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Wang D, Dai L, Cui Z, Xing W, Huang X, Yang H, Shan Y. Association between periodontal diseases and chronic obstructive pulmonary disease: Evidence from sequential cross-sectional and prospective cohort studies based on UK Biobank. J Clin Periodontol 2024; 51:97-107. [PMID: 37850252 DOI: 10.1111/jcpe.13890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/12/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
AIM To investigate the association between periodontal diseases, airflow limitation and incident chronic obstructive pulmonary disease (COPD) in a large-scale prospective UK Biobank cohort. MATERIALS AND METHODS Our approach comprised a cross-sectional study and a prospective cohort. Periodontal diseases were determined based on the participants' self-reported dental symptoms, including painful gums, bleeding gums and loose teeth. Logistic regression and Cox proportional hazards models were used to evaluate the association of periodontal diseases with airflow limitation and incident COPD in the cross-sectional study and the prospective cohort, respectively. RESULTS The cross-sectional study involved 495,610 participants. Multivariable analysis found that periodontal diseases were significantly associated with airflow limitation (odds ratio = 1.036, 95% confidence interval [CI]: 1.015-1.059). The cohort study included 379,266 participants with a median follow-up period of 12.68 years. An elevated risk of incident COPD was associated with the presence of periodontal diseases (hazard ratio: 1.248, 95% CI: 1.174-1.326). The effect was consistent among subgroups, including baseline age (≤65 or >65 years), sex, smoking status and diabetes mellitus. CONCLUSIONS Periodontal diseases are associated with airflow limitation and elevated COPD incidence. Maintaining good periodontal health in patients with chronic bronchitis and emphysema may help prevent the onset of COPD.
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Affiliation(s)
- Dongyun Wang
- Stomatological Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Liang Dai
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, China
| | - Zhengqian Cui
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen, China
| | - Weili Xing
- Internal Medicine, Distinct Health Care, Guangzhou, China
| | - Xiaoyan Huang
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, China
| | - Hongyu Yang
- Stomatological Center, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ying Shan
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, China
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2
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Subbappa A, Lokesh KS, Chaya SK, Kaleem Ullah M, Siddaiah JB, Bhojraj N, Mahesh PA. Unmasking the Silent Threat: Periodontal Health's Impact on COPD Severity and Hospitalization. J Pers Med 2023; 13:1714. [PMID: 38138940 PMCID: PMC10744674 DOI: 10.3390/jpm13121714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVE This study investigated the relationship between chronic obstructive pulmonary disease (COPD) and periodontitis, focusing on how periodontal health impacts COPD airflow limitation, exacerbations, and hospitalization. BACKGROUND Periodontitis, a multifactorial inflammatory disease, is characterized by destruction of tooth-supporting structures, while COPD is a global pulmonary disorder with high mortality. METHODS A total of 199 COPD patients aged over 40 years underwent lung function tests (spirometry), 6 min walk test, and St George's Respiratory Questionnaire-COPD (SGRQ-C) to assess lung health. Periodontal indices such as probing depth (PD), clinical attachment loss (CAL), and plaque index (PI) were assessed. RESULTS We found a significant negative correlation between periodontal disease severity and lung function (lower FEV1, FVC, and FEV1/FVC ratio) after adjusting for smoking. Likewise, periodontal parameters (PPD, PI, and CAL) exhibited negative correlations with lung function. These periodontal indices were independently associated with airflow limitation severity, exacerbations frequency, and prior-year hospitalization. Linear regression indicated that each unit increase in PPD, PI, and CAL corresponded to estimated increases in GOLD airflow limitation grading (0.288, 0.718, and 0.193, respectively) and number of exacerbations (0.115, 0.041, and 0.109, respectively). In logistic regression, PPD, PI, and CAL adjusted odds ratios (ORs) were estimated to increase by 1.29 (95%CI: 1.03-1.62), 3.04 (95%CI: 1.28-7.2), and 1.26 (95%CI: 1.06-1.49), respectively, for hospitalization in previous year. CONCLUSION Periodontitis is associated with COPD airflow limitation, exacerbation, and hospitalization, with PI being the most clinically relevant periodontal factor. Dentists and physicians should monitor and increase awareness among COPD patients to maintain oral hygiene for prevention of periodontal diseases and mitigate its effect on COPD progression.
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Affiliation(s)
- Anitha Subbappa
- Department of Periodontology, JSS Dental College & Hospital, JSS Academy of Higher Education and Research, Mysuru 570015, India;
| | - Komarla Sundararaja Lokesh
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (K.S.L.); (S.K.C.); (J.B.S.)
| | - Sindaghatta Krishnarao Chaya
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (K.S.L.); (S.K.C.); (J.B.S.)
| | - Mohammed Kaleem Ullah
- Centre for Excellence in Molecular Biology and Regenerative Medicine (A DST-FIST Supported Center), Department of Biochemistry (A DST-FIST Supported Department), JSS Medical College, JSS Academy of Higher Education and Research, Mysore 570015, India;
- Division of Infectious Disease and Vaccinology, School of Public Health, University of California, Berkeley, CA 94720, USA
| | - Jayaraj Biligere Siddaiah
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (K.S.L.); (S.K.C.); (J.B.S.)
| | - Nandlal Bhojraj
- Department of Periodontology, JSS Dental College & Hospital, JSS Academy of Higher Education and Research, Mysuru 570015, India;
| | - Padukudru Anand Mahesh
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru 570015, India; (K.S.L.); (S.K.C.); (J.B.S.)
- Special Interest Group—Environment and Respiratory Diseases, JSS Academy of Higher Education and Research, Mysuru 570015, India
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Tamiya H, Mitani A, Abe M, Nagase T. Putative Bidirectionality of Chronic Obstructive Pulmonary Disease and Periodontal Disease: A Review of the Literature. J Clin Med 2023; 12:5935. [PMID: 37762876 PMCID: PMC10531527 DOI: 10.3390/jcm12185935] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/24/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide and is currently the third leading cause of death globally. The long-term inhalation of toxic substances, mainly cigarette smoke, deteriorates pulmonary function over time, resulting in the development of COPD in adulthood. Periodontal disease is an inflammatory condition that affects most adults and is caused by the bacteria within dental plaque. These bacteria dissolve the gums around the teeth and the bone that supports them, ultimately leading to tooth loss. Periodontal disease and COPD share common risk factors, such as aging and smoking. Other similarities include local chronic inflammation and links with the onset and progression of systemic diseases such as ischemic heart disease and diabetes mellitus. Understanding whether interventions for periodontal disease improve the disease trajectory of COPD (and vice versa) is important, given our rapidly aging society. This review focuses on the putative relationship between COPD and periodontal disease while exploring current evidence and future research directions.
