Periodontal therapy reduces plasma levels of interleukin-6, C-reactive protein, and fibrinogen in patients with severe periodontitis and refractory arterial hypertension

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROTOCOL REGISTRATION

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

Could the periodontal therapy improve the cardiologic patient health? A narrative review

BACKGROUND

Cardiovascular diseases (CVD) is the major cause of mortality globally, with increasing evidence suggesting a link between periodontitis, and CVD. This study aims to explore the association between periodontitis and CVD, and the impact of periodontal therapy on cardiovascular health.

METHODS

This review synthesized findings from preclinical and clinical studies, without publication year restrictions, examining periodontitis and CVD through various lenses. Scientific databases were inspected with keywords related to periodontitis and CVD.

RESULTS

The review identifies a substantial association between periodontitis and an increased risk of several CVD, supported by both epidemiological and interventional studies. Results suggest the complexity of the relationship, influenced by factors like the severity of periodontitis and the presence of other systemic conditions. Clinical data indicates that periodontal therapy, particularly non-surgical periodontal therapy, may reduce systemic inflammatory markers and thus may play a role in the primary and secondary prevention of CVD events, highlighting the potential of periodontal therapy to not only maintain oral health but also to modulate cardiovascular risk factors.

CONCLUSIONS

Current evidence supports a significant association between periodontitis and increased cardiovascular risk, promoting integrated healthcare approaches that consider oral health as a key-component of cardiovascular care and wellbeing.

Oral health as a modifiable risk factor for cardiovascular diseases

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide with a high socioeconomic burden. Increasing evidence supports a convincing connection with increased cardiovascular risk of periodontal diseases (PD), a group of widespread, debilitating, and costly dysbiotic relapsing-remitting inflammatory diseases of the tissues supporting the teeth. Herein, we ensembled the best available evidence on the connection between CVDs and PD to review the recently emerging concept of the latter as a non-traditional risk factor for CVDs. We focused on oral dysbiosis, inflammation-associated molecular and cellular mechanisms, and epigenetic changes as potential causative links between PD and CVDs. The available evidence on the effects of periodontal treatment on cardiovascular risk factors and diseases was also described.

Interaction between hypertension and periodontitis

OBJECTIVE

The possible association between hypertension and periodontitis and the effect of hypertension on periodontal treatment were investigated by evaluating salivary and gingival crevicular fluid (GCF) interleukin (IL)-6 and C reactive protein (CRP) levels.

METHODS

Forty-two healthy individuals without any previously diagnosed systemic disease [10 periodontally healthy (control) and 10 periodontitis (CP)] and subjects with hypertension [13 periodontally healthy (HP) and 9 with periodontitis (CP + HP)] participated in the study. GCF and saliva samples were obtained at baseline and 4 weeks after Phase I periodontal treatment. Biochemical parameters were analyzed using ELISA.

RESULTS

Before the periodontal treatment, significantly higher GCF IL-6 and CRP levels were detected in CP + HP and CP groups compared to HP and control groups (p < 0.01). Salivary CRP level in CP + HP group was found to be higher than the control group (p < 0.05). Statistically significant gingival and plaque index measurements (p < 0.01) might suggest a possible effect of hypertension on periodontal status. Periodontal treatment significantly improved the clinical indices; however, biochemical parameters did not change after the treatment.

CONCLUSION

The association of hypertension with periodontitis through local salivary and GCF inflammatory mediators might be possible in disease process.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

The effect of non-surgical periodontal therapy on salivary IL-6 levels in patients with moderate to severe generalized chronic periodontitis

BACKGROUND

Gene regulation of IL-6 is characterized by the presence of inflammatory cytokines, bacterial products, viral infection, and activation of the diacylglycerol-, cyclic AMP-, or Ca + + -activated signal transduction pathways.

AIM

Scaling and root planning (SRP), a non-surgical periodontal therapy, was studied in connection to several clinical parameters for its effect on salivary IL-6 levels in patients with generalized chronic periodontitis.

METHODS

For this study, a total of 60 GCP patients were included. Plaque index (PI), gingival index (GI), pocket probing depth (PPD), bleeding on probing percentage (BOP%), and clinical attachment loss were among the clinical indicators covered (CAL).

RESULTS

Following SRP, mean IL-6 levels in patients with GCP were significantly higher in the pre-treatment group (2.93 5.17 pg/ml; p 0.05) than in the posttreatment group (5.78 8.26 pg/ml; baseline). Pre- and post-treatment IL-6 levels for PI (pre), BOP percent (pre/post), GI (post), and PPD were found to be positively correlated (post). In patients with GCP, the study showed a statistically significant correlation between periodontal metrics and salivary IL-6.

CONCLUSIONS

Changes in periodontal indices and IL-6 levels that are statistically significant over time indicate that non-surgical treatment is effective, and IL-6 can be regarded as a potent disease activity marker.

Periodontitis and systemic inflammation as independent and interacting risk factors for mortality: evidence from a prospective cohort study

BACKGROUND

Recent studies have highlighted the role of low-grade systemic inflammation in linking periodontitis to cardiovascular disease (CVD) outcomes, but many aspects remain unclear. This study examines the independent and reciprocal associations of periodontitis and low-grade systemic inflammation with all-cause and CVD mortality in a large-scale cohort.

METHODS

A total of 3047 participants from the prospective, population-based Study of Health in Pomerania (SHIP-START) were followed for a period of 13.0 ± 2.4 years. For the association between various inflammation/periodontitis measures and mortality, hazard ratios (HRs) were obtained from covariate-adjusted Cox proportional hazards models. Interactions were analysed in joint models: on the multiplicative scale, HRs were reported and on the additive scale, relative excess risks due to interaction (RERI) were calculated. Subject and variable-specific interval records were used to account for time-varying exposures and covariates.

RESULTS

During the observation period, 380 (12.5%) individuals died from CVD (n = 125) or other causes (n = 255). All markers of periodontitis and inflammation showed apparent associations with all-cause mortality (HRs per SD-increase: mean PPD: 1.068 (95% confidence interval (CI): 0.988-1.155), mean CAL: 1.205 (95% CI: 1.097-1.323), missing teeth: 1.180 (95% CI: 1.065-1.307), periodontitis score: 1.394 (95% CI: 1.202-1.616), leukocytes: 1.264 (95% CI: 1.163-1.374), fibrinogen: 1.120 (95% CI: 1.030-1.218), CRP: 1.231 (95% CI: 1.109-1.366), inflammation score: 1.358 (95% CI: 1.210-1.523)). For CVD mortality, all PPD related variables showed significant associations. Interaction modelling revealed some variation with respect to mortality type and exposure combinations. On the additive scale, RERIs for periodontitis score and inflammation score implied 18.9% and 27.8% excess mortality risk for all-cause and CVD mortality, respectively. On the multiplicative scale, the HRs for interaction were marginal.

