Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST)

Carotid Artery Calcification Detected on Panoramic Radiography Is Significantly Related to Cerebrovascular Accident, Coronary Artery Disease, and Poor Oral Health: A Retrospective Cross-Sectional Study

Panoramic radiography imaging modality is widely used by dentists for diagnosing dental and jaw conditions. It can also detect carotid artery calcification (CAC), indicative of calcified atherosclerotic plaques in the carotid arteries. This cross-sectional retrospective study at the University of Tennessee Health Science Center investigated the link between CAC identified on panoramic radiograph (PR) and cerebrovascular accident (CVA), coronary artery disease (CAD), and poor oral health. Data from 314 CAC patients collected from 2014 to 2023 included age at diagnosis, gender, and clinical histories of hypertension, hyperlipidemia, diabetes mellitus, CVA, CAD, and the decay, missing, and filled permanent teeth (DMFT) index. These patients were age- and gender-matched with non-CAC patients for analysis. The findings revealed high prevalences of hypertension (86.2%), hyperlipidemia (57.6%), diabetes mellitus (30.7%), CVA (15.5%), and CAD (28.7%) amongst CAC patients and the average DMFT index was 26.6. A comparative analysis of 276 matched controls demonstrated significant differences in hypertension (85.9% vs. 57.6%), hyperlipidemia (58.3% vs. 33.7%), diabetes (32.6% vs. 22.1%), CVA history (14.9% vs. 5.1%), CAD (26.1% vs. 9.8%), and DMFT scores (26.3 vs. 23.7), all indicating strong associations between CAC and these health conditions. The adjusted analysis showed that hypertension (aOR: 3.20 [95% CI: 2.06-5.07]), hyperlipidemia (aOR: 1.70 [95% CI: 1.14-2.50]), CVA (aOR: 2.20 [95% CI: 1.13-4.30]), and CAD (aOR: 2.10 [95% CI: 1.28-3.60]) were significantly associated with CAC. Notably, only 41.7% of the patients received a medical consultation after CAC detection on PR. It is crucial for dentists to refer patients for further evaluation.

Association of periodontitis and tooth loss with extent of coronary atherosclerosis in patients with type 2 diabetes mellitus

Aim

The objective was to investigate the association of periodontitis and tooth loss with extent of diabetic coronary atherosclerosis.

Materials and methods

272 patients who were hospitalized at Shanghai East hospital and underwent a coronary artery calcium (CAC) CT scan were enrolled in this study. Individuals were grouped based on their CAC scores into a normal-to-mild coronary atherosclerosis (AS) group (0 ≤ score ≤ 100, n=184) and a moderate-to-severe group (score≥101, n=88). Periodontitis parameters and number of missing teeth were evaluated for every patient. The severity of periodontitis was categorized as mild, moderate, or severe. The taxonomic composition of the microbiota was determined using full-length 16S ribosomal RNA gene sequencing. Salivary inflammatory factors were tested by ELISA.

Results

Clinical attachment loss (CAL) (P =0.05) and the number of teeth lost (P = 0.016) were significantly higher in the moderate-to-severe coronary AS group, with these differences being more obvious in younger patients and patients with short-duration diabetes. Multivariate logistic regression analysis revealed that CAL (OR = 1.231, 95% CI = 1.066-1.214, P = 0.047) and having 10-19 missing teeth (OR = 1.604, 95% CI = 1.393-6.555, P = 0.05) were strongly associated with the presence of moderate-to-severe coronary AS. Salivary IL-6 and TNF-α levels, as well as levels of Porphyromonas gingivalis and Neisseria mucosa, were significantly elevated in the moderate-to-severe coronary AS group.

Conclusion

It was found that both tooth loss and CAL were related to the extent of diabetic coronary AS. Saliva inflammatory factors and oral bacteremia may be new biomarkers for moderate-to-severe coronary AS.

Thrombus Aspirates From Patients With Acute Ischemic Stroke Are Infiltrated by Viridans Streptococci

BACKGROUND

Acute ischemic stroke may be due to embolism from ruptured atherosclerotic carotid arteries. DNA of oral bacteria, mainly the viridans streptococci group, has been detected in thrombus aspirates of patients with ischemic stroke as well as in carotid endarterectomy samples. Because viridans streptococci are known to possess thrombogenic properties, we studied whether their presence in thrombus aspirates and in carotid artery specimens can be confirmed using bacterial immunohistochemistry.

METHODS AND RESULTS

Thrombus aspirates from 61 patients with ischemic stroke (70.5% men; mean age, 66.8 years) treated with mechanical thrombectomy, as well as carotid endarterectomy samples from 20 symptomatic patients (65.0% men; mean age, 66.2 years) and 48 carotid artery samples from nonstroke autopsy cases (62.5% men; mean age, 66.4 years), were immunostained with an antibody cocktail against 3 species (Streptococcus sanguinis, Streptococcus mitis, and Streptococcus gordonii) of viridans streptococci. Of the thrombus aspirates, 84.8% were immunopositive for viridans streptococci group bacteria, as were 80.0% of the carotid endarterectomy samples, whereas immunopositivity was observed in 31.3% of the carotid artery samples from nonstroke autopsies. Most streptococci were detected inside neutrophil granulocytes, but there were also remnants of bacterial biofilm as well as free bacterial infiltrates in some samples.

CONCLUSIONS

Oral streptococci were found in aspirated thrombi of patients with acute ischemic stroke as well as in carotid artery samples. Our results suggest that viridans streptococci group bacteria may play a role in the pathophysiology of ischemic stroke.

Associations Among Tooth Loss, Periodontitis, and Carotid Intima-Media Thickness: the Nagahama Study

AIMS

This study aimed to clarify the relationships among tooth loss, periodontal condition, and subclinical atherosclerosis from the aspect of intensity, extent, and duration of inflammation.

METHODS

This cross-sectional study included 9,778 people from the Nagahama Study, a large-scale, general population-based study conducted in Japan. The number of teeth and periodontal status, including the attachment level (AL) and pocket depth (PD) of representative teeth from six regions, were evaluated by dentists. The maximum intima-media thickness (IMT) of the common carotid artery was used as an index of atherosclerosis.

RESULTS

In the multivariate analysis adjusted for conventional risk factors, a large number of missing teeth (＜9 remaining teeth), which related to long-lasting inflammation indicative of the highest stage of periodontitis, was identified as an independent determinant of IMT in a general population (coefficient: 0.042; 95% confidence interval [CI]: 0.016 to 0.068). The presence of two or more regions with an AL ≥4 mm, which is indicative of the progressing, long-lasting stages of periodontal inflammation, was also independently associated with IMT (coefficient: 0.016; 95% CI: 0.004 to 0.028). On the contrary, PD, a measure of the early and reversible phases of periodontal inflammation, and loss of AL in the group without tooth loss were not significantly associated with IMT, because of the limited degree of accumulated periodontitis.

CONCLUSION

The present results suggest that the association between periodontitis and atherosclerosis depends on the inflammation intensity, extent, and duration.

Oral health status and risk of incident diabetes: a prospective cohort study of 213,389 individuals aged 45 and over

AIMS

To examine whether simple measures of oral health are associated with incident diabetes.

METHODS

This prospective cohort study linked data from the 45 and Up Study, Australia, to administrative health records. The study participants were 213,389 men and women, aged ≥ 45 years, with no diabetes at baseline. The oral health of participants was assessed by questionnaire. Incident diabetes cases were ascertained based on self-report in follow-up questionnaires, linked data on medical and pharmaceutical claims, and hospitalisation data up until 2019. The association between oral health and incident diabetes were calculated using multivariable cox proportional hazards models.

RESULTS

During 2,232,215 person-years of follow-up, 20,487 (9.6%) participants developed diabetes. Compared with those with ≥20 teeth, the adjusted hazard ratio (aHR) for incident diabetes was 1.12 (95% Confidence Interval (CI): 1.08, 1.17) for 10-19 teeth, 1.20 (1.14, 1.26) for 1-9 teeth and 1.15 (1.09, 1.21) for no teeth. Compared with those with excellent/very good teeth and gums, the aHR for incident diabetes was 1.07 (1.03, 1.12) for fair and 1.13 (1.07, 1.20) for poor teeth and gums.

CONCLUSIONS

Simple measures of oral health were associated with risk of developing diabetes, demonstrating the potential importance of oral health screening for diabetes prevention.

