ArticlePDF AvailableLiterature Review

Periodontitis and respiratory diseases: A systematic review with meta‐analysis



Objective: to conduct a systematic review and meta-analysis to evaluate the recent scientific literature addressing the association between periodontitis and asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. Materials and methods: the search for studies was carried out using MedLine/PubMed, Embase, Lilacs, Web of Science, Scopus, and SciELO databases, including the gray literature (ProQuest). Reference lists of selected articles were also searched. Studies having varying epidemiological designs assessing the association between periodontitis and respiratory diseases in humans subjects were eligible for inclusion. Three independent reviewers performed the selection of articles and data extraction. Fixed and random effects meta-analysis were performed for the calculation of the association measurements (Odds Ratio - OR) and 95% confidence intervals (95%CI). Results: 3,234 records were identified in the database search, with only 13 studies meeting the eligibility criteria and 10 studies contributed data for meta-analysis. Using a random effects models periodontitis was associated with asthma: ORadjusted: 3.54 (95%CI: 2.47 - 5.07), I2 = 0%, with COPD: ORadjusted: 1.78 (95%CI: 1.04 - 3.05), I2 = 37.9%, and with pneumonia: ORadjusted: 3.21 (95%CI: 1.997 - 5.17), I2 = 0%. Conclusions: the main findings of this systematic review validated an association between periodontitis and asthma, COPD and pneumonia.
Oral Diseases. 2020;26:439–446.
Received: 23 Septem ber 2019 
  Revised: 8 Oc tober 2 019 
  Accepted: 27 Oc tober 2019
DOI: 10.1111/odi.13228
Periodontitis and respiratory diseases: A systematic review
with meta-analysis
Isaac Suzart Gomes-Filho1| Simone Seixas da Cruz2,1| Soraya Castro Trindade1|
Johelle de Santana Passos-Soares3,1| Paulo Cirino Carvalho-Filho4|
Ana Cláudia Morais Godoy Figueiredo5| Amanda Oliveira Lyrio6|
Alexandre Marcelo Hintz1| Mauricio Gomes Pereira6| Frank Scannapieco7
© 2019 John Wiley & Sons A /S. Published by Jo hn Wiley & Sons Ltd. A ll right s rese rved
1Depar tment of Health , Feira de Santana
State Universit y, Bahia, B razil
2Depar tment of Epidemi ology, Federal
University of Recôncavo of Bahia, B ahia,
3Department of Preventive Dentistry,
Federal Univer sity of Bahia, Salvado r, Brazil
4Bahiana School of Medicine and Public
Health , Salva dor, Brazil
5Epidemi ology Surve illance, Feder al District
Health State Dep artment, Brasília, Brazil
6Faculty of Health Sciences, Universit y of
Brasí lia, Br asília, Distrito Fede ral, Brazil
7Depar tment of Oral Biology, Uni versit y of
Buffalo, Buf falo, NY, USA
Isaac Su zart G omes-F ilho, Department of
Health , Feira de Santana State Un iversity,
Avenida Ge túlio Vargas, 379, Centro, Feira
de Santana, Bahia, Brazil.
Objective: To conduct a systematic review and meta-analysis to evaluate the recent
scientific literature addressing the association between periodontitis and asthma,
chronic obstructive pulmonary disease (COPD), and pneumonia.
Materials and Methods: The search for studies was carried out using MEDLINE/
PubMed, EMBASE, Lilacs, Web of Science, Scopus, and SciELO databases, including
the gray literature (ProQuest). Reference lists of selected articles were also searched.
Studies having varying epidemiological designs assessing the association between
periodontitis and respiratory diseases in human subjects were eligible for inclusion.
Three independent reviewers performed the selection of articles and data extrac-
tion. Fixed and random effects meta-analysis were performed for the calculation of
the association measurements (Odds Ratio—OR) and 95% confidence intervals (95%
Results: A total of 3,234 records were identified in the database search, with only
13 studies meeting the eligibility criteria and 10 studies contributed data for meta-
analysis. Using a random effects models periodontitis was associated with asthma:
ORadjusted: 3.54 (95% CI: 2.47–5.07), I2 = 0%; with COPD: OR adjusted: 1.78 (95%
CI: 1.04–3.05), I2 = 37.9%; and with pneumonia: OR adjusted: 3.21 (95% CI: 1.997
5.17), I2 = 0%.
Conclusions: The main findings of this systematic review validated an association
between periodontitis and asthma, COPD and pneumonia.
asthma, chronic obstructive pulmonar y disease, periodontitis, pneumonia, respiratory
The association between periodontitis and several respirator y
diseases has been investigated in the last decades. While several
systematic reviews have suggested an association between respi-
ratory diseases and poor oral health (Cagnani et al., 2016; Ferreira
et al., 2019; Mendes, Dos Santos, & Moraschini, 2018; Moraschini,
Calasans-Maia, & C alasans-Maia, 2018; Shi et al., 2018; Tan, Wang,
Pan, & Zhao, 2016; Zeng et al., 2012), one recent systematic review
on the subject, which included studies from 2002 to 2012, con-
cluded that the findings showed a weak association bet ween peri-
odontitis and pulmonary diseases (Linden, Lyons, & Scannapieco,
2013). Although several studies have shown that improvements in
oral hygiene prevent several respiratory diseases, this question re-
mains unresolved.
Respiratory diseases and periodontitis are among the most com-
mon diseases of humans worldwide (Beasley, Semprini, & Mitchell,
2015; Tonetti, Chapple, Jepsen, & Sanz, 2015). Pneumonia, a com-
mon infectious disease of the lung parenchyma, is more prevalent
among the elderly, and the oral microbiota plays an important role
in the natural history of some forms of the disease (Raghavendran,
Mylotte, & Scannapieco, 20 07; Sabharwal, Gomes-Filho, Stellrecht,
& Scannapieco, 2018).
Asthma is a chronic inflammatory disease affecting both young
and old (Beasley et al., 2015). An increasing number of studies have
observed an association with periodontal disease (Gomes-Filho et
al., 2014; Khassawneh, Alhabashneh, & Ibrahim, 2019; Soledade-
Marques et al., 2018). The same has been seen for chronic obstruc-
tive pulmonary diseases (COPD), a chronic condition comprised of
both bronchitis and emphysema characterized by airflow obstruc-
tion due to increased chronic inflammatory response within the air-
way. A number of investigations have suggested that periodontitis
and COPD share common underlying processes, for example, neu-
trophil-rich inflammation with subsequent proteolytic destruction
of connective tissues (Barros, Suruki, Loewy, Beck, & Offenbacher,
2013; Chung, Hwang, Kim, & Kim, 2016; Harland, Furuta, Takeuchi,
Tanaka, & Yamashita, 2018; Ledić et al., 2013; Takeuchi et al., 2019).
However, the precise pathophysiological mechanisms to explain the
underlying nature of the association are still uncertain.
The course of the pulmonary diseases can be affected by
both infectious and inflammatory process, such as periodontitis
(Azarpazhooh & Leake, 2006; Vadiraj, Nayak, Choudhary, Kudyar,
& Spoor thi, 2013). The microorganisms present in the periodontal
pocket, specially anaerobic bacteria, can be aspirated into the lower
airway (Bansal, Khatri, & Taneja, 2013). Epithelial sensitization and
the hematogenous spread of the proinflammatory mediators such
as cytokines and metalloproteinases produced in the diseased peri-
odontal tissue (Guan et al., 2009; Tâlvan, Mohor, Chisnoiu, Cristea,
& Câmpian, 2017) can incr ease the inflammator y burden, exacerbat-
ing disease activity to diminish airflow (Gueders et al., 2008). This
inflammatory burden can be amplified by stimulation of the liver,
eliciting the production of acute-phase proteins, such as C-reactive
protein, interleukin-6, transferrin, apolipoprotein b, and amyloid A
protein, which in turn potentiate the inflammatory response by lung
tissues (Endo et al., 2010).
Seven recent systematic reviews assessing the association be-
tween poor oral health and pulmonary diseases have been published
to date: 3 related to the association between periodontal clinical
parameters and asthma (Ferreira et al., 2019; Mendes et al., 2018;
Moraschini et al., 2018), 3 focused on the relationship between
worse periodontal condition and COPD (Shi et al., 2018; Tan et al.,
2016; Zeng et al., 2012), and 1 regarding the association between
periodontal disease and pneumonia (Cagnani et al., 2016). All these
reviews concluded that periodontal disease is associated with the
target respiratory disease. However, the findings were presented
only based on the association between periodontal clinical param-
eters, such as probing depth (PD), clinical attachment level (C AL),
bleeding on probing (BOP) or plaque index (PI), and the respirator y
disease, instead of the association bet ween periodontitis, as a clini-
cal entit y, and asthma, COPD, or pneumonia.
