Effect of periodontal therapy on arterial structure and function among aboriginal australians: a randomized, controlled trial

Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients

Objectives

This narrative review aims to update the current evidence and offer insight into the new non-invasive ultrasound techniques used to early identify degenerative vascular changes in subjects with periodontitis and to investigate if these methodologies could be useful to identify subclinical cardiovascular disease (CVD) dysfunction in periodontitis patients and to monitor changes in CVD risk after periodontal treatment.

Methods

Studies examining the assessment of vascular endothelial function through the latest methodologies were analyzed. Systematic reviews, observational studies, and clinical trials in the English language were identified using PubMed, Web of Science, and Google Scholar databases with key search terms such as "periodontitis," "endothelial dysfunction (ED)," "arterial stiffness," and "periodontal therapy."

Results

Several mechanisms are involved in the association between periodontitis and CVD. The key players are periodontal bacteria and their toxins, which can enter the circulation and infiltrate blood vessel walls. The increase in proinflammatory molecules such as interleukins and chemokines, c-reactive protein, fibrinogen, and oxidative stress also plays a decisive role. In addition, an increase in parameters of ED, arterial stiffness, and atherosclerosis, such as carotid intima-media thickness, pulse wave velocity, and flow-mediated dilatation, has been shown in periodontal patients.

Conclusions

The literature today agrees on the association of periodontitis and CVD and the positive role of periodontal therapy on systemic inflammatory indices and cardiovascular outcomes. Hopefully, these non-invasive methodologies could be extended to periodontal patients to provide a comprehensive understanding of the CVD-periodontitis link from the perspective of a personalized medicine approach in periodontology.

Effect of non-surgical periodontal therapy on risk markers of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in the world. Patients with periodontitis have a higher risk of CVD, although a causal relationship between these conditions remains unclear. Non-surgical periodontal therapy (NSPT) is able to control inflammation at local and systemic levels. This study aimed to analyze the effect of NSPT on CVD risk markers.

METHODS

Four electronic databases were searched from their inception to April 1, 2023, to identify and select articles without any language restrictions. Eleven CVD-related markers (e.g., C-reactive protein [CRP], Interleukin-6 [IL-6]) were selected. Meta-analyses were performed using random and fixed effect models. The differences were expressed as weighted mean differences (WMD) and 95% confidence interval (95% CI).

RESULTS

From 1353 studies, twenty-one randomized controlled clinical trials were included in the meta-analysis. Results showed a significant decrease in CRP, IL-6, and systolic blood pressure (SBP) after NSPT.

CONCLUSION

Moderate certainty evidence shows that NSPT has a positive effect on the reduction of IL-6 and SBP in patients with periodontitis, while low certainty evidence shows that NSPT is effective for reduction of CRP. Moderate certainty evidence showed that NSPT did not show a positive effect on low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG), and low certainty evidence showed that NSPT did not show a positive effect on Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), diastolic blood pressure (DBP), and flow-mediated dilatation (FMD).

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews), number CRD42022377565.

Role of oral health in heart and vascular health: A population-based study

BACKGROUND AND AIM

Conditions such as hypertension, cardiovascular diseases, and hypercholesterolemia, are a major public health challenge. This study investigates the influence of oral health indicators, including gum bleeding, active dental caries, tooth mobility, and tooth loss, on their prevalence in Hungary, considering socioeconomic, demographic, and lifestyle factors.

MATERIALS AND METHODS

Data from the 2019 Hungarian European Health Interview Survey with 5,603 participants informed this analysis. Data were accessed from the records maintained by the Department of Health Informatics at the University of Debrecen between September and November 2023. Variable selection employed elastic net regularization and k-fold cross-validation, leading to high-performing predictors for weighted multiple logistic regression models. Sensitivity analysis confirmed the findings' validity.

RESULTS

Significant links were found between poor oral health and chronic cardiac conditions. Multiple teeth extractions increased hypertension risk (OR = 1.67, 95% CI: [1.01-2.77]); dental prosthetics had an OR of 1.45 [1.20-1.75]. Gum bleeding was associated with higher cardiovascular disease (OR = 1.69 [1.30-2.21]) and hypercholesterolemia risks (OR = 1.40 [1.09-1.81]).

CONCLUSIONS

Oral health improvement may reduce the risk of cardiac conditions. This underscores oral health's role in multidisciplinary disease management.

Systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of non-surgical periodontal treatment in patients with concurrent systemic conditions

OBJECTIVE

To conduct a systematic review of the published scientific evidence to evaluate the efficacy of nonsurgical periodontal therapy (NSPT) in treating periodontitis in patients with concurrent systemic conditions (diabetes, CVD, erectile dysfunction, chronic kidney disease, rheumatoid arthritis, polycystic ovarian syndrome, obesity, pregnancy). We hypothesised that NSPT results in better periodontal outcomes when compared to untreated controls after follow-up.

MATERIALS AND METHODS

A systematic search (PUBMED/EMBASE) was conducted from 1995 to 2023 to identify randomised controlled trials (RCTs) with a minimum follow-up of 3 months. The primary outcome was the difference in mean probing depth (PD), and the secondary outcomes were mean clinical attachment loss (CAL), percentage of sites with PD ≤ 3 mm (%PD ≤ 3 mm) and percentage of sites with bleeding on probing (%BOP) between the treated and untreated control group in patients with comorbidities.

RESULTS

The electronic search resulted in 2,403 hits. After removing duplicates, 1,565 titles and abstracts were screened according to the eligibility criteria, resulting in 126 articles for full-text screening. Following this, 44 studies were analysed. Restricting to studies with low bias or some concerns, NSPT group demonstrated a 0.55 mm lower mean PD (95%CI: -0.69; -0.41) after 3 months compared to the control group.

CONCLUSION

Compared to the untreated controls, NSPT notably reduced mean PD, mean CAL, and %BOP while increasing %PD ≤ 3 mm in patients with concurrent systemic conditions. These findings suggest that NSPT is also an effective procedure in managing periodontitis in patients with concurrent systemic conditions.

TRIAL REGISTRATION

This systematic review was registered under the protocol registration number CRD42021241517/PROSPERO.

Effect of endodontic treatment on endothelial dysfunction and subclinical atherosclerosis-a prospective intervention study

OBJECTIVE

The objective of this study is to investigate the effect of endodontic treatment on flow-mediated dilatation (FMD) and carotid intima-media thickness (c-IMT) in patients with apical periodontitis (AP).

MATERIAL AND METHOD

The study includes 32 young men having AP with a mean age of 25.78 years free from cardiovascular disease (CVD) and its risk factors, including periodontitis. All subjects underwent complete physical and dental examination, echocardiography, and ultrasound assessment of FMD on the brachial artery and c-IMT on the carotid artery at baseline and 12 months after the endodontic treatment. Data were analyzed using paired Student's t-test and Pearson's correlation coefficient (r) test using SPSS 26 version.

RESULTS

Endodontic treatment leads to the improvement of FMD significantly from a pooled baseline value of 4.84 ± 1.55% to 7.68 ± 2.08% (p < 0.05). The study also depicts a statistically significant difference between c-IMT (mean = 0.62 ± 0.11 mm) before treatment as compared to 12 months after treatment (mean = 0.59 ± 0.11 mm) (p < 0.05).

CONCLUSION

Endodontic treatment leads to improved FMD and decreased c-IMT suggesting that treating AP can be help revert the early stages of CVD.

CLINICAL RELEVANCE

AP could be a potential etiological factor of future CVD and should be treated as soon as diagnosed.

Association of severely damaged endodontically infected tooth with carotid plaque and abnormal carotid intima-media thickness: a retrospective analysis

OBJECTIVE

We investigated the association of severely damaged endodontically infected tooth with carotid artery plaque and abnormal mean carotid intima-media thickness (CIMT) ≥ 1.0 mm.

