Periodontal inflamed surface area: quantifying inflammatory burden

Periodontitis and systemic diseases: a record of discussions of working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

There has been an explosion in research into possible associations between periodontitis and various systemic diseases and conditions.

AIM

To review the evidence for associations between periodontitis and various systemic diseases and conditions, including chronic obstructive pulmonary disease (COPD), pneumonia, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and cancer, and to document headline discussions of the state of each field. Periodontal associations with diabetes, cardiovascular disease and adverse pregnancy outcomes were not discussed by working group 4.

RESULTS

Working group 4 recognized that the studies performed to date were largely cross-sectional or case-control with few prospective cohort studies and no randomized clinical trials. The best current evidence suggests that periodontitis is characterized by both infection and pro-inflammatory events, which variously manifest within the systemic diseases and disorders discussed. Diseases with at least minimal evidence of an association with periodontitis include COPD, pneumonia, chronic kidney disease, rheumatoid arthritis, cognitive impairment, obesity, metabolic syndrome and cancer. The working group agreed that there is insufficient evidence to date to infer causal relationships with the exception that organisms originating in the oral microbiome can cause lung infections.

CONCLUSIONS

The group was unanimous in their opinion that the reported associations do not imply causality, and establishment of causality will require new studies that fulfil the Bradford Hill or equivalent criteria. Precise and community-agreed case definitions of periodontal disease states must be implemented systematically to enable consistent and clearer interpretations of studies of the relationship to systemic diseases. The members of the working group were unanimous in their opinion that to develop data that best inform clinicians, investigators and the public, studies should focus on robust disease outcomes and avoid surrogate endpoints. It was concluded that because of the relative immaturity of the body of evidence for each of the purported relationships, the field is wide open and the gaps in knowledge are large.

The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease

OBJECTIVES

The objective of this study was to systematically review the epidemiological evidence for an association between periodontitis (PD) and incident atherosclerotic cardiovascular disease (ACVD), including coronary heart disease (CHD), cerebrovascular disease and peripheral arterial disease.

METHODS

Systematic review of cohort and case-control studies on the association of clinically or radiographically diagnosed PD and ACVD.

RESULTS

Overall, 12 studies were included in this study (six studies on CHD, three studies on cerebrovascular disease, two studies on both coronary heart and cerebrovascular disease mortality and one study on peripheral arterial disease).All but one study reported positive associations between various periodontal disease measures and the incidence of ACVD, at least in specific subgroups. The association was stronger in younger adults and there was no evidence for an association between PD and incident CHD in subjects older than 65 years. Only one study evaluated the association between PD and secondary cardiovascular events.

CONCLUSIONS

There is evidence for an increased risk of ACVD in patients with PD compared to patients without. However, this may not apply to all groups of the population. There is insufficient evidence for an association between PD and the incidence of secondary cardiovascular events.

Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

This consensus report is concerned with the association between periodontitis and atherosclerotic cardiovascular disease (ACVD). Periodontitis is a chronic multifactorial inflammatory disease caused by microorganisms and characterized by progressive destruction of the tooth supporting apparatus leading to tooth loss; as such, it is a major public health issue.

AIMS

This report examined biological plausibility, epidemiology and early results from intervention trials. PLAUSIBILITY: Periodontitis leads to entry of bacteria in the blood stream. The bacteria activate the host inflammatory response by multiple mechanisms. The host immune response favors atheroma formation, maturation and exacerbation.

EPIDEMIOLOGY

In longitudinal studies assessing incident cardiovascular events, statistically significant excess risk for ACVD was reported in individuals with periodontitis. This was independent of established cardiovascular risk factors. The amount of the adjusted excess risk varies by type of cardiovascular outcome and across populations by age and gender. Given the high prevalence of periodontitis, even low to moderate excess risk is important from a public health perspective.

INTERVENTION

There is moderate evidence that periodontal treatment: (i) reduces systemic inflammation as evidenced by reduction in C-reactive protein (CRP) and improvement of both clinical and surrogate measures of endothelial function; but (ii) there is no effect on lipid profiles--supporting specificity. Limited evidence shows improvements in coagulation, biomarkers of endothelial cell activation, arterial blood pressure and subclinical atherosclerosis after periodontal therapy. The available evidence is consistent and speaks for a contributory role of periodontitis to ACVD. There are no periodontal intervention studies on primary ACVD prevention and there is only one feasibility study on secondary ACVD prevention.

CONCLUSIONS

It was concluded that: (i) there is consistent and strong epidemiologic evidence that periodontitis imparts increased risk for future cardiovascular disease; and (ii) while in vitro, animal and clinical studies do support the interaction and biological mechanism, intervention trials to date are not adequate to draw further conclusions. Well-designed intervention trials on the impact of periodontal treatment on prevention of ACVD hard clinical outcomes are needed.

Infection and inflammatory mechanisms

This introductory article examines the potential mechanisms that may play a role in the associations between periodontitis and the systemic conditions being considered in the EFP/AAP Workshop in Segovia, Spain. Three basic mechanisms have been postulated to play a role in these interactions; metastatic infections,inflammation and inflammatory injury, and adaptive immunity. The potential role of each alone and together is considered in in vitro and animal studies and in human studies when available. This is not a systematic or critical review, but rather an overview of the field to set the stage for the critical reviews in each of the working groups.

Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases

BACKGROUND

This consensus report is concerned with the association between periodontitis and atherosclerotic cardiovascular disease (ACVD). Periodontitis is a chronic multifactorial inflammatory disease caused by microorganisms and characterized by progressive destruction of the tooth supporting apparatus leading to tooth loss; as such, it is a major public health issue.

AIMS

This report examined biological plausibility, epidemiology and early results from intervention trials. PLAUSIBILITY: Periodontitis leads to entry of bacteria in the blood stream. The bacteria activate the host inflammatory response by multiple mechanisms. The host immune response favors atheroma formation, maturation and exacerbation.

EPIDEMIOLOGY

In longitudinal studies assessing incident cardiovascular events, statistically significant excess risk for ACVD was reported in individuals with periodontitis. This was independent of established cardiovascular risk factors. The amount of the adjusted excess risk varies by type of cardiovascular outcome and across populations by age and gender. Given the high prevalence of periodontitis, even low to moderate excess risk is important from a public health perspective.

INTERVENTION

There is moderate evidence that periodontal treatment: (i) reduces systemic inflammation as evidenced by reduction in C-reactive protein (CRP) and improvement of both clinical and surrogate measures of endothelial function; but (ii) there is no effect on lipid profiles - supporting specificity. Limited evidence shows improvements in coagulation, biomarkers of endothelial cell activation, arterial blood pressure and subclinical atherosclerosis after periodontal therapy. The available evidence is consistent and speaks for a contributory role of periodontitis to ACVD. There are no periodontal intervention studies on primary ACVD prevention and there is only one feasibility study on secondary ACVD prevention.