Therefore, the present systematic review with meta-analysis of
observational or interventional investigations in humans aimed to re-
view the most recent scientific evidence on the association between
periodontitis and the three aforementioned respiratory diseases.
2.1 | Registration and protocol
A search for systematic reviews on the topic was conducted in
the International Prospective Register of Systematic Reviews—
PROSPERO database, and no records were found. The systematic
review was registered in PROSPERO: CRD42019126056.
The PRISMA state ment wa s used to guide the writ ing of th is sys-
tematic review (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group,
200 9).
2.2 | Eligibility criteria for the studies
Cross-sectional, case–control, cohort or randomized, controlled
clinical trials, conducted with human subjects’ age ≥18 years, were
included in this review to investigate the association between peri-
odontitis and asthma, COPD, and pneumonia, without restriction
of the language used, over the period of January 1, 2010 to June
19, 2019. Case studies and reviews, investigations with sample size
<100 individuals, and those without clear description of the diag-
nostic criteria for periodontitis and/or respirator y disease or self-
referred by participants were excluded.
2.3 | Information sources
Studies were accessed using the following electronic databases;
MEDLINE through PubMed, EMBASE, LIL ACS, Web of Science,
Scopus, and SciELO. Reference lists of articles selected for the sys-
tematic review were examined, as well as specific databases con-
taining texts from the gray literature (ProQuest), such as master's
dissertations, doctoral theses.
2.4 | Search strategies
The descriptors used and their synonyms were identified in the
Medical Subject Headings—MeSH. The uniterms employed in English
for the search strategies were Periodontitis, Periodontal Disease,
Gingivitis, Asthma, Pneumonia, and Chronic Obstructive Pulmonary
Disease. The Boolean operators were AND and OR. This search
strateg y was adapted for the other electronic databases (Appendix
S1). Peer Review Electronic Search Strategy—PRESS evaluated the
quality of search strategies (McGowan et al., 2016).
2.5 | Study selection
Following exclusion of duplicates, studies were selected by reading
titles and abstracts using the State of the Art through Systematic
Review program version 3.4. (START, 2013) by three reviewers
(I.S.G.F., S.S.C., and P.C.C.F.) that were unaware of the decisions
made by their peers during the article selection process. Three
investigators (I.S.G.F., S.S.C., and A.C.M.G.F.) independently read
the ful l te xt of the sele cted article s an d th ose th at met t he eligib il-
ity criteria were included in the systematic review. In cases where
there was a divergence between the researchers, the inclusion
or exclusion of the articles was adjudicated through a consensus
among them.
2.6 | Extraction of data
The investigators (I.S.G.F., J.S.P.S., and S.C.T.) performed and organ-
ized the extraction of data from the included articles using the fol-
lowing fields: author's name, year of publication, place and year of
study, objective, study design, sample size, criteria for the diagnosis
of the periodontitis and respiratory diseases (asthma, COPD, and
pneumonia), association measurement, confounding covariables,
and the main findings. When data were not available, the authors of
the studies were contacted (Appendix S1).
2.7 | Evaluation of study quality
To evaluate the quality of the selected studies, the Quality Access
Scale instrument—Newcastle–Ottawa was used (Modesti et al.,
2016; Wells et al., 2014). The researchers (I.S.G.F., A.O.L., and
A.M.H.) also performed the quality evaluation of all studies, and
then, the information was confronted with consensus among them.
2.8 | Data analysis
Data analysis was performed using the statistical package STATA®
version 15 (StataCorp LLC), Serial number: 301506206729. To
evaluate the statistical heterogeneity of the data used for the meta-
analysis, the chi-square test (p < .10) and the Higgins and Thompson
I-square (I2) were used. In order to identif y the magnitude of data in-
consistency, the I2 score was used. I2 values above 50% represented
high inconsistency, values of 25% to 50%, moderate inconsistency
and I2 value less than 25%, low inconsistency (Higgins & Thompson,
Global association measurements between periodontitis and
th e main res pi rator y disease ou tc om es (a sth ma , COP D, an d pne u-
monia), the Odds Ratio (OR), and 95% confidence interval (95%
CI) were obtained with fixed and random effects meta-analysis
using the DerSimonian–Laird method and the forest plot graph.
Cohort study findings reported as relative risk or cross-sectional
study findings reported as prevalence ratio were converted to an
odds ratio according to criteria defined by Zhang (Zhang & Yu,
The inspection of the Begg's funnel plot and Egger's test, with
a statistical significance of p < .10 (Egger & Altman, 2001; Egger,
Davey Smith, Schneider, & Minder, 1997), to evaluate the publication
bias were also done, along with the Galbraith graphic for evaluation
of heterogeneit y among the studies in accordance with their distri-
bution (Dinnes, Deeks, Kirby, & Roderick, 20 05), acknowledging the
limitations of this meta-analytic measurement.
2.9| Quality of evidence of the present study—
GRADE system
GRADE system (Atkins et al., 2004) was used to evaluate the qual-
ity of the evidence of the present study. It has five items that may
decrease its quality, as follows: risk of bias, inconsistency, indirect
evidence, inaccuracy, and publication bias. Other three items may
impact the quality of evidence: magnitude of the effect, dose–re-
sponse gradient, and possible confounding adjustment. The final
quality of evidence may be scored as follows: high qualit y ≥4 points,
moderate quality—3 points, low quality—2 points, and very low evi-
dence—1 point.
A total of 3,234 records were identified. After duplicates were
removed, the titles and abstract s were read. Of the 92 articles
that were selected for complete reading, only 13 texts met the
eligibility criteria of this systematic review related to the asso-
ciation between periodontitis and respiratory diseases, with
3 studies targeting asthma, 7 on COPD, and 3 on pneumonia
(Figure 1).
3.1 | General characteristics and quality of studies
The 13 studies considered for this review included 22,327 participants
(with 740 indi vidua ls with asthma, 20,921 with COPD studie s, and 66 6
with pneumonia). Of the 13 studies identified, 8 were case–control,
3 were cohort and 2 were cross-sectional design. Most of them were
conducted in Asia (53.85%—7 studies, of which 4 were conducted in
Ja pan), foll ow e d by Sout h Ame r ic a (3 0.7 7%— 4 stu die s , al l con duc ted in
Brazil), North America (7.69%—1 study), and Europe (7.69%—1 study).
There was a diversity of diagnostic definitions for periodontitis
used in the studies. Among them, 15,38% used criteria of the Center
for Disease Control/American Association of Periodontology (Eke,
Page, Wei, Thornton-Evans, & Genco, 2012; Page & Eke, 2007).
About 15.38% used the Community Periodontal Index—CPI (WHO,
2013). About 15.38% used the United States Third National Health
and Nutrition Examination Survey (Albandar, Brunelle, & Kingman,
1999). About 15,38% used Armitage classification system for peri-
odontal diseases (Armitage, 1999). And 23.10% used Gomes-Filho
et al. (2007, 2018) criterion. The remaining studies, one (7.69%) used
CAL >4 mm at 60% of the measured sites and the other (7.69%) used
the case definition of ≥4 teeth with ≥1 site with PD ≥4 mm and CAL
≥3 mm (Appendix S1).
Regarding the diagnosis of the respiratory diseases, from the 3
studies that evaluated the association between periodontitis and
asthma, 2 followed the recommendation of the Global Initiative of
Asthma (GINA, 2012). Similarly, from the 7 studies on the relation-
ship between periodontitis and COPD, 6 followed the statement of
the Global Initiative for Chronic Obstructive Lung Disease (Pauwels
et al., 2001). Regarding pneumonia, each study employed different
criteria to diagnose the disease.
