Association among oral health parameters, periodontitis, and its treatment and mortality in patients undergoing hemodialysis

Association of periodontitis with cardiovascular and all-cause mortality in hypertensive individuals: insights from a NHANES cohort study

BACKGROUND

The objective of this research is to clarify the impact of periodontitis on overall and cardiovascular-related death rates among hypertensive individuals.

METHOD

A total of 5665 individuals with hypertension were included from the National Health and Nutrition Examination Survey (NHANES) data spanning 2001-2004 and 2009-2014. These individuals were divided into two groups based on the presence or absence of periodontitis and further stratified by the severity of periodontitis. We employed weighted multivariate Cox proportional hazards regression and Kaplan-Meier curves (log-rank test) to evaluate the impact of periodontitis on all-cause and cardiovascular mortality. Additional analyses, including adjustments for various covariates, subgroups, and sensitivity analyses, were conducted to ensure the robustness and reliability of our results.

RESULT

Over an average follow-up duration of 10.22 years, there were 1,122 all-cause and 297 cardiovascular deaths. Individuals with periodontitis exhibited an elevated risk of all-cause mortality (HR = 1.33, 95% CI 1.18-1.51; p < 0.0001) and cardiovascular mortality (HR = 1.48, 95% CI 1.15-1.89; p = 0.002). Moreover, we observed a progressive increase in both all-cause mortality and cardiovascular mortality (p for trend are both lower than 0.001) and correlating with the severity of periodontitis. These associations remained consistent across various subgroup and sensitivity analyses.

CONCLUSION

Our findings suggest a significant association between periodontitis and increased risks of all-cause and cardiovascular mortality among hypertensive individuals. Notably, the severity of periodontitis appears to be a critical factor, with moderate to severe cases exerting a more pronounced impact on all-cause mortality. Additionally, cardiovascular disease mortality significantlly increases in individuals with varying degrees of periodontitis.

Periodontitis and risk of mortality in patients with chronic kidney disease: A systematic review with meta-analysis

Studies examining the link between periodontitis and survival outcomes have yielded conflicting results in patients with chronic kidney disease (CKD). This systematic review with meta-analysis aims to assess the association between periodontitis and cardiovascular or all-cause mortality in CKD patients. A thorough search was conducted on the PubMed, Web of Science, and Embase databases for studies investigating the association between periodontitis and survival outcomes in CKD patients. Two authors independently scanned the titles or abstracts and then identified the eligible full-text article based on the PECOS criteria: Participants (CKD patients), Exposure (periodontitis), Comparison (mild/no periodontitis), Outcomes (cardiovascular or all-cause mortality), and Study design (retrospective or prospective cohort). Six cohort studies, including 7731 patients, were identified. The included studies had low-to-moderate risk of bias. The mean/median follow-up duration ranged from 18.1 months to 8.67 years. The all-cause mortality rate was 44.8% for patients with periodontitis and 28.0% for controls. Meta-analysis showed that periodontitis, defined through clinical attachment loss (CAL), was significantly associated with an increased risk of all-cause (adjusted hazard ratio [HR] 1.24; 95% confidence intervals [CI] 0.89-1.72; I2  = 80.9%) and cardiovascular mortality (HR 1.57; 95% CI 1.08-2.27; I2  = 34.0%). Additionally, a significant association between periodontitis and the risk of cardiovascular or all-cause mortality was observed in studies with a predominance of females, follow-up duration ≥5 years, all stages of CKD, and low risk of bias subgroups. Periodontitis is significantly associated with an increased risk of all-cause and cardiovascular mortality in CKD patients within low risk of bias subgroup or based on defining periodontitis through CAL. Registration number: PROSPERO CRD42018512391.

Association between periodontitis and mortality of patients with cardiovascular diseases: A cohort study based on NHANES

BACKGROUND

The association between periodontitis and cardiovascular disease (CVD) has been widely explored, but little is known about the effect of periodontitis on the mortality of CVD patients. This study aims to clarify the effect of periodontitis on all-cause and cause-specific mortality of CVD patients.

METHODS

We included 2,135 individuals with CVD from the National Health and Nutrition Examination Survey. Mortality data were ascertained by linkage to National Death Index records through 31 December 2019. We used Cox proportional hazards models for all-cause mortality and competing risk models for CVD and cancer mortality to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Further covariate adjustments, stratification analyses, and a variety of sensitivity analyses were conducted to test the reliability and robustness of the results.

RESULTS

The all-cause mortality in CVD patients with moderate/severe periodontitis was significantly higher than in those with no/mild periodontitis (HR: 1.25; 95% CI: 1.02-1.52; P = 0.03). The all-cause mortality in participants with severe clinical attachment loss was significantly higher (HR: 1.07; 95% CI: 1.01-1.14; P = 0.01). However, no discrepancy in CVD or cancer mortality was observed between CVD patients with different periodontal status.

CONCLUSIONS

Our findings from a longitudinal study with a large sample indicated significant but slightly higher all-cause mortality in CVD patients with moderate/severe periodontitis than in those with no/mild periodontitis.

Effects of periodontal treatment on the C-reactive protein levels in hemodialysis patients: A systematic review and meta-analysis

AIM

This systematic review provides a summary of the scientific evidence concerning effects of periodontal treatment on the C-reactive protein (CRP) levels in hemodialysis patients.

MATERIAL AND METHODS

Eight databases were accessed until May 2020 for interventional studies which evaluated CRP levels in hemodialysis patients before and after periodontal treatment. Inclusion criteria were studies involving hemodialysis patients with gingivitis or periodontitis, without restriction of year, language, and publication status. Random effects meta-analysis was performed. The risk of bias in eligible studies was assessed using the Joanna Briggs Institute's Critical Appraisal tools for use in systematic reviews. Certainty of evidence was also evaluated using GRADE approach.

