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Periodontal disease and respiratory disease: A systematic review of the evidence
Abstract
ABSTRACT
Objective: The purpose of this systematic review (SR) was
to answer the focused research question: Is there an association
between periodontal disease and pneumonia or chronic
obstructive pulmonary disease (COPD)? Method: Databases
and keywords searched included: Medline, PubMed, and the
Cochrane Database of Systematic Reviews on combinations
of lung disease, obstructive pneumonia, and periodontal
disease. The literature searches were limited to 1997 to 2011;
humans; and in English. Inclusion criteria were RCTs/clinical
trials, SRs/meta analysis, and longitudinal, cohort, case control,
multicenter and epidemiological studies for links between
COPD or pneumonia and periodontal disease. Results and
Discussion: 114 articles from databases, and 22 from hand
searching were scrutinized for predetermined inclusion and
exclusion criteria. Of these, 17 and 4 (n=21) respectively
met the criteria, were analyzed and scored independently
by each reviewer to extract evidence: 1) seven well designed
studies and 3 systematic reviews provided fair evidence of an
association between periodontal disease and pneumonia; 2)
two small scale studies, at lower levels of quality of evidence,
indicated conflicting results; 3) five well designed longitudinal
or matched case control studies provided fair evidence of an
association between periodontal disease and COPD; 4) four
large scale, retrospective studies also supported this association.
Conclusion: A causal association between respiratory diseases
(pneumonia or COPD) and periodontal diseases remains
conjectural. The conclusions reached based on this SR indicate
there is fair evidence—Grade B, Level II-2—supporting: 1) an
association of pneumonia and periodontal disease concurring
with previous reviews; 2) an association between COPD and
periodontal disease.
... A meta-analysis conducted by Zeng et al. [14] on periodontal disease and risk of COPD concluded that periodontal disease is a significant and independent risk factor of COPD. The systematic review conducted by Agado and Bowen [15] on periodontal disease and respiratory disease depicted a fair evidence (Grade B, Level II-2) to support an association between COPD and periodontal disease. ...
Background:
The relationship between oral health and systemic conditions has been increasingly debated over recent decades with one such discussion existing about oral hygiene and periodontitis with chronic obstructive pulmonary disease (COPD). Hence, a study was conducted to assess and compare the oral hygiene status and periodontal status of age and gender-matched participants with and without COPD and to correlate oral hygiene status and periodontal status with lung function status among them.
Materials and methods:
This hospital-based study included a study population of 117 participants (39 patients of COPD and 78 participants without COPD) 35-75 years of age with at least 20 natural teeth. Participant's demographic details and history of smoking were recorded. Lung function was recorded using a spirometer. Periodontal health was assessed by measuring Probing Pocket Depth (PPD), Clinical Attachment Loss (CAL), and Oral Hygiene Index (OHI) by a trained and calibrated examiner.
Results:
Higher mean of PPD, CAL, and OHI is being reported in the present study with 4.07 versus 3.50, 0.58 versus 0.24, and 5.24 versus 3.60, respectively, among patients with and without COPD which was statistically significant. The risk of having COPD was 0.4 times more in participants having poor oral hygiene and 0.07 times more in patients smoking. Smoking and oral hygiene, as independent variables, have a significant influence on COPD which is a dependent variable. A weak correlation was found of poor oral hygiene and loss of attachment among participants with COPD.
Conclusion:
Periodontitis and respiratory disease share a common risk factor, i.e., smoking. Smoking has a definite relation with periodontitis and COPD. Oral hygiene is significantly associated with increased risk for COPD when age and gender effects have been matched and when adjusted for smoking. However, no association was found of PPD with COPD.
... Examples of these issues are impacts on people's eating and swallowing abilities, diet type and speech. 1 Association between poor oral health and adverse medical outcomes such as aspiration pneumonia and cardiovascular disease have also been suggested. [2][3][4][5] Despite the recognition of oral hygiene as an important part of nursing care, 6,7 dependent frail elderly in hospitals and long-term care facilities are at risk of having poor oral health. [8][9][10] Reasons include limited access to dentists/ oral hygienists and variability in oral care knowledge and practice among nurses and care staff. ...
