History of Periodontitis Diagnosis and Edentulism as Predictors of Cardiovascular Disease, Stroke, and Mortality in Postmenopausal Women

The role of periodontitis in the development of atherosclerotic cardiovascular disease in participants with the components of metabolic syndrome: a systematic review and meta-analysis

OBJECTIVES

Prevention of atherosclerotic cardiovascular disease (ASCVD) is important in individuals with metabolic syndrome components (MetS), and periodontitis may play an important role in this process. This study aims to evaluate the association between periodontitis and ASCVD in participants with the components of MetS, including obesity, dysglycemia, hypertension, and dyslipidemia.

MATERIALS AND METHODS

This study conducted followed the MOOSE reporting guidelines and the PRISMA 2020 guidelines. EMBASE, MEDLINE, Web of Science, Cochrane Library, PubMed and OpenGrey were searched for observational studies about the linkage of periodontitis to ASCVD in people with MetS components up to April 9, 2023. Cohort, case-control and cross-sectional studies were included after study selection. Quality evaluation was carried out using the original and modified Newcastle-Ottawa Scale as appropriate. Random-effects model was employed for meta-analysis.

RESULTS

Nineteen studies were finally included in the quality analysis, and all of them were assessed as moderate to high quality. Meta-analyses among fifteen studies revealed that the participants with periodontitis were more likely to develop ASCVD in those who have dysglycemia (RR = 1.25, 95% CI = 1.13-1.37; p < 0.05), obesity (RR = 1.13, 95% CI = 1.02-1.24; p < 0.05), dyslipidemia (RR = 1.36, 95% CI = 1.13-1.65; p < 0.05), or hypertension (1.20, 95% CI = 1.05-1.36; p < 0.05).

CONCLUSIONS

Periodontitis promotes the development of ASCVD in participants with one MetS component (obesity, dysglycemia, hypertension or dyslipidemia).

CLINICAL RELEVANCE

In people with MetS components, periodontitis may contribute to the ASCVD incidence.

Patient awareness of the association between periodontal and systemic diseases in an academic setting

BACKGROUND

Periodontal diseases (PD) have been increasingly associated with several systemic conditions such as cardiovascular disease (CVD), diabetes mellitus (DM), rheumatoid arthritis (RA), and Alzheimer's disease (AD). This study aimed to gain insight into patients' awareness of the association between PD and systemic diseases.

METHODS

A survey was developed to analyze patient awareness of the association between PD and systemic diseases. Descriptive and categorical variables were summarized with counts and percentages. Chi-squared tests were used to evaluate differences between variables. A linear logistical regression model was used to assess the simultaneous, independent association between each variable.

RESULTS

Data from 161 completed surveys were analyzed. The majority of the participants (61.49%) reported awareness of symptoms of PD, but only 36.36% identified all its major symptoms. Individuals reporting awareness of the association between PD and systemic diseases was 48.4%, 31.7%, 14.9%, and 9.9% for CVD, DM, RA, and AD, respectively. Patients aged ≥51 years and males were more aware of the association between PD and CVD. Increased awareness of an association between PD and DM was observed among patients who had a higher frequency of dental visits and those with a self-reported history of DM.

CONCLUSIONS

This study provides insight that, even with the vast amount of scientific knowledge on the inter-relationships that exist between PD and systemic diseases, most patients are still unaware of these associations. This research identified that improvement of health literacy surrounding PD, their symptoms, and their association with systemic diseases may be warranted.

Periodontitis is associated with stroke

BACKGROUND

Periodontitis is considered as a risk factor for cardiovascular diseases and atherosclerosis. However, the relationship between periodontitis and stroke is rarely studied. Therefore, we aimed to explore the relationship between periodontitis and stroke.

METHODS

Statistical analysis was performed using the complex sampling design. We analyzed data on 6,460 participants, representing 92,856,028 American citizens aged 30 years or older, who had valid data on periodontitis and stroke from the National Health and Nutrition Examination Survey 2009-2014. We used clinical attachment level and probing pocket depth precisely to determine periodontitis and it is the first time to use such a precise method for exploring the relationship between periodontitis and stroke.

RESULTS

39.9% of participants had periodontitis and 2.1% of participants had a record of stroke diagnosis. Stroke was associated with severity levels of periodontitis (p for trend = 0.018). The odds ratio for stroke was significantly elevated in the severe periodontitis and moderate periodontitis participants compared to participants without periodontitis (OR for severe periodontitis: 2.55, 95% CI 1.25-5.21; OR for moderate periodontitis: 1.71, 95% CI 1.17-2.50). After adjusting for race/ethnicity and sex, the association remained significant (p for trend = 0.009). After further adjusting for BMI, hypercholesterolemia, diabetes, alcohol consumption and physical activity, the association still existed (p for trend = 0.027). The association was significant consistently after further adjusting for age (p for trend = 0.033).

CONCLUSIONS

In this nationally representative study, we found an association between periodontitis and stroke. The risk of stroke in participants with severe periodontitis and moderate periodontitis was 2.55 times and 1.71times as high as those without periodontitis. Dental health management may be of benefit to stroke prevention.

Periodontal disease and subsequent risk of cardiovascular outcome and all-cause mortality: A meta-analysis of prospective studies

Studies reported periodontal disease (PD) periodontal disease is associated with many systemic diseases, including cardiovascular outcomes and all-cause mortality. However, the precise mechanistic link for these relationship remained unclear. We therefore performed a meta-analysis of cohort studies to investigate the association of PD with the risk of cardiovascular outcomes and all-cause mortality. We systematically searched the databases of PubMed, EmBase, and the Cochrane library to identify eligible studies until April 2023. The investigated outcomes included major adverse cardiovascular events (MACEs), coronary heart disease (CHD), myocardial infarction (MI), stroke, cardiac death, and all-cause mortality. The summary relative risk (RR) with 95% confidence interval (CI) were calculated using the random-effects model. Thirty-nine cohort studies with 4,389,263 individuals were selected for final meta-analysis. We noted PD were associated with elevated risk of MACEs (RR: 1.24; 95%CI: 1.15-1.34; P<0.001), CHD (RR: 1.20; 95%CI: 1.12-1.29; P<0.001), MI (RR: 1.14; 95%CI: 1.06-1.22; P = 0.001), stroke (RR: 1.26; 95%CI: 1.15-1.37; P<0.001), cardiac death (RR: 1.42; 95%CI: 1.10-1.84; P = 0.007), and all-cause mortality (RR: 1.31; 95%CI: 1.07-1.61; P = 0.010). Sensitivity analyses indicated the pooled conclusions for cardiovascular outcomes and all-cause mortality are robustness. The associations of PD with the risk of ardiovascular outcomes and all-cause mortality could affected by region, study design, PD definition, follow-up duration, and study quality. This study found the risk of cardiovascular outcomes and all-cause mortality were elevated in PD patients, and the intervention for PD should be applied to prevent the risk of cardiovascular outcomes.

Periodontal Diseases and Heart Diseases: A Systemic Review

Introduction

Up to 50% of people worldwide are affected by periodontal disease (PD); cardiovascular diseases are a serious concern for the major portion of the world's population. Observational data have shown a connection between PD and CVD. The current systemic review investigates the incidence of the CVD in individuals with PD through various designs of the previous research.

Materials and Methods

An extensive online search in the various databanks of EMBASE, Medline, Pubmed, and Scopus was conducted. The keywords searched were: "PD, CVD, myocardial infarction, coronary heart disease (CHD), and stroke; technique of diagnosis and the degree of PD were assessed clinically or by self-report." The studies selected were longitudinal research design and randomized trials. To ascertain the risk of mortality due to cardiac issues in periodontal diseases, meta-analysis, and meta-regression were carried out. The diagnosis techniques for periodontal diseases, severity, and impact of gender, were also examined.

Results

After full-text screening, 32 longitudinal cohort studies were included. PD patients had a significantly greater risk of CVD than non-PD patients (RR: 1.20). Clinical and self-reported PD diagnoses did not differ in CVD risk (RR = 0.97). Men were at increased risk for both severe PD (RR: 1.25), and CVD (RR: 1.16). The risk of stroke was the highest among all forms of CVD (RR = 1.24), and the risk of CHD was significantly elevated (RR = 1.14).

Conclusion

Current review showed that populations with PD consistently and modestly have an elevated risk of CVD. Men and those with severe PD are at higher CVD risk, which suggests population-targeted therapies may be helpful.

Longitudinal association of edentulism with cognitive impairment, sarcopenia and all-cause mortality among older Chinese adults

BACKGROUND

Tooth loss may be a surrogate for systemic health and aging. However, no previous studies have systematically assessed multiple outcomes relevant to aging trajectory in this area, and many important confounders were not adjusted in most previous studies. This study aims to prospectively evaluate the associations of complete tooth loss (edentulism) with broad markers of sarcopenia, cognitive impairment and mortality.

METHODS

Data were derived from the China Health and Retirement Longitudinal Study, a nationally representative household study of the Chinese population aged 45 years and older. Multivariate Weibull proportional hazards regression was used to assess the association between edentulism with sarcopenia and all-cause mortality. Average changes in cognitive function by edentulism was estimated by mixed-effects linear regression models.

