Oral health in patients on inhaled corticosteroid treatment

Association between periodontal disease and chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) and periodontal disease are chronic inflammatory conditions that significantly affect an individual's overall health and well-being. Generally, the prevalence of periodontitis is higher in patients with COPD than those without COPD, which may partly be attributed to common risk factors in COPD, such as smoking, respiratory infections, and inflammation. In particular, periodontitis may exacerbate the progression of COPD and further deteriorate the respiratory system by promoting inflammatory responses and bacterial infections. Immunocytes, including neutrophils, and microorganisms such as Fusobacterium nucleatum originating from oral biofilms are believed to be crucial factors influencing to COPD. Furthermore, the potential benefits of treating periodontal disease in COPD outcomes have been investigated. Although the relationship between COPD and periodontal disease has been preliminarily studied, there is currently a lack of large-scale clinical studies to validate this association. In addition to clinical examinations, investigating biomarkers and microbiology may contribute to explore the underlying mechanisms involved in the management of these conditions. This review aims to contribute to a better understanding of the clinical and basic research aspects of COPD and periodontitis, allowing for potential therapeutic approaches and interdisciplinary management strategies.

The association between respiratory diseases and periodontitis: A systematic review and meta-analysis

AIM

To evaluate (1) whether periodontitis has an influence on the prevalence/incidence of respiratory diseases (chronic obstructive pulmonary disease [COPD], asthma, community-acquired pneumonia [CAP], obstructive sleep apnoea [OSA] and COVID-19), and (2) what is the impact of periodontal therapy on the onset or progression of respiratory diseases.

MATERIALS AND METHODS

An electronic search was performed on Pubmed, Cochrane Library and Scopus databases up to October 2021, to identify studies answering the PECOS and PICOS questions.

RESULTS

Seventy-five articles were selected. Meta-analyses identified statistically significant associations of periodontitis with COPD (nstudies  = 12, odds ratio [OR] = 1.28, 95% confidence interval [CI] [1.16; 1.42], p < .001), and OSA (ns  = 6, OR = 1.65, 95% CI [1.21; 2.25], p = .001), but not for asthma (ns  = 9, OR = 1.53, 95% CI [0.82; 2.86], p = .181). For acute conditions, two studies were found for CAP, while for COVID-19, significant associations were found for the need of assisted ventilation (ns  = 2, OR = 6.24, 95% CI [2.78; 13.99], p < .001) and COVID-related mortality (ns  = 3, OR = 2.26, 95% CI [1.36, 3.77], p = .002). Only four intervention studies were found, showing positive effects of periodontal treatment on COPD, asthma and CAP.

CONCLUSIONS

A positive association between periodontitis and COPD, OSA and COVID-19 complications has been found, while there is a lack of intervention studies.

The Effect of Acknowledged and Novel Anti-Rheumatic Therapies on Periodontal Tissues-A Narrative Review

Rheumatoid arthritis (RA) and periodontal disease (PD) are chronic complex inflammatory diseases with several common susceptibility factors, especially genetic and environmental risk factors. Although both disorders involve a perturbation of the immune–inflammatory response at multiple levels, one major difference between the two is the different locations in which they develop. RA is triggered by an exaggerated autoimmune response that targets joints, while periodontal disease occurs as a consequence of the subgingival periodontopathogenic microbiota. Current treatment models in both pathologies involve the stratification of patients to allow therapeutic individualization according to disease stage, complexity, progression, lifestyle, risk factors, and additional systemic diseases. Therapeutic guidelines for RA comprise of five main classes of drugs: non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, glucocorticoids, and disease-modifying anti-rheumatic drugs (DMARDs): biologic and non-biologic. Although various treatment options are available, a definitive treatment remains elusive, therefore research is ongoing in this area. Several alternatives are currently being tested, such as matrix metalloproteinases (MMP) inhibitors, toll-like receptors (TLR) blockers, pro-resolution mediators, anti-hypoxia inducing factors, stem cell therapy, NLRP3 inhibitors and even natural derived compounds. Although the link between PD and rheumatoid arthritis has been investigated by multiple microbiology and immunology studies, the precise influence and causality is still debated in the literature. Furthermore, the immunomodulatory effect of anti-rheumatic drugs on the periodontium is still largely unknown. In this narrative review, we explore the mechanisms of interaction and the potential influence that anti-rheumatoid medication, including novel treatment options, has on periodontal tissues and whether periodontal health status and treatment can improve the prognosis of an RA patient.

