Tuesday, June 30, 2009

More periodontitis = heart disease risk evidence

Patients with moderate to severe periodontitis need evaluation for heart disease risk

Link to periodontitis strengthen evidence that inflammation contributes atherosclerotic CVD

Philadelphia, PA, 30 June 2009 – Additional research is called for and patients with moderate to severe periodontitis should receive evaluation and possible treatment to reduce their risk of atherosclerotic cardiovascular disease (CVD), according to a special consensus paper by editors of The American Journal of Cardiology and Journal of Peridontology in the July 1, 2009 issue of The American Journal of Cardiology (http://www.ajconline.org), published by Elsevier.

Periodontitis, a bacterially-induced, localized, chronic inflammatory disease, destroys connective tissue and bone that support the teeth. Periodontitis is common, with mild to moderate forms affecting 30 to 50% of adults and the severe generalized form affecting 5 to 15% of all adults in the USA. In addition, there is now strong evidence that people with periodontitis are at increased risk of atherosclerotic CVD — the accumulation of lipid products within the arterial vascular wall.

The explanation for the link between periodontitis and atherosclerotic CVD is not yet clear, but a leading candidate is inflammation caused by the immune system. In recent years the inflammation is now recognized as a significant active participant in many chronic diseases. Other explanations for periodontitis and atherosclerotic CVD are common risk factors such as smoking, diabetes mellitus, genetics, mental anxiety, depression, obesity, and physical inactivity.

Regardless of the cause, the expert panel believes that the current evidence is strong enough to recommend that doctors assess atherosclerotic CVD in their patients with periodontitis. The research recommends that patients with moderate to severe periodontitis should be informed that there may be an increased risk of atherosclerotic CVD associated with periodontitis, and those patients with one or more known major risk factor for atherosclerotic CVD should consider a medical evaluation if they have not done so in the past 12 months.

"This consensus paper is important because it will draw attention to the fact that patients with periodontitis, especially moderate and severe forms of the disease, can have increased risk for coronary disease," commented to David Dionne, Executive Publisher of The American Journal of Cardiology.

Orange Juice Bad For Teeth, Whitening Not So Much

OJ Worse for Teeth than Whitening, Says Eastman Institute for Oral Health Researchers

With the increasing popularity of whitening one’s teeth, researchers at the Eastman Institute for Oral Health, part of the University of Rochester Medical Center, set out to learn if there are negative effects on the tooth from using whitening products.

Eastman Institute’s YanFang Ren, DDS, PhD, and his team determined that the effects of 6 percent hydrogen peroxide, the common ingredient in professional and over-the-counter whitening products, are insignificant compared to acidic fruit juices. Orange juice markedly decreased hardness and increased roughness of tooth enamel.

Unlike ever before, researchers were able to see extensive surface detail thanks to a new focus-variation vertical scanning microscope. “The acid is so strong that the tooth is literally washed away,” said Ren, whose findings were recently published in Journal of Dentistry. “The orange juice decreased enamel hardness by 84 percent.” No significant change in hardness or surface enamel was found from whitening.

Weakened and eroded enamel may speed up the wear of the tooth and increase the risk for tooth decay to quickly develop and spread. “Most soft drinks, including sodas and fruit juices, are acidic in nature,” Ren said. “Our studies demonstrated that the orange juice, as an example, can potentially cause significant erosion of teeth.”

It’s long been known that juice and sodas have high acid content, and can negatively affect enamel hardness. “There are also some studies that showed whitening can affect the hardness of dental enamel, but until now, nobody had compared the two,” Ren explained. “This study allowed us to understand the effect of whitening on enamel relative to the effect of a daily dietary activity, such as drinking juices.

“It’s potentially a very serious problem for people who drink sodas and fruit juices daily,” said Ren, who added that dental researchers nationwide are increasingly studying tooth erosion, and are investing significant resources into possible preventions and treatments. “We do not yet have an effective tool to avert the erosive effects, although there are early indications that higher levels of fluoride may help slow down the erosion.”

A Texas-based company, Beyond Dental and Health, sponsored the trial in part by providing the 6 percent hydrogen peroxide.