RESULTS

During the 5-year follow-up, the prevalence of edentulism among adults aged 45 and over was 15.4%. Participants with edentulism had a greater decline in cognitive function compared to those without (β=-0.70, 95%CI:-1.09, -0.31, P < 0.001). The association of edentulism and all-cause mortality for 45-64 age group (HR = 7.50, 95%CI: 1.99, 28.23, P = 0.003), but not statistically significant for the ≥ 65 age group (HR = 2.37, 95%CI: 0.97, 5.80, P = 0.057). Effects of edentulism on sarcopenia are statistically significant for all age groups (45-64 age group: HR = 2.15, 95%CI: 1.27, 3.66, P = 0.005; ≥65 age group: HR = 2.15, 95%CI: 1.27, 3.66, P = 0.002).

CONCLUSIONS

These findings could have important clinical and public health implications, as tooth loss is a quick and reproducible measurement that could be used in clinical practice for identifying persons at risk of accelerated aging and shortened longevity, and who may benefit most from intervention if causality is established.

Myeloperoxidase: A Circulating Marker of Inflammation and Tooth Infection

BACKGROUND

Atherosclerotic cardiovascular disease and tooth infection are common in primary care, and both significantly reduce quality of life. Our study aimed to examine signs of vascular inflammation associated with loss of tooth vitality before and after a single tooth extraction.

METHODS

An observational cohort study was performed with adults who had a nonvital tooth and an indicated desire for tooth extraction. Concentrations of total cholesterol, high-density lipoprotein-cholesterol, high-sensitivity C-reactive protein (hs-CRP), myeloperoxidase (MPO), and troponin T were measured in venous blood serum or plasma at baseline and 6-weeks after tooth extraction.

RESULTS

Circulating hs-CRP levels were > 3 mg/dL in 15 participants (68.2%) and MPO levels were > 350 pmol/L in 9 (40.9%) of 22 participants at baseline. After tooth extraction (n = 18), MPO levels decreased significantly compared with baseline (P < .00006) and hs-CRP levels moved directionally downward. The response rate for MPO was 88.9% (confidence interval: 65.1%-98.6%) from visit 1 to visit 2. Those with high MPO levels at baseline demonstrated larger reductions in MPO levels by visit 2 than those with lower baseline MPO levels (r = .81; P < .0001). A total of 13 individuals (72.2%) achieved MPO levels < 350 pmol/L and 11 (61.1%) achieved hs-CRP levels < 3 mg/dL at visit 2. Total cholesterol, high-density lipoprotein-cholesterol, and troponin T levels did not significantly change from visit 1 to visit 2.

CONCLUSION

A link between dental infection and circulating levels of inflammation was observed, suggesting that oral infection could be a risk factor for atherosclerotic cardiovascular disease.

The effects of dental visits on the occurrence of acute hospitalization for systemic diseases among patients aged 75 years or older: A propensity score-matched study

BACKGROUND

Although several studies examined the association between oral status and the risk of systemic diseases, few have examined whether dental visits affect the occurrence of acute hospitalization due to systemic diseases. This study examined the effects of dental visits on preventing the occurrence of acute hospitalization due to systemic diseases in adults aged ≥ 75 years, in order to optimize the healthcare system for older adults.

METHODS

This propensity-score-matched retrospective cohort study was conducted using medical insurance claims data from Hokkaido, Japan. We analyzed 432,292 adult outpatients aged ≥ 75 years between September 2016 and February 2017 (baseline period). The exposure variable was visits to the dental office during the baseline period. The primary outcome variable was the occurrence of acute hospitalization due to pneumonia, urinary tract infections, cerebrovascular diseases, or coronary heart diseases between March 2017 and March 2019.

RESULTS

Among the 432,292 patients before propensity score matching, 149,639 (34.6%) had visited the dental office. One-to-one propensity score matching produced 149,289 matched pairs adjusted for the differences in all covariables (age, sex, copayment rate, annual health checkup, chronic diseases, and residential area). In these matched pairs, the risk ratio of the occurrence of acute hospitalization due to pneumonia, urinary tract infections, and cerebrovascular diseases was lower among patients who had visited dental office than among those who did not.

CONCLUSIONS

Dental visits appeared to be effective in preventing acute hospitalization due to systemic diseases, thus, dental care services would be an important component of healthcare for older adults.

Suboptimal oral health and the risk of cardiovascular disease in the presence of competing death: a data linkage analysis

OBJECTIVE

The objective of this study is to simultaneously assess the associations between suboptimal oral health (SOH) and cardiovascular disease (CVD) and competing death (CD).

METHODS

Ontario residents aged 40 years and over who participated in the Canadian Community Health Survey 2003 and 2007-2008 were followed until December 31, 2016 for the incidence of CVD or CD. SOH was assessed based on self-rated oral health and inability to chew. Multivariable competing risk analysis was adjusted for socioeconomic characteristics, behavioural factors and intermediate health outcomes.

RESULTS

The study sample included 36,176 participants. Over a median follow-up of 9.61 years, there were 2077 CVD events and 3180 CD events. The fully adjusted models indicate 35% (HR = 1.35, 95% CI: 1.12-1.64) increase in the risk of CVD and 57% (HR = 1.57, 95% CI: 1.33-1.85) increase in the risk of CD among those who reported poor oral health as compared to those who reported excellent oral health. The fully adjusted models also indicate 11% (HR = 1.11, 95% CI: 0.97-1.27) increase in the hazard of CVD and 37% (HR = 1.37, 95% CI: 1.24-1.52) increase in the hazard of CD among those who reported inability to chew.

CONCLUSION

This study provides important information to contextualize CVD risk among those with SOH. The competing risk analysis indicates that those with SOH may benefit from additional interventions to prevent CVD and CD. Accordingly, managing the risk of CVD among those with SOH should fall under a more comprehensive approach that aims at improving their overall health and well-being.

Periodontitis and edentulism as risk indicators for mortality: Results from a prospective cohort study with 20 years of follow-up

AIM

To investigate the association between periodontitis and edentulism with cardiovascular disease (CVD) and all-cause mortality.

METHODS

Baseline data of 506 subjects including 256 angiographically verified coronary artery disease patients and 250 matched participants in cardiovascular health from the Kuopio Oral Health and Heart study were collected from 1995-1996. Mortality data were accrued until May 31, 2015, and related to baseline periodontal health and edentulism, assessed as exposure and collected by means of clinical and radiographic examination by a single examiner. Cox proportional hazards regression models were fit using covariates such as age, gender, smoking, BMI, and education. The final sample size for the periodontitis models ranged from 358 to 376, while the edentate models included 413 to 503 subjects for CVD and all-cause mortality, respectively with no missing values in the predictor, confounders, and outcome.

RESULTS

The strongest association was found between edentulism and CVD and all-cause mortality (HR: 1.9 ^CVD , HR: 1.6^all-cause ; p < .01).

CONCLUSIONS

Edentulism considered as a poor oral health marker was associated strongly with CVD mortality while periodontitis was not.

Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years

AIM

To evaluate the association between periodontal disease and all-cause mortality in a longitudinal cohort study over 50 years.

MATERIALS AND METHODS

Participants (N = 1156) in the Veterans Affairs Dental Longitudinal Study, aged 25-85 years at enrollment in 1968, received comprehensive medical and oral exams approximately every 3 years through 2007. Periodontal status was defined using person-level, mean whole-mouth radiographic alveolar bone loss (ABL) scores using a five-point Schei ruler, each unit representing 20% increments of ABL. Time-varying Cox regression models estimated hazard ratios (HRs) for the association between continuous and categorical ABL and mortality, adjusting for covariates.

RESULTS

Each one-unit increase in mean ABL score was associated with a 14% increase in the hazard of mortality (adjusted HR = 1.14, 95% confidence interval [CI] 1.02, 1.27). When assessed categorically, HRs for average scores of 2 to <3 and 3 to ≤5 showed increasing associations with hazard of mortality, relative to 0 to <1 (adjusted HR = 1.17, 95% CI 0.94, 1.46; and HR = 1.65, 95% CI 0.94, 2.85, respectively). By contrast, we observed null associations for average scores of 1 to <2 relative to 0 to <1 (adjusted HR = 1.00, 95% CI 0.86, 1.17).

CONCLUSIONS

Time-varying periodontal status assessed using radiographic ABL was positively associated with all-cause mortality even after confounder adjustment.

Periodontal disease is associated with the risk of cardiovascular disease independent of sex: A meta-analysis

Objectives

Studies have established a link between periodontal disease and cardiovascular disease (CVD), but it is unclear whether there is a sex difference in their association.

Methods

The PubMed, Embase, and Cochrane databases were searched until June, 21 2022. Cardiovascular outcomes included any CVD, myocardial infarction (MI), coronary heart disease (CHD), or stroke. Studies reported the prevalence of CVD in patients with periodontal disease and the relationship between periodontal disease and CVD. The study is registered with PROSPERO (CRD42022333663). The level of evidence and recommendations is assessed by the Grading of Recommendations for Assessment, Development and Evaluation (GRADE).