Over all, the study quality assessment s were high—76.91% with a
mean of 7.46, and no article was found to have low quality (Appendix
Of the total number of studies included in the review, 3
(Appendix S1) evaluated the relationship between periodontitis
and respiratory diseases but, one had only crude association mea-
surement between periodontitis and COPD (Chung et al., 2016),
and in the other, two did not co ntain the association meas urement
or mea ns to obt ai n it (Si et al. , 2012 ; Ter as hima et al. , 2017). Of the
10 remaining studies that presented the adjusted association mea-
surement , only 3 investigations were included in the meta-analy-
sis to generate the summary association measurement between
periodontitis and asthma (Gomes-Filho et al., 2014; Khassawneh
et al., 2019; Soledade-Marques et al., 2018). Four studies between
periodontitis and COPD (Barros et al., 2013; Harland et al., 2018;
Ledić et al., 2013; Takeuchi et al., 2019). And 3 articles between
periodontitis and pneumonia (Gomes-Filho et al., 2014; Iwasaki
et al., 2018; Melo Neto et al., 2013). In these investigations, the
FIGURE 1 Flowchart of the search,
selection, and inclusion of the studies
related to the association between
periodontitis and respiratory diseases
[Colour figure can be viewed at]
Records identified through database searching
MEDLINE/PubMed: 493 EMBASE: 667
Lilacs: 34 Web of Science: 580
Scopus: 820 SciELO: 13
(n = 2,607)
Included Eligibility Idenficaon
Additional records identified
through other sources
ProQuest: 527
(n = 527)
Records after duplicates removed
(n = 1,995)
Records screened
(n = 1,995)
Records excluded
(n = 1,926)
Full-text articles assessed
for eligibility
(n = 69)
Full-text articles excluded,
with reasons
(n = 56)
Studies included in
qualitative synthesis
(n = 13)
Studies included in
quantitative synthesis
(n = 11)
Asthma: 03 studies;
COPD: 07 studies;
Pneumonia: 03 studies.
Asthma: 03 studies;
COPD: 05 studies;
Pneumonia: 03 studies.
(n = 1,139)
covariables most frequently considered in the adjustment of
the association measurements were age (92.31% of the studies),
smoking habit (76.92%), body mass index (53.85%), sex (46.15%),
schooling level (38.46%), and alcoholic beverage consumption
(23.08%). Articles excluded from the systematic review are pre-
sented in Appendix S1.
3.2 | Periodontitis and respiratory diseases
To obtain the global association measurement, analysis of the unad-
justed (Figure S1) and adjusted OR were performed according to the
type of respiratory disease.
For the association between periodontitis and asthma, the me-
ta-analysis yielded an adjusted OR of 3.54 (95% CI: 2.47–5.07), with
an I2 as 0% (95% CI: 0%–90%), representing a strong global associa-
tion, and low heterogeneity among the studies (Figure 2).
In relation to COPD, the met a-analysis yielded an adjusted OR
of 1.78 (95% CI: 1.04–3.05), with an I2 as 37.9% (95% CI: 0%–79%),
representing a moderate summary association between peri-
odontitis and COPD, and moderate variation among the studies
(Figure 2).
Regarding pneumonia, the meta-analysis yielded an adjusted
OR of 3.21 (95% CI: 1.99–5.17 ), with an I2 as 0% (95% CI: 0%–90%),
representing a strong global association between periodontitis and
pneumonia, and low inconsistency among the studies (Figure 2).
The Galbraith graphic (Figure S2) showed the distribution of
studies, responsible for the heterogeneity in this meta-analysis. This
finding reinforced the impossibility of using the sensitivity and me-
ta-regression analysis. The funnel graphic (Figure S3) indicates the
existence of publication bias for this final association measurement,
since the studies are diffusely distributed, confirmed with Egger's
test (p = .08).
The main findings of this systematic review showed a moderate to
strong association between periodontitis and respiratory diseases,
with high methodological quality among most of the studies and low
to moderate heterogeneity of the selected investigations. Previous
systematic reviews related to the association between periodon-
tal clinical parameters and asthma (Ferreira et al., 2019; Mendes
et al., 2018; Moraschini et al., 2018); worse periodontal condition
and COPD (Shi et al., 2018; Tan et al., 2016; Zeng et al., 2012); and
periodontal disease and pneumonia (Cagnani et al., 2016) showed
a positive relationship between periodontal clinical parameters and
the respiratory disease of interest.
Another relevant aspect of this systematic review is the het-
erogeneity observed among the studies. Although the heteroge-
neity appears low, some inconsistency among the studies exists
and it can be attributed not only to the diversity of the criteria for
defi nin g the expo su re an d the ou tcome , but also due to po pu lat io n
differences including socioeconomic–demographic conditions,
lifestyle, access to healthcare services, and other health-related
characteristics. For these reasons, a recent classification of het-
erogeneity was not used for the present study since it indicates
I2 close to 0% as no heterogeneity (Higgins, 2008). For the calcu-
lation of the summary association measurement, some additional
an aly ses we re no t poss ib l e to per form, su ch as th e sens it i vit y anal-
ysis, meta-regression, and subgroup analysis, since the number of
observations was less than 10 studies. These analyses would favor
the identification of possible variables that influenced the final
global association measurement.
Among the general characteristics of the systematic review in-
vestigations, the sample size varied greatly among the 13 selected
studies, with 8 presenting samples smaller than 500 participants,
with 3 having samples smaller than 200 subjects (Ledić et al., 2013;
Melo Neto et al., 2013; Terashima et al., 2017). Comparison groups
with small numbers of individuals in each group can influence the
final measurement, presenting spurious associations (Rothman,
Greeland, & Lash, 2011). Therefore, for the present systematic re-
view, the eligibility criteria employed the exclusion of studies with
sample sizes less than 100 subject s. For the calculation of the me-
ta-analysis, this measure was also used in an attempt to reduce the
possibility of the influence of cross-sectional analysis on the final
findings, although there were only two studies with this design: one
conducted with a sample of 5,878 subjec ts (Chung et al., 2016) and
the other with 1,474 subjec ts (Harland et al., 2018). Thus, the exis-
tence of a causal association is favored and reinforced by the consis-
tency of similar findings from several empirical, independent studies
on a given topic (Rothman et al., 2011).
The use of confounding covariables in the association analysis
was also evaluated in the selected studies. The vast majority in-
cluded in their final models a confounder analysis using covariables
that were related to the exposure and outcome factors, considered
important factors in the investigation. This measure helps to neu-
tralize the influence of other factors on the association between the
periodontitis and the respiratory diseases, reinforcing the impor-
tance of the epidemiological concept of multicausality (Rothman et
al., 2011).
It should be noted that the objective of this systematic review
was not to evaluate studies that associate the periodontal clinical
parameters, such as PD, CAL, BOP, or PI, separately with the respi-
ratory disease. Periodontitis is an impor tant public health problem
and needs to be measured and evaluated as a clinical entity, that is,
the role of periodontitis in asthma, COPD, or pneumonia. Many pre-
vious systematic reviews (Cagnani et al., 2016; Ferreira et al., 2019;
Mendes et al., 2018; Moraschini et al., 2018; Shi et al., 2018; Tan et
al., 2016; Zeng et al., 2012) presented their conclusions only on the
basis of the relationship between one or more periodontal clinical
parameter with the abovementioned respiratory diseases, which is
different from the main objective of this review.
Among the limitations of this systematic review, potential pub-
lication bias stands out, regardless of the use of many databases,
in addition to publications from the gray literature and contacting
authors of published ar ticles that did not present enough data.
Another significant limitation was the small number of studies used
in the meta-analysis that employed the final summary association
measurements, which prevented further analysis for the identifica-
tion of interfering covariables, and the exclusive positive association
between the exposure and the outcome among the investigations
related to periodontitis and asthma, as well as periodontitis and
Another limitation was the multiple diagnostic for pneumonia
among the studies that related it to periodontitis (Gomes-Filho et
al., 2014; Iwasaki et al., 2018; Melo Neto et al., 2013). For obtain-
ing the meta-analytic measurement, a study was included where
the outcome was mortality due to pneumonia, considered a prox y
variable for diagnosis of this respirator y disease (Iwasaki et al.,
2018). These is su es impacted the qualit y of evidence ( At ki ns et al.,
2004), because it was rated overall as low or very low (Appendix
The strengths of this review include the use of research tech-
niques and validated instruments. PRESS was used to evaluate the
quality of search strategies (McGowan et al., 2016). START was
employed for exclusion of duplicates studies (START, 2013). The
Newcastle–Ottawa Quality Survey Scale (Modesti et al., 2016;
Wells et al., 2014) to assess the quality of the investigations and the
PRISMA statement (Moher et al., 2009) to guide selection of studies
were included for analysis.
Additionally, other strengths were the inclusion of studies with
moderate and high methodological quality, usage of adjusted asso-
ciation measurement to calculate the global measurement, employ-
ment of investigations that use clinical periodontitis case definition
for diagnosis of the participants, and finally, several number of data-
bases for screening of the studies.
The findings of this systematic review validated previous studies
reporting associations between periodontitis and asthma, COPD,
and pneumonia. This evidence should be interpreted with caution.
There is a need for further research to minimize methodological and
clinical heterogeneity between studies, particularly concerning the
characteristics of the samples and the definition of the most relevant
In addition, both periodontitis and the respiratory diseases are
relevant public health problems and these findings argue for addi-
tional meas ures to implement oral health prevention and health pro-
motion measures for these respirator y diseases.