Oral health and 10-year cardiovascular risk in US adults: mediating role of inflammatory diet and vitamin D

OBJECTIVE

To investigate whether E-DII or vitamin D mediates the relationship between oral health and cardiovascular disease (CVD) risk.

METHODS

This study involved 6616 participants aged over 30 years old from the National Health and Nutrition Examination Survey (NHANES) in 2009-2014. Dietary inflammation and 10-year CVD risk were evaluated via the Energy-adjusted Dietary Inflammatory Index (E-DII) and the Framingham Risk Score (FRS), respectively. We used correlation analysis and mediation analysis to investigate the role of dietary inflammation and vitamin D in the relationship between oral health and CVD risk.

RESULTS

Oral health indicators and CVD risk were positively correlated with E-DII (r > 0, P < 0.001) and negatively correlated with vitamin D levels (r < 0, P < 0.001). The estimated mediating role of E-DII and vitamin D in the overall association between oral health and 10-year risk of CVD ranged from 4.9 to 7.5% and 6.6 to 11.6%, respectively. Furthermore, the mediation proportion of E-DII and vitamin D levels in the total association between oral health indicators and FRS were increased in participants without periodontitis.

CONCLUSION

Both E-DII and serum vitamin D were mediated the association between oral problems and 10-year CVD risk, especially in participants without periodontitis. Among them, E-DII played a positive mediating role, and serum vitamin D levels was a negative mediator.

CLINICAL RELEVANCE

Anti-inflammatory diet and prevention of vitamin D deficiency might reduce the impact of oral problems on cardiovascular disease risk to some extent. The study highlights the important role of oral health and dietary inflammation and vitamin D in primary prevention of cardiovascular disease.

Association between Dental and Cardiovascular Diseases: A Systematic Review

Background

The link between dental, infective and obstructive cardiovascular diseases is debatable.

Aim

To systematically review the literature to assess the association between dental conditions and development of cardiovascular disease.

Methods

The systematic review was conducted following the PRISMA guidelines using PubMed (Medline), Web of Science, Scopus, EMBASE and SciELO.

Results

Out of 6680 records, 82 articles were eligible for inclusion after reviewing titles and abstracts. No association between dental disease and cardiovascular disease has been observed in 10 studies while a potential link has been suggested by the remaining trials. Tooth loss and periodontitis are the main evaluated oral conditions while coronary artery disease, stroke, atherosclerosis and myocardial infarction represent the major cardiovascular events. The interaction between these two clinical entities is based on direct mechanism mediated by systemic inflammatory response, leakage of cytokines and endothelial cells invasion by oral pathogens and indirect mechanism mediated by common risk factors or confounders.

Conclusions

It seems that tooth loss, periodontitis and poor oral hygiene increase the risk of atherosclerotic cardiovascular events, and subsequently oral health care professionals could contribute to public health cardiovascular control efforts.

Risk Factors and Immunoinflammatory Mechanisms Leading to Atherosclerosis: Focus on the Role of Oral Microbiota Dysbiosis

Cardiovascular diseases (CVD), including myocardial infarction and stroke, are currently the leading cause of morbidity, disability and mortality worldwide. Recently, researchers have focused their attention on the alterations of the gut and oral microbiota, investigating the possible role of their dysbiosis in the pathogenesis and/or progression of CVD. In this regard, it has been shown that endothelial dysfunction, a major feature of CVD, can also be induced by chronic periodontal infection, due to a systemic pro-inflammatory condition, as suggested by increased plasma levels of acute phase proteins, IL-6 and fibrinogen. Moreover, proatherogenic dysfunctions can also be promoted by direct bacterial invasion of the endothelium. This review reports the current evidence about the possible role of oral microbiota dysbiosis and the related immunoinflammatory components in the pathophysiology of atherosclerosis and associated CVD. It is concluded that integration of oral microbiota sampling into clinical practice may result in a more accurate assessment of CV risk in patients and even modify their prognosis.

The Oral Health of a Group of 19th Century South Australian Settlers in Relation to Their General Health and Compared with That of Contemporaneous Samples

The aims of this study are to determine the oral health status of a rare sample of 19th-century migrant settlers to South Australia, how oral conditions may have influenced their general health, and how the oral health of this group compares with contemporaneous samples in Australia, New Zealand, and Britain. Dentitions of 18 adults and 22 subadults were investigated using non-destructive methods (micro-CT, macroscopic, radiographic). Extensive carious lesions were identified in seventeen adults and four subadults, and from this group one subadult and sixteen adults had antemortem tooth loss. Sixteen adults showed evidence of periodontal disease. Enamel hypoplastic (EH) defects were identified in fourteen adults and nine subadults. Many individuals with dental defects also had skeletal signs of comorbidities. South Australian individuals had the same percentage of carious lesions as the British sample (53%), more than other historic Australian samples, but less than a contemporary New Zealand sample. Over 50% of individuals from all the historic cemeteries had EH defects, suggesting systemic health insults during dental development were common during the 19th century. The overall oral health of the South Australian settlers was poor but, in some categories, (tooth wear, periapical abscess, periodontal disease), better than the other historic samples.

Glucose as a Risk Factor for Periodontitis in Kidney Transplantation Patients

BACKGROUND

Various factors including diabetes and oxidative stress are associated with periodontal inflammation. End-stage renal disease causes various systemic abnormalities in patients, including cardiovascular disaese, metabolic abnormalities, and infection. Even after kidney transplantation (KT), these factors are known to be associated with inflammation. Our study, therefore, aimed to study risk factors associated with periodontitis in KT patients.

METHODS

Patients who visited Dongsan Hospital, Daegu, Korea since 2018 and have undergone KT were selected. As of November 2021, 923 participants, with full data including hematologic factors were studied. Periodontitis was diagnosed based on residual bone level in panoramic views. Patients were studied by the presence of periodontitis.

RESULTS

From 923 KT patients, 30 were diagnosed with periodontal disease. Fasting glucose levels were higher in patients with periodontal disease, and total bilirubin levels were lower. When divided by fasting glucose levels, high glucose level showed increase of periodontal disease with odds ratio of 1.031 (95% confidence interval 1.004-1.060). After adjusting for confounders, the results were significant with odds ratio of 1.032 (95% CI 1.004-1.061).

CONCLUSIONS

Our study showed that KT patients, of whom uremic toxin clearance has been revolted, are yet at risk of periodontitis by other factors, such as high blood glucose levels.

Relationship between carotid intima-media thickness and periodontal disease in a Japanese urban population with and without hypertension: The Suita Study

AIM

To investigate the association between periodontal disease and atherosclerosis and to examine whether the association is modified by hypertension status.

MATERIALS AND METHODS

In this cross-sectional study, 1472 Japanese individuals aged 50-79 years who underwent a medical check-up, dental examination, and carotid ultrasonography were studied. Carotid atherosclerosis was expressed as the maximum and mean carotid intima-media thickness (max-IMT, mean-IMT) and the presence of stenosis (≥75%). Periodontal status was examined by the Community Periodontal Index (CPI, codes 0-4). The participants were divided into three groups according to the periodontal status (CPI0-2, CPI3, CPI4).

RESULTS

A positive correlation was found between mean-IMT and periodontal disease after adjustment for cardiovascular risk factors in the entire cohort (mean-IMT in hypertensives: CPI0-2: 0.848 mm, CPI3: 0.857 mm, CPI4: 0.877 mm; normotensives: 0.782, 0.802, 0.826). In the entire cohort, the multivariable-adjusted odds ratio of stenosis based on mean-IMT significantly increased according to periodontal status in normotensives (odds ratio; CPI0-2: 1, CPI3: 1.39, CPI4: 2.53; p-value for trend = .004) but showed only marginal significant increase in hypertensives (1, 1.15, 1.55; p-value for trend = .063). No significant relationships were observed for max-IMT in all analyses.

CONCLUSION

We observed an association between periodontal disease and atherosclerosis in normotensive and hypertensive participants.

The association between denture use and cardiovascular diseases. The United States National Health and Nutrition Examination Survey 2009-2018

Introduction

Poor dental health is associated with cardiovascular diseases (CVD). However, the relationship between CVD and denture use is currently unknown. This study aimed to investigate whether denture use is associated with CVD among American adults.

Methods

10,246 non-pregnant subjects aged 30-59 years from five cycles (2009-2018) of the United States National Health and Nutrition Examination Survey (NHANES) were included in this study. Participants who were observed by a dental examiner wearing denture/partial denture/plates were defined as denture users. CVD was defined as self-reported coronary heart disease, myocardial infarction, angina pectoris, stroke, and congestive heart failure. The association between denture use and CVD was analyzed using logistic regression with adjustment for potential cofounders.