CONCLUSIONS

It was concluded that: (i) there is consistent and strong epidemiologic evidence that periodontitis imparts increased risk for future cardiovascular disease; and (ii) while in vitro, animal and clinical studies do support the interaction and biological mechanism, intervention trials to date are not adequate to draw further conclusions. Well-designed intervention trials on the impact of periodontal treatment on prevention of ACVD hard clinical outcomes are needed.

The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease

OBJECTIVES

The objective of this study was to systematically review the epidemiological evidence for an association between periodontitis (PD) and incident atherosclerotic cardiovascular disease (ACVD), including coronary heart disease (CHD), cerebrovascular disease and peripheral arterial disease.

METHODS

Systematic review of cohort and case-control studies on the association of clinically or radiographically diagnosed PD and ACVD.

RESULTS

Overall, 12 studies were included in this study (six studies on CHD, three studies on cerebrovascular disease, two studies on both coronary heart and cerebrovascular disease mortality and one study on peripheral arterial disease). All but one study reported positive associations between various periodontal disease measures and the incidence of ACVD, at least in specific subgroups. The association was stronger in younger adults and there was no evidence for an association between PD and incident CHD in subjects older than 65 years. Only one study evaluated the association between PD and secondary cardiovascular events.

CONCLUSIONS

There is evidence for an increased risk of ACVD in patients with PD compared to patients without. However, this may not apply to all groups of the population. There is insufficient evidence for an association between PD and the incidence of secondary cardiovascular events.

Effect of leaving chronic oral foci untreated on infectious complications during intensive chemotherapy

BACKGROUND

Leukaemic patients receiving intensive chemotherapy and patients undergoing autologous stem-cell transplantation (ASCT) are routinely screened for oral foci of infection to reduce infectious complications that could occur during therapy. In this prospective study we assessed the effect of leaving chronic oral foci of infection untreated on the development of infectious complications in intensively treated haematological patients.

METHODS

We included and prospectively evaluated all intensively treated leukaemic patients and patients undergoing ASCT who were referred to our medical centre between September 2012 and May 2014, and who matched the inclusion/exclusion criteria. Acute oral foci of infection were removed before chemotherapy or ASCT, whereas chronic oral foci were left untreated.

RESULTS

In total 28 leukaemic and 35 ASCT patients were included. Acute oral foci of infection were found in 2 leukaemic (7%) and 2 ASCT patients (6%), and chronic oral foci of infection in 24 leukaemic (86%) and 22 ASCT patients (63%). Positive blood cultures with microorganisms potentially originating from the oral cavity occurred in 7 patients during treatment, but were uneventful on development of infectious complications.

CONCLUSIONS

Our prospective study supports the hypothesis that chronic oral foci of infection can be left untreated as this does not increase infectious complications during intensive chemotherapy.

Relationship between interleukin 1α levels in the gingival crevicular fluid in health and in inflammatory periodontal disease and periodontal inflamed surface area: A correlative study

Background:

Periodontitis has been suggested as a source of inflammation for pathological changes in distant sites. Interleukin-1 alpha (IL-1α) has shown to have specific roles in inflammation, immunity, tissue breakdown, and tissue homeostasis. This study assessed the correlation of periodontal inflamed surface area (PISA) index with the gingival crevicular fluid (GCF) levels of IL-1α, which would be helpful in evaluating the validity of PISA index in terms of reflection of the disease.

Materials and Methods:

A total of 40 subjects were recruited for this study and 20 subjects with healthy gingiva (Group I) served as controls and 20 subjects served as cases with periodontitis (Group II). Samples of GCF were obtained from one site in each patient by placing color-coded, calibrated, volumetric microcapillary pipettes extracrevicularly, and subjected to ELISA test.

Results:

There was a statistical significance for mean probing depth (PD) and periodontal epithelial surface area (PESA) (P < 0.01), mean bleeding on probing and PISA, IL-1α (P < 0.01) and PESA (P < 0.05) in Group I. Statistical significance was found between PISA and IL-1α in Group I (P < 0.01). A positive correlation was found in Group II between mean PD and mean attachment loss (P < 0.01), PISA, IL-1α and PESA (P < 0.01), PISA and IL-1α levels (P < 0.01) which was statistically significant.

Conclusion:

The inflammatory burden index was statistically significant in the periodontitis group correlating with higher IL-1α levels, which clearly indicates the validity of PISA index.

Management of diabolical diabetes mellitus and periodontitis nexus: Are we doing enough?

Periodontitis is the commonest oral disease affecting population worldwide. This disease is notorious for the devastation of tooth supporting structures, ensuing in the loss of dentition. The etiology for this disease is bacterial biofilm, which accumulates on the teeth as dental plaque. In addition to the biofilm microorganisms, other factors such as environmental, systemic and genetic are also responsible in progression of periodontitis. Diabetes mellitus (DM) is metabolic disorder which has an impact on the global health. DM plays a crucial role in the pathogenesis of periodontitis. Periodontitis is declared as the “sixth” major complication of DM. Evidence based literature has depicted an enhanced incidence and severity of periodontitis in subjects with DM. A “two way” relationship has been purported between periodontitis and DM. Mutual management of both conditions is necessary. Periodontal therapy (PT) may assist to diminish the progression of DM and improve glycemic control. Various advanced technological facilities may be utilized for the purpose of patient education and disease management. The present paper clarifies the etio-pathogenesis of periodontitis, establishing it as a complication of DM and elaborating the various mechanisms involved in the pathogenesis. The role of PT in amelioration of DM and application of digital communication will be discussed. Overall, it is judicious to create an increased patient cognizance of the periodontitis-DM relationship. Conjunctive efforts must be undertaken by the medical and oral health care professionals for the management of periodontitis affected DM patients.

Association between periodontitis and mortality in stages 3-5 chronic kidney disease: NHANES III and linked mortality study

INTRODUCTION

Periodontitis may add to the systemic inflammatory burden in individuals with chronic kidney disease (CKD), thereby contributing to an increased mortality rate. This study aimed to determine the association between periodontitis and mortality rate (all-cause and cardiovascular disease-related) in individuals with stage 3-5 CKD, hitherto referred to as "CKD".

METHODS

Survival analysis was carried out using the Third National Health and Nutrition Examination Survey (NHANES III) and linked mortality data. Cox proportional hazards regression was employed to assess the association between periodontitis and mortality, in individuals with CKD. This association was compared with the association between mortality and traditional risk factors in CKD mortality (diabetes, hypertension and smoking).

RESULTS

Of the 13,784 participants eligible for analysis in NHANES III, 861 (6%) had CKD. The median follow-up for this cohort was 14.3 years. Adjusting for confounders, the 10-year all-cause mortality rate for individuals with CKD increased from 32% (95% CI: 29-35%) to 41% (36-47%) with the addition of periodontitis. For diabetes, the 10-year all-cause mortality rate increased to 43% (38-49%).

