Oral infection-inflammatory pathway, periodontitis, is a risk factor for endothelial dysfunction in patients with coronary artery disease

Presence of dysfunctional soluble guanylate cyclase in mesenteric resistance arteries from rats with mild ligature-induced periodontitis

Periodontitis is notable for its high prevalence in the oral cavity and its association with systemic diseases. Functional alterations in vasomotor activity occur in the arteries of rats with mild periodontitis, primarily due to decreased soluble guanylate cyclase (sGC) enzyme activity. This study aims to investigate the functional response of mesenteric resistance arteries (MRA) obtained from rats with mild periodontitis. Vascular reactivity of MRAs from rats in the ligature (L) or sham (S) groups was assessed using a wire myograph. Additionally, antioxidant enzyme activity, the presence of nitrated proteins, cyclic guanosine monophosphate (cGMP) levels, and electron paramagnetic resonance (EPR) spectroscopy were analyzed. The MRAs from the L group showed lower pD2 values in response to sodium nitroprusside or sildenafil and decreased Emax to the sGC stimulator Bay 41-2271 compared to the S group. However, no differences were observed between the groups with respect to the sGC activator Bay 60-2770. The L group exhibited increased nitrotyrosine protein expression, enhanced catalase activity, and reduced superoxide dismutase activity, along with decreased cGMP content after SNP stimulation. The EPR spectrum of the L group showed a weak peak at g 6.00, compared to the S group, confirming the oxidation of sGC heme-iron (Fe+2) to heme-Fe+3. In the early phase of bilateral ligature-induced periodontitis in rats, functional changes in the nitric oxide (NO)-cGMP pathway occur in the MRA due to reduced sGC activity and excessive production of iNOS-derived NO, superoxide anion, or a combination of both.

The association between the oral microbiome and hypertension: a systematic review

Background

This study systematically reviewed the available evidence regarding the potential association between oral microbiota and hypertension.

Methods

A comprehensive search of online databases was conducted by two independent investigators for all relevant articles. All observational studies that assessed the association between oral microbiota and hypertension were included. Quality appraisal was conducted using the NOS tool.

Results

A total of 17 studies comprising 6007 subjects were included. The studies varied with respect to sample type and microbial analysis method. All studies, except one, found significant differences in microbial composition between hypertensive and normotensive subjects. However, there were substantial inconsistencies regarding the specific differences identified. Still, a few taxa were repeatedly found enriched in hypertension including Aggregatibacter, Kingella, Lautropia, and Leptotrachia besides the red complex periodontal pathogens. When considering only studies that controlled for false discovery rates and confounders, Atopobium, Prevotella, and Veillonella were identified as consistently associated with hypertension.

Conclusion

There are significant differences in the oral microbiome between hypertensive and normotensive subjects. Despite the heterogeneity between the included studies, a subset of microbial taxa seems to be consistently enriched in hypertension. Further studies are highly recommended to explore this association.

Registration

PROSPERO database (ID: CRD42023495005).

Effects of Combined Periodontal, Endodontic, and Dentoalveolar Surgical Treatments on Laboratory Parameters in Patients with Hyperlipidemia-A Clinical Interventional Study

Background: Patients with hyperlipidemia are of interest because of the possible interplay between chronic local dental infections and hyperlipidemia. This interventional clinical study aimed to evaluate the oral health status of hyperlipidemic patients receiving lipid-lowering therapy for at least 6 months and the effects of non-surgical and surgical dental treatments on serum C-reactive protein (CRP) levels and lipid markers. Methods: Twenty-eight patients with controlled hyperlipidemia and 18 healthy controls were enrolled in the study. All participants underwent dental examinations (clinical evaluation, X-ray imaging, and microbial analysis of subgingival and supragingival plaque samples) at baseline. Hyperlipidemic patients received periodontal, endodontic, and dentoalveolar surgical treatments. Serum CRP and lipid parameters were assessed at baseline, 1 week, and 3 months, while subgingival and supragingival plaque samples were analyzed at baseline and 3 months after completing dental treatments. Results: At the 3-month follow-up, clinical periodontal characteristics, including the plaque index, gingival index, and periodontal probing depth, improved significantly (p < 0.05). A significant shift in microflora was observed in both subgingival and supragingival plaque samples (p < 0.05), alongside improvements in periodontal values and a significant reduction in serum CRP levels (p < 0.05). Serum cholesterol levels decreased significantly, while moderate improvements in serum triglycerides, low-density lipoprotein, and high-density lipoprotein levels were observed but were not statistically significant (p > 0.05). Conclusions: Treating local dental inflammation is associated with a significant decrease in CRP and cholesterol levels and may serve as beneficial adjunct therapy alongside lipid-lowering therapy in patients with hyperlipidemia.

Hypertensive patients with periodontitis as predictors of cardiovascular and all-cause mortality: a long-term cohort study

OBJECTIVES

The aim of this study is to examine the potential correlation between periodontitis and the risk of cardiovascular mortality and all-cause mortality in individuals diagnosed with hypertension, despite the established association between periodontitis and hypertension.

METHODS

The study utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted in 1999-2014 involving hypertensive individuals. Following the criteria proposed by Eke et al., periodontitis was classified. Survival estimates were calculated using Kaplan Meier analyses and a Kaplan Meier curve was generated. Weighted multivariate cox regression were employed to assess the association between periodontitis and all-cause mortality, as well as cardiovascular mortality.

RESULTS

Of the 21,645 individuals, 6,904 individuals were diagnosed with periodontitis. The Kaplan-Meier survival analysis revealed significantly higher rates of all-cause mortality (34.766% vs. 14.739%) and cardiovascular mortality (12.469% vs. 3.736%) in the periodontitis group compared to the non-periodontitis group. Hazard ratios (HRs) for all-cause mortality were 3.19 (95% CI 2.88-3.53) and for cardiovascular mortality were 3.80 (95% CI 3.13-4.61) in individuals with periodontitis compared to those without periodontitis.

CONCLUSION

Periodontitis is a risk factor for mortality in patient with hypertension, especially if it is moderate to severe. Improving periodontal health could lead to better outcomes for these patients.

Differential expression of FSTL1 and its correlation with the pathological process of periodontitis

AIMS

This study aimed to elucidate the alterations in Follistatin-like protein 1 (FSTL1) and its association with the pathological process of periodontitis.

METHODS

This study included 48 patients with periodontitis and 42 healthy controls. The expression level of FSTL1 in the gingiva was determined by RT-qPCR, validated using the dataset GSE16134, and subsequently examined by western blotting. Bioinformatics analysis revealed a single-cell distribution of FSTL1, characteristic of angiogenesis and immune cell infiltration. The expression and distribution of FSTL1, vascular endothelial marker protein CD31 and myeloperoxidase (MPO), the indicator of neutrophil activity, were determined by immunohistochemistry (IHC). A series of correlation analyses was performed to determine the associations between FSTL1 and clinical parameters, including probing depth (PD) and clinical attachment loss (CAL), and their potential role in angiogenesis (CD31) and neutrophil infiltration (MPO).

RESULTS

FSTL1 was significantly upregulated in the gingiva of patients with periodontitis compared to their healthy counterparts. In addition, FSTL1 was positively correlated with the clinical parameters PD (r = .5971, p = .0005) and CAL (r = .6078, p = .0004). Bioinformatic analysis and IHC indicated that high FSTL1 expression was significantly correlated with angiogenesis and neutrophil infiltration in periodontitis. Moreover, receiver operating characteristic (ROC) analysis demonstrated that FSTL1 could serve as an independent indicator for evaluating the severity of periodontitis (area under the curve [AUC] = 0.9011, p < .0001).

CONCLUSION

This study demonstrated FSTL1 upregulation in periodontitis and its potential contribution to the disease via angiogenesis and neutrophil infiltration.

