Treatment of periodontal diseases reduces chronic systemic inflammation in maintenance hemodialysis patients

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.

Association between periodontal inflamed surface area and systemic inflammatory biomarkers among pre-dialysis chronic kidney disease patients

Background

Several studies have shown an association between chronic kidney disease (CKD) and periodontitis. However, only few studies have quantified the burden of periodontal inflammation in pre-dialysis CKD patients. The aim of this study was to determine the association between periodontal inflamed surface area (PISA) and systemic inflammatory biomarkers among pre-dialysis CKD patients.

Materials and Methods

120 pre-dialysis CKD participants were recruited into this study. 60 participants constituted Group A (those with periodontitis) while 60 participants constituted Group B (those without periodontitis). Full periodontal examination was carried out in the participants for the estimation of PISA. Blood samples also collected to determine levels of high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) in all participants. Independent t-test was used to compare means of PISA, hsCRP and IL-6 levels in the two groups. Pearson correlation analysis was used to determine association between PISA and (hsCRP and IL-6).

Results

The mean value of hsCRP was significantly higher in Group A compared to Group B (3.41 mg/L vs. 2.18 mg/L). PISA moderately correlated with hsCRP (r = 0.4, P < 0.01) in both groups. hsCRP also moderately correlated with IL-6 (r = 0.6, P < 0.001) in both groups.

Conclusion

This study demonstrates that there was an association between PISA and hsCRP. Increased hsCRP level in Group A revealed the inflammatory burden imposed by periodontitis.

The effect of scaling and root planning on the periodontal condition in hemodialysis patients: A clinical trial study

Background and Aims

Periodontitis is very common in kidney patients undergoing hemodialysis. The two diseases interact with each other so that kidney failure exacerbates periodontal disease and periodontal disease increases the severity of the renal failure. This study aimed to compare the effect of scaling and root planning on the periodontal status of hemodialysis patients and the healthy control group.

Methods

A clinical trial study of 60 subjects, 30 subjects in the dialysis group with chronic periodontitis, and 30 with chronic periodontitis who were systemically healthy was conducted. After a health education session, gingival pocket depth (PD) measurement, and clinical attachment level (CAL), scaling was performed for both groups. Then, the mentioned indices were measured consequently, at 4 and 8 weeks of treatment. Improvement in both groups was analyzed by Mann-Whitney and paired sample t-test at the significance level of 0.05 by SPSS software.

Results

In both groups, the decrease in PD and CAL was steadily observed from the first to the third time and the changes from the first to the second and the first to the third time were significant however it was not significant between the second and third time. Mean PD and CAL in the dialysis group were higher than in the nondialysis group, which was significant (p < 0.001) for the mean PD. The mean improvement of PD and CAL in dialysis patients was 14.31 ± 10.48 and 17.60 ± 7.83%, respectively, and the mean improvement of PD in the nondialysis group was significantly higher than in the dialysis group (p = 0.008).

Conclusion

Periodontal treatment (scaling) causes more improvement in periodontal clinical parameters in healthy people with periodontitis than in dialysis patients.

The impact of a needs-oriented dental prophylaxis program on bacteremia after toothbrushing and systemic inflammation in children, adolescents, and young adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) still leads to high mortality rates, mainly due to cardiovascular disease. One important influencing factor is persisting low-grade chronic inflammation partly maintained by gingivitis that favors transient bacteremia during daily activities such as toothbrushing.

METHODS

To examine whether intensive dental prophylaxis can restore oral health, reduce the prevalence of bacteremia and degree of systemic inflammation indicated by CRP levels, we conducted this pilot study examining 30 CKD patients aged 6-26 years, 15 receiving intensive prophylaxis (IP), 15 receiving treatment as usual (TAU) serving as control group. There were three appointments for examination, each 10 ± 1 weeks apart (at baseline, after intervention periods one and two, when TAU also received IP, and the IP group stopped prophylaxis).

RESULTS

The gingival index (GI) in the IP group decreased by 90% (GI 0.09; p=0.001), resulting in almost healthy gingiva. There was no significant change in CRP or prevalence of bacteremia. General prevalence of bacteremia after toothbrushing was 9.5% affecting 7 (26%) of the participants. In three participants, bacteremia dissolved after IP, in one after TAU. Two patients developed bacteremia ≥ 10 weeks after ending IP. We identified eight different bacterial species.

