Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk

Genetic risk variants implicate impaired maintenance and repair of periodontal tissues as causal for periodontitis-A synthesis of recent findings

Periodontitis is a complex inflammatory disease in which the host genome, in conjunction with extrinsic factors, determines susceptibility and progression. Genetic predisposition is the strongest risk factor in the first decades of life. As people age, chronic exposure to the periodontal microbiome puts a strain on the proper maintenance of barrier function. This review summarizes our current knowledge on genetic risk factors implicated in periodontitis, derived (i) from hypothesis-free systematic whole genome-profiling studies (genome-wide association studies [GWAS] and quantitative trait loci [QTL] mapping studies), and independently validated through further unbiased approaches; (ii) from monogenic and oligogenic forms of periodontitis; and (iii) from syndromic forms of periodontitis. The genes include, but are not limited to, SIGLEC5, PLG, ROBO2, ABCA1, PF4, and CTSC. Notably, CTSC and PLG gene mutations were also identified in non-syndromic and syndromic forms of prepubertal and early-onset periodontitis. The functions of the identified genes in this review suggest that the pathways affected by the periodontitis-associated gene variants converge in functions involved in the maintenance and repair of structural integrity of the periodontal tissues. Particularly, these genes play a role in the healing of inflamed and ulcerated periodontal tissues, including roles in fibrinolysis, extrusion of cellular debris, extracellular matrix remodeling and angiogenesis. Syndromes that include periodontitis in their phenotype indicate that neutrophils play an important role in the regulation of inflammation in the periodontium. The established genetic susceptibility genes therefore collectively provide new insights into the molecular mechanisms and plausible causal factors underlying periodontitis.

Evaluation of Haematological Ratios at: Different Stages of Canine Periodontal Disease

This is a retrospective study about haematological ratios in different stages of canine periodontal disease in one single breed, more specifically the Portuguese Podengo. The aim of the study was to assess the clinical significance of five haematological ratios, namely neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), mean platelet volume-to-platelet count ratio (MPV/PLT), monocyte-to-lymphocyte ratio (MLR), and platelet-to-neutrophil ratio (PNR), easily obtained through the parameters provided by the complete blood count, in the stages of gingivitis and periodontitis, compared to clinical healthy individuals. Receiver operating characteristic curves were generated to identify ideal sensitivity and specificity cut-offs for cases of gingivitis or periodontitis. Our study included 80 dogs, which comprised 24 healthy dogs, 26 diagnosed with gingivitis, and 30 with periodontitis. The median NLR was significantly lower in periodontitis than in clinical healthy dogs (p = 0.040) and in dogs with gingivitis (p = 0.037). The median PLR was significantly lower in cases of gingivitis (p = 0.020) and periodontitis (p = 0.024) than in healthy dogs. MPV/PLT and MLR did not demonstrate significant differences between any of the three groups. The median PNR was significantly lower in gingivitis than in control dogs (p = 0.019). PNR had the highest accurate results, in distinguishing between healthy individuals and those with gingivitis, with an area under the curve of 0.692 (95% CI [0.539-0.845], p = 0.020). However, even this index had weak discriminatory power between the groups in the analysis. The impact of systemic inflammation generated by canine periodontal disease can thus be seen through some of these indices. However, the results obtained here demonstrate the need for complementarity with other methods to diagnose canine periodontal disease and reinforce the need for additional studies with more markers of systemic inflammatory response.

Experimental peri-implantitis induces neuroinflammation: An exploratory study in rats

PURPOSE

Cumulating evidence supports the close association between periodontal diseases, neuroinflammation and neurodegenerative pathologies, except for peri-implantitis (PI). Thus, this study explored the association between experimental PI and neuropathological changes in the rat brain.

MATERIALS AND METHODS

After bilateral first molars extraction, experimental PI was induced at titanium implants placed in the maxillae by lipopolysaccharide injections and ligature placement. Following 28-weeks of disease progression, the maxillae and brains were retrieved from 6 rats. Healthy brains from 3 rats were used as control. Brains were analyzed by immunohistochemistry to detect signs of neuroinflammation (interleukin (IL)-6 and tumor necrosis factor (TNF)-α)), microglial activation (IBA-1) and astrogliosis (GFAP). To explore signs of neurodegeneration, hematoxylin/eosin and Nissl stainings were used. Also, four different antibodies against amyloid beta (Aβ 1-42) were tested.

RESULTS

Chronic PI lesions showed peri-implant bone resorption accompanied by large inflammatory infiltrates. IL-6+ and TNF-α+ cells were found within the CA1 and Dentate Gyrus regions of the hippocampus of the PI-affected group, while almost no immune-positivity was detected in the control (p < 0.05). Detection of activated GFAP+ microglia and IBA-1+ astrocytes surface were significantly higher at the CA areas, and cerebral cortex of the PI-affected group, in comparison with control (p < 0.05). Shrunk neurons with pyknotic nuclei were inconsistently found among the PI-affected group, and these were almost not detected in control. No positive Aβ reactivity was detected in any of the samples.

CONCLUSION

Chronic experimental PI lesions led to an increased detection of IL-6 and TNF-α, GFAP+ microgliosis and IBA-1+ astrocytosis, and in some cases, neurodegeneration, in the rat brain.

Association of periodontitis with cardiometabolic and haemostatic parameters

OBJECTIVE

To investigate the association between periodontitis and cardiometabolic and haemostatic parameters.

MATERIALS AND METHODS

Between 2014 and 2019, 54 individuals needing full mouth extraction, and 50 control individuals, were recruited for a combined cross-sectional (individuals versus controls) and longitudinal (individuals before and after extraction) study. Periodontitis severity was measured using the periodontal inflamed surface area (PISA). Blood was drawn to measure the haemostatic (Factor VIII, von Willebrand factor [VWF], endogenous thrombin potential, d-dimer, clot lysis time) and cardiovascular risk (C-reactive protein [CRP], lipid profile) parameters, prior to and 12 weeks post-extraction. The results were analysed group-wise.

RESULTS

The mean VWF and CRP levels were higher and the high-density lipoprotein levels were lower in the individuals prior to extraction compared to the controls. The VWF was significantly correlated with the PISA (a 21% unit increase in VWF per 1000 mm2 increase in PISA, 95%CI: 6-36%, p = 0.01). The other analyses were comparable between the individuals and controls, and did not change in the individuals after the extraction.

CONCLUSION

VWF levels are associated with periodontitis severity; they do not improve after full-mouth extraction. Severe periodontitis in control individuals does not induce substantial changes in their haemostatic or inflammatory systems.