Asymmetric Dimethylarginine as a Potential Mediator in the Association between Periodontitis and Cardiovascular Disease: A Systematic Review of Current Evidence

Background: Periodontitis, a chronic inflammatory disease, has been associated with an elevated risk of cardiovascular disease (CVD). Asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, has emerged as a potential biomarker linking periodontitis, endothelial dysfunction, and CVD. This systematic review aimed to synthesize the existing evidence on the relationship between ADMA, periodontitis, and CVD, and to evaluate ADMA's potential as a biomarker for periodontal disease progression and its correlation with endothelial dysfunction. Methods: A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science databases from their inception to March 2023. Observational and interventional studies assessing ADMA levels in patients with periodontitis and/or CVD were included. The methodological quality of the included studies was evaluated using the NIH Quality Assessment Tools. Due to the heterogeneity of the included studies, a qualitative synthesis was performed. Results: Cross-sectional studies consistently demonstrated significantly elevated ADMA levels in patients with periodontitis and CVD compared to healthy controls. The prospective cohort study indicated that successful periodontal treatment was associated with a significant reduction in ADMA levels and concomitant improvement in endothelial function. The pilot cohort study reported a significant decrease in ADMA levels following periodontal therapy in patients with chronic kidney disease. However, the randomized controlled trials did not demonstrate significant alterations in ADMA levels or endothelial function subsequent to periodontal treatment in patients with periodontitis alone. Conclusions: Periodontal treatment may effectively reduce ADMA levels and improve endothelial function, particularly in patients with comorbidities. These findings suggest that ADMA is a promising biomarker linking periodontitis, endothelial dysfunction, and CVD. However, the limitations of this study include the small number of studies, heterogeneity in the study designs, and a lack of long-term follow-up data. Further high-quality, longitudinal studies are required to confirm its clinical utility and elucidate the underlying mechanisms of these relationships. The integration of periodontal care into CVD prevention and management strategies warrants consideration, as it may contribute to mitigating the cardiovascular risk associated with periodontitis.

The effect of periodontal treatments on endothelial function in degrees of periodontitis patients: A systematic review and meta-analysis

OBJECTIVE

This article focus on patients with moderate-to-severe periodontitis and periodontitis patients with cardiovascular disease. After they received periodontal initial therapy or antimicrobial drug treatment, was there any improvement in endothelial function during short- and long-term followups?

METHOD

Relevant randomized controlled trials and clinical trials up to 30th June 2024 were identified and retrieved from electronic databases including PubMed, Cochrane Library, Web of Science and CNKI databases, with periodontitis therapy, periodontal disease and endothelial function as the keywords. The weighted (WMD) or standardized mean difference (SMD) was calculated using a fixed- or random-effect model and assessed heterogeneous results.

RESULT

Generally, 14 studies published between 2004 and 2022 were eligible for the meta-analysis, which are all randomised clinical trials. A total of 491 periodontitis patients were screened. All participants received whole-mouth supragingival and subgingival scaling and root planing of the teeth, some trials combined with antimicrobial drug treatment as well as extracting teeth that could not be saved. The outcome indicators were measured by flow-mediated dilatation(FMD) levels. The results of the short term (≤3 months) periodontitis initial therapy group showed positive results (WMD = -3.78,95%CI = [-5.49,-2.07], P<0.0001), while the results of the long term (6 months) periodontitis therapy group exhibited significant difference (WMD = -0.96,95%CI = [-2.06,0.14],P = 0.09). Furthermore, study population were categorized according to the severity of periodontitis, the presence of comorbidities, endothelial dysfunction, and the inclusion of extractions and antimicrobial therapy in the treatment process. The effects of each of these factors on FMD were explored and the results of these subgroups all support periodontitis therapy.

CONCLUSION

The results showed that periodontal treatment enhances endothelial function. Additionally, after subgroup analysis of long-term and short-term follow-up, patients with severe periodontitis, and different periodontal treatments, periodontal therapy was shown to increase FMD levels.

Effect of non-surgical periodontal therapy on risk markers of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in the world. Patients with periodontitis have a higher risk of CVD, although a causal relationship between these conditions remains unclear. Non-surgical periodontal therapy (NSPT) is able to control inflammation at local and systemic levels. This study aimed to analyze the effect of NSPT on CVD risk markers.

METHODS

Four electronic databases were searched from their inception to April 1, 2023, to identify and select articles without any language restrictions. Eleven CVD-related markers (e.g., C-reactive protein [CRP], Interleukin-6 [IL-6]) were selected. Meta-analyses were performed using random and fixed effect models. The differences were expressed as weighted mean differences (WMD) and 95% confidence interval (95% CI).

RESULTS

From 1353 studies, twenty-one randomized controlled clinical trials were included in the meta-analysis. Results showed a significant decrease in CRP, IL-6, and systolic blood pressure (SBP) after NSPT.

CONCLUSION

Moderate certainty evidence shows that NSPT has a positive effect on the reduction of IL-6 and SBP in patients with periodontitis, while low certainty evidence shows that NSPT is effective for reduction of CRP. Moderate certainty evidence showed that NSPT did not show a positive effect on low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG), and low certainty evidence showed that NSPT did not show a positive effect on Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), diastolic blood pressure (DBP), and flow-mediated dilatation (FMD).

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews), number CRD42022377565.

Oral health as a modifiable risk factor for cardiovascular diseases

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide with a high socioeconomic burden. Increasing evidence supports a convincing connection with increased cardiovascular risk of periodontal diseases (PD), a group of widespread, debilitating, and costly dysbiotic relapsing-remitting inflammatory diseases of the tissues supporting the teeth. Herein, we ensembled the best available evidence on the connection between CVDs and PD to review the recently emerging concept of the latter as a non-traditional risk factor for CVDs. We focused on oral dysbiosis, inflammation-associated molecular and cellular mechanisms, and epigenetic changes as potential causative links between PD and CVDs. The available evidence on the effects of periodontal treatment on cardiovascular risk factors and diseases was also described.

[Periodontitis : An underestimated risk of cardiovascular diseases]

Epidemiological studies have identified periodontitis as a contributing factor to cardiovascular risk. Periodontitis is a chronic inflammatory disease that affects the tissues supporting the teeth. Although the nature of the association between periodontitis and cardiovascular disease (CVD) remains to be defined, the low-grade systemic inflammation and chronic bacteremia associated with periodontitis appear to be involved in the development of atherosclerosis and associated cardiovascular pathologies. Periodontal treatment has been shown to improve cardiovascular health parameters. A bidirectional preventive approach, involving the management of both periodontitis and cardiovascular risk factors, could lead to a reduction in morbidity and mortality related to cardiovascular disease.

Effect of endodontic treatment on endothelial dysfunction and subclinical atherosclerosis-a prospective intervention study

OBJECTIVE

The objective of this study is to investigate the effect of endodontic treatment on flow-mediated dilatation (FMD) and carotid intima-media thickness (c-IMT) in patients with apical periodontitis (AP).

MATERIAL AND METHOD

The study includes 32 young men having AP with a mean age of 25.78 years free from cardiovascular disease (CVD) and its risk factors, including periodontitis. All subjects underwent complete physical and dental examination, echocardiography, and ultrasound assessment of FMD on the brachial artery and c-IMT on the carotid artery at baseline and 12 months after the endodontic treatment. Data were analyzed using paired Student's t-test and Pearson's correlation coefficient (r) test using SPSS 26 version.

RESULTS

Endodontic treatment leads to the improvement of FMD significantly from a pooled baseline value of 4.84 ± 1.55% to 7.68 ± 2.08% (p < 0.05). The study also depicts a statistically significant difference between c-IMT (mean = 0.62 ± 0.11 mm) before treatment as compared to 12 months after treatment (mean = 0.59 ± 0.11 mm) (p < 0.05).

