Effects of Periodontal Therapy on Systemic Markers of Inflammation in Patients With Metabolic Syndrome: A Controlled Clinical Trial

Specifying a target trial protocol to estimate the effect of preconception treatment of periodontitis on time-to-pregnancy: A commentary and applied example

BACKGROUND

The target trial framework was developed as a strategy to design and analyze observational epidemiologic studies with the aim of reducing bias due to analytic decisions. It involves designing a hypothetical randomized trial to answer a question of interest and systematically considering how to use observational data to emulate each trial component.

AIMS

The primary aim of this paper is to provide a detailed example of the application of the target trial framework to a research question in oral epidemiology.

MATERIALS AND METHODS

We describe the development of a hypothetical target trial and emulation protocol to evaluate the effect of preconception periodontitis treatment on time-to-pregnancy. We leverage data from Pregnancy Study Online (PRESTO), a preconception cohort, to ground our example in existing observational data. We discuss the decision-making process for each trial component, as well as limitations encountered.

RESULTS

Our target trial application revealed data limitations that precluded us from carrying out the proposed emulation. Implications for data quality are discussed and we provide recommendations for researchers interested in conducting trial emulations in the field of oral epidemiology.

DISCUSSION

The target trial framework has the potential to improve the validity of observational research in oral health, when properly applied.

CONCLUSION

We encourage the broad adoption of the target trial framework to the field of observational oral health research and demonstrate its value as a tool to identify directions for future research.

An Assessment of Periodontal Status and Oral Hygiene in Patients with Hypertension in the South-West Region of Romania

Background: This cross-sectional analytical study evaluates oral hygiene and periodontal status in patients with hypertension, given the established link between cardiovascular diseases and poor periodontal health. Methods: A total of 24 hypertensive patients (15 male; 9 female) and 30 healthy controls (19 male; 11 female) from Craiova, Romania, were assessed using Periodontal Probing Depth (PPD), the Plaque Index (PLQ), and the Bleeding on Probing Index (BPI). Results: The mean age was 62.2 years in the hypertensive group and 47.4 years in the control group. Oral hygiene was poorer in hypertensive patients (PLQ: 73% vs. 24.1% in controls), with higher PPD (5.2 mm vs. 3.7 mm) and BPI (82% vs. 23%). Among patients with dental implants, PLQ was 24% in hypertensive individuals vs. 15.6% in controls, PPD was 4.4 mm vs. 2.9 mm, and BPI was 44% vs. 15.5%. Conclusions: These findings indicate a higher risk of periodontal disease in hypertensive patients, though dental implants may decrease some adverse effects by improving oral hygiene and periodontal health in this population. In conclusion, our study highlights that patients with high blood pressure have a less favorable periodontal status compared to healthy controls.

Doxycycline-Loaded pH-Sensitive Microparticles as a Potential Site-Specific Drug Delivery System against Periodontitis

A significant obstacle to the healing process of periodontitis is the development of bacterial biofilms within the periodontal pockets. The efficacy of bacterial biofilm therapy is often hindered by the inadequate penetration of antibacterial agents and the nonspecific targeting of bacteria. This study proposes a novel strategy involving the utilization of pH-sensitive microparticles (MPs) of doxycycline (DOX) to enhance biofilm penetration and enable targeted delivery of DOX to infection sites associated with periodontitis. The MPs were developed using a double-emulsion technique with poly(d,l-lactide-co-glycolide) and chitosan in a 1:1 ratio. The morphology of DOX-MP exhibits a spherical form with a particle size of 3.54 ± 0.32 μm and a PDI of 0.221 ± 0.02. The DOX-MP also had great encapsulation efficiency (69.43% ± 5.32) and drug loading efficiency (14.81% ± 1.32) with regulated drug release kinetics and accelerated release rates under low-pH conditions. The antimicrobial activity was evaluated against Escherichia coli and Staphylococcus aureus, and the results indicated the absence of any viable bacterial colonies after 18 h at twice the minimum inhibitory concentration value. Hydrogel-based MPs deliver DOX to the periodontal pocket infection site for ease of use. In situ hydrogels used Pluronic F127 and F68 as the main polymer composition and hydroxypropyl methylcellulose as the adhesion polymer. This formulation exhibited a liquid state at room temperature (25 °C) but went through gelation at 36 °C. The formulation also had good mucoadhesive characteristics (42.65 ± 3.53 dyn/cm2) and good drug permeation at acidic pH in Mueller-Hinton Broth media with the addition of E. coli and S. aureus bacteria. Ex vivo antibacterial activity significantly reduced the microbial count, biofilm quantity, and metabolic activity, confirming the desired antibacterial effect. Hence, the utilization of free drugs and DOX-MPs did not exhibit a notable dissimilarity, showing that integrating the drug into the matrix was not hindering its antibacterial efficacy.

Impact of subgingival periodontal treatment on systemic markers of inflammation in patients with metabolic syndrome: a systematic review of randomized clinical trials

Introduction

This study synthesizes evidence on the impact of subgingival periodontal treatment combined with antibiotics on reducing systemic inflammation markers-C-reactive protein (CRP), interleukins, and tumor necrosis factor-alpha (TNF-α)-in patients with metabolic syndrome (MS) and periodontal disease (PD), compared to supragingival periodontal treatment with placebo.

Methods

Randomized clinical trials (RCTs) published in English, Spanish, or Portuguese that addressed the research question were included. A search was conducted in eight databases (PubMed, EMBASE, CINAHL, LILACS, Scopus, WoS Core Collection, Dentistry & Oral Science Source, and Cochrane Central) on June 20, 2023. Risk of bias was assessed using the Cochrane RoB 2 tool, and evidence certainty was evaluated following GRADE guidelines. A qualitative synthesis of the evidence was performed.

Results

Two RCTs with 228 participants (ages 35-65) were included. Montero et al. reported significant reductions in CRP levels favoring the treatment group at 3 months (2.7 mg/L ± SE: 0.4 vs. 3.9 mg/L ± SE: 0.6; p = 0.001) and 6 months (2.9 mg/L ± SE: 0.4 vs. 4.0 mg/L ± SE: 0.8; p = 0.004). Lopez et al., however, found no significant differences throughout follow-up. Only Montero et al. reported on interleukin 1β and TNF-α, observing significant reductions at 3 months for interleukin 1β (0.9 pg/dl ± SE: 0.1 vs. 2.3 pg/dl ± SE: 0.5; p = 0.046) and TNF-α (6.4 pg/dl ± SE: 0.8 vs. 10.0 pg/dl ± SE: 2.3; p = 0.037).

Discussion

The evidence is limited by the small number of comparative RCTs. One RCT with low risk of bias demonstrated significant reductions in CRP, interleukins, and TNF-α levels at 3 months and CRP at 6 months. The other, with unclear risk of bias, showed no differences in CRP up to 12 months. Findings suggest that subgingival periodontal treatment with antibiotics reduces systemic inflammation for up to 6 months in patients with MS and PD. However, larger RCTs with standardized methods and longer follow-up are needed to confirm these results.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022366056, PROSPERO (CRD42022366056).

Crosstalk between periodontitis and cardiovascular risk

Recent demographic developments resulted in an aged society with a rising disease burden of systemic and non-communicable diseases (NCDs). In cardiovascular disease (CVD), a NCD with high morbidity and mortality, recent preventive strategies include the investigation of comorbidities to reduce its significant economic burden. Periodontal disease, an oral bacterial-induced inflammatory disease of tooth-supporting tissue, is regulated in its prevalence and severity by the individual host response to a dysbiotic oral microbiota. Clinically, both NCDs are highly associated; however, shared risk factors such as smoking, obesity, type II diabetes mellitus and chronic stress represent only an insufficient explanation for the multifaceted interactions of both disease entities. Specifically, the crosstalk between both diseases is not yet fully understood. This review summarizes current knowledge on the clinical association of periodontitis and CVD, and elaborates on how periodontitis-induced pathophysiological mechanisms in patients may contribute to increased cardiovascular risk with focus on atherosclerosis. Clinical implications as well as current and future therapy considerations are discussed. Overall, this review supports novel scientific endeavors aiming at improving the quality of life with a comprehensive and integrated approach to improve well-being of the aging populations worldwide.

The systemic impact of non-surgical treatment of peri-implantitis with or without adjunctive systemic metronidazole: Secondary analysis of a randomized clinical trial

OBJECTIVES

The aim of this study was to evaluate the systemic effect of non-surgical peri-implantitis treatment (NSPIT) with or without the administration of systemic metronidazole.

METHODS

In this secondary analysis from a previously published clinical trial (NCT03564301), peri-implantitis patients were randomized into two groups: test, receiving NSPIT plus 500 mg of oral systemic metronidazole three times a day for 7 days (n = 10); and control group, receiving NSPIT plus placebo (n = 11). Serum samples were obtained at baseline, 3 and 6 months after therapy to determine levels of inflammatory biomarkers, lipid fractions and complete blood counts.