METHODS

A retrospective analysis of 1502 control participants and 1552 participants with severely damaged endodontically infected tooth who received routine medical and dental checkup in Health Management Center, Xiangya Hospital was performed. Carotid plaque and CIMT were measured with B-mode tomographic ultrasound. Data were analyzed using logistic and linear regression.

RESULTS

Severely damaged endodontically infected tooth group had a significantly higher prevalence of carotid plaque (41.62%) compared to 32.22% of carotid plaque in control group. Participants with severely damaged endodontically infected tooth had a significantly higher prevalence of abnormal CIMT (16.17%) and a significantly increased level of CIMT (0.79 ± 0.16 mm) in comparison to 10.79% of abnormal CIMT and 0.77 ± 0.14 mm CIMT in control participants. Severely damaged endodontically infected tooth was significantly related with formation of carotid plaque [1.37(1.18-1.60), P < 0.001], top quartile length [1.21(1.02-1.44), P = 0.029] and top quartile thickness [1.27(1.08-1.51), P = 0.005] of carotid plaque and abnormal CIMT [1.47(1.18-1.83), P < 0.001]. Severely damaged endodontically infected tooth was significantly associated with both single [1.277(1.056-1.546), P = 0.012] and multiple carotid plaques [1.488(1.214-1.825), P < 0.001] and instable carotid plaques [1.380(1.167-1.632), P < 0.001]. Presence of severely damaged endodontically infected tooth increased 0.588 mm of carotid plaque length (P = 0.001), 0.157 mm of carotid plaque thickness (P < 0.001) and 0.015 mm of CIMT (P = 0.005).

CONCLUSION

Severely damaged endodontically infected tooth was associated with carotid plaque and abnormal CIMT.

CLINICAL RELEVANCE

Early treatment of endodontically infected tooth is warranted.

Exploring the Reported Strengths and Limitations of Aboriginal and Torres Strait Islander Health Research: A Narrative Review of Intervention Studies

High quality intervention research is needed to inform evidence-based practice and policy for Aboriginal and Torres Strait Islander communities. We searched for studies published from 2008-2020 in the PubMed database. A narrative review of intervention literature was conducted, where we identified researcher reported strengths and limitations of their research practice. A total of 240 studies met inclusion criteria which were categorised as evaluations, trials, pilot interventions or implementation studies. Reported strengths included community engagement and partnerships; sample qualities; Aboriginal and Torres Strait Islander involvement in research; culturally appropriate and safe research practice; capacity building efforts; providing resources or reducing costs for services and communities; understanding local culture and context; and appropriate timelines for completion. Reported limitations included difficulties achieving the target sample size; inadequate time; insufficient funding and resources; limited capacity of health workers and services; and inadequate community involvement and communication issues. This review highlights that community consultation and leadership coupled with appropriate time and funding, enables Aboriginal and Torres Strait Islander health intervention research to be conducted. These factors can enable effective intervention research, and consequently can help improve health and wellbeing outcomes for Aboriginal and Torres Strait Islander people.

Provision of Dental Care to Indigenous South Australians and Impacts on Improved General Health: Study Protocol

BACKGROUND

Indigenous South Australians carry a disproportionate burden of dental diseases, with approximately 80 percent of Indigenous adults having both periodontal disease and dental caries. The chronic inflammatory nature of many dental conditions means there are widespread systemic impacts, particularly on type 2 diabetes, chronic kidney disease and cardiovascular disease. Evidence suggests there are barriers experienced by Indigenous South Australians in accessing timely and culturally safe dental care. This study aims to: (1) elicit the views of Indigenous South Australians regarding their perspectives of what comprises culturally safe dental care; (2) provide such dental care and; (3) assess any changes in both oral and general health using point-of-care testing following receipt of timely, comprehensive and culturally safe dental care.

METHODS/DESIGN

This mixed-methods study will involve qualitative interviews and an intervention without randomisation. The qualitative component will comprise seeking perspectives of Indigenous South Australians regarding what culturally safe dental care means for them. For the intervention component, participants will take part in oral epidemiological examinations at baseline and 12-month follow-up (after receipt of dental care), which will include collection of saliva, plaque and calculus, as well as completion of a self-report questionnaire. The primary outcome measures-changes in type 2 diabetes (HbA1c), cardiovascular disease (CRP) and chronic kidney disease (ACR)-will be obtained by blood/urine spot from a finger prick/urine collection at baseline and 12-month follow-up via point-of-care testing.

RESULTS

Participant recruitment will commence in July 2022. The first results are expected to be submitted for publication one year after recruitment begins.

DISCUSSION

The project will have a number of important outcomes, including increased understanding of what culturally safe dental care means for Indigenous South Australians, the delivery of such care, and empirical evidence of how culturally safe dental care leads to better prognosis for chronic diseases linked with poor oral health. This will be important for health services planning, especially in the Aboriginal Community Controlled Health Organisation sector, where the management of dental diseases in a culturally safe manner for better chronic disease outcomes is currently insufficiently understood, planned and budgeted for.

Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Systemic inflammation is implicated in the onset and progression of several chronic diseases. Periodontitis is a potential trigger of systemic inflammation.

PURPOSE

To comprehensively appraise all the evidence on the effects of the treatment of periodontitis on systemic inflammation assessed by serum C-reactive protein (CRP) levels.

DATA SOURCES

Six electronic databases were searched up to 10 February 2022 to identify and select articles in English language only.

STUDY SELECTION

Twenty-six randomized controlled clinical trials reporting changes amongst 2579 participants about CRP levels at 6 months or more after treatment.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Meta-analyses were performed using random and fixed effect models.

RISK OF BIAS

Risk of bias (RoB 2.0 tool) and quality of evidence (GRADEpro GDT tool) analyses were completed.

DATA SYNTHESIS

Treatment of periodontitis reduced CRP levels by 0.69 mg/L (95% confidence interval: -0.97 to -0.40) after 6 months, but limited evidence was retrieved from studies with longer follow-ups. Similar findings were observed in participants with other co-morbidities in addition to periodontitis. Greatest reductions were observed in participants with concentrations of CRP >3 mg/L at baseline.

LIMITATIONS

High level of heterogeneity.

CONCLUSIONS

Treatment of periodontitis reduces serum CRP levels (up to 6 months follow-up) to a degree equivalent to that observed after traditional lifestyle or drug interventions. This evidence supports a causal association between periodontitis and systemic inflammation.

Cross-sectional analysis of the association of periodontitis with carotid intima media thickness and atherosclerotic plaque in the Hamburg City health study

BACKGROUND

Previous epidemiological studies regarding the association between chronic periodontitis (CP) and carotid intima-media thickness (cIMT) and subclinical atherosclerosis have been inconclusive.

OBJECTIVE

The aim of this study was to determine whether CP is associated with subclinical atherosclerosis in a large population-based cohort study conducted in northern Germany (the Hamburg City Health study).

METHODS

Baseline data from 5781 participants of the Hamburg City Health Study with complete oral health and carotid ultrasound data (50.7% female, mean age: 62.1 ± 8.4 years) were evaluated. A standardized duplex sonography of the carotid artery was performed with measurement of carotid intima-media thickness (cIMT) and atherosclerotic plaques. Oral health was assessed by recording the decayed, missing, and filled teeth (DMFT) index, clinical attachment loss (CAL), bleeding on probing (BOP), and the dental plaque index (PI). Correlations were tested for statistical significance by means of descriptive statistics and multivariate regression analyses.

