Systemic inflammation in cardiovascular and periodontal disease: comparative study

Does the Self-Reported Behavioural Automaticity Index provide a valid measure of toothbrushing behaviour in adults?

BACKGROUND

Studies to promote regular toothbrushing usually rely on self-reports of toothbrushing frequency (SRF). However, toothbrushing frequency measures may be open to responder bias since twice-daily toothbrushing is a commonly accepted social norm. The validity of SRF measures is unclear, meaning that their use as outcomes in interventional work may be flawed. The study's aim was to compare two different self-reported toothbrushing measures: SRF and the Self-Reported Behavioural Automaticity Index (SRBAI); with measurement of observed toothbrushing frequency tracked over 6 weeks. A secondary aim was to explore the interaction effect of various moderators (age, ethnicity, socioeconomic status (SES), sex, self-efficacy, participant personality and routine preference) upon the correlation between SRBAI and observed toothbrushing frequency.

METHODS

One hundred and sixty-four adults were recruited via a number of different community groups and workplaces outside the dental setting. After consent, participants completed a questionnaire which collected demographic and participant characteristics measures (age, ethnicity, SES, sex, self-efficacy, participant personality and routine preference) and self-reported toothbrushing habits. Participants then attached a 'Brushlink' device to their toothbrush for 6 weeks to track their observed toothbrushing frequency.

RESULTS

Using the Pearson correlation coefficient, a moderately strong positive linear association (r = 0.65) between SRBAI and observed toothbrushing frequency was found. By comparison, the correlation between SRF and observed toothbrushing frequency was weak (r = 0.39). There was a weak positive association between self-reported behaviour frequency and SRBAI score (r = 0.35). Using multivariable linear regression, no statistically significant interactional effect was demonstrated for any moderator variable upon the correlation coefficient of SRBAI and observed toothbrushing frequency.

CONCLUSIONS

The SRBAI provided a stronger association with observed toothbrushing frequency than the SRF measure. A moderately strong relationship between SRBAI and observed toothbrushing frequency was found, compared to a weak positive relationship between self-reported behaviour frequency and SRBAI score. This suggests that the SRBAI score could be a suitable proxy to measure observed toothbrushing behaviour and preferable to SRF in interventional work.

Can delta neutrophil index values predict the success of periodontal treatment in patients with periodontitis?

OBJECTIVES

The aim of this study was to evaluate the effect of delta neutrophil index (DNI) on non-surgical periodontal therapy (NSPT), whose role has been documented in the pathogenesis and follow-up of periodontal disease.

METHODS AND MATERIALS

The study included 35 patients with stage 3, grade A periodontitis (test group) and 35 patients without periodontal disease (control group). Initially, periodontal parameters were recorded and blood samples were taken from all patients. For patients with periodontitis, periodontal parameter measurements and blood sample analyses were repeated 3 months after NSPT.

RESULTS

After NSPT, DNI, CRP (C-reactive protein), neutrophil count, WBC (white blood cell), and neutrophil-lymphocyte ratio (NLR) values decreased in the test group, but did not reach a statistically significant level (p > 0.05). When the inflammatory variables were examined, significantly higher CRP, IG (immature granulocytes), DNI, neutrophil count, and WBC were observed in the test group compared to the control group (p < 0.05). In the test group, periodontal parameters were lower 3 months after NSPT than at baseline (p < 0.05).

CONCLUSION

Consistent with previous findings in the literature, the patients with periodontitis were determined to have higher levels of DNI, CRP, neutrophils, and WBC, compared to the individuals without periodontitis. Although a decrease was seen in DNI after NSPT, this was not at a significant level.

CLINICAL RELEVANCE

DNI is a guide in the evaluation of inflammation at the onset of periodontal disease, but studies with a larger number of cases are needed to use these parameters in the evaluation of treatment success.

TRIAL REGISTRATION

This study was retrospectively registered on December 27, 2022, with the number NCT05666622 at http://www.

CLINICALTRIALS

gov .

The Effect of Saliva and Dental Caries of the Patients with Hashimoto Thyroiditis on Cytokine Levels

BACKGROUND

This study aimed to evaluate the effect of dental caries and oral health of patients on salivary cytokine levels with Hashimoto's thyroiditis (HT).

MATERIAL AND METHODS

The study included 30 patients (n = 30) diagnosed with HT. The standardization of the participants was achieved with specific biochemical parameters, and the sociodemographic information of the patients was obtained through anamnesis. A pH meter was employed for salivary pH measurement. After determining the oral problems of the patients, necessary treatments were applied. Following 3 months of treatment, saliva samples were taken to evaluate cytokine levels (TNF-α, IL-6, IL-8, and CRP) and for ELISA analyses. The Wilcoxon test was used for pairwise comparison of nonparametric data, and the Chi-square test was employed to analyze categorical variables at P < 0.05.

RESULTS

There was a significant decrease in salivary TNF-α, IL-6, IL-8, and CRP levels between the measurements before and after 3 months of treatment (P < 0.05). In addition, a significant increase was found in salivary pH (P < 0.05).

CONCLUSIONS

The salivary cytokine levels decrease and the inflammatory response improves when the inflammation in the periodontal tissues and dental caries is treated.

Periodontitis Severity Grading Scale and C-Reactive Protein: A Possible Relation

Background C-reactive protein (CRP) is the first acute-phase protein and is an exceptional investigative marker for local and systemic inflammation. The periodontitis severity grading scale (PSGS) indicates the extent of periodontal inflammation. Therefore, the aim of the study was to explore the correlation between the markers of systemic and periodontal inflammation as assessed by CRP and the PSGS in participants with periodontitis. Materials and methods The present study enrolled 85 systemically healthy participants with periodontitis. PSGS and CRP levels were measured in each participant. Descriptive and inferential statistics were applied for analysis. Results The PSGS scores ranged from 24 to 213, and the CRP levels ranged from 0.5 to 3.23 mg/l. This shows a positive correlation between the periodontal scale and CRP. A nonsignificant (p-value > 0.05) correlation exists between age and CRP score, and a significant association was seen between gender and severity of periodontitis with p-value < 0.02. A highly significant association between gender and CRP score was found with p-value < 0.001. Conclusion The level of serum CRP dramatically increased with the severity of periodontitis. The results of this study point to a highly significant correlation between markers of systemic and periodontal inflammation, as well as a strength of association between the two markers.

The Influence of Periodontal Disease on Oral Health Quality of Life in Patients with Cardiovascular Disease: A Cross-Sectional Observational Single-Center Study

Background and Objectives: Cardiovascular disease is a leading cause of global death with a rising prevalence and a heavy economic burden. Periodontal disease has been associated with cardiovascular diseases—including incident coronary heart disease, peripheral artery disease and ischemic stroke. The study evaluates the quality of life of patients with cardiovascular and periodontal disease from the point of view of oral health by using the short version of the Oral Health Impact Profile (OHIP-14) questionnaire. Materials and Methods: This study included a total of 221 patients (61.86 ± 15.03 years old) selected from the Emergency Hospital of Sibiu, Romania. The participants self-completed the OHIP-14 questionnaire and they benefited from an oral health examination conducted to assess the presence and the severity of periodontal disease. Results: Out of the 147 patients with cardiovascular disease, 77.5% had periodontal disease (32.6% stage I, 29.2% stage II, and 15.6% stage III and IV). The presence of periodontal disease was associated with a lower oral-health-related quality of life (p < 0.001, ANOVA) and with a higher OHIP-14 score in patients with cardiovascular disease (18.67 ± 8.17, p < 0.001 ANOVA). No significant difference was observed concerning patient sex and background; however, age, body mass index and the lack of an appropriate oral hygiene routine had a strong association with the individual quality of life. The general OHIP-14 score was higher in patients with periodontal disease and associated cardiovascular disease, the presence of both cardiovascular and periodontal disease being associated with a lower quality of life. Conclusions: By increasing the patients’ awareness to oral healthcare measures, better outcomes and improved oral-health-related quality of life could be observed.