CONCLUSION

There is a strong, association between periodontitis and increased mortality in individuals with CKD. Sources of chronic systemic inflammation (including periodontitis) may be important contributors to mortality in patients with CKD.

Oral health information from the dentist to the diabetologist

BACKGROUND

Diabetes care includes annual evaluation of micro- and macrovascular complications, however, oral pathologies are not included. We studied retrieving oral health information, in particular periodontal disease, from the dentist and studied the association between the reported periodontal condition and variables of both diabetes and dental care.

METHODS

During their annual comprehensive diabetes evaluation, patients were asked to deliver an oral health questionnaire (OHQ) to their dentist. Based on the returned OHQs, the process of retrieving oral health information from the dentist was analyzed. In addition, reported oral health measures with special emphasis to periodontitis, using a Periodontal Screening Index (PSI), were related to diabetes-related variables.

RESULTS

We included 889 patients of whom 102 patients (11%) did not visit a dentist at all and 252 (28%) were edentulous. The response rate was <50% for oral information on patients with diabetes. For the second aim, OHQs of 207 patients could be further analyzed. A moderate to high PSI-score was found in 106 patients, of whom 65% were untreated for periodontitis. Furthermore high PSI-scores were associated with poor oral hygiene, soft tissue pathologies and periodontal treatment, but not significantly with glycemic control and presence of diabetes complications.

CONCLUSION

The transfer of information from the dentist to the diabetologist is far from optimal. An OHQ can be a valuable tool for the identification of patients with diabetes with poor oral health especially untreated periodontal disease, which is helpful for proper diabetes management.

Association between periodontitis and medical expenditure in older adults: A 33-month follow-up study

AIM

Along with rapid aging, medical expenditure for older adults has been increasing in Japan. Research has shown that periodontitis is a useful predictor for excess medical expenditure; however, limited information is available on the elderly population after adequately considering confounding factors. The aim of the present study was to evaluate the association between periodontitis and long-term medical expenditure in elderly Japanese.

METHODS

Baseline health and periodontal examinations were carried out in June 2008. Japanese adults (n = 245) aged 80 years were classified into quartiles based on periodontal inflamed surface area (PISA), which quantifies the degree of periodontal inflammation. Medical care use and costs were monitored by assessment of the National Health Insurance claim files from the baseline survey through the end of February 2011. Multivariable analysis of the differences in medical expenditure among PISA quartiles was carried out using linear regression with robust standard errors.

RESULTS

The participants in the fourth (with the largest PISA) and third quartiles had significantly higher inpatient medical expenditure compared with those of the first quartile (P < 0.01 and = 0.04, respectively). Participants in the fourth quartile had significantly higher total medical expenditure (P < 0.01) compared with the first quartile. A trend was observed of higher inpatient and total medical expenditure with increasing PISA.

CONCLUSIONS

A significant association was found between periodontitis and future increase in medical expenditure, suggesting that periodontitis might be a modifiable factor for the reduction of excess medical expenditure among elderly Japanese. Geriatr Gerontol Int 2016; 16: 856-864.

Rheumatoid arthritis-associated autoantibodies in non-rheumatoid arthritis patients with mucosal inflammation: a case-control study

Introduction

Rheumatoid arthritis–associated autoantibodies (RA-AAB) can be present in serum years before clinical onset of rheumatoid arthritis (RA). It has been hypothesized that initiation of RA-AAB generation occurs at inflamed mucosal surfaces, such as in the oral cavity or lungs. The aim of this study was to assess systemic presence of RA-AAB in patients without RA who had oral or lung mucosal inflammation.

Methods

The presence of RA-AAB (immunoglobulin A [IgA] and IgG anti-cyclic citrullinated peptide 2 antibodies (anti-CCP2), IgM and IgA rheumatoid factor (RF), IgG anti-carbamylated protein antibodies and IgG and IgA anti-citrullinated peptide antibodies against fibrinogen, vimentin and enolase) were determined in sera of non-RA patients with periodontitis (PD, n = 114), bronchiectasis (BR, n = 80) or cystic fibrosis (CF, n = 41). Serum RA-AAB levels were compared with those of periodontally healthy controls (n = 36). Patients with established RA (n = 86) served as a reference group. Association of the diseases with RA-AAB seropositivity was assessed with a logistic regression model, adjusted for age, sex and smoking.

Results

Logistic regression analysis revealed that IgG anti-CCP seropositivity was associated with BR and RA, whereas the association with PD was borderline significant. IgA anti-CCP seropositivity was associated with CF and RA. IgM RF seropositivity was associated with RA, whereas the association with BR was borderline significant. IgA RF seropositivity was associated with CF and RA. Apart from an influence of smoking on IgA RF in patients with RA, there was no influence of age, sex or smoking on the association of RA-AAB seropositivity with the diseases. Anti-CarP levels were increased only in patients with RA. The same held for IgG reactivity against all investigated citrullinated peptides.

Conclusion

Although overall levels were low, RA-AAB seropositivity was associated with lung mucosal inflammation (BR and CF) and may be associated with oral mucosal inflammation (PD). To further determine whether mucosal inflammation functions as a site for induction of RA-AAB and precedes RA, longitudinal studies are necessary in which RA-AAB of specifically the IgA isotype should be assessed in inflamed mucosal tissues and/or in their inflammatory exudates.

Association Between Periodontal Disease and Kidney Function Decline in African Americans: The Jackson Heart Study

BACKGROUND

Chronic kidney disease (CKD) remains a prevalent public health problem that disproportionately affects African Americans, despite intense efforts targeting traditional risk factors. Periodontal disease, a chronic bacterial infection of the oral cavity, is both common and modifiable and has been implicated as a novel potential CKD risk factor. The authors seek to examine to what extent periodontal disease is associated with kidney function decline.

METHODS

This retrospective cohort study examines 699 African American participants with preserved kidney function (defined by estimated glomerular filtration rate (eGFR) >60 mL/minute/1.73 m(2) at baseline) who underwent complete dental examinations as part of the Dental-Atherosclerosis Risk in Communities study (1996 to 1998) and subsequently enrolled in the Jackson Heart Study (2000 to 2004). Using multivariable Poisson regression, the authors examined the association of periodontal disease (severe versus non-severe) with incident CKD, defined as incident eGFR <60 mL/minute/1.73 m(2) and rapid (5% annualized) eGFR decline at follow-up among those with preserved eGFR at baseline.

RESULTS

Mean (± SD) age at baseline was 65.4 (± 5.2) years, and 16.3% (n = 114) had severe periodontal disease. There were 21 cases (3.0%) of incident CKD after a mean follow-up of 4.8 (± 0.6) years. Compared with participants with non-severe periodontal disease, those with severe periodontal disease had a four-fold greater rate of incident CKD (adjusted incidence rate ratio 4.18 [95% confidence interval 1.68 to 10.39], P = 0.002).

