Atherosclerosis is central to the pathology of cardiovascular diseases, a group of diseases in which arteries become occluded with atheromas that may rupture, leading to different cardiovascular ...events, such as myocardial infarction or ischemic stroke. There is a large body of epidemiologic and animal model evidence associating periodontitis with atherosclerotic disease, and many potential mechanisms linking these diseases have been elucidated. This chapter will update knowledge on these mechanisms, which generally fall into 2 categories: microbial invasion and infection of atheromas; and inflammatory and immunologic. With respect to the invasion and infection of atheromas, it is well established that organisms from the subgingival biofilm can enter the circulation and lodge in most distant tissues. Bacteremias resulting from oral interventions, and even oral hygiene activities, are well documented. More recently, indirect routes of entry of oral organisms (via phagocytes or dendritic cells) have been described for many oral organisms, into many tissues. Such organisms include the periodontal pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Tannerella forsythia, and Fusobacterium nucleatum. Intracellular survival of these organisms with dissemination to distant sites (The Trojan Horse approach) has been described. Their relative contribution to atheroma formation and progression has been studied mainly in experimental research, with results demonstrating that these organisms can invade endothelial cells and phagocytic cells within the atheroma, leading to pathogenic changes and progression of the atheroma lesion. The second category of mechanisms potentially linking periodontitis to atherosclerosis includes the dumping of inflammatory mediators originating from periodontal lesions into the systemic circulation. These inflammatory mediators, such as C‐reactive protein, matrix metalloproteinases, fibrinogen, and other hemostatic factors, would further accelerate atheroma formation and progression, mainly through oxidative stress and inflammatory dysfunction. Moreover, direct effects on lipid oxidation have also been described. In summary, the evidence supports the concept that periodontitis enhances the levels of systemic mediators of inflammation that are risk factors for atherosclerotic diseases.
Currently, two principal forms of destructive periodontal disease are recognized – chronic periodontitis and aggressive periodontitis – but their distinction in epidemiologic studies has been rather ...problematic because of substantial overlap of their primary features. This review critically appraises some key features relevant to the epidemiology of human periodontitis that underlie its core ‘identity’ as a bacterial biofilm‐induced, inflammatory disease and discusses its impact within the larger context of aging populations. The currently adopted epidemiologic methodologies/definitions that result in the almost ubiquitous prevalence of periodontitis indeed overestimate the occurrence of the disease that may actually put individuals at a true biologic, functional or psychosocial disadvantage. Use of these definitions has inevitably promoted the inference that periodontitis constitutes an insurmountable oral health problem. In contrast, reliance solely on physical measurements of probing depth and/or attachment loss under‐recognizes the true impact that periodontitis may have on the well‐being of individuals. It is currently unclear whether inclusion of the psychosocial and systemic dimensions of the disease in case definitions would result in higher or lower prevalence estimates. The review concludes that periodontitis should no longer be defined solely by gingival/periodontal inflammation in the presence of increased probing depths and attachment loss but should incorporate additional dimensions capturing impaired function, esthetics, and impact on general health and quality of life. A multidimensional approach to the assessment of periodontitis would facilitate an improved understanding of its epidemiology and consequences.
Diabetes mellitus (a group of metabolic disorders characterized by hyperglycemia) and periodontitis (a microbially induced inflammatory disorder that affects the supporting structures of teeth) are ...both common, chronic conditions. Multiple studies have demonstrated that diabetes mellitus (type 1 and type 2) is an established risk factor for periodontitis. Findings from mechanistic studies indicate that diabetes mellitus leads to a hyperinflammatory response to the periodontal microbiota and also impairs resolution of inflammation and repair, which leads to accelerated periodontal destruction. The cell surface receptor for advanced glycation end products and its ligands are expressed in the periodontium of individuals with diabetes mellitus and seem to mediate these processes. The association between the two diseases is bidirectional, as periodontitis has been reported to adversely affect glycemic control in patients with diabetes mellitus and to contribute to the development of diabetic complications. In addition, meta-analyses conclude that periodontal therapy in individuals with diabetes mellitus can result in a modest improvement of glycemic control. The effect of periodontal infections on diabetes mellitus is potentially explained by the resulting increase in levels of systemic proinflammatory mediators, which exacerbates insulin resistance. As our understanding of the relationship between diabetes mellitus and periodontitis deepens, increased patient awareness of the link between diabetes mellitus and oral health and collaboration among medical and dental professionals for the management of affected individuals become increasingly important.
