Assessment of partial-mouth periodontal examination protocols for periodontitis surveillance

Synergistic effect of periodontitis and C-reactive protein levels on mortality: NHANES 2001-2004

Periodontitis is associated with elevated C-reactive protein (CRP) levels. Although the coexistence of periodontitis and elevated CRP levels may heighten the risk of mortality, previous studies have not confirmed their synergistic effect. Understanding this interaction is crucial for identifying potential interventions to reduce mortality risk in individuals with periodontitis. This study aimed to assess the synergistic effects of periodontitis and elevated CRP levels on mortality in 7,938 adult individuals who participated in the National Health and Nutrition Examination Study 2001-2004. The association of periodontitis status and CRP levels with mortality was assessed using a survey-weighted Cox model. The interactive effect was estimated; the synergistic effect of CRP levels and periodontitis status on mortality was assessed using the relative excess risk due to interaction (RERI). Periodontitis was diagnosed in 1,065 (13.4%) participants. Compared with the participants without periodontitis and possessing CRP levels of ≤ 0.5 mg/dL, those with periodontitis (hazard ratio [HR], 1.38) or CRP levels of > 0.5 mg/dL (HR 1.23) had higher HRs. The participants with both periodontitis and CRP levels of > 0.5 mg/dL had the highest HR of 2.01. The additive scale interactive effect of the periodontal status and CRP levels, measured using RERI 0.41 (-0.07, 0.95), was positive and nearly significant in the total population. The synergy between the periodontal status and CRP levels was more prominent in the participants aged ≥60 years than that in younger individuals. Periodontitis with high CRP levels may indicate a high mortality rate, indicating the importance of active monitoring and intensive management of periodontitis and inflammatory markers.

Association between periodontitis with the all-cause and cause specific mortality among the population with hyperlipidemia

BACKGROUND

To explore the association between periodontitis and all-cause as well as cause-specific mortality rates in U.S. adults with hyperlipidemia.

METHODS

Participants were extracted from NHANES during 1988-1994, 1999-2004 and 2009-2014 periods. To assess the association between moderate-to-severe periodontitis and mortality rates for both all-cause and cause-specific mortality, hazard ratios (HRs), time ratios (TRs), and their respective 95% confidence intervals (CIs) were calculated using Cox proportional hazards and Weibull accelerated failure time (AFT) models.

RESULTS

Over a median follow-up duration of 11.83 years, 4,623 deaths of 16,848 participants were recorded. Multivariate Cox regression and AFT analyses showed moderate-to-severe periodontitis were associated with an increased risk of all-cause (HR: 1.31, 95% CI: 1.20-1.44, P < 0.001; TR: 0.85, 95% CI: 0.80-0.90, P < 0.001), cardiovascular disease (CVD)-related (HR: 1.36, 95% CI: 1.14-1.63, P = 0.001; TR: 0.83, 95% CI: 0.75-0.92, P < 0.001) and cancer-related mortality ( HR: 1.35, 95% CI: 1.12-1.63, P = 0.002; TR: 0.82, 95% CI: 0.72-0.93, P = 0.002). Meanwhile, there was a significant upward trend in the risk of mortality with increasing severity of periodontitis (P for trend < 0.001).

CONCLUSIONS

Our study highlights the moderate-to-severe periodontitis is associated with an increased risk of all-cause, CVD-related and cancer-related mortality among U.S. adults with hyperlipidemia. And the mortality risk increasing alongside the severity of periodontitis.

Relationship between serum uric acid levels and periodontitis-A cross-sectional study

OBJECTIVES

Whether there is an association between serum uric acid level (sUA) and periodontitis remains unclear. The aim of this study was to investigate the association between moderate/severe periodontitis and sUA in US adults.

MATERIALS AND METHODS

A total of 3398 participants were included in the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2014. The independent variable was sUA and the dependent variable was periodontitis. SUA for continuous variables, periodontitis as classification variables. Covariate including social demographic variables, life style, systemic diseases, etc. Multiple linear regression models were used to investigate the distribution of differences in covariates between different independent groups. To investigate the association between serum uric acid levels and moderate/severe periodontitis, three models were used (Model 1: unadjusted model; Model 2: adjusted for age, sex, and race/ethnicity; Model 3: adjusted for age, sex, race/ethnicity, education, household income/poverty ratio, smoking behavior, alcohol consumption, dental floss frequency, obesity, hypertension, diabetes, high cholesterol, hyperlipidemia, and sleep disorders).

RESULTS

Among the 3398 patients, 42.5% had moderate/severe periodontitis. Multivariate logistic regression analysis showed that sUA was significantly associated with moderate/severe periodontitis (OR = 1.10, 95%CI: (1.03, 1.16), P = 0.0020) after adjusting for potential confounding factors. In addition, it may vary by race/ethnicity and gender. The association between sUA levels and the prevalence ofperiodontitis was U-shaped in women and non-Hispanic blacks.

CONCLUSION

sUA level is associated with moderate to severe periodontitis. However, the association between sUA levels and the occurrence of periodontitis in women and non-Hispanic blacks followed a U-shaped curve.

CLINICAL RELEVANCE

sUA may directly or indirectly contribute to the global burden of periodontal disease, but there is little evidence that sUA is directly related to periodontitis.This study further supports that high uric acid levels are closely related to periodontitis and may contribute to the control of periodontitis. It also provides new insights into whether it can be used as an indicator to assess the risk or progression of periodontitis. More studies are needed to confirm the relationship between sUA and periodontitis.

Association of periodontitis with all-cause and cause-specific mortality among individuals with depression: a population-based study

To detect the association between periodontitis and all-cause as well as cause-specific mortality rates among adults diagnosed with depression. Participants diagnosed with depression were selected from NHANES across three periods (1988-1994; 1999-2004; 2009-2014). Cox proportional hazards and Weibull accelerated failure time (AFT) models were utilized to calculate hazard ratios (HRs), time ratios (TRs), and their 95% confidence intervals (CIs) to evaluate the association between moderate-to-severe periodontitis and all-cause as well as cause-specific mortality among participants with depression. white blood counts and C-reactive protein were used to assess the mediating role of systemic inflammation. Among the 1,189 participants with a median follow-up of 9.25 years, 133 deaths were recorded. After adjusting for multiple variables, moderate-to-severe periodontitis was obvious associated with an increased risk of cancer-related mortality in individuals with depression (Cox: HR 3.22, 95% CI 1.51-6.83, P = 0.002; AFT: TR 0.70, 95% CI 0.52-0.94, P = 0.017). Neither WBC nor CRP significantly mediate the association between periodontitis and cancer-related mortality. The risk of cancer-related mortality rose with the severity of periodontitis (P for trend = 0.021). However, no association was observed between moderate-to-severe periodontitis and other kinds of mortality. Moderate-to-severe periodontitis is linked to an elevated risk of cancer-related mortality among adults diagnosed with depression, with the mortality risk increasing alongside the severity of periodontitis. No significant mediating effect of systemic inflammation was found in this association. These findings highlight the importance of addressing periodontal health in individuals with depression. By uncovering the association between periodontitis and mortality in this population, our study underscores the potential benefits of preventive dental care and periodontal treatment in reducing the risk of cancer-related mortality in individuals with depression.

Dietary patterns and periodontitis: A systematic review

The systematic review aimed to investigate the associations between index-based dietary patterns and the risk and severity of periodontitis. Four public databases were searched for relevant published articles. Two independent researchers conducted the study selection, quality assessment, and data extraction. Methodological quality of the selected studies was evaluated using Joanna Briggs Institute Checklists. The review was registered with PROSPERO (CRD42023395049). Twenty-five studies were eligible for this review, including 23 cross-sectional studies and two prospective cohort studies. The most utilized dietary indices were the Healthy Eating Index (HEI), the Mediterranean Diet Score (MDS), and the Dietary Inflammatory Index (DII). The results indicated a positive association between higher diet quality (i.e., higher HEI and MDSs and lower DII scores) and healthier periodontal status. Subgroup meta-analysis for four studies utilizing HEI and CDC/AAP case definition indicates the protective effect of higher HEI scores on the risk of periodontitis (OR [95% CI] = 0.77[0.68, 0.88]) with statistical significance (Z = 3.91 [p < 0.0001]). Dietary assessment was conducted by validated food frequency questionnaires (FFQ) in 52% of the studies and 24-h dietary recalls in 36% of the studies. One study utilized a validated 15-item questionnaire to measure patients' adherence to the Mediterranean Diet (QueMD). The quality assessment showed that all studies were of high quality. High HEI and MDSs and low DII scores were associated with a low risk of periodontitis and better periodontal conditions. The standardized and repeatable diet guidelines might be provided for preventing periodontitis. Future prospective studies and clinical trials are needed to confirm this causal association.

All-cause and cause-specific mortality in US adults with periodontal diseases: A prospective cohort study

AIM

This prospective cohort study investigated the association between periodontal diseases (PDs) and all-cause and cause-specific mortality.

MATERIALS AND METHODS

We utilized adult participants recruited from six National Health and Nutrition Examination Survey cycles (1999-2014) and linked mortality data from the National Death Index up to December 2019. Baseline clinical periodontal examinations were performed by trained and calibrated examiners. All-cause and cause-specific mortality was modelled through multivariable Cox proportional hazards and Fine-Gray models to account for competing risks. All models were adjusted for demographic and lifestyle variables, clinical measurements and comorbidities.

