Periodontal health improves systemic inflammatory and haemostatic status in subjects with coronary heart disease

The Dynamics of Oxidized LDL during Atherogenesis

Accumulating evidence indicates that oxidized low-density lipoprotein (OxLDL) is a useful marker for cardiovascular disease. The uptake of OxLDL by scavenger receptors leads to the accumulation of cholesterol within the foam cells of atherosclerotic lesions. OxLDL has many stimulatory effects on vascular cells, and the presence of OxLDL in circulating blood has been established. According to the classical hypothesis, OxLDL accumulates in the atherosclerotic lesions over a long duration, leading to advanced lesions. However, recent studies on time-course changes of OxLDL in vivo raised a possibility that OxLDL can be transferred between the lesions and the circulation. In this paper, the in vivo dynamics of OxLDL are discussed.

Trimeric form of intracellular ATP synthase subunit β of Aggregatibacter actinomycetemcomitans binds human interleukin-1β

Bacterial biofilms resist host defenses and antibiotics partly because of their decreased metabolism. Some bacteria use proinflammatory cytokines, such as interleukin (IL)-1β, as cues to promote biofilm formation and to alter virulence. Although one potential bacterial IL-1β receptor has been identified, current knowledge of the bacterial IL-1β sensing mechanism is limited. In chronic biofilm infection, periodontitis, Aggregatibacter actinomycetemcomitans requires tight adherence (tad)-locus to form biofilms, and tissue destroying active lesions contain more IL-1β than inactive ones. The effect of IL-1β on the metabolic activity of A. actinomycetemcomitans biofilm was tested using alamarBlue™. The binding of IL-1β to A. actinomycetemcomitans cells was investigated using transmission electron microscopy and flow cytometry. To identify the proteins which interacted with IL-1β, different protein fractions from A. actinomycetemcomitans were run in native-PAGE and blotted using biotinylated IL-1β and avidin-HRP, and identified using mass spectroscopy. We show that although IL-1β slightly increases the biofilm formation of A. actinomycetemcomitans, it reduces the metabolic activity of the biofilm. A similar reduction was observed with all tad-locus mutants except the secretin mutant, although all tested mutant strains as well as wild type strains bound IL-1β. Our results suggest that IL-1β might be transported into the A. actinomycetemcomitans cells, and the trimeric form of intracellular ATP synthase subunit β interacted with IL-1β, possibly explaining the decreased metabolic activity. Because ATP synthase is highly conserved, it might universally enhance biofilm resistance to host defense by binding IL-1β during inflammation.

Novel Endothelial Biomarkers: Implications for Periodontal Disease and CVD

Endothelial cells are actively involved in various aspects of vascular biology and different stages of atherosclerosis. Endothelial function is increasingly used as an important outcome measure in cardiovascular research. Endothelial progenitor cells (EPCs) are closely linked to endothelial function, and their biomarkers have received much attention. EPCs may not only serve as a pool of progenitor cells and possess the capacity to repair the damaged vasculature, but also act as potent effectors in systemic inflammation, suggesting that EPCs may play a critical role in maintaining endothelial function and the progression of cardiovascular disease (CVD). Emerging evidence shows an association of periodontal infections (gingivitis and periodontitis) with endothelial dysfunction, while the relevant mechanisms remain unknown. Our recent finding of the association of periodontitis with EPCs warrants their utilization as additional biomarkers in future studies on periodontal medicine. This review starts with a brief account on the current understanding of the nature of periodontal infections and their link with systemic inflammation and endothelial dysfunction. The paper also provides an update on endothelial biology and function as well as the novel biomarkers of EPCs and concludes with clinical studies on periodontal diseases and CVD.

Chronic periodontitis and C-reactive protein levels

BACKGROUND

This study aims to analyze the relationship between chronic periodontitis and C-reactive protein (CRP) by considering associated variables in individuals with or without cardiovascular disease.

