Dementia and the Risk of Periodontitis: A Population-Based Cohort Study

Periodontitis is an immune-related adverse event associated with immune checkpoint inhibitors: A multi-center cohort study

Immune checkpoint inhibitors (ICIs) cause immune-related adverse events (irAEs) across various organ systems including oral health complications such as dry mouth and stomatitis. In this study, we aimed to determine the risk of periodontitis among patients on immune checkpoint inhibitors (ICIs) and to test the associations between ICI-associated periodontitis and other immune-related adverse events (irAEs). We performed a retrospective cohort study involving adult cancer patients between January 2010 and November 2021. Patients on an ICI were propensity score-matched to patients not on an ICI. The primary outcome was the occurrence of periodontitis. ICIs included programmed cell death 1 (PD-1) inhibitors programmed cell death ligand 1 (PD-L1) inhibitors, and cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors. The risk of periodontitis following ICI use was derived through a Cox proportional hazard model and Kaplan-Meier survival analysis. Overall, 868 patients on an ICI were matched to patients not on an ICI. Among the ICI cohort, 41 (4.7 %) patients developed periodontitis. The incidence rate of periodontitis was significantly higher in patients on an ICI than in patients not on an ICI (55.3 vs 25.8 per 100 patient-years, incidence rate ratio = 2.14, 95 % CI = 1.38-3.33). Both the use of PD-L1 inhibitors (multivariate HR = 2.5, 95%CI = 1.3-4.7) and PD-1 inhibitors (multivariate HR = 2.0, 95%CI = 1.2-3.2) were associated with the risk of periodontitis. The presence of immune-related periodontitis was associated with better overall survival (not reached vs 17 months, log-rank p-value<0.001), progression-free survival (14.9 vs 5.6 months, log-rank p-value = 0.01), and other concomitant immune-related cutaneous adverse events. In conclusion, ICI was associated with an increased risk of periodontitis. Immune-related periodontitis as an irAE was associated with better cancer survival and concomitant cutaneous irAEs.

Dementia exacerbates periodontal bone loss in females

BACKGROUND

Periodontitis is a chronic inflammatory disease defined by the pathologic loss of the periodontal ligament and alveolar bone in relation to aging. Although clinical cohort studies reported that periodontitis is significantly elevated in males compared to females, emerging evidence indicates that females with dementia are at a greater risk for periodontitis and decreased alveolar bone.

OBJECTIVE

This study aimed to evaluate whether dementia is a potential sex-dependent risk factor for periodontal bone loss using an experimental model of periodontitis induced in the triple transgenic (3x-Tg) dementia-like mice and clinical samples collected from senior 65 plus age patients with diagnosed dementia.

MATERIALS AND METHODS

We induced periodontitis in dementia-like triple-transgenic (3x-Tg) male and female mice and age-matched wild-type (WT) control mice by ligature placement. Then, alveolar bone loss and osteoclast activity were evaluated using micro-CT and in situ imaging assays. In addition, we performed dental examinations on patients with diagnosed dementia. Finally, dementia-associated Aβ42 and p-Tau (T181) and osteoclastogenic receptor activator of nuclear factor kappa-Β ligand (RANKL) in gingival crevicular fluid (GCF) collected from mice and clinical samples were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Alveolar bone loss and in situ osteoclast activity were significantly elevated in periodontal lesions of 3x-Tg females but not males, compared to wild-type control mice. In addition, we also observed that the probing pocket depth (PPD) was also significantly elevated in female patients with dementia. Using ELISA assay, we observed that females had elevated levels of osteoclastogenic RANKL and dementia-associated Aβ42 and p-Tau (T181) in the GCF collected from experimental periodontitis lesions and clinical samples.

CONCLUSION

Altogether, we demonstrate that females with dementia have an increased risk for periodontal bone loss compared to males.

Periodontitis: A Plausible Modifiable Risk Factor for Neurodegenerative Diseases? A Comprehensive Review

The aim of this comprehensive review is to summarize recent literature on associations between periodontitis and neurodegenerative diseases, explore the bidirectionality and provide insights into the plausible pathogenesis. For this purpose, systematic reviews and meta-analyses from PubMed, Medline and EMBASE were considered. Out of 33 retrieved papers, 6 articles complying with the inclusion criteria were selected and discussed. Additional relevant papers for bidirectionality and pathogenesis were included. Results show an association between periodontitis and Alzheimer's disease, with odds ratios of 3 to 5. A bidirectional relationship is suspected. For Parkinson's disease (PD), current evidence for an association appears to be weak, although poor oral health and PD seem to be correlated. A huge knowledge gap was identified. The plausible mechanistic link for the association between periodontitis and neurodegenerative diseases is the interplay between periodontal inflammation and neuroinflammation. Three pathways are hypothesized in the literature, i.e., humoral, neuronal and cellular, with a clear role of periodontal pathogens, such as Porphyromonas gingivalis. Age, gender, race, smoking, alcohol intake, nutrition, physical activity, socioeconomic status, stress, medical comorbidities and genetics were identified as common risk factors for periodontitis and neurodegenerative diseases. Future research with main emphasis on the collaboration between neurologists and dentists is encouraged.

Highlighting the Effect of Pro-inflammatory Mediators in the Pathogenesis of Periodontal Diseases and Alzheimer's Disease

Alzheimer's disease (AD) is a neurological condition that is much more common as people get older. It may start out early or late. Increased levels of pro-inflammatory cytokines and microglial activation, both of which contribute to the central nervous system's inflammatory state, are characteristics of AD. As opposed to this, periodontitis is a widespread oral infection brought on by Gram-negative anaerobic bacteria. By releasing pro-inflammatory cytokines into the systemic circulation, periodontitis can be classified as a "low-grade systemic disease." Periodontitis and AD are linked by inflammation, which is recognized to play a crucial part in both the disease processes. The current review sought to highlight the effects of pro-inflammatory cytokines, which are released during periodontal and Alzheimer's diseases in the pathophysiology of both conditions. It also addresses the puzzling relationship between AD and periodontitis, highlighting the etiology and potential ramifications.