CONCLUSIONS

We were able to show that IP can effectively treat gingivitis. It might be a promising approach to reduce systemic inflammation and subsequently lower premature cardiovascular disease, despite the lack of statistical significance. Future research requires a larger patient cohort to enable matched treatment groups with long-term follow-up and molecular detection methods for bacteremia. A higher resolution version of the Graphical abstract is available as Supplementary information.

Periodontal Treatment Needs of Hemodialized Patients

End-stage renal failure is the reason for complications in many systems and organs, and the applied pharmacotherapy often causes the deepening of already existing pathologies within the oral cavity, such as: caries, periodontal diseases, mucosal lesions or reduced saliva secretion. Reduced saliva secretion results in an increased accumulation of dental plaque, its mineralization and prolonged retention, which leads to the development of gingival and periodontal inflammation. There is some evidence that chronic kidney diseases are influenced by periodontal health. The aim of the work was to evaluate the dental needs by the usage of clinical assessment of periodontal tissues of patients suffering from end-stage chronic kidney disease, arterial hypertension or/and diabetes mellitus.

MATERIAL AND METHODS

228 patients underwent the research. 180 patients were hemodialized in Diaverum dialysis stations (42 of them were diagnosed with end stage chronic disease, 79 with the end stage chronic disease and arterial hypertension, 16 with end stage chronic kidney disease and diabetes, 43 with end-stage chronic disease, arterial hypertension and diabetes) and 48 patients of the Conservative Dentistry with Endodontics Clinic of Academic Centre of Dentistry of Silesian Medical University in Bytom and patients of the dentistry division of Arnika Clinic in Zabrze not diagnosed with any of the aforementioned diseases. The scheme of the research comprised 2 parts: analysis of the general health and assessment of the periodontal status which contain the following indices: Periodontal Probing Depth (PPD), Clinical Attachment Lost (CAL), Bleeding Index or Bleeding on Probing Index (BI or BOP), Community Periodontal Index for Treatment Needs (CPITN).

RESULTS

Significantly lower percentage of patients with healthy periodontal tissues and higher percentage with periodontal pockets deeper than 3.5 mm and the loss of trainers connective of 5 mm or higher were in the examined group. The values of the bleeding index were significantly lower in control group. The analysis of the CPITN index indicates higher percentage of patients qualified as CPI 1 or 2 in the control group while in the examined one most of the patients turned out to require specialist periodontal treatment.

CONCLUSIONS

there is a direct relationship between periodontal status and end-stage renal disease which typically includes other chronical civilization ailments. It is important to develop a scheme for the easy and rapid examination of periodontal status, to determine the treatment needs in this area, which will allow precise assignment of long-term dialyzed patients to the range of prophylactic and therapeutic procedures.

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.

Characterization of the subgingival microbiota in the peritoneal dialysis patients with periodontitis

BACKGROUND AND OBJECTIVE

Periodontitis is an oral chronic inflammatory disease caused by dental plaque. It is comorbid with numerous systemic diseases and associated with several predisposing factors, such as chronic kidney disease (CKD). Peritoneal dialysis is one of the ultimate treatments for patients with severe CKD. However, peritoneal dialysis patients with periodontitis often will be accompanied with more poor oral hygiene and periodontal clinical indexes. This study aimed to compare the microbial flora of periodontitis patients with or without peritoneal dialysis.

METHODS

Sixteen peritoneal dialysis patients with periodontitis (P group) and 16 patients with periodontitis only (C group) were selected. Subgingival plaque samples of them were processed for bioinformatics analysis by 16S rDNA gene sequencing.

RESULTS

The diversity indices and species richness in the P group were insignificantly higher than that in the C group (P > 0.05). The two groups exhibited different microbial community structure. At Genus level, Prevotellaceae, Selenomonas, Aggregatibacter, Anaeroglobus, TM7_[G-5], and Centipeda were significantly enriched in the P group than those in the C group.

CONCLUSIONS

This study demonstrated that specific microbes enriched in the subgingival flora of peritoneal dialysis patients with periodontitis.