RESULTS

Both treatment modalities produced improvements in clinical and radiographic parameters. After 6 months from NSPIT, a substantial reduction in C-reactive protein (6.9 mg/dL; 95% CI: 3.7 to 9.9, p < .001) and low-density lipoprotein cholesterol (21.8 mg/dL; 95% CI: -6.9 to 50.5, p = .013) as well as a modest increase in neutrophils counts (0.4 × 103/μL; 95% CI: -0.4 to 1.1, p = .010) was observed in the control group while the test group showed a significant reduction of TNF-α (110.1; 95% CI: 38.9 to 181.4, p = .004).

CONCLUSIONS

NSPIT showed a short-term beneficial systemic effect regardless of adjunctive use of systemic metronidazole.

Periodontitis and atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease (ASCVD) is a major global health concern linked to significant morbidity and mortality. Recent research has explored the relationship between ASCVD and periodontitis, a prevalent inflammatory oral condition. Epidemiological studies have suggested a strong association between periodontitis and ASCVD, even proposing that periodontal disease could be a modifiable risk factor for cardiovascular conditions. This review critically analyzes the current evidence for a potential causal role for periodontitis in ASCVD. While randomized controlled trials have demonstrated reductions in surrogate markers of cardiovascular risk following periodontal interventions, these studies remain inconclusive regarding their direct effects on cardiovascular events. Preclinical studies in animal models have suggested a potential causal relationship between periodontitis and ASCVD, proposing several biological mechanisms to explain this connection. These studies, however, are limited in their ability to definitively prove causality. The positive associations observed in epidemiological studies between periodontitis and ASCVD may also be influenced by various biases, such as confounding and collider stratification. Moreover, our systematic review of Mendelian randomization studies on the causal relationship between periodontitis and ASCVD found no evidence of a genetic causality, further challenging the causal hypothesis. This review underscores the need for further high-quality research clarifying the relationship between periodontitis and ASCVD to better guide clinical practice and public health policy.

The role of interleukin-20 on inflammatory stress and periodontal tissue destruction in patients with metabolic syndrome and periodontitis

BACKGROUND

There is an increasing occurrence of periodontitis and metabolic syndrome (MetS), which is resulting in a decline in the overall quality of life. Both disorders can occur together since they are both linked to insulin resistance and systemic inflammation. However, evidence for a role of interleukin (IL)-20 in this comorbidity is very limited. This cross-sectional study aimed to comprehensively investigate, for the first time, the levels of RANKL/OPG, MMP-8 and OSI as well as the role of IL-20 in patients with MetS and periodontitis.

METHODS

The study included a total of 80 individuals, divided into four groups: 20 individuals who were healthy both systemically and periodontally, 20 individuals who were systemically healthy but had periodontitis, 20 individuals who had MetS but were periodontally healthy, and 20 individuals who had both MetS and periodontitis. Periodontal clinical parameters (plaque index, gingival index, bleeding on probing, clinical attachment loss, probing pocket depth) were evaluated. Gingival crevicular fluid (GGF) and serum samples were collected and used for biochemical assays. Enzyme-linked immunosorbent assay was used to determine the levels of IL-20, receptor activator of nuclear factor kappa B ligand (RANKL)/osteoprotegerin (OPG), matrix metalloproteinase-8 (MMP-8) and oxidative stress index (OSI).

RESULTS

IL-20 levels measured in serum and GCF were statistically significantly highest in patients with MetS and periodontitis (p = 0.001). Significant positive correlation was observed between serum and GCF IL-20 values and periodontal parameters (p < 0.05). There was a positive correlation between RANKL and RANKL/OPG levels and IL-20 and clinical parameters (p < 0.05). OSI values were found to be increased in the presence of both periodontitis and MetS (p = 0.001) and were positively correlated with serum and GCF IL-20 (p < 0.05).

CONCLUSIONS

These data from the study suggest a correlation between IL-20 and both MetS and periodontitis. IL-20 may potentially worsen the condition of periodontal tissue by increasing both the oxidative stress levels, periodontal collagen degredation and the ratio of RANKL to OPG.

TRIAL REGISTRATION

This study was registered on ClinicTrials.gov (NCT06092853), 2023-10-10, retrospectively registered.

Periodontal disease and cardiovascular disease: umbrella review

BACKGROUND

Periodontal disease (PD) is an infectious and inflammatory condition that affects the tissues surrounding and supporting the teeth. It has been suggested that PD may be associated with cardiovascular disease (CVD), one of the leading causes of mortality worldwide. Our study aimed to investigate the association between PD and CVD through an umbrella review.

METHODS

A comprehensive search was conducted until April 2024 across various electronic databases, including PubMed, Cochrane Library, Scopus, SciELO, Web of Science, Google Scholar, ProQuest Dissertations and Theses, and OpenGrey. Systematic reviews with or without meta-analysis were considered for inclusion, without any limitations on time or language, provided they examined primary studies linking PD with CVD. The AMSTAR-2 tool was employed to assess the quality and overall confidence of the included studies.

RESULTS

After the initial search, a total of 516 articles were identified. Following the application of selection criteria, 41 articles remained for further consideration. All these studies indicated an association between PD and CVD, with odds ratios and risk ratios ranging from 1.22 to 4.42 and 1.14 to 2.88, respectively.

CONCLUSIONS

Systematic reviews with high overall confidence support the association between PD, tooth loss, and cardiovascular diseases. However, it is crucial to interpret these results with caution due to methodological limitations. The potential public health relevance justifies preventive and corrective oral health strategies. Additionally, the need for rigorous future research is highlighted to strengthen the evidence and guide effective public health strategies.

Effect of non-surgical periodontal therapy on risk markers of cardiovascular disease: a systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in the world. Patients with periodontitis have a higher risk of CVD, although a causal relationship between these conditions remains unclear. Non-surgical periodontal therapy (NSPT) is able to control inflammation at local and systemic levels. This study aimed to analyze the effect of NSPT on CVD risk markers.

METHODS

Four electronic databases were searched from their inception to April 1, 2023, to identify and select articles without any language restrictions. Eleven CVD-related markers (e.g., C-reactive protein [CRP], Interleukin-6 [IL-6]) were selected. Meta-analyses were performed using random and fixed effect models. The differences were expressed as weighted mean differences (WMD) and 95% confidence interval (95% CI).

RESULTS

From 1353 studies, twenty-one randomized controlled clinical trials were included in the meta-analysis. Results showed a significant decrease in CRP, IL-6, and systolic blood pressure (SBP) after NSPT.

CONCLUSION

Moderate certainty evidence shows that NSPT has a positive effect on the reduction of IL-6 and SBP in patients with periodontitis, while low certainty evidence shows that NSPT is effective for reduction of CRP. Moderate certainty evidence showed that NSPT did not show a positive effect on low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC) and triglycerides (TG), and low certainty evidence showed that NSPT did not show a positive effect on Interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), diastolic blood pressure (DBP), and flow-mediated dilatation (FMD).

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO (International Prospective Register of Systematic Reviews), number CRD42022377565.

Impact of dental health intervention on cardiovascular metabolic risk: a pilot study of Japanese adults

This study aimed to determine whether a dental health education program would reduce cardiometabolic risk (obesity, hypertension, dyslipidemia, and hyperglycemia) in people with periodontitis. We used annual check-up data provided by the Japanese company's health insurance union. Of 182 male employees with cardiometabolic risk and periodontal pockets at baseline, 21 participants of the dental health education program and 21 non-participants matched for age, the presence of obesity, and periodontal pocket at baseline were allocated to the intervention (mean age, 53.3 ± 7.0) and the non-intervention groups (mean age, 52.9 ± 7.0), respectively. The program focused on self-removal of dental plaque with a toothbrush and interdental brush and comprised five sessions over 12 months. In the intervention group, waist circumference (cm) and diastolic blood pressure (mmHg) decreased from 88.4 ± 6.3 to 86.8 ± 6.3 and from 85.7 ± 8.2 to 82.6 ± 8.3, respectively (P < 0.05). Intergroup comparison showed significant improvement of systolic blood pressure (mmHg) in the intervention group (-3.7 ± 12.5) compared with the non-intervention group (4.0 ± 15.9) (P < 0.05) with no significant differences in the other parameters. The intervention group had a decrease in plaque accumulation and periodontitis symptoms, such as the depth of periodontal pocket and the presence of periodontal pocket and bleeding on probing, but an increase in the frequency of interdental brushing and duration of tooth brushing. Our findings show that dental self-care may improve blood pressure in people with cardiometabolic risk factors and periodontitis.

Oral health as a modifiable risk factor for cardiovascular diseases

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide with a high socioeconomic burden. Increasing evidence supports a convincing connection with increased cardiovascular risk of periodontal diseases (PD), a group of widespread, debilitating, and costly dysbiotic relapsing-remitting inflammatory diseases of the tissues supporting the teeth. Herein, we ensembled the best available evidence on the connection between CVDs and PD to review the recently emerging concept of the latter as a non-traditional risk factor for CVDs. We focused on oral dysbiosis, inflammation-associated molecular and cellular mechanisms, and epigenetic changes as potential causative links between PD and CVDs. The available evidence on the effects of periodontal treatment on cardiovascular risk factors and diseases was also described.

