Lower Number of Teeth Is Related to Higher Risks for ACVD and Death-Systematic Review and Meta-Analyses of Survival Data

Tooth Loss is a Risk Factor for Cardiovascular Disease Mortality: A Systematic Review with Meta-analyses

INTRODUCTION

The current evidence linking tooth loss and cardiovascular disease mortality is inconclusive. Thus, the aim of this systematic review was to explore the association between tooth loss and cardiovascular disease (CVD) mortality.

METHODS

A comprehensive literature search of databases and gray literature included: Web of Science, Scopus, PubMed, Cochrane Central Register of Controlled Trials, Google Scholar, various digital repositories. The included studies reported on CVD mortality and tooth loss. The Newcastle-Ottawa scale was used to assess the quality of included studies. Random-effects meta-analysis method, sub-group analysis (based on the tooth loss categories (edentulous and fewer than 10 teeth present), meta-regression (based on the number. of confounders), publication bias, and sensitivity analysis were performed.

RESULTS

Twelve articles met the eligibility criteria with an overall "Good" quality. A significant association between tooth loss (edentulous or less than 10 teeth present) and CVD mortality was found in the primary meta-analysis, which compiled data from 12 studies. The estimated hazard ratio was 1.66 (95% CI: 1.32-2.09), and there was high heterogeneity (I2 = 82.42). Subgroup analysis revealed that the edentulous subgroup showed a higher risk with no significant heterogeneity, while the subgroup with fewer than 10 teeth showed a higher risk with substantial heterogeneity. Meta-regression analysis did not reveal any significant impact (P = .626) on whether variations in the number of confounders across studies would substantially affect the overall findings. No publication bias was detected and the sensitivity analysis based on the critical confounders also confirmed that tooth loss as a risk factor for CVD mortality (hazard ratio = 1.52, 95% CI: 1.28-1.80), (I2 51.82%).

CONCLUSION

The present systematic review reported that being edentulous or having lesser than 10 teeth is a predictive indicator of CVD mortality.

Association between missing teeth number and all-cause and cardiovascular mortality: NHANES 1999-2004 and 2009-2014

BACKGROUND

The association between tooth loss and all-cause and cardiovascular mortality requires further investigation.

METHODS

This study included 17993 participants from the National Health and Nutrition Examination Surveys (NHANES) 1999-2004 and 2009-2014. Weighted multivariable Cox proportional hazard models were used to assess the association between tooth loss and all-cause and cardiovascular mortality. Restricted cubic splines (RCS) were incorporated in the models to explore potential nonlinear relationships.

RESULTS

Over a median follow-up of 116 months, 2152 participants died, including 625 cardiovascular deaths. Compared to participants without missing teeth, participants with 11-19 missing teeth had the highest risk of all-cause mortality (hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.43-2.51), while participants with 6-10 missing teeth had the highest risk of cardiovascular mortality (HR 2.51, 95% CI 1.68-3.76). RCS analyses revealed nonlinear associations between number of missing teeth and all-cause (p < 0.001) and cardiovascular (p = 0.001) mortality. With < 10 missing teeth, each additional missing tooth increased all-cause and cardiovascular mortality by 6% (HR 1.06, 95% CI 1.03-1.09) and 9% (HR 1.09, 95% CI 1.03-1.15), respectively. However, when the number of missing teeth was ≥10, the risk of mortality did not continue to increase with more missing teeth. A significant interaction was found between tooth loss and age (p < 0.001 for both outcomes).

CONCLUSION

We observed an inverted L-shaped association between tooth loss and mortality, wherein risks increased with more missing teeth until 10, but did not continue increasing thereafter. The association was stronger in adults < 65 years old.

Endodontic Inflammatory Disease and Future Cardiovascular Events and Mortality: A Report from the PAROKRANK Study

INTRODUCTION

Prospective studies assessing the relation between endodontic inflammatory disease and subsequent cardiovascular events are few. The present aim was to explore associations between endodontic variables and future cardiovascular events in patients with myocardial infarction and matched controls participating in the PAROKRANK (Periodontitis and Its Relation to Coronary Artery Disease) study.

METHODS

Eight-hundred five patients hospitalized for a first myocardial infarction and 805 controls were recruited between 2010 and 2014. Signs of endodontic inflammatory disease were assessed in panoramic radiographs taken at baseline. Mortality and morbidity data during the approximately 8 years of follow up were obtained from national registries. The risk for future cardiovascular events (first of mortality and nonfatal myocardial infarction, stroke, or hospitalization for heart failure) was analyzed with the log-rank test and Cox proportional hazards regression adjusted for the following confounders: sex, age, smoking, myocardial infarction, diabetes, education, marital status, family history of cardiovascular disease, and marginal periodontitis.