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.

Influence of the treatment of periodontal disease in serum concentration of sirtuin 1 and mannose-binding lectin

BACKGROUND

Increased levels of periodontal pathogens disrupt the homeostasis between the host and its microbiota and increase susceptibility to periodontal diseases. Periodontitis increases the serum concentration of mannose-binding lectin (MBL), which exacerbates local inflammatory processes. In animal studies, sirtuin 1 (SIRT1) was associated with protection against inflammation. This study analyzed the influence of non-surgical periodontal treatment on serum levels of MBL and SIRT1.

METHODS

Forty patients with periodontitis and 38 periodontally healthy individuals (aged 45 to 79 years) were included. Periodontitis patients received scaling and root planing using machine driven and hand instruments. Clinical parameters, inflammatory biomarkers, MBL, and SIRT1 levels were measured at baseline and at post-treatment.

RESULTS

For all patients, an inverse correlation was observed between serum concentrations of MBL and SIRT1 (r = -0.30; P = 0.006). Periodontal treatment reduced serum concentrations of MBL (1,099.35 ± 916.59 to 861.42 ± 724.82 ng/mL; P < 0.001) and C-reactive protein (6.05 ± 8.99 to 2.49 ± 2.89 mg/L; P = 0.009). By contrast, SIRT1 serum levels increased (1.06 ± 1.03 to 1.66 ± 1.64 ng/mL; P < 0.001) following periodontal treatment.

CONCLUSIONS

Periodontal treatment was associated with decreased serum concentrations of MBL and CRP and increased serum levels of SIRT1. Prospective studies are needed to assess the impact of these biomarkers on pathophysiology of periodontitis.

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.

Periodontal and chronic kidney disease association: A systematic review and meta-analysis

AIM

Chronic kidney disease (CKD) and kidney failure is increasing globally and evidence from observational studies suggest periodontal disease may contribute to kidney functional decline.

METHODS

Electronic searches of the PubMed, EMBASE, Web of Science, Scopus and Cochrane Library databases were conducted for the purposes of conducting a systematic review. Hand searching of reference lists was also performed. Meta-analysis of observational studies involving periodontal disease and chronic kidney disease in adults was performed.

RESULTS

A total of 17 studies was selected from an initial 4055 abstracts. Pooled estimates indicated the odds of having CKD were 60% higher among patients with periodontitis: pooled OR 1.60 (95% CI 1.44-1.79, I² 35.2%, P = 0.11) compared to those without. Conversely, a similar magnitude but non-significant higher odds of having periodontal disease was found among people with CKD 1.69 (95% CI: 0.84, 3.40, I² = 89.8%, P < 0.00) versus non-CKD. Meta-regression revealed study quality based on the Newcastle-Ottawa Scale and statistical adjustment for potential confounders explained almost 35% of the heterogeneity in the studies investigating the association between CKD and periodontitis.

CONCLUSIONS

Moderate evidence for a positive association between periodontitis and CKD exists. Evidence for the opposite direction is extremely weak based on significant heterogeneity between studies.

Chronic Periodontitis is a Risk Factor of Renal Dysfunction in Patients with Type 2 Diabetes

BACKGROUND

This study explores the association between chronic periodontitis and renal dysfunction in type 2 diabetic mellitus (T2DM) patients.

METHODS

An observational study was conducted in 169 T2DM patients with chronic periodontitis. Patients were divided into 2 groups according to presence of normal renal function (n=111) and renal dysfunction (n=58), and oral health behavior-related variables were obtained by questionnaire. Periodontal status was examined, and pocket probing depth (PD), clinical attachment level (CAL), and bleeding index (BI) were measured.

RESULTS

The severe periodontitis group had a significant higher HbA1c level (8.53 ± 1.61%) as compared with the mild and moderate periodontitis groups (7.68±1.58%) and (7.35±1.45%), P=0.001. Compared with patients with normal renal function, patients with renal dysfunction had a higher PD value, higher CAL value, fewer remaining teeth, and were less likely to have remaining teeth ≥20. The percentage of sites with PD ≥4 mm (52.8% vs. 41.67%) was significantly greater in patients with renal dysfunction. There was no difference in the scores of oral health knowledge assessment between the 2 groups. After adjustment by gender, age, BMI, smoking, hypertension, and HbA1c, the percentage of the sites with PD≥4 mm was an independent risk factor of renal dysfunction in T2DM patients.