The association between periodontitis and cerebrovascular disease, and dementia. Scientific report of the working group of the Spanish Society of Periodontology and the Spanish Society of Neurology

OBJECTIVE

This article reviews the scientific evidence on the relationship between periodontitis and neurological disease, and particularly cerebrovascular disease and dementia. We also issue a series of recommendations regarding the prevention and management of periodontitis and these neurological diseases at dental clinics and neurology units.

DEVELOPMENT

In response to a series of questions proposed by the SEPA-SEN working group, a literature search was performed, with no restrictions on study design, to identify the most relevant articles on the association between periodontitis and cerebrovascular disease and dementia from the perspectives of epidemiology, treatment, and the biological mechanisms involved in these associations.

CONCLUSIONS

Periodontitis increases the risk of ischaemic stroke and Alzheimer dementia. Recurrent bacterial infections and increased low-grade systemic inflammation seem to be possible biological mechanisms underlying this association. Limited evidence suggests that various oral health interventions can reduce the future risk of cerebrovascular disease and dementia.

Structural brain feature is associated with changes of masticatory performance in healthy elderly people: Evidence from longitudinal neuroimaging research over two years

BACKGROUND

Human neuroimaging studies have revealed the association between brain structure and masticatory function. However, the majority of the studies adopted a cross-sectional design, which hardly reveals the change in masticatory function and brain structure between different timepoints, and the dynamical association between changes in masticatory function and changes in brain structure has not been elucidated.

OBJECTIVE

With a longitudinal design, we assessed the association between changes in masticatory performance (MP) and regional brain volume.

METHODS

Twenty-two elderly participants received assessments of the number of missing teeth and MP (via colour-changeable chewing gum) when they entered the study (i.e. the initial stage, T0 ), approximately 6 months later (T0.5 ), and approximately 1-2 years later (T1 ). Difficulty of food intake was assessed using a questionnaire. The participants received magnetic resonance imaging (MRI) at T0 and T1 . The brain volume of the motor-related area was estimated using FreeSurfer for MRI data. The associations between different stages were analysed using Spearman's rho correlation coefficients.

RESULTS

(1) Individually, a smaller volume of right primary motor cortex at T0 was associated with increased MP from T0 to T1 , suggesting the brain's role in changing oral functions; (2) higher MP at T0 was associated with an increased volume of the left superior frontal cortex from T0 to T1 p, suggesting a potential effect on brain plasticity, and (3) increased difficulty to eat was associated with decrease MP but not brain volume of motor-related area.

CONCLUSIONS

The preliminary findings revealed a complicated pattern of structural brain features and masticatory function in elderly people, and either the hypothesis that the brain predisposes masticatory function or the hypothesis that mastication reshapes the brain is oversimplified.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Investigating the potential clinical impact of periodontitis on the progression of Alzheimer's disease: a prospective cohort study

OBJECTIVES

This study aimed to investigate the effect of periodontitis and current occlusal relationship on the progression rate of Alzheimer's disease (AD).

METHODS

Ninety Alzheimer's patients, who were divided into three groups as Stage I (n=42), Stage II (n=29), and Stage III (n=19), based on the Clinical Dementia Rating Scale, were included in the study. Cognitive status of the patients was evaluated with Standardized Mini-Mental Test (SMMT) at baseline and repeated 6 months later. Clinical periodontal examinations were recorded and occlusal relationship status was classified according to the Eichner Index.

RESULTS

Of 90 Alzheimer's patients, 65 were toothed individuals with periodontitis and 25 were edentulous individuals without active periodontal disease. Stage II and Stage III toothed Alzheimer's patients had higher percentage of bleeding on probing (BOP%) and clinical attachment level (CAL) values than Stage I patients (p<0.05). Stage III Alzheimer's patients had significantly higher probing pocket depth (PPD) values than Stage I individuals (p<0.05). ΔSMMT values showed positive correlation with BOP% (r=0.308, p=0.013) and PPD (r=0.275, p=0.027). Among the evaluated parameters, being in the AD Stage II-Stage III, having periodontitis and age variable had significant effects on ΔSMMT levels (p<0.05).

CONCLUSIONS

Within the limits of our study, it can be concluded that periodontitis may increase the severity and also accelerate the progression rate of AD.

CLINICAL RELEVANCE

These results are precious to show the necessity of proper oral hygiene activities and regular dental visits in patients with toothed AD.

CLINICAL TRIAL REGISTRATION

This study was registered and approved by clinical trials (NCT05807100).

Parkinson's disease is positively associated with periodontal inflammation

BACKGROUND

Parkinson's disease (PA) affects 1% of the global population above 60 years. PA pathogenesis involves severe neuroinflammation that impacts systemic and local inflammatory changes. We tested the hypothesis that PA is associated with periodontal tissue inflammation promoting a greater systemic inflammatory burden.

METHODS

We recruited 60 patients with Stage III, Grade B periodontitis (P) with and without PA (n = 20 for each). We also included systemically and periodontally healthy individuals as controls (n = 20). Clinical periodontal parameters were recorded. Serum, saliva, and gingival crevicular fluid (GCF) samples were collected to measure the inflammatory and neurodegenerative targets (YKL-40, fractalkine, S100B, alpha-synuclein, tau, vascular cell adhesion protein-1 (VCAM-1), brain-derived neurotrophic factor (BDNF), neurofilament light chain (NfL).

RESULTS

Parkinson's patients in this study had mild to moderate motor dysfunctions, which did not prevent them from performing optimal oral hygiene control. Periodontal parameters and GCF volume were significantly higher in the P and P+PA groups than in the control group. PA was associated with significantly increased bleeding on probing (BOP) compared to P-alone (p < 0.05), while other clinical parameters were similar between P and P+PA groups. In saliva and serum, YKL-40 levels were higher in the P+PA group than in P and C groups (p < 0.001). GCF NfL levels from shallow sites were significantly higher in the P+PA group compared to the C group (p = 0.0462). GCF S100B levels from deep sites were higher in the P+PA group than in healthy individuals (p = 0.0194).

CONCLUSION

The data suggested that PA is highly associated with increased periodontal inflammatory burden-bleeding upon probing and inflammatory markers-in parallel with PA-related neuroinflammation.