Results

4.4% (95% CI, 3.9-5.0) participants had CVD, and 3.5% (95% CI, 2.8-4.5) participants were denture users. Denture use was associated with CVD [OR = 4.26, 95% CI (2.90-6.28), P < 0.01], which remained significant [adjusted OR = 1.82, 95% CI (1.15-2.88), P < 0.01] after adjustments for sociodemographic characteristics, smoking, alcohol use, drug addiction, body mass index (BMI), and abnormal medical conditions including gum problem, hypertension, diabetes, and hyperlipidemia. Women with dentures had significantly higher odds of CVD [adjusted OR = 2.13, 95% CI (1.10-4.11), P = 0.025].

Conclusion

In this nationally representative survey, denture use was associated with CVD. Denture use may be an unconventional risk factor for assessing CVD risks, especially in women. Future studies are required to investigate whether CVD and denture use is causally related.

Causal Effect of Tooth Loss on Cardiovascular Diseases

Many studies suggest associations between oral health and cardiovascular diseases, but there is a lack of causal evidence. Exploiting exogenous variation in tooth loss in US adults due to differential childhood exposure to fluoridated water, this study investigated the causal effect of tooth loss on cardiovascular diseases. A total of 722,519 participants in the Behavioral Risk Factor Surveillance System (BRFSS) waves 2006, 2008, or 2010 (birth years 1940-1978) were included in the analytical sample. To identify the effect of tooth loss on having a history of coronary heart disease (CHD) or stroke, instrumental variable analysis exploited childhood exposure to drinking water fluoride as an instrument. The weighted prevalence of CHD and stroke histories was 5.1% and 2.1%, respectively. First-stage regression indicated that childhood exposure to drinking water fluoride was a strong instrument for the number of lost teeth in adulthood (coefficient -0.61; 95% confidence interval [CI] -0.80, -0.41; F = 37.47). The probability of CHD was significantly higher by 1.04 percentage points (95% CI 0.57, 1.50) per lost tooth. The effect of tooth loss on stroke was significant only for people aged ≥60 y (coefficient 0.93 percentage points; 95% CI 0.14, 1.71). These findings are supportive of a causal effect of tooth loss on cardiovascular diseases among US adults, particularly in older age.

Perceptions of the oral health of their patients reported by Brazilian medical residents in psychiatry

Persons with severe mental disorders have higher chances of presenting oral health problems than persons in the general population. Mental disorders are considered public-health problems worldwide. Interpreting statements on oral health made by medical students receiving instruction in psychiatry is essential to provide elements for reflection on their difficulties, barriers or limited knowledge in managing their patients' oral health. Based on the presupposition that doctors provide their patients with no instruction or support concerning oral complaints, because these do not symbolize the same challenges as those emerging from severe mental disorders. The aim of this study was to interpret symbolic meanings of statements expressed by medical residents in psychiatry at a specialized university outpatient clinic, about their patients' oral health. Qualitative research using the Qualitative-Clinical method was conducted, adopting the theoretical reference of medical psychology. Data were analyzed by the Clinical-Qualitative Content method and the Seven-Step technique. Based on 06 interviews analyzed, the following categories emerged: "What do I do? Psychiatrists' dilemmas about not understanding their role in patients' oral health; and "Dentists do not participate in Balint' so-called "collusion in anonymity". It was concluded that among others, the paradigm consisted of a sociological composition, therefore it was stronger than personal decisions that might eventually oppose the barriers to interdisciplinary work posed by the institutional model, which were intertwined with paradigmatic barriers. Thus, specialist training should include a dental perspective, so that oral examinations would always be included in the physical examinations, from an interdisciplinary perspective of the integrity of health-care.

Tooth loss and periodontal status in patients with cardiovascular disease in the Serbian population: A randomized prospective study

OBJECTIVES

Chronic periodontal infections may predispose to cardiovascular disease. Since tooth loss may be due to periodontitis it is assumed that tooth loss can also predisposes cardiovascular disease. The aim was to investigate the possible relationship between the severity of the clinical picture of periodontitis and the occurrence of cardiovascular disease.

METHODS

We evaluated the association between clinical periodontal parameters, tooth loss and cardiovascular incident. A total of 100 subjects (50 subjects diagnosed with cardiovascular disease and 50 in control group without cardiovascular disease) underwent a dental examination. Tooth loss in all participants was caused only as a consequence of periodontitis. In addition to periodontal status, conventional risk factors for cardiovascular diseases (hypertension, smoking, obesity, hypercholesterolemia, diabetes) were measured, too.

RESULTS

Periodontal status was worse in patients in the group with cardiovascular disease compared to the group without cardiovascular disease. A significant association was observed between tooth loss levels and cardiovascular disease. In the group of patients who had cardiovascular disease, tooth loss was more than 50%. In the group of patients without cardiovascular disease, tooth loss was about 20% of the total number of teeth. A significant association was observed between tooth loss levels and cardiovascular disease prevalence.

CONCLUSION

This study presents relationship between number of teeth and cardiovascular disease, indicating a link between oral health and cardiovascular disease.

Factors affecting provision of oral health care for people with special health care needs: A systematic review

Background

Special health care needs (SHCNs) individuals experience higher levels of dental problems including accessing oral health (OH) facilities. Improving standard of OH care in SHCNs requires identifying barriers and enablers. The aim of this study was to perform a systematic review of prior researches to identify OH care barriers and enablers for SHCN individuals.

Methods

Electronic searching was conducted systematically in PubMed and Cochrane databases. The PICOS parameters were formulated for the inclusion of studies, and the PRISMA method was used to select the articles. Two reviewers independently screened the articles for eligibility and to minimise the risk of bias in the studies and also searched the contents of key articles, quality of methodology, outcomes and reference lists of all the studies included.

Results

A total of 1316 (PubMed 956, Cochrane 360) studies were found initially and after title and abstract screening and also removal of duplication, reviewers selected 53 papers from PubMED and 19 articles from Cochrane to go through full articles and led to the final confirmation of 21 studies. Common challenges included lack of OH knowledge and awareness, difficulty in accessing treatment, transportation problem, treatment cost, and lack of inter-professional collaboration for specialized services. Potential solutions included OHE training and services for patients and caregivers, easy access to dental services, specialized dental practitioners and use of a combination of expertise to meet the demands of SHCN individuals.

Conclusion

This brief analysis will establish dental obstacles to the provision of information to policymakers for SHCN population at organizational, individuals and policy levels. It will help in effective planning for providing and improving OH care quality in caregivers.

Evaluation of Common Factors of Periodontitis and Cardiovascular Disease in Patients with the Acute Coronary Syndrome

Periodontitis is a multifactorial disease causing inflammatory destruction of supporting structures of the dentition and eventually leading to its loss. This study was designed to evaluate common risk factors for periodontitis and acute coronary syndrome in the study population and demonstrate the systemic impact of periodontitis on the occurrence of acute coronary syndrome. A total of 160 patients (35 female and 125 male) were enrolled in the study. Considering the age range, the largest group of patients (118 patients) was between 55 and 65 years, which accounted for 73.8% of the total study population. There were 35 patients (21.9%) in the age group of 45 to 54 years, while the youngest age group of 35 to 44 years had as many as seven patients. Medical history and physical examination, including periodontal status, were performed. API, PD, CAL, and CPITN were evaluated. Common risk factors for periodontitis and acute coronary syndrome were assessed. The study assessed risk factors such as hypertension, diabetes, dyslipidemia, general health, smoking, height, weight, and hip circumference. In light of the above-described etiopathogenesis of atherosclerotic disease and its association with periodontal disease, it is important to emphasize preventing and treating periodontitis, especially in patients in the so-called high-risk group for cardiovascular disease. Dentists’ introduction of an appropriate prophylactic and therapeutic plan may constitute both primary and secondary prevention of cardiovascular diseases.

