Lower risk for cardiovascular mortality for patients with root filled teeth in a Finnish population.

AIM: To investigate the relationship of radiographic evidence of root filled teeth to cardiovascular outcomes. METHODOLOGY: Baseline data for 506 subjects including 256 angiographically verified heart disease patients and 250 matched cardiologically healthy controls participating in the Kuopio Oral Health and Heart study were collected in 1995-1996. Cardiovascular disease (CVD) mortalities were accrued until 31 May 2015 and appended to the baseline data. Mortality status data were obtained from the Finnish National Death Register where all mortality cases and the causes of death are compiled for all Finnish citizens. Of the 506 participants, 473 subjects who had no missing values in the predictor, outcome or confounding factors were included in the analyses to assess the relationship of radiographic evidence of root filled teeth with prevalent coronary artery disease (CAD) cross sectionally and also with CVD mortality longitudinally. Multivariable logistic regression was used for the cross-sectional part and proportional hazard regression analyses for the longitudinal part of the study were used adjusting for age, sex, smoking, edentulism, diabetes, hypertension, total/HDL cholesterol ratio and income. Additionally, whether this association was independent of periodontitis, and a systemic marker of inflammation, serum C-reactive protein (CRP) was examined. RESULTS: Having ≥1 root filled teeth was associated with 84% lower odds of prevalent CAD with Odds Ratio (OR) = 0.16, 95% confidence interval (CI) 0.09-0.28, P < 0.0001. The OR for edentulism was 1.32 (CI: 0.73-2.38), P = 0.36, suggesting a nonsignificant increase in risk. Prospectively, having at least one root filled teeth was associated with a 49% lower risk of CVD mortality (hazard ratio [HR] = 0.51, CI = 0.27-0.97, P = 0.04) whilst edentulism was associated with nonsignificantly increased risk for CVD mortality: HR = 1.25 (CI: 0.65-2.42), P = 0.36. Adjustment for periodontitis or serum CRP levels changed the OR or HR slightly but the associations remained significant. CONCLUSIONS: Having ≥1 root filled teeth was associated with significantly lower odds for prevalent CAD cross sectionally and lower risk of cardiovascular mortality prospectively. These reduced associations with CVD were independent of periodontitis or serum CRP levels.

Oral Infections, Metabolic Inflammation, Genetics, and Cardiometabolic Diseases.

Although several epidemiologic studies reported plausible and potentially causal associations between oral infections and cardiometabolic diseases (CMDs), controversy still lingers. This might be due to unrecognized confounding from metabolic inflammation and genetics, both of which alter the immune responses of the host. Low-grade inflammation termed metainflammation is the hallmark of obesity, insulin resistance, type 2 diabetes, and CMDs. According to the common soil theory, the continuum of obesity to CMDs is the same pathology at different time points, and early metainflammations, such as hyperglycemia and obesity, display many adverse cardiometabolic characteristics. Consequently, adipose tissue is now considered a dynamic endocrine organ that expresses many proinflammatory cytokines such as TNF-α, IL-6, plasminogen activator inhibitor 1, and IL-1ß. In metainflammation, IL-1ß and reactive oxygen species are generated, and IL-1ß is a pivotal molecule in the pathogenesis of CMDs. Note that the same cytokines expressed in metainflammation are also reported in oral infections. In metabolic inflammation and oral infections, the innate immune system is activated through pattern recognition receptors-which include transmembrane receptors such as toll-like receptors (TLRs), cytosolic receptors such as nucleotide-binding oligomerization domain-like receptors, and multiprotein complexes called inflammasome. In general, TLR-2s are presumed to recognize lipoteichoic acid of Gram-positive microbes-and TLR-4s, lipopolysaccharide of Gram-negative microbes-while nucleotide-binding oligomerization domain-like receptors detect both Gram-positive and Gram-negative peptidoglycans on the bacterial cell walls. However, a high-fat diet activates TLR-2s, and obesity activates TLR-4s and induces spontaneous increases in serum lipopolysaccharide levels (metabolic endotoxemia). Moreover, genetics controls lipid-related transcriptome and the differentiation of monocyte and macrophages. Additionally, genetics influences CMDs, and this creates a confounding relationship among oral infections, metainflammation, and genetics. Therefore, future studies must elucidate whether oral infections can increase the risk of CMDs independent of the aforementioned confounding factors.