The author s also de clare no conflict s of interes t related to the stud y.
I. S. Gomes-Filho, S. S. Cruz, S. C. Trindade, J. S. Passos-Soares,
P. C. Carvalho-Filho, A. C. M. G. Figueiredo, A. O. Lyrio, A. M.
Hintz,M. G. Pereira, F. Scannapieco declare that we have made
substantial contributions to the research design, or the acquisi-
tion, analysis or interpretation of data; to drafting the paper or
revising it critically; and that we all have approved the submitted
FIGURE 2 Forest plot of the meta-
analysis with adjusted association
measurements between periodontitis and
respiratory diseases, such as pneumonia,
chronic obstruc tive pulmonar y disease,
and asthma, and 95% confidence intervals
of all the evaluated studies
Isaac Suzart Gomes-Filho https://orcid.
Soraya Castro Trindade
Albandar, J. M., Brunelle, J. A., & Kingman, A. (1999). Destructive peri-
odontal disease in adults 30 years of age and older in the United
States, 1988–1994. Journal of Periodontology, 70(1) , 13–2 9. http s :// .13
Armitage, G . C . (1999). Development of a classification system for peri-
odontal diseases and conditions. Annals of Periodontology, 4(1), 1–6.
htt ps :// /10.190 2/annals.1999.4.1.1
Atkins, D., Best, D., Briss, P. A ., Eccles, M., Falck-Ytter, Y., Flottorp, S.,
… GRADE Working Group (2004). Grading qualit y of evidence
and strength of recommendations. BMJ: British Medical Journal,
328(7454), 1490.
Azarpazhooh, A., & Leake, J. L. (2006). Systematic review of the as-
sociation between respiratory diseases and oral health. Journal
of Periodontology, 77(9), 1465–1482 . https ://
Bansal, M., Khatri, M., & Taneja, V. (2013). Potential role of periodontal
infection in respirator y diseases - a review. Journal of Medicine and
Life, 6(3), 244–248.
Barros, S. P., Suruki, R., Loewy, Z. G., Beck, J. D., & Offenbacher, S. (2013).
A cohort study of the impact of tooth loss and periodontal disease
on res pirator y even ts am on g CO PD sub jec ts: Mod ula to r y rol e of sy s-
temic biomarkers of inflammation. PLoS ONE, 8(8), e68592. https :// al.pone.0068592
Beasley, R., Semprini, A., & Mitchell, E. A. (2015). Risk factors for asthma:
Is prevention possible? Lancet, 386(9998) , 1075–1085. https ://doi.
Cagnani, A., Barros, A. M. D. S., Sousa, L. L. A. D., Zanin, L., Bergamaschi,
C. D. C., Peruzzo, D. C., & Flório, F. M. (2016). Periodont al disease
as a risk f actor for aspiration pneumonia: A systematic review.
Bioscience Journal, 32(3), 813–821. https :// BJ-
v32n3 a2016-33210
Chung, J. H., Hwang, H. J., Kim, S. H., & Kim, T. H. (2016). Associations
between periodontitis and chronic obstructive pulmonary disease:
The 2010 to 2012 Korean National Health and Nutrition Examination
Surv ey. Journal of Periodontology, 87(8), 864–871. https ://doi.
Din ne s, J., Deeks , J., Kir by, J., & Ro de ri ck , P. (20 05). A me th od ol ogical re-
view of how heterogeneity has been examined in systematic reviews
of diagnostic test accuracy. Health Technology Assessment, 9(12),
1–113. https ://
Egger, M.Davey Smit h, G., & Altman, D. G. (2001). Systematic reviews in
health care: Meta-analysis in context (2ed edn). London, UK: BMJ.
Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias
in meta-analysis detected by a simple, graphical test. BMJ: British
Medical Journal, 315(7109), 629–634.
Eke, P. I., Page, R . C., Wei, L ., Thornton-Evans, G., & Genco, R. J. (2012).
Update of the case definitions for population-based surveillance of
periodontitis. Journal of Periodontology, 83(12), 1449–1454. https ://
Endo, Y., Tomofuji, T., Ekuni, D., Irie, K., Azuma, T., Tamaki, N., … Morita,
M. (2010). Experimental periodontitis induces gene expression
of proinflammatory cytokines in liver and white adipose tissues
in obesity. Journal of Periodontology, 81(4), 520–526. https ://doi.
Ferreira, M. K. M., Ferreira, R. D. O., Castro, M. M. L., Magno, M. B.,
Almeida, A . P. C. P. S. C., Fagundes, N. C. F., … Lima, R. R. (2019). Is
there an association between asthma and periodontal disease among
adults? Systematic review and meta-analysis. Life Sciences, 223, 74
87. https ://
GINA (2012). Global initiative for asthma. Globa l strategy for asthma m an-
agement and prevention. Revised 2012. Vancouver.
Gomes-Filho, I. S., Cruz, S. S., Rezende, E. J. C., dos Santos, C .
A. S . T., Soledade, K. R., Mag alhães, M. A., Cerqueira, E.
M. M. (2007). Exposure measurement in the association be-
tween periodontal disease and prematurity/low birth weight.
Journal of Clinical Periodontology, 34(11), 957–963. https ://doi.
org /10.1111/j .1600 -051X .20 07.01141.x
Gomes-Filho, I. S., Soledade-Marques, K. R ., Seixas da Cruz, S., de
Santana Passos-Soares, J., Trindade, S. C., Souza-Machado, A., …
Freitas Coelho, J. M. (2014). Does periodont al infection have an
effec t on severe asthma in adults? Journal of Periodontology, 85(6),
e179–187. https ://
Gomes-Filho, I. S., Trindade, S. C., Passos-Soares, J. S., Figueiredo, A.
C. M. G., Vianna, M., & Cruz, S. S. (2018). Clinical diagnosis crite-
ria for periodontal disease: An update. Journal of Dental Health,
Oral Disorders & Therapy, 9(5), 354–356. https ://
Guan, S. M., Shu, L., Fu, S. M., Liu, B., Xu, X. L., & Wu, J. Z. (2009).
Prevotella intermedia upregulates MMP-1 and MMP-8 expression in
human periodontal ligament cells. FEMS Microbiology Letters, 299(2),
214–222. https ://
Gueders, M. M., Ber tholet, P., Perin, F., Rocks, N., Maree, R ., Botta, V., …
Cata ldo, D. D. (200 8). A novel form ulation of inhaled doxycycline re-
duces allergen-induced inflammation, hyperresponsiveness and re-
modeling by matrix metalloproteinases and cytokines modulation in
a mouse model of asthma. Biochemical Pharmacology, 75(2), 514–526.
https ://
Harland, J., Furuta, M., Takeuchi, K., Tanaka, S., & Yamashita, Y. (2018).
Periodontitis modifies the association between smoking and chronic
obstructive pulmonary disease in Japanese men. Journal of Oral
Science, 60(2), 226–231. https :// sd.17-0225
Higgins , J. P. (2008). Cochrane handbook para revisões sistemáticas de in-
tervenções versão 5.0.1.The Cochrane Collaboration.
Higgins , J. P., & Thompson, S. G . (20 02). Quantifying heterogeneity in a
meta-analysis. Statistics in Medicine, 21(11), 1539–1558. ht tps ://doi.
org /10.10 02/sim.118 6
Iwasaki, M., Taylor, G. W., Awano, S., Yoshida, A., Kataok a, S., Ansai, T., &
Nakamura, H. (2018). Periodontal disease and pneumonia mortality
in haemodialysis patients: A 7-year cohor t study. Journal of Clinical
Periodontology, 45(1), 38–45. https :// /10.1111/jcpe.12828
Khassawneh, B., Alhabashneh, R., & Ibrahim, F. (2019). The associa-
tion between bronchial asthma and periodontitis: A case-control
study in Jordan. Journal of Asthma, 56(4), 404–410. ht tps ://doi.
org/10.1080/02770 903.2018.1466315
Ledić, K., Marinković, S., Puhar, I., Spalj, S., Popović-G rle, S., Ivić-Kardum ,
M., … Plancak, D. (2013). Periodontal disease increases risk for
chronic obstructive pulmonary disease. Collegium Antropologicum,
37(3), 937–942.