Clinical Condition of the Oral Cavity in the Adult Polish Population below 70 Years of Age after Myocardial Infarction-A Case-Control Study

According to recent scientific consensus, there is an increasing amount of evidence on the correlation between oral health and cardiovascular disease morbidity. The aim of the present study was to investigate the number of missing teeth, the presence of residual roots with necrotic pulp and teeth with caries, the type of teeth deficiencies, and periodontal status in patients after myocardial infarction (MI). A total of 151 patients after MI and 160 randomly selected controls without history of MI were enrolled in the study. Epidemiological data were collected, and dental examination was performed. Findings showed significantly more women, subjects with lower level of education, lower income, higher percentage of nicotine addiction, more frequent presence of arterial hypertension, diabetes, and obesity than in the study group. Moreover, oral status of the subjects who suffered from MI was inferior to the control group. An average patient from the study group had 11 missing teeth, when compared to four missing teeth in an average control subject (p < 0.0001). The majority of patients in the control group had occlusal contacts in intercuspal position in premolars and molars (group A), in contrast to the patients after MI, who had at least one missing supporting zone (group B) (p < 0.0001). Severe periodontitis was found in 50.3% of tests and in 30.4% of controls (p < 0.0001). A correlation was found between the edentulousness and the risk of myocardial infarction after adjusting for other known risk factors of cardiovascular diseases (OR = 3.8; 95% CI = 3.01−7.21; p < 0.0001). This case−control study showed that MI patients had more missing teeth, more residual roots with necrotic pulp, much higher incidence of edentulism and occlusal contacts in intercuspal position in fewer than four occlusal supporting zones, as well as worse periodontal status when compared to healthy subjects without a history of MI. Due to the methodology of unmatched controls, the presented results must be interpreted with caution.

Association between type 2 diabetes (T2D) and tooth loss: a systematic review and meta-analysis

BACKGROUND

Several studies have assessed the relationship between type 2 diabetes (T2D) and tooth loss; however, results have been inconsistent. Therefore, the present systematic review and meta-analysis of observational studies was designed to examine the association between T2D and tooth loss.

METHODS

This systematic review and meta-analysis was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. We searched all the relevant studies in international databases of Scopus, PubMed, ProQuest, Web of Science, Cochrane Library, and Google scholar search engine until February 2022. The heterogeneity of the studies was calculated using the I² index. Measure of effect and 95% confidence interval (CI) were extracted from each study. The results of the study were analyzed using the random effects model.

RESULTS

In the present study, 22 eligible studies were included. Meta-analysis of unadjusted and adjusted results showed that T2D significantly increased the risk of tooth loss, and Odds Ratio (OR) unadjusted was 1.87 (95% CI: 1.62-2.13, p < 0.001), and OR adjusted was 1.20 (95% CI: 1.10-1.30, p < 0.001), respectively. Subgroup analysis based on study design for adjusted OR indicated that in the cohort study (OR: 1.29, 95% CI: 1.07-1.51), in the cross-sectional study (OR: 1.15, 95% CI: 1.06-1.23), and in the case-control study (OR: 5.10, 95% CI: 1.01-9.18) there was a significant association between T2D and tooth loss. Other subgroups analyses showed consistent results and no publication bias existed.

CONCLUSIONS

The findings suggest that T2D is associated with increased risk of tooth loss. This conclusion may provide useful evidence for correlated clinical researches.

Alteration of Oral and Perioral Soft Tissue in Mice following Incisor Tooth Extraction

Oral and perioral soft tissues cooperate with other oral and pharyngeal organs to facilitate mastication and swallowing. It is essential for these tissues to maintain their morphology for efficient function. Recently, it was reported that the morphology of oral and perioral soft tissue can be altered by aging or orthodontic treatment. However, it remains unclear whether tooth loss can alter these tissues’ morphology. This study examined whether tooth loss could alter lip morphology. First, an analysis of human anatomy suggested that tooth loss altered lip morphology. Next, a murine model of tooth loss was established by extracting an incisor; micro-computed tomography revealed that a new bone replaced the extraction socket. Body weight was significantly lower in the tooth loss (UH) group than in the non-extraction control (NH) group. The upper lip showed a greater degree of morphological variation in the UH group. Proteomic analysis and immunohistochemical staining of the upper lip illustrated that S100A8/9 expression was higher in the UH group, suggesting that tooth loss induced lip inflammation. Finally, soft-diet feeding improved lip deformity associated with tooth loss, but not inflammation. Therefore, soft-diet feeding is essential for preventing lip morphological changes after tooth loss.

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

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

Oral health care beliefs among care personnel working with older people - follow up of oral care education provided by dental hygienists

Objectives

The proportion of older people in the population is increasing rapidly. Along with this comes an increase in the number of people requiring assistance in daily living, including oral care. Swedish law stipulates that care personnel who work with older people should be offered oral health education every year. The aim of this study was to investigate oral health care beliefs among such personnel.

Methods

A questionnaire study was conducted among 2167 personnel providing care to older people at special accommodation sites and in home care. Data were collected using the Nursing Dental Coping Beliefs Scale. Descriptive statistics were calculated and logistic regression analysis was performed.

Results

Personnel working in home care had lower odds of having an internal locus of control than those working in special accommodation, and personnel with less than 10 years of working experience had lower odds than their more experienced counterparts. Men had higher odds of having an external locus of control than women.

Conclusions

It seems important to ensure that home care personnel and less experienced personnel attend oral care educational sessions, and to encourage male staff to focus on oral care work.

Association between internal carotid artery calcifications detected as incidental findings and clinical characteristics associated with atherosclerosis: A dental volumetric tomography study

PURPOSE

To evaluate the presence of calcifications in the internal carotid artery (ICA) in cone-beam computed tomography (CBCT), and to verify the association of these findings with sex, age, dental condition, and risk factors associated with vascular disorders.

METHODS

The CBCT scans used in this study were obtained from the database of a private dental clinic requested for the planning of rehabilitation with dental implants. The selection criteria were patients aged 40 years and above. Out of a pool of 1176 CBCT examinations, a total of 284 scans of adult patients were evaluated by two blinded observers. Data were collected from patients' medical records.

RESULTS

ICA calcifications were present in 63.0% of the examinations. Most calcifications were in the intracranial pathway (166). Despite being present in a smaller number 57 (C1), extracranial calcifications were more severe. Spearman's ρ coefficients (rS) indicated that the number of missing teeth was directly associated with the presence of calcifications (p = 0.042) and severity (p = 0.020). The age variable also had a direct relationship with the presence of calcifications (p ≤ 0.0001), increasing its frequency and severity over the years. In addition, hypertension (p = 0.036) and use of antihypertensive drugs (p = 0.015) were directly associated.

CONCLUSIONS

There is a high occurrence of ICA calcifications in CBCT as incidental findings in adult patients, and it is directly associated with age, number of missing teeth and hypertension.

Optimising oral health in frail older people

There is a link between oral health and systemic health. Conditions such as dementia and pneumonia are associated with poor oral health.

Frail older people receive regular care from medical and nursing staff but tend not to see dentists regularly or only seek treatment when there is a dental problem. Collaboration between dentists and other health professionals is therefore increasingly important.

Oral health should be assessed regularly. This enables early referral to a dentist.

Anticholinergic drugs, particularly in polypharmacy, can have a profound deleterious effect on salivary function and oral health. A medication review may enable the anticholinergic burden to be reduced.

In addition to regular brushing, oral preventive products may be appropriate in frail older people.

Association of tooth loss with morbidity and mortality by diabetes status in older adults: a systematic review

OBJECTIVE

This systematic review assesses the association of tooth loss (TL), as the exposure, with morbidity and mortality by diabetes mellitus (DM) status, as the outcome, in older adults.

BACKGROUND

Individuals with DM have higher prevalence of severe TL and increased risk of developing morbidities and mortality. No systematic review has evaluated the association between TL with morbidity and mortality by DM status.

MATERIAL AND METHODS

Comprehensive searches used multiple publication databases containing reports published between 01/01/2000 and 04/21/2021. Two authors independently evaluated included studies for quality and risk of bias using the Critical Appraisal Skills Programme (CASP) checklist for cohort and Center for Evidence-Based Medicine (CEBM) critical appraisal sheet for cross-sectional studies, while a third author arbitrated decisions to resolve disagreements.

RESULTS

Thirteen studies met the inclusion criteria: eight cross-sectional and five cohort. Qualitative review of the included studies indicated TL is associated with increased incidence and prevalence of DM. TL is also associated with DM-related morbidities including greater prevalence of heart disease, diabetic retinopathy, metabolic syndrome; poorer health-related quality of life; poorer survival of participants with chronic kidney disease; and increased medical expenditure. Overall, the quality of the evidence reviewed was medium, as per the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

CONCLUSIONS/PRACTICAL IMPLICATIONS

This review found significant associations of TL with prevalence and incidence of DM and adverse DM-related outcomes. An interprofessional team-care approach that includes an oral health component could benefit the prevention and management of DM.