Corticosteroid Use and Periodontal Disease: A Systematic Review

Periodontitis affects the teeth supporting structures, such as periodontal tissues. We aimed to evaluate the association between periodontal disease and corticosteroid use. We searched in MEDLINE, Web of Sciences, SCOPUS, LILACS, and Cochrane databases, using the descriptors "Periodontal diseases" AND ("adrenal cortex hormones" OR "adrenal cortex hormones" OR ("adrenal" AND "cortex" AND "hormones") OR "adrenal cortex hormones" OR "corticosteroid"). We selected the summaries of observational studies, addressing periodontal disease in patients using corticosteroids. The search resulted in 403 articles. After applying the selection criteria, eight studies remained; being two retrospective cohorts and six cross-sectional studies. There are few studies with appropriate methodology to produce sound evidence about the causal relationship between the use of corticosteroids and periodontitis. However, two retrospective cohorts confirmed that chronic corticosteroid use is associated with the incidence of periodontal disease. Dental staff must be aware of this association for better management of periodontal disease therapy in patients using corticosteroids.

Risk of Periodontal Diseases in Patients With Chronic Obstructive Pulmonary Disease: A Nationwide Population-based Cohort Study

Several studies have reported an association between chronic obstructive pulmonary disease (COPD) and periodontal diseases. However, a large-scale population-based cohort study was previously absent from the literature. Therefore, we evaluated the risk of periodontal diseases in patients with COPD in a nationwide population.From the National Health Insurance claims data of Taiwan, we identified 22,332 patients with COPD who were newly diagnosed during 2000 to 2010. For each case, two individuals without COPD were randomly selected and frequency matched by age, sex, and diagnosis year. Both groups were followed up till the end of 2011.The overall incidence of periodontal diseases was 1.19-fold greater in the COPD group than in the comparison group (32.2 vs 26.4 per 1000 person-years; 95% confidence interval [CI] 1.15-1.24). Compared with non-COPD patients, the adjusted hazard ratios of patients with COPD increased with the number of emergency room visits (from 1.14 [95% CI 1.10-1.19] to 5.09 [95% CI 4.53-5.72]) and admissions (from 1.15 [95% CI 1.10-1.20] to 3.17 [95% CI 2.81-3.57]). In addition, the adjusted hazard ratios of patients with COPD treated with inhaled corticosteroids (1.22, 95% CI 1.11-1.34) and systemic corticosteroids (1.15, 95% CI 1.07-1.23) were significantly higher than those of patients not treated with corticosteroids.Patient with COPD are at a higher risk of developing periodontal diseases than the general population. Our results also support that the risk of periodontal diseases is proportional to COPD control. In addition, patients who receive corticosteroid treatment are at a higher risk of developing periodontal diseases.

Oral health-related quality-of-life and mental health in individuals with chronic obstructive pulmonary disease (COPD)

OBJECTIVES

To investigate the association between oral health, oral health-related quality-of-life (OHRQoL) and mental health-related quality-of-life (QoL) in persons with chronic obstructive pulmonary disease (COPD) with respect to demographic, social and clinical oral health variables.

MATERIALS AND METHODS

One hundred participants were included in a cross-sectional study at a hospital in Norway. Data were collected via the Oral Health Impact Profile (OHIP-14), the SF-36v2 Health Survey Mental Component (MCS), other self-reported factors, an interview and a clinical examination. Multiple regression analyses were performed. The Regional Committee for Medical and Health Research Ethics approved the study. RESULTS. Higher education (p < 0.01), being a smoker (p < 0.05) and experience of oral health problems (p < 0.001) were significantly associated with oral health-related quality-of-life (OHRQoL). Furthermore, those with feelings of dry mouth (p < 0.05) and impaired OHRQoL (p < 0.001) experienced more mental health problems.

CONCLUSIONS

This study demonstrated that oral health and personal factors are related to mental health-related QoL and OHRQoL in individuals with COPD. This finding shows the need to focus on oral care.

Glucocorticoids reduce alveolar and trabecular bone in mice

Glucocorticoid (GC) treatment is the main cause of secondary osteoporosis. There are some controversies about the relationships between alveolar bone loss and bone loss at the appendicular and axial skeleton.

OBJECTIVE

To assess, in parallel, the effects of GCs on alveolar bone and on the tibia in a mice model.

METHODS

Five-month-old male Swiss-Webster mice were randomized into two groups. Pellets releasing 5 mg/kg/day of prednisolone or control pellets were subcutaneously implanted for 28 days. After euthanasia, the right tibia and the right hemimandible of each mouse were analyzed by histomorphometry and microcomputed tomography. Alveolar bone consists of a thin slab between the incisor and the molar roots connected with the alveolar processes. A 2D-frontal section was done through the pulp chamber of the first molar and was used to measure the thickness of the alveolar bone slab. A 2D-sagittal section was done through the pulp chamber of the three molars and was used to measure bone volume in the alveolar processes.

RESULTS

At day 28, thickness and bone volume of alveolar bone were significantly decreased in the GC group (P<0.05). At the tibia, GCs decreased bone formation with a reduced mineral apposition rate and bone formation rate and a significant decrease in BV/TV and Tb.Th (P<0.05).

