Associations of periodontal disease with femoral bone mineral density and estrogen replacement therapy: cross-sectional evaluation of US adults from NHANES III

Age- and sex-related differences of periodontal bone resorption, cognitive function, and immune state in APP/PS1 murine model of Alzheimer's disease

BACKGROUND

The existence of an interconnected mechanism between cognitive disorders and periodontitis has been confirmed by mounting evidence. However, the role of age or sex differences in this mechanism has been less studied. This study aims to investigate sex and age differences in the characterization of periodontal bone tissue, immune state and cognitive function in amyloid precursor protein/presenilin 1(APP/PS1) murine model of Alzheimer's disease (AD).

METHODS

Three- and twelve-month-old male and female APP/PS1 transgenic mice and wild-type (WT) littermates were used in this study. The Morris water maze (MWM) was used to assess cognitive function. The bone microarchitecture of the posterior maxillary alveolar bone was evaluated by microcomputed tomography (micro-CT). Pathological changes in periodontal bone tissue were observed by histological chemistry. The proportions of helper T cells1 (Th1), Th2, Th17 and regulatory T cells (Tregs) in the peripheral blood mononuclear cells (PBMCs) and brain samples were assessed by flow cytometry.

RESULTS

The learning ability and spatial memory of 12-month-old APP/PS1 mice was severely damaged. The changes in cognitive function were only correlated with age and genotype, regardless of sex. The 12-month-old APP/PS1 female mice exhibited markedly periodontal bone degeneration, evidenced by the decreased bone volume/total volume (BV/TV), trabecular thickness (Tb.Th), and bone mineral density (BMD), and the increased trabecular separation (Tb.Sp). The altered periodontal bone microarchitecture was associated with genotype, age and females. The flow cytometry data showed the increased Th1 and Th17 cells and the decreased Th2 cells in the brain and PBMC samples of 12-month-old APP/PS1 mice, compared to age- and sex-matched WT mice. However, there was no statistical correlation between age or sex and this immune state.

CONCLUSIONS

Our data emphasize that age and sex are important variables to consider in evaluating periodontal bone tissue of APP/PS1 mice, and the cognitive impairment is more related to age. In addition, immune dysregulation (Th1, Th2, and Th17 cells) was found in the brain tissue and PBMCs of APP/PS1 mice, but this alteration of immune state was not statistically correlated with sex or age.

Association between periodontitis and osteoporosis in United States adults from the National Health and Nutrition Examination Survey: a cross-sectional analysis

OBJECTIVE

This cross-sectional study aimed to investigate the association between periodontitis and osteoporosis among US adults as well as the subgroup of menopausal women.

BACKGROUND

Periodontitis and osteoporosis are both chronic inflammatory diseases characterized by local or systemic bone resorption. Since they share many risk factors, and the significant decrease in estrogen along with menopause is unfavorable for both diseases, it's reasonable to assume that there exists some links between the two diseases, especially during the menopause.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) 2009-2010 and 2013-2014. Periodontitis (defined according to the CDC/AAP definition) and osteoporosis (assessed by the dual-energy radiation absorptiometry) data were available for 5736 participants, and 519 subjects were enrolled in the subgroup of menopausal women aged 45-60 years old. We used binary logistic regression analysis to examine the association between the two diseases both in crude and fully adjusted model.

RESULTS

In the fully adjusted model, osteoporosis was significantly associated with an increased risk of periodontal disease (OR:1.66, 95% CI: 1.00-2.77) in the whole population. As to the subgroup of menopausal women, osteoporosis group had an adjusted OR of 9.66 (95% CI: 1.13-82.38) for developing severe periodontitis in the fully adjusted model.

CONCLUSIONS

Osteoporosis is significantly associated with periodontitis and the association is even more pronounced in menopausal women with severe periodontitis.

The relationship between FOSB and SOCS3 gene polymorphisms and the susceptibility to periodontitis and osteopenia in the Chinese population

The aim is to analyze the relationship and significance of the FOS, FOSB, Suppressors of cytokine signaling (SOCS), and hypoxia-inducible factor 1 (HIF1) gene loci and their polymorphisms with periodontitis and osteopenia in the Chinese population. In this case-control study, data on questionnaires, periodontal examination, bone mineral density, and FOS, FOSB, SOCS3, and HIF1 gene loci and their polymorphisms were obtained from 474 participants. The data were analyzed using the analysis of variance, Kruskal-Wallis test, χ² test, and logistic regression. The incidence of osteopenia was significantly increased in patients with periodontitis compared to controls (58.6 vs. 34.4%, P < 0.001). Accordingly, the risk was increased 2.21-fold compared with controls (95% CI 2.09-4.95). Osteopenia patients had a significantly higher risk of periodontitis than patients with normal bone density (OR = 3.22, 95% CI 2.09-4.94). There were significant positive associations between FOSB and SOCS3 polymorphisms and periodontitis and osteopenia susceptibility. Individuals carrying the G/G genotype of the FOSB gene rs708905 locus had an increased risk of periodontitis (OR = 5.06, 95% CI 2.36-10.86) and osteopenia (OR = 3.26, 95% CI 1.34-7.96). Compared with the C/C genotype, the A/A genotype of the FOSB rs8105114 locus was associated with a significantly higher risk of periodontitis (OR = 2.14, 95% CI 1.02-4.53) and osteopenia (OR = 2.85, 95% CI 1.12-7.22). Compared with the A/A genotype, the risk of periodontitis in the G/G genotype of the SOCS3 rs7207782 locus was increased 3.10-fold (P < 0.001), and the risk of osteopenia was increased 2.01-fold (P = 0.023). There was a bidirectional relationship between periodontitis and osteopenia. The rs708905 G/G and rs8105114 A/A genotypes of FOSB and the rs7207782 G/G genotype of SOCS3 were risk factors for both periodontitis and osteopenia in the Chinese population, which could increase knowledge about disease‑specific and cross‑disease genetic pattern.

High serum iron markers are associated with periodontitis in post-menopausal women: A population-based study (NHANES III)

AIM

To investigate the association between increased serum markers of iron (ferritin and transferrin saturation) and the severity and extent of periodontitis in post-menopausal (PM) women.