CONCLUSIONS

Severe periodontal disease is prevalent among a population at high risk for CKD and is associated with clinically significant kidney function decline. Further research is needed to determine if periodontal disease treatment alters the trajectory of renal deterioration.

Effect of application of a PVP-iodine solution before and during subgingival ultrasonic instrumentation on post-treatment bacteraemia: a randomized single-centre placebo-controlled clinical trial

BACKGROUND

To assess the effect of concomitant subgingival rinsing with 10% PVP-iodine during subgingival instrumentation on the prevalence and magnitude of bacteraemia of oral origin.

MATERIALS AND METHODS

Subgingival instrumentation was performed with water or PVP-iodine rinse in patients with periodontitis. Prior to instrumentation, subjects gargled for 1 min with the allocated liquid. Pockets were then rinsed for 1 min and subgingivally instrumented with liquid-cooled (water/PVP-iodine) ultrasonic scalers (1 min). Two minutes later, a blood sample from the arm vein was drawn using a lysis centrifugation blood culture system for quantitative microbiological analysis. Non-parametric statistical tests were performed to assess differences in the prevalence and extent of bacteraemia between groups.

RESULTS

Of the 19 samples in each group, oral-borne bacteraemia was detected in 10 of the control and 2 of the test samples. With an average of 3.0 [1; 5] colony forming units, significantly less bacteria and bacteraemia were found in the test group compared to the controls (12.2 [1; 46]) (p = 0.003). Anaerobic bacteria were not found in the test group.

CONCLUSIONS

Bacteraemia after subgingival instrumentation with concomitant PVP-iodine rinsing is reduced but not eliminated. Therefore, it might be recommended for patients at a high risk of endocarditis or infection of endoprostheses. However, preventive antibiotic treatment should not be omitted.

Bacteriophage and their potential roles in the human oral cavity

The human oral cavity provides the perfect portal of entry for viruses and bacteria in the environment to access new hosts. Hence, the oral cavity is one of the most densely populated habitats of the human body containing some 6 billion bacteria and potentially 35 times that many viruses. The role of these viral communities remains unclear; however, many are bacteriophage that may have active roles in shaping the ecology of oral bacterial communities. Other implications for the presence of such vast oral phage communities include accelerating the molecular diversity of their bacterial hosts as both host and phage mutate to gain evolutionary advantages. Additional roles include the acquisitions of new gene functions through lysogenic conversions that may provide selective advantages to host bacteria in response to antibiotics or other types of disturbances, and protection of the human host from invading pathogens by binding to and preventing pathogens from crossing oral mucosal barriers. Recent evidence suggests that phage may be more involved in periodontal diseases than were previously thought, as their compositions in the subgingival crevice in moderate to severe periodontitis are known to be significantly altered. However, it is unclear to what extent they contribute to dysbiosis or the transition of the microbial community into a state promoting oral disease. Bacteriophage communities are distinct in saliva compared to sub- and supragingival areas, suggesting that different oral biogeographic niches have unique phage ecology shaping their bacterial biota. In this review, we summarize what is known about phage communities in the oral cavity, the possible contributions of phage in shaping oral bacterial ecology, and the risks to public health oral phage may pose through their potential to spread antibiotic resistance gene functions to close contacts.

Short-term effects of 2% atorvastatin dentifrice as an adjunct to periodontal therapy: a randomized double-masked clinical trial

BACKGROUND

The pleiotropic effects of statins, such as immunomodulation and anti-inflammatory effects, may also improve periodontal conditions. The aim of the present study is to assess the effectiveness of a dentifrice medicated with 2% atorvastatin in improving clinical periodontal parameters as a complement to non-surgical periodontal treatment (NSPT).

METHODS

A randomized, double-masked clinical trial was performed with two parallel groups: 1) atorvastatin group (NSPT plus medicated 2% atorvastatin dentifrice) and 2) placebo group (NSPT plus placebo dentifrice). The effectiveness of these treatments was assessed using periodontal measurements obtained at baseline and 1 month later. The measurements were probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), gingival index (GI), and periodontal inflamed surface area (PISA). Multiple linear regression models were used to compare outcome variables after adjusting for sex, diabetes, and tobacco use.

RESULTS

A total of 36 individuals participated in this study (atorvastatin group, n = 18; placebo group, n = 18). Both groups showed improvements in periodontal parameters. The atorvastatin group showed a decrease of 297.63 mm(2) in PISA (95% confidence interval = 76.04 to 519.23; P = 0.01), which was significantly greater than the reduction observed in the placebo group. There was also a significantly greater reduction in mean PD, percentage of sites with PD ≥5 mm, mean CAL, percentage of sites with CAL ≥5 mm, BOP, and GI in the atorvastatin group compared with the placebo group.

CONCLUSION

NSPT plus 2% atorvastatin medicated dentifrice was more effective in improving clinical periodontal parameters than NSPT plus a placebo dentifrice.

Effect of intensive oral hygiene regimen during pregnancy on periodontal health, cytokine levels, and pregnancy outcomes: a pilot study

BACKGROUND

Data are limited on the potential effect of intensive oral hygiene regimens and periodontal therapy during pregnancy on periodontal health, gingival crevicular fluid (GCF) and serum cytokines, and pregnancy outcomes.

METHODS

A clinical trial was conducted on 120 community-dwelling, 16- to 35-year-old pregnant women at 16 to 24 weeks of gestation. Each participant presented with clinical evidence of generalized, moderate-to-severe gingivitis. Oral hygiene products were provided, together with instructions for an intensive daily regimen of hygiene practices. Non-surgical therapy was provided at baseline. Oral examinations were completed at baseline and again at 4 and 8 weeks. In addition, samples of blood and GCF were collected at baseline and week 8. Mean changes in clinical variables and GCF and serum cytokine levels (interleukin [IL]-1β, IL-6, tumor necrosis factor [TNF]-α) between baseline and week 8 were calculated using paired t test. Pregnancy outcomes were recorded at parturition.

RESULTS

RESULTS indicated a statistically significant reduction in all clinical variables (P <0.0001) and decreased levels of TNF-α (P = 0.0076) and IL-1β (P = 0.0098) in GCF during the study period. The rate of preterm births (<37 weeks of gestation) was 6.7% (P = 0.113) and low birth weight (<2,500 g) was 10.2% (P = 1.00).

CONCLUSIONS

Among the population studied, intensive instructions and non-surgical periodontal therapy provided during 8 weeks at early pregnancy resulted in decreased gingival inflammation and a generalized improvement in periodontal health. Large-scale, randomized, controlled studies are needed to substantiate these findings.