CONCLUSION

In patients with T2DM, those with periodontitis may be more susceptible to decreased kidney function.

Intensive Periodontal Treatment Reduces Risks of Hospitalization for Cardiovascular Disease and All-Cause Mortality in the Hemodialysis Population

Periodontal disease (POD) is associated with the risk of atherosclerotic vascular disease in patients on hemodialysis (HD). The association between POD treatment and cardiovascular diseases (CVDs) is still unknown. A total of 3613 patients who received HD and intensive POD treatment between 1 January 1998, and 31 December 2011 were identified from the National Health Insurance Research Database as the treatment cohort. The comparison cohort comprised patients without POD treatment who were matched to the patients in the treatment cohort at a 1:1 ratio by the propensity score. All CVDs defined by International Classification of Diseases, Ninth Revision (International Classification of Diseases, Ninth Revision (ICD-9)) codes were ascertained by hospital records for nonfatal events. The first CVD was used to define incidence. Relative risks were estimated by hazard ratios from the Cox proportional hazard model with adjustment for demographic variables and cardiovascular risk factors. Compared with the comparison cohort, the adjusted hazard ratio of hospitalization for CVDs was 0.78 (95% confidence interval = 0.73–0.84, p < 0.001) in the treatment cohort The treatment cohort exhibited significantly lower cumulative incidences of CVDs (log-rank test p < 0.001) and mortality (log-rank test p < 0.001). Intensive POD treatment was associated with reduced risks of CVDs and overall mortality in patients on HD.

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.

Evidence that periodontal treatment improves biomarkers and CVD outcomes

AIM

The aim of this review was to critically appraise the evidence on the impact of periodontal treatment of cardiovascular diseases (CVDs) biomarkers and outcomes.

METHODS

A systematic search was performed in Cinhal, Cochrane, Embase and Medline for relevant articles up to July 2012. Duplicate screening and reference hand searching were performed. Data were then summarized and evidence graded in tables.

RESULTS

The search resulted in: (a) no evidence on the effects of periodontal therapy on subclinical atherosclerosis, serum levels of CD40 ligand, serum amyloid A and monocyte chemoattractant protein-1, (b) limited evidence on the effects of periodontal therapy on arterial blood pressure, leucocyte counts, fibrinogen, tissue necrosis factor-α, sE-selectin, von Willebrand factors, d-dimers, matrix metalloproteinases, oxidative stress and CVD events, and (c) moderate evidence suggesting a negligible effect of periodontal therapy in reducing interleukin-6 and lipids levels, whilst a positive effect in reducing serum C-reactive protein levels and improving endothelial function.

CONCLUSIONS

Periodontal therapy triggers a short-term inflammatory response followed by (a) a progressive and consistent reduction of systemic inflammation and (b) an improvement in endothelial function. There is however limited evidence that these acute and chronic changes will either increase or reduce CVD burden of individuals suffering from periodontitis in the long term.

Evidence that periodontal treatment improves biomarkers and CVD outcomes

AIM

The aim of this review was to critically appraise the evidence on the impact of periodontal treatment of cardiovascular diseases (CVDs) biomarkers and outcomes.

METHODS

A systematic search was performed in Cinhal, Cochrane, Embase and Medline for relevant articles up to July 2012. Duplicate screening and reference hand searching were performed. Data were then summarized and evidence graded in tables.

RESULTS

The search resulted in: (a) no evidence on the effects of periodontal therapy on subclinical atherosclerosis, serum levels of CD40 ligand, serum amyloid A and monocyte chemoattractant protein-1, (b) limited evidence on the effects of periodontal therapy on arterial blood pressure, leucocyte counts, fibrinogen, tissue necrosis factor-a, sE-selectin, von Willebrand factors, d-dimers, matrix metalloproteinases, oxidative stress and CVD events, and (c) moderate evidence suggesting a negligible effect of periodontal therapy in reducing interleukin-6 and lipids levels, whilst a positive effect in reducing serum C-reactive protein levels and improving endothelial function.