RESULTS

Overall, 15,030 participants were included, with a median length of follow-up of 9 years. Risk of all-cause mortality was 22% greater in people with PD than the control group (adjusted hazard ratio [HR]: 1.22, 95% confidence interval [CI]: 1.12-1.31). Risks of mortality by cardiovascular diseases (CVD), respiratory disease and diabetes were highest in participants with severe PD (CVD-sub-distribution HR [SHR]: 1.38, 95% CI: 1.16-1.64; respiratory-SHR: 1.62, 95% CI: 1.07-2.45; diabetes-SHR: 1.68, 95% CI: 1.12-2.53).

CONCLUSIONS

Severe PD is associated with all-cause and cause-specific mortality among US adults after multivariable adjustment.

Healthy lifestyles ameliorate an increased risk of periodontitis associated with polycyclic aromatic hydrocarbons

The risk of chronic inflammatory diseases has been linked to exposure to polycyclic aromatic hydrocarbons (PAHs). However, limited data are available regarding their impact on periodontitis. This study aims to explore the association between PAHs and periodontitis while also evaluating the potential modifying effects of healthy lifestyles. We included 17,031 participants from the US National Health and Nutrition Examination Survey (NHANES, 2001-2004 and 2009-2014). A meta-analysis-based environment-wide association study (EWAS) was adopted to identify environmental chemicals for the mean probing pocket depth (PPD) and the mean attachment loss (AL). PAHs were further evaluated concerning the cross-sectional association with Mod/Sev periodontitis using multivariable logistic regression models. Moreover, healthy lifestyle scores were estimated to assess their modifying effect on the PAH-periodontitis association. EWAS analysis identified several urinary PAH metabolites as significant risk factors for the mean PPD and AL (false discovery rate <0.05, Q > 0.05). Periodontitis severity was positively associated with eight individual and total PAH concentrations. Stratifying the participants in terms of healthy lifestyle scores did not reveal any association in the healthy group. Moreover, the association weakened in never-smokers and individuals with sufficient physical activity and normal weight. PAH exposure was a risk factor for periodontitis. A healthier lifestyle was observed to offset the risk potentials of PAHs for periodontitis. Smoking cessation, physical activity, and weight loss might be recommended as a healthy lifestyle strategy for ameliorating PAH-related periodontitis.

Association of specific nutritional intake with periodontitis

BACKGROUND

The present study aimed to evaluate nutritional intake among a group of male patients in the dental clinic with and without periodontal disease to search for associations between nutritional profile and periodontal health.

METHODS

To this purpose, nutritional intake of macronutrients, fiber, vitamins, and minerals were compared evaluating both clinical parameters and periodontal status. Non periodontitis patients were compared with stage III and IV periodontitis and its extension according to the 2017 classification.

RESULTS

After multivariate analysis, statistically significant associations were found between the dietary intake of energy, total fat, cholesterol, calcium, saturated fat, monounsaturated fat and folic acid and iodine and periodontitis status. This study reports an inverse association between cholesterol and iodine and periodontitis and a direct association with saturated fat, monounsaturated fat, and folic acid.

CONCLUSIONS

Maintaining an adequate intake of fat, iodine, calcium, and cholesterol and avoiding an excessive intake of energy, saturated fat, monounsaturated fat, and folic acid could be important to controlling periodontitis.

Association between weight-adjusted-waist index and periodontitis risk: A cross-sectional study

BACKGROUND

There may be an association between obesity and periodontitis, yet no studies have investigated the correlation between the new obesity indicator, the weight-adjusted-waist Index (WWI), and periodontitis.

OBJECTIVE

This study aims to investigate the association between the novel obesity index, weight-adjusted-waist index, and periodontitis.

SUBJECTS AND METHODS

WWI was utilized to assess obesity, through measuring waist circumference (WC) and body weight. We analyzed cross-sectional NHANES data from 2009 to 2014 (1) using multivariate logistic regression to explore WWI's association with moderate/severe periodontitis; (2) conducting subgroup analyses and interaction tests; and (3) fitting smoothed curves to the age-stratified logistic regression model.

RESULTS

The study involved 11,256 individuals, with 48.55% having moderate/severe periodontitis. Upon adjusting for all relevant variables, a significant correlation between WWI and moderate/severe periodontitis was observed (OR = 1.08, 95% CI: 1.01-1.17). Compared to the lowest quartile of WWI, there was a significant increase in the likelihood of moderate/severe periodontitis in Quartile 2 (OR = 1.21, 95% CI: 1.06-1.39) and Quartile 3 (OR = 1.23, 95% CI: 1.07-1.42). Subgroup analyses for gender, age, education, smoking, and diabetes highlighted a positive association between WWI and moderate/severe periodontitis in all subgroups, except for the diabetic population and individuals aged 65 years and older.

CONCLUSION

The analysis revealed a positive correlation between WWI, a novel obesity index, and moderate/severe periodontitis prevalence through diverse modeling approaches.

Periodontitis and the risk of all-cause and cause-specific mortality among US adults with diabetes: A population-based cohort study

AIM

To evaluate the association between periodontitis, all-cause and cause-specific mortality, and its prognostic utility among adults with diabetes.

MATERIALS AND METHODS

Periodontal health records were retrieved from the NHANES database for 4297 participants with diabetes aged >30 years at baseline during 1988-1994, 1999-2004 and 2009-2014. Multivariable Cox proportional hazards regression model was applied to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for moderate/severe periodontitis with all-cause and cause-specific mortality in participants with diabetes. Area under the curve (AUC) was used to assess predictive value.

RESULTS

During a median follow-up of 15.41 years, 1701 deaths occurred. After multivariate adjustments, moderate/severe periodontitis was significantly associated with increased risk of all-cause (HR: 1.27; 95% CI: 1.07-1.50; p = .005) and cardiovascular disease (CVD)-related (HR: 1.35, 95% CI: 1.03-1.76, p = .031) mortality in participants with diabetes. The absolute risk difference based on the cumulative incidence information was 0.022 (5-year, 95% CI: 0.021-0.023) and 0.044 (10-year, 95% CI: 0.041-0.048). Periodontitis improved the prediction of all-cause (AUC: 0.652; 95% CI: 0.627-0.676) and CVD-related (AUC: 0.649; 95% CI: 0.624-0.676) mortality over standard risk factors (all-cause: AUC: 0.631; 95% CI: 0.606-0.656; CVD-related: AUC: 0.629; 95% CI: 0.604-0.655).

CONCLUSIONS

Moderate/severe periodontitis is associated with an increased risk of all-cause and CVD-related mortality in adults with diabetes. Periodontitis might represent a marker for residual risk.

Association between carotenoid intake and periodontitis in diabetic patients

This study aimed to evaluate the association between dietary carotenoid intake and periodontitis in diabetic patients. Data on diabetic patients were collected from the National Health and Nutrition Examination Survey (NHANES) 2009-2014 for this cross-sectional study. Dietary intake of carotenoids was assessed through the first 24-hour dietary recall interview. Full-mouth periodontal examinations were conducted by trained dental examiners. Subgroup analysis was conducted in terms of age, gender, the number of missing teeth, cardiovascular disease, smoking, and anti-diabetic drugs. Totally 1914 diabetic patients were included, with 1281 (66.93%) in the periodontitis group. After adjusting for age, gender, race, education, smoking, dental implants, hepatitis, and the number of missing teeth, α-carotene intake ≥55.82 mcg was associated with lower odds of periodontitis than α-carotene intake <55.82 mcg [OR = 0.70, 95% CI: 0.53-0.91, P = 0.010]; lutein and zeaxanthin intake ≥795.95 mcg was associated with decreased odds of periodontitis than lutein and zeaxanthin intake <795.95 mcg (OR = 0.75, 95%CI: 0.57-0.98, P = 0.039). The association between carotenoid intake and periodontitis varied across different subpopulations. In diabetes, dietary intake of α-carotene and lutein and zeaxanthin was inversely associated with the odds of periodontitis, which may facilitate clinical periodontitis management.

Prevalence and Severity of Circumferential Alveolar Bone Loss Using CBCT Images: A Retrospective Study of 20,620 Surfaces of 5155 Teeth

Periodontal disease is a site-specific disease affecting the supporting tissues of the teeth. It is useful for the clinician to have information about the prevalence and severity of alveolar bone loss (ABL) according to the site, location, and position of the teeth for a better treatment plan and expected prognosis. This study aimed to assess the prevalence and severity of ABL at mesial, distal, buccal and lingual sites of teeth in different locations, positions and sides of the dentition. The ABL of 20,620 sites of 5155 teeth in 212 patients was assessed using cone-beam computed tomography from the cemento-enamel junction to the crest of the alveolar bone. The prevalence of ABL was higher in the interproximal sites as well as anterior and mandibular teeth compared to their counterparts. Buccal sites and anterior teeth revealed higher ABL levels than the other tooth sites and posterior teeth, respectively. Furthermore, associations in the severity of ABL were observed between distal and mesial sites, buccal and lingual sites, maxillary and mandibular teeth, anterior and posterior teeth, and right and left sides. This study showed that the prevalence and severity of ABL differ from one tooth site to another and according to the tooth's location in the dentition. Higher prevalences were found in the interproximal sites, anterior teeth and mandibular teeth; higher ABL was found in buccal and distal sites, with the strongest associations between distal and mesial sites, buccal and lingual sites, and right and left sides.