MATERIALS AND METHODS

Data from 982 PM women participating in NHANES III were analysed. Exposures were high ferritin (≥300 μg/ml) and transferrin saturation (≥45%). The primary outcome was moderate/severe periodontitis defined according to Centers for Disease Control and Prevention and the American Academy of Periodontology. The extent of periodontitis was also assessed as outcome: proportion of sites affected by clinical attachment loss ≥4 mm and probing depth ≥4 mm. Crude and adjusted prevalence ratio (PR) and mean ratio (MR) were estimated using Poisson regression.

RESULTS

The prevalence of moderate/severe periodontitis was 27.56%. High ferritin was associated with moderate/severe periodontitis in the crude (PR 1.55, p = .018) and in the final adjusted model (PR 1.53, p = .008). High ferritin and transferrin saturation levels were associated with a higher proportion of sites with clinical attachment loss ≥4 mm (p < .05).

CONCLUSIONS

The increasing serum iron markers seem to contribute to periodontitis severity and extent in PM women.

Oral Osteomicrobiology: The Role of Oral Microbiota in Alveolar Bone Homeostasis

Osteomicrobiology is a new research field in which the aim is to explore the role of microbiota in bone homeostasis. The alveolar bone is that part of the maxilla and mandible that supports the teeth. It is now evident that naturally occurring alveolar bone loss is considerably stunted in germ-free mice compared with specific-pathogen-free mice. Recently, the roles of oral microbiota in modulating host defense systems and alveolar bone homeostasis have attracted increasing attention. Moreover, the mechanistic understanding of oral microbiota in mediating alveolar bone remodeling processes is undergoing rapid progress due to the advancement in technology. In this review, to provide insight into the role of oral microbiota in alveolar bone homeostasis, we introduced the term “oral osteomicrobiology.” We discussed regulation of alveolar bone development and bone loss by oral microbiota under physiological and pathological conditions. We also focused on the signaling pathways involved in oral osteomicrobiology and discussed the bridging role of osteoimmunity and influencing factors in this process. Finally, the critical techniques for osteomicrobiological investigations were introduced.

Oral health and emotional well-being in premenopausal and postmenopausal women: a cross-sectional cohort study

Background

Menopause, the absence of ovarian sex steroids, is frequently accompanied by emotional and physiological changes in a woman´s body, as well as oral health changes. The present study aimed to evaluate the association between the periodontal health status and emotional and physical well-being among postmenopausal women (PMW) in comparison with regularly menstruating premenopausal women (RMPW).

Methods

A total of 115 women (PMW, n = 56, mean age ± SD: 54 ± 5; RMPW, n = 59, mean age ± SD: 41 ± 4) received a comprehensive medical assessment and a full-mouth oral examination. All completed the Women’s Health Questionnaire (WHQ) to measure emotional and physical well-being. The corresponding bone mineral density (BMD) scores were obtained from participants´ medical records.

Results

Tooth loss was significantly higher in PMW than RMPW after adjusting for age (3.88 ± 2.41 vs 2.14 ± 2.43, p < 0.05). No significant difference was found in the prevalence of periodontitis between the two groups (PMW: 39.2%, RMPW: 32.2%, p > 0.05). The prevalence of periodontitis was associated with fewer daily brushing sessions in PMW (p = 0.021). Based on the WHQ, both PMW and RMPW with periodontitis had higher ‘’depressed mood’’ scores compared to periodontally healthy women (p = 0.06 and p = 0.038, respectively). The women who reported fewer daily toothbrushing sessions found to have higher depressive mood scores (p = 0.043).

Conclusions

Presence of periodontitis is associated with the emotional and physical well-being of women and reinforcement of oral healtcare is recommended at different stages of a woman’s life including menopause to reduce the risk for early tooth loss in women.

Low bone mineral density is associated with severe periodontitis at the end of the second decade of life: A population-based study

AIM

To evaluate the association between low bone mineral density (BMD) and severe periodontitis at the end of the second decade of life.

MATERIALS AND METHODS

This population-based study analysed 2032 youngers (18-19 years old) of the RPS cohort. BMD of lumbar spine (BMD-LS) and of the whole body (BMD-WB) were assessed by dual x-ray emission densitometry. Low BMD-LS (Z-score ≤ -2) and low BMD-WB (Z-score ≤ -1.5) were correlated with severe periodontitis. The extent of periodontal disease was also evaluated as the following outcomes: proportions of teeth affected by clinical attachment loss ≥5 mm and probing depth ≥5 mm. Multivariate models by sex, education, family income, risk of alcohol dependence, smoking, plaque, bleeding index, and body mass index were estimated through logistic regression (binary outcomes) and Poisson regression (continuous outcomes).

RESULTS

The prevalence of severe periodontitis was 10.97%. Low BMD-LS (odds ratio [OR] = 2.08, confidence interval [CI] = 1.12-3.85, p = .01) and low BMD-WB (OR = 1.34, CI = 1.001-1.81, p = .04) were associated with severe periodontitis in the final multivariate models. Low BMD-LS and BMD-WB were also associated with a greater extent of periodontitis (p < .05).

CONCLUSIONS

Low BMD was found to be associated with the severity and extent of periodontitis in adolescents. Adolescents at peak bone mass age presenting low BMD are more likely to be affected by severe periodontitis.

Analysis of the relationship between periodontitis and osteoporosis/fractures: a cross-sectional study

BACKGROUND

Chronic periodontitis is a multifactorial inflammatory disease resulting in patients exhibiting high levels of inflammatory factors causing systemic inflammatory bone destruction that may lead to osteoporosis development. The association between periodontitis and osteoporosis has been documented; however, the findings remain unclear. This study aimed to identify the association between periodontitis and osteoporosis using a cross-sectional study design and Korean Genome and Epidemiology Study (KoGES) health examinee data.

METHODS

This cross-sectional study used epidemiological data from the KoGES during 2004-2016. Of 125,324 participants (age, 40-79 years), 9969 with periodontitis and 115,332 controls (without periodontitis) were selected. We analyzed the history of osteoporosis and fractures of all participants. All participants were examined according to age, sex, income group, obesity, smoking habits, alcohol consumption, and food intake. To analyze the odds ratio (OR) of periodontitis for those with osteoporosis and fractures, a logistic regression model was used.

