Periodontal disease and liver cirrhosis: A systematic review

The oral microbial odyssey influencing chronic metabolic disease

INTRODUCTION

Since the oral cavity is the gateway to the gut, oral microbes likely hold the potential to influence metabolic disease by affecting the gut microbiota.

METHOD

A thorough review of literature has been performed to link the alterations in oral microbiota with chronic metabolic disease by influencing the gut microbiota.

RESULT

A strong correlation exists between abnormalities in oral microbiota and several systemic disorders, such as cardiovascular disease, diabetes, and obesity, which likely initially manifest as oral diseases. Ensuring adequate oral hygiene practices and cultivating diverse oral microflora are crucial for the preservation of general well-being. Oral bacteria have the ability to establish and endure in the gastrointestinal tract, leading to the development of prolonged inflammation and activation of the immune system. Oral microbe-associated prophylactic strategies could be beneficial in mitigating metabolic diseases.

CONCLUSION

Oral microbiota can have a profound impact on the gut microbiota and influence the pathogenesis of metabolic diseases.

The Link Between Apical Periodontitis and Gastrointestinal Diseases-A Systematic Review

INTRODUCTION

This systematic review aimed to examine a potential link between apical periodontitis (AP) and gastrointestinal diseases (GIDs).

METHODS

The protocol of the review has been registered in PROSPERO (CRD42022330771). The following engines were used with the aim of searching for relevant literature: PubMed, Web of Science, Scopus, Cochrane Central Register of Controlled Trials, and grey literature, from inception to May 2022. There were no language restrictions included. Study selection, data collection, and synthesis have been performed by 2 independent reviewers. For the purpose of estimating the quality of studies, the Newcastle-Ottawa Scale was used.

RESULTS

Four matched case control studies, as well as a single longitudinal cohort study were included in the final review. These were published between 2012 and 2017, and comprised 537 participants whose age range was 18 to 87 years. It was not possible to perform a meta-analysis due to different study designs and evaluated outcomes of included studies. Except for one study that was categorized as "Good," overall, for 4 out of 5 studies the quality was assessed as "Fair".

CONCLUSIONS

This review highlighted sparse knowledge present in the literature concerned with the association between AP and GIDs. Available evidence reveals a potential link between impaired endodontic status, assessed by the number of root-filled teeth with periapical radiolucency, and GIDs. More research is needed to ascertain this association.

Association Between Pre-Transplant Oral Health and Post-Liver Transplant Complications

Oral disease is linked with systemic inflammation and various systemic conditions, including chronic liver disease. Liver transplantation (LT) candidates often need dental infection focus eradication, and after LT, there is high risk of many inflammation-related complications. We studied whether pre-LT dental status is associated with the occurrence of post-LT complications. This study included 225 adult LT recipients whose teeth were examined and treated before LT, and 40 adult LT recipients who did not have pre-LT dental data available. Data on post-LT complications were collected from the national liver transplant registry and followed up until the end of July 2020. Worse pre-LT dental status was associated with a higher risk of acute rejection post-LT compared to patients with good dental status. Worse dental status was also associated with higher 1-year-post-LT ALT levels and lower albumin levels. In conclusion, poor pre-LT oral health seems to associate with an increased risk of post-LT acute rejection and with elevated ALT levels and decreased albumin levels, suggesting an effect on post-LT liver health. Therefore, prevention and treatment of oral and dental diseases should be promoted early in the course of liver disease.

Role of Oral Health, Frailty, and Minimal Hepatic Encephalopathy in the Risk of Hospitalization: A Prospective Multi-Center Cohort of Outpatients With Cirrhosis

BACKGROUND & AIMS

Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis.

METHODS

North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split.

RESULTS

A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P = .026), composite MHE + frailty score (P = .0016), ascites (P = .004), prior HE (P = .008), and hydrothorax (P = .004) were associated with admissions using the training and validation subsets.

CONCLUSIONS

In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.

Periodontal health status in cirrhotic patients: a systematic review and meta-analysis

OBJECTIVES

Liver cirrhosis is a disease with widespread prevalence and high mortality. Oral manifestations, particularly periodontal-related manifestations such as bleeding gums, red and swollen gums, are common in cirrhotic patients but may often be overshadowed by other systemic complications, making them easy to ignore. So this article conducts a systematic review and meta-analysis of periodontal health status in patients with cirrhosis.

MATERIAL AND METHODS

We performed electronic searches on the following databases: PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library. Risk of bias evaluation was carried out according to the Fowkes and Fulton guidelines. Meta-analyses were performed with tests for sensitivity and statistical heterogeneity.