CONCLUSIONS

Periodontal therapy triggers a short-term inflammatory response followed by (a) a progressive and consistent reduction of systemic inflammation and (b) an improvement in endothelial function. There is however limited evidence that these acute and chronic changes will either increase or reduce CVD burden of individuals suffering from periodontitis in the long term.

Periodontal disease and chronic kidney disease among Aboriginal adults; an RCT

BACKGROUND

This study will assess measures of vascular health and inflammation in Aboriginal Australian adults with chronic kidney disease (CKD), and determine if intensive periodontal intervention improves cardiovascular health, progression of renal disease and periodontal health over a 24-month follow-up.

METHODS

The study will be a randomised controlled trial. All participants will receive the periodontal intervention benefits, with the delayed intervention group receiving periodontal treatment 24 months following baseline. Inclusion criteria include being an Aboriginal Australian, having CKD (a. on dialysis; b. eGFR levels of < 60 mls/min/1.73 m(2) (CKD Stages 3 to 5); c. ACR ≥ 30 mg/mmol irrespective of eGFR (CKD Stages 1 and 2); d. diabetes plus albuminuria (ACR ≥ 3 mg/mmol) irrespective of eGFR), having moderate or severe periodontal disease, having at least 12 teeth, and living in Central Australia for the 2-year study duration. The intervention involves intensive removal of dental plaque biofilms by scaling, root-planing and removal of teeth that cannot be saved. The intervention will occur in three visits; baseline, 3-month and 6-month follow-up. The primary outcome will be changes in carotid intima-media thickness (cIMT). Secondary outcomes will include progression of CKD or death as a consequence of CKD/cardiovascular disease. Progression of CKD will be defined by time to the development of the first of: (1) new development of macroalbuminuria; (2) 30 % loss of baseline eGFR; (3) progression to end stage kidney disease defined by eGFR < 15 mLs/min/1.73 m(2); (4) progression to end stage kidney disease defined by commencement of renal replacement therapy. A sample size of 472 is necessary to detect a difference in cIMT of 0.026 mm (SD 0.09) at the significance criterion of 0.05 and a power of 0.80. Allowing for 20 % attrition, 592 participants are necessary at baseline, rounded to 600 for convenience.

DISCUSSION

This will be the first RCT evaluating the effect of periodontal therapy on progression of CKD and cardiovascular disease among Aboriginal patients with CKD. Demonstration of a significant attenuation of CKD progression and cardiovascular disease has the potential to inform clinicians of an important, new and widely available strategy for reducing CKD progression and cardiovascular disease for Australia's most disadvantaged population.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trial Registry ANZCTR12614001183673.

Intensive Periodontal Treatment Reduces Risk of Infection-Related Hospitalization in Hemodialysis Population: A Nationwide Population-Based Cohort Study

Periodontal disease (PD) is prevalent and correlated with malnutrition and inflammation in patients on hemodialysis (HD). Periodontal therapy improves systemic inflammatory and nutritional markers in HD population. The relationship between intensive PD therapy and clinical infectious outcomes in patients on HD remains unclear.In total, 4451 patients who underwent HD and intensive PD treatment between January 1, 1998 and December 31, 2010 were selected from the National Health Insurance Research Database as the case cohort. The comparison cohort was selected by matching a patient without PD with each PD treated patient at a 1:1 ratio according to a propensity score. The rates of hospitalizations for infectious diseases for both cohorts were analyzed and compared.Compared with the comparison cohort, the hazard ratio (HR) of hospitalization for overall infectious diseases was 0.72 (95% confidence interval [CI] = 0.66-0.78, P < 0.001) for the intensive PD treatment cohort. The intensive PD treated cohort had a significantly lower risk of acute and subacute infective endocarditis (HR = 0.54, 95% CI = 0.35-0.84, P < 0.01), pneumonia (HR = 0.71, 95% CI = 0.65-0.78, P < 0.001), and osteomyelitis (HR = 0.77, 95% CI = 0.62-0.96, P < 0.05) than did the comparison cohort.The intensive PD treatment of patients with HD was associated with reduced risks of overall infectious diseases, acute and subacute infective endocarditis, pneumonia, and osteomyelitis. Our study concurs the role of a conventional intervention in enhancing infectious diseases outcomes.