Systemic Impact of Subgingival Infection Control in Periodontitis Patients with Cardiovascular Disease: A Narrative Review

INTRODUCTION

Periodontitis, an infectious inflammatory condition, is a key contributor to sustained systemic inflammation, intricately linked to atherosclerotic cardiovascular disease (CVD), the leading cause of death in developed nations. Treating periodontitis with subgingival mechanical instrumentation with or without adjunctive antimicrobials reduces the microbial burden and local inflammation, while also potentially bringing systemic benefits for patients with both periodontitis and CVD. This review examines systemic effects of subgingival instrumentation with or without antimicrobial products in individuals with periodontitis and CVD, and explores intricate pathogenetic interactions between periodontitis and CVD.

MATERIAL AND METHODS

English-language databases (PubMed MEDLINE and Cochrane Library) were searched for studies assessing the effects of nonsurgical periodontal therapies in periodontitis patients with or without CVD.

RESULTS

While the ability of periodontal therapy to reduce mortality- and morbidity-related outcomes in CVD patients with periodontitis remains uncertain, some studies indicate a decrease in inflammatory markers and blood cell counts. Subgingival mechanical instrumentation delivered over multiple short sessions carries lower risks of adverse effects, particularly systemic inflammation, compared to the full-mouth delivery, making it a preferable option for CVD patients.

CONCLUSIONS

Subgingival mechanical instrumentation, ideally conducted in a quadrant-based therapeutic approach, to decontaminate periodontal pockets has the potential to reduce both local and systemic inflammation with minimal adverse effects in patients suffering from periodontitis and concurrent CVD.

Systemic benefits of periodontal therapy in patients with obesity and periodontitis: a systematic review

This systematic review aimed to answer the focused question: "What are the benefits of subgingival periodontal therapy on blood hematological and biochemical index, biomarkers of inflammation and oxidative stress, quality of life, and periodontal pathogen counts in patients with obesity and periodontitis?". A systematic literature search was performed in six databases: PubMed, Embase, LILACS, Web of Science, Cochrane and SCOPUS and other sources, and a manual search was conducted as well. Inclusion criteria were randomized and non-randomized clinical trials, and before-and-after studies on patients with obesity subjected to periodontal therapy. The results were synthesized qualitatively. Risk of bias within studies was assessed using RoB 2 and ROBINS-I tools. The certainty of evidence was evaluated following the GRADE approach. Three randomized controlled trials and 15 before-and-after studies were included. Randomized controlled trials were considered to have a low risk of bias, as compared to before-and-after studies assessed as having low, serious, and critical risks of bias. Non-surgical periodontal therapy plus azithromycin, chlorhexidine, and cetylpyridinium chloride reduced blood pressure and decreased serum levels of HbA1c, hsCRP, IL-1β, and TNF-α. Salivary resistin level also decreased in patients with obesity and periodontitis after therapy and chlorhexidine mouth rinse. Before-and-after data suggest an improvement in total cholesterol, LDL, triglycerides, insulin resistance, C3, GCF levels of TNF-α, chemerin, vaspin, omentin-1, visfatin, 8-OHdG, and periodontal pathogen counts after therapy.

Impact of N-terminal pro-B-type natriuretic peptide and related inflammatory biomarkers on periodontal treatment outcomes in patients with periodontitis: An explorative human randomized-controlled clinical trial

BACKGROUND

N-terminal portion of the B-type natriuretic propeptide (NT-proBNP) has potentially been shown to play an important role in the development of periodontitis and cardiovascular disease (CVD). This study evaluated the efficacy of periodontal treatment on NT-proBNP and related CVD biomarkers and explored whether subjects harboring high NT-proBNP at baseline showed increased clinical benefits with the non-surgical periodontal treatment performed with full-mouth scaling and root planing (FM-SRP) at 6-month follow-up.

METHODS

Forty-eight patients with stage III periodontitis were randomized to receive minimal standard oral care (SOC) (n = 24) or FM-SRP (n = 24) protocol. Clinical periodontal parameters (probing depth, clinical attachment loss, bleeding on probing), serum NT-proBNP, α1-antitrypsin, C-reactive protein (hs-CRP), endothelial cell-specific molecule-1 (ECM-1), and neutrophil gelatinase-associated lipocalin (NGAL) concentrations were assessed at baseline and at 1-, 3-, and 6- month follow-up.

RESULTS

At 6 months, FM-SRP was more effective than SOC in reducing periodontal parameters and mean proportions of NT-proBNP (p = 0.004), hs-CRP (p = 0.003), α1-antitrypsin (p = 0.012), ECM-1 (p = 0.014), and NGAL (p = 0.045). At 6-month follow-up, the reduced NT-proBNP, α1-antitrypsin, hs-CRP, ECM-1, and NGAL levels were significantly correlated with the extent of periodontitis (p < 0.05). Furthermore, the analysis of variance analysis evidenced that, at 6-month follow-up, FM-SRP significantly impacted the reduction of NT-proBNP, hs-CRP, ECM-1, and NGAL. Moreover, high levels of NT-proBNP, hs-CRP, ECM-1, and NGAL at baseline significantly influenced the efficacy of periodontal treatment positively.

CONCLUSION

In this study, FM-SRP was more effective than SOC in reducing clinical variables and NT-proBNP levels, although subjects who harbored high NT-proBNP concentrations at baseline showed greater clinical benefits of periodontal treatment at 6-month follow-up.

Periodontitis and atherosclerotic cardiovascular disease: A critical appraisal

In spite of intensive research efforts driving spectacular advances in terms of prevention and treatments, cardiovascular diseases (CVDs) remain a leading health burden, accounting for 32% of all deaths (World Health Organization. "Cardiovascular Diseases (CVDs)." WHO, February 1, 2017, https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)). Cardiovascular diseases are a group of disorders affecting the heart and blood vessels. They encompass a collection of different conditions, among which atherosclerotic cardiovascular disease (ASCVD) is the most prevalent. CVDs caused by atherosclerosis, that is, ASCVD, are particularly fatal: with heart attack and stroke being together the most prevalent cause of death in the world. To reduce the health burden represented by ASCVD, it is urgent to identify the nature of the "residual risk," beyond the established risk factors (e.g., hypertension) and behavioral factors already maximally targeted by drugs and public health campaigns. Remarkably, periodontitis is increasingly recognized as an independent cardiovascular risk factor.

Periodontal treatment and microbiome-targeted therapy in management of periodontitis-related nonalcoholic fatty liver disease with oral and gut dysbiosis

A growing body of evidence from multiple areas proposes that periodontal disease, accompanied by oral inflammation and pathological changes in the microbiome, induces gut dysbiosis and is involved in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). A subgroup of NAFLD patients have a severely progressive form, namely nonalcoholic steatohepatitis (NASH), which is characterized by histological findings that include inflammatory cell infiltration and fibrosis. NASH has a high risk of further progression to cirrhosis and hepatocellular carcinoma. The oral microbiota may serve as an endogenous reservoir for gut microbiota, and transport of oral bacteria through the gastro-intestinal tract can set up a gut microbiome dysbiosis. Gut dysbiosis increases the production of potential hepatotoxins, including lipopolysaccharide, ethanol, and other volatile organic compounds such as acetone, phenol and cyclopentane. Moreover, gut dysbiosis increases intestinal permeability by disrupting tight junctions in the intestinal wall, leading to enhanced translocation of these hepatotoxins and enteric bacteria into the liver through the portal circulation. In particular, many animal studies support that oral administration of Porphyromonas gingivalis, a typical periodontopathic bacterium, induces disturbances in glycolipid metabolism and inflammation in the liver with gut dysbiosis. NAFLD, also known as the hepatic phenotype of metabolic syndrome, is strongly associated with metabolic complications, such as obesity and diabetes. Periodontal disease also has a bidirectional relationship with metabolic syndrome, and both diseases may induce oral and gut microbiome dysbiosis with insulin resistance and systemic chronic inflammation cooperatively. In this review, we will describe the link between periodontal disease and NAFLD with a focus on basic, epidemiological, and clinical studies, and discuss potential mechanisms linking the two diseases and possible therapeutic approaches focused on the microbiome. In conclusion, it is presumed that the pathogenesis of NAFLD involves a complex crosstalk between periodontal disease, gut microbiota, and metabolic syndrome. Thus, the conventional periodontal treatment and novel microbiome-targeted therapies that include probiotics, prebiotics and bacteriocins would hold great promise for preventing the onset and progression of NAFLD and subsequent complications in patients with periodontal disease.

Nonsurgical periodontal treatment during pregnancy and rates of preterm birth

BACKGROUND

Periodontitis during pregnancy is associated with an increased risk of preterm birth (<37 weeks of gestation) or low birthweight (<2500 g) offspring. Beyond periodontal disease, the risk of preterm birth varies both by previous history of preterm birth and in association with social determinants prevalent among vulnerable and marginalized populations. This study hypothesized that the timing of periodontal treatment during pregnancy and/or social vulnerability measures modified the response to dental scaling and root planing for the treatment of periodontitis and prevention of preterm birth.