METHODS

A sample of 359 individuals of both sexes (aged ≥40 years) was assessed. Among these individuals, 144 subjects were admitted to the hospital because of a first occurrence of acute myocardial infarction; 80 subjects were in the hospital for reasons other than acute myocardial infarction; and 135 subjects were living in the community. A questionnaire was applied to obtain demographic and lifestyle characteristics. Complete clinical periodontal examinations and anthropometric assessments were performed. CRP levels, plasma glucose levels, lipid profiles, and blood tests were performed to investigate any conditions that might have suggested infection and/or inflammation. CRP evaluations were performed using nephelometry. Individuals were considered to have periodontal disease if they simultaneously presented at least four teeth with one or more sites with probing depth ≥4 mm, clinical attachment loss ≥3 mm, and bleeding on probing. Procedures for descriptive analyses and logistic regression were used.

RESULTS

In the chronic periodontitis group, mean CRP levels were higher than those in the group without chronic periodontitis (2.6 ± 2.6 mg/L versus 1.78 ± 2.7 mg/L, respectively). The final model showed that individuals with chronic periodontitis were more likely to have high CRP levels (adjusted odds ratio: 2.26; 95% confidence interval: 1.30 to 3.93) considering the effects of age, schooling level, sex, smoking, high-density lipoprotein cholesterol, and diabetes.

CONCLUSION

In this study, chronic periodontitis is associated with elevated plasma CRP levels, even after controlling for several potential confounders.

A systematic review of the effectiveness of oral health promotion activities among patients with cardiovascular disease

AIMS

This study aimed to review the effectiveness of oral health promotion activities conducted among patients with cardiovascular disease.

METHODS AND RESULTS

Three electronic databases were searched for effective papers using standardized search methods, and key findings of effective studies were summarized. The initial search yielded 3101 papers but only 8 studies met the criteria for this review: 3 were randomized controlled studies, 3 were pre-/post group interventions, 1 was a randomized split-mouth study, and 1 was a quasi-experimental study. Studies retrieved concerned oral health promotion activities in patients with coronary heart disease, hypertension, heart transplantation, and stroke. Interventions comprised periodontal treatment performed by dental personnel, and oral hygiene interventions provided by nursing home care assistants. Outcomes included improvements in periodontal health, and modifications of systemic inflammatory markers. No studies, however, evaluated the effects of oral health promotion interventions on oral microflora.

CONCLUSION

There are limited studies on the efficacy of oral health promotion activities in patients with cardiovascular disease, particularly stroke patients. Oral health promotion activities appear to produce improvements in periodontal health, and also result in changes to systemic markers of inflammation and endothelial function (at least) in the short term. Whether these effects can ultimately lower the risk of secondary cardiovascular events has not yet been determined.

Lipoproteins and lipoprotein metabolism in periodontal disease

A growing body of evidence indicates that the incidence of atherosclerosis is increased in subjects with periodontitis - a chronic infection of the oral cavity. This article summarizes the evidence that suggests periodontitis shifts the lipoprotein profile to be more proatherogenic. LDL-C is elevated in periodontitis and most studies indicate that triglyceride levels are also increased. By contrast, antiatherogenic HDL tends to be low in periodontitis. Periodontal therapy tends to shift lipoprotein levels to a healthier profile and also reduces subclinical indices of atherosclerosis. In summary, periodontal disease alters lipoprotein metabolism in ways that could promote atherosclerosis and cardiovascular disease.

Metabolic syndrome, insulin resistance, and periodontitis: a cross-sectional study in a middle-aged French population

AIM

Metabolic syndrome consists of a cluster of clinical and biological abnormalities, influenced by insulin resistance and promoting cardiovascular diseases. We examined the relationships between metabolic syndrome, its various components, insulin resistance, and periodontitis.