From the Acta Prize Lecture 2014: the periodontal-systemic connection seen from a microbiological standpoint

OBJECTIVE

To give an overview of the periodontal-systemic connection seen from a microbiologist.

METHODS

Original research papers, review articles and workshop proceedings were consulted.

RESULTS

Periodontal bacteria can cross epithelial cells, enter the circulation, invade endothelial cells, induce endothelial cell dysfunction and activate inflammatory and immune responses. Several studies support the association between periodontitis (PD) and cardiovascular disease. Severe PD involves a risk for development of type 2 diabetes. Maternal PD is moderately associated with adverse pregnancy outcome and pre-eclampsia. Dental plaque can contain respiratory pathogens able to promote chronic obstructive pulmonary disease and pneumonia. Periodontal bacterial DNA has been detected in synovial fluid of patients with rheumatoid arthritis. Minor evidence exists for associations between PD and chronic kidney disease, obesity, cancer, metabolic syndrome and cognitive impairment. Concerns can be raised as to the interpretation of some study results due to heterogeneity in definitions used for PD, too much weight upon in vitro studies with a few selected organisms and failing recognition that the majority of the periodontal microbiota is not yet cultivated.

CONCLUSION

Periodontal bacteria may participate in extra-oral infections such as CVD, diabetes, APO, pre-eclampsia, COPD, pneumonia, RA, CKD, obesity, cancer, MetS and cognitive impairment. Most knowledge is based on associations which do not necessarily imply causality. Future studies should reach consensus on the definition of PD and systemic disease outcomes, recognize the full spectrum of the microbiota in PD and bacteremia, including not-yet-cultivated organisms and delineate the clinical significance of genetic strain variations and the role of periodontopathogenic vs gut organisms within atheromatous lesions. For demonstration of causality, large, long-term clinical studies should use well-defined criteria for PD and robust disease outcomes to elucidate the importance of PD intervention and prevention.

Periodontitis: Tip of the iceberg in chronic kidney disease

The prevalence of chronic kidney disease (CKD) is constantly escalating not only in industrialized countries but throughout the world. It is of major significance because of to its high morbidity and mortality. Strategies to tackle this worldwide health problem include identification of its associated risk factors, comorbidities, and complications as well as proper management to handle all the pertinent issues. Periodontal disease, a treatable infectious state of the dental supporting tissues, is common in CKD patients. Its association with CKD is believed to be in a reciprocal or bidirectional fashion and has been massively studied. This paper, therefore, aims to review the recent evidence pertaining to the association between periodontal disease and a variety of renal illnesses. Most of the current evidence was collected from cross-sectional studies and clinical trials. There is substantial evidence indicating that periodontal disease contributes markedly to the chronic systemic inflammatory burden, leading to cardiovascular and cerebrovascular complications, the principal causes of death among chronic renal disease patients. Furthermore, several studies demonstrated that proper periodontal intervention could help improve systemic inflammation and even nutritional status among CKD patients, resulting in a better quality of life. Suggestions have been made that periodontal disease should be diagnosed early, and managed and controlled to, at least, eradicate a source of inflammation in this population. Awareness of such an important issue should be increased in the relevant medical personnel.

An ignored cause of inflammation in patients undergoing continuous ambulatory peritoneal dialysis: periodontal problems

AIM

We aimed to assess whether there is a significant relation between periodontal health status and inflammation in uremic patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and also to reveal the efficiency of periodontal treatment in patients with various degrees of periodontal problems.

PATIENTS AND METHODS

Overall, 68 patients undergoing CAPD were included in the study. Clinical indices and measurements were obtained at baseline and panoramic radiographies were used for the diagnosis. According to the baseline values, patients were stratified into four groups according to the severity of periodontal problems as follows: healthy/gingivitis, slight-to-moderate, and severe periodontitis. A control examination was performed 3 months after the periodontal treatment for only 43 patients. Clinical and laboratory parameters before and after treatment were compared.