Results

Twenty-six studies were included. In patients with periodontal disease, the prevalence of CVD was 7.2% [9 studies; 95% confidence interval (CI): 2.7-13.6%], and prevalence for CHD, hypertension, stroke, and heart failure was 6.6, 25.3, 1, and 1.1%, respectively. There was a significant association between periodontal disease and CVD in men [odds ratio (OR) = 1.22; 95% CI: 1.12-1.34] and women (OR = 1.11; 95% CI: 1.05-1.17), with no significant sex difference (P > 0.05).

Conclusion

Cardiovascular disease is relatively common in patients with periodontal disease, and an increased risk of CVD is associated with periodontal disease independent of sex. Interventions targeting periodontal disease may be beneficial for CVD.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333663.

Periodontitis and implant complications in diabetes

Epidemiologic evidence indicates that periodontitis is more frequent in patients with uncontrolled diabetes mellitus than in healthy controls, suggesting that it could be considered the "sixth complication" of diabetes. Actually, diabetes mellitus and periodontitis are two extraordinarily prevalent chronic diseases that share a number of comorbidities all converging toward an increased risk of cardiovascular disease. Periodontal treatment has recently been shown to have the potential to improve the metabolic control of diabetes, although long-term studies are lacking. Uncontrolled diabetes also seems to affect the response to periodontal treatment, as well as the risk to develop peri-implant diseases. Mechanisms of associations between diabetes mellitus and periodontal disease include the release of advanced glycation end products as a result of hyperglycemia and a range of shared predisposing factors of genetic, microbial, and lifestyle nature. This review discusses the evidence for the risk of periodontal and peri-implant disease in diabetic patients and the potential role of the dental professional in the diabetes-periodontal interface.

Denture wearing status, cardiovascular health profiles, and mortality in edentulous patients: A prospective study with a 27-year follow-up

OBJECTIVES

Life's Simple 7 (LS7) metrics provide insight into improving cardiovascular health (CVH) and help reduce mortality risks. Edentulous older adults have a higher mortality risk than dentulous ones, probably due to worse oral function. It is reported that wearing dentures will decrease the mortality risk factor by improving oral function. This prospective study aimed to investigate if denture wearing could modify the association between CVH profile and mortality risk among edentulous elderly.

METHODS

From the Third National Health and Nutrition Examination Survey (NHANES III), 1,735 edentulous older adults (mean age 69.4 years old) with CVH profiles and data on denture wearing status were selected for this study. CVH profiles according to LS7 metrics were classified into poor, intermediate, or ideal. Denture wearers were defined as those wearing complete dentures in both arches all the time or only when awake. Multivariable Cox proportional-hazards regression was conducted to estimate the association of CVH profiles with all-cause and cardiovascular mortality. Stratified analyses and the testing of interaction terms were used to evaluate the difference between the association in edentulous patients with and without dentures.

RESULTS

A total of 1,420 (81.8%) older adults died during the 27-year follow-up, with 475 (27.6%) cases attributable to heart disease. After controlling for potential confounders, edentulous patients with an ideal CVH (LS7 = 10-14) had a lower mortality risk than those with poor CVH (LS7 = 0-4). Furthermore, we observed an effect modification by denture use (P_interaction = 0.046), with the role of ideal CVH in mitigating mortality among the denture wearers (Hazard Ratio = 0.440 [0.329-0.588]), while no significant association among those without dentures. Similar results were achieved for cardiovascular mortality, but there was no effect modification of denture use (P_interaction = 0.352).

CONCLUSION

In this study, a favorable cardiovascular health profile presents a protective effect on all-cause mortality only among edentulous patients wearing dentures instead of non-wearer.

CLINICAL SIGNIFICANCE

Denture usage could improve oral function (e.g., chewing, smiling, speaking, etc.) and promote general health. Effect modification found in this study indicates having ideal CVH alone cannot substantially reduce mortality risk among edentulous patients. Therefore, health care professionals should keep an eye on the elderly not wearing dentures as they are probably more at risk for adverse health outcomes. It remains unclear if denture wearing has a causal relation with lower mortality risks, and further research is needed.

Oral Lesions Associated with COVID-19 and the Participation of the Buccal Cavity as a Key Player for Establishment of Immunity against SARS-CoV-2

BACKGROUND

Some oral lesions have been described in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); the possibility has been raised that the buccal lesions observed in patients with the coronavirus disease 2019 (COVID-19) are due to this virus and the patient's systemic condition. The aim of this review was to integrate the knowledge related to the oral lesions associated with COVID-19 and the participation of the buccal cavity in the establishment of immunity against SARS-CoV-2.

METHODS

A literature search on the manifestations of buccal lesions from the beginning of the pandemic until October 2021 was carried out by using the PubMed database. A total of 157 scientific articles were selected from the library, which included case reports and reports of lesions appearing in patients with COVID-19.

RESULTS

Oral lesions included erosions, ulcers, vesicles, pustules, plaques, depapillated tongue, and pigmentations, among others. The oral cavity is a conducive environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, immunodeficiencies, and autoimmunity primarily.

CONCLUSIONS

The oral cavity is an accessible and privileged environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; the direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, in particular those related to immunodeficiencies and autoimmunity.

The additive effect of periodontitis with hypertension on risk of systemic disease and mortality

BACKGROUND

Recent evidence suggests that periodontitis (PD) causes hypertension, which is a precursor to development of other systemic diseases. The aim of this study was to examine the effect of hypertension and PD on the risk of subsequent systemic disease.

METHODS

This longitudinal cohort study included 244,393 UK Biobank participants who were free of systemic disease other than hypertension at baseline. Self-reported responses of painful gums or loose teeth were surrogates for PD. Hypertensives were identified by clinical diagnosis, or elevated blood pressure (≥140/90 mmHg). Systemic diseases including cancer, cardiovascular disease (CVD), and diabetes were identified from linked diagnostic codes. Multivariable Cox proportional hazard models were used to quantify the risk of systemic diseases and all-cause mortality, stratified by hypertensive and PD status.

RESULTS

The average age of the study population was 55.4 years (standard deviation [SD:] 8.1 years), and 130,220 (53.3%) participants were female. At baseline, 131,566 (53.8%) participants were hypertensive and 4.5% reported PD. The incidence rates of all systemic diseases were higher in hypertensive than non-hypertensive participants of the same PD status. In hypertensives, an additive effect was observed for PD on the risks of CVD (adjusted hazard ratio [HR]: 1.35, 95% confidence interval [CI]: 1.21-1.53) and respiratory disease (HR: 1.11, 95% CI: 0.95-1.30) compared to hypertensive healthy controls.

CONCLUSIONS

Hypertensives with PD have exacerbated risks of several systemic diseases. Future interventional studies should consider the effect of periodontal treatment on systemic outcomes in targeted hypertensive populations.

Poor oral health and risks of total and site-specific cancers in China: A prospective cohort study of 0.5 million adults

BACKGROUND

There is a strong connection between oral health and overall wellness. We aim to examine the association between poor oral health and the risk of developing or dying of cancer, and whether the association differs by residential area.

METHODS

Between 2004 and 2008, a total of 510,148 adults free of cancer were included from the China Kadoorie Biobank study and thereafter followed up to 2015. Poor oral health was assessed from a self-reported baseline questionnaire and defined as a combination of rarely brushing teeth and always gum bleeding. We used Cox proportional hazards models to estimate the hazard ratio (HR) of cancer risk and its associated 95% confidence interval (CI) according to oral health status.

FINDINGS

Overall, 14.9% of participants (19.7% in rural areas and 8.8% in urban areas) reported poor oral health at baseline. After 4,602,743 person-years of follow-up, we identified 23,805 new cancer cases and 11,973 cancer deaths, respectively. Poor oral health was associated with higher risks of total cancer incidence (HR: 1.08, 95% CI: 1.04-1.12) and death (HR: 1.10, 95% CI: 1.05-1.16). For the site-specific cancers, poor oral health was significantly associated with higher risk of stomach cancer incidence (cases: 2964, HR: 1.10, 95% CI: 1.00-1.22), esophageal cancer incidence (cases: 2119, HR: 1.19, 95% CI: 1.07-1.33), esophageal cancer death (cases: 1238, HR: 1.29, 95% CI: 1.12-1.49), liver cancer incidence (cases: 2565, HR: 1.18, 95% CI: 1.06-1.32), and liver cancer death (cases: 1826, HR: 1.20, 95% CI: 1.05-1.36). This positive association was stronger among rural residents compared to urban residents (interaction test P < 0.01).

INTERPRETATION

Our findings indicate that poor oral health is associated with higher risk for cancers, especially digestive system cancers. Promotion of oral health in the general population, especially for rural residents, could have valuable public health significance in preventing major systemic diseases.

FUNDING

Supported by grants (2021YFC2500400, 2016YFC0900500, 2016YFC0900501, 2016YFC0900504) from the National Key Research and Development Program of China, grants from the Kadoorie Charitable Foundation in Hong Kong and grants grants (088158/Z/09/Z, 104085/Z/14/Z, 202922/Z/16/Z) from Wellcome Trust in the UK. CKB is supported by the Kadoorie Charitable Foundation (KCF) in Hong Kong.

Edentulism is associated with increased risk of all-cause mortality in adult men

BACKGROUND

Prior reports of positive associations between edentulism and all-cause mortality have been limited by onetime assessments of edentulism and inadequate control of known confounding variables. The authors aimed to assess the association between edentulism and mortality using a longitudinal clinical oral health cohort.

