A cross-sectional study of the associations between periodontitis and carotid arterial calcifications in an elderly population

Defined shapes of carotid artery calcifications on panoramic radiographs correlate with specific signs of cardiovascular disease on ultrasound examination

OBJECTIVE

The aim was to optimize diagnostics for carotid artery calcifications (CACs) on panoramic radiographs (PRs) to identify cardiovascular disease (CVD) by investigating how 4 defined CAC shapes are associated with ultrasound (US) findings indicating CVD.

STUDY DESIGN

The study included 414 participants (802 neck sides) from the Malmö Offspring Dental Study, examined with PRs. The PRs were assessed for CAC shapes stratified into 4 categories: single, scattered, vessel-width defining, and vessel-outlining. The carotid arteries were examined with US for signs of CVD: the presence of plaques, largest individual area of a plaque, number of plaques, and percentage reduction of the lumen. Associations between the different CAC categories and US characteristics were analyzed.

RESULTS

All categories of CAC were significantly associated with a higher degree of US findings indicating CVD compared with no CAC (P < .001). The most significant differences were found for vessel-outlining CAC, with the mean of the largest individual plaque area of 17.9 vs 2.3 mm2, mean number of plaques 1.6 vs 0.2, and mean percentage reduction of the lumen 24.1% vs 3.5% (all P < .001).

CONCLUSIONS

Independent of shape, CACs detected on PRs were associated with a higher degree of US findings of CVD. This was most pronounced for vessel-outlining CAC. With refined differential diagnostics of CACs in PRs, dentists may contribute to improved identification of patients in need of cardiovascular prevention.

Chronic periodontitis and risk of cerebro-cardiovascular diseases among older Koreans

BACKGROUND AND OBJECTIVE

There is a relative lack of evidence from observational studies of older populations investigating the association between chronic periodontitis and cerebro-cardiovascular diseases. Accordingly, we investigated the risk of cerebro-cardiovascular diseases according to the severity of chronic periodontitis among older adults.

METHODS

Data on older adults with chronic periodontitis were extracted from the Korea National Health Insurance Service-Senior Cohort Database using diagnosis codes and dental procedures. Participants were divided into two exposure groups. Among 46 737 participants eligible for inclusion, 21 905 (46.9%) had newly diagnosed mild chronic periodontitis, and 24 832 (53.1%) had newly diagnosed severe chronic periodontitis. To determine the risk of cerebro-cardiovascular diseases, including ischemic stroke, haemorrhagic stroke, and myocardial infarction, multivariable-adjusted Cox proportional hazards modelling was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) in this retrospective follow-up study.

RESULTS

A total of 3453 (7.4%) outcomes were identified during a mean follow-up of 6.1 years. Kaplan-Meier analysis revealed that disease-free probability was lower in the severe group than in the mild group (log-rank P < .001). In the multivariable-adjusted model, the HR for cerebro-cardiovascular diseases in the severe group (relative to the mild group) was 1.16 (95% CI: 1.09-1.25). In individual outcome analysis, ischemic stroke and myocardial infarction were associated with chronic periodontitis severity, but haemorrhagic stroke was not.

CONCLUSION

The severity of chronic periodontitis could be associated with the risk of cerebro-cardiovascular diseases in older adults.

Association between Periodontitis and Aortic Calcification: A Cohort Study

The present study investigated the association between the presence of periodontitis and aortic calcification (AC) risk among Chinese adults. A total of 6059 individuals who underwent regular health check-ups and received a diagnosis of periodontitis between 2009 and 2016 were included. The outcome was AC, assessed by a chest low-dose spiral CT scan. Cox proportional hazards regression analysis was used to assess the association between periodontitis and AC risk after adjusting for several confounders. After a median follow-up period of 2.3 years (interquartile range: 1.03-4.97 years), 843 cases of AC were identified, with 532 (12.13%) and 311 (18.59%) patients in the non-periodontitis group and periodontitis group, respectively. Multivariate analyses demonstrated that, compared with those without periodontitis, the hazard ratio and 95% confidence interval for AC risk in participants with periodontitis was 1.18 (1.02-1.36) (P = .025) in the fully adjusted model. Stratified analyses showed that the positive relationship between periodontitis and AC was more evident in males and participants <65 years of age (p_interaction = .005 and .004, respectively). Our results show that the presence of periodontitis was positively associated with AC among Chinese adults, especially among males and younger participants.