Association between periodontitis and mortality of patients with cardiovascular diseases: A cohort study based on NHANES

BACKGROUND

The association between periodontitis and cardiovascular disease (CVD) has been widely explored, but little is known about the effect of periodontitis on the mortality of CVD patients. This study aims to clarify the effect of periodontitis on all-cause and cause-specific mortality of CVD patients.

METHODS

We included 2,135 individuals with CVD from the National Health and Nutrition Examination Survey. Mortality data were ascertained by linkage to National Death Index records through 31 December 2019. We used Cox proportional hazards models for all-cause mortality and competing risk models for CVD and cancer mortality to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Further covariate adjustments, stratification analyses, and a variety of sensitivity analyses were conducted to test the reliability and robustness of the results.

RESULTS

The all-cause mortality in CVD patients with moderate/severe periodontitis was significantly higher than in those with no/mild periodontitis (HR: 1.25; 95% CI: 1.02-1.52; P = 0.03). The all-cause mortality in participants with severe clinical attachment loss was significantly higher (HR: 1.07; 95% CI: 1.01-1.14; P = 0.01). However, no discrepancy in CVD or cancer mortality was observed between CVD patients with different periodontal status.

CONCLUSIONS

Our findings from a longitudinal study with a large sample indicated significant but slightly higher all-cause mortality in CVD patients with moderate/severe periodontitis than in those with no/mild periodontitis.

Multiple Imputation for Partial Recording Periodontal Examination Protocols

AIM

Partial-mouth recording protocols often result in underestimation of population prevalence and extent of periodontitis. We posit that multiple imputation of measures such as clinical attachment loss for nonselected tooth sites in partial-mouth samples can reduce bias in periodontitis estimates.

METHODS

Multiple imputation for correlated site-level dichotomous outcomes in a generalized estimating equations framework is used to impute site-level binary indicators for clinical attachment loss exceeding a fixed threshold in partial-mouth samples. Periodontitis case definitions are applied to the imputed "complete" dentitions, enabling estimation of prevalence and other summaries of periodontitis for partial-mouth samples as if for full-mouth examinations. A multiple imputation-bootstrap procedure is described and applied for point and variance estimation of these periodontitis measures. The procedure is evaluated with pseudo-partial-mouth samples based on random site selection protocols of 28 to 84 periodontal sites repeatedly generated from full-mouth periodontal examinations of 3,621 participants in the 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) survey.

RESULTS

Multiple imputation applied to partial-mouth samples overestimated periodontitis mean extent, defined as the number of sites with clinical attachment loss 3 mm or greater, by 9.5% in random site selection protocols with 84 sites and overestimated prevalence by 5% to 10% in all the evaluated protocols.

CONCLUSIONS

In the 2013 to 2014 NHANES data, multiple imputation of site-level periodontal indicators provides less biased estimates of periodontitis prevalence and extent than has been reported from estimates based on the direct application of full-mouth case definitions to partial-mouth samples. Multiple imputation provides a promising solution to the longstanding, vexing problem of estimation bias in partial-mouth recording, with potential application to a wide array of case definitions, periodontitis measures, and partial recording protocols.

KNOWLEDGE TRANSFER STATEMENT

Partial-mouth sampling, while a resource-efficient strategy for obtaining oral disease estimates, often results in underestimation of periodontitis metrics. Multiple imputation for nonselected periodontal sites produces pseudo-full-mouth data sets that may be analyzed and combined to produce estimates with small bias.

The correlation between periodontitis and uncontrolled hypertension is mediated by inflammatory markers: results from a cross-sectional study of urban elderly population in southeast China

BACKGROUND

Periodontal diseases is considered the most important global oral health burden according to the world health organization (WHO) (Oral health. https://www.who.int/news-room/fact-sheets/detail/oral-health#Overviewth (who.int). Accessed 21 Sep 2023). It is a common local inflammatory disease associated with hypertension, this study aims to explore the relationship between periodontitis and uncontrolled hypertension and whether inflammation indication such as white blood cell (WBC) count or neutrophil count is a mediator of this relationship.

METHODS

One thousand four hundred eighty-eight elders attending annual physical and oral examinations in Zhejiang province were included in this study. The staging of Periodontitis was classified as none, mild-moderate and severe. Participants are categorized into two groups based on blood pressure: hypertensive( positive high blood pressure( HBP) history or underwent HBP medication or blood pressure( BP) ≥ 140/90 mmHg) and uncontrolled hypertensive (systolic blood pressure( SBP) ≥ 140 mmHg or distolic blood pressure( DBP) ≥ 90 mmHg). Peripheral blood samples were collected, information on hypertension history and potential confounders (age, sex, smoking, alcohol consumption, exercise frequency, diabetes) was collected in questionnaires. The correlation between periodontitis and hypertension was investigated using logistics regression analyses, mediation analysis was assessed for the effect of inflammation on hypertension.

RESULTS

The study population includes 1,488 participants aged 55-90 years. Odds of uncontrolled hypertension increased significantly along with periodontitis in the regression models both in unadjusted model (odds ratio( OR): 1.407, 95% confidence intervals( CI): 1.037 ~ 1.910) and fully adjusted model (OR: 1.950, 95% CI: 1.127 ~ 3.373). Mediation analysis confirmed that WBC and neutrophic count function as a full mediator of the association between periodontitis and uncontrolled hypertension either in the unadjusted or the adjusted model.

CONCLUSIONS

In a study of urban elderly population in southeast China, periodontitis is found to be significantly associated with uncontrolled hypertension, such relation is mediated by WBC and neutrophil count. Periodontitis can increase the difficulty of controlling hypertension. Promotion of periodontal health strategies in the dental setting could help reduce the burden of hypertension and its complications.

Associations of periodontitis with risk of all-cause and cause-specific mortality among us adults with chronic kidney disease

OBJECTIVES

To investigate the associations of periodontitis with risk of all-cause and cause-specific mortality in a nationally representative sample of adults with chronic kidney disease (CKD) in the United States.

METHODS

This prospective cohort study included 4,271 individuals aged ≥30 years at baseline with CKD participants in the National Health and Nutrition Examination Survey (NHANES) during 1988-1994, 1999-2004, and 2009-2014. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2 and/or urinary albumin/creatinine ratio (uACR) ≥30 mg/g. Multivariate cox proportional hazards regression models were used to estimate the hazard ratios (HRs) and 95 % confidence intervals (CIs) of all-cause and cause-specific mortality in participants with CKD according to periodontitis. The associations of the quartiles of mean clinical attachment loss (CAL) and mean periodontal probing depth (PPD) levels with mortality were examined using the first quartile as the reference group.

RESULTS

During a median of 8.67 years of follow-up, 2,146 deaths were documented. After multivariate adjustments, moderate/severe periodontitis was significantly associated with all-cause (HR:1.28; 95 % CI:1.11-1.47; P = 0.001) and cardiovascular disease (CVD)-related mortality (HR:1.44; 95 % CI:1.14-1.81; P = 0.002) in participants with CKD. Compared with the reference group of mean CAL and mean PPD levels, all-cause (CAL: HR, 1.58; 95 % CI, 1.32-1.89, P <0.001; PPD: HR, 1.35, 95 % CI, 1.09-1.67, P = 0.011) and CVD-related mortality (CAL: HR, 1.70, 95 % CI, 1.21-2.40, P = 0.001) were increased for participants in the highest quartile.

CONCLUSIONS

This study suggests that moderate/severe periodontitis and high levels of mean CAL and mean PPD are associated with an increased risk of all-cause mortality, and moderate/severe periodontitis and mean CAL associated with CVD-related mortality among adults with CKD in the US.

CLINICAL SIGNIFICANCE

This study details the association between periodontitis and the increased risk of all-cause mortality and CVD-related mortality in a large, representative sample of adults with CKD.

The co-occurrence of the two main oral diseases: periodontitis and dental caries

OBJECTIVES

Limited studies are available testing through multiple regression models the association between the two main oral diseases: dental caries and periodontitis. The aim of this cross-sectional population-based study was to verify whether dental caries and periodontitis co-occur in a representative sample of the South Korea population.

MATERIALS AND METHODS

A total of 23,405 subjects representative of 36.2 million of adults (KNHANES) were examined. Univariate and multiple regression analyses using 7 different models were applied, controlling for age, gender, smoking status, frequency of toothbrushing, use of interproximal toothbrushes and flossing, educational level, income, gum diseases treatment and tooth filling in the previous year, BMI, Vitamin D serum levels, alcoholism, diabetes status, stress and carbohydrates dietary intake.

RESULTS

In the fully adjusted model, participants with periodontitis had, respectively, a mean of 0.82 (95% CI: 0.41-1.23) and of 0.36 (95% CI: 0.22-0.50) more untreated decayed surfaces and teeth than participants without periodontitis, with an OR to have at least one untreated decayed surface of 1.96 (95% CI: 1.66-2.32). However, cumulative caries experience (DF scores) and periodontitis were not associated.

CONCLUSIONS

In this large nationally representative population, periodontitis and untreated dental caries co-occur. However, when considering cumulative caries experience (DF scores), the two diseases do not appear related.

CLINICAL RELEVANCE

In light of their possible co-occurrence, clinicians should implement integrative diagnostic, preventive and treatment strategies for both diseases.

