Association between dental factors and mortality

Endodontic Inflammatory Disease and Future Cardiovascular Events and Mortality: A Report from the PAROKRANK Study

INTRODUCTION

Prospective studies assessing the relation between endodontic inflammatory disease and subsequent cardiovascular events are few. The present aim was to explore associations between endodontic variables and future cardiovascular events in patients with myocardial infarction and matched controls participating in the PAROKRANK (Periodontitis and Its Relation to Coronary Artery Disease) study.

METHODS

Eight-hundred five patients hospitalized for a first myocardial infarction and 805 controls were recruited between 2010 and 2014. Signs of endodontic inflammatory disease were assessed in panoramic radiographs taken at baseline. Mortality and morbidity data during the approximately 8 years of follow up were obtained from national registries. The risk for future cardiovascular events (first of mortality and nonfatal myocardial infarction, stroke, or hospitalization for heart failure) was analyzed with the log-rank test and Cox proportional hazards regression adjusted for the following confounders: sex, age, smoking, myocardial infarction, diabetes, education, marital status, family history of cardiovascular disease, and marginal periodontitis.

RESULTS

In total, 285 future events were observed during the follow-up period. Unadjusted analyses revealed that ≥1 root-filled tooth increased the risk of a future event. After adjustment, the number of remaining teeth and non-root-filled teeth decreased the risk of future events, whereas a higher Decayed, Missing and Filled Teeth score increased the risk and ≥1 primary apical periodontitis decreased the risk of suffering cardiovascular events. A higher Decayed, Missing and Filled Teeth score and decayed teeth increased the risk of all-cause mortality.

CONCLUSIONS

Tooth loss is a strong indicator of an increased risk for future cardiovascular events. Root-filled teeth seem of limited value as a risk indicator when accounting for other risk factors. The potential effect of dental interventions on future events should be assessed in future research.

Association between apical periodontitis and secondary outcomes of atherosclerotic cardiovascular disease: A case-control study

AIM

To evaluate the association between apical periodontitis (AP) and atherosclerotic cardiovascular disease (ASCDV).

METHODOLOGY

A total of 65 periodontally and systemically healthy patients (age ≥ 40 years) were included in the study. Periapical status was assessed through dental examination and periapical radiographs; 33 subjects had AP (AP+), while 32 acted as control (AP-). Moreover, data regarding their periapical index (PAI) score and the Decayed, Missing, and Filled Teeth (DMFT) index were recorded. All subjects underwent echo-colour Doppler assessment of carotid intima-media thickness (CIMT), carotid plaques, degree of stenosis using the North American Symptomatic Carotid Surgery Trial (NASCET) method, maximum diameter of the abdominal aorta (maximum AA) and common iliac arteries (CIA) diameters. Furthermore, peripheral blood flow was also measured using the ankle-brachial index (ABI). Simple and multiple regression analyses were performed.

RESULTS

Among AP+ patients, 57.58% disclosed at least one sign of subclinical carotid atherosclerosis. Multiple regression analysis identified AP as a significant risk indicator for carotid plaques [OR = 4.87 (1.27, 18.98; p = .021)] and marked carotid intima-media thickenings (OR = 14.58 [1.22, 176.15], p = .035). A significant association was established between AP and other cardiovascular (CV) variables (CIMT, NASCET, and maximum AA). On the contrary, a higher PAI score does not correlate to increased odds of carotid alterations, and the presence of AP did not prove any significant change in CIA and ABI. No significant correlation was established between DMFT and other variables.

CONCLUSIONS

Results from the current study highlight that the presence of AP may be regarded as a risk indicator for ASCVD, with AP being associated with 5-fold increased odds of having carotid plaques and 15-fold increased odds of having marked carotid intima-media thickenings. Further studies should be conducted in order to verify whether AP treatment could be beneficial for ASCVD signs.