CLINICAL RELEVANCE

Treatment of periodontitis has been shown to improve the cardiometabolic blood profile of patients with established cardiometabolic disease. However, whether periodontitis treatment improves cardiometabolic and haemostatic profiles in people without cardiometabolic disease is uncertain.

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.

Is Periodontitis Associated with Age-Related Cognitive Impairment? The Systematic Review, Confounders Assessment and Meta-Analysis of Clinical Studies

It has been suggested that molecular pathological mechanisms responsible for periodontitis can be linked with biochemical alterations in neurodegenerative disorders. Hypothetically, chronic systemic inflammation as a response to periodontitis plays a role in the etiology of cognitive impairment. This study aimed to determine whether periodontitis (PDS) is a risk factor for age-related cognitive impairment (ACI) based on evidence of clinical studies. A comprehensive, structured systematic review of existing data adhering to the Preferred Reporting Items for Systematic Review and Meta Analyses (PRISMA) guidelines was carried out. Five electronic databases, PubMed, Embase, Scopus, Web of Science, and Cochrane, were searched for key terms published in peer-reviewed journals until January 2021. The Newcastle-Ottawa scale was used to assess the quality of studies and risk of bias. The primary and residual confounders were explored and evaluated. A meta-analysis synthesizing quantitative data was carried out using a random-effects model. Seventeen clinical studies were identified, including 14 cohort, one cross-sectional, and two case-control studies. Study samples ranged from 85 to 262,349 subjects, with follow-up between 2 and 32 years, and age above 45 years, except for two studies. The findings of studies suggesting the PDS-ACI relationship revealed substantial differences in design and methods. A noticeable variation related to the treatment of confounders was observed. Quality assessment unveiled a moderate quality of evidence and risk of bias. The subgroups meta-analysis and pooled sensitivity analysis of results from seven eligible studies demonstrated overall that the presence of PDS is associated with an increased risk of incidence of cognitive impairment (OR = 1.36, 95% CI 1.03-1.79), particularly dementia (OR = 1.39, 95% CI 1.02-1.88) and Alzheimer's disease (OR = 1.03 95% CI 0.98-1.07)). However, a considerable heterogeneity of synthesized data (I2 = 96%) and potential publication bias might affect obtained results. While there is a moderate statistical association between periodontitis and dementia, as well as Alzheimer's disease, the risk of bias in the evidence prevents conclusions being drawn about the role of periodontitis as a risk factor for age-related cognitive impairment.

Periodontal disease and a poor response to periodontal treatment were associated with an increased risk of incident diabetes: A longitudinal cohort study in Sweden

AIM

To investigate whether periodontal disease or the response to periodontal treatment could influence the risk of future diabetes.

MATERIALS AND METHODS

The eligible population consisted of 8983 individuals referred for periodontal treatment between 1980 and 2015. Diabetes incidence was obtained from the Swedish registers for cause of death, hospital discharge, and national diabetes registers. Data concerning treatment outcome 1 year after treatment were available for 5258 individuals. Poor response to treatment was defined as having >10% sites with probing pocket depth ≥5 mm and bleeding on probing (BOP) at ≥20% of the sites.

RESULTS

Among the 8983 individuals during a median follow-up of 21.3 years, 1117 cases of diabetes occurred. The number of teeth and BOP at baseline were significantly associated with incident diabetes in a dose-dependent manner after adjusting for age, sex, smoking, education level, and civil status [incident rate ratio (IRR) = 0.88 (95% confidence interval [CI] 0.84-0.93), p < .001 and IRR = 1.06 (95% CI 1.02-1.11), p = .003, respectively]. Poor response to treatment (14%) was associated with an increased risk (37%) for future diabetes (95% CI 1.12-1.68, p = .002) compared with good responders.

CONCLUSIONS

Periodontal disease with increased tooth loss and BOP, as well as poor response to treatment, was associated with an increased risk for diabetes.

Periodontitis and Number of Teeth in the Risk of Coronary Heart Disease: An Updated Meta-Analysis

Background

A positive link between periodontitis and chronic systemic disease has been indicated. However, few studies focused on the loss of teeth. Our analysis aims to analyze the relationship of periodontitis and number of teeth with the risk of coronary heart disease (CHD).

Material/Methods

A meta-analysis was conducted on qualified data extracted from the PubMed, Embase, and Cochrane Library databases. Only cohort studies were included in this study. We screened articles that assessed the periodontal condition and teeth number as well as the incidence or mortality of CHD. Hazard ratio (HR) and relative risk (RR) were calculated by Stata SE software.

Results

A total of 11 prospective studies with over 200 000 total participants were analyzed. Ten studies reported on periodontitis and CHD, and 4 studies included data on number of teeth. After adjusting for multivariate factors, there was a significant association between periodontitis and the risk of CHD (RR, 1.18; 95% confidence interval [CI], 1.10–1.26); the RR of CHD in the edentulous population was 1.20 (95% CI, 1.08–1.34). Moreover, results on the RR values for number of teeth were as follows: 24–17 teeth (RR, 1.12; 95% CI, 1.05–1.19); 16–11 (RR, 1.28; 95% CI, 1.15–1.42); and ≤10 (RR, 1.55; 95% CI, 1.43–1.69).

Conclusions

Our study showed that periodontitis is a risk factor for CHD and that the number of removed teeth is positively correlated with the risk of CHD. During clinical assessment, both factors need to be considered as factors associated with cardiovascular risks.

Diabetes and Oral Health: Summary of Current Scientific Evidence for Why Transdisciplinary Collaboration Is Needed

This Perspective provides a brief summary of the scientific evidence for the often two-way links between hyperglycemia, including manifest diabetes mellitus (DM), and oral health. It delivers in a nutshell examples of current scientific evidence for the following oral manifestations of hyperglycemia, along with any available evidence for effect in the opposite direction: periodontal diseases, caries/periapical periodontitis, tooth loss, peri-implantitis, dry mouth (xerostomia/hyposalivation), dysbiosis in the oral microbiome, candidiasis, taste disturbances, burning mouth syndrome, cancer, traumatic ulcers, infections of oral wounds, delayed wound healing, melanin pigmentation, fissured tongue, benign migratory glossitis (geographic tongue), temporomandibular disorders, and osteonecrosis of the jaw. Evidence for effects on quality of life will also be reported. This condensed overview delivers the rationale and sets the stage for the urgent need for delivery of oral and general health care in patient-centered transdisciplinary collaboration for early detection and management of both hyperglycemia and oral diseases to improve quality of life.