MATERIALS AND METHODS

The study included 276 subjects (35-74 years) recruited within a cross-sectional survey on cardiovascular risk factors. Twenty-one were excluded because of infectious risk or total tooth loss. Clinical attachment loss (CAL), probing pocket depth (PD), gingival and plaque indexes were recorded. Periodontitis was classified into moderate and severe forms.

RESULTS

The mean age was 58, 41% of the subjects had moderate and 39% had severe periodontitis. In univariate comparisons, periodontitis was associated with metabolic syndrome (p=0.050), most of its components, and HOMA index (homoeostasis model assessment of insulin resistance). After adjustment for confounders, only HOMA index remained associated with severe periodontitis (odds ratio [OR]=3.97 [95% confidence interval: 1.22-12.9], OR=3.78 [1.14-12.5] for third and fourth versus the first quartile of the HOMA index, respectively). The HOMA index was also associated with the number of periodontal sites with CAL>or=4 mm, CAL>or=5 mm, or PD>or=4 mm (greater number for higher HOMA-index values). This relationship disappeared in never-smokers.

CONCLUSIONS

Our data support the relationships between metabolic disturbances and periodontitis, with a central role of insulin resistance.

Oxidized low-density lipoprotein increases interleukin-8 production in human gingival epithelial cell line Ca9-22

BACKGROUND AND OBJECTIVE

Recent epidemiological studies have shown a correlation between periodontitis and hyperlipidemia. We have found high levels of oxidized low-density lipoprotein (OxLDL) in the gingival crevicular fluid of dental patients. In the present study, we tried to examine the possible role of OxLDL in periodontal inflammation in vitro.

MATERIAL AND METHODS

Cells of the human gingival epithelial cell line Ca9-22 were cultured in media containing OxLDL, and the amounts of interleukin-8 (IL-8) and prostaglandin E(2) (PGE(2)) produced were measured using ELISAs.

RESULTS

Production of IL-8 by Ca9-22 cells was significantly increased when the cells were treated with OxLDL, but not with native LDL or acetylated LDL. Production of PGE(2) by Ca9-22 cells was enhanced by co-incubation with OxLDL and interleukin-1 beta (IL-1 beta). Scavenger receptor inhibitors, fucoidan and dextran sulfate, inhibited the OxLDL-induced IL-8 and PGE(2) production in the presence of IL-1 beta. The p(38) MAPK inhibitors SB203580 and SB202190 and the ERK inhibitor PD98059 inhibited the OxLDL-induced IL-8 production. Among oxidized lipids and chemically modified LDL, 7-ketocholesterol enhanced IL-8 production.

CONCLUSION

This is the first report to show that OxLDL enhances IL-8 production in epithelial cells.

Non-surgical periodontal therapy lowers serum inflammatory markers: a pilot study

BACKGROUND

Evidence suggests an association between periodontal disease and coronary heart disease (CHD). C-reactive protein (CRP), fibrinogen, and white blood cell (WBC) counts are markers of inflammation, and their systemic levels have been associated with CHD risk. This pilot study investigated the effect of non-surgical periodontal therapy on systemic levels of CRP, fibrinogen, and WBC counts in subjects with CHD or no CHD (NCHD).

METHODS

Twenty-seven angiographically defined patients with CHD and 18 subjects with NCHD aged >or=40 years were recruited for the study. Periodontal disease was measured through the clinical parameters bleeding on probing (BOP) and probing depth (PD). All subjects received non-surgical periodontal therapy that included oral hygiene instructions and subgingival scaling and root planing. Systemic levels of inflammatory markers (CRP, fibrinogen, and WBC counts) were measured prior to and 1 month after periodontal therapy.

RESULTS

Seventeen subjects with CHD and 11 subjects with NCHD completed the study. Subjects with CHD or NCHD experienced significant reductions in BOP (59% and 34%, respectively; P <0.05) and PD (41% and 35%, respectively; P <0.05), with non-significant intergroup differences (P >0.05). In all subjects, CRP, fibrinogen, and WBC counts were reduced significantly (21% to 40%) after periodontal therapy (P <0.05).