Calcified carotid artery atheromas in individuals with cognitive dysfunction

OBJECTIVE

The aim of this case-control study was to investigate whether cognitively impaired individuals have a higher burden of calcified carotid artery atheroma (CCAA) than controls without cognitive impairment.

MATERIAL AND METHODS

The study included 154 cases with Alzheimer's disease (n = 52), mild cognitive impairment (n = 51), or subjective cognitive decline (n = 51) diagnosed at a university memory clinic. Seventy-six cognitively healthy controls were sampled through the Swedish population register. All participants underwent clinical oral and panoramic radiographic examinations. Two oral and maxillofacial radiologists performed blinded analyses of the panoramic radiographs for signs of CCAA, which was registered as absent or present and, if present, unilateral or bilateral. Consensus assessment was used for all statistical analyses.

RESULTS

CCAA was common (40%) in this middle-aged and older Swedish population. We found no differences in the prevalence of CCAA between cases and controls (40% vs. 42%).

CONCLUSION

Cognitively impaired patients do not have a higher burden of CCAA than matched controls without cognitive impairment.

Oral health status among 60-year-old individuals born in 1941-1943 and 1954-1955 and 81-year-old individuals born in 1922-1924 and 1933-1934, respectively: a cross-sectional study

OBJECTIVE

This study aimed to analyze the oral health status of four different birth cohorts: two cohorts of 60-year-olds born in 1941-1943 and 1954-1955 and 2 cohorts of 81-year-olds born in 1920-1922 and 1933-1934.

MATERIAL AND METHODS

The study was based on data from an ongoing longitudinal population project, The Swedish National Study on Aging and Care (SNAC). Oral health status was repeatedly examined clinically and radiographically in 2001-2003 and 2014-2015, including 60- and 81-year-olds, in total 412 individuals. Statistical analyses were performed using independent-samples t test and Pearson's χ² test.

RESULTS

More individuals were dentate in 2014-2015 compared to 2001-2003 in the two age groups: 60 and 81 years (p < 0.001 for both). The mean number of teeth increased in the 60-year-olds from 24.2 to 27.0 and in the 81-year-olds from 14.3 to 20.2. The numbers of at least one intact tooth increased for both age groups (p < 0.001 and p < 0.004, respectively). In the age groups 81 years, there was an increase in having at least one PPD ≥ 6 mm (p < 0.016) and bone loss ≥ 5 mm (p < 0.029) between the two examinations. No such differences were found in the age groups of 60 years.

CONCLUSION

Over 13 years, oral health improved for both 60- and 81-year-old age groups. The most significant changes were in the 81-year-olds where oral health had improved except for periodontal status.

CLINICAL RELEVANCE

More natural teeth and impaired periodontal status potentially impact oral health and should increase focus on preventive and supportive dental care in older individuals.

Association between Periodontitis and Carotid Artery Calcification: A Systematic Review and Meta-Analysis

Recent studies have supported the relationship between periodontitis and carotid artery calcification (CAC), but still uncertain. This systematic review is aimed at evaluating the association between periodontitis and CAC. The search was conducted in four electronic databases: PubMed, EMBASE, Web of Science, and The Cochrane Library, supplemented by checking references of included articles and related review articles. Eligibility assessment and data extraction were conducted independently. The quality assessment and publication bias analysis were performed. The association between periodontitis and CAC was presented in odd ratio (OR) with 95% confidence interval (CI). Additional outcomes included the percentage of alveolar bone loss in CAC versus non-CAC. Twelve studies were included, and 10 were performed quantity analysis. Periodontitis with secure definition (OR = 2.02, 95%CI = 1.18 − 3.45) and insecure definition (OR = 10.78, 95%CI = 4.41 − 26.34) was associated with CAC. And a higher average percentage of alveolar bone loss (weighted mean difference = 10.84%; 95%CI = 6.40 − 15.48) was also observed in CAC patients compared to non-CAC patients. No significant publication bias was found. The results of this systematic review and meta-analysis revealed a significant relationship between periodontitis and CAC.

Association of high cardiovascular risk and diabetes with calcified carotid artery atheromas depicted on panoramic radiographs

OBJECTIVE

To evaluate whether estimates of risk of future cardiovascular events and death and established or unknown diabetes are significantly associated with calcified carotid artery atheromas (CCAAs) on panoramic radiographs (PRs). The main focus was on men and women without previous myocardial infarction (MI).