Beyond the mouth: the impact of periodontal disease on dementia

DATA SOURCES

The authors searched Medline via PubMed, Scopus, CINAHL, Web of Science, and PsycINFO for relevant studies published until April 2022.

STUDY SELECTION

Longitudinal studies that assessed periodontal health as the exposure and cognitive decline and/or dementia as the outcome were included. Case reports, reviews, cross-sectional studies, and animal studies were excluded. DATA EXTRACTION AND SYNTHESIS: Two authors independently reviewed studies for inclusion, extracted data, and assessed study quality. Meta-analysis was conducted to generate pooled odds ratios (ORs) for cognitive decline and hazard ratios (HRs) for dementia. Sources of heterogeneity were explored through subgroup analyses.

RESULTS

A total of 24 studies were included for cognitive decline and 23 for dementia. Poor periodontal health was associated with increased odds of cognitive decline (OR = 1.23; 95% CI: 1.05-1.44) and dementia (HR = 1.21; 95% CI: 1.07-1.38). Tooth loss also appeared to increase the risk independently. However, significant heterogeneity existed between studies.

CONCLUSIONS

Poor periodontal health may increase the risk of cognitive decline and dementia, but the quality of evidence was low. Further high-quality, longitudinal studies with standardized assessments are needed to establish causality.

The impact of aromatherapy-based oral care on oral conditions, salivary pH, and halitosis in older adults with dementia: Pilot study

Inadequate oral care and poor oral health in older adults are known to increase the risk of dementia. Dementia patients residing in long-term care facilities are especially vulnerable to oral diseases due to their care-resistant behavior. This study aimed to investigate the effects of a 7-day oral care program based on an aroma solution in 58 dementia patients (29 each in the experimental and control groups) admitted to a long-term care hospital in South Korea. The experimental group received oral care with a solution containing peppermint, tea tree, and lemon essential oils, and the control group with a saline solution. The effectiveness of oral care was assessed by the participants' oral condition, salivary pH, and halitosis. The experimental group showed significant improvements (P<.001) in all three outcomes, indicating that oral care with an aroma solution can improve the oral health of older dementia patients residing in long-term care facilities.

Onset of oral lichen planus following dental treatments: A nested case-control study

INTRODUCTION

The exposure to amalgam restorations has been reported to bring about altered immunity followed by inflammation and infection.

AIMS

This study aimed at identifying whether patients who received restorative or endodontic treatments, or tooth extraction, would have altered odds of developing oral lichen planus (OLP).

MATERIAL AND METHODS

In this population-based nested case-control study, 421 cases of OLP and 1,684 controls were included after propensity score matching. Logistic regression was used to estimate the adjusted odds ratio (aOR) of OLP in individuals who had received amalgam and composite resin restorations, root canal therapy, and tooth extraction over a follow-up duration of five years.

RESULTS

There were no significantly different odds of OLP for those who underwent either amalgam (aOR = 0.948, 95% CI = 0.853-1.053, p = 0.3170) or resin restorations (aOR = 1.007, 95% CI = 0.978-1.037, p = 0.6557) in both anterior and posterior teeth in an observational period of five  years after restorations. Root canal therapy was associated with significantly lower odds of OLP, with each additional root canal therapy attenuating the risk of OLP at an aOR of 0.771 (95% CI = 0.680-0.874, p = 0.0001) for both anterior (aOR = 0.786, 95% CI = 0.626-0.986, p = 0.0372) and posterior teeth (aOR = 0.762, 95% CI = 0.650-0.893, p = 0.0008). Likewise, each tooth extraction reduced the risk of OLP, with an aOR of 0.846 (95% CI = 0.772-0.927, p = 0.0003), especially for anterior teeth (aOR = 0.733, 95% CI = 0.595-0.904, p = 0.0037).

CONCLUSIONS

We reported no significant association between dental restorations and consequent OLP, and significantly lower odds of OLP following both root canal therapy and tooth extraction.

Confounding in observational studies evaluating the association between Alzheimer's disease and periodontal disease: A systematic review

Background

Studies investigating the association between periodontitis and Alzheimer's disease (AD) suggested indirect (periodontitis would increase the circulation of inflammation-inducible molecules) and direct (periodontopathogens might colonize brains affected by Alzheimer's disease) pathways. While there seems to be a positive relationship between periodontitis and AD, concerns have been raised about the role of confounding.

Aim

To systematically review the literature to assess confounding and their level of heterogeneity in the association between periodontitis and AD. Also, to examine data reporting and interpretation regarding confounding bias.

Methods

This review followed the PRISMA guidelines and was registered within PROSPERO. Electronic searches were performed in seven main databases and three others to capture the "grey literature". The PECO strategy was used to identify observational studies (cross-sectional, case-control, or cohort studies) assessing the association between periodontal disease and AD without restricting publication language and year. Critical appraisal was performed according to the Joanna Briggs Institute guidelines. Confounders were evaluated following a two-step approach.

Results

A total of 3255 studies were found, of which 18 (13 case-control, four cross-sectional, and one cohort) met the eligibility criteria. Participants with AD were 1399 (mean age 64 ± 9 to 84.8 ± 5.6 years), whereas those without AD were 1730 (mean age 62.6 ± 7.1 to 81.4 ± 4.6). Female patients composed most of the sample for both groups. The confounding variables "age" and "sex" were present in all studies. Four studies used the 2017 AAP/EFP periodontal classification. Most studies had a low risk of bias. Fifty percent of the articles did not consider confounding; variation in the adjustment approaches was observed. Additionally, 62% of the studies did not mention bias, and 40% did not discuss any limitations about confounders.

Conclusions

Given the study's limitations, caution must be taken to properly interpret the association between periodontitis and AD.Registration: CRD42022293884.

Antibodies against Periodontal Microorganisms and Cognition in Older Adults

INTRODUCTION

Markers of poor oral health are associated with impaired cognition and higher risk of Alzheimer disease (AD) and thus may help predict AD.

OBJECTIVES

The aim of this study was to evaluate the cross-sectional association between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and cognition in middle-aged and older adults.

