Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia

Evidence is increasing that oral health has important impacts on systemic health. This paper presents data from the third National Health and Nutrition Examination Survey (NHANES III) describing the prevalence of dental caries and periodontal diseases in the older adult population. It then evaluates published reports and presents data from clinical and epidemiologic studies on relationships among oral health status, chronic oral infections (of which caries and periodontitis predominate), and certain systemic diseases, specifically focusing on type 2 diabetes and aspiration pneumonia. Both of these diseases increase in occurrence and impact in older age groups. The NHANES III data demonstrate that dental caries and periodontal diseases occur with substantial frequency and represent a burden of unmet treatment need in older adults. Our review found clinical and epidemiologic evidence to support considering periodontal infection a risk factor for poor glycemic control in type 2 diabetes; however, there is limited representation of older adults in reports of this relationship. For aspiration pneumonia, several lines of evidence support oral health status as an important etiologic factor. Additional clinical studies designed specifically to evaluate the effects of treating periodontal infection on glycemic control and improving oral health status in reducing the risk of aspiration pneumonia are warranted. Although further establishing causal relationships among a set of increasingly more frequently demonstrated associations is indicated, there is evidence to support recommending oral care regimens in protocols for managing type 2 diabetes and preventing aspiration pneumonia.     

Periodontal disease and cancer: Epidemiologic studies and possible mechanisms

Epidemiologic and cancer control studies on the association of periodontal disease and cancer risk mostly suggest a positive association with overall cancer risk and certain specific types of cancer. These findings are generally consistent among cross-sectional and longitudinal studies. In this paper, we review epidemiologic studies and current knowledge on periodontal disease and cancer, with a focus on those studies conducted in the years following the Joint European Federation of Periodontology/American Academy of Periodontology Workshop on “Periodontitis and Systemic Diseases” in November 2012. This review also explores the role of chronic inflammation as a biologically plausible mechanistic link between periodontal disease and risk of cancer. Furthermore, it highlights studies that have examined the potential importance of certain periodontal pathogens in this association.     

A review of the influence of periodontal treatment in systemic diseases

The effects and consequences of periodontal diseases might not be confined to the oral cavity. A great body of evidence has arisen supporting the claim demonstrating an association with several systemic conditions and diseases. With different levels of evidence, an association between periodontal disease and cardiovascular disease, diabetes, psoriasis, rheumatoid arthritis, pregnancy outcomes and respiratory diseases has been established. However, the true nature of this association, if it is causal, still remains elusive. For a better understanding of the complex relationships linking different conditions, interventional studies now begin to focus on the possible outcomes of periodontal treatment in relation to the events, symptoms and biomarkers of several systemic disorders, assessing if periodontal treatment has any impact on them, hopefully reducing their severity or prevalence. Therefore, we proceeded to review the recent literature on the subject, attempting to present a brief explanation of the systemic condition or disease, what proposed mechanisms might give biological plausibility to its association with periodontal disease, and finally and more importantly, what data are currently available pertaining to the effects periodontal treatment may have. Raising awareness and discussing the possible benefits of periodontal treatment on overall systemic health is important, in order to change the perception that periodontal diseases are only limited to the oral cavity, and ultimately providing better and comprehensive care to patients.     

Hypertension and periodontitis: A joint report by the Italian society of hypertension (SIIA) and the Italian society of periodontology and implantology (SIdP)

An accumulating body of evidence supports an independent association between high blood pressure (BP) and periodontitis, possibly mediated by low-grade inflammation. This joint report by the Italian Society of Hypertension (SIIA) and the Italian Society of Periodontology and Implantology (SIdP) working group on Hypertension and Periodontitis (Hy-Per Group) provides a review of the evidence on this topic encompassing epidemiology, biological plausibility, relevance, magnitude, and treatment management. Consensus recommendations are provided for health professionals on how to manage BP in individuals showing signs of poor oral health. In summary, (1) large epidemiological studies highlight that individuals with periodontal diseases have increased risk for high/uncontrolled BP independent of confounders; (2) mechanistically, low-grade inflammation might have a causal role in the association; (3) BP profile and control might benefit from periodontal treatment in pre-hypertensive and hypertensive individuals; (4) oral health status should be evaluated as a potential risk factor for high/uncontrolled BP, and effective oral care should be included as an adjunct lifestyle measure during hypertension management. Further research is needed to optimize BP management in individuals with poor oral health.     