Mechanisms underlying the association between periodontitis and atherosclerotic disease

Atherosclerosis is central to the pathology of cardiovascular diseases, a group of diseases in which arteries become occluded with atheromas that may rupture, leading to different cardiovascular events, such as myocardial infarction or ischemic stroke. There is a large body of epidemiologic and animal model evidence associating periodontitis with atherosclerotic disease, and many potential mechanisms linking these diseases have been elucidated. This chapter will update knowledge on these mechanisms, which generally fall into 2 categories: microbial invasion and infection of atheromas; and inflammatory and immunologic. With respect to the invasion and infection of atheromas, it is well established that organisms from the subgingival biofilm can enter the circulation and lodge in most distant tissues. Bacteremias resulting from oral interventions, and even oral hygiene activities, are well documented. More recently, indirect routes of entry of oral organisms (via phagocytes or dendritic cells) have been described for many oral organisms, into many tissues. Such organisms include the periodontal pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Tannerella forsythia, and Fusobacterium nucleatum. Intracellular survival of these organisms with dissemination to distant sites (The Trojan Horse approach) has been described. Their relative contribution to atheroma formation and progression has been studied mainly in experimental research, with results demonstrating that these organisms can invade endothelial cells and phagocytic cells within the atheroma, leading to pathogenic changes and progression of the atheroma lesion. The second category of mechanisms potentially linking periodontitis to atherosclerosis includes the dumping of inflammatory mediators originating from periodontal lesions into the systemic circulation. These inflammatory mediators, such as C-reactive protein, matrix metalloproteinases, fibrinogen, and other hemostatic factors, would further accelerate atheroma formation and progression, mainly through oxidative stress and inflammatory dysfunction. Moreover, direct effects on lipid oxidation have also been described. In summary, the evidence supports the concept that periodontitis enhances the levels of systemic mediators of inflammation that are risk factors for atherosclerotic diseases.

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

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

The association between periodontal disease severity and metabolic syndrome in Vietnamese patients

OBJECTIVE

To investigate the association between periodontal disease severity and metabolic syndrome (MetS) in a group of Vietnamese patients.

METHODS

A total of 412 participants (114 males, 298 females, average age 57.8 ± 5.7 years) including 206 patients with MetS and 206 participants without MetS were selected for this study. Information on sociodemographic characteristics, dental behaviours and smoking status was collected from a self-administrated questionnaire. Periodontal status including plaque index (PI), gingival index (GI) pocket depth (PD) and clinical attachment level (CAL) was recorded. Logistic regression analyses were used to evaluate the association between severity of periodontal disease and MetS with adjustments for related confounders.

RESULTS

The prevalence of moderate and severe periodontitis assessed by GI, PD and CAL was all significantly higher in the MetS group than in the control group and was significantly increased by a number of MetS components. Logistic regression, adjusted for confounders, showed that people with mean PI ≥2.51 or GI ≥1.01 or number of teeth with bleeding on probing of ≥20 teeth or PD ≥3.66 or CAL ≥3.66 showed a significant association with greater OR for MetS compared to counterparts (P < .05). The OR for MetS was 4.06 (95% CI 2.11-7.84) in severe periodontitis patients compared to non-periodontitis participants (P < .001).

CONCLUSION

Much severe and extensive periodontal disease was found in MetS participants and increased with number of MetS components. Participants with higher periodontal parameters had a higher risk of MetS.

Periodontitis, edentulism and glycemic control in patients with type 2 diabetes: a cross-sectional study

OBJECTIVES

To compare the glycemic control in non-smoking patients with type 2 diabetes according to their periodontal and dental status.

RESEARCH DESIGN AND METHODS

This cross-sectional study investigated patients previously diagnosed with type 2 diabetes and under antidiabetic medication. Clinical data and fasting blood glucose (FBG) levels were collected from medical and dental records. Patients were divided into three groups according to dental and periodontal diagnosis: no or mild periodontitis (NO/MILD, n=96), moderate or severe periodontitis (MOD/SEV, n=74) and edentulous (n=141). FBG levels were compared between groups. Logistic regression was also applied to estimate the OR of presenting hyperglycemia.

RESULTS

Edentulous patients had significantly higher FBG levels of 155.7±70.9 (mean±SD mg/dL) than those in the MOD/SEV (136.6±33.8) and the NO/MILD (123.1±36.7) groups. Differences between the latter two groups were also significant. Edentulous patients had adjusted ORs of 4.53, 4.27 and 3.95 of having FBG≥126, ≥150 and ≥180 mg/dL, respectively, in comparison with NO/MILD group. The MOD/SEV group also presented significant odds of having FBG≥126 mg/dL (OR=2.66) and ≥150 mg/dL (OR=2.45) than the NO/MILD group.

CONCLUSIONS

Patients in the MOD/SEV group had worse glycemic control than the ones in the NO/MILD group. However, edentulous patients presented higher glycemic levels than both dentate groups, and also presented with higher odds of having hyperglycemia.

Surgical treatment of the residual periodontal pocket

The ultimate goal of periodontal therapy is to prevent further disease progression in order to reduce the risk of tooth loss. This objective can be achieved through a number of therapeutic modalities comprising both the nonsurgical and surgical phases of periodontal therapy. Nonsurgical periodontal treatment has been shown to control periodontal infection and to arrest progression of the disease in a significant number of cases. However, despite completion of nonsurgical treatment, a number of periodontal pockets, defined as 'residual', often remain. The presence of residual pockets may jeopardize tooth survival and be a risk factor of further disease progression, and ultimately tooth loss. Therefore, the aim of this review is to analyze the knowledge available on the indications for and the performance of periodontal surgical treatment of residual pockets in terms of 'traditional' (clinical, microbiological), patient-based and systemic health outcomes.

Association between missing tooth count and mortality: A systematic review

PURPOSE

The purpose of this review was to analyze existing literature on the relationship between tooth count and mortality by evaluating the findings in the context of methodological variations. We aimed at addressing the question of whether preserving natural teeth can impact mortality.

STUDY SELECTION

PubMed, Web of Science and CINAHL databases were systematically searched using various combinations of related and synonymous keywords for "tooth count" and "mortality". The references of included articles were also evaluated for inclusion. Overall 49 studies found to be eligible were critically evaluated and their key findings were summarized.

RESULTS

Studies were conducted in various continents and differed substantially in regards to their sample size, population, methodology, the definition of the tooth count variable, the confounders as well as the mediators accounted for in the analysis. Follow-up period ranged from 1 to 56 years.