Accuracy of clinical and radiographic recording protocols for diagnosing periodontitis

OBJECTIVE

To compare the accuracy of periodontal examination at 6-sites full-mouth protocol with clinical and radiographic partial-mouth recording protocols (PRPs) to diagnose periodontitis considering new 2018 case definition.

METHODS

Periodontitis was diagnosed by full-mouth assessment of clinical attachment level (CAL) at 6-sites (n = 8529) according to 2018 case definition (standard reference). Three clinical and radiographic PRPs were considered: (i) 4 interproximal sites of all teeth (4-sites, full-mouth); (ii) 6-sites on Community Periodontal Index of Treatment Needs (CPITN) teeth (6-sites, CPITN teeth); (iii) 4-sites on CPITN teeth (4-sites, CPITN teeth); (iv) radiographic examination on interproximal sites of all teeth (rM-D, full-mouth); and (v) radiographic examination on interproximal sites of CPITN teeth (rM-D, CPITN teeth) using Image J®. Sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV), accuracy, and Κappa (k) were estimated (α = 0.05).

RESULTS

The 4-sites, full-mouth protocol showed 100% sensitivity and NPV, 79.87% PPV, low specificity (38.32%), 69.30% accuracy, and poor agreement (k = 0.468). 6-sites and 4-sites CPITN teeth protocols showed 100% PPV and specificity, sensitivity and NPV of >60%, accuracy of >80%, and good agreement (k > 0.65). All clinical PRPs outperformed radiographic protocols.

CONCLUSION

Clinical PRPs using index teeth are highly accurate in diagnosing periodontitis considering 2018 case definition.

Association between oral health and cognitive function among Chinese older adults: the Taizhou imaging study

BACKGROUND

We aimed to investigate the association between oral health and cognitive function in a sample of older adults from a Chinese rural community.

METHODS

The cross-sectional cognitive function of 677 individuals were assessed by Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). A comprehensive profile of the oral health status was evaluated by questionnaire and clinical examination.

RESULTS

Multiple covariates-adjusted regression models demonstrated decayed teeth (DT) and decayed/missing/filled teeth (DMFT) were negatively associated with MoCA score (all p < 0.05). Calculus index (CI) and clinical attachment loss (CAL) were significantly associated with the lower MoCA, short-term memory and executive function score, respectively (all p < 0.05). Additionally, participants with missing teeth unrestored tend to get lower MMSE and MoCA scores (p < 0.05). The results also showed that increased DT and CI were modestly associated with higher odds of cognitive impairment (p < 0.05).

CONCLUSIONS

There is an association between oral health and global cognition. Poor periodontal status was strongly associated with worse global cognition performance, especially in the short-term memory and executive domain for the aging population.

Association between breastfeeding and periodontitis in Korean women using Korea National Health and Nutrition Examination Survey (KNHANES): a cross-sectional study

OBJECTIVES

The effect of breastfeeding on periodontal disease in women remains unclear. This cross-sectional study used data from the Korean National Health and Nutrition Examination Survey to explore the association between breastfeeding and periodontitis in Korean women using data from the Korean National Health and Nutrition Examination Survey (KNHANES VII).

MATERIALS AND METHODS

Cross-sectional data was analyzed from the KNHANES 2016-2018. The study population included 5,587 parous women aged ≥ 30 years. The outcome variable was the presence or absence of periodontitis. The explanatory variable, period of breastfeeding, was defined as "none", "1-11 months", and "more than 12 months". Confounder variables (socio-educational, personal healthcare practice, and systemic medical characteristics) were adjusted for in the logistic regression analysis.

RESULTS

Approximately 60% of the participants breastfed for ≥ 12 months. In all statistical models, the prevalence of periodontitis was approximately 60% greater in women that did not breastfeed compared to women that had breastfed for 12 months or longer. When adjusted for age, statistical significance was only present in the 50-59 years age group (adjusted odds ratio [aOR], 1.678; 95% confidence interval [CIs], 1.046-2.691).

CONCLUSION

Our study shows that women that breastfed for a relatively long duration had a lower risk of periodontitis. Therefore, breastfeeding may be beneficial for women's periodontal health. These results are expected to be helpful in oral health education for pregnant women.

Association between the quality of plant-based diets and periodontitis in the U.S. general population

AIM

To investigate the relationship between plant-based diet indices (PDIs) and periodontitis and serum IgG antibodies against periodontopathogens in the U.S.

POPULATION

MATERIALS AND METHODS

We analysed cross-sectional data on 5651 participants ≥40 years of age from the Third National Health and Nutrition Examination Survey. Food frequency questionnaire data were used to calculate the overall PDI, healthy plant-based diet index (hPDI), and unhealthy plant-based diet index (uPDI). Periodontitis was defined using a half-reduced Centers for Disease Control and Prevention and American Academy of Periodontology case definition. Serum antibodies against 19 periodontopathogens were used to classify the population into two subgroups using hierarchical clustering. Survey-weighted multivariable logistic regressions were applied to assess the associations of PDI/hPDI/uPDI z-scores with periodontitis and hierarchical clusters after adjusting for potential confounders.

RESULTS

A total of 2841 (50.3%) participants were defined as having moderate/severe periodontitis. The overall PDI z-score was not significantly associated with the clinical and bacterial markers of periodontitis. By considering the healthiness of plant foods, we observed an inverse association between hPDI z-score and periodontitis (odds ratio [OR] = 0.925, 95% confidence interval [CI]: 0.860-0.995). In contrast, higher uPDI z-score (adherence to unhealthful plant foods) might increase the risk of periodontitis (OR = 1.100; 95% CI: 1.043-1.161). Regarding antibodies against periodontopathogens, the participants in cluster 2 had higher periodontal antibodies than those in cluster 1. The hPDI z-score was positively associated with cluster 2 (OR = 1.192; 95% CI: 1.112-1.278). In contrast, an inverse association between uPDI z-score and cluster 2 was found (OR = 0.834; 95% CI: 0.775-0.896).

CONCLUSIONS

Plant-based diets were associated with periodontitis, depending on their quality. A healthy plant-based diet was inversely related to an increased risk of periodontitis but positively related to elevated antibody levels against periodontopathogens. For an unhealthy plant-based diet, the opposite trends were observed.

Serum antibodies to periodontal pathogens are related to allergic symptoms

BACKGROUND

The association between periodontitis and allergic symptoms has been investigated. However, the difference in immune signatures between them remains poorly understood. This cross-sectional study assessed the relationship between serum immunoglobulin G (IgG) antibodies to periodontal pathogens and allergic symptoms in a nationwide population cohort.

METHODS

Two phases of the Third National Health and Nutrition Examination Survey (NHANES III) were used as discovery dataset (n = 3700) and validation dataset (n = 4453), respectively. Based on the antibodies against 19 periodontal pathogens, we performed an unsupervised hierarchical clustering to categorize the population into three clusters. In the discovery dataset, cluster 1 (n = 2847) had the highest level of IgG antibodies, followed by clusters 2 (n = 588) and 3 (n = 265). Data on allergic symptoms (asthma, hay fever, and wheezing) were obtained using a self-reported questionnaire. Survey-weighted multivariable logistic regression evaluated the association between these clusters and allergic symptoms.

RESULTS

In the discovery dataset, the participants with lower levels of antibodies to periodontal pathogens exhibited a higher risk of asthma (odds ratio [OR]_{cluster 3 vs. cluster 1} = 1.820, 95% confidence interval [CI]: 1.153-2.873) and wheezing (OR_{cluster 3 vs. cluster 1} = 1.550, 95% CI: 1.095-2.194) compared to those with higher periodontal antibodies, but the non-significant association with hay fever. Consistent results were found in the validation dataset.

CONCLUSIONS

Serum IgG titers to periodontal pathogens were inversely associated with the risk of asthma and wheezing, suggesting the potentially protective role against allergic conditions.

Serum Antioxidant Vitamins Mediate the Association between Periodontitis and Metabolically Unhealthy Overweight/Obesity

BACKGROUND

Periodontal disease is associated with metabolic syndrome and obesity. This cross-sectional study aimed to investigate whether serum antioxidant vitamins could mediate the association between periodontitis and a metabolically unhealthy phenotype in the overweight and obese population; Methods: We included 6158 Americans (body mass index (BMI) ≥ 25 kg/m²) from the Third National Health and Nutrition Examination Survey (NHANES III). Periodontitis was defined using a half-reduced CDC/AAP (Centers for Disease Control and Prevention/American Academy of Periodontology) definition. Having two or more metabolic abnormalities was defined as a metabolically unhealthy overweight and obese (MUO) phenotype. Mediation analysis of four oxidative stress biomarkers (serum antioxidant vitamins A, C, D, and E) was conducted; Results: Of participants with overweight and obesity, 2052 (33.3%) Americans were categorized as having periodontitis. Periodontitis increased dyslipidemia risk and systemic inflammation in the overweight and obese population. In the multivariable logistic regression model, periodontitis was positively associated with MUO (adjusted odds ratio = 1.238; 95% confidence interval: 1.091 to 1.406). These findings were validated in an independent cohort. Serum vitamins C and D were estimated to mediate 19.3% and 8.4% of the periodontitis-MUO association.

CONCLUSIONS

Periodontitis might decrease serum vitamins C and D and induce a metabolically unhealthy state among adults with overweight and obesity.