Aim
To explore the contribution of hospital pharmacists in the collaborative development and implementation of standardised oral care treatment and referral guidelines, and its subsequent impact on the overall quality of oral health practice for older sub‐acute patients.
Method
Assessments were conducted of oral health pre‐ and post‐introduction of a multifaceted intervention process, involving the development of guidelines and procedures for oral health assessment and referral by dental, medical, nursing, pharmacy and speech pathology staff. Participants’ oral health was assessed using the Oral Health Assessment Tool (OHAT) in the pre‐ and post‐intervention phases at baseline and 10–14 days thereafter.
Results
Participants (n = 73, mean age 81 years, 66% female) in the pre‐intervention group reported no significant change in total OHAT scores and oral health at days 10–14 of admission. In the post‐intervention phase (n = 73, mean age 82 years, 66% female) the mean total OHAT score decreased significantly from a baseline of 2.81 at admission to 2.29 at days 10–14 reflecting, an 18.5% improvement (p < 0.005).
Conclusion
This study highlighted the importance of a multidisciplinary team, including a pharmacist, in improving oral health practice for older people in a sub‐acute hospital setting.
... Host defense capabilities are destroyed by hydrolytic enzymes associated with oral disease and cytokines. 11 Recent research also suggests that poor dental health may have an association with Alzheimer's disease. 10 Lipopolysaccharide, a component of P gingivalis, was found in 4 of 10 brain samples with Alzheimer's disease. ...
Despite substantial improvement in the oral health status of populations around the world, dental disease still remains a significant social burden. There is an increasing amount of evidence describing how dental disease impairs overall health. Empirical evidence shows that poor oral health affects quality of life1. Dental disease in the elderly is more prevalent than many other common chronic diseases and increases the onset and severity of complex diseases such as diabetes mellitus (DM), cardiovascular and respiratory diseases.2
A relationship between poor periodontal health and respiratory disease has been suggested by a number of recent studies. The present study was undertaken to evaluate potential association between respiratory diseases and periodontal health status and to co-relate the severity of periodontal disease with that of chronic obstructive pulmonary disease (COPD).
150 patients of COPD (test group) and 50 Patients without COPD (control group) were recruited for the study. Information regarding patient's demographic and socioeconomic status and lifestyle (history of smoking) were considered in the study. Patients with COPD were grouped into mild, moderate and severe category on the basis of Spirometry. Periodontal health was assessed by measuring probing pocket depth, Clinical Attachment Loss (CAL) and Oral Hygiene Index (OHI).
The results showed that the subjects with COPD had significantly more mean CAL) and a higher mean OHI than those without COPD. The risk for COPD appeared to be significantly elevated when attachment loss was found to be severe. A trend was noted in that lung function appeared to diminish as the amount of attachment loss increased.
On the basis of the observed results of the study it can be concluded that the risk for COPD appeared to be significantly elevated when attachment loss was found to be severe. It is conceivable that oral interventions that improve oral health status may prove to lower the severity of lung infection in susceptible populations.
Post-operative pulmonary infection often appears to result from aspiration of pathogens colonizing the oral cavity. It was hypothesized that impaired periodontal status and pathogenic oral bacteria significantly contribute to development of aspiration pneumonia following neurosurgical operations. Further, the prophylactic effects of a single dose preoperative cefazolin on the oral bacteria were investigated.
A matched cohort of 18 patients without postoperative lung complications was compared to 5 patients who developed pneumonia within 48 hours after brain surgery. Patients waiting for elective operation of a single brain tumor underwent dental examination and saliva collection before surgery. Bacteria from saliva cultures were isolated and periodontal disease was scored according to type and severity. Patients received 15 mg/kg cefazolin intravenously at the beginning of surgery. Serum, saliva and bronchial secretion were collected promptly after the operation. The minimal inhibitory concentrations of cefazolin regarding the isolated bacteria were determined. The actual antibiotic concentrations in serum, saliva and bronchial secretion were measured by capillary electrophoresis upon completion of surgery. Bacteria were isolated again from the sputum of postoperative pneumonia patients.
