M. Petrini
Oct 26, 2020
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0
Influential Citations
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Journal
Journal of Dental Research
Abstract
What is the impact of periodontal disease on health, and could it have any effects on overall mortality? Periodontitis is a chronic inflammatory disease caused by a dysbiotic biofilm in genetically predisposed hosts; it is the sixth most frequent disease in the world, affecting the 10% of the population in its severe forms. The local effects of periodontitis are the destruction of supportive periodontal tooth tissues, which in the final sequelae cause mobility and then tooth loss, with a significant deterioration in quality of life. Oral pathogens can spread in the vascular system, stimulate the production of cytokines and cross-reactive antibodies, and promote the onset and persistence of systemic inflammation, atheroma formation, and dyslipidemia (Sanz et al. 2020). Patients with periodontitis have increased systemic levels of inflammatory biomarkers, like C-reactive proteins (CRP), and after periodontal therapy, in concomitance with the periodontal healing, a decrease of these parameters has been recorded (Graziani et al. 2010; Sanz et al. 2020). Periodontitis and cardiovascular diseases (CVDs) share not only genetic risk factors but also bacterial and inflammatory pathophysiology, and subjects with poor oral hygiene or those poor responders to periodontal treatment had a higher incidence of acute CVDs (Sanz et al. 2020). Systemically healthy patients with chronic periodontitis have a higher risk of developing diabetes, and those with both pathologies show a higher prevalence of related complications (Graziani et al. 2018). In obese patients, periodontitis is associated with altered hormone production, with consequent effects on pancreatic islet hormone secretion, mean blood glucose, appetite, body weight, and immune function (Solini et al. 2019). In 2016, periodontitis was linked to 57 systemic diseases, and its role in causing/increasing the severity of these conditions has been deeply investigated in the past years. It has been estimated that more than one-third of the clinical trials registered in periodontology in 2016 studied the association between periodontitis and systemic diseases (Monsarrat et al. 2016). Together, these pathologies represent the largest cause of death worldwide, but currently, the literature fails to demonstrate the impact of periodontitis on mortality. So, could periodontitis or its final sequela, edentulism, be an independent risk factor for mortality? Since 2007, Söder et al. has hypothesized that periodontitis in young adults increases the risk of premature death (Söder et al. 2007). Recently, many studies and surveys have investigated the correlation between periodontitis and mortality in patients affected by specific conditions, like type 2 diabetes, cancer, chronic kidney disease, and other conditions. However, they focused on defined populations, with specific conditions and a limited sample size. The review and meta-analysis published by Romandini et al. (2021) summarized the evidence of 57 studies, involving 5.71 million participants. A qualitative and quantitative analysis of data with the relative statistical analysis permitted the researchers to obtain strong and reliable evidence about the role of periodontitis and edentulism on increasing mortality. Epidemiological evidence based on 19 studies and 640,446 subjects showed that periodontitis was significantly associated with increased risk of all-cause mortality and deaths due to CVDs, cancer, coronary heart disease (CHD), and cerebrovascular diseases, but not pneumonia. The relative risk (RR) of periodontal patients for mortality was 2.58 for CHD and 3.11 for cerebrovascular disease with respect to a population with periodontal health (Romandini et al. 2021). These results were supported by also considering only high-quality studies: subjects with periodontitis had more than twice the risk of allcause and CVD mortality. Epidemiological evidence, biological plausibility, and interventional studies supported the impact of periodontitis with mortality (Romandini et al. 2021). Interestingly, this association seems not to be influenced by the severity of periodontitis but by age; in particular, this association was more evident in subjects younger than 65 y. However, when considering the effects of periodontitis on systemic health and diseases, we should be aware that data are based only on dentate patients, in which the periodontal ligament is still present. So, potentially, we are not considering all causes of severe periodontitis treated with the extraction of all teeth. In these patients, local inflammation is maintained and has a sustained systemic impact for many years, with consequences for health. It is necessary to point out that edentulism would have contributed to underestimating the impact of periodontitis on systemic health and mortality, especially in older subjects. Indeed, the New Classification of Periodontal Disease considers the parameter “tooth loss” when grading the severity of the disease (Papapanou et al. 2018). Unfortunately, for ethical reasons, current evidence on edentulism and mortality can rely only on cohort studies, which often do not specify the cause of tooth 970527 JDRXXX10.1177/0022034520970527Journal of Dental Research X(X)The Vital Importance of Gum Health research-article2020