OBJECTIVE

This study aimed to determine the association of timing of dental scaling and root planing for gravidae with a diagnosed periodontal disease on the rates of preterm birth or low birthweight offspring among subgroups or strata of gravidae as part of the Maternal Oral Therapy to Reduce Obstetric Risk randomized controlled trial. All participants in the study had clinically diagnosed periodontal disease and differed by the timing of the periodontal treatment (dental scaling and root planing at <24 weeks [per protocol] or after delivery) or by baseline characteristics. Although all participants met the well-accepted clinical criteria for periodontitis, not all participants acknowledged a priori that they had periodontal disease.

STUDY DESIGN

This was a per-protocol analysis of data from 1455 participants of the Maternal Oral Therapy to Reduce Obstetric Risk trial evaluating dental scaling and root planing on the risk of preterm birth or low birthweight offspring. Adjusted multiple logistic regression to control for confounders was used to estimate associations comparing the timing of periodontal treatment in pregnancy to receiving treatment after pregnancy (referent control) on rates of preterm birth or low birthweight among subgroups of gravidae with known periodontal disease. Study analyses were stratified, and the associations with the following characteristics-body mass index, self-described race and ethnicity, household income, maternal education, recency of immigration, and self-acknowledgment of poor oral health, were explored.

RESULTS

Dental scaling and root planing during the second or third trimester of pregnancy were associated with an increased adjusted odds ratio of preterm birth among those at the lower body mass index strata (18.5 to <25.0 kg/m²) (adjusted odds ratio, 2.21; 95% confidence interval, 1.07-4.98), but not among individuals who were overweight (body mass index of 25.0 to <30.0 kg/m²; adjusted odds ratio, 0.68; 95% confidence interval, 0.29-1.59) or obese (body mass index of ≥30 kg/m²; adjusted odds ratio, 1.26; 95% confidence interval, 0.65-2.49). There was no significant difference in pregnancy outcomes related to the other evaluated variables: self-described race and ethnicity, household income, maternal education, immigration status, or self-acknowledgment of poor oral health.

CONCLUSION

In this per-protocol analysis of the Maternal Oral Therapy to Reduce Obstetric Risk trial, dental scaling and root planing had no preventive benefit against adverse obstetrical outcomes and were associated with increased odds of preterm birth among individuals at lower body mass index strata. There was no significant difference in the occurrence of preterm birth or low birthweight after dental scaling and root planing periodontitis treatment concerning other analyzed social determinants of preterm birth.

Treatment of periodontitis and C-reactive protein: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Systemic inflammation is implicated in the onset and progression of several chronic diseases. Periodontitis is a potential trigger of systemic inflammation.

PURPOSE

To comprehensively appraise all the evidence on the effects of the treatment of periodontitis on systemic inflammation assessed by serum C-reactive protein (CRP) levels.

DATA SOURCES

Six electronic databases were searched up to 10 February 2022 to identify and select articles in English language only.

STUDY SELECTION

Twenty-six randomized controlled clinical trials reporting changes amongst 2579 participants about CRP levels at 6 months or more after treatment.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of studies. Meta-analyses were performed using random and fixed effect models.

RISK OF BIAS

Risk of bias (RoB 2.0 tool) and quality of evidence (GRADEpro GDT tool) analyses were completed.

DATA SYNTHESIS

Treatment of periodontitis reduced CRP levels by 0.69 mg/L (95% confidence interval: -0.97 to -0.40) after 6 months, but limited evidence was retrieved from studies with longer follow-ups. Similar findings were observed in participants with other co-morbidities in addition to periodontitis. Greatest reductions were observed in participants with concentrations of CRP >3 mg/L at baseline.

LIMITATIONS

High level of heterogeneity.

CONCLUSIONS

Treatment of periodontitis reduces serum CRP levels (up to 6 months follow-up) to a degree equivalent to that observed after traditional lifestyle or drug interventions. This evidence supports a causal association between periodontitis and systemic inflammation.

Effect of periodontal treatment on glycated haemoglobin and metabolic syndrome parameters: A randomized clinical trial

AIM

To assess the effect of periodontal treatment on HbA1c and diagnostic parameters of patients with metabolic syndrome (MetS).

MATERIALS AND METHODS

One hundred and fifty-eight patients with MetS and moderate and severe periodontitis were included. They were randomized into a test group (n = 79), which received non-surgical periodontal treatment, and a control group (n = 79), which received no treatment. Medical treatment was delivered to both groups. Clinical periodontal, anthropometric and serological parameters were assessed at baseline, 3 and 6 months. The main outcome was glycated haemoglobin (HbA1c) levels, and the secondary outcomes were changes in the MetS parameters, C-reactive protein (CRP) and HOMA indexes.

RESULTS

Significant reductions in all periodontal parameters were observed in the test group, compared with the control group, at 3 and 6 months (p < .001). HbA1c levels, MetS parameters, CRP and HOMA indexes showed no significant differences between the test group and the control group at 3 and 6 months.

CONCLUSIONS

Periodontal treatment led to a substantial reduction in periodontal inflammation, although there was no significant effect on the parameters used for MetS diagnosis in patients with early diagnosed and well-controlled MetS.

Periodontal Disease in Obese Patients; Interleukin-6 and C-Reactive Protein Study: A Systematic Review

Periodontal disease (PD) and obesity are characterized by a dysregulated inflammatory state. Both conditions trigger inflammatory and immune responses with an increase in proinflammatory cytokines such as Interleukin 6 (IL-6) and the release of inflammatory mediators such as C-reactive protein (CRP). Individuals with a high body mass index (BMI) present a chronic inflammatory state. The aim of the present study was to perform a systematic review of inflammatory markers (IL-6 and CRP) in obese patients with PD and their possible relationship by analyzing the levels of these markers. A digital literature search was performed in three databases-PubMed, SciElo and Medigraphic-through an advanced search for original articles, employing IL-6 and CRP in obese patients with PD, within a publication period from 2010 to 2021. PRISMA guidelines, the JADAD scale and a qualitative analysis of scientific evidence were performed using the Cochrane collaboration method and the RoB 2 assessment tool. Ten articles were included in this analysis with the variables recorded and associated with subjects with obesity and PD. Of the ten articles included, three analyzed IL-6 and CRP, four analyzed IL-6 and three analyzed CRP. In conclusion, and based on the available evidence, the aforementioned markers of inflammation demonstrate that there is a relationship between PD and obesity.

Serum Antioxidant Vitamins Mediate the Association between Periodontitis and Metabolically Unhealthy Overweight/Obesity

BACKGROUND

Periodontal disease is associated with metabolic syndrome and obesity. This cross-sectional study aimed to investigate whether serum antioxidant vitamins could mediate the association between periodontitis and a metabolically unhealthy phenotype in the overweight and obese population; Methods: We included 6158 Americans (body mass index (BMI) ≥ 25 kg/m²) from the Third National Health and Nutrition Examination Survey (NHANES III). Periodontitis was defined using a half-reduced CDC/AAP (Centers for Disease Control and Prevention/American Academy of Periodontology) definition. Having two or more metabolic abnormalities was defined as a metabolically unhealthy overweight and obese (MUO) phenotype. Mediation analysis of four oxidative stress biomarkers (serum antioxidant vitamins A, C, D, and E) was conducted; Results: Of participants with overweight and obesity, 2052 (33.3%) Americans were categorized as having periodontitis. Periodontitis increased dyslipidemia risk and systemic inflammation in the overweight and obese population. In the multivariable logistic regression model, periodontitis was positively associated with MUO (adjusted odds ratio = 1.238; 95% confidence interval: 1.091 to 1.406). These findings were validated in an independent cohort. Serum vitamins C and D were estimated to mediate 19.3% and 8.4% of the periodontitis-MUO association.

CONCLUSIONS

Periodontitis might decrease serum vitamins C and D and induce a metabolically unhealthy state among adults with overweight and obesity.