RESULTS

The search in the databases resulted in 326 records, from which only seven met the eligibility criteria and therefore were submitted to qualitative evaluation. The meta-analysis revealed that, in general, the reduction in CRP levels had moderate and statistically significant effect size (standardized mean difference [SMD] = 0.45; confidence interval [CI] 95% = 0.25, 0.65; p < .001). Statistical heterogeneity was low (I2  = 0.0%; p = .771). Most studies showed moderate risk of bias.

CONCLUSION

Based on low certainty of evidence, the results suggest that periodontal treatment can significantly contribute to reduce CRP levels among hemodialysis patients. However, more randomized clinical studies, with follow-up longer than 12 months, using standardized diagnostic methods and controlling confounding factors, should be performed to strengthen the evidence.

Associations of periodontitis with risk of all-cause and cause-specific mortality among us adults with chronic kidney disease

OBJECTIVES

To investigate the associations of periodontitis with risk of all-cause and cause-specific mortality in a nationally representative sample of adults with chronic kidney disease (CKD) in the United States.

METHODS

This prospective cohort study included 4,271 individuals aged ≥30 years at baseline with CKD participants in the National Health and Nutrition Examination Survey (NHANES) during 1988-1994, 1999-2004, and 2009-2014. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2 and/or urinary albumin/creatinine ratio (uACR) ≥30 mg/g. Multivariate cox proportional hazards regression models were used to estimate the hazard ratios (HRs) and 95 % confidence intervals (CIs) of all-cause and cause-specific mortality in participants with CKD according to periodontitis. The associations of the quartiles of mean clinical attachment loss (CAL) and mean periodontal probing depth (PPD) levels with mortality were examined using the first quartile as the reference group.

RESULTS

During a median of 8.67 years of follow-up, 2,146 deaths were documented. After multivariate adjustments, moderate/severe periodontitis was significantly associated with all-cause (HR:1.28; 95 % CI:1.11-1.47; P = 0.001) and cardiovascular disease (CVD)-related mortality (HR:1.44; 95 % CI:1.14-1.81; P = 0.002) in participants with CKD. Compared with the reference group of mean CAL and mean PPD levels, all-cause (CAL: HR, 1.58; 95 % CI, 1.32-1.89, P <0.001; PPD: HR, 1.35, 95 % CI, 1.09-1.67, P = 0.011) and CVD-related mortality (CAL: HR, 1.70, 95 % CI, 1.21-2.40, P = 0.001) were increased for participants in the highest quartile.

CONCLUSIONS

This study suggests that moderate/severe periodontitis and high levels of mean CAL and mean PPD are associated with an increased risk of all-cause mortality, and moderate/severe periodontitis and mean CAL associated with CVD-related mortality among adults with CKD in the US.

CLINICAL SIGNIFICANCE

This study details the association between periodontitis and the increased risk of all-cause mortality and CVD-related mortality in a large, representative sample of adults with CKD.

Periodontal treatment and subsequent clinical outcomes and medical care costs: A retrospective cohort study

INTRODUCTION

Periodontitis is a common oral disease associated with coronary artery disease (CAD), cerebrovascular disease (CBVD) and type 2 diabetes (T2D). We studied if periodontitis treatment improves clinical outcomes and reduces medical care costs in patients with CAD, CBVD or T2D.

METHODS

We used clinic records and claims data from a health care system to identify patients with periodontitis and CAD, CBVD or T2D, and to assess periodontal treatments, hospitalizations, medical costs (total, inpatient, outpatient, pharmacy), glycated hemoglobin, cardiovascular events, and death following concurrent disease diagnoses. We compared clinical outcomes according to receipt of periodontal treatment and/or maintenance care in the follow-up period, and care costs according to treatment status within one year following concurrent disease diagnoses, while adjusting for covariates. The data were analyzed in 2019-21.

RESULTS

We identified 9,503 individuals, 4,057 of whom were in the CAD cohort; 3,247 in the CBVD cohort; and 4,879 in the T2D cohort. Patients who were selected and elected to receive treatment and maintenance care were less likely to be hospitalized than untreated individuals (CAD: OR = 0.71 (95% CI: 0.55, 0.92); CBVD: OR = 0.73 (0.56, 0.94); T2D: OR = 0.80 (0.64, 0.99)). Selection to treatment and/or maintenance care was not significantly associated with cardiovascular events, mortality, or glycated hemoglobin change. Total care costs did not differ significantly between treated and untreated groups over 4 years. Treated patients experienced lower inpatient costs but higher pharmacy costs.

CONCLUSIONS

Patients with periodontitis and CAD, CBVD or T2D who were selected and elected to undergo periodontal treatment or maintenance care had lower rates of hospitalizations, but did not differ significantly from untreated individuals in terms of clinical outcomes or total medical care costs.

Chronic Kidney Disease and Periodontitis Interplay-A Narrative Review

Periodontitis (PO), a chronic microbially-induced inflammation of the supporting tissues of the tooth, is linked to various systemic diseases. We analyze its bidirectional relationship to chronic kidney disease (CKD), a major health-care problem with impressive excess mortality. Overwhelming associative relationship between CKD and PO are analyzed. Major pathophysiologic mechanisms that link CKD to PO are then presented: systemic inflammation, endothelial dysfunction, and imbalance of oxidative stress characteristic of CKD have a role in PO development and might influence escape mechanisms of oral microbiota. Subclinical local and systemic inflammation induced by PO might influence in turn CKD outcomes. Homeostatic changes induced by CKD such as mineral bone disorders, acidosis, uremic milieu, or poor salivary flow are also relevant for the occurrence of PO. There is insufficient evidence to recommend a standardized diagnostic and therapeutic approach regarding association of PO to CKD.