CONCLUSION

Although the amount of alveolar bone is very low in the mouse, this study shows that GCs can induce an alveolar bone loss in long-term treated animals.

Inhaled corticosteroid-related tooth problems in asthmatics

BACKGROUND

The recent Global Initiative for Asthma guideline states that inhaled corticosteroids (ICSs) may induce osteoporosis as a systemic adverse effect. New ICSs, such as fluticasone propionate, have a high topical potency and may therefore induce tooth problems as a result of direct exposure without hepatic metabolism more frequently than older ICSs.

OBJECTIVE

We evaluated asthma patients who underwent long-term treatment with a new ICS to determine if they had tooth problems that were related to osteoporosis of the mandible.

METHODS

When the conventional bone mineral density (BMD) of asthmatics that received the ICS treatment for at least one year was measured using dual-energy X-ray absorptiometry, the BMD of the mandible was also measured. The T-score of the mandible BMD was then determined based on the mean BMD +/- the standard deviation of normal young adults.

RESULT

Asthma patients with tooth loss (n = 36) and with caries or other tooth problems (n = 28) were found to have a significantly higher prevalence of osteoporosis in the mandible than those without tooth problems (n = 17; 22.2%, 7.1%, 0%, respectively; chi(2) = 6.34, p < 0.05). In addition, the presence of mandibular osteoporosis (odds ratio: 6.14, p = 0.02) and a T-score of < -1.0 for the femoral neck (odds ratio: 3.25, p = 0.01) were found to be significant risk factors for tooth loss in the asthma patients. Finally, the T-score of the mandible was found to be correlated with age (r = -0.316, p < 0.01), and with the T-scores of the lumbar spine (r = 0.413, p < 0.001) and femoral neck (r = 0.446, p < 0.001).

CONCLUSION

Tooth loss in asthma patients undergoing long-term treatment with a topically potent ICS was found to be related to a decrease in BMD, especially in the mandible. Therefore, patients using these types of ICS should have their mandibular BMD checked regularly, especially if they have any risk factors for osteoporosis. In addition, it would be wise for such patients to reduce their ICS dose.

Hydrocortisone Affects the Expression of Matrix Metalloproteinases (MMP-1, -2, -3, -7, and -11) and Tissue Inhibitor of Matrix Metalloproteinases (TIMP-1) in Human Gingival Fibroblasts

BACKGROUND

There is a positive correlation between the course of periodontal disease and psychosocial stress status. Stress leads to activation of the hypothalamic-pituitary-adrenal axis, resulting in increased cortisol release. The present study evaluates the effect of two different hydrocortisone concentrations on mRNA expression of matrix metalloproteinases (MMPs) and tissue inhibitor of matrix metalloproteinases (TIMPs) in cultured, human gingival fibroblasts.

METHODS

Gingival fibroblasts were stimulated with 10(-7) or 10(-9) M hydrocortisone for 24 hours; untreated cells served as controls. Alterations in the expression of MMP-1, -2, -3, -7, -11 and TIMP-1 and -2 were evaluated using real-time polymerase chain reaction and Western blotting. beta-actin mRNA expression was used as a reference to normalize gene expression.

RESULTS

Although the higher hydrocortisone concentration upregulated MMP-1, -2, -7, -11, and TIMP-1 (P <0.05) expression, the lower concentration induced downregulation or diminished upregulation. The lower hydrocortisone concentration induced a 23-fold increase in MMP-3 gene expression, whereas the higher concentration induced less upregulation; however, protein expression was regulated similarly by both hydrocortisone concentrations. The effect of hydrocortisone on TIMP-2 expression was not significant (P >0.05).

CONCLUSIONS

Hydrocortisone produced a dose-dependent regulation of MMP and TIMP expression. The higher hydrocortisone concentration significantly upregulated expression of MMP-1, -2, -7, and -11 and TIMP-1 in human gingival fibroblasts, which may constitute a mechanism underlying the increased periodontal breakdown associated with psychosocial stress status.

Therapeutic doses of glucocorticoids: implications for oral medicine

Glucocorticoids can cause adverse systemic side-effects ranging from iatrogenic Cushing's syndrome during treatment, to hypothalamic-pituitary-adrenal axis suppression and clinically significant adrenal insufficiency when the agents are discontinued. While the oral route of administration is most often implicated, it is now becoming more apparent that inhaled and topical administration also can cause these effects. Given the high therapeutic value of glucocorticoids, the ability to prescribe these agents while maintaining a low risk-to-benefit ratio for patients is critical. The aim of this review is to provide oral healthcare practitioners with a practical guide to commonly used glucocorticoids, their adverse effects, and perioperative use.