RESULTS

Of the 368 potentially eligible articles, 12 studies were included for qualitative analysis, and 9 contributed to the meta-analysis. In terms of periodontal-related parameters, cirrhotic patients presented a greater mean of clinical attachment loss (CAL) (weighted mean differences [WMD] = 1.078, 95% confidence interval [95% CI]: 0.546-1.609, p < 0.001), probing depth (PD) (WMD = 0.796, 95% CI: 0.158 to 1.434, p = 0.015) and alveolar bone loss (ABL) (WMD = 3.465, 95% CI: 2.946-3.984, p < 0.001) than those without, while no statistical difference was found in the papillary bleeding index (PBI) (WMD = 0.166, 95% CI: -0546 to 0.878, p = 0.647) and bleeding on probing (BOP) (WMD = 4.913, 95% CI: -3.099 to 12.926, p = 0.229). The prevalence of periodontitis was higher in cirrhotic patients than in the control group (odds ratio [OR] = 2.630, 95% CI: 1.531-4.520, p < 0.001).

CONCLUSIONS

The results indicate that cirrhotic patients have poor periodontal conditions and a higher prevalence of periodontitis. We advocate that they should receive regular oral hygiene and basic periodontal treatment.

Interpreting tree ensemble machine learning models with endoR

Tree ensemble machine learning models are increasingly used in microbiome science as they are compatible with the compositional, high-dimensional, and sparse structure of sequence-based microbiome data. While such models are often good at predicting phenotypes based on microbiome data, they only yield limited insights into how microbial taxa may be associated. We developed endoR, a method to interpret tree ensemble models. First, endoR simplifies the fitted model into a decision ensemble. Then, it extracts information on the importance of individual features and their pairwise interactions, displaying them as an interpretable network. Both the endoR network and importance scores provide insights into how features, and interactions between them, contribute to the predictive performance of the fitted model. Adjustable regularization and bootstrapping help reduce the complexity and ensure that only essential parts of the model are retained. We assessed endoR on both simulated and real metagenomic data. We found endoR to have comparable accuracy to other common approaches while easing and enhancing model interpretation. Using endoR, we also confirmed published results on gut microbiome differences between cirrhotic and healthy individuals. Finally, we utilized endoR to explore associations between human gut methanogens and microbiome components. Indeed, these hydrogen consumers are expected to interact with fermenting bacteria in a complex syntrophic network. Specifically, we analyzed a global metagenome dataset of 2203 individuals and confirmed the previously reported association between Methanobacteriaceae and Christensenellales. Additionally, we observed that Methanobacteriaceae are associated with a network of hydrogen-producing bacteria. Our method accurately captures how tree ensembles use features and interactions between them to predict a response. As demonstrated by our applications, the resultant visualizations and summary outputs facilitate model interpretation and enable the generation of novel hypotheses about complex systems.

Oral Health and Liver Disease: Bidirectional Associations—A Narrative Review

Several links between chronic liver disease and oral health have been described and are discussed in this narrative review. Oral manifestations such as lichen planus, ulcers, xerostomia, erosion and tongue abnormalities seem to be particularly prevalent among patients with chronic liver disease. These may be causal, coincidental, secondary to therapeutic interventions, or attributable to other factors commonly observed in liver disease patients. In addition, findings from both experimental and epidemiological studies suggest that periodontitis can induce liver injury and contribute to the progression of chronic liver disease through periodontitis-induced systemic inflammation, endotoxemia, and gut dysbiosis with increased intestinal translocation. This has brought forward the hypothesis of an oral-gut-liver axis. Preliminary clinical intervention studies indicate that local periodontal treatments may lead to beneficial liver effects, but more human studies are needed to clarify if treatment of periodontitis truly can halt or reverse progression of liver disease and improve liver-related outcomes.

Deciphering the toxicological role of Porphyromonas gingivalis derived endotoxins in liver diseases

Periodontitis is a most prevalent and infectious multifactorial inflammatory disease and is characterized by the progressive destruction of the tooth-supporting tissues. Porphyromonas gingivalis, a Gram‑negative oral anaerobe, mainly causes periodontitis and it is one of the most important risk factors responsible for aggravation of existing systemic diseases. Several experimental and clinical studies have shown the positive association between periodontitis and different forms of liver disease. Periodontal diseases increase the prevalence of non-alcoholic fatty liver diseases and cirrhosis. Infected periodontium and pathogens in the periodontal microenvironments release pathogen-associated molecular patterns such as peptidoglycan, lipopolysaccharides, gingipain, fimbria, bacterial DNA, etc, and damage-associated molecular patterns such as interleukins-1α, β, - 8, and galectin-3, etc. These virulence factors and cytokines enter the bloodstream, disseminate into the whole body, and induce a variety of systemic pathological effects, including liver diseases (steatosis and fibrosis). Maintaining oral hygiene by scaling and root planning significantly improves liver damage in patients with periodontitis. Dentists and physicians should have more awareness in understanding the bidirectional nature of the relationship between oral and systemic diseases. Importantly, periodontitis condition aggravates simple fatty liver into fibrotic disease and therefore, the aim of this review is to understand the possible link between periodontitis and liver diseases.