CONCLUSIONS

Although high variability in the studies precludes a definite conclusion about the relationship between number of teeth and mortality, the overall finding from this review is that reduced tooth count is associated with higher mortality. However the impact of factors such as smoking, health-care access, baseline co-morbidity and risk profile, dental and periodontal health, the presence of dental prosthesis as well as socio-economic status, in mediating whole or part of the association cannot be overlooked and needs further investigation using more standard methodologies. Any differences in males vs. females, as well as among different age groups, will also need further consideration in the future studies.

Poor Response to Periodontal Treatment May Predict Future Cardiovascular Disease

Periodontal disease has been associated with cardiovascular disease (CVD), but whether the response to the treatment of periodontal disease affects this association has not been investigated in any large prospective study. Periodontal data obtained at baseline and 1 y after treatment were available in 5,297 individuals with remaining teeth who were treated at a specialized clinic for periodontal disease. Poor response to treatment was defined as having >10% sites with probing pocket depth >4 mm deep and bleeding on probing at ≥20% of the sites 1 y after active treatment. Fatal/nonfatal incidence rate of CVD (composite end point of myocardial infarction, stroke, and heart failure) was obtained from the Swedish cause-of-death and hospital discharge registers. Poisson regression analysis was performed to analyze future risk of CVD. During a median follow-up of 16.8 y (89,719 person-years at risk), those individuals who did not respond well to treatment (13.8% of the sample) had an increased incidence of CVD ( n = 870) when compared with responders (23.6 vs. 15.3%, P < 0.001). When adjusting for calendar time, age, sex, educational level, smoking, and baseline values for bleeding on probing, probing pocket depth >4 mm, and number of teeth, the incidence rate ratio for CVD among poor responders was 1.28 (95% CI, 1.07 to 1.53; P = 0.007) as opposed to good responders. The incidence rate ratio among poor responders increased to 1.39 (95% CI, 1.13 to 1.73; P = 0.002) for those with the most remaining teeth. Individuals who did not respond well to periodontal treatment had an increased risk for future CVD, indicating that successful periodontal treatment might influence progression of subclinical CVD.

Serum lipids modify periodontal infection - interleukin-6 association

AIM

The aim of this study was to investigate whether the systemic response against a local inflammatory process in periodontium is dependent on the individual's serum lipid composition.

MATERIAL AND METHODS

This study was based on a subpopulation of the Health 2000 Survey that included 878 subjects who were aged between 45 and 64 years, dentate, non-diabetic and non-rheumatic. The inflammatory condition of periodontium was measured by means of the number of teeth with deepened (4 mm or deeper) periodontal pockets. Systemic inflammation was assessed by means of the serum levels of interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α). The association between an inflammatory condition in the periodontium and the systemic inflammatory response was analysed using linear regression models.

RESULTS

The number of teeth with deepened periodontal pockets was associated with elevated serum IL-6 levels among subjects with an unfavourable lipid composition (low-density lipoprotein cholesterol ≥3.7 mmol/l or high-density lipoprotein cholesterol <1.3 mmol/l). There was no association between serum TNF-α levels and the number of teeth with deepened periodontal pockets in these data.

CONCLUSION

The systemic response against the inflammatory condition of periodontium varied between individuals. The variation appeared to be dependent on the serum lipid composition or related factors.

Periodontitis, cardiovascular disease and pregnancy outcome--focal infection revisited?

Over the last two decades there has been a renewed interest around the possible effects of periodontal disease on both cardiovascular health and pregnancy outcome (among other diseases), a topic which has interested science for hundreds of years. These have led to a range of studies, workshops and consensus documents being published, with corresponding coverage in general and professional media. In this article the authors summarise the history and supporting theories behind such associations, whether clinical studies have been able to confirm these and what this might mean for general practitioners who are questioned on this topic by patients.

Evaluation of various hematological parameters in patients with periodontitis after nonsurgical therapy at different intervals

Background and Objective:

Chronic low-level bacteremia and a systemic inflammatory response have been suggested as a pathogenetic link between periodontal disease and atherosclerosis. The objective of this study is to evaluate the effect of nonsurgical periodontal therapy on various hematological parameters in patients with periodontitis.

Materials and Methods:

A total of 30 periodontitis patients were selected for the study. Clinical parameters such as plaque index, gingival index, and probing pocket depth were assessed. For each patient, venous blood sample were collected, and the estimation of total leukocyte count (TLC), differential leukocyte count, platelet count, and erythrocyte sedimentation rate (ESR) was carried out. All the clinical and hematological parameters were measured at baseline, 1 week and 2 weeks after nonsurgical periodontal therapy.

Results:

The study results showed that there was a statistically significant decrease in TLC, ESR, and platelet count at 1 week and 2 weeks following nonsurgical periodontal therapy.

Conclusion:

In this study, it has been concluded that there is a decrease in the hematological parameters after nonsurgical periodontal therapy, which may also reduce the risk of atherosclerosis formation in the blood vessel and possibly prevent cardiovascular diseases.

Evidence that periodontal treatment improves biomarkers and CVD outcomes

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inflammatory mechanisms linking periodontal diseases to cardiovascular diseases

AIMS

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

METHODS

This article is a literature review.

RESULTS

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

CONCLUSIONS

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

Evidence that periodontal treatment improves biomarkers and CVD outcomes

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Refractory chronic spontaneous urticaria and permanent atrial fibrillation associated with dental infection: Mere coincidence or something more to it?

Controversy surrounds the role of dental infection/inflammation in the oral cavity in chronic spontaneous urticaria (CSU) and atrial fibrillation (AF), which is mainly due to scarce literature in this area. Therefore, this case report and review of literature illustrate a possible association between the acute-phase response (APR) and clinical conditions, such as CSU and dental infection/inflammation of oral cavity and AF.We describe a 36-year-old man with an 8-year history of difficult-to-treat, uncontrolled CSU, co-existent with dental infection/inflammatory processes of oral cavity and permanent atrial fibrillation (AF). In the presented case, the most likely triggering or aggravating/maintaining factor of the symptoms was the inflammation/dental infection of the oral cavity because of rapid reduction of the urticarial symptoms, drug doses, and serum CRP levels after the dental therapy. Dental treatment may have a beneficial effect on the systemic inflammatory response, reducing/normalizing the circulating levels of APR markers. APR activation appears to worsen CSU course, early identification and treatment of infectious/inflammatory foci in the oral cavity would form the mainstay of supportive therapy for CU probably through reduction of the systemic inflammatory burden. APR associated with infectious/inflammatory foci in the oral cavity could be taken into account as a predisposing agents to AF.