RESULTS

In total, 285 future events were observed during the follow-up period. Unadjusted analyses revealed that ≥1 root-filled tooth increased the risk of a future event. After adjustment, the number of remaining teeth and non-root-filled teeth decreased the risk of future events, whereas a higher Decayed, Missing and Filled Teeth score increased the risk and ≥1 primary apical periodontitis decreased the risk of suffering cardiovascular events. A higher Decayed, Missing and Filled Teeth score and decayed teeth increased the risk of all-cause mortality.

CONCLUSIONS

Tooth loss is a strong indicator of an increased risk for future cardiovascular events. Root-filled teeth seem of limited value as a risk indicator when accounting for other risk factors. The potential effect of dental interventions on future events should be assessed in future research.

Association Between the Frequency of Tooth Brushing and the Risk of Cardiovascular Disease: A Systematic Review and Meta-analysis

Several epidemiological studies suggested that frequency of tooth brushing may be associated with cardiovascular disease (CVD) risk, but the results remain inconclusive. Therefore, the aim of this study was to synthesize frequency of tooth brushing and CVD risk using meta-analysis. Science Direct, PubMed, CINAHL, and OVID were searched through October 15, 2022. The random-effects model was used to quantitatively assess the combined risk estimation. In addition, we performed the sensitivity analysis to evaluate the robustness of the study results by excluding the included studies one by one. A total of 9 cohort studies containing 10 reports with 803,019 individuals were included in the meta-analysis. Pooled results showed that compared with the lowest brushing frequency, the highest brushing frequency (relative risk = 0.85, 95% confidence interval: 0.80-0.90) significantly reduced the risk of cardiovascular disease. There was moderate heterogeneity among included studies (P = .002, I2 = 65.4%). The exclusion of any one study did not materially change the combined risk estimates. Our meta-analysis supported the hypothesis that higher frequency of tooth brushing can reduce the risk of CVD, which may have important implications for conducting research on the prevention strategies of CVD.

Development and external validation of prediction models for critical outcomes of unvaccinated COVID-19 patients based on demographics, medical conditions and dental status

Background

Multiple prediction models were developed for critical outcomes of COVID-19. However, prediction models using predictors which can be easily obtained in clinical practice and on dental status are scarce.

Aim

The study aimed to develop and externally validate prediction models for critical outcomes of COVID-19 for unvaccinated adult patients in hospital settings based on demographics, medical conditions, and dental status.

Methods

A total of 285 and 352 patients from two hospitals in the Netherlands were retrospectively included as derivation and validation cohorts. Demographics, medical conditions, and dental status were considered potential predictors. The critical outcomes (death and ICU admission) were considered endpoints. Logistic regression analyses were used to develop two models: for death alone and for critical outcomes. The performance and clinical values of the models were determined in both cohorts.

Results

Age, number of teeth, chronic kidney disease, hypertension, diabetes, and chronic obstructive pulmonary diseases were the significant independent predictors. The models showed good to excellent calibration with observed: expected (O:E) ratios of 0.98 (95%CI: 0.76 to 1.25) and 1.00 (95%CI: 0.80 to 1.24), and discrimination with shrunken area under the curve (AUC) values of 0.85 and 0.79, based on the derivation cohort. In the validation cohort, the models showed good to excellent discrimination with AUC values of 0.85 (95%CI: 0.80 to 0.90) and 0.78 (95%CI: 0.73 to 0.83), but an overestimation in calibration with O:E ratios of 0.65 (95%CI: 0.49 to 0.85) and 0.67 (95%CI: 0.52 to 0.84).

Conclusion

The performance of the models was acceptable in both derivation and validation cohorts. Number of teeth was an additive important predictor of critical outcomes of COVID-19. It is an easy-to-apply tool in hospitals for risk stratification of COVID-19 prognosis.

Caries risk and social determinants of health: A big data report

BACKGROUND

Oral health is influenced by social determinants of health (SDH), predisposing people and communities to greater risk of developing caries. This study evaluated the association between caries risk in adults and SDH such as ZIP Codes, systemic diseases, payment methods, and race or ethnicity.

METHODS

The BigMouth Dental Data Repository (n = 57,211) was used to extract clinical and SDH data from patients' dental electronic health records for 2019. Caries risk categories were used as ZIP Code data was merged with the Social Deprivation Index, a composite measure of area-level deprivation based on 7 demographic characteristics collected in the American Community Survey.