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Affiliation(s)
- Hiroyuki Tamiya
- Division for Health Service Promotion, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Akihisa Mitani
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Masanobu Abe
- Department of Sensory and Motor System Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8654, Japan
| | - Takahide Nagase
- The Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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4
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Kelly N, Blackwood B, Credland N, Stayt L, Causey C, Winning L, McAuley DF, Lundy FT, El Karim I. Oral health care in adult intensive care units: A national point prevalence study. Nurs Crit Care 2023; 28:773-780. [PMID: 37125669 DOI: 10.1111/nicc.12919] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND The importance of good oral hygiene for patients in Intensive Care Units (ICUs) is well recognized, however, the most effective way to achieve good oral care in the ICU is unclear. AIM This study aimed to provide a national picture of oral care practices in adult ICUs in the United Kingdom (UK) to identify areas for improvement. STUDY DESIGN A national one-day point prevalence study was undertaken in adult ICUs in the UK in the period from 30th September to 14th October 2021. Data were collected on all patients in the ICU on the date of data collection. Using a validated electronic data collection form, anonymised data were collected on methods and frequency of oral care provided, and the use of oral care protocols within the ICU. Data were analysed using descriptive analysis. RESULTS Data from 195 patients in 15 ICUs in England, Wales and Northern Ireland were collected. Written oral care protocols were available for use in the care of 65% (n = 127) of patients. 73% (n = 142) of patients received oral care within the 24-h period. Oral care methods included toothbrushing 41% (n = 79), foam sticks 3% (n = 5), moisturizing the oral cavity 10% (n = 19) and mouth rinse with chlorhexidine 3% (n = 5) and other oral care methods not specified 12% (n = 23). 44% (n = 85) of patients had an oral assessment within the 24-h period and variable assessment methods were used. CONCLUSION There is large variability in oral care provision and methods for intubated ICU patients and a lack of consensus was revealed in the study. Oral assessment is conducted less frequently using multiple tools. Optimal oral care standards and further research into oral care provision is pivotal to address this important patient-relevant practice. RELEVANCE TO CLINICAL PRACTICE Oral care is a fundamental part of care for ICU patients, however, there is a large degree of variability, and oral care is often not based upon oral assessment. The use of an oral care protocol and oral assessments would help to improve patient care, ease of use for staff and provide a tailored oral care plan for patients, improving efficiency and preventing wasted resources.
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Affiliation(s)
- Niamh Kelly
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Nicki Credland
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - Louise Stayt
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Christine Causey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Lewis Winning
- Division of Restorative Dentistry & Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Fionnuala T Lundy
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Ikhlas El Karim
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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5
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Satyanarayana D, Kulkarni S, Doshi D, Reddy MP, Khaled S, Srilatha A. Periodontal health status among chronic obstructive pulmonary disease with age- and gender-matched controls. J Indian Soc Periodontol 2023; 27:524-529. [PMID: 37781331 PMCID: PMC10538517 DOI: 10.4103/jisp.jisp_479_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 10/03/2023] Open
Abstract
Background Periodontal disease and chronic obstructive pulmonary disease (COPD) share a pathogenic mechanism that involves activating and using inflammatory cytokines and neutrophils, which generate pathological changes in various tissues with a chronic degenerative outcome. Aim the aim of this study was to assess and compare the periodontal health status among COPD patients with age- and gender-matched controls. Materials and Methods All the patients aged >30 years who were diagnosed with COPD by the physician were included as cases, while people who are apparently healthy and age and gender matched with cases were included as controls. Data on demographic details, socioeconomic status (Kuppuswamy scale), deleterious oral habits, and oral hygiene practices were obtained. The Simplified Oral Hygiene Index (OHI-S) and the WHO basic oral health survey proforma (1997) were used to obtain the data on oral hygiene and periodontal status respectively. Results Most cases had moderate COPD severity (58.25%). The overall mean OHI-S, CPI, and LOA were higher among cases (3.92 ± 0.95, 3.68 ± 0.60, and 2.33 ± 1.10, respectively) in comparison to controls. Further, among cases, the mean oral hygiene and periodontitis increased with increased severity of COPD. Although among both cases and controls, gender, tobacco use, and alcohol consumption influenced their periodontal status, significant odds of higher risk were seen only among cases. Further, subjects with COPD had higher odds of having poor oral hygiene, deeper pocket depths, and LOA. Conclusion A strong association between COPD and periodontitis was observed. The oral hygiene and periodontal disease worsened with the severity of COPD.
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Affiliation(s)
- Dantala Satyanarayana
- Department of Public Health Dentistry, MNR Dental College and Hospital, Sangareddy, Telangana, India
| | - Suhas Kulkarni
- Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Hospital, Hyderabad, Telangana, India
| | - Dolar Doshi
- Department of Public Health Dentistry, Government Dental College and Hospital, Hyderabad, Telangana, India
| | - Madupu Padma Reddy
- Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Hospital, Hyderabad, Telangana, India
| | - Sana Khaled
- Department of Oral and Maxillofacial Pathology, Sri Balaji Dental College, Hyderabad, Telangana, India
| | - Adepu Srilatha
- Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Hospital, Hyderabad, Telangana, India
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Isola G, Santonocito S, Lupi SM, Polizzi A, Sclafani R, Patini R, Marchetti E. Periodontal Health and Disease in the Context of Systemic Diseases. Mediators Inflamm 2023; 2023:9720947. [PMID: 37214190 PMCID: PMC10199803 DOI: 10.1155/2023/9720947] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 09/04/2022] [Accepted: 04/07/2023] [Indexed: 05/24/2023] Open
Abstract
During recent years, considerable progress has been made in understanding the etiopathogenesis of periodontitis in its various forms and their interactions with the host. Furthermore, a number of reports have highlighted the importance of oral health and disease in systemic conditions, especially cardiovascular diseases and diabetes. In this regard, research has attempted to explain the role of periodontitis in promoting alteration in distant sites and organs. Recently, DNA sequencing studies have revealed how oral infections can occur in distant sites such as the colon, reproductive tissues, metabolic diseases, and atheromas. The objective of this review is to describe and update the emerging evidence and knowledge regarding the association between periodontitis and systemic disease and to analyse the evidence that has reported periodontitis as a risk factor for the development of various forms of systemic diseases in order to provide a better understanding of the possible shared etiopathogenetic pathways between periodontitis and the different forms of systemic diseases.