The Impact of Chronic Kidney Disease on Nutritional Status and Its Possible Relation with Oral Diseases

Several studies have demonstrated a strong relation between periodontal diseases and chronic kidney disease (CKD). The main mechanisms at the base of this link are malnutrition, vitamin dysregulation, especially of B-group vitamins and of C and D vitamins, oxidative stress, metabolic acidosis and low-grade inflammation. In particular, in hemodialysis (HD) adult patients, an impairment of nutritional status has been observed, induced not only by the HD procedures themselves, but also due to numerous CKD-related comorbidities. The alteration of nutritional assessment induces systemic manifestations that have repercussions on oral health, like oral microbiota dysbiosis, slow healing of wounds related to hypovitaminosis C, and an alteration of the supporting bone structures of the oral cavity related to metabolic acidosis and vitamin D deficiency. Low-grade inflammation has been observed to characterize periodontal diseases locally and, in a systemic manner, CKD contributes to the amplification of the pathological process, bidirectionally. Therefore, CKD and oral disease patients should be managed by a multidisciplinary professional team that can evaluate the possible co-presence of these two pathological conditions, that negatively influence each other, and set up therapeutic strategies to treat them. Once these patients have been identified, they should be included in a follow-up program, characterized by periodic checks in order to manage these pathological conditions.

Impact of Red Complex Bacteria and TNF-α Levels on the Diabetic and Renal Status of Chronic Kidney Disease Patients in the Presence and Absence of Periodontitis

Scientific evidence shows a positive association in the etiopathogenesis of periodontitis and chronic kidney disease (CKD). Various confounding factors, such as obesity, diabetes, and inflammation, also play a significant role in the progression of CKD, which remains unexplored. We hypothesise the role of red complex bacteria with various confounding factors associated with chronic kidney disease. The study comprised a total of 120 participants categorised into 4 groups: the control group (C), periodontitis subjects without CKD (P), periodontally healthy chronic kidney disease subjects (CKD), and subjects having both periodontitis and CKD (P + CKD), with 30 subjects in each group. Demographic variables, and periodontal, renal, and diabetic parameters were recorded. Tumour necrosis factor (TNF)-α levels and those of red complex bacteria such as Prophyromonas gingivalis (P.g), Treponema denticola (T.d), and Tonerella forsythia (T.f) were assessed, and the obtained results were statistically analysed. Among the various demographic variables, age showed a level of significance. Mean PI, GI, CAL, and PPD (the proportion of sites with PPD ≥ 5 mm and CAL ≥ 3 mm) were elevated in the P + CKD group. Diabetic parameters such as fasting blood sugar (FBS) and HbA1c levels were also greater in the P + CKD group. Renal parameters such as eGFR and serum creatinine levels were greater in CKD patients. The estimation of red complex periodontal pathogens such as Pg, Td and Tf levels were significantly greater in the P and P + CKD groups. Pearson correlation analysis revealed significant correlation of red complex bacteria with all variables. Greater levels of P.g, T.d and T.f were found in the P groups, thus indicating their important role in the initiation and progression of inflammation of periodontitis and CKD, with diabetes as one of the confounding factors. The study also confirmed a log-linear relationship between TNF-α levels and red complex bacteria, thereby demonstrating the role of inflammatory biomarkers in periodontal disease progression that could contribute to the development of systemic inflammation such as CKD.

Periodontitis Exacerbates and Promotes the Progression of Chronic Kidney Disease Through Oral Flora, Cytokines, and Oxidative Stress

Periodontitis is a type of systemic immune inflammation that is caused by the complex infection of a variety of microorganisms in the subgingival plaque and the imbalance of the microbial ecological environment in the mouth. Periodontitis and chronic kidney disease (CKD) share many risk factors, such as obesity, smoking, and age. A growing body of data supports a strong correlation between periodontitis and kidney disease. Evidence supports the role of periodontal inflammation and elevated serum inflammatory mediators in renal atherosclerosis, renal deterioration, and end-stage renal disease (ESRD) development. Periodontitis is a risk factor for kidney disease. However, to our knowledge, there are few studies detailing the possible link between periodontitis and CKD. This review summarizes the possible mechanisms underlying periodontitis and CKD. More importantly, it highlights novel and potential pathogenic factors for CKD, including bacteria, pro-inflammatory mediators and oxidative stress. However, most research on the relationship between periodontitis and systemic disease has not determined causality, and these diseases are largely linked by bidirectional associations. Future research will focus on exploring these links to contribute to new treatments for CKD.

Causal Inference Between Chronic Periodontitis and Chronic Kidney Disease: A Bidirectional Mendelian Randomization Analysis in a European Population

Background

Previous epidemiological studies have shown significant associations between chronic periodontitis (CP) and chronic kidney disease (CKD), but the causal relationship remains uncertain. Aiming to examine the causal relationship between these two diseases, we conducted a bidirectional two-sample Mendelian randomization (MR) analysis with multiple MR methods.

Methods

For the casual effect of CP on CKD, we selected seven single-nucleotide polymorphisms (SNPs) specific to CP as genetic instrumental variables from the genome-wide association studies (GWAS) in the GLIDE Consortium. The summary statistics of complementary kidney function measures, i.e., estimated glomerular filtration rate (eGFR) and blood urea nitrogen (BUN), were derived from the GWAS in the CKDGen Consortium. For the reversed causal inference, six SNPs associated with eGFR and nine with BUN from the CKDGen Consortium were included and the summary statistics were extracted from the CLIDE Consortium.

Results

No significant causal association between genetically determined CP and eGFR or BUN was found (all p > 0.05). Based on the conventional inverse variance-weighted method, one of seven instrumental variables supported genetically predicted CP being associated with a higher risk of eGFR (estimate = 0.019, 95% CI: 0.012-0.026, p < 0.001).

Conclusion

Evidence from our bidirectional causal inference does not support a causal relation between CP and CKD risk and therefore suggests that associations reported by previous observational studies may represent confounding.