Design of a Medical Triage Evidence-Based Clinical Management Protocol and Implementation of Medical Triage On-Line Training for Use by Mission of Mercy Volunteers

Evidence-based protocols in safety net settings can help standardize care practices, increase organizational workflow, and enhance quality outcomes for those receiving services. The purpose of this quality improvement project is two-fold: to design an evidence-based medical triage clinical management protocol, and, to influence adherence to that protocol by safety net medical triage volunteers through an on-line volunteer orientation. Leadership skills were required to help translate evidence-based practice recommendations into useful tools to assist in directing practice. Project outcomes included successful multidisciplinary practice change, significantly improved volunteer knowledge surrounding medical triage protocol parameters, increased organizational workflow, and enhanced quality client outcomes.

Serpine1 Mediates Porphyromonas gingivalis Induced Insulin Secretion in the Pancreatic Beta Cell Line MIN6

Periodontitis is an inflammatory disease resulting in destruction of gingiva and alveolar bone caused by an exuberant host immunological response to periodontal pathogens. Results from a number of epidemiological studies indicate a close association between diabetes and periodontitis. Results from cross-sectional studies indicate that subjects with periodontitis have a higher odds ratio of developing insulin resistance (IR). However, the mechanisms by which periodontitis influences the development of diabetes are not known. Results from our previous studies using an animal model of periodontitis suggest that periodontitis accelerates the onset of hyperinsulinemia and IR. In addition, LPS from a periodontal pathogen, Porphyromonas gingivalis (Pg), stimulates Serpine1 expression in the pancreatic beta cell line MIN6. Based on these observations, we hypothesized that a periodontal pathogen induces hyperinsulinemia and Serpine1 may be involved in this process. To test this hypothesis, we co-incubated Pg with the pancreatic beta cell line MIN6 and measured the effect on insulin secretion by MIN6 cells. We further determined the involvement of Serpine1 in insulin secretion by downregulating Serpine1 expression. Our results indicated that Pg stimulated insulin secretion by approximately 3.0 fold under normoglycemic conditions. In a hyperglycemic state, Pg increased insulin secretion by 1.5 fold. Pg significantly upregulated expression of the Serpine1 gene and this was associated with increased secretion of insulin by MIN6 cells. However, cells with downregulated Serpine1 expression were resistant to Pg stimulated insulin secretion under normoglycemic conditions. We conclude that the periodontal pathogen, Pg, induced insulin secretion by MIN6 cells and this induction was, in part, Serpine1 dependent. Thus, Serpine1 may play a pivotal role in insulin secretion during the accelerated development of hyperinsulinemia and the resulting IR in the setting of periodontitis.

C-reactive protein expression is up-regulated in apical lesions of endodontic origin in association with interleukin-6

INTRODUCTION

C-reactive protein (CRP) is the prototype component of acute-phase proteins induced ultimately by interleukin (IL)-6 in the liver, but it is unknown whether periradicular tissues locally express CRP. The present study aimed to identify whether CRP messenger RNA synthesis occurs in situ within apical lesions of endodontic origin (ALEOs) and healthy periodontal ligament and its association with IL-6 and to determine their protein levels and tissue localization.

METHODS

Patients with asymptomatic apical periodontitis and healthy volunteers presenting at the School of Dentistry, University of Chile, Santiago, Chile, were enrolled. ALEOs and healthy teeth were obtained and processed for either immunohistochemistry and double immunofluorescence to assess IL-6 and CRP tissue localization, whereas healthy periodontal ligaments were processed as controls for real-time reverse-transcription polymerase chain reaction for their RNA expression levels and multiplex assay to determine their protein levels. Statistic analysis was performed using the unpaired t test or Mann-Whitney test according to data distribution and Pearson correlation.

RESULTS

IL-6 and CRP were synthesized in ALEOs, whereas their RNA expression and protein levels were significantly higher when compared with healthy periodontal ligament. IL-6 and CRP immunolocalized to the inflammatory cells, vascular endothelial cells, and mesenchymal cells. Both, IL-6 and CRP colocalized in ALEOs, and a positive correlation was found between their expression levels (P < .05).

CONCLUSIONS

IL-6 and CRP messenger RNA are constitutively expressed in periodontal ligament and up-regulated in ALEOs along with higher protein levels. Given their pleiotropic effects, IL-6 and CRP protein levels in apical tissues might partially explain the development and progression of ALEOs as well as potentially asymptomatic apical periodontitis-associated systemic low-grade inflammation.

Polymorphisms in the interleukin-10 gene and chronic periodontitis in patients with atherosclerotic and aortic aneurysmal vascular diseases

Background

Chronic periodontitis (CP), atherosclerotic and aortic aneurysmal vascular diseases (VD) are chronic inflammatory conditions with multifactorial etiologies, including involvement of predisposing genetic factors. In a previous study, polymorphisms in the gene for the anti-inflammatory interleukin-1 receptor antagonist were associated with CP in patients with VD.

Objective

This study investigates whether polymorphisms in the gene for the anti-inflammatory interleukin-10 (IL10) could be related to CP in the same manner.

Methods

Seventy-two patients with VD of whom 35 had CP were genotyped for single nucleotide polymorphisms (SNPs) in the IL10 −592 (rs1800872), −819 (rs1800871), and −1,082 (rs1800896) gene by Taqman rtPCR method and by DNA sequencing.

Results

The C alleles and C/C genotypes of IL10 −592 and IL10 −819 frequencies were significantly higher, while the frequencies of the IL10 −592 (C/A) and IL10 −819 (C/T) heterozygote genotypes were significantly lower in the VD group with CP compared to those without CP. The IL10 haplotype ATA frequency (−1,082, −819, −592) showed a trend to a significant difference between the two groups indicating protection against CP.

Conclusions

Taken together, our findings suggest an independent association of genetic polymorphisms in the IL-10 gene locus with CP in patients with VD. Development of CP and the implications on vascular disease emphasize the importance of early detection and adequate treatment of periodontitis among these patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Tooth loss, periodontitis, and statins in a population-based follow-up study

BACKGROUND

Statins, frequently prescribed in lipid-lowering therapies, seem to have additional beneficial effects on periodontitis and tooth loss. If this is true, then chronic treatment with statins should also result in diminished tooth loss as a long-term response.

METHODS

A 5-year population-based follow-up study of tooth loss was performed comparing participants treated with statins (n = 134) with those not on the drugs (Study of Health in Pomerania). Negative binomial regression models were used to analyze the count variable of the outcome, including risk factors for tooth loss and measures of cholesterol metabolism.

