Increased prevalence of cardiovascular and autoimmune diseases in periodontitis patients: a cross-sectional study

Bidirectional Association between Periodontitis and Thyroid Disease: A Scoping Review

Periodontitis is a chronic inflammatory disease of the tissues surrounding and supporting the teeth. Due to the development of chronic inflammation, periodontitis can contribute to the development of several systemic diseases, including thyroid disease. Thyroid pathology includes benign, malignant, and autoimmune conditions leading to hypothyroidism, hyperthyroidism, or euthyroidism. Alterations in thyroid hormones, especially hypothyroidism, can reveal significant oral manifestations, including periodontitis. This scoping review aims to explore the probable causal relationship between periodontitis and thyroid disease, in terms of epidemiology, pathogenesis, and treatment. The search strategy follows the PRISMA-ScR guidelines. PubMed, Scopus, Web of Science, and Cochrane were searched from January 2014 to January 2024, entering the MESH terms "periodontitis" and "thyroid". Of 153 initial records, 20 articles were selected and discussed. There is a high prevalence of periodontitis among patients with thyroid disease, including thyroid cancer. The causes at the basis of this association are genetic factors, the oral microbiome, and proinflammatory cytokines. Periodontal treatment, specifically scaling and root planning, can ameliorate thyroid parameters. Although there are a few randomized controlled studies in the literature, this review lays the foundation for a bidirectional relationship between periodontitis and thyroid disease, the link to which is, once again, systemic inflammation.

Periodontal disease in patients with thyroid diseases: A systematic review with meta-analysis

PURPOSE

The imbalance of thyroid hormones affects the metabolic activity of various tissues, including periodontium. Also, autoimmune diseases present an increased tendency to suffer from periodontal disease. Therefore, our systematic review was designed to answer the question "Is there a relationship between thyroid diseases and periodontal disease?".

MATERIALS AND METHODS

Following the inclusion and exclusion criteria, 10 studies were included in this systematic review using the databases PubMed, Scopus and Web of Science (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines).

RESULTS

Based on the meta-analysis, patients with thyroid diseases (especially with hypothyroidism) demonstrated significantly worse periodontal status than systemically healthy controls. Moreover, according to the cross-sectional studies, 5.74 ​% of periodontitis patients reported the concomitance of thyroid diseases.

CONCLUSIONS

In summary, the included studies suggest a potential relationship between thyroid diseases and periodontal disease. However, further research is necessary to reliably assess the oral health in patients with hypothyroidism and hyperthyroidism.

Food-derived bioactive peptides potentiating therapeutic intervention in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects the joints of the human body and is projected to have a prevalence age-standardized rate of 1.5 million new cases worldwide by 2030. Several conventional and non-conventional preventive and therapeutic interventions have been suggested but they have their side effects including nausea, abdominal pain, liver damage, ulcers, heightened blood pressure, coagulation, and bleeding. Interestingly, several food-derived peptides (FDPs) from both plant and animal sources are increasingly gaining a reputation for their potential in the management or therapy of RA with little or no side effects. In this review, the concept of inflammation, its major types (acute and chronic), and RA identified as a chronic type were discussed based on its pathogenesis and pathophysiology. The conventional treatment options for RA were briefly outlined as the backdrop of introducing the FDPs that potentiate therapeutic effects in the management of RA.

Association of cardiovascular health and periodontitis: a population-based study

BACKGROUND

There is a strong association between cardiovascular disease (CVD) and periodontitis. This study utilized the Life Essentials 8 (LE8) score, a composite measure of cardiovascular health (CVH), to elucidate the relationship between CVH and periodontitis.

METHODS

Data from 8,649 nationally representative participants in the National Health and Nutrition Examination Survey (NHANES) were analyzed. The independent variable in our study was the CVH score (a higher CVH score indicates better cardiovascular health), and the dependent variable was the presence or absence of periodontitis. The association between CVH and periodontitis was investigated using weighted multivariable logistic regression models and restricted cubic spline (RCS). We controlled for potential confounders such as age, sex, race, education, and socioeconomic status to minimize bias.

RESULTS

There was a negative association between the total CVH score and the odds of periodontitis. After adjusting for all covariates, a 10-point increase in total CVH score was associated with a 10% lower in the odds of periodontitis [0.90 (0.87, 0.93)]. Participants with a higher CVH had 40% lower odds of periodontitis compared with those with a lower CVH. Socioeconomic status (education and income) modified this association (P for interaction < 0.05).

CONCLUSION

Our study suggests that better cardiovascular health, as indicated by higher CVH scores, is associated with a reduced likelihood of periodontitis among US adults. The relationship between CVH and periodontitis appears to be influenced by socioeconomic status, emphasizing the need for targeted interventions in populations with lower socioeconomic status.

Association between cardiovascular diseases and periodontal disease: more than what meets the eye

Cardiovascular diseases (CVDs) are inflammatory diseases of coronary arteries accompanying atheroma formation that can spawn impairment and, in severe cases, death. CVDs are the leading cause of death in the world. In recent decades, investigators have focused their impact on CVD by periodontal disease (PD). PD is a risk factor that can trigger the formation, maturation, and instability of atheroma in the arteries. Two mechanisms have been proposed to explain this relationship: periodontopathic pathogens explicitly invade the circulation or indirectly increase systemic levels of inflammatory mediators. It has been suggested that improvement in disease state has a positive effect on others. This review summarizes evidence from epidemiological studies as well as researches focusing on potential causation channels to deliver a comprehensive representation of the relationship between PD and CVD.

Alterations of HDL's to piHDL's Proteome in Patients with Chronic Inflammatory Diseases, and HDL-Targeted Therapies

Chronic inflammatory diseases, such as rheumatoid arthritis, steatohepatitis, periodontitis, chronic kidney disease, and others are associated with an increased risk of atherosclerotic cardiovascular disease, which persists even after accounting for traditional cardiac risk factors. The common factor linking these diseases to accelerated atherosclerosis is chronic systemic low-grade inflammation triggering changes in lipoprotein structure and metabolism. HDL, an independent marker of cardiovascular risk, is a lipoprotein particle with numerous important anti-atherogenic properties. Besides the essential role in reverse cholesterol transport, HDL possesses antioxidative, anti-inflammatory, antiapoptotic, and antithrombotic properties. Inflammation and inflammation-associated pathologies can cause modifications in HDL's proteome and lipidome, transforming HDL from atheroprotective into a pro-atherosclerotic lipoprotein. Therefore, a simple increase in HDL concentration in patients with inflammatory diseases has not led to the desired anti-atherogenic outcome. In this review, the functions of individual protein components of HDL, rendering them either anti-inflammatory or pro-inflammatory are described in detail. Alterations of HDL proteome (such as replacing atheroprotective proteins by pro-inflammatory proteins, or posttranslational modifications) in patients with chronic inflammatory diseases and their impact on cardiovascular health are discussed. Finally, molecular, and clinical aspects of HDL-targeted therapies, including those used in therapeutical practice, drugs in clinical trials, and experimental drugs are comprehensively summarised.