RESULTS

The adjusted odds ratio (aOR) of periodontitis for osteoporosis was 2.16 (95% confidence interval [CI], 2.01-2.31; P < 0.001). The aOR of periodontitis for any fracture was 1.54 (95% CI 1.46-1.62; P < 0.001).

CONCLUSION

Osteoporosis and fractures are associated with periodontitis. Performing regular oral hygiene and examinations of bone mineral density are recommended to prevent aggravation of osteoporosis and periodontitis.

Influence of body mass index and obesity upon the association between periodontitis and sleep apnea-hypopnea syndrome

OBJECTIVES

We aimed to explore the association between periodontitis and sleep apnea-hypopnea syndrome (SAHS) and the possible influence of body mass index (BMI) and obesity upon this association.

MATERIALS AND METHODS

A case-control study was made involving 114 subjects (60 patients with SAHS and 54 controls). A thorough periodontal evaluation was carried out, and demographic and clinical data were collected.

RESULTS

Periodontitis was more prevalent in SAHS (80%) than in the controls (48.1%). The recorded statistically significant association (OR = 4.31; p = 0.001) was seen to weaken in the multivariate model (OR = 2.03; p = 0.204), with BMI adopting a more influential role. The apnea-hypopnea index (AHI) was correlated to probing depth (PD) (r = 0.40; p = 0.002) and clinical attachment level (CAL) (r = 0.41; p = 0.001). The periodontal parameters were seen to be higher in obese SAHS patients (BMI ≥ 30 kg/m²) than in non-obese SAHS patients (BMI < 30 kg/m²).

CONCLUSIONS

The greater prevalence and severity of periodontitis in patients with SAHS were fundamentally influenced by BMI. On the other hand, periodontitis was more severe in patients with severe SAHS.

CLINICAL RELEVANCE

Patients with SAHS have a greater prevalence of periodontitis, fundamentally related to increased obesity. Therefore, obese subjects with SAHS should be screened for periodontal disease.

Effects of estrogen on root repair after orthodontically induced root resorption in ovariectomized rats

INTRODUCTION

This study aimed to investigate the effects of estrogen on root repair after orthodontically induced root resorption.

METHODS

Seventy-two 6-week-old female Wistar rats were randomly divided into 3 groups: ovariectomy only (OVX), ovariectomy plus estradiol injection (OVX + E2), and sham operation (control). E2 was administrated to all the experimental animals after the establishment of the root repair model. One-way analysis of variance with the Tukey post-hoc test was used to analyze the experimental results.

RESULTS

Micro-computed tomography and hematoxylin and eosin staining showed that the total volumes of resorption lacunae were significantly smaller in the control and OVX + E2 groups than those in the OVX group. Alkaline phosphatase and tartrate-resistant acid phosphatase stainings suggested that the cementoblastic activities and the amount of new cementum formation were inhibited while the activities of osteoclasts were obvious in the OVX group. The immunohistochemistry stainings revealed that the osteoprotegerin to receptor activator of nuclear factor-кB ligand ratio and the phosphorylated extracellular signal-regulated kinases to extracellular signal-regulated kinases ratio of the control and OVX + E2 groups were significantly greater than those of the OVX group.

CONCLUSIONS

These findings demonstrated that estrogen administration might be a solution to reduce orthodontically induced root resorption through the activation of extracellular signal-regulated kinase-1/2 pathway and enhancement of cementogenesis.

Trabecular bone score, a new bone quality index, is associated with severe periodontitis

BACKGROUND

The association between systemic bone loss and periodontitis remains unresolved; and the trabecular bone score (TBS) is a new index for assessing decreased bone quality. Therefore, this cross-sectional study investigated the association between TBS and severe periodontitis.

METHODS

Eight hundred and five Thai participants, aged 30 to 82 years, underwent bone quality assessment. Their mean TBS was calculated from dual-energy X-ray absorptiometry images at the L1 to L4 lumbar spine using TBS software. Each participant was classified as normal, partially degraded, or degraded TBS. Full-mouth periodontal examinations determined plaque score, probing depth, clinical attachment level (CAL), and the number of remaining teeth. The participants were classified as non-severe or severe periodontitis. Differences in periodontal parameters between the TBS groups were analyzed using one-way ANOVA. The association between TBS and severe periodontitis was assessed with multivariate binary logistic regression. For severe periodontitis, the additive interaction between TBS and oral hygiene status was also analyzed.

RESULTS

The mean CAL was 0.9-mm higher in the degraded TBS group compared with the normal TBS group. Degraded TBS was associated with severe periodontitis with an adjusted odds ratio (OR) of 2.10 (95% confidence interval [CI] = 1.03 to 4.26). The combination of degraded TBS and plaque score ≥80% increased the adjusted OR to 5.71 (95% CI = 1.15 to 28.43).

CONCLUSIONS

Degraded TBS is associated with severe periodontitis and has a synergistic effect with poor oral hygiene, suggesting monitoring decreased bone quality and good oral hygiene for promoting the periodontal-systemic health of these individuals.

Oestrogen receptor Rsa I gene polymorphism in osteoporosis periodontitis patients with or without dental fluorosis

Background & objectives:

There is a paucity of information on association between dental fluorosis, osteoporosis and periodontitis. The aim of this pilot study was to evaluate oestrogen receptor (ER) Rsa 1 gene polymorphism in osteoporosis periodontitis patients with and without dental fluorosis.

Methods:

Twenty one primary osteoporotic patients suffering from periodontitis with dental fluorosis and 20 primary osteoporotic patients suffering from periodontitis without dental fluorosis participated in this study. Periodontitis was diagnosed based on age, gender T-scores using clinical parameters such as plaque scores, gingival bleeding scores and probing pocket depth, clinical attachment level (CAL) and severity of dental fluorosis. DNA was genotyped at the RsaI RFLP (in exon 5) inside the ER gene to study ER Rsa I gene polymorphism in osteoporosis periodontitis patients with and without dental fluorosis.

Results:

Patients with dental fluorosis had higher degree of osteoporosis than those without fluorosis. CAL was significantly higher (P<0.05) in those with dental fluorosis compared with those without. Rr heterozygote (21.95%) was observed in patients without fluorosis whereas RR mutant homozygote was absent in both the groups. Rr wild homozygote type was seen more in the patients with fluorosis (51.21%). Significant differences were found in distribution of these genotypes between patients with and without dental fluorosis.

