Association between obstructive sleep apnea and comorbidities with periodontal disease in adults

Clinical and radiographic periodontal status in hypertensive patients with or without obstructive sleep apnea 10 years after diagnosis and CPAP initiation

OBJECTIVES

Through inflammation and hyposalivation, obstructive sleep apnea (OSA) is suggested to affect periodontal status over time. Our aim was to compare the clinical and radiographic periodontal status of hypertensive patients with or without long-term presence of OSA, treated or untreated with continuous positive airway pressure treatment (CPAP).

MATERIALS AND METHODS

In 2007-2009, a screening for OSA was conducted among 394 hypertensive primary care patients. Polygraphy was used to create three groups: no OSA, non-CPAP, or adherent CPAP based on the apnea hypopnea index (AHI). After 10 years, a cross-sectional sleep and periodontal examination including a clinical and radiographic examination, a questionnaire, and a matrix metalloproteinase-8 (MMP-8) chair-side test was conducted. Based on levels of alveolar bone, bleeding on probing (BoP), and probing pocket depth (PPD), patients were categorized into four periodontal stages: periodontal health/gingivitis and three periodontal disease stages. Periodontal status and periodontal stages were compared between the OSA (n = 49), non-CPAP (n = 38), or adherent CPAP (n = 34) groups.

RESULTS

The 121 patients (53% women) had a median age of 71 years. No differences were seen between the OSA groups regarding median number of teeth (p = .061), teeth/implants, (p = .107), plaque index (p = .245), BoP (p = .848), PPD ≥ 4 mm (p = .561), PPD ≥ 6 mm (p = .630), presence of MMP-8 (p = .693) except for bone loss (p = .011). Among patients with stage periodontal health/gingivitis a significant difference was seen, as 70% of those were categorized as no OSA, 20% as non-CPAP, and 10% as adherent CPAP (p = .029). Differences were not seen in periodontal disease stages.

CONCLUSIONS

Hypertensive patients with obstructive sleep apnea (OSA) did not have an adverse clinical periodontal status compared to patients without OSA. However, when combining radiographic and clinical status into periodontal stages, patients without OSA more frequently exhibited periodontal health or gingivitis compared to patients without OSA, regardless of CPAP treatment.

Relationship between periodontal disease and obstructive sleep apnea in adults: A systematic review

The purpose of this systematic review was to evaluate whether there are scientific evidence regarding the association between periodontitis and obstructive sleep apnea (OSA) in adults. An electronic search was performed on MEDLINE/PubMed for prospective and retrospective longitudinal studies, cohort studies, and case-control studies conducted in human adults affected by both OSA and periodontitis. Two reviewers extracted the data using a custom Excel spreadsheet. A methodological assessment of the quality of the studies was performed using the Newcastle-Ottawa Scale. Fourteen studies were included. All studies evaluated the association between periodontitis and OSA. None of the studies evaluated the cause-effect relationship. Eleven studies found a significant positive relationship between periodontitis and OSA, whereas three found no statistically significant association. Several study limitations were observed, such as lack of standardization of study groups, diagnosis of periodontitis and OSA, and differences in study design. Evidence of a plausible association between periodontitis and OSA was found. The possible relationship could be explained by systemic inflammation, oral breathing, and the comorbid relationship attributable to common risk factors. Observational and randomized controlled studies are needed to clarify the mechanism of interaction between the two conditions.

Genetically predicted obstructive sleep apnea is causally associated with an increased risk for periodontitis

BACKGROUND

Although obstructive sleep apnea (OSA) and periodontitis are associated, whether this association is causative is uncertain.

METHODS

We conducted a bidirectional Mendelian randomization (MR) analysis using data from publically accessible genome-wide association studies. The single-nucleotide polymorphisms (SNPs) for OSA were derived from 16,761 cases and 201,194 controls. The pooled data of periodontitis association involved up to 17,353 individuals. Disease-associated single-nucleotide polymorphisms were selected as an instrumental variable at the genome-wide significance level (p < 5.0 × 10- 6). Subsequently, the causal effects were estimated using three different methods: inverse variance weighting (IVW), MR-Egger, and weighted median. Then, these causal estimates were expressed as dominance ratios [odds ratio (OR)].