Generation of periodontal ligament stem cells from human iPSCs with a chemically defined condition

Human periodontal ligament stem cells (PDLSCs) play an important role in periodontal tissue regeneration. The generation of PDLSCs from human induced pluripotent stem cells (iPSCs) by simulating the development pattern of PDLSCs in vivo provided a new way to obtain a large and stable source of PDLSCs. However, animal-derived components were still necessary for current differentiation protocols, which could cause safety and ethical problems and hinder the clinical application of iPSCs-derived PDLSCs. Here, we established a novel protocol to induce iPSCs into PDLSCs by chemically defined conditions. We first induced iPSCs into neural crest-like cells by inhibiting TGF-β pathway, BMP pathway and Notch pathway using SB431542, LDN and DAPT, respectively. The iPSC-induced neural crest-like cells were further cultured in chemically defined medium containing recombinant human bFGF as well as the rho-associated protein kinase inhibitor Y27632 to generate PDLSCs. The characteristics of iPSCs-derived PDLSCs and the bi-potentiality of osteogenesis and adipogenesis differentiation were verified in vitro. The establishment of the chemically defined differentiation system breaks through the limitation brought from animal-derived components and enables us to obtain a large number of PDLSCs, which holds a significant value to the research and treatment of periodontal diseases.

Tooth retention predicts good physical performance in older adults

BACKGROUND

Oral health is closely related to both physical and psychological well-being, as it enables individuals to eat, speak, and socialize. The number of teeth is the most used indicator of oral health. Several reports document a relationship of dental status with a variety of indicators of general health but longitudinal studies employing standardized physical performance tests are infrequent in the scientific literature.

SUBJECTS AND METHODS

The Italian elderly participating in the Pro.V.A. longitudinal Study (3099 subjects aged 65+ at baseline, 2196 at the 5-year follow-up 1 and 1641 at the 7-year follow- up 2) underwent detailed interview and extensive clinical and instrumental examination that included validated physical performance measures. Participants were classified into 4 groups according to the number of remaining teeth: 0, 1-7, 8-19, and 20+. To explore the association of the number of remaining teeth with physical function and disability, we performed logistic regression analyses with models progressively adjusted for a wide number of covariates, namely anthropometric (gender, age, BMI), comorbidity (cardio-vascular, osteoarticular, and neurological diseases including depression), muscle strength (assessed for upper and lower limbs), lifestyle (smoking status, alcohol use, leisure time activities) and socioeconomical status (education, income, marital status, loneliness).

RESULTS

Dental status correlated with most comorbidities, lifestyle, and socio-economic variables at the univariate analysis at baseline and at follow-ups. A good dental status was significantly associated with better physical functioning and lower disability. The presence of 20+ teeth resulted significantly protective (reference group: 0 teeth) versus mobility-related disability (OR = 0.67), disability (OR = 0.54) and inability to perform heavy duties (OR = 0.62), at follow up 1 and low physical performance score (OR = 0.59) at follow up 2. Conversely, the detrimental effect of edentulism, explored in subjects with or without dentures, was present but not as straightforward. Conclusion. The assessment of a geriatric patient should include an oral evaluation as a good dental status is a crucial component of successful aging.

Association between Oral Pathology, Carotid Stenosis, and Oral Bacterial DNA in Cerebral Thrombi of Patients with Stroke

Methods

Thrombus aspirates and control arterial blood were taken from 71 patients (70.4% male; mean age, 67.4 years) with acute ischemic stroke. Tooth pathology was registered using CT scans. Carotid stenosis was estimated with CTA and ultrasonography. The presence of bacterial DNA from aspirated thrombi was determined using quantitative PCR. We also analyzed the presence of these bacterial DNAs in carotid endarterectomies from patients with peripheral arterial disease.

Results

Bacterial DNA was found in 59 (83.1%) of the thrombus aspirates (median, 8.6-fold). Oral streptococcal DNA was found in 56 (78.9%) of the thrombus aspirates (median, 5.1-fold). DNA from A. actinomycetemcomitans and P. gingivalis was not found. Most patients suffered from poor oral health and had in median 19.0 teeth left. Paradoxically, patients with better oral health had more oral streptococcal DNA in their thrombus than the group with the worst pathology (p = 0.028). There was a trend (OR 7.122; p = 0.083) in the association of ≥50% carotid artery stenosis with more severe dental pathology. Oral streptococcal DNA was detected in 2/6 of carotid endarterectomies.

Conclusions

Stroke patients had poor oral health which tended to associate with their carotid artery stenosis. Although oral streptococcal DNA was found in thrombus aspirates and carotid endarterectomy samples, the amount of oral streptococcal DNA in thrombus aspirates was the lowest among those with the most severe oral pathology. These results suggest that the association between poor oral health and acute ischemic stroke is linked to carotid artery atherosclerosis.

Association between metabolic syndrome and periodontitis: The role of lipids, inflammatory cytokines, altered host response, and the microbiome

Periodontitis has been associated with many systemic diseases and conditions, including metabolic syndrome. Metabolic syndrome is a cluster of conditions that occur concomitantly and together they increase the risk of cardiovascular disease and double the risk of type 2 diabetes. In this review, we focus on the association between metabolic syndrome and periodontitis; however, we also include information on diabetes mellitus and cardiovascular disease, since these two conditions are significantly intertwined with metabolic syndrome. With regard to periodontitis and metabolic syndrome, to date, the vast majority of studies point to an association between these two conditions and also demonstrate that periodontitis can contribute to the development of, or can worsen, metabolic syndrome. Evaluating the effect of metabolic syndrome on the salivary microbiome, data presented herein support the hypothesis that the salivary bacterial profile is altered in metabolic syndrome patients compared with healthy patients. Considering periodontitis and these three conditions, the vast majority of human and animal studies point to an association between periodontitis and metabolic syndrome, diabetes, and cardiovascular disease. Moreover, there is evidence to suggest that metabolic syndrome and diabetes can alter the oral microbiome. However, more studies are needed to fully understand the influence these conditions have on each other.

Association Between Pulsatile Components of Blood Pressure and Severe Tooth Loss in Rural Ecuador: The Three Villages Study

Background: Arterial hypertension has been associated with severe tooth loss, but differential associations with individual components of blood pressure (BP) have scarcely been investigated. We assessed the independent associations between pulsatile/steady components of BP and severe tooth loss in community-dwelling adults residing in 3 rural Ecuadorian villages. Methods: Individuals aged ≥40 years living in Atahualpa, El Tambo, and Prosperidad were identified during door-to-door surveys. Data collection focused on the number of remaining teeth and measurements of pulsatile/steady components of BP. Multivariate models were fitted to assess independent associations between pulsatile/steady BP components and severe tooth loss, after adjusting for relevant covariates. Results: A total of 1543 individuals were included. Oral exams identified 426 (28%) individuals with severe tooth loss. BP levels ≥140/90 mm Hg were determined in 481 (31%) individuals. The mean pulse pressure (PP) level was 55.3 ± 19 mm Hg. For systolic BP (SBP), the mean level was 133.1 ± 23.5 mm Hg, and for diastolic BP (DBP) it was 77.8 ± 11.5 mm Hg. Univariate models showed significant associations between severe tooth loss and SBP and PP, but not with DBP. However, the significance was taken away in fully adjusted generalized linear models. Age remained as an independent significant covariate in models using SBP and PP. Causal mediation analyses disclosed that percentages of the effect of severe tooth loss mediated by age were 99.5% for SBP and 98.9% for PP. Conclusion: This study shows that age captures most of the effect of the association between pulsatile components of BP and severe tooth loss.

Periodontitis related to cardiovascular events and mortality: a long-time longitudinal study

OBJECTIVE

The present study assessed if individuals ≥ 60 years of age with periodontitis are more likely to develop stroke or ischemic heart diseases, or at a higher risk of death for 17 years.

MATERIAL AND METHODS

At baseline individuals ≥ 60 received a dental examination including a panoramic radiograph. Periodontitis was defined as having ≥ 30% sites with ≥ 5-mm distance from the cementoenamel junction to the marginal bone level. Medical records were annually reviewed from 2001 to 2018. Findings from the medical records identifying an ICD-10 code of stroke and ischemic heart diseases or death were registered.