METHODS

The PAROKRANK (Periodontitis and its Relation to Coronary Artery Disease) study included patients with a first MI and matched control subjects. In this substudy, 738 patients (138 women) and 744 control subjects (144 women) with available PRs were assessed for CCAA. Cardiovascular risk estimates were determined according to the Framingham Risk Score (FRS) and Systematic COronary Risk Evaluation (SCORE). Established and previously unknown diabetes was also determined.

RESULTS

CCAA was detected on PRs in 206 control subjects (28%) and 251 patients (34%). FRS was significantly associated with CCAA among control subjects (P = .04) and patients (P = .001). SCORE was associated with CCAA among control subjects (P < .01) but not patients (P = .07). Among men, FRS and SCORE were associated with CCAA in both control subjects and patients. Diabetes was not significantly associated with CCAA after adjustments.

CONCLUSIONS

Elevated cardiovascular risk scores were associated with CCAA on PRs among control subjects. Diabetes was not independently associated with CCAA, possibly owing to selection bias.

Association Between Periodontal Disease and Atherosclerotic Cardiovascular Diseases: Revisited

Atherosclerotic cardiovascular disease (ACVD) is an inflammatory disease of the coronary arteries associated with atheroma formation, which can cause disability and often death. Periodontitis is ranked as the sixth most prevalent disease affecting humans affecting 740 million people worldwide. In the last few decades, researchers have focused on the effect of periodontal disease (PD) on cardiovascular disease. The aim of this review was to investigate the association between these two diseases. PD is a potential risk factor that may initiate the development, maturation, and instability of atheroma in the arteries. Two mechanisms were proposed to explain such association, either periodontal pathogens directly invade bloodstream or indirectly by increasing systemic level of inflammatory mediators. Interestingly, it has been suggested that improvement in the condition of one disease positively impact the condition of the other one. Highlighting the association between these two diseases, the importance of early diagnosis and treatment of PD and its impact on cardiovascular status may be of great value in reducing the complications associated with ACVDs. Further in vitro and in vivo studies with longer follow up are necessary to confirm the causal relationship between PD and ACVDs.

Assessment of carotid artery calcifications on digital panoramic radiographs and their relationship with periodontal condition and cardiovascular risk factors

OBJECTIVE

The main purpose of this study is to determine the presence of carotid artery calcification (CAC) detected on digital panoramic radiographs (DPRs) retrospectively and correlate the findings with cardiovascular risk factors including gender, age, smoking status, hypertension, diabetes, and hyperlipidemia, along with atherosclerotic cardiovascular disease and periodontal status.

METHODS

This clinical study is registered at ClinicalTrials.gov as NCT04017078. DPRs, periodontal status and cardiovascular risk factors of 1,101 patients (576 males, 525 females) were evaluated. The patients were grouped based on whether CAC was detected in dental DPRs [CAC (+)] or not [CAC (-)]. Periodontal status was categorised as gingivitis, periodontitis, and gingivitis with reduced periodontium (periodontally stable patient).

RESULTS

Out of 1,101 patients, whose mean age was 42.1 ± 15.5 years and 525 (47.7%) were female, 34 (3.1%) were diagnosed with CAC on DPRs. No significant difference was observed between groups considering gender, hypertension, diabetes, hyperlipidemia, smoking, and periodontal status. Patients aged 40-55 years (n = 398, 36.15%) and patients older than 55 years (n = 222, 20.16%) were associated with CAC (odds ratio = 4.49, 95% confidence interval = 1.65-12.17, P = 0.003; odds ratio = 4.41, 95% confidence interval = 1.33-14.61, P = 0.015, respectively).

CONCLUSION

Among all parameters, only age exhibited significant correlation with an increased risk of carotid calcification. Further studies with prospective designs and larger study populations are needed.

Carotid artery calcification in panoramic radiographs associates with oral infections and mortality

AIM

To study the prevalence of carotid artery calcification (CAC) in relation to apical and marginal periodontitis, subgingival dysbiotic bacterial species and serum and saliva immune responses against them. In addition, the aim was to analyse the association of CAC with angiographically verified coronary artery disease (CAD) and mortality.

METHODOLOGY

In the present random Parogene cohort, the patients had an indication for coronary angiography. Apical and marginal periodontitis were diagnosed during clinical and radiographic oral examinations, and CAC on panoramic radiographs (n = 492). Presence and severity of CAD were registered from angiography. Subgingival dysbiotic bacterial species were quantitated using checkerboard DNA-DNA-hybridization, and serum and saliva antibody levels were determined by immunoassays. The cohort was followed-up for 10 years or until death (median 9.9, range 0.21-10.4) via linkage to the national death register. The statistical models were adjusted for age, gender, smoking, hypertension, diabetes and dyslipidemia.