CONCLUSIONS

Both periodontitis and inflammation were significantly associated with all-cause mortality and CVD mortality. On the additive scale, a substantial excess risk was observed due to the interaction of periodontitis and inflammation, suggesting that the greatest treatment benefit may be achieved in patients with both periodontitis and high systemic inflammation. As periodontal therapy has been reported to also reduce systemic inflammation, the possibility of a reduction in CVD mortality risk by anti-inflammatory treatments, including periodontal interventions, seems worthy of further investigation.

Exploring the Relationship between Periodontitis, Anti-Periodontitis Therapy, and Extra-Oral Cancer Risk: Findings from a Nationwide Population-Based Study

This study aimed to evaluate the systemic impact of periodontitis, previously considered a local disease, on cancer occurrence. We enrolled 683,854 participants, comparing cancer incidence among those with and without periodontitis and assessing the impact of periodontal treatment on cancer risk. Regardless of gender, age, Charlson comorbidity index, or the use of non-steroidal anti-inflammatory drugs, periodontitis patients had a lower overall cancer risk than controls. However, men with periodontitis had a higher risk of prostate cancer (adjusted hazard ratio [aHR] = 1.22; 95% confidence interval [CI] = 1.10-1.35), and both men and women had a higher risk of thyroid cancer (women: aHR = 1.20, 95%CI = 1.04-1.38; men: aHR = 1.51, 95% CI = 1.15-1.99). Patients with periodontitis who received treatment showed a reduced cancer risk (aHR = 0.41; 95% CI = 0.38-0.44) compared to untreated patients. Proper treatment for periodontitis may lower an individual's cancer risk more than if they did not have the disease at all, suggesting that periodontitis is a modifiable risk factor for cancer.

The Effect of Non-Surgical Periodontal Treatment on Patients with Combined Refractory Arterial Hypertension and Stage III, Grade B Periodontitis: A Preliminary Prospective Clinical Study

We sought to evaluate the effects of non-surgical periodontal treatment (NSPT) on periodontal clinical parameters, systemic blood pressure (BP), and plasma levels of systemic inflammation markers in patients with combined refractory arterial hypertension (RAH) and stage III grade B periodontitis. Twenty-seven participants with RAH and periodontitis received NSPT. The analyzed clinical parameters were probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), and plaque index (PI). An assessment was performed for systemic BP, complete blood count, coagulogram, creatinine measurement, C-reactive protein (CRP), glycated hemoglobin, cholesterol, glutamic oxaloacetic transaminase, glutamate pyruvic transaminase, waist-hip ratio, and body mass index. In the follow-up period, twenty-two patients were evaluated at baseline and after 90 and 180 days. The data were submitted for statistical analysis (α = 0.05%). As expected, the clinical results showed a significant improvement in the percentages of PI, BOP, PD, and CAL, which were statistically significant at 90 and 180 days (p < 0.0001). Importantly, NSPT significantly reduced the blood level of CRP (p < 0.02). However, no significant reduction in BP parameters was noted in the evaluated follow-up periods. NSPT, despite the benefits in periodontal clinical parameters, reduced the plasma level of CRP but not the BP in patients with combined RAH and periodontitis.

Effects of nonsurgical periodontal therapy on serum creatinine level in systemically healthy individuals with periodontitis: An interventional study

Background

Several studies have suggested a relationship between periodontitis and serum creatinine levels. Both low and high serum creatinine levels have been reported in individuals with periodontitis. The impact of periodontal therapy on serum creatinine levels has not been fully investigated yet. The aim of the study is to estimate the influence of nonsurgical periodontal therapy (NSPT) on serum creatinine levels in systemically healthy individuals with periodontitis at stage II and stage III with grade A and grade B.

Materials and Methods

Sixty-eight systemically healthy individuals included in the study were divided into Group A (GA) (Periodontally healthy) and Group B (GB) (Periodontitis: stage II and III with grade A and grade B). Gingival index, sulcular bleeding index, probing pocket depth, clinical attachment level, body mass index, and serum creatinine levels were recorded at baseline for both GA and GB, 90 days after NSPT for GB only. Collected data were analyzed statistically.

Results

Serum creatinine levels in GB were significantly higher when compared with GA and serum creatinine levels in GB before and 90 days after NSPT were statistically insignificant.

Conclusions

Serum creatinine levels were higher in individuals with periodontitis when compared with periodontally healthy individuals and NSPT has no considerable influence on the serum creatinine levels in individuals with periodontitis. Further studies are required to confirm these findings.

Alzheimer's Disease: A Systems View Provides a Unifying Explanation of Its Development

Alzheimer's disease (AD) is a debilitating neurodegenerative disorder affecting 50 million people globally. It is characterized by the presence of extracellular senile plaques and intracellular neurofibrillary tangles, consisting of amyloid-β and hyperphosphorylated tau proteins, respectively. Despite global research efforts, there is currently no cure available, due in part to an incomplete understanding of the disease pathogenesis. Numerous possible mechanisms, or hypotheses, explaining the origins of sporadic or late-onset AD have been proposed, including the amyloid-β, inflammatory, vascular, and infectious hypotheses. However, despite ample evidence, the failure of multiple trial drugs at the clinical stage illuminates the possible pitfalls of these hypotheses. Systems biology is a strategy which aims to elucidate the interactions between parts of a whole. Using this approach, the current paper shows how the four previously mentioned hypotheses of AD pathogenesis can be intricately connected. This approach allows for seemingly contradictory evidence to be unified in a system-focused explanation of sporadic AD development. Within this view, it is seen that infectious agents, such as P. gingivalis, may play a central role. The data presented here shows that when present, P. gingivalis or its virulence factors, such as gingipains, may induce or exacerbate pathologies underlying sporadic AD. This evidence supports the view that infectious agents, and specifically P. gingivalis, may be suitable treatment targets in AD.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the third update of a review originally published in 2014, and most recently updated in 2019. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

An information specialist searched five bibliographic databases up to 17 November 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There are no new completed RCTs on this topic since we published our last update in 2019. We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Osteoimmunology in Periodontitis: Local Proteins and Compounds to Alleviate Periodontitis

Periodontitis is one of the most common oral diseases resulting in gingival inflammation and tooth loss. Growing evidence indicates that it results from dysbiosis of the oral microbiome, which interferes with the host immune system, leading to bone destruction. Immune cells activate periodontal ligament cells to express the receptor activator of nuclear factor kappa-B (NF-κB) ligand (RANKL) and promote osteoclast activity. Osteocytes have active roles in periodontitis progression in the bone matrix. Local proteins are involved in bone regeneration through functional immunological plasticity. Here, we discuss the current knowledge of cellular and molecular mechanisms in periodontitis, the roles of local proteins, and promising synthetic compounds generating a periodontal regeneration effect. It is anticipated that this may lead to a better perception of periodontitis pathophysiology.