RESULTS

When adjusted for age and sex, statins were associated with reduced tooth loss during the follow-up period (incidence risk ratio [IRR] = 0.70, 95% confidence interval [CI] = 0.50 to 0.99, P = 0.04). When additionally adjusted for risk factors of periodontal breakdown, IRR was 0.72 (95% CI = 0.52 to 1.01). There was significant interaction with low-density lipoprotein cholesterol (LDL-c) at baseline. After stratification by LDL-c, statins were associated with reduced tooth loss, resulting in IRR = 0.89 (95% CI = 0.44 to 1.83) and 0.64 (95% CI = 0.43 to 0.95), P = 0.03, at LDL-c concentrations ≤100 mg/dL and >100 mg/dL (2.58 mmol/L), respectively. The data also showed reduced tooth loss associated with the 5-year reduction in LDL-c levels on a mmol/L basis and independently of statins (IRR = 0.87, 95% CI = 0.80 to 0.96, P = 0.004).

CONCLUSION

Long-term treatment with systemically administered statins may have the beneficial effect of protecting against tooth loss.

Smoking-related cotinine levels and host responses in chronic periodontitis

BACKGROUND AND OBJECTIVE

Smoking has been reported to increase the risk of periodontal disease by disrupting the balance of immune responses and tissue repair processes; however, this risk varies among smokers. Cotinine levels in saliva are routinely used to measure the level of smoking, and reflect the quantity of nicotine, and other smoking-related xenobiotics that challenge host systems. This study delineated characteristics of inflammatory mediators in saliva and serum antibody responses to both periodontal pathogens and commensal bacteria in smokers as they related to cotinine levels.

MATERIALS AND METHODS

This case-control study (n = 279) examined salivary inflammatory mediator responses [interleukin (IL)-1ß, IL-10, prostaglandin E2, myeloperoxidase and plasminogen activator inhibitor-1], and serum IgG antibody responses to three periodontal pathogens (Aggregatibacter actinomyce-temcomitans, Porphyromonas gingivalis, Treponema denticola) and five commensal oral microorganisms (Veillonella parvula, Streptococcus sanguis, Prevotella loescheii, Actinomyces naeslundii, Capnocytophaga ochracea).

RESULTS

The patients were stratified into health (n = 30), gingivitis (n = 55) and periodontitis (n = 184); cotinine levels correlated with reported smoking habits in health, less so with gingivitis, and were not correlated in periodontitis. Of the inflammatory mediators/acute phase proteins, only IL-1ß levels were positively associated (p < 0.001) with the pack years and cotinine levels. As might be predicted, patients with periodontitis smoked more (p < 0.001) and had higher levels of cotinine. IL-1ß and antibody to A. actinomycetemcomitans, P. gingivalis and T. denticola were significantly higher in the patients with periodontitis than either patients with gingivitis or who were healthy.

CONCLUSIONS

Generally, antibody to the pathogens and commensals was lower with decreased cotinine levels. Smoking exacerbated differences in both inflammatory mediators and three antibody in periodontal disease compared to healthy subjects.

Local and systemic inflammatory responses to experimentally induced gingivitis

This study profiled the local and systemic inflammatory responses to experimentally induced gingivitis. Eight females participated in a 21-day experimental gingivitis model followed by a 14-day resolution phase. Bleeding on probing and plaque index scores were assessed before, during, and after resolution of gingival inflammation, and samples of saliva, GCF, and plasma were collected. Samples were assessed for biomarkers of inflammation using the BioPlex platform and ELISA. There were no significant changes in GCF levels of cytokines during the experimental phase; however, individual variability in cytokine profiles was noted. During resolution, mean GCF levels of IL-2, IL-6, and TNF-α decreased and were significantly lower than baseline levels (P = 0.003, P = 0.025, and P = 0.007, resp.). Furthermore, changes in GCF levels of IL-2, IL-6, and TNF-α during resolution correlated with changes in plaque index scores (r = 0.88, P = 0.004; r = 0.72, P = 0.042; r = 0.79, P = 0.019, resp.). Plasma levels of sICAM-1 increased significantly during the experimental phase (P = 0.002) and remained elevated and significantly higher than baseline levels during resolution (P < 0.001). These results support the concept that gingivitis adds to the systemic inflammatory burden of an individual.

Tooth loss may predict poor cognitive function in community-dwelling adults without dementia or stroke: the PRESENT project

Periodontal disease is a potential predictor of stroke and cognitive impairment. However, this association is unclear in adults aged 50 yr and above without a history of stroke or dementia. We evaluated the association between the number of teeth lost, indicating periodontal disease, and cognitive impairment in community-dwelling adults without any history of dementia or stroke. Dental examinations were performed on 438 adults older than 50 yr (315 females, mean age 63±7.8 yr; 123 males, mean age 61.5±8.5 yr) between January 2009 and December 2010. In the unadjusted analysis, odds ratios (OR) of cognitive impairment based on MMSE score were 2.46 (95% CI, 1.38-4.39) and 2.7 (95% CI, 1.57-4.64) for subjects who had lost 6-10 teeth and those who had lost more than 10 teeth, respectively, when compared with subjects who had lost 0-5 teeth. After adjusting for age, education level, hypertension, diabetes, hyperlipidemia, and smoking, the relationship remained significant (OR, 2.0; 95% CI, 1.08-3.69, P=0.027 for those with 6-10 teeth lost; OR, 2.26; 95% CI, 1.27-4.02, P=0.006 for those with more than 10 teeth lost). The number of teeth lost is correlated with cognitive impairment among community-dwelling adults aged 50 and above without any medical history of stroke or dementia.

Comparison of red blood cell parameters in smokers and nonsmokers with chronic periodontitis

OBJECTIVE

Recent studies suggest that chronic periodontitis can lead to a decrease in levels of red blood cell (RBC) and hemoglobin concentration. Smoking is an established risk factor for periodontitis. The present study was carried out to evaluate the effect of cigarette smoking on the various parameters of RBC in the subjects with chronic periodontitis.

METHODS

A total of 77 males with chronic periodontitis were divided into 38 nonsmokers (group I) and 39 current smokers (group II). Clinical parameters recorded were probing pocket depth and clinical attachment level. Laboratory blood investigations included hemoglobin concentration, RBC count, packed cell volume, mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration and erythrocyte sedimentation rate.

RESULTS

In group II probing pocket depth and clinical attachment level and erythrocyte sedimentation rate were significantly higher than in group I. The RBC count, hemoglobin concentration, and packed cell volume were significantly lower in group II compared to group I. While the mean corpuscular volume, mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration were comparable in both the groups.