Impact of rheumatic diseases on oral health and quality of life.

OBJECTIVE: We investigated the effects of rheumatic diseases on oral symptoms, health habits, and quality of life in subjects with and without rheumatic diseases. The hypothesis was that patients with rheumatic diseases have more oral symptoms impairing their quality of life than healthy controls. METHODS: A questionnaire was mailed to a random sample of 1500 members of the Finnish Rheumatism Association, including those with and without rheumatic diseases. We focused on symptoms of the mouth and temporomandibular area, and health habits. Oral Health Impact Profile (OHIP14) was used to evaluate the oral health-related quality of life. We analyzed differences between subjects with and without rheumatic diseases, controlled for age, gender, smoking, and non-rheumatic chronic diseases. RESULTS: Completed questionnaires were received from 995 participants (response rate 66%). Of them, 564 reported rheumatic disease, 431 were used as controls. The patients reported significantly more all orofacial symptoms than controls. Severe dry mouth was reported by 19.6% of patients and 2.9% of controls (P < 0.001), and temporomandibular joint symptoms by 59.2% and 27.2% (P < 0.001), respectively. In the OHIP-14 questionnaire, the mean total score was significantly higher in patients (8.80 ± 11.15) than in controls (3.93 ± 6.60; P < 0.001). CONCLUSION: The study hypothesis was confirmed by showing that the patients with rheumatic diseases reported oral discomfort and reduced quality of life more often when compared with controls.

Inhibitory activity in vitro of probiotic lactobacilli against oral Candida under different fermentation conditions.

Clinical studies have shown that probiotics positively affect oral health by decreasing gum bleeding and/or reducing salivary counts of certain oral pathogens. Our aim was to investigate the inhibitory effect of six probiotic lactobacilli against opportunistic oral Candida species. Sugar utilisation by both lactobacilli and Candida was also assessed. Agar overlay assay was utilised to study growth inhibition of Candida albicans, Candida glabrata and Candida krusei by Lactobacillus rhamnosus GG, Lactobacillus casei Shirota, Lactobacillus reuteri SD2112, Lactobacillus brevis CD2, Lactobacillus bulgaricus LB86 and L. bulgaricus LB Lact. The inhibitory effect was measured at pH 5.5, 6.4, and 7.2, respectively, and in the presence of five different carbohydrates in growth medium (glucose, fructose, lactose, sucrose, and sorbitol). Growth and final pH values were measured at two-hour time points to 24 h. L. rhamnosus GG showed the strongest inhibitory activity in fructose and glucose medium against C. albicans, followed by L. casei Shirota, L. reuteri SD2112 and L. brevis CD2. None of the lactobacilli tested affected the growth of C. krusei. Only L. rhamnosus GG produced slight inhibitory effect on C. glabrata. The lower pH values led to larger inhibition zones. Sugar fermentation profiles varied between the strains. L. casei Shirota grew in the presence of all sugars tested, whereas L. brevis CD2 could utilise only glucose and fructose. All Candida species metabolised the available sugars but the most rapid growth was observed with C. glabrata. The results suggest that commercially available probiotics differ in their inhibitory activity and carbohydrate utilisation; the above properties are modified by different pH values and sugars with more pronounced inhibition at lower pH.

Ca(OH)2 application modes: in vitro alkalinity and clinical effect on bacteria.

AIM: To compare five calcium hydroxide (CH) products, CH-gutta-percha Plus points(®) (CHGP) and conventional CH paste, for their ability to maintain alkalinity and to assess the clinical antimicrobial effect of CHGP. METHODOLOGY: Calcium hydroxide products were tested in the presence of standardized dentine powder or by titrating them with 1 mol HCl, expressed in mL (±SD). In a clinical trial, 21 single-rooted teeth with primary apical periodontitis were medicated with CHGP or with conventional CH paste. Bacterial samples were taken before and after chemo-mechanical preparation, after dressing and after leaving canals empty but sealed. To compare groups, anova with Tukey's test was used in the laboratory study and Fisher's exact test in the clinical study. Significance level was set at 5%. RESULTS: Pure CH with water (8.5 ± 0.1) and Calasept (9.3 ± 0.1) maintained the highest alkalinity, followed by the gel-like products DS CaOH gel (7.3 ± 0.3) and Ultracal XS (6.8 ± 0.2) and then Biokalkki (6.3 ± 0.3) and Calxyl blue (5.1 ± 0.2). All CH paste products had higher values compared with CHGP (1.6 ± 0.1) (P < 0.05). Saturated solutions of the products were all neutralized to pH 8.6 within 24 h by dentine powder addition. Clinically, culture-negative results were obtained in 5/10 canals in the CHGP group and 7/11 with conventional CH (P > 0.05). CONCLUSIONS: Aqueous CH mixtures kept high pH better than viscous gel products or CHGP. Dentine powder had equal buffering effect on each product tested. CHGP and traditional CH paste both had an antimicrobial effect in the clinical setting, but there was no significant difference between the groups.

