Impact of chronic periodontitis on quality-of-life and on the level of blood metabolic markers.

CONTEXT: Despite the recognition that systemic factors can alter the risk to the chronic periodontitis (CP), only recently has evidence begun to emerge, still under investigation, that infections of the oral cavity are related with low quality-of-life (QoL) and are able to influence the occurrence and severity of certain conditions and systemic diseases. AIMS: The aim of this study was to evaluate the impact of CP on the QoL and on the metabolic systemic condition of CP patients. SETTINGS AND DESIGNS: Cross-sectional, case-controlled, age- and gender-matched study. SUBJECTS AND METHODS: Quality-of-life assessment (Functional Assessment of Chronic Illness Therapy-Fatigue), periodontal examinations and blood tests were obtained from 20 CP patients and 20 age- and gender-matched healthy controls (HC). STATISTICAL ANALYSIS USED: parametric paired t-test for numerical data (metabolic parameters) and nonparametric paired Wilcoxon signed rank test to compare the QoL ordinal data of both groups. Statistical significance was determined at the 0.05 level.
RESULTS: Healthy controls had fewer negative impacts in all QoL areas studied. CP patients showed higher levels of low-density lipoprotein cholesterol, glucose, and uric acid compared with the HC.
CONCLUSIONS: Chronic periodontitis negatively affected the overall well-being and systemic condition of a group of Brazilian individuals.

INTRODUCTION

Oral health significantly influences an individuals’ quality-of-life (QoL). Many studies have shown that the absence of teeth affects food intake as well as social behavior.[12] However, the recognition of the importance of oral health in the welfare of an individual is quite recent;[34] however, this awareness has increased significantly in recent years.

Periodontal diseases are among the most common dental conditions. Chronic periodontitis (CP) is an oral disease that leaves sequels, impairing buccal esthetics and function. Periodontal health is a key element to a harmonious smile, esthetics, and systemic balance. From the psychological point of view, CP generates insecurity, emotional liability, exacerbation of defense mechanisms, which can worsen preexisting diseases, including infectious ones.[5]

Diseases in general have been objectively identified through clinical and laboratory data. However, the subjective nature of their effects has not been fully explored.[6] Epidemiological studies have endeavored to determine the impact caused by many diseases on QoL through specific questionnaires assessing the individual's dental history and his behavioral aspects.[7] Despite the recognition that systemic factors can alter the risk to the CP, only recently has evidence begun to emerge, still under investigation, that infections of the oral cavity are related with low QoL,[8] and are able to influence the occurrence and severity of certain conditions and systemic diseases.[9]

Therefore, the aim of this study was to evaluate the impact of CP on the overall well-being of a group of patients with CP, by evaluating their QoL and some blood metabolic markers compared with healthy individuals.

SUBJECTS AND METHODS

Twenty patients with CP based on the criteria defined by the American Academy of Periodontology,[10] and 20 age- and gender-matched healthy controls (HC) were enrolled in this cross-sectional case–controlled study performed at the Dental Clinic of Center for Health at Veiga de Almeida University (UVA), Rio de Janeiro, Brazil.

All subjects were randomly selected among patients referred for periodontal (CP group) and restorative treatment (HC) at the Dental Clinic, after approval by the Ethics and Research Committee of UVA (CEP/UVA protocol number 285-11), according to the following criteria:

The inclusion criteria for the CP group were the presence of clinical attachment level (CAL) ≥3 mm in at least two proximal sites of two nonadjacent teeth.[11] For the control group: Probing depth (PD) <3 mm in all elements and absence of CAL

The exclusion criteria for the CP group were patients who had received periodontal treatment in the last year and individuals with aggressive periodontitis. And for both groups: Being pregnant or nursing, patients who have a medical condition that could affect the periodontal tissues such as HIV, or any other significant systemic disease that could interfere in the periodontium, patients that had used medications such as nonsteroidal anti-inflammatory, or antibiotic therapy within the last 6 months.

Examiner calibration

Examiner calibration was performed during development of a pilot study that preceded the present investigation. All measures (CAL) and (PD) were carried out by just one examiner at different times, observing intervals of 1-week. All teeth from 8 patients with CP, and six sites per tooth were examined. The inter-class correlation coefficient was 0.82 and 0.84, for CAL and PD, respectively, which indicated an intra-examiner agreement statistically acceptable.

Quality-of-life measurement

The QoL questionnaire (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F], version 4), validated internationally, was used as it contains psychometric properties for evaluation of chronic diseases. FACIT-F was previously tested and validated for use in Portuguese.[1213] In the present study, it aimed to assess whether periodontal changes interfered with an individual's QoL over the last 12 months.

The general issues in the QoL questionnaire are divided into four domains: Physical, social/family, functional, and emotional, containing seven questions per domain, with the following scores (negative impact) for each item: (0) Not at all, (1) a little, (2) more or less, (3) very much, and (4) a lot. For each domain, the scores: 0–10-represent low impact, 11–18-medium impact, and 19–28-high impact.