Interpretation & conclusions:

This preliminary study showed the presence of ER I gene polymorphism in osteoporosis periodontitis patients without dental fluorosis. Further studies with large sample size are needed to confirm the association shown in this preliminary study.

Significant association between skeletal bone mineral density and moderate to severe periodontitis in fair oral hygiene individuals

AIM

This cross-sectional study aimed to investigate the association between skeletal bone mineral density (BMD) and periodontitis in Thai adults and elders.

METHODS

This study comprised 3282 participants aged 30-82 years. BMD was assessed at 3 skeletal sites using dual-energy X-ray absorptiometry. Each participant's BMD status was classified as normal, osteopenia or osteoporosis. Periodontal assessments were the number of remaining teeth, plaque score, probing depth and clinical attachment level (CAL). The participants were classified into no/mild or moderate/severe periodontitis groups. The mean periodontal variables between BMD categories were compared. The association between the BMD status and moderate/severe periodontitis was analyzed using binary logistic regression.

RESULTS

Among the BMD categories, the greatest mean CAL and the lowest mean number of remaining teeth were found in the osteoporosis group. The mean CAL difference between the osteoporosis and normal BMD groups was 0.3 mm. In 337 participants with a plaque score of less than 40%, there was a significant association between osteoporosis and moderate/severe periodontitis.

CONCLUSION

Skeletal BMD in the osteoporosis range was associated with moderate/severe periodontitis in individuals with fair oral hygiene, suggesting the benefit of special attention to the skeletal bone health of these individuals.

Estrogen signaling impacts temporomandibular joint and periodontal disease pathology

Women experience a higher incidence of oral diseases including periodontal diseases and temporomandibular joint disease (TMD) implicating the role of estrogen signaling in disease pathology. Fluctuating levels of estrogen during childbearing age potentiates facial pain, high estrogen levels during pregnancy promote gingivitis, and low levels of estrogen during menopause predisposes the TMJ to degeneration and increases alveolar bone loss. In this review, an overview of estrogen signaling pathways in vitro and in vivo that regulate pregnancy-related gingivitis, TMJ homeostasis, and alveolar bone remodeling is provided. Deciphering the specific estrogen signaling pathways for individual oral diseases is crucial for potential new drug therapies to promote and maintain healthy tissue.

Difference in the expression of inflammatory mediators in gingival crevicular fluid in postmenopausal patients with chronic periodontitis with and without menopausal hormone therapy

Objective

Hormonal changes experience by women produce significant changes in the periodontium. The aim of this study is to assess whether menopausal hormone therapy, in patients diagnosed with moderate chronic periodontitis and menopause presents a beneficial effect, in terms of clinical and immunological outcomes.

Study design

Thirty subjects with moderate chronic periodontitis and menopause were selected and assigned to two groups in accordance to the presence of menopausal hormone therapy. Periodontal clinical parameters, microbiological samples and immunological variables were assessed in both groups. Inter-group differences were evaluated using non-paired Student t-tests and chi square tests. Also, Pearson coefficient correlation was performed to determine the correlation between variables.

Results

There were statistically significant differences between groups for clinical attachment level, probing pocket depth, interleukin 1β and interleukin 6. Smoking habit, deeper PPD and higher Il-6 levels in non-menopausal hormone therapy users group, tend to increase the interleukin 1ß GCF levels. These findings were supported by serum estrogen levels. The variables levels were higher in the menopausal hormone therapy users group.

Conclusion

Within the limitations of the present study, the hypothesis that menopausal hormone therapy user’s women will show better periodontal status and differences in immunological variables respect to those being non-menopausal hormone therapy users was supported.

Sex hormone replacement therapy in periodontology-A systematic review

OBJECTIVE

To analyse whether sex hormone replacement therapy (HRT) improves periodontal parameters and dental implants osseointegration in humans.

MATERIALS AND METHODS

Electronic databases and hand searches were performed from June to August 2018 in SciELO, LILACS and PubMed/MEDLINE. Human observational and interventional studies that evaluated the following parameters were included: clinical attachment loss (CAL), probing pocket depth (PPD), bleeding on probing (BOP), radiographic bone loss (RBL) or osseointegration.

RESULTS

Initial search retrieved 1,282 non-duplicated articles. Fifteen studies were selected after inclusion criteria were applied. All studies were performed in postmenopausal women. Mean differences for PPD reduction ranged from 0.02 to 0.2 mm in HRT-positive patients; mean CAL gain -0.18 to 0.54 mm; mean RBL reduction -0.87 to 0.15 mm; and mean BOP reduction 9%-30.3%. Failure rate of dental implants increased -5.5% to 11.21% when HRT was used.

CONCLUSIONS

Very low but consistent evidence suggests a reduction in BOP and no impact on RBL in postmenopausal women receiving HRT. There are inconsistent reports that suggest that HRT in postmenopausal women: (a) improves or does not impact PPD reduction and CAL gain; and (b) does not impact or increase implant loss. In summary, there is no evidence to support HRT prescription for either men or women for periodontal/implant placement purposes.

Association between osteoporosis treatment and severe periodontitis in postmenopausal women

OBJECTIVE

To estimate the association between osteoporosis treatment and severe periodontitis in postmenopausal women.

METHODS

This cross-sectional study comprised of 492 postmenopausal women, 113 women in osteoporosis treatment, and 379 not treated. Osteoporosis treatment consisted of systemic estrogen alone, or estrogen plus progestin, and calcium and vitamin D supplements, for at least 6 months. Severe periodontitis was defined as at least two interproximal tooth sites with clinical attachment loss of at least 6 mm, and at least one interproximal site with probing depth of at least 5 mm; and dental caries experience was measured using the decayed, missing, and filled teeth (DMFT) index. Analysis included descriptive statistics and Poisson multivariate analysis with robust variance.

RESULTS

Women receiving osteoporosis treatment had less periodontal probing depth, less clinical attachment loss, and less gingival bleeding than women not receiving treatment for osteoporosis (P ≤ 0.05). In the osteoporosis treatment group, the estimated mean DMFT index score was approximately 20, the most frequent component being the number of missing teeth, and in the nontreated group, the DMFT index was approximately 19. The prevalence of severe periodontitis was 44% lower in the osteoporosis treatment group than in the nontreatment group. The prevalence ratioadjusted was 0.56, 95% confidence interval was 0.31 to 0.99 (P = 0.05), after adjustments for smoking, age, family income, and visit to the dentist.