Linden, G. J., Lyons, A., & Scannapieco, F. A. (2013). Periodontal systemic
associations: Review of the evidence. Journal of Periodontology, 84(4
Suppl), S8–S19. https ://
McGowan, J., Sampson, M., Salzwedel, D. M., Cogo, E., Foerster, V., &
Lefebvre, C . (2016). PRESS peer review of elec tronic search strate-
gies: 2015 guideline statement. Journal of Clinical Epidemiology, 75,
40–46. https :// epi.2016.01.021
Melo Neto, J. P., Melo, M. S. A. E., Santos-Pereira, S. A., Mar tinez, E. F.,
Okajima, L. S., & Saba-Chujfi, E. (2013). Periodontal infections and
community-acquired pneumonia: A case-control study. European
Journal of Clinical Microbiology and Infectious Diseases, 32(1), 27–32.
htt ps ://doi.o rg/10.1007/s10096- 012-1710-y
Mendes , V., Dos Santos, G. O., & Moraschini, V. (2018). Interrelation
of periodontal parameters between asthmatics and nonasthmatics
subjects: A systematic review and meta-analysis. Journal of Dentistry,
69, 32–40. https ://
Modesti, P. A., Reboldi, G., Cappuccio, F. P., Agyemang, C., Remuzzi, G.,
Rapi, S., … Parati, G. (2016). Panethnic differences in blood pressure
in Europe: A systematic review and meta-analysis. PLoS ONE, 11(1) ,
e0147601. https :// al.pone.0147601
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group
(2009). Preferred reporting items for systematic reviews and me-
ta-analyses: T he PRISMA st atement. PLoS Medicine, 6(7), e1000097.
0.1371/journ al.pmed.1000097
Moraschini, V., Calasans-Maia, J. A., & C alasans-Maia, M. D. (2018).
Association between asthma and periodontal disease: A systematic
review and meta-analysis. Journal of Periodontology, 89(4), 4 40–455.
htt ps ://doi.o rg /10.1902/ jop.2 017.170363
Page, R. C., & Eke, P. I. (20 07). Case definitions for use in popula-
tion-based surveillance of periodontitis. Journal of Periodontology,
78(7 Suppl), 1387–1399. https :// /10.1902/jop.20 07.060264
Pauwels, R. A., Buist, A. S., Calverley, P. M., Jenkins, C. R., Hurd, S. S.,
& Commit tee, G. S. (2001). Global strategy for the diagnosis, man-
agement, and prevention of chronic obstructive pulmonary disease.
NHLBI/WHO Global Initiative for Chronic Obstr uctive Lung Disease
(GOLD) Workshop summary. American Journal of Respirator y and
Critical Care Medicine, 163 (5), 1256–1276. https ://
Raghavendran, K ., Mylotte, J. M., & Scannapieco, F. A. (2007). Nursing
home-associated pneumonia, hospital-acquired pneumonia and ven-
tilator-associated pneumonia: The contribution of dental biofilms
and periodontal inflammation. Periodontology 2000, 44, 164–177.
https : // .1111/j.16 00 -0757.20 06.0 0206.x
Rothman, K. J., Greeland, S., & Lash, T. L. (2011). Modern epidemiology
(3rd ed). Porto Alegre: Ar tmed.
Sabhar wal, A., Gomes-Filho, I. S., Stellrecht, E., & Scannapieco, F. A.
(2018). Role of periodo nta l therapy in man agement of common com-
plex systemic diseases and conditions: An update. Periodontology
2000, 78(1), 212–226. https ://
Shi, Q., Zhang, B., Xing, H., Yang, S., Xu, J., & Liu, H. (2018). Patients with
chronic obstructive pulmonary disease suffer from worse periodon-
tal health-evidence from a meta-analysis. Frontiers in Physiology, 9,
33. https :// 0033
Si, Y., Fan, H., Song, Y., Zhou, X., Zhang, J., & Wang, Z. (2012). Association
between periodontitis and chronic obstructive pulmonary disease in
a Chinese population. Journal of Periodontology, 83(10), 1288–1296.
https ://
Soledade-Marques, K. R., Gomes-Filho, I. S., da Cruz, S. S., Passos-Soares,
J. D. S., Trindade, S. C., Cerqueira, E. D. M. M., Souza-Machado,
A. (2018). Association between periodontitis and severe as thma in
adults: A case-control study. Oral Diseases, 24(3), 442–448. https ://
doi .org/10.1111/odi .12737
START (2013). State of the art through systematic review - START. (Version
3.3). São Carlos - SP.
Takeuchi, K., Matsumoto, K., Furuta, M., Fukuyama, S., Takeshita, T.,
Ogata, H., … Yamashita, Y. (2019). Periodontitis is associated with
chronic obstructive pulmonary disease. Journal of Dental Research,
98(5), 534–540. htt ps :// 34519 833630
Tâlvan, E. T., Mohor, C., Chisnoiu, D., Cristea, V., & Câmpian, R . S.
(2017). E xpression of interleukin (IL)-1β, IL-8, IL-10 and IL-13 in
chronic adult. Archives of Medicine, 9(3), 4. https ://
1989-5216.100 0219
Tan, L., Wang, H., Pan, C., & Zhao, J. (2016). Periodontal health and
chronic obstructive pulmonar y disease stratified by smoking: A me-
ta-analysis. International Journal of Clinical and Experimental Medicine,
9(12), 23190–23197.
Terashima, T., Chubachi, S., Matsuzaki, T., Nakajima, T., Satoh, M., Iwami,
E., … Betsuyaku, T. (2017). The association between dental health and
nutritional status in chronic obstructive pulmonary disease. Chronic
Respiratory Disease, 14(4), 334–3 41. https :// .1177/14799
7 2 3 1 6 6 4 3 0 7 6
Tonetti, M. S., Chapple, I. L ., Jepsen, S., & Sanz, M. (2015). Primary and
secondary prevention of periodontal and peri-implant diseases:
Introduction to, and objectives of the 11th European Workshop
on Periodontology consensus conference. Journal of Clinical
Periodontology, 42(Suppl 16), S1–S4. https ://
Vadiraj, S., Nayak, R., Choudhary, G. K., Kudyar, N., & Spoor thi, B. R.
(2013). Perio dontal pathogens and respirator y diseases- evaluating
their potential association: A clinical and microbiological study. The
Journal of Contemporary Dental Practice, 14 (4 ), 610 –61 5. h ttps ://doi.
org/10.5005/jp-journ als-10024-1373
Wells, G., Shea, B., O'Connell, D., Peterson, J., Welch, V., Losos, M., &
2014). The Newcastle-Ottawa Scale (NOS) for assessing the quality
of nonrandomised studies in meta-analyses. In. The Ottawa Hospital:
Research Institute.
WHO (2013). Oral health surveys: Basic methods (5th edn). School of
Dentistry, University of São Paulo, Brazil.
Zeng, X. T., Tu, M. L., Liu, D. Y., Zheng, D., Zhang, J., & Leng, W. (2012).
Periodontal disease and risk of chronic obstructive pulmonary dis-
ease: A meta-analysis of observational studies. PLoS ONE, 7(10) ,
e46508. https :// al.pone.0046508
Zhang, J., & Yu, K. F. (1998). W hat's the relative risk? A method of cor-
recting the odds ratio in cohor t studie s of common outcomes. JAMA,
280(19), 1690–1691. https ://
Additional supporting information may be found online in the
Suppor ting Information section.
How to cite this article: Gomes-Filho IS, da Cruz SS, Castro
Trindade S, et al. Periodontitis and respiratory diseases:
A systematic review with meta-analysis. Oral Dis.
2020;26:439–446. https ://
... According to the meta-analysis by Gomes-Filho et al., which included five studies, periodontitis was significantly associated with COPD (adjusted OR = 1.78, 95% CI = 1.04-3.05), and the I 2 was 37.9% (95% CI: 0-79%), indicating moderate between-study variability [23]. They also pointed out that the diagnostic definitions of periodontal disease used in the studies varied. ...
Full-text available
The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide and is currently the third leading cause of death globally. The long-term inhalation of toxic substances, mainly cigarette smoke, deteriorates pulmonary function over time, resulting in the development of COPD in adulthood. Periodontal disease is an inflammatory condition that affects most adults and is caused by the bacteria within dental plaque. These bacteria dissolve the gums around the teeth and the bone that supports them, ultimately leading to tooth loss. Periodontal disease and COPD share common risk factors, such as aging and smoking. Other similarities include local chronic inflammation and links with the onset and progression of systemic diseases such as ischemic heart disease and diabetes mellitus. Understanding whether interventions for periodontal disease improve the disease trajectory of COPD (and vice versa) is important, given our rapidly aging society. This review focuses on the putative relationship between COPD and periodontal disease while exploring current evidence and future research directions.
