatric comorbidities, and maxillofacial confounders. The first-onset mean time of TMD as the consequence of dysthymia was 3.56 years (sd = 2.74, min = 0.08, median = 2.99, max = 9.73).This study demonstrates that dysthymia increases the risk of TMD in elderly and female-predominant patients who use more psychiatric health resources.

Periodontal Status in Morbidly Obese Patients With and Without Obstructive Sleep Apnea Syndrome Risk: A Cross-Sectional Study

BACKGROUND

This cross-sectional study aims to investigate the correlation between obstructive sleep apnea syndrome (OSAS) risk with periodontal disease and anthropometric measures in Class III obese patients.

METHODS

Anthropometric measurements were taken from 108 patients of both sexes, aged 30 to 60 years. The Berlin questionnaire (Bq) and the Epworth sleepiness scale (ESS) were applied to determine the risk for OSAS. Full-mouth periodontal status was determined by probing depth, clinical attachment level, gingival bleeding index, and the presence of calculus. Unpaired Student t, χ(2), Fisher exact, and Mann-Whitney U tests were applied to analyze the differences between high and low risk for OSAS groups.

RESULTS

Overall, 81.5% of the patients showed high risk for OSAS, 46.3% had excessive daytime sleepiness, 41.5% were positive for both the Bq and ESS, and 97.2% had periodontal disease (periodontitis = 85.2% and gingivitis = 60.2%). Patients with periodontal disease showed high risk for OSAS (82.9%) and ESS (45.7%). However, there was no influence of periodontal disease on OSAS risk. Periodontitis was not associated with the ESS (odds ratio [OR] = 1.84, 95% confidence interval [CI] = 0.54 to 6.26) or Bq (OR = 0.87, 95% CI = 0.10 to 7.84), nor was gingivitis associated with the ESS (OR = 1.25, 95% CI = 0.48 to 3.25) or Bq (OR = 0.23, 95% CI = 0.03 to 1.84). Waist circumference (P = 0.03), neck circumference (NC, P <0.001), and the percentage of predicted NC (PPNC, P <0.001) were significantly larger in the patients at high risk for OSAS than in those at low risk for OSAS. Daytime sleepiness was also associated with NC (P = 0.02) and PPNC (P = 0.02).

CONCLUSION

There was no association between periodontal disease and OSAS risk in Class III obese patients, but OSAS risk was associated with both NC and PPNC.

Increased Risk of Parkinson's Disease in Patients With Obstructive Sleep Apnea: A Population-Based, Propensity Score-Matched, Longitudinal Follow-Up Study

Obstructive sleep apnea (OSA), characterized by repetitive episodes of apnea/hypopnea and hypoxia, is associated with systemic inflammation and induces metabolic, endocrine, and cardiovascular diseases. Inflammation might have an impact on neurodegenerative diseases. This study investigates the possible association between OSA and Parkinson's disease (PD). Random samples out of 1 million individuals were collected from Taiwan's National Health Insurance database. A total of 16,730 patients with newly diagnosed OSA from 2002 to 2008 were recruited and compared with a cohort of 16,730 patients without OSA matched for age, gender, and comorbidities using propensity scoring. All patients were tracked until a diagnosis of PD, death, or the end of 2011.During the mean 5.6-year follow-up period, the incidence rates of PD were 2.30 per 1000 person-years in the OSA cohort and 1.71per 1000 person-years in the comparison group. The incidence rate ratio (IRR) for PD was greater in older patients (≧ 65 years) and male patients with OSA than the controls, respective IRRs being 1.34 and 1.47. After adjustment for the comorbidities, patients with OSA were 1.37 times more likely to have PD than patients without (95% CI = 1.12-1.68, P < 0.05). Subgroup analysis showed that older patients and patients with coronary artery disease, stroke, or chronic kidney disease had a higher risk for PD than their counter parts. Log-rank analysis revealed that patients with OSA had significantly higher cumulative incidence rates of PD than the comparison group (P = 0.0048). Patients with OSA are at an increased risk for subsequent PD, especially elderly male patients.

Periodontitis and Sleep Disordered Breathing in the Hispanic Community Health Study/Study of Latinos

STUDY OBJECTIVES

To investigate the association between sleep disordered breathing (SDB) and severe chronic periodontitis.

DESIGN

Cross-sectional data analysis from the Hispanic Community Health Study/Study of Latinos.

SETTING

Community-based setting with probability sampling from four urban US communities.