A novel adiponectin receptor agonist (AdipoAI) ameliorates type 2 diabetes-associated periodontitis by enhancing autophagy in osteoclasts

BACKGROUND AND OBJECTIVE

Type 2 diabetes (T2D)-associated periodontitis is severe and refractory in many cases. Considered an inflammatory disease, T2D predisposes to periodontitis by increasing whole-body inflammation. One mechanism of increased inflammation is thatT2D is mediated by loss of production or function of the anti-inflammatory hormone adiponectin. In our previous report, AdipoRon, an adiponectin receptor agonist, and AdipoAI, a newly discovered, more specific agonist, attenuated T2D-associated inflammation by inhibiting osteoclastogenesis and LPS-induced endotoxemia. Autophagy plays an important role during osteoclast differentiation and function. The impact of AdipoAI on osteoclast function and autophagy involved in osteoclastogenesis is not known. Here, we compare AdipoRon and AdipoAI potency, side effects and mechanism of action in T2D-associated periodontitis.

METHODS

The RAW 264.7 cell line was used for in vitro studies. We analyzed the potential cytotoxicity of AdipoAI using the CCK-8 assay. The anti-osteoclastogenic potential of AdipoAI was studied by real-time qPCR and tartrate-resistant acid phosphatase staining. The actions of AdipoAI involved in autophagy were tested by real-time qPCR, western blot and immunofluorescence staining. In the diet-induced obesity model of T2D, we investigated the impact of AdipoAI on fasting blood glucose, alveolar bone loss, and gingival inflammation in mice with experimental periodontitis.

RESULTS

AdipoRon inhibited osteoclastogenesis and AdipoAI inhibited osteoclastogenesis at lower doses than AdipoRon without any cytotoxicity. In DIO mice with experimental periodontitis, AdipoAI reduced mouse body weight in 14 days, reducing fasting glucose levels, alveolar bone destruction, osteoclast number along the alveolar bone surface, and decreased the expression of pro-inflammatory factors in periodontal tissues. AdipoAI and AdipoRon also enhanced LC3A/B expression when cultured with RANKL.3-Methyladenine, a known autophagy inhibitor, decreased LC3A/B expression and reversed the inhibition of osteoclastogenesis during AdipoAI treatment.

CONCLUSIONS

Our results demonstrate that AdipoAI ameliorates the severity of T2D-associated periodontitis by enhancing autophagy in osteoclasts at lower doses than AdipoRon without demonstrable side effects. Thus, AdipoAI has pharmaceutical potential for treating diabetes-associated periodontal disease.

Epidemiologic relationship between periodontitis and type 2 diabetes mellitus

Background

To systematically review the epidemiologic relationship between periodontitis and type 2 diabetes mellitus (T2DM).

Methods

Four electronic databases were searched up until December 2018. The manual search included the reference lists of the included studies and relevant journals. Observational studies evaluating the relationship between T2DM and periodontitis were included. Meta-analyses were conducted using STATA.

Results

A total of 53 observational studies were included. The Adjusted T2DM prevalence was significantly higher in periodontitis patients (OR = 4.04, p = 0.000), and vice versa (OR = 1.58, p = 0.000). T2DM patients had significantly worse periodontal status, as reflected in a 0.61 mm deeper periodontal pocket, a 0.89 mm higher attachment loss and approximately 2 more lost teeth (all p = 0.000), than those without T2DM. The results of the cohort studies found that T2DM could elevate the risk of developing periodontitis by 34% (p = 0.002). The glycemic control of T2DM patients might result in different periodontitis outcomes. Severe periodontitis increased the incidence of T2DM by 53% (p = 0.000), and this result was stable. In contrast, the impact of mild periodontitis on T2DM incidence (RR = 1.28, p = 0.007) was less robust.

Conclusions

There is an evident bidirectional relationship between T2DM and periodontitis. Further well-designed cohort studies are needed to confirm this finding. Our results suggest that both dentists and physicians need to be aware of the strong connection between periodontitis and T2DM. Controlling these two diseases might help prevent each other’s incidence.

Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis

OBJECTIVE

Many clinical studies have been carried out to investigate the relationship between periodontitis and rheumatoid arthritis (RA). Owing to limited evidence and inconsistent findings among these studies, it is unclear whether periodontitis would increase the risk for RA. This meta-analysis was performed to evaluate whether periodontitis represents a risk factor for RA.

METHODS

PubMed, Cochrane Library, Embase, Web of Science, and Wanfang were searched for eligible studies that compared periodontitis patients with controls. A pooled odds ratio (OR) and 95% confidence interval (CI) were calculated to assess the association between periodontitis and RA.

RESULTS

Thirteen studies including a total of 706611 periodontitis patients and 349983 control subjects were included. The pooled OR of RA risk between periodontitis and controls was (OR: 1.69; 95% CI: 1.31-2.17; P<0.0001), indicating that the patients in periodontitis group had a 69% greater risk for RA than people in control group. When stratified by disease type, the pooled results showed periodontitis represents a risk factor for incident RA (OR=1.70, 95%CI: 0.75-3.85, P<0.001) and mixed RA (OR=1.61, 95%CI: 1.26-2.06; P<0.001). When stratified by disease duration, the pooled results showed periodontitis represents a risk factor for RA disease duration>5 years (OR=2.88, 95%CI: 0.66-12.62, P=0.018), disease duration<5 years (OR=2.59, 95%CI: 0.83-8.11, P<0.001), mixed disease duration (OR=1.53; 95%CI: 1.05-2.22, P<0.001).

CONCLUSION

Our meta-analysis revealed an increased risk of RA in patients with periodontitis compared to healthy controls. Moreover, when stratified by disease type, there was a higher risk between incident RA and periodontitis. When stratified by disease duration, the patients with periodontitis might be more closely associated with the RA patients with disease duration >5 years.

Citrullination in periodontium is associated with Porphyromonas gingivalis

OBJECTIVE

To analyse the citrulline level in the periodontium in association with the presence of or antibody levels against Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis.

DESIGN

Gingival crevicular fluid (GCF), subgingival biofilm and blood serum were sampled from 98 subjects (26 with RA, 72 without RA (NoRA)). GCF was analyzed for the level of citrulline, for interleukin (IL)-1β, IL-17, IL-10 and monocyte-chemoattractant protein (MCP)-1. Microorganisms were identified in subgingival biofilms. Antibodies againstP. gingivalis, and Aggregatibacter actinomycetemcomitans were quantified in serum.