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.

The association between oral health status and the clinical outcome of cirrhotic patients on the waiting list for liver transplantation

Liver transplantation (LT) candidates often present with poor oral hygiene, which could potentially lead to systemic infections and sepsis owing to their cirrhotic state. In this study, we investigated the oral health status of LT candidates and propose guidance for the detection and treatment of encountered oral lesions among these patients. The decayed, missing, and filled teeth (DMFT) index was determined through oral examination. The presence of dental calculus was detected using panoramic radiography and defined by the radiopaque dental calculus (RDC). From January 2011 to August 2018, 56 LT candidates were enrolled with a median follow-up of 39 months. The overall mean numbers of decayed, missing, and filled teeth among these patients were 2.7 ± 2.8, 10.9 ± 8.3, and 5.4 ± 4.5, respectively. Eighteen patients (32.1%) had RDC. The 5-year survival rates of all 56 patients was 57.7%, while that of those who either received LT (23 patients) or not were 82.1% and 39.8%, respectively. A Cox regression model revealed better overall survival of patients after LT (adjusted hazard ratio [aHR] = 0.067, p = 0.001), worse survival among patients with RDC (aHR = 3.468, p = 0.010), at Child-Pugh stages B and C (aHR for stage B = 11.889, p = 0.028; aHR for stage C = 19.257, p = 0.013) compared to patients at Child-Pugh stage A, and those with a model for end-stage liver disease (MELD) score ≥25 (aHR = 13.721, p = 0.018). This study demonstrates that RDC was associated with worse prognosis in LT candidates. We therefore recommend that interprofessional collaboration should be a routine preoperative procedure for the evaluation of oral hygiene among LT candidates.

Oral-Gut Microbiome Axis in Gastrointestinal Disease and Cancer

It is well-known that microbiota dysbiosis is closely associated with numerous diseases in the human body. The oral cavity and gut are the two largest microbial habitats, playing a major role in microbiome-associated diseases. Even though the oral cavity and gut are continuous regions connected through the gastrointestinal tract, the oral and gut microbiome profiles are well-segregated due to the oral-gut barrier. However, the oral microbiota can translocate to the intestinal mucosa in conditions of the oral-gut barrier dysfunction. Inversely, the gut-to-oral microbial transmission occurs as well in inter- and intrapersonal manners. Recently, it has been reported that oral and gut microbiomes interdependently regulate physiological functions and pathological processes. Oral-to-gut and gut-to-oral microbial transmissions can shape and/or reshape the microbial ecosystem in both habitats, eventually modulating pathogenesis of disease. However, the oral-gut microbial interaction in pathogenesis has been underappreciated to date. Here, we will highlight the oral-gut microbiome crosstalk and its implications in the pathogenesis of the gastrointestinal disease and cancer. Better understanding the role of the oral-gut microbiome axis in pathogenesis will be advantageous for precise diagnosis/prognosis and effective treatment.

Oral–Gut Microbiome Axis in Gastrointestinal Disease and Cancer

It is well-known that microbiota dysbiosis is closely associated with numerous diseases in the human body. The oral cavity and gut are the two largest microbial habitats, playing a major role in microbiome-associated diseases. Even though the oral cavity and gut are continuous regions connected through the gastrointestinal tract, the oral and gut microbiome profiles are well-segregated due to the oral–gut barrier. However, the oral microbiota can translocate to the intestinal mucosa in conditions of the oral–gut barrier dysfunction. Inversely, the gut-to-oral microbial transmission occurs as well in inter- and intrapersonal manners. Recently, it has been reported that oral and gut microbiomes interdependently regulate physiological functions and pathological processes. Oral-to-gut and gut-to-oral microbial transmissions can shape and/or reshape the microbial ecosystem in both habitats, eventually modulating pathogenesis of disease. However, the oral–gut microbial interaction in pathogenesis has been underappreciated to date. Here, we will highlight the oral–gut microbiome crosstalk and its implications in the pathogenesis of the gastrointestinal disease and cancer. Better understanding the role of the oral–gut microbiome axis in pathogenesis will be advantageous for precise diagnosis/prognosis and effective treatment.

Fibrosis and the intestinal microbiome; a focus on chronic liver disease

The role of the microbiome in progression of liver disease is an exciting area of research that is advancing rapidly supported by the development of next-generation sequencing and bioinformatics tools that simultaneously identify the composition and function of the microbiome. Changes in the microbiome are associated with pathogenesis of chronic liver disease; specifically, changes in microbiome composition predict disease severity and specific microbial signatures can be used to distinguish between mild disease, advanced fibrosis and cirrhosis. Future work combining functional metagenomic analysis with preclinical mechanistic studies will be key to advancing our understanding of how the microbiome affects the pathogenesis of different chronic liver disease aetiologies and to identify personalised therapeutics based on modulation of the microbiome and its function.