Periodontal disease and systemic conditions: a bidirectional relationship

For decades, physicians and dentists have paid close attention to their own respective fields, specializing in medicine pertaining to the body and the oral cavity, respectively. However, recent findings have strongly suggested that oral health may be indicative of systemic health. Currently, this gap between allopathic medicine and dental medicine is quickly closing, due to significant findings supporting the association between periodontal disease and systemic conditions such as cardiovascular disease, type 2 diabetes mellitus, adverse pregnancy outcomes, and osteoporosis. Significant effort has brought numerous advances in revealing the etiological and pathological links between this chronic inflammatory dental disease and these other conditions. Therefore, there is reason to hope that the strong evidence from these studies may guide researchers towards greatly improved treatment of periodontal infection that would also ameliorate these systemic illnesses. Hence, researchers must continue not only to uncover more information about the correlations between periodontal and systemic diseases but also to focus on positive associations that may result from treating periodontal disease as a means of ameliorating systemic diseases.     

Coronary heart disease and periodontitis -- a case control study in Chilean adults

OBJECTIVES: To investigate the association between periodontal disease parameters and coronary ischemic disease among 30-50-year-old Chileans. MATERIAL AND METHODS: Cases were 30-50-year-olds who were hospitalized in one of four Cardiologic Units in Santiago, Chile, for acute myocardial infarction, unstable angina or angina pectoris. Controls had undergone surgery due to gall bladder stones or abdominal hernia. Information on blood pressure, serum cholesterol, body weight and height, age, occupation, smoking, diabetes and use of antidepressants was obtained. A total of 86 persons participated based on informed consent, but the analysis is based on 61 persons, for whom a complete set of data was obtained. Cases and controls were given a clinical periodontal examination comprising assessment of number of teeth present, periodontal pocket depth and clinical attachment level at six sites per tooth. The association between mean attachment level; mean pocket probing depth; number of teeth present and case status was analyzed by conditional logistic regression controlling for known risk factors for CHD. RESULTS: The mean attachment level was positively associated with case status (OR = 3.17; 95% CI = [1.31; 7.65]), as was the mean pocket depth (OR = 8.64; 95% CI = [1.22; 61.20]). The number of teeth present was not statistically significantly associated with case status (OR = 0.93; 95% CI = [0.83; 1.04]). CONCLUSION: The results are in accordance with those of several previous reports. If the results reflect a causal link between periodontal diseases and CHD they emphasize the need for better control of periodontal diseases. If the associations are-non-causal, they still demonstrate that CHD and periodontal diseases cluster in the same sections of the population, which is important from a public health point of view.     

Chronic oral infection: An emerging risk factor of cerebral small vessel disease

Chronic oral infections (gingivitis/periodontitis) have been associated with age‐related diseases such as diabetes, coronary heart disease, and acute ischemic stroke. In addition, imaging surrogates of cerebrovascular ischemia beyond acute ischemic stroke (i.e., silent strokes and brain white matter hyperintensities) may also be associated with chronic oral infections. The pathology underlying lacunar strokes and brain white matter hyperintensities (WMH) relates to small vessel disease in the brain. In this review, we highlight recent progress in exploring potential associations of oral infections with cerebral small vessel disease and its surrogates (silent strokes, white matter hyperintensities) and clinical sequelae (i.e., vascular dementia). Recent evidence suggests that periodontitis aggravates cerebral small vessel disease and increases lacunar stroke risk. Moreover, periodontitis interacts with Alzheimer's disease to increase the severity of clinical dementia and to accelerate its manifestations. The results suggest that periodontitis may be an emerging risk factor of small vessel disease‐associated cerebrovascular disorders and that the risk increase may be mediated by the systemic inflammation resulting from chronic oral infections. Large cohort studies employing state‐of‐the‐art magnetic resonance techniques to identify specific cerebral pathologies as a function of time, oral health status, and systemic inflammation are needed to further substantiate the hypothesis.     