RESULTS

Moderate and severe CP were associated with the prevalence of cIMT ≥ 1 mm (none or mild CP: 5.1%, moderate CP: 6.1%, severe CP: 10%) and mean cIMT (none or mild CP: 0.72 mm, moderate CP: 0.75 mm, severe CP: 0.78 mm) in bivariate analyses (p < .001). Additionally, severe and moderate CP were associated with higher prevalence of carotid atherosclerotic plaques (plaque = yes: none or mild CP: 23.9%, moderate CP: 29%, severe CP: 40.2%,). After adjustment for age, sex, smoking, diabetes, hypertension, educational level, hypercholesterolemia, and hsCRP, severe CP still correlated significantly with cIMT and the prevalence of cIMT ≥1 mm and/or presence of carotid atherosclerotic plaques.

CONCLUSION

In this study, severe CP was associated with increased cIMT and higher prevalence of carotid plaques independent of common risk factors.

Meta-analysis of the association between periodontal disease, periodontal treatment and carotid intima-media thickness

Periodontal disease is a major threat to oral health and would further contribute to systemic diseases without timely control. We aimed to evaluate the relation between periodontal disease, periodontal treatment and carotid intima-media thickness (CIMT) based on available epidemiological and clinical evidence. PubMed and Scopus were searched for relevant studies through May 2021. Observational studies reporting risk estimates with 95% confidence intervals (95% CIs) for the association between periodontal disease (including periodontitis and gingivitis) and risk of increased CIMT (defined as CIMT value that exceeded the cut-off value of clinical and prognostic significance), as well as interventional studies providing mean values with standard deviations of CIMT before and after periodontal intervention, were included. Random-effect models for meta-analysis were used to calculate the summary effect estimates with 95% CIs. A total of 406 citations were retrieved from electronic databases and 45 full-text articles were screened, leaving 11 articles using ultrasound to measure CIMT with 8744 participants included. Pooled results of seven cross-sectional studies involving 8558 participants indicated that compared to those without periodontitis, patients with periodontitis and those with severe periodontitis had an odds ratio of 1.42 (95% CI: 1.16, 1.75) and 1.70 (95% CI: 1.24, 2.33) for increased CIMT, respectively. Although publication bias was detected in these results, odds ratios corrected by the trim-and-fill method were still statistically significant. Results of four non-randomized controlled trials with 186 patients suggested that periodontal intervention may help reduce CIMT in patients with periodontal disease in the short term. Periodontitis, especially severe periodontitis, was significantly associated with the risk of increased CIMT. Periodontal intervention might help slow the progression of carotid intima-media thickening in patients with periodontal disease in the short term.

C3-targeted host-modulation approaches to oral inflammatory conditions

Periodontitis is an inflammatory disease caused by biofilm accumulation and dysbiosis in subgingival areas surrounding the teeth. If not properly treated, this oral disease may result in tooth loss and consequently poor esthetics, deteriorated masticatory function and compromised quality of life. Epidemiological and clinical intervention studies indicate that periodontitis can potentially aggravate systemic diseases, such as, cardiovascular disease, type 2 diabetes mellitus, rheumatoid arthritis, and Alzheimer disease. Therefore, improvements in the treatment of periodontal disease may benefit not only oral health but also systemic health. The complement system is an ancient host defense system that plays pivotal roles in immunosurveillance and tissue homeostasis. However, complement has unwanted consequences if not controlled appropriately or excessively activated. Complement overactivation has been observed in patients with periodontitis and in animal models of periodontitis and drives periodontal inflammation and tissue destruction. This review places emphasis on a promising periodontal host-modulation therapy targeting the complement system, namely the complement C3-targeting drug, AMY-101. AMY-101 has shown safety and efficacy in reducing gingival inflammation in a recent Phase 2a clinical study. We also discuss the potential of AMY-101 to treat peri-implant inflammatory conditions, where complement also seems to be involved and there is an urgent unmet need for effective treatment.

Effect of periodontal treatments on blood pressure

BACKGROUND

An association has been hypothesized between periodontitis and hypertension. Periodontal therapy is believed to reduce systemic inflammatory mediators and increase endothelial function, thus having the potential to prevent and treat hypertension.

OBJECTIVES

To assess the effect and safety of different periodontal treatment modalities on blood pressure (BP) in people with chronic periodontitis.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched for randomized controlled trials (RCTs) up to November 2020 in the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, seven other databases, and two clinical trials registries. We contacted the authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

RCTs and quasi-RCTs aiming to detect the effect of periodontal treatment on BP were eligible. Participants should have been diagnosed with chronic periodontitis and hypertension (or no hypertension if the study explored the preventive effect of periodontal treatment). Participants in the intervention group should have undergone subgingival scaling and root planing (SRP) and any other type of periodontal treatments, compared with either no periodontal treatment or alternative periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for study identification, data extraction, and risk of bias assessment. We used a formal pilot-tested data extraction form for data extraction, and the Cochrane risk of bias tool for risk of bias assessment. We planned the meta-analysis, test for heterogeneity, sensitivity analysis, and subgroup analysis. We assessed the certainty of evidence using GRADE. The primary outcome was change in systolic BP (SBP) and diastolic BP (DBP).

MAIN RESULTS

We included eight RCTs. Five had low risk of bias, one had unclear risk of bias, and two had high risk of bias. Four trials compared periodontal treatment with no treatment. We found no evidence of a difference in the short-term change of SBP and DBP for people diagnosed with periodontitis and other cardiovascular diseases except hypertension (very low-certainty evidence). We found no evidence of a difference in long-term changes in SBP (mean difference [MD] -2.25 mmHg, 95% confidence interval [CI] -9.41 to 4.92; P = 0.54; studies = 2, participants = 108; low-certainty evidence) and DBP (MD -2.55 mmHg, 95% CI -6.90 to 1.80; P = 0.25; studies = 2, participants = 103; low-certainty evidence). Concerning people diagnosed with periodontitis, in the short term, two studies of low certainty reported no changes in SBP (MD -0.14 mmHg, 95% CI -4.05 to 3.77; P = 0.94; participants = 294) and DBP (MD -0.15 mmHg, 95% CI -2.47 to 2.17; P = 0.90; participants = 294), and we found no evidence of a difference in SBP and DBP over a long period based on low certainty of evidence. Three studies compared intensive periodontal treatment with supra-gingival scaling. We found no evidence of a difference in changes in SBP and DBP for any length of time in people diagnosed with periodontitis (very low-certainty evidence). In people diagnosed with periodontitis and hypertension, we found one study reporting a significant reduction in the short term in SBP (MD -11.20 mmHg, 95% CI -15.40 to -7.00; P < 0.001; participants = 101; moderate-certainty evidence) and DBP (MD -8.40 mmHg, 95% CI -12.19 to -4.61; P < 0.0001; participants = 101; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We found no evidence of a difference of an impact of periodontal treatments on BP in most comparisons assessed in this review, and given the low certainty of evidence and the lack of relevant studies we could not draw conclusions about the effect of periodontal treatment on BP in people with chronic periodontitis. We found only one study suggesting that periodontal treatment may reduce SBP and DBP over a short period in people with hypertension and chronic periodontitis, but the certainty of evidence was moderate.

Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review

AIM

To investigate the effect of treatment of periodontitis on systemic health outcomes, pregnancy complications, and associated quality of life.

MATERIALS AND METHODS

Systematic electronic searches were conducted to identify randomized controlled trials with minimum 6-month follow-up and reporting on the outcomes of interest. Qualitative and quantitative analyses were performed as deemed suitable.

RESULTS

Meta-analyses confirmed reductions of high-sensitivity C-reactive protein (hs-CRP) [0.56 mg/L, 95% confidence interval (CI) (-0.88, -0.25), p < .001]; interleukin (IL)-6 [0.48 pg/ml, 95% CI (-0.88, -0.08), p = .020], and plasma glucose [1.33 mmol/l, 95% CI (-2.41, -0.24), p = .016], and increase of flow-mediated dilation (FMD) [0.31%, 95% CI (0.07, 0.55), p = .012] and diastolic blood pressure [0.29 mmHg, 95% CI (0.10, 0.49), p = .003] 6 months after the treatment of periodontitis. A significant effect on preterm deliveries (<37 weeks) was observed [0.77 risk ratio, 95% CI (0.60, 0.98), p = .036]. Limited evidence was reported on quality-of-life (QoL) outcomes in the included studies.