RESULTS

The results showed that the odds of being in the high caries risk group were higher for people in the 49- to 64-year age group (adjusted odds ratio [aOR], 2.24; 95% CI, 2.08 to 2.40; P ≤ .001), men (aOR, 1.19; 95% CI, 1.13 to 1.25; P ≤ .001), people who had comorbidities (diabetes: aOR, 1.16; 95% CI, 1.08 to 1.24; P ≤ .001; cardiovascular disease: aOR, 1.40; 95% CI, 1.32 to 1.50), and people with an Social Deprivation Index score above the 75th percentile (aOR, 2.39; 95% CI, 2.21 to 2.58; P ≤ .001). In addition, Hispanic and Black people had higher odds of being at high caries risk than other races or ethnicities (Hispanic: aOR, 3.05; 95% CI, 2.32 to 4.00; Black: aOR, 2.05; 95% CI, 1.02 to 4.01).

CONCLUSIONS

This study shows the association of caries risk with higher social deprivation, reinforcing the role of structural and upstream factors in oral health. This study is unique in using recorded ZIP Code information and assessing caries risk levels for those regions.

PRACTICAL IMPLICATIONS

The physical and structural environment should be considered contributors to caries risk in people.

Suboptimal oral health and the risk of cardiovascular disease in the presence of competing death: a data linkage analysis

OBJECTIVE

The objective of this study is to simultaneously assess the associations between suboptimal oral health (SOH) and cardiovascular disease (CVD) and competing death (CD).

METHODS

Ontario residents aged 40 years and over who participated in the Canadian Community Health Survey 2003 and 2007-2008 were followed until December 31, 2016 for the incidence of CVD or CD. SOH was assessed based on self-rated oral health and inability to chew. Multivariable competing risk analysis was adjusted for socioeconomic characteristics, behavioural factors and intermediate health outcomes.

RESULTS

The study sample included 36,176 participants. Over a median follow-up of 9.61 years, there were 2077 CVD events and 3180 CD events. The fully adjusted models indicate 35% (HR = 1.35, 95% CI: 1.12-1.64) increase in the risk of CVD and 57% (HR = 1.57, 95% CI: 1.33-1.85) increase in the risk of CD among those who reported poor oral health as compared to those who reported excellent oral health. The fully adjusted models also indicate 11% (HR = 1.11, 95% CI: 0.97-1.27) increase in the hazard of CVD and 37% (HR = 1.37, 95% CI: 1.24-1.52) increase in the hazard of CD among those who reported inability to chew.

CONCLUSION

This study provides important information to contextualize CVD risk among those with SOH. The competing risk analysis indicates that those with SOH may benefit from additional interventions to prevent CVD and CD. Accordingly, managing the risk of CVD among those with SOH should fall under a more comprehensive approach that aims at improving their overall health and well-being.

Causal Effect of Tooth Loss on Cardiovascular Diseases

Many studies suggest associations between oral health and cardiovascular diseases, but there is a lack of causal evidence. Exploiting exogenous variation in tooth loss in US adults due to differential childhood exposure to fluoridated water, this study investigated the causal effect of tooth loss on cardiovascular diseases. A total of 722,519 participants in the Behavioral Risk Factor Surveillance System (BRFSS) waves 2006, 2008, or 2010 (birth years 1940-1978) were included in the analytical sample. To identify the effect of tooth loss on having a history of coronary heart disease (CHD) or stroke, instrumental variable analysis exploited childhood exposure to drinking water fluoride as an instrument. The weighted prevalence of CHD and stroke histories was 5.1% and 2.1%, respectively. First-stage regression indicated that childhood exposure to drinking water fluoride was a strong instrument for the number of lost teeth in adulthood (coefficient -0.61; 95% confidence interval [CI] -0.80, -0.41; F = 37.47). The probability of CHD was significantly higher by 1.04 percentage points (95% CI 0.57, 1.50) per lost tooth. The effect of tooth loss on stroke was significant only for people aged ≥60 y (coefficient 0.93 percentage points; 95% CI 0.14, 1.71). These findings are supportive of a causal effect of tooth loss on cardiovascular diseases among US adults, particularly in older age.