Systemic Metabolic Signatures of Oral Diseases

Systemic metabolic signatures of oral diseases have been rarely investigated, and prospective studies do not exist. We analyzed whether signs of current or past infectious/inflammatory oral diseases are associated with circulating metabolites. Two study populations were included: the population-based Health-2000 (n = 6,229) and Parogene (n = 452), a cohort of patients with an indication to coronary angiography. Health-2000 participants (n = 4,116) provided follow-up serum samples 11 y after the baseline. Serum concentrations of 157 metabolites were determined with a nuclear magnetic resonance spectroscopy-based method. The associations between oral parameters and metabolite concentrations were analyzed using linear regression models adjusted for age, sex, number of teeth, smoking, presence of diabetes, and education (in Health-2000 only). The number of decayed teeth presented positive associations with low-density lipoprotein diameter and the concentrations of pyruvate and citrate. Negative associations were found between caries and the unsaturation degree of fatty acids (FA) and relative proportions of docosahexaenoic and omega-3 FAs. The number of root canal fillings was positively associated with very low-density lipoprotein parameters, such as diameter, cholesterol, triglycerides, and number of particles. Deepened periodontal pockets were positively associated with concentrations of cholesterol, triglycerides, pyruvate, leucine, valine, phenylalanine, and glycoprotein acetyls and negatively associated with high-density lipoprotein (HDL) diameter, FA unsaturation degree, and relative proportions of omega-6 and polyunsaturated FAs. Bleeding on probing (BOP) was associated with increased concentrations of triglycerides and glycoprotein acetyls, as well as decreased proportions of omega-3 and omega-6 FAs. Caries at baseline predicted alterations in apolipoprotein B-containing lipoproteins and HDL-related metabolites in the follow-up, and both caries and BOP were associated with changes in HDL-related metabolites and omega-3 FAs in the follow-up. Signs of current or past infectious/inflammatory oral diseases, especially periodontitis, were associated with metabolic profiles typical for inflammation. Oral diseases may represent a modifiable risk factor for systemic chronic inflammation and thus cardiometabolic disorders.

Tooth loss, denture use, and all-cause and cause-specific mortality in older adults: a community cohort study

Objectives

The available evidence on the connections between tooth loss, denture use, and mortality from all causes or specific causes among older adults is inconclusive. Therefore, we aimed to investigate the association between tooth loss, denture use, and all-cause and cause-specific mortality in older adults.

Methods

A cohort of 5,403 participants aged 65 and older were recruited in the 2014 Chinese Longitudinal Healthy Longevity Survey wave and followed up in the 2018 wave. Cox proportional hazard models were used to examine the association between the number of natural teeth, denture use, and all-cause and cause-specific mortality.

Results

During a mean (SD) follow-up of 3.1  years (1.3), 2,126 deaths (39.3%) occurred. Individuals with 0 and 1-9 teeth had higher mortality due to all-cause, cardiovascular disease (CVD), cancer, and other causes (all p-trend <0.05) than those with 20+ teeth. At the same time, no association was found with respiratory disease mortality. Participants who used dentures had lower mortality due to all causes [hazard ratios (HR) 0.79, 95% confidence intervals (CI) 0.71-0.88], CVD (HR 0.80, 95% CI 0.64-1.00), respiratory disease (HR 0.66, 95% CI 0.48-0.92), and other causes (HR 0.77, 95% CI 0.68-0.88) than those without dentures. Joint analysis revealed that older adults with fewer natural teeth and no dentures had higher mortality. Additionally, interaction analyses showed that the effects of the number of natural teeth on all-cause mortality were more pronounced in older adults aged <80  years (p-value for interaction = 0.03).

Conclusion

Having fewer natural teeth, particularly less than 10 teeth, is linked to an increased risk of mortality from all causes, including CVD, cancer, and other causes, but not respiratory disease. The use of dentures would mitigate the adverse impact of tooth loss on all-cause and some cause-specific mortality.