CONCLUSIONS

Treatment of periodontitis results in systemic health improvements including improvement in cardiometabolic risk, reduction in systemic inflammation and the occurrence of preterm deliveries. Further research is however warranted to confirm whether these changes are sustained over time. Further, appropriate QoL outcomes should be included in the study designs of future clinical trials.

What is the future of Periodontal Medicine?

In the last five decades, considerable progress has been made towards understanding the etiology and pathogenesis of periodontal diseases and their interactions with the host. The impact of an individual periodontal condition on systemic homeostasis became more evident because of this knowledge and prompted advances in studies that associate periodontitis with systemic diseases and conditions. The term Periodontal Medicine describes how periodontal infection/inflammation can affect extraoral health. This review presents the current scientific evidence on the most investigated associations between periodontitis and systemic diseases and conditions, such as cardiovascular diseases, diabetes, preterm birth and low birth weight, and pneumonia. Additionally, other associations between periodontitis and chronic inflammatory bowel disease, colorectal cancer, and Alzheimer's disease that were recently published and are still poorly studied were described. Thus, the aim of this review was to answer the following question: What is the future of Periodontal Medicine? Epidemiological evidence and the evidence of biological plausibility between periodontitis and general health reinforce the rationale that the study of Periodontal Medicine should continue to advance, along with improvements in the epidemiological method, highlighting the statistical power of the studies, the method for data analysis, the case definition of periodontitis, and the type of periodontal therapy to be applied in intervention studies.

Impact of endodontic and periodontal diseases and treatments on the aorta and liver of obese and non-obese rats

AIM

To evaluate the impact of the presence and treatment of periodontal disease (PD) and apical periodontitis (AP) on the aorta and liver of obese and non-obese rats.

METHODOLOGY

One hundred and forty Wistar rats were divided into two groups, according to the diet administered: normal diet (-n), without obesity; and cafeteria diet (-c), with induced obesity. These groups were divided into seven subgroups according to the specific experimental protocols: naïve control (NC); AP; AP with treatment (APt); PD; PE with treatment (PDt); AP and PD (APPD); and AP and PD with treatment (APPDt). AP and PD lesions were induced for four weeks. Four weeks after treatments, the animals were euthanatized, and the aorta and liver were dissected for histological evaluation. For the comparison of the thickness of the aorta between groups, the Kruskal-Wallis test was used, followed by the Mann-Whitney test. For the analysis of other variables related to the aorta and liver outcomes, logistic regression was carried out.

RESULTS

Both PD and AP were associated with the development of histological alterations in the aortic arch, with no significant difference between obese and non-obese animals (p = .17). The aorta thickness was increased significantly (p < .05) with the combination of PD and AP in obese rats (APPDt-c group) compared with the other groups (NC-n, APt-n, APt-c and AP-c). The logistic regression models revealed that the untreated (OR = 7.78; 95%CI = 2.4-25) and treated (OR = 2.9; 95%CI = 1.0-8.4) groups were significantly more likely to have endothelial alterations compared with the control groups (p = .002). Obesity (OR = 16.5; 95%CI = 3.4-81.3) was the only predictor variable of liver steatosis (p < .001).

CONCLUSION

Histological alterations in the aortic arch of obese and non-obese rats were observed in the presence of periodontal disease and apical periodontitis. The combination of PD and AP increased the aorta thickness in obese rats. A reduction of vascular endothelial lesions was observed with the treatments of PD and AP.

Vascular consequences of inflammation: a position statement from the ESH Working Group on Vascular Structure and Function and the ARTERY Society

: Inflammation is a physiological response to aggression of pathogenic agents aimed at eliminating the aggressor agent and promoting healing. Excessive inflammation, however, may contribute to tissue damage and an alteration of arterial structure and function. Increased arterial stiffness is a well recognized cardiovascular risk factor independent of blood pressure levels and an intermediate endpoint for cardiovascular events. In the present review, we discuss immune-mediated mechanisms by which inflammation can influence arterial physiology and lead to vascular dysfunction such as atherosclerosis and arterial stiffening. We also show that acute inflammation predisposes the vasculature to arterial dysfunction and stiffening, and alteration of endothelial function and that chronic inflammatory diseases such as rheumatoid arthritis, inflammatory bowel disease and psoriasis are accompanied by profound arterial dysfunction which is proportional to the severity of inflammation. Current findings suggest that treatment of inflammation by targeted drugs leads to regression of arterial dysfunction. There is hope that these treatments will improve outcomes for patients.

Modelling the Validity of Periodontal Disease Screening Questions in a Nondental Clinical Setting

Objective

Periodontal examinations are time-consuming and potentially uncomfortable for recipients. We modelled if self-reported questions alone, or combined with objective evidence of periodontal bone loss observable from radiographs, are accurate predictors of periodontitis.

Methods

Self-reported data from the Australian National Survey of Adult Oral Heath 2004-06 were compared with clinical periodontal examinations to assess the validity of 8 periodontitis screening questions in predicting moderate/severe periodontitis. To model alveolar bone loss, a proxy variable simulating radiographic clinical attachment level (rCAL) was created. Three multivariable binary logistic regression models were constructed: responses to 8 screening questions alone (Model 1), screening questions combined with 5 classic periodontitis risk indicators (age, sex, smoking status, country of birth, and diabetes status) (Model 2), and the addition of rCAL (Model 3). Predictive validity was determined via sensitivity (Se) and specificity (Sp) scores and graphically represented using area under the receiver operator characteristic curves (AUROC).

Results

Data from 3630 participants periodontally examined determined that 32.4% exhibited periodontitis. Periodontitis risk indicators were all significantly associated with periodontitis case status. Six of 8 screening questions (Model 1) were weak periodontitis predictors (Se = 0.28; Sp = 0.89; AUROC = 0.61). Combining 13 variables for (Model 2) improved prediction (Se = 0.55; Sp = 0.81; AUROC = 0.77). The addition of rCAL (Model 3) improved diagnostic capacity considerably (AUROC = 0.86).

Conclusions

Self-reported questions combined with classic risk indicators are “useful” for periodontitis screening. Addition of radiographs markedly improved diagnostic validity. Based on modelling, nondental health care professionals may provisionally screen for periodontitis with minimal training.

Oral health of aboriginal people with kidney disease living in Central Australia

Background

Associations between kidney disease and periodontal disease are not well documented among Aboriginal people of Australia. The purpose of this investigation was to report and compare demographic, oral health, anthropometric and systemic health status of Aboriginal Australians with kidney disease and to compare against relevant Aboriginal Australians and Australian population estimates. This provides much needed evidence to inform dental health service provision policies for Aboriginal Australians with kidney disease.

Methods

Sample frequencies and means were assessed in adults represented in six datasets including: (1) 102 Aboriginal Australians with kidney disease residing in Central Australia who participated in a detailed oral health assessment; (2) 312 Aboriginal participants of the Northern Territory’s PerioCardio study; (3) weighted estimates from 4775 participants from Australia’s National Survey of Adult Oral Health (NSAOH); (4) Australian 2016 Census (all Australians); (5) National Health Survey 2017–2018 (all Australians) and; (6) Australian Health Survey: Biomedical Results for Chronic Diseases, 2011–2012 (all Australians). Oral health status was described by periodontal disease and experience of dental caries (tooth decay). Statistically significant differences were determined via non-overlapping 95% confidence intervals.