Ursodeoxycholic acid attenuates the expression of proinflammatory cytokines in periodontal cells

BACKGROUND

Ursodeoxycholic acid (UDCA) is one of the first-line therapeutic medications used in treatment of cholestatic liver disease. Considering that periodontitis is epidemiologically linked to liver diseases, the question arises weather UDCA holds anti-inflammatory properties on periodontal health. Herein, we provide information that support anti-inflammatory effects of UDCA on three different periodontium-related cell types.

METHODS

Gingival fibroblasts and the oral human squamous carcinoma cell line HSC-2 were exposed to interleukin (IL)1β and tumor necrosis factor (TNF)α with and without UDCA. Murine RAW 264.7 macrophages were incubated with sterile-filtered human saliva also in the presence of UDCA. The expression of inflammatory cytokines was measured by reverse transcription-polymerase chain reaction. Immunoassay was applied to detect the production of IL6. Immunostaining was performed for the p65 subunit to further support the anti-inflammatory role of UDCA.

RESULTS

We report here that UDCA significantly reduced the IL1β and TNFα-induced expression of IL1, IL6, and IL8 in gingival fibroblasts and the HSC-2 cell line. In RAW 264.7 macrophages, UDCA attenuated the expression of IL1α, IL1β, and IL6 that was increased by saliva. Immunoassay confirmed the capacity of UDCA to reduce inflammation-induced production of IL6 in gingival fibroblasts, HSC-2 and RAW 264.7 cells. Immunostaining revealed the blocking of nuclear translocation of p65 in gingival fibroblasts.

CONCLUSIONS

Taken together, UDCA can attenuate the provoked expression of inflammatory cytokines in oral fibroblasts, oral human squamous carcinoma cells and macrophages in vitro. These data support the hypothesis that patients with cholestatic liver disease might benefit from UDCA with respect to periodontal health.

Dental problems and chronic diseases in mentally ill homeless adults: a cross-sectional study

Background

Dental problems (DPs) and physical chronic diseases (CDs) are highly prevalent and incident in people with low socioeconomic status such as homeless individuals. Yet, evidence on the association between DPs and physical CDs in this population is limited. In the present study, we assessed the association between DPs and type and number of CDs in individuals experienced chronic homelessness and serious mental health problems.

Methods

We analyzed cross-sectional baseline data from 575 homeless adults with serious mental health problems participating in the Toronto site of the At Home/Chez Soi randomized controlled trial. Chronic DPs (lasting at least 6 months) were the primary exposure variable. Presence of self-reported CDs, including heart disease, effect of stroke, hypertension, diabetes, asthma, chronic bronchitis/emphysema, stomach or intestinal ulcer, inflammatory bowel disease, migraine, thyroid problems, arthritis, kidney/bladder problems, liver disease (other than hepatitis), and iron-deficiency anemia, were the primary outcomes. The total number of CDs was also analyzed as a secondary outcome.

Logistic regression models were used to assess the association between DPs with each of the studied CDs, and negative binomial regression was used to test the association between DPs with the number of CDs.

Results

In our 575 homeless participants (68.5% males) with mean age 40.3 (11.8) years, a high proportion had DPs (42.5%). The presence of DPs was positively associated with heart disease (adjusted odds ratio (AOR):4.19,1.67–10.52), diabetes (AOR:2.17,1.13–4.17), chronic bronchitis (AOR:2.34,1.28–4.29), stomach or intestinal ulcer (AOR:3.48,1.80–6.73), inflammatory bowel disease (AOR:2.52,1.38–4.60), migraine (AOR:1.80,1.20–2.72), arthritis (AOR:2.71,1.71–4.29), kidney/bladder problems (AOR:2.43,1.30–4.54), and iron-deficiency anemia (AOR:3.28,1.90–5.65). DPs were also associated with a higher number of CDs (IRR: 1.62,1.38–1.90).

Conclusion

Dental health problems in homeless individuals with serious mental disorders are associated with several CDs. Dental care should be better integrated into existing social and health programs serving this population to improve their overall health status.

The AH/CS study is registered with the International Standard Randomized Control Trial Number Register (ISRCTN42520374).