PARTICIPANTS

12,469 adults aged 18-74 y.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Severe chronic periodontitis was defined using the Centers for Disease Control and Prevention/American Academy of Periodontology case classification based on full-mouth periodontal assessments performed by calibrated dentists. SDB was evaluated in standardized home sleep tests, and defined as the number of apnea plus hypopnea events associated with ≥ 3% desaturation, per hour of estimated sleep. SDB was quantified using categories of the apnea-hypopnea index (AHI): 0.0 events (nonapneic); 0.1-4.9 (subclinical); 5.0-14.9 (mild); and ≥ 15 (moderate/severe). Covariates were demographic characteristics and established periodontitis risk factors. C-reactive protein was a potential explanatory variable. Using survey estimation, multivariable binary logistic regression estimated odds ratios (OR) and 95% confidence limits (CL). Following adjustment for confounding, the SDB and periodontitis relationship remained statistically significant, but was attenuated in strength and no longer dose-response. Compared with the nonapneic referent, adjusted odds of severe periodontitis were 40% higher with subclinical SDB (OR = 1.4, 95% CL: 1.0, 1.9), 60% higher with mild SDB (OR = 1.6, 95% CL: 1.1, 2.2) and 50% higher with moderate/severe SDB (OR = 1.5, 95% CL: 1.0, 2.3) demonstrating an independent association between SDB and severe periodontitis.

CONCLUSIONS

This study identifies a novel association between mild sleep disordered breathing and periodontitis that was most pronounced in young adults.

Investigating the association between obstructive sleep apnea and periodontitis

BACKGROUND

Obstructive sleep apnea (OSA) is a sleep disorder characterized by disruptions of normal sleep architecture. Chronic periodontitis is a chronic disease of the periodontium that elicits a general inflammatory response to local dental plaque. It has been suggested that periodontal disease may increase in severity with increasingly severe OSA because both disease entities share common inflammatory pathways, acting synergistically to alter the host response. The aim of this study is to analyze the association between severity of OSA and the prevalence/severity of periodontitis.

METHODS

One hundred patients from a large veterans administration sleep study center (n = 26 normal, n = 21 mild, n = 19 moderate, n = 34 severe) diagnosed with an overnight polysomnogram underwent a comprehensive periodontal examination. Periodontal parameters measured included the following: 1) mean periodontal probing depth (PD); 2) clinical attachment level (CAL); 3) gingival recession; and 4) percentage of sites with bleeding on probing, plaque, PD ≥5 mm, and CAL ≥3 mm.

RESULTS

Seventy-three percent of the sampled population had moderate/severe periodontal disease. χ(2) analyses revealed no significant differences in the prevalence of periodontal disease between the apnea-hypopnea index (AHI) groups, with a negligible Spearman correlation coefficient of 0.246 between AHI severity and periodontal disease severity categories. Analysis of covariance indicated a significant association between AHI severity categories and percentage of sites with plaque, after adjusting for age. Multivariable logistic regression analysis predicting moderate/severe periodontitis with AHI score, age, and smoking status indicated a significant association with age (P = 0.028) but no significant association with the other two predictors.

CONCLUSION

OSA was not significantly associated with the prevalence of moderate/severe periodontitis and the periodontal parameters examined, except percentage plaque.

Do salivary and serum collagenases have a role in an association between obstructive sleep apnea syndrome and periodontal disease? A preliminary case-control study

OBJECTIVES

Despite increasing evidence for an association of obstructive sleep apnea syndrome (OSAS) and periodontal disease, the pathophysiological linking mechanisms remain unclear. This study aims to evaluate the salivary and serum matrix metalloproteinase-2, -8, -9 (MMP-2, -8, -9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), myeloperoxidase (MPO), neutrophil elastase (NE), neutrophil gelatinase-associated lipocalin (NGAL), as well as degree of activation of MMP-2, -9 of patients with and without OSAS.

DESIGN

A total of 50 individuals were included in the study. There were 13, 17 and 20 individuals, respectively in the control (non-OSAS) group, mild-to-moderate OSAS and severe OSAS groups. Saliva, serum samples and clinical periodontal parameters were collected. Biofluid samples were analysed by immunofluorometric assay (IFMA), enzyme-linked immunosorbent assay (ELISA), western immunoblotting and gelatine zymography. Statistical analyses were performed using D'Agostino-Pearson omnibus normality test, Kruskal-Wallis test and Spearman rho rank correlation analysis.