METHODS

The authors used data from the Department of Veterans Affairs Dental Longitudinal Study, an ongoing, closed-panel cohort study from 1968 through 2019 (N = 1,229). Dentition status was evaluated through triennial clinical examinations. Mortality was assessed via the National Death Registry. The authors used Cox regression models to estimate the association between edentulism and all-cause mortality after covariate adjustment. Furthermore, the authors calculated propensity scores and assessed hazard ratios (HRs) in a trimmed, matched, and inverse probability weighted sample.

RESULTS

Participants who were edentulous (N = 112) had 1.24 (95% CI, 1.00 to 1.55) times the hazard of all-cause mortality compared with those who were nonedentulous, after adjustment with time-varying covariates. Use of propensity scores in the model resulted in slightly elevated HRs compared with the standard Cox model, regardless of propensity score method; adjusted HRs were 1.35 (95% CI, 1.01 to 1.80) after matching, 1.26 (95% CI, 1.00 to 1.59) after trimming, and 1.29 (95% CI, 1.18 to 1.42) after inverse probability weighting.

CONCLUSIONS

Edentulism was associated with an increased risk of all-cause mortality in a cohort that captured incident edentulism. This association was consistent after multiple methods to account for confounding.

PRACTICAL IMPLICATIONS

The findings of this study suggest that edentulism is associated with an increase in risk of mortality, after accounting for salient confounding variables using multiple approaches. Efforts to improve equitable access to tooth-preserving treatments are critical.

Dietary carbohydrate intake is associated with the subgingival plaque oral microbiome abundance and diversity in a cohort of postmenopausal women

Limited research exists on carbohydrate intake and oral microbiome diversity and composition assessed with next-generation sequencing. We aimed to better understand the association between habitual carbohydrate intake and the oral microbiome, as the oral microbiome has been associated with caries, periodontal disease, and systemic diseases. We investigated if total carbohydrates, starch, monosaccharides, disaccharides, fiber, or glycemic load (GL) were associated with the diversity and composition of oral bacteria in subgingival plaque samples of 1204 post-menopausal women. Carbohydrate intake and GL were assessed from a food frequency questionnaire, and adjusted for energy intake. The V3-V4 region of the 16S rRNA gene from subgingival plaque samples were sequenced to identify the relative abundance of microbiome compositional data expressed as operational taxonomic units (OTUs). The abundance of OTUs were centered log(2)-ratio transformed to account for the compositional data structure. Associations between carbohydrate/GL intake and microbiome alpha-diversity measures were examined using linear regression. PERMANOVA analyses were conducted to examine microbiome beta-diversity measures across quartiles of carbohydrate/GL intake. Associations between intake of carbohydrates and GL and the abundance of the 245 identified OTUs were examined by using linear regression. Total carbohydrates, GL, starch, lactose, and sucrose intake were inversely associated with alpha-diversity measures. Beta-diversity across quartiles of total carbohydrates, fiber, GL, sucrose, and galactose, were all statistically significant (p for PERMANOVA p < 0.05). Positive associations were observed between total carbohydrates, GL, sucrose and Streptococcus mutans; GL and both Sphingomonas HOT 006 and Scardovia wiggsiae; and sucrose and Streptococcus lactarius. A negative association was observed between lactose and Aggregatibacter segnis, and between sucrose and both TM7_[G-1] HOT 346 and Leptotrichia HOT 223. Intake of total carbohydrate, GL, and sucrose were inversely associated with subgingival bacteria alpha-diversity, the microbial beta-diversity varied by their intake, and they were associated with the relative abundance of specific OTUs. Higher intake of sucrose, or high GL foods, may influence poor oral health outcomes (and perhaps systemic health outcomes) in older women via their influence on the oral microbiome.

The association between sleep disturbances and tooth loss among post-stroke patients

ABSTRACT Background: Loss of teeth has been associated with neurological and sleep disorders. It is considered to be a predictor of stroke and leads to modifications of airway patency and predisposition to obstructive sleep apnea. Objective: To investigate sleep quality, risk of obstructive sleep apnea and excessive sleepiness among post-stroke patients with tooth loss attending the Neurovascular Clinic of the Federal University of São Paulo. Methods: The prevalence rates of different types of stroke were assessed among 130 patients with different degrees of tooth loss, along with the presence of sleep disturbances, risk of obstructive sleep apnea and excessive daytime sleepiness. Results: The prevalence of ischemic stroke was 94.6%, with either no significant disability or slight disability. Our sample had poor sleep quality, and a high risk of obstructive sleep apnea, but without excessive daytime sleepiness. Half of our sample had lost between 9 and 31 teeth, and more than 25% had edentulism. The majority used full removable dental prostheses, and more than half of these individuals slept without removing the prosthesis. Conclusions: We found high prevalence of poor sleep quality and high risk of obstructive sleep apnea among post-stroke patients with tooth loss. This indicates the need for further studies on treating and preventing sleep disturbances in stroke patients with tooth loss.

Antimicrobial Activity of Eucalyptus globulus, Azadirachta indica, Glycyrrhiza glabra, Rheum palmatum Extracts and Rhein against Porphyromonas gingivalis

Novel plant-derived antimicrobials are of interest in dentistry, especially in the treatment of periodontitis, since the use of established substances is associated with side effects and concerns of antimicrobial resistance have been raised. Thus, the present study was performed to quantify the antimicrobial efficacy of crude plant extracts against Porphyromonas gingivalis, a pathogen associated with periodontitis. The minimal inhibitory concentrations (MICs) of Eucalyptus globulus leaf, Azadirachta indica leaf, Glycyrrhiza glabra root and Rheum palmatum root extracts were determined by broth microdilution for P. gingivalis ATCC 33277 according to CLSI (Clinical and Laboratory Standards Institute). The MICs for the E. globulus, A. indica and G. glabra extracts ranged from 64 mg/L to 1024 mg/L. The lowest MIC was determined for an ethanolic R. palmatum extract with 4 mg/L. The MIC for the anthraquinone rhein was also measured, as the antimicrobial activity of P. palmatum root extracts can be partially traced back to rhein. Rhein showed a remarkably low MIC of 0.125 mg/L. However, the major compounds of the R. palmatum root extract were not further separated and purified. In conclusion, R. palmatum root extracts should be further studied for the treatment of periodontitis.

Reliability of C-reactive Protein as a Biomarker for Cardiovascular and Oral Diseases in Young and Old Subjects

BACKGROUND

Increased C-reactive protein (CRP) levels are associated with various diseases such as cardiovascular diseases (CVDs), periodontal diseases, and other inflammatory diseases and can be an effective biomarker for predicting future risks of periodontal diseases.

AIMS

The present trial was carried out to evaluate if CRP levels are lower in healthy and young individuals as compared to individuals with high body mass index (BMI), gingival index, and CVDs by assessing CRP levels in young and old individuals (more than 45 years).

MATERIALS AND METHODS

A total of 174 participants were recruited for the study and were divided into three following groups: Less than 45 years healthy participants (n = 124), more than 45 years healthy participants, and more 45-year-old participants with CVDs (n = 25). The collected data were subjected to the statistical analysis.

RESULTS

In Group I, females had a CRP level of 8476 ± 6.86 pg, females of Group II had a CRP value of 13,262 ± 3.76, and in females of Group III CRP value was 22,761 ± 6.24 pg. These values, respectively, for males were 8494 ± 7.68, 13,840 ± 4.82, and 13,839 ± 3.8. In smokers, the CRP values for Group I, II, and III were 29,012 ± 14.66, 12,568 ± 4.16, and 16,826 ± 3.42, respectively.

CONCLUSION

CRP levels were higher in males as compared to females. Higher BMI was associated with higher values of CRP. The participants with higher BMI presented higher CRP values irrespective of age.

What is the future of Periodontal Medicine?

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

Association Between Tooth Loss and Longitudinal Changes in B-Type Natriuretic Peptide Over 5 Years in Postmenopausal Women: The Nagahama Study

There is disparity between the sexes in cardiovascular diseases including heart failure (HF). This study aimed to investigate the effect of periodontal disease (PD) on plasma B-type natriuretic peptide (BNP) concentration across sex, age, and menopausal status, as well as the interaction effect of PD and diabetes mellitus (DM) on BNP. This large-scale prospective cohort study enrolled 7539 individuals with no myocardial infarctions or angina pectoris at baseline from the general Japanese population. The association between baseline number of missing teeth (MT) and the longitudinal changes in BNP over 5 years (ΔBNP) was evaluated according to sex and menopausal status. Among 7539 participants, 3190 were postmenopausal women with a mean age ± standard deviation of 61.1 ± 7.6 at baseline. Multivariate analysis revealed a positive association between MT and ΔBNP among postmenopausal women even after adjusting for covariates, including traditional HF risk factors (coefficient, 0.210; 95% confidence interval [CI], 0.107 to 0.312; P < 0.001), but not in men aged > 50. Including an interaction term (MT × DM) in the multivariate model revealed a positive interaction between MT and DM in ΔBNP among postmenopausal women (coefficient for interaction, 1.365; 95% CI, 0.902 to 1.827; P for interaction < 0.001). In conclusion, our study showed a positive association between MT and ΔBNP, as well as a positive effect of the interactive association between MT and DM, among postmenopausal women. Our results suggest a sex difference of an adverse effect of PD on initial myocardial wall stress in the ventricles.