Objectives
We assessed peri‐implantitis prevalence, incidence rate, and associated risk factors by analyzing electronic oral health records (EHRs) in an educational institution.
Methods
We used a ...validated reference cohort comprising all patients receiving dental implants over a 3.5‐year period (2,127 patients and 6,129 implants). Electronic oral health records of a random 10% subset were examined for an additional follow‐up of ≥2.5 years to assess the presence of radiographic bone loss, defined as >2 mm longitudinal increase in the distance between the implant shoulder and the supporting peri‐implant bone level (PBL) between time of placement and follow‐up. “Intact” implants had no or ≤2 mm PBL increase from baseline. Electronic oral health record notes were reviewed to corroborate a definitive peri‐implantitis diagnosis at implants with progressive bone loss. A nested case–control analysis of peri‐implantitis‐affected implants randomly matched by age with “intact” implants from peri‐implantitis‐free individuals identified putative risk factors.
Results
The prevalence of peri‐implantitis over an average follow‐up of 2 years was 34% on the patient level and 21% on the implant level. Corresponding incidence rates were 0.16 and 0.10 per patient‐year and implant‐year, respectively. Multiple conditional logistic regression identified ill‐fitting fixed prosthesis (OR = 5.9; 95% CI: 1.6–21.1), cement‐retained prosthesis (OR = 4.5; 2.1–9.5), and radiographic evidence of periodontitis (OR = 3.6; 1.7–7.6) as statistically associated with peri‐implantitis. Implant location in the mandible (OR = 0.02; 0.003–0.2) and use of antibiotics in conjunction with implant surgery (OR = 0.19; 0.05–0.7) emerged as protective exposures.
Conclusions
Approximately 1/3 of the patients and 1/5 of all implants experienced peri‐implantitis. Ill‐fitting/ill‐designed fixed and cement‐retained restorations, and history of periodontitis emerged as the principal risk factors for peri‐implantitis.
Studies conducted over the past 25 years have focussed on the role of periodontitis, an inflammatory condition of microbial aetiology that destroys the tooth‐supporting tissues, as a systemic ...inflammatory stressor that can act as an independent risk factor of atherosclerotic vascular disease (AVSD) and adverse pregnancy outcomes (APOs). It has been suggested that periodontitis‐associated bacteraemias and systemic dissemination of inflammatory mediators produced in the periodontal tissues may result in systemic inflammation and endothelial dysfunction, and that bacteria of oral origin may translocate into the feto‐placental unit. Epidemiological studies largely support an association between periodontitis and ASVD/APOs, independently of known confounders; indeed, periodontitis has been shown to confer statistically significantly elevated risk for clinical events associated with ASVD and APOs in multivariable adjustments. On the other hand, intervention studies demonstrate that although periodontal therapy reduces systemic inflammation and improves endothelial function, it has no positive effect on the incidence of APOs. Studies of the effects of periodontal interventions on ASVD‐related clinical events are lacking. This review summarises key findings from mechanistic, association and intervention studies and attempts to reconcile the seemingly contradictory evidence that originates from different lines of investigation.
Background and objectives
There is still debate regarding potential relationships between maternal periodontitis during pregnancy and adverse pregnancy outcomes. The aim of this systematic review was ...to synthesize the available epidemiological evidence on this association.
Data sources
Combined electronic and hand search of MEDLINE, EMBASE, WEB OF SCIENCE and Cochrane Central Register databases.