Cystatin C-based estimated glomerular filtration rate and periodontitis

BACKGROUND AND OBJECTIVE

Accumulating evidence suggests that decreased kidney function characterised by low estimated glomerular filtration rate (eGFR) may be associated with periodontitis. Recent studies have suggested that the use of cystatin C strengthens the association between the eGFR and the risks of adverse outcomes in decreased kidney function. The aim of this cross-sectional study was to investigate the association of cystatin C-based eGFR (eGFRcys) and creatinine-based eGFR (eGFRcreat), the commonly used method to assess kidney function, with periodontitis in 502 Japanese women (average age, 68.6 years).

MATERIALS AND METHODS

GFR was estimated from serum cystatin C and serum creatinine, respectively, using the Japanese equation for GFR. Participants were classified into five groups according to their eGFRcys and eGFRcreat values. Poisson regression models with robust error variance assessed the associations of eGFRcys and eGFRcreat with periodontitis. Tests for trends were performed by fitting the five-category eGFR variables in their continuous form to the regression models.

RESULTS

Participants with eGFRcys < 50 ml/min/1.73 m(2) were at significantly higher risk of periodontitis compared with the reference group (≥90 ml/min/1.73 m(2) ) (adjusted relative risk = 2.12, 95% confidence interval = 1.12 to 4.02). Additionally, there was a trend towards a higher risk of periodontitis among participants with lower eGFRcys values (p for trend in the multivariable model = 0.008). In contrast, eGFRcreat did not show a significant association with periodontitis.

CONCLUSION

The findings of this study of Japanese older women showed that eGFRcys had a stronger and more linear association with periodontitis than eGFRcreat.

The implication of periodontitis in vascular endothelial dysfunction

BACKGROUND

Periodontitis is the most common oral infection seen in humans worldwide. It is characterized by gradual destruction of tooth supporting tissues, eventually leading to loss of tooth. The periodontal biofilm associated with periodontitis comprises of gram-positive and gram-negative bacteria, instrumental for the initiation and progression of periodontitis. Evidence-based literature has identified the nature of periodontal infection as a possible causative condition in the inducement of 'low-grade systemic inflammation and infection'. The periodontal pathogens exert systemic effects via the haematogenous route.

AIM

The present review provides an insight into the pathophysiology of the endothelial dysfunction with reference to periodontal infection and highlights the association between periodontitis and endothelial dysfunction. Various studies addressing the implication of periodontitis on endothelial dysfunction will be described, with a focus of periodontal treatment on improvement of endothelial function.

MATERIALS AND METHODS

Studies examining the effects of periodontitis on vascular endothelial function were segregated. Studies conducted on both animal and human models were identified using MEDLINE database search with key search terms such as 'Periodontitis', 'vascular endothelium', 'endothelial dysfunction', 'periodontal bacteria' and 'periodontal therapy'. Systematic reviews and meta-analysis were also screened. Only studies published in English language were considered. The review has been prepared by screening MEDLINE database from 1989 to 2012.

RESULTS AND CONCLUSIONS

Chronic periodontitis results in altered vascular response, increased expression of pro-inflammatory cytokines and adhesion molecules inducing vascular endothelial dysfunction. Periodontal therapy may ameliorate the perturbed vascular endothelial function.

Periodontal disease and metabolic syndrome: a qualitative critical review of their association

BACKGROUND

Metabolic syndrome (MetS) is a conglomerate of several physical conditions/diseases that, as a group, increases the risk of mortality resulting from development of T2DM and cardiovascular diseases (CVD). These conditions/diseases include glucose intolerance/insulin resistance, hypertension, obesity, and dyslipidemia. The results from epidemiological studies suggest that there is an association between metabolic syndrome (MetS) and periodontitis, it is therefore important to understand the current status of the association and a possible contribution of periodontitis to MetS.

OBJECTIVE

This review will qualitatively analyze published papers on the association of MetS and periodontitis/periodontal disease to clarify the current status of the association and suggest future directions for studies which may unravel the causal relationship between them.

RESULTS

Of 309 papers related to MetS and periodontitis, 26 are original research papers that investigated the relationship/association between periodontal disease and MetS. Criteria used to assess periodontitis and MetS as well as overall study designs and patient recruitment criteria varied greatly among these studies.

CONCLUSION

All these studies demonstrated a positive association between periodontal disease and MetS. However, due to the heterogeneity of criteria to assess periodontitis and MetS and also paucity of longitudinal studies, it is difficult to determine the relative contribution of periodontitis to MetS. Age and the number of positive components of MetS appear to strengthen the relationship, however, incidence of each disease entity increases with ageing. Thus, mechanistic studies are also necessary to unravel the inter-relationship between periodontitis and MetS. In this regard, a use of animal models will be helpful as they are more uniform in regards to genetic background and have minimum confounding factors. Finally, development of accurate, quantitative assessment of gingival inflammation are necessary in order to determine the influence of periodontal disease on the development of MetS and its components.

Is gingival bleeding a symptom of patients with type 1 von Willebrand disease? A case-control study

BACKGROUND

Von Willebrand disease (VWD) is the most common inherent bleeding disorder resulting in prolonged bleeding time. Gingival bleeding is a frequently reported symptom of VWD. However, gingival bleeding is also known as a leading symptom of plaque-induced gingivitis and untreated periodontal disease. Gingival bleeding in VWD patients (VWD) may be triggered by gingival inflammation and not a genuine symptom. Thus, this study evaluated whether type 1 VWD determines an increased susceptibility to gingival bleeding in response to the oral biofilm.

METHODS

Fifty cases and 40 controls were examined haematologically (VWF antigen, VWF Ristocetin cofactor, factor VIII activity) and periodontally [Gingival Bleeding Index (GBI), bleeding on probing (BOP), Plaque Control Record (PCR), periodontal inflamed surface area (PISA), vertical probing attachment level].

RESULTS

GBI was significantly higher in controls (12.2%) than in VWD (10%). The study failed to find a significant difference regarding BOP between VWD (17%) and controls (17.2%). Multiple regressions identified PCR and PISA to be associated with GBI and BOP. VWD was negatively associated with GBI. Smoking and number of remaining teeth was negatively associated with BOP.

CONCLUSION

VWD is not associated with a more pronounced inflammatory response to the oral biofilm in terms of GBI and BOP.

Treatment of periodontitis improves the atherosclerotic profile: a systematic review and meta-analysis

AIM

Systematic review and meta-analyses to study the robustness of observations that treatment of periodontitis improves the atherosclerotic profile.

MATERIAL AND METHODS

Literature was searched in Medline-PubMed, Cochrane CENTRAL and EMBASE, based on controlled periodontal intervention trials, including also a non-intervention group. Data were extracted and meta-analyses were performed.