Effect of periodontal treatment on the glomerular filtration rate, reduction of inflammatory markers and mortality in patients with chronic kidney disease: A systematic review

Aim

To assess the effect of periodontal treatment (PT) on glomerular filtration rate (GFR), systemic inflammation, or mortality in patients with chronic kidney disease (CKD).

Methods

A literature search was performed on PubMed and Web of Science databases on articles published until December 2019. The PRISMA guidelines were used throughout the manuscript.

Results

Of the total studies found, only 18 met the inclusion criteria; four retrospective and 14 prospective studies (including 3 randomized controlled trials–RCT). After PT, 3 studies investigated GFR, 2 found significant improvement; 11 (including 2 RCTs) investigated C-reactive protein levels, 9 found a significant improvement (including the 2 RCTs); 5 (including 3 RCTs) investigated Interleukine-6 level, 4 found a significant improvement (including 2 RCTs) and 2 studies evaluated mortality, one (retrospective study) found a significant difference.

Conclusions

Within the limitations of the present study, PT seems to improve CKD status, especially by reducing the systemic inflammation. Further RCTs are needed to confirm the results and specifically assess the influence of different types of PT in CKD patients. Taking into consideration the ability of PT to prevent further tooth loss and denutrition, early management of periodontitis is extremely important in patients with impaired renal function.

Poor oral hygiene and dental caries predict high mortality rate in hemodialysis: a 3-year cohort study

The aim of this study was to investigate the impact of oral hygiene, periodontal diseases, and dental caries on all-cause mortality in hemodialysis. This prospective cohort study included 266 patients with end-stage renal disease who were undergoing hemodialysis. Medical interviews, blood biochemical tests, and comprehensive dental examinations including periodontal pocket examination on all teeth and dental plaque accumulation by debris index-simplified (DI-S), were performed. Survival rates were assessed at a 3-year follow-up. Overall, 207 patients were included in the longitudinal analysis, and 38 subjects died during the follow-up period. Cox proportional hazards analysis of the multivariate model demonstrated that the highest tertile of DI-S had a significantly higher risk of all-cause mortality than the lowest two tertiles after adjustment for age, sex, smoking habit, body mass index, diabetes, prior cardiovascular disease, hemodialysis vintage, high sensitivity C-reactive protein, albumin, and number of remaining teeth (hazard ratio, 3.04; 95% confidence interval, 1.50–6.17; p = 0.002). Moreover, the number of decayed teeth significantly increased the hazard ratio to 1.21 (95% confidence interval, 1.06.1.37; p = 0.003). This study suggests that accumulated dental plaque and untreated decay, but not periodontal disease, may be independently associated with all-cause mortality in patients undergoing hemodialysis.

Salivary microbiome in patients undergoing hemodialysis and its associations with the duration of the dialysis

Background

Chronic kidney disease (CKD) patients, especially those with end stage renal disease (ESRD) undergoing hemodialysis (HD), exhibit high prevalence of periodontitis. This cross-sectional study aimed to investigate the periodontal status of HD patients and its relationship with salivary microbiome.

Methods

One hundred eight HD patients and one hundred healthy control individuals were recruited. They were subjected to periodontal examination followed by saliva samples collection for 16S rRNA gene sequencing.

Results

The HD patients were with worse periodontal health status, and exhibited higher salivary microbial diversity and lower richness. The periodontal pathogens were significantly enriched in the HD patients. The inferred functional analyze showed microbes enriched in the HD patients were mainly related to metabolism. Despite the periodontal status and overall structure of the microbiome were not significantly altered as the HD duration prolonged, the abundance of Lachnospiraceae [G-2] sp. |HMT_096| is positively correlated with the duration of HD and the community periodontal index (CPI). Five OTUs (operational taxonomic units) belonging to the phyla Firmicutes were enriched as the duration prolonged, and four OTUs originated from the phyla Proteobacteria were negatively related with the CPI index. ESRD patients undergoing HD exhibited microbiota structural, compositional and functional differences compared with the healthy controls. And the species changed as the duration of hemodialysis prolonged.

Conclusions

End stage renal disease changes salivary microbiome and is a risk factor for oral dysbiosis.

Influence of Chronic Periodontitis on the Long-Term Mortality and Cardiovascular Events in Kidney Transplant Recipients

Chronic periodontitis (CP) is associated with cardiovascular disease and mortality in different populations. The aim of this study was to examine an association of CP with hard endpoints in patients after kidney transplantation during a 15-year follow-up period. Study group consist of 117 patients (77M/40F, median age 44 years) divided into two subgroups: those with initially advanced CP (CPITN 3-4) and those with no or moderate CP (CPITN 0-2). All cardiovascular events, graft losses, and re-transplantations were recorded. All deaths were noted and verified, including those occurred after the return to dialysis therapy, the causes of death were identified. Cox regression with Firth's penalized maximum likelihood models were used for data analysis. During the observation period, 49 deaths occurred. Advanced CP (n = 35) was not associated with overall mortality but was associated with increased risk of death with functioning graft (DWFG) [HR 3.54 (1.20-10.45); p < 0.05]. Risk of graft loss was not associated with CP status. In conclusion, an advanced CP was independently associated with increased risk of DWFG, but not all-cause or cardiovascular mortality after renal transplantation.

Effects of non-surgical periodontal therapy on systemic inflammation and metabolic markers in patients undergoing haemodialysis and/or peritoneal dialysis: a systematic review and meta-analysis

BACKGROUND

This systematic review aimed to investigate whether non-surgical periodontal therapy (NSPT) can reduce systemic inflammatory levels and improve metabolism in patients undergoing haemodialysis (HD) and/or peritoneal dialysis (PD).