RESULTS

The frequency of periodontal disease was found to be high in uremic patients on CAPD. The frequency and severity of periodontitis was also found to be significantly (p < 0.01) higher in patients with high sensitive C-reactive protein levels and longer duration of peritoneal dialysis (p < 0.01). In addition, the periodontitis rate was found to be higher in patients with cardiovascular disease (p < 0.05) and diabetes mellitus (p < 0.01).

CONCLUSION

A meticulous periodontal examination should be a routine part of management of the uremic patients on CAPD because periodontal disease could be one of the hidden sources of unexplained inflammatory status.

Periodontal treatment reduces chronic systemic inflammation in peritoneal dialysis patients

Chronic systemic inflammation, a non traditional risk factor of cardiovascular diseases, is associated with increasing mortality in chronic kidney disease, especially peritoneal dialysis patients. Periodontitis is a potential treatable source of systemic inflammation in peritoneal dialysis patients. Clinical periodontal status was evaluated in 32 stable chronic peritoneal dialysis patients by plaque index and periodontal disease index. Hematologic, blood chemical, nutritional, and dialysis-related data as well as highly sensitive C-reactive protein were analyzed before and after periodontal treatment. At baseline, high sensitive C-reactive protein positively correlated with the clinical periodontal status (plaque index; r = 0.57, P < 0.01, periodontal disease index; r = 0.56, P < 0.01). After completion of periodontal therapy, clinical periodontal indexes were significantly lower and high sensitivity C-reactive protein significantly decreased from 2.93 to 2.21 mg/L. Moreover, blood urea nitrogen increased from 47.33 to 51.8 mg/dL, reflecting nutritional status improvement. Erythropoietin dosage requirement decreased from 8000 to 6000 units/week while hemoglobin level was stable. Periodontitis is an important source of chronic systemic inflammation in peritoneal dialysis patients. Treatment of periodontal diseases can improve systemic inflammation, nutritional status and erythropoietin responsiveness in peritoneal dialysis patients.

Prevalence and severity of oral disease in adults with chronic kidney disease: a systematic review of observational studies

BACKGROUND

Oral disease may be increased in people with chronic kidney disease (CKD) and, due to associations with inflammation and malnutrition, represents a potential modifiable risk factor for cardiovascular disease and mortality. We summarized the prevalence of oral disease in adults with CKD and explored any association between oral disease and mortality.

METHODS

We used systematic review of observational studies evaluating oral health in adults with CKD identified in MEDLINE (through September 2012) without language restriction. We summarized prevalence and associations with all-cause and cardiovascular mortality using random-effects meta-analysis. We explored for sources of heterogeneity between studies using meta-regression.

RESULTS

Eighty-eight studies in 125 populations comprising 11 340 adults were eligible. Edentulism affected one in five adults with CKD Stage 5D (dialysis) {20.6% [95% confidence interval (CI), 16.4-25.6]}. Periodontitis was more common in CKD Stage 5D [56.8% (CI, 39.3-72.8)] than less severe CKD [31.6% (CI, 19.0-47.6)], although data linking periodontitis with premature death were scant. One-quarter of patients with CKD Stage 5D reported never brushing their teeth [25.6% (CI, 10.2-51.1)] and a minority used dental floss [11.4% (CI, 6.2-19.8)]; oral pain was reported by one-sixth [18.7% (CI, 8.8-35.4)], while half of patients experienced a dry mouth [48.4% (CI, 37.5-59.5)]. Data for kidney transplant recipients and CKD Stages 1-5 were limited.

CONCLUSIONS

Oral disease is common in adults with CKD, potentially reflects low use of preventative dental services, and may be an important determinant of health in this clinical setting.