Red complex periodontal pathogens are risk factors for liver cirrhosis

Periodontal disease has been associated with liver disease; however, the identities of the periodontal disease-causing bacteria in patients with viral liver disease remain unknown. The aim of the present study was to determine the counts of the 3 periodontal pathogens that form the red complex in chronic periodontitis (Porphyromonas gingivalis, Tannerella forsythia and Treponema denticola) and 3 other bacteria (Aggregatibacter actinomycetemcomitans, Prevotella intermedia and Fusobacterium necrophorum) in patients with liver disease. A total of 47 patients with liver disease were divided into two groups based on the counts of the red complex bacteria: group A (high counts of red complex bacteria) and group B (low counts of red complex bacteria). The counts of the 6 types of bacteria in saliva and the prevalence of P. gingivalis-specific fimA genotype were determined. In addition, salivary occult blood tests and serological assays were performed. Univariate and multivariate logistic regression analyses were used to analyze the risk factors between the two groups of patients. Hepatitis C virus-related liver disease was the most frequent (41/47; 87.2%) occurrence followed by liver cirrhosis (LC; 12/47; 25.5%) and oral lichen planus (32/47; 68.1%). The significant risk factors between the two groups were LC, albumin (Alb) level, ratios of each bacteria and prevalence of the fimA II genotype. The 3 factors identified in the multivariate analysis to be associated with the red complex bacteria count were low Alb level (<3.7 g/dl), LC and fimA II genotype, with adjusted odds ratios of 6.93, 4.72 and 4.08, respectively (P<0.05). These data indicated that patients with LC were at increased risk of presenting with the red complex bacteria leading to periodontal disease progression. Therefore, these patients may need to take additional care of their oral health compared with patients without LC, which may prove beneficial for the maintenance of their general health.

Periodontitis in individuals with liver cirrhosis: A case-control study

AIM

The aim of this study was to evaluate the association between liver cirrhosis and periodontitis.

METHODS

This case-control study included 294 individuals, 98 cases with liver cirrhosis and 196 controls. A full-mouth periodontal examination was performed and plaque index, probing depth, clinical attachment level and bleeding on probing were recorded. The association of risk variables with periodontitis was tested through univariate analysis and multivariate logistic regression, stratified by alcohol status.

RESULTS

A high prevalence of periodontitis was observed among cases (62.2%) when compared to controls (41.8%). Individuals with cirrhosis presented a chance ~2 higher of having periodontitis than controls (OR = 2.28; 95% CI 1.39-3.78; p < .001). Significant variables associated with periodontitis in the final logistic models were as follows: (a) no/occasional alcohol use model-number of teeth up 14, age ≥45-55 years, male sex and smoking; (b) moderate and intensive alcohol use models-cirrhosis, number of teeth up 14, age ≥45-55 years, male sex and smoking.

CONCLUSIONS

An important risk association between liver cirrhosis and periodontitis was observed. Additionally, the intensive alcohol use significantly increased the risk for periodontitis.

Quality of life, work ability and oral health among patients with chronic liver diseases

BACKGROUND

This study aimed to explore the associations between health-related quality of life and work ability with the oral health status of patients with chronic liver disease.

MATERIAL AND METHODS

A cross-sectional study included 150 patients with chronic liver disease, consecutively seen at University Hospital, Salvador, Brazil. Oral health was evaluated by the Decayed, Missing, and Filled Teeth (DMFT) index and by the presence of gingivitis and periodontitis. Salivary flow was "reduced" when <1.0 mL/min. Health-related quality of life was evaluated by using the 36-Item Short Form Health Survey questionnaire (SF-36); work ability was evaluated by the Work Ability Index questionnaire.

RESULTS

All health-related quality of life indicators were systematically lower among the 99 patients with reduced salivary flow than among the 51 patients with normal salivary flow. Physical Functioning, Role-Physical, and Physical Component Summary scores were strongly correlated (P < 0.005 or less) with the number of Missing Teeth and with DMFT index. Reduced salivary flow was associated (P < 0.05) with poor work ability. Patients with poor or moderate work ability presented higher (P < 0.001) means of the DMFT index than those with good or excellent work ability.

CONCLUSIONS

Patients with chronic liver disease who present poor oral health presented low health-related quality of life and poor work ability. These findings reinforce the need of these patients for specialized stomatological care.

Periodontitis is associated with incident chronic liver disease-A population-based cohort study

BACKGROUND & AIMS

Chronic liver disease is a major health concern worldwide and the identification of novel modifiable risk factors may benefit subjects at risk. Few studies have analyzed periodontitis as a risk factor for liver complications. We studied whether periodontitis is associated with incident severe liver disease.

METHODS

The study comprised 6165 individuals without baseline liver disease who participated in the Finnish population-based Health 2000 Survey (BRIF8901) during 2000-2001, a nationally representative cohort. Follow-up was until 2013 for liver-related admissions, liver cancer and mortality from National Hospital Discharge, Finnish Cancer Registry and Causes of Death Register, Statistics Finland. Mild to moderate periodontitis was defined as ≥1 tooth with periodontal pocket ≥4 mm deep, and advanced periodontitis as ≥5 teeth with such pockets. Multiple confounders were considered.