RESULTS

A total of 102 (20.7%) patients had detectable CAC, which was moderate in 81 (16.4%) and severe in 21 (4.3%). CAC was associated (OR, 95% CI) with severe apical periodontitis (2.25, 1.15-4.41), root canal fillings (1.15, 1.04-1.26), alveolar bone loss (2.66, 1.21-5.84), severe periodontal inflammation (2.23, 1.11-4.47), high level of gram-negative subgingival species (2.73, 1.34-5.50), saliva IgG against dysbiotic species (1.05, 1.01-1.10/unit) and severe (2.58, 1.36-4.90) and chronic (2.13, 1.15-3.93) CAD. A total of 105 (20.7%) patients died during the follow-up and 53 (10.4%) deaths were because of cardiovascular diseases (CVD). Severe CAC predicted worse survival with HRs (95% CI) of 3.08 (1.58-6.06) for all-cause and 3.43 (1.42-8.25) for CVD death.

CONCLUSIONS

CAC on panoramic tomography was associated with (i) apical and marginal periodontitis and dysbiotic bacterial species giving rise to an immunological response, and with (ii) severe, chronic CAD and increased mortality. The results further emphasize the role of oral infections in CAD and the importance of referring a patient with CAC for a cardiovascular evaluation.

Periodontal diseases and association with atherosclerotic disease

Cardiovascular diseases still account for the majority of deaths worldwide, although significant improvements in survival, after being affected by cardiovascular disease, have been achieved in the last decades. Periodontal diseases are also a common global burden. Several studies have shown a link between cardiovascular disease and periodontitis, although evidence is still lacking regarding the direct cause-effect relation. During the 2012 "Periodontitis and systemic diseases" workshop, the available evidence on the association between cardiovascular and periodontal diseases was discussed, covering biologic plausibility and clinical studies. The objective of the present narrative review was to update the previous reviews presented at the 2012 workshop, following similar methodological approaches, aiming to critically assess the available evidence. With regard to biologic plausibility, two aspects were reviewed: (a) for microbiologic mechanisms, assessing periodontal bacteria as a contributing factor to atherosclerosis based on seven "proofs," substantial evidence was found for Proofs 1 through 6, but not for Proof 7 (periodontal bacteria obtained from human atheromas can cause atherosclerosis in animal models), concluding that periodontal pathogens can contribute to atherosclerosis; (b) mechanistic studies, addressing five different inflammatory pathways that could explain the links between periodontitis and cardiovascular disease with the addition of some extra pathways , suggest an association between both entities, based on the presence of higher levels of these inflammatory markers in patients with periodontitis and cardiovascular disease, vs healthy controls, as well as on the evidence that periodontal treatment reduces serum levels of these mediators. When evidence from clinical studies was analyzed, two aspects were covered: (a) epidemiologic studies support the estimation that the incidence of atherosclerotic disease is higher in individuals with periodontitis than in individuals with no reported periodontitis, irrespective of many common risk factors, but with a substantial variability in the definitions used in reporting of exposure to periodontal diseases in different studies; (b) intervention trials have shown that periodontal therapy can reduce serum inflammatory mediators, improve the lipids profile, and induce positive changes in other cardiovascular disease surrogate measures, but no evidence is available to support that adequate periodontal therapy is able to reduce the risk for cardiovascular diseases, or the incidence of cardiovascular disease events in periodontitis patients.

Periodontal conditions, retinopathy, and serum markers in individuals with type 1 diabetes

BACKGROUND

The prevalence of diabetes is high and increasing. Periodontitis has been identified as a risk factor in both type 1 and 2 diabetes. The study purpose was to assess periodontal conditions, retinopathy, and serum glutamic acid decarboxylase antibody (GADA) titers in relation to retinopathy in individuals with type 1 diabetes (T1D).

METHODS

The study is a case series. Adult individuals with a diagnosis of T1D (n = 85) monitored ≥5 years were recruited from an endocrinology clinic. Peripheral venous blood samples were analyzed including assessments of serum HbA1c levels and GADA titers. Medical and periodontal conditions were examined, and the data assessed. Independent t tests, binary and multivariate analyses, χ² and odds ratios were employed.