METHODS

The study population consisted of participants of the third National Health and Nutrition Examination Survey (NHANES III) (1988 to 1994), who were 60 y and older, among whom cognition and IgG antibodies against 19 periodontal microorganisms were measured (N = 5,162).

RESULTS

In multivariable quantile regression analyses, the Orange-Red (Prevotella melaninogenica, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis) and Yellow-Orange (Staphylococcus intermedius, Streptococcus oralis, Streptococcus mutans, Fusobacterium nucleatum, Peptostreptococcus micros, Capnocytophaga ochracea) cluster scores were negatively associated with cognition. A 1-unit higher cluster score for the Orange-Red cluster was associated on average with a lower cognitive score (β for 30th quantile = -0.2640; 95% confidence interval [CI], -0.3431 to -0.1848). Similarly, a 1-unit higher score for the Yellow-Orange cluster was associated with a lower cognitive score (β for 30th quantile = -0.2445; 95% CI, -0.3517 to -0.1372).

CONCLUSION

Groups of IgG antibodies against periodontal microorganisms were associated with lower cognition among free living adults 60 years and older, who were previously undiagnosed with cognitive impairment. Though poor oral health precedes the development of dementia and AD, oral health information is currently not used, to our knowledge, to predict dementia or AD risk. Combining our findings with current algorithms may improve risk prediction for dementia and AD.

KNOWLEDGE TRANSLATION STATEMENT

IgG antibodies against periodontal microorganisms were associated with lower cognition among adults 60 years and older previously undiagnosed with cognitive impairment. Periodontal disease may predict cognition among older adults.

Is there a casual relation between air pollution and dementia?

Dementia has been cited as a critical public health risk in the contemporary world, while few empirical researchers try to reveal the casual relationship between air pollutant concentrations (APCs) and dementia, especially given the increasing prevalence of air pollution on a global scale. Accordingly, this paper tries to infer the causal relationship between APCs and dementia. The 59,605 valid data was compiled through a combination of the statistic from the China Family Panel Study, China Environmental Statistics Yearbook, World Meteorological Association and China National Bureau of Statistics. The RD design of this study utilizes the discontinuous variation in APCs and dementia as one crosses the Huai River boundary, which is an arbitrary heating policy that causes the significant difference in APCs between the north and south of China. We used stata17.0 to analyze the data. The results of the RD regression indicated that a 100 μ g/m3 rise in APCs led to an increase of 42.4% in the hazard ratio of suffering dementia (Coeff=-0.58, SD= 0.23, P < 0.05). Meanwhile, heterogeneous models revealed that the hazard ratio of suffering dementia by APCs was more significant in the older compared to younger (coeff= 1.35 vs coeff= 1.55, P < 0.05), male compared to female (coeff= 1.62 vs coeff= 0.71, P < 0.05), smoking compared to non-smoke (coeff= 2.12 vs coeff= 0.93, P < 0.05), and thin groups compared to medium and obesity (coeff= 2.05 vs coeff= 1.22, coeff= 1.28, P < 0.05). In addition, the O3 and SO2 were the air pollutants with the highest (coeff= 1.54, P < 0.05) and lowest effects (coeff= 0.81, P < 0.05) on the hazard ratio of suffering dementia among the five APCs, respectively. And the robustness of the results was ensured by changing the RD bandwidth, polynomial order. The results indicated that APCs significantly induced the hazard ratio of suffering dementia of Chinese residents, which provides empirical evidence in supporting the Chinese government to invest more in combating air pollution and ensure the public health of Chinese residents.

Patients with obstructive sleep apnea are at great risk of flavor disorders: a 15-year population-based cohort study

OBJECTIVE

Obstructive sleep apnea (OSA) results from upper airway remodeling, which has been suggested to alter sensory and motor neuron function due to hypoxia or snore vibration. This study investigated whether OSA was associated with the risk of flavor disorder (FD).

MATERIALS AND METHODS

Seven thousand and eight hundred sixty-five patients with OSA and 7865 propensity score-matched controls without OSA were enrolled between 1999 and 2013 through a nationwide cohort study. The propensity score matching was based on age, sex, comorbidities including hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), asthma, ankylosing spondylitis, and Charlson comorbidity index, and co-medications during the study period, including statins and angiotensin-converting enzyme (ACE) inhibitors. The adjusted hazard ratio (aHR) of incident FD following OSA was derived using a Cox proportional hazard model. A log-rank test was used to evaluate the time-dependent effect of OSA on FD. Age, sex, comorbidities, and co-medications were stratified to identify subgroups susceptible to OSA-associated FD.

RESULTS

Patients with OSA were at a significantly great risk of FD (aHR = 1.91, 95% CI = 1.08-3.38), which was time-dependent (log-rank test p = 0.013). Likewise, patients with hyperlipidemia were at a significant great risk of FD (aHR = 2.99, 95% CI = 1.33-6.69). Subgroup analysis revealed that female patients with OSA were at higher risks of FD (aHR = 2.39, 95%CI = 1.05-5.47).

CONCLUSIONS

Patients with OSA were at significantly great risk of incident FD during the 15-year follow-up period, especially in female patients with OSA.

CLINICAL RELEVANCE

Timely interventions for OSA may prevent OSA-associated FD.

Is There an Association Between Parkinson's Disease and Periodontitis? A Systematic Review and Meta-Analysis

BACKGROUND

Multiple observational studies have yielded controversial results regarding the association between Parkinson's disease (PD) and periodontitis.

OBJECTIVE

This systematic review and meta-analysis was conducted to ascertain their bidirectional relationship.

METHODS

A literature search for relevant studies was performed in PubMed, EMBASE, the Cochrane Library, and Web of Science databases from inception to December 19, 2022. Effect sizes (ES) with 95% confidence intervals were pooled under the random-effects model. Then, leave-one-out sensitivity analysis and contour-enhanced funnel plot were applied to assess the stability of the results.