The oral microbiome: Role of key organisms and complex networks in oral health and disease

States of oral health and disease reflect the compositional and functional capacities of, as well as the interspecies interactions within, the oral microbiota. The oral cavity exists as a highly dynamic microbial environment that harbors many distinct substrata and microenvironments that house diverse microbial communities. Specific to the oral cavity, the nonshedding dental surfaces facilitate the development of highly complex polymicrobial biofilm communities, characterized not only by the distinct microbes comprising them, but cumulatively by their activities. Adding to this complexity, the oral cavity faces near-constant environmental challenges, including those from host diet, salivary flow, masticatory forces, and introduction of exogenous microbes. The composition of the oral microbiome is shaped throughout life by factors including host genetics, maternal transmission, as well as environmental factors, such as dietary habits, oral hygiene practice, medications, and systemic factors. This dynamic ecosystem presents opportunities for oral microbial dysbiosis and the development of dental and periodontal diseases. The application of both in vitro and culture-independent approaches has broadened the mechanistic understandings of complex polymicrobial communities within the oral cavity, as well as the environmental, local, and systemic underpinnings that influence the dynamics of the oral microbiome. Here, we review the present knowledge and current understanding of microbial communities within the oral cavity and the influences and challenges upon this system that encourage homeostasis or provoke microbiome perturbation, and thus contribute to states of oral health or disease.

[Effect of scaling and root planing on serum C-reactive protein levels in patients with moderate to severe chronic periodontitis: a systematic review and Meta-analysis]

OBJECTIVE

To evaluate the effect of scaling and root planing (SRP) on serum C-reactive protein (CRP) levels in patients with moderate to severe chronic periodontitis.

METHODS

We searched the PubMed, Web of Science, EMBASE, Cochrane, CNKI, Wanfang, and VIP databases from the inception to July 8th, 2019. Two reviewers independently screened literature, extracted data, and evaluated the bias risk of included studies. Then, a meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 13 randomized controlled clinical trials and 12 prospective clinical trials were included. Meta-analysis showed that serum CRP levels decreased at 2 and 3 months after SRP (P<0.05), and no significant difference in serum CRP levels was found at 6 months (P=0.49).

CONCLUSIONS

SRP can reduce serum CRP levels in systematically healthy patients with moderate to severe chronic periodontitis at 2 and 3 months after SRP.

Salivary and serum markers of angiogenesis in periodontitis in relation to smoking

OBJECTIVE

Angiogenesis is essential in maintenance of periodontal homeostasis, and it is regulated by growth factors and cytokines, including basic fibroblast growth factor (b-FGF), endoglin, platelet and endothelial cell adhesion molecule (PECAM-1), vascular endothelial growth factor (VEGF), soluble intercellular adhesion molecule-1 (sICAM-1), and soluble vascular cell adhesion molecule-1 (sVCAM-1). In this study, the salivary and serum concentrations of these angiogenesis-related proteins in relation to smoking and periodontitis were examined.

MATERIAL AND METHODS

Full-mouth periodontal status together with unstimulated whole saliva and serum samples was collected from 78 individuals, including 40 periodontitis patients (20 smokers and 20 nonsmokers) and 38 periodontally healthy controls (20 smokers and 18 nonsmokers). The Luminex®-xMAP™ technique was used for protein analyses.

RESULTS

Concentrations of all tested proteins in saliva as well as VEGF in serum were significantly higher in periodontitis patients than in healthy controls. In smokers, serum concentrations of endoglin (p = 0.017) and sICAM-1 (p = 0.001) were elevated in comparison to nonsmokers. After adjusting for smoking and gender, periodontitis associated significantly with salivary concentrations of b-FGF, PECAM-1, VEGF, sICAM-1, and sVCAM-1 (p < 0.01).

CONCLUSION

Taken together, salivary concentrations of b-FGF, PECAM-1, and VEGF associate with periodontitis. The suppressive effect of smoking on salivary marker levels is limited to periodontitis patients only.

CLINICAL RELEVANCE

Smoking-related suppression of salivary marker levels is observed only in periodontitis patients.

Interleukin-6, tumor necrosis factor-α, C-reactive protein, and hematological parameters in experimental periodontal disease after β-adrenergic blockade

BACKGROUND

Changes in the levels of C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6) observed during periodontal disease were linked with vascular manifestations. Recent studies showed that the beta-blocker propranolol reduces the pathological parameters associated with certain molecules at sites of bone injury. Hence, in this study, we evaluated the activity of propranolol on hematological parameters and systemic concentrations of inflammatory proteins in a model of experimental periodontitis.

MATERIALS AND METHODS

Periodontal disease was induced in rats. After euthanasia, the number of inflammatory cells in each rat was quantified using histopathological assays. In addition, hematological parameters were quantitated using automated analysers, cytokine levels were determined using an enzyme-linked immunosorbent assay, and CRP levels were determined using a high-sensitivity immunoturbidimetric assay.

RESULTS

Low doses of propranolol suppressed the systemic production of CRP, TNF-α, and IL-6; however, the hematological parameters were not affected.

CONCLUSIONS

β-adrenergic activation indirectly contributes to the pattern of systemic inflammatory molecules observed in periodontal disease. These molecules may initiate cardiovascular diseases as a consequence of periodontitis.

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.

Periodontal, metabolic, and cardiovascular disease: Exploring the role of inflammation and mental health

Previous evidence connects periodontal disease, a modifiable condition affecting a majority of Americans, with metabolic and cardiovascular morbidity and mortality. This review focuses on the likely mediation of these associations by immune activation and their potential interactions with mental illness. Future longitudinal, and ideally interventional studies, should focus on reciprocal interactions and cascading effects, as well as points for effective preventative and therapeutic interventions across diagnostic domains to reduce morbidity, mortality and improve quality of life.

Association of clinical measures of periodontal disease with blood pressure and hypertension among postmenopausal women

BACKGROUND

Hypertension and periodontal disease are common conditions among postmenopausal women. Periodontal disease has been found associated with hypertension in previous studies, but data in postmenopausal women is limited.

METHODS

We assessed the cross-sectional associations of clinically measured periodontal disease with prevalent hypertension and measured systolic blood pressure (SBP) among 1341 postmenopausal women enrolled in the Buffalo Osteoporosis and Periodontal Disease (OsteoPerio) study, an ancillary study of the Women's Health Initiative-Observational Study.