RESULTS

Gingivitis was found in 68.2%, periodontitis in 21.2%, and retinopathy in 64.7%, GADA (≥35 U/mL) in 54.1%, and serum HbA1c > 48 mmol/mol in 94.3% of the individuals. The unadjusted odds ratio for periodontitis to differentiate a diagnosis of retinopathy was 7.3 (95%CI 1.6, 4.4, P <0.01). Multivariate analyses identified the following dependent factors to differentiate retinopathy; age, T1D duration, gingivitis, periodontitis at P < 0.001, sex, and serum GADA at P < 0.01, and by the number of remaining teeth at P < 0.05.

CONCLUSION

Retinopathy as a complication to T1D is linked to the duration of diabetes, age of the individual and with increasing severity to periodontitis. Periodontal intervention studies are warranted.

Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction

Cardiovascular disease is a common cause of morbidity and premature mortality. Cardiovascular disease can be prevented when risk factors are identified early. Calcified carotid artery atheromas (CCAAs), detected in panoramic radiographs, and periodontitis have both been associated with increased risk of cardiovascular disease. This case-control study aimed to 1) investigate associations between periodontitis and CCAA detected in panoramic radiographs and 2) determine the risk of future myocardial infarctions due to CCAA combined with periodontitis. We evaluated 1,482 participants (738 cases and 744 controls) with periodontitis and CCAAs recruited from the PAROKRANK study (Periodontitis and Its Relation to Coronary Artery Disease). Participants were examined with panoramic radiographs, including the carotid regions. Associations between myocardial infarction and periodontitis combined with CCAA were evaluated in 696 cases and 696 age-, sex-, and residential area–matched controls. Periodontitis was evaluated radiographically (as degree of bone loss) and with a clinical periodontal disease index score (from clinical and radiographic assessments). We found associations between CCAA and clinical periodontal disease index score among cases (odds ratio [OR], 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR, 1.70; 95% CI, 1.22 to 2.38; P < 0.01), although not between CCAA and the degree of bone loss. In a multivariable model, myocardial infarction was associated with CCAA combined with periodontitis, as assessed by degree of bone loss (OR, 1.75; 95% CI, 1.11 to 2.74; P = 0.01). When the cohort was stratified by sex, only men showed a significant association between myocardial infarction and CCAA combined with periodontitis. Participants with clinically diagnosed periodontitis exhibited CCAA in panoramic radiographs more often than those without periodontitis, irrespective of the presence of a recent myocardial infarction. Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. These findings implied that patients in dental care might benefit from dentists assessing panoramic radiographs for CCAA—particularly, patients with periodontitis who have not received any preventive measures for cardiovascular disease.

Increased Risk of Carotid Atherosclerosis in Male Patients with Chronic Periodontitis: A Nationwide Population-Based Retrospective Cohort Study

Carotid artery stenosis is a narrowing or constriction of any part of the carotid arteries, usually caused by atherosclerosis. However, no studies have specifically evaluated the association between carotid atherosclerosis (CA) and chronic periodontitis (CP). This study was to investigate the role of CP in increasing the subsequent risk of CA in the overall Taiwanese population. We carried out this retrospective cohort study, employing data derived from the National Health Insurance Research Database. A total of 72,630 patients who were newly diagnosed with CP from 2001 to 2012 were selected. For a propensity-matched control group, 72,630 healthy patients without CP were picked at random, matched according to age, sex, and index year from the general population. Cox proportional hazard regression analysis, which included sex, age, and comorbidities, was adopted to assess the hazard ratio (HR) of CA between the CP cohort and non-CP cohort. The average ages of the CP and non-CP groups were 44.02 ± 14.63 years and 44.15 ± 14.41 years, respectively. The follow up durations were 8.65 and 8.59 years for CP and non-CP groups, respectively. The results demonstrated that 305 and 284 patients with newly diagnosed CA were found in the CP cohort and non-CP cohort, respectively. There was no significant difference of developing CA in the CP cohort compared with the non-CP cohort (adjusted HR) 1.01, 95% confidence interval (CI, 0.86–1.19). However, multivariate Cox regression analysis indicated that the male group had significantly higher incidence risk of CA (log rank p = 0.046). In conclusion, this nationwide retrospective cohort study indicated that male patients with CP exhibited a significantly higher risk of CA than those without CP.

Long-term skill improvement among general dental practitioners after a short training programme in diagnosing calcified carotid artery atheromas on panoramic radiographs

PURPOSE

To study general dental practitioners (GDPs) ability to detect calcified carotid artery atheromas (CCAAs) in panoramic radiographs (PRs) and if their diagnostic accuracy in long term is improved after a short training programme.