RESULTS

The MR analysis revealed that genetically determined OSA promotes the development of periodontitis [ IVW OR = 1.117, 95% confidence interval (CI) = 1.001-1.246, p = 0.048). Furthermore, no causal effect of genetically predicted periodontitis on OSA was noted in the reverse MR analysis (IVW OR = 1, 95% CI: 0.95-1.06, p = 0.87). The trend in results from the MR-Egger regression and weighted median (WM) was consistent with that in results from the IVW method. The robustness of the results was confirmed by the sensitivity analysis.

CONCLUSIONS

In summary, the results of our MR investigation suggest an association between OSA and periodontitis, proposing that early screening and treatment of OSA is beneficial for the prevention and prognosis of periodontitis.

Relationship of obstructive sleep apnea with periodontal condition and its local and systemic risk factors

OBJECTIVE

Obstructive sleep apnea (OSA) and periodontitis share risk factors, such as age, obesity, stress, and cardiovascular events, which have a bidirectional cause-effect relationship through systemic inflammation. Our objective was to determine the relationship between OSA and the periodontal condition and its associated local and systemic risk factors.

MATERIAL AND METHODS

This was an observational case-control study involving 60 patients. Local oral risk factors and the systemic condition of each patient were evaluated. All patients underwent polysomnography for the diagnosis of OSA. Chi-squared, one-way ANOVA, and Bonferroni's tests were performed.

RESULTS

A higher percentage of patients with periodontitis had severe OSA (66.66%); however, no statistically significant association was found between the two pathologies (p = 0.290). In terms of systemic risk factors, an association was found between arterial hypertension and severe OSA (p = 0.038), and in terms of local factors, an association was found between the use of removable prostheses and severe OSA (p = 0.0273).

CONCLUSION

In the general population, patients with periodontitis showed a higher prevalence of severe OSA. Obesity and hypothyroidism were the most prevalent systemic findings in patients with OSA and periodontitis. Arterial hypertension and osteoarthritis were found to be associated with severe OSA. The local risk factors associated with periodontitis and severe OSA were removable partial dentures and misfit resins.

CLINICAL RELEVANCE

To study the factors that can facilitate the progression of OSA and periodontitis, physicians and dentists should be advised to provide comprehensive care for patients with both pathologies.

Association between sleep-disordered breathing and periodontitis: a meta-analysis

BACKGROUND

Systemic inflammation is a feature of sleep-disordered breathing (SDB) as well as periodontitis. The association between SDB and periodontitis, however, has been inconsistent in previous studies. In order to fully evaluate the above association, we conducted a meta-analysis.

MATERIAL AND METHODS

Observational studies related to the aim of the meta-analysis were identified by search of PubMed, Embase, Web of Science, Wanfang, and CNKI databases. Only studies with SDB diagnosed with the objective polysomnography examination were included. The results were analyzed using a random-effects model that incorporated potential heterogeneity between studies.

RESULTS

Ten cross-sectional or case-control studies with 43,296 participants contributed to the meta-analysis. Pooled results showed that SDB was significantly associated with periodontitis (odds ratio [OR]: 1.83, 95% confidence interval [CI]: 1.52 to 2.20, I2 = 40%, p < 0.001). Sensitivity analysis showed consistent association for severe periodontitis (OR: 1.39, 95% CI: 1.20 to 1.61, I2 = 0%, p < 0.001). Subgroup analyses showed consistent results in patients with mild (OR: 1.66, p < 0.001), moderate (OR: 2.23, p = 0.009), and severe SDB (OR: 2.66, p < 0.001). Moreover, the association between SDB and periodontitis was consistent in Asian and non-Asian studies, in cross-sectional and case-control studies, in studies with univariate and multivariate regression models, and in studies with different quality scores (p for subgroup effects all < 0.05).

CONCLUSIONS

Polysomnography confirmed diagnosis of SDB is associated with periodontitis in adult population.

Biomarkers for the severity of periodontal disease in patients with obstructive sleep apnea:IL-1 β, IL-6, IL-17A, and IL-33

Objective

This study aims to compare the salivary and gingival crevicular fluid (GCF) concentrations of five cytokines: IL-1β, IL-6, IL-17A, IL-33, and Tumor Necrosis Factor-alpha (TNF-α) in patients with OSA and their association with periodontitis.