Managing the Systemic Impact of Periodontitis

Periodontitis is a microbially driven host-mediated disease that leads to loss of periodontal attachment and bone. It is associated with elevation of systemic inflammatory markers and with the presence of systemic co-morbidities. Furthermore, periodontal treatment leads to a 24-48 h-long acute local and systemic inflammatory response. This systemic response might increase the burden of patients with compromised medical history and/or uncontrolled systemic diseases. The correlation between periodontitis and systemic diseases, the impact of periodontitis on the quality of life and public health, the effects of periodontal treatment on systemic health and disease, and the available methods to manage systemic inflammation after periodontal therapy are discussed. The main focus then shifts to a description of the existing evidence regarding the impact of periodontitis and periodontal treatment on systemic health and to the identification of approaches aiming to reduce the effect of periodontitis on systemic inflammation.

A Cross-Sectional Study for Association between Periodontitis and Benign Prostatic Hyperplasia Using the Korean Genome and Epidemiology Study Data

Recently, several studies have suggested the relationship between periodontitis and prostatic disease. However, epidemiological studies on the association between periodontitis and benign prostatic hyperplasia (BPH) are scarce. Hence, we aimed to identify the association between the two diseases using data from the Korean Genome and Epidemiology Study. Among the 173,209 participants, 3297 men with periodontitis and 35,292 controls (without periodontitis) were selected. The history of BPH in participants with periodontitis and the controls were also investigated. Two-tailed analyses, independent t-tests, and chi-square tests were used for statistical analysis. The adjusted odds ratio (OR) for BPH was 1.50 (95% confidence interval, 1.35–1.68; p < 0.001) after adjusting for past medical histories. The adjusted OR for BPH was 1.57 (95% confidence interval, 1.41–1.76; p < 0.001) after adjusting for anthropometric and laboratory data. Collectively, this study provides evidence that periodontitis is associated with BPH. This finding supports the use of regular dental checkups and periodontal treatments to reduce the prevalence and progression of BPH.

The frequency of periodontitis in end-stage renal disease on hemodialysis in a sample of Egyptian population: multi-center clinical cross-sectional study

BACKGROUND

There is a general assumption that periodontal disease is highly prevalent among patients with chronic renal failure undergoing hemodialysis. The aim of the study to estimate the frequency of periodontitis in patients on hemodialysis among a sample of the Egyptian population, as well as the correlation between different clinical parameters of periodontal status with serum creatinine and blood urea. This may rule out the bidirectional relationship between periodontitis and renal failure in patients on hemodialysis.

METHODS

The study was conducted on 263 hemodialysis patients (165 males and 98 females) at three dialysis centers in Benha Governorate, Egypt (Benha Hospital, Tukh hospital, Qalyub hospital). Periodontal parameters including plaque index (PI), gingival index (GI), clinical attachment level (CAL), and probing pocket depth (PPD) had been recorded in these patients. Serum urea and creatinine levels had been measured, the data had been collected and undergone statistical analysis.

RESULTS

Frequency of periodontitis was 85.6% with stage III is the most prevalent stage. There was a significant positive strong correlation between age and periodontitis stage (rs = 0.707, p < 0.001). There was a positive correlation between clinical parameters and serum creatinine level.

CONCLUSION

In the present study, a high frequency of periodontitis had been found among ESRD patients on hemodialysis in the severe form (stage III) periodontitis. There was a significant direct correlation between the severity of periodontitis and CAL with a duration of hemodialysis. There was a weak insignificant association between periodontal indices (PD, BOP, and plaque score) and duration of hemodialysis.

Effect of periodontal treatments on blood pressure

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

What is the future of Periodontal Medicine?

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

Serum Inflammatory and Prooxidant Marker Levels in Different Periodontal Disease Stages

BACKGROUND

Periodontitis has been associated to systemic diseases and this association could be due to an increase in circulating inflammatory and oxidative stress biomarkers in the periodontal disease. This study aimed to evaluate the relationship between inflammatory and pro-oxidant markers according to different stages of periodontitis.

METHODS

This cross-sectional study included 70 subjects who were divided into three groups according to periodontitis stage: stage II (n = 22), stage III (n = 30), and stage IV (n = 18). We evaluated periodontal parameters and levels of high-sensitivity C-reactive protein (hsCRP), fibrinogen, and malondialdehyde (MDA) in serum, and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in urine.

RESULTS

Serum hsCRP and fibrinogen levels were associated with periodontitis severity, which were higher in stage IV than in stages III and II of periodontitis (p = 0.003 and p = 0.025, respectively). We observed a slight yet insignificant increase in MDA levels related to periodontitis severity. Probing depth and clinical attachment loss were associated with serum fibrinogen and hsCRP levels. However, there were no significant associations between periodontal variables and MDA and 8-OHdG levels.

CONCLUSION

Our data support an association between periodontitis and systemic inflammation, which increases with periodontal disease severity. This indicates the importance of the early diagnosis and treatment of periodontal disease to avoid the development or worsening of systemic inflammatory diseases.

Periodontal inflamed surface area is associated with hs-CRP in septuagenarian Japanese adults in cross-sectional findings from the SONIC study

Periodontal disease is a chronic inflammatory condition that affects various peripheral organs. The periodontal inflamed surface area (PISA) quantifies periodontitis severity and the spread of inflammatory wounds. This study aimed to investigate the association between PISA and high-sensitivity C-reactive protein (hs-CRP), a systemic inflammation marker. This study included 250 community-dwelling septuagenarians (69–71 years). We collected information on their medical (e.g., diabetes and dyslipidemia) and dental examinations (e.g., measurement of the probing pocket depth). Generalized linear model analysis was used to explore the association between PISA and hs-CRP levels. There was a significant difference in hs-CRP levels between groups with PISA ≥ 500 and < 500 (p = 0.017). Moreover, the generalized linear model analysis revealed a significant association between PISA and hs-CRP levels (risk ratio = 1.77; p = 0.033) even after adjusting other factors. Further, we found a correlation between PISA and hs-CRP (Spearman’s rank correlation coefficient, rs = 0.181; p = 0.023). Our findings suggest that PISA is an effective index for estimating the effect of periodontitis on the whole body, enabling medical-dental cooperation.