RESULTS

GCF citrulline level was the lowest (by trend) in NoRA group without periodontitis. In NoRA, but not in RA an association between GCF citrulline level and P. gingivalis antibody levels was found and the GCF citrulline levels were higher in P. gingivalis positive samples. Any association of A. actinomycetemcomitans with GCF citrulline level did not exist. A model of univariate variance analysis (p = 0.001) showed a dependence of GCF citrulline level from the number of sites with PD (probing depth) ≥5 mm (p = 0.003) and the GCF MCP-1/CCL2 level (p = 0.019). Compared with NoRA in RA the number of teeth was lower, the number of sites with PD ≥ 5 mm was less, GCF levels of interleukin-17 and MCP-1/CCL2 were higher and those of IL-10 lower. Yeasts were only cultured in 15 RA patients (p < 0.001).

CONCLUSION

Citrullination in periodontium might be associated with P. gingivalis supporting the potential role as a trigger in the development of RA. Pathogenesis of periodontal disease in RA patients seems to differ from that in NoRA and should be investigated further.

Relationship between hypothyroidism and periodontitis: A scoping review

AIM

The objective of this study was to assess the existing literature to determine if a relationship exists between hypothyroidism and periodontitis.

METHODS

We used a modified approach to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses by searching five databases in addition to the gray literature. Keywords in the title and abstract fields, as well as subject headings for both periodontal disease and hypothyroidism, were used to search the existing literature for publications relevant to evaluation of the thyroid-periodontitis relationship.

RESULTS

The authors screened 847 unique publications which, after applying inclusion and exclusion criteria, yielded 29 publications, which were further analyzed for relevance and applicability. Most of the included papers were cross-sectional studies and retrospective chart reviews. Following critical analysis, four publications, including one abstract, were used to further assess the hypothyroid-periodontitis relationship.

CONCLUSIONS

There are very few high-quality studies describing the potential association between hypothyroidism and periodontitis. In general, and among the included papers with the fewest confounding factors, a positive relationship between hypothyroidism and periodontitis was found. Further well-controlled, prospective clinical and immunologic studies will be required to confirm that relationship.

Gingimaps: Protein Localization in the Oral Pathogen Porphyromonas gingivalis

Porphyromonas gingivalis is an oral pathogen involved in the widespread disease periodontitis. In recent years, however, this bacterium has been implicated in the etiology of another common disorder, the autoimmune disease rheumatoid arthritis. Periodontitis and rheumatoid arthritis were known to correlate for decades, but only recently a possible molecular connection underlying this association has been unveiled. P. gingivalis possesses an enzyme that citrullinates certain host proteins and, potentially, elicits autoimmune antibodies against such citrullinated proteins. These autoantibodies are highly specific for rheumatoid arthritis and have been purported both as a symptom and a potential cause of the disease. The citrullinating enzyme and other major virulence factors of P. gingivalis, including some that were implicated in the etiology of rheumatoid arthritis, are targeted to the host tissue as secreted or outer-membrane-bound proteins. These targeting events play pivotal roles in the interactions between the pathogen and its human host. Accordingly, the overall protein sorting and secretion events in P. gingivalis are of prime relevance for understanding its full disease-causing potential and for developing preventive and therapeutic approaches. The aim of this review is therefore to offer a comprehensive overview of the subcellular and extracellular localization of all proteins in three reference strains and four clinical isolates of P. gingivalis, as well as the mechanisms employed to reach these destinations.

Prevalence of Periodontal Disease and Periodontopathic Bacteria in Anti-Cyclic Citrullinated Protein Antibody-Positive At-Risk Adults Without Arthritis

IMPORTANCE

The prevalence of periodontitis is increased in patients with rheumatoid arthritis (RA) and periodontopathic bacteria can citrullinate proteins. Periodontitis may, therefore, be an initiator of RA and a target for prevention. Periodontal disease and periodontal bacteria have not been investigated in at-risk individuals with RA autoimmunity but no arthritis.

OBJECTIVE

To examine periodontal disease and periodontopathic bacteria in anti-cyclic citrullinated protein (anti-CCP) antibody-positive at-risk individuals without arthritis.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study took place at a teaching hospital from April 27, 2015, to May 8, 2017. Forty-eight anti-CCP-positive individuals without arthritis (CCP+ at-risk) were recruited nationally. Twenty-six patients with early RA (ERA) and 32 healthy control individuals were recruited locally. Data were analyzed between June 1, 2017, and December 1, 2017.

INTERVENTIONS

Periodontal assessment and examination of joints using ultrasonography.

MAIN OUTCOMES AND MEASURES

Prevalence of diseased periodontal sites, clinical periodontitis, and periodontal inflamed surface area in CCP+ at-risk individuals compared with patients with ERA and healthy individuals matched for age and smoking. Paired-end sequencing of DNA from subgingival plaque from diseased and healthy periodontal sites was performed and DNA was profiled and analyzed.

RESULTS

A total of 48 CCP+ at-risk individuals (mean [SD] age, 51.9 [11.4] years; 31 [65%] female), 26 patients with ERA (mean [SD] age, 54.4 [16.7] years; 14 [54%] female), and 32 healthy individuals (mean [SD] age, 49.4 [15.3] years; 19 [59%] female) were recruited. Of 48 CCP+ at-risk individuals, 46 had no joint inflammation on ultrasonography. Thirty-five CCP+ at-risk individuals (73%), 12 healthy individuals (38%), and 14 patients with ERA (54%) had clinical periodontitis. The median (interquartile range) percentage of periodontal sites with disease was greater in CCP+ at-risk individuals compared with healthy individuals (3.3% [0%-11.3%] vs 0% [0%-0.7%]) and similar to patients with ERA (1.1% [0%-13.1%]). Median (interquartile range) periodontal inflamed surface area was higher in CCP+ at-risk individuals compared with healthy individuals (221 mm2 [81-504 mm2] vs 40 mm2 [12-205 mm2]). Patients with CCP+ at-risk had increased relative abundance of Porphyromonas gingivalis (but not Aggregatibacter actinomycetemcomitans) at healthy periodontal sites compared with healthy individuals (effect size, 3.00; 95% CI, 1.71-4.29) and patients with ERA (effect size, 2.14; 95% CI, 0.77-3.52).

CONCLUSIONS AND RELEVANCE

This study found increased prevalence of periodontitis and P gingivalis in CCP+ at-risk individuals. This suggests periodontitis and P gingivalis are associated with disease initiation and could be targets for preventive interventions in RA.