RESULTS

From 3928 screened studies, 25 trials met the eligibility criteria. These trials enrolled 1748 periodontitis patients. Seven trials enrolled periodontitis patients that were otherwise healthy, 18 trials recruited periodontal patients with various co-morbidities, such as CVD or diabetes. None of the trials used hard clinical endpoints of CVD. However, improvement of endothelial function has been consistently reported. Meta-analyses demonstrated significant weighted mean difference (WMD) for hsCRP (-0.50 mg/l, 95% CI:-0.78; -0.22), IL-6 (-0.48 ng/l, 95% CI: -0.90; -0.06), TNF-α (-0.75 pg/ml, 95% CI: -1.34; -0.17), fibrinogen (-0.47 g/l, 95% CI: -0.76; -0.17), total cholesterol (-0.11 mmol/l, 95% CI: -0.21; -0.01) and HDL-C (0.04 mmol/l, 95% CI: 0.03; 0.06) favouring periodontal intervention. Importantly, periodontitis patients with co-morbidity benefitted most from periodontal therapy; significant WMD were observed for levels of hsCRP (-0.71 mg/l, 95% CI: -1.05; -0.36), IL-6 (-0.87 ng/l, 95% CI: -0.97; -0.78), triglycerides (-0.24 mmol/l, 95% CI: -0.26; -0.22), total cholesterol (-0.15 mmol/l, 95% CI: -0.29; -0.01), HDL-C (0.05 mmol/l, 95% CI: 0.03; 0.06) and HbA1c (-0.43%, 95% CI: -0.60; -0.25).

CONCLUSIONS

This systematic review and meta-analyses demonstrate that periodontal treatment improves endothelial function and reduces biomarkers of atherosclerotic disease, especially in those already suffering from CVD and/or diabetes.

Effect of periodontal treatment on glycemic control of patients with diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

The aim of the present study was to investigate whether non-surgical periodontal treatment reduces glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) levels in diabetic patients.

MATERIALS AND METHODS

An electronic search was carried out on MEDLINE (through PubMed interface), EMBASE and the Cochrane Central Register of Controlled Trials. Randomized controlled trials with a minimum of 3 months follow up were included. The risk of bias was assessed for each study. A meta-analysis was carried out to evaluate the effect of non-surgical periodontal treatment on HbA1c and FPG levels. The effect of the adjunctive use of antimicrobials was also assessed.

RESULTS

A total of 15 studies were included. A reduction of -0.38% (95% confidence interval [CI] -0.23 to -0.53) after 3-4 months (P < 0.001) and of -0.31% (95% CI 0.11 to -0.74) after 6 months (P = 0.15) of follow-up was found for HbA1c, favoring the treatment group. Similarly, in treated patients, a significantly greater decrease in FPG was observed in respect to control participants. Such difference amounted to -9.01 mg/dL (95% CI -2.24 to -15.78) after 3-4 months (P = 0.009) and -13.62 mg/dL (95% CI 0.45 to -27.69) after 6 months (P = 0.06) from treatment, respectively. In participants treated with adjunctive antimicrobials, a non-significant increase of HbA1c was observed 3 months after treatment, whereas FPG decreased by 0.27 mg/dL (95% CI 39.56 to -40.11; P = 0.99).

CONCLUSIONS

The meta-analysis showed that non-surgical periodontal treatment improves metabolic control in patients with both periodontitis and diabetes.

Periodontitis and chronic kidney disease: a systematic review of the association of diseases and the effect of periodontal treatment on estimated glomerular filtration rate

AIM

The aim of this systematic review (SR) was to evaluate the association between periodontitis and chronic kidney disease (CKD) and the effect of periodontal treatment (PT) on the estimated glomerular filtration rate (eGFR).

METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched up to and including September 30, 2012 to observational (S1) and interventional (S2) studies on the association of periodontitis with CKD. Studies were considered eligible for inclusion if they reported the eGFR. Search was conducted by two independent reviewers. The methodological quality of the observational studies was assessed using the Newcastle-Ottawa Scale (NOS) adapted for this review, and the Cochrane's Collaboration risk of bias assessment tool. A random-effects odds-ratio meta-analysis was conducted to estimate the degree of association between periodontitis and CKD.

RESULTS

Search strategy identified 2456 potentially eligible articles, of which four cross-sectional, one retrospective, and three interventional studies were included. Four S1, 80.0% reported some degree of association between periodontitis and CKD. Similarly, such an outcome was supported by pooled estimates (OR: 1.65, 95% Confidence Interval: 1.35, 2.01, p < 0.00001, χ(2)  = 1.70, I(2 ) = 0%). All interventional studies found positive outcomes related to treatment.

CONCLUSION

There is quite consistent evidence to support the positive association between periodontitis and CKD, as well as the positive effect of PT on eGFR.

Periodontal status and bacteremia with oral viridans streptococci and coagulase negative staphylococci in allogeneic hematopoietic stem cell transplantation recipients: a prospective observational study

AIM

This study was aimed to investigate whether any association could be found between the presence of an inflamed and infected periodontium (e.g., gingivitis and periodontitis) and the development of bacteremia during neutropenia following allogeneic hematopoietic stem cell transplantation (HSCT).

METHODS

Eighteen patients underwent a periodontal examination before HSCT. Patients were classified as periodontally healthy [all periodontal pocket depths (PPD) ≤ 4 mm and bleeding on probing (BOP) ≤ 10%) or as having gingivitis/periodontitis (PPD ≥ 4 mm and BOP > 10%]. Oral mucositis (OM) was scored using the daily mucositis score. Blood cultures were taken at least twice weekly.

RESULTS

Five patients were periodontally healthy, while 13 patients had gingivitis or periodontitis. Twelve patients (67%) developed bacteremia during neutropenia, of which 11 patients (61%) had one or more episodes of bacteremia due to coagulase-negative staphylococci (CONS, most often Staphylococcus epidermidis) or to oral viridans streptococci (OVS), or both. Patients with gingivitis/periodontitis more often had bacteremia than those with a healthy periodontium (p = 0.047), and BOP was associated with bacteremia (p = 0.049). All patients developed ulcerative OM, but its severity and duration were not associated with bacteremia. OM duration and the length of stay in the hospital were strongly correlated (R = 0.835, p ≤ 0.001).

CONCLUSION

This study indicates that periodontal infections may contribute to the risk of developing OVS and CONS bacteremia during neutropenia following HSCT. While our results point to the importance of periodontal evaluation and management before HSCT, further studies on periodontal contribution to systemic infectious complications are warranted.

Periodontitis and insulin resistance: casual or causal relationship?