Radiographically screened periodontitis is associated with deteriorated oral-health quality of life: A cross-sectional study

Periodontitis is greatly related to worse perceived oral health-related quality of life (OHRQoL), yet this association has never been explored using radiographically screened periodontal bone loss. Here we have radiographically screened patients for periodontitis via a validated method and assessed its association with measures of OHRQoL. From a total of 10,267 participants (6,112 females and 4,155 males), self-reported general health questionnaire, body mass index, self-reported oral health behaviours, panoramic x-rays and the oral health impact profile (OHIP-14) were gathered. Radiographically screened periodontitis was measured through a radiographic-based periodontal bone loss (R-PBL) approach. We compared the respective variables according to the R-PBL status and explored using multiple logistic regression adjusted for the significant variables. Overall, patients with periodontitis shown significantly different sociodemographic, health measures and oral hygiene characteristics. All domains of the OHIP-14 were significantly worsened in the periodontitis group, and further confirmed through adjusted logistic regression (p<0.001). Active smoking, number of missing teeth, sex and age were the most impactful variables in this relationship. Our results demonstrate the existence of a link between radiographically screened periodontitis and OHRQoL, mostly upheld by active smoking, number of missing teeth, sex and age.

Abnormal Micronutrient Intake Is Associated with the Risk of Periodontitis: A Dose-response Association Study Based on NHANES 2009-2014

The association between micronutrient intake and the risk of periodontitis has received much attention in recent years. However, most studies focused on the linear relationship between them. This study aimed to explore the dose-response association between micronutrient intake and periodontitis. A total of 8959 participants who underwent a periodontal examination, and reported their micronutrient intake levels were derived from the US National Health and Nutrition Examination Survey (NHANES, 2009-2014) database. Logistic regression was performed to evaluate associations between micronutrient intake and periodontitis after propensity score matching (PSM), and restricted cubic splines (RCS) analysis was conducted to explore the dose-response associations. Following PSM, 5530 participants were included in the RCS analysis. The risk of periodontitis was reduced with sufficient intake of the following micronutrients: vitamin A, vitamin B1, vitamin B2, and vitamin E. In addition, the risk of periodontitis was increased with excessive intake of the following micronutrients: vitamin B1 (1.8 mg/day, males; 1.3 mg/day, females), vitamin C (90 mg/day, males), and copper (1.1 mg/day, combined). In conclusion, a linear association was found between vitamin A, vitamin B2, vitamin C, and copper and periodontitis-namely, a sufficient intake of vitamin A and vitamin B2 might help reduce the prevalence of periodontitis; by contrast, a high intake of vitamin C and copper increased the risk. In addition, a nonlinear dose-response association was found for the incidence of periodontitis with vitamin B1 and vitamin E. When within reasonable limits, supplemental intake helped reduce the prevalence of periodontitis, while excessive intake did not help significantly and might even increase the risk. However, confounding factors, such as health awareness, should still be considered.

Correlation between periodontitis and prostate-specific antigen levels in the elderly Chinese male population

Background

The comparison of prostate-specific antigen (PSA) levels among older individuals with different periodontal statuses has not been fully investigated. Here we aimed to explore the correlation between the staging and grading of periodontitis and PSA levels in an elderly Chinese male population, which may lead to a biopsy recommendation and prevent prostate cancer as early as possible.

Methods

The study included 996 individuals aged ≥ 55 years who participated in routine postretirement physical examinations. Periodontal data included probing depth and gingival recession on four sites/tooth and on two diagonal quadrants (1–3 or 2–4) while excluding third molars, and clinical attachment loss was calculated. Periodontal status was classified as none, mild-moderate or severe periodontitis according to the Centers for Disease Control and Prevention and the American Academy of Periodontology case definition. Blood samples, oral health status and sociodemographic characteristics were collected by using general and oral examinations and questionnaires. Linear and logistic regressions were used to estimate the correlation between periodontitis severity and PSA levels, respectively.

Results

A total of 479 men had mild-moderate periodontitis and 355 had severe periodontitis; 162 men were periodontally healthy individuals. After adjusting for potential confounders, PSA levels were significantly lower in the individuals without periodontitis than in those with mild-moderate (P = 0.04) or severe (P = 0.03) periodontitis. However, PSA levels did not significantly correlate with periodontitis severity (P = 0.06). Although the ORs of elevated PSA were not significant, individuals with PSA ≥ 4.0 ng/mL were more likely to have periodontitis.

Conclusions

In a sample of an elderly Chinese male population, after adjusting for possible confounders, serum PSA levels in individuals with periodontitis were significantly higher than those in individuals without periodontitis, but serum PSA did not significantly correlate with periodontitis severity.

Periodontitis, age-related diseases and diabetes in an endocrinological outpatient setting (PARADIES): a cross-sectional analysis on predictive factors for periodontitis in a German outpatient facility

BACKGROUND

Diabetes mellitus (DM) is a risk factor for periodontitis. Data on risk-modifying factors for periodontitis in diabetes patients are limited.

AIMS

We tested whether sex, age, type of diabetes, metabolic state, comorbidities, complications, measures of well-being and quality of life are predicting periodontitis in a German diabetes outpatient cohort.

METHODS

In total, 1180 out of 1293 participating DM patients completed questionnaires on quality of life, dental hygiene and health. All patients also filled out a modified version of the periodontitis risk questionnaire by the American Association for Periodontology, from which the status of "assumed periodontitis" was deducted. In a subset of participants (n = 461), we measured or inquired the most recent Community Parodontal Index (CPI), providing an objective measure for clinically diagnosed periodontitis. For all subjects, DM history and phenotype, major metabolic parameters (HbA1c, BMI, LDL and total cholesterol levels), general health risk factors, comorbidities and medication were collected.

RESULTS

Clinically diagnosed (CPI > 2) and assumed periodontitis was detected in 60-67% of our patients. Male sex and oral health-related quality of life were associated with clinically diagnosed periodontitis. Male sex, age, smoking, dental hygiene, dental control and diabetes-related quality of life independently predicted assumed periodontitis.

CONCLUSION

In DM patients, quality of life and lifestyle factors which systemically alter microvascular and immunological functions seem to predict periodontitis. Further studies are needed for replication and for pathomechanistic clarification.

Exploring periodontitis misclassification mechanisms under partial-mouth protocols

AIM

To investigate the sources of periodontitis misclassification under partial-mouth protocols (PMPs) and to explore possible approaches to enhancing protocol validity.

MATERIALS AND METHODS

Using data from 10,680 adults with 244,999 teeth from the National Health and Nutrition Examination Survey, we compared tooth-, site-, and quadrant-specific periodontal parameters and case identification under full-mouth protocols and PMPs. Separately, we utilized population measures of tooth-specific periodontal severity to generate PMPs with tooth selection based on the population ranking of clinical severity and assessed the sensitivity of case identification.

RESULTS

Symmetry of clinical severity was generally confirmed, with the exception of lingual inter-proximal sites, which yielded greater sensitivity in identifying periodontitis compared to buccal sites due to more severe pocketing and attachment loss on average. Misclassification of severe periodontitis occurred more frequently under commonly implemented PMPs compared to ranking-based selection of teeth, which yielded sensitivity estimates of 70.1%-79.4% with the selection of 8 teeth and reached 90% with the selection of only 14 teeth.

CONCLUSIONS

Clinical symmetry and sources of periodontitis misclassification were confirmed. The proposed selection of teeth based on population rankings of clinical severity yielded optimal sensitivity estimates for the detection of severe periodontitis and may present a favourable alternative to current options.

Association of high-density lipoprotein cholesterol and periodontitis severity in Chinese elderly: a cross-sectional study

OBJECTIVES

Periodontitis is a local inflammatory disease of high prevalence worldwide. Increasing evidence has shown its association with cardiovascular diseases. While high-density lipoprotein is an important protective factor in preventing cardiovascular diseases, this study aims to examine whether high-density lipoprotein cholesterol (HDL-C) level is associated with different status of periodontitis.

MATERIALS AND METHODS

A total of 874 Chinese retirees (≥ 60 years of age) with different statuses of periodontitis were enrolled. Periodontal clinical data were collected to define periodontal disease severity (no, mild-moderate, severe). Peripheral blood was collected for serum lipid profile analysis. Linear and logistic regression analysis with adjustment for potential confounders (gender, age, BMI, alcohol intake, exercise frequency, smoking habits) were used to determine the association of periodontitis with HDL-C.

RESULTS

After adjustments for confounders, linear regression analyses revealed a significant relationship between the decreased HDL-C and periodontitis severity (p < 0.05). Although the multivariable-adjusted ORs of decreased HDL-C were not statistically significant, logistic regression analyses showed Chinese elderly with severe periodontitis had higher odds of exhibiting clinically abnormal HDL-C levels than those without periodontitis.

CONCLUSIONS

The elderly population with periodontitis showed HDL-C levels significantly lower than those without periodontitis. The severity of periodontitis was positively correlated with serum HDL-C levels.

CLINICAL RELEVANCE

Periodontitis reduces HDL-C level in the elderly population, indicating that oral health should be paid attention to in the prevention and treatment of dyslipidemia.

Accuracy of Estimating Periodontitis and Its Risk Association Using Partial-Mouth Recordings for Surveillance Studies: A Systematic Review and Meta-Analysis

Objectives

Our aim is to conduct an up-to-date systematic review and meta-analysis pertaining to the accuracy of using the partial-mouth recording protocol (PRP) in surveillance studies to estimate the periodontitis prevalence, extent, severity, and its risk associations.