RESULTS

A total of 34 studies and 24 studies were included for systematic review and quantitative meta-analysis, respectively. Pooled ES indicated that periodontitis was not significantly associated with PD risk (HR = 1.13, 95% CI 0.88-1.45, n = 3; OR = 1.94, 95% CI 0.55-6.90, n = 7), while the Mendelian randomization study revealed no association between PD and periodontitis risk (coefficient [B] = -0.0001, standard error = 0.0001, p = 0.19). Furthermore, PD patients exhibited higher levels of periodontal pocket depth (SMD = 1.10, 95% CI 0.53-1.67), clinical attachment level (SMD = 1.40, 95% CI 0.55-2.26), plaque index (SMD = 0.81, 95% CI 0.22-1.39), and Oral Health Impact Profile-14 score (SMD = 0.91, 95% CI 0.33-1.49) compared to healthy controls.

CONCLUSIONS

Our meta-analysis identified no bidirectional association between PD risk and periodontitis risk, though the prevalence of periodontitis and poorer oral status was higher in PD patients.

Neuroinflammation: A Distal Consequence of Periodontitis

Periodontitis, a chronic, inflammatory disease, induces systemic inflammation and contributes to the development of neurodegenerative diseases. The precise etiology of the most common neurodegenerative disorders, such as sporadic Alzheimer's, Parkinson's diseases and multiple sclerosis (AD, PD, and MS, respectively), remains to be revealed. Chronic neuroinflammation is a well-recognized component of these disorders, and evidence suggests that systemic inflammation is a possible stimulus for neuroinflammation development. Systemic inflammation can lead to deleterious consequences on the brain if the inflammation is sufficiently severe or if the brain shows vulnerabilities due to genetic predisposition, aging, or neurodegenerative diseases. It has been proposed that periodontal disease can initiate or contribute to the AD pathogenesis through multiple pathways, including key periodontal pathogens. Dysbiotic oral bacteria can release bacterial products into the bloodstream and eventually cross the brain-blood barrier; these bacteria can also cause alterations to gut microbiota that enhance inflammation and potentially affect brain function via the gut-brain axis. The trigeminal nerve has been suggested as another route for connecting oral bacterial products to the brain. PD and MS are often preceded by gastrointestinal symptoms or aberrant gut microbiome composition, and alterations in the enteric nervous system accompany the disease. Clinical evidence has suggested that patients with periodontitis are at a higher risk of developing PD and MS. This nexus among the brain, periodontal disease, and systemic inflammation heralds new ways in which microglial cells, the main innate immune cells, and astrocytes, the crucial regulators of innate and adaptive immune responses in the brain, contribute to brain pathology. Currently, the lack of understanding of the pathogenesis of neurodegeneration is hindering treatment development. However, we may prevent this pathogenesis by tackling one of its possible contributors (periodontitis) for systemic inflammation through simple preventive oral hygiene measures.

Correlation study of periodontitis with cognitive impairment

OBJECTIVES

This study aimed to determine the association of periodontitis with cognitive impairment by evaluating periodontal conditions in middle-aged and elderly people of normal cognition and cognitive impairment.

METHODS

Forty patients with cognitive impairment and thirty-five healthy controls were included in this study. Mini-mental state examination (MMSE) was used to evaluate the level of cognitive function in all patients and controls. Periodontal conditions including severity of periodontitis, number of remaining teeth, percentage of bleeding on probing, probing depth (PD), and attachment level (AL) were examined. Periodontal conditions were compared between patients and controls, and the correlation between periodontal conditions and cognitive-function level was analyzed. Statistical analysis was performed with SPSS 26.0.

RESULTS

The distribution of severity of periodontitis significantly differed between patients and controls (χ2=13.309 and P=0.001). The proportion of severe periodontitis in the cognitive-impairment group was significantly higher than that in the healthy controls (P<0.05). The percentage of sites with PD≥6 mm and AL≥5 mm in the cognitive-impairment group was higher than that in the controls, whereas the percentage of sites with PD=1-3 mm and AL=0-2 mm was higher in the controls (P<0.05). No significant difference in percentage of bleeding on probing was found in the two groups (P>0.05). Patients with cognitive impairment had fewer teeth than the controls (P<0.05). The level of cognitive function, assessed by MMSE, was positively correlated with the number of teeth and the percentage of sites with AL=0-2 mm, and it was negatively correlated with the percentage of sites with AL≥5 mm (P<0.05).

CONCLUSIONS

A correlation existed between periodontitis and cognitive impairment. Further study is essential to explore the specific relationship and related mechanism between periodontitis and cognitive impairment.

Risk of primary Sjogren's Syndrome following human papillomavirus infections: a nationwide population-based cohort study

Introduction

Viral infection is an exogeneous factor for primary Sjogren's syndrome (pSS). This study investigated the association between human papillomavirus (HPV) infections and pSS through a nationwide population based cohort study.

Methods

Patients with HPV infections between January, 1999 and December, 2013 were included. The incidence of new-onset pSS in patients with HPV infections and non-HPV controls were derived. The multiple Cox regression model derived the risk of pSS in patients with HPV infections. Subgroup analysis and sensitivity analysis were performed to validate the association.

Results

During a follow-up period of 12 years, the adjusted hazard ratio (aHR) of pSS in patients with HPV infections was significantly higher than that in non-HPV controls (aHR=1.64, 95% CI=1.47-1.83, P<0.001). The risk of pSS increased with age and the risk increased by 2.64-fold (95% CI= 2.37-2.93) for those older than 45 years. The significant association between HPV infections and the risk of pSS persisted in the sensitivity analysis restricted in HPV infections that lasted over 12 months (aHR=1.63, 95%CI=1.45-1.83, P<0.0001). Subgroup analyses revealed that both male (aHR=1.83, 95%CI=1.47-2.28, P<0.0001) and female (aHR=1.58, 95%CI=1.40-1.79, P<0.0001) patients with HPV infections and HPV-infected patients aged between 16 and 45 years (aHR=1.60, 95%CI=1.34-1.91, P<0.0001) and over 45 years (aHR=1.67, 95%CI=1.46-1.91, P<0.0001) were associated with a significantly greater risk of pSS.

Conclusion

Patients with HPV infections presented with a significantly higher risk of pSS, regardless of age and sex.