CONCLUSIONS

Periodontal treatment resulted in significant decreases in BOP and PD and lowered serum inflammatory markers in patients with CHD or NCHD. This may result in a decreased risk for CHD in the treated patients. These findings will allow pursuit of a large-scale randomized intervention trial in this population.

Increased levels of circulating endothelial progenitor cells in subjects with moderate to severe chronic periodontitis

AIM

Emerging evidence shows that periodontal disease is associated with endothelial dysfunction. The purpose of this study was to determine the association between chronic periodontitis (CP) and circulating endothelial progenitor cells (EPC).

MATERIALS AND METHODS

Eighty-six non-smoking subjects (36 males and 50 females, aged 35-80 years) were recruited, including 23 subjects with no or mild CP and 63 subjects with moderate to severe CP. The levels of circulating EPC were quantitatively determined by fluorescence-activated cell analysis, including CD34+/kinase insert domain-containing receptor (KDR)+ (more mature EPC) and CD133+/KDR+ (less mature EPC). Periodontal conditions, the intima-media thickness of carotid arteries and circulating biomarkers were examined.

RESULTS

Subjects with moderate to severe CP exhibited an increased risk of high EPC count, compared with those with no or mild CP: CD34+/KDR+ EPC [odds ratio (OR)=9.5, 95% confidence interval (95% CI) 1.5-61.0, p=0.018; CD133+/KDR+ EPC, OR=4.6, 95% CI 1.1-19.5, p=0.039]. C-reactive protein was significantly associated with high CD34+/KDR+ EPC count and age was inversely related with high EPC count. Age, gender and CD34+/KDR+ EPC were independent variables of increased carotid intima-media thickness (p<0.05).

CONCLUSION

This study shows for the first time that moderate to severe CP is associated with an increased level of circulating EPC.

Detection of oxidized low-density lipoproteins in gingival crevicular fluid from dental patients

BACKGROUND AND OBJECTIVE

Oxidative modification of low-density lipoprotein (LDL) occurs in various diseased tissues and sites of local inflammation. For example, an increased plasma oxidized low-density lipoprotein (OxLDL) level is a well-known risk marker for cardiovascular diseases. Gingival crevicular fluid, the exudate from gingival tissues into the sulci, can be easily collected in a non-invasive manner. However, the possible presence of OxLDL in gingival crevicular fluid has not been studied. In this study, we established a procedure to measure OxLDL in human gingival crevicular fluid.

MATERIAL AND METHODS

Human gingival crevicular fluid was sampled with paper points or paper strips. The gingival crevicular fluid samples from healthy gingival sulci (pocket depth < 4 mm, n = 14) were subjected to western blot and/or sandwich ELISA. The amounts of OxLDL and LDL were measured by sandwich ELISA using an anti-oxidized phosphatidylcholine monoclonal antibody and two anti-apolipoprotein B antibodies. Venous blood samples were analyzed biochemically.

RESULTS

We tested two methods of gingival crevicular fluid collection, namely paper points and paper strips. Gingival crevicular fluid could be collected very safely with paper points and they showed good recovery of LDL and OxLDL throughout the analysis. Apolipoprotein B, the major protein component in LDL, was detected in gingival crevicular fluid by western blot, and OxLDL was found to be present in gingival crevicular fluid by ELISA. The OxLDL/LDL ratio in gingival crevicular fluid was 17.0 times higher than that in plasma.

CONCLUSION

This is the first report to show the presence of apolipoprotein B and apolipoprotein B- oxidized phosphatidylcholine complex, which correspond to LDL and OxLDL, respectively, in gingival crevicular fluid.