Impact of Intermittent Fasting on Metabolic Syndrome and Periodontal Disease-A Suggested Preventive Strategy to Reduce the Public Health Burden

Metabolic syndrome (MetS) prevalence continues to climb significantly worldwide in today's ad libitum society. MetS has tremendous societal and economic ramifications, making it imperative to develop effective strategies for preventing and controlling it to alleviate this growing burden. Periodontal disease and MetS are associated with several risk factors. Studies in the past have demonstrated that obesity, cardiovascular illness, and type 2 diabetes mellitus have a negative effect on the severity of the periodontal disease. Patients with metabolic syndrome have elevated serum levels of proinflammatory mediators such as tumor necrosis factor-alpha interleukin-6 and C-reactive protein. Similar inflammatory mediators, such as interleukin-6, tumor necrosis factor-alpha, and C-reactive protein, are increased in patients with severe periodontal disease. Remarkably, intermittent fasting is underpinned by scientific evidence, claiming to be the most effective non-pharmacological, potential therapeutic alternative for combating a wide range of metabolic, inflammatory, and lifestyle-related diseases. Nonetheless, an insufficient investigation has been performed to determine whether intermittent fasting has therapeutic benefits on periodontal inflammation and diseases. Here, we show the interrelationship between metabolic syndrome and periodontal disease and contextualize the beneficial impact of intermittent fasting in modulating the chronic metabolic and periodontal inflammatory response. We also anticipate that this review paves the way for further exploration of intermittent fasting as a unique research paradigm representing a cost-effective alternative strategy to conventional disease management in patients with periodontal diseases and metabolic syndrome which may serve as the foundation for an integrative vision relevant to primary, diagnostic, and therapeutic purposes.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the third update of a review originally published in 2014, and most recently updated in 2019. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

An information specialist searched five bibliographic databases up to 17 November 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There are no new completed RCTs on this topic since we published our last update in 2019. We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

Cardiovascular Diseases and Periodontitis

Periodontitis is a chronic inflammatory disease of the tooth-supporting connective tissue and alveolar bone that is initiated by a bacterial biofilm in periodontal pockets. It affects about half of adults in the Western world, and is associated with a range of systemic comorbidities, e.g., cardiovascular disease (CVD), diabetes and rheumatoid arthritis, and these diseases share overlapping systemic and target tissue inflammatory mechanisms. Indeed, mounting evidence has indicated that their association is causal and built on the presence of systemic low-grade inflammation (LGI). Prior research linking periodontitis to CVD has mainly been derived from experimental studies, observational data, and small interventional trials with surrogate markers of CVD, e.g., endothelial dysfunction. However, recent data from randomised studies have demonstrated that intensive treatment of periodontitis can reduce blood pressure in patients with hypertension in conjunction with reduction of systemic inflammatory markers. Furthermore, targeted anti-inflammatory therapy has been shown to reduce recurrent events in patients with established CVD and LGI. Along this line, the concept of residual inflammatory risk has emerged as an independent new risk factor for atherothrombotic CVD. The present review summarizes translational evidence indicating that periodontitis is a risk factor for CVD dependent on LGI, and we conclude that treatment of periodontitis is likely to contribute importantly to reduction of residual inflammatory risk.

Unexpected Relationships: Periodontal Diseases: Atherosclerosis-Plaque Destabilization? From the Teeth to a Coronary Event

Atherosclerotic cardiovascular disease (ASCVD) and periodontal disease (PD) are global health problems. High frequency of ASCVD is associated with the spread of many risk factors, including poor diet, sedentary lifestyle, diabetes, hyperlipidemia, obesity, smoking, hypertension, chronic kidney disease, hypertension, hyperhomocysteinemia, hyperuricemia, excessive stress, virus infection, genetic predisposition, etc. The pathogenesis of ASCVD is complex, while inflammation plays an important role. PD is a chronic, multifactorial inflammatory disease caused by dysbiosis of the oral microbiota, causing the progressive destruction of the bone and periodontal tissues surrounding the teeth. The main etiological factor of PD is the bacteria, which are capable of activating the immune response of the host inducing an inflammatory response. PD is associated with a mixed microbiota, with the evident predominance of anaerobic bacteria and microaerophilic. The "red complex" is an aggregate of three oral bacteria: Tannerella forsythia Treponema denticola and Porphyromonas gingivalis responsible for severe clinical manifestation of PD. ASCVD and PD share a number of risk factors, and it is difficult to establish a causal relationship between these diseases. The influence of PD on ASCVD should be treated as a factor increasing the risk of atherosclerotic plaque destabilization and cardiovascular events. The results of observational studies indicate that PD significantly increases the risk of ASCVD. In interventional studies, PD treatment was found to have a beneficial effect in the prevention and control of ASCVD. This comprehensive review summarizes the current knowledge of the relationship between PD and ASCVD.

Effect of periodontal treatments on blood pressure

BACKGROUND

An association has been hypothesized between periodontitis and hypertension. Periodontal therapy is believed to reduce systemic inflammatory mediators and increase endothelial function, thus having the potential to prevent and treat hypertension.

OBJECTIVES

To assess the effect and safety of different periodontal treatment modalities on blood pressure (BP) in people with chronic periodontitis.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched for randomized controlled trials (RCTs) up to November 2020 in the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, seven other databases, and two clinical trials registries. We contacted the authors of relevant papers regarding further published and unpublished work.

SELECTION CRITERIA

RCTs and quasi-RCTs aiming to detect the effect of periodontal treatment on BP were eligible. Participants should have been diagnosed with chronic periodontitis and hypertension (or no hypertension if the study explored the preventive effect of periodontal treatment). Participants in the intervention group should have undergone subgingival scaling and root planing (SRP) and any other type of periodontal treatments, compared with either no periodontal treatment or alternative periodontal treatment in the control group.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for study identification, data extraction, and risk of bias assessment. We used a formal pilot-tested data extraction form for data extraction, and the Cochrane risk of bias tool for risk of bias assessment. We planned the meta-analysis, test for heterogeneity, sensitivity analysis, and subgroup analysis. We assessed the certainty of evidence using GRADE. The primary outcome was change in systolic BP (SBP) and diastolic BP (DBP).

MAIN RESULTS

We included eight RCTs. Five had low risk of bias, one had unclear risk of bias, and two had high risk of bias. Four trials compared periodontal treatment with no treatment. We found no evidence of a difference in the short-term change of SBP and DBP for people diagnosed with periodontitis and other cardiovascular diseases except hypertension (very low-certainty evidence). We found no evidence of a difference in long-term changes in SBP (mean difference [MD] -2.25 mmHg, 95% confidence interval [CI] -9.41 to 4.92; P = 0.54; studies = 2, participants = 108; low-certainty evidence) and DBP (MD -2.55 mmHg, 95% CI -6.90 to 1.80; P = 0.25; studies = 2, participants = 103; low-certainty evidence). Concerning people diagnosed with periodontitis, in the short term, two studies of low certainty reported no changes in SBP (MD -0.14 mmHg, 95% CI -4.05 to 3.77; P = 0.94; participants = 294) and DBP (MD -0.15 mmHg, 95% CI -2.47 to 2.17; P = 0.90; participants = 294), and we found no evidence of a difference in SBP and DBP over a long period based on low certainty of evidence. Three studies compared intensive periodontal treatment with supra-gingival scaling. We found no evidence of a difference in changes in SBP and DBP for any length of time in people diagnosed with periodontitis (very low-certainty evidence). In people diagnosed with periodontitis and hypertension, we found one study reporting a significant reduction in the short term in SBP (MD -11.20 mmHg, 95% CI -15.40 to -7.00; P < 0.001; participants = 101; moderate-certainty evidence) and DBP (MD -8.40 mmHg, 95% CI -12.19 to -4.61; P < 0.0001; participants = 101; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We found no evidence of a difference of an impact of periodontal treatments on BP in most comparisons assessed in this review, and given the low certainty of evidence and the lack of relevant studies we could not draw conclusions about the effect of periodontal treatment on BP in people with chronic periodontitis. We found only one study suggesting that periodontal treatment may reduce SBP and DBP over a short period in people with hypertension and chronic periodontitis, but the certainty of evidence was moderate.

Impact of the treatment of periodontitis on systemic health and quality of life: A systematic review

AIM

To investigate the effect of treatment of periodontitis on systemic health outcomes, pregnancy complications, and associated quality of life.

MATERIALS AND METHODS

Systematic electronic searches were conducted to identify randomized controlled trials with minimum 6-month follow-up and reporting on the outcomes of interest. Qualitative and quantitative analyses were performed as deemed suitable.

RESULTS

Meta-analyses confirmed reductions of high-sensitivity C-reactive protein (hs-CRP) [0.56 mg/L, 95% confidence interval (CI) (-0.88, -0.25), p < .001]; interleukin (IL)-6 [0.48 pg/ml, 95% CI (-0.88, -0.08), p = .020], and plasma glucose [1.33 mmol/l, 95% CI (-2.41, -0.24), p = .016], and increase of flow-mediated dilation (FMD) [0.31%, 95% CI (0.07, 0.55), p = .012] and diastolic blood pressure [0.29 mmHg, 95% CI (0.10, 0.49), p = .003] 6 months after the treatment of periodontitis. A significant effect on preterm deliveries (<37 weeks) was observed [0.77 risk ratio, 95% CI (0.60, 0.98), p = .036]. Limited evidence was reported on quality-of-life (QoL) outcomes in the included studies.

CONCLUSIONS

Treatment of periodontitis results in systemic health improvements including improvement in cardiometabolic risk, reduction in systemic inflammation and the occurrence of preterm deliveries. Further research is however warranted to confirm whether these changes are sustained over time. Further, appropriate QoL outcomes should be included in the study designs of future clinical trials.

