Periodontitis and Renal Disease

Periodontitis, a chronic bacterial infection of the oral cavity, is a novel risk factor for atherosclerotic cardiovascular disease (CVD). Given the numerous shared risk factors for CVD and chronic kidney disease (CKD), we hypothesized that periodontitis also is associated with renal insufficiency in the Dental Atherosclerosis Risk in Communities study.
Methods: We conducted a cross-sectional study of 5,537 middle-aged black and white men and women. Periodontitis was determined by using an independent clinically derived definition and categorized as healthy/gingivitis,
initial, and severe. Renal insufficiency is defined as glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2.  Results: A total of 2,276 individuals had initial periodontitis, and 947 individuals had severe periodontal disease. One hundred ten individuals (2%) had a GFR less than 60 mL/min/1.73 m2. Compared with healthy/gingivitis, initial and
severe periodontal disease were associated with a GFR less than 60 mL/min/1.73 m2 (odds ratio, 2.00; 95% confidence interval, 1.23 to 3.24) forinitial periodontal disease and an odds ratio of 2.14 for severe disease
(95% confidence interval, 1.19 to 3.85) after adjustment for important risk factors for CVD and CKD. S
Conclusion: This is the first study to show an association of periodontal disease with prevalent renal insufficiency. A prospective study is necessary to determine the exact nature of the observed relationship.

April 2005 • Volume 45 • Number 4 Pathogenesis and Treatment of Kidney Disease and Hypertension Periodontal disease is associated with renal insufficiency in the Atherosclerosis Risk In Communities (ARIC) study Abhijit V. Kshirsagar, MD, MPH Kevin L. Moss John R. Elter, DMD, PhD James D. Beck, PhD Steve Offenbacher, DDS, PhD Ronald J. Falk, MD

* Division of Nephrology and Hypertension, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC* Division of Dental Ecology, School of Dentistry, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA * The Atherosclerosis Risk in Communities study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute
contracts no. N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022. In addition, this study is supported by National Institute for Dental and Craniofacial Research grant no. DE13019 and by the General Clinical Research Center grant no. RR00046. Dr. Kshirsagar’s efforts were supported by a grant from Renal Research Institute. * ⁎Address reprint requests to Abhijit V. Kshirsagar, MD, MPH, Division of Nephrology and Hypertension, CB 7155 348 MacNider Hall, Chapel
Hill, NC 27599-7155. * Email address: sagar@med.unc.edu (Abhijit V. Kshirsagar)

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Managing Risk Factors in Successful Nonsurgical Treatment of Perio 

Risk Factors Several important epidemiologic studies have recently identified important systemic risk factors for periodontitis. Three most important systemic risk factors are smoking, diabetes mellitus, and osteoporosis/osteopenia associated with estrogen deficiency. 

Smoking has been known to be a risk factor in other major diseases, especially cancer and heart disease. From a survey of the health of the US population itreported that smoking increased the relative risk of the population to periodontitis almost four times. He calculates that smoking may be responsible for more than half of the adult periodontitis cases in the United States. Among current smokers, 75% of their periodontitis was attributable to smoking. They suggest that a large portion of adult periodontitis may be preventable through prevention and cessation of cigarette smoking. Smokers have a higher number of periodontal disease sites, greater loss of alveolar bone, and increased tooth loss. The severity of the disease increases with both the extent and duration of the smoking exposure. Nicotine and other toxic substances in tobacco smoke lead to increased periodontal breakdown by altering the host's ability to neutralize infection by inducing deleterious effects on various neutrophil functions that are vital to maintenance of gingival and periodontal health. Smoking can exacerbate periodontal disease by altering the host's response to plaque, resulting in destruction of surrounding healthy periodontal tissue and possibly even causing direct local damage to tissue that appears cumulative. 