Tooth survival after endodontic treatment

BACKGROUND

There are several measures that are, or could be, in use in relation to estimating the outcome of endodontic treatments. It is important to reflect on when and why a certain outcome measure is used; when caring for an individual patient it is obvious that the goal always should be a tooth in a healthy state, that is striving to remove any infection and aim for the tooth to have healthy periapical tissues. For patients in general and for society, it is also interesting to know if endodontic treatments will lead to retention of teeth in a functioning state. From epidemiological studies, with high prevalence of root filled teeth with periapical radiolucencies, it is implied that dentists and/or patients accept the retention of a root filled tooth with persistent apical periodontitis. In conjunction with an endodontic treatment the prognosis is considered and since the prognostic factors seem to be somewhat different depending on whether one is considering for example the outcome 'healthy periapical tissues' or 'tooth survival' they are equally important to know. Factors affecting the outcome 'healthy periapical tissues' probably has to do with removal of infection and reconstituting the barrier to prevent leakage whilst 'tooth survival' is more likely associated with factors outside of the classical endodontic field such as restorability and avoidance of further destruction of tooth substance. Objective This narrative review will focus on tooth survival after endodontic treatment and root canal treatment will be the focus. Method The search was performed in PubMed. Results As a crude estimation, there is to be an annual loss of 2% of teeth which have received a root canal treatment. Conclusion Of the pre-, peri- and postoperative factors that have been studied in conjunction with root canal treatments the restoration of the tooth is the factor that has been most extensively studied. Many studies imply that root filled teeth restored with indirect restorations have a better survival than teeth restored with direct restorations, it is not possible to determine whether this indeed is a prognostic factor. Registration None.

Evolution and development of methodologies in social and behavioural science research in relation to oral health

The aim of this introductory paper is to provide an overview of key methodological developments in social and behavioural research in oral health. In the first section, we provide a brief historical perspective on research in the field. In the second section, we outline key methodological issues and introduce the seven papers in the theme. Conceptual models can contextualize research findings and address the 'why' and 'how' instead of 'what' and 'how many'. Many models exist, albeit they need to be evaluated (and adapted) for use in oral health research and in specific settings. The increasing availability of big data can facilitate this with data linkage. Through data linkage, it is possible to explore and understand in a broader capacity the array of factors that influence oral health outcomes and how oral health can influences other factors. With advances in statistical approaches, it is feasible to consider casual inferences and to quantify these effects. There is a need for not only individual efforts to embrace causal inference research but also systematic and structural changes in the field to yield substantial results. The value of qualitative research in co-producing knowledge with and from human participants in addressing 'the how' and 'the why' factors is also key. There have been calls to employ more sophisticated qualitative methods together with mixed methods approaches as ways of helping to address the complex or Wicked Problems in population oral health. In the final section, we outline possible future methodological directions in social and behavioural oral health research including participatory approaches and the development of core outcome sets. Our overriding goal in the paper is to facilitate a critical debate in relation to methodological issues which can be used to improve understanding and generate knowledge in population oral health and that this, in turn, will help inform oral health policy and practices.

Why and how we can use data linkage in oral health research: a narrative review

OBJECTIVES

Poor oral health, impacting health and wellbeing across the life-course, is a costly and wicked problem. Data (or record) linkage is the linking of different sets of data (often administrative data gathered for non-research purposes) that are matched to an individual and may include records such as medical data, housing information and sociodemographic information. It often uses population-level data or 'big data'. Data linkage provides the opportunity to analyse complex associations from different sources for total populations. The aim of the paper is to explore data linkage, how it is important for oral health research and what promise it holds for the future.

METHODS

This is a narrative review of an approach (data linkage) in oral health research.

RESULTS

Data linkage may be a powerful method for bringing together various population datasets. It has been used to explore a wide variety of topics with many varied datasets. It has substantial current and potential application in oral health research.