Methods

Samples of saliva and GCF were obtained from 84 patients classified into four groups according to periodontal and OSA diagnosis: G1(H) healthy patients, G2(P) periodontitis and non-OSA patients, G3(OSA) OSA and non-periodontitis patients, and G4(P-OSA) periodontitis and OSA patients. The cytokines in the samples were quantified using multiplexed bead immunoassays. Data were analyzed with the Kruskal-Wallis test, Dunn's multiple comparisons test, and the Spearman correlation test.

Results

Stage III periodontitis was the highest in patients with severe OSA (69%; p=0.0142). Similar levels of IL-1β and IL-6 in saliva were noted in G2(P) and G4(P-OSA). The IL-6, IL-17A and IL-33 levels were higher in the GCF of G4(P-OSA). There was a significant positive correlation between IL-33 in saliva and stage IV periodontitis in G4(P-OSA) (r _s  = 0.531). The cytokine profile of the patients in G4(P-OSA) with Candida spp. had an increase of the cytokine's levels compared to patients who did not have the yeast.

Conclusions

OSA may increase the risk of developing periodontitis due to increase of IL-1β and IL-6 in saliva and IL-6, IL-17A and IL-33 in GCF that share the activation of the osteoclastogenesis. Those cytokines may be considered as biomarkers of OSA and periodontitis.

Patients with obstructive sleep apnea can favor the predisposing factors of periodontitis by the presence of P. melaninogenica and C. albicans, increasing the severity of the periodontal disease

Objective

The aim of this study was to analyze the cultivable oral microbiota of patients with obstructive sleep apnea (OSA) and its association with the periodontal condition.

Methods

The epidemiology profile of patients and their clinical oral characteristics were determined. The microbiota was collected from saliva, subgingival plaque, and gingival sulcus of 93 patients classified into four groups according to the periodontal and clinical diagnosis: Group 1 (n = 25), healthy patients; Group 2 (n = 17), patients with periodontitis and without OSA; Group 3 (n = 19), patients with OSA and without periodontitis; and Group 4 (n = 32), patients with periodontitis and OSA. Microbiological samples were cultured, classified, characterized macroscopically and microscopically, and identified by MALDI-TOF-MS. The distribution of complexes and categories of microorganisms and correlations were established for inter- and intra-group of patients and statistically evaluated using the Spearman r test (p-value <0.5) and a multidimensional grouping analysis.

Result

There was no evidence between the severity of OSA and periodontitis (p = 0.2813). However, there is a relationship between the stage of periodontitis and OSA (p = 0.0157), with stage III periodontitis being the one with the highest presence in patients with severe OSA (prevalence of 75%; p = 0.0157), with more cases in men. The greatest distribution of the complexes and categories was found in oral samples of patients with periodontitis and OSA (Group 4 P-OSA); even Candida spp. were more prevalent in these patients. Periodontitis and OSA are associated with comorbidities and oral conditions, and the microorganisms of the orange and red complexes participate in this association. The formation of the dysbiotic biofilm was mainly related to the presence of these complexes in association with Candida spp.

Conclusion

Periodontopathogenic bacteria of the orange complex, such as Prevotella melaninogenica, and the yeast Candida albicans, altered the cultivable oral microbiota of patients with periodontitis and OSA in terms of diversity, possibly increasing the severity of periodontal disease. The link between yeasts and periodontopathogenic bacteria could help explain why people with severe OSA have such a high risk of stage III periodontitis. Antimicrobial approaches for treating periodontitis in individuals with OSA could be investigated in vitro using polymicrobial biofilms, according to our findings.

Incidence and risk of periodontitis in obstructive sleep apnea: A meta-analysis

Introduction

At present, the possible relationship between obstructive sleep apnea and periodontitis has been reported. The link remains ambiguous and unclear. The objective of this study is to assess the association between OSA and periodontitis.

Methods

Three databases, including Pubmed, Embase, and the Web of Science, were systematically searched to identify eligible studies that from their establishment to February 2022 for relevant studies. Subsequently, a meta-analysis was conducted to determine the relationship of pooled-effects more accurately.

Results

A summary analysis of the 9 results from the studies covering 43,414 individuals showed a statistical association results of the between OSA and the incidence rate of periodontitis(OR = 0.52; 95% CI: 0.49–0.55; I² = 98.43%; P = 0.000). In addition, OSA patients and the risk of the population were statistically significantly associated with an increased risk of periodontitis.(OR = 1.56; 95% CI: 1.06–2.06; P = 0.00).