Removable dental prostheses and cardiovascular survival: a 15-year follow-up study.

OBJECTIVES: In previous studies, increasing number of teeth predicted better survival and the acute needs for dental treatment predicted mortality. We sought to investigate whether restored dentitions by various removable dental prostheses impact cardiovascular (CVD) longevity. METHODS: Kuopio Oral Health and Heart study was initiated as a cross-sectional investigation with 256 subjects with diagnosed coronary artery disease [CAD] and 250 age- and sex-matched controls without CAD in 1995-1996. The mean age of both groups was 61, 30% were females. We appended mortality follow-up records to the baseline data and formulated this 15-year follow-up study. We examined the relationship between various types of dental prostheses and cardiovascular mortality by proportional hazard regression analyses. We also explored their correlation to oral and systemic inflammatory markers such as asymptotic dental score and C-reactive protein. RESULTS: In a model adjusted for age, sex and smoking, groups having only natural teeth (NT), removable partial denture(s) [PD] and NT, a PD and a full denture [FD], and FD/FD or FD/NT demonstrated the following hazard ratios for mortality (95% confidence interval). NT both arches: 1.00 [reference]; PD and NT: 0.75 [0.22-2.56]; PD and FD: 1.99 [1.05-3.81]; and FD opposed by FD or NT: 1.71 [0.93-3.13], respectively [p for trend=0.05]. Although statistically not significant, those with PD and NT with mean a number of teeth [Nteeth] of 15.4 had better survival compared with those who had all NT [Nteeth=22.5]; while those who had FD and PD [Nteeth=6.5] had shorter longevity than those with FD/FD or FD/NT [Nteeth=3.5]. CONCLUSIONS: Although not all subgroups of dental prostheses reached significant relationship with CVD mortality, our study suggests that not only the number [quantity] of remaining teeth but their maintenance [quality] removing potential inflammatory foci, such as pericoronitis or retained root tips, may positively impact on cardiovascular survival.

Treponema denticola associates with increased levels of MMP-8 and MMP-9 in gingival crevicular fluid.

OBJECTIVES: The aim was to assess the association between the presence of site-specific subgingival micro-organisms and the levels of matrix metalloproteinases-8 and matrix metalloproteinases-9 (MMP-8 and MMP-9) in gingival crevicular fluid (GCF). MATERIALS AND METHODS: The patient group consisted of 56 subjects with periodontitis and the control group of 43 subjects without periodontitis. GCF samples from four test sites for each subject were collected. Polymerase chain reaction was used to detect the presence of Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, and Treponema denticola. MMP-8 concentrations were analyzed by a time-resolved immunofluorometric assay, and MMP-9 levels were determined by enzyme-linked immunosorbent assay. Student's unpaired t-test, chi-square test, and Fisher's exact P-value were calculated. RESULTS: The presence of T. denticola in the test sites was significantly higher in the patient group than in the control group. The presence of T. forsythia and T. denticola was associated with increased levels of MMP-8 in the test sites. Respectively, site-specific presence of T. denticola was associated with an increase in MMP-9 levels in three of the four test sites. CONCLUSIONS: The presence of subgingival micro-organisms in GCF, particularly T. denticola, appeared to induce a host response with an increased release of MMP-8 and MMP-9 in the test sites.

Increased infection risk postliver transplant without pretransplant dental treatment.