Bidirectional Relationship Between Osteoarthritis and Periodontitis: A Population-Based Cohort Study Over a 15-year Follow-Up

Objective

To identify the relationship between osteoarthritis and periodontitis.

Methods

144,788 periodontitis patients and 144,788 propensity score-matched controls without history of periodontitis were enrolled in this cohort study. A Cox proportional hazard model was used to estimate the risk of osteoarthritis. Survival analysis was utilized to assess the time-dependent effect of periodontitis on osteoarthritis. Age and gender were stratified to identify subgroups at risk. A symmetrical case-control analysis was designed to determine the relationship between present periodontitis and history of osteoarthritis.

Results

Patients with periodontitis had higher risk of osteoarthritis (hazard ratio, HR =1.15, 95% CI =1.12-1.17, p < 0.001) and severe osteoarthritis that led to total knee replacement or total hip replacement (TKR/THR) (HR =1.12, 95% CI =1.03-1.21, p < 0.01) than controls, which was time-dependent (log-rank test p < 0.01). The effect of periodontitis on osteoarthritis was significant in both genders and age subgroups over 30 years-old (all p < 0.001). Among them, females (HR=1.27, 95% CI = 1.13-1.42, p < 0.001) and patients aged over 51 (HR= 1.21, 95% CI =1.10-1.33, p < 0.001) with periodontitis were predisposed to severe osteoarthritis. In addition, periodontitis patients were more likely to have a history of osteoarthritis (odds ratio = 1.11, 95% CI = 1.06 - 1.17, p < 0.001).

Conclusions

These findings suggest an association between periodontitis and a higher risk of osteoarthritis, including severe osteoarthritis that led to TKR/THR. Likewise, periodontitis is more likely to develop following osteoarthritis. A bidirectional relationship between osteoarthritis and periodontitis was observed.

Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation

Successful weaning from ventilators not only improves the quality of life of patients, but also reduces medical expenses. The aim of this study was to explore the association between nutritional provision and successful ventilator weaning. In this retrospective study data from the Respiratory Care Center of Chung Shan Medical University Hospital between October, 2017 and July, 2019 on patient characteristics, amount of nutrition delivered, and clinical outcomes were retrieved. A total of 280 ventilated patients were enrolled and divided into successful extubation and failed weaning groups. There were 178 males (63.6%) and 102 females (36.4%) with a mean age of 67.3 ± 16.9 years. The successful extubation group consisted of patients who tended towards ideal body weight during the weaning process (BMI 23.9 ± 5.0 versus 22.7 ± 4.8 kg/m², p < 0.001). Patients from both groups initially received the same nutritional intervention, while patients of successful extubation received significantly more calories and protein after weaning (23.8 ± 7.8 kcal versus 27.8 ± 9.1 kcal, p < 0.001 and 0.97 ± 0.36 g versus 1.14 ± 0.42 g, p < 0.001). Successful weaning was associated with higher survival rate (p = 0.016), shortened hospital stay (p = 0.001), and reduced medical costs (p < 0.001). Overall, nutritional support with high calories and protein was associated with the probability of successful ventilator weaning in patients undergoing prolonged mechanical ventilation. Adequate nutrition is a determinant of successful ventilator weaning.

Risk of Autoimmune Diseases Following Optic Neuritis: A Nationwide Population-Based Cohort Study

Objectives

Optic neuritis is (ON) is believed to be an immune-mediated disease; however, the association between optic neuritis and autoimmune diseases remains unclear. This study aimed to identify the incidence rate and adjusted hazard ratio (aHR) of autoimmune diseases in patients with optic neuritis.

Methods

This nationwide, population-based, retrospective cohort study collected patients’ data between 1999 and 2013 from the National Health Insurance Research Database in Taiwan. A total of 9,235 patients were included. Using 1:4 propensity scoring, 1,847 patients were enrolled in the optic neuritis group and 7,388 in the non-optic neuritis group according to age, sex, comorbidities, and corticosteroid use. Follow-up was started from the index date and the endpoint was a diagnosis of new-onset autoimmune diseases including, myasthenia gravis (MG), psoriatic arthritis (PsA), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and ankylosing spondylitis (AS).

Results

The Kaplan-Meier curves depicted that patients with optic neuritis had a higher cumulative incidence of autoimmune diseases than patients without optic neuritis. Cox proportional hazard regression showed that patients with optic neuritis were at a high risk of autoimmune diseases (aHR: 1.40; 95% C.I., 1.05–1.87), including MG (aHR: 4.16, 95% C.I.: 1.33–12.94), SLE (aHR: 3.33, 95% C.I.: 1.24–8.97), and AS (aHR: 2.86, 95% C.I.: 1.54–5.31). Subgroup analysis provided that patients with optic neuritis aged below 65 years (aHR: 1.42, 95% C.I.: 1.03–1.96) or who were females (aHR: 1.59, 95% C.I.: 1.11–2.27) had a significantly increased risk of autoimmune diseases compared to respective controls. The use of corticosteroids reduced the risk of autoimmune diseases in patients with optic neuritis (aHR for corticosteroids non-users: 1.46, 95% C.I.: 1.03–2.07).

Conclusion

Patients with optic neuritis presented with a high risk of autoimmune diseases such as MG, SLE, and AS, especially patients with optic neuritis who were young or females. Corticosteroids attenuated the link between optic neuritis and subsequent autoimmune diseases.

Human Papillomavirus Infection and the Risk of Erectile Dysfunction: A Nationwide Population-Based Matched Cohort Study

BACKGROUND

Male patients with genital warts are known for higher rates of sexual dysfunction. This study was conducted to investigate whether human papillomaviruses (HPV) infection is associated with an increased risk of erectile dysfunction (ED).

METHODS

Patients aged over 18 with HPV infection (n = 13,296) and propensity score-matched controls (n = 53,184) were recruited from the Longitudinal Health Insurance Database (LHID). The primary endpoint was the diagnosis of ED. Chi-square tests were used to analyze the distribution of demographic characteristics. The Cox proportional hazards regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of ED in both groups, after adjusting for sex, age, relevant comorbidities, co-medication, and surgery.