Diet and lifestyle measures to protect the ageing heart

Coronary heart disease (CHD) is a leading cause of mortality and morbidity in the UK and risk increases substantially with age. It is estimated that more than 1 in 3 men and around 1 in 4 women aged 75 and over is currently living with the condition. Evidence from epidemiologic studies indicates that the same factors that are associated with increased risk of CHD in middle-aged people are relevant in older adults. Clinical trials have shown that changing these risk factors in older adults can reduce CHD risk as effectively as it does in middle-aged adults. A diet that is low in fat (particularly saturates), rich in carbohydrate (particularly whole-grains), contains plenty of fruits and vegetables, and a portion of oily fish each week and is not too high in salt can offer significant protection against heart disease. Such diets, together with regular physical activity, avoidance of smoking, sensible drinking habits and maintenance of a healthy body weight, may prevent the majority of cardiovascular disease in Western populations. The greatest benefit will be achieved by adopting these habits throughout the life-course.

Periodontal therapy reduces plasma levels of interleukin-6, C-reactive protein, and fibrinogen in patients with severe periodontitis and refractory arterial hypertension

BACKGROUND

Recent epidemiologic studies suggest that inflammation is the link between periodontal diseases and cardiovascular complications. This study aimed to evaluate the effects of non-surgical periodontal treatment on plasma levels of inflammatory markers (interleukin [IL]-6, C-reactive protein [CRP], and fibrinogen) in patients with severe periodontitis and refractory arterial hypertension.

METHODS

Twenty-two patients were examined and randomly divided into two groups. The test group was composed of 11 patients (mean age, 48.9 +/- 3.9 years) who received periodontal treatment, whereas the control group had 11 patients (mean age, 49.7 +/- 6.0 years) whose treatment was delayed for 3 months. Demographic and clinical periodontal data were collected, and blood tests were performed to measure the levels of IL-6, CRP, and fibrinogen at baseline and 3 months later.

RESULTS

The clinical results showed that the mean percentages of sites with bleeding on probing, probing depth (PD) 4 to 5 mm, PD > or =6 mm, clinical attachment loss (CAL) 4 to 5 mm, and CAL > or =6 mm were significantly reduced in the test group 3 months after periodontal treatment. There were no significant differences between the data at baseline and 3 months in the control group. Periodontal treatment significantly reduced the blood levels of fibrinogen, CRP, and IL-6 in the test group.

CONCLUSION

Non-surgical periodontal therapy was effective in improving periodontal clinical data and in reducing the plasma levels of IL-6, CRP, and fibrinogen in hypertensive patients with severe periodontitis.

Association between chronic dental infection and acute myocardial infarction

INTRODUCTION

In patients with cardiovascular diseases several risk factors such as high blood pressure, diabetes, smoking and drinking habits, genetic disposition, and chronic inflammation must be considered. The aim of this study was to investigate whether there is a correlation between dental origin infections and the presence of an acute myocardial infarction (AMI).

METHODS

A total of 125 patients who had experienced a myocardial infarction and 125 healthy individuals were included in this study. The oral examination was carried out following the consent of the ethics committee and the National Board for Radiation Protection and included the number of teeth, endodontically treated teeth, periodontal screening index (PSI), clinical attachment level, and radiographic apical lesions (radiograph examination). The medical examination included, among others, blood glucose level, C-reactive protein (CRP) serum levels, and leukocyte number.

RESULTS

The study demonstrated that patients with AMI exhibited an unfavorable dental state of health. After statistical adjustment for age, gender, and smoking, they exhibited a significantly higher number of missing teeth (P = .001), less teeth with root canal fillings (P = .0015), a higher number of radiologic apical lesions (P = .001), and a higher PSI value (P = .001) compared with individuals without myocardial infarction. The medical data showed a nonsignificant correlation between CRP and the number of radiologic apical lesions.

CONCLUSIONS

This study presents evidence that patients who have experienced myocardial infarction also exhibit an unfavorable dental state of health in comparison to healthy patients and suggests an association between chronic oral infections and myocardial infarction.

Cardiovascular disease and periodontitis: an update on the associations and risk

BACKGROUND

Associations between periodontitis and cardiovascular diseases have been recognized.