... Typical taxa of the respiratory system, such as Haemophilus and Pseudomonas, are regularly identified in the infant oral cavity (Segal et al., 2013). Several studies in adults have shown an association between oral bacteria and the risk of respiratory diseases such as influenza, pneumonia, and chronic obstructive pulmonary disease (Scannapieco and Ho, 2001;Pragman et al., 2019;Takeuchi et al., 2019;Gomes-Filho et al., 2020;Imai et al., 2021). This finding indicates that respiratory health may be associated with the oral microbiome. ...
Full-text available
The oral cavity is home to the second most diverse microbiome in the human body. This community contributes to both oral and systemic health. Acquisition and development of the oral microbiome is a dynamic process that occurs over early life; however, data regarding longitudinal assembly of the infant oral microbiome is scarce. While numerous factors have been associated with the composition of the infant oral microbiome, early feeding practices (breastfeeding and the introduction of solids) appear to be the strongest determinants of the infant oral microbiome. In the present review, we draw together data on the maternal, infant, and environmental factors linked to the composition of the infant oral microbiome, with a focus on early nutrition. Given evidence that breastfeeding powerfully shapes the infant oral microbiome, the review explores potential mechanisms through which human milk components, including microbes, metabolites, oligosaccharides, and antimicrobial proteins, may interact with and shape the infant oral microbiome. Infancy is a unique period for the oral microbiome. By enhancing our understanding of oral microbiome assembly in early life, we may better support both oral and systemic health throughout the lifespan.
Aims Brensocatib is a reversible inhibitor of dipeptidyl peptidase 1 (cathepsin C), in development to treat chronic non–cystic fibrosis bronchiectasis. The phase 2, randomized, placebo-controlled WILLOW trial (NCT03218917) was conducted to examine whether brensocatib reduced the incidence of pulmonary exacerbations. Brensocatib prolonged the time to the first exacerbation and led to fewer exacerbations than placebo. Because brensocatib potentially affects oral tissues due to its action on neutrophil-mediated inflammation, we analyzed periodontal outcomes in the trial participants. Materials and Methods Patients with bronchiectasis were randomized 1:1:1 to receive once-daily oral brensocatib 10 or 25 mg or placebo. Periodontal status was monitored throughout the 24-week trial in a prespecified safety analysis. Periodontal pocket depth (PPD) at screening, week 8, and week 24 was evaluated. Gingival inflammation was evaluated by a combination of assessing bleeding upon probing and monitoring the Löe-Silness Gingival Index on 3 facial surfaces and the mid-lingual surface. Results At week 24, mean ± SE PPD reductions were similar across treatment groups: −0.07 ± 0.007, −0.06 ± 0.007, and −0.15 ± 0.007 mm with brensocatib 10 mg, brensocatib 25 mg, and placebo, respectively. The distribution of changes in PPD and the number of patients with multiple increased PPD sites were similar across treatment groups at weeks 8 and 24. The frequencies of gingival index values were generally similar across treatment groups at each assessment. An increase in index values 0–1 and a decrease in index values 2–3 over time and at the end of the study were observed in all groups, indicating improved oral health. Conclusions In patients with non–cystic fibrosis bronchiectasis, brensocatib 10 or 25 mg had an acceptable safety profile after 6 months’ treatment, with no changes in periodontal status noted. Improvement in oral health at end of the study may be due to regular dental care during the trial and independent of brensocatib treatment. Knowledge Transfer Statement The results of this study suggest that 24 weeks of treatment with brensocatib does not affect periodontal disease progression. This information can be used by clinicians when considering treatment approaches for bronchiectasis and suggests that the use of brensocatib will not be limited by periodontal disease risks. Nevertheless, routine dental/periodontal care should be provided to patients irrespective of brensocatib treatment.
Full-text available
Background A possible relationship between periodontitis (PD) and COVID-19 and its adverse outcomes has been suggested. Hence, the present systematic review and meta-analysis aimed to investigate the available evidence regarding the potential association between periodontitis (PD) and COVID-19 and its adverse outcomes. Materials and methods PubMed, Scopus, Web of Science, and Google Scholar were searched for relevant studies published up to April 15 th , 2023. Studies that evaluated the association between PD and COVID-19 were included. Risk of bias was evaluated by two reviewers, and meta-analyses were performed using RevMan 5.3 software. Results A total of 22 studies involving 92,535 patients from USA, Europe, Asia, the Middle East and South America were included; of these, 12 were pooled into the meta-analysis. Most of the studies (19 studies) reported a significant association between PD and COVID-19. The pooled data found a significant association between PD and COVID-19 outcomes: more severe symptoms (OR = 6.95, P = 0.0008), ICU admissions (OR = 3.15, P = 0.0001), and mortality (OR = 1.92, P = 0.21). Additionally, compared to mild PD, severe PD was significantly associated with higher risks of severe COVID-19 outcomes: severe symptoms ( P = 0.02); ICU admission ( P = 0.0001); and higher mortality rates ( P = 0.0001). The results also revealed 58% higher risk for COVID-19 infection in patients with PD ( P = 0.00001). Conclusions The present findings suggest a possible association between poor periodontal health and the risk of poor COVID-19 outcomes. However, owing to the observed methodological heterogeneity across the included studies, further prospective cohort studies with standardized methodologies are warranted to further unravel the potential association between periodontal disease and COVID-19 and its adverse outcomes.
Subject. The subject of this research is the immunological parameters of the blood serum and the oral fluid. Objectives. The objective of this research is to study the levels of serum and oral cytokines TNF-α, IFN-γ, IL-4, MCP-1 in women with secondary amenorrhea for at least one year. Methodology. There were 109 women under the supervision of the Ural State Medical University Department of Preventive Dentistry and Propedeutics of Dental Disease. The main group consisted of 76 women with generalized moderate chronic periodontitis (K05.31)and secondary amenorrhea for at least one year. The control group consisted of 33 post-menopausal women with generalized slight chronic periodontitis in remission. The patients of the both groups underwent laboratory serum and oral fluid testing using enzyme-linked immunosorbent assay. The levels of cytokines TNF-α, IFN-γ, IL-4, MCP-1 were measured in samples using Vector-Best’s tests systems (Vector-Best, Koltsovo, Novosibirsk Region, Russia). The systemic bone mineral density was measured using dual energy X-ray absorptiometry (DXA) with Discovery W QDR Series X-Ray Bone Densitometer (Hologic Inc., USA). Conclusion. The levels of interleikins TNF-α, IFN-γ and chemokine MCP-1 were found to be elevated in the blood serum and the oral fluid of women generalized moderate chronic periodontitis against the background of secondary amenorrhea for at least one year. In contrast, the serum values of IL-4 revealed statistically lower levels in comparison with the same values of IL-4 in the patients from the control group. We defined the statistically significant (at 0.05) correlation between parameters of salivary IL-4 levels and spine bone mineral density, and also the statistically significant (at 0.05) weak negative correlation between parameters of blood IFN-γ levels and right-hip bone mineral density.
Full-text available
Objectives: Studies have suggested contradictory results on the relationship between chronic obstructive pulmonary disease (COPD) and periodontal disease (PD). The aim of this study was to determine whether PD increased the risk of COPD and COPD-related clinical events. Design: A systematic review and meta-analysis. Data sources: PubMed, Ovid EMBASE and Ovid CENTRAL were searched from inception to 22 February 2023. Eligibility criteria for studies: We included trials and observational studies evaluating association of PD with the risk of COPD or COPD-related events (exacerbation and mortality), with statistical adjustment for smoking. Data extraction and synthesis: Two investigators independently extracted data from selected studies using a standardised Excel file. Quality of studies was evaluated using the Newcastle-Ottawa Scale. OR with 95% CI was pooled in a random-effect model with inverse variance method. Results: 22 observational studies with 51 704 participants were included. Pooled analysis of 18 studies suggested that PD was weakly associated with the risk of COPD (OR: 1.20, 95% CI 1.09 to 1.32). However, in stratified and subgroup analyses, with strict adjustment for smoking, PD no longer related to the risk of COPD (adjusting for smoking intensity: OR: 1.14, 95% CI 0.86 to 1.51; smokers only: OR: 1.46, 95% CI 0.92 to 2.31; never smokers only: OR: 0.93, 95% CI 0.72 to 1.21). Moreover, PD did not increase the risk of COPD-related exacerbation or mortality (OR: 1.18, 95% CI 0.71 to 1.97) in the pooled result of four studies. Conclusions: This study demonstrates PD confers no risk for COPD and COPD-related events when strictly adjusted by smoking. Large-scale prospective cohort studies with control of potential confounding factors are warranted to validate the present findings.