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Affiliation(s)
- Gaetano Isola
- Department of General Surgery and Surgical-Medical Specialties, School of Dentistry, University of Catania, Catania, Italy
| | - Simona Santonocito
- Department of General Surgery and Surgical-Medical Specialties, School of Dentistry, University of Catania, Catania, Italy
| | - Saturnino Marco Lupi
- Department of Clinical Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Alessandro Polizzi
- Department of General Surgery and Surgical-Medical Specialties, School of Dentistry, University of Catania, Catania, Italy
| | - Rossana Sclafani
- Department of General Surgery and Surgical-Medical Specialties, School of Dentistry, University of Catania, Catania, Italy
| | - Romeo Patini
- Institute of Dentistry and Maxillofacial Surgery, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Enrico Marchetti
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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7
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Vollmer A, Vollmer M, Lang G, Straub A, Shavlokhova V, Kübler A, Gubik S, Brands R, Hartmann S, Saravi B. Associations between Periodontitis and COPD: An Artificial Intelligence-Based Analysis of NHANES III. J Clin Med 2022; 11:jcm11237210. [PMID: 36498784 PMCID: PMC9737076 DOI: 10.3390/jcm11237210] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
A number of cross-sectional epidemiological studies suggest that poor oral health is associated with respiratory diseases. However, the number of cases within the studies was limited, and the studies had different measurement conditions. By analyzing data from the National Health and Nutrition Examination Survey III (NHANES III), this study aimed to investigate possible associations between chronic obstructive pulmonary disease (COPD) and periodontitis in the general population. COPD was diagnosed in cases where FEV (1)/FVC ratio was below 70% (non-COPD versus COPD; binary classification task). We used unsupervised learning utilizing k-means clustering to identify clusters in the data. COPD classes were predicted with logistic regression, a random forest classifier, a stochastic gradient descent (SGD) classifier, k-nearest neighbors, a decision tree classifier, Gaussian naive Bayes (GaussianNB), support vector machines (SVM), a custom-made convolutional neural network (CNN), a multilayer perceptron artificial neural network (MLP), and a radial basis function neural network (RBNN) in Python. We calculated the accuracy of the prediction and the area under the curve (AUC). The most important predictors were determined using feature importance analysis. Results: Overall, 15,868 participants and 19 feature variables were included. Based on k-means clustering, the data were separated into two clusters that identified two risk characteristic groups of patients. The algorithms reached AUCs between 0.608 (DTC) and 0.953% (CNN) for the classification of COPD classes. Feature importance analysis of deep learning algorithms indicated that age and mean attachment loss were the most important features in predicting COPD. Conclusions: Data analysis of a large population showed that machine learning and deep learning algorithms could predict COPD cases based on demographics and oral health feature variables. This study indicates that periodontitis might be an important predictor of COPD. Further prospective studies examining the association between periodontitis and COPD are warranted to validate the present results.
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Affiliation(s)
- Andreas Vollmer
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
- Correspondence:
| | - Michael Vollmer
- Department of Oral and Maxillofacial Surgery, Tuebingen University Hospital, Osianderstrasse 2-8, 72076 Tuebingen, Germany
| | - Gernot Lang
- Department of Orthopedics and Trauma Surgery, Medical Centre-Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany
| | - Anton Straub
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Veronika Shavlokhova
- Division of Medicine, Department of Oral and Maxillofacial Surgery, University Hospital Ruppin-Brandenburg, Brandenburg Medical School, Fehrbelliner Straße 38, 16816 Neuruppin, Germany
| | - Alexander Kübler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Sebastian Gubik
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Roman Brands
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Stefan Hartmann
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital of Würzburg, 97070 Würzburg, Germany
| | - Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Centre-Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79106 Freiburg, Germany
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8
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Ouyang Y, Liu J, Wen S, Xu Y, Zhang Z, Pi Y, Chen D, Su Z, Liang Z, Wang Y, Guo L. Association between chronic obstructive pulmonary disease and periodontitis: The common role of innate immune cells? Cytokine 2022; 158:155982. [PMID: 35932499 DOI: 10.1016/j.cyto.2022.155982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 11/19/2022]
Abstract
Innate immune cells are of broad interest in a variety of diseases. These cells include neutrophils, macrophages, dendritic cells and mast cells, etc. Innate immune cells are often mentioned in inflammatory diseases as the first line of defense against pathogens' invasion. As chronic obstructive pulmonary disease and periodontitis are inflammatory diseases, innate immune cells play an important role in the development of both diseases. COPD and periodontitis are common epidemic diseases with a very high prevalence, thus affecting a large number of people and also reducing the quality of life of patients. In addition, epidemiological studies suggested a link between the two, creating a co-morbid burden, but the mechanism of the link is yet to be explained. This article discusses the possible mechanism of the link between the two diseases in terms of innate immune cells and discusses possible future targeted therapies that could alleviate the burden on patients.
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Affiliation(s)
- Yuanting Ouyang
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Jiaohong Liu
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Siyi Wen
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Yixin Xu
- Department of Orthodontic, Stomatological Hospital, Southern Medical University, China
| | - Zhiyi Zhang
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Yixing Pi
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Ding Chen
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Zhikang Su
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Zitian Liang
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Yan Wang
- Guangzhou Medical University, Guangzhou, Guangdong, China; Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Diseases, Guangzhou, Guangdong, China.
| | - Lvhua Guo
- Guangzhou Medical University, Guangzhou, Guangdong, China; Department of Prosthodontics, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China.
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9
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The role of Th17 cells: explanation of relationship between periodontitis and COPD? Inflamm Res 2022; 71:1011-1024. [PMID: 35781342 DOI: 10.1007/s00011-022-01602-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/13/2022] [Indexed: 11/05/2022] Open
Abstract
Periodontitis and chronic obstructive pulmonary disease (COPD) are chronic inflammatory diseases with common risk factors, such as long-term smoking, age, and social deprivation. Many observational studies have shown that periodontitis and COPD are correlated. Moreover, they share a common pathophysiological process involving local accumulation of inflammatory cells and cytokines and damage of soft tissues. The T helper 17 (Th17) cells and the related cytokines, interleukin (IL)-17, IL-22, IL-1β, IL-6, IL-23, and transforming growth factor (TGF)-β, play a crucial regulatory role during the pathophysiological process. This paper reviewed the essential roles of Th17 lineage in the occurrence of periodontitis and COPD. The gaps in the study of their common pathological mechanism were also evaluated to explore future research directions. Therefore, this review can provide study direction for the association between periodontitis and COPD and new ideas for the clinical diagnosis and treatment of the two diseases.