RESULTS

A total of 79 subjects experienced a severe liver event during follow-up. When adjusted for age, sex and number of teeth, hazards ratios by Cox regression regarding incident severe liver disease were, for mild to moderate periodontitis, 2.12 (95% CI 0.98-4.58), and, for advanced periodontitis, 3.69 (95% CI 1.79-7.60). These risk estimates remained stable after additionally adjusting for alcohol use, smoking, metabolic risk, serum gamma-glutamyltransferase, dental-care habits, lifestyle and socioeconomic status. Periodontal disease-associated liver risk was accentuated among subjects with non-alcoholic fatty liver disease or heavy alcohol use at baseline.

CONCLUSIONS

Periodontitis was associated with incident liver disease in the general population independently of various confounders. As a preventable disease, periodontal disease might present a modifiable risk factor for chronic liver disease.

Altered Microbiome in Patients With Cirrhosis and Complications

In patients with cirrhosis, the gut microbiome are affected by multiple gut and systemic alterations. These changes lead to dysbiosis in the microbiota of different parts of the body, resulting in inflammation. The constant immune stimulation resulting in part from dysbiosis is associated with morbidity in patients with cirrhosis. Dysbiosis as a dynamic event worsens with decompensation such as with hepatic encephalopathy, infections or acute-on-chronic liver failure (ACLF). These microbial patterns could be applied as diagnostic and prognostic measures in cirrhosis in the outpatient and inpatient setting. Current therapies for cirrhosis have differing impacts on gut microbial composition and functionality. Dietary modifications and the oral cavity have emerged as newer targetable factors to modulate the microbiome, which could affect inflammation and, potentially improve outcomes. Additionally, fecal microbial transplant is being increasingly studied to provide compositional and functional modulation of the microbiome. Ultimately, a combination of targeted therapies may be needed to provide an optimal gut milieu to improve outcomes in cirrhosis.

Periodontal therapy favorably modulates the oral-gut-hepatic axis in cirrhosis

Cirrhosis is associated with a systemic proinflammatory milieu, endotoxemia, and gut dysbiosis. The oral cavity could be an additional source of inflammation. We aimed to determine the effect of periodontal therapy in cirrhosis through evaluating endotoxemia, inflammation, cognition, and quality of life (QOL). Age-matched cirrhotic and noncirrhotic subjects exhibiting chronic gingivitis and/or mild or moderate periodontitis underwent periodontal therapy with follow-up at 30 days. Saliva/stool for microbial composition and serum for Model for End-stage Liver Disease (MELD) score, endotoxin and lipopolysaccharide binding protein (LBP) and immune-inflammatory markers (IL-1β; IL-6; histatins 1, 3, 5; and lysozyme) were collected at baseline and day 30. The cognitive function and QOL were also evaluated similarly. A separate group of cirrhotic patients were followed for the same duration without periodontal therapy. Cirrhotics, especially those with hepatic encephalopathy (HE), demonstrated improved dysbiosis in stool and saliva, and improved endotoxin, LBP, and salivary and serum inflammatory mediators following periodontal therapy. These parameters, which were higher in HE at baseline, became statistically similar posttherapy. Pretherapy vs. posttherapy QOL and cognition also improved in HE patients following oral interventions. On the other hand, LBP and endotoxin increased over time in cirrhotic patients not receiving therapy, but the rest of the parameters, including microbiota remained similar over time in the no-therapy group. This proof-of-concept study demonstrates that periodontal therapy in cirrhosis, especially in those with HE, is associated with improved oral and gut dysbiosis, systemic inflammation, MELD score, and cognitive function, which was not observed in those who did not receive therapy over the same time period. NEW & NOTEWORTHY Systematic periodontal therapy in cirrhotic outpatients improved endotoxemia, as well as systemic and local inflammation, and modulated salivary and stool microbial dysbiosis over 30 days. This was associated with improved quality of life and cognition in patients with prior hepatic encephalopathy. In a cirrhotic group that was not provided periodontal therapy, there was an increase in endotoxin and lipopolysaccharide binding protein in the same duration. The oral cavity could be an important underdefined source of inflammation in cirrhosis.

Association of tooth loss with liver cancer incidence and chronic liver disease mortality in a rural Chinese population

BACKGROUND

Tooth loss has been reported to be associated with the risk of liver cancer in several prior studies in economically advantaged countries. Whether this relationship is also evident in economically disadvantaged populations is not known.

METHODS

We analyzed data from the Nutrition Intervention Trials, two randomized placebo-controlled trials of vitamin/mineral supplementation in Linxian, China. Participants who reported having lost permanent teeth were examined to determine the number of teeth remaining. In the 30-year follow-up period, 329 liver cancers were diagnosed and 368 chronic liver disease deaths occurred. Tooth loss was categorized based on loess smoothed age-specific predicted quartiles. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the two outcomes.