Conclusions

Our results indicated that OSA may be associated with an increased risk of periodontitis. Further studies are required to confirm the link and explore the underlying mechanism of the link.

Periodontitis severity in obstructive sleep apnea patients

OBJECTIVES

This cross-sectional study investigated the stages of periodontitis in obstructive sleep apnea (OSA) patients and risk factors associated with periodontitis severity among them.

MATERIALS AND METHODS

A total of 194 patients underwent a polysomnography/polygraphy and were referred to periodontal examination. According to apnea-hypopnea index (AHI), patients were classified as mild OSA (AHI < 15) and moderate to severe OSA (AHI ≥ 15), whereas periodontitis severity was determined by the clinical attachment level (CAL) according to the recent Classification of Periodontal Diseases and Conditions. Patients were grouped into two categories: stages 1 and 2, and stages 3 and 4.

RESULTS

Higher AHI values were reported in OSA patients exhibiting periodontitis stages 3 and 4 compared to OSA patients with periodontitis stages 1 and 2 (p = 0.043) and the non-periodontitis group (p = 0.044). A positive correlation was found between AHI and mean CAL (r = 0.215; p = 0.004), and between AHI and plaque scores (r = 0.292; p < 0.001). Following a multivariable regression analysis, AHI was a significant predictor of mean CAL (β = 0.169; p = 0.031), explaining 16.4% of variability in mean CAL (adjusted R² = 0.164; p < 0.001). Older patients had higher odds for an increased mean CAL (β = 0.266; p = 0.001), as well as patients smoking or formerly smoking (β = 0.305; p < 0.001) whereas visiting a dental medicine doctor once a year or more often was associated with a decreased mean CAL (β =  - 0.182; p = 0.02).

CONCLUSIONS

OSA was associated with severe stages of periodontitis along with increased age, smoking, low frequency of dental visits, and poor oral hygiene.

CLINICAL RELEVANCE

Screening for periodontitis is recommended for patients with more severe forms of OSA.

Obstructive Sleep Apnea and Periodontal Disease: A Systematic Review

Background and Objectives: The objective of this study was to evaluate the association between periodontal disease and obstructive sleep apnea syndrome (OSAS). Materials and Methods: Electronic search using PubMed, Scopus, LILACS, and Cochrane library was carried out for randomized controlled trials, cohort, case-control, longitudinal and epidemiological studies on humans published from January 2009 until September 2020. The participants had to be male and female adults who were diagnosed with OSAS either by overnight polysomnography (carried out at a sleep laboratory or at home) or by a home sleep testing monitor (Apnea Risk Evaluation System). Methodological quality assessment was carried out using the Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies while an adapted form of NOS was used for cross-sectional studies. Results: Ten studies fulfilled the inclusion criteria of our review, 5 were case-control studies, and 5 cross-sectional. Sample size ranged from 50 to 29,284 subjects, for a total of 43,122 subjects, 56% of them were male, their age ranged from 18 to 85 years old. The heterogeneity among the studies regarding the classification of periodontal disease, and the different methods for OSAS severity assessment, complicated the comparison among the studies. Conclusions: There is low evidence of a possible association between OSAS and periodontitis. The pathophysiological mechanism, cause-effect, or dose-response relationship are still unclear. Further studies are needed and should use a precise classification of OSAS subjects, while the new classification of periodontitis from the World Workshop of Chicago 2017 should be used for the periodontal assessment.