RESULTS

Associations between periodontitis and incidence of ischemic heart disease were found in this 17-year follow-up study in all individuals 60-93 years (HR: 1.5, CI: 1.1-2.1, p = 0.017), in women (HR: 2.1, CI: 1.3-3.4, p = 0.002), and in individuals 78-96 years (HR: 1.7, CI: 1.0-2.6, p = 0.033). Periodontitis was associated with mortality in all individuals (HR: 1.4, CI: 1.2-1.8, p = 0.002), specifically in men (HR: 1.5, CI: 1.1-1.9, p = 0.006) or in ages 60-72 years (HR: 2.2, CI: 1.5-3.2, p = 0.000). Periodontitis was more prevalent among men (OR: 1.8, CI: 1.3-2.4, p = 0.000).

CONCLUSIONS

Individuals with periodontitis have an increased risk for future events of ischemic heart diseases and death.

CLINICAL RELEVANCE

Improving periodontal health in older individuals may reduce overall mortality and ischemic heart diseases. Both dental and medical professionals should be aware of the associations and ultimately cooperate.

Periodontal Disease Association with Large-Artery Atherosclerotic Stroke

OBJECTIVES

We investigated whether periodontal disease is associated with specific stroke subtype.

MATERIALS AND METHODS

This is a single-center cross-sectional study. Periodontal disease was assessed in stroke and transient ischemic attack patients. Strokes caused by large-artery atherosclerosis were classified as intracranial atherosclerosis or extracranial atherosclerosis as well as anterior or posterior circulation disease.

RESULTS

Consecutive patients (N=265) were enrolled (age 64 ± 12.8, 49% white, 46% black, and 56% male). A third (N=87) had moderately severe periodontal disease. Twenty percent (N=42) were strokes due to large-artery atherosclerosis. Large-artery strokes had a higher proportion of patients with periodontal disease than without periodontal disease (31% vs.16%, X² p=0.01). There was also a higher proportion of patients with periodontal disease (12% vs. 5%) with stroke due to posterior circulation disease (crude odds ratio or OR 3.0, 95% CI 1.1-7.9, p=0.03), which persisted after adjustment for covariates (adjusted OR 3.1, 95% CI 1.04-9.1, p=0.004). Periodontal disease patients had a higher rate of large-artery stroke due to intracranial atherosclerosis compared to those without periodontal disease (20% vs. 8%; crude OR 2.6, 95% CI 1.3-5.6, p=0.01), and this association persisted after adjustment (adjusted OR 2.6, 95% CI 1.1-5.8, p=0.004).

CONCLUSIONS

We report a higher proportion of stroke due to large-artery atherosclerosis in patients with periodontal disease compared to those without periodontal disease. We report an independent association between periodontal disease and intracranial atherosclerosis, as well as between periodontal disease and posterior circulation disease.

Association between denture use, chewing ability, and all-cause mortality in middle-aged and older adults who exercised regularly in Korea

Herein, using data from the Korean Longitudinal Study of Aging (2006–2018), we evaluated denture use and chewing ability to determine the status of oral health in middle-aged adults who exercised regularly; further, we investigated the relationship of oral health with all-cause mortality. From the basic survey conducted in 2006, we interviewed 10,254 participants who were followed up until death. The participants were grouped based on regular exercise into REG (n = 3921) and non-REG (n = 6290) groups. The mortality rate was higher in the non-REG group than in the REG group (35.8% versus 26.9%; p < 0.001). The mortality rate was higher in denture users (versus non-denture users), non-drinkers (versus alcohol drinkers), and those on medical aid (versus national health insurance). The mortality rate was higher in participants with poor masticatory ability, lower education level, and poor subjective health perception (p < 0.001). Denture use and masticatory discomfort were not significant risk factors for mortality in the non-REG group (p > 0.05). In conclusion, masticatory discomfort was a risk factor for increased mortality in middle-aged Korean adults who exercised regularly, at least once a week. Thus, assessment of masticatory ability could be a useful indicator of life expectancy in middle-aged adults.

Poor Oral Health in Patients with Schizophrenia: a Meta-Analysis of Case-Control Studies

Patients with schizophrenia have high rates of comorbid physical illness, but there has been less attention to dental diseases in these patients. This meta-analysis of case-control studies systematically examined the oral health in patients with schizophrenia. Case-control studies comparing the oral health in patients with schizophrenia and healthy controls were screened and identified. Standardized mean difference (SMD) with its 95% confidence interval (CI) was calculated using RevMan version 5.3. Three case-control studies comprising 306 patients with schizophrenia and 306 healthy controls were included in this meta-analysis. All studies were rated as "high quality". Patients with schizophrenia had significantly higher scores of decayed, missing and filled teeth (SMD = 0.83, 95%CI: 0.57, 1.09, p < 0.001; I² = 51%), missing teeth (SMD = 0.79, 95%CI: 0.59, 0.98, p < 0.001; I² = 19%), and decayed teeth (SMD = 0.89, 95%CI: 0.24, 1.54, p = 0.008; I² = 92%) when compared to healthy controls. Similarly, patients with schizophrenia had significantly lower filled teeth scores (SMD = -0.76, 95%CI: -1.44, -0.09, p = 0.03; I² = 93%) when compared to healthy controls. This meta-analysis found that patients with schizophrenia were likely to have worse oral health when compared to healthy controls.

Tailored Doxycycline Hyclate Loaded In Situ Gel for the Treatment of Periodontitis: Optimization, In Vitro Characterization, and Antimicrobial Studies

Currently, periodontitis is treated by oral dosage forms (antibiotics) which shows systemic side effects and failed to reach the therapeutic concentration (above minimum inhibitory concentration, MIC) in the periodontal pocket. The present study aimed to overcome the above issues, by designing tailored doxycycline hyclate laden in situ gel by Poloxamer 407, chitosan, and polyethylene glycol 600. The in situ gel-forming system has attracted attention owing to its ability of sustained drug release above MIC, easy administration (syringeability), and high drug retention (localization) in the periodontal cavity. The Box-Behnken design (BBD) was used to tailor and optimize the concentration of Poloxamer 407 (X₁ = 14.3%), chitosan (X₂ = 0.58%), and polyethylene glycol 600 (X₃ = 1.14%) to achieve sufficient syringeability (149 N), t_90% (1105 min), and viscosity at non-physiological condition (512 cps) and physiological condition (5415 cps). The optimized in situ gel was clear and isotonic (RBCs test). The gelation temperature of the optimized in situ was 34 ± 1°C with sufficient mucoadhesive strength (26 ± 2 dyn/cm²), gel strength (29 ± 2 sec), and texture profile for periodontal application. The in vitro drug release studies showed sustain release from optimized in situ gel (24h) in comparison to marketed gel (7h). The antimicrobial activity (cup plate technique) of the in situ gel was equivalent to the marketed doxycycline gel, which suggests that the doxycycline hyclate retained its antimicrobial efficacy when formulated as in situ gelling system. In conclusion, BBD was effectively utilized to optimize in situ gel with minimum level of polymers to achieve the required characteristics of the in situ gel for sustaining drug delivery to treat periodontitis.

Causal Effect of Tooth Loss on Functional Capacity in Older Adults in England: A Natural Experiment

BACKGROUND/OBJECTIVES

Tooth loss is associated with reduced functional capacity, but so far, there is no relevant causal evidence reported. We investigated the causal effect of tooth loss on the instrumental activities of daily living (IADL) among older adults in England.

DESIGN

Natural experiment study with instrumental variable analysis.

SETTING

The English Longitudinal Study of Aging (ELSA) combined with the participants' childhood exposure to water fluoride due to the community water fluoridation.

PARTICIPANTS

Five thousand six hundred and thirty one adults in England born in 1945-1965 participated in the ELSA wave seven survey (conducted in 2014-2015; average age: 61.0 years, 44.6% men).

MEASUREMENTS

The number of natural teeth predicted by the exogenous geographical and historical variation in exposure to water fluoride from age 5 to 20 years old (instrumental variable) was used as an exposure variable. The outcome, having any limitations in IADL (preparing a hot meal, shopping for groceries, making telephone calls, taking medications, doing work around the house or garden, or managing money), was assessed by self-reported questionnaires.

RESULTS

Linear probability model with Two-Stage Least Squares estimation was fitted. Being exposed to fluoridated water was associated with having more natural teeth in later life (coefficient: 0.726; 95% confidence interval (CI) = 0.311, 1.142; F = 11.749). Retaining one more natural tooth reduced the probability of having a limitation in IADL by 3.1 percentage points (coefficient: -0.031; 95% CI = -0.060, -0.002).

CONCLUSION

Preventing tooth loss maintains functional capacity among older adults in England. Given the high prevalence of tooth loss, this effect is considerable. Further research on the mechanism of the observed causal relationship is needed.