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10
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Mainas G, Ide M, Rizzo M, Magan-Fernandez A, Mesa F, Nibali L. Managing the Systemic Impact of Periodontitis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:621. [PMID: 35630038 PMCID: PMC9147054 DOI: 10.3390/medicina58050621] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 01/22/2023]
Abstract
Periodontitis is a microbially driven host-mediated disease that leads to loss of periodontal attachment and bone. It is associated with elevation of systemic inflammatory markers and with the presence of systemic co-morbidities. Furthermore, periodontal treatment leads to a 24-48 h-long acute local and systemic inflammatory response. This systemic response might increase the burden of patients with compromised medical history and/or uncontrolled systemic diseases. The correlation between periodontitis and systemic diseases, the impact of periodontitis on the quality of life and public health, the effects of periodontal treatment on systemic health and disease, and the available methods to manage systemic inflammation after periodontal therapy are discussed. The main focus then shifts to a description of the existing evidence regarding the impact of periodontitis and periodontal treatment on systemic health and to the identification of approaches aiming to reduce the effect of periodontitis on systemic inflammation.
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Affiliation(s)
- Giuseppe Mainas
- Periodontology Unit, Centre for Host-Microbiome Interactions, Dental Institute, King’s College London, London SE1 9RT, UK; (G.M.); (M.I.)
| | - Mark Ide
- Periodontology Unit, Centre for Host-Microbiome Interactions, Dental Institute, King’s College London, London SE1 9RT, UK; (G.M.); (M.I.)
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, School of Medicine, University of Palermo, 90133 Palermo, Italy;
| | - Antonio Magan-Fernandez
- Department of Periodontics, School of Dentistry, University of Granada, 18071 Granada, Spain; (A.M.-F.); (F.M.)
| | - Francisco Mesa
- Department of Periodontics, School of Dentistry, University of Granada, 18071 Granada, Spain; (A.M.-F.); (F.M.)
| | - Luigi Nibali
- Periodontology Unit, Centre for Host-Microbiome Interactions, Dental Institute, King’s College London, London SE1 9RT, UK; (G.M.); (M.I.)
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11
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. Arch Bronconeumol 2022; 58:334-344. [PMID: 35315327 DOI: 10.1016/j.arbres.2021.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD.
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Affiliation(s)
- José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Tarrasa, Tarrasa, Barcelona, España
| | | | - Eusebi Chiner
- Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, España
| | - Leopoldo Palacios
- Unidad de Gestión Clínica El Torrejón, Distrito Sanitario Huelva-Costa y Condado-Campiña, Huelva, España
| | - Carme Hernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Dispositivo transversal hospitalización a domicilio, Dirección Médica y Enfermera, Hospital Clínic, Universidad de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | | | - Jesús Molina
- Centro de Salud Francia, Dirección Asistencial Oeste, Fuenlabrada, Madrid, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | | | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Borja G Cosío
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Baleares, España
| | - Ciro Casanova
- Unidad de Investigación, Servicio de Neumología, Hospital Universitario de La Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Tenerife, España
| | - Marc Miravitlles
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
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12
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Pulmonary disease and periodontal health: a meta-analysis. Sleep Breath 2022; 26:1857-1868. [PMID: 35122603 DOI: 10.1007/s11325-022-02577-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Research has shown a positive relationship between pulmonary and periodontal disease. However, the relationship remains unclear. The aim of this meta-analysis was to evaluate the associations between pulmonary disease and periodontal health. MATERIALS AND METHODS MEDLINE, PubMed, EMBASE, Web of Science, Science Citation Index, Wanfang, and CNKI were searched for all the relevant studies of relationship between pulmonary disease and periodontal health. Weighted mean difference (WMD)/odds ratio (OR) with 95% confidence interval (CI) was used to assess the strength of the association. RESULTS Thirty-seven studies were included in this meta-analysis. Pooled analysis showed a significant association between pulmonary and periodontal disease (adjusted OR, 1.93; 95%CI: 1.60-2.33; P < 0.05), and pooled adjusted OR was 1.64, 3.03, and 2.21 in COPD, asthma, and pneumonia, respectively. The pooled analysis also showed that patients with pulmonary disease suffered from worse periodontal health as most periodontal indexes in those patients were poorer. CONCLUSIONS There is a strong association between pulmonary disease and periodontal health. Clinical trials analyzing the causality and pathological basis of the association of these two diseases are needed.