OBJECTIVE: Infections cause considerable morbidity after liver transplantation (LT). Acute liver failure is a rapidly progressing life-threatening condition where pretransplant dental evaluation is not always possible. We investigated how missing pretransplant dental treatment in acute or subacute liver failure correlates with post-transplant infectious complications. SUBJECTS AND METHODS: Medical and dental data came from hospital records and infection data from the Finnish LT registry. The follow-up was until February 2011. Of 51 patients (LT during 2000-2006), 16 had and 35 did not have dental treatment pretransplant. RESULTS: Univariate Cox regression analysis demonstrated a 2.46-fold (95% CI 1.06-5.69) infection risk among the patients omitted from dental treatment. After adjustment for either pretransplant factors alone or both pre- and post-transplant factors, the corresponding infection risk increased, respectively, to 8.17-fold (95% CI 2.19-30.6) and 8.54-fold (95% CI 1.82-40.1). This increased risk involved a variety of bacterial, viral, and fungal infections of various sources both < 6 and > 6 months after transplantation. CONCLUSION: High risk of infections was noticed in acute liver failure patients without pretransplant dental treatment, but a more severe medical condition might have influenced the results. We encourage eradication of dental infection foci whenever clinical condition allows.

Dietary sugar utilisation by putative oral probiotics.

Probiotic consumption and repeated probiotic intake have shown promising results as adjunct therapies in prevention and alleviation of some chronic disease conditions in the gastrointestinal tract. Recent evidence suggests that probiotics may also be beneficial in preventing oral diseases. An efficient probiotic candidate in the mouth, however, should not impose any risk to oral tissues, such as acid demineralisation of tooth enamel because of sugar fermentation. The aim of the present in vitro study was to evaluate the utilisation of some sugars and sugar alcohols by yogurt starter Lactobacillus delbrueckii subsp. bulgaricus strains and to assess the influence of these carbohydrate sources on cell surface properties. For comparsion, a commercially available probiotic, Lactobacillus rhamnosus GG, was used. The results showed that lactose, glucose and fructose were readily metabolised by all strains tested. However, strain-specific metabolic patterns were observed when other sugars and sugar alcohols were used as sole carbohydrate source in the growth medium. Surface properties of the bacteria such as hydrophobicity and surface-associated proteins appeared to vary with the carbohydrate content of the growth medium. Based on these results it can be concluded that among the L. delbrueckii subsp. bulgaricus strains probiotic candidate strains are available that warrant further studies due to their inability to ferment sugars with pronounced cariogenic properties.

Approaches to caries prevention and therapy in the elderly.

The population of the world is aging. A greater proportion of older people are retaining increasing numbers of natural teeth. Aging is associated with changes in oral architecture and muscle weakness, making personal oral hygiene more difficult, particularly for the oldest and most frail individuals. Furthermore, there is exposure of root dentin with its higher pH for demineralization in addition to enamel as a substrate for caries. Aging is also associated, for many in the developed world, with taking multiple medications, with the associated risk of dry mouth. These variables combine to increase caries risk in older vulnerable populations. Caries occurs on both the crowns of teeth (predominantly around existing restorations) and the exposed roots. Prevention needs to be aggressive to control disease in this combination of circumstances, with multiple strategies for limiting the damage associated with caries in this population. This paper explores the evidence that is available supporting preventive strategies, including fluorides in various forms, chlorhexidine, and calcium phosphate supplementation.

Are sugar-free confections really beneficial for dental health?

BACKGROUND: Various sugar substitutes have been introduced and are widely used in confections and beverages to avoid tooth decay from sugar and other fermentable carbohydrates. One group of sugar substitutes are sugar alcohols or polyols. They have been specifically used in foods for diabetic patients because polyols are not readily absorbed in the intestine and blood stream, preventing post-prandial elevation of glucose level. Additionally they may lower caloric intake. METHODS: We searched PubMed, Cochrane Controlled Trials Registry, Cochrane Oral Health Review, Centre for Reviews and Dissemination in the UK, National Library for Public Health and a Centre for Evidence Based Dentistry website up to the end of October 2010, using the search terms 'sugar alcohol' or 'sugar-free' or 'polyols' and combined with a search with terms 'dental caries' or 'dental erosion'. RESULTS: Xylitol, a polyol, has been approved by the US Food and Drug Administration for its non-cariogenic properties that actually reduce the risk of dental decay and recently, the European Union also officially approved a health claim about xylitol as a 'tooth friendly' component in chewing gums. Although the presence of acidic flavourings and preservatives in sugar-free products has received less attention, these additives may have adverse dental health effects, such as dental erosion. Furthermore, the term sugar-free may generate false security because people may automatically believe that sugar-free products are safe on teeth. CONCLUSION: We concluded that polyol-based sugar-free products may decrease dental caries incidence but they may bring another dental health risk, dental erosion, if they contain acidic flavouring. There is a need for properly conducted clinical studies in this area.