RESULTS

ED developed in 181 patients of the study group. The incidence density of ED was 2.53 per 1000 person-years for the HPV group and 1.51 per 1000 person-years for the non-HPV group, with an adjusted HR (95% CI) of 1.63 (1.37-1.94). In stratification analysis, adjusted HR of diabetes-, chronic obstructive pulmonary disease (COPD-), and stroke-subgroup were 2.39, 2.51, and 4.82, with significant p values for interaction, respectively. Sensitivity analysis yields consistent findings.

CONCLUSIONS

The patients with HPV infection had a higher risk of subsequent ED in comparison to the non-HPV controls. The mechanism behind such association and its possible role in ED prevention deserves further study in the future.

Higher Dementia Risk in People With Gastroesophageal Reflux Disease: A Real-World Evidence

Background

Whether or not patients with gastroesophageal reflux disease (GERD) have a higher risk of developing subsequent dementia remains unknown, and no observational evidence from population-based data is available. This study was to determine whether patients with GERD have a higher future risk of developing dementia.

Methods

For the period 2000–2012, datasets from the Longitudinal Health Insurance Database (LHID, subset of National Health Insurance Research Database in Taiwan) were analyzed. Definition of GERD was based on ICD-9-CM codes 530.11 and 530.81 and prescriptions for PPIs. After matching gender, age, index year, and comorbidities, each GERD patient was matched with four control patients without GERD. Future risk of dementia was evaluated, and sensitivity analysis of subgroups was conducted to clarify the potential association.

Results

In the present study, 13,570 patients were included in the GERD cohort and 54,280 patients were included in the control cohort. Patients with GERD showed higher risk developing dementia than control group, with an aHR of 1.34 (95% C.I., 1.07, 1.67). In GERD patients between above 70 years old, the risk of developing dementia was higher than that of the control groups (aHR = 1.34; 95% C.I., 1.01, 1.77).

Conclusion

Patients with GERD showed higher incidence of dementia, and elder patients had the highest risk of developing dementia. Clinicians should be concern of the association between GERD and dementia and should develop strategies to prevent dementia while managing patients with GERD.

Age-dependent oral manifestations of neurofibromatosis type 1: a case-control study

INTRODUCTION

Most craniofacial manifestations of neurofibromatosis type 1 (NF1) are considered as a result of tumor compression. We sought to determine salivary changes, caries, and periodontal complications in NF1 patients without tumors in the oral cavity.

OBJECTIVE AND METHODS

Eleven NF1 patients without tumors in the oral cavity and 29 matched controls without NF1 were enrolled in this case-control study. Demographic information, medical history, and data of intraoral examinations, including the Decayed, Missing, and Filled Teeth (DMFT) scores and Russel's periodontal index (PI), were recorded. The functional salivary analysis was performed for sialometry, salivary pH values, and amylase activity. Ingenuity Systems Pathway Analysis (IPA) was conducted to identify mutually activated pathways for NF1-associated oral complications.

RESULTS

NF1 patients were associated with periodontitis (OR = 1.40, 95% CI = 1.06-1.73, P = 0.04), gingivitis (OR = 1.55, 95% CI = 1.09-2.01, P = 0.0002), and decreased salivary flow rates (OR = 1.40, 95% CI = 1.05-1.76, P = 0.005). Periodontal destruction, salivary changes, and dental caries in NF1 patients were age-dependent. Subgroup analyses based on age stratification suggested that salivary flow rates and salivary amylase activities were significantly low in NF1 patients aged over 20 years and that salivary pH values, PI and DMFT scores were significantly high among NF1- controls aged over 20. All oral complications were not significantly presented in NF1 patients aged below 20 years. IPA analyses suggested that cellular mechanisms underlying NF1-associated oral complications involved chronic inflammatory pathways and fibrosis signaling pathway.

CONCLUSION

NF1 patients without tumors in the oral cavity presented a comparatively high prevalence of age-dependent oral complications, including periodontal destruction and salivary gland dysfunction, which were associated with chronic inflammatory pathogenesis.

Tooth Loss-Associated Mechanisms That Negatively Affect Cognitive Function: A Systematic Review of Animal Experiments Based on Occlusal Support Loss and Cognitive Impairment

Background

There is a dose-response relationship between tooth loss and cognitive impairment, while tooth loss can be an independent risk factor for Alzheimer's disease (AD) and vascular dementia (VaD). Tooth loss can also accelerate nerve damage and neurodegeneration. However, the associated mechanisms remain poorly understood.

Objective

To conduct a systematic review of animal experiments on cognitive decline caused by the loss of occlusal support performed over the past 10 years and summarize the possible underlying mechanisms.

Methods

“Tooth Loss,” “Edentulous,” “Tooth Extraction and Memory Loss,” “Cognition Impairment,” and “Dementia” were used as keywords to search PubMed, Embase, SCI, ScienceDirect, and OpenGrey. A total of 1,317 related articles from 2010 to 2021 were retrieved, 26 of which were included in the review after screening according to predetermined inclusion and exclusion criteria. Comprehensiveness was evaluated using ARRIVE guidelines and the risk of bias was assessed using SYCLE'S risk of bias tool.

Results

The putative mechanisms underlying the cognitive impairment resulting from the loss of occlusal support are as follows: (1) The mechanical pathway, whereby tooth loss leads to masticatory motor system functional disorders. Masticatory organ activity and cerebral blood flow decrease. With reduced afferent stimulation of peripheral receptors (such as in the periodontal membrane) the strength of the connections between neural pathways is decreased, and the corresponding brain regions degenerate; (2) the aggravation pathway, in which tooth loss aggravates existing neurodegenerative changes. Tooth loss can accelerates nerve damage through apoptosis and mitochondrial autophagy, increases amyloid deposition in the brain; and (3) the long-term inflammatory stress pathway, which involves metabolic disorders, microbial-gut-brain axis, the activation of microglia and astrocytes, and inflammatory cascade effect in central nervous system.

Conclusion

The loss of occlusal support may lead to cognitive dysfunction through the reduction of chewing-related stimuli, aggravation of nerve damage, and long-term inflammatory stress.