Systemic inflammatory response to non-surgical treatment in hypertensive patients with periodontal infection

Hypertension is associated with chronic inflammation in the tissues and organs that are involved in the regulation of arterial pressure, such as kidneys and blood vessels. Periodontal disease affects systemic inflammatory markers, leading to endothelial dysfunction, atherosclerotic plaque instability, dyslipidaemia, and insulin resistance. These conditions can also cause an increase in the blood pressure. Nonsurgical periodontal therapies, such as scaling and root planning, can affect systemic markers of inflammation. We evaluated the effect of scaling and root planning on serum levels of inflammation biomarkers in hypertensive patients. The sample consisted of 19 hypertensive patients with Periodontitis. The patients underwent laboratory tests that included glycaemia, cholesterol, triglycerides and blood count. Blood pressure was measured before periodontal therapy, and the second blood pressure recording was obtained at the re-evaluation appointment. Quantification of peripheral blood cytokines was performed using the Milliplex Inflammation Human Cytokine kit (Interleukin 1-β, Interleukin-4, Interleukin-6, Interleukin-8, Interleukin-10, Interleukin-12 P70, Interleukin-17A, vascular endothelial growth factor and tumor necrosis factor-alpha). All cytokine levels decreased from the initial examination to reassessment. Cytokines that reflected a statistically significant difference included Interleukin-1β and endothelial vascular growth factor (P = .04 and P = .004). Hypertensive patients with periodontitis undergoing non-surgical periodontal treatment exhibited a decrease in proinflammatory cytokine levels. Non-surgical periodontal treatment decreases the levels of systemic proinflammatory cytokines in controlled hypertensive patients.

Exploring the Role of Interleukin-6 Receptor Inhibitor Tocilizumab in Patients with Active Rheumatoid Arthritis and Periodontal Disease

BACKGROUND

The aim of our study was to explore the influence of weekly subcutaneous administration of interleukin-6 (IL-6) receptor inhibitor tocilizumab (TCZ) on periodontal status in a local longitudinal study of patients with rheumatoid arthritis (RA) and periodontal disease (PD).

METHODS

We performed a 6-month prospective study in 51 patients with chronic periodontitis and moderate-to-severe RA starting TCZ in accordance with local recommendations. Extensive rheumatologic (clinical activity, inflammatory, serological biomarkers) and periodontal (visible plaque index, gingival index, bleeding on probing, probing pocket depth, clinical attachment loss) assessments were done. Changes in RA activity and periodontal status were reassessed after 3 and 6 months.

RESULTS

We demonstrated significant correlations between periodontal status, disease activity, and serologic biomarkers (p < 0.05). Tocilizumab significantly improved the gingival index scores and decreased the number of sites with bleeding on probing after only 3 months (p < 0.05), while the probing pocket depth significantly decreased after 6 months; overall, clinical attachment loss presented only slight changes without any statistical significance as well as teeth count and plaque levels (p > 0.05).

CONCLUSION

IL-6 inhibition is able to improve periodontal outcomes in patients with RA and concomitant PD, which is essentially related to a dramatic decrease in serum inflammatory mediators.

Periodontal therapy and treatment of hypertension-alternative to the pharmacological approach. A systematic review and meta-analysis

AIM

Quantitative comparison of the effects of intensive (IPT) or conventional (CPT) periodontal treatment on arterial blood pressure, endothelial function and inflammatory/metabolic biomarkers.

MATERIALS AND METHODS

A systematic search was conducted to identify randomized controlled trials (RCT) of IPT (supra and subgingival instrumentation). Eight RCTs were included in the meta-analysis. Difference in change of systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after IPT or CPT were the primary outcomes. The secondary outcomes included: endothelial function and selected inflammatory/anti-inflammatory (CRP, IL-6, IL-10, IFN-γ) and metabolic biomarkers (HDL, LDL, TGs).

RESULTS

The overall effect estimates (pooled Weighted Mean Difference (WMD)) of the primary outcome for SBP and DBP was -4.3 mmHg [95%CI: -9.10-0.48], p = 0.08 and -3.16 mmHg [95%CI: -6.51-0.19], p = 0.06 respectively. These studies were characterized by high heterogeneity. Therefore, random effects model for meta-analysis was performed. Sub-group analyses confirmed statistically significant reduction in SBP [WMD = -11.41 mmHg (95%CI: -13.66, -9.15) P < 0.00001] and DBP [WMD = -8.43 mmHg (95%CI: -10.96,-5.91)P < 0.00001] after IPT vs CPT among prehypertensive/hypertensive patients, while this was not observed in normotensive individuals. The meta-analyses showed significant reductions in CRP and improvement of endothelial function following IPT at all analysed timepoints.

CONCLUSIONS

IPT leads to improvement of the cardiovascular health in hypertensive and prehypertensive individuals.

Specific inhibition of IL-6 receptor attenuates inflammatory bone loss in experimental periodontitis

BACKGROUND

Periodontal pathogenesis takes into consideration that disease results from a complex inflammatory immune response. Among the major cytokines related to periodontal damage, interleukin (IL)-6 enhances a cascade of tissue destruction. Tocilizumab (TCZ) is a humanized monoclonal anti-human IL-6 receptor that inhibits IL-6-mediated proinflammatory activity. This study aimed to elucidate whether TCZ inhibits the deleterious effect of ligature-induced periodontitis.

METHODS

Experimental ligature-induced periodontitis was treated with systemic administration of TCZ intraperitoneally in three different concentration dosages (2 mg/kg, 4 mg/kg, and 8 mg/kg. Euthanasia occurred at 7 and 14 days after the initiation of the study. Local changes in the alveolar bone were measured by bone volume, the ratio of bone volume, and trabecular thickness using microcomputed tomography. Attachment loss and inflammatory infiltrate were evaluated by histology. Immune response was analyzed focusing on the Th17 pattern.

RESULTS

TCZ inhibited alveolar bone resorption and attachment loss in 7 and 14 days for all dosage groups in comparison to controls (P  < 0.05). Besides, TCZ induced lower expression of inflammatory infiltrate (P <0.05) and less production of Th17-related cytokines (P <0.05) and RANKL (P <0.05).

CONCLUSIONS

The inhibition of IL-6-mediated proinflammatory activity by IL-6R blocking reduced alveolar bone resorption and attachment loss supported by the modulation of the Th17 periodontal response. Considering the inflammatory status, modulatory therapy may be a promising approach to periodontal disease.

Individual predisposition and the intricate interplay between systemic biomarkers and periodontal risk in a general population

BACKGROUND

Increasing age is associated with systemic diseases as well as with periodontal diseases. We wondered whether a biological age score constructed exclusively from systemic biomarkers would reflect periodontal risk factors at baseline and tooth loss as well as periodontal outcome during 10 years follow-up.

METHODS

From the Study of Health in Pomerania (SHIP) 2256 participants (1072 male, 1184 female) were studied for the relationship of the systemic biomarkers glycated hemoglobin (HbA1c), low density lipoprotein cholesterol (LDL), fibrinogen, white blood cell count, blood pressure, and waist circumference to their age. Construction of a biological age (BA) score allowed its comparison with the participants' actual chronological age (CA) and their predisposition to periodontal disease.

RESULTS

Though nearly identical in CA, participants appearing younger than their true age had a significantly reduced burden of periodontal risk factors. If BA > CA, then risk factors were more frequent including smoking, oral hygiene, dental visits, education, and income. After 10 years, in participants with identical CA, tooth loss followed their BA calculated at baseline, that is, with BA > CA fewer teeth were preserved. Similarly, periodontal measures varied according to BA; sex differences were obvious. Most significant were BA-related differences in inflammatory and anthropometry parameters.