Results

Aboriginal Australians with kidney disease were significantly older, less likely to have a tertiary qualification or be employed compared with both PerioCardio study counterparts and NSAOH participants. Severe periodontitis was found in 54.3% of Aboriginal Australians with kidney disease, almost 20 times the 2.8% reported in NSAOH. A higher proportion of Aboriginal Australians with kidney disease had teeth with untreated caries and fewer dental restorations when compared to NSAOH participants. The extent of periodontal attachment loss and periodontal pocketing among Aboriginal Australians with kidney disease (51.0%, 21.4% respectively) was several magnitudes greater than PerioCardio study (22.0%, 12.3% respectively) and NSAOH (5.4%, 1.3% respectively) estimates.

Conclusions

Aboriginal Australians with kidney disease exhibited more indicators of poorer oral health than both the general Australian population and a general Aboriginal population from Australia’s Northern Territory. It is imperative that management of oral health among Aboriginal Australians with kidney disease be included as part of their ongoing medical care.

Association between periodontitis and pulse wave velocity: a systematic review and meta-analysis

OBJECTIVES

Severe periodontitis has been associated with endothelial dysfunction and arterial stiffness. The present study aimed to provide a critical appraisal and a meta-analysis of the literature investigating pulse wave velocity (PWV) in patients with and without severe periodontitis and to assess whether treatments influence PWV.

MATERIALS AND METHODS

English literature was searched on multiple databases up to April 2020 by two independent reviewers. Studies comparing PWV between patients with and without severe periodontitis or assessing the impact of periodontal treatments on PWV were searched and retrieved. Pool data analyses with random effect models were performed. The risk of bias was assessed using Newcastle-Ottawa Scale and RoB2 tools.

RESULTS

Seventeen studies were selected. Of these, 10 were used for the meta-analysis. Twelve were cross-sectional studies and 5 interventional studies, including 3176 patients, of whom 1894 had severe periodontitis and 1282 were considered as the controls (without severe periodontitis). Based on carotid-femoral PWV measurement, patients with severe periodontitis (n = 309) have a significantly higher PVW than patients with non-severe periodontitis (n = 213), with a mean difference of 0.84 m/s (95% CI 0.50-1.18; p < 0.0001; I² = 5%). Similarly, carotid-radial or brachial-ankle PWV values were significantly higher in patients with severe periodontitis. Results concerning the effect of non-surgical periodontal therapy were not conclusive. Overall, 9 studies (53%) were classified at a low risk of bias.

CONCLUSIONS

The present study demonstrates that patients with severe periodontitis have higher PWV compared to patients with non-severe periodontitis.

CLINICAL SIGNIFICANCE

Severe periodontitis is associated with arterial stiffness, supporting the mutual involvement of dentists and physicians.

Lessons learned from a periodontal intervention to reduce progression of chronic kidney disease among Aboriginal Australians

Objective

Periodontal disease is associated with chronic kidney disease (CKD), with both conditions being highly prevalent among Australia’s Aboriginal population. This paper reflects on the lessons learned following implementation of a periodontal intervention in the Central Australian region of the Northern Territory among Aboriginal adults with CKD.

Results

Between Oct 2016 and May 2019, research staff recruited 102 eligible participants. This was far below the anticipated recruitment rate. The challenges faced, and lessons learned, were conceptualised into five specific domains. These included: (1) insufficient engagement with the Aboriginal community and Aboriginal community-controlled organisations; (2) an under-appreciation of the existing and competing patient commitments with respect to general health and wellbeing, and medical treatment to enable all study commitments; (3) most study staff employed from outside the region; (4) potential participants not having the required number of teeth; (5) invasive intervention that involved travel to, and time at, a dental clinic. A more feasible research model, which addresses the divergent needs of participants, communities and service partners is required. This type of approach, with sufficient time and resourcing to ensure ongoing engagement, partnership and collaboration in co-design throughout the conduct of research, challenges current models of competitive, national research funding.

Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients

BACKGROUND

To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk.

METHODS

We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach.

RESULTS

We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients.

CONCLUSIONS

The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.

Periodontal therapy and cardiovascular risk

Cardiovascular diseases are the worldwide leading cause of mortality. Cardiovascular diseases are noncommunicable conditions with a complex pathogenesis, and their clinical manifestations include major cardiovascular events such as myocardial infarction and stroke. Epidemiologic evidence suggests a consistent association between periodontitis and increased risk of cardiovascular diseases. Some evidence supports a beneficial effect of the treatment of periodontitis on both surrogate and hard cardiovascular outcomes. This narrative review has been conducted as an update of the most recent evidence on the effects of periodontitis treatment on cardiovascular outcomes since the last commissioned review of the European Federation of Periodontology-American Academy of Periodontology World Workshop in 2012. Newer evidence originating from published randomized controlled trials confirms a positive effect of periodontal treatment on surrogate measures of cardiovascular diseases, whereas there have been no randomized controlled trials investigating the effect of periodontal treatment on the incidence of cardiovascular disease events such as myocardial infarction and stroke. In conclusion, there is sufficient evidence from observational and experimental studies on surrogate cardiovascular measures to justify the design and conduct of appropriately powered randomized controlled trials investigating the effect of effective periodontal interventions on cardiovascular disease outcomes (ie, myocardial infarction and stroke) with adequate control of traditional cardiovascular risk factors.

Effect of Non-Surgical Periodontal Treatment on Oxidative Stress Markers in Leukocytes and Their Interaction with the Endothelium in Obese Subjects with Periodontitis: A Pilot Study

Aim: The primary objective of this pilot study was to evaluate the effect of non-surgical periodontal treatment. The secondary aim was to evaluate the effect of dietary therapy on both parameters of oxidative stress in leukocytes and leukocyte-endothelial cell interactions in an obese population. Methods: This was a pilot study with a before-and-after design. Forty-nine obese subjects with periodontitis were randomized by means of the minimization method and assigned to one of two groups, one of which underwent dietary therapy while the other did not. All the subjects underwent non-surgical periodontal treatment. We determined periodontal, inflammatory and oxidative stress parameters—total reactive oxygen species (ROS), superoxide production, intracellular Ca²⁺, mitochondrial membrane potential and superoxide dismutase (SOD) activity. We also evaluated interactions between leukocytes and endothelium cells—velocity, rolling flux and adhesion—at baseline and 12 weeks after intervention. Results: Periodontal treatment improved the periodontal health of all the patients, with a reduction in serum retinol-binding protein 4 (RBP4), total superoxide production and cytosolic Ca²⁺ in leukocytes. In the patients undergoing dietary therapy, there were less leukocyte adhesion to the endothelium, an effect that was accompanied by a decrease in TNFα, P-selectin and total ROS and an increase in SOD activity. Conclusions: Whereas non-surgical periodontal treatment induces an improvement in leukocyte homeostasis, dietary therapy as an adjuvant reduces systemic inflammation and increases antioxidant status which, in turn, modulates leukocyte-endothelium dynamics.

Reporting quality and spin in abstracts of randomized clinical trials of periodontal therapy and cardiovascular disease outcomes

OBJECTIVE

Poor reporting in randomized clinical trial (RCT) abstracts reduces quality and misinforms readers. Spin, a biased presentation of findings, could frequently mislead clinicians to accept a clinical intervention despite non-significant primary outcome. Therefore, good reporting practices and absence of spin enhances research quality. We aim to assess the reporting quality and spin in abstracts of RCTs evaluating the effect of periodontal therapy on cardiovascular (CVD) outcomes.

METHODS

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and 17 trial registration platforms were searched. Cohort, non-randomized, non-English studies, and pediatric studies were excluded. RCT abstracts were reviewed by 2 authors using the CONSORT for abstracts and spin checklists for data extraction. Cohen's Kappa statistic was used to assess inter-rater agreement. Data on the selected RCT publication metrics were collected. Descriptive analysis was performed with non-parametric methods. Correlation analysis between quality, spin and bibliometric parameters was conducted.