CONCLUSIONS

The results suggest that women treated with estrogen for postmenopausal osteoporosis have a lower prevalence of severe periodontitis than women not receiving treatment.

Bone Density and Clinical Periodontal Attachment in Postmenopausal Women: A Systematic Review and Meta-Analysis

Osteoporosis is a systemic skeletal disease characterized by low bone mineral density (BMD) and has been considered a risk factor for periodontal disease. The aim of this systematic review and meta-analysis was to verify the scientific evidence for the association of periodontal attachment loss with low BMD in postmenopausal women. A systematic search of the literature was performed in databases until August 2016, in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Eligibility criteria included studies that compared clinical attachment loss (CAL) between postmenopausal women with low and normal BMD. Studies using similar methodology, with lower and higher risk of bias, were pooled into 3 different meta-analyses to compare CAL among women with normal BMD, osteoporosis, and osteopenia. In the first meta-analysis, mean CAL was compared among groups. In the other 2 meta-analyses, the mean percentages of sites with CAL ≥4 mm and ≥6 mm were respectively compared among groups. From 792 unique citations, 26 articles were selected for the qualitative synthesis. Eleven of the studies were appraised as presenting low risk of bias, and the association between low BMD and CAL was observed in 10 of these studies. Thirteen cross-sectional articles were included in the meta-analysis for osteoporosis and 9 in the osteopenia analysis. Women with low BMD presented greater mean CAL than those with normal BMD (osteoporosis = 0.34 mm [95% confidence interval (CI), 0.20–0.49], P < 0.001; osteopenia = 0.07 mm [95% CI, 0.01–0.13], P = 0.02). Only studies with lower risk of bias were available for the analysis of CAL severity. Women with low BMD presented more severe attachment loss, represented as mean percentage of sites with CAL ≥4 mm (osteoporosis = 3.04 [95% CI, 1.23–4.85], P = 0.001; osteopenia = 1.74 [95% CI, 0.36–3.12], P = 0.01) and CAL ≥6 mm (osteoporosis = 5.07 [95% CI, 2.74–7.40], P < 0.001). This systematic review and meta-analysis indicates that postmenopausal women with osteoporosis or osteopenia may exhibit greater CAL compared with women with normal BMD.

Comparison of bone mineral density among pre- and post-menopausal women with and without chronic generalized periodontitis

Background

There have been a very limited number of studies regarding the assessment of bone mineral density (BMD) using dual energy X-ray absorptiometry scan. Hence, the purpose of the study was to assess the relationship between BMD and periodontal health in three different study groups.

Materials and Methods

The study comprised of thirty female individuals who were categorized into three groups: ten premenopausal women with healthy periodontium (Group A), ten premenopausal women with generalized chronic periodontitis (Group B), and ten postmenopausal women with generalized chronic periodontitis (Group C). Number of teeth, plaque index, probing depth, clinical attachment level, interproximal alveolar bone loss, T-score for dual femur and posteroanterior (PA) spine, and BMD for dual femur and PA spine of each individual were recorded in all the three groups.

Results

The BMD and T-score of dual femur and PA spine were found to be low in Group C when compared to Group A and B which was statistically significant.

Conclusion

Postmenopausal women with generalized chronic periodontitis (Group C) exhibited severe periodontal destruction with less BMD. Hence, it is suggested that periodontitis may be a risk indicator for osteoporosis in postmenopausal women and vice versa.

Longitudinal Study of Bone Density and Periodontal Disease in Men

Bone loss is a feature of both periodontitis and osteoporosis, and periodontal destruction may be influenced by systemic bone loss. This study evaluated the association between periodontal disease and bone mineral density (BMD) in a cohort of 1347 (137 edentulous) older men followed for an average of 2.7 years. Participants were recruited from the Osteoporotic Fractures in Men Study. Random half-mouth dental measures included clinical attachment loss (CAL), pocket depth (PD), calculus, plaque, and bleeding. BMD was measured at the hip, spine, and whole-body, by dual-energy x-ray absorptiometry, and at the heel by ultrasound. After adjustment for age, smoking, race, education, body mass index, and calculus, there was no association between number of teeth, periodontitis, periodontal disease progression, and either BMD or annualized rate of BMD change. We found little evidence of an association between periodontitis and skeletal BMD among older men.

Associations between the number of natural teeth in postmenopausal women and hormone replacement therapy

OBJECTIVES

Increasing research suggests that periodontal status is associated with hormone replacement therapy in postmenopausal women. This study was performed to assess the relationship between the number of natural teeth and ever use of hormone replacement therapy in postmenopausal women using nationally representative Korean data.

METHODS

Data from the Korea National Health and Nutrition Examination Survey between 2010 and 2012 were used, and the analysis in this study was confined to a total of 4869 respondents over 19 years old who had gone through menopause and who had no missing data for the reproductive factors and outcome variables in that study. The total number of natural teeth was then calculated after excluding third molars. The time of day when tooth brushing was done was recorded as representative oral health behavior. Multiple logistic regression analyses were used to assess association between the number of natural teeth and the use of hormone replacement therapy.

RESULTS

Among participants who had ever used hormone replacement therapy, the proportions (percentage and standard error) with no teeth, 1-9 teeth, 10-19 teeth, 20-27 teeth, and 28 teeth were 5.0±2.4%, 6.7±1.4%, 12.5±1.7%, 18.9±1.0%, and 20.7±1.6%, respectively (P<0.05). The adjusted odds ratio and 95% confidence interval for having fewer than 20 teeth <20 was 0.624 [0.464-0.840] for the individuals using hormone replacement therapy, after adjustments.

CONCLUSIONS

The analysis revealed that the use of hormone replacement therapy by postmenopausal women showed positive effects for retention of natural teeth. Lack of hormone replacement therapy may be considered to be an independent risk indicator for tooth loss in Korean postmenopausal women.

Association of osteoporosis and bone medication with the periodontal condition in elderly women

This study investigated whether osteoporosis and its treatment may affect periodontal condition in elderly women. The findings highlighted that women with osteoporosis had a higher chance to present severe periodontitis than women with normal bone mineral density (BMD), particularly those who were not treated for osteoporosis.