Methods

Medline and Embase databases were searched for studies which assessed the periodontitis prevalence, severity, extent, or its risk associations using PRPs versus full-mouth recording protocols (FRPs); searches were conducted up until May 26, 2021. The risk of bias and the applicability of the studies were assessed using the QUADAS-2 tool. Both qualitative data synthesis and quantitative data synthesis were performed, and comparisons were done for the accuracy and precision of PRPs for different periodontitis outcomes. The study's protocol was registered through the International Platform of Registered Systematic Review and Meta-analysis Protocols (registration number: INPLASY202160032).

Results

A total of 14 studies were included. The studies had a considerable degree of heterogeneity, along with a moderate risk of bias and applicability concerns. Several factors influenced the accuracy or precision of using PRPs, including the age, distribution of periodontitis in the studied population, PRP selection, total PRP sites, the threshold for minimum sites with CAL, and the severity of periodontitis case definitions. Overall, the PRP with the highest accuracy and precision mainly included (1) a full-mouth protocol at the following partial sites: mesiobuccal-midbuccal-distolingual (MB-B-DL), mesiobuccal-distolingual (MB-DL), mesiobuccal-midbuccal-distobuccal (MB-B-DB), mesiobuccal-distobuccal (MB-DB), and 84 sites using the random site selection method (RSSM) and (2) random-half-mouth (RHM) protocols.

Conclusions

The PRPs with the highest overall accuracy and precision in estimating the periodontitis prevalence, extent, severity, and risk associations included the full-mouth assessment at the following partial sites: MB-B-DL, MB-DL, MB-B-DB, MB-DB, and 84 sites using RSSM and RHM protocols.

Accuracy and precision of using partial-mouth recordings to study the prevalence, extent and risk associations of untreated periodontitis

To study the accuracy and precision of estimating the prevalence, extent and associated risks of untreated periodontitis using partial-mouth recording protocols (PRPs) Methods: A purposive sample of 431 individuals who had never been treated for periodontal disease was recruited from screening clinics at the King Saud bin Abdul-Aziz University for Health Sciences. Data were collected using questionnaires and clinical examinations. The prevalence, extent and risk associations of periodontitis were evaluated. Three PRPs were compared to full-mouth recordings (FRPs) in terms of the sensitivity, specificity, predictive values, and absolute bias. Results: The prevalence of periodontitis was estimated with the highest accuracy and precision by examinations of the full mouth at the mesiobuccal and distolingual sites (FM)MB-DL, followed by random half-mouth (RHM) recordings. The extent of periodontitis was estimated with high precision using all the PRPs, and the absolute bias ranged from -0.6 to -2.3. The absolute bias indicated by OR for risk associations was small for the three PRPs and ranged from -0.8 to 0.8. Conclusion: (FM)MB-DL and RHM were the PRPs with moderate to high levels of accuracy and precision for estimating the prevalence and risk associations of periodontitis. The extent of periodontitis was estimated with high precision using all three PRPs. The results of this study showed that the magnitude and direction of bias were associated with the severity of periodontitis, the selected PRPs and the magnitude of the risk associations.

Periodontal disease prevalence, extent, and risk associations in untreated individuals

Objectives

to examine the prevalence, extent, and risk associations of untreated periodontitis.

Materials and Methods

A purposive sample of subjects who were never treated for periodontal conditions was clinically examined after collecting information about their sociodemographic characteristics, medical conditions, oral health behaviors, perceived stress, and perceived social support.

Results

A total of 431 subjects were recruited (response rate, 97.0%), and their mean age (SD) was 35.4 (13.3) years. Overall, high plaque levels were observed in all untreated individuals. The prevalence of periodontitis and severe (stage III/IV) periodontitis using the American Academy of Periodontology and European Federation of Periodontology (AAP/EFP) classification were 85.4% and 48.5%, respectively. The prevalence of moderate‐severe and severe periodontitis using the definitions of the Centers for Disease Control and Prevention (CDC) and AAP were 78.4% and 31.1%, respectively. The extent of periodontitis expressed as mean% of clinical attachment loss (CAL) ≥ 3 mm and CAL ≥ 5 mm were 34.9% and 14.4%, respectively, while the mean% of a periodontal probing depth (PPD) ≥4 mm and PPD ≥6 mm were 22.0% and 9.2%, respectively. Risk determinants associated with AAP/EFP periodontitis after the adjustment for other variables were age ≥35 years (odds ratio [OR] = 11.5) and lower income (OR = 2.5). Adjusted risk associations with stage II/IV periodontitis included age ≥35 years (OR = 8.2), males (OR = 2.5), lower income (OR = 2.3), and lower perceived stress (OR = 2.0). Adjusted risk associations with CDC/AAP moderate‐severe periodontitis included age ≥35 years (OR = 12.0), lower income (OR = 2.1), and current cigarette smoking (OR = 4.2). Adjusted risk associations with CDC/AAP severe periodontitis included age ≥35 years (OR = 4.5), males (OR = 1.9), lower education (OR = 2.0), lower income (OR = 1.7), uncontrolled diabetes mellitus (OR = 2.0), and current cigarette smoking (OR = 2.3).

Conclusions

The prevalence and extent of periodontitis were high in untreated subjects. Risk associations with untreated periodontitis included age ≥35 years, males, lower income, lower education, current cigarette smoking, uncontrolled diabetes mellitus, and lower perceived stress.

Implication of thyroid function in periodontitis: a nationwide population-based study

Possible links between periodontitis and various cardiometabolic and autoimmune diseases have been advocated on the basis of chronic inflammation or oxidative stress. However, the association between periodontitis and thyroid dysfunction is under-researched. Participants without previous thyroid disease or ongoing thyroid-related medication were included from a nationwide population-level survey. Participants were categorized into tertiles of thyroid stimulating hormone (TSH) levels (first tertile < 1.76 mIU/L; second tertile 1.76-2.83 mIU/L; third tertile > 2.83 mIU/L), and periodontal condition was assessed using the Community Periodontal Index. Of the total of 5468 participants, 1423 had periodontitis (26%). A significant difference in the weighted prevalence of periodontitis according to TSH tertiles was observed, with the highest prevalence in the first tertile (26.5%) and the lowest prevalence in the third tertile (20.9%, p = 0.003). Subjects in the first TSH tertile had higher odds for periodontitis than those in the third tertile (OR 1.36, 95% CI 1.10-1.68; p for trend = 0.005) after adjusting for covariates. This association was consistent across subgroups and within sensitivity analyses among subjects without specific factors affecting thyroid function or diseases reported to be related to periodontitis. The present study demonstrated that low TSH levels were associated with significantly higher odds for periodontitis.

Combined association of cognitive impairment and poor oral health on mortality risk in older adults: Results from the NHANES with 15 years of follow-up

Background

Cognitive impairment and poor oral health are frequently seen among older adults. Both conditions have been identified as risk factors for mortality. However, the combined associations of cognitive impairment and poor oral health with mortality have not been well studied and are therefore the aim of this cohort study.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (1999–2002) linked with mortality data obtained from the 2015 public‐use linked mortality file. Cognitive impairment was defined as a digit symbol substitution test score lower than the lowest quartile. Oral health status was assessed based on presence of untreated caries, moderate to severe periodontitis, and edentulism. The combined effects of caries/periodontitis or edentulism and cognitive impairment on all‐cause and cardiometabolic mortality were examined using the Cox proportional hazard models after adjusting for potential confounders including demographic characteristics, lifestyle, biomarkers, and comorbidities.

Results

In total, 1973 participants were enrolled in the prospective study. At a median follow‐up of 13.4 years, 978 participants had died (264 deaths because of cardiometabolic disease). Cognitive impairment, periodontitis, and edentulism were each found to be significant predictors of all‐cause mortality. Caries, however, was not significantly related to mortality. When analyzing these predictors in combination, a diagnosis of cognitive impairment and periodontitis was associated with an 83.1% increase in all‐cause mortality risk and an 87.7% increase in cardiometabolic mortality risk compared with healthy controls. Similarly, the risk for all‐cause mortality was highest in cases where impaired cognition and edentulism co‐occurred (adjusted hazard ratio = 1.701, 1.338–2.161).

Conclusion

Concomitant presence of cognitive impairment and periodontitis or edentulism can be associated with a higher risk of mortality among older U.S. adults.

Is systemic inflammation a missing link between periodontitis and hypertension? Results from two large population-based surveys

OBJECTIVE

The primary objective was to investigate the relationship between periodontitis and hypertension in two independent large surveys. The secondary objective was to ascertain whether systemic inflammation had a mediation effect in the association.

METHODS

This cross-sectional study analysed representative samples of the US (n = 3460; NHANES 2009/10) and Korean (n = 4539; 2015 KNHANES VI-3) populations. The association between periodontitis (exposure), hypertension (outcome) and inflammatory markers [C-reactive protein (CRP) and white blood cell counts (WBC)] (mediators) was assessed using multivariate linear and logistic regression models and mediation analysis.