RESULTS

Clinical attachment level (CAL) and number of teeth missing were positively associated with SBP among those not taking antihypertensive medication in crude and multivariable adjusted linear regression models (both P < 0.05). Alveolar crestal height (ACH) and gingival bleeding on probing were associated with higher SBP in crude but not multivariable adjusted models. Neither probing pocket depth (PPD) nor severity categories of periodontitis were associated with SBP. Number of teeth missing was significantly associated with prevalent hypertension in crude and multivariable adjusted models (OR = 1.14, per 5 teeth; P = 0.04). ACH was associated with prevalent hypertension in crude but not adjusted models. CAL, PPD, gingival bleeding, and severity of periodontitis were not significantly associated with prevalent hypertension.

CONCLUSIONS

These results suggest that measures of oral health including CAL and number of teeth missing are associated with blood pressure in postmenopausal women. Prospective studies are needed to further investigate these associations and the potential underlying mechanisms for these relationships.

Evaluation of Serum C-reactive Protein Levels in Subjects with Aggressive and Chronic Periodontitis in Comparison with Healthy Controls: A Clinico-biochemical Study

Aim:

Evaluation and comparison of serum C-reactive protein (CRP) levels in subjects with chronic and aggressive periodontitis.

Materials and Methods:

Based on the periodontal status, 45 subjects were selected and divided into three groups. Group I – subjects with clinically healthy periodontium, Group II – generalized aggressive periodontitis (GAP), and Group III – chronic periodontitis (CP). Blood samples were collected from subjects for measurement of CRP. Periodontal parameters include plaque index (PI), gingival index, bleeding index (BI), probing pocket depth (PPD), and clinical attachment loss (CAL) were assessed. CRP levels were assessed by means of a commercially available high sensitivity-CRP enzyme immunoassay kit.

Results:

CRP levels were increased in Group III (6.0671 ± 3.15639 mg/L) and Group II subjects (4.5453 ± 2.88116 mg/L) compared to the Group I (1.0180 ± 0.94069 mg/L). CRP levels showed a positive correlation with all clinical parameters in Group I subjects. BI (r = 0.073), PI (r = 0.120) showed a positive correlation with CRP level in Group II and a positive correlation was also seen for PI (r = 0.492), PPD (r = 0.340), CAL (r = 0.160), and CRP level in Group III subjects.

Conclusion:

The mean CRP levels were found to be greater in CP compared to GAP subjects, but there was no statistically significant difference.

Modeling vascular inflammation and atherogenicity after inhalation of ambient levels of ozone: exploratory lessons from transcriptomics

BACKGROUND

Epidemiologic studies have linked inhalation of air pollutants such as ozone to cardiovascular mortality. Human exposure studies have shown that inhalation of ambient levels of ozone causes airway and systemic inflammation and an imbalance in sympathetic/parasympathetic tone.

METHODS

To explore molecular mechanisms through which ozone inhalation contributes to cardiovascular mortality, we compared transcriptomics data previously obtained from bronchoalveolar lavage (BAL) cells obtained from healthy subjects after inhalational exposure to ozone (200 ppb for 4 h) to those of various cell samples from 11 published studies of patients with atherosclerotic disease using the Nextbio genomic data platform. Overlapping gene ontologies that may be involved in the transition from pulmonary to systemic vascular inflammation after ozone inhalation were explored. Local and systemic enzymatic activity of an overlapping upregulated gene, matrix metalloproteinase-9 (MMP-9), was measured by zymography after ozone exposure.

RESULTS

A set of differentially expressed genes involved in response to stimulus, stress, and wounding were in common between the ozone and most of the atherosclerosis studies. Many of these genes contribute to biological processes such as cholesterol metabolism dysfunction, increased monocyte adherence, endothelial cell lesions, and matrix remodeling, and to diseases such as heart failure, ischemia, and atherosclerotic occlusive disease. Inhalation of ozone increased MMP-9 enzymatic activity in both BAL fluid and serum.

CONCLUSIONS

Comparison of transcriptomics between BAL cells after ozone exposure and various cell types from patients with atherosclerotic disease reveals commonly regulated processes and potential mechanisms by which ozone inhalation may contribute to progression of pre-existent atherosclerotic lesions.

Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases

AIMS

In this article, inflammatory mechanisms that link periodontal diseases to cardiovascular diseases are reviewed.

METHODS

This article is a literature review.

RESULTS

Studies in the literature implicate a number of possible mechanisms that could be responsible for increased inflammatory responses in atheromatous lesions due to periodontal infections. These include increased systemic levels of inflammatory mediators stimulated by bacteria and their products at sites distant from the oral cavity, elevated thrombotic and hemostatic markers that promote a prothrombotic state and inflammation, cross-reactive systemic antibodies that promote inflammation and interact with the atheroma, promotion of dyslipidemia with consequent increases in pro-inflammatory lipid classes and subclasses, and common genetic susceptibility factors present in both disease leading to increased inflammatory responses.

CONCLUSIONS

Such mechanisms may be thought to act in concert to increase systemic inflammation in periodontal disease and to promote or exacerbate atherogenesis. However, proof that the increase in systemic inflammation attributable to periodontitis impacts inflammatory responses during atheroma development, thrombotic events or myocardial infarction or stroke is lacking.

Evidence that periodontal treatment improves biomarkers and CVD outcomes

AIM

The aim of this review was to critically appraise the evidence on the impact of periodontal treatment of cardiovascular diseases (CVDs) biomarkers and outcomes.

METHODS

A systematic search was performed in Cinhal, Cochrane, Embase and Medline for relevant articles up to July 2012. Duplicate screening and reference hand searching were performed. Data were then summarized and evidence graded in tables.

RESULTS

The search resulted in: (a) no evidence on the effects of periodontal therapy on subclinical atherosclerosis, serum levels of CD40 ligand, serum amyloid A and monocyte chemoattractant protein-1, (b) limited evidence on the effects of periodontal therapy on arterial blood pressure, leucocyte counts, fibrinogen, tissue necrosis factor-a, sE-selectin, von Willebrand factors, d-dimers, matrix metalloproteinases, oxidative stress and CVD events, and (c) moderate evidence suggesting a negligible effect of periodontal therapy in reducing interleukin-6 and lipids levels, whilst a positive effect in reducing serum C-reactive protein levels and improving endothelial function.

CONCLUSIONS

Periodontal therapy triggers a short-term inflammatory response followed by (a) a progressive and consistent reduction of systemic inflammation and (b) an improvement in endothelial function. There is however limited evidence that these acute and chronic changes will either increase or reduce CVD burden of individuals suffering from periodontitis in the long term.

Comparison of serum amyloid A protein and C-reactive protein levels as inflammatory markers in periodontitis

PURPOSE

The purpose of this study was to compare serum amyloid A (SAA) protein levels with high-sensitive C-reactive protein (hs-CRP) levels as markers of systemic inflammation in patients with chronic periodontitis. The association of serum titers of antibodies to periodontal microbiota and SAA/hs-CRP levels in periodontitis patients was also studied.

METHODS

A total of 110 individuals were included in this study. Patients were assessed for levels of hs-CRP and SAA. Nonfasting blood samples were collected from participants at the time of clinical examination. The diagnosis of adipose tissue disorders was made according to previously defined criteria. To determine SAA levels, a sandwich enzyme-linked immunosorbent assay was utilized. Paper points were transferred to a sterile tube to obtain a pool of samples for polymerase chain reaction processing and the identification of Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Tannerella forsythia. The serum level of IgG1 and IgG2 antibodies to P. gingivalis, A. actinomycetemcomitans, and T. forsythia was also determined.