CONCLUSION

Endodontic treatment leads to improved FMD and decreased c-IMT suggesting that treating AP can be help revert the early stages of CVD.

CLINICAL RELEVANCE

AP could be a potential etiological factor of future CVD and should be treated as soon as diagnosed.

The Effect of Non-Surgical Periodontal Treatment on Patients with Combined Refractory Arterial Hypertension and Stage III, Grade B Periodontitis: A Preliminary Prospective Clinical Study

We sought to evaluate the effects of non-surgical periodontal treatment (NSPT) on periodontal clinical parameters, systemic blood pressure (BP), and plasma levels of systemic inflammation markers in patients with combined refractory arterial hypertension (RAH) and stage III grade B periodontitis. Twenty-seven participants with RAH and periodontitis received NSPT. The analyzed clinical parameters were probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), and plaque index (PI). An assessment was performed for systemic BP, complete blood count, coagulogram, creatinine measurement, C-reactive protein (CRP), glycated hemoglobin, cholesterol, glutamic oxaloacetic transaminase, glutamate pyruvic transaminase, waist-hip ratio, and body mass index. In the follow-up period, twenty-two patients were evaluated at baseline and after 90 and 180 days. The data were submitted for statistical analysis (α = 0.05%). As expected, the clinical results showed a significant improvement in the percentages of PI, BOP, PD, and CAL, which were statistically significant at 90 and 180 days (p < 0.0001). Importantly, NSPT significantly reduced the blood level of CRP (p < 0.02). However, no significant reduction in BP parameters was noted in the evaluated follow-up periods. NSPT, despite the benefits in periodontal clinical parameters, reduced the plasma level of CRP but not the BP in patients with combined RAH and periodontitis.

Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Systemic inflammation is implicated in the onset and progression of several chronic diseases. Periodontitis is a potential trigger of systemic inflammation.

PURPOSE

To comprehensively appraise all the evidence on the effects of the treatment of periodontitis on systemic inflammation assessed by serum C-reactive protein (CRP) levels.

DATA SOURCES

Six electronic databases were searched up to 10 February 2022 to identify and select articles in English language only.

STUDY SELECTION

Twenty-six randomized controlled clinical trials reporting changes amongst 2579 participants about CRP levels at 6 months or more after treatment.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Meta-analyses were performed using random and fixed effect models.

RISK OF BIAS

Risk of bias (RoB 2.0 tool) and quality of evidence (GRADEpro GDT tool) analyses were completed.

DATA SYNTHESIS

Treatment of periodontitis reduced CRP levels by 0.69 mg/L (95% confidence interval: -0.97 to -0.40) after 6 months, but limited evidence was retrieved from studies with longer follow-ups. Similar findings were observed in participants with other co-morbidities in addition to periodontitis. Greatest reductions were observed in participants with concentrations of CRP >3 mg/L at baseline.

LIMITATIONS

High level of heterogeneity.

CONCLUSIONS

Treatment of periodontitis reduces serum CRP levels (up to 6 months follow-up) to a degree equivalent to that observed after traditional lifestyle or drug interventions. This evidence supports a causal association between periodontitis and systemic inflammation.

Potential Roles of Selectins in Periodontal Diseases and Associated Systemic Diseases: Could They Be Targets for Immunotherapy?

Periodontal diseases are predisposing factors to the development of many systemic disorders, which is often initiated via leukocyte infiltration and vascular inflammation. These diseases could significantly affect human health and quality of life. Hence, it is vital to explore effective therapies to prevent disease progression. Periodontitis, which is characterized by gingival bleeding, disruption of the gingival capillary's integrity, and irreversible destruction of the periodontal supporting bone, appears to be caused by overexpression of selectins in periodontal tissues. Selectins (P-, L-, and E-selectins) are vital members of adhesion molecules regulating inflammatory and immune responses. They are mainly located in platelets, leukocytes, and endothelial cells. Furthermore, selectins are involved in the immunopathogenesis of vascular inflammatory diseases, such as cardiovascular disease, diabetes, cancers, and so on, by mediating leukocyte recruitment, platelet activation, and alteration of endothelial barrier permeability. Therefore, selectins could be new immunotherapeutic targets for periodontal disorders and their associated systemic diseases since they play a crucial role in immune regulation and endothelium dysfunction. However, the research on selectins and their association with periodontal and systemic diseases remains limited. This review aims to discuss the critical roles of selectins in periodontitis and associated systemic disorders and highlights the potential of selectins as therapeutic targets.

Roles of Oxidative Stress and Inflammation in Vascular Endothelial Dysfunction-Related Disease

Oxidative stress and chronic inflammation play an important role in the pathogenesis of atherosclerosis. Atherosclerosis develops as the first step of vascular endothelial dysfunction induced by complex molecular mechanisms. Vascular endothelial dysfunction leads to oxidative stress and inflammation of vessel walls, which in turn enhances vascular endothelial dysfunction. Vascular endothelial dysfunction and vascular wall oxidative stress and chronic inflammation make a vicious cycle that leads to the development of atherosclerosis. Simultaneously capturing and accurately evaluating the association of vascular endothelial function with oxidative stress and inflammation would be useful for elucidating the pathophysiology of atherosclerosis, determining treatment efficacy, and predicting future cardiovascular complications. Intervention in both areas is expected to inhibit the progression of atherosclerosis and prevent cardiovascular complications.

Invasive dental treatment and acute vascular events: A systematic review and meta-analysis

BACKGROUND

Acute infection/inflammation increases the risk of acute vascular events (AVEs). Invasive dental treatments (IDTs) trigger short-term acute inflammation.

PURPOSE

The aim of this work is to critically appraise the evidence linking IDTs and AVEs.

DATA SOURCES

Six bibliographical databases were searched up to 31 August 2021. A systematic review following PRISMA guidelines was performed.

STUDY SELECTION

Intervention and observational studies reporting any AVEs following IDT were included.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Data were pooled using fixed-effect, inverse variance weights analysis.

RISK OF BIAS

Risk of bias was assessed by the Newcastle-Ottawa Quality Assessment Scale for observational studies and the Cochrane Handbook-Rob 2.0 for randomized controlled trials.

DATA SYNTHESIS

In 3 out of 16 clinical studies, a total of 533,175 participants, 124,344 myocardial infarctions, and 327,804 ischaemic strokes were reported. Meta-analysis confirmed that IDT did not increase incidence ratios (IR) for combined vascular events either at 1-4 weeks (IR of 1.02, 95% CIs: 0.92 to 1.13) and at 5-8 weeks (IR of 1.04, 95% CIs: 0.97 to1.10) after treatment.

LIMITATIONS

A high level of heterogeneity (study designs and time point assessments) was found.

CONCLUSION

Patients who received IDT exhibited no substantial increase in vascular risk over 8 weeks post treatment.

Periodontitis activates the NLRP3 inflammasome in serum and saliva

BACKGROUND

Nod-like receptor family pyrin domain-containing protein-3 (NLRP3) complex inflammasome has potentially been shown to play an important role in the development of periodontitis and diabetes. The objective of this study was to analyze the association between serum and salivary NLRP3 concentrations in patients with periodontitis and type-II diabetes mellitus (DM) and to evaluate whether this association was influenced by potential confounders.

METHODS

For the present study, a cohort of healthy controls (n = 32), and patients with periodontitis (n = 34), type-II DM (n = 33), and a combination of periodontitis + type-II DM (n = 34) were enrolled. Patients were characterized on the basis of their periodontal status and analyzed for demographic characteristics, serum mediators, and for serum and salivary concentrations of NLRP3. A uni- and multivariate model was established to analyze whether periodontitis, type-II DM, and CRP influenced serum and salivary NLRP3 concentrations.