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13
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. [Translated article] Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. ARCHIVOS DE BRONCONEUMOLOGÍA 2022. [DOI: 10.1016/j.arbres.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Fungi—A Component of the Oral Microbiome Involved in Periodontal Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1373:113-138. [DOI: 10.1007/978-3-030-96881-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Kataoka S, Kimura M, Yamaguchi T, Egashira K, Yamamoto Y, Koike Y, Ogawa Y, Fujiharu C, Namai T, Taguchi K, Takahashi M, Kameda A, Kasen T, Hano A, Kubota K, Sato M, Yamaga H, Nohara K, Shirasawa M, Sekine C, Fukuda M, Aoki A, Takeuchi Y, Mugiyama M, Mori K, Sawada K, Kashiwagi Y, Kitamura M, Hayashi T, Nakagawa T, Murakami S. A cross-sectional study of relationships between periodontal disease and general health: The Hitachi Oral Healthcare Survey. BMC Oral Health 2021; 21:644. [PMID: 34911523 PMCID: PMC8672581 DOI: 10.1186/s12903-021-01990-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/22/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This cross-sectional study performed to clarify the relationship between periodontal disease and non-communicable diseases (NCDs), such as obesity, diabetes mellitus, impaired glucose tolerance (IGT), chronic obstructive pulmonary disease (COPD), and atherosclerotic cardiovascular disease (ASCVD) by introducing dental examinations into the annual health examinations conducted by Japanese companies, and to highlights the importance of a medical system that connects dental and medical professionals. METHODS A total of 1.022 Hitachi Ltd. employees were enrolled in this cross-sectional study. We examined correlations and odds ratios (ORs) between the dental and overall health of employees using stratification and multiple logistic regression analyses based on the periodontal health indicators, general health indicators, and occlusal force. RESULTS The adjusted OR of PPD for obesity (OR, 1.42; 95% confidence interval [CI], 1.09-1.84; p = 0.009), IGT (OR, 1.48; 95% CI, 1.00-2.20; p = 0.049), and COPD (OR, 1.38; 95% CI, 1.02-1.88; p = 0.038) significantly differed. The adjusted OR of body mass index (OR, 1.28; 95% CI 1.15-1.42; p < 0.001), haemoglobin A1C (HbA1c) (OR, 4.34; 95% CI, 1.89-9.98; p < 0.001), fasting blood glucose (FBG) levels (OR, 1.08; 95% CI 1.04-1.11; p < 0.001), postbronchodilator forced expiratory volume in one second/forced vital capacity ratio (%FEV1) (OR, 0.95; 95% CI 0.91-1.00; p = 0.031) and smoking (OR, 2.32; 95% CI 1.62-3.33; p < 0.001) for severe periodontal disease also significantly differed. Occlusal force was significantly reduced in employees aged 50-59 years compared to those aged 40-49 years. Both PPD, HbA1c, FBG levels were significantly associated with occlusal force among employees with moderate/severe periodontitis. PPD was significantly associated with occlusal force among employees with and moderate COPD, and ASCVD. %FEV1 was significantly associated with occlusal force among employees with IGT. CONCLUSIONS This cross-sectional study revealed mutual relationships among periodontal disease, NCDs, and occlusal force on Japanese corporate workers. We demonstrated that a comprehensive, regional healthcare system centred on annual integrated dental and physical health examinations in the workplace will benefit employees and positively impact corporate health insurance.
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Affiliation(s)
- Shinsuke Kataoka
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Mitsuo Kimura
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Tsuguno Yamaguchi
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Kenji Egashira
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Yu Yamamoto
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Yasushi Koike
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Yuki Ogawa
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Chika Fujiharu
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Toshiko Namai
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Kanako Taguchi
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Momoko Takahashi
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Asami Kameda
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Tomoka Kasen
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Asami Hano
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Konomi Kubota
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Masayuki Sato
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Hiroaki Yamaga
- Research and Development Head Quarters, LION Corporation, Odawara, Kanagawa, Japan
| | - Kaori Nohara
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Mikiko Shirasawa
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Chika Sekine
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Maki Fukuda
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Arisa Aoki
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Yurina Takeuchi
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Misaki Mugiyama
- The LION Foundation for Dental Health (Public Interest Incorporated Foundation), Sumida, Tokyo, Japan
| | - Kenta Mori
- Faculty of Dentistry, Osaka University, Suita, Osaka, Japan
| | - Keigo Sawada
- Faculty of Dentistry, Osaka University, Suita, Osaka, Japan
| | | | | | - Takeshi Hayashi
- Hitachi Health Care Center, Hitachi Limited, Hitachi, Ibaraki, Japan
| | - Tohru Nakagawa
- Hitachi Health Care Center, Hitachi Limited, Hitachi, Ibaraki, Japan
| | - Shinya Murakami
- Faculty of Dentistry, Osaka University, Suita, Osaka, Japan.
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Kouanda B, Sattar Z, Geraghty P. Periodontal Diseases: Major Exacerbators of Pulmonary Diseases? Pulm Med 2021; 2021:4712406. [PMID: 34765263 PMCID: PMC8577952 DOI: 10.1155/2021/4712406] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/16/2021] [Indexed: 12/13/2022] Open
Abstract
Periodontal diseases are a range of polymicrobial infectious disorders, such as gingivitis and periodontitis, which affect tooth-supporting tissues and are linked to playing a role in the exacerbation of several pulmonary diseases. Pulmonary diseases, such as pneumonia, chronic obstructive pulmonary disease (COPD), asthma, tuberculosis, COVID-19, and bronchiectasis, significantly contribute to poor quality of life and mortality. The association between periodontal disease and pulmonary outcomes is an important topic and requires further attention. Numerous resident microorganisms coexist in the oral cavity and lungs. However, changes in the normal microflora due to oral disease, old age, lifestyle habits, or dental intervention may contribute to altered aspiration of oral periodontopathic bacteria into the lungs and changing inflammatory responses. Equally, periodontal diseases are associated with the longitudinal decline in spirometry lung volume. Several studies suggest a possible beneficial effect of periodontal therapy in improving lung function with a decreased frequency of exacerbations and reduced risk of adverse respiratory events and morbidity. Here, we review the current literature outlining the link between the oral cavity and pulmonary outcomes and focus on the microflora of the oral cavity, environmental and genetic factors, and preexisting conditions that can impact oral and pulmonary outcomes.
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Affiliation(s)
- Bakey Kouanda
- Department of Medicine, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Zeeshan Sattar
- Department of Medicine, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
| | - Patrick Geraghty
- Department of Medicine, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
- Department of Cell Biology, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
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17
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Kedlaya MN, Ramesh A, Hosmane GB, Bhandary R, Sajna HR, Thomas B. Comparative evaluation of serum cotinine levels in chronic periodontitis and chronic obstructive pulmonary disease. J Indian Soc Periodontol 2021; 25:405-410. [PMID: 34667383 PMCID: PMC8452176 DOI: 10.4103/jisp.jisp_546_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 03/14/2021] [Accepted: 05/08/2021] [Indexed: 11/16/2022] Open
Abstract
Context: Periodontitis and chronic obstructive pulmonary disease (COPD) are chronic progressive inflammatory conditions. Smoking has been associated with both chronic periodontitis and COPD. Hence, the present study was designed to correlate serum levels of cotinine with the severity of periodontal disease with or without COPD. Settings and Design: A total of eighty patients, twenty healthy individuals, twenty patients with chronic generalized periodontitis without smoking and without COPD, twenty patients who are smokers with chronic periodontitis without COPD and twenty patients who are smokers with chronic periodontitis and COPD in the age range of 43–65 years were selected for the study. Subjects and Methods: Serum cotinine level assessment, smoking history, and periodontal examination were done in all the patients and the data obtained were statistically analyzed. Results: The mean serum cotinine level was highest in smokers with chronic periodontitis and COPD (93.642 ± 14.727) and it differed significantly between the four groups (P < 0.001). There is a significant positive correlation between the number of cigarettes and serum cotinine levels in both groups involving smoking. There was no significant correlation between serum cotinine level and clinical attachment loss in chronic periodontitis smokers with or without COPD. Conclusions: The result of this study indicates that increased smoking with COPD causes a higher chance of progression of periodontal destruction but it is not statistically significant. Furthermore, this study indicates that the assessment of serum cotinine levels is a reliable method to evaluate smoking exposure.