Periodontal health, oral health behaviours, and chronic obstructive pulmonary disease

Aim: To evaluate the associations of periodontal health status and oral health behaviours with chronic obstructive pulmonary disease (COPD).
Materials and Methods: We conducted a case–control study of 306 COPD patients and 328 controls with normal pulmonary function. Their periodontal status and respiratory function were clinically examined and information on oral health behaviours was obtained using a validated questionnaire.
Results: Patients with COPD had fewer teeth and a higher plaque index than the controls. Univariate analysis showed that tooth brushing times and method, experience of dental floss use, dental visit and regular supra-gingival scaling, and oral health knowledge were significantly related to the risk of COPD. After adjusting for age, sex, and body mass index and stratifying by smoking status, inappropriate tooth brushing method ( p =0.025 among non-smokers), lower regular supra-gingival scaling ( p =0.027 among non-smokers and p <0.0001 among former smokers), and poorer oral health knowledge ( p <0.0001 among non-smokers and p =0.019 among former smokers and p =0.044 among current smokers) remained significantly associated with COPD.
Conclusions: Poor periodontal health, dental care, and oral health knowledge were significantly associated with an increased risk of COPD. Our findings indicate the importance of promoting dental care and oral health knowledge that can be integrated into the prevention and treatment of COPD.     

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.     

Periodontal manifestations of inflammatory bowel disease: emerging epidemiologic and biologic evidence

Inflammatory bowel disease and periodontitis are both described as a disproportionate mucosal inflammatory response to a microbial environment in susceptible patients. Moreover, these two conditions share major environmental and lifestyle‐related risk factors. Despite this intriguing pathogenic parallel, large‐scale studies and basic research have only recently considered periodontal outcomes as relevant data. There are mounting and consistent arguments, from recent epidemiologic studies and animal models, that these two conditions might be related. This article is a comprehensive and critical up‐to‐date review of the current evidence and future prospects in understanding the biologic and epidemiologic relationships between periodontal status and inflammatory bowel disease.     

Significance of epidemiologic research in the understanding of periodontal disease

This review describes the development of periodonlal index systems which during the last 50 yr have made it possible to gradually expand our understanding of the etiology and pathogenesis of periodontal diseases. Modern epidemiologic research on the prevalence and severity of periodontal diseases is based on a substantial amount of scientific data collected since the early 1940's. The work of a number of innovative researchers has eventually resulted in the clarification of one unsolved problem after the other. At the same time new ideas have been developed for the inclusion of public health aspects in the epidemiologic analyses. The assessment of periodontal treatment needs has become an issue of great importance in many countries of the world and has initiated a discussion and studies on the role of the possibilities for self-assessment of treatment needs. A completely new area of interest has developed when recent epidemiologic surveys demonstrated a substantial increase in the numbers of elderly people together with a substantial increase in the number of teeth per elderly person     

Osteoporosis,jawbones and periodontal disease

The association between osteoporosis and jawbones remains an argument of debate. Both osteoporosis and periodontal diseases are bone resorptive diseases; it has been hypothesized that osteoporosis could be a risk factor for the progression of periodontal disease and vice versa. Hypothetical models linking the two conditions exist: in particular, it is supposed that the osteoporosis-related bone mass density reduction may accelerate alveolar bone resorption caused by periodontitis, resulting in a facilitated periodontal bacteria invasion. Invading bacteria, in turn, may alter the normal homeostasis of bone tissue, increasing osteoclastic activity and reducing local and systemic bone density by both direct effects (release of toxins) and/or indirect mechanisms (release of inflammatory mediators). Current evidence provides conflicting results due to potential biases related to study design, samples size and endpoints. The aim of this article is to review and summarize the published literature on the associations between osteoporosis and different oral conditions such as bone loss in the jaws, periodontal diseases, and tooth loss. Further well-controlled studies are needed to better elucidate the inter-relationship between systemic and oral bone loss and to clarify whether dentists could usefully provide early warning for osteoporosis risk. Key words:Osteoporosis, periodontitis, oral bone loss, tooth loss, edentulism, bone mineral density.     

Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

This review evaluates evidence for a bidirectional relationship between diabetes and periodontal diseases. A comprehensive Medline search of the post-1960 English language literature was employed to identify primary research reports of relationships between diabetes and periodontal diseases. Reports included in the review on the adverse effects of diabetes on periodontal health (DM-->PD) were restricted to those comparing periodontal health in subjects with and without diabetes. Review of adverse affects of periodontal infection on glycemic control included reports of periodontal treatment studies and follow-up observational studies in which changes in glycemic control could be assessed. Observational studies reporting DM-->PD provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal diseases in the large majority of reports (supportive evidence in 44/48 total reviewed; 37/41 cross-sectional and 7/7 cohort). Additionally, there were no studies reviewed with superior design features to refute this association. Treatment studies provided direct evidence to support periodontal infection having an adverse, yet modifiable, effect on glycemic control. However, not all investigations reported an improvement in glycemic control after periodontal treatment. Additional evidence to support the effect of severe periodontitis on increased risk for poorer glycemic control comes from 2 follow-up observational studies. The evidence reviewed supports viewing the relationship between diabetes and periodontal diseases as bidirectional. Further rigorous, systematic study is warranted to establish that treating periodontal infections can be influential in contributing to glycemic control management and possibly to the reduction of the burden of complications of diabetes mellitus.     

Insulin resistance and periodontal disease: an epidemiologic overview of research needs and future directions

Poor periodontal health is known to be associated with Type 2 diabetes mellitus (DM). This relationship and underlying mechanisms are discussed elsewhere in this issue. Less is known concerning the link between the metabolic precursors to DM, including insulin resistance (IR), and its possible association with periodontitis. Indeed, there has been relatively little research to date in human populations concerning periodontal disease, IR, and the subsequent risk of chronic diseases, including DM. This paper will present an epidemiologist's view of how IR may link periodontal disease with DM and suggest several avenues of investigation to help clarify some of the outstanding issues.     

Potential associations between chronic respiratory disease and periodontal disease: analysis of National Health and Nutrition Examination Survey III

BACKGROUND: Associations between poor oral health and chronic lung disease have recently been reported. The present study evaluated these potential associations by analyzing data from the National Health and Nutrition Examination Survey III (NHANES III), which documents the general health and nutritional status of randomly selected United States subjects from 1988 to 1994. METHODS: This cross-sectional, retrospective study of the NHANES III database included a study population of 13,792 subjects > or = 20 years of age with at least 6 natural teeth. A history of bronchitis and/or emphysema was recorded from the medical questionnaire, and a dichotomized variable combined those with either chronic bronchitis and/or emphysema, together considered as chronic obstructive pulmonary disease (COPD). Subject lung function was estimated by calculating the ratio of forced expiratory volume (FEV) after 1 second (FEV1)/forced vital capacity (FVC). Oral health status was assessed from the DMFS/T index (summary of cumulative caries experience), gingival bleeding, gingival recession, gingival probing depth, and periodontal attachment level. Unweighted analyses were used for initial examination of the data, and a weighted analysis was performed in a final logistic regression model adjusting for age, gender, race and ethnicity, education, income, frequency of dental visits, diabetes mellitus, smoking, and alcohol use. RESULTS: The mean age of all subjects was 44.4 +/- 17.8 years (mean +/- SD): COPD = 51.2 +/- 17.9 years and subjects without COPD = 43.9 +/- 17.7 years. Subjects with a history of COPD had more periodontal attachment loss than subjects without COPD (1.48 +/- 1.35 mm versus 1.17 +/- 1.09 mm, P = 0.0001). Subjects with mean attachment loss (MAL) > or = 3.0 mm had a higher risk of COPD than those having MAL < 3.0 mm (odds ratio, 1.45; 95% CI, 1.02 to 2.05). A trend was noted in that lung function appeared to diminish with increasing periodontal attachment loss. CONCLUSIONS: The findings of the present analysis support recently published reports that suggest an association between periodontal disease and COPD.     