RESULTS

In comparison to type-II DM patients and healthy controls, patients with periodontitis (serum, P = 0.003; saliva P = 0.012) and periodontitis + type-II DM (serum, P = 0.028; saliva, P = 0.003) had elevated serum and salivary NLRP3 concentrations. The multivariate regression model showed that periodontitis (P = 0.029) and HDL-cholesterol (P = 0.012) were significant predictors of serum NLRP3 concentrations whereas periodontitis (P = 0.036) and CRP (P = 0.012) were significant predictors of salivary NLRP3.

CONCLUSION

The results of the present study showed that periodontitis and periodontitis + type-II DM patients had higher serum and salivary NLRP3 concentrations in comparison to healthy controls and patients with type-II DM. Periodontitis was demonstrated to be a significant predictor of both serum and salivary NLRP3 concentrations.

Poor tooth brushing behavior is associated with high risk of cardiovascular events: A prospective observational study

BACKGROUNDS

Poor oral care is associated with cardiovascular disease. The aim of this study was to determine the impact of tooth brushing behavior on the incidences of future cardiovascular events in a general population including patients with cardiovascular disease.

METHODS

This was a prospective observational study which included 692 participants (437 men and 255 women, mean age, 63 ± 16 years). The participants were divided into three groups according to the frequency and duration of tooth brushing: low frequency and short duration group (<twice/day and <2 min/procedure), low frequency or short duration group (<twice/day or <2 min/procedure), and non-low frequency and non-short duration group (≥twice/day and ≥2 min/procedure). We assessed the associations of tooth brushing behavior with major adverse cardiovascular events (MACEs) including death from cardiovascular causes, acute myocardial infarction, hospitalization for heart failure, and stroke.

RESULTS

During a median follow-up period of 28.5 (15.4-35.1) months, 32 events occurred (10 deaths from cardiovascular causes, one acute myocardial infarction, 13 hospitalizations for heart failure, and eight strokes). Kaplan-Meier curves for MACEs among the groups were significantly different (P = 0.001). After adjustment for cardiovascular risk factors, the combination of low frequency and short duration of tooth brushing was significantly associated with high incidences of MACEs compared with the incidences of MACEs for the combination of non-low frequency and non-short duration of tooth brushing (hazard ratio, 3.06; 95% confidence interval, 1.24-7.63; P = 0.02).

CONCLUSIONS

The combination of decreased frequency and duration of tooth brushing is associated with a higher risk of cardiovascular events.

CLINICAL TRIAL REGISTRATION INFORMATION

URL for Clinical Trial: http://UMIN; Registration Number for Clinical Trial: UMIN000003409.

Effect of periodontal treatments on blood pressure

BACKGROUND

An association has been hypothesized between periodontitis and hypertension. Periodontal therapy is believed to reduce systemic inflammatory mediators and increase endothelial function, thus having the potential to prevent and treat hypertension.

OBJECTIVES

To assess the effect and safety of different periodontal treatment modalities on blood pressure (BP) in people with chronic periodontitis.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched for randomized controlled trials (RCTs) up to November 2020 in the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, seven other databases, and two clinical trials registries. We contacted the authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

RCTs and quasi-RCTs aiming to detect the effect of periodontal treatment on BP were eligible. Participants should have been diagnosed with chronic periodontitis and hypertension (or no hypertension if the study explored the preventive effect of periodontal treatment). Participants in the intervention group should have undergone subgingival scaling and root planing (SRP) and any other type of periodontal treatments, compared with either no periodontal treatment or alternative periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for study identification, data extraction, and risk of bias assessment. We used a formal pilot-tested data extraction form for data extraction, and the Cochrane risk of bias tool for risk of bias assessment. We planned the meta-analysis, test for heterogeneity, sensitivity analysis, and subgroup analysis. We assessed the certainty of evidence using GRADE. The primary outcome was change in systolic BP (SBP) and diastolic BP (DBP).

MAIN RESULTS

We included eight RCTs. Five had low risk of bias, one had unclear risk of bias, and two had high risk of bias. Four trials compared periodontal treatment with no treatment. We found no evidence of a difference in the short-term change of SBP and DBP for people diagnosed with periodontitis and other cardiovascular diseases except hypertension (very low-certainty evidence). We found no evidence of a difference in long-term changes in SBP (mean difference [MD] -2.25 mmHg, 95% confidence interval [CI] -9.41 to 4.92; P = 0.54; studies = 2, participants = 108; low-certainty evidence) and DBP (MD -2.55 mmHg, 95% CI -6.90 to 1.80; P = 0.25; studies = 2, participants = 103; low-certainty evidence). Concerning people diagnosed with periodontitis, in the short term, two studies of low certainty reported no changes in SBP (MD -0.14 mmHg, 95% CI -4.05 to 3.77; P = 0.94; participants = 294) and DBP (MD -0.15 mmHg, 95% CI -2.47 to 2.17; P = 0.90; participants = 294), and we found no evidence of a difference in SBP and DBP over a long period based on low certainty of evidence. Three studies compared intensive periodontal treatment with supra-gingival scaling. We found no evidence of a difference in changes in SBP and DBP for any length of time in people diagnosed with periodontitis (very low-certainty evidence). In people diagnosed with periodontitis and hypertension, we found one study reporting a significant reduction in the short term in SBP (MD -11.20 mmHg, 95% CI -15.40 to -7.00; P < 0.001; participants = 101; moderate-certainty evidence) and DBP (MD -8.40 mmHg, 95% CI -12.19 to -4.61; P < 0.0001; participants = 101; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We found no evidence of a difference of an impact of periodontal treatments on BP in most comparisons assessed in this review, and given the low certainty of evidence and the lack of relevant studies we could not draw conclusions about the effect of periodontal treatment on BP in people with chronic periodontitis. We found only one study suggesting that periodontal treatment may reduce SBP and DBP over a short period in people with hypertension and chronic periodontitis, but the certainty of evidence was moderate.

Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review

AIM

To investigate the effect of treatment of periodontitis on systemic health outcomes, pregnancy complications, and associated quality of life.

MATERIALS AND METHODS

Systematic electronic searches were conducted to identify randomized controlled trials with minimum 6-month follow-up and reporting on the outcomes of interest. Qualitative and quantitative analyses were performed as deemed suitable.

RESULTS

Meta-analyses confirmed reductions of high-sensitivity C-reactive protein (hs-CRP) [0.56 mg/L, 95% confidence interval (CI) (-0.88, -0.25), p < .001]; interleukin (IL)-6 [0.48 pg/ml, 95% CI (-0.88, -0.08), p = .020], and plasma glucose [1.33 mmol/l, 95% CI (-2.41, -0.24), p = .016], and increase of flow-mediated dilation (FMD) [0.31%, 95% CI (0.07, 0.55), p = .012] and diastolic blood pressure [0.29 mmHg, 95% CI (0.10, 0.49), p = .003] 6 months after the treatment of periodontitis. A significant effect on preterm deliveries (<37 weeks) was observed [0.77 risk ratio, 95% CI (0.60, 0.98), p = .036]. Limited evidence was reported on quality-of-life (QoL) outcomes in the included studies.

CONCLUSIONS

Treatment of periodontitis results in systemic health improvements including improvement in cardiometabolic risk, reduction in systemic inflammation and the occurrence of preterm deliveries. Further research is however warranted to confirm whether these changes are sustained over time. Further, appropriate QoL outcomes should be included in the study designs of future clinical trials.

Short-term effect of ligature-induced periodontitis on cardiovascular variability and inflammatory response in spontaneously hypertensive rats

BACKGROUND

We previously reported that periodontal disease (PD) induces high arterial pressure variability (APV) consistent with sympathetic overactivity and elicits myocardial inflammation in Balb/c mice. However, it is unknown whether PD can change APV and heart rate variability (HRV) in spontaneously hypertensive (SHR) and normotensive Wistar-Kyoto (WKY) rats. This study aimed to evaluate the hemodynamic level, HRV, and APV associating with myocardial inflammation and plasma concentrations of oxide nitric (NO) in SHR and WKY rats with PD.