INTRODUCTION

This study investigated whether osteoporosis increases the frequency and severity of chronic periodontitis in elderly women and evaluated the influence of vitamin D and osteoporosis treatment in the periodontal condition.

METHODS

In this cross-sectional study, elderly women were selected among 1266 subjects evaluated for lumbar spine and proximal femur bone mineral density (BMD) using dual energy X-ray absorptiometry. Sociodemographic, clinical characteristics, and complete periodontal examination were recorded. Serum 25-hydroxyvitamin D levels were measured by chemiluminescence.

RESULTS

Forty-eight elderly women with normal BMD and 86 with osteoporosis were selected. Women with osteoporosis presented higher frequency of sites with clinical attachment level ≥6 mm (p = 0.003) and gingival recession ≥3 mm (p = 0.002) than those with normal BMD and were more than twice as likely to present severe periodontitis (odds ratio (OR) = 2.49, 95 % CI [1.14 to 5.43]). Osteoporotic women who were not treated for the condition had more chance to present severe periodontitis (OR = 3.16, 95 % CI [1.28 to 7.82]) than those who did use bisphosphonates (OR = 2.04, 95 % CI [0.85 to 4.89]). Among the participants who presented low levels of vitamin D, those with osteoporosis exhibited a higher chance to present severe periodontitis than those with normal BMD (p = 0.027), but the association between vitamin D levels and osteoporosis was not statistically significant after adjustment (p = 0.198).

CONCLUSIONS

Elderly women with osteoporosis have a greater chance to present periodontitis, with higher severity than those with normal BMD. Osteoporosis treatment provides protection for periodontitis.

Periodontal treatment outcomes in post menopausal women receiving hormone replacement therapy

Purpose:

To evaluate the effect of hormone replacement therapy(HRT) on periodontal treatment outcomes in a group of postmenopausal women with periodontitis.

Materials and Methods:

23 post-menopausal chronic periodontitis patients were included in this study. The test group(n=11) consisted of women who started HRT with this study and received conjugated estrogen and medroxyprogesteron. The control group(n=12) was women not taking any HRT or supplement therapy. Study groups received the same periodontal treatment. All subjects examiend by recording the following: plaque index (PI), sulcus bleeding index (SBI), periodontal pocket depth (PD) and relative attachment level (RAL) from 6 sites in each tooth. Measurements were recorded at the baseline, 1 month, 3 months, and 6 months following periodontal treatment. Serum estrogene level and bone mineral density was recorded at baseline and 6 months following periodontal treatment.

Results:

The GI change was greater in the control group. There wasn’t significant difference by means of PD, the attachment gain was significantly greater in the HRT receiving group.

Conclusion:

HRT seems to have a positive effect on periodontal treatment outcomes.

Influence of sex steroids on inflammation and bone metabolism

Sex steroids are central to sexual development and reproduction, exerting pleiotropic effects on multiple tissues and organs throughout the lifespan of humans. Sex steroids are fundamental to skeletal development, bone homeostasis and immune function. The composite effect of sex-specific genetic architecture and circulating levels of sex-steroid hormones closely parallels differences in the immune response and may account for corresponding sex-related differences in risk for chronic periodontitis, with men exhibiting greater susceptibility than women. Age-associated reductions in sex steroids also provide insight into apparent temporal increases in susceptibility to periodontitis and alveolar bone loss, particularly among women. Chronic infection and inflammatory conditions, such as periodontal disease, provide a unique platform for exploring the interface of sex steroids, immunity and bone metabolism.

Effects of oestrogen deficiency on the alveolar bone of rats with experimental periodontitis

Periodontitis is an inflammatory disease characterized by loss of connective tissue and alveolar bone, and osteoporosis is a common disease characterized by a systemic impairment of bone mass and microarchitecture. To date, the association between periodontitis and osteoporosis has remained to be fully elucidated. In the present study, an experimental rat model of periodontitis was used to explore the effects of oestrogen deficiency-induced osteoporosis on the maxillary alveolar bone. Forty-four female, six-month-old Sprague-Dawley rats were randomly divided into four groups: Control, ligature, ovariectomized (OVX), and OVX + ligature. One month after ovariectomy, rats in the ligature and OVX + ligature groups received ligatures on their first and second maxillary molars for 1 month. Fluorescent labelling was performed prior to sacrificing the animals. At the end of the experiment, the maxillae and serum were collected and subjected to micro-computed tomography analysis, confocal laser-scanning microscopic observation, Van Gieson's fuchsin staining, tartrate-resistant acid phosphatase staining and ELISA. Ligatures slightly reduced the alveolar bone mineral density (BMD) and bone formation rate, but significantly reduced alveolar crest height (ACH). Ovariectomy reduced the alveolar BMD, impaired the trabecular structure, reduced the bone formation rate and increased the serum levels of bone resorption markers. Animals in the OVX + ligature group exhibited a lower alveolar BMD, a poorer trabecular structure, a reduced ACH, a lower bone formation rate and higher serum levels of bone resorption markers compared with those in the control group. The results of the present study showed that ovariectomy enhanced alveolar bone loss and reduced the ACH of rats with experimental periodontitis. Thus, post-menopausal osteoporosis may influence the progression of periodontitis.

Association between periodontal disease and osteoporosis by gender: a nationwide population-based cohort study

Periodontitis and osteoporosis are primary concerns in public health and clinical management. The aim of this study was to investigate the association between periodontitis and osteoporosis by gender.Data were retrieved from the National Health Insurance Research Database, Taiwan. A diagnosis of periodontitis was defined on the basis of subgingival curettage, periodontal flap operation, and gingivectomy (excluding those with restorative or aesthetic indications). Multiple logistic regression was used for analysis. After adjusting for age, sex, income, and geographical region, there was a significant association between periodontitis and osteoporosis among women (odds ratio: 1.96; 95% confidence interval 1.17-3.26). The association between periodontitis and osteoporosis was significant among women.

The association between periodontal disease, tooth loss and bone mineral density in a Korean population

OBJECTIVE

We aimed to evaluate whether clinical attachment loss (CAL), a measure of the severity of periodontal disease or number of teeth present is associated with bone mineral density (BMD).