Rheumatoid arthritis (RA) and cardiovascular disease

Patients with rheumatoid arthritis (RA) suffer cardiovascular events 1.5-2 fold than the general population, and cardiovascular (CV) events are leading cause of death in patients with RA. It is known that patients with RA have endothelial dysfunction, related with impaired function of endothelial progenitor cells (EPCs). The mechanistic pathways leading to endothelial function are complicated, but understanding these mechanisms may open new frontiers of management and therapies to patients suffering from atherosclerosis. Inflammation is a key factor in atherosclerosis, including endothelial function, plaque stabilization and post infarct remodeling; thus, inhibition of TNF-α may affect the inflammatory burden and plaque vulnerability leading to less cardiovascular events and myocardial infarctions. An aggressive management of inflammation may lead to a significant improvement in the clinical cardiovascular outcome of patients with RA. The clinical evidence that showed a reduced risk of CV events following treatment with anti-inflammatory agents may suggest a new approach to treat atherosclerosis, i.e., inhibition of inflammation using biological medications that were primarily aimed to treat the high scale inflammation of RA and other autoimmune-inflammatory diseases, but may be useful also to prevent progression of atherosclerosis.

Severe periodontitis is more common in HIV- infected patients

OBJECTIVE

To assess periodontitis prevalence and severity in HIV infected patients as compared to controls. Furthermore, to assess whether HIV infection characteristics are associated with periodontitis.

DESIGN

cross-sectional controlled study.

METHODS

We assessed prevalence and severity of periodontitis in 258 HIV-infected patients and 539 historical controls with the Dutch Periodontal Screening Index (DPSI). HIV characteristics were collected from medical charts. Age-related diseases and oral care were assessed with questionnaires.

RESULTS

Severe periodontitis (DPSI 4) was more prevalent in HIV-infected patients than in controls (66% vs. 36%, p = 0.002). HIV-infection, increasing age and male sex were significant risk factors for severe periodontitis. In particular, older male HIV patients have a higher risk of severe periodontitis. Clinical, immunological and virologic characteristics, and antiretroviral therapy were not associated with periodontitis prevalence or severity. HIV-infected patients rate the importance of their oral health as high, although many do not disclose their HIV infection to their dentists.

CONCLUSIONS

Prevalence and severity of periodontitis are higher in HIV-infected patients compared to controls, particularly in older males. Awareness of the increased prevalence of periodontitis associated with HIV-infection among patients and health-care professionals could significantly improve oral health and quality of life of HIV-infected patients.

Expression of human and Porphyromonas gingivalis glutaminyl cyclases in periodontitis and rheumatoid arthritis-A pilot study

OBJECTIVES

Human glutaminyl cyclases (QC and isoQC) play an important role in maintaining inflammatory conditions. Meanwhile a glutaminyl cyclase synthesized by Porphyromonas gingivalis (PgQC), a key pathogen in developing periodontitis and a potential link of periodontitis with rheumatoid arthritis (RA), was discovered. This study was aimed to determine the expression of QC, isoQC and PgQC in patients with chronic periodontitis (CP) and RA.

DESIGN

Thirty volunteers were enrolled in a pilot study and divided into 3 groups (healthy, CP and RA individuals). Blood samples, biofilm and gingival crevicular fluid (GCF) were analysed for mRNA expression of QC, isoQC and P. gingivalis QC. Major bacteria being associated with periodontal disease were quantified in subgingival biofilm and protein levels for monocyte chemoattractant protein (MCP)-1, MCP-3 and interleukin (IL)-1β) were determined in the GCF. Expression of PgQC on the mRNA and protein levels was assessed in two P. gingivalis strains.

RESULTS

PgQC is expressed in P. gingivalis strains and the protein seems to be located mainly in peri-plasmatic space. mRNA expression of QC was significantly increased in the peripheral blood from RA patients vs. healthy subjects and CP patients (p = 0.013 and p = 0.003, respectively). In GCF of RA patients, QC mRNA was detected more frequently than in healthy controls (p = 0.043). In these samples IL-1β levels were also elevated compared to GCF from periodontally healthy individuals (p = 0.003). PgQC was detected in eight out of the 13 P. gingivalis positive biofilm samples.

CONCLUSION

Activity of QC may play a supportive role in maintaining chronic periodontal inflammation and destruction in RA. PgQC is expressed in vivo but further research is needed to evaluate biological importance of this enzyme and if it constitutes a potential target in periodontal antimicrobial therapy.

Association of clinical measures of periodontal disease with blood pressure and hypertension among postmenopausal women

BACKGROUND

Hypertension and periodontal disease are common conditions among postmenopausal women. Periodontal disease has been found associated with hypertension in previous studies, but data in postmenopausal women is limited.

METHODS

We assessed the cross-sectional associations of clinically measured periodontal disease with prevalent hypertension and measured systolic blood pressure (SBP) among 1341 postmenopausal women enrolled in the Buffalo Osteoporosis and Periodontal Disease (OsteoPerio) study, an ancillary study of the Women's Health Initiative-Observational Study.

RESULTS

Clinical attachment level (CAL) and number of teeth missing were positively associated with SBP among those not taking antihypertensive medication in crude and multivariable adjusted linear regression models (both P < 0.05). Alveolar crestal height (ACH) and gingival bleeding on probing were associated with higher SBP in crude but not multivariable adjusted models. Neither probing pocket depth (PPD) nor severity categories of periodontitis were associated with SBP. Number of teeth missing was significantly associated with prevalent hypertension in crude and multivariable adjusted models (OR = 1.14, per 5 teeth; P = 0.04). ACH was associated with prevalent hypertension in crude but not adjusted models. CAL, PPD, gingival bleeding, and severity of periodontitis were not significantly associated with prevalent hypertension.

CONCLUSIONS

These results suggest that measures of oral health including CAL and number of teeth missing are associated with blood pressure in postmenopausal women. Prospective studies are needed to further investigate these associations and the potential underlying mechanisms for these relationships.

Inhibition of angiotensin II receptor I prevents inflammation and bone loss in periodontitis

BACKGROUND

Periodontal disease is characterized by alveolar bone destruction and degenerative lesions of the periodontal ligament (PDL); it is initiated by bacterial infection of the oral cavity, but the clinical effects are secondary to an aberrant host immune response. Primary hypertension (PH), which causes significant morbidity and mortality worldwide, has also been shown to be an inflammatory disease characterized by aberrant immune cell infiltration and activation. Clinical retrospective studies have shown a link between PH and periodontitis with PH exacerbating periodontitis and vice versa, but the pathophysiologic mechanisms responsible for this remain unknown.

METHODS

In this study, we investigate the underlying mechanisms behind PH exacerbation of periodontitis by using a bacteria-induced periodontitis model in normotensive and hypertensive (Nos3^-/- ) mice treated with or without an Angiotensin II (Ang II) specific receptor 1 (AT1) antagonist, losartan. The histologic analyses including immunohistochemistry, immunofluorescence were carried out. The qRT-PCR and ELISAs were applied for the target gene and protein detection.