RESULTS

Overall, persons in the highest quartile of age-specific tooth loss had an increased risk of liver cancer (HR = 1.27, 95%CI: 0.96, 1.67) which was not statistically significant. Results varied by sex and body mass index (BMI), however. Women in the highest quartile of age-specific tooth loss had a significantly increased risk (HR = 1.64, 95%CI: 1.04, 2.59), while men did not (HR = 1.08, 95%CI = 0.75, 1.57), and persons with a BMI > 23.0 kg/m2 (HR = 1.71, 95%CI: 1.00, 2.92) had a significantly increased risk, while persons with a BMI <23.0 kg/m2 did not (HR = 1.14, 95%CI: 0.82, 1.5). No relationships with chronic liver disease mortality were observed.

CONCLUSIONS

In a rural, economically disadvantaged population, persons with the highest levels of age-specific tooth loss had an increased risk of liver cancer. The results, which were stronger among women and persons with greater BMI, suggest that periodontal disease may increase risk of liver cancer.

Unique subgingival microbiota associated with periodontitis in cirrhosis patients

Liver cirrhosis is a severe disease with major impact on the overall health of the patient including poor oral health. Lately, there has been increasing focus on oral diseases as cirrhosis-related complications due to the potential impact on systemic health and ultimately mortality. Periodontitis is one of the most common oral diseases in cirrhosis patients. However, no studies have investigated the composition of the subgingival microbiome in patients suffering from periodontitis and liver cirrhosis. We analysed the subgingival microbiome in 21 patients with periodontitis and cirrhosis using long-reads Illumina sequencing. The subgingival microbiota was dominated by bacteria belonging to the Firmicutes phylum and to a lesser extend the Actinobacteria and Bacteroidetes phyla. Bacteria usually considered periodontal pathogens, like Porhyromonas ginigivalis, Tannerella forsythia, Treponema denticola, generally showed low abundancy. Comparing the microbiota in our patients with that of periodontitis patients and healthy controls of three other studies revealed that the periodontitis-associated subgingival microbiota in cirrhosis patients is composed of a unique microbiota of bacteria not normally associated with periodontitis. We hypothesise that periodontitis in cirrhosis patients is a consequence of dysbiosis due to a compromised immune system that renders commensal bacteria pathogenic.

One or two ligatures inducing periodontitis are sufficient to cause fatty liver

BACKGROUND

Periodontitis is a chronic disease that due to an intense inflammatory response triggers systemic changes such as hepatic alterations. This study aimed to compare hepatic damage in rats that received experimental periodontitis at one or two periodontal sites with ligatures.

MATERIAL AND METHODS

Eighteen rats were separated into three groups: control, without ligature; periodontitis 1, with one ligature; and periodontitis 2, with two ligatures. The following parameters were assessed: gingival bleeding index, probing pocket depth, tooth mobility, alveolar bone loss, malondialdehyde (MDA) and myeloperoxidase (MPO) activity in periodontal tissue; histopathological evaluation of hepatic tissue (steatosis score); glutathione levels (GSH), MDA, MPO, cholesterol and triglycerides in the liver; and serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST).

RESULTS

Periodontal evaluation data showed that the periodontitis model worked well. The groups with periodontitis did not differ significantly in relation to MPO activity and MDA levels in the gingival samples, but they were significantly different when compared with the control group. Steatosis was observed in the histological analysis of the groups with periodontitis, but between the periodontitis groups, two ligatures did not cause increase in steatosis score. The levels of GSH, MDA, total cholesterol and triglycerides in the hepatic tissue were not altered between groups with periodontitis, but they showed significant differences in comparison with the control group. The activity of MPO in hepatic tissue and serum levels of AST and ALT did not present significant difference among the three groups.

CONCLUSION

In conclusion, our results demonstrated that one or two ligatures inducing periodontitis were both sufficient to cause fatty liver. Steatosis caused by two ligatures did not present larger extension and severity than steatosis caused by one ligature.

Effect of painless STA on tooth extraction of elderly patients with periodontal diseases