RESULTS

SAA and hs-CRP levels were higher in periodontitis patients than in controls (P<0.05). In bivariate analysis, high levels of hs-CRP (>3 mg/L) and SAA (>10 mg/L) were significantly associated with chronic periodontitis (P=0.004). The Spearman correlation analysis between acute-phase proteins showed that SAA positively correlated with hs-CRP (r=0.218, P=0.02). In the adjusted model, chronic periodontitis was associated with high levels of SAA (odds ratio [OR], 5.5; 95% confidence interval [CI], 1.6-18.2; P=0.005) and elevated hs-CRP levels (OR, 6.1, 95% CI, 1.6-23.6; P=0.008). Increased levels of serum IgG2 antibodies to P. gingivalis were associated with high levels of SAA (OR, 3.6; 95% CI, 1.4-8.5; P=0.005) and high concentrations of hs-CRP (OR, 4.3; 95% CI, 1.9-9.8; P<0.001).

CONCLUSIONS

SAA and hs-CRP concentrations in patients with chronic periodontitis are comparably elevated. High serum titers of antibodies to P. gingivalis and the presence of periodontal disease are independently related to high SAA and hs-CRP levels.

Associations between Periodontal Disease Parameters and Coronary Heart Disease in Greek Adults: A Cross-sectional Study

Aim

Several forms of periodontal disease have been associated with the development of coronary heart disease. The current retrospective study was conducted to investigate the possible relationship between periodontal disease parameters and defined coronary heart disease (CHD) in Greek adult patients.

Materials and methods

The study sample consisted of 880 individuals, 400 males and 480 females, aged 40 to 78 years. Data were collected by means of an interviewer administered questionnaire and an oral clinical examination. Statistical analysis of the questionnaire items was performed by using multiple regression analysis model in order to assess possible associations between coronary heart disease as dependent variable and epidemiological variables, biomarkers and periodontal disease parameters as independent variables.

Results

The occurrence of hypertension (OR = 0.01, 95% CI = 0.09-1.33), high level of triglycerides (OR = 0.08, 95% CI = 0.06-2.27) and total cholesterol (OR = 0.08, 95% CI = 0.07- 1.27), low level of high-density lipoprotein (OR = 0.12, 95% CI = 0.09-3.70) and smoking (OR = 1.83, 95% CI = 0.38-8.88) were significantly associated with the presence of coronary heart disease, whereas the periodontal parameters examined were not associated with the occurrence of it.

Conclusion

No associations were observed between periodontal disease parameters and defined coronary heart disease. However, the recorded associations strengthen the role of hypertension, lipids and smoking as causative risk factors of coronary heart disease.

How to cite this article

Chrysanthakopoulos NA, Oikonomou AA, Chrysanthakopoulos PA, Saini R. Associations between Periodontal Disease Parameters and Coronary Heart Disease in Greek Adults: A Cross-sectional Study. Int J Experiment Dent Sci 2015;4(1):4-10.

Evaluation of serum anti-cardiolipin antibodies after non-surgical periodontal treatment in chronic periodontitis patients

The present study investigated the effect of non-surgical periodontal therapy on serum level of anti-cardiolipin antibodies (aCLA), which are potentially involved in the pathogenesis of cardiovascular diseases in periodontal patients. Twenty volunteers (11 females and 9 males) with the mean age of 40.55 years participated in this study. Generalized chronic periodontitis was diagnosed through clinical periodontal examination at baseline visit. This examination included measuring the probing pocket depth and clinical attachment loss. Plaque index and gingival index were also recorded. After baseline examination, all the subjects received full-mouth non-surgical periodontal treatment. Subjects returned for a final visit 6 weeks after the last session of scaling for reevaluation of the periodontal parameters. At baseline and final visits 2 ml of venous blood was collected from each patient and an available commercially enzyme-linked immunosorbent assay was used for analyzing aCLA (IgM and IgG). The collected data were analyzed using the paired sample t test. Mean levels of both forms of aCLA, before and after treatment, showed statistically significant difference (P = 0.003 for IgM and P = 0.001 for IgG). In addition, study results showed significant reductions in periodontal parameters after non-surgical periodontal therapy (P < 0.001). The results of this study suggested that successful periodontal therapy can improve the serum level of one of the inflammatory biomarkers involved in the cardiovascular problems.

Association among oral health parameters, periodontitis, and its treatment and mortality in patients undergoing hemodialysis

BACKGROUND

Chronic periodontitis (CP) is a continuous, reversible source of inflammation with a potential impact on mortality in patients undergoing hemodialysis (HD). This study investigates the impact of oral health indicators, CP, and its treatment on survival rates in a group of patients undergoing HD.

METHODS

Clinically stable patients undergoing HD were referred for a dental examination. All patients were prospectively followed in the dialysis clinic, and all-cause mortality was recorded. Three groups of patients were analyzed: those who received CP treatment, those who did not, and patients without CP as a control group.

RESULTS

A total of 122 patients (79 males and 43 females, aged 23 to 77 years; mean age: 50 years; range: 23 to 77 years) were enrolled. Forty percent reported having rarely been evaluated by a dentist, and 59% had CP. There were 34 fatal events during a mean follow-up time of 64.1 ± 11.2 months. Oral factors associated with death in the univariate analysis were decreased frequency of dental visits; non-use of dental floss; increased decayed, missing, and filled teeth index; presence of CP; and absence of CP treatment. Patients with CP had a higher risk of death from all causes compared with patients without CP in the univariate analysis for untreated patients (hazard ratio 2.65 [95% confidence interval 1.06 to 6.59]; P = 0.036) and to a lesser extent for treated patients (2.36 [1.01 to 5.59]; P = 0.047). These significant differences were not maintained after adjustments for confounders in the multivariate model.

CONCLUSIONS

These results suggest that poor oral health, including CP, is a common finding in patients undergoing HD. The results of this study call for intervention trials to test the hypothesis that treatment of CP improves survival in maintenance of patients undergoing HD.

Crevicular fluid and serum concentrations of progranulin and high sensitivity CRP in chronic periodontitis and type 2 diabetes

Introduction. This study was designed to correlate the serum and gingival crevicular fluid (GCF) levels of progranulin (PGRN) and high sensitivity C-reactive protein (hs CRP) in chronic periodontitis and type 2 diabetes mellitus (DM). Design. PGRN and hs CRP levels were estimated in 3 groups: healthy, chronic periodontitis, and type 2 DM with chronic periodontitis. Results. The mean PGRN and hs CRP concentrations in serum and GCF were the highest for group 3 followed by group 2 and the least in group 1. Conclusion. PGRN and hs CRP may be biomarkers of the inflammatory response in type 2 DM and chronic periodontitis.

Estimate of CRP and TNF-alpha level before and after periodontal therapy in cardiovascular disease patients

INTRODUCTION

Epidemiological studies show that individuals with periodontitis have a radically amplified threat to develop cardiovascular disease. CRP& TNF-α, are acute phase proteins monitored as a marker of inflammatory status, which have been identified as a major risk factor for atherosclerotic complications. Elevated CRP & TNF-α level in periodontitis patients have been reported by several groups. The present study was performed to determine whether presence of periodontitis and periodontal therapy could influence the serum levels of CRP & TNF-α in cardiovascular disease patients.