RESULTS

We find that PH worsens bone resorption and PDL destruction in periodontitis and that treatment with losartan, rescues this. We also show that PH increases dendritic cell (DC) and osteoclast (OC) infiltration in periodontitis, which is also dependent on Ang II. Finally, we show that PH augments the pro-inflammatory state in periodontitis infiltrating DCs in an Ang II-dependent manner and use in vitro studies to show that Ang II directly augments DC Toll-like receptor 4 (TLR4) signaling.

CONCLUSION

Our studies show a central role for Ang II as a pro-inflammatory Toll-like receptor mediator in the pathogenesis of PH-exacerbated periodontitis, indicating that Ang II may be a reasonable target in patients with PH and periodontitis comorbidity.

Oral Manifestations of Systemic Lupus Erythematosus Patients in Qatar: A Pilot Study

Objective

The purpose of this pilot study was to assess the prevalence of oral manifestations among systemic lupus erythematosus (SLE) patients in Qatar, in order to warrant future studies that would investigate each one of these manifestations with detail and further scrutiny.

Methods

Study procedures took place between November 2014 and April 2016. All patients visiting the outpatient rheumatology clinics at Hamad General Hospital, Doha, Qatar, were asked to join. The American College of Rheumatology (ACR) 1997 criteria of SLE were used. The patients were examined initially by a rheumatologist and were later scheduled for an appointment with a dentist at the same institution. A total of 77 patients were recruited for the study.

Results

Prevalence rates for the different oral manifestations ranged from 2.4% for soft palate ulcers, cheilitis, and oral candida to 88.1% for the presence of cavitation. Gingivitis, periodontal disease, cavities, and missing teeth were observed in more than 50% of the sample. The prevalence of periodontal disease and missing teeth was higher among those with an SLE duration > 8 years. On the contrary, the prevalence of gingivitis and cavities was higher among those with an SLE duration ≤ 8 years.

Conclusion

This study found high rates of gingivitis, periodontal disease, cavities, and missing teeth among SLE patients in Qatar. It is recommended that healthcare providers of such patients monitor the presence of any oral manifestations in order to arrange for early treatment and prevention efforts. Future prospective longitudinal studies with adequate sample size and power are needed in order to ascertain any causation factors or common etiology pathways.

Association between a history of periodontitis and the risk of systemic lupus erythematosus in Taiwan: A nationwide, population-based, case-control study

Objective

To examine the association between a history of periodontitis (PD) and incident systemic lupus erythematosus (SLE)

Methods

We used 2003–2012 claims data from the Taiwanese National Health Insurance Database to identify 7,204 incident SLE patients during 2007–2012 as the study group, along with randomly selecting 72,040 non-SLE patients matched (1:10) for age, gender, and first diagnosis date (index date) as the control group. The correlation between PD and SLE risk was estimated using conditional logistic regression analysis, after making adjustments for confounders (including a history of diabetes and number of non-PD related dental visits before the index date). To evaluate the effects of PD severity and the lag time which occurred since the last PD visit on SLE development, odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for subgroups of patients with PD according to their number of visits, cumulative cost and also the time gaps between their last PD-related visit and the index date.

Results

A statistically significant association between a history of PD and newly diagnosed SLE was observed (OR, 1.21; 95% CI, 1.14–1.28; p-value, <0.001). The association was both dose- and time-dependent and was found to be strongest when the interval between the last PD-related visit and the index date was less than three months (OR, 1.83; 95% CI, 1.61–2.09; p-value, <0.001). The association between PD exposure and SLE risk was consistently significant among subgroups stratified based on age, gender, or DM status.

Conclusions

The results of this nationwide, population-based, case-control study suggest that there is a significant association between a history of PD and incident SLE in Taiwan. This weak association is limited to lack of information on individual smoking status in the database.

Gingival tissue, an extrasynovial source of malondialdehyde-acetaldehyde adducts, citrullinated and carbamylated proteins

BACKGROUND AND OBJECTIVE

Postranslational modification of proteins can lead to the production of autoantibodies and loss of immune tolerance. This process has been hypothesised to be a critical factor in the pathogenesis of rheumatoid arthritis. The objective of this study was to demonstrate that inflamed human gingival tissue provides an extrasynovial source of malondialdehyde-acetaldehyde adducts, citrullinated and carbamylated proteins all of which are considered to be linked to the development of rheumatoid arthritis. Identification of such modified proteins in inflamed gingiva may explain, in part, how inflammation of the periodontal tissues may influence the development of rheumatoid arthritis.

MATERIAL AND METHODS

Gingival biopsies of healthy, mild and moderate periodontitis were triple stained with antibodies against malondialdehyde-acetaldehyde adducts, citrullinated and carbamylated proteins.

RESULTS

Assessment of healthy gingival tissue revealed negligible staining for carbamylated, malondialdehyde-acetaldehyde (MAA), or citrullinated proteins. Mild periodontitis was positive for all three modifications. Furthermore, there was an increase in staining intensity for carbamylated, citrullinated and MAA-modified proteins in moderate periodontitis. Negative staining results were observed for the isotype controls.

CONCLUSION

This study provides evidence for the presence of citrullinated, carbamylated and MAA adduct modified proteins in inflamed periodontal tissues. The potential for these proteins to play a role in autoimmunity in a multi-system inflammatory syndromic disease model now needs to be determined.

Periodontal disease and periodontal bacteria as triggers for rheumatoid arthritis

There is an epidemiological association between periodontitis and rheumatoid arthritis (RA), which is hypothesised to lead to enhanced generation of RA-related autoantibodies that can be detected years before the onset of RA symptoms. Periodontitis is a common dysbiotic disease; tissue damage occurs because the immune system fails to limit both the resident microbial community and the associated local immune response. Certain periodontal bacteria, including Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, may contribute to RA autoantibody production through direct post-translational modification of proteins or, indirectly, by influencing neutrophil-mediated neo-epitope generation. Oral bacteria that invade the blood may also contribute to chronic inflammatory responses and generation of autoantibodies. The putative association between periodontitis and the development of RA raises the potential of finding novel predictive markers of disease and disease progression and for periodontitis treatment to be included in the future as an adjunct to conventional RA immunotherapy or as part of a preventive strategy.

Pre-symptomatic autoimmunity in rheumatoid arthritis: when does the disease start?