The malnutrition inflammation complex syndrome-the micsing factor in the perio-chronic kidney disease interlink

The patients who undergo Maintenance Haemodialysis (MHD) have a high prevalence of Protein-Energy Malnutrition (PEM) and inflammation. Because these two conditions often occur concomitantly in the MHD patients, they have been referred to together as the Malnutrition-Inflammation Complex Syndrome (MICS) or Malnutrition-inflammation atherosclerosis, to underscore the atherosclerotic complications of this entity. MICS is also reported to correlate with a poor outcome, including a decreased quality of life, refractory anaemia and significantly greater rates of hospitalization and mortality in the MHD patients .Indeed, MICS may be the major cause of the paradoxical exposure-outcome association, which is also known as reverse epidemiology of the cardiovascular disease risk factors in the maintenance dialysis patients. Periodontitis is a chronic inflammatory disease of the supporting tissues from the dentition, which results from the infection of and the interaction of selected bacterial species with the components of the host response in disease-susceptible individuals as the haemodialysis (HD) patients. Only in recent years, did an emerging evidence link the dental infection, especially periodontitis, to an increased risk of atherosclerosis and thrombosis. In the HD patients, studies have been showing a positive link between periodontal disease and systemic inflammation on correlation between the levels of CRP and immunoglobulin G of Porphyromonas gingivalis. Recent researches have confirmed that the periodontal health is poor in haemodialysis patients and that it correlates with the markers of malnutrition and inflammation.

Effect of nonsurgical periodontal treatment on C-reactive protein levels in maintenance hemodialysis patients

OBJECTIVE

C-reactive protein (CRP) has been implicated as a possible mediator of the association between periodontitis and several systemic diseases. This study evaluated the impact of nonsurgical periodontal treatment on the serum levels of CRP in chronic kidney disease (CKD) patients on hemodialysis.

METHODS

A total of 77 CKD patients on hemodialysis were included in this study. At baseline, periodontal examination was assessed for all the patients, and chronic periodontitis was defined through clinical attachment level and probing pocket depth, according to the American Association of Periodontology. Nonsurgical periodontal treatment was performed and serum levels of CRP were evaluated at baseline and 8 weeks after periodontal treatment.

RESULTS

Periodontal treatment resulted in significant reductions in CRP levels (p < 0.001). The difference between pre- and posttreatment CRP concentrations did not show any significant relationship with the severity of periodontitis.

CONCLUSIONS

Periodontitis is an important source of systemic inflammation in CKD patients. Nonsurgical periodontal treatment can effectively reduce the serum level of CRP in these patients.

A randomized controlled trial of intensive periodontal therapy on metabolic and inflammatory markers in patients With ESRD: results of an exploratory study

BACKGROUND

Periodontitis is a novel risk factor for inflammation and cardiovascular disease in the dialysis population. Limited information exists about the impact of periodontal therapy in patients receiving dialysis.

STUDY DESIGN

Randomized controlled trial to assess feasibility and gather preliminary data.

SETTING & PARTICIPANTS

Dialysis patients with moderate/severe chronic periodontitis.

INTERVENTION

Intensive treatment, consisting of scaling and root planing, extraction of hopeless teeth, and placement of local-delivery antibiotics, was performed at the baseline visit for treatment-group patients and after study completion for control-group patients.

OUTCOMES

Outcomes were feasibility (screening, recruitment, enrollment, adverse events, and study withdrawal/completion), clinical periodontal parameters (probing depth, clinical attachment level, bleeding on probing, gingival index, and plaque index), and serum albumin and interleukin 6 levels at 3 and 6 months postintervention.

RESULTS

342 dialysis patients were approached for participation: 53 were randomly assigned, with 26 participants assigned to immediate treatment and 27 assigned to a control arm for treatment after 6 months. 51 patients completed baseline appointments; 46 were available for 3-month follow-up, 45 were available for 6-month follow-up examinations, and 43 completed all visits. At 3 months, there was a statistically significant improvement for the treatment group compared to the control group for 3 periodontal parameters: mean probing depth (P = 0.008), extent of probing depth ≥4 mm (P = 0.02), and extent of gingival index ≥1 (P = 0.01). However, by 6 months, the difference between groups was no longer present for any variable except probing depth ≥4 mm (P = 0.04). There was no significant difference between groups for serum albumin or high-sensitivity interleukin 6 level at any time when adjusted for body mass index, diabetic status, and plaque index.

LIMITATIONS

Small sample size and relatively healthy population, imbalance in diabetes.

CONCLUSIONS

This small trial demonstrates successful cooperation between dentists and nephrologists and successful recruitment, treatment, and retention of dialysis patients with periodontitis. Larger studies with longer follow-up are needed to determine whether treatment can improve markers of inflammation and morbidity.