CONCLUSIONS

The results support the assumption that risk profiles aggregated in BA constitute a characteristic susceptibility pattern unique to each individual, common to both systemic and periodontal diseases. Although BA was constructed exclusively from systemic measures at baseline, BA reflects the oral conditions at follow-up.

Inflammation in Periodontal Disease: Possible Link to Vascular Disease

Inflammation is a well-organized protective response to pathogens and consists of immune cell recruitment into areas of infection. Inflammation either clears pathogens and gets resolved leading to tissue healing or remains predominantly unresolved triggering pathological processes in organs. Periodontal disease (PD) that is initiated by specific bacteria also triggers production of inflammatory mediators. These processes lead to loss of tissue structure and function. Reactive oxygen species and oxidative stress play a role in susceptibility to periodontal pathogenic bacterial infections. Periodontal inflammation is a risk factor for systemic inflammation and eventually cardiovascular disease (CVD). This review discusses the role of inflammation in PD and its two way association with other health conditions such as diabetes and CVD. Some of the mechanisms underpinning the links between inflammation, diabetes, CVD and PD are also discussed. Finally, we review available epidemiological data and other reports to assess possible links between oral health and CVD.

Correlations between the properties of saliva and metabolic syndrome: A prospective observational study

Saliva tests, which are easy to perform and non-invasive, can be used to monitor both oral disease (especially periodontal disease) and physical conditions, including metabolic syndrome (MetS). Therefore, in the present study the associations between saliva test results and MetS were investigated based on medical health check-up data for a large population. In total, 1,888 and 2,296 individuals underwent medical check-ups for MetS and simultaneous saliva tests in 2017 and 2018, respectively. In the saliva tests, the buffer capacity of saliva, salivary pH, the salivary white blood cell count, the number of cariogenic bacteria in saliva, salivary occult blood, protein, and ammonia levels were tested using a commercially available kit. The relationships between the results of the saliva tests and MetS components were examined in cross-sectional and longitudinal multivariate analyses. Significant relationships were detected between salivary protein levels and serum HbA1c levels or blood pressure levels and between the buffer capacity of saliva and serum triglyceride levels. In addition, salivary pH was increased irreversibly by impaired renal function. This study suggested that saliva tests conducted during health check-ups of large populations might be a useful screening tool for periodontal disease and MetS/MetS components.

Oral Dysbiosis and Autoimmunity: From Local Periodontal Responses to an Imbalanced Systemic Immunity. A Review

The current paradigm of onset and progression of periodontitis includes oral dysbiosis directed by inflammophilic bacteria, leading to altered resolution of inflammation and lack of regulation of the inflammatory responses. In the construction of explanatory models of the etiopathogenesis of periodontal disease, autoimmune mechanisms were among the first to be explored and historically, for more than five decades, they have been described in an isolated manner as part of the tissue damage process observed in periodontitis, however direct participation of these mechanisms in the tissue damage is still controversial. Autoimmunity is affected by genetic and environmental factors, leading to an imbalance between the effector and regulatory responses, mostly associated with failed resolution mechanisms. However, dysbiosis/infection and chronic inflammation could trigger autoimmunity by several mechanisms including bystander activation, dysregulation of toll-like receptors, amplification of autoimmunity by cytokines, epitope spreading, autoantigens complementarity, autoantigens overproduction, microbial translocation, molecular mimicry, superantigens, and activation or inhibition of receptors related to autoimmunity by microorganisms. Even though autoreactivity in periodontitis is biologically plausible, the associated mechanisms could be related to non-pathologic responses which could even explain non-recognized physiological functions. In this review we shall discuss from a descriptive point of view, the autoimmune mechanisms related to periodontitis physio-pathogenesis and the participation of oral dysbiosis on local periodontal autoimmune responses as well as on different systemic inflammatory diseases.

The Concept of Sustainable Development of Modern Dentistry

This paper concerns the assessment of the current state of dentistry in the world and the prospects of its sustainable development. A traditional Chinese censer was adopted as the pattern, with a strong and stable support on three legs. The dominant diseases of the oral cavity are caries and periodontal diseases, with the inevitable consequence of toothlessness. From the caries 3.5–5 billion people suffer. Moreover, each of these diseases has a wide influence on the development of systemic complications. The territorial range of these diseases and their significant differentiation in severity in different countries and their impact on disability-adjusted life years index are presented (DALY). Edentulousness has a significant impact on the oral health-related quality of life (OHRQoL). The etiology of these diseases is presented, as well as the preventive and therapeutic strategies undertaken as a result of modifying the Deming circle through the fives’ rules idea. The state of development of Dentistry 4.0 is an element of the current stage of the industrial revolution Industry 4.0 and the great achievements of modern dental engineering. Dental treatment examples from the authors’ own clinical practice are given. The systemic safety of a huge number of dentists in the world is discussed, in place of the passive strategy of using more and more advanced personal protective equipment (PPE), introducing our own strategy for the active prevention of the spread of pathogenic microorganisms, including SARS-CoV-2. The ethical aspects of dentists’ activity towards their own patients and the ethical obligations of the dentist community towards society are discussed in detail. This paper is a polemic arguing against the view presented by a group of eminent specialists in the middle of last year in The Lancet. It is impossible to disagree with these views when it comes to waiting for egalitarianism in dental care, increasing the scope of prevention and eliminating discrimination in this area on the basis of scarcity and poverty. The views on the discrimination of dentistry in relation to other branches of medicine are far more debatable. Therefore, relevant world statistics for other branches of medicine are presented. The authors of this paper do not agree with the thesis that interventional dental treatment can be replaced with properly implemented prophylaxis. The final remarks, therefore, present a discussion of the prospects for the development of dentistry based on three pillars, analogous to the traditional Chinese censer obtaining a stable balance thanks to its three legs. The Dentistry Sustainable Development (DSD) > 2020 model, consisting of Global Dental Prevention (GDP), Advanced Interventionist Dentistry 4.0 (AID 4.0), and Dentistry Safety System (DSS), is presented.