METHODS

Electronic databases (PubMed, EMBASE, CENTRAL, CNKI, and WFPD) were searched for randomized controlled trials (RCTs) performed through July 2019. The risk of bias within studies was assessed with the Cochrane Collaboration's risk assessment tool. The systemic inflammatory and metabolic outcomes included the highly sensitive C-reactive protein (hs-CRP), interleukin 6 (IL-6), tumour necrosis factor-a (TNF-a), the albumin (Alb), and lipid metabolite levels. Meta-analyses (MAs) were performed to calculate the overall effect size where appropriate.

RESULTS

Five RCTs were included in this study. Compared with untreated periodontitis groups, the dialysis patients after NSPT significantly showed decreased hs-CRP levels at less than or equal to 2 months (standardized mean difference: - 1.53, 95% confidence interval - 2.95 to - 0.11). No significant difference was found in IL-6 and Alb levels following NSPT at either the 3- or 6- month follow-ups. No MAs could be performed on the TNF-a level and the lipid metabolic markers.

CONCLUSIONS

NSPT can moderately reduce serum hs-CRP levels in HD and/or PD patients, but did not significantly change IL-6 or Alb levels. For TNF-a and lipid metabolism markers, no sufficient evidence supports that these levels are changed after NSPT. Additional scientific research is necessary to assess the effects of NSPT on systemic inflammation and metabolic parameters in dialysis patients.

Periodontal Disease in Patients Receiving Dialysis

Chronic kidney disease (CKD) is characterized by kidney damage with proteinuria, hematuria, and progressive loss of kidney function. The final stage of CKD is known as end-stage renal disease, which usually indicates that approximately 90% of normal renal function is lost, and necessitates renal replacement therapy for survival. The most widespread renal replacement therapy is dialysis, which includes peritoneal dialysis (PD) and hemodialysis (HD). However, despite the development of novel medical instruments and agents, both dialysis procedures have complications and disadvantages, such as cardiovascular disease due to excessive blood fluid and infections caused by impaired immunity. Periodontal disease is chronic inflammation induced by various pathogens and its frequency and severity in patients undergoing dialysis are higher compared to those in healthy individuals. Therefore, several investigators have paid special attention to the impact of periodontal disease on inflammation-, nutrient-, and bone metabolism-related markers; the immune system; and complications in patients undergoing dialysis. Furthermore, the influence of diabetes on the prevalence and severity of manifestations of periodontal disease, and the properties of saliva in HD patients with periodontitis have been reported. Conversely, there are few reviews discussing periodontal disease in patients with dialysis. In this review, we discuss the available studies and review the pathological roles and clinical significance of periodontal disease in patients receiving PD or HD. In addition, this review underlines the importance of oral health and adequate periodontal treatment to maintain quality of life and prolong survival in these patients.

Carious status and supragingival plaque microbiota in hemodialysis patients

Objective

The aim of this study was to evaluate the carious status and the microbial profiles of supragingival plaque in patients with chronic kidney disease undergoing hemodialysis.

Methods

This study included 30 patients with chronic kidney disease undergoing hemodialysis as well as 30 control subjects. Dental examination was performed and the decayed-missing-filled-teeth was recorded. Supragingival plaque was taken and analyzed using 16S rRNA gene amplicon by Illumina MiSeq sequencing to detect microbial composition and community diversity and structure.

Results

The level of decayed-missing-filled-teeth was higher in the hemodialysis group than that in the control group. Microbial analysis showed a decrease in α diversity and a increase in relative abundance and prevalence of many acidogenic and aciduric caries related species in the supragingival plaque samples of the hemodialysis patients, including Streptococcus mutans, Lactobacillus salivarius, Lactobacillus fermentum, Lactobacillus vaginalis, Scardovia wiggsiae F0424, and Actinomyces naeslundii.

Conclusion

Our results suggested that the hemodialysis patients were more susceptible to caries. More attentions for caries prevention and treatment should be paid to improve their life quality, and even to reduce their cardiovascular events and survival.

The directional and non-directional associations of periodontitis with chronic kidney disease: A systematic review and meta-analysis of observational studies

This systematic review aimed to assess the current evidence on the directional and non-directional associations of periodontitis with chronic kidney disease (CKD). Electronic search for observational studies on the association of periodontitis with CKD was performed in MEDLINE, EMBASE, PubMed, Open GREY and Cochrane library up to June 5, 2017. Two reviewers conducted study selection, data collection and assessment of methodological quality using the original and modified Newcastle-Ottawa Scale. Cohort, case-control and cross-sectional studies were included, which clearly defined periodontitis and CKD or reported acceptable clinical parameters of these 2 diseases in adults. Meta-analysis was employed to estimate the pooled odds ratio on the non-directional association and the incidence rate ratio (IRR) for the directional association. Among 2530 potential eligible articles, 47 were finally included. Most of them investigated a non-directional association of periodontitis with CKD, including 7 case-control studies and 38 cross-sectional studies; 24 studies had statistical analysis on the non-directional association and 75% of them reported significant results, which were supported further by the meta-analysis (random: odds ratio = 2.12, P < .001; χ²  = 25.74, I²  = 88.3%). None of the studies focused on the directional association of CKD (as the exposure) with periodontitis (as the outcome), whereas 2 retrospective cohort studies explored a directional association of periodontitis (as the exposure) with CKD (as the outcome) (random: IRR=2.10, P > .05; fixed: IRR=1.76, P < .05; χ²  = 4.65, I²  = 78.3%). Overall, the high heterogeneity of studies limits the significance of these results. There is substantial evidence on the non-directional association of periodontitis with CKD, while there are limited studies on the directional association. Well-designed prospective studies with longer follow-ups in representative communities are needed to clarify the directional association and enhance the quality of the evidence on this topic.

Prevalence of Periodontitis in Patients Undergoing Hemodialysis: a Case Control Study

Objectives:

To assess the prevalence of periodontal disease among patients undergoing renal dialysis.