METHODS

Three weeks after bilateral ligation of the first mandibular molar, or Sham operation, the rats received catheters into the femoral artery and had their arterial pressure (AP) recorded the following day. Subsequently, plasma, heart, and jaw were collected. The NO was quantified by the chemiluminescence method in plasma, and the myocardial IL-1β concentrations were evaluated by ELISA. In the jaw was evaluated linear alveolar bone loss induced by PD.

RESULTS

The linear alveolar bone loss in jaws of SHR with PD was higher than in all other groups. AP and heart rate were higher in SHR than in their WKY counterparts. SHR with PD showed lower AP than control SHR. HRV and APV were different between SHR and WKY rats; however, no differences in these parameters were found between the animals with PD and their control counterparts. Plasma NO and myocardial IL-1β concentrations were higher in SHR with PD as compared to control WKY. A significant correlation was found between linear alveolar bone loss and plasma NO and myocardial IL-1β concentrations.

CONCLUSION

Our results demonstrated that short-term PD lowered the AP in SHR, which might be due to the higher levels of plasma NO. Even though PD did not affect either HRV or APV, it did induce myocardial inflammation, which can determine cardiovascular dysfunction in long-term PD.

What is the future of Periodontal Medicine?

In the last five decades, considerable progress has been made towards understanding the etiology and pathogenesis of periodontal diseases and their interactions with the host. The impact of an individual periodontal condition on systemic homeostasis became more evident because of this knowledge and prompted advances in studies that associate periodontitis with systemic diseases and conditions. The term Periodontal Medicine describes how periodontal infection/inflammation can affect extraoral health. This review presents the current scientific evidence on the most investigated associations between periodontitis and systemic diseases and conditions, such as cardiovascular diseases, diabetes, preterm birth and low birth weight, and pneumonia. Additionally, other associations between periodontitis and chronic inflammatory bowel disease, colorectal cancer, and Alzheimer's disease that were recently published and are still poorly studied were described. Thus, the aim of this review was to answer the following question: What is the future of Periodontal Medicine? Epidemiological evidence and the evidence of biological plausibility between periodontitis and general health reinforce the rationale that the study of Periodontal Medicine should continue to advance, along with improvements in the epidemiological method, highlighting the statistical power of the studies, the method for data analysis, the case definition of periodontitis, and the type of periodontal therapy to be applied in intervention studies.

Effect of periodontal disease on oxidative stress markers in patients with atherosclerosis

OBJECTIVES

The aim of this study was to investigate the effect of periodontal inflammation on oxidative stress in patients with atherosclerosis by considering serum and saliva total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI).

MATERIALS AND METHODS

In the study, there were 4 groups, with 20 individuals in each group. These groups consisted of individuals who had periodontitis with atherosclerosis (group A-P), were periodontally healthy with atherosclerosis (group A-C), were systemically healthy with periodontitis (group P), and were systemically and periodontally healthy (group C). Clinical periodontal parameters were recorded. PISA values were calculated. Atherosclerosis severity was determined by the Gensini score. The ratio of TAS/TOS resulting in the OSI levels of the serum and saliva samples was examined biochemically.

RESULTS

Group A-P serum TAS and group C saliva OSI values were lower than those of the other groups (p < 0.05). Group A-P serum TOS and OSI values were higher than those of the other groups (p < 0.05). Groups A-C and P serum TOS and OSI values were higher than those of group C (p < 0.05). In the multivariate linear regression analysis, group A-P and PISA values were independently associated with serum TOS and OSI values (p < 0.05). Group A-P, group P, and PISA values were independently associated with saliva OSI values (p < 0.05).

CONCLUSIONS

Periodontitis and atherosclerosis may have systemic oxidative stress-increasing effects. The coexistence of periodontitis and atherosclerosis increases oxidative stress beyond that seen in either condition alone. Periodontitis can be associated with increased systemic TOS and OSI values in patients with atherosclerosis.

STATEMENT OF CLINICAL RELEVANCE

Oxidative status is affected more severely when periodontitis and atherosclerosis coexist rather than when either exists alone. Periodontitis can cause increasing effect on serum TOS and OSI and decreasing effect on TAS in patients with atherosclerosis. The increase in oxidative stress markers with the presence of periodontal disease in patients with atherosclerosis emphasizes that controlling periodontal diseases, a treatable disease, may contribute to the prognosis of atherosclerosis.

Periodontitis, Blood Pressure, and the Risk and Control of Arterial Hypertension: Epidemiological, Clinical, and Pathophysiological Aspects-Review of the Literature and Clinical Trials

Purpose of Review

Arterial hypertension is an important risk factor for cardiovascular disease. In the world, about 45% of people suffer from arterial hypertension, while good blood pressure control is achieved by only approximately 50% of all hypertensive patients treated. The reason for the high prevalence of arterial hypertension and its poor control is low knowledge of hypertensinogenic factors. One such factor is periodontitis, which is a disease of social importance.

Recent Findings

It has been shown that the occurrence of periodontitis leads to an increase in blood pressure, increasing the risk of arterial hypertension. Periodontitis can also lead to ineffectiveness of antihypertensive treatment. Some interventional studies have shown that treatment of periodontitis reduced blood pressure in patients with arterial hypertension. The pathogenesis of arterial hypertension in periodontitis is complex and concerns mainly the impairment of the vasodilatation properties of the endothelium.

Summary

Hygiene and periodontitis treatment should be a method of preventing arterial hypertension and a method of increasing the effectiveness of antihypertensive treatment.

Systemic inflammatory response to non-surgical treatment in hypertensive patients with periodontal infection

Hypertension is associated with chronic inflammation in the tissues and organs that are involved in the regulation of arterial pressure, such as kidneys and blood vessels. Periodontal disease affects systemic inflammatory markers, leading to endothelial dysfunction, atherosclerotic plaque instability, dyslipidaemia, and insulin resistance. These conditions can also cause an increase in the blood pressure. Nonsurgical periodontal therapies, such as scaling and root planning, can affect systemic markers of inflammation. We evaluated the effect of scaling and root planning on serum levels of inflammation biomarkers in hypertensive patients. The sample consisted of 19 hypertensive patients with Periodontitis. The patients underwent laboratory tests that included glycaemia, cholesterol, triglycerides and blood count. Blood pressure was measured before periodontal therapy, and the second blood pressure recording was obtained at the re-evaluation appointment. Quantification of peripheral blood cytokines was performed using the Milliplex Inflammation Human Cytokine kit (Interleukin 1-β, Interleukin-4, Interleukin-6, Interleukin-8, Interleukin-10, Interleukin-12 P70, Interleukin-17A, vascular endothelial growth factor and tumor necrosis factor-alpha). All cytokine levels decreased from the initial examination to reassessment. Cytokines that reflected a statistically significant difference included Interleukin-1β and endothelial vascular growth factor (P = .04 and P = .004). Hypertensive patients with periodontitis undergoing non-surgical periodontal treatment exhibited a decrease in proinflammatory cytokine levels. Non-surgical periodontal treatment decreases the levels of systemic proinflammatory cytokines in controlled hypertensive patients.

Periodontal therapy and treatment of hypertension-alternative to the pharmacological approach. A systematic review and meta-analysis

AIM

Quantitative comparison of the effects of intensive (IPT) or conventional (CPT) periodontal treatment on arterial blood pressure, endothelial function and inflammatory/metabolic biomarkers.

MATERIALS AND METHODS

A systematic search was conducted to identify randomized controlled trials (RCT) of IPT (supra and subgingival instrumentation). Eight RCTs were included in the meta-analysis. Difference in change of systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after IPT or CPT were the primary outcomes. The secondary outcomes included: endothelial function and selected inflammatory/anti-inflammatory (CRP, IL-6, IL-10, IFN-γ) and metabolic biomarkers (HDL, LDL, TGs).