Potential Advantages of Peroxoborates and Their Ester Adducts Over Hydrogen Peroxide as Therapeutic Agents in Oral Healthcare Products: Chemical/Biochemical Reactivity Considerations In Vitro, Ex Vivo And In Vivo

Peroxides present in oral healthcare products generally exert favourable protective activities against the development and progression of tooth decay, plaque, gingivitis, and halitosis, etc. However, despite the high level of research focus on hydrogen and carbamide peroxides as therapeutically active (and tooth-whitening) agents, to date the use of alternative chemical forms of peroxides such as peroxoborates for these purposes has received only scant attention. Intriguingly, peroxoborate and its esters with polyols, such as glycerol, have a very diverse chemistry/biochemistry in aqueous solution, for which there is an increasing amount of evidence that it remains distinctive from that of hydrogen peroxide; such properties include self-associative and hydrolytic equilibria, and their abilities to participate in electrophile- or nucleophile-scavenging, metal ion-complexing, redox and free radical reactions, for example. Therefore, the purpose of this detailed commentary is to evaluate both differences and similarities between the molecular/biomolecular reactivities of peroxoborate species and hydrogen peroxide in vitro, ex-vivo and in vivo. It encompasses brief sectional accounts regarding the molecular heterogeneity of peroxoborates, the release of bioactive agents therefrom, and their oxidative attack on oral cavity biomolecules (the nucleophilic or electrophilic character of these oxidations are discussed). Further areas explored are the abilities of borates and peroxoborates to enhance the solubility of iron ions in aqueous solution, their involvements in free radical biochemistry (particularly the complexation of oxygen radical-promoting transition metal ions by, and antioxidant properties of, peroxoborate-polyol ester adducts), and the specific inhibition of protease enzymes. Further aspects focus on the tooth-whitening, oral malodor neutralizing, and potential mutagenic and genotoxic properties of peroxoborates, along with possible mechanisms for these processes. The abilities of peroxoborates, and peroxides in general, to modulate the activities of inflammatory mediators and vitamins, antioxidant or otherwise, are also explored.

Evaluation of salivary and serum asymmetric dimethylarginine (ADMA) levels in patients with periodontal and cardiovascular disease as subclinical marker of cardiovascular risk

BACKGROUND

Asymmetric dimethylarginine (ADMA) plays a crucial role in endothelial function and maybe a link for the known interaction of periodontitis and coronary heart disease (CHD). In this pilot study, we compared the impact of gingival health, periodontitis (CP), CHD, or of both diseases (CP + CHD) on salivary and serum ADMA levels.

METHODS

The clinical and periodontal characteristics, serum, and saliva samples were collected from 35 patients with CP, 33 patients with CHD, 35 patients with both CP + CHD, and 35 healthy subjects. Levels of ADMA and C-reactive protein (CRP) were assessed with a commercially available kit.

RESULTS

The median (25% and 75% percentile) concentrations of salivary and serum ADMA were significantly higher in the CHD group [serum: 1.5 (1.2 to 1.8) μmol/L; salivary 1.3 (1 to 1.7) μmol/g protein, P < 0.01] and in the CP + CHD [serum: 1.8 (1.4 to 2.0) μmol/L; salivary 1.5 (1.2 to 1.7) μmol/g protein, P < 0.001] group compared to CP patients and controls. In univariate models, CP (P = 0.034), CHD (P < 0.001), and hs-CRP (P < 0.001) were significantly associated with serum ADMA, whereas in a multivariate model, hs-CRP remained a significant predictor of serum ADMA (P < 0.001). In a multivariate model, the significant predictors of salivary ADMA levels were hs-CRP (P < 0.001) and education socioeconomic status (P = 0.042).

CONCLUSIONS

Patients with CHD and CP + CHD presented higher levels of salivary and serum ADMA compared to healthy subjects and CP patients. hs-CRP was a significant predictor of increased salivary and serum ADMA levels.

Periodontal disease and cancer: Epidemiologic studies and possible mechanisms

Epidemiologic and cancer control studies on the association of periodontal disease and cancer risk mostly suggest a positive association with overall cancer risk and certain specific types of cancer. These findings are generally consistent among cross‐sectional and longitudinal studies. In this paper, we review epidemiologic studies and current knowledge on periodontal disease and cancer, with a focus on those studies conducted in the years following the Joint European Federation of Periodontology/American Academy of Periodontology Workshop on “Periodontitis and Systemic Diseases” in November 2012. This review also explores the role of chronic inflammation as a biologically plausible mechanistic link between periodontal disease and risk of cancer. Furthermore, it highlights studies that have examined the potential importance of certain periodontal pathogens in this association.

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.

Cross-Sectional Analysis of the Association between Periodontitis and Cardiovascular Disease Using the Korean Genome and Epidemiology Study Data

This cross-sectional study aimed to evaluate the association between periodontitis and cardiovascular disease (CVD) by reviewing and discussing the role of the oral microbiome in periodontitis and CVD. This prospective cohort study used epidemiological data from the Korean Genome and Epidemiology Study from 2004 to 2016. We selected 9973 patients with periodontitis and 125,304 controls (non-periodontitis) from 173,209 participants and analyzed their medical histories to determine the relationship between cerebral stroke/ischemic heart disease and periodontitis. The participants were questioned about any previous history of hypertension, diabetes mellitus, hyperlipidemia, cerebral stroke (hemorrhagic or ischemic), ischemic heart disease (angina or myocardial infarction), and periodontitis. Their body mass index, smoking habit, alcohol intake, nutritional intake, and income were recorded. The Chi-square test, independent t-test, and two-tailed analyses were used for statistical analysis. The adjusted OR (aOR) of periodontitis for stroke was 1.35 (95% confidence interval (CI) = 1.16–1.57, p < 0.001). The aOR of periodontitis for ischemic heart disease was 1.34 (95% CI = 1.22–1.48, p < 0.001). We concluded that periodontitis was associated with CVD and may be a risk factor for CVD. However, further studies are required to determine the association between periodontal treatment and CVD.

Higher Prevalence of Periodontitis and Decayed, Missing and Filled Teeth in Patients with Psoriasis

OBJECTIVE

 The aim of this study is to describe the prevalence and severity of periodontitis and decayed, missing and filled teeth (DMFT) index in patients with psoriasis. As a secondary aim, verify if periodontitis was a risk indicator for psoriasis.

MATERIALS AND METHODS

 A total of 69 patients diagnosed with psoriasis (48.7 ± 14.6 years) and 74 healthy controls (40.3 ± 12.9 years) participated in the study. Probing pocket depth, clinical attachment loss (CAL), bleeding on probing, plaque index, and DMFT index were measured in all subjects. Periodontitis was defined as the presence of at least three interproximal sites with CAL ≥3 mm in different teeth and severe periodontitis should involve at least two interproximal sites in different teeth with CAL ≥5 mm.

STATISTICAL ANALYSIS

 The Mann-Whitney test was used to analyze the demographics and the clinical data. The significance level was 5%. A multivariate logistic regression was conducted, and the odds ratio were calculated to express the risk to develop psoriasis.

RESULTS

 Patients with psoriasis had significantly more sites with CAL ≥3 mm (p < 0.03) and CAL ≥5 mm (p < 0.0001), less sites with plaque (p < 0.0001), fewer teeth (p < 0.0001), and a high DMFT index (p < 0.02) as compared with controls. Severe periodontitis was significantly more frequent (87.1% × 58.1%) and was a risk indicator for psoriasis after adjusting for sex, age, race, and smoking habits (odds ratio: 3.7, 95% confidence interval: 1.5-9.0, p < 0.003).