It is well recognised that a state of autoimmunity, in which immunological tolerance is broken, precedes the development of symptoms in the majority of patients with rheumatoid arthritis (RA). For individuals who will later develop seropositive disease, this manifests as autoantibodies directed against proteins that have undergone specific post-translational modifications. There is evidence that the induction of this autoantibody response occurs at peripheral extra-articular mucosal sites, such as the periodontium and lung. In addition to their utility as diagnostic markers, these autoantibodies may have a pathogenic role that helps localise disease to the synovium. Alongside the development of autoantibodies, other factors contributing to pre-symptomatic autoimmunity may include dysbiosis of the gastrointestinal tract, abnormal development of lymphoid tissue, and dysregulated autonomic and lipid-mediated anti-inflammatory signalling. These factors combine to skew the balance between pro-inflammatory and anti-inflammatory signalling in a manner that is permissive for the development of clinical arthritis. We present data to support the concept that the transitions from at-risk states to systemic autoimmunity and then to classifiable RA depend on multiple “switches”. However, further prospective studies are necessary to define the molecular basis of these switches and the specific features of pre-symptomatic autoimmunity, so that preventative treatments can be targeted to individuals at high risk for RA. In this review, we analyse mechanisms that may contribute to the development of autoimmunity in at-risk individuals and discuss the relationship between this pre-symptomatic state and subsequent development of RA.

Association between periodontitis and arterial hypertension: A systematic review and meta-analysis

BACKGROUND

Several studies have shown that periodontal diseases are associated with hypertension (HT). However, heterogeneity among populations, diagnosis criteria, and shared risk factors represent some difficulties in terms of interpretation. Therefore, the aim of this study was to determine the magnitude of the association between periodontal diseases and HT.

METHODS AND RESULTS

A systematic review and meta-analysis, including studies published up to June 2016, have been performed. Sixteen studies assessing the association between periodontal diseases and HT have been included. The meta-analysis considering all included studies (moderate to severe periodontitis) showed that the presence of HT was associated with the presence of periodontal diseases (OR, 1.50; 95% CI, 1.27-1.78). To reduce potential bias, a stratified analysis has been performed illustrating the impact of inclusion criteria and adjustments on the magnitude of the association. Interestingly, when only studies with secure diagnosis of severe periodontitis and HT were considered, an OR=1.64 (95% CI, 1.23-2.19) has been measured.

CONCLUSIONS

Periodontal diseases are associated with a higher risk of HT especially for severe periodontitis. However, no conclusions could be made regarding the causative involvement of periodontal diseases mainly due to the reduced number of available prospective studies and remaining questions regarding underlying biological mechanisms.

Impaired Porphyromonas gingivalis-Induced Tumor Necrosis Factor Production by Dendritic Cells Typifies Patients With Rheumatoid Arthritis

OBJECTIVE

The prevalence of periodontitis is increased in patients with rheumatoid arthritis (RA), and the severity of periodontitis can affect the level of arthritis. Porphyromonas gingivalis is one of the main bacteria involved in periodontitis. Our aim was to determine if there are differences in the innate immune response against P gingivalis between healthy controls and RA patients.

METHODS

Monocyte-derived dendritic cells (DCs) from healthy controls, RA patients, and patients with psoriatic arthritis (PsA) were stimulated with P gingivalis, a range of other bacteria, and Toll-like receptor agonists. Cytokine production was determined, and blocking studies were performed to determine which receptors were involved in differential recognition of P gingivalis. Effects on T cell cytokines were also determined in cultures of peripheral blood mononuclear cells (PBMCs).

RESULTS

Upon stimulation with P gingivalis, RA patient DCs produced less tumor necrosis factor as compared to healthy control DCs, which was not observed in PsA patients or upon stimulation with other bacteria. In addition, P gingivalis-mediated activation of RA patient PBMCs showed a clear reduction of interferon-γ production. Among the various possible underlying mechanisms investigated, only blockade of CR3 abolished the difference between RA patients and healthy controls, suggesting the involvement of CR3 in this process.

CONCLUSION

Immune cells from RA patients display a reduced response to P gingivalis, which has functional consequences for the immune response. This may result in prolonged survival of P gingivalis, possibly driving autoantibody formation and a self-perpetuating loop of chronic inflammation. The possible role of CR3 in this process warrants further investigation.

Relationship Between Prehypertension/Hypertension and Periodontal Disease: A Prospective Cohort Study

BACKGROUND

Most cross-sectional studies have found a significant positive relationship between periodontal disease and prehypertension/hypertension. However, these studies had limitations and there are few prospective cohort studies in young adults. The purpose of this prospective cohort study was to investigate whether periodontal disease was related to prehypertension/hypertension in Japanese university students.

METHODS

Students (n = 2,588), who underwent health examinations before entering university and before graduation, were included in the analysis. The association between periodontal disease such as the percentage of bleeding on probing (BOP) and community periodontal index (CPI) scores, and change in blood pressure status was determined.

RESULTS

At the reexamination, the numbers of participants with prehypertension (systolic blood pressure 120-139mm Hg or diastolic blood pressure 80-89mm Hg) and hypertension (≥140/90mm Hg) were 882 (34.1%) and 109 (4.2%), respectively. In a logistic regression model, the risk of hypertension was significantly associated with male (odds ratio (OR): 6.31; 95% confidence interval (CI): 2.63-15.13; P < 0.001), no habitual physical activity at baseline (OR: 2.90; 95% CI: 1.56-5.38; P < 0.01) and periodontal disease defined as the presence of both probing pocket depth (PPD) ≥ 4mm and BOP ≥ 30% at baseline (OR: 2.74; 95% CI: 1.19-6.29; P = 0.02) in participants with prehypertension at baseline. On the other hand, the risk of prehypertension was not associated with presence of periodontal disease (OR: 0.93; 95% CI: 0.51-1.70; P = 0.82).

CONCLUSION

In the short-term prospective cohort study, a significant association between presence of periodontal disease and hypertension was observed in Japanese university students.

Modulation of inflammasome activity by Porphyromonas gingivalis in periodontitis and associated systemic diseases

Inflammasomes are large multiprotein complexes localized in the cytoplasm of the cell. They are responsible for the maturation of pro-inflammatory cytokines such as interleukin-1β (IL-1β) and IL-18 as well as for the activation of inflammatory cell death, the so-called pyroptosis. Inflammasomes assemble in response to cellular infection, cellular stress, or tissue damage; promote inflammatory responses and are of great importance in regulating the innate immune system in chronic inflammatory diseases such as periodontitis and several chronic systemic diseases. In addition to sensing cellular integrity, inflammasomes are involved in the homeostatic mutualism between the indigenous microbiota and the host. There are several types of inflammasomes of which NLRP3 is best characterized in microbial pathogenesis. Many opportunistic bacteria try to evade the innate immune system in order to survive in the host cells. One of these is the periodontopathogen Porphyromonas gingivalis which has been shown to have several mechanisms of modulating innate immunity by limiting the activation of the NLRP3 inflammasome. Among them, ATP-/P2X₇- signaling is recently associated not only with periodontitis but also with development of several systemic diseases. The present paper reviews multiple mechanisms through which P. gingivalis can modify innate immunity by affecting inflammasome activity.