METHODS

The study population consisted of 5383 people aged 50 years and older who participated in the Dong-gu Study. BMD at the lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry. Oral examination included assessments of the number of teeth present and CAL. Number of teeth present was categorized into three equal categories. CAL values were divided into tertiles in terms of the percentage of sites with CAL ≥4 mm. Analysis of covariance was used to compare the adjusted means of BMD according to the tooth number and the tertiles of CAL.

RESULTS

There was a significant association between the number of teeth present and BMD in men. Compared with men with 22 or more teeth, men with 10 and less teeth had lower BMD. CAL was significantly associated with lower BMD at the lumbar spine in women.

CONCLUSION

Our data indicate that tooth loss and CAL were associated with low BMD. However, the magnitude of these associations was relatively small and the clinical significance was unclear.

Introduction to Through-Transmission Alveolar Ultrasonography (TAU) in Dental Medicine

Through-transmission alveolar ultrasonography (TAU) is a novel imaging modality in dental medicine. A brief introduction to through-transmission ultrasonography (TTU) is followed by a description of the first commercially available TAU device, the Cavitat CAV 4000 (Cavitat Medical Technologies, Inc., Alba, TX). Recent associations between systemic osteoporosis, oral osteoporosis, periodontal diseases, and cardiovascular diseases underline the importance of early detection and treatment of oral cancellous bone pathologies associated with low bone density (LBD), such as regional ischemic osteoporosis, chronic nonsuppurative osteomyelitis, bone marrow edema, and cavitational ischemic osteonecrosis (osteocavitation). While the impact of osteoporosis on maxillofacial bones is acknowledged, there is a lack of reliable prevalence rate, and the National Institutes of Health (NIH) recommend that more attention should be paid to skeletal health, especially in persons with conditions known to be associated with secondary osteoporosis. TAU, a safe and effective imaging modality, can be a valuable tool in research as well as for the clinical assessment of alveolar cancellous bone pathologies associated with LBD and ischemia.

Do patients with osteoporosis have an increased prevalence of periodontal disease? A cross-sectional study

The study examined if women with osteoporosis were at increased risk of periodontal disease. Three hundred eighty females aged 45-65 years with recent dual-energy X-ray absorptiometry (DXA) scans of the spine and proximal femur agreed to a dental examination. No association was established between the presence of severe periodontal disease and osteoporosis.

INTRODUCTION

The purpose of this study is to determine whether patients with osteoporosis have an increased severity and extent of periodontal disease, taking full account of confounding factors.

METHODS

Volunteer dentate women (45-65 years), who had undergone recent DXA of the femur and lumbar spine, received a clinical examination of their periodontal tissues by a single trained operator who was blind to the subject's osteoporosis status. Clinical examinations were performed within 6 months of the DXA. Basic Periodontal Examination score, gingival bleeding score, periodontal pocket depth, recession and calculus were the periodontal outcome measures. Potential confounding factors were recorded. Logistic regression was performed for the dichotomous outcome measure of severe periodontal disease (present or absent) with osteoporotic status, adjusting for confounding factors.

RESULTS

There were 380 dentate participants for whom DXA data were available. Of these, 98 had osteoporosis. When compared with osteoporotic subjects, those with normal bone mineral density were significantly younger (p = 0.01), had a higher body mass index (p = 0.03) and had more teeth (p = 0.01). The prevalence of severe periodontal disease in the sample was 39 %. The unadjusted odds ratio for the association between osteoporosis and severe periodontal disease was 1.21 (0.76 to 1.93). The adjusted odds ratio analysis including other covariates (age, smoking, hormone replacement therapy, alcohol) was 0.99 (0.61 to 1.61).

CONCLUSION

No association was established between the presence of severe periodontal disease and osteoporosis.

Osteoporosis, jawbones and periodontal disease

The association between osteoporosis and jawbones remains an argument of debate. Both osteoporosis and periodontal diseases are bone resorptive diseases; it has been hypothesized that osteoporosis could be a risk factor for the progression of periodontal disease and vice versa. Hypothetical models linking the two conditions exist: in particular, it is supposed that the osteoporosis-related bone mass density reduction may accelerate alveolar bone resorption caused by periodontitis, resulting in a facilitated periodontal bacteria invasion. Invading bacteria, in turn, may alter the normal homeostasis of bone tissue, increasing osteoclastic activity and reducing local and systemic bone density by both direct effects (release of toxins) and/or indirect mechanisms (release of inflammatory mediators). Current evidence provides conflicting results due to potential biases related to study design, samples size and endpoints. The aim of this article is to review and summarize the published literature on the associations between osteoporosis and different oral conditions such as bone loss in the jaws, periodontal diseases, and tooth loss. Further well-controlled studies are needed to better elucidate the inter-relationship between systemic and oral bone loss and to clarify whether dentists could usefully provide early warning for osteoporosis risk.

Potential implications of adjuvant endocrine therapy for the oral health of postmenopausal women with breast cancer

Current adjuvant treatment modalities for breast cancer that express the estrogen receptor or progesterone receptor include adjuvant anti-estrogen therapies, and tamoxifen and aromatase inhibitors. Bone, including the jaw, is an endocrine-sensitive organ, as are other oral structures. This review examines the potential links between adjuvant anti-estrogen treatments in postmenopausal women with hormone receptor positive breast cancer and oral health. A search of PubMed, EMBASE, CENTRAL, and the Web of Knowledge was conducted using combinations of key terms "breast," "cancer," "neoplasm," "Tamoxifen," "Aromatase Inhibitor," "chemotherapy," "hormone therapy," "alveolar bone loss," "postmenopausal bone loss," "estrogen," "SERM," "hormone replacement therapy," and "quality of life." We selected articles published in peer-reviewed journals in the English. The authors found no studies reporting on periodontal diseases, alveolar bone loss, oral health, or oral health-related quality of life in association with anti-estrogen breast cancer treatments in postmenopausal women. Periodontal diseases, alveolar bone density, tooth loss, and conditions of the soft tissues of the mouth have all been associated with menopausal status supporting the hypothesis that the soft tissues and bone of the oral cavity could be negatively affected by anti-estrogen therapy. As a conclusion, the impact of adjuvant endocrine breast cancer therapy on the oral health of postmenopausal women is undefined. The structures of the oral cavity are influenced by estrogen; therefore, anti-estrogen therapies may carry the risk of oral toxicities. Oral health care for breast cancer patients is an important but understudied aspect of cancer survivorship.