In the meantime, Ren advises that consumers be aware of the acidic nature of beverages, including sodas, fruit juices, sports and energy drinks. The longer teeth are in contact with the acidic drinks, the more severe the erosion will be. People who sip their drinks slowly over 20 minutes are more likely to have tooth erosion than those who finish a drink quickly. It’s also very important to keep good oral hygiene practices, Ren added, by brushing twice daily with fluoride toothpaste, and see a dentist for a fluoride treatment at least once a year if you are at risk.

Periodontitis can lead to cerebrovascular disease

Link found between history of periodontitis and cerebrovascular disease in men

Research news from Annals of Neurology

The potential role of periodontitis, an inflammatory disease of the gums, in the risk of cardiovascular disease, particularly ischemic stroke, has received growing attention during the last decade. A new study is the first prospective cohort study to use clinical measures of periodontitis to evaluate the association between this disease and the risk of cerebrovascular disease. The study is published in Annals of Neurology, the official journal of the American Neurological Association

Led by Thomas Dietrich of the University of Birmingham School of Dentistry, and Elizabeth Krall of the Boston VA and the Boston University School of Dental Medicine, the study analyzed data from 1,137 men in the VA Normative Aging and Dental Longitudinal Study, an ongoing study begun in the 1960s with healthy male volunteers from the greater Boston area. A trained periodontist conducted dental exams every three years that included full mouth X-rays and periodontal probing at each tooth. Cerebrovascular disease was defined as a stroke or transient ischemic attack (TIA) and follow-up lasted an average of 24 years.

The results showed a significant association between periodontal bone loss and the incidence of stroke or TIA, independent of cardiovascular risk factors. This association was much stronger among men younger than 65 years old.

There are several possible pathways that could explain the association found in the study. There could be direct or indirect effects of the periodontal infection and the inflammatory response, or some people may have an increased pro-inflammatory susceptibility that could contribute to both cerebrovascular disease and periodontal disease.

The study found that only periodontal bone loss, which would indicate a history of periodontal disease, not probing depth, which would indicate current inflammation, was associated with the incidence of cerebrovascular disease. Also, the stronger association in younger men seen in this and other studies may indicate a pro-inflammatory susceptibility in some men that is reflected in periodontal destruction at a younger age.

The authors note that if periodontitis caused cerebrovascular disease, it could be an important risk factor, given its relatively high prevalence and the strength of the association in younger men. It is also possible that people with periodontitis may pay less attention to health in general (e.g., they may not take medications as regularly). The authors conclude: "Large epidemiologic studies using molecular and genetic approaches in various populations are necessary to determine the strength of the association between periodontitis and cerebrovascular disease and to elucidate its biologic basis."

Friday, June 26, 2009

Preventing Gum Disease Fights Memory Loss

Keeping your teeth brushed and flossed can cut down on gum disease, drastically reducing risk of heart attack and stroke, dentists have warned for years. Now researchers at West Virginia University have found a clean mouth may also help preserve memory.

The National Institutes of Health (NIH) has awarded a $1.3 million grant over four years to further build on studies linking gum disease and mild to moderate memory loss.

“Older people might want to know there’s more reason to keep their mouths clean – to brush and floss – than ever,” said Richard Crout, D.M.D., Ph.D., an expert on gum disease and associate dean for research in the WVU School of Dentistry. “You’ll not only be more likely to keep your teeth, but you’ll also reduce your risk of heart attack, stroke and memory loss.”

Crout will share the grant with gerontologist Bei Wu, Ph.D., formerly of WVU and now a researcher at the University of North Carolina; Brenda L. Plassman, Ph.D., of Duke University, a nationally recognized scientist in the field of memory research, and Jersey Liang, Ph.D., a professor at the University of Michigan. Wu is the principal investigator.

The team will look at health records over many years of several thousand Americans.

“This could have great implications for health of our aging populations,” Crout said. “With rates of Alzheimer’s skyrocketing, imagine the benefits of knowing that keeping the mouth free of infection could cut down on cases of dementia.”

The research builds on an ongoing study of West Virginians aged 70 and older. Working with the WVU School of Medicine, School of Dentistry researchers have given oral exams and memory tests to 270 elderly people in more than a dozen West Virginia counties.

Funded by a $419,000 two-year grant, they’ve discovered that about 23 percent of the group suffers from mild to moderate memory loss.

A blood draw is also part of the study for research subjects who agree.

“If you have a gum infection, you’ll have an increased level of inflammatory byproducts, Crout explained. “We’re looking for markers in the blood that show inflammation to see if there is a link to memory problems. We’d like to go full circle and do an intervention – to clean up some of the problems in the mouth and then see if the inflammatory markers go down.”