Methods:

Sixty hemodialysis patients (30 males, 30 females) with a mean age of 44.4±9.5 years comprised the study group. Periodontal parameters such as plaque index (PI), bleeding on probing (BOP), probing pocket depth (PPD) and clinical attachment level (CAL) were measured in these patients and 60 age and sex-matched control subjects. The data was tabulated and analyzed.

Results:

The mean duration of dialysis was 5.50±3.02 years. The plaque index (PI) bleeding on probing (BOP), Periodontal probing depth (PPD) and clinical attachment level (CAL) were significantly higher in patients undergoing hemodialysis than in control subjects. The mean clinical attachment level was significantly higher among the dialysis patients (2.78±0.83 mm) than the control subjects (1.97±0.53 mm). The plaque index and bleeding on probing also showed a similar pattern in patients undergoing hemodialysis compared to control patients. The prevalence and severity of periodontal disease seems to be higher in patients undergoing dialysis.

Conclusion:

From the observations of this study, it can be concluded that patients undergoing hemodialysis are more prone to periodontal diseases. Further studies with a larger population and a comparison with the duration of dialysis may further substantiate the current findings.

Association between periodontal disease and mortality in people with CKD: a meta-analysis of cohort studies

BACKGROUND

Periodontal disease occurs relatively prevalently in people with chronic kidney disease (CKD), but it remains indeterminate whether periodontal disease is an independent risk factor for premature death in this population. Interventions to reduce mortality in CKD population consistently yield to unsatisfactory results and new targets are necessitated. So this meta-analysis aimed to evaluate the association between periodontal disease and mortality in the CKD population.

METHODS

Pubmed, Embase, Web of Science, Scopus and abstracts from recent relevant meeting were searched by two authors independently. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for overall and subgroup meta-analyses. Statistical heterogeneity was explored by chi-square test and quantified by the I2 statistic.

RESULTS

Eight cohort studies comprising 5477 individuals with CKD were incorporated. The overall pooled data demonstrated that periodontal disease was associated with all-cause death in CKD population (RR, 1.254; 95% CI 1.046-1.503; P = 0.005), with a moderate heterogeneity, I2 = 52.2%. However, no evident association was observed between periodontal disease and cardiovascular mortality (RR, 1.30, 95% CI, 0.82-2.06; P = 0.259). Besides, statistical heterogeneity was substantial (I2 = 72.5%; P = 0.012). Associations for mortality were similar between subgroups, such as the different stages of CKD, adjustment for confounding factors. Specific to all-cause death, sensitivity and cumulative analyses both suggested that our results were robust. As for cardiovascular mortality, the association with periodontal disease needs to be further strengthened.

CONCLUSIONS

We demonstrated that periodontal disease was associated with an increased risk of all-cause death in CKD people. Yet no adequate evidence suggested periodontal disease was also at elevated risk for cardiovascular death.

Severe periodontitis and higher cirrhosis mortality

Background

Periodontitis and edentulism are prevalent in patients with cirrhosis, but their clinical significance is largely unknown.

Objective

The objective of this article is to determine the association of severe periodontitis and edentulism with mortality in patients with cirrhosis.

Methods

A total of 184 cirrhosis patients underwent an oral examination. All-cause and cirrhosis-related mortality was recorded. The associations of periodontitis and edentulism with mortality were explored by Kaplan-Meier survival plots and Cox proportional hazards regression adjusted for age, gender, cirrhosis etiology, Child-Pugh score, Model for End-Stage Liver Disease score, smoker status, present alcohol use, comorbidity, and nutritional risk score.

Results

The total follow-up time was 74,197 days (203.14 years). At entry, 44% of the patients had severe periodontitis and 18% were edentulous. Forty-four percent of the patients died during follow-up. Severe periodontitis was associated with higher all-cause mortality in the crude analysis (HR 1.56, 95% CI 1.06-2.54), but not in the adjusted analysis (HR 1.45, 95% CI 0.79-2.45). Severe periodontitis was even more strongly associated with higher cirrhosis-related mortality (crude HR 2.19, 95% CI 1.07-4.50 and adjusted HR 2.29, 95% CI 1.04-4.99). No association was found between edentulism and mortality.

Conclusion

The presence of severe periodontitis predicted a more than double one-year cirrhosis mortality. These findings may motivate intervention trials on the effect of periodontitis treatment in patients with cirrhosis.

Associations between Periodontal Microbiota and Death Rates

It is conceived that specific combinations of periodontal bacteria are associated with risk for the various forms of periodontitis. We hypothesized that such specificity is also related to human cause-specific death rates. We tested this hypothesis in a representative sample of the US population followed for a mean duration of 11 years and found that two specific patterns of 21 serum antibodies against periodontal bacteria were significantly associated with increased all-cause and/or diabetes-related mortalities. These data suggested that specific combinations of periodontal bacteria, even without inducing clinically significant periodontitis, may have a significant impact on human cause-specific death rates. Our findings implied that increased disease and mortality risk could be transmittable via the transfer of oral microbiota, and that developing personalized strategies and maintaining healthy oral microbiota beyond protection against periodontitis would be important to manage the risk.

Factors associated with regular dental visits among hemodialysis patients

AIM

To investigate awareness and attitudes about preventive dental visits among dialysis patients; to clarify the barriers to visiting the dentist.

METHODS

Subjects included 141 dentate outpatients receiving hemodialysis treatment at two facilities, one with a dental department and the other without a dental department. We used a structured questionnaire to interview participants about their awareness of oral health management issues for dialysis patients, perceived oral symptoms and attitudes about dental visits. Bivariate analysis using the χ² test was conducted to determine associations between study variables and regular dental check-ups. Binominal logistic regression analysis was used to determine factors associated with regular dental check-ups.