Tobacco Use as a Risk Factor

Tobacco, particularly tobacco smoking , has a substantial influence on periodontal health and disease. It is associated with an increased disease rate in terms of periodontal bone loss, periodontal attachment loss, as well as periodontal pocket formation. In addition, it exerts a masking effect on gingival symptoms of inflammation. Risk assessment based on an increasing body of investigations over the past few years suggests that the tobacco attributable risk is considerable, estimated odds ratios being of the order 2.5 to 6.0 or even greater. Although the mechanisms by which tobacco exerts its influence are obscure, information available to date does not support the view that its action simply relates to other environmental factors such as the dental plaque or some specific microflora. It seems more likely that it primarily has a systemic influence affecting host response or susceptibility. The chief novelty of the present report is that current data suggest that, although the overall disease prevalence is decreasing, the proportion of periodontal disease attributed to tobacco is stable or even increasing. This seems to be analogous to what has been observed for other smoking-associated chronic diseases. This, in turn, indicates that periodontal disease behaves like several other chronic diseases and, further, that tobacco should be considered a major risk factor for chronic periodontal disease. J Petiodontol 1994;65:545–550.     

Further evidence for periodontal disease as a risk indicator for adverse pregnancy outcomes

Background: Although there is increasing evidence to suggest an association between periodontal disease and adverse pregnancy outcomes, the issue remains controversial. Study objective: This study tested the hypothesis that periodontal disease is a risk indicator for preterm delivery of low-birthweight infants. Materials and methods: The study sample comprised 443 pregnant women with a mean (± standard deviation) age of 24.13 (±5.30) years. At first visit, maternal oral health status was assessed by the measurement of probing pocket depth and clinical attachment loss, and periodontal status was graded as absent, mild, moderate or severe. An association was sought between pregnancy outcomes and maternal periodontal status. Results: While controlling for other factors, significant associations were found between pregnancy outcomes and maternal periodontal index scores. Conclusion: This study provides further evidence that periodontal disease is a risk indicator for adverse pregnancy outcomes.Key words: Periodontal disease, low birthweight, preterm birth     

Association between periodontitis and chronic kidney disease: Systematic review and meta‐analysis

A systematic review and meta‐analysis were conducted to evaluate the association between periodontitis (PD) and chronic kidney disease (CKD) and to explore the potential influence of periodontal treatment in patients with CKD. Databases (PubMed, Web of Science, Science direct, Cochrane Database) were screened for relevant articles, focusing on the periodontal status of patients with CKD, published until December 2017. Five hundred and fifty‐three articles were identified, and 37 fulfilled the inclusion criteria and were considered in this systematic review. Seventeen articles were included in the meta‐analysis and 7 in the review focusing on the impact of periodontal treatment. Most of the identified studies indicated an increased incidence of PD in patients with CKD. Meta‐analysis showed an association between CKD and PD, and strength of this association was increased when severe PD was considered (OR = 2.39 (1.70–3.36)). The association could be observed even after adjustment for major CKD risk factors or use of precise diagnosis criteria (OR = 2.26 for severe PD (1.69–3.01)). Analysis of cohort studies indicated an incident rate ratio (IRR) of 1.73. Periodontitis is associated with CKD after multivariable adjustment. Further studies are necessary to determine whether prevention or treatment of PD can reduce the incidence and/or severity of CKD.     

Clinical and public health implications of periodontal and systemic diseases: An overview

Severe periodontitis is defined by extensive loss of the tooth attachment apparatus. It is the sixth most common human disease and is estimated to affect 11.2% of the global adult population, hence representing a significant healthcare, social, and economic burden. Since the 1990s, multiple epidemiologic, experimental, and interventional studies have evidenced how periodontitis may also impact systemic health and it has been independently associated with the majority of chronic noncommunicable diseases. The evidence supporting these associations, mainly focusing on diabetes, pregnancy complications, and cardiovascular disease, was thoroughly reviewed in 2012 by an international consensus workshop. In the last 5 years, however, important advances have been made, not only in our understanding of the etiopathogenesis of periodontitis, or concerning the mounting evidence regarding the independent associations between periodontitis, diabetes, and cardiovascular disease, but also with many other systemic diseases including metabolic disease and obesity, rheumatoid arthritis, certain cancers, respiratory diseases, and cognitive disorders including Alzheimer's disease. This review describes these scientific advances by gathering together the existing evidence on the importance and relevance of the associations between periodontitis and many systemic diseases.