CONCLUSIONS

Use of population data linkage is increasing in oral health research where the approach has been very useful in exploring the complexity of oral health. It offers promise for exploring many new areas in the field.

Oral frailty indicators to target major adverse health-related outcomes in older age: a systematic review

A well-preserved oral function is key to accomplishing essential daily tasks. However, in geriatric medicine and gerodontology, as age-related physiological decline disrupts several biological systems pathways, achieving this objective may pose a challenge. We aimed to make a systematic review of the existing literature on the relationships between poor oral health indicators contributing to the oral frailty phenotype, defined as an age-related gradual loss of oral function together with a decline in cognitive and physical functions, and a cluster of major adverse health-related outcomes in older age, including mortality, physical frailty, functional disability, quality of life, hospitalization, and falls. Six different electronic databases were consulted by two independent researchers, who found 68 eligible studies published from database inception to September 10, 2022. The risk of bias was evaluated using the National Institutes of Health Quality Assessment Toolkits for Observational Cohort and Cross-Sectional Studies. The study is registered on PROSPERO (CRD42021241075). Eleven different indicators of oral health were found to be related to adverse outcomes, which we grouped into four different categories: oral health status deterioration; decline in oral motor skills; chewing, swallowing, and saliva disorders; and oral pain. Oral health status deterioration, mostly number of teeth, was most frequently associated with all six adverse health-related outcomes, followed by chewing, swallowing, and saliva disorders associated with mortality, physical frailty, functional disability, hospitalization, and falls, then decline in oral motor skills associated with mortality, physical frailty, functional disability, hospitalization, and quality of life, and finally oral pain was associated only with physical frailty. The present findings could help to assess the contribution of each oral health indicator to the development of major adverse health-related outcomes in older age. These have important implications for prevention, given the potential reversibility of all these factors.

Removable partial dentures and mortality among partially edentulous adults

OBJECTIVES

The aim of this study was to evaluate whether the use of removable partial dentures (RPDs) has an effect on long-term survival outcomes amongst partially edentulous adults.

METHODS

Data were extracted from the Third National Health and Nutrition Examination Survey and linked to public-use mortality files for the period up to 2019. Partially edentulous adults with fewer than 20 teeth were included. RPD use and dentition status were determined by clinical examination. The cohort was propensity score weighted to create a sample which was balanced across 27 covariates (sociodemographics, health behaviors and insurance, laboratory markers, and general health status). Survival analysis was undertaken to compute absolute (mortality rate and median survival time) and relative (event time ratio [ETR]) measures of exposure effect.

RESULTS

The analyzed cohort included 1246 participants, which equated to 22,557 person-years of follow-up. The difference in all-cause mortality rate between RPD wearers and non-wearers was found to be -6.5 (95% CI: -11.6 to -1.4), with the median survival time in RPD wearers being 3.1 years longer (20.3 years versus 17.2 years). A 26% increase in survival time was observed in RPD wearers (ETR: 1.26, 95% CI: 1.17 to 1.37) and it was found that, for every 7.5 individuals treated with RPDs, one death would be prevented after 10 years of treatment.

CONCLUSIONS

The use of RPDs may have long-term benefits in reducing mortality amongst adults with a non-functional dentition, but further research is needed to validate these findings and assess the factors mediating the relationship.

CLINICAL SIGNIFICANCE

The use of RPDs may have long-term benefits in reducing mortality amongst adults with a non-functional dentition.

Periapical and Endodontic Status of Patients with Inflammatory Bowel Disease: Age- and Sex- matched Case-control Study

AIM

Crohn's disease (CD) and ulcerative colitis (UC) are two chronic recurrent inflammatory processes of the gastrointestinal tract, grouped under the name Inflammatory Bowel Disease (IBD), causing clinical episodes of intestinal inflammation. The aim of this study was to investigate the possible association between IBD and the prevalence of apical periodontitis and root canal treatment.