The number and severity of coexisting periodontal diseases were significantly greater in patients with postoperative pneumonia in comparison to the control group (p = 0.031 and p = 0.002, respectively). The relative risk of developing postoperative pneumonia in high periodontal score patients was 3.5 greater than in patients who had low periodontal score (p < 0.0001). Cefazolin concentration in saliva and bronchial secretion remained below detectable levels in every patient.
Presence of multiple periodontal diseases and pathogenic bacteria in the saliva are important predisposing factors of postoperative aspiration pneumonia in patients after brain surgery. The low penetration rate of cefazolin into the saliva indicates that its prophylactic administration may not be sufficient to prevent postoperative aspiration pneumonia. Our study suggests that dental examination may be warranted in order to identify patients at high risk of developing postoperative respiratory infections.
The objective of this study was to investigate the preventive effect of oral hygiene on pneumonia and respiratory tract infection, focusing on elderly people in hospitals and nursing homes, by systematically reviewing effect estimates and methodological quality of randomized controlled trials (RCTs) and to provide an overview of additional clinical studies in this area. Literature searches were conducted in the Medline database, the Cochrane library databases, and by hand-searching reference lists. Included publications were analyzed for intervention (or topic) studied, main conclusions, strength of evidence, and study design. RCTs were further analyzed for effect magnitudes and methodological details. Absolute risk reductions (ARRs) and numbers needed to treat (NNTs) were calculated. Fifteen publications fulfilled the inclusion criteria. There was a wide variation in the design and quality of the studies included. The RCTs revealed positive preventive effects of oral hygiene on pneumonia and respiratory tract infection in hospitalized elderly people and elderly nursing home residents, with ARRs from 6.6% to 11.7% and NNTs from 8.6 to 15.3 individuals. The non-RCT studies contributed to inconclusive evidence on the association and correlation between oral hygiene and pneumonia or respiratory tract infection in elderly people. Mechanical oral hygiene has a preventive effect on mortality from pneumonia, and non-fatal pneumonia in hospitalized elderly people and elderly nursing home residents. Approximately one in 10 cases of death from pneumonia in elderly nursing home residents may be prevented by improving oral hygiene. Future research in this area should be focused on high-quality RCTs with appropriate sample size calculations.
The purpose of this study was to look for a relationship between history of respiratory tract infection (RTI) and oral health in very old subjects.
302 frail elders (mean age: 85 years) living in a medical care facility were examined by one dentist.
The incidence of RTI over 1 year had been recorded along with markers of nutritional status and degree of dependency. The oral examination comprised an evaluation of hygiene, quality of prostheses and the prevalence of caries, periodontal disease and mucosal disorders.
One third (33%) of the subjects had experienced at least one episode of RTI, and a fifth (19%) had visited the dentist in emergency. The incidence of RTI had been greater among dentate subjects and those who came to the dentist in emergency. The dentate subjects with a history of RTI had higher plaque score (P = 0.02). Half (49%) of the subjects had oral disorders that could develop in a dental emergency and these subjects had had a higher risk of RTI (relative risk: 1.9, 95% confidence interval: 1.1-3.9). The presence of selected oral disorders associated with low serum albumin increased the relative risk of having had RTI to 3.2 (1.5-6.7). The association between presence of actual oral health problems and previous experience of RTI was more noticeable in those who had poor general health or were more debilitated.
The present study suggests that poor oral hygiene and the presence of potential emergency could be major risk factors for RTI among the frail elderly.