Smoking Cessation Cigarette smoking has long been known to be a significant risk factor for both coronary heart disease and periodontal disease. Smoking cessation can slow the progression of periodontal disease, alerting dental patients who smoke about the need to quit, and making them aware of resources that can help them quit, is an important part of periodontal treatment. The severity of the periodontal disease increases with both the extent and duration of the smoking exposure. Because of staining and adverse cosmetic effects from smoking. FREE QUITLINE (877-724-1090) or (1- 800-ACS-2345), An educational program on smoking cessation should be part of a nonsurgical periodontal treatment regime.  According to the American Cancer Society publication, "Information on Quitting Smoking," available from the ACS, nicotine substitutes can treat the very difficult withdrawal symptoms and craving that 70% to 90% of smokers say is their only reason for not giving up cigarettes. By using the patches, a smoker's withdrawal symptoms are reduced, allowing the smoker to deal with the psychological aspects of quitting. Lack of success is often related to the onset of withdrawal symptoms. By using the patch, these symptoms are reduced and smokers who want to quit have a better chance of success. 

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Diabetes Mellitus It has been reported for many years that diabetics have an increased susceptibility to periodontitis.   Bone formation has been shown to be suppressed, which can promote osteopenia in the alveolar bone, with loss of crestal bone height as well as in the rest of the skeletal system. However, it has also been found that the relationship between diabetes and periodontal disease is bidirectional. While diabetes has been known to create a more severe periodontal condition, periodontal disease can also exacerbate the diabetic condition. It has been demonstrated that diabetic patients with severe periodontal disease are more likely to have poor glycemic control than patients without periodontal disease. It appears that the periodontal disease renders the diabetic condition more difficult to control. 

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Osteoporosis/osteopenia has also long been suspected as a risk factor for periodontal disease. The osteoporotic/osteopenic women compared with women with normal bone mineral density exhibited a higher frequency of alveolar bone height loss and crestal and subcrestal density loss. Estrogen deficiency was associated with the increased frequency of alveolar bone crestal density loss. Osteopenia is reduced bone mass in the body, and represents an early stage of osteoporosis. Osteoporosis (porous bone) is a disease characterized by even greater loss of bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. 

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Heart Disease and Stroke  

Periodontal inflammation may also relate to increased risk of heart disease and stroke. Previous studies have demonstrated an association between periodontal disease severity and increased risk of coronary heart disease and stroke.  This association may be because of an underlying inflammatory response trait, which places an individual at high risk for developing both periodontal disease and atherosclerosis. He further suggests that periodontal disease produces endotoxins and cytokines which initiate and exacerbate parthenogenesis and thromboembolic events. Beck studied 1,147 men and found risk from periodontal disease for coronary heart disease, fatal coronary heart disease, and stroke to be as high as 2.8 times greater than for those without periodontal disease. One suspected mechanism involves periodontal bacteria gaining entry into the systemic circulation, with the bactermia causing changes in blood vessel walls that lead to atherosclerosis. Recently, in a study of 50 human specimens removed from carotid arteries, periodontal pathogens were present in all specimens, with 26% being Porphyromonas gingivalis. It was suspected that these microorganisms may play a role in the development and progression of atherosclerosis, leading to coronary vascular disease. Oral infection may exacerbated atherosclerotic plaque accumulation in the aorta. Cytokines are involved in the destruction of both periodontal tissue and alveolar bone and can stimulate increased production of an important "marker" of systemic inflammation, produced by the liner, called C-reactive protein (CRP). The mean level of CRP in the diseased patients was almost eight times higher, a highly significant difference. The disease group was treated with scaling and root planing, resulting in a 65% reduction in CRP in 3 months, remaining at a reduced rate at 6 months. He concluded that periodontal disease induces CRP, known to be a risk factor for cardiac disease, possibly by contributing to atheroma formation, and that periodontal infection is a significant risk factor for CVD, linked through bacteremia and inflammatory mediators.  

They studied the effect of a 6-month regimen of low-dosage doxycycline (Periostat, Collagenex), a nonantimicrobial formulation known to decrease cytokines and MMPs, on patients with the acute coronary syndromes, which include acute myocardial infarction and unstable angina. Using low-dosage doxycycline twice/day, identical to the dosage and usage in managing periodontal disease, they observed a 60% reduction in CRP levels.  Increased levels of this pro-inflammatory cytokine are often detected in the acute myocardial infarction (heart attack) patient. Elevated levels of IL 6 stimulate the liver to again synthesize CRP, which correlates with reduced stability of plaque in the blood vessels, possibly resulting in thrombosis. There was also a significant reduction in MMP 9 levels, which are also often increased in the acute condition. This proteolytic enzyme creates the breakdown of the collagen cap formed in the blood vessel over the atherosclerotic plaque. This "cap" provides the body's defense to prevent thrombosis. When the cap is broken down, the plaque can rupture and result in an embolus and stroke, or heart attack.