Association between metabolic syndrome and periodontitis: The role of lipids, inflammatory cytokines, altered host response, and the microbiome

Periodontitis has been associated with many systemic diseases and conditions, including metabolic syndrome. Metabolic syndrome is a cluster of conditions that occur concomitantly and together they increase the risk of cardiovascular disease and double the risk of type 2 diabetes. In this review, we focus on the association between metabolic syndrome and periodontitis; however, we also include information on diabetes mellitus and cardiovascular disease, since these two conditions are significantly intertwined with metabolic syndrome. With regard to periodontitis and metabolic syndrome, to date, the vast majority of studies point to an association between these two conditions and also demonstrate that periodontitis can contribute to the development of, or can worsen, metabolic syndrome. Evaluating the effect of metabolic syndrome on the salivary microbiome, data presented herein support the hypothesis that the salivary bacterial profile is altered in metabolic syndrome patients compared with healthy patients. Considering periodontitis and these three conditions, the vast majority of human and animal studies point to an association between periodontitis and metabolic syndrome, diabetes, and cardiovascular disease. Moreover, there is evidence to suggest that metabolic syndrome and diabetes can alter the oral microbiome. However, more studies are needed to fully understand the influence these conditions have on each other.

Is There a Causal Link Between Periodontitis and Cardiovascular Disease? A Concise Review of Recent Findings

There is substantial evidence in support of an association between periodontitis and cardiovascular disease. The most important open question related to this association is causality. This article revisits the question of causality by reviewing intervention studies and systematic reviews and meta analyses published in the last 3 years. Where are we now in answering this question? Whilst systematic reviews and epidemiological studies continue to support an association between the diseases, intervention studies fall short in determining causality. There is a dearth of good-quality, blinded randomised control trials with cardiovascular disease outcomes. Most studies use surrogate markers/biomarkers for endpoints, and this is problematic as they may not be reflective of cardiovascular disease status. This review further highlights another issue with surrogate markers/biomarkers: the potential for collider bias. Ethical considerations surrounding nontreatment have led to calls for a well-annotated database containing in-depth dental health data. Finally, a relatively new and important risk factor for cardiovascular disease, clonal haematopoiesis of indeterminate potential, is discussed. Clonal haematopoiesis of indeterminate potential increases cardiovascular risk by more than 40%, and inflammation is a contributing factor. The impact of periodontal disease on this emerging risk factor has yet to be explored. Although the question of causality in the association between periodontal disease and cardiovascular disease remains unanswered, the importance of good oral health in maintaining good heart health is reiterated.

The effect of adjunctive systemic antibiotics on microbial populations compared to scaling and root planing alone for the treatment of periodontitis: A pilot randomized clinical trial

AIM

To investigate the microbial shift after periodontitis being treated by scaling and root planing (SRP) with or without adjunctive antibiotics, and to assess the relationship between oral microbiota and systemic factors.

METHODS

A 6-month pilot randomized controlled trial recruited 14 subjects with severe periodontitis, divided into test group and control group to receive full-mouth SRP with or without amoxicillin (500mg) and metronidazole (200mg) (t.i.d. 7d). Clinical examination, collection of subgingival plaque and saliva, and blood tests were performed at baseline pre-treatment, three months, and six months post-treatment. The V3V4 region of 16S DNA was sequenced; taxonomic assignment was based on the Human Oral Microbiome Database.

RESULTS

The periodontal condition significantly improved in both groups; the test group showed a greater improvement in plaque index, probing depth, and bleeding index than the control group. The test group demonstrated significantly lower microbial richness and diversity, and less abundant Porphyromonas than the control group in at three months for both subgingival microbiome and salivary microbiome. However, the microbial differences narrowed within six months. The subgingival and salivary microbiota shifted synergistically. Glucose was positively related to subgingival Porphyromonas; mean platelet volume was positively related to subgingival Leptotrichia.

CONCLUSIONS

Systemic administration of amoxicillin and metronidazole along with SRP had an advantage over SRP alone in clinical improvement and infection control in both the subgingival region and saliva three months post-treatment. Microbial advantage nearly disappeared at six months; however, the clinical advantage lasted longer. The use of antibiotics also has potential benefits for systemic inflammation and glucose. This article is protected by copyright. All rights reserved.

The use of probiotics can reduce the severity of experimental periodontitis in rats with metabolic syndrome: an immunoenzymatic and microtomographic study

BACKGROUND

This study evaluated the effects of Bifidobacterium animalis subsp. lactis HN019 (B. lactis HN019) in the development of periodontitis (PE), associated or not with metabolic syndrome, (MS) in rats.

METHODS

96 rats were grouped according to a food protocol: high-fat diet for induction of MS or standard diet for the control groups (C). They were subdivided into groups with (+) and without (-) PE, receiving (*) or not (**) probiotic (PROB): C -**, CP-*, PE+**, PEP+*, MS-**, MSP-*, MSPE+** and MSPEP+*. PROB administration started on the 8^th week of the study and PE was induced on the 14^th week by placing ligature on the animals' lower first molars. Euthanasia occurred in the 16^th week. Biomolecular analyzes, immunoenzymatic assays, and microtomographic analyses were performed. The data obtained were analyzed statistically (p <0.05).

RESULTS

The PEP and MSPEP groups showed lower levels of alveolar bone loss when compared to the PE and MSPE groups, respectively (p <0.05). The immunoenzymatic analysis showed higher levels of interleukin (IL)-1β and a higher receptor activator of NF-kappaB ligand (RANKL)/ osteoprotegerin (OPG) ratio in the MSPE group when compared to the MSPEP group (p <0.05). The PEP group showed lower levels of tumor necrosis factor (TNF)-α and IL-6 when compared to the PE group. The use of PROB attenuated dyslipidemia parameters in animals with MS, with or without PE.

CONCLUSION

B. lactis HN019 reduced more significantly the severity of PE in rats with MS, modulating both systemic metabolic and immunoinflammatory parameters in periodontal tissues. This article is protected by copyright. All rights reserved.

Impact of endodontic and periodontal diseases and treatments on the aorta and liver of obese and non-obese rats

AIM

To evaluate the impact of the presence and treatment of periodontal disease (PD) and apical periodontitis (AP) on the aorta and liver of obese and non-obese rats.

METHODOLOGY

One hundred and forty Wistar rats were divided into two groups, according to the diet administered: normal diet (-n), without obesity; and cafeteria diet (-c), with induced obesity. These groups were divided into seven subgroups according to the specific experimental protocols: naïve control (NC); AP; AP with treatment (APt); PD; PE with treatment (PDt); AP and PD (APPD); and AP and PD with treatment (APPDt). AP and PD lesions were induced for four weeks. Four weeks after treatments, the animals were euthanatized, and the aorta and liver were dissected for histological evaluation. For the comparison of the thickness of the aorta between groups, the Kruskal-Wallis test was used, followed by the Mann-Whitney test. For the analysis of other variables related to the aorta and liver outcomes, logistic regression was carried out.

RESULTS

Both PD and AP were associated with the development of histological alterations in the aortic arch, with no significant difference between obese and non-obese animals (p = .17). The aorta thickness was increased significantly (p < .05) with the combination of PD and AP in obese rats (APPDt-c group) compared with the other groups (NC-n, APt-n, APt-c and AP-c). The logistic regression models revealed that the untreated (OR = 7.78; 95%CI = 2.4-25) and treated (OR = 2.9; 95%CI = 1.0-8.4) groups were significantly more likely to have endothelial alterations compared with the control groups (p = .002). Obesity (OR = 16.5; 95%CI = 3.4-81.3) was the only predictor variable of liver steatosis (p < .001).

CONCLUSION

Histological alterations in the aortic arch of obese and non-obese rats were observed in the presence of periodontal disease and apical periodontitis. The combination of PD and AP increased the aorta thickness in obese rats. A reduction of vascular endothelial lesions was observed with the treatments of PD and AP.

Periodontitis, Blood Pressure, and the Risk and Control of Arterial Hypertension: Epidemiological, Clinical, and Pathophysiological Aspects-Review of the Literature and Clinical Trials

Purpose of Review

Arterial hypertension is an important risk factor for cardiovascular disease. In the world, about 45% of people suffer from arterial hypertension, while good blood pressure control is achieved by only approximately 50% of all hypertensive patients treated. The reason for the high prevalence of arterial hypertension and its poor control is low knowledge of hypertensinogenic factors. One such factor is periodontitis, which is a disease of social importance.

Recent Findings

It has been shown that the occurrence of periodontitis leads to an increase in blood pressure, increasing the risk of arterial hypertension. Periodontitis can also lead to ineffectiveness of antihypertensive treatment. Some interventional studies have shown that treatment of periodontitis reduced blood pressure in patients with arterial hypertension. The pathogenesis of arterial hypertension in periodontitis is complex and concerns mainly the impairment of the vasodilatation properties of the endothelium.

Summary

Hygiene and periodontitis treatment should be a method of preventing arterial hypertension and a method of increasing the effectiveness of antihypertensive treatment.