Respiratory infectious diseases such as bacterial pneumonia and bronchitis are common and costly, especially in institutionalized and elderly inpatients. Respiratory infection is thought to rely in part on the aspiration of oropharyngeal flora into the lower respiratory tract and failure of host defense mechanisms to eliminate the contaminating bacteria, which then multiply to cause infection. It has been suggested that dental plaque may act as a reservoir of respiratory pathogens, especially in patients with periodontal disease. However, the impact of poor oral health on oral respiratory pathogen colonization and lung infection is uncertain, especially in ambulatory, non-institutionalized populations. To begin to assess potential associations between respiratory diseases and oral health, data from the National Health and Nutrition Examination Survey I (NHANES I) were analyzed. This database contains information on the general health status of 23,808 individual Of these, 386 individuals reported a suspected respiratory condition that was further assessed by a physician. These subjects were categorized as having a confirmed chronic respiratory disease (chronic bronchitis or emphysema) or an acute respiratory disease (influenza, pneumonia, acute bronchitis). They were compared to those not having a respiratory disease. Initial non-parametric analysis noted that individuals with a confirmed chronic respiratory disease (n = 41) had significantly greater oral hygiene index scores than subjects without respiratory disease (n = 193; P = 0.0441). Logistic regression analysis of data from these subjects, which considered age, race, gender, smoking status, and simplified oral hygiene index (OHI), suggested that subjects having the median OHI value were 1.3 times more likely to have a chronic respiratory disease relative to those with and OHI of O. Similarly, subjects with the maximum OHI value were 4.5 times more likely to have a chronic respiratory disease than those with an OHI of O. No evidence was found to support an association between the periodontal index and any respiratory disease. These results suggest OHI to have a residual effect on chronic respiratory disease of both practical and statistical significance.
Recent research indicated that periodontal infection may worsen systemic diseases, including pulmonary disease. Respiratory infections, such as pneumonia and the exacerbation of chronic obstructive pulmonary disease, involve the aspiration of bacteria from the oropharynx into the lower respiratory tract.
A group of 100 cases (hospitalized patients with respiratory disease) and a group of 100 age-, sex-, and race-matched outpatient controls (systemically healthy patients from the outpatient clinic, Department of Periodontics, Government Dental College and Hospital, Calicut, Kerala, India) were selected for the study. Standardized measures of oral health that were performed and compared included the gingival index (GI), plaque index (PI), and simplified oral hygiene index (OHI). Data regarding probing depths and clinical attachment levels (CALs) were recorded at four sites per tooth and compared statistically. The χ(2) and Student t tests were used for statistical analyses.
The comparison of study-population demographics on the basis of age, sex, education, and income showed no significant differences between groups. Patients with respiratory disease had significantly greater poor periodontal health (OHI and PI), gingival inflammation (GI), deeper pockets, and CALs compared to controls. In the case group, patients with a low income were 4.4 times more prone to periodontal disease compared to high-income patients. Smokers had significantly higher CALs compared to non-smokers in the control group.
The findings of the present analysis support an association between respiratory and periodontal disease.
This study evaluated the role of periodontal pathogens in 50 hospitalized patients with hospital acquired pneumonia compared with 30 healthy controls. Specimens of oropharyngeal aspirate, dental plaque bronchoalveolar lavage and blood cultured 1 or more pathogens in around 80% of patients, predominatel Staphylococcus aureus, followed by coagulase-negative staphylococci, Streptococcus pneumoniae and Klebsiell pneumoniae. Antibiotic sensitivity patterns showed concordance of bacterial cultures from dental plaque an oropharyngeal cavity in 13 patients. C-reactive protein (CRP) levels were significantly higher in patients than ii controls and there was a significant correlation between serum and salivary CR1' levels. Dental plaque bioflln may promote oral and oronpharyngeal colonization of respiratory pathogens in hospitalized subiects.
To evaluate the association of periodontal health and parameters of quality of life assessed in 306 Chinese patients with chronic obstructive pulmonary disease (COPD).
Periodontal status and respiratory function in 306 COPD patients were clinically evaluated and their quality of life was assessed using the standardized St George's Respiratory Questionnaire (SGRQ).