This study compared the effects of tooth extractions under novel painless single tooth anesthesia (STA) and conventional anesthesia on elderly patients with periodontal diseases, and the impact of painless STA on clinical indicators of the patients. Elderly patients (n=116) with periodontal diseases who were treated in Jinan Central Hospital were selected to undergo extraction operation on loose teeth; all the patients were randomly divided into two groups. The tooth extraction operations were performed after painless STA and cartridge anesthesia; the effects of the tooth extraction operations and the operation time were recorded; Visual Analogue Scale (VAS), Kuttner facial expression scale, Frankl treatment compliance scale and Houpt behavior rating scale were utilized to assess and record the clinical indicators of the patients during the operations; the impacts of the two anesthesia techniques on the effect of the tooth extraction of patients with periodontal diseases were comprehensively analyzed. Compared with conventional cartridge anesthesia, painless STA could effectively shorten the operation time (P<0.01); the Frankl treatment compliance score and Houpt behavior rating score of patients receiving painless STA were remarkably higher than those of patients receiving conventional cartridge anesthesia (P<0.01); during the operation, painless STA could effectively reduce the blood pressure and slow the heart rate by comparing with cartridge anesthesia (P<0.01, P<0.05); the scores of STA and Kuttner facial expressions in patients receiving painless STA were significantly lower than those in patients receiving conventional cartridge anesthesia (P<0.01); after the operation, the incidence of adverse reactions, such as pain and swelling, in patients receiving painless STA was obviously decreased compared with that in patients receiving conventional cartridge anesthesia (P<0.01). The novel painless STA can notably shorten the time of tooth extraction of elderly patients with periodontal diseases, reduce postoperative pain and swelling, increase the compliance of the operation, alleviate the impact of tooth extraction operation on the clinical indicators of the patients and relieve the pain of patients caused by the operation.

Oral Health and Quality of Life in Candidates for Liver Transplantation

BACKGROUND

There is a gap in the scientific literature about the association between oral health and the health-related quality of life of patients on the liver transplantation waiting list. The aim of this work was to describe aspects of oral health and quality of life of patients on a liver transplantation waiting list.

METHODS

This was a cross-sectional study among 116 patients with chronic hepatic disease: 29 on a liver transplantation waiting list (Model for End-Stage Liver Disease score ≥15) and 87 under monitoring in a gastroenterology service in a Brazilian university hospital. Oral health was evaluated according to criteria recommended by the World Health Organization and by the European Association of Dental Public Health. Health-related quality of life was evaluated by means of the 36-Item Short-Form Health Survey (SF-36).

RESULTS

Patients on the liver transplantation waiting list presented poorer health-related quality of life than those who were not on the list in the domains physical functioning, role physical, bodily pain, general health perceptions, and social functioning and in the physical component summary. Periodontitis affected 72.4% of the patients on the liver transplantation waiting list, but only 27.6% of the patients not on that list. Reduced salivary flow was associated with poorer mental health component summary in hepatitis C patients.

CONCLUSIONS

Patients on the liver transplantation waiting list presented poorer health-related quality of life than those who were not on the list, mainly in the indicators concerning physical health, as well as higher frequencies of decayed teeth and periodontitis. The mental health component summary was associated with reduced salivary flow in hepatitis C patients.

Microbiota, cirrhosis, and the emerging oral-gut-liver axis

Cirrhosis is a prevalent cause of morbidity and mortality, especially for those at an advanced decompensated stage. Cirrhosis development and progression involves several important interorgan communications, and recently, the gut microbiome has been implicated in pathophysiology of the disease. Dysbiosis, defined as a pathological change in the microbiome, has a variable effect on the compensated versus decompensated stage of cirrhosis. Adverse microbial changes, both in composition and function, can act at several levels within the gut (stool and mucosal) and have also been described in the blood and oral cavity. While dysbiosis in the oral cavity could be a source of systemic inflammation, current cirrhosis treatment modalities are targeted toward the gut-liver axis and do not address the oral microbiome. As interventions designed to modulate oral dysbiosis may delay progression of cirrhosis, a better understanding of this process is of the utmost importance. The concept of oral microbiota dysbiosis in cirrhosis is relatively new; therefore, this review will highlight the emerging role of the oral-gut-liver axis and introduce perspectives for future research.

Association Between High Serum Total Cholesterol and Periodontitis: National Health and Nutrition Examination Survey 2011 to 2012 Study of American Adults

BACKGROUND

Clinical studies have suggested that lipids increase activity of white blood cells. The objective of this study is to examine whether high serum total cholesterol (STC) is associated with periodontitis.

METHODS

A total of 1,061 participants from the 2011 to 2012 National Health and Nutrition Examination Survey who underwent both periodontal examination and laboratory test for STC was included. To examine effects of high STC on periodontitis, odds ratios were calculated, adjusting for age, sex, education, income, smoking status, diabetes, body mass index, and calcium levels.

RESULTS

Statistically significant associations were observed between borderline as well as high STC and periodontitis. Study participants with STC between 200 and 239 mg/dL (borderline) were 1.67 times (95% confidence interval [CI]: 1.13 to 2.47) as likely to have periodontitis as those with normal levels (≤199 mg/dL), and those with STC ≥240 mg/dL (high) were 2.22 times (95% CI: 1.27 to 3.87) as likely to have periodontitis as those with normal levels.

CONCLUSIONS

Positive significant association was observed between STC and periodontitis. Results of the present study provide insight into potential risk factors for periodontitis. High STC levels could be a potential risk factor for the disease; however, further studies need to be conducted to understand the actual relationship between STC levels and periodontitis and to establish causality and directional association.