RESULTS

24 RCTs were selected for CONSORT analysis and 14 fulfilled the criteria for spin analysis. Several important RCT elements per CONSORT were neglected in the abstract including description of the study population (100%), explicitly stated primary outcome (87%), methods of randomization and blinding (100%), trial registration (87%). No RCT examined true outcomes (CVD events). A significant fraction of the abstracts appeared with at least one form of spin in the results and conclusions (86%) and claimed some treatment benefit in spite of non-significant primary outcome (64%). High-quality reporting had a significant positive correlation with reporting of trial registration (p = 0.04) and funding (p = 0.009). Spinning showed marginal negative correlation with reporting quality (p = 0.059).

CONCLUSION

Poor adherence to the CONSORT guidelines and high levels of data spin were found in abstracts of RCTs exploring the effects of periodontal therapy on CVD outcomes. Our findings indicate that journal editors and reviewers should consider strict adherence to proper reporting guidelines to improve reporting quality and reduce waste.

Periodontitis and cardiovascular diseases: Consensus report

BACKGROUND

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

MATERIAL AND METHODS

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations RESULTS AND CONCLUSIONS: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Periodontitis and Cardiovascular Diseases. Consensus Report

Background

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

Material and Methods

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

Results and Conclusions

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Geographical analysis of evaluated chronic disease programs for Aboriginal and Torres Strait Islander people in the Australian primary health care setting: a systematic scoping review

BACKGROUND

Targeted chronic disease programs are vital to improving health outcomes for Indigenous people globally. In Australia it is not known where evaluated chronic disease programs for Aboriginal and Torres Strait Islander people have been implemented. This scoping review geographically examines where evaluated chronic disease programs for Aboriginal people have been implemented in the Australian primary health care setting. Secondary objectives include scoping programs for evidence of partnerships with Aboriginal organisations, and use of ethical protocols. By doing so, geographical gaps in the literature and variations in ethical approaches to conducting program evaluations are highlighted.

METHODS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a published protocol. This scoping review was undertaken in accordance with the Joanna Briggs Institute (JBI) scoping review methodology. The search included 11 academic databases, clinical trial registries, and the grey literature.

RESULTS

The search resulted in 6894 citations, with 241 retrieved from the grey literature and targeted organisation websites. Title, abstract, and full-text screening was conducted by two independent reviewers, with 314 citations undergoing full review. Of these, 74 citations evaluating 50 programs met the inclusion criteria. Of the programs included in the geographical analysis (n = 40), 32.1% were implemented in Major Cities and 29.6% in Very Remote areas of Australia. A smaller proportion of programs were delivered in Inner Regional (12.3%), Outer Regional (18.5%) and Remote areas (7.4%) of Australia. Overall, 90% (n = 45) of the included programs collaborated with an Aboriginal organisation in the implementation and/or evaluation of the program. Variation in the use of ethical guidelines and protocols in the evaluation process was evident.

CONCLUSIONS

A greater focus on the evaluation of chronic disease programs for Aboriginal people residing in Inner and Outer Regional areas, and Remote areas of Australia is required. Across all geographical areas further efforts should be made to conduct evaluations in partnership with Aboriginal communities residing in the geographical region of program implementation. The need for more scientifically and ethically rigorous approaches to Aboriginal health program evaluations is evident.

Natural History of Atherosclerosis and Abdominal Aortic Intima-Media Thickness: Rationale, Evidence, and Best Practice for Detection of Atherosclerosis in the Young

Atherosclerosis underlies most myocardial infarctions and ischemic strokes. The timing of onset and the rate of progression of atherosclerosis differ between individuals and among arterial sites. Physical manifestations of atherosclerosis may begin in early life, particularly in the abdominal aorta. Measurement of the abdominal aortic intima-media thickness by external ultrasound is a non-invasive methodology for quantifying the extent and severity of early atherosclerosis in children, adolescents, and young adults. This review provides an evidence-based rationale for the assessment of abdominal aortic intima-media thickness-particularly as an age-appropriate methodology for studying the natural history of atherosclerosis in the young in comparison to other methodologies-establishes best practice methods for assessing abdominal aortic intima-media thickness, and identifies key gaps in the literature, including those that will identify the clinical relevance of this measure.

Association of Apical Periodontitis with Cardiovascular Disease via Noninvasive Assessment of Endothelial Function and Subclinical Atherosclerosis

INTRODUCTION

Chronic infections of endodontic origin might predispose to the onset of cardiovascular disease (CVD). The studies depicting the link between apical periodontitis (AP) and CVD are few, and the association is very controversial; also, the markers used are expensive, which makes them difficult to use in general practice. The purpose of this study was to investigate whether an association exists between AP and CVD using noninvasive methods (ie, flow-mediated dilatation [FMD] and carotid intima-media thickness [c-IMT]).

METHODS

This cross-sectional study included 120 men between 20 and 40 years old free from periodontal disease, CVD, and traditional cardiovascular risk factors; 60 subjects had AP, and 60 acted as controls. All subjects underwent complete physical and dental examination, echocardiography, ultrasound assessment of FMD of the right brachial artery, and c-IMT. Data were analyzed using the Mann-Whitney U test and the Spearman rank correlation (r_s) test.

RESULTS

FMD was found to be significantly impaired in patients with AP (mean = 4.9% ± 2.05%) compared with healthy controls (mean = 9.74% ± 2.59%, P = .000). The study also depicts statistically significant differences between c-IMT of the AP (mean = 0.64 ± 0.12 mm) and control (mean = 0.54 ± 0.08 mm) groups (P = .000). A significant inverse correlation between c-IMT and FMD was observed (r_s = -0.381, P = .000).

CONCLUSIONS

Impaired FMD and greater c-IMT in subjects with AP suggests a potential association between endodontic infection and CVD.

Impact of anti-infective periodontal therapy on parameters of vascular health

AIM

This study assessed the impact of anti-infective periodontal therapy on the status of vascular health.

MATERIALS AND METHODS

Periodontal and vascular health of 55 patients with severe untreated chronic periodontitis was evaluated before and 12 months after anti-infective periodontal therapy. Observed parameters were bleeding on probing (BoP), pocket probing depth (PPD), periodontal inflamed surface area index (PISA), pulse wave velocity (PWV), augmentation index (AIx), central pulse pressure (PPao) and peripheral systolic pressure (RRsys).

RESULTS

ΔPISA (baseline-12 months) correlated with ΔPWV (τ 0.21; p < .03), ΔAIx (τ 0.29; p < .002) and ΔPPao (τ 0.23; p < .02). ΔBoP% (baseline-12 months) correlated with ΔPWV (τ 0.18; p < .05) and ΔAIx (τ 0.25; p < .01), while mean ΔPPD (baseline-12 months) correlated with ΔPWV (τ 0.24; p < .01) and ΔAIx (τ 0.21; p < .03). Grouping patients evenly into three groups based on tertiles of BoP resolution after 12 months revealed a significant decrease in the observed PWV median value by -0.6 m/s (p < .04) in the best response tertile (ΔBoP ≥ 88%). In the worst response tertile (ΔBoP ≤ 66%), by contrast, significant increase in PPao (+10.5 mmHg; p < .02) and AIx (+5.5; p < .02) was observed.

CONCLUSION

Efficacious resolution of periodontal inflammation may beneficially impact on vascular health.