Patient well-being encompasses the physical, mental, psychological, and social health of an individual. To adequately treat an individual and increase their quality of life, whole-person, patient-centred care needs to be utilised. This review aims to concisely summarise ways to improve patients' well-being through and in dentistry. Oral health is tied to one's quality of life through oral function, overall health, self-perception, social acceptance, and social interaction. These relationships demonstrate the importance of utilising oral health to increase patient quality of life, unify health professions in patient treatment, use preventative medicine, and empower patients about their health. To do so, the dental profession can increase the scope of practice to provide preventative health screening and education on general health, have more open communication, collaborate with other health care professionals, and have broader consultations. This will allow for better continuity of care and shift the focus of treatment to the whole person instead of a symptom. Whilst there are barriers that need to be resolved and cost feasibility requires more exploration, the potential benefit to patients is apparent.
Full-text available
Objective: Oral health is intricately linked with systemic health. However, the knowledge and practice levels of medical practitioners (MPs) about this concern are extremely variable. The current study, therefore, sought to assess the status of knowledge and practice of MPs concerning the link between periodontal disease and different systemic conditions as well as the efficacy of a webinar as an interventional tool in enhancing knowledge of MPs of Jazan Province of Saudi Arabia. Methods: This prospective interventional study involved 201 MPs. A 20-item questionnaire on evidence-based periodontal/systemic health associations was used. The participants answered the questionnaire before and 1 month after a webinar training that explained the mechanistic interrelation of periodontal and systemic health. McNemar test was performed for statistical analysis. Results: Out of the 201 MPs who responded to the pre-webinar survey, 176 attended the webinar and hence were included in the final analyses. Sixty-eight (38.64%) were female, and 104 (58.09%) were older than 35 years. About 90% of MPs reported not being trained on oral health. Pre-webinar, 96 (54.55%), 63 (35.80%), and 17 (9.66%) MPs rated their knowledge about the association of periodontal disease with systemic diseases as limited, moderate, and good, respectively. Post-webinar, these figures improved remarkably: 36 (20.45%), 88 (50.00%), and 52 (29.55%) MPs rated their knowledge as limited, moderate, and good, respectively. Around 64% of MPs had relatively good levels of knowledge about the positive influence of periodontal disease treatment on diabetic patients' blood glucose levels. Conclusions: MPs revealed low levels of knowledge on the oral and systemic disease interrelationship. Conducting webinars on the oral-systemic health interrelationship seems to improve the overall knowledge and understanding of MPs.
Full-text available
Background The association between periodontitis and post-bronchodilator lung function is unclear. We aimed to determine the associations between symptoms of severe periodontitis (SSP) and post-bronchodilator lung function in the Chinese population. Methods A cross-sectional study (China Pulmonary Health study) was conducted from 2012 to 2015 in a large Chinese nationally representative sample of 49,202 participants aged 20–89 years. Data on demographic characteristics and periodontal symptoms of participants were collected by questionnaire. Participants who had at least one of the two severe symptoms (tooth mobility and natural tooth loss) in the past year were defined to have SSP, which was set as one variable for analyses. Post-bronchodilator lung function data including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were collected by spirometry. Results The values of post-FEV1, post-FVC and post-FEV1/FVC of the participants with SSP were all significantly lower than the participants without SSP (all p < 0.001). SSP were significantly associated with post-FEV1/FVC < 0.7 (p < 0.001). In the multiple regression analyses, SSP were still negatively associated with post-FEV1(b = -0.04, 95%CI (-0.05 -0.03), p < 0.001), post-FEV1/FVC (b = -0.45, 95%CI (-0.63, -0.28), p < 0.001) and significantly associated with post-FEV1/FVC < 0.7 (OR = 1.08, 95%CI 1.01—1.16, p = 0.03) after full adjustment for potential confounders. Conclusions Our data suggest that SSP were negatively associated with post-bronchodilator lung function in the Chinese population. Longitudinal cohort studies are needed to confirm these associations in the future.
Periodontitis is a chronic inflammatory disease caused by Porphyromonas gingivalis and other bacteria, and human periodontal ligament stem cells (hPDLSCs) are a promising candidate for the treatment of periodontal supporting tissue defects. This study aimed to investigate the effect of 1α,25-dihydroxyvitamin D3 [1,25(OH)2VitD3] on osteogenic differentiation of hPDLSCs in an in vitro periodontitis model and whether it can improve inflammatory status. hPDLSCs were in vitro isolated and identified. After treatment with 1,25(OH)2VitD3 and ultrapure pure Porphyromonas gingivalis lipopolysaccharide (LPS-G), the viability of hPDLSCs was detected using Cell Counting Kit-8, the expressions of osteogenic markers and inflammatory genes using Western blotting and quantitative reverse transcription PCR (qRT-PCR), the levels of inflammatory factors in cells using enzyme linked immunosorbent assay (ELISA), and the fluorescence signal intensity of osteoblastic markers and inflammatory genes in cells using immunofluorescence assay. It was found that 1,25(OH)2VitD3 reversed the inhibition of hPDLSCs proliferation by LPS-G; LPS-G exhibited inhibitory effect on ALP, Runx2, and OPN expressions, and such inhibitory effect was significantly weakened when co-acting with 1,25(OH)2VitD3. Meanwhile, LPS-G upregulated the expressions of inflammatory genes IL-1β and Casp1, whereas 1,25(OH)2VitD3 antagonized such an effect and improved the inflammatory status. In conclusion, 1,25(OH)2VitD3 can reverse the inhibitory effect of LPS-G on hPDLSCs proliferation and osteogenic differentiation and suppress LPS-G-induced upregulation of inflammatory gene expressions.
Full-text available
Periodontitis was reported to be associated with chronic obstructive pulmonary disease (COPD), and both diseases are related to smoking. To identify associations between periodontitis, smoking, and COPD, this cross-sectional study enrolled 1474 Japanese men (mean age 55.2 ± 8.9 years) surveyed between 2003 and 2006. Periodontal status was evaluated by using the community periodontal index. Periodontitis was defined as the presence of at least one sextant with a pocket depth ≥4 mm. Lung function was measured by spirometry, and COPD was defined as ratio of forced expiratory volume after 1 second to forced vital capacity of <0.70. Logistic regression analysis showed that the association between COPD and smoking was stronger for men with periodontitis (odds ratio 2.45; 95% confidence interval 1.37-4.37) than for those without periodontitis (odds ratio 1.64; 95% confidence interval 0.91-2.94), after adjusting for age, number of present teeth, body mass index, alcohol intake, occupation, hypertension, and diabetes. The association between smoking and COPD was significant for men with periodontitis but was weaker for those without periodontitis. These findings suggest that periodontitis modifies the association between smoking and COPD.
Full-text available
Background and Objective: It is widely accepted that there is an association between chronic obstructive pulmonary disease (COPD) and periodontitis. However, whether the periodontal status of the COPD patients is worse than that of the non-COPD subjects is seldom assessed. The findings currently available are inconsistent, some even contradictory. Therefore, we performed this meta-analysis to compare the periodontal health status of COPD patients and non-COPD subjects. Methods: PubMed and Embase were searched for all of the eligible studies which comparing the periodontal status between COPD patients and non-COPD subjects. The results of periodontal parameters in each study were extracted and the mean differences and 95% confidence intervals (CIs) for each parameter were calculated to determine their overall effects. Results: In total, 14 studies involving 3348 COPD patients and 20612 non-COPD controls were included and 9 periodontal indexes were analyzed. The mean differences (95% CIs) between COPD and non-COPD subjects for probing depth, clinical attachment loss, level of alveolar bone loss, plaque index, oral hygiene index, bleeding index, bleeding on probing, gingival index, and remaining teeth were 0.261 (0.020–0.501), 0.480 (0.280–0.681), 0.127 (0.000–0.254), 0.226 (0.043–0.408), 0.802 (0.326–1.279), 0.241 (−0.106 to 0.588), 6.878 (5.489–8.266), 0.364 (0.036–0.692), and −3.726 (−5.120 to −2.331), respectively. Conclusion: In summary, this meta-analysis demonstrates that the COPD patients suffer from worse periodontal health status, indicated by deeper periodontal pockets, high level of clinical attachment loss, worse oral hygiene, more inflammation and bleeding in the gingival tissue, and lower number of remaining teeth. Nevertheless, considering the limitations in our meta-analysis, more high-quality, and well-designed studies focusing on the periodontal health of the COPD patients are required to validate our conclusion.