METHODS

Fourteen GDPs had their diagnostic accuracy regarding CCAA in PR assessed at baseline, 2 weeks and 1 year after training. Comparison was made with a reference standard based on consensus results from two experienced oral and maxillofacial radiologists. At each session, 100 radiographs were assessed individually by the GDPs. After the baseline assessment, the GDPs participated in a 2-hour training programme comprising a lecture and diagnostic training by calibration. The GDPs results before and after training were compared, as well as between follow-up sessions.

RESULTS

A significant improvement in diagnostic accuracy was observed with increased sensitivity (from 41.8% to 55.7%, P = 0.02) without a significant decrease in specificity (from 87.2% to 86.7%, P = 0.87). The Kappa values also increased (from 0.66 to 0.71, P = 0.04). At 1-year follow-up, the improvement compared to baseline remained significant. There were no significant changes between the 2-week and 1-year follow-up assessment.

CONCLUSION

A short training programme can significantly and sustainable improve GDPs diagnostic accuracy regarding CCAA.

Calcified carotid artery atheromas in panoramic radiographs are associated with a first myocardial infarction: a case-control study

OBJECTIVE

The aim of this case-control study was to investigate whether patients with a first myocardial infarction (MI) had a higher prevalence of calcified carotid artery atheromas (CCAAs) on panoramic radiographs (PRs) than age-, gender-, and residential area-matched controls without MI.

STUDY DESIGN

Six hundred ninety-six cases with a first MI and 696 controls were included in this substudy of the Swedish multicentre PAROKRANK study. All participants underwent panoramic radiography, and the PRs were evaluated for CCAAs.

RESULTS

The prevalence of CCAAs detected by PR was 33.8% (235 of 696) in cases and 27.6% (192 of 696) in controls (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.04-1.44; P = .012). Among males, 32.7% of cases (184 of 562) and 26.5% of controls (149 of 562) displayed CCAAs on PRs (OR 1.24; 95% CI 1.03-1.48; P = .022). Among both genders, bilateral CCAAs were significantly more common among cases than among controls (P = .002).

CONCLUSIONS

Cases with recent MIs had a significantly higher prevalence of CCAAs on PRs compared with controls without MIs. This difference between groups was more pronounced for bilateral CCAAs. These findings supported the hypothesis that CCAA detection could serve as a risk indicator for future MIs.

Oxidative Stress in Oral Diseases: Understanding Its Relation with Other Systemic Diseases

Oxidative stress occurs in diabetes, various cancers, liver diseases, stroke, rheumatoid arthritis, chronic inflammation, and other degenerative diseases related to the nervous system. The free radicals have deleterious effect on various organs of the body. This is due to lipid peroxidation and irreversible protein modification that leads to cellular apoptosis or programmed cell death. During recent years, there is a rise in the oral diseases related to oxidative stress. Oxidative stress in oral disease is related to other systemic diseases in the body such as periodontitis, cardiovascular, pancreatic, gastric, and liver diseases. In the present review, we discuss the various pathways that mediate oxidative cellular damage. Numerous pathways mediate oxidative cellular damage and these include caspase pathway, PERK/NRF2 pathway, NADPH oxidase 4 pathways and JNK/mitogen-activated protein (MAP) kinase pathway. We also discuss the role of inflammatory markers, lipid peroxidation, and role of oxygen species linked to oxidative stress. Knowledge of different pathways, role of inflammatory markers, and importance of low-density lipoprotein, fibrinogen, creatinine, nitric oxide, nitrates, and highly sensitive C-reactive proteins may be helpful in understanding the pathogenesis and plan better treatment for oral diseases which involve oxidative stress.

Review. The Link between Periodontal Disease, Inflammation and Atherosclerosis — an Interdisciplinary Approach

Periodontal disease is a chronic inflammatory disease that results from the activity of altered oral microbiome, leading to altered immune reaction, destruction of tissues supporting the teeth, and oral bone loss. This disease is particularly associated with an expressed systemic inflammation, being considered nowadays an inflammatory disorder. At the same time, inflammation has been recognized to play a major role in the development of atherosclerotic lesions. Atheromatous plaque formation is triggered by alterations in the structure of the endothelium, which lead to the expression of adhesion molecules and recruitment of immune cells such as macrophages, in the arterial wall. While the association between periodontal disease, inflammation and cardiovascular diseases has been well established, the causality relation between these three entities has not been demonstrated so far. This review presents the most common advances in understanding the complex link between periodontal disease, inflammation and atherosclerosis, as a common pathway leading to increased cardiovascular risk.