Alzheimer disease and the periodontal patient: New insights, connections, and therapies

Loss of cognitive function in the aging population, particular those with Alzheimer disease, presents unique challenges to health practitioners. For the dental practitioner these include management of periodontal diseases, caries, and other dental conditions in this special population. It is well established in the cognitively impaired patient that a lack of adherence to dental hygiene routines and professional care leads to increases in the prevalence and severity of these dental conditions, leading to increased loss of teeth. More recent evidence has indicated a possible role of the microbiota of dental plaque associated with periodontal diseases in the development and progression of Alzheimer disease, thereby supporting a two-way interaction of these two diseases. New therapies are needed to address the potential upstream events that may precede overt signs of Alzheimer disease. One of these approaches would be to target these various bacterial, viral, and other microbial pathogens associated with periodontal disease that can translocate into the bloodstream and then to distal sites, such as the brain. Such microbial translocation would lead to local inflammation and buildup of the hallmark signs of Alzheimer disease, including amyloid beta deposits, tau fragmentation and tangles, breakdown of host protective molecules, such as the apolipoproteins, and neuron toxicity. In this review, evidence for the biological basis of the role of the periodontal disease microflora on the initiation and progression of Alzheimer disease will be presented with a focus on the potential role of the keystone pathogen Porphyromonas gingivalis with its family of gingipain enzymes. The various mechanisms for which P. gingivalis gingipains may contribute to the initiation and progression of Alzheimer disease are presented. Small-molecule inhibitors of these gingipains and their effects on reducing biological markers of Alzheimer disease may have beneficial effects for the initiation and progression of loss of cognitive function in Alzheimer disease. In addition to these targeted therapies for specific periodontal pathogens, considerations for the dental practitioner in applying more general approaches to reducing the periodontal plaque microflora in the management of the cognitively impaired patient are discussed for this special population.

Number of teeth is independently associated with ischemic stroke: A case-control study

Poor oral health has been suggested as a potential risk factor for the occurrence of cardiovascular events. The present study aimed to test the hypothesis that the number of permanent natural teeth (NT) is independently associated with the occurrence of ischemic stroke (IS) or transient ischemic attack (TIA) in a southern Brazilian population. This case-control study enrolled 458 subjects, 229 hospital patients diagnosed with IS or TIA (cases) and 229 patients with no history of cardiovascular disease (controls). NT was assessed through a head and neck multidetector computed tomography angiography (MDCTA) and panoramic radiographs. The participants were matched by age and sex. Sociodemographic and medical confounding variables were obtained from the hospital charts and through a structured questionnaire. Multivariate logistic regression analysis were carried out to estimate the association between NT and the occurrence of IS or TIA. The mean age was 58.37 ± 10.75 years, with 46.7% males. Adjusted analyses showed an independent association between IS or TIA and hypertension (OR = 6.34, 95%CI = 3.93-10.24), smoking (OR = 4.70, 95%CI = 2.76-7.99) and NT (lower quartile: ≤7 teeth) (OR = 5.59, 95%CI = 2.88-10.86). The number of permanent natural teeth was inversely and independently associated with the occurrence of IS or TIA in this population. Present findings suggest a gradient effect on the association between oral health and IS.

Severe periodontitis is associated with the serum levels of hypersensitive C reactive protein and lipoprotein-associated phospholipase A2 in the patients of acute ischemic stroke

BACKGROUND

Periodontitis is associated with the pathogenesis of atherosclerotic plaque, and hypersensitive C reactive protein (hs-CRP) and lipoprotein-associated phospholipase A2 (Lp-PLA2) are the serum biomarkers of the stability of atherosclerotic plaque. Whether periodontitis is associated with the serum level of hs-CRP and Lp-PLA2 of acute ischemic stroke remains unclear.

MATERIAL AND METHODS

We recruited 103 cases with acute ischemic stroke within 7 days after stroke onset. Pocket depth and clinical attachment loss were assessed by oral examination to define the severe periodontitis. Demographic information including gender, age and body weight index, income level, education level, past medical history include smoking history, drinking history, ischemic stroke history, coronary heart disease, hypertension, diabetes and hyperlipidemia were collected, and serum biomarkers including white blood cell (WBC), fibrinogen, total cholesterol (TC), triglyceride (TG), lower density lipoprotein (LDL-C), high density lipoprotein (HDL-C), hs-CRP, HemoglobinA1c (HbAlc), Homocysteine (HCY) and Lp-PLA2 were tested.

RESULTS

65 (63.1%) cases were diagnosed as severe periodontitis. Severe periodontitis group showed more male, age, drinking history, higher levels of hs-CRP and Lp-PLA2. Multivariate logistic regression showed that severe periodontitis was were significantly associated with hs-CRP (OR = 2.367, 95%CI: 1.182-4.738; P = .015) and Lp-PLA2 (OR = 2.577, 95% CI: 1.010-6.574; P = .048).

CONCLUSIONS

Severe periodontitis is independently associated with the serum Level of hs-CRP and Lp-PLA2 in patients with acute ischemic stroke. Whether the improvement of periodontitis could decrease the occurrence and re-occurrence of ischemic stroke by stablizating atherosclerotic plaque need be further studied in future.

Lower Number of Teeth Is Related to Higher Risks for ACVD and Death-Systematic Review and Meta-Analyses of Survival Data

Tooth loss reflects the endpoint of two major dental diseases: dental caries and periodontitis. These comprise 2% of the global burden of human diseases. A lower number of teeth has been associated with various systemic diseases, in particular, atherosclerotic cardiovascular diseases (ACVD). The aim was to summarize the evidence of tooth loss related to the risk for ACVD or death. Cohort studies with prospective follow-up data were retrieved from Medline-PubMed and EMBASE. Following the PRISMA guidelines, two reviewers independently selected articles, assessed the risk of bias, and extracted data on the number of teeth (tooth loss; exposure) and ACVD-related events and all-cause mortality (ACM) (outcome). A total of 75 articles were included of which 44 were qualified for meta-analysis. A lower number of teeth was related to a higher outcome risk; the pooled risk ratio (RR) for the cumulative incidence of ACVD ranged from 1.69 to 2.93, and for the cumulative incidence of ACM, the RR ranged from 1.76 to 2.27. The pooled multiple adjusted hazard ratio (HR) for the incidence density of ACVD ranged from 1.02 to 1.21, and for the incidence density of ACM, the HR ranged from 1.02 to 1.30. This systematic review and meta-analyses of survival data show that a lower number of teeth is a risk factor for both ACVD and death. Health care professionals should use this information to inform their patients and increase awareness on the importance of good dental health and increase efforts to prevent tooth loss.

The Impact of Oral Health on Respiratory Viral Infection

Influenza virus and severe acute respiratory syndrome coronavirus (SARS-CoV-2) have caused respiratory diseases worldwide. Coronavirus disease 2019 (COVID-19) is now a global health concern requiring emergent measures. These viruses enter the human body through the oral cavity and infect respiratory cells. Since the oral cavity has a complex microbiota, influence of oral bacteria on respiratory virus infection is considered. Saliva has immune molecules which work as the front line in the biophylactic mechanism and has considerable influence on the incidence and progression of respiratory viral infection. Salivary scavenger molecules, such as gp340 and sialic acid, have been reported to exert anti-influenza virus activity. Salivary secretory immunoglobulin A (SIgA) has potential to acquire immunity against these viruses. Biological features of the oral cavity are thought to affect viral infection in respiratory organs in various ways. In this review, we reviewed the literature addressing the impact of oral conditions on respiratory infectious diseases caused by viruses.

Association between periodontitis and severity of COVID-19 infection: A case-control study

AIM

COVID-19 is associated with an exacerbated inflammatory response that can result in fatal outcomes. Systemic inflammation is also a main characteristic of periodontitis. Therefore, we investigated the association of periodontitis with COVID-19 complications.

MATERIALS AND METHODS

A case-control study was performed using the national electronic health records of the State of Qatar between February and July 2020. Cases were defined as patients who suffered COVID-19 complications (death, ICU admissions or assisted ventilation), and controls were COVID-19 patients discharged without major complications. Periodontal conditions were assessed using dental radiographs from the same database. Associations between periodontitis and COVID 19 complications were analysed using logistic regression models adjusted for demographic, medical and behaviour factors.

RESULTS

In total, 568 patients were included. After adjusting for potential confounders, periodontitis was associated with COVID-19 complication including death (OR = 8.81, 95% CI 1.00-77.7), ICU admission (OR = 3.54, 95% CI 1.39-9.05) and need for assisted ventilation (OR = 4.57, 95% CI 1.19-17.4). Similarly, blood levels of white blood cells, D-dimer and C Reactive Protein were significantly higher in COVID-19 patients with periodontitis.

CONCLUSION

Periodontitis was associated with higher risk of ICU admission, need for assisted ventilation and death of COVID-19 patients, and with increased blood levels of biomarkers linked to worse disease outcomes.