MATERIAL AND METHODS

New literature since the last European Workshop on Periodontology has been reviewed.

RESULTS

The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1-2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear.

CONCLUSIONS

Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case-control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

Attitudes, awareness and oral health-related quality of life in patients with diabetes

The purpose of this study was to assess the knowledge diabetic patients have of their risk for periodontal disease, their attitude towards oral health and their oral health-related quality of life (OHRQL). One hundred and one consecutive patients (age range 31-79 years) recruited from a diabetic outpatient clinic participated in the study. Twenty-seven per cent of participants had type 1 diabetes, 66% type 2 and 7% did not know what type of diabetes they had. The length of time since participants were diagnosed as diabetic ranged from 1 to 48 years. Metabolic control of diabetes as determined by HbA1c levels ranged from 6.2% to 12.0% compared with the normal range of 4.5-6.0%. Thirty-three per cent of participants were aware of their increased risk for periodontal disease, 84% of their increased risk for heart disease, 98% for eye disease, 99% for circulatory problems and 94% for kidney disease. Half of the participants who were aware of their increased risk for periodontal disease had received this information from a dentist. Dental attendance was sporadic, with 43% reporting attendance within the last year. OHRQL was not significantly affected by the presence of diabetes in the group surveyed, in comparison with a previous survey of non-diabetic patients. A significant association was found between metabolic control and dentate status. Awareness of the potential associations between diabetes, oral health and general health needs to be increased in diabetic patients.

A role for non-antimicrobial actions of tetracyclines in combating oxidative stress in periodontal and metabolic diseases: a literature review

This review addresses the role of adjunctive tetracycline therapy in the management of periodontal diseases and its efficacy in reducing inflammatory burden, oxidative stress and its sequelae in patients with coexisting features of metabolic syndrome. Removal of the dimethylamine group at C4 of the tetracycline molecule reduces its antibiotic properties, enhancing its non-antimicrobial actions; this strategy has aided the development of several chemically modified tetracyclines such as minocycline and doxycycline, by altering different regions of the molecule for focused action on biological targets. Tetracyclines are effective in reducing inflammation by inhibiting matrix metalloproteinases, preventing excessive angiogenesis, inhibiting apoptosis and stimulating bone formation. There are important applications for tetracyclines in the management of diabetic, dyslipidaemic periodontal patients who smoke. The diverse mechanisms of action of tetracyclines in overcoming oxidative stress and enhancing matrix synthesis are discussed in this review.

Associations between periodontal diseases and systemic diseases: a review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular diseases and osteoporosis

The aim of this review article is to examine the associations between periodontal diseases and common systemic diseases, namely diabetes, respiratory diseases, cardiovascular diseases and osteoporosis. A substantial number of review articles have been published to elucidate the relationships between these diseases; however, none provide a complete overview on this topic from the aspects of definition, classification, clinical characteristics and manifestations, inter-relationships and interactions, proposed schematic mechanisms, clinical implications and management of periodontal patients with these systemic diseases. The aim of this article is to provide an overall understanding and general concepts of these issues in a concise and inter-related manner.

Strategic partnerships between academic dental institutions and communities

BACKGROUND

A landmark report from the U.S. surgeon general identified disparities in oral health care as an urgent and high-priority problem. A parallel development in the dental education community is the growing consensus that significant curriculum reform is long overdue.

METHODS

The authors performed a literature review and conducted a series of structured interviews with key institutional and community stakeholders from seven geographical regions of the United States. They investigated a wide range of partnerships between community-based dental clinics and academic dental institutions.

RESULTS

On the basis of their interviews and literature review, the authors identified common themes and made recommendations to the dental community to improve access to care while enhancing the dental curriculum.