Dental Diseases Increase Risk of Aortic Arch Calcification Independent of Renal Dysfunction in Older Adults: Shenzhen Community Cohort Study

Many studies have documented that dental diseases were associated with an increased risk of cardiovascular diseases. Aortic arch calcification (AoAC) is a powerful predictor of cardiovascular diseases. However, whether the status of dental health is associated with AoAC is still unknown. 9463 participants over the age of 60 from Shenzhen community centers were included in the cross-sectional analysis. Physical examination data, blood biochemical tests, and AoAC scores calculated by chest radiography were collected and analyzed. Among them, 2630 participants were followed up for AoAC progression up to 36 months. Participants with AoAC suffered more tooth loss than those without AoAC (77.62% vs. 72.91%; p < 0.001). Association rule analysis suggested a strong association between dental diseases and AoAC. Tooth loss or decay increased the risk of AoAC progression (HR 1.459; 95%CI 1.284−1.658) after adjusting other risk factors including renal dysfunction. Dental diseases are potential predictors for AoAC in elderly people, which are independent of renal dysfunction.

An updated review on the link between oral infections and atherosclerotic cardiovascular disease with focus on phenomics

Atherosclerotic cardiovascular diseases (ACVD) and oral infections such as periodontal disease, dental caries, and apical periodontitis are diseases that affect a great portion of the worldwide population. Both are complex in nature and several studies show that they share etiological factors but a causal relationship between them has not been yet established due to the lack of well-designed clinical trials. Many studies in the recent years show convincing evidence of different mechanisms that might be involved in this association including chronic inflammation and immune response. However, some of these mechanisms are controversial because of confounding factors. It has been suggested that maladaptive inflammatory reactivity, determined in part by single nucleotide polymorphisms (SNPs) in pathway genes, could influence the association between oral infections, and cardiovascular diseases as pleiotropic genes. That is, these conditions could be outcomes of similar inflammatory pathways. Phenomics, the study of the changes in phenotypes or traits considering environmental variables and genetics is efficient in assessing and determining pleiotropic genes. Future research should focus on analyzing a combination of oral inflammatory conditions instead of focusing on one inflammatory phenotype alone and consider pleiotropy as a mechanistic contributor for these associations. Further, prospective observational studies seeking to follow the development of oral disease and subclinical ACVD will foster the understanding of the impact of oral health on general systemic health. Lastly, to demonstrate that oral infections would increase risk for subclinical ACVD development, clinical trials proposing to treat those infections considering genetic background and all other confounders are needed.

Oral frailty indicators to target major adverse health-related outcomes in older age: a systematic review

A well-preserved oral function is key to accomplishing essential daily tasks. However, in geriatric medicine and gerodontology, as age-related physiological decline disrupts several biological systems pathways, achieving this objective may pose a challenge. We aimed to make a systematic review of the existing literature on the relationships between poor oral health indicators contributing to the oral frailty phenotype, defined as an age-related gradual loss of oral function together with a decline in cognitive and physical functions, and a cluster of major adverse health-related outcomes in older age, including mortality, physical frailty, functional disability, quality of life, hospitalization, and falls. Six different electronic databases were consulted by two independent researchers, who found 68 eligible studies published from database inception to September 10, 2022. The risk of bias was evaluated using the National Institutes of Health Quality Assessment Toolkits for Observational Cohort and Cross-Sectional Studies. The study is registered on PROSPERO (CRD42021241075). Eleven different indicators of oral health were found to be related to adverse outcomes, which we grouped into four different categories: oral health status deterioration; decline in oral motor skills; chewing, swallowing, and saliva disorders; and oral pain. Oral health status deterioration, mostly number of teeth, was most frequently associated with all six adverse health-related outcomes, followed by chewing, swallowing, and saliva disorders associated with mortality, physical frailty, functional disability, hospitalization, and falls, then decline in oral motor skills associated with mortality, physical frailty, functional disability, hospitalization, and quality of life, and finally oral pain was associated only with physical frailty. The present findings could help to assess the contribution of each oral health indicator to the development of major adverse health-related outcomes in older age. These have important implications for prevention, given the potential reversibility of all these factors.

Removable partial dentures and mortality among partially edentulous adults

OBJECTIVES

The aim of this study was to evaluate whether the use of removable partial dentures (RPDs) has an effect on long-term survival outcomes amongst partially edentulous adults.

METHODS

Data were extracted from the Third National Health and Nutrition Examination Survey and linked to public-use mortality files for the period up to 2019. Partially edentulous adults with fewer than 20 teeth were included. RPD use and dentition status were determined by clinical examination. The cohort was propensity score weighted to create a sample which was balanced across 27 covariates (sociodemographics, health behaviors and insurance, laboratory markers, and general health status). Survival analysis was undertaken to compute absolute (mortality rate and median survival time) and relative (event time ratio [ETR]) measures of exposure effect.