METHODS

Forty cardiovascular disease subjects participated in the study. They were classified into two groups. Group A (Control) where no periodontal treatment was given, Group B (Test) where periodontal treatment (scaling & root planing) was performed. Periodontal clinical parameters like OHI-S, probing pocket depth, were evaluated together with serum CRP, TNF-α, at baseline and reassessed after 8 weeks for all the subjects in both the groups.

RESULTS

The CRP & TNF-α levels in both the groups decreased but the decrease in the Group A was minimal and was not statistically significant (P > 0.05); whereas in Group B where periodontal therapy was performed, there was statistically significant decrease.

CONCLUSION

It can be concluded from the study that there can be a possible causal relationship between pathogenesis of periodontal disease and CVD as inferred from the statistical significant outcome in the form of decreased inflammatory biomarkers after the periodontal treatment.

Orosomucoid, a new biomarker in the association between obesity and periodontitis

Epidemiological data indicate an association between periodontitis and obesity. The biological mechanisms of this relationship remain unclear. A cross-sectional study was conducted to evaluate the relationship between periodontitis and the common systemic inflammatory markers in 32 morbidly obese patients recruited in a Clinical Nutrition department. Periodontal condition was evaluated using pocket depth (PD) measurement, a classical clinical marker of ongoing periodontitis. Major periodontal risk factors were recorded (age, gender, diabetes and smoking status), as well as plasma levels of inflammatory markers (CRP, orosomucoid, IL-6) and adipokines (adiponectin, leptin). All patients included in the sample exhibited evidence of periodontitis, 16 of whom were diagnosed as having severe disease. Adjusted logistic regression analysis indicated that the severity of periodontitis was associated with the plasma level of orosomucoid (p<0.04) after adjustment for age, gender and smoking. Our study thus suggests that the severity of periodontitis, in morbidly obese patients, is associated with the increase of orosomucoid levels.

Serum amyloid A stimulates macrophage foam cell formation via lectin-like oxidized low-density lipoprotein receptor 1 upregulation

Elevated levels of serum amyloid A (SAA) is a risk factor for cardiovascular diseases, however, the role of SAA in the pathophysiology of atherosclerosis remains unclear. Here we show that SAA induced macrophage foam cell formation. SAA-stimulated foam cell formation was mediated by c-jun N-terminal kinase (JNK) signaling. Moreover, both SAA and SAA-conjugated high density lipoprotein stimulated the expression of the important scavenger receptor lectin-like oxidized low-density lipoprotein receptor 1 (LOX1) via nuclear factor-κB (NF-κB). A LOX1 antagonist carrageenan significantly blocked SAA-induced foam cell formation, indicating that SAA promotes foam cell formation via LOX1 expression. Our findings therefore suggest that SAA stimulates foam cell formation via LOX1 induction, and thus likely contributes to atherogenesis.

Transcriptional profiling of bone marrow stromal cells in response to Porphyromonas gingivalis secreted products

Periodontitis is an infectious inflammatory disease that destroys the tooth-supporting (periodontal) tissues. Porphyromonas gingivalis is an oral pathogen highly implicated in the pathogenesis of this disease. It can exert its effects to a number of cells, including osteogenic bone marrow stromal cells which are important for homeostastic capacity of the tissues. By employing gene microarray technology, this study aimed to describe the overall transcriptional events (>2-fold regulation) elicited by P. gingivalis secreted products in bone marrow stromal cells, and to dissect further the categories of genes involved in bone metabolism, inflammatory and immune responses. After 6 h of challenge with P. gingivalis, 271 genes were up-regulated whereas 209 genes were down-regulated, whereas after 24 h, these numbers were 259 and 109, respectively. The early (6 h) response was characterised by regulation of genes associated with inhibition of cell cycle, induction of apoptosis and loss of structural integrity, whereas the late (24 h) response was characterised by induction of chemokines, cytokines and their associated intracellular pathways (such as NF-κB), mediators of connective tissue and bone destruction, and suppression of regulators of osteogenic differentiation. The most strongly up-regulated genes were lipocalin 2 (LCN2) and serum amyloid A3 (SAA3), both encoding for proteins of the acute phase inflammatory response. Collectively, these transcriptional changes elicited by P. gingivalis denote that the fundamental cellular functions are hindered, and that the cells acquire a phenotype commensurate with propagated innate immune response and inflammatory-mediated tissue destruction. In conclusion, the global transcriptional profile of bone marrow stromal cells in response to P. gingivalis is marked by deregulated homeostatic functions, with implications in the pathogenesis of periodontitis.

Influence of periodontal therapy on C-reactive protein level: a systematic review and meta-analysis

The influence of oral infections, especially periodontal disease, on systemic diseases has been extensively discussed in the literature. Because periodontal disease is a persistent infection, it promotes an inflammatory response. C-reactive protein is a marker for inflammatory reactions that is frequently studied, since elevated levels of this protein are related to coronary events.

OBJECTIVE

The aim of this study was to investigate the effect of periodontal therapy on reducing the serum levels of C-reactive protein, by means of a systematic review of the literature and meta-analysis.

MATERIAL AND METHODS

A systematic review of the English-language literature was conducted in the PUBMED-MEDLINE database, using the key words "periodontal disease", "C-reactive protein", "periodontal therapy" and "periodontal treatment", in accordance with the terms for Medical Subject Headings (MeSH), to evaluate the effect of periodontal therapy on C-reactive protein levels. A qualitative analysis of studies of randomized clinical trial design was performed using CONSORT, with subsequent meta-analysis.

RESULTS

The literature search initially retrieved 46 potentially relevant studies available in the databases. From these, in accordance with the inclusion criteria, only 11 were selected, of which only 4 fulfilled the criteria of randomized clinical trial design. According to CONSORT, the studies evaluated generally presented good quality with regard to the criteria analyzed. Through meta-analysis, the reduction in mean levels of C-reactive protein (-0.231; p=0.000) after introducing periodontal treatment was estimated. The result was statistically significant, without evidence of heterogeneity between the studies (p=0.311).

CONCLUSIONS

The findings indicated that non-surgical periodontal treatment had a positive effect with regard to reduction of the serum levels of C-reactive protein.

Periodontal disease, hypertension, and blood pressure among older adults in Puerto Rico

BACKGROUND

Current scientific evidence addressing the relationship between periodontitis and hypertension is limited to studies producing inconsistent results.

METHODS

All participants of an ongoing representative cohort of Puerto Rican elderly who were ≥70 years old and residing in the San Juan metropolitan area were invited to this cross-sectional study. Periodontal probing depth (PD) and attachment loss (AL) were summarized using the Centers for Disease Control and Prevention and the American Academy of Periodontology definition for severe periodontitis (≥2 teeth with AL ≥6 mm and ≥1 tooth with PD ≥5 mm). Three repeated blood pressure (BP) measurements taken were averaged using a standardized auscultatory method. Information on hypertension history, use of antihypertensive medications, and potential confounders (age, sex, smoking, heavy and binge drinking, diabetes, use of preventive dental services, flossing, body mass index, consumption of fruits, vegetables, whole wheat bread, and high-fiber cereal) was collected during in-person interviews. High BP was defined as average systolic BP ≥140 mm Hg or diastolic ≥90 mm Hg. Multivariate logistic regression models were used to study the relationship between severe periodontitis, hypertension history, and high BP.