RESULTS

There were no significant differences in patient demographics between the two participating facilities, including attitudes about dental visits. Therefore, we included all patients in the following analyses. Few patients (4.3%) had been referred to a dentist by a medical doctor or nurse. Although 80.9% of subjects had a primary dentist, only 34.0% of subjects received regular dental check-ups. The most common reasons cited for not seeking dental care were that visits are burdensome and a lack of perceived need. Patients with gum swelling or bleeding were much more likely to be in the group of those not receiving routine dental check-ups (χ² test, P < 0.01). Logistic regression analysis demonstrated that receiving dental check-ups was associated with awareness that oral health management is more important for dialysis patients than for others and with having a primary dentist (P < 0.05).

CONCLUSION

Dialysis patients should be educated about the importance of preventive dental care. Medical providers are expected to participate in promoting dental visits among dialysis patients.

Oral behavior, dental, periodontal and microbiological findings in patients undergoing hemodialysis and after kidney transplantation

BACKGROUND

Aim of this single center cross-sectional study was to investigate oral behavior, dental, periodontal and microbiological findings in patients undergoing hemodialysis (HD) and after kidney transplantation (KT).

METHODS

Patients undergoing HD for end-stage renal failure and after KT were investigated. Oral health behavior was recorded using a standardized questionnaire, e.g. dental behavior, tooth brushing, oral hygiene aids. Oral investigation included screening of oral mucosa, dental findings (DMF-T) and periodontal situation (Papilla bleeding index [PBI] periodontal probing depth [PPD] and clinical attachment loss [CAL]). Additionally, microbiological analysis of subgingival biofilm samples (PCR) was performed.

STATISTICAL ANALYSIS

Student's t-test or Mann-Whitney-U-test, Fisher's exact test (α = 5 %).

RESULTS

A total of 70 patients (HD: n = 35, KT: n = 35) with a mean age of 56.4 ± 11.1 (HD) and 55.8 ± 10.9 (KT) years were included. Lack in use of additional oral hygiene (dental floss, inter-dental brush) was found. KT group presented significantly more gingivial overgrowth (p = 0.01). DMF-T was 19.47 ± 5.84 (HD) and 17.61 ± 5.81 (KT; p = 0.21). Majority of patients had clinically moderate and severe periodontitis; showing a need for periodontal treatment of 57 % (HD) and 71 % (KT; p = 0.30). Significantly higher prevalence of Parvimonas micra and Capnocytophaga species in the HD group were found (p < 0.01).

CONCLUSION

Periodontal treatment need and lack in oral behavior for both groups indicate the necessity of an improved early treatment and prevention of dental and periodontal disease, e.g. in form of special care programs. Regarding microbiological findings, no major differences between KT and HD patients were found.

Associations between the number of natural teeth and renal dysfunction

The purpose of the present study was to investigate the association between the number of natural teeth and measures of kidney dysfunction, such as urinary albumin/creatinine ratio (ACR) and estimated glomerular filtration (eGFR) rate, using nationally representative data.The data used were from the Korea National Health and Nutrition Examination Survey with cross-sectional design, which was conducted between 2011 and 2012; the sample analyzed in this study consisted of a total of 10,388 respondents, each of whom was 19 years or older and had no missing outcome variables. The association between the number of natural teeth and kidney function was assessed by multiple logistic regression and model was adjusted for age, sex, waist conference, smoking, drinking, exercise, education, income, frequency of tooth brushing per day, diabetes, metabolic syndrome, urinary ACR, and eGFR.The mean age, body mass index, and waist circumference were significantly higher among those with lower kidney function (urinary ACR ≥30 mg/g and eGFR <60 mL/min/1.73m). Urinary ACR and eGFR were associated with loss of natural teeth. As urinary ACR increased, the number of natural teeth decreased accordingly. Conversely, the number of natural teeth increased with an increase in eGFR.This study showed that the number of natural teeth is inversely associated with the presence of kidney disease. Severity of tooth loss may be considered an independent risk indicator for kidney disease among Koreans. More epidemiological studies are warranted to investigate the role of tooth loss in kidney disease, to confirm this relationship and to test possible underlying mechanisms.

Effect of Nd:YAG laser-assisted non-surgical periodontal therapy on clinical periodontal and serum biomarkers in patients with and without coronary artery disease: A short-term pilot study

BACKGROUND/OBJECTIVE

We hypothesized that nonsurgical-periodontal-therapy (NSPT) with adjunct Nd:YAG laser therapy is more effective in reducing periodontal inflammatory parameters (plaque index [PI], bleeding-on-probing [BOP], and probing-pocket-depth [PPD]) and serum interleukin-1beta (IL-1β) and matrix metalloproteinase-9 (MMP-9) levels in patients with and without coronary artery disease (CAD) than NSPT alone. The aim of this short-term pilot study was to assess the effect of NSPT + Nd:YAG laser therapy on periodontal parameters and serum IL-1β and MMP-9 levels in patients with and without CAD.

STUDY DESIGN

A prospective randomized clinical study was conducted on 87 patients who were divided into two groups: Group-1: 44 patients with CAD and periodontal disease (PD) and Group-2: 43 patients with PD alone. Treatment-wise, these individuals were randomly divided into two subgroups: (i) NSPT alone and (ii) NSPT + Nd:YAG laser therapy. Demographic information was collected using a self-completed questionnaire. Periodontal parameters (PI, BOP, and PPD) and serum IL-1β and MMP-9 levels were measured at baseline and after 3 months of treatment. P-values <0.05 were considered statistically significant.

RESULTS

At 3 months follow-up, PI (P < 0.01), BOP (P < 0.01), PPD ≥ 4 mm (P < 0.01), and serum IL-1β (P < 0.01) and MMP-9 (P < 0.01) levels were significantly higher in patients treated with NSPT alone than those treated with NSPT + Nd:YAG laser therapy. Among patients that underwent NSPT + laser therapy in both groups, periodontal parameters and serum IL-1β, and MMP-9 levels were comparable at 3-months follow-up.