RESULTS

The overall effect estimates (pooled Weighted Mean Difference (WMD)) of the primary outcome for SBP and DBP was -4.3 mmHg [95%CI: -9.10-0.48], p = 0.08 and -3.16 mmHg [95%CI: -6.51-0.19], p = 0.06 respectively. These studies were characterized by high heterogeneity. Therefore, random effects model for meta-analysis was performed. Sub-group analyses confirmed statistically significant reduction in SBP [WMD = -11.41 mmHg (95%CI: -13.66, -9.15) P < 0.00001] and DBP [WMD = -8.43 mmHg (95%CI: -10.96,-5.91)P < 0.00001] after IPT vs CPT among prehypertensive/hypertensive patients, while this was not observed in normotensive individuals. The meta-analyses showed significant reductions in CRP and improvement of endothelial function following IPT at all analysed timepoints.

CONCLUSIONS

IPT leads to improvement of the cardiovascular health in hypertensive and prehypertensive individuals.

Inflammation in Periodontal Disease: Possible Link to Vascular Disease

Inflammation is a well-organized protective response to pathogens and consists of immune cell recruitment into areas of infection. Inflammation either clears pathogens and gets resolved leading to tissue healing or remains predominantly unresolved triggering pathological processes in organs. Periodontal disease (PD) that is initiated by specific bacteria also triggers production of inflammatory mediators. These processes lead to loss of tissue structure and function. Reactive oxygen species and oxidative stress play a role in susceptibility to periodontal pathogenic bacterial infections. Periodontal inflammation is a risk factor for systemic inflammation and eventually cardiovascular disease (CVD). This review discusses the role of inflammation in PD and its two way association with other health conditions such as diabetes and CVD. Some of the mechanisms underpinning the links between inflammation, diabetes, CVD and PD are also discussed. Finally, we review available epidemiological data and other reports to assess possible links between oral health and CVD.

The association between metabolic syndrome and periodontitis in Spain: Results from the WORALTH (Workers' ORAL healTH) Study

INTRODUCTION

Evidence of an association between periodontitis and MetS (metabolic syndrome) remains controversial. The objective of this study is to evaluate the association between periodontitis and MetS in a cross-sectional population survey.

MATERIAL AND METHODS

WORALTH (Workers' ORAL healTH) Study is a cross-sectional survey, conducted on a representative sample of the Spanish employed population, including 5154 participants. An oral examination following the World Health Organization (WHO) criteria evaluated the periodontal status using the Community Periodontal Index (CPI) and Clinical Attachment Levels (CAL). Logistic regression analysis with adjustment for potential confounders was used to evaluate the association between periodontitis and MetS, and its individual components.

RESULTS

Participants presenting a CPI = 4 were more likely to have MetS than subjects with CPI < 4 [odds ratio, OR = 1.41; 95% confidence interval (CI) 1.10-1.81; p < 0.001]. High blood pressure was the component with stronger association with periodontal status (OR = 1.94 for CAL ≥6 mm; 95% CI 1.49-2.53; p < 0.001). After stratifying for sex, the association was higher in women (OR = 2.20 for CPI = 4; 95% CI 1.31-3.62; p < 0.001). Non-metabolically healthy subjects, obese or not, presented a worse periodontal condition.

CONCLUSION

Severe periodontitis (CPI = 4) was associated with MetS in a representative sample of the Spanish employed population. This association seems to be independent of body mass index and other potential confounders.

A review of T helper 17 cell-related cytokines in serum and saliva in periodontitis

Periodontitis is a chronic inflammatory disease with a complex underlying immunopathology. Cytokines, as molecular mediators of inflammation, play a role in all stages of disease progression. T helper 17 (Th17) cells are thought to play a role in periodontitis. Th17 cell development and maintenance requires a pro-inflammatory cytokine milieu, with many of the cytokines implicated in the pathogenesis of periodontitis. Serum and saliva are easily accessible biofluids which can represent the systemic and local environment to promote the development of Th17 cells. Here we review human clinical studies that investigate IL-1β, IL-4, IL-6, IL-10, IL-17A, IL-17F, IL-21, IL-22, IL-23, IL-25, IL-31, IL-33, IFN-γ, sCD40L and TNF-α in serum and saliva in periodontitis. We highlight their putative role in the pathogenesis of periodontitis and place them within a wider context of animal and other clinical studies.

Periodontitis is associated with hypertension: a systematic review and meta-analysis

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10-1.35] and severe PD (OR = 1.49; 95% CI: 1.09-2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88-6.11] and DBP (2.03 mmHg; 95% CI: 1.25-2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

Mechanisms underlying the association between periodontitis and atherosclerotic disease

Atherosclerosis is central to the pathology of cardiovascular diseases, a group of diseases in which arteries become occluded with atheromas that may rupture, leading to different cardiovascular events, such as myocardial infarction or ischemic stroke. There is a large body of epidemiologic and animal model evidence associating periodontitis with atherosclerotic disease, and many potential mechanisms linking these diseases have been elucidated. This chapter will update knowledge on these mechanisms, which generally fall into 2 categories: microbial invasion and infection of atheromas; and inflammatory and immunologic. With respect to the invasion and infection of atheromas, it is well established that organisms from the subgingival biofilm can enter the circulation and lodge in most distant tissues. Bacteremias resulting from oral interventions, and even oral hygiene activities, are well documented. More recently, indirect routes of entry of oral organisms (via phagocytes or dendritic cells) have been described for many oral organisms, into many tissues. Such organisms include the periodontal pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Tannerella forsythia, and Fusobacterium nucleatum. Intracellular survival of these organisms with dissemination to distant sites (The Trojan Horse approach) has been described. Their relative contribution to atheroma formation and progression has been studied mainly in experimental research, with results demonstrating that these organisms can invade endothelial cells and phagocytic cells within the atheroma, leading to pathogenic changes and progression of the atheroma lesion. The second category of mechanisms potentially linking periodontitis to atherosclerosis includes the dumping of inflammatory mediators originating from periodontal lesions into the systemic circulation. These inflammatory mediators, such as C-reactive protein, matrix metalloproteinases, fibrinogen, and other hemostatic factors, would further accelerate atheroma formation and progression, mainly through oxidative stress and inflammatory dysfunction. Moreover, direct effects on lipid oxidation have also been described. In summary, the evidence supports the concept that periodontitis enhances the levels of systemic mediators of inflammation that are risk factors for atherosclerotic diseases.

Periodontal therapy and cardiovascular risk

Cardiovascular diseases are the worldwide leading cause of mortality. Cardiovascular diseases are noncommunicable conditions with a complex pathogenesis, and their clinical manifestations include major cardiovascular events such as myocardial infarction and stroke. Epidemiologic evidence suggests a consistent association between periodontitis and increased risk of cardiovascular diseases. Some evidence supports a beneficial effect of the treatment of periodontitis on both surrogate and hard cardiovascular outcomes. This narrative review has been conducted as an update of the most recent evidence on the effects of periodontitis treatment on cardiovascular outcomes since the last commissioned review of the European Federation of Periodontology-American Academy of Periodontology World Workshop in 2012. Newer evidence originating from published randomized controlled trials confirms a positive effect of periodontal treatment on surrogate measures of cardiovascular diseases, whereas there have been no randomized controlled trials investigating the effect of periodontal treatment on the incidence of cardiovascular disease events such as myocardial infarction and stroke. In conclusion, there is sufficient evidence from observational and experimental studies on surrogate cardiovascular measures to justify the design and conduct of appropriately powered randomized controlled trials investigating the effect of effective periodontal interventions on cardiovascular disease outcomes (ie, myocardial infarction and stroke) with adequate control of traditional cardiovascular risk factors.