Serum proteins associated with periodontitis relapse post-surgery: A pilot study

BACKGROUND

The knowledge of which genes and proteins that are connected to the susceptibility to gingivitis with subsequent local tissue degradation seen in periodontitis is insufficient. Changes of serum proteins associated with recurrence of bleeding on probing (BOP) and increased periodontal pocket depths (PPD) after surgical treatment of periodontitis could reveal molecules that could be early signals of tissue destruction and/or of importance for systemic effects in other tissues or organs.

METHODS

We performed a longitudinal pilot study and followed 96 inflammation-related proteins over time in serum from patients who underwent surgical treatment of periodontitis (n= 21). The samples were taken before (time 0), and then at 3, 6, and 12 months after surgery. Changes in protein levels were analysed in relation to the clinical outcome measures, that is, proportion of surfaces affected by BOP and PPD.

RESULTS

Changes in treatment outcomes with early signs of relapse in periodontitis after surgical treatment, for example, increased BOP and PPDs, were during 12-months follow up associated with increased serum levels of high-sensitivity C-reactive protein (hs-CRP) and programmed death-ligand 1 (PD-L1), and reduced serum levels of cystatin-D protein.

CONCLUSION

This study shows that clinical signs of recurrence of periodontitis after surgery are reflected in serum, but larger studies are needed for verification. Our novel findings of an association between increased PD-L1- and decreased cystatin D-levels and recurrence in periodontitis are interesting because PD-L1 has been shown to facilitate bacterial infections and chronic inflammation and cystatin D to inhibit tissue destruction. Our results justify mechanistic studies regarding the role of these molecules in periodontitis.

Is sexual dysfunction associated with periodontal status in perimenopausal women?: A pilot study

OBJECTIVE

The current study aimed to investigate the possible relationship between periodontal status and sexual dysfunction in perimenopausal women.

MATERIALS AND METHODS

This study was conducted on 106 participants. After the evaluation of the sexual functioning of participants with the Female Sexual Function Index (FSFI), their periodontal status and decayed-missing-filled teeth (DMFT) were assessed using appropriate indexes and obtained results were recorded for comparisons. Participants were divided into two groups by the periodontal status. Patients with periodontitis were grouped by the stage and the extent of the disease. Besides, participants were grouped according to the bleeding on probing (BOP) ratios for more detailed analyses.

RESULTS

A negative significant correlation was observed between total FSFI scores and each of the clinical periodontal parameters. Total FSFI scores and the scores of arousal, lubrication, orgasm, satisfaction, and pain domains were significantly lower in periodontitis patients (p < .05). When the patients were grouped as having localized or generalized periodontitis or whether they had stage-I, -II, and -III periodontitis, no statistically significant differences were observed in the distribution of general sexual dysfunction parameters across the groups (p > .05).

CONCLUSION

Periodontal status in perimenopausal women may be associated with sexual dysfunction.

Periodontal therapy and treatment of hypertension-alternative to the pharmacological approach. A systematic review and meta-analysis

AIM

Quantitative comparison of the effects of intensive (IPT) or conventional (CPT) periodontal treatment on arterial blood pressure, endothelial function and inflammatory/metabolic biomarkers.

MATERIALS AND METHODS

A systematic search was conducted to identify randomized controlled trials (RCT) of IPT (supra and subgingival instrumentation). Eight RCTs were included in the meta-analysis. Difference in change of systolic blood pressure (SBP) and diastolic blood pressure (DBP) before and after IPT or CPT were the primary outcomes. The secondary outcomes included: endothelial function and selected inflammatory/anti-inflammatory (CRP, IL-6, IL-10, IFN-γ) and metabolic biomarkers (HDL, LDL, TGs).

RESULTS

The overall effect estimates (pooled Weighted Mean Difference (WMD)) of the primary outcome for SBP and DBP was -4.3 mmHg [95%CI: -9.10-0.48], p = 0.08 and -3.16 mmHg [95%CI: -6.51-0.19], p = 0.06 respectively. These studies were characterized by high heterogeneity. Therefore, random effects model for meta-analysis was performed. Sub-group analyses confirmed statistically significant reduction in SBP [WMD = -11.41 mmHg (95%CI: -13.66, -9.15) P < 0.00001] and DBP [WMD = -8.43 mmHg (95%CI: -10.96,-5.91)P < 0.00001] after IPT vs CPT among prehypertensive/hypertensive patients, while this was not observed in normotensive individuals. The meta-analyses showed significant reductions in CRP and improvement of endothelial function following IPT at all analysed timepoints.

CONCLUSIONS

IPT leads to improvement of the cardiovascular health in hypertensive and prehypertensive individuals.

Effect of dental intervention on improvements in metabolic syndrome patients: a randomized controlled clinical trial

Background

Metabolic syndrome (MetS), caused by the accumulation of visceral fat, is considered a major cause of cardiovascular disease. This randomized controlled trial aimed to clarify the effect of dental intervention, including prosthodontics and/or periodontal treatment, combined with dietary and exercise guidance on MetS.

Methods

In total, 112 patients who met the Japanese waist circumference criteria of MetS were recruited. The intervention group (ITG) received dental intervention along with dietary and exercise guidance, while the control group (CTG) received dietary and exercise guidance alone. Three outcome measurements were obtained before intervention (BL), 1 month after intervention (1M), and 3 months after intervention (3M).

Results

Body water rate (p = 0.043) was significantly higher in ITG than in CTG at 1M. Simultaneously, fasting blood sugar level (p = 0.098) tended to be lower in ITG than in CTG. Lean mass (p = 0.037) and muscle mass (p = 0.035) were significantly higher and body weight (p = 0.044) significantly lower in ITG than in CTG at 3M. Body mass index (p = 0.052) tended to be lower in ITG than in CTG.

Conclusions

Dental intervention combined with lifestyle guidance may improve anthropometric status and reduce the risk of MetS.

Trial registration

University Hospital Medical Information Network Center Unique UMIN000022753. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000026176.

Impact of periodontal therapy on systemic markers of inflammation in patients with metabolic syndrome: A randomized clinical trial

AIM

To determine the impact of periodontal treatment on systemic markers of inflammation in patients with metabolic syndrome (MetS) and periodontitis.

MATERIALS AND METHODS

In this parallel-arm, double-blind, randomized controlled clinical trial, 63 patients with MetS and severe periodontitis were randomly assigned to receive either intensive periodontal treatment (IPT; scaling and root planing plus azithromycin 500 mg every day for 3 days) or minimal periodontal treatment (MPT; supragingival professional mechanical plaque removal plus a placebo). The primary outcome was the impact of the tested interventions on high-sensitivity C-reactive protein (hs-CRP) serum levels at 6 months. As secondary outcomes, differences in the levels of cytokines, markers of prothrombotic states, carbohydrate and lipid metabolism, as well as blood pressure, were measured at 3 and 6 months after therapy.

RESULTS

The intention-to-treat population consisted of 63 subjects randomly assigned to either the MPT (n = 31) or the IPT (n = 32) group. At baseline, mean hs-CRP was 3.9 mg/L (standard deviation [SD] = 2.9) and 3.9 mg/L (SD = 3.4), respectively, and no significant differences in cardiometabolic risk profiles were detected between the groups. Adjusting for baseline hs-CRP, sex, age, smoking status and body mass index, hs-CRP at 6 months was 1.2 mg/L (95% CI 0.4; 2.0; P = .004) lower in the IPT group than in the MPT group. In the secondary outcomes, significant reductions in IL-1β, TNF-α, HbA1c and blood pressure were observed in the IPT group at 3 months compared with the MPT group.

CONCLUSION

Effective periodontal treatment significantly reduced hs-CRP after 6 months in patients with MetS and severe periodontitis. Periodontal therapy might be useful to reduce cardiovascular risk in these patients.

Periodontitis is associated with hypertension: a systematic review and meta-analysis

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10-1.35] and severe PD (OR = 1.49; 95% CI: 1.09-2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88-6.11] and DBP (2.03 mmHg; 95% CI: 1.25-2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

Mechanical Debridement with Antibiotics in the Treatment of Chronic Periodontitis: Effect on Systemic Biomarkers-A Systematic Review

In this systematic review, we assessed the effectiveness of systemic antibiotics as an adjunctive therapy to mechanical debridement in improving inflammatory systemic biomarkers, as compared to mechanical debridement alone, among adults with chronic periodontitis. We searched relevant electronic databases for eligible randomized controlled trials. Two review authors independently screened, extracted data, and assessed risk of bias. We conducted meta-analysis, assessed heterogeneity, and assessed certainty of evidence using GRADEPro software. We included 19 studies (n = 1350 participants), representing 18 randomized controlled trials and found very little or no impact of antibiotics on inflammatory biomarkers. A meta-analysis of eight studies demonstrated a mean reduction of 0.26 mm in the periodontal pockets at three months (mean difference [MD] −0.26, 95%CI: −0.36 to −0.17, n = 372 participants, moderate certainty of evidence) in favor of the antibiotics. However, results from five studies reporting clinical attachment level (mm) yielded little or no difference at three months (MD −0.16, 95% CI: −0.35 to 0.03, n = 217 participants) between antibiotic and placebo groups. There is little or no evidence that adjunctive systemic antibiotics therapy improves inflammatory systemic biomarkers, compared to mechanical debridement alone, among adults with chronic periodontitis.