Periodontopathogenic bacteria in subglottic samples from patients undergoing elective intubation for general anesthesia: A pilot study

BACKGROUND

Translocation of periodontal pathogens into the respiratory tract could either cause pneumonia or disrupt local defense mechanisms, predisposing the host to infection by respiratory pathogens. The objective of this pilot study was to evaluate the levels of periodontopathogenic bacteria in subglottic samples of intubated and mechanically ventilated patients and the impact of oral decontamination with chlorhexidine (CHX) on subglottic levels of these microorganisms.

METHODS

Patients scheduled to undergo elective surgical procedures requiring endotracheal intubation and mechanical ventilation for at least 3 hours were included. Following full-mouth periodontal examination, patients were randomly assigned to groups that rinsed preoperatively with 0.12% CHX or 0.9% saline (control). After 3 hours of orotracheal intubation, subglottic contents were collected. Quantification of Aggregatibacter actinomycetemcomitans (A. actinomycetemcomitans), Porphyromonas gingivalis (P. gingivalis), and Tannerella forsythia (T. forsythia) in subglottic samples was determined using quantitative real-time polymerase chain reaction. Data were analyzed by Fisher Exact Probability, unpaired Student's t and Mann-Whitney tests.

RESULTS

Of the 69 patients included, 43 completed study participation. There were no differences between control and CHX groups in subglottic detection rates and abundance levels of P. gingivalis (P = 0.59), T. forsythia (P = 0.83) and A. actinomycetemcomitans (P = 0.07). Moreover, our data indicate that periodontal health has no impact on subglottic levels of P. gingivalis, T. forsythia, and A. actinomycetemcomitans.

CONCLUSIONS

Periodontal pathogens were detected in subglottic samples of intubated and mechanically ventilated patients. Moreover, a single CHX rinse prior to endotracheal intubation may have no effect on subglottic contamination by P. gingivalis, T. forsythia, and A. actinomycetemcomitans.

Impact of Poor Oral Health on Community-Dwelling Seniors: A Scoping Review

The aim of this scoping review was to determine health-related impacts of poor oral health among community-dwelling seniors. Using MeSH terms and keywords such as elderly, general health, geriatrics, 3 electronic databases-Medline, CINAHL, and Age Line were searched. Title and abstracts were independently screened by 3 reviewers, followed by full-texts review. A total of 131 articles met our inclusion criteria, the majority of these studies were prospective cohort (77%, n = 103), and conducted in Japan (42 %, n = 55). These studies were categorized into 16 general health outcomes, with mortality (24%, n = 34), and mental health disorders (21%, n = 30) being the most common outcomes linked with poor oral health. 90% (n = 120) of the included studies reported that poor oral health in seniors can subsequently lead to a higher risk of poor general health outcomes among this population. Improving access to oral healthcare services for elderly can help not only reduce the burden of oral diseases in this population group but also address the morbidity and mortality associated with other general health diseases and conditions caused due to poor oral health. Findings from this study can help identify shortcomings in existing oral healthcare programs for elderly and develop future programs and services to improve access and utilization of oral care services by elderly.

Risk of incident cardiovascular disease in people with periodontal disease: A systematic review and meta-analysis

OBJECTIVES

Cardiovascular disease (CVD) is a major cause of mortality; periodontal disease (PD) affects up to 50% of the world's population. Observational evidence has demonstrated association between CVD and PD. Absent from the literature is a systematic review and meta-analysis of longitudinal cohort studies quantifying CVD risk in PD populations compared to non-PD populations. To examine the risk of incident CVD in people with PD in randomised controlled trials and longitudinal cohort studies.

MATERIAL AND METHODS

We searched Medline, EMBASE and Cochrane databases up to 9th Oct 2019 using keywords and MeSH headings using the following concepts: PD, CVD, longitudinal and RCT study design. CVD outcomes included but were not restricted to any CVD, myocardial infarction, coronary heart disease (CHD) and stroke. Diagnosis method and severity of PD were measured either clinically or by self-report. Studies comparing incident CVD in PD and non-PD populations were included. Meta-analysis and meta-regression was performed to determine risk of CVD in PD populations and examine the effects of PD diagnosis method, PD severity, gender and study region.

RESULTS

Thirty-two longitudinal cohort studies were included after full text screening; 30 were eligible for meta-analysis. The risk of CVD was significantly higher in PD compared to non-PD (relative risk [RR]: 1.20, 95% CI: 1.14-1.26). CVD risk did not differ between clinical or self-reported PD diagnosis (RR = 0.97, 95% CI: 0.87-1.07,). CVD risk was higher in men (RR: 1.16, 95% CI: 1.08-1.25) and severe PD (RR: 1.25, 95% CI: 1.15-1.35). Among all types of CVD, the risk of stroke was highest (RR = 1.24; 95% CI:1.12-1.38), the risk of CHD was also increased (RR = 1.14; 95% CI:1.08-1.21).

CONCLUSION

This study demonstrated modest but consistently increased risk of CVD in PD populations. Higher CVD risk in men and people with severe PD suggests population-targeted interventions could be beneficial.

Periodontitis, Edentulism, and Risk of Mortality: A Systematic Review with Meta-analyses

Periodontitis has been independently associated with the chronic noncommunicable diseases that most frequently lead to death worldwide. The aim of the present systematic review was to study whether people with periodontitis/edentulism are at increased risk of all-cause and cause-specific mortality as compared with those without periodontitis/edentulism. Cohort studies were included that 1) evaluated periodontitis or edentulism as exposures in relation to all-cause or cause-specific mortality as an outcome and 2) reported effect estimates as hazard ratios, risk ratios, or odds ratios with 95% CIs or crude numbers. Two review authors independently searched for eligible studies, screened the titles and abstracts, did full-text analysis, extracted the data from the published reports, and performed the risk-of-bias assessment. In case of disagreement, a third review author was consulted. Study results were summarized through random effects meta-analyses. A total of 57 studies were included, involving 48 cohorts and 5.71 million participants. Periodontitis was associated with increased risk of all-cause mortality (risk ratio, 1.46 [95% CI, 1.15 to 1.85]) and mortality due to cardiovascular diseases (1.47 [1.14 to 1.90]), cancer (1.38 [1.24 to 1.53]), coronary heart disease (2.58 [2.20 to 3.03]), cerebrovascular diseases (3.11 [2.42 to 3.98]), but not pneumonia (0.98 [0.69 to 1.38]). Edentulism (all types) was associated with increased risk of all-cause mortality (1.66 [1.46 to 1.88]) and mortality due to cardiovascular diseases (2.03 [1.50 to 2.74]), cancer (1.55 [1.24 to 1.94]), pneumonia (1.72 [1.07 to 2.78]), coronary heart disease (2.98 [2.43 to 3.65]), and cerebrovascular diseases (3.18 [2.24 to 4.51]). Periodontitis and its ultimate sequela (edentulism) are associated with an increased risk of all-cause and cause-specific mortality (PROSPERO CRD42018100095).

Relationship of periodontitis and edentulism to angiographically diagnosed coronary artery disease: A cross-sectional study

OBJECTIVE

The objective of the study is to examine the connection between oral status and the extent of coronary artery disease (CAD), which is diagnosed by angiography.

BACKGROUND

Periodontitis and tooth loss have been linked to atherosclerosis and CAD in previous studies. However, no distinct connection was revealed due to the diversity of the results and the variety of diagnostic methods. To provide a more consistent data pool and stronger evidence, there is a need for studies with standard measurements and diagnostic criteria.

METHODS

309 patients, who consulted to Ankara University, Faculty of Medicine, Department of Cardiology and had coronary angiography, were enrolled to this study. Individuals were grouped based on their coronary angiography results, as CAD (+) (n = 233) and CAD (-) (n = 76). Studied parameters included cardiovascular risk factors, plaque index (PI), remaining teeth count, bleeding on probing (BOP), and probing pocket depth (PPD). Periapical radiographs were taken from teeth with ≥4 mm PPD. Oral status was categorized as periodontally healthy subjects/patients with gingivitis (Group 1), patients with periodontitis (Group 2), and edentulous subjects (Group 3).

RESULTS

PI (P < 0.001), PPD (P = 0.001), BOP (P = 0.004), the number of patients with less than 10 teeth (P = 0.014), and edentulism (P = 0.009) were significantly higher in CAD (+) patients, who were mostly older (P < 0.001) and male (P < 0.001). Multivariate logistic regression analysis revealed that Group 2 (odds ratio = 2.48, 95% confidence interval = 1.24-4.95, P = 0.010) and Group 3 (odds ratio = 2.01, 95% confidence interval = 1.14-5.17, P = 0.040) were highly associated with CAD. Two and three stenosed vessels were significantly higher in Groups 2 and 3 compared to Group 1 (P = 0.003).

CONCLUSIONS

It was found that both edentulism and periodontitis were related to CAD.