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Affiliation(s)
- Madhurya Nagaraj Kedlaya
- Department of Periodontology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Amitha Ramesh
- Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Nitte deemed to be University, Mangalore, Karnataka, India
| | - Giridhar Belur Hosmane
- Department of Pulmonary Medicine, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, Karnataka, India
| | - Rahul Bhandary
- Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Nitte deemed to be University, Mangalore, Karnataka, India
| | | | - Biju Thomas
- Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Nitte deemed to be University, Mangalore, Karnataka, India
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18
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Effect of periodontal therapy on COPD outcomes: a systematic review. BMC Pulm Med 2021; 21:92. [PMID: 33736634 PMCID: PMC7976708 DOI: 10.1186/s12890-021-01429-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/02/2021] [Indexed: 01/02/2023] Open
Abstract
Background Latest evidence suggests that periodontitis is prevalent among patients with chronic obstructive pulmonary disease (COPD), while recent studies have also reported a potential benefit of periodontal treatment on several COPD outcomes. This systematic review aims to determine the impact of periodontal treatment on exacerbation rate, lung function and quality of life of COPD patients. Methods A systematic search of electronic databases of PubMed, Scopus, Virtual Health Library, ScienceDirect, Wiley Online Library, Web of Science, ProQuest Dissertation and Theses Global and Google Scholar was conducted. Search restricted to studies involving human subjects which were published from January 2000 to March 2020 in English language. Distiller Systematic Review software was used for data management. Risk of bias was assessed using Risk of Bias 2 (RoB2) and Risk of Bias for non-randomized studies of intervention (ROBINS-I) tools. Overall quality of evidence was judged based on Grading of Recommendations Assessment, Development and Evaluation working group methodology. Results Out of 1442 articles retrieved, 7 full text articles were included in the review. Limited evidence suggests that periodontal treatment in patients with COPD and periodontitis is associated with reduced exacerbation frequency and a slower lung function decline rate, while its effects on quality of life remain unclear. In addition, periodontal treatment in COPD is associated with lower hospitalization rates and reduced all-cause mortality. Significant methodological differences were noted amongst included studies, while very low-to-moderate overall quality of evidence was demonstrated. Conclusions Although it is reasonable to advise COPD patients not to neglect their dental health, further studies are warranted to determine the role of periodontal therapy on COPD clinical outcomes. Trial Registration: PROSPERO 2020 (CRD42020158481). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020158481 Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01429-2.
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19
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Jung ES, Lee KH, Choi YY. Association between oral health status and chronic obstructive pulmonary disease in Korean adults. Int Dent J 2020; 70:208-213. [DOI: 10.1111/idj.12535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/29/2019] [Accepted: 10/02/2019] [Indexed: 12/31/2022] Open
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Dental problems and chronic diseases in mentally ill homeless adults: a cross-sectional study. BMC Public Health 2020; 20:419. [PMID: 32228526 PMCID: PMC7106680 DOI: 10.1186/s12889-020-08499-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Dental problems (DPs) and physical chronic diseases (CDs) are highly prevalent and incident in people with low socioeconomic status such as homeless individuals. Yet, evidence on the association between DPs and physical CDs in this population is limited. In the present study, we assessed the association between DPs and type and number of CDs in individuals experienced chronic homelessness and serious mental health problems. Methods We analyzed cross-sectional baseline data from 575 homeless adults with serious mental health problems participating in the Toronto site of the At Home/Chez Soi randomized controlled trial. Chronic DPs (lasting at least 6 months) were the primary exposure variable. Presence of self-reported CDs, including heart disease, effect of stroke, hypertension, diabetes, asthma, chronic bronchitis/emphysema, stomach or intestinal ulcer, inflammatory bowel disease, migraine, thyroid problems, arthritis, kidney/bladder problems, liver disease (other than hepatitis), and iron-deficiency anemia, were the primary outcomes. The total number of CDs was also analyzed as a secondary outcome. Logistic regression models were used to assess the association between DPs with each of the studied CDs, and negative binomial regression was used to test the association between DPs with the number of CDs. Results In our 575 homeless participants (68.5% males) with mean age 40.3 (11.8) years, a high proportion had DPs (42.5%). The presence of DPs was positively associated with heart disease (adjusted odds ratio (AOR):4.19,1.67–10.52), diabetes (AOR:2.17,1.13–4.17), chronic bronchitis (AOR:2.34,1.28–4.29), stomach or intestinal ulcer (AOR:3.48,1.80–6.73), inflammatory bowel disease (AOR:2.52,1.38–4.60), migraine (AOR:1.80,1.20–2.72), arthritis (AOR:2.71,1.71–4.29), kidney/bladder problems (AOR:2.43,1.30–4.54), and iron-deficiency anemia (AOR:3.28,1.90–5.65). DPs were also associated with a higher number of CDs (IRR: 1.62,1.38–1.90). Conclusion Dental health problems in homeless individuals with serious mental disorders are associated with several CDs. Dental care should be better integrated into existing social and health programs serving this population to improve their overall health status. The AH/CS study is registered with the International Standard Randomized Control Trial Number Register (ISRCTN42520374).
