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Periodontitis, carotid calcifications and future cardiovascular diseases in older individuals
Kristianstad University, Faculty of Health Science, Research environment Oral Health - Public Health - Quality of Life (OHAL). Kristianstad University, Faculty of Health Science, Avdelningen för oral hälsa.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background. Periodontitis is a chronic inflammatory disease with a microbiological etiology affecting the supporting tissues of the tooth. The disease affects approximately 50% of the adult population. The prevalence of periodontitis increases with age. The complex bacterial infection, as well as an exaggerated host inflammatory reaction, may trigger subclinical atherosclerosis. Aims. The overall aim of the present thesis was to study the associations between periodontitis, cardiovascular diseases and mortality. The specific aims were: I) to evaluate the use and value of panoramic radiographs in assessing carotid calcifications in relation to other used methods (gold standards) and to assess the literature on carotid calcifications defined from panoramic radiographs and concurrent diagnosis of stroke and periodontitis, II) to evaluate if periodontitis is associated with the presence of carotid arterial calcifications diagnosed on panoramic radiographs in an elderly population, III) to assess if carotid calcifications detected on panoramic radiographs are associated with future events of stroke, and/or ischemic heart diseases over 10–13 years in individuals between 60 and 96 years, IV) to assess if individuals ≥ 60 years of age with periodontitis are more likely to develop stroke or ischemic heart diseases or are at higher risk of death over a period of 17 years. Methods: A literature review based on peer-reviewed studies was performed evaluating the use of panoramic radiographs in assessing carotid calcifications compared to other methods. In study II, III, IV older individuals, 60 years and older participating in the Swedish National Study of Aging and Care (SNAC) were included in the studies. A dental hygienist performed a dental clinical and radiographic examination. Probing depths (PD) and bleeding on probing (BOP) was registered. From radiographic panoramic images, the distances between the alveolar bone level and the cement enamel junction (CEJ) were measured. In study II, a diagnosis of periodontitis was declared, using a composite definition; if a distance between the alveolar bone level and the CEJ ≥5 mm on panoramic radiographs at >10% of sites and PD ≥5 mm at one or more teeth and with BOP >20% of teeth. In study IV, an indicator of a history of periodontal disease was declared if a distance between the alveolar bone level and the CEJ ≥5 mm on panoramic radiographs at ≥30% of sites. Evidence of a radiopaque nodular mass in the intervertebral space at or below the vertebrae C3-C4 was identified as carotid calcification. In addition, a medical research team performed the medical examinations, and a medical doctor (JB) reviewed all medical records for information about events of stroke and ischemic heart diseases. Stroke and ischemic heart diseases were registered according to the ICD 10 codes: ICD 60-69 for stroke and ICD: 20-25 for ischemic heart diseases. Study I was a review of the literature, in study II, a cross-sectional study design was employed. In studies III and IV, a longitudinal prospective study design was used. Results: On the use of panoramic radiographs in assessing carotid calcifications in relation to other used methods, the sensitivity and specificity varied between studies published. Furthermore, only a small number of studies were found concerning carotid calcifications and stroke. These studies were primarily retrospective. Four studies were found on the association between periodontitis and carotid calcification. Study II identified that older individuals with periodontitis had a significantly higher prevalence of carotid calcifications than individuals who did not have a diagnosis of periodontitis. In study III, a significant association was found between carotid calcifications on panoramic radiographs and 13- year incidence of stroke using a logistic regression analysis adjusted for confounders (BMI, diabetes type 2, hypertension) in the 60-72 years. A statistically significant crude association between radiographic evidence of carotid calcifications and incidence of ischemic heart diseases was found in individuals between 60-72 years. Such an association was, however, not identified among individuals older than 72 years. In study IV, Cox regression analysis was used, adjusted for confounders (age group, BMI >30, diabetes type 2, gender, hypertension, history of AMI, history of stroke, periodontitis, smoking) and with a definition of periodontitis as having a distance between the alveolar bone level and the CEJ ≥5 mm in panoramic radiographs at ≥ 30% of sites. Periodontitis increased the risk for ischemic heart diseases in all individuals, in women and in the 78-96 years age group (OO). Associations between periodontitis, and mortality were found in all individuals, in men and in the 60-72 years age group (YO) in the long term follow-up. Conclusions: 1. 1. Study I identified that there are studies which have assessed the value of panoramic radiographs in relation to other used methods (gold standards). The sensitivity and the specificity varied, with the specificity being more often higher. Few studies have considered the relationship between radiographic evidence of carotid calcifications and stroke. Four studies identified a relationship between a diagnosis of periodontitis and carotid calcifications on panoramic radiographs. 2. Study II identified a significant association between periodontitis and carotid calcification in individuals 60-96 years. 3. Study III identified that signs of carotid calcifications assessed from panoramic radiographs from the 60-96-year-old individuals were consistent with an incident of stroke and/or ischemic heart diseases over 13 years follow-up. 4. Study IV identified that periodontitis was associated with future ischemic heart diseases in all individuals, in women and in the 78- 96 years age group. Periodontitis was associated with mortality in all indviduals, in men and in the 60-72 years age group.