Citrullination in the periodontium--a possible link between periodontitis and rheumatoid arthritis

OBJECTIVES

The aim of the present study was to assess human and bacterial peptidylarginine deiminase (PAD) activity in the gingival crevicular fluid (GCF) in the context of serum levels of antibodies against citrullinated epitopes in rheumatoid arthritis and periodontitis.

MATERIALS AND METHODS

Human PAD and Porphyromonas gingivalis-derived enzyme (PPAD) activities were measured in the GCF of 52 rheumatoid arthritis (RA) patients (48 with periodontitis and 4 without) and 44 non-RA controls (28 with periodontitis and 16 without). Serum antibodies against citrullinated epitopes were measured by ELISA. Bacteria being associated with periodontitis were determined by nucleic-acid-based methods.

RESULTS

Citrullination was present in 26 (50%) RA patients and 23 (48%) controls. PAD and PPAD activities were detected in 36 (69%) and 30 (58%) RA patients, respectively, and in 30 (68%) and 21 (50%) controls, respectively. PPAD activity was higher in RA and non-RA patients with periodontitis than in those without (p = 0.038; p = 0.004), and was detected in 35 of 59 P. gingivalis-positive samples, and in 16 of 37 P. gingivalis-negative samples in association with high antibody levels against that species.

CONCLUSIONS

PAD and PPAD activities within the periodontium are elevated in RA and non-RA patients with periodontitis. PPAD secreted by P. gingivalis residing in epithelial cells may exert its citrullinating activity in distant regions of the periodontium or even distant tissues.

CLINICAL RELEVANCE

In periodontitis, the citrullination of proteins/peptides by human and bacterial peptidylarginine deiminases may generate antibodies after breaching immunotolerance in susceptible individuals.

Periodontitis and etanercept discontinuation risk in anti-tumor necrosis factor-naive rheumatoid arthritis patients: a nationwide population-based cohort study

OBJECTIVE

The objective of this study was to investigate the association between periodontitis (PD) and etanercept (ETN) discontinuation in anti-tumor necrosis factor (anti-TNF)-naive patients with rheumatoid arthritis (RA).

METHODS

This retrospective nationwide population-based cohort study identified 3359 anti-TNF-naive patients with RA (age at diagnosis ≥16 years) in whom ETN treatment was initiated using administrative data. We identified PD exposure within 5 years before ETN initiation and during ETN treatment. Cox proportional hazard models were used to assess ETN discontinuation risk associated with PD within 5 years before ETN initiation, shown as hazard ratios with 95% confidence intervals (CIs). Stratified analyses were performed on the basis of PD during ETN treatment to avoid violating the Cox regression assumptions.

RESULTS

Patients with PD history during the 5 years before ENT initiation had a higher risk of ETN discontinuation compared with those without such history; the hazard ratios of ETN discontinuation were 1.27 (95% CI, 1.01-1.60) and 1.17 (95% CI, 1.06-1.30) among patients with and without PD during ETN treatment, respectively. Other risk factors included age older than 65 years and daily prednisolone dose greater than 10 mg/d within 1 year before ETN initiation. Concomitant methotrexate, leflunomide, salazopyrin, or hydroxychloroquine administration had a protective effect on ETN discontinuation in patients without PD during ETN treatment, but the protective effect by leflunomide, salazopyrin, and hydroxychloroquine was attenuated in patients with PD during ETN treatment (P for interaction <0.05).

CONCLUSIONS

A PD history within 5 years before ETN administration was associated with increased ETN discontinuation risk in anti-TNF-naive patients with RA.

Additive interaction of oral health disorders on risk of hypertension in a Japanese urban population: the Suita Study

BACKGROUND

This study assessed the relationship between different oral health markers-periodontitis, gingival bleeding, tooth number, and occlusal status-and hypertension in a Japanese urban population.

METHODS

A total of 1,643 participants with no prior cardiovascular disease (mean age = 66.6 years; 43.4% women) underwent comprehensive health checkups, including a lifestyle questionnaire and dental examination in the Suita Study.

RESULTS

In the multivariable-adjusted logistic model, none of the individual oral health markers, namely severe periodontitis, gingival bleeding, lowest quartile of tooth number, and malocclusion, were significantly associated with increased odds of hypertension. The additive effects of oral health markers on hypertension were examined and showed that, compared with subjects with no component of the oral health markers, the multivariale-adjusted odds ratio of hypertension in those with ≥3 components was 1.82 (95% confidence interval (CI) = 1.23-2.72; P = 0.003). In the subpopulation without antihypertensive medication (n = 1,148; 59.8% women), a significant graded relationship between multivariable-adjusted systolic blood pressure and the number of components was found (P trend = 0.03), and, compared with subjects with no component of the oral health markers, having ≥3 components was related to a higher systolic blood pressure (β = 5.41; 95% CI = 1.16-9.66; P = 0.01).

CONCLUSIONS

There is an additive relationship between oral health disorders and risk of hypertension. Our results suggest that the existence of moderate or severe oral health disorders-that is, several concomitant oral health disorders-is associated with risk of hypertension.

Association between hypertension and periodontitis: possible mechanisms

This review is to examine the current literatures on the relationship between periodontitis and hypertension as well as to explore the possible biological pathways underlying the linkage between these health conditions. Hypertension is one of the major risk factors for cardiovascular diseases. Oxidative stress and endothelial dysfunction are among the critical components in the development of hypertension. Inflammation has received much attention recently and may contribute to a pivotal role in hypertension. Periodontitis, a chronic low-grade inflammation of gingival tissue, has been linked to endothelial dysfunction, with blood pressure elevation and increased mortality risk in hypertensive patients. Inflammatory biomarkers are increased in hypertensive patients with periodontitis. Over the years, various researches have been performed to evaluate the involvement of periodontitis in the initiation and progression of hypertension. Many cross-sectional studies documented an association between hypertension and periodontitis. However, more well-designed prospective population trials need to be carried out to ascertain the role of periodontitis in hypertension.

When and where does inflammation begin in rheumatoid arthritis?

PURPOSE OF REVIEW

The cause of rheumatoid arthritis (RA), as well as the timing and anatomic site at which RA-related autoimmunity is initiated, is currently unknown. An improved understanding of the initial steps in the development of RA would provide insights into disease pathogenesis that could ultimately lead to more effective treatments and/or novel preventive strategies in RA.