Although they are known to share pathophysiological processes, the relationship between periodontitis and chronic obstructive pulmonary disease (COPD) is not fully understood. The aim of the present study was to test the hypothesis that periodontitis is associated with a greater risk of development of COPD, when smoking is taken into account. The analysis in a 5-y follow-up population-based cohort study was based on 900 community-dwelling Japanese adults (age: 68.8 ± 6.3 [mean ± SD], 46.0% male) without COPD aged 60 or older with at least 1 tooth. Participants were classified into 3 categories according to baseline periodontitis severity (no/mild, moderate, and severe). COPD was spirometrically determined by a fixed ratio of <0.7 for forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) and by FEV 1 /FVC below the lower limit of normal. Poisson regression was used to calculate the relative risk (RR) of developing COPD according to the severity of periodontitis. The population attributable fraction (PAF) was also calculated. During follow-up, 22 (2.4%) subjects developed COPD. Compared with no/mild periodontitis subjects, a significantly increased risk of COPD occurred among severe periodontitis subjects (RR = 3.55; 95% confidence interval [CI], 1.18 to 10.67), but no significant differences were observed between the no/mild and moderate categories (RR = 1.48; 95% CI, 0.56 to 3.90). After adjustment for potential confounders, including smoking intensity, the relationship between severe periodontitis and risk of COPD remained significant (RR = 3.51; 95% CI, 1.15 to 10.74). Likewise, there was a positive association of periodontitis severity with risk of COPD (P for trend = 0.043). The PAF for COPD due to periodontitis was 22.6%. These data highlight the potential importance of periodontitis as a risk factor for COPD. © International & American Associations for Dental Research 2019.
This systematic review and meta-analysis aimed to investigate a possible association between asthma and periodontal disease in adults. This study was conducted by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the searches were performed on the following databases: PubMed, Scopus, Web of Science, Cochrane, LILACS, OpenGrey e Google Scholar. In this systematic review, observational studies with adult humans, which evaluated patients with and without asthma, were selected to verify the association between both diseases. To qualitative analysis, Fowkes and Fulton guidelines was used and for the quantitative analysis, it was used the mean and standard deviation from each group (with and without asthma), using confidence interval (CI) 95% and heterogeneity were tested using I ² index. Furthermore, a summary of the overall strength of evidence was presented using Grading of recommendations, assessment, development, and evaluation (GRADE). 3395 studies were identified, 11 were included on this systematic review to qualitative analysis and 6 of them to quantitative synthesis. Six meta-analyses were performed to the following clinical parameters: plaque index (PI), gingival index (GI), bleeding on probing (BOP), papillary bleeding index (PBI), calculus index (CI), clinical attachment loss (CAL). The meta-analysis results for CI was (p < 0.00001, I2 = 0%) PBI (p < 0.00001, I2 = 0%), CAL (p = 0,03, I ² = 98%) showed higher means for the asthmatic group. For BOP (p = 0.20 I2 = 83%), GI (p = 0.14 I2 = 97%) and PI (p = 0.53 I2 = 95%) non-statistical difference was found. The level of evidence analysis (GRADE) presented a low level of evidence among the clinical parameters. This systematic review and meta-analysis observed that asthmatic individuals present more periodontal disease, especially gingivitis, when compared to healthy individuals, but further studies with similar methods are necessary to evaluate interactions between both diseases.
The goal of this review is to summarize the results of randomized trials reported since 2010 that assessed the effect of periodontal interventions on at least one systemic outcome in human subjects of any age, gender or ethnicity. Oral outcome measures included gingivitis, pocket depth, clinical attachment loss and/or radiographic bone loss and oral hygiene indices. Studies were excluded if the trial was not completed or if treatment was not randomized. The results suggest that nonsurgical periodontal intervention provided to pregnant women is safe and improves periodontal status without preventing adverse pregnancy outcomes. Nonsurgical periodontal intervention was also found to provide modest improvement in glycemic control in individuals with type 2 diabetes mellitus and periodontitis. Also, improving oral care through mechanical or chemical control of dental-plaque biofilm formation can contribute to the prevention of respiratory infections in differing clinical settings, including hospitals and nursing homes, and in patients with chronic obstructive pulmonary disease. No clinical trials were reported that tested the effect of periodontal interventions on medical outcomes of atherosclerosis, cardiovascular diseases, stroke, rheumatoid arthritis, Alzheimer's disease, chronic kidney disease or malignant neoplasia. © 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Objective: Our aim is to study the association between bronchial asthma (BA) and periodontitis in northern Jordan. Methods: A case-control study of 260 subjects; 130 with BA and 130 without BA (controls) were recruited from pulmonary clinics at a university hospital in northern Jordan. BA was physician diagnosed and on anti-asthma medications for ≥12 months. Periodontitis was defined as the presence of ≥ 4 teeth with ≥ 1 site with probing pocket depth (PPD) ≥ 4 mm and clinical attachment level (CAL) ≥ 3 mm. Results: Mean age for the participants was 45.3 years (range, 18–65) and 58.1% were females. Patients with BA had lower education and tended to live in rural areas. Periodontitis was present in 52 (40.0%) patients with BA and 26 (20.0%) in the control group, p<0.005. In binary logistic regression, patients with BA were more likely to have periodontitis than controls (adjusted odd ratio (OR) = 2.91, 95% CI (1.39-6.11), p = 0.005. Patients with BA had higher percentage of sites with: PPD ≥ 3, CAL ≥ 3, and CAL ≥ 4 than controls, p < 0.05. The risk (adjusted OR = 5.27, 95% CI (1.59-17.51) and CAL ≥ 3 were higher in patients on oral corticosteroids compared to inhaled corticosteroids, p<0.05. Conclusions: Bronchial asthma had a positive association with periodontitis, and treatment with oral corticosteroids increased the risk of periodontal disease. Large and longitudinal studies are needed to better identify this significant association.
Background: The aim of this systematic review (SR) is to evaluate the association between asthma and periodontal parameters. Methods: An electronic search without date or language restrictions was carried out in MEDLINE, Cochrane, Web of Science, and LILACS until May 2017. In addition, manual search and in the grey literature were also conducted. The search process, data analysis, and quality assessment were performed by two independent reviewing authors. Eligibility criteria included prospective and retrospective cohort studies, case-controls, and randomized clinical trials. For the meta-analysis, the inverse variance method was used in fixed or random effect models, which were chosen according to heterogeneity. The estimates of the intervention effects were expressed as the mean differences. Results: The search and selection process yielded 21 studies, published between 1979 and 2017. The meta-analysis showed a statistically significant difference for the parameters of gingival bleeding, plaque index, and gingival index for asthmatic participants with P<0.0001, P<0.0001, and P=0.0005, respectively. Conclusions: The data from this SR suggest that asthmatic patients may be more susceptible to negative periodontal changes, althought further high-quality research wuold be welcome.
Aim: To evaluate the association between periodontal disease and pneumonia mortality in hemodialysis patients. Materials and methods: This prospective cohort study included 211 patients (mean age, 64.4 years) undergoing hemodialysis at a single medical center. The patients underwent a baseline clinical dental examination in 2008 and were then followed up until July 2015. Periodontal disease was defined as the presence of clinical attachment loss of ≥4 mm in ≥30% of the probed sites. The primary endpoint, i.e., death from pneumonia, was determined by reviewing death certificates, and was analyzed using the competing-risks regression model. Results: At baseline, 92 patients (43.6%) had periodontal disease. The median follow-up period was 84 months (interquartile range, 36-86 months). Of the 68 deaths that occurred, 21 were from pneumonia. The multivariable competing-risks regression model showed that periodontal disease was significantly associated with death from pneumonia (adjusted subhazard ratio, 3.49; 95% confidence interval, 1.14-10.64), after adjusting for other baseline health characteristics. Conclusions: The results of this study suggest that periodontal disease is independently associated with pneumonia mortality in hemodialysis patients. Future studies evaluating the potential effect of oral interventions for periodontal health improvement on pneumonia in hemodialysis patients would be of great interest. This article is protected by copyright. All rights reserved.
Background: The aim of this systematic review is to evaluate the association between asthma and periodontal disease. Methods: An electronic search without date or language restrictions was carried out in MEDLINE, Cochrane, Web of Science, and LILACS until May 2016. In addition, manual search and in the grey literature were also conducted. The search process, data analysis, and quality assessment were performed by two independent reviewing authors. Eligibility criteria included prospective and retrospective cohort studies, case-controls, and randomized clinical trials. Results: The search and selection process yielded 21 studies, published between 1979 and 2017. The meta-analysis showed a statistically significant difference for the parameters of gingival bleeding, plaque index, and gingival index for asthmatic participants with P<0.0001, P<0.0001, and P= 0.0005, respectively. Conclusions: The data from this systematic review strongly suggest the association of asthma with periodontal disease.