Association of periodontal disease with atherosclerosis in 70-year-old Japanese older adults

Periodontal disease and arteriosclerotic disease are greatly affected by aging. In this study, the association of conventional risk factors and periodontal disease with atherosclerosis was longitudinally examined in Japanese older adults. Subjects in this study were 490 community-dwelling septuagenarians (69-71 years) randomly recruited from the Basic Resident Registry of urban or rural areas in Japan. At the baseline examination, all subjects underwent socioeconomic and medical interviews; medical examinations, including examinations for carotid atherosclerosis, hypertension, diabetes mellitus, and dyslipidemia; and conventional dental examinations, including a tooth count and measurement of probing pocket depth (PPD). After 3 years, 182 septuagenarians who had no atherosclerosis at the baseline examination were registered and received the same examination as at the baseline. In the re-examination conducted 3 years after the baseline survey, 131 (72.0%) of the 182 participants who had no atherosclerosis at the baseline examination were diagnosed with carotid atherosclerosis. Adjusting and analyzing the mutual relationships of the conventional risk factors for atherosclerosis by multiple logistic regression analysis for the 171 septuagenarians with a full set of data, the proportion of teeth with PPD ≥ 4 mm was independently related to the prevalence of atherosclerosis (odds ratio: 1.029, P < 0.022). This longitudinal study of Japanese older adults suggests that periodontal disease is associated with the onset/progression of atherosclerosis. Maintaining a healthy periodontal condition may be an important factor in preventing the development and progression of atherosclerosis.

Update and review of the gerodontology prospective for 2020's: Linking the interactions of oral (hypo)-functions to health vs. systemic diseases

New lines of evidence suggest that the oral-systemic medical links and oral hypo-function are progressively transcending beyond the traditional clinical signs and symptoms of oral diseases. Research into the dysbiotic microbiome, host immune/inflammatory regulations and patho-physiologic changes and subsequent adaptations through the oral-systemic measures under ageism points to pathways leading to mastication deficiency, dysphagia, signature brain activities for (neuro)-cognition circuitries, dementia and certain cancers of the digestive system as well. Therefore, the coming era of oral health-linked systemic disorders will likely reshape the future of diagnostics in oral geriatrics, treatment modalities and professional therapies in clinical disciplines. In parallel to these highlights, a recent international symposium was jointly held by the International Association of Gerontology and Geriatrics (IAGG), Japanese Society of Gerodontology (JSG), the representative of USA and Taiwan Academy of Geriatric Dentistry (TAGD) on Oct 25th, 2019. Herein, specific notes are briefly addressed and updated for a summative prospective from this symposium and the recent literature.

Tobacco Products, Periodontal Health and Education Level: Cohort Study from Sweden

Background: The aim of this study is to investigate if using tobacco products (including snuff, smoking tobacco and dual-using) associates with periodontal health, education level and mortality in a Swedish cohort, hypothesizing that tobacco products affect periodontal health, associate with lower education and increase the risk of death. Method: Study cohort of 1080 subjects aged 31–40 years (528 men, 552 women) was clinically examined and interviewed in 1985 and followed for mortality until 2015. Subjects were classified into two groups: “tobacco users” and “non-users”. Associations between periodontal health parameters, tobacco products, education level and age of death were analysed. SPSS was used for analyses. Results: Tobacco products, as well as education level associated, with poor periodontal health. Tobacco users and lower education was linked to higher plaque-, calculus- and gingival-index scores than non-users (p < 0.001). They also had significantly higher prevalence of deep periodontal pockets (≥5 mm) (p < 0.001 and 0.010, respectively), missing teeth (p = 0.010 and 0.003, respectively) and lower education level (p < 0.001) compared with non-users. However, tobacco product users did not die significantly earlier than non-users. Conclusion: Tobacco products had a negative impact on periodontal health. Tobacco product users were less educated. However, using tobacco products may not cause premature death.

The Association Between Periodontitis and Cardiovascular Disease: an Update

PURPOSE OF THE REVIEW

The purpose of this review is to provide an update on the data regarding periodontitis and its association with cardiovascular disease (CVD), as well as a closer look at the connection between periodontitis and valvular heart disease.

RECENT FINDINGS

The body of literature that demonstrates an association between periodontitis and CVD is growing, and there is increasing evidence that periodontal disease (PD) can have negative cardiovascular effects. Far less data is available for the management of periodontitis specifically in those with valvular heart disease. However, recent studies suggest that routine preoperative dental evaluation practices may not be necessary in all patients and, similar to changes in antibiotic prophylaxis, may only be indicated for a select group of individuals. There is a strong association between PD and CVD, although a causal relationship is yet to be elucidated. Further data is needed in this regard, as well as in determining the appropriate management of PD in those with valvular heart disease.

Periodontal disease and incident dementia: The Atherosclerosis Risk in Communities Study (ARIC)

OBJECTIVE

To test the hypothesis that periodontal disease would be associated with increased risk for dementia and mild cognitive impairment (MCI) by assessing dementia/MCI outcomes after a baseline periodontal examination.

METHODS

Participants enrolled in the Atherosclerosis Risk in Communities study with a clinical periodontal examination (or edentulous participants) at visit 4 (1996-1998; mean ± SD age 63 ± 6 years, 55% female, 21% black) and adjudicated dementia outcomes through 2016 were included (n = 8,275). A subgroup of 4,559 participants had adjudicated dementia and MCI assessments at visit 5 (2011-2013). Participants received a full-mouth periodontal examination and were classified into periodontal profile classes (PPCs) based on the severity and extent of gingival inflammation and attachment loss. MCI and dementia were determined via neurocognitive testing, neurological examination and history, informant interviews, and brain MRI in a subset. Cox proportional hazards models regressed incident dementia on PPCs. Relative risk regression models were used for the composite of MCI/dementia.

RESULTS

The cumulative incidence and incidence density of dementia during follow-up (average 18.4 years) were 19% (n = 1,569) and 11.8 cases per 1,000 person-years. Multivariable adjusted hazard ratios for incident dementia among participants with severe PPC or edentulism (vs periodontal healthy) were 1.22 (95% confidence interval [CI] 1.01-1.47) and 1.21 (95% CI 0.99-1.48), respectively. For the combined dementia/MCI outcome, adjusted risk ratios among participants with mild/intermediate PPC, severe PPC, or edentulism (vs periodontal healthy) were 1.22 (95% CI 1.00-1.48), 1.15 (95% CI 0.88-1.51), and 1.90 (95% CI 1.40-2.58). Results were stronger among younger (≤62 years) participants (p for interaction = 0.02).

CONCLUSION

Periodontal disease was modestly associated with incident MCI and dementia in a community-based cohort of black and white participants.

The association between number of teeth and physical function limitation among older adults in the USA

AIM

To examine the association between the number of teeth and physical function limitation (PFL), as an indicator of frailty, among older adults in the USA.

BACKGROUND

Physical function limitation is common among the elderly and potentially associated with oral health, particularly the number of extracted teeth.

MATERIALS AND METHODS

Data from the Behavioral Risk Factor Surveillance System 2014 (BRFSS, 2014), a cross-sectional national interview survey of US population, were analyzed. The number of participating older adults aged 65 and over was 158 962. The association between PFL, outcome and number of extracted teeth, demographic data, socio-economic status, smoking, general health, comorbidity conditions and body mass index (BMI) was assessed using logistic regression analyses.

RESULTS

The prevalence of PFL was 28%. In the fully adjusted model, the number of extracted teeth had a significant association with PFL: edentulous older adults had higher odds for PFL, (odds ratio [OR]:1.36; 95%CI: 1.22, 1.52). Similarly, those who lost 6 teeth or more but not all were likely to have PFL (OR 1.35: 95% CI: 1.23, 1.48).

CONCLUSIONS

There was a significant association between the number of extracted teeth and PFL among US older adults aged 65 and more, based on the data from BRFSS 2014. The findings indicate that losing teeth may be a potential risk for PFL.

Relationship of periodontitis and edentulism to angiographically diagnosed coronary artery disease: A cross-sectional study

OBJECTIVE

The objective of the study is to examine the connection between oral status and the extent of coronary artery disease (CAD), which is diagnosed by angiography.

BACKGROUND

Periodontitis and tooth loss have been linked to atherosclerosis and CAD in previous studies. However, no distinct connection was revealed due to the diversity of the results and the variety of diagnostic methods. To provide a more consistent data pool and stronger evidence, there is a need for studies with standard measurements and diagnostic criteria.