RECENT FINDINGS

Systemic inflammation and autoimmunity in RA begin long before the onset of detectable joint inflammation. Emerging data suggest that RA-related autoimmunity may be initiated at a mucosal site years before the onset of joint symptoms. The candidate sites of origin include the oral, lung and gastrointestinal mucosa, as data consistent with this hypothesis have been generated for each location. Individual patients may undergo initiation events at unique sites, but still converge on similar joint findings as the disease process evolves.

SUMMARY

Investigations are needed to determine when and where RA begins, including comprehensive prospective studies of individuals in the preclinical period of RA that can provide insight into the relationship between mucosal inflammation, RA-related autoantibody generation and subsequent joint inflammation in RA.

Lessons to be learned from periodontitis

PURPOSE OF REVIEW

This article reviews the link between periodontitis and rheumatoid arthritis (RA) with regard to similarities in genetic risk factors and immunopathogenesis. Emphasis is paid to the potential role of the periodontal pathogen Porphyromonas gingivalis in the etiopathogenesis of both periodontitis and RA, in particular by post-translational modification of arginine into citrulline.

RECENT FINDINGS

P. gingivalis, a major periodontal pathogen, is presently known as the only bacterium in the oral flora which contains a peptidyl arginine deiminase enzyme (PAD). This enzyme is necessary for citrullination. As a result, citrullinated proteins and P. gingivalis PAD, PAD2 and PAD4 (expressed by infiltrating neutrophils) are found in periodontal tissues. Autoantibodies directed to citrullinated proteins, so-called anticitrullinated protein antibodies (ACPAs), are found to be present in gingival crevicular fluid originating from inflamed gingival tissue. Furthermore, treatment studies have revealed that nonsurgical periodontal treatment, that is removal of sub-gingival calculus and biofilm deposits, is accompanied by a reduction in the severity of RA.

SUMMARY

In this study the similarities in immune response and tissue degradation between RA and periodontitis are reviewed. It is shown that the two diseases share the same environmental and genetic risk factors, apart from the fact that there is a link between both diseases via citrullination of proteins by human PAD and P. gingivalis PAD.

Periodontitis in established rheumatoid arthritis patients: a cross-sectional clinical, microbiological and serological study

Introduction

The association between rheumatoid arthritis (RA) and periodontitis is suggested to be linked to the periodontal pathogen Porphyromonas gingivalis. Colonization of P. gingivalis in the oral cavity of RA patients has been scarcely considered. To further explore whether the association between periodontitis and RA is dependent on P. gingivalis, we compared host immune responses in RA patients with and without periodontitis in relation to presence of cultivable P. gingivalis in subgingival plaque.

Methods

In 95 RA patients, the periodontal condition was examined using the Dutch Periodontal Screening Index for treatment needs. Subgingival plaque samples were tested for presence of P. gingivalis by anaerobic culture technique. IgA, IgG and IgM antibody titers to P. gingivalis were measured by ELISA. Serum and subgingival plaque measures were compared to a matched control group of non-RA subjects.

Results

A higher prevalence of severe periodontitis was observed in RA patients in comparison to matched non-RA controls (27% versus 12%, p < 0.001). RA patients with severe periodontitis had higher DAS28 scores than RA patients with no or moderate periodontitis (p < 0.001), while no differences were seen in IgM-RF or ACPA reactivity. Furthermore, RA patients with severe periodontitis had higher IgG- and IgM-anti P. gingivalis titers than non-RA controls with severe periodontitis (p < 0.01 resp. p < 0.05), although subgingival occurrence of P. gingivalis was not different.

Conclusions

Severity of periodontitis is related to severity of RA. RA patients with severe periodontitis have a more robust antibody response against P. gingivalis than non-RA controls, but not all RA patients have cultivable P. gingivalis.

Association between a history of periodontitis and the risk of rheumatoid arthritis: a nationwide, population-based, case-control study

OBJECTIVE

To investigate the association between the risk of rheumatoid arthritis (RA) and a history of periodontitis.

METHODS

This nationwide, population-based, case-control study used administrative data to identify 13 779 newly diagnosed patients with RA (age ≥16 years) as the study group and 137 790 non-patients with RA matched for age, sex, and initial diagnosis date (index date) as controls. Using conditional logistic regression analysis after adjustment for potential confounders, including geographical region and a history of diabetes and Sjögren's syndrome, ORs with 95% CI were calculated to quantify the association between RA and periodontitis. To evaluate the effects of periodontitis severity and the lag time since the last periodontitis visit on RA development, ORs were calculated for subgroups of patients with periodontitis according to the number of visits, cumulative cost, periodontal surgery and time interval between the last periodontitis-related visit and the index date.

RESULTS

An association was found between a history of periodontitis and newly diagnosed RA (OR=1.16; 95% CI 1.13 to 1.21). The strength of this association remained statistically significant after adjustment for potential confounders (OR=1.16; 95% CI 1.12 to 1.20), and after variation of periodontitis definitions. The association was dose- and time-dependent and was strongest when the interval between the last periodontitis-related visit and the index date was <3 months (OR=1.64; 95% CI 1.49 to 1.79).

CONCLUSIONS

This study demonstrates an association between periodontitis and incident RA. This association is weak and limited to lack of individual smoking status.

Autoantibodies to the β(1)-Adrenoceptor from Patients with Periodontitis as a Risk Factor for Cardiac Dysfunction

The presence of serum autoantibodies in periodontitis (P) patients against β₁-adrenoceptor (β₁-AR), using cardiac membranes or a synthetic β₁-AR peptide corresponding to the second extracellular loop of human β₁-AR as antigens, permit us to detect circulating antibody from 40 P patients but not in 20 normal individuals (control). Simultaneously, the P patients exhibited a decrease in HRV. Anti-β₁-AR IgG titters correlated with the decrease in HRV of the same patients and the anti-β₁-AR peptide IgG displayed partial agonist-like activity and modified the contractility of isolated atria, produced cyclic nucleotides, and inhibited the β₁-AR agonistic activity of isoproterenol. We demonstrated in this study an association between periodontitis infection and an increased risk of cardiac disease, thereby highlighting the role of anti-β₁-AR autoantibodies in alteration of myocardial contractility.

Periodontitis and blood pressure: the concept of dental hypertension

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

Rheumatoid arthritis and periodontitis; a possible link via citrullination

Rheumatoid Arthritis (RA) and chronic and aggressive periodontitis are chronic inflammatory disorders characterized by deregulation of the host inflammatory response. Increased secretion of pro-inflammatory mediators results in soft and hard tissue destruction of the synovium and periodontium respectively. Both diseases share risk factors and have pathological pathways in common, resulting in loss of function and disability as a final clinical outcome. This article discusses possible interactions, particularly related to the periodontal pathogen Porphyromonas gingivalis, which could explain the observed association between these two prevalent diseases.