The SGRQ scores were all significantly correlated with major lung function parameters (r(2) = -0.37 to -0.28; all p < 0.0001) and Medical Research Council dyspnoea scale (r(2) = 0.23 to 0.30; all p < 0.0001). The SGRQ scores also correlated with the 6-min walk test (r(2) = -0.15 to -0.13; all p < 0.05). Of periodontal health parameters, missing tooth number and plaque index appeared to be related to the scores of quality of life. The age- and gender-adjusted Pearson's correlation coefficients between missing teeth and total score, symptoms score, and activity score were 0.09, 0.12, and 0.12, respectively (all p < 0.05). The Pearson's correlation coefficients between plaque index and symptoms score and activity score were 0.09 and 0.09 (p < 0.05). After adjusting for age, gender, body mass index, and smoking status, missing teeth remained significantly associated with symptom score (p = 0.030) and activity score (p = 0.033) while plaque index was significantly associated with symptom score (p = 0.007).
Poor periodontal health as reflected by missing teeth and plaque index was significantly associated with lower quality of life in COPD patients. Our findings indicate the importance of promoting dental care in current public health strategies to improve the quality of life in COPD patients.
To evaluate the possible association between periodontitis and nosocomial lower respiratory tract infection (LRTI).
A case-control study was conducted at a General Hospital in Feira de Santana, Bahia, Brazil. The sample consisted of 103 individuals: 22 cases (presence of nosocomial LRTI) and 81 controls (absence of nosocomial LRTI). The diagnosis of periodontitis was based on probing depth, gingival recession, clinical attachment loss and bleeding on probing. The diagnosis of nosocomial LRTI was made in accordance with established medical criteria.
Invasive ventilation was much more frequent in cases (95.5%) than in controls (7.4%). An orotracheal tube was used in 81.8% of cases and in 7.4% of controls; bronchoaspiration was suspected in 81.8% of cases and in 6.2% of controls. There was no statistically significant difference in any of the clinical periodontal parameters between cases and controls. The crude odds ratio (OR) value for individuals with periodontitis having LRTI was not statistically significant [OR(crude)=1.70; 95% confidence interval:(0.60-4.87)]. After including age, smoking and duration of hospitalization in the logistic regression, the adjusted OR for individuals with periodontitis having LRTI was statistically significant [OR(adjusted)=3.67 (1.01-13.53); p=0.049].
A marginal association between periodontitis and LRTI was found when smoking, age and length of hospitalization were included as covariates. Patients with LRTI had a high frequency of suspected bronchoaspiration and this could explain the possible association of periodontal disease and LRTI found in this and other studies. Additional studies are needed to further clarify the possible relationship between periodontal disease and LRTI.
The effect of oral conditions on medical outcomes is not well understood. The purpose of this epidemiological investigation was to examine whether the risk for chronic obstructive pulmonary disease (COPD) is enhanced among individuals with a history of periodontal disease as assessed by radiographic alveolar bone loss (ABL). Subjects were selected from the VA Dental Longitudinal Study, a long-term study of aging and health in male veterans who were medically healthy at baseline. Subjects are not VA patients. Those subjects with a forced expiratory volume in 1 second (FEV1) less than 65% of predicted volume were categorized as having COPD. ABL was assessed by using full-mouth series periapical films measured by a Schei ruler. Bone loss at each interproximal site was measured in 20% increments, and the mean whole-mouth bone loss score was calculated. Logistic regression analysis was used to determine the independent contribution of bone loss measurement at baseline to the subsequent risk of developing COPD over a 25-year follow-up period. Covariates included measures of smoking, height, age, education, and alcohol consumption. Of the 1,118 medically healthy dentate men at baseline, 261 subsequently developed COPD. We found that ABL status at baseline was an independent risk factor for COPD, with subjects in the worst population quintile of bone loss (mean ABL > 20% per site) found to be at significantly higher risk (OR = 1.8; 95% CI = 1.3, 2.5). The results of this analysis indicate that increased ABL is associated with an increased risk for COPD