Place, publisher, year, edition, pages
Malmö: Malmö universitet, Avdelningen för parodontologi & Högskolan i Kristianstad, Fakulteten för hälsovetenskap , 2019. , p. 69
National Category
Dentistry
Identifiers
URN: urn:nbn:se:hkr:diva-20119DOI: 10.24834/978-91-7877-021-2Libris ID: cn798fz59j958ljsISBN: 9789178770205 (print)OAI: oai:DiVA.org:hkr-20119DiVA, id: diva2:1371535
Public defence
2019-11-29, 11:00
Supervisors
Available from: 2019-11-20 Created: 2019-11-20 Last updated: 2019-11-20Bibliographically approved
List of papers
1. Assessment of carotid calcifications on panoramic radiographs in relation to other used methods and relationship to periodontitis and stroke: a literature review
Open this publication in new window or tab >>Assessment of carotid calcifications on panoramic radiographs in relation to other used methods and relationship to periodontitis and stroke: a literature review
2014 (English)In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 72, no 6, p. 401-412Article, review/survey (Refereed) Published
Abstract [en]

Objectives. To assess the literature on carotid calcifications defined from panoramic radiographs (PMX) and concurrent diagnosis of stroke and periodontitis.

Materials and methods. A literature search screening for publications using search terms such as PMX and carotid calcification, stroke and periodontitis was performed in November 2012.

Results. A total of 189 articles were retrieved, among which 30 were included in the review. The sensitivity for PMX findings of carotid calcifications (CC) compared to a diagnosis by Doppler sonography varied between 31.1–100%. The specificity for PMX findings of carotid calcifications compared to a diagnosis by Doppler sonography varied between 21.4–87.5%. Individuals with CC findings from PMX have more periodontitis and risk for stroke.

Conclusions. There is a shortage of well-designed studies in older dentate individuals assessing the associations between periodontitis and radiographic evidence of CC and in relation to stroke or other cardiovascular diseases.

Statement of Clinical Relevance. Carotid calcifications are prevalent in patients with periodontitis and such individuals may have an increased risk for stroke. The absence of signs of carotid calcification on panoramic radiographs is indicative of no calcification of carotid arteries.

Keywords
panoramic radiograph, carotid calcification, periodontitis, review
National Category
Dentistry
Identifiers
urn:nbn:se:hkr:diva-11659 (URN)10.3109/00016357.2013.847489 (DOI)000340259700001 ()24432815 (PubMedID)
Available from: 2014-01-21 Created: 2014-01-21 Last updated: 2019-11-20Bibliographically approved
2. A cross-sectional study of the associations between periodontitis and carotid arterial calcifications in an elderly population
Open this publication in new window or tab >>A cross-sectional study of the associations between periodontitis and carotid arterial calcifications in an elderly population
2015 (English)In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 74, no 2, p. 115-120Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate if the presence of periodontitis is associated with carotid arterial calcifications diagnosed on panoramic radiographs in an elderly population.