CONCLUSION

NSPT + Nd:YAG laser therapy may be more effective in reducing periodontal inflammation and serum IL-1β and MMP-9 levels in patients with and without CAD than NSPT alone. Lasers Surg. Med. 48:929-935, 2016. © 2016 Wiley Periodicals, Inc.

Association between periodontitis and mortality in stages 3-5 chronic kidney disease: NHANES III and linked mortality study

INTRODUCTION

Periodontitis may add to the systemic inflammatory burden in individuals with chronic kidney disease (CKD), thereby contributing to an increased mortality rate. This study aimed to determine the association between periodontitis and mortality rate (all-cause and cardiovascular disease-related) in individuals with stage 3-5 CKD, hitherto referred to as "CKD".

METHODS

Survival analysis was carried out using the Third National Health and Nutrition Examination Survey (NHANES III) and linked mortality data. Cox proportional hazards regression was employed to assess the association between periodontitis and mortality, in individuals with CKD. This association was compared with the association between mortality and traditional risk factors in CKD mortality (diabetes, hypertension and smoking).

RESULTS

Of the 13,784 participants eligible for analysis in NHANES III, 861 (6%) had CKD. The median follow-up for this cohort was 14.3 years. Adjusting for confounders, the 10-year all-cause mortality rate for individuals with CKD increased from 32% (95% CI: 29-35%) to 41% (36-47%) with the addition of periodontitis. For diabetes, the 10-year all-cause mortality rate increased to 43% (38-49%).

CONCLUSION

There is a strong, association between periodontitis and increased mortality in individuals with CKD. Sources of chronic systemic inflammation (including periodontitis) may be important contributors to mortality in patients with CKD.

Comparison the efficacy of herbal mouthwash with chlorhexidine on gingival index of intubated patients in Intensive Care Unit

Background:

Intubated patients in Intensive Care Unit (ICU) are not able to take care of their mouth health, so they are at risk of bacterial colonization and dental plaques formation that can lead to systemic diseases such as pneumonia and gingivitis.

Aims:

In randomized, double-blind clinical study, the efficacy of natural herbal mouthwash containing Salvadora persica ethanol extract and Aloe vera gel was compared with chlorhexidine on gingival index (GI) of intubated patients in ICU.

Materials and Methods:

Seventy-six intubated patients (18–64 years old with mean age 40.35 ± 13.2) in ICU were admitted to this study. The patients were randomly divided into two groups: (1) Herbal mouthwash and (2) chlorhexidine solution. Before the intervention, the GIs was measured by modified GI device into two groups. The mouth was rinsed by mouthwashes every 2–3 h for 4 days. 2 h after the last intervention, GIs were determined.

Results:

Along with mechanical methods, herbal mouthwash in reducing GI was statistically significant than that of chlorhexidine (P < 0.05).

Conclusion:

The results of this study introduce a new botanical extract mouthwash with dominant healing effects on GI (1.5 ± 0.6) higher than that of synthetic mouthwash, chlorhexidine (2.31 ± 0.73).

Does Treatment of Periodontal Disease Influence Systemic Disease?

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

Current status of collaborative relationships between dialysis facilities and dental facilities in Japan: results of a nationwide survey

BACKGROUND

Recent studies have reported an association between periodontal disease and mortality among dialysis patients. Therefore, preventive dental care should be considered very important for this population. In Japan, no systematic education has been undertaken regarding the importance of preventive dental care for hemodialysis patients--even though these individuals tend to have oral and dental problems. The aim of this study was to investigate the current state of collaborative relationships between hemodialysis facilities and dental services in Japan and also to identify strategies to encourage preventive dental visits among hemodialysis outpatients.

METHODS

A nationwide questionnaire on the collaborative relationship between dialysis facilities and dental facilities was sent by mail to all medical facilities in Japan offering outpatient hemodialysis treatment.

RESULTS

Responses were obtained from 1414 of 4014 facilities (35.2%). Among the 1414 facilities, 272 (19.2%) had a dental service department. Approximately 100,000 dialysis outpatients were receiving treatment at these participating facilities, which amounts to one-third of all dialysis patients in Japan. Of those patients, 82.9% received hemodialysis at medical facilities without dental departments. Only 87 of 454 small clinics without in-house dental departments (19.2%) had collaborative registered dental clinics. Medical facilities with registered dental clinics demonstrated a significantly more proactive attitude to routine collaboration on dental matters than facilities lacking such clinics.

CONCLUSIONS

Our nationwide survey revealed that most dialysis facilities in Japan have neither an in-house dental department nor a collaborative relationship with a registered dental clinic. Registration of dental clinics appears to promote collaboration with dental facilities on a routine basis, which would be beneficial for oral health management in hemodialysis patients.

Endotoxemia in end-stage kidney disease

Chronic unexplained inflammation remains a prevalent and clinically significant problem for patients with end-stage kidney disease (ESKD), especially in the dialysis population. The causes of persistent inflammation are likely to be multifactorial, but the underlying mechanisms remain to be elucidated. Endotoxins are reported to play a significant role in the pathogenesis of inflammation in patients with ESKD. However, blood endotoxin measurement with the Limulus amoebocyte lysate (LAL) assay is difficult with current detection systems. The reported degree and prevalence of endotoxemia varies in the literature. There are questions as to whether endotoxemia is truly present; whether the varied findings are due to methodological issues with the LAL assay and whether any endotoxemia that might be present plays a role in chronic inflammation frequently observed in ESKD patients. This review will discuss the challenges of accurate blood endotoxin detection, the potential source of blood endotoxins, and the significance of endotoxemia to patient with ESKD.