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According to the results, long-term antibiotic medication would prevent myocardial infarcts in patients that do not have periodontitis, or related signs of inflammation such as disease-causing bacteria or antibodies to those bacteria. Periodontitis appears to be such a significant chronic infection that the effect of antibiotic treatment in preventing cardiovascular events is lost in patients that suffer from
it. During one year of observation, patients with no signs of periodontitis were more likely to avoid new cardiovascular events. A total of 79% survived without a new cardiovascular event compared with
74% of patients without teeth and 66% of those with periodontitis.
The article Paju S, Pussinen PJ, Sinisalo J, Mattila K, Dogan B, Ahlberg J, Valtonen V, Nieminen MS, Asikainen S. Clarithromycin reduces
recurrent cardiovascular events in patients without periodontitis is published online before print in the journal Atherosclerosis on the 4th
of January http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T12-4HYN57P-1&_user=10&_handle=V-WA-A-W-WWY-MsSWYWW-UUW-U-AABEVAZWBZ-AABZEEDUBZ-CDYWBDAYB-WWY-U&_fmt=summary&_coverDate=01%2F04%2F2006&_rdoc=8&_orig=browse&_srch=%23toc%234878%239999%23999999999%2399999!&_cdi=4878&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=4fe8808ca115aea2ca1bcdd906008882
 

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 Oral Bone Loss in Post-Menopausal Females In a preliminary research study, Payne and Golub24 studied postmenopausal women with osteoporosis or osteopenia, presumed to be at greater risk of progressive alveolar bone loss associated with periodontitis. All of the postmenopausal patients underwent periodontal maintenance and half of them took Periostat, while the other group received placebo capsules over the 1-year time period. The group treated with the drug showed minimal loss of alveolar bone height (1.7%) and alveolar bone density (3.8%) versus the placebo group, in which the losses were almost four times greater. No sites in the treated group showed loss of attachment, and 2.4% of the sites showed a gain of greater than 2 mm, versus no sites in the placebo. The data indicated that Periostat can reduce the loss of alveolar bone height and density, and reduce attachment loss in the osteoporosis patients. A large scale clinical trial is underway now to further verify these results. A study by Grossi examined the effects of local debridement and systemic antibiotics on glycemic control in diabetic patients. The use of these antibiotics, along with periodontal therapy, was needed to significantly improve the metabolic controls. In patients with diabetes mellitus who were administered the sub-antimicrobial 20-mg dose (Periostat), there was evidence of improved long-term glycosemic control based on reduced values of glycosylated hemoglobin (HbA1).  Educating the diabetic patient to maintain a regular schedule of periodontal care for optimal periodontal health is a priority for these patients when discussing their treatment options with them. 

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Periodontal disease was associated with increased risk for preterm birth, and that as many as 18% of these births might be connected with periodontal disease. Clearly, pregnant women should be convinced by health professionals to maintain optimal periodontal condition throughout their pregnancies, through regular periodontal care, to prevent this serious risk. The Prevalence and Relationship between Periodontal Disease and Pre-term Low Birth Weight Infants at King KhalidUniversity Hospital in Riyadh, Saudi ArabiaSameer Abdullah Mokeem, BDS, MS, PhD; Ghadeer Nabeel Molla, BDS; Thikriat Saleh Al-Jewair, BDS J Contemporary Dental Practice 2004; 5(2): Spring 2004
 

 Results of Nonsurgical Treatment treatment of aggressive periodontal disease by a regimen of repeated mechanical debridement plus adjunctive systemic therapy with Periostat resulted in average reductions in pocket depth of 3 mm or more; 70% of the patients who completed the study were current or past smokers. 

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Tooth Loss

In the Journal of Periodontology, researchers found that tooth loss due to periodontal disease is associating with the risk indicators of age, male gender, smoking, lack of professional maintenance, inadequate oral hygiene, diabetes mellitus, hypertension, rheumatoid arthritis and anterior tooth type.

The most common medical history finding in all patients was diabetes mellitus at 19.2% followed by hypertension at 13.6%. More men lost their teeth than women, and current and past smokers accounted for almost 31%. For a copy of the study, call the American Academy of Periodontology