Effects of periodontal treatment on carotid intima-media thickness in patients with lifestyle-related diseases: Japanese prospective multicentre observational study

Atherosclerosis, a chronic inflammatory disease in arterial blood vessels, is one of the major causes of death in worldwide. Meanwhile, periodontal disease is a chronic inflammatory disease caused by infection with periodontal pathogens such as P. gingivalis (Porphyromonas gingivalis). Several studies have reported association between periodontal infection and atherosclerosis, but direct investigation about the effects of periodontal treatment on atherosclerosis has not been reported. We have planned Japanese local clinics to determine the relationship between periodontal disease and atherosclerosis under collaborative with medical and dental care. A prospective, multicentre, observational study was conducted including 38 medical patients with lifestyle-related diseases in the stable period under consultation at participating medical clinics and 92 periodontal patients not undergoing medical treatment but who were consulting at participating dental clinics. Systemic and periodontal examinations were performed before and after periodontal treatment. At baseline, LDL-C (low-density lipoprotein cholesterol) levels and percentage (%) of mobile teeth were positively related to plasma IgG (immunoglobulin) antibody titer against P. gingivalis with multivariate analysis. Corresponding to improvements in periodontal clinical parameters after treatment, right and left max IMT (maximum intima-media thickness) levels were decreased significantly after treatment (SPT-S: start of supportive periodontal therapy, SPT-1y: at 1 year under SPT, and SPT-3y: at 3 years under SPT). The present study has clarified our previous univariate analysis results, wherein P. gingivalis infection was positively associated with progression of atherosclerosis. Thus, routine screening using plasma IgG antibody titer against P. gingivalis and periodontal treatment under collaborative with medical and dental care may prevent cardiovascular accidents caused by atherosclerosis.

Assessment of arterial stiffness in periodontitis using a novel pulse wave imaging methodology

AIM

We investigated the cross-sectional relationship between periodontal status and arterial stiffness, assessed through a novel Pulse Wave Imaging methodology.

METHODS

Eighty volunteers were enrolled (39% male, age range 24-78 years) and 33 pairs were formed of periodontitis patients/periodontally healthy controls, matched by age and gender. A full-mouth periodontal examination was performed and the degree of stiffness of the right and left carotid arteries was assessed by measuring pulse wave velocity (PWV) and the uniformity in pulse wave propagation (R² ). Wilcoxon signed-rank tests for paired observations were used to compare periodontitis patients and healthy controls. Univariate and multivariate analyses were performed to analyze the association between PWV and R² and potential explanatory variables.

RESULTS

Patients with periodontitis had a statistically significantly lower uniformity in wave propagation (R² ) than controls (p = .01), but PWV did not differ between the two groups. Univariate analysis showed a significant negative association between R² and periodontitis, body mass index and smoking; periodontitis remained statistically associated with R² in the multivariate analyses.

CONCLUSIONS

Patients with periodontitis and no established cardiovascular disease presented with lower degree of uniformity in the transmission of the pulse wave through the carotid arteries, suggesting an association between periodontitis and arterial stiffness/functional alterations.

Caries and periodontal disease in Indigenous adults in Australia: a case of limited and non-contemporary data

Objective The aim of the present study was to identify all evidence about the prevalence and severity of clinically measured caries and periodontal disease in Indigenous adults in Australia published in peer-reviewed journals and to summarise trends over time. In addition, we examined whether the studies investigated associations between putative risk factors and levels of caries and periodontal disease. Methods PubMed was searched in September 2014, with no date limitations, for published peer-reviewed articles reporting the prevalence rates and/or severity of caries and periodontal disease in Indigenous adults living in Australia. Articles were excluded if measurement was not based on clinical assessment and if oral disease was reported only in a specific or targeted sample, and not the general population. Results The search identified 18 papers (reporting on 10 primary studies) that met the inclusion criteria. The studies published clinical data about dental caries and/or periodontal disease in Australian Indigenous adults. The studies reported on oral health for Indigenous adults living in rural (40%), urban (10%) and both urban and rural (50%) locations. Included studies showed that virtually all Indigenous adults living in rural locations had periodontal disease. The data also showed caries prevalence ranged from 46% to 93%. Although 10 studies were identified, the peer-reviewed literature was extremely limited and no published studies were identified that provided statistics for a significant proportion of Australia (Victoria, Tasmania, Queensland or the Australian Capital Territory). There were also inconsistencies in how the data were reported between studies, making comparisons difficult. Conclusions This review highlights a lack of robust and contemporary data to inform the development of policies and programs to address the disparities in oral health in Indigenous populations living in many parts of Australia. What is known about the topic? Many studies report that Indigenous people in Australia have poorer general health compared with non-Indigenous people. What does this paper add? This paper documents the available caries and periodontal disease prevalence and experience for Indigenous adults in Australia published in peer-reviewed journals. It demonstrates significant limitations in the data, including no data in several large Australian jurisdictions, inconsistency with reporting methods and most data available being for Indigenous adults living in rural locations. Therefore, the oral health data available in the peer-reviewed literature do not reflect the situation of all Indigenous people living in Australia. What are the implications for practitioners? It is important for oral health practitioners to have access to current and relevant statistics on the oral health of Indigenous Australians. However, we have highlighted significant evidence gaps for this population group within the peer-reviewed literature and identified the limitations of the available data upon which decisions are currently being made. This paper also identifies ways to capture and report oral health data in the future to enable more meaningful comparisons and relevance for use in policy development.

A Fully-Automatic Method to Segment the Carotid Artery Layers in Ultrasound Imaging: Application to Quantify the Compression-Decompression Pattern of the Intima-Media Complex During the Cardiac Cycle

The aim of this study was to introduce and evaluate a contour segmentation method to extract the interfaces of the intima-media complex in carotid B-mode ultrasound images. The method was applied to assess the temporal variation of intima-media thickness during the cardiac cycle. The main methodological contribution of the proposed approach is the introduction of an augmented dimension to process 2-D images in a 3-D space. The third dimension, which is added to the two spatial dimensions of the image, corresponds to the tentative local thickness of the intima-media complex. The method is based on a dynamic programming scheme that runs in a 3-D space generated with a shape-adapted filter bank. The optimal solution corresponds to a single medial axis representation that fully describes the two anatomical interfaces of the arterial wall. The method is fully automatic and does not require any input from the user. The method was trained on 60 subjects and validated on 184 other subjects from six different cohorts and four different medical centers. The arterial wall was successfully segmented in all analyzed images (average pixel size = 57 ± 20 mm), with average segmentation errors of 47 ± 70 mm for the lumen-intima interface, 55 ± 68 mm for the media-adventitia interface and 66 ± 90 mm for the intima-media thickness. The amplitude of the temporal variations in IMT during the cardiac cycle was significantly higher in the diseased population than in healthy volunteers (106 ± 48 vs. 86 ± 34 mm, p = 0.001). The introduced framework is a promising approach to investigate an emerging functional parameter of the arterial wall by assessing the cyclic compression-decompression pattern of the tissues.

Periodontal therapy and glycaemic control among individuals with type 2 diabetes: reflections from the PerioCardio study

OBJECTIVES

Diabetes mellitus and periodontal disease are highly prevalent among Indigenous Australian adults. Untreated periodontitis impacts glycaemic control in people with diabetes. The aim of this study was to report on the effect of periodontal therapy on glycaemic control among people with obesity.

METHODS

This subgroup analysis is limited to 62 participants with diabetes from the original 273 Aboriginal Australian adults enrolled into the PerioCardio study. Intervention participants received full-mouth non-surgical periodontal scaling during a single, untimed session while controls were untreated. Endpoints of interest included change in glycated haemoglobin (HbA1c), C-reactive protein (CRP) and periodontal status at 3 months post-intervention.

RESULTS

There were more females randomized to the treatment group (n = 17) than control (n = 10) while the control group had a higher overall body mass index (BMI) [mean (SD)] 33.1 (9.7 kg m^-2 ) versus 29.9 (6.0 kg m^-2 ). A greater proportion of males were followed up at 3 months compared to females, P = 0.05. Periodontal therapy did not significantly reduce HbA1c: ancova difference in means 0.22 mmol mol^-1 (95% CI -6.25 to 6.69), CRP: ancova difference in means 0.64 (95% CI -1.08, 2.37) or periodontal status at 3 months.