Insulin resistance (IR) is now considered as a chronic and low level inflammatory condition. It is closely related to altered glucose tolerance, hypertriglyceridemia, abdominal obesity, and coronary heart disease. IR is accompanied by the increase in the levels of inflammatory cytokines like interleukin-1 and 6, tumor necrosis factor-α. These inflammatory cytokines also play a crucial part in pathogenesis and progression of insulin resistance. Periodontitis is the commonest of oral diseases, affecting tooth investing tissues. Pro-inflammatory cytokines are released in the disease process of periodontitis. Periodontitis can be attributed with exacerbation of IR. Data in the literature supports a "two way relationship" between diabetes and periodontitis. Periodontitis is asymptomatic in the initial stages of disease process and it often escapes diagnosis. This review presents the blurred nexus between periodontitis and IR, underlining the pathophysiology of the insidious link. The knowledge of the association between periodontitis and IR can be valuable in planning effectual treatment modalities for subjects with altered glucose homeostasis and diabetics. Presently, the studies supporting this association are miniscule. Further studies are mandatory to substantiate the role of periodontitis in the deterioration of IR.

Periodontal inflammatory burden correlates with C-reactive protein serum level

OBJECTIVE

The aim of study was to present a new method for evaluation of the periodontal inflammatory burden, to apply the method to the adult population and to correlate it with serum levels of C-reactive protein (CRP).

MATERIALS AND METHODS

On 515 extracted teeth was measured the neck circumferences (NC). The average values of the NC were obtained for 16 male and 16 female individual tooth types. In the clinical part of this study 238 dentate subjects were included. The subgingival area, inflamed area and periodontal wound size were calculated from NC, probing depth and BOP. The sum of the inflamed and ulcerated subgingival areas of all teeth represented the total periodontal inflammatory burden of an individual. Serum levels of CRP were measured by immunochemical method.

RESULTS

The average subgingival area in 238 subjects was calculated to be 13.11 ± 6.35 cm(2) and inflammatory burden area 9.25 ± 5.57 cm(2). The periodontal bleeding wound (p < 0.05) was significantly larger in men. The increased serum levels of CRP correlated with periodontal inflammatory burden (p < 0.05).

CONCLUSIONS

This new method quantifies the inflammatory burden caused by periodontal disease. The size of the inflammatory burden is correlated with increased serum levels of CRP.

Adjunctive clinical effect of a water-cooled Nd:YAG laser in a periodontal maintenance care programme: a randomized controlled trial

BACKGROUND

Various laser systems are currently available for intra-oral use. Neodymium:Yttrium-Aluminium Garnet lasers(Nd:YAG) have been approved by the US Food and Drug Administration for soft tissue treatment in the oral cavity.

OBJECTIVES

The aim of this study was to test whether the use of a water-cooled Nd:YAG laser during a maintenance care programme as an adjunct to supragingival and subgingival debridement (scaling and root planing, SRP) with hand and ultrasonic instruments results in clinical improvement compared with SRP alone.

MATERIAL AND METHODS

This study was an examiner-blind, randomized and controlled clinical trial using a split-mouth design. Thirty subjects were selected, originally diagnosed with moderate to severe generalized periodontitis, following a periodontal maintenance care programme (PMC). Immediately after SRP in two randomly assigned contra-lateral quadrants, all pockets ≥5 mm were additionally treated with a Nd:YAG laser (1064 nm, 4W, 250-μsec pulse). Clinical assessments [probing pocket depth PPD, bleeding on pocket probing (BOPP)] were performed pre-treatment and at 6 months. Based on these assessments, the periodontal inflamed surface area (PISA) was calculated.

RESULTS

At 6 months, the clinical parameters had significantly improved for both regimens. No statistically significant differences between treatment modalities were observed for PPD and BOPP scores at any time. PISA scores supported these findings.

CONCLUSIONS

In residual pockets ≥5 mm, treated in a PMC, the adjunctive use of an Nd:YAG laser does not provide a clinically significant additional advantage.

Prevalence and severity of periodontitis in Indonesian patients with rheumatoid arthritis

BACKGROUND

Patients with rheumatoid arthritis (RA) may have more prevalent and severe periodontitis than healthy controls. Periodontitis may increase the systemic inflammation in RA. The aim of this study is to assess periodontitis prevalence and severity and its potential association with systemic inflammation in Indonesian patients with RA.

METHODS

A full-mouth periodontal examination including probing depth, gingival recession, plaque index, and bleeding on probing was performed in 75 Indonesians with RA and 75 age-, sex-, and smoking-matched Indonesian controls. A validated questionnaire was used to assess smoking, body mass index, education, and medical conditions. In addition, in all participants, the use of drugs was noted, and erythrocyte sedimentation rates and serum levels of high-sensitivity C-reactive protein (hsCRP), rheumatoid factor, and anti-citrullinated protein antibodies were measured. Differences in periodontitis prevalence and 12 measures of periodontitis severity between patients with RA and controls were analyzed using univariate analyses.

RESULTS

No significant differences in periodontitis prevalence and 11 measures of periodontitis severity between patients with RA and controls were observed. Conversely, patients with RA had a significantly lower surface area of healthy pocket epithelium versus controls (P = 0.008), and a tendency toward higher hsCRP levels was observed in patients with RA with severe periodontitis compared with patients with RA with no mild or moderate periodontitis (P = 0.063). It has to be noted that all patients with RA were on anti-inflammatory drugs, whereas none of the controls used such drugs.

CONCLUSION

Prevalence and severity of periodontitis in Indonesian patients with RA is comparable to controls but with less healthy pocket epithelium than in controls and a tendency toward a higher inflammatory state in patients with RA and severe periodontitis.

Periodontitis in established rheumatoid arthritis patients: a cross-sectional clinical, microbiological and serological study

Introduction

The association between rheumatoid arthritis (RA) and periodontitis is suggested to be linked to the periodontal pathogen Porphyromonas gingivalis. Colonization of P. gingivalis in the oral cavity of RA patients has been scarcely considered. To further explore whether the association between periodontitis and RA is dependent on P. gingivalis, we compared host immune responses in RA patients with and without periodontitis in relation to presence of cultivable P. gingivalis in subgingival plaque.

Methods

In 95 RA patients, the periodontal condition was examined using the Dutch Periodontal Screening Index for treatment needs. Subgingival plaque samples were tested for presence of P. gingivalis by anaerobic culture technique. IgA, IgG and IgM antibody titers to P. gingivalis were measured by ELISA. Serum and subgingival plaque measures were compared to a matched control group of non-RA subjects.

Results

A higher prevalence of severe periodontitis was observed in RA patients in comparison to matched non-RA controls (27% versus 12%, p < 0.001). RA patients with severe periodontitis had higher DAS28 scores than RA patients with no or moderate periodontitis (p < 0.001), while no differences were seen in IgM-RF or ACPA reactivity. Furthermore, RA patients with severe periodontitis had higher IgG- and IgM-anti P. gingivalis titers than non-RA controls with severe periodontitis (p < 0.01 resp. p < 0.05), although subgingival occurrence of P. gingivalis was not different.

Conclusions

Severity of periodontitis is related to severity of RA. RA patients with severe periodontitis have a more robust antibody response against P. gingivalis than non-RA controls, but not all RA patients have cultivable P. gingivalis.