METHODOLOGY

A case-control study design matched to age and sex was used. The study group (SG) included 28 patients with IBD (13 with CD, 15 with UC). Another 28 healthy subjects, without IBD and age- and sex- matched, were included in the control group (CG). Radiographic records were analyzed and apical periodontitis (AP) was diagnosed as radiolucent periapical lesions (RPLs), using the periapical index score (PAI). Student's t test, χ² test and multivariate logistic regression were used in the statistical analysis.

RESULTS

In the CG, only 17 subjects (61%) had at least one tooth with AP, while in the SG group they were 23 patients (82%) (OR = 2.98; CI 95% = 0.87 - 10.87; p = 0.08). The number of subjects with one or more root filled teeth (RFT) in the CG was 14 (50%), while in the SG they were 22 (79%) (OR = 3.67; 95% CI = 1.14 - 11.79; p = 0.026). At least one RFT with AP was evident in 3 subjects (10.7%) in the control group, while in the study group 15 patients (53.6%) showed RFT with AP (OR = 9.60; 95% CI = 2.35 - 39.35; p = 0.001). In the multivariate logistic regression analysis, only endodontic status was found to be associated with IBD (OR = 1.86; 95% CI = 1.24 - 2.80; p = 0.003).

CONCLUSION

IBD, ulcerative colitis and Crohn´s disease, is associated with higher prevalence of RFT and higher percentage of RFT with periapical lesions. Dentists should consider these findings when caring for IBD patients by monitoring the evolution of periapical lesions of endodontically treated teeth.

Systemic Antibiotics Influence Periodontal Parameters and Oral Microbiota, But Not Serological Markers

The use of systemic antibiotics may influence the oral microbiota composition. Our aim was to investigate in this retrospective study whether the use of prescribed antibiotics associate with periodontal status, oral microbiota, and antibodies against the periodontal pathogens. The Social Insurance Institution of Finland Data provided the data on the use of systemic antibiotics by record linkage to purchased medications and entitled reimbursements up to 1 year before the oral examination and sampling. Six different classes of antibiotics were considered. The Parogene cohort included 505 subjects undergoing coronary angiography with the mean (SD) age of 63.4 (9.2) years and 65% of males. Subgingival plaque samples were analysed using the checkerboard DNA-DNA hybridisation. Serum and saliva antibody levels to periodontal pathogens were analysed with immunoassays and lipopolysaccharide (LPS) activity with the LAL assay. Systemic antibiotics were prescribed for 261 (51.7%) patients during the preceding year. The mean number of prescriptions among them was 2.13 (range 1-12), and 29.4% of the prescriptions were cephalosporins, 25.7% penicillins, 14.3% quinolones, 12.7% macrolides or lincomycin, 12.0% tetracycline, and 5.8% trimethoprim or sulphonamides. In linear regression models adjusted for age, sex, current smoking, and diabetes, number of antibiotic courses associated significantly with low periodontal inflammation burden index (PIBI, p < 0.001), bleeding on probing (BOP, p = 0.006), and alveolar bone loss (ABL, p = 0.042). Cephalosporins associated with all the parameters. The phyla mainly affected by the antibiotics were Bacteroidetes and Spirochaetes. Their levels were inversely associated with the number of prescriptions (p = 0.010 and p < 0.001) and directly associated with the time since the last prescription (p = 0.019 and p < 0.001). Significant inverse associations were observed between the number of prescriptions and saliva concentrations of Prevotella intermedia, Tannerella forsythia, and Treponema denticola and subgingival bacterial amounts of Porphyromonas gingivalis, P. intermedia, T. forsythia, and T. denticola. Saliva or serum antibody levels did not present an association with the use of antibiotics. Both serum (p = 0.031) and saliva (p = 0.032) LPS activity was lower in patients having any antibiotic course less than 1 month before sampling. Systemic antibiotics have effects on periodontal inflammation and oral microbiota composition, whereas the effects on host immune responses against the periodontal biomarker species seem unchanged.