CONCLUSION

Smoking may have an effect on levels of various RBC parameters in patients with chronic periodontitis.

Heat-shock protein 60 kDa and atherogenic dyslipidemia in patients with untreated mild periodontitis: a pilot study

Identification of predictors of cardiovascular risk can help in the prevention of pathologic episodes and the management of patients at all stages of illness. Here, we investigated the relationships between serum levels of Hsp60 and dyslipidemia in patients with periodontitis by performing a cross-sectional study of 22 patients with mild periodontitis without any prior treatment for it (i.e., drug naïve) and 22 healthy controls, matched for age and body mass index (BMI). All subjects were evaluated for periodontal status, gingival inflammation, and oral hygiene. Levels of circulating Hsp60, C-reactive protein (CRP), and plasma lipids were measured, and small, dense low-density lipoproteins (LDL) were indirectly assessed by determining the triglycerides/high-density lipoproteins (HDL) cholesterol ratio. We also assessed by immunohistochemistry Hsp60 levels in oral mucosa of patients and controls. No difference was found in CRP levels or plasma lipids between the two groups, but subjects with periodontitis showed, in comparison to controls, higher levels of small, dense LDL (p  = 0.0355) and circulating Hsp60 concentrations (p < 0.0001). However, levels of mucosal Hsp60 did not change significantly between groups. Correlation analysis revealed that circulating Hsp60 inversely correlated with HDL-cholesterol (r  = -0.589, p  = 0.0039), and positively with triglycerides (r  = +0.877, p < 0.0001), and small, dense LDL (r  = +0.925, p < 0.0001). Serum Hsp60 significantly correlated with the degree of periodontal disease (r  = +0.403, p  = 0.0434). In brief, untreated patients with mild periodontitis had increased small, dense LDL and serum Hsp60 concentrations, in comparison to age- and BMI-matched controls and both parameters showed a strong positive correlation. Our data indicate that atherogenic dyslipidemia and elevated circulating Hsp60 tend to be linked and associated to periodontal pathology. Thus, the road is open to investigate the potential value of elevated levels of circulating Hsp60 as predictor of risk for cardiovascular disease when associated to dyslipidemia in periodontitis patients.

Total tooth loss and systemic correlates of inflammation: role of obesity

Obesity and edentulism are both associated with multiple systemic disorders with an inflammatory background including periodontal diseases. This study aimed to evaluate the different impact of obesity on inflammation in dentate and toothless subjects. The data came from the population-based, cross-sectional study SHIP (Study of Health in Pomerania). We determined anthropometric measures including BMI, waist-to-hip ratio (WHR), diagnostic periodontal parameters, and systemic metabolites. It was shown that measures of systemic markers of inflammation and lipid or glucose metabolism (P < 0.001) were increased with higher WHR. When adjusted for age, sex, smoking, diabetes, education, physical activity, and last dentist's appointment, C-reactive protein (CRP), fibrinogen, and leukocyte count were significantly related to WHR increasing from the first to the fourth WHR quartile (P < 0.001) as well as to the BMI. In both dentate and edentulous subjects higher WHR contributes significantly to increasing systemic CRP and fibrinogen with sex differences. In toothless subjects, while still dependent on increasing WHR, the inflammatory markers CRP and fibrinogen were higher than in dentate subjects, thereby revealing effect modification between sex and edentulism (P < 0.010). In conclusion, subjects with total tooth loss, although devoid of periodontal inflammation, may exhibit increased levels of systemic inflammatory mediators. Possible implications are discussed with respect to obesity and its relationship to inflammation.

Rheumatoid arthritis and periodontitis - inflammatory and infectious connections. Review of the literature

An association between oral disease/periodontitis and rheumatoid arthritis (RA) has been considered since the early 1820s. The early treatment was tooth eradication. Epidemiological studies suggest that the prevalence of RA and periodontitis may be similar and about 5% of the population are aged 50 years or older. RA is considered as an autoimmune disease whereas periodontitis has an infectious etiology with a complex inflammatory response. Both diseases are chronic and may present with bursts of disease activity. Association studies have suggested odds ratios of having RA and periodontitis varying from 1.8:1 (95% CI: 1.0–3.2, NS) to 8:1 (95% CI: 2.9–22.1, p<0.001). Genetic factors are driving the host responses in both RA and periodontitis. Tumor necrosis factor-α, a proinflammatory cytokine, regulates a cascade of inflammatory events in both RA and periodontitis. Porphyromonas gingivalis is a common pathogen in periodontal infection. P. gingivalis has also been identified in synovial fluid. The specific abilities of P. gingivalis to citrullinate host peptides by proteolytic cleavage at Arg-X peptide bonds by arginine gingipains can induce autoimmune responses in RA through development of anticyclic citrullinated peptide antibodies. In addition, P. gingivalis carries heat shock proteins (HSPs) that may also trigger autoimmune responses in subjects with RA. Data suggest that periodontal therapies combined with routine RA treatments further improve RA status.

Cholesterol, C-Reactive Protein, and Periodontitis: HMG-CoA-Reductase Inhibitors (Statins) as Effect Modifiers

Common risk factors of periodontitis and cardiovascular diseases fuel the debate on interrelationships between them. The aim is to prove whether statins may influence periodontal parameters by affecting either of these factors. Out of the 4,290 subjects of SHIP (Study of Health in Pomerania), we included subjects aged >30 years (219 with statins, 2937 without) and excluded edentulous. We determined periodontal measures, cholesterol fractions, and inflammation markers. Statin use and periodontal risk factors were assessed. Gingival plaque and periodontal attachment loss were associated with systemic LDL cholesterol (P < 0.001) and C-reactive protein CRP (P = 0.019) revealing interaction with statin use. When adjusted for age, sex, smoking, diabetes, education, and dental service, statins were identified as effect modifiers abolishing the relationship between attachment loss and LDL and between gingival plaque and LDL (interactions P < 0.001). No statin-related interaction was detected with increase in CRP. The interaction supports the view of inter-relationships between periodontal and systemic inflammatory mediators.

Number of teeth is related to atherosclerotic plaque in the carotid arteries in an elderly population

BACKGROUND

Periodontal disease has been associated with cardiovascular disorders with an atherosclerotic background, and number of teeth (NT) has been suggested as a possible risk indicator for cardiovascular disease. The objective of this study is to investigate whether NT was related to the intima-media thickness (IMT) and to atherosclerotic plaque in carotid arteries in an elderly population.