Deep Neck Infection Risk in Patients with Sleep Apnea: Real-World Evidence

(1) Background: Sleep apnea may be a risk factor for deep neck infection (DNI). The objective of this study was to investigate the effects of sleep apnea on DNI. (2) Methods: In this first nationwide retrospective cohort study on the sleep apnea–DNI correlation, we obtained data from the Longitudinal Health Insurance Database 2005, a subset of the Taiwan National Health Insurance Research Database. Patients who were newly diagnosed with sleep apnea between 1997 and 2012 were identified, and patients without sleep apnea were matched at a 1:4 ratio in age, sex, socioeconomic status, and urbanization level. The primary outcome of this study was DNI occurrence. The treatment modalities for sleep apnea and the comorbidities that occurred during the study period were also analyzed. (3) Results: Our sleep apnea and comparison (non-sleep apnea) cohorts comprised 6114 and 24,456 patients, respectively. We compared the cumulative incidence of DNI between these cohorts and found a greater incidence of DNI in the sleep apnea cohort (p < 0.001). A strong sleep apnea–DNI association was found following analysis via the adjusted Cox proportional-hazards model (full model hazard ratio, 1.71; 95% confidence interval, 1.28–2.28; p < 0.001). In the subgroup analysis, sleep apnea increased DNI risk in men, in those aged < 50 years, and in those without diabetes mellitus, end-stage renal disease, liver cirrhosis, autoimmune disease, obesity, tonsillectomy, or adenotonsillectomy. (4) Conclusions: Our results confirmed sleep apnea to be an independent risk factor for DNI. Physicians should be aware of the potential occurrence of DNI in patients with sleep apnea.

Periodontal disease, sleep duration, and white blood cell markers in the 2009 to 2014 National Health and Nutrition Examination Surveys

BACKGROUND

Elevated levels of inflammatory biomarkers are consistently associated with chronic conditions, for which periodontitis and sleep are established risk factors. We examined the relationships between periodontitis, hours of sleep and white blood cell (WBC) markers among a nationally representative sample of US adults.

METHODS

Cross-sectional study using existing demographic, examination, laboratory and questionnaire data on 11,813 participants (5,814 men and 5,999 women, mean age ± SE; range: 52.74 ± 0.24; 30 to 80 years) from the 2009 to 2014 National Health and Nutrition Examination Surveys. Unadjusted, sex- and age-adjusted, as well as fully adjusted linear and logistic regression models were conducted in addition to generalized structural equations models, while considering sampling design complexity. β, odds ratios with their 95% confidence intervals, indirect effects and mediation proportions were estimated.

RESULTS

The weighted mean WBC count was 7,130 cells/µL, with the WBC 5-part differential estimated in terms of percentages of lymphocytes (29.50%), monocytes (7.99%), neutrophils (59.03%), eosinophils (2.84%), and basophils (71.88%). Furthermore, 36.2% of participants reported <7 hours of sleep and 49.8% had periodontitis. In fully adjusted models controlling for sociodemographic, lifestyle, and health characteristics, neither WBC markers nor periodontitis were related to hours of sleep. By contrast, periodontitis was directly related to WBC count and %neutrophils and inversely related to %lymphocytes, especially among men. However, the relationship of periodontitis with %neutrophils and %lymphocytes may be modified by hours of sleep, as it was specific to individuals reporting ≥7 hours of sleep.

CONCLUSION

Periodontitis may be directly related to WBC count and %neutrophils and inversely related to %lymphocytes, especially among men and individuals reporting ≥7 hours of sleep, with implications for primary and secondary prevention.

Impact of Habitual Snoring on Subjective Dental Esthetics in University Population

OBJECTIVE

The aims of this study were to assess the prevalence of snoring in the University population and to test the null hypothesis that there is no impact of habitual snoring on the self-perceived of dental esthetics.

MATERIALS AND METHODS

Berlin Questionnaire and esthetic component of the index of orthodontic treatment need was given to 700 students and employees aged 17-59 years (22 ± 4.5). Both snorers and nonsnorers were assessed for orthodontic treatment need. Chi-square and Student t-test were used to compare the difference between both groups using SPSS Statistics for Windows, Version 23.0. (IBM Corp, Armonk, NY).

RESULTS

The prevalence of snoring was 19.2% (male 11.8% and female 7.4%). Nodded off or fall asleep during driving a car or while waiting at least twice a month were reported in 46%. The prevalence of tiredness and fatigue after sleep from 3 to 4 times a week was 36.9% and during the working time was 33.6%. Based on the Berlin Questionnaire stratification for risk of obstructive sleep apnea (OSA), 8.2% were considered as a high-risk patient for OSA, (males: 3.8% and females: 4.4%). About 38.3% of the participants with habitual snoring have gone through orthodontic treatment, while only 28.5% of nonsnoring participant have done that. About 12.3% of snoring participant consider themselves in need of orthodontic treatment compared to 6.6% of a nonsnoring participant (P < 0.04).

CONCLUSION

The null hypothesis is rejected; snoring has an impact on the self-perceived of dental esthetics. Snoring participant seeks orthodontic treatment more than the nonsnoring participant in our University population.