Edentulism and all-cause mortality among Brazilian older adults: 11-years follow-up

We assessed the association between edentulism and all-cause mortality among community-dwelling older adults from São Paulo, Brazil, from 2006 to 2017. This prospective cohort study used data from the Health, Well-being and Aging Study (SABE, Portuguese acronym). Edentulism was evaluated by means of clinical oral examination and all-cause mortality data were obtained from state official records. Covariates included socioeconomic factors (age, sex, and schooling); health behavior (smoking, alcohol intake, and physical activity); dental care (prostheses use); general health (multimorbidity); and nutritional status (underweight). Kaplan-Meier survival curves were stratified by edentulism and compared using the log-rank test. Cox proportional hazards model was applied to calculate hazard ratios (HRs) for the association between edentulism and mortality after adjusting for covariates. The study sample included 1,687 participants (age, 60-102 years; edentulous: 47.2%). In the 11 years of follow-up, we analyzed 10,494 person-years and 566 deaths. In bivariate analysis, edentulous older adults were found to be at a higher risk of dying from all causes than the dentate participants (HR: 1.81; 95%CI: 1.53-2.15). After sequential adjustment for socioeconomic factors, health behavior, dental care, general health, and nutritional status, this association was attenuated, but remained significant (HR: 1.34; 95%CI: 1.10-1.63). In conclusion, edentulism is a significant predictor of all-cause mortality among older adults.

Volumetric osseous changes in the completely edentulous maxilla after sinus grafting and lateral bone augmentation: a systematic review

The aim of this systematic review was to evaluate the volumetric changes associated with different bone grafting techniques in the completely edentulous atrophic maxilla before dental implant placement. A search was performed according to the PRISMA guidelines. A PICO question was formed, and the PubMed, Scopus, Embase, and Cochrane Library databases were searched, covering the period 2000-2018. Relevant data were extracted from the results regarding study population, surgical details, technical information on volumetric data acquirement, and volumetric outcome after bone augmentation procedures before implant placement. Six articles with a combined population of 84 patients were included. All patients had a completely edentulous maxilla, with a crestal horizontal width of <3-4mm or a crestal vertical height of <6-7mm. The iliac bone and ascending ramus were most frequently used as grafts. Five of the six studies reported volumes of sinus inlay graft (SIG) and four reported volumes of lateral bone augmentation (LBA). Radiographic analyses of the augmented areas differed among the studies. Volume loss after bone augmentation procedures ranged from 5% to 50% for SIG and from 5% to 47% for LBA. All surgical augmentation techniques for the edentulous maxilla are prone to resorption; no procedure seemed to be superior, but some interesting observations were made.

The Buffalo OsteoPerio Studies: Summary of our findings and the unique contributions of Robert J. Genco, DDS, PhD

PURPOSE

Robert ("Bob") Genco was a member of the research team that established the Buffalo Osteoporosis and Periodontal Disease (OsteoPerio) study. Here we detail the scientific discoveries emanating from this enduring collaboration.

STUDY COHORTS

OsteoPerio is ancillary to the Women's Health Initiative Observational Study (WHI-OS). WHI-OS is a longitudinal study of 93,000 postmenopausal women aged 50-79 enrolled at 40 U.S. centers (enrolled 1993-1998). OsteoPerio enrolled 1342 women 3 years later (1997-2001) from the Buffalo WHI-OS participants to study the association of osteoporosis and periodontal disease. OsteoPerio has 5-year (N=1026) and 17-year (N=518) follow-up examinations.

PARTICIPANTS

In addition to information on health status from the WHI-OS, OsteoPerio further included comprehensive oral examinations assessing probing pocket depth, clinical attachment loss, gingival bleeding, alveolar crestal height, and DMFT. Systemic bone density (measured by DXA), blood, saliva and plaque also were collected at all three visits.

SUMMARY

Findings from these studies are summarized here.

Factors Associated with Tooth Loss in Postmenopausal Women: A Community-Based Cross-Sectional Study

Many studies have indicated that menopause affects periodontal health and tooth loss. The possible mechanism might due to several hormonal changes and low bone mineral density (BMD) during the transition period. However, few studies have explored the role of oral hygiene in the number of remaining teeth (NRT) in postmenopausal women (PMW). The aim of this study was to explore the prevalence of and factors associated with NRT less than 20 in PMW. A community-based, cross-sectional study was conducted in coastal Yunlin County, Taiwan. NRT was calculated based on natural and filled teeth. BMD was detected by dual-energy X-ray absorptiometry at the collaborating hospital. Logistic regression analyses were used to identify the factors associated with NRT in rural PMW. Six hundred and ten rural PMW with mean age 65.4 years enrolled in this study. The mean NRT was 17.6 (standard deviation [SD] = 10.4), with 43.9% having <20 and 13.9% edentulous. More than half (65.9%) reported that they seldom brushed their teeth after meals, 79.2% rarely used dental floss, and 80% did not regularly undergo tooth scaling by a dentist. The majority of women had low BMD, including 48.7% with osteopenia and 20.7% with osteoporosis. After adjusting for potentially confounding variables, NRT <20 was associated with infrequent tooth scaling (odds ratio [OR] = 2.78, 95% confidence interval [CI] = 1.70–4.56) and dental floss use (OR = 2.01, 95% CI = 1.24–3.26), but not BMD. A high prevalence of NRT <20 was found among rural PMW, but poor oral hygiene rather than low BMD was the major contributing factor. It is an emerging issue for primary healthcare providers and clinicians to initiate oral hygiene promotion programs for these disadvantaged women.

Association of the Dietary Index Underpinning the Nutri-Score Label with Oral Health: Preliminary Evidence from a Large, Population-Based Sample

The 2017 implementation in France of the front-of-package nutrition label known as ‘Nutri-Score’ was intended as a public health strategy to help individuals make healthier food choices at the point of purchase and thus help reduce chronic disease on the population level. Nutri-Score and the associated individual-level dietary index are based on the British Food Standards Agency Nutrient Profiling System (FSAm-NPS-DI). Prior research has shed light on the relation between the dietary index and various physical health outcomes, yet no studies have explored the link with oral health. We analyzed the cross-sectional association of the dietary index with oral health in a population-based sample of 33,231 adults from the French NutriNet-Santé cohort. Oral health (main dependent variable) was assessed in 2016 with the General Oral Health Assessment Index; FSAm-NPS-DI (main independent variable) was calculated using ≥3 non-consecutive 24-h dietary records, following established methodology; lower scores corresponded to better diet quality. Age-specific associations were explored via multivariable linear regression. Fully-adjusted models showed modest yet significant associations between the dietary index and oral health in younger (18–59 years) and older (60+ years) participants, with the strength of the model being more pronounced in the former compared with the latter age group (F value: 28.5 versus 6.3, both p < 0.0001). Higher diet quality was associated with a somewhat lower risk of oral health problems. Albeit preliminary, the findings support the relevance of dietary indices underpinning nutrition labels such as the Nutri-Score. Future research is needed to confirm the associations.

Body site-dependent variations of microbiota in pancreatic cancer pathophysiology

Lack of specific symptoms and reliable biomarkers, along with aggressive nature and resistance to therapies makes pancreatic cancer (PC) one of the leading causes of death from cancer worldwide. The search for new diagnostic, prognostic, predictive, and therapeutic tools that could improve clinical outcomes of patients has led, in recent years, to the investigation of potential roles for the microbiota in the pathogenesis of this disease. The human microbiota encompasses trillions of microorganisms residing within several body tissues and organs, where they provide beneficial functions for host homeostasis and health. Derangements of the microbial ecology in different anatomic districts have been described in PC, as in many other diseases, both in patients and in animal models. In detail, infection from the gastric pathogen Helicobacter pylori and changes in composition and diversity of oral, intestinal, and pancreatic microbiota have been found to associate with PC. Future research should assess how to potentially exploit such differences in microbiota composition as diagnostic, prognostic, or predictive biomarkers, and as targets for therapeutic interventions, in the hope of improving the dismal prognosis of this insidious cancer.

The Microbiomes of Pancreatic and Duodenum Tissue Overlap and Are Highly Subject Specific but Differ between Pancreatic Cancer and Noncancer Subjects

BACKGROUND

In mice, bacteria from the mouth can translocate to the pancreas and impact pancreatic cancer progression. In humans, oral bacteria associated with periodontal disease have been linked to pancreatic cancer risk. It is not known if DNA bacterial profiles in the pancreas and duodenum are similar within individuals.

METHODS

Tissue samples were obtained from 50 subjects with pancreatic cancer or other conditions requiring foregut surgery at the Rhode Island Hospital (RIH), and from 34 organs obtained from the National Disease Research Interchange. 16S rRNA gene sequencing was performed on 189 tissue samples (pancreatic duct, duodenum, pancreas), 57 swabs (bile duct, jejunum, stomach), and 12 stool samples.

RESULTS

Pancreatic tissue samples from both sources (RIH and National Disease Research Interchange) had diverse bacterial DNA, including taxa typically identified in the oral cavity. Bacterial DNA across different sites in the pancreas and duodenum were highly subject specific in both cancer and noncancer subjects. Presence of genus Lactobacillus was significantly higher in noncancer subjects compared with cancer subjects and the relative abundance of Fusobacterium spp., previously associated with colorectal cancer, was higher in cancer subjects compared with noncancer subjects.

CONCLUSIONS

Bacterial DNA profiles in the pancreas were similar to those in the duodenum tissue of the same subjects, regardless of disease state, suggesting that bacteria may be migrating from the gut into the pancreas. Whether bacteria play a causal role in human pancreatic cancer needs to be further examined.

IMPACT

Identifying bacterial taxa that differ in cancer patients can provide new leads on etiologically relevant bacteria.