RESULTS

The study population comprised 182 adults. In multivariate analysis, there was no association between severe periodontitis and hypertension history (odds ratio [OR] = 0.99; 95% confidence interval [CI]: 0.40 to 2.48). Severe periodontitis was associated with high BP, with OR of 2.93 (95% CI: 1.25 to 6.84), after adjusting for age, sex, smoking, and binge drinking. This association was stronger when restricted to those with hypertension or taking antihypertensive medications: OR = 4.20 (95% CI: 1.28 to 13.80).

CONCLUSION

The results of this study suggest that periodontitis may contribute to poor BP control among older adults.

Oral health status of CHD and non-CHD adults of Lahore, Pakistan

BACKGROUND

Evidence on association of oral health and coronary heart diseases (CHD) is mounting in the literature. This study was designed to observe an association between status of oral health and cardiac diseases in Pakistani adults.

MATERIALS AND METHODS

A case-control study was conducted on CHD and non-CHD adults aged >30 years. Age-gender matched individuals without CHD, fulfilling the inclusion criteria as for CHD patients were selected for comparison. Bleeding on probing (BOP), periodontal pocket depth (PPD) and tooth loss were noted as oral health parameters.

RESULTS

45 CHD patients and 35 non-CHD individuals were examined. 53.75% were males and 46.25% females, 37.5% subjects were uneducated, 65% belonged to lower income group, 58.75% subjects were ≥obese and 88.75% were non-smokers. Mean of percent sites of BOP (P =0.007), PPD (P =0.031) and tooth loss (P =0.021) were significantly higher in study group. In stepwise logistic regression analysis, BOP and tooth loss showed a significant positive association with CHD; however, association of PPD was not significant.

CONCLUSION

Oral health parameters were significantly higher in CHD patients. Bleeding on probing and tooth loss was positively associated with CHD after adjusting for other socio-demographic variables.

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

Background:

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

Aim:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Effect of phase I periodontal therapy on anti-cardiolipin antibodies in patients with acute myocardial infarction associated with chronic periodontitis

BACKGROUND

Serum anti-cardiolipin (aCL) antibodies are prevalent in patients with periodontal diseases. These increased aCL concentrations were identified to play a modulating role in cardiovascular diseases. The present study aims to explore the effect of phase I periodontal therapy on immunoglobulin (Ig)M and IgG aCL antibodies in patients with acute myocardial infarction (AMI) associated with chronic periodontitis.

METHODS

A cross-sectional randomized clinical study was conducted within two groups comprising a sample size of 72 patients (n = 36 each). Group 1 had clinical features of AMI, and group 2 had clinical features of AMI associated with chronic periodontitis. After a thorough clinical and oral examination, the plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (AL) were recorded. Serum sample collection by venipuncture was done for estimation of serum IgM and IgG aCL concentration by using an enzyme-linked immunosorbent assay method. In group 2, phase I periodontal therapy was performed, and clinical and biochemical parameters were reanalyzed after 1 month.

RESULTS

In group 2, the mean PI, GI, PD, clinical AL, and serum IgM and IgG aCL antibody levels were significantly higher than in group 1 patients. In addition, study results showed significant alterations in concentrations of serum IgM (P = 0.008) and IgG (P <0.001) aCL along with periodontal parameters after phase I periodontal therapy.

CONCLUSION

The phase I periodontal therapy altered levels of serum IgG and IgM aCL antibodies in patients with AMI associated with chronic periodontitis.

Chronic periodontitis and C-reactive protein levels

BACKGROUND

This study aims to analyze the relationship between chronic periodontitis and C-reactive protein (CRP) by considering associated variables in individuals with or without cardiovascular disease.

METHODS

A sample of 359 individuals of both sexes (aged ≥40 years) was assessed. Among these individuals, 144 subjects were admitted to the hospital because of a first occurrence of acute myocardial infarction; 80 subjects were in the hospital for reasons other than acute myocardial infarction; and 135 subjects were living in the community. A questionnaire was applied to obtain demographic and lifestyle characteristics. Complete clinical periodontal examinations and anthropometric assessments were performed. CRP levels, plasma glucose levels, lipid profiles, and blood tests were performed to investigate any conditions that might have suggested infection and/or inflammation. CRP evaluations were performed using nephelometry. Individuals were considered to have periodontal disease if they simultaneously presented at least four teeth with one or more sites with probing depth ≥4 mm, clinical attachment loss ≥3 mm, and bleeding on probing. Procedures for descriptive analyses and logistic regression were used.

RESULTS

In the chronic periodontitis group, mean CRP levels were higher than those in the group without chronic periodontitis (2.6 ± 2.6 mg/L versus 1.78 ± 2.7 mg/L, respectively). The final model showed that individuals with chronic periodontitis were more likely to have high CRP levels (adjusted odds ratio: 2.26; 95% confidence interval: 1.30 to 3.93) considering the effects of age, schooling level, sex, smoking, high-density lipoprotein cholesterol, and diabetes.

CONCLUSION

In this study, chronic periodontitis is associated with elevated plasma CRP levels, even after controlling for several potential confounders.

Interaction between periodontal disease and systemic secondary amyloidosis: from inflammation to amyloidosis

BACKGROUND

It has become increasingly clear in recent years that periodontal disease can cause a dramatic increase in the levels of markers of systemic inflammation, and that periodontal treatment can result in reduction in the levels of these markers. We have previously shown that the prevalence of moderate to severe periodontitis was significantly higher in patients with familial Mediterranean fever (FMF) with amyloidosis than in patients with FMF without amyloidosis. Thus, the aim of this study is to investigate if chronic periodontitis is associated with secondary amyloidosis in the Black Sea region of Turkey.

METHODS

A total of 112 patients with biopsy-proven secondary amyloidosis (59 patients with FMF, 40 patients who were either chronically infected or had malignant disease, 13 patients with periodontitis) and 22 healthy subjects, were included in this study. Periodontal health and disease were evaluated using gingival index (GI), papillary bleeding index (PBI), plaque index (PI), and periodontal disease index (PDI). The concentrations of serum acute phase reactants (APRs) were measured at baseline and at 4 to 6 weeks after completion of the non-surgical periodontal therapy.

RESULTS

The prevalence of moderate to severe periodontitis was 47.5% in patients with FMF, 72.5% in patients who were either chronically infected or had malignant disease, and 84.6% in patients with periodontitis. Serum levels of APRs in patients with amyloidosis were reduced significantly after non-surgical periodontal therapy (P <0.01).

CONCLUSIONS

Periodontitis can increase the levels of APRs and potentiate the development of amyloidosis either by themselves or association with traditional factors, such as FMF and other chronic inflammatory diseases. Thus, preventing or treating periodontitis might prevent or at least alleviate the progression of amyloidosis. Periodontal evaluation should be performed as part of a medical assessment and considered as an etiologic factor for secondary amyloidosis.