RESULTS

There were no statistically significant differences in clinical periodontal parameters between the study groups. Salivary NE and proMMP-2 levels were significantly lower in the OSAS groups than the control group (p<0.05). Serum proMMP-9 concentration and the degree of MMP-9 activation in saliva were significantly lower in the severe OSAS group than the control group (p<0.05). There were significant correlations between salivary and serum proMMP-9 and -2 concentrations (p<0.05). Serum proMMP-2, NE and salivary proMMP-9 and -2 negatively correlated with indicators of OSAS severity (p<0.05).

CONCLUSIONS

The present findings do not support a pathophysiological link between the severity of OSAS and clinical periodontal status via neutrophil enzymes or MMPs.

Obstructive sleep apnea and risk of osteoporosis: a population-based cohort study in Taiwan

BACKGROUND

Obstructive sleep apnea (OSA) is associated with metabolic, endocrine, and cardiovascular diseases. It is characterized by repetitive episodes of apnea/hypopnea and hypoxia in tissues, which might also impact bone metabolism. This study investigates the possible association between OSA and osteoporosis.

METHODS

Random samples of 1 million individuals were collected from Taiwan's National Health Insurance database. A total of 1377 patients with newly diagnosed OSA from 2000 to 2008 were recruited and compared with a matched cohort of 20 655 patients without OSA. All patients were tracked until an osteoporosis diagnosis, death, or the end of 2011.

RESULTS

During the 6-year follow-up period, the incidence rates of osteoporosis in the OSA cohort and comparison group were 2.52 and 1.00 per 1000 person-years, respectively. Patients with OSA were found to be at 2.74 times the risk of osteoporosis than patients without OSA (95% confidence interval 1.69-4.44, P < .05), after adjustment for age, gender, diabetes, hypertension, coronary artery disease, obesity, stroke, hyperlipidemia, chronic kidney disease, gout, monthly income, and geographical location. Subgroup analysis showed that older patients and female patients had a higher risk for osteoporosis than their younger and male counterparts. Log-rank analysis revealed that patients with OSA patients had significantly higher cumulative incidence rates of osteoporosis than the comparison group (P < .0001).

CONCLUSION

People diagnosed with OSA are at increased risk for subsequent osteoporosis.

Discovering medical conditions associated with periodontitis using linked electronic health records

AIM

To use linked electronic medical and dental records to discover associations between periodontitis and medical conditions independent of a priori hypotheses.

MATERIALS AND METHODS

This case-control study included 2475 patients who underwent dental treatment at the College of Dental Medicine at Columbia University and medical treatment at NewYork-Presbyterian Hospital. Our cases are patients who received periodontal treatment and our controls are patients who received dental maintenance but no periodontal treatment. Chi-square analysis was performed for medical treatment codes and logistic regression was used to adjust for confounders.

RESULTS

Our method replicated several important periodontitis associations in a largely Hispanic population, including diabetes mellitus type I (OR = 1.6, 95% CI 1.30-1.99, p < 0.001) and type II (OR = 1.4, 95% CI 1.22-1.67, p < 0.001), hypertension (OR = 1.2, 95% CI 1.10-1.37, p < 0.001), hypercholesterolaemia (OR = 1.2, 95% CI 1.07-1.38, p = 0.004), hyperlipidaemia (OR = 1.2, 95% CI 1.06-1.43, p = 0.008) and conditions pertaining to pregnancy and childbirth (OR = 2.9, 95% CI: 1.32-7.21, p = 0.014). We also found a previously unreported association with benign prostatic hyperplasia (OR = 1.5, 95% CI 1.05-2.10, p = 0.026) after adjusting for age, gender, ethnicity, hypertension, diabetes, obesity, lipid and circulatory system conditions, alcohol and tobacco abuse.

CONCLUSIONS

This study contributes a high-throughput method for associating periodontitis with systemic diseases using linked electronic records.

Replacement of Missing Anterior Teeth in a Patient with Chronic Mouth Breathing and Tongue Thrusting

The loss of anterior teeth has serious functional, esthetic disabilities, in addition to compromising the patients' quality of life. Various etiologies can be attributed to the anterior tooth loss, including trauma, caries, and periodontal diseases. The chronic mouth breathing due to nasal adenoids is known to enhance the gingival and periodontal diseases. The dental literature proves the association of nasal breathing, tongue thrusting, and anterior open bite. Arch shape and tooth position are primarily determined by the equilibrium of the forces from tongue and perioral musculature. Increased force from tongue musculature in the tongue thrusting patient leads to flaring of anterior teeth, making them susceptible for periodontal and traumatic tooth loss. Replacement of the anterior teeth in this patient will also help in restoration of anterior guidance, which is critical for the health of temporomandibular joint, posterior teeth, and musculature.