CONCLUSION

 Patients with psoriasis have higher prevalence of severe periodontitis and higher DMFT than control patients. Severe periodontitis may be a risk indicator for psoriasis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the second update of a review originally published in 2014, and first updated in 2017. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, two trials registries, and the grey literature to September 2019. We placed no restrictions on the language or date of publication. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to August 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Assessment of Vitamin C and Antioxidant Profiles in Saliva and Serum in Patients with Periodontitis and Ischemic Heart Disease

Vitamin C and antioxidants play a crucial role in endothelial function and may be a link for the known interaction of periodontitis and ischemic heart disease (CAD). This pilot study evaluates the association of gingival health, periodontitis, CAD, or both conditions with salivary and serum vitamin C and antioxidant levels. The clinical and periodontal characteristics, serum, and saliva samples were collected from 36 patients with periodontitis, 35 patients with CAD, 36 patients with periodontitis plus CAD, and 36 healthy controls. Levels of vitamin C, antioxidants, and C-reactive protein (hs-CRP) were assessed with a commercially available kit. The median concentrations of salivary and serum vitamin C and antioxidants (α-tocopherol, β-carotene, lutein, and lycopene) were significantly lower in the CAD group (p < 0.001) and in the periodontitis plus CAD group (p < 0.001) compared to periodontitis patients and controls. In univariate models, periodontitis (p = 0.034), CAD (p < 0.001), and hs-CRP (p < 0.001) were significantly negatively associated with serum vitamin C; whereas, in a multivariate model, only hs-CRP remained a significant predictor of serum vitamin C (p < 0.001). In a multivariate model, the significant predictors of salivary vitamin C levels were triglycerides (p = 0.028) and hs-CRP (p < 0.001). Patients with CAD and periodontitis plus CAD presented lower levels of salivary and serum vitamin C compared to healthy subjects and periodontitis patients. hs-CRP was a significant predictor of decreased salivary and serum vitamin C levels.

Effects of non-surgical periodontal therapy on inflammatory markers of psoriasis: A randomized controlled trial

AIM

The purpose of this randomized controlled clinical study was to evaluate the effect of non-surgical mechanical periodontal therapy on the inflammatory status and severity of psoriasis in subjects with psoriasis.

MATERIAL AND METHODS

The study population consisted of 92 periodontitis patients with psoriasis vulgaris suffering from an untreated periodontal disease. Two randomized groups were formed from these patients: immediate periodontal therapy (test group, n = 46) and delayed periodontal therapy (control group, n = 46). Periodontal clinical measures, on salivary interleukin 2, interleukin 6 and secretory immunoglobulin A levels and the Psoriasis Area and Severity Index (PASI) scores were evaluated at baseline and on the 8th week in control and test groups.

RESULTS

Eight weeks after completion of non-surgical periodontal therapy (test group) or initial examination (control group), a significant decrease was observed in interleukin 2, interleukin 6 level and in PASI score, whereas a significant increase was observed in secretory immunoglobulin A levels in the test group (p < .05).

CONCLUSION

Within the limits of this study, the results suggest that effective periodontal therapy improves the psoriasis condition in patients afflicted by both diseases.

A review of the influence of periodontal treatment in systemic diseases

The effects and consequences of periodontal diseases might not be confined to the oral cavity. A great body of evidence has arisen supporting the claim demonstrating an association with several systemic conditions and diseases. With different levels of evidence, an association between periodontal disease and cardiovascular disease, diabetes, psoriasis, rheumatoid arthritis, pregnancy outcomes and respiratory diseases has been established. However, the true nature of this association, if it is causal, still remains elusive. For a better understanding of the complex relationships linking different conditions, interventional studies now begin to focus on the possible outcomes of periodontal treatment in relation to the events, symptoms and biomarkers of several systemic disorders, assessing if periodontal treatment has any impact on them, hopefully reducing their severity or prevalence. Therefore, we proceeded to review the recent literature on the subject, attempting to present a brief explanation of the systemic condition or disease, what proposed mechanisms might give biological plausibility to its association with periodontal disease, and finally and more importantly, what data are currently available pertaining to the effects periodontal treatment may have. Raising awareness and discussing the possible benefits of periodontal treatment on overall systemic health is important, in order to change the perception that periodontal diseases are only limited to the oral cavity, and ultimately providing better and comprehensive care to patients.

Levels of High-Sensitivity C-Reactive Protein in Heart Transplant Patients With and Without Periodontitis

OBJECTIVES

The outcomes of heart transplantation are very favorable, but inflammation still plays a critical role in deterioration of chronic transplants. Periodontal diseases are not limited to supporting the structures of the teeth, but they also cause systemic inflammation. Based on the importance of inflammation in heart transplant recipients and the association between periodontal disease and systemic inflammation, this study explored whether periodontitis may be a modifier of serum high-sensitivity C-reactive protein in heart transplant patients.

MATERIALS AND METHODS

Our study included 33 patients who had heart transplant procedures at the Baskent University Hospital. Clinical periodontal parameters were recorded to assess the periodontal status. On the same day as clinical measurements, blood samples were collected to measure the serum levels of highsensitivity C-reactive protein.

RESULTS

Of the 33 heart transplant patients, 9 patients (27.3%) were diagnosed with periodontitis, 4 (12.1%) were periodontally healthy, and 20 (60.6%) had gingivitis. In the group with periodontitis, serum highsensitivity C-reactive protein levels were significantly higher than the periodontally healthy and gingivitis groups (P = .006). In addition, Spearman correlation analyses showed that serum high-sensitivity C-reactive protein was positively correlated with probing depth (r = 0.358; P = .041), clinical attachment level (r = 0.352; P = .045), and gingival recession (r = 0.422; P = .014).

CONCLUSIONS

We found that elevated levels of serum high-sensitivity C-reactive protein in heart transplant patients were associated with periodontitis. Thus, these findings reinforce the need for the inclusion of regular periodontal visits after transplant.

Effect of non-surgical periodontal therapy on the fibrinogen levels in chronic periodontitis patients

Objective

This study aimed to evaluate the effect of non-surgical periodontal therapy on the fibrinogen levels in chronic periodontitis patients when compared to the levels seen in healthy subjects.

Materials and methods

A total of 30 subjects, with an average age of 38 ± 25 years, were enrolled in the present study. They were divided into two groups, namely Group 1 (15 periodontally healthy subjects) and Group 2 (15 moderate to severe chronic periodontitis patients). The periodontal condition of each periodontitis patient was assessed by recording the probing pocket depth (PD), clinical attachment level (CAL), plaque index (PI), and bleeding index (BI) both before and after periodontal therapy had been administered for one month. Additionally, blood samples were collected from the healthy subjects and the periodontitis patients before and after the periodontal treatment in order to assay the plasma fibrinogen levels.