Number of teeth is associated with all-cause and disease-specific mortality

BACKGROUND

Tooth loss has been shown to correlate with multiple systemic comorbidities. However, the associations between the number of remaining natural teeth (NoT) and all-cause mortality have not been explored extensively. We aimed to investigate whether having fewer NoT imposes a higher risk in mortality. We tested such hypotheses using three groups of NoT (20-28,10-19, and 0-9), edentulism and without functional dentition (NoT < 19).

METHODS

The National Health and Nutrition Examination Survey in the United States (NHANES) (1999-2014) conducted dental examinations and provided linkage of mortality data. NHANES participants aged 20 years and older, without missing information of dental examination, age, gender, race, education, income, body-mass-index, smoking, physical activities, and existing systemic conditions [hypertension, total cardiovascular disease, diabetes, and stroke (N = 33,071; death = 3978), or with femoral neck bone mineral density measurement (N = 13,131; death = 1091)] were analyzed. Cox proportional hazard survival analyses were used to investigate risks of all-cause, heart disease, diabetes and cancer mortality associated with NoT in 3 groups, edentulism, or without functional dentition.

RESULTS

Participants having fewer number of teeth had higher all-cause and disease-specific mortality. In fully-adjusted models, participants with NoT0-9 had the highest hazard ratio (HR) for all-cause mortality [HR(95%CI) = 1.46(1.25-1.71); p < .001], mortality from heart diseases [HR(95%CI) = 1.92(1.33-2.77); p < .001], from diabetes [HR(95%CI) = 1.67(1.05-2.66); p = 0.03], or cancer-related mortality [HR(95%CI) = 1.80(1.34-2.43); p < .001]. Risks for all-cause mortality were also higher among the edentulous [HR(95%CI) = 1.35(1.17-1.57); p < .001] or those without functional dentition [HR(95%CI) = 1.34(1.17-1.55); p < .001].

CONCLUSIONS

Having fewer NoT were associated with higher risks for all-cause mortality. More research is needed to explore possible biological implications and validate our findings.

Endodontic inflammatory disease: A risk indicator for a first myocardial infarction

AIM

To study the association between endodontic inflammatory disease and a first myocardial infarction (MI).

METHODOLOGY

The study comprised 805 patients with recent experience of a first MI, each gender, age and geographically matched with a control. Panoramic radiographs were available for 797 patients and 796 controls. Endodontic inflammatory disease was assessed radiographically. The sum of decayed, missing and filled teeth (DMFT) was calculated, and the number of root filled teeth and teeth with periapical lesions were recorded. The associated risk of a first MI was expressed as odds ratios (OR) with 95% confidence intervals (CI), unadjusted and adjusted for confounders (family history of cardiovascular disease, smoking habits, marital status, education and diabetes).

RESULTS

Patients who had suffered a first MI had higher DMFT (mean 22.5 vs. 21.9, p = .013) and more missing teeth (mean 7.5 vs. 6.3; p < .0001) than the healthy controls. The number of missing teeth was associated with an increased risk of a first MI (adjusted OR 1.04; CI 1.02-1.06). Conversely, decay-free, filled teeth were associated with decreased risk (adjusted OR 0.98; CI 0.96-1.00). Analysis based on age disclosed the following variables to be associated with an increased risk of a first MI: number of decayed teeth (adjusted OR 1.18; CI 1.02-1.37, in patients <60 years), any primary periapical lesion (adjusted OR 1.57; CI 1.08-2.29, in patients <65 years) and the proportion of root filled teeth (adjusted OR 1.18; CI 1.03-1.36, in patients ≥65 years).

CONCLUSIONS

More missing teeth was independently associated with an increased risk of a first MI. In addition, endodontic inflammatory disease may contribute as an independent risk factor to cardiovascular disease since untreated caries, periapical lesions and root fillings, depending on age, were significantly associated with a first MI.