Researchers don’t yet understand whether microorganisms in the mouth create health problems or whether the body’s inflammatory response is to blame. It may be a combination of both.

Researchers also don’t know much about mild to moderate memory loss, even though the connection between severe dementia and gum disease is well known, Crout said.

In the future, dentists may routinely administer memory tests to their older patients, he said.

“A dentist may see a longtime, older patient with an area of the mouth that’s showing signs of inflammation because of not being properly cleaned daily,” Crout said. “Many times we as clinicians, however, don’t think of this as due to a memory problem. The patient may not be flossing or brushing properly as we have instructed they should. But this research indicates that the problem may be due to memory loss as opposed to noncompliance.”

Friday, June 12, 2009

56% with rheumatoid arthritis have periodontitis

Anti-TNF therapy can improve periodontal status after 6 months

Over half (56%) of people with rheumatoid arthritis (RA) also have periodontitis (a chronic inflammatory disease of the gum and surrounding ligaments and bones that hold the teeth in place), displaying fewer teeth than healthy matched controls, high prevalence of oral sites presenting dental plaque and advanced attachment loss (the extent of periodontal support that has been destroyed around a tooth) (chi square p<0.05), according to the results of a new study presented today at EULAR 2009, the Annual Congress of the European League Against Rheumatism in Copenhagen, Denmark. In addition, these patients were found to have significantly higher RA disease activity and anti-CCP (cyclic citrullinated peptide) antibody levels than others with RA who did not exhibit periodontitis (r=0.84, p<0.05; r=0.78, p<0.05).

The study also showed that, after six months of anti-TNF therapy (prescribed to control RA inflammation and destruction), a statistically significant improvement in periodontal status was seen in 20 (80%) of the 25 participants (mean age 41.5+3.7 years; mean disease duration 7.2+4.8 years), suggesting that the biological therapy may also be able to modulate the inflammatory process in the periodontium (the tissues investing and supporting the teeth, including the cementum, periodontal ligament, alveolar bone, and gingival / gums).

Dr Codrina Ancuta of the Grigore T Popa University of Medicine and Pharmacy, Rehabilitation Hospital, Iasi, Romania, who led the study, said: "There is a growing body of evidence to demonstrate an association between periodontal disease and systemic conditions involving inflammatory rheumatic disease (especially RA), cardiovascular disease and diabetes. However, further cross-disciplinary research among rheumatologists and periodontologists is required to fully understand the underlying mechanisms that link RA and periodontitis, and to explore how patients can be managed more holistically using treatments such as anti-TNFs and some lifestyle approached that may simultaneously address both conditions."

The prospective observational study compared 25 consecutive RA patients receiving anti-TNFs with 25 systemically healthy individuals matched for age, gender and periodontal status at baseline and six months, assessing both groups for periodontal status (visible plaque scores, marginal bleeding scores, attachment loss, number of present teeth), and the RA patient group in terms of RA parameters (erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), anti-CCP antibodies, disease activity and disability scores). Statistical analysis was conducted in SPSS-14 (a statistical analysis computer programme) p<0.05.

Moderate to Severe Periodontitis may be a Risk Factor for Developing RA in Non-Smokers

A second study presented at EULAR 2009 showed that, although smoking is an established risk factor for both RA and periodontitis, non-smoking individuals with moderate to severe periodontitis may also be at a greater risk for the development of RA. Those with RA who had moderate to severe periodontitis also developed significantly higher Anti-Citrullinated Peptide Antibody (ACPA) levels than those with no-mild periodontitis.

The retrospective study identified 45 RA patients based on their hospital discharge diagnostic codes from a cohort of 6,661 participants of the Atherosclerosis Risk in Communities (ARIC) study, from whom serum was obtained at the time of a detailed periodontal assessment during the period 1996-1998. RA participant sera were assessed for ACPA and rheumatoid factor (RF) positivity using ELISA (enzyme-linked immunosorbent assay). Participants were classified as having incident RA (n=33) if their first hospital discharge code occurred after periodontitis classification.