Results

The clinical parameters were found to be improved after one month of periodontal therapy, with the statistical difference in the mean values of the BI and PD being highly significant (P < 0.01), while the statistical differences concerning the PI and CAL were significant (P < 0.05). The fibrinogen levels (mg/dL) for the periodontitis patients before and after treatment were 342.26 ± 69.00 and 352.93 ± 64.3 mg/dL, respectively. The level was 269.85 ± 43.68 mg/dL for the healthy subjects. In terms of the between-group comparison, the fibrinogen levels of the healthy subjects were observed to be highly significantly lower than the levels of the periodontitis patients before and after the treatment (P < 0.01), in contrast the statistical analysis showed a non-significant difference in the fibrinogen levels (P > 0.05) before and after the periodontal treatment. In addition, the statistical analysis revealed non-significant correlation between the fibrinogen levels and all the periodontal parameters (P > 0.05).

Conclusion

The non-surgical periodontal therapy proved to be effective in improving the clinical periodontal condition of the periodontitis patients, while the plasma fibrinogen levels were not found to be influenced by the periodontal therapy. Further studies are needed to evaluate the fibrinogen levels over a longer duration after periodontal treatment in patients following a periodontal maintenance program.

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.

Oral Administration of Porphyromonas gingivalis Alters the Gut Microbiome and Serum Metabolome

Periodontal disease induced by periodontopathic bacteria like Porphyromonas gingivalis is demonstrated to increase the risk of metabolic, inflammatory, and autoimmune disorders. Although precise mechanisms for this connection have not been elucidated, we have proposed mechanisms by which orally administered periodontopathic bacteria might induce changes in gut microbiota composition, barrier function, and immune system, resulting in an increased risk of diseases characterized by low-grade systemic inflammation. Accumulating evidence suggests a profound effect of altered gut metabolite profiles on overall host health. Therefore, it is possible that P. gingivalis can affect these metabolites. To test this, C57BL/6 mice were administered with P. gingivalis W83 orally twice a week for 5 weeks and compared with sham-inoculated mice. The gut microbial communities were analyzed by pyrosequencing the 16S rRNA genes. Inferred metagenomic analysis was used to determine the relative abundance of KEGG pathways encoded in the gut microbiota. Serum metabolites were analyzed using nuclear magnetic resonance (NMR)-based metabolomics coupled with multivariate statistical analyses. Oral administration of P. gingivalis induced a change in gut microbiota composition. The distributions of metabolic pathways differed between the two groups, including those related to amino acid metabolism and, in particular, the genes for phenylalanine, tyrosine, and tryptophan biosynthesis. Also, alanine, glutamine, histidine, tyrosine, and phenylalanine were significantly increased in the serum of P. gingivalis-administered mice. In addition to altering immune modulation and gut barrier function, oral administration of P. gingivalis affects the host's metabolic profile. This supports our hypothesis regarding a gut-mediated systemic pathology resulting from periodontal disease.IMPORTANCE Increasing evidence suggest that alterations of the gut microbiome underlie metabolic disease pathology by modulating gut metabolite profiles. We have shown that orally administered Porphyromonas gingivalis, a representative periodontopathic bacterium, alters the gut microbiome; that may be a novel mechanism by which periodontitis increases the risk of various diseases. Given the association between periodontal disease and metabolic diseases, it is possible that P. gingivalis can affect the metabolites. Metabolite profiling analysis demonstrated that several amino acids related to a risk of developing diabetes and obesity were elevated in P. gingivalis-administered mice. Our results revealed that the increased risk of various diseases by P. gingivalis might be mediated at least in part by alteration of metabolic profiles. The findings should add new insights into potential links between periodontal disease and systemic disease for investigators in periodontal disease and also for investigators in the field of other diseases, such as metabolic diseases.

Hypertension: Focus on autoimmunity and oxidative stress

Understanding the causal role of the immune and inflammatory responses in hypertension has led to questions regarding the links between hypertension and autoimmunity. Immune pathology in primary hypertension mimics several autoimmune mechanisms observed in the pathogenesis of systemic lupus erythematosus, psoriasis, systemic sclerosis, rheumatoid arthritis and periodontitis. More importantly, the prevalence of hypertension in patients with these autoimmune diseases is significantly increased, when compared to control populations. Clinical and epidemiological evidence is reviewed along with possible mechanisms linking hypertension and autoimmunity. Inflammation and oxidative stress are linked in a self-perpetuating cycle that significantly contributes to the vascular dysfunction and renal damage associated with hypertension. T cell, B cell, macrophage and NK cell infiltration into these organs is essential for this pathology. Effector cytokines such as IFN-γ, TNF-α and IL-17 affect Na⁺/H⁺ exchangers in the kidney. In blood vessels, they lead to endothelial dysfunction and loss of nitric oxide bioavailability and cause vasoconstriction. Both renal and vascular effects are, in part, mediated through induction of reactive oxygen species-producing enzymes such as superoxide anion generating NADPH oxidases and dysfunction of anti-oxidant systems. These mechanisms have recently become important therapeutic targets of novel therapies focused on scavenging oxidative (isolevuglandin) modification of neo-antigenic peptides. Effects of classical immune targeted therapies focused on immunosuppression and anti-cytokine treatments are also reviewed.

The Association of Bite Instability and Comorbidities in Elderly People

Objective The purpose was to evaluate the association between bite instability and comorbidities, comprehensive geriatric evaluations, or disabilities in elderly people. Methods A dentist examined the oral function, such as the bite stability, number of teeth, and the use of dentures, in 119 patients (93 women, mean age: 86.7±7.8) in 2 nursing homes for the elderly. The association between the oral function and the prevalence of diseases, including hypertension, diabetes mellitus, and dementia, was analyzed. Results The median number of teeth was 0 [0, 4]. The patients were divided into a bite-stable group (n=78, 66%) and bite-unstable group (n=41, 34%). The prevalence of hypertension was significantly higher in the bite-stable group than in the bite-unstable group (83% vs. 63%, respectively; p=0.0149), whereas the prevalence of diabetes mellitus was significantly lower in the bite-stable group than in the bite-unstable group (10% vs. 27%, respectively; p=0.0190). The prevalence of a cognitive function decline was significantly lower in the bite-stable group as well (59% vs. 83%, p=0.0082). According to the simplified comprehensive geriatric assessment 7, the bite-stable group scored significantly higher for instrumental activities of daily living (ADL) than the bite-unstable group (54% vs. 24%, respectively; p=0.0021). A multivariate logistic regression analysis demonstrated that bite instability was independently correlated with hypertension, diabetes mellitus, and instrumental activities of daily living. Conclusion Bite instability was independently associated with a decreased prevalence of hypertension or increased prevalence of diabetes mellitus and low levels of instrumental ADL in the elderly.