Are oral and dental diseases linked to cancer?

OBJECTIVE: Infection and inflammation play a role in carcinogenesis, and highly prevalent oral and dental diseases have been significantly linked to some types of cancer. This article reviews current literature in this area. MATERIALS AND METHODS: Open literature review using the PubMed database and focused on publications from 2000 to 2010. RESULTS: Numerous potential mechanisms are implicated in the oral disease/carcinogenesis paradigm, including infection- and inflammation-associated cell pathology and microbial carcinogen metabolism. Poor oral hygiene is associated with oral cancer, but there is also evidence of a possible link between oral or dental infections and malignancies in general. CONCLUSION: Oral infections may trigger malignant transformation in tissues of the mouth and other organs. However, scientific evidence to date remains weak and further well-conducted studies are warranted before cancer can be properly added to the list of oral infection-related systemic diseases.

Antifungal susceptibility and virulence attributes of bloodstream isolates of Candida from Hong Kong and Finland.

Candida bloodstream infection has dramatically increased in the last decade due to the growing number of immunocompromised populations worldwide. In this study, we evaluated the antifungal susceptibility profiles and virulence attributes of Candida bloodstream isolates (CBIs) derived from Hong Kong and Finland, information which are vital for devising empirical clinical strategies. Susceptibility testing of a wide range of antifungals including fluconazole, itraconazole, voriconazole, ketoconazole, 5-fluorocytosine, amphotericin B and caspofungin was performed. Haemolytic activity and secretion of proteinase of CBIs were also examined. All CBIs derived from Hong Kong were susceptible to all the antifungals tested whilst some CBIs from Finland were resistant to azoles and caspofungin. C. albicans, C. glabrata and C. tropicalis showed higher haemolytic activity whereas C. parapsilosis and C. guilliermondii were non-haemolytic in general. Proteinase activity of the Finland C. albicans isolates was significantly higher than the Hong Kong isolates. Our data provide a glimpse of the possible evolutionary changes in pathogenic potential of Candida that may be occurring in different regions of the world. Therefore, continuous surveillance and availability of local data should be taken into consideration when treating candidemia patients.

Prevotella nigrescens and Porphyromonas gingivalis are associated with signs of carotid atherosclerosis in subjects with and without periodontitis.

BACKGROUND AND OBJECTIVE: Oral microorganisms may be involved in the development of cardiovascular diseases, and Porphyromonas gingivalis is one of the periodontal microorganisms that has been found in carotid atheroma. The aim of this work was to study subgingival microorganisms and early carotid lesions in subjects with and without periodontitis. MATERIAL AND METHODS: Eighty-eight subjects with periodontitis and 40 subjects without periodontitis underwent dental examinations in 2003. The presence of the periodontal microorganisms Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Prevotella nigrescens and Tannerella forsythia was analyzed from subgingival plaque using PCR amplification. The common carotid artery was scanned using ultrasound and the calculated intima-media area (cIMA) was measured. The association between periodontitis, the cIMA value and the presence of periodontal microorganisms, together with several confounders, was studied in a multiple logistic regression model. RESULTS: Smoking [odds ratio (OR) = 5.64; p = 0.001), level of education (OR = 5.02; p < 0.05) and the presence of P. gingivalis (OR = 6.50; p < 0.05) were associated with periodontitis. Explanatory factors for the increased cIMA were periodontitis (OR = 4.22; p < 0.05), hypertension (OR = 4.81; p < 0.05), high body mass index (OR = 5.78; p < 0.01), male gender (OR = 3.30; p < 0.05) and poor socioeconomic status (OR = 4.34; p < 0.05). P. nigrescens (OR 4.08; p < 0.05) and P. gingivalis (OR 7.63; p < 0.01) also appeared as explanatory variables associated with increased cIMA values. CONCLUSION: This cross-sectional study showed that P. nigrescens and P. gingivalis were significantly associated with increased cIMA values.