RESULTS

Participants with periodontitis were more likely to have hypertension (NHANES: OR = 1.3, 95% CI: 1.0-1.6, P = 0.025; KNHANES: OR = 1.2, 95% CI: 1.0-1.4, P = 0.041) and actual systolic blood pressure ≥ 140 mmHg (NHANES: OR = 1.6, 95% CI: 1.1-2.3, P < 0.001; KNHANES: OR = 1.3, 95% CI :1.0-1.6, P < 0.031) than those without the disease. These associations were independent of age, gender, BMI, education level, smoking, alcohol consumption, creatinine, physical activity, presence of other comorbidities and confirmed in participants not taking antihypertensive medications. Diagnosis of periodontitis was directly associated with WBC (in both surveys: NHANES: β ± SE = 0.3 ± 0.1, P < 0.004; KNHANES: β ± SE = 0.3 ± 0.1, P < 0.001) and with CRP levels (in one survey: NHANES: β ± SE = 0.1 ± 0.03, P < 0.007; KNHANES: β ± SE = 0.1 ± 0.04, P > 0.213). Mediation analyses confirmed that CRP acted as a mediator in the association between periodontitis and hypertension in both populations (mediated effect: NHANES: β ± SE = 0.010 ± 0.003, P < 0.001; KNHANES: β ± SE = 0.003 ± 0.001, P = 0.015). WBC acted as a mediator in the KNHANES (mediated effect: β ± SE = 0.004 ± 0.001, P = 0.004) whilst in the NHANES, its effect was dependent of CRP inclusion in the model (mediated effect WBC + CRP: β ± SE = 0.002 ± 0.001, P = 0.001).

CONCLUSIONS

These findings suggest that periodontitis is closely linked to hypertension and systemic inflammation is, in part, a mediator of this association.

Periodontitis is associated with cardiovascular diseases: A 13-year study

AIM

To prospectively evaluate the association between periodontitis and the incidence of cardiovascular diseases (CVDs) in Thai adults.

MATERIALS AND METHODS

Medical data from the questionnaires and physical examinations of 1850 participants aged 47-73 years from EGAT study were gathered. Random half-mouth periodontal examination of each participant was performed by calibrated periodontists, and periodontal status was defined. The incidence of new CVD events, including coronary heart disease (CHD) and stroke, was verified by cardiologists. The Cox proportional hazard regression model was used to estimate hazard ratios (HRs).

RESULTS

The prevalence of no/mild, moderate and severe periodontitis in the study participants was 11.7%, 52.7% and 35.6%, respectively. During the 13-year follow-up, CVD events occurred in 110 (5.9%) participants, with 82 (4.4%) from CHD and 28 (1.5%) from stroke. After adjusting for cardiovascular risk factors, a significant association between severe periodontitis and the incidence of CHD was found compared with the no/mild periodontitis group with an HR of 4.53 (95% confidence intervals: 1.08-19.02). However, no significant association was seen when considering total CVD events and stroke outcome.

CONCLUSIONS

This study demonstrates that severe periodontitis is associated with an increased incidence of CHD, independent of established cardiovascular risk factors.

The role of dental insurance in mitigating mortality among working-age U.S. adults with periodontitis

AIM

To assess the relationship of dental insurance with all-cause mortality and mortality due to cardiovascular diseases (CVD), diabetes mellitus (DM), and cerebrovascular diseases (CBD) among those with periodontitis.

MATERIALS AND METHODS

NHANES III and its associated mortality data set were used in this study. The outcome variables were "all-cause mortality" and "combined mortality" due to CVD, DM, and CBD. The independent variable was dental insurance stratified over periodontitis status. Unweighted frequencies with weighted column percentages were used for descriptive statistics, and chi-square test was applied for significance. Cox proportional hazard models were used for stratified multivariable analyses. All analyses were performed in SAS v9.4 accounting for survey data complexities. Significance level was kept at 5%.

RESULTS

The mortality was 14.58% for all-cause mortality and 4.06% for combined mortality among those with periodontitis in this study. Dental insurance significantly reduced the hazard of all-cause mortality among those with periodontitis (HR: 0.75; 95% CI: 0.61 - 0.93), adjusted for covariates. However, no association of dental insurance with combined mortality was observed among periodontitis group.

CONCLUSIONS

Dental insurance reduces hazard of all-cause mortality among those with periodontitis. Dental insurance ensures access to dentists and improves oral and dental health. Longitudinal study is needed to establish causality.

White Blood Cell Count Mediates the Association Between Periodontal Inflammation and Cognitive Performance Measured by Digit Symbol Substitution Test Among Older U.S. Adults

Background

Systemic effects of periodontal infection may increase the risk of central neuroinflammation, aggravating impaired cognition. This study aims to examine whether systemic inflammatory factors mediate the possible association between periodontal inflammation and cognitive function.

Methods

We conducted a cross-sectional analysis of 766 participants aged ≥ 60 years and who had completed periodontal and cognitive examinations in the National Health and Nutrition Examination Survey (NHANES) 2001–2002. We used multivariable linear regression to investigate the overall association between periodontal health and cognitive function as measured by the digit symbol substitution test (DSST). Bleeding on probing (BOP) and periodontal inflamed surface area (PISA) were used to assess the periodontal inflammatory activity and burden, respectively. Mediation analyses were used to test the indirect effects of the BOP/PISA on DSST via C-reactive protein, white blood cell (WBC) count, and fibrinogen.

Results

Participants with superior periodontal health obtained higher DSST scores than those with poorer periodontal health, adjusting for demographic factors and chronic conditions. Concerning the inflammatory activity, WBC count acted as a full mediator in the association between BOP and DSST (β = −0.091; 95% confidence interval [CI] = −0.174 to −0.008) and mediated 27.5% of the total association. Regarding the inflammatory burden, WBC count acted as a partial mediator in the association between PISA and DSST (β = −0.059; 95% CI = −0.087 to −0.031) and mediated 20.3% of the total association.

Conclusion

Our study indicated the potential role of systemic inflammatory factors as a mediator of associations between periodontal inflammation and cognitive function in the U.S. geriatric population.

Accuracy of Panoramic Radiograph for Diagnosing Periodontitis Comparing to Clinical Examination

In this study, we explore the diagnostic accuracy of a Radiographic-based Periodontal Bone Loss (R-PBL) method as a screening tool for periodontitis, in the form of radiographic bone loss, under the 2018 case definition in comparison to the 2012 case definition. The analysis was based on 456 patients (253 females and 203 males), screened for periodontal status in the Study of Periodontal Health in Almada-Seixal (SoPHiAS) project and subjected to a panoramic dental X-ray. Patients were diagnosed for the presence of periodontitis following the 2018 and 2012 case definition. R-PBL classification was defined by alveolar bone loss and diagnosed as no periodontitis (≥80% remaining alveolar bone), mild to moderate periodontitis (66% to 79%), or severe periodontitis (<66%). We appraise the X-ray quality to look for the influence on the performance of R-PBL. Sensitivity, specificity, accuracy, and precision, through several indicators, were determined. Performance measurement was assessed through binary and multiclass Receiver operating characteristic/are under the curve (ROC/AUC) analyses. Our results show that the tested R-PBL method under the 2018 case definition is a reliable tool in periodontitis cases screening. This method does not replace clinical periodontal evaluation, but rather, it screens patients towards a definitive periodontitis diagnosis. These results will contribute to support the development of automated prediction systems towards periodontitis surveillance.

Prevalence and severity of periodontal disease in a historical Austrian population

Objective

To assess the prevalence and severity of periodontitis based on different diagnostic methods in a historical Austrian population from the early middle ages.

Background

The description of the oral health status of archaeological material can provide interesting insights into prevalence, severity, and extent of oral diseases. Herein, the periodontal health status of the skeletal remains of medieval Avars (700‐800 AD), which were considered as one of the earliest Avarian settlements in Austria, was investigated.

Methods

The skeletal remains of 128 Avars were examined; age and gender were estimated by standard forensic methods and tooth loss and root caries were recorded. Periodontitis was assessed by (a) measurement of the alveolar bone levels (ABL) and (b) evaluation of the interdental septa.

Results

A mean ABL of 4.8 mm was determined, root caries tended to accumulate in teeth with a higher alveolar bone loss, and on average, 6.2 teeth were lost antemortem. Independent of the diagnostic method >90% of the subjects were judged as periodontally diseased, and age and tooth type were significant predictors. However, on the tooth level the presence of periodontitis varied considerably depending on the diagnostic method; that is, 7.6% versus 47.2% of the teeth were judged as healthy based on ABL or interdental septa, respectively.

Conclusion

The periodontal status of the skeletal remains of medieval Avars revealed a considerable high prevalence of periodontitis (ie, >90% of this population displayed periodontal tissue breakdown). However, the diagnostic method, disease definition, and data presentation should be considered when comparing results of archaeological material.

The 2018 periodontitis case definition improves accuracy performance of full-mouth partial diagnostic protocols

We aimed to compare the accuracy performance of the new 2018 periodontitis case definition by the European Federation of Periodontology (EFP)/ American Association of Periodontology (AAP) with Centers for Disease Control (CDC)/AAP 2012 in full-mouth partial recording protocols (PRP). Retrospective data from NHANES 2011-2012 and 2013-2014 were analyzed. For each case definition, full-mouth diagnostic was defined as the reference standard. Patients were diagnosed for the presence of periodontitis and staging for each PRP. Sensitivity, specificity, accuracy and precision, through several indicators, were determined. Performance measurement was assessed through binary and multiclass ROC/AUC analyses. Our performance analysis shows that the new 2018 classification outperforms the 2012 classification regarding the diagnosis and staging of periodontitis on full-mouth PRPs. This recent case definition has strengthened the utility of PRPs and its improvements certainly explain the observed findings. Also, our findings contribute to the reliability of PRPs and its use in future worldwide epidemiological surveys.