METHODS

309 patients, who consulted to Ankara University, Faculty of Medicine, Department of Cardiology and had coronary angiography, were enrolled to this study. Individuals were grouped based on their coronary angiography results, as CAD (+) (n = 233) and CAD (-) (n = 76). Studied parameters included cardiovascular risk factors, plaque index (PI), remaining teeth count, bleeding on probing (BOP), and probing pocket depth (PPD). Periapical radiographs were taken from teeth with ≥4 mm PPD. Oral status was categorized as periodontally healthy subjects/patients with gingivitis (Group 1), patients with periodontitis (Group 2), and edentulous subjects (Group 3).

RESULTS

PI (P < 0.001), PPD (P = 0.001), BOP (P = 0.004), the number of patients with less than 10 teeth (P = 0.014), and edentulism (P = 0.009) were significantly higher in CAD (+) patients, who were mostly older (P < 0.001) and male (P < 0.001). Multivariate logistic regression analysis revealed that Group 2 (odds ratio = 2.48, 95% confidence interval = 1.24-4.95, P = 0.010) and Group 3 (odds ratio = 2.01, 95% confidence interval = 1.14-5.17, P = 0.040) were highly associated with CAD. Two and three stenosed vessels were significantly higher in Groups 2 and 3 compared to Group 1 (P = 0.003).

CONCLUSIONS

It was found that both edentulism and periodontitis were related to CAD.

Gender Differences in the Levels of Periodontal Destruction, Behavioral Risk Factors and Systemic Oxidative Stress in Ischemic Stroke Patients: A Cohort Pilot Study

Background: Due to the higher frequency of ischemic stroke in men compared to women, we aimed to determine if gender differences exist regarding periodontal status and several plasma biomarkers in patients with a recent large artery atherosclerosis ischemic stroke (IS). Material and methods: Patients with their first IS within less than six weeks who were able to undergo periodontal examinations were evaluated. Demographic data, periodontal status, oxidative stress parameters/plasma antioxidant capacity, and C-reactive protein in patients who suffered a recent large artery atherosclerosis ischemic stroke were reccorded. Results: 93 patients were included in the study. More men were smokers (12/57 vs. 3/36) and consumed alcohol (17/57 vs. 3/36), and more women had higher glycemic values (p = 0.023), total cholesterol (p < 0.001), LDL (low-density lipoprotein)-cholesterol (p = 0.010), and HDL (high-density lipoprotein)-cholesterol (p = 0.005) levels. Significantly more men than women had moderate plus severe periodontal disease (p = 0.018), significantly higher levels of nitric oxide (p = 0.034), and significantly lower levels of total antioxidant capacity (p = 0.028). Conclusions: In this pilot study, men seem to be more prone to oxidative stress and to develop more severe forms of periodontitis among patients with stroke, but the results need validation on a larger sample.

Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea

AIMS

Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associations with cardiovascular disease. This study aimed to evaluate whether oral hygiene behaviour can alleviate cardiovascular risk associated with oral health status using a nationwide population-based cohort.

METHODS AND RESULTS

The data of 247 696 healthy adults aged 40 years or older who underwent an oral health screening programme and had no history of major cardiovascular events were extracted from the National Health Insurance System-National Health Screening Cohort. After a median follow-up of 9.5 years, 14 893 major cardiovascular events occurred including cardiac death, myocardial infarction, stroke, and heart failure. The risk of cardiovascular events was higher when a subject had periodontal disease, a higher number of dental caries, or more tooth loss. Performing one more tooth brushing a day was associated with a 9% significantly lower risk of cardiovascular events after multivariable adjustment. Regular dental visits (once a year or more) for professional cleaning were also shown to reduce cardiovascular risk by 14%. Improved oral hygiene behaviours were shown to attenuate the cardiovascular risk originating from periodontal disease, dental caries, and tooth loss.

CONCLUSION

Oral hygiene care such as frequent tooth brushing and regular dental visits for professional cleaning reduced the risk of future cardiovascular events in healthy adults. This study also suggests that improved oral hygiene behaviour may modify the association between oral health and cardiovascular diseases.

Tooth Loss Predicts Myocardial Infarction, Heart Failure, Stroke, and Death

We investigated whether oral health, represented by missing teeth, was associated with an increased risk of cardiovascular disease, including myocardial infarction (MI), heart failure (HF), stroke, and all-cause mortality. Subjects who underwent routine dental examinations and health checkups provided by the Korean National Health Insurance from 2007 to 2008 ( n = 4,440,970) were followed up for incident MI, HF, stroke, and death until 2016. During follow-up of 7.56 y, 68,063 (1.5%) subjects died, and 31,868 (0.7%) were admitted for MI, 22,637 (0.5%) for HF, and 30,941 (0.7%) for stroke. Cardiovascular events and mortality increased in proportion to tooth loss. Tooth loss was an independent risk factor for cardiovascular events after multivariable analysis adjusted for cardiovascular risk, behavioral, and income factors. Each missing tooth was associated with an approximately 1% increase in MI (HR, 1.010; 95% CI, 1.007 to 1.014), 1.5% increase in HF (HR, 1.016; 95% CI, 1.013 to 1.019) and stroke (HR, 1.015; 95% CI, 1.012 to 1.018), and 2% increase in mortality (HR, 1.022; 95% CI, 1.020 to 1.023). Having ≥5 missing teeth substantially increased risk for cardiovascular outcomes, and even a small number of missing teeth (1 to 4) was associated with an increased risk for MI, stroke, and death. This association was consistent in subgroup analyses and especially strong among the younger subjects (age <65 y) and those with periodontitis. In this large Korean nationwide cohort study, we found that tooth loss showed a dose-dependent association with incident MI, HF, ischemic stroke, and all-cause death and was a good predictor of cardiovascular outcome. In clinical practice, the number of missing teeth can aid physicians in discriminating patients with a higher cardiovascular risk.

Association between metabolic syndrome and tooth loss: A systematic review and meta-analysis

BACKGROUND

The authors conducted a systematic review and meta-analysis to verify the existence and level of scientific evidence concerning the association between metabolic syndrome (MetS), as the main exposure, and tooth loss (TL), as the outcome.

TYPES OF STUDIES REVIEWED

Through electronic databases and partially through gray literature, the authors identified observational studies in adults. The authors used no date or language restrictions. The authors evaluated the studies' methodological quality by using the Newcastle-Ottawa Scale. The authors conducted a random-effects model meta-analysis. The authors assessed the quality of evidence by using the Grading of Recommendations Assessment, Development and Evaluation criteria.

RESULTS

Twelve studies met the eligibility criteria, and 9 were retained for the meta-analysis. Most were cross-sectional studies with good methodological quality. Participants with MetS had fewer teeth (standardized mean difference, -2.77; 95% confidence interval, -4.56 to -0.98) and an increased likelihood of lacking functional dentition (odds ratio, 2.37; 95% confidence interval, 1.89 to 2.96) than did those without MetS. The overall quality of evidence was very low.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Better-conducted longitudinal studies are necessary to establish a causal relationship between MetS and TL to inform the best strategies to prevent TL in populations with MetS.

Practical Guidelines for Physicians in Promoting Oral Health in Frail Older Adults

Good oral health in old age is particularly important for maintaining adequate oral function, preventing pain and discomfort, controlling localized or systemic inflammation, sustaining social interaction, and preserving quality of life. Given that oral health is an integral part of general health and well-being, and that major chronic systemic and oral diseases share common risk factors, oral health prevention and promotion should be embedded within routine medical assessment and care provision. The role of medical physicians, particularly primary care physicians, geriatricians, and elderly care physicians, in community and long-term care facilities in assessing and promoting oral health in frail older adults is critical and has been emphasized in recent European recommendations. All physicians should appreciate the importance of oral health and incorporate an initial oral health screening into routine medical assessment and care. A short interview with patients and carers on current oral health practices may help to assess the risk for rapid oral health deterioration. The interview should be followed by an oral health assessment, using validated tools, for nondental health care providers. Based on these findings, the physician should decide on necessary follow-up procedures, which may include oral health counseling and/or dental referral. Oral health counseling should include advice on daily oral, mucosal, and denture hygiene; denture maintenance; dietary advice; smoking cessation; limitation of harmful alcohol consumption; management of xerostomia; and frequent dental review. To enable physicians to perform the tasks recommended in this publication, appropriate teaching at both undergraduate and postgraduate levels must be delivered in addition to provision of appropriate continuing education courses.