Periodontitis and Hypertension: Is the Association Causal?

High blood pressure (BP) and periodontitis are two highly prevalent conditions worldwide with a significant impact on cardiovascular disease (CVD) complications. Poor periodontal health is associated with increased prevalence of hypertension and may have an influence on BP control. Risk factors such as older age, male gender, non-Caucasian ethnicity, smoking, overweight/obesity, diabetes, low socioeconomic status, and poor education have been considered the common denominators underpinning this relationship. However, recent evidence indicates that the association between periodontitis and hypertension is independent of common risk factors and may in fact be causal in nature. Low-grade systemic inflammation and redox imbalance, in particular, represent the major underlying mechanisms in this relationship. Neutrophil dysfunction, imbalance in T cell subtypes, oral-gut dysbiosis, hyperexpression of proinflammatory genes, and increased sympathetic outflow are some of the pathogenetic events involved. In addition, novel findings indicate that common genetic bases might shape the immune profile towards this clinical phenotype, offering a rationale for potential therapeutic and prevention strategies of public health interest. This review summarizes recent advances, knowledge gaps and possible future directions in the field.

Periodontal status, vascular reactivity, and platelet aggregation changes in rats submitted to hypercholesterolemic diet and periodontitis

BACKGROUND AND OBJECTIVES

Periodontitis can corroborate with development and progression of atherosclerosis and a possible bidirectional interaction between both pathologies has been hypothesized. The aim of this work was to study the interactions between diet-induced hypercholesterolemia and ligature-induced periodontitis in Wistar rats submitted to both conditions.

MATERIAL AND METHODS

Animals were divided into four experimental groups: C (control: standard diet without periodontitis), Perio (periodontitis plus standard diet), HC (high cholesterol diet without periodontitis), and HC + Perio (high cholesterol diet plus periodontitis). The diets were offered for 45 days and a silk ligature was applied in the lower first molars of Perio and HC-Perio animals on day 34 and maintained for 11 days until euthanasia. The mandibles were excised, and alveolar bone loss was determined by macroscopic and micro-tomographic (µ-CT) imaging. Blood samples were obtained, and platelet aggregation was induced in plasma rich in platelets by adenosine diphosphate (ADP) and collagen. Endothelium-dependent vascular reactivity and protein expression of endothelial (eNOS), phosphorylated endothelial (peNOS), and inducible (iNOS) nitric oxide synthases were evaluated in aorta samples.

RESULTS

The HC diet combined with periodontitis (HC + Perio group) was associated with an increased alveolar bone loss, when compared to the other groups. Both in Perio and HC groups, platelet aggregation induced by ADP or collagen was increased, while maximum aortic relaxation induced by acetylcholine was decreased. Periodontitis or HC diet alone decreased the expression of peNOS and HC diet increased the expression of iNOS. In contrast, no additive or synergistic effects were found in vascular reactivity or in platelet aggregation when the two conditions were associated (HC + Perio group).

CONCLUSION

Hypercholesterolemia accelerated the process of bone loss induced by periodontitis while a high cholesterol diet or periodontitis individually increased platelet aggregation and vascular reactivity in rats without additive or synergistic effects, when associated.

[Obstructive Sleep disordered breathing, sleep bruxism and periodontal diseases]

Sleep disordered breathing (SDB) may be associated with sleep bruxism and periodontal diseases. Through a review of the current literature, this article aims to describe the characteristics of sleep bruxism and its relationship with SDB as well as the current evidence supporting an association between periodontal diseases and SDB. Sleep bruxism is characterized by muscle clenching and tooth grinding during sleep, typically during N2 sleep stage and in association with micro-arousals. The probability of observing sleep bruxism is almost 4 times higher in the presence of SDB, with a close temporal relationship between the episode of upper airway obstruction or oxygen desaturation and the episode of bruxism, which most often occurs in the 0-10 seconds following the obstruction. These findings support the hypothesis that sleep bruxism is triggered by SDB and may have a "protective" role being a muscular activity that helps restore the permeability of the upper airways. On the other hand, SDB have been linked to periodontal diseases. Periodontal diseases are inflammatory and dysbiotic disorders that can have a negative impact on oral health (leading to the destruction of the periodontium and tooth loss) and on general health. Recently, it has been observed that SDB patients have a 1.6 to 4-fold higher risk of having or developing severe periodontitis, suggesting that SDB may be a new risk factor for periodontal diseases. Dentists, who are part of the team of sleep medicine specialists, have a key role in the detection, prevention and treatment of SDB and their relationship with sleep bruxism and periodontal diseases.

Distal Consequences of Oral Inflammation

Periodontitis is an incredibly prevalent chronic inflammatory disease, which results in the destruction of tooth supporting structures. However, in addition to causing tooth and alveolar bone loss, this oral inflammatory disease has been shown to contribute to disease states and inflammatory pathology at sites distant from the oral cavity. Epidemiological and experimental studies have linked periodontitis to the development and/or exacerbation of a plethora of other chronic diseases ranging from rheumatoid arthritis to Alzheimer's disease. Such studies highlight how the inflammatory status of the oral cavity can have a profound impact on systemic health. In this review we discuss the disease states impacted by periodontitis and explore potential mechanisms whereby oral inflammation could promote loss of homeostasis at distant sites.

The Role of the Microbiota in the Diabetic Peripheral Artery Disease

Vascular complications of diabetes mellitus represent a major public health problem. Although many steps forward have been made to define the causes and to find the best possible therapies, the problem remains crucial. In recent years, more and more evidences have defined a link between microbiota and the initiation, promotion, and evolution of atherosclerotic disease, even in the diabetic scenario. There is an urgency to develop the knowledge of modern medicine about the link between gut microbiota and its host's metabolic pathways, and it would be useful to understand and justify the interindividual diversity of clinical disease presentation of diabetic vascular complication even if an optimization of pharmacological treatment has been made or in the case of young patients where hypertension, dyslipidemia, and diabetes are not able to justify a very quick progress of atherosclerotic process. The aim of the present review is to gather all the best available evidence in this regard and to define a new role of the microbiota in this field, from biomarker to possible therapeutic target.

Association of Apical Periodontitis with Cardiovascular Disease via Noninvasive Assessment of Endothelial Function and Subclinical Atherosclerosis

INTRODUCTION

Chronic infections of endodontic origin might predispose to the onset of cardiovascular disease (CVD). The studies depicting the link between apical periodontitis (AP) and CVD are few, and the association is very controversial; also, the markers used are expensive, which makes them difficult to use in general practice. The purpose of this study was to investigate whether an association exists between AP and CVD using noninvasive methods (ie, flow-mediated dilatation [FMD] and carotid intima-media thickness [c-IMT]).

METHODS

This cross-sectional study included 120 men between 20 and 40 years old free from periodontal disease, CVD, and traditional cardiovascular risk factors; 60 subjects had AP, and 60 acted as controls. All subjects underwent complete physical and dental examination, echocardiography, ultrasound assessment of FMD of the right brachial artery, and c-IMT. Data were analyzed using the Mann-Whitney U test and the Spearman rank correlation (r_s) test.

RESULTS

FMD was found to be significantly impaired in patients with AP (mean = 4.9% ± 2.05%) compared with healthy controls (mean = 9.74% ± 2.59%, P = .000). The study also depicts statistically significant differences between c-IMT of the AP (mean = 0.64 ± 0.12 mm) and control (mean = 0.54 ± 0.08 mm) groups (P = .000). A significant inverse correlation between c-IMT and FMD was observed (r_s = -0.381, P = .000).

CONCLUSIONS

Impaired FMD and greater c-IMT in subjects with AP suggests a potential association between endodontic infection and CVD.