Association of Periodontal Disease and Edentulism With Hypertension Risk in Postmenopausal Women

BACKGROUND

Multiple cross-sectional epidemiologic studies have suggested an association between periodontal disease and tooth loss and hypertension, but the temporality of these associations remains unclear. The objective of our study was to evaluate the association of baseline self-reported periodontal disease and edentulism with incident hypertension.

METHODS

Study participants were 36,692 postmenopausal women in the Women's Health Initiative-Observational Study who were followed annually from initial periodontal assessment (1998-2003) through 2015 (mean follow-up 8.3 years) for newly diagnosed treated hypertension. Cox proportional hazards regression with adjustment for potential confounders was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Edentulism was significantly associated with incident hypertension in crude (HR (95% CI) = 1.38 (1.28-1.49)) and adjusted (HR (95% CI) = 1.21 (1.11-1.30)) models. This association was stronger among those <60 years compared to ≥60 years (P interaction 0.04) and among those with <120 mm Hg systolic blood pressure, compared to those with ≥120 mm Hg (P interaction 0.004). No association was found between periodontal disease and hypertension.

CONCLUSIONS

These findings suggest that edentulous postmenopausal women may represent a group with higher risk of developing future hypertension. As such improved dental hygiene among those at risk for tooth loss as well as preventive measures among the edentulous such as closer blood pressure monitoring, dietary modification, physical activity, and weight loss may be warranted to reduce disease burden of hypertension. Further studies are needed to clarify these results and further elucidate a potential role of periodontal conditions on hypertension risk.

SIRT6 overexpression inhibits cementogenesis by suppressing glucose transporter 1

Cementum, which shares common features with bone in terms of biochemical composition, is important for the homeostasis of periodontium during periodontitis and orthodontic treatment. Sirtuin 6 (SIRT6), as a member of the sirtuin family, plays key roles in the osteogenic differentiation of bone marrow mesenchymal stem cells. However, the involvement of SIRT6 in cementoblast differentiation and mineralization and the underlying mechanisms remain unknown. In this study, we observed that the expression of SIRT6 increased during cementoblast differentiation initially. Analysis of the gain- and loss-of-function indicated that overexpressing SIRT6 in OCCM-30 cells suppresses cementoblast differentiation and mineralization and downregulating SIRT6 promotes cementogenesis. GLUT1, a glucose transporter necessary in cementogenesis, was inhibited by SIRT6. Overexpressing GLUT1 in SIRT6-overexpressed OCCM-30 cells rescued the inhibitory effect of SIRT6 on cementoblast differentiation and mineralization. Moreover, AMPK was activated after overexpressing SIRT6 and inhibited cementoblast differentiation and mineralization. Downregulating the expression of SIRT6 inhibited AMPK activity. Meanwhile, GLUT1 overexpression significantly decreased AMPK activity. Overall, on one hand, SIRT6 inhibited cementoblast differentiation and mineralization by suppressing GLUT1. On the other hand, SIRT6 inhibited cementoblast differentiation and mineralization by activating the AMPK pathway. GLUT1 overexpression also rescued the increased AMPK pathway activated by SIRT6.

Distribution of Cervicocephalic Atherosclerotic Lesions and Their Correlation with Cardiovascular Risk Factors in a Population of Amerindians. The Atahualpa Project

BACKGROUND

No information is available on the distribution of cervicocephalic atherosclerosis in Amerindians. We aimed to assess the distribution of these lesions and their correlation with cardiovascular risk factors in Amerindians living in rural Ecuador.

METHODS

Atahualpa residents aged ≥40years underwent head CT for assessment of carotid siphon calcifications (CSC) and sonographic examination for measurement of the carotid intima media thickness (cIMT). CSC were used as a surrogate of intracranial atherosclerosis and the cIMT as a surrogate of extracranial atherosclerosis. Linear regression and multinomial logistic regression models were fitted to assess the association between cIMT and CSC, and to evaluate differences in risk factors across individuals with atherosclerosis involving both arterial beds when compared with those with extra- or intracranial atherosclerosis alone, or no atherosclerosis.

RESULTS

Of 590 participants, 145 had high calcium content in the carotid siphons and 87 had a cIMT >1mm (25% versus 15%, P < .001). Thirty-eight (7%) individuals had atherosclerosis at both vascular beds, 107 (18%) had intracranial atherosclerosis, and 49 (8%) had extracranial atherosclerosis alone. The cIMT and CSC were independently associated (P = .008). When compared with participants without atherosclerosis, those with atherosclerosis at both vascular beds were older, more often male, hypertensive and diabetic. Subjects with intracranial atherosclerosis alone were older, and those with extracranial atherosclerosis alone reported less physical activity than those without atherosclerosis.

CONCLUSION

Intracranial atherosclerosis is more common than extracranial atherosclerosis in Amerindians. Traditional risk factors only explain a minority of cases of cervicocephalic atherosclerosis in this population.

Charlson comorbidity index as a predictor of periodontal disease in elderly participants

Purpose

This study investigated the validity of the Charlson comorbidity index (CCI) as a predictor of periodontal disease (PD) over a 12-year period.

Methods

Nationwide representative samples of 149,785 adults aged ≥60 years with PD (International Classification of Disease, 10th revision [ICD-10], K052-K056) were derived from the National Health Insurance Service-Elderly Cohort during 2002-2013. The degree of comorbidity was measured using the CCI (grade 0-6), including 17 diseases weighted on the basis of their association with mortality, and data were analyzed using multivariate Cox proportional-hazards regression in order to investigate the associations of comorbid diseases (CDs) with PD.

Results

The multivariate Cox regression analysis with adjustment for sociodemographic factors (sex, age, household income, insurance status, residence area, and health status) and CDs (acute myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular accident, dementia, pulmonary disease, connective tissue disorders, peptic ulcer, liver disease, diabetes, diabetes complications, paraplegia, renal disease, cancer, metastatic cancer, severe liver disease, and human immunodeficiency virus [HIV]) showed that the CCI in elderly comorbid participants was significantly and positively correlated with the presence of PD (grade 1: hazard ratio [HR], 1.11; P<0.001; grade ≥2: HR, 1.12, P<0.001).

Conclusions

We demonstrated that a higher CCI was a significant predictor of greater risk for PD in the South Korean elderly population.

Adherence to National Dietary Guidelines in Association with Oral Health Impact on Quality of Life

We aimed to assess the association between oral health, in terms of its impact on quality of life, and diet quality expressed as adherence to dietary guidelines. We analyzed cross-sectional data from the French NutriNet-Santé general population-based e-cohort (N = 18,263 adults; mean age = 56.5 ± 13.8 years). The main independent variable, oral health-related quality of life, was assessed in 2016 with the GOHAI instrument (maximum score = 60). The main dependent variable, diet’s nutritional quality, was assessed with the mPNNS-GS score (maximum score = 13.5) measuring adherence to French dietary guidelines and computed on the basis of repeated 24-h dietary records. Multivariable linear regression models were fit. Mean GOHAI score was 54.5 ± 4.3 and mean mPNNS-GS score was 7.7 ± 1.6. Among participants aged 18–64 years, those scoring ≤50 on GOHAI (poor oral health with a detrimental impact on quality of life) were less likely to adhere to dietary guidelines than participants scoring 57–60 points (good oral health) (beta = −0.18, 95% CI: −0.26, −0.09; p < 0.0001). Among participants aged 65+ years, those scoring 51–56 points on GOHAI (average oral health with some negative impact on quality of life) were less likely to adhere to dietary guidelines than were participants scoring in the range 57–60 (beta = −0.23, 95% CI: −0.33, −0.13; p < 0.0001). The findings suggested modest age-dependent associations between oral health-related quality of life and diet quality. Confirmation is needed longitudinally with representative samples and accounting for diet quality evolution.

Periodontitis, edentulism and glycemic control in patients with type 2 diabetes: a cross-sectional study

OBJECTIVES

To compare the glycemic control in non-smoking patients with type 2 diabetes according to their periodontal and dental status.

RESEARCH DESIGN AND METHODS

This cross-sectional study investigated patients previously diagnosed with type 2 diabetes and under antidiabetic medication. Clinical data and fasting blood glucose (FBG) levels were collected from medical and dental records. Patients were divided into three groups according to dental and periodontal diagnosis: no or mild periodontitis (NO/MILD, n=96), moderate or severe periodontitis (MOD/SEV, n=74) and edentulous (n=141). FBG levels were compared between groups. Logistic regression was also applied to estimate the OR of presenting hyperglycemia.

RESULTS

Edentulous patients had significantly higher FBG levels of 155.7±70.9 (mean±SD mg/dL) than those in the MOD/SEV (136.6±33.8) and the NO/MILD (123.1±36.7) groups. Differences between the latter two groups were also significant. Edentulous patients had adjusted ORs of 4.53, 4.27 and 3.95 of having FBG≥126, ≥150 and ≥180 mg/dL, respectively, in comparison with NO/MILD group. The MOD/SEV group also presented significant odds of having FBG≥126 mg/dL (OR=2.66) and ≥150 mg/dL (OR=2.45) than the NO/MILD group.

CONCLUSIONS

Patients in the MOD/SEV group had worse glycemic control than the ones in the NO/MILD group. However, edentulous patients presented higher glycemic levels than both dentate groups, and also presented with higher odds of having hyperglycemia.