Spatiotemporal signal detection using continuous shrinkage priors

Periodontal disease (PD) is a chronic inflammatory disease that affects the gum tissue and bone supporting the teeth. Although tooth-site level PD progression is believed to be spatio-temporally referenced, the whole-mouth average periodontal pocket depth (PPD) has been commonly used as an indicator of the current/active status of PD. This leads to imminent loss of information, and imprecise parameter estimates. Despite availability of statistical methods that accommodates spatiotemporal information for responses collected at the tooth-site level, the enormity of longitudinal databases derived from oral health practice-based settings render them unscalable for application. To mitigate this, we introduce a Bayesian spatiotemporal model to detect problematic/diseased tooth-sites dynamically inside the mouth for any subject obtained from large databases. This is achieved via a spatial continuous sparsity-inducing shrinkage prior on spatially varying linear-trend regression coefficients. A low-rank representation captures the nonstationary covariance structure of the PPD outcomes, and facilitates the relevant Markov chain Monte Carlo computing steps applicable to thousands of study subjects. Application of our method to both simulated data and to a rich database of electronic dental records from the HealthPartners® Institute reveal improved prediction performances, compared with alternative models with usual Gaussian priors for regression parameters and conditionally autoregressive specification of the covariance structure.

Hormone-related events and periodontitis in women

AIM

While the short-term effects of hormonal events on gingival inflammation have been well described, long-term effects on the periodontium have received less attention. The aim of this cross-sectional population-based study was to evaluate the association between hormone-related events and periodontitis in a representative sample of the postmenopausal women of South Korea.

MATERIALS AND METHODS

A total of 10,273 postmenopausal women representative of 6.1 million of Koreans were examined. Periodontitis and severe periodontitis were defined according to the Community Periodontal Index (CPI ≧ 3 and CPI = 4, respectively). Univariate and multivariate regression analyses using 3 different models were applied controlling for age, smoking, marital status, educational level, income, BMI, hypertension, stress and frequency of toothbrushing.

RESULTS

Severe periodontitis was directly associated with a longer reproductive life (p-trend = .027) and with a longer duration of breastfeeding (48-72 vs. 1-17 months: OR = 1.49; 95% CI: 1.01-2.21). Conversely, early menopausal age (<46 vs. 49-50 years: OR = 0.74; 95% CI: 0.56-0.97), history of artificial menopause (OR = 0.72; 95% CI: 0.53-0.97), having had more than 6 pregnancies (vs. 4: OR = 0.73; 95% CI: 0.55-0.97), having had more than three abortions (vs. 0: OR = 0.51; 95% CI: 0.28-0.93) and having had the first birth age >26 years (vs. <21 years: OR = 0.71; 95% CI: 0.52-0.97) were inversely associated with severe periodontitis.

CONCLUSIONS

In this large nationally representative population, severe periodontitis was related to menopausal age, reproductive life length, number of pregnancies/abortions, first birth age and breastfeeding duration, while it was not to oral contraceptive and hormone replacement therapy usages.

Association between dental health and obstructive coronary artery disease: an observational study

Background

The association between dental health and coronary artery disease (CAD) remains a topic of debate. This study aimed to investigate the association between dental health and obstructive CAD using multiple dental indices.

Methods

Eighty-eight patients (mean age: 65 years, 86% male) were prospectively enrolled before undergoing coronary CT angiography (n = 52) or invasive coronary angiography (n = 36). Obstructive CAD was defined as luminal stenosis of ≥50% for the left main coronary artery or ≥ 70% for the other epicardial coronary arteries. All patients underwent thorough dental examinations to evaluate 7 dental health indices, including the sum of decayed and filled teeth, the ratio of no restoration, the community periodontal index of treatment needs, clinical attachment loss, the total dental index, the panoramic topography index, and number of lost teeth.

Results

Forty patients (45.4%) had obstructive CAD. Among the 7 dental health indices, only the number of lost teeth was significantly associated with obstructive CAD, with patients who had obstructive CAD having significantly more lost teeth than patients without obstructive CAD (13.08 ± 10.4 vs. 5.44 ± 5.74, p < 0.001). The number of lost teeth was correlated with the number of obstructed coronary arteries (p < 0.001). Multiple binary logistic regression analysis revealed that having ≥10 lost teeth was independently associated with the presence of obstructive CAD (odds ratio: 8.02, 95% confidence interval: 1.80–35.64; p = 0.006).

Conclusions

Tooth loss was associated with the presence of obstructive CAD in patients undergoing coronary evaluation. Larger longitudinal studies are needed to determine whether there is a causal relationship between tooth loss and CAD.

Prevalence of periodontitis: misclassification, under-recognition or over-diagnosis using partial and full-mouth periodontal examination protocols

OBJECTIVE

The aim of this cross-sectional study was to assess the bias in estimating the prevalence of periodontitis due to partial-mouth periodontal examination protocols (PMPE) and to relate the severity and extent of periodontal damage to periodontitis misclassification when applying case definitions by Centres of Disease Control and Prevention and American Academy of Periodontology (CDC/AAP).

MATERIALS AND METHODS

A full-mouth periodontal examination (FMPE) was performed in 721 adults living in North Italy to identify moderate and severe periodontitis. These results were compared with those obtained with two PMPE protocols analyzing two interproximal sites on all teeth (fMB-DL) or four interproximal sites in two random diagonal quadrants (pMDB-MDL).

RESULTS

Both PMPE systems estimated the prevalence of moderate periodontitis with limited bias (-2.79% for pMDB-MDL and -3.49% for fMB-DL), whereas produced larger relative biases for severe periodontitis (-28.74% versus - 14.55%). The percentage of under-recognition of existing periodontal disease was 8.9% under fMB-DL and 15.5% under pMDB-MDL. The diagnosis of moderate and severe periodontal disease was correctly assigned to individuals with on average 8% and 30% of pathological sites, respectively.

CONCLUSION

These findings suggest that PMPE systems provide high level of bias when using CDC/AAP case definitions.

Differential Misclassification of Disease under Partial-Mouth Sampling

Aim:

The effect of misclassification of a cluster-level dichotomous outcome (disease) due to partial-cluster sampling on its association with a dichotomous exposure is investigated.

Methods:

Disease (e.g., chronic periodontitis) is deemed to exist in a cluster (e.g., full mouth) when a condition of interest (e.g., pocket depth or clinical attachment loss exceeding an established threshold) is present in number and pattern across observations (e.g., tooth sites) in the cluster according to a specific criterion. When a subset of observations within each cluster is selected (i.e., partial-mouth sampling), specificity of disease is 100% (in the absence of site-level measurement error), whereas sensitivity is imperfect and generally unknown. Using conditional probability arguments, we investigate disease misclassification under partial-cluster sampling and its impact on the estimated disease-exposure association when the exposure is cluster level and measured without error.

Results:

When the probability of disease varies by exposure status, outcome misclassification at the cluster level is differential under partial-cluster sampling and depends on 1) the partial recording protocol, including the number of observations sampled and the particular sites selected in a cluster; 2) the joint probability structure of the condition within clusters; and 3) the criterion for disease. A numeric example demonstrates that disease-exposure odds ratios under partial-cluster random sampling can be biased in either direction (toward or away from the null) relative to gold-standard odds ratios under full-cluster sampling.

Conclusions:

In general, misclassification of disease is differential under partial-cluster sampling. In particular, sensitivity and negative predictive values depend on exposure status, which leads to biased inference.

Knowledge Transfer Statement:

Partial-mouth sampling causes disease misclassification probabilities, including sensitivity, to vary by exposure groups when disease prevalence differs between groups. As a result, disease-exposure associations may be under- or overestimated by standard analysis procedures for periodontal data relative to full-mouth estimates. Procedures that address bias are needed for partial-recording protocols.

Impact of periodontitis as representative of chronic inflammation on long-term clinical outcomes in patients with atrial fibrillation

Objectives

Relationship between atrial fibrillation (AF) and inflammation was shown in previous studies. However, there was limited data about the association between the periodontitis and AF in the long-term follow-up. The aim of this study was to evaluate the impact of periodontitis on long-term clinical outcomes in patients with AF.

Methods

The Kosin University echocardiography, ECG and periodontitis database were reviewed from 2013 to 2015 to identify patients with AF. Those patients were divided into two groups according to the presence of periodontitis and clinical events including any arrhythmic attack, thromboembolic and bleeding and death were collected during a median of 18 months.

Results

Among 227 patients with AF, 47 (20.7%) patients had periodontitis. Major adverse cardiac events (MACE) were significantly higher in patients with periodontitis compared with those without periodontitis (p<0.001). Arrhythmias including AF, atrial tachycardia, atrial premature beat, ventricular tachycardia and ventricular premature beat also occurred in 44 (93.6%) patients, which was higher significantly higher incidence in patients with periodontitis than in those without periodontitis (p<0.001). In univariate analysis, age, CHA₂DS₂-VASc, left atrial volume index (LAVi) and periodontitis were significantly associated with arrhythmic events and MACE including bleeding events, thromboembolic events, arrhythmic events and mortality. In multivariate analysis, LAVi (p=0.005) and periodontitis (p<0.001) were independent risk factors for arrhythmic events and periodontitis (p<0.001) for MACE at the long-term follow-up.

Conclusions

The periodontitis as representative of chronic inflammation was an independent predictor of arrhythmic events and MACE in patients with AF.