Domiciliary Dental Care for Medically Compromised Patients in Aging and Super-aged Societies: Policy and Education

Domiciliary dental care (DDC) is a specialized dental service provided at patients' residences, especially for medically compromised patients. The importance of DDC has been highlighted in aging and super-aged societies. Confronted with burdens of a super-aged society, governmental efforts have promoted DDC in Taiwan. To provoke awareness of DDC in healthcare professionals, a series of continuing medical education (CME) lessons on DDC for dentists and nurse practitioners were organized between 2020 and 2021 at a tertiary medical center and demonstrating center of DDC in Taiwan, during which 66.7% of participants were very satisfied. Through political and educational efforts of the government and medical centers, an increasing number of healthcare professionals participating in DDC was observed, including both those in hospitals and those who were primary care practitioners. CME modules may promote DDC and improve the accessibility to dental care for medically compromised patients.

Exposure to environmental air pollutants as a risk factor for primary Sjögren's syndrome

Background

Environmental etiology of primary Sjögren's syndrome (pSS), an autoimmune disease, has been proposed. This study determined whether the exposure to air pollutants was an independent risk factor for pSS.

Methods

Participants were enrolled from a population-based cohort registry. Daily average concentrations of air pollutants from 2000 to 2011 were divided into 4 quartiles. Adjusted hazard ratios (aHRs) of pSS for exposure to air pollutants were estimated in a Cox proportional regression model adjusting for age, sex, socioeconomic status, and residential areas. A subgroup analysis stratified by sex was conducted to validate the findings. Windows of susceptibility indicated years of exposure which contributed the most to the observed association. Ingenuity Pathway Analysis was used to identify underlying pathways of air pollutant-associated pSS pathogenesis, using Z-score visualization.

Results

Two hundred patients among 177,307 participants developed pSS, with a mean age of 53.1 years at acumulative incidence of 0.11% from 2000 to 2011. Exposure to carbon monoxide (CO), nitric oxide (NO), and methane (CH4) was associated with a higher risk of pSS. Compared to those exposed to the lowest concentration level, the aHRs for pSS were 2.04 (95%CI=1.29-3.25), 1.86 (95%CI=1.22-2.85), and 2.21 (95%CI=1.47-3.31) for those exposed to high levels of CO, NO, and CH4, respectively. The findings persisted in the subgroup analysis, in which females exposed to high levels of CO, NO, and CH4 and males exposed to high levels of CO were associated with significantly great risk of pSS. The cumulative effect of air pollution on pSS was time-dependent. The underlying cellular mechanisms involved chronic inflammatory pathways including the interleukin-6 signaling pathway.

Conclusion

Exposure to CO, NO, and CH4 was associated with a high risk of pSS, which was biologically plausible.

Association between systemic rheumatic diseases and dementia risk: A meta-analysis

BACKGROUND AND AIMS

Epidemiological studies have been conducted on the relationship between systemic rheumatic diseases (SRDs) and dementia. Therefore, we focused on determining the extent of alliances bounded by SRDs, along with the risk of dementia.

MATERIALS AND METHODS

Two independent reviewers assessed all studies retrieved from the PubMed, EMBASE, Scopus, and Web of Science databases between January 1, 2000 and November 30, 2021. Only observational studies that estimated the possibility of dementia in participants with SRD were considered. The random-effects model was applied to forecast pooled risk ratios (RRs) and 95% confidence intervals (CI). Heterogeneity among the studies was evaluated using the Q and I² statistics. The quality of the included studies was assessed using the Newcastle-Ottawa Scale. Funnel plots were used to calculate the risk of bias.

RESULTS

Seventeen observational studies with 17,717,473 participants were recruited. Our findings showed that among the participants with SRDs, those with osteoarthritis, systemic lupus erythematosus, and Sjogren's syndrome were highly related to an elevated risk of dementia (pooled RR: 1.31; 95% CI: 1.15-1.49, p<0.001; pooled RR: 1.43; 95% CI: 1.19-1.73, p<0.001; and pooled RR: 1.26; 95% CI: 1.14-1.39, p<0.001, respectively). However, participants with rheumatoid arthritis (RA) were not associated with an increased risk of dementia (pooled RR: 0.98; 95% CI: 0.90-1.07, p<0.001).

CONCLUSION

This systematic review and meta-analysis demonstrated an increased dementia risk among SRDs participants, except for RA.

Fibromyalgia and periodontitis: Bidirectional associations in population-based 15-year retrospective cohorts

BACKGROUND

To determine the bidirectional link between periodontitis and fibromyalgia.

METHODS

In this cohort study, 196,428 periodontitis patients and 196,428 propensity score-matched non-periodontitis controls were enrolled. A Cox proportional hazard model was utilized to estimate the risk of fibromyalgia and survival analysis was adopted to assess the time-dependent effect of periodontitis on fibromyalgia. Subgroup analyses stratified by age, sex, and tracking period were conducted to identify susceptible populations. A parallel and symmetrical cohort that recruited 141,439 fibromyalgia patients and 141,439 propensity score-matched non-fibromyalgia controls ascertained the inverse effect of fibromyalgia on incident periodontitis.

RESULTS

Patients with periodontitis were more likely to develop fibromyalgia than non-periodontitis controls (HR = 1.42, 95% CI = 1.39-1.44, P < 0.001), which persisted in the survival analysis (log-rank test P < 0.0001). This effect was significant in both sexes and all age subgroups, and was particularly evident in males (HR = 1.52, 95% CI = 1.48-1.56, P < 0.001) and younger periodontitis patients (HR = 1.55, 95% CI = 1.50-1.60, P < 0.001). Fibromyalgia patients who never had periodontitis presented with greater risk for periodontitis over time (HR = 1.43, 95% CI = 1.40 - 1.45, P < 0.001; log-rank test P < 0.0001).

CONCLUSIONS

Patients of both sexes and all age subgroups with periodontitis presented with a greater risk of fibromyalgia. Subgroups that were the most susceptible to periodontitis-associated fibromyalgia were periodontitis patients that were males and below 30 years old. Risks of periodontitis were also greater in fibromyalgia patients who never had periodontitis.