CONCLUSIONS

Reducing disparities in access to oral health care and the need for reform of the dental curriculum may be addressed, in part, by a common solution: strategic partnerships between academic dental institutions and communities. Practice Implications. Organized dentistry and individual practitioners, along with other major stakeholders, can play a significant role in supporting reform of the dental curriculum and improving access to care.

Dental caries and periodontitis: contrasting two infections that have medical implications

Both dental decay and periodontal disease are diagnosable and treatable bacterial infections. They are distinctly different infections, with dental decay occurring on the supragingival surfaces of the teeth and periodontal infections occurring in the gingival tissue approximating the subgingival plaque. The bacteria involved and the pathophysiology of these infections are distinctly different.

Low-grade inflammation in chronic infectious diseases: paradigm of periodontal infections

Increasing evidence implicates periodontitis, a chronic inflammatory disease of the tooth-supporting structures, as a potential risk factor for increased morbidity or mortality for several systemic conditions including cardiovascular disease (atherosclerosis, heart attack, and stroke), pregnancy complications (spontaneous preterm birth [SPB]), and diabetes mellitus. Cross-sectional, case-control, and cohort studies indicate that periodontitis may confer two- and up to sevenfold increase in the risk for cardiovascular disease and premature birth, respectively. Given the recently acquired knowledge that systemic inflammation may contribute in the pathogenesis of atherosclerosis and may predispose to premature birth, research in the field of periodontics has focused on the potential of this chronic low-grade inflammatory condition to contribute to the generation of a systemic inflammatory phenotype. Consistent with this hypothesis clinical studies demonstrate that periodontitis patients have elevated markers of systemic inflammation, such as C-reactive protein (CRP), interleukin 6 (IL-6), haptoglobin, and fibrinogen. These are higher in periodontal patients with acute myocardial infarction (AMI) than in patients with AMI alone, supporting the notion that periodontal disease is an independent contributor to systemic inflammation. In the case of adverse pregnancy outcomes, studies on fetal cord blood from SBP babies indicate a strong in utero IgM antibody response specific to several oral periodontal pathogens, which induces an inflammatory response at the fetal-placental unit, leading to prematurity. The importance of periodontal infections to systemic health is further strengthened by pilot intervention trials indicating that periodontal therapy may improve surrogate cardiovascular outcomes, such as endothelial function, and may reduce four- to fivefold the incidence of premature birth. Nevertheless, further research is needed to fully discern the underlying mechanisms by which local chronic infections can have an impact on systemic health, and in this endeavor periodontal disease may serve as an ideal disease model.

Effect of Periodontal Treatment on Serum C-Reactive Protein Levels: A Systematic Review and Meta-Analysis

BACKGROUND

Systemic inflammation is increasingly being recognized as a risk factor for adverse cardiovascular events. Evidence is accumulating that associates periodontal disease with a higher risk for atherosclerotic plaque formation. A positive association between circulating C-reactive protein (CRP) levels and periodontal disease may be responsible for these observations. We undertook a systematic review and conducted a meta-analysis of the available evidence to examine the effect of periodontal treatment on systemic CRP levels and to assess the quality of the available evidence.

METHODS

We conducted a systematic search of the English-language literature on the effect of periodontal treatment on CRP levels, as assessed by high-sensitivity assays, at least 2 months after periodontal treatment. The search was conducted in MEDLINE between 1966 and July 2005 and the Cochrane Central Register of Controlled Trials. We performed a meta-analysis using the DerSimonian and Laird random-effects model.

RESULTS

The literature search yielded 814 citations of which 10 met the inclusion criteria. The meta-analysis of the randomized controlled trials (RCTs) showed that the difference in serum CRP levels is not significantly different between the two arms. Similarly, results from the single-cohort studies showed that the difference on serum CRP levels was not significantly different before and after treatment.

CONCLUSIONS

There is now a large body of evidence to indicate that systemic inflammation is present in patients with periodontal disease. Thus, information from RCTs and single-cohort studies does not support the hypothesis that periodontal treatment can reduce systemic CRP levels.

Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation

SCIENTIFIC RATIONALE FOR STUDY: Bacteremia occurs with various frequency after oral procedures. Periodontal disease may affect the incidence, magnitude, duration and bacterial spectrum of bacteremia.

PRINCIPLE FINDINGS

The incidence and magnitude of bacteremia after scaling was significantly higher in periodontitis than in gingivitis patients and healthy control individuals. In periodontitis patients, the magnitude of bacteremia was associated with gingival index, plaque index and number of sites with bleeding on probing, but not with probing pocket depth measurements.

PRACTICAL IMPLICATIONS

The prevention and treatment of periodontal diseases appear to be crucial for the prevention of bacteremia associated with oral procedures.

Gingivitis, dental caries and tooth loss: risk factors for cardiovascular diseases or indicators of elevated health risks

OBJECTIVES

The results of earlier studies connecting dental diseases to cardiovascular diseases are inconsistent. Our aim in this cross-sectional study was to investigate whether there are associations of dental diseases and diagnosed angina pectoris among the 1966 Northern Finland Birth Cohort.

MATERIALS AND METHODS

A postal questionnaire was sent to all cohort members in 1997-1998. The number of replies totalled 8690. Angina pectoris was determined by asking whether the respondent had been diagnosed with angina pectoris. Gingivitis, dental caries and tooth loss were determined on the basis of self-reported gingival bleeding, presence of dental caries and six or more missing teeth.

RESULTS

We found overall associations of gingivitis (odds ratio (OR) 1.52, confidence interval (CI) 1.04-2.22), dental caries (OR 1.50, CI 1.04-2.18) and tooth loss (OR 1.53, CI 0.69-3.42) with the presence of angina pectoris. The associations were modified by gender and socioeconomic status. In addition, gingivitis, dental caries and tooth loss were also associated with several cardiovascular risk factors.

CONCLUSION

There were associations of self-reported gingivitis, dental caries and tooth loss with angina pectoris. However, the associations between dental diseases and cardiovascular risk factors suggest that the associations may be because of confounding.

C-reactive protein in patients with coexistent periodontal disease and acute coronary syndromes

AIM

To evaluate periodontal disease (PD) influence on changes in high-sensitivity C-reactive protein (hsCRP) concentrations in patients with acute coronary syndromes and coexistent PD.

MATERIALS AND METHODS

Dental examinations were carried out in a group of 50 consecutive patients, less than 60 years old, hospitalized as a result of acute coronary syndromes. The patients were divided into two groups on the basis of own-constructed combined PD score (group 2: more advanced; and group 1: less advanced PD) as well as clinical attachment loss (CAL) - group 4: CAL >3 mm; group 3: CAL <or=3 mm. Blood samples for hsCRP estimation were taken at admission, after 10/12 days and long term after acute coronary syndromes.

RESULTS

A statistically significant decrease in hsCRP was observed among three consecutive blood sample examinations in groups 2 and 4, whereas it was only seen between examination 1 and examination 2 in groups 1 and 3.

CONCLUSIONS

Although no statistically significant difference of hsCRP was found between studied groups, patients with less advanced PD, either estimated with the use of own-constructed combined score or on the basis of CAL, have significantly longer diminution of inflammatory response monitored with hsCRP concentrations.

(A2) Oral health and general health

The interactions between oral and systemic health are bi-directional and complex, involving many pathways. Regarding health as not merely the absence of disease, but as a state of total well-being, these interactions profoundly influence the progress of many diseases, and the quality of life and economic performance of HIV-infected individuals and populations. The evidence base for specific interactions is currently weak, partly because few good-quality studies have been published, partly because of the naïveté of the instruments currently available for recording these interactions and their inherent complexity. Recording quality of life should be a fundamental aspect of all future studies. The most significant conclusion of this Workshop is the need for all involved in oral health research and oral health care to be seen as, and to act as, essential partners in comprehensive care for whole patients and communities.