RESULTS

The analyzed cohort included 1246 participants, which equated to 22,557 person-years of follow-up. The difference in all-cause mortality rate between RPD wearers and non-wearers was found to be -6.5 (95% CI: -11.6 to -1.4), with the median survival time in RPD wearers being 3.1 years longer (20.3 years versus 17.2 years). A 26% increase in survival time was observed in RPD wearers (ETR: 1.26, 95% CI: 1.17 to 1.37) and it was found that, for every 7.5 individuals treated with RPDs, one death would be prevented after 10 years of treatment.

CONCLUSIONS

The use of RPDs may have long-term benefits in reducing mortality amongst adults with a non-functional dentition, but further research is needed to validate these findings and assess the factors mediating the relationship.

CLINICAL SIGNIFICANCE

The use of RPDs may have long-term benefits in reducing mortality amongst adults with a non-functional dentition.

Is the Number of Missing Teeth Associated With Mortality? A Longitudinal Study Using a National Health Screening Cohort

This study aimed to estimate the risk of mortality related to the number of missing teeth in a South Korean population. The ≥ 40-year-old population of the Korean National Health Insurance Service-Health Screening Cohort 2002–2003 was analyzed. Participants were selected from a total of 220,189 participants and included in groups of 0 teeth lost, 1–2 teeth lost, and ≥ 3 teeth lost. Among the total population, 17,211 participants were included in no missing teeth, 1–2 missing teeth, and ≥ 3 missing teeth and were randomly matched 1:1:1 for age and sex. Mortality from specific causes and all-cause mortality were compared among the groups. The hazard ratio (HR) of the number of missing teeth for all-cause mortality or each cause of mortality was analyzed using Cox proportional hazard models. According to the cause of death, the HRs for metabolic disease, digestive disease, and trauma were greater in the group with ≥ 3 missing teeth than in the no missing teeth group. The group with ≥ 3 missing teeth indicated a 1.19-fold higher HR for all-cause mortality than the no missing teeth group [95% confidence intervals (95% CIs) = 1.12–1.27, P &lt; 0.001]. The group with 1- 2 missing teeth did not show a higher HR for all-cause mortality. In the group with 1–2 missing teeth, the HRs for mortality from mental disease and digestive disease were higher than those in the no missing teeth group. The group with 1–2 missing teeth did not show a higher HR for all-cause mortality. The number of missing teeth was linked with a higher risk of mortality. For specific causes of mortality, mortality from metabolic disease, digestive disease, and trauma was higher in the participants with the number of missing teeth.

The validity of self-reported number of teeth and edentulousness among Norwegian older adults, the HUNT Study

Background

Number of teeth is an established indicator of oral health and is commonly self-reported in epidemiological studies due to the costly and labor-intensive nature of clinical examinations. Although previous studies have found self-reported number of teeth to be a reasonably accurate measure, its accuracy among older adults ≥ 70 years is less explored. The aim of this study was to assess the validity of self-reported number of teeth and edentulousness in older adults and to investigate factors that may affect the accuracy of self-reports.

Methods

This study included two different samples of older adults ≥ 70 years drawn from the fourth wave of the Trøndelag Health Study (the HUNT Study), Norway. Sample 1 (n = 586) was used to evaluate the validity of self-reported number of teeth and sample 2 (n = 518) was used to evaluate self-reported edentulousness. Information on number of teeth and background variables (education, smoking, cognitive function, and self-perceived general and oral health) were self-reported in questionnaires, while clinical oral health examinations assessed number of teeth, number of teeth restored or replaced by fixed prosthodontics and edentulousness. Spearman and Pearson correlation coefficients, Bland–Altman plot, chi-square test and kappa statistics were used to assess the agreement between self-reported and clinically recorded number of teeth.

Results

The mean difference between self-reported and clinically recorded number of teeth was low (− 0.22 teeth), and more than 70% of the participants reported their number of teeth within an error of two teeth. Correlations between self-reports and clinical examinations were high for the total sample (0.86 (Spearman) and 0.91 (Pearson)). However, a lower correlation was found among participants with dementia (0.74 (Spearman) and 0.85 (Pearson)), participants having ≥ 20 teeth (0.76 (Spearman) and 0.67 (Pearson)), and participants with ≥ 5 teeth restored or replaced by fixed prosthodontics (0.75 (Spearman) and 0.77 (Pearson)). Self-reports of having teeth or being edentulous were correct in 96.3% of the cases (kappa value 0.93, p value < 0.001).

Conclusions

Among older Norwegian adults, self-reported number of teeth agreed closely with clinical tooth counts and nearly all the edentulous participants correctly reported having no teeth.