Study eligibility criteria
Original publications reporting data from cross‐sectional, case‐control or prospective cohort epidemiological studies on the association between periodontal status and preterm birth, low birthweight (LBW) or pre‐eclampsia. The search was not limited to publications in English. All selected studies provided data based on professional assessments of periodontal status, and outcome variables, including preterm birth (<37 weeks gestation), LBW (<2500 g), gestational age, small for gestational age, birthweight, pregnancy loss or miscarriage, or pre‐eclampsia.
Participants
Pregnant women with or without periodontal disease, and with or without adverse pregnancy outcomes, assessed either during pregnancy or postpartum. No intervention studies were included. Study appraisal and synthesis methods – Publications were assessed based on predefined screening criteria including type of periodontal assessment, consistency in the timing of the periodontal assessment with respect to gestational age, examiner masking and consideration of additional exposures and confounders.
Results
Maternal periodontitis is modestly but significantly associated with LBW and preterm birth, but the use of a categorical or a continuous exposure definition of periodontitis appears to impact the findings: Although significant associations emerge from case‐control and cross‐sectional studies using periodontitis “case definitions,” these were substantially attenuated in studies assessing periodontitis as a continuous variable. Data from prospective studies followed a similar pattern, but associations were generally weaker. Maternal periodontitis was significantly associated with pre‐eclampsia.
Limitations
There is a high degree of variability in study populations, recruitment and assessment, as well as differences in how data are recorded and handled. As a result, studies included in meta‐analyses show a high degree of heterogeneity.
Conclusions and implications of key findings
Maternal periodontitis is modestly but independently associated with adverse pregnancy outcomes, but the findings are impacted by periodontitis case definitions. It is suggested that future studies employ both continuous and categorical assessments of periodontal status. Further use of the composite outcome preterm LBW is not encouraged.
A classification scheme for periodontal and peri‐implant diseases and conditions is necessary for clinicians to properly diagnose and treat patients as well as for scientists to investigate etiology, ...pathogenesis, natural history, and treatment of the diseases and conditions. This paper summarizes the proceedings of the World Workshop on the Classification of Periodontal and Peri‐implant Diseases and Conditions. The workshop was co‐sponsored by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) and included expert participants from all over the world. Planning for the conference, which was held in Chicago on November 9 to 11, 2017, began in early 2015.
An organizing committee from the AAP and EFP commissioned 19 review papers and four consensus reports covering relevant areas in periodontology and implant dentistry. The authors were charged with updating the 1999 classification of periodontal diseases and conditions and developing a similar scheme for peri‐implant diseases and conditions. Reviewers and workgroups were also asked to establish pertinent case definitions and to provide diagnostic criteria to aid clinicians in the use of the new classification. All findings and recommendations of the workshop were agreed to by consensus.
This introductory paper presents an overview for the new classification of periodontal and peri‐implant diseases and conditions, along with a condensed scheme for each of four workgroup sections, but readers are directed to the pertinent consensus reports and review papers for a thorough discussion of the rationale, criteria, and interpretation of the proposed classification. Changes to the 1999 classification are highlighted and discussed. Although the intent of the workshop was to base classification on the strongest available scientific evidence, lower level evidence and expert opinion were inevitably used whenever sufficient research data were unavailable.
The scope of this workshop was to align and update the classification scheme to the current understanding of periodontal and peri‐implant diseases and conditions. This introductory overview presents the schematic tables for the new classification of periodontal and peri‐implant diseases and conditions and briefly highlights changes made to the 1999 classification. It cannot present the wealth of information included in the reviews, case definition papers, and consensus reports that has guided the development of the new classification, and reference to the consensus and case definition papers is necessary to provide a thorough understanding of its use for either case management or scientific investigation. Therefore, it is strongly recommended that the reader use this overview as an introduction to these subjects. Accessing this publication online will allow the reader to use the links in this overview and the tables to view the source papers (Table ).
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