Five-year changes in periodontal disease measures among postmenopausal females: the Buffalo OsteoPerio study

BACKGROUND

Understanding of longitudinal characteristics of periodontal disease in older females is limited. This study examined 5-year changes in periodontal disease measures among postmenopausal females.

METHODS

Participants were 1,025 postmenopausal, 53- to 83-year-old females who completed baseline (1997 to 2001) and 5-year follow-up (2002 to 2006) whole-mouth oral examinations in a study ancillary to the Women's Health Initiative. Periodontal disease was characterized using probing depth (PD), clinical attachment level (CAL), alveolar crest height (ACH), and tooth loss. Differences in measures between examinations were used to characterize patterns of change.

RESULTS

Baseline prevalence of none/mild, moderate, and severe periodontal disease defined using criteria of the Centers for Disease Control and Prevention was 27%, 58%, and 15%, respectively. Tooth loss attributable to periodontitis occurred in 13% of females. Mean ± SD changes in whole-mouth mean measures showed progression when based on ACH (-0.19 ± 0.49 mm) yet relatively stable disease when based on PD (0.11 ± 0.42 mm) and CAL (0.06 ± 0.58 mm). Mean change in worst-site ACH was greater (P <0.001) in females with severe periodontitis and osteoporosis at baseline and with tooth loss during follow-up. Periodontal changes did not differ according to baseline age, hormone therapy use, smoking status, or age at menopause.

CONCLUSIONS

Five-year changes in periodontal measures among generally healthy postmenopausal females were, on average, small and did not suggest a consistent pattern of disease progression. Females with history of severe periodontitis or osteoporosis may experience accelerated oral bone loss despite stability or small improvement in routine probing measures.

Change in bone mineral density and tooth loss in Japanese community-dwelling postmenopausal women: a 5-year cohort study

The aim of this longitudinal study was to investigate the association between the change in bone mineral density (BMD) and tooth loss in Japanese community-dwelling postmenopausal women. The subjects were 404 women. At baseline (2005) and follow-up (2010), BMDs of the lumbar spine and right femoral neck were measured using dual-energy X-ray absorptiometry (QDR4500a) and participants were classified by tertiles of the annual percentage change in BMD. The number of teeth was counted at the baseline and follow-up to calculate the number of lost teeth over 5 years. Poisson regression analysis was conducted with tertiles of the changes in BMDs of the lumbar spine and femoral neck as the main exposures to estimate their influence on the number of lost teeth. Participants in the tertile with a greater decrease in BMD at each skeletal site (lumbar spine and femoral neck, respectively) had a larger number of lost teeth, controlling for possible confounders. The adjusted relative risks (95% confidence interval) for the mean number of lost teeth in the first, second, and third tertiles were 1.00, 1.15 (0.91-1.45), and 1.38 (1.11-1.72) for the lumbar spine and 1.00, 1.17 (0.93-1.47), and 1.27 (1.01-1.59) for the femoral neck, respectively. In conclusion, a significant relationship exists between a change in BMD and the number of lost teeth during 5-year study period in Japanese community-dwelling postmenopausal women.

Effect of hormone replacement therapy (HRT) on periodontal status of postmenopausal women

BACKGROUND

The risks/benefits balance of hormone replacement therapy (HRT) is controversial. The aim of this study was to assess the periodontal status of a postmenopausal women group receiving HRT and to determine the effects of HRT on clinical measures of periodontal disease.

MATERIAL/METHODS

Ninety-one postmenopausal women, 52 taking HRT (HRT+) and 39 not taking HRT (HRT-), completed the study. Clinical parameters measured included visible supragingival plaque, probing pocket depth (PD) and clinical attachment level (CAL). Gingival status was recorded as gingival bleeding on probing (BOP). Previous oral contraceptive use and current and past smoking status were also assessed.

RESULTS

Data indicated that PD and CAL were not significantly different between HRT+ patients and HRT- patients (P=0.8067 and P=0.1627, respectively). The HRT+ group exhibited significantly lower visible plaque levels compared to the control group (P<0.0001). The percentage of gingival sites with positive BOP was significantly lower in the HRT+ group compared to the HRT- group (34.85% vs. 65.15%; P=0.0007). Plaque accumulation was also tested in ANCOVA as a possible explanatory variable for the differences observed in gingival bleeding. The ANCOVA showed no significant differences in gingival bleeding between HRT+ and HRT- women (P=0.4677). No significant differences in past smoking status and oral contraceptive use were detected between HRT+ and HRT- women (P=0.9999 and P=0.0845, respectively).

CONCLUSIONS

These findings indicated that long-term HRT was not associated with relevant effects on periodontal status and clinical measures of periodontal disease, thus suggesting that HRT may not confer protection against periodontitis in postmenopausal women.

Is long-term bisphosphonate therapy associated with benefits to the periodontium in postmenopausal women?

OBJECTIVE

The aim of this study was to compare the periodontium of postmenopausal women with known low bone mineral density who are receiving long-term bisphosphonate therapy with those who are not.

METHODS

The periodontal status of 28 white postmenopausal women with low bone density using bisphosphonate therapy for at least 2 years was compared with that of a matching group not using such therapy. All women underwent a cone-beam CT scan of the jaw and a complete periodontal examination evaluating for plaque score, periodontal probing depth, clinical attachment loss, bleeding on probing, and alveolar bone height.

RESULTS

Bisphosphonate users had higher plaque score, lower probing depth, and lesser clinical attachment loss compared with the controls. These differences were determined to be significant by both t test and Wilcoxon's tests. Bleeding on probing was lower and the alveolar bone height was higher in the bisphosphonate group than in controls, but these differences were not statistically significant. Linear models showed no significant interactions between plaque score and bisphosphonate use, suggesting that the association of periodontal status and outcome measures was constant across all levels of plaque scores. Bisphosphonate use was a significant factor for probing depth but was not significant for the other parameters when adjusted for plaque score.

CONCLUSIONS

Long-term bisphosphonate use seems to have some beneficial effects on the periodontium of postmenopausal women with low bone density, across all levels of plaque score.