The impact of periodontal treatment on inflammatory markers and cellular parameters associated with atherosclerosis in patients after myocardial infarction

Introduction

The aim of this study was to analyze whether periodontal treatment affects the cardiovascular risk profile of patients after myocardial infarction (MI).

Material and methods

The study included 30 patients with chronic periodontitis (ChP). Sociodemographic and medical variables were collected. Patients were provided with scaling and root planing (SRP) 3 months after MI (1^st visit). Periodontal examination and blood tests were performed immediately before SRP, then 1 month and 6 months after treatment (2^nd and 3^rd visit, respectively).

Results

A statistically significant decrease in blood hsCRP concentration and a decrease in the number of white blood cells (WBC) and neutrophils between the first and the second visit were observed. At 6 months after SRP, the mean platelet volume (MPV) had increased with respect to the value at 1 month after treatment. Multivariate analysis showed that the associations between: 1) change in LDL-C concentration and change in approximal plaque index value (b = –0.546, p = 0.005); 2) change in the number of monocytes and change in the plaque index value (b = 0.616, p = 0.01); 3) change in MPV and change in probing pocket depth (b = 0.567, p = 0.018) are all independent of the classic cardiovascular risk factors.

Conclusions

The obtained results indicate the existence of a relationship between the state of periodontal tissues on one hand and mediators of atherosclerosis and the number of immunologically competent cells on the other hand.

Periodontal, metabolic, and cardiovascular disease: Exploring the role of inflammation and mental health

Previous evidence connects periodontal disease, a modifiable condition affecting a majority of Americans, with metabolic and cardiovascular morbidity and mortality. This review focuses on the likely mediation of these associations by immune activation and their potential interactions with mental illness. Future longitudinal, and ideally interventional studies, should focus on reciprocal interactions and cascading effects, as well as points for effective preventative and therapeutic interventions across diagnostic domains to reduce morbidity, mortality and improve quality of life.

Periodontal treatment on patients with cardiovascular disease: Systematic review and meta-analysis

Background

Atherosclerotic cardiovascular disease is the main cause of mortality in developed countries. It is a chronic and systemic inflammatory disease with a multifactorial etiology. Periodontal disease is one of the many factors that contribute to its development.

Objective

To analyze the effects of periodontal treatment on cardiovascular risk parameters in patients with atherosclerotic cardiovascular disease.

Material and Methods

A systematic research was conducted in the Pubmed/Medline databases for clinical trials published up to and including the year 2017.

Results

Ten articles were included for analysis. Periodontal treatment reduced C-reactive protein levels (77.8% of clinical trials), tumor necrosis factor-alpha (66.7%), interleukin-6 (100%) and leukocytes (50%). Fibrinogen levels also improved considerably (66.7%). Effects on lipid parameters were more limited, whereby only oxidized low density lipoprotein and very low density lipoprotein cholesterol decreased significantly. Meta-analysis showed a statistically significant decreased in C-reactive protein and leukocytes values when patients were submitted to non-surgical periodontal treatment in contrast to receiving no treatment at all (mean difference 1.199 mg/L, 95% confidence interval: 1.100-1.299, p<0.001; and mean difference 0,79 g/L, 95% confidence interval: 0.717-0.879, p<0.001, respectively).

Conclusions

Periodontal treatment has a beneficial effect on some of the biochemical parameters considered to represent cardiovascular risk. Further randomized clinical trials are necessary, with longer follow-up periods including regular periodic monitoring, in order to determine the extent of the impact of periodontal treatment.

Key words:Periodontal disease, cardiovascular disease, atherosclerosis, periodontal therapy, periodontal treatment.

Periodontal therapy and endothelial function in coronary artery disease: A randomized controlled trial

OBJECTIVE

To assess the effects of periodontal treatment on endothelial function in patients with coronary artery disease.

MATERIALS AND METHODS

A randomized controlled trial was conducted with 69 patients with stable coronary disease and severe periodontitis. The test group received nonsurgical periodontal therapy consisting of personalized oral hygiene instructions, subgingival scaling, and root planing per quadrant, whereas the control group received equal treatment after the study period. Endothelial function was assessed by measurement of brachial artery flow-mediated dilation, concentrations of sVCAM-1, sICAM-1, and P-selectin in serum before and 3 months after periodontal therapy.

RESULTS

The test group exhibited statistically better periodontal parameters-plaque, probing depth, periodontal attachment loss, and bleeding on probing. No significant improvements were observed in the control (1.37%) and test (1.39%) groups in flow-mediated dilation, with no significant between-group difference. sVCAM-1 concentration increased in the control group (997.6 ± 384.4-1201.8 ± 412.5; p = 0.03), whereas in the test group, no significant changes were observed (915.1 ± 303.8-1050.3 ± 492.3; p = 0.17), resulting in a significant difference between the two groups (p = 0.04). The same pattern was observed for concentrations of sICAM-1.

CONCLUSION

Periodontal treatment did not provide better vasodilation in patients with coronary disease in a short-term follow-up period, although it maintained blood concentrations of markers of vascular inflammation.

Invasive Dental Treatment and Risk for a First Myocardial Infarction

Invasive dental treatment is suggested to be associated with an increased risk for the development of cardiovascular events. We tested the hypothesis that the incidence of a first myocardial infarction (MI) within 4 wk after invasive dental treatments is increased. A registry-based case-control study within nationwide health care and population registries in Sweden was performed. The case patients included 51,880 individuals with a first fatal or nonfatal MI between January 2011 and December 2013. For each case, 5 control subjects, free from prior MI and matched for age, sex, and geographic area of residence, were randomly selected from the national population registry through risk set sampling with replacement, resulting in 246,978 control subjects. Information on dental treatments was obtained from the Dental Health Register, and the procedures were categorized into invasive dental treatments or other dental treatments. Conditional logistic regression was used to estimate odds ratios (ORs) for MI with corresponding 95% confidence intervals (CIs). In addition to the matching variables, adjustments were made for the following confounders: diabetes, previous cardiovascular disease (CVD), CVD drug treatment, education, and income. The mean age for case patients and controls subjects was 72.6 ± 13.0 y and 72.3 ± 13.0 y, respectively. Case patients more often had previous CVD (49% vs. 23%; P < 0.001) and diabetes (19% vs. 11%; P < 0.001) and received more treatment with CVD drugs (68% vs. 56%; P < 0.001) than control subjects. There was no association between invasive dental treatments during the 4 wk preceding the MI index date (crude OR = 0.99; 95% CI, 0.92 to 1.06; adjusted for confounders OR = 0.98; 95% CI, 0.91 to 1.06). This study did not support the hypothesis of an increased incidence of MI after recent invasive dental treatment.

Role of oral and gut microbiome in nitric oxide-mediated colon motility

Periodontal disease (PD), a severe form of gum disease, is among the most prevalent chronic infection in humans and is associated with complex microbial synergistic dysbiosis in the subgingival cavity. The immune system of the body interacts with the microbes as the plaque extends and propagates below the gingival sulcus. Once bacteria reach the gingival sulcus, it can enter the blood stream and affect various areas of the human body. The polymicrobial nature of periodontal disease, if left untreated, promotes chronic inflammation, not only within the oral cavity, but also throughout the human body. Alterations seen in the concentrations of healthy gut microbiota may lead to systemic alterations, such as gut motility disorders, high blood pressure, and atherosclerosis. Although gut microbiome has been shown to play a vital role in intestinal motility functions, the role of oral bacteria in this setting remains to be investigated. It is unclear whether oral microbial DNA is present in the large intestine and, if so, whether it alters the gut microbiome. In addition, polybacterial infection induced PD reduced nitric oxide (NO) synthesis and antioxidant enzymes in rodent colon. In this review, we will discuss the interactions between oral and gut microbiome, specifics of how the oral microbiome may modulate the activities of the gut microbiome, and possible ramifications of these alterations.