METHODS

In a population-based study including 1,016 participants aged 70 years, the NT was self-reported by 947 of the participants. Carotid artery IMT was evaluated by ultrasound. The occurrence of plaque was also measured. Logistic regression was used to analyze the associations between NT and the number of carotid arteries with plaque.

RESULTS

A significant inverse relationship was found between the NT and the number of carotid arteries with plaque after adjustment for age, sex, smoking, body mass index, waist/hip ratio, blood glucose, triglycerides, cholesterol, C-reactive protein, leukocyte count, blood pressure, and Framingham risk score, with odds ratio of 0.89, 95% confidence interval of 0.82 to 0.98, and P = 0.016. The relationship was fairly linear, suggesting a dose-response relationship. When NT was divided into quintiles using the first one as referent, the relationship persisted for all quintiles except for the second one. However, no relationship to IMT was seen.

CONCLUSION

The present study further emphasizes that tooth loss could be an easily obtained risk indicator for atherosclerosis.

Mechanisms involved in the association between periodontal diseases and cardiovascular disease

It is now well accepted that besides the cholesterol associated mechanisms of atherogenesis, inflammation plays a crucial role in all stages of the development of the atherosclerotic lesion. This 'inflammation hypothesis' raises the possibility that through systemic elevations of pro-inflammatory cytokines, periodontal diseases might also contribute to systemic inflammation and, therefore, to atherogenesis. In fact, there is evidence that periodontal diseases are associated with higher systemic levels of high-sensitivity C-reactive protein and a low grade systemic inflammation. This phenomenon has been explained based on mechanisms associated with either the infectious or the inflammatory nature of periodontal diseases. The purposes of this article were to review (1) the evidence suggesting a role for oral bacterial species, particularly periodontal pathogens, in atherogenesis; (2) the potential mechanisms explaining an etiological role for oral bacteria in atherosclerosis; (3) the evidence suggesting that periodontal infections are accompanied by a heightened state of systemic inflammation; (4) the potential sources of systemic inflammatory biomarkers associated with periodontal diseases; and (5) the effects of periodontal therapy on systemic inflammatory biomarkers and cardiovascular risk.

Effects of nonsurgical periodontal therapy on C-reactive protein and serum lipids in Jordanian adults with advanced periodontitis

BACKGROUND AND OBJECTIVE

Data on whether periodontal therapy affects serum CRP levels are inconclusive. The aim of this study was to determine if nonsurgical periodontal therapy has any effect on CRP and serum lipid levels in patients with advanced periodontitis.

MATERIAL AND METHODS

Thirty-six systemically healthy patients, ≥ 40 years of age and with advanced periodontitis, were recruited for the study. Patients were randomized consecutively to one of two groups: the treatment group (n = 18) or the control group (n = 18). Treated subjects received nonsurgical periodontal therapy, which included oral hygiene instructions and subgingival scaling and root planing. Systemic levels of inflammatory markers [C-reactive protein (CRP) and the lipid profile] were measured at baseline and 3 mo after periodontal therapy.

RESULTS

Nonsurgical periodontal therapy in the treatment group resulted in a significant reduction in the serum CRP level. The average CRP level decreased from 2.3 mg/dL at baseline to 1.8 mg/dL (p < 0.005) after 3 mo of periodontal therapy. The average reduction (95% confidence interval) in CRP was 0.498 (95% confidence interval = 0.265-0.731). In the treatment group, the reduction in CRP was significantly, linearly and directly correlated with the reduction in the plaque index, the gingival index and the percentage of sites with pocket depth ≥ 7 mm (Pearson correlation coefficient = 0.746, 0.425 and 0.621, respectively). Nonsurgical periodontal therapy had no effect on the lipid parameters.

CONCLUSION

This study demonstrated that nonsurgical periodontal therapy results in a significant reduction in the serum CRP level. The effect of this outcome on systemic disease is still unknown.

Periodontitis and blood pressure: the concept of dental hypertension

Chronic periodontitis is a common inflammatory disorder that is being contemplated as a risk factor for atherosclerotic complications. Current epidemiological evidence also supports its potential association with increases in blood pressure levels and hypertension prevalence. Furthermore, data from cross-sectional studies suggest that in hypertensive subjects periodontitis may enhance the risk and degree of target organ damage. A possible pathogenetic background of an effect of periodontitis on blood pressure should include the systemic generalization of the local oral inflammation, the role of the host immune response, the direct microbial effect on the vascular system and alterations in endothelial function. Inversely, the concept of hypertension unfavorably affecting periodontal tissues cannot be excluded. The two conditions share multiple common risk factors that should be readily controlled for when assessing a possible association. Thoroughly designed prospective and interventional trials are needed in order to determine the impact of periodontitis on blood pressure regulation and incident hypertension and its integration in the clinical approach of both dental and hypertensive patients.

The effect of full-mouth tooth extraction on glycemic control among patients with type 2 diabetes requiring extraction of all remaining teeth: a randomized clinical trial

BACKGROUND AND OBJECTIVE

Several studies have shown that periodontitis can complicate the severity of diabetes by worsening the degree of glycemic control. The purpose of this study was to determine the effect of full-mouth tooth extraction on glycemic control among type 2 diabetic patients.

MATERIAL AND METHODS

A total of 58 patients with type 2 diabetes mellitus and advanced periodontitis who were requiring extraction of all remaining teeth were randomized consecutively into treatment (full-mouth tooth extraction) and control groups (no treatment). Eight patients were lost to follow-up or reported use of antibiotics, leaving 50 patients to be included in the analysis. All patients had all their remaining teeth in a hopeless condition. Relevant data were collected, and glycosylated hemoglobin (HbA(1c) ) and fasting blood glucose levels were measured at baseline and at follow-up times of 3 and 6 mo.

RESULTS

At baseline, the mean (SD) HbA(1c) level was 8.6% (1.24) in the treatment group and 7.7% (0.87) in the control group. In the treatment group, the mean HbA(1c) level decreased significantly from 8.6% at baseline to 7.4% after 3 mo of denture treatment, and continued to decrease to 7.3% after 6 mo. In the control group, the mean HbA(1c) decreased from 7.7% at baseline to 7.5% after 3 mo, and remained almost the same after 6 mo. After adjusting for the baseline HbA(1c) , the mean reduction in HbA(1c) after 3 mo in the treatment group [1.23% (0.79)] was significantly higher than the mean reduction in the control group [0.28% (0.87)].

CONCLUSION

Full-mouth tooth extraction resulted in an improvement in glycemic control among diabetic patients. Large-scale multicentre clinical trials are needed to confirm the current evidence.