Oral involvement in a case of AA amyloidosis: a case report

Introduction

Deposition of amyloid fibrils derived from circulating acute-phase reactant serum amyloid A protein causes systemic amyloidosis, a serious inflammatory disorder. We document a male patient who developed reactive amyloidosis (AA type), most likely secondary to his long standing periodontitis.

Case presentation

A 67-year-old Turkish man complained of pain in his oral cavity (burning mouth) especially on the tongue, and had difficulty chewing and swallowing foods. A careful dental/periodontal examination was performed, including assessment of plaque, gingival condition and periodontal probing depths on all his remaining teeth. Prosthetic rehabilitation was provided three months after the completion of his periodontal and surgical therapy. The concentration of serum inflammatory markers including erythrocyte sedimentation rate, white blood cell count, fibrinogen and high sensitive C-reactive protein were measured at baseline, at the second and sixth weeks, and at three and six months after the periodontal and surgical therapy.

Conclusions

Oral examination revealed a few papules on the dorsum of the tongue with two slightly painful, small ulcers, localized on the vestibule of the mouth. The mean probing depth was 9.10 ± 0.84 mm. Biopsies of the tongue, buccal mucosa and retromolar trigone were performed and amyloid deposits were found. The serum inflammatory markers improved more dramatically at the second week of periodontal therapy than any other time intervals.

Amyloidosis may manifest as periodontal destruction that leads to severe chronic periodontitis. Proper periodontal treatment may alleviate systemic inflammatory mediators caused by the amyloidosis.

Non-surgical periodontal therapy lowers serum inflammatory markers: a pilot study

BACKGROUND

Evidence suggests an association between periodontal disease and coronary heart disease (CHD). C-reactive protein (CRP), fibrinogen, and white blood cell (WBC) counts are markers of inflammation, and their systemic levels have been associated with CHD risk. This pilot study investigated the effect of non-surgical periodontal therapy on systemic levels of CRP, fibrinogen, and WBC counts in subjects with CHD or no CHD (NCHD).

METHODS

Twenty-seven angiographically defined patients with CHD and 18 subjects with NCHD aged >or=40 years were recruited for the study. Periodontal disease was measured through the clinical parameters bleeding on probing (BOP) and probing depth (PD). All subjects received non-surgical periodontal therapy that included oral hygiene instructions and subgingival scaling and root planing. Systemic levels of inflammatory markers (CRP, fibrinogen, and WBC counts) were measured prior to and 1 month after periodontal therapy.

RESULTS

Seventeen subjects with CHD and 11 subjects with NCHD completed the study. Subjects with CHD or NCHD experienced significant reductions in BOP (59% and 34%, respectively; P <0.05) and PD (41% and 35%, respectively; P <0.05), with non-significant intergroup differences (P >0.05). In all subjects, CRP, fibrinogen, and WBC counts were reduced significantly (21% to 40%) after periodontal therapy (P <0.05).

CONCLUSIONS

Periodontal treatment resulted in significant decreases in BOP and PD and lowered serum inflammatory markers in patients with CHD or NCHD. This may result in a decreased risk for CHD in the treated patients. These findings will allow pursuit of a large-scale randomized intervention trial in this population.

The American Journal of Cardiology and Journal of Periodontology editors' consensus: periodontitis and atherosclerotic cardiovascular disease

ACKNOWLEDGMENT

This Editors' Consensus is supported by an educational grant from Colgate-Palmolive, Inc., New York, New York, and is based on a meeting of the authors held in Boston, Massachusetts, on January 9, 2009.

DISCLOSURE

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Kornman is a full-time employee and shareholder of Interleukin Genetics, Waltham, Massachusetts, which owns patents on genetic biomarkers for chronic inflammatory diseases. Dr. Genco is a consultant to Merck, Whitehouse Station, New Jersey. Dr. Ridker has received research support from AstraZeneca, Wilmington, Delaware; Novartis; Pfizer, New York, New York; Roche, Nutley, New Jersey; Sanofi-Aventis, Bridgewater, New Jersey; and Abbott Laboratories, Abbott Park, Illinois. Dr. Ridker has received non-financial research support from Amgen, Thousand Oaks, California. Dr. Ridker is a co-inventor on patents held by Brigham and Women's Hospital that relate to the use of inflammatory biomarkers in cardiovascular disease. Dr. Ridker is a research consultant for Schering-Plough, Kenilworth, New Jersey; Sanofi-Aventis; AstraZeneca; Isis, Carlsbad, California; Novartis; and Vascular Biogenics, Tel Aviv, Israel. Dr. Van Dyke is a co-inventor on patents held by Boston University, Boston, Massachusetts, that relate to inflammation control, including consulting fees. Dr. Roberts has received honoraria for speaking from Merck, Schering-Plough, AstraZeneca, and Novartis. All other individuals in a position to control content disclosed no relevant financial relationships.

Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis

BACKGROUND

Periodontal disease is common among adults in the US and is a potential source of chronic inflammation. Recent data have suggested an important role for chronic inflammation in the development of coronary heart disease (CHD).

OBJECTIVE

To aid the United States Preventive Services Task Force (USPSTF) in evaluating whether periodontal disease is an independent novel risk factor for incident CHD.

METHODS

Studies were identified by searching Medline (1966 through March 2008) and reviewing prior systematic reviews, reference lists, and consulting experts. Prospective cohort studies that assessed periodontal disease, Framingham risk factors, and coronary heart disease incidence in the general adult population without known CHD were reviewed and quality rated using criteria developed by the USPSTF. Meta-analysis of good and fair quality studies was conducted to determine summary estimates of the risk of CHD events associated with various categories of periodontal disease.

RESULTS

We identified seven articles of good or fair quality from seven cohorts. Several studies found periodontal disease to be independently associated with increased risk of CHD. Summary relative risk estimates for different categories of periodontal disease (including periodontitis, tooth loss, gingivitis, and bone loss) ranged from 1.24 (95% CI 1.01-1.51) to 1.34 (95% CI 1.10-1.63). Risk estimates were similar in subgroup analyses by gender, outcome, study quality, and method of periodontal disease assessment.

CONCLUSION

Periodontal disease is a risk factor or marker for CHD that is independent of traditional CHD risk factors, including socioeconomic status. Further research in this important area of public health is warranted.

A systematic review and meta-analyses on C-reactive protein in relation to periodontitis

AIM

Elevated plasma C-reactive protein (CRP) is regarded as a risk predictor for cardiovascular diseases. This systematic review explored the robustness of observations that CRP is elevated in periodontitis. Similarly, the effect of periodontal therapy on CRP levels was investigated.

MATERIAL AND METHODS

Selection of publications was based on: (1) cross-sectional (case-control) studies; (2) longitudinal (treatment) studies; (3) high-sensitivity CRP measurement; (4) median and/or mean (+/-SD) values presented; and (5) subjects with no systemic disorders.

RESULTS

Screening of the initially 448 identified studies and reference checking resulted in 18 suitable papers. The majority of the studies showed that CRP levels are higher in patients than in controls. Often, studies showed that patients had CRP levels >2.1 mg/l. A meta-analysis of 10 cross-sectional studies showed that the weighted mean difference (WMD) of CRP between patients and controls was 1.56 mg/l (p<0.00001). Evidence from available treatment studies (n=6) showed lower levels of CRP after periodontal therapy. Eligible treatment studies in a meta-analysis demonstrated a WMD of reductions of CRP after therapy of 0.50 mg/L (95% CI 0.08-0.93) (p=0.02).