Periodontitis, Porphyromonas, and the pathogenesis of rheumatoid arthritis

Epidemiological data indicate a link between rheumatoid arthritis (RA) and periodontal disease (PD). In vitro and in vivo studies have sought to dissect potential mechanisms by which PD may contribute to initiation and progression of RA. However, these are both multifactorial, chronic diseases, and their complex etiologies and pathogenesis themselves remain incompletely understood. Could there really be an etiological link or does this simply represent a statistical coincidence muddied by common risk factors? This review seeks to provide background on these two diseases in the context of recent discoveries suggesting that their pathogenesis may be related. In particular, the process of citrullination, a post-translational protein modification, has been highlighted as a process common to both diseases. The evidence for a relationship between the diseases is explored and its potential mechanisms discussed.

Periodontal inflamed surface area and C-reactive protein as predictors of HbA1c: a study in Indonesia

Periodontitis may exert an infectious and inflammatory burden, evidenced by increased C-reactive protein (CRP). This burden may impair blood glucose control (HbA1c). The aim of our study was to analyze whether periodontitis severity as measured with the periodontal inflamed surface area (PISA) and CRP predict HbA1c levels in a group of healthy Indonesians and a group of Indonesians treated for type 2 diabetes mellitus (DM2). A full-mouth periodontal examination, including probing pocket depth, gingival recession, clinical attachment loss, plaque index and bleeding on probing, was performed in 132 healthy Indonesians and 101 Indonesians treated for DM2. Using these data, PISA was calculated. In addition, HbA1c and CRP were analyzed. A validated questionnaire was used to assess smoking, body mass index (BMI), education and medical conditions. In regression analyses, it was assessed whether periodontitis severity and CRP predict HbA1c, controlling for confounding and effect modification (i.e., age, sex, BMI, pack years, and education). In healthy Indonesians, PISA and CRP predicted HbA1c as did age, sex, and smoking. In Indonesians treated for DM2, PISA did not predict HbA1c. Periodontitis may impair blood glucose regulation in healthy Indonesians in conjunction with elevated CRP levels. The potential effect of periodontitis on glucose control in DM2 patients may be masked by DM2 treatment. Clinical relevance: periodontitis may impair blood glucose control through exerting an inflammatory and infectious burden evidenced by increased levels of CRP.

Brain abscess associated with Aggregatibacter actinomycetemcomitans: case report and review of literature

INTRODUCTION

Aggregatibacter actinomycetemcomitans is considered a major pathogen in localized and generalized aggressive periodontitis. A. actinomycetemcomitans has been found in various extra oral infections and most frequently in endocarditis. We report a patient with multiple brain abscesses due to infection with A. actinomycetemcomitans and review the English language literature related to this subject.

CASE REPORT

A 42-year-old patient with no underlying medical conditions presented with multiple brain lesions initially thought to be metastatic lesions of a tumour of unknown origin. Findings during drainage and subsequent histopathological conclusions made infection more likely. Culture of drained material remained negative; however, 16S rDNA polymerase chain reaction and sequence analysis on direct material revealed A. actinomycetemcomitans as the causative agent of the infection. The most likely source of infection was the poor dentition of the patient. After repeated drainage of the lesions and antibiotic treatment the patient gradually improved, although cognitive impairment remained.

CONCLUSIONS

Our report illustrates that a poor dental condition, notably destructive periodontal disease, can be a risk for life-threatening extra oral disease, and thus contributes to the total inflammatory burden of the body.

Rheumatoid arthritis and periodontitis; a possible link via citrullination

Rheumatoid Arthritis (RA) and chronic and aggressive periodontitis are chronic inflammatory disorders characterized by deregulation of the host inflammatory response. Increased secretion of pro-inflammatory mediators results in soft and hard tissue destruction of the synovium and periodontium respectively. Both diseases share risk factors and have pathological pathways in common, resulting in loss of function and disability as a final clinical outcome. This article discusses possible interactions, particularly related to the periodontal pathogen Porphyromonas gingivalis, which could explain the observed association between these two prevalent diseases.

Periodontitis prevalence and severity in Indonesians with type 2 diabetes

BACKGROUND

The prevalence of diabetes mellitus type 2 (DM2) in Indonesia is high and still rising. Periodontitis is associated with DM2. No study has investigated this association in Indonesia, nor has any study investigated this association using a variety of methods to operationalize periodontitis. The present study compares prevalence and severity of periodontitis in patients with DM2 to healthy controls, using different methods to operationalize periodontitis.

METHODS

A total of 78 subjects with DM2 and 65 healthy control subjects underwent a full-mouth periodontal screening assessing probing depth, gingival recession, plaque index, and bleeding on probing. Using these measurements, the prevalence and severity of periodontitis was operationalized in various ways. Differences in the prevalence and severity of periodontitis between subjects with DM2 and healthy subjects were analyzed using univariate analyses. In regression analyses, the prevalence and severity of periodontitis were predicted on the basis of DM2 presence, controlling for confounders and effect modification.

RESULTS

Prevalence of periodontitis was significantly higher in subjects with DM2 compared to healthy subjects, showing odds ratios of 5.0 and 6.1. Likewise, periodontitis severity was significantly higher in subjects with DM2.

CONCLUSION

Indonesian subjects with DM2 had more prevalent and more severe periodontitis than healthy Indonesian subjects, independent of confounding factors or the methods used to operationalize periodontitis.

Increased prevalence of cardiovascular and autoimmune diseases in periodontitis patients: a cross-sectional study

BACKGROUND

Associations between periodontitis and cardiovascular and autoimmune diseases are most often assessed in patients with a particular cardiovascular or autoimmune disease. To prevent selection bias, this study assesses the existence of associations between periodontitis and cardiovascular and autoimmune diseases in patients attending a dental or periodontal clinic.

METHODS

Data were collected from 1,276 randomly selected dental records from patients attending a dental (n = 588) or periodontal (n = 688) clinic. Data on the prevalence of cardiovascular and autoimmune diseases were obtained from a validated health questionnaire. Data on the presence of periodontitis were taken from patients' dental records.

RESULTS

In uncontrolled analyses, the prevalence of hypertension, diabetes mellitus (DM), and rheumatoid arthritis (RA) is significantly increased in patients with periodontitis. Controlled for confounding, periodontitis was associated with DM, with an odds ratio of 4 (1.03 to 15.3), in the dental clinic. DM was not associated with periodontitis in periodontal clinics. Hypertension does not seem to be associated with periodontitis when controlling for confounders. Periodontitis may be associated with RA in both clinic types.

CONCLUSIONS

The increased prevalence of cardiovascular and autoimmune diseases among patients with periodontitis attending dental or periodontal clinics may, at least in part, be influenced by confounding. However, the increased prevalence of DM and RA in patients with periodontitis could not be explained by confounding.