The association of periodontal diseases with metabolic syndrome and obesity

Periodontitis is a multifactorial chronic inflammatory disease associated with dysbiotic plaque biofilms and characterized by progressive destruction of the tooth-supporting apparatus. Globally, it is estimated that 740 million people are affected by its severe form. Periodontitis has been suggested to be linked to obesity and metabolic syndrome. Obesity, defined as excessive fat accumulation, is a complex multifactorial chronic inflammatory disease, with a high and increasing prevalence. Metabolic syndrome is defined as a cluster of obesity, dyslipidemia, hypertension, and dysglycemia. Obesity, metabolic syndrome and periodontitis are among the most common non-communicable diseases and a large body of evidence from epidemiologic studies supports the association between these conditions. Extensive research has established plausible mechanisms to explain how these conditions can negatively impact each other, pointing to a bidirectional adverse relationship. At present there is only limited evidence available from a few intervention studies. Nevertheless, the global burden of periodontitis combined with the obesity epidemic has important clinical and public health implications for the dental team. In accordance with the common risk factor approach for tackling non-communicable diseases, it has been proposed that oral healthcare professionals have an important role in the promotion of periodontal health and general well-being through facilitation of healthy lifestyle behaviours.

Periodontal diseases and association with atherosclerotic disease

Cardiovascular diseases still account for the majority of deaths worldwide, although significant improvements in survival, after being affected by cardiovascular disease, have been achieved in the last decades. Periodontal diseases are also a common global burden. Several studies have shown a link between cardiovascular disease and periodontitis, although evidence is still lacking regarding the direct cause-effect relation. During the 2012 "Periodontitis and systemic diseases" workshop, the available evidence on the association between cardiovascular and periodontal diseases was discussed, covering biologic plausibility and clinical studies. The objective of the present narrative review was to update the previous reviews presented at the 2012 workshop, following similar methodological approaches, aiming to critically assess the available evidence. With regard to biologic plausibility, two aspects were reviewed: (a) for microbiologic mechanisms, assessing periodontal bacteria as a contributing factor to atherosclerosis based on seven "proofs," substantial evidence was found for Proofs 1 through 6, but not for Proof 7 (periodontal bacteria obtained from human atheromas can cause atherosclerosis in animal models), concluding that periodontal pathogens can contribute to atherosclerosis; (b) mechanistic studies, addressing five different inflammatory pathways that could explain the links between periodontitis and cardiovascular disease with the addition of some extra pathways , suggest an association between both entities, based on the presence of higher levels of these inflammatory markers in patients with periodontitis and cardiovascular disease, vs healthy controls, as well as on the evidence that periodontal treatment reduces serum levels of these mediators. When evidence from clinical studies was analyzed, two aspects were covered: (a) epidemiologic studies support the estimation that the incidence of atherosclerotic disease is higher in individuals with periodontitis than in individuals with no reported periodontitis, irrespective of many common risk factors, but with a substantial variability in the definitions used in reporting of exposure to periodontal diseases in different studies; (b) intervention trials have shown that periodontal therapy can reduce serum inflammatory mediators, improve the lipids profile, and induce positive changes in other cardiovascular disease surrogate measures, but no evidence is available to support that adequate periodontal therapy is able to reduce the risk for cardiovascular diseases, or the incidence of cardiovascular disease events in periodontitis patients.

Cross-Sectional Analysis of the Association between Periodontitis and Cardiovascular Disease Using the Korean Genome and Epidemiology Study Data

This cross-sectional study aimed to evaluate the association between periodontitis and cardiovascular disease (CVD) by reviewing and discussing the role of the oral microbiome in periodontitis and CVD. This prospective cohort study used epidemiological data from the Korean Genome and Epidemiology Study from 2004 to 2016. We selected 9973 patients with periodontitis and 125,304 controls (non-periodontitis) from 173,209 participants and analyzed their medical histories to determine the relationship between cerebral stroke/ischemic heart disease and periodontitis. The participants were questioned about any previous history of hypertension, diabetes mellitus, hyperlipidemia, cerebral stroke (hemorrhagic or ischemic), ischemic heart disease (angina or myocardial infarction), and periodontitis. Their body mass index, smoking habit, alcohol intake, nutritional intake, and income were recorded. The Chi-square test, independent t-test, and two-tailed analyses were used for statistical analysis. The adjusted OR (aOR) of periodontitis for stroke was 1.35 (95% confidence interval (CI) = 1.16–1.57, p < 0.001). The aOR of periodontitis for ischemic heart disease was 1.34 (95% CI = 1.22–1.48, p < 0.001). We concluded that periodontitis was associated with CVD and may be a risk factor for CVD. However, further studies are required to determine the association between periodontal treatment and CVD.

Reporting quality and spin in abstracts of randomized clinical trials of periodontal therapy and cardiovascular disease outcomes

OBJECTIVE

Poor reporting in randomized clinical trial (RCT) abstracts reduces quality and misinforms readers. Spin, a biased presentation of findings, could frequently mislead clinicians to accept a clinical intervention despite non-significant primary outcome. Therefore, good reporting practices and absence of spin enhances research quality. We aim to assess the reporting quality and spin in abstracts of RCTs evaluating the effect of periodontal therapy on cardiovascular (CVD) outcomes.

METHODS

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and 17 trial registration platforms were searched. Cohort, non-randomized, non-English studies, and pediatric studies were excluded. RCT abstracts were reviewed by 2 authors using the CONSORT for abstracts and spin checklists for data extraction. Cohen's Kappa statistic was used to assess inter-rater agreement. Data on the selected RCT publication metrics were collected. Descriptive analysis was performed with non-parametric methods. Correlation analysis between quality, spin and bibliometric parameters was conducted.

RESULTS

24 RCTs were selected for CONSORT analysis and 14 fulfilled the criteria for spin analysis. Several important RCT elements per CONSORT were neglected in the abstract including description of the study population (100%), explicitly stated primary outcome (87%), methods of randomization and blinding (100%), trial registration (87%). No RCT examined true outcomes (CVD events). A significant fraction of the abstracts appeared with at least one form of spin in the results and conclusions (86%) and claimed some treatment benefit in spite of non-significant primary outcome (64%). High-quality reporting had a significant positive correlation with reporting of trial registration (p = 0.04) and funding (p = 0.009). Spinning showed marginal negative correlation with reporting quality (p = 0.059).

CONCLUSION

Poor adherence to the CONSORT guidelines and high levels of data spin were found in abstracts of RCTs exploring the effects of periodontal therapy on CVD outcomes. Our findings indicate that journal editors and reviewers should consider strict adherence to proper reporting guidelines to improve reporting quality and reduce waste.

Periodontitis and cardiovascular diseases: Consensus report

BACKGROUND

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

MATERIAL AND METHODS

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations RESULTS AND CONCLUSIONS: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Periodontitis and Cardiovascular Diseases. Consensus Report

Background

In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease.

Material and Methods

There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

Results and Conclusions

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis

BACKGROUND

There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the second update of a review originally published in 2014, and first updated in 2017. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system.

OBJECTIVES

To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, two trials registries, and the grey literature to September 2019. We placed no restrictions on the language or date of publication. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to August 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies).

DATA COLLECTION AND ANALYSIS

Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD.

AUTHORS' CONCLUSIONS

For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.

The sex paradox in the interplay between periodontitis, obesity, and serum C-reactive protein: Data from a general population

BACKGROUND

Women are generally periodontally healthier than men but they exhibit higher systemic levels of inflammatory markers. Our aim is to evaluate whether this paradox may be explained by different ramifications of adiposity or body shape.

METHODS

In 3,268 subjects from the Study of Health in Pomerania, we determined anthropometric and periodontal parameters, C-reactive protein (CRP), and fibrinogen as markers of inflammation. Behavioural and environmental risk factors and hand grip strength were assessed as factors interfering with the outcomes in question. We evaluated sex-specific associations of adiposity characteristics and periodontal variables such as probing depth (PD) with CRP and fibrinogen.

RESULTS

After adjusting for age, waist-to-hip ratio (WHR), glycated hemoglobin, smoking, education, and grip strength, the opposite sex role of periodontitis and obesity on CRP levels were confirmed. WHR and body mass index (BMI) were associated with CRP in both men and women (P < 0.001). CRP was associated with PD in men (P = 0.001) but not in women (P = 0.11). When adjusted for BMI this association was attenuated in men by 15% (P = 0.002) but in women by 70% (P = 0.58). PD was related to plaque and bleeding on probing (P < 0.001) in both sexes and also to WHR in women (P = 0.026) and men (P = 0.002). BMI attenuated this association in women but not in men. HbA1c contributed significantly to PD in women (P = 0.013) but not in men (P = 0.76).

CONCLUSIONS

Systemic CRP concentrations are affected by periodontitis and obesity in men. In women adiposity is more significant than in men overriding the impact of periodontal measures.