CONCLUSIONS

There is strong evidence from cross-sectional studies that plasma CRP in periodontitis is elevated compared with controls. There is modest evidence on the effect of periodontal therapy in lowering the levels of CRP.

Association between Vitamin D Receptor Gene Polymorphisms and Susceptibility to Chronic Kidney Disease and Periodontitis

BACKGROUND/AIMS

Chronic kidney disease (CKD) and periodontitis (PD) are serious public-health concerns. Vitamin D is a fat-soluble steroid hormone that interacts with its nuclear receptor (VDR) to regulate a variety of biological processes, such as bone metabolism, immune response modulation and transcription of several genes involved in CKD and PD disease mechanisms. The aim of this work was to investigate the association between polymorphisms in the VDR gene and end-stage renal disease (ESRD) and PD.

METHODS

222 subjects with and without ESRD (in hemodialysis) were divided into groups with and without PD. Polymorphisms TaqI and BsmI in the VDR gene were analyzed by PCR restriction fragment length polymorphism. The significance of differences in allele, genotype and haplotype frequencies between groups was assessed by the chi2 test (p value <0.05) and odds ratio (OR).

RESULTS

Allele G was associated with protection against ESRD: groups without versus with ESRD (GG) x (GA+AA): OR = 2.5, 95% CI = 1.4-4.6, p = 0.00; (G x A): OR = 1.5, 95% CI = 1.0-2.3, p = 0.02; (TG + CG) x (TA + CA): OR = 1.5, 95% CI = 1.0-2.3, p = 0.02. No association was observed between the study polymorphisms and susceptibility to or protection against PD.

CONCLUSION

Allele G of the VDR BsmI polymorphism was associated with protection against ESRD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anti-cardiolipin and increased serum adhesion molecule levels in patients with aggressive periodontitis

BACKGROUND

We observed that a significant proportion of patients with periodontitis have elevated serum levels of beta2-glycoprotein-I-dependent anti-cardiolipin (anti-CL). These prothrombotic autoantibodies, commonly found to be elevated in patients with systemic lupus erythematosus and the antiphospholipid syndrome, are associated with adverse pregnancy outcomes, such as fetal involution, prematurity, and low birth weight, and with cardiovascular sequelae, such as atherosclerosis, stroke, and myocardial infarction. Anti-CL is known to promote vascular inflammation and thrombosis.

METHODS

We measured serum levels of markers of vascular inflammation, including soluble intercellular adhesion molecule (sICAM)-1, soluble vascular cell adhesion molecule (sVCAM)-1, and sE-selectin, in 190 subjects with generalized aggressive or chronic periodontitis and in 90 periodontally healthy subjects.

RESULTS

sVCAM-1 and sE-selectin levels were significantly higher in patients with elevated anti-CL (>15 U/ml). This relationship also was observed in the never-smoker subset of subjects, even after correction for demographic and periodontal variables. Within the diagnostic categories, sICAM-1, sVCAM-1, and sE-selectin were significantly higher in generalized aggressive periodontitis patients who had elevated anti-CL compared to those with normal anti-CL. Statistical correction for demographic and periodontal variables indicated that elevated anti-CL remained significantly associated with increased sVCAM-1 and sE-selectin in generalized aggressive periodontitis patients.

CONCLUSIONS

Systemic markers of vascular inflammation in patients with aggressive periodontitis are associated with elevated levels of anti-CL. We hypothesize that a subset of periodontitis patients with elevated antiphospholipid antibodies could represent a subgroup at increased risk for obstetrical and cardiovascular sequelae.

Low-grade inflammation in chronic infectious diseases: paradigm of periodontal infections

Increasing evidence implicates periodontitis, a chronic inflammatory disease of the tooth-supporting structures, as a potential risk factor for increased morbidity or mortality for several systemic conditions including cardiovascular disease (atherosclerosis, heart attack, and stroke), pregnancy complications (spontaneous preterm birth [SPB]), and diabetes mellitus. Cross-sectional, case-control, and cohort studies indicate that periodontitis may confer two- and up to sevenfold increase in the risk for cardiovascular disease and premature birth, respectively. Given the recently acquired knowledge that systemic inflammation may contribute in the pathogenesis of atherosclerosis and may predispose to premature birth, research in the field of periodontics has focused on the potential of this chronic low-grade inflammatory condition to contribute to the generation of a systemic inflammatory phenotype. Consistent with this hypothesis clinical studies demonstrate that periodontitis patients have elevated markers of systemic inflammation, such as C-reactive protein (CRP), interleukin 6 (IL-6), haptoglobin, and fibrinogen. These are higher in periodontal patients with acute myocardial infarction (AMI) than in patients with AMI alone, supporting the notion that periodontal disease is an independent contributor to systemic inflammation. In the case of adverse pregnancy outcomes, studies on fetal cord blood from SBP babies indicate a strong in utero IgM antibody response specific to several oral periodontal pathogens, which induces an inflammatory response at the fetal-placental unit, leading to prematurity. The importance of periodontal infections to systemic health is further strengthened by pilot intervention trials indicating that periodontal therapy may improve surrogate cardiovascular outcomes, such as endothelial function, and may reduce four- to fivefold the incidence of premature birth. Nevertheless, further research is needed to fully discern the underlying mechanisms by which local chronic infections can have an impact on systemic health, and in this endeavor periodontal disease may serve as an ideal disease model.

Elevated serum interleukin-6 (IL-6) in solid-organ transplant recipients is positively associated with tissue destruction and IL-6 gene expression in the periodontium

BACKGROUND

The number of transplanted solid organs and life expectancy after transplantation are steadily rising worldwide. Inflammation is widely recognized as playing a pivotal role in transplant rejection, and several studies have shown that serum interleukin-6 (IL-6) levels can identify individuals who are at greater risk for rejection. Given the known association between IL-6 and chronic periodontitis, the aim of our study was to assess the periodontal status of solid-organ transplant subjects compared to systemically healthy controls, to quantify the IL-6 levels in the serum and periodontal tissues, and to explore their association.

METHODS

Forty-seven heart and kidney transplant and 18 systemically healthy age-matched individuals were recruited. Subjects received a complete periodontal examination, and blood and periodontal tissue samples were collected for quantification of IL-6 protein and mRNA levels, respectively.

RESULTS

Transplant subjects had significantly higher serum IL-6 levels and slightly but statistically significantly increased mean probing depths than healthy controls. Multivariable linear regression analysis adjusting for gender, diabetes, smoking, and immunosuppressant dose showed that the mean probing depth, number of missing teeth, and mean percentage of sites with > or =4 mm attachment loss were independent predictors for elevated serum IL-6 levels. Transplant subjects with chronic periodontitis had higher mean serum IL-6 levels than those without chronic periodontitis, and there was a positive correlation between periodontal IL-6 gene expression levels and serum IL-6 protein levels.

CONCLUSIONS

Periodontal tissue destruction and local IL-6 synthesis are associated with elevated serum IL-6 levels in transplant recipients. This may have serious implications in solid-organ transplant deterioration and chronic rejection.