MATERIALS AND METHODS: Study individuals were randomly selected from the Swedish civil registration database representing the aging population (60-96 years) in Karlskrona, Sweden. Bleeding on probing (BOP) and the deepest probing measurement at each tooth were registered. The proportions of teeth with a probing depth ≥5 mm and the proportion of teeth with bleeding on probing were calculated. Analog panoramic radiographs were taken and the proportion of sites with a distance ≥5 mm between the alveolar bone level and the cement-enamel junction (CEJ) were assessed. A diagnosis of periodontitis was declared if a distance between the alveolar bone level and the CEJ ≥5 mm could be identified from the panoramic radiographs at >10% of sites, probing depth of ≥5 mm at one tooth or more and with BOP at >20% of teeth.

RESULTS: Readable radiographs were obtained from 499 individuals. Carotid calcification was identified in 39.1%. Individuals were diagnosed with periodontitis in 18.4%. Data analysis demonstrated that individuals with periodontitis had a higher prevalence of carotid calcifications (Pearson χ (2) = 4.05 p < 0.05) and with a likelihood of 1.5 (95% CI = 1.0, 2.3, p < 0.05).

CONCLUSIONS: Data analysis demonstrated a significant association between periodontitis and carotid calcification.

Keywords
Carotid arterial calcifications, panoramic radiographs, periodontitis
National Category
Dentistry
Identifiers
urn:nbn:se:hkr:diva-14053 (URN)10.3109/00016357.2015.1050603 (DOI)000366811600006 ()26066062 (PubMedID)
Available from: 2015-06-17 Created: 2015-06-17 Last updated: 2019-11-20Bibliographically approved
3. Carotid calcifications in panoramic radiographs are associated with future stroke or ischemic heart diseases: a long-term follow-up study
Open this publication in new window or tab >>Carotid calcifications in panoramic radiographs are associated with future stroke or ischemic heart diseases: a long-term follow-up study
2019 (English)In: Clinical Oral Investigations, ISSN 1432-6981, E-ISSN 1436-3771, Vol. 23, no 3, p. 1171-1179Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To assess if carotid calcifications detected in panoramic radiographs are associated with future events of stroke, and/or ischemic heart diseases over 10-13 years in individuals between 60 and 96 years.

MATERIALS AND METHODS: Baseline (2001-2004) panoramic radiographs were assessed for evidence of carotid calcifications from individuals with no previous history of stroke and/or ischemic heart diseases. A radiopaque nodular mass adjacent to the cervical vertebrae, at or below the intervertebral space C3-C4, was interpreted as carotid calcification. Annual medical records were searched for ICD 10 codes through 2014.

RESULTS: Signs of carotid calcification was demonstrated in 238/635 (37.5%) of the study individuals. Signs of carotid calcification was associated with future stroke and/or ischemic heart diseases (χ2 = 9.1, OR 1.6, 95% CI 1.2, 2.2, p < 0.002). In individuals 60-72 years, a significant association between radiographic signs of carotid calcification and stroke and/or ischemic heart diseases (χ2 = 12.4, OR 2.4, 95% CI 1.5, 4.0, p < 0.000) (adjusted for high blood pressure, diabetes type 2, BMI; OR 1.9, 95% CI 1.1, 3.5, p = 0.03). Individuals (60-72 years) with radiographic evidence of carotid calcifications had a mean cumulative stroke and/or ischemic heart diseases survival time of 12.1 years compared to those without such evidence (13.0 years) (log rank Mantel-Cox χ2 = 10.7, p = 0.001).

CONCLUSIONS: Evidence of carotid calcifications in panoramic radiographs is associated with an event of stroke and/or ischemic heart diseases in 60-96-year-old individuals.

CLINICAL RELEVANCE: Radiographic evidence of carotid calcifications is associated with stroke and/or ischemic heart diseases. Patients with signs of carotid calcifications should therefore be referred for medical examination.

Keywords
Carotid calcification, Ischemic heart diseases, Panoramic radiographs, Stroke
National Category
Dentistry
Identifiers
urn:nbn:se:hkr:diva-19476 (URN)10.1007/s00784-018-2533-8 (DOI)29967974 (PubMedID)
Available from: 2019-06-25 Created: 2019-06-25 Last updated: 2019-11-20Bibliographically approved

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