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21
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Yang L, Dunlap DG, Qin S, Fitch A, Li K, Koch CD, Nouraie M, DeSensi R, Ho KS, Martinson JJ, Methé B, Morris A. Alterations in Oral Microbiota in HIV Are Related to Decreased Pulmonary Function. Am J Respir Crit Care Med 2020; 201:445-457. [PMID: 31682463 PMCID: PMC7049920 DOI: 10.1164/rccm.201905-1016oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/29/2019] [Indexed: 12/23/2022] Open
Abstract
Rationale: Mechanisms of HIV-associated chronic obstructive pulmonary disease (COPD) are poorly understood. The oral microbiome shapes the lung microbiome, and gut dysbiosis can affect lung diseases; however, relationships of the oral and gut microbiome to COPD in HIV have not been explored.Objectives: To examine alterations in the oral and gut microbiome associated with pulmonary disease in persons with HIV (PWH).Methods: Seventy-five PWH and 93 HIV-uninfected men from the MACS (Multicenter AIDS Cohort Study) performed pulmonary function testing. Sequencing of bacterial 16S ribosomal RNA in saliva and stool was performed. We used nonmetric multidimensional scaling, permutational multivariate ANOVA, and linear discriminant analysis to analyze communities by HIV and lung function.Measurements and Main Results: Oral microbiome composition differed by HIV and smoking status. Alterations of oral microbial communities were observed in PWH with abnormal lung function with increases in relative abundance of Veillonella, Streptococcus, and Lactobacillus. There were no significant associations between the oral microbiome and lung function in HIV-uninfected individuals. No associations with HIV status or lung function were seen with the gut microbiome.Conclusions: Alterations of oral microbiota in PWH were related to impaired pulmonary function and to systemic inflammation. These results suggest that the oral microbiome may serve as a biomarker of lung function in HIV and that its disruption may contribute to COPD pathogenesis.
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Affiliation(s)
- Libing Yang
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Center for Medicine and the Microbiome, Department of Medicine
- School of Medicine, Tsinghua University, Beijing, China; and
| | | | - Shulin Qin
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Center for Medicine and the Microbiome, Department of Medicine
| | - Adam Fitch
- Center for Medicine and the Microbiome, Department of Medicine
| | - Kelvin Li
- Center for Medicine and the Microbiome, Department of Medicine
| | - Carl D. Koch
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Center for Medicine and the Microbiome, Department of Medicine
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine and
| | - Rebecca DeSensi
- Division of Pulmonary, Allergy and Critical Care Medicine and
| | - Ken S. Ho
- Division of Infectious Disease, Department of Medicine, and
| | - Jeremy J. Martinson
- Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Center for Medicine and the Microbiome, Department of Medicine
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine and
- Center for Medicine and the Microbiome, Department of Medicine
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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22
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Gomes-Filho IS, Cruz SSD, Trindade SC, Passos-Soares JDS, Carvalho-Filho PC, Figueiredo ACMG, Lyrio AO, Hintz AM, Pereira MG, Scannapieco F. Periodontitis and respiratory diseases: A systematic review with meta-analysis. Oral Dis 2019; 26:439-446. [PMID: 31715080 DOI: 10.1111/odi.13228] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis to evaluate the recent scientific literature addressing the association between periodontitis and asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. MATERIALS AND METHODS The search for studies was carried out using MEDLINE/PubMed, EMBASE, Lilacs, Web of Science, Scopus, and SciELO databases, including the gray literature (ProQuest). Reference lists of selected articles were also searched. Studies having varying epidemiological designs assessing the association between periodontitis and respiratory diseases in human subjects were eligible for inclusion. Three independent reviewers performed the selection of articles and data extraction. Fixed and random effects meta-analysis were performed for the calculation of the association measurements (Odds Ratio-OR) and 95% confidence intervals (95% CI). RESULTS A total of 3,234 records were identified in the database search, with only 13 studies meeting the eligibility criteria and 10 studies contributed data for meta-analysis. Using a random effects models periodontitis was associated with asthma: ORadjusted: 3.54 (95% CI: 2.47-5.07), I2 = 0%; with COPD: OR adjusted: 1.78 (95% CI: 1.04-3.05), I2 = 37.9%; and with pneumonia: OR adjusted: 3.21 (95% CI: 1.997-5.17), I2 = 0%. CONCLUSIONS The main findings of this systematic review validated an association between periodontitis and asthma, COPD and pneumonia.
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Affiliation(s)
| | - Simone Seixas da Cruz
- Department of Health, Feira de Santana State University, Bahia, Brazil.,Department of Epidemiology, Federal University of Recôncavo of Bahia, Bahia, Brazil
| | | | - Johelle de Santana Passos-Soares
- Department of Health, Feira de Santana State University, Bahia, Brazil.,Department of Preventive Dentistry, Federal University of Bahia, Salvador, Brazil
| | | | | | - Amanda Oliveira Lyrio
- Faculty of Health Sciences, University of Brasília, Brasília, Distrito Federal, Brazil
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Periodontal Pathogens as Risk Factors of Cardiovascular Diseases, Diabetes, Rheumatoid Arthritis, Cancer, and Chronic Obstructive Pulmonary Disease-Is There Cause for Consideration? Microorganisms 2019; 7:microorganisms7100424. [PMID: 31600905 PMCID: PMC6843669 DOI: 10.3390/microorganisms7100424] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/30/2022] Open
Abstract
Cardiovascular diseases, chronic obstructive pulmonary diseases, diabetes, rheumatoid arthritis, and cancer are the most common noncommunicable diseases (NCDs). These NCDs share risk factors with periodontal disease (PD), a preventable risk factor linked to lifestyle. The discussion regarding the association between these chronic diseases is more complex. There is still a significant knowledge gap particularly of the causal relationship between PD and NCDs. In this paper, we present fundamental knowledge of the mechanisms and roles of putative periodontal bacteria to gather several hypotheses, evidence that clinical studies thus far have not produced. Although the causal hypotheses are not yet clearly established on a biological basis, prevention and prophylactic measures are recommended to prevent even the possibility of such potential risk factors.