The hazard ratio (HR) of developing RA in subjects with moderate to severe periodontitis (n=27) was found to be 2.6 (95% CI=1.0-6.4, p=0.04), compared to those with no / mild periodontitis (n=6). Among lifetime non-smokers who developed RA, the Hazard Ratio was 8.8 (95% CI=1.1-68.9, p=0.04). Periodontitis severity was not shown to be independently associated with RA incidence among current and former smokers. ACPA levels were significantly higher in participants with moderate to severe periodontitis than in those with no / mild periodontitis (222.5 Units vs. 8.4 Units, p=0.04). These findings indicate that periodontitis may be a risk factor both for the development of RA, and for the development of more severe ACPA-positive disease.

Tuesday, June 2, 2009

Periodontology+Cardiology= joint recommendations

Recently published consensus paper encourages periodontists and cardiologists to join together to promote patient health

Cardiovascular disease (CVD), the leading killer in the United States, is a major public health issue contributing to 2,400 deaths each day. Periodontal disease, a chronic inflammatory disease that destroys the bone and tissues that support the teeth affects nearly 75 percent of Americans and is the major cause of adult tooth loss. While the prevalence rates of these disease states seem grim, research suggests that managing one disease may reduce the risk for the other.

A consensus paper on the relationship between heart disease and gum disease was recently developed by the American Academy of Periodontology (AAP) and The American Journal of Cardiology (AJC). The paper is published concurrently in the online versions of the AJC, a peer-reviewed journal circulated to 30,000 cardiologists, and the Journal of Periodontology (JOP), the official publication of the AAP. Developed in concert by cardiologists and periodontists, the paper includes clinical recommendations for both medical and dental professionals to use in managing patients living with, or who are at risk for, either disease. As a result of the paper, cardiologists may now examine a patient's mouth, and periodontists may begin asking questions about heart health and family history of heart disease.

Specific clinical recommendations include:

Patients with periodontitis who have 1 known major atherosclerotic CVD risk factor such as smoking, immediate family history for CVD, or history of dyslipidemia should consider a medical evaluation if they have not done so within the past 12 months.
A periodontal evaluation should be considered in patients with atherosclerotic CVD who have: signs or symptoms of gingival disease; significant tooth loss, and unexplained elevation of hs-CRP or other inflammatory biomarkers.
A periodontal evaluation of patients with atherosclerotic CVD should include a comprehensive examination of periodontal tissues, as assessed by visual signs of inflammation and bleeding on probing; loss of connective tissue attachment detected by periodontal probing measurements; and bone loss assessed radiographically. If patients have untreated or uncontrolled periodontitis, they should be treated with a focus on reducing and controlling the bacterial accumulations and eliminating inflammation.
When periodontitis is newly diagnosed in patients with atherosclerotic CVD, periodontists and physicians managing patients' CVD should closely collaborate in order to optimize CVD risk reduction and periodontal care.
The clinical recommendations were developed at a meeting held in early 2009 of top opinion-leaders in both cardiology and periodontology. The consensus paper also summarizes the scientific evidence that links periodontal disease and cardiovascular disease and explains the underlying biologic and inflammatory mechanisms that may be the basis for the connection.

According to Kenneth Kornman, DDS, PhD, Editor of the Journal of Periodontology and a co-author of the consensus report, the cooperation between the cardiology and periodontal communities is an important first step in helping patients reduce their risk of these associated diseases. "Inflammation is a major risk factor for heart disease, and periodontal disease may increase the inflammation level throughout the body. Since several studies have shown that patients with periodontal disease have an increased risk for cardiovascular disease, we felt it was important to develop clinical recommendations for our respective specialties. Therefore, you will now see cardiologists and periodontists joining forces to help our patients."

While additional research will help identify the precise relationship between periodontal disease and cardiovascular disease, recent emphasis has been placed on the role of inflammation - the body's reaction to fight off infection, guard against injury or shield against irritation. While inflammation initially intends to have a protective effect, untreated chronic inflammation can lead to dysfunction of the affected tissues, and therefore to more severe health complications.

"Both periodontal disease and cardiovascular disease are inflammatory diseases, and inflammation is the common mechanism that connects them," says Dr. David Cochran, DDS, PhD, President of the AAP and Chair of the Department of Periodontics at the University of Texas Health Science Center at San Antonio. "The clinical recommendations included in the consensus paper will help periodontists and cardiologists control the inflammatory burden in the body as a result of gum disease or heart disease, thereby helping to reduce further disease progression, and ultimately to improve our patients' overall health. That is our common goal."