CONCLUSIONS

Non-surgical periodontal therapy did not significantly reduce glycated haemoglobin in participants with type 2 diabetes. Reasons are likely to be multifactorial and may be influenced by persistent periodontal inflammation at the follow-up appointments. Alternatively, the BMI of study participants may impact glycaemic control via alternative mechanisms involving the interplay between inflammation and adiposity meaning HbA1c may not be amenable to periodontal therapy in these individuals.

Periodontitis and arterial stiffness: a systematic review and meta-analysis

INTRODUCTION AND AIMS

Patients with periodontitis have a higher risk of cardiovascular diseases, although a causal relationship between these conditions remains unclear. Arterial stiffness is considered a marker of arteriosclerosis and a risk factor for cardiovascular diseases. A systematic review of the literature on clinical studies using pulse wave velocity (PWV) to assess arterial stiffness in patients with periodontitis was carried out to answer the following questions: (i) Do patients with periodontitis have impaired arterial stiffness compared to non-periodontal diseased subjects? (ii) Is periodontal treatment effective as a means to improve arterial stiffness in patients with periodontitis?

LITERATURE REVIEW

Literature search was done on different databases up to September 2014. All clinical studies (excluding case reports) using PWV in patients with periodontitis were retrieved for a full-text evaluation. A total of 10 studies were included. Patients with periodontitis have increased arterial stiffness compared to controls (PWV mean difference 0.85 m/s; 95% confidence interval: 0.53-1.16; p<0.00001). The only two interventional studies showed contradictory results on the effects of periodontal treatment on PWV.

CONCLUSION

Patients with periodontitis appear to have higher values of PWV compared to controls. The effect of periodontal treatment on arterial stiffness remains unclear.

Periodontal disease and chronic kidney disease among Aboriginal adults; an RCT

BACKGROUND

This study will assess measures of vascular health and inflammation in Aboriginal Australian adults with chronic kidney disease (CKD), and determine if intensive periodontal intervention improves cardiovascular health, progression of renal disease and periodontal health over a 24-month follow-up.

METHODS

The study will be a randomised controlled trial. All participants will receive the periodontal intervention benefits, with the delayed intervention group receiving periodontal treatment 24 months following baseline. Inclusion criteria include being an Aboriginal Australian, having CKD (a. on dialysis; b. eGFR levels of < 60 mls/min/1.73 m(2) (CKD Stages 3 to 5); c. ACR ≥ 30 mg/mmol irrespective of eGFR (CKD Stages 1 and 2); d. diabetes plus albuminuria (ACR ≥ 3 mg/mmol) irrespective of eGFR), having moderate or severe periodontal disease, having at least 12 teeth, and living in Central Australia for the 2-year study duration. The intervention involves intensive removal of dental plaque biofilms by scaling, root-planing and removal of teeth that cannot be saved. The intervention will occur in three visits; baseline, 3-month and 6-month follow-up. The primary outcome will be changes in carotid intima-media thickness (cIMT). Secondary outcomes will include progression of CKD or death as a consequence of CKD/cardiovascular disease. Progression of CKD will be defined by time to the development of the first of: (1) new development of macroalbuminuria; (2) 30 % loss of baseline eGFR; (3) progression to end stage kidney disease defined by eGFR < 15 mLs/min/1.73 m(2); (4) progression to end stage kidney disease defined by commencement of renal replacement therapy. A sample size of 472 is necessary to detect a difference in cIMT of 0.026 mm (SD 0.09) at the significance criterion of 0.05 and a power of 0.80. Allowing for 20 % attrition, 592 participants are necessary at baseline, rounded to 600 for convenience.

DISCUSSION

This will be the first RCT evaluating the effect of periodontal therapy on progression of CKD and cardiovascular disease among Aboriginal patients with CKD. Demonstration of a significant attenuation of CKD progression and cardiovascular disease has the potential to inform clinicians of an important, new and widely available strategy for reducing CKD progression and cardiovascular disease for Australia's most disadvantaged population.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trial Registry ANZCTR12614001183673.

Does Treatment of Periodontal Disease Influence Systemic Disease?

Periodontal diseases are the most common human diseases globally, with gingivitis affecting up to 90% and periodontitis affecting 50% of adults. Tooth enamel is the only nonshedding tissue in the human body. In the absence of proper oral hygiene measures, microbial biofilm (dental plaque) develops on the teeth to include more than 700 different bacterial species, along with viruses, fungi, archea, and parasites. With time, ecological imbalances promote the growth of selected commensal species that induce host inflammatory pathways resulting in tissue destruction, including ulceration of the periodontal epithelium.

The Epidemiologic and Clinical Findings of Patients with Buerger Disease

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Arterial stiffness in periodontitis patients and controls. A case–control and pilot intervention study

Increased arterial stiffness (AS) is an important indicator for atherosclerotic cardiovascular disease (ACVD). Epidemiologically, periodontitis and ACVD are associated. Therefore, we aimed to investigate AS in periodontitis patients and controls. In addition, we explored the effect of periodontal therapy on AS in a sub-group of cases. Pulse-wave velocity (PWV), a non-invasive chair-side function test for AS, was measured in periodontitis patients (n=57; mean age 46.6 years) and compared with a reference group (n=48; mean age 45.5 years). In addition, 45 cases (mean age 46.9 years) were 6 months followed after periodontal treatment, to explore a possible effect on arterial function. Periodontitis patients showed a significantly increased PWV compared with the reference group (8.01±0.20 vs. 7.36±0.22 m s(-1) respectively; P=0.029) and this remained significant after adjustments for ACVD risk factors (P=0.019). After periodontal therapy, no significant reduction in PWV was seen (8.00±1.8 to 7.82±1.6 m s(-1); P=0.13), but systolic blood pressure (SBP) was significantly reduced (119.8±14.6 to 116.9±15.1 mm Hg; P=0.040). It can be concluded that periodontitis is associated with increased AS. This confirms with a new parameter the association of periodontitis with ACVD. Although periodontal treatment did not lower AS significantly, a modest reduction of SBP after 6 months was observed.

Salivary inflammatory cytokines may be novel markers of carotid atherosclerosis in a Japanese general population: the Suita study

OBJECTIVE

Salivary biomarkers have been recently useful of periodontal disease, which is also risk factor of atherosclerosis. However, there are few studies of the association between salivary inflammatory cytokines and carotid atherosclerosis. We aimed to clarify the association between salivary inflammatory cytokines and periodontal disease and carotid atherosclerosis in a general urban population.

METHODS

We studied 608 Japanese men and women (mean age: 65.4 years) in the Suita study. Carotid atherosclerosis was evaluated by high-resolution ultrasonography with atherosclerotic indexes of intima-media thickness (IMT). Periodontal status was evaluated by the Community Periodontal Index (CPI). Salivary levels of interleukin-1β, interleukin-6, tumor necrosis factor-α (TNF-α), and prostaglandin E2 (PGE2) were measured by enzyme linked immunosorbent assay. The risks of carotid atherosclerosis (≥75th percentiles of mean- [0.88 mm] and Max-IMT [1.50 mm]) according to the quartiles of salivary inflammatory cytokines were compared using of adjusted-logistic regression models.

RESULTS AND CONCLUSION

All salivary inflammatory cytokines were positively associated with CPI. The adjusted odds ratios for carotid atherosclerosis of mean-IMT in the highest quartile of interleukin-6 and TNF-α were higher than those in the lowest quartiles (OR = 2.32 and 2.88; 95% confidence intervals = 1.19-4.51 and 1.51-5.49, respectively). The adjusted odds ratio for carotid atherosclerosis of mean-IMT in the highest quartile of PGE2 was greater than those in the lowest quartile in women (OR = 2.78; 95% confidence intervals = 1.11-6.95). In conclusion, higher levels of salivary inflammatory cytokines were associated with both periodontal disease and carotid atherosclerosis. Selected salivary inflammatory cytokines may be useful screening markers for periodontal disease and carotid atherosclerosis.