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24
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Qiao P, Shi Q, Zhang R, E L, Wang P, Wang J, Liu H. Psoriasis Patients Suffer From Worse Periodontal Status-A Meta-Analysis. Front Med (Lausanne) 2019; 6:212. [PMID: 31632975 PMCID: PMC6779717 DOI: 10.3389/fmed.2019.00212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/16/2019] [Indexed: 12/31/2022] Open
Abstract
Background and Objective: Patients with psoriasis have a significantly elevated risk of periodontitis compared with the nonpsoriasis controls. However, the data regarding the difference in the periodontal health status of the psoriasis patients and the nonpsoriasis controls are limited and inconsistent; hence, a specialized meta-analysis that quantitatively compared the periodontal status between the psoriasis and nonpsoriasis subjects by evaluating the related clinical periodontal indexes was needed. The aim of this meta-analysis was to quantitatively evaluate whether the periodontal status of psoriasis patients is worse than that of nonpsoriasis subjects. Methods: We searched PubMed and EMBASE for all eligible studies that compared the periodontal status between psoriasis patients and nonpsoriasis subjects. The studies were screened based on pre-established inclusion criteria. After extracting the available periodontal indexes from the included studies, the weighted mean difference (WMD) with 95% confidence intervals (CIs) was calculated by pooling the mean and standard deviations (SD) of each index. Results: In total, 8 studies, including 812 psoriasis patients and 772 nonpsoriasis subjects, were included in our meta-analysis, and the publication dates ranged from 2013 to 2019; eight periodontal indexes were analyzed. The WMD (95% CIs) for each index were: bleeding on probing (%), 9.188 (4.046–14.330, P < 0.001); probing depth (mm), 0.524 (0.183–0.865, P = 0.003); clinical attachment loss (mm), 0.408 (0.051–0.765, P = 0.025); plaque index, 0.186 (−0.170 to 0.543, P = 0.306); gingival index, 0.458 (−0.413 to 1.328, P = 0.303), remaining teeth, −1.709 (−2.106 to −1.312, P < 0.001); missing teeth, 1.130 (0.275–1.985, P = 0.010); the level of alveolar bone loss (mm), 0.400 (0.102–0.698, P = 0.008). Conclusion: In summary, our meta-analysis revealed that psoriasis patients suffer from worse periodontal health than do nonpsoriasis subjects, mainly characterized by worse gingival inflammation, more alveolar bone loss, fewer remaining teeth and more missing teeth. Considering the limitations of this meta-analysis, more high-quality and well-designed studies are needed to validate our conclusions in the future.
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Affiliation(s)
- Pengyan Qiao
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Quan Shi
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rong Zhang
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lingling E
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Peihuan Wang
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Juncheng Wang
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hongchen Liu
- Department of Stomatology, First Medical Center, Chinese PLA General Hospital, Beijing, China
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25
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Prevalence of Periodontitis and its Association with Reduced Pulmonary Function: Results from the Korean National Health and Nutrition Examination Survey. ACTA ACUST UNITED AC 2019; 55:medicina55090581. [PMID: 31510089 PMCID: PMC6780062 DOI: 10.3390/medicina55090581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/28/2019] [Accepted: 09/06/2019] [Indexed: 01/16/2023]
Abstract
Background and Objectives: The current study was performed to evaluate the prevalence of periodontitis and to examine the association between reduced pulmonary function and periodontitis using Sixth Korea National Health and Nutrition Examination Survey (KNHANES) in 2014. Materials and Methods: A cross-sectional evaluation was conducted to estimate the prevalence of periodontitis and to examine the association between periodontitis and reduced pulmonary function while adjusting for sociodemographic characteristics and current smoking status in survey participants between 40 and 79 years old. The presence of periodontitis was evaluated by community periodontal index defined by the World Health Organization, and the assessments of reduced pulmonary function data were made as “normal,” “restrictive impairment,” or “obstructive impairment.” Results: A total of 4004 survey participants representing 25.4 million Koreans were included in the study. Overall, 41.1% of the study population were determined to have periodontitis, and 22.1% had reduced pulmonary function; 7.9% and 14.2% had restrictive- and obstructive- pulmonary impairments, respectively. Age, male gender, and current smoking status were positive predictors for periodontitis. Insurance coverage by workplace and higher education were protective factors against periodontitis. The association between periodontitis and restrictive impairment (adjusted odds ratio (OR) = 1.059, 95% CI 0.729–1.540) or obstructive impairment (adjusted OR = 1.140, 95% CI 0.849–1.530) was not significant. Conclusions: For Koreans, 40–79 years old, age, smoking status, gender, education, and insurance coverage were significant predictors of periodontitis. The prevalence of periodontitis was not significantly associated with reduced pulmonary function. To better understand the relationship between periodontitis and reduced pulmonary function, well-designed and larger scale epidemiologic studies are needed.
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Lopez-de-Andrés A, Vazquez-Vazquez L, Martinez-Huedo MA, Hernández-Barrera V, Jimenez-Trujillo I, Tapias-Ledesma MA, de Miguel-Diez J, Jiménez-García R. Is COPD associated with periodontal disease? A population-based study in Spain. Int J Chron Obstruct Pulmon Dis 2018; 13:3435-3445. [PMID: 30425473 PMCID: PMC6203114 DOI: 10.2147/copd.s174898] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background Periodontal disease is more prevalent and more severe among men and women suffering from chronic obstructive pulmonary disease (COPD) compared with healthy adults. The objectives of this paper were to assess the association between periodontal disease and COPD, controlling the effect of sociodemographic characteristics, oral health status, lifestyle variables, and comorbidities. Second, we identified which of the variables analyzed were independently associated with periodontal disease among COPD sufferers. Methods This descriptive study was done with data from the National/European Health Interview Surveys, conducted in years 2006, 2011/12, and 2014 in Spain. We included subjects ≥40 years of age. COPD status was self-reported. One non-COPD patient was matched by age, gender, and the year of survey for each COPD case. The presence of periodontal disease was defined using the answers "my teeth bleed spontaneously or while brushing" or/and "my teeth move" to the question: "Do you suffer of any of these dental and oral disorders or diseases?" Independent variables included demographic, socioeconomic, and health care-related variables, oral health status, and presence of comorbidities. Results The prevalence of periodontal disease was higher among COPD patients than their matched non-COPD controls (26.5% vs 22.2%; P<0.001). Adjusted odds ratio (AOR) of periodontal disease for subjects with COPD was 1.21 (95% CI: 1.12-1.30). Suffering mental disorders (AOR: 1.61; 95% CI: 1.32-1.97) was positively associated with higher risk of periodontal disease. Older age, having a private dental health insurance, and university education were variables associated with lower rates of periodontal disease. Conclusion Prevalence of periodontal disease was higher among those with COPD compared to non-COPD controls. Dentists and physicians should increase their awareness with their COPD patients, especially those who are younger, with lower education, and suffer depression and/or anxiety.
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Affiliation(s)
- Ana Lopez-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain,
| | - Luis Vazquez-Vazquez
- Human Anatomy and Embryology Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain
| | | | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain,
| | - Isabel Jimenez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain,
| | - Miguel A Tapias-Ledesma
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain,
| | - Javier de Miguel-Diez
- Respiratory Department, Gregorio Marañon General University Hospital, Medical School, Complutense University, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, Spain,
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