Periodontal examination

An oral mirror (Trinity, São Paulo, Brazil) and periodontal probe (Trinity) were used for the clinical examination. The distance from the gingival margin to the bottom of the gingival sulcus, was recorded at six points of all teeth, except third molars, three in the buccal (mesiobuccal, buccal, and distobuccal) and three lingual or palatal (mesiopalatal or mesiolingual, lingual or palatal and disto-lingual or disto-palatal). First, the PD was recorded. Then the CAL was recorded adding the value of the gingival recession (distance from the cementoenamel junction to the gingival margin) to the value of PD.

Blood metabolic evaluation

Blood tests were requested of all participants and were carried out in laboratories in Rio de Janeiro, Brazil, following the same methodology. The constituents of the lipid profile were measured by an enzymatic colorimetric method. High-density lipoprotein (HDL) (mg/dL) was obtained by enzymatic colorimetric assay HDL-cholesterol plus (Automation, Modular Roche Diagnostics AG, Mannheim, Germany); low density lipoprotein (LDL) concentrations (mg/dL) were analyzed by Cobas Integra 700 automatic analyzer (Roche Diagnostics, Basel, Switzerland); total cholesterol (mg/dL) was determined enzymatically using an automated procedure (Modular Roche Diagnostics AG, Mannheim, Germany).

The fasting plasma glucose (mg/dL) was determined by the GOD-PAD Automation method (Roche). Uric acid (mg/dL) was measured by a colorimetric test kit Pap 80 (ABX Diagnostic-SP France).

Statistical analysis

Statistical evaluation was done using SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, US). First, the normality of numerical data (metabolic systemic parameters) was evaluated by the Kolmogorov–Smirnov test. Subsequently, the parametric paired t-test was used to compare the means of CP and HC groups. Paired nonparametric Wilcoxon signed rank test was applied to compare the QoL ordinal data of both groups. Statistical significance was determined when P < 0.05.

RESULTS

In the both test (CP) and control (HC) groups, 8 (40%) patients were men and 12 (60%) were women. In CP group, the ages ranged between 35 and 68 years old (mean age and (standard deviation [SD] were 54.3 ± 10.02). In HC group, the ages ranged between 35 and 65 years old (mean age and [SD] were 50.2 ± 8.79).

The QoL assessment showed that the control group had fewer negative impacts in all areas studied in relation to the CP group [Table 1]. It is important to note that the social/familiar domain in the control group had a 14.1 average, indicating medium impact. All other domains in the control group had an average below 11, indicating low impact. In the CP group, only one domain showed medium impact (emotional). All other domains had a high impact.

Table 1

Mean (and SD) of ordinal QoL and numerical BT values of CP and HC patients

The individuals with CP showed statistically higher levels of LDL cholesterol (P = 0.012), glucose (P < 0.001), and uric acid (P = 0.001) compared with the control group. For the other blood tests (HDL, total cholesterol, and triglycerides), significant differences were not observed (P > 0.05) [Table 1].

DISCUSSION

Chronic periodontitis is a chronic infection that produces local and systemic inflammatory responses. The high incidence of CP in the general population has generated increasing interest among researchers not only concerning the local effects, already well-known, but also on its systemic effects.[14] The present cross-sectional case–controlled study found that people with CP have a lower QoL and higher systemic levels of important blood metabolic markers than healthy individuals. In order to limit the influence of confounding factors for CP, cases and controls were matched by age and gender, and smokers were excluded of the study.

Current measures of dental health status are primarily clinical in nature. Information about a patient's symptoms is not routinely collected,[15] although both systemic health and QoL are compromised when oral diseases affect a patient. Several oral-condition specific health status measures have been developed over the last 10 years,[16] however, self-report fatigue questionnaires have rarely been used in dentistry to evaluate the relationships between oral diseases and general aspects of health. As CP clearly affects the general health of individuals, the use of such questionnaires appears to be of interest to study the consequences of CP in terms of well-being and QoL.[17]

The FACIT-F (version 4) questionnaire is currently considered a good tool for assessing the quality of a patients’ life with chronic disease and therefore was chosen for this work to check the impact of CP on the QoL. This questionnaire also allows the identification of small changes in the patients’ perceptions and feelings throughout the observation period, assisting the decisions on how best to direct the therapeutic process.[9] This questionnaire assesses four domains: Physical, social/familiar, emotional, and functional. All the patients with CP had significant higher scores in all areas. Among the results, the physical domain was the one that most affected individuals with CP, especially because of pain; in the questions concerning emotional stress (fear and anxiety) and limitations, the scores for negative impact were approximately double for the CP group compared to control, which was similar to other studies;[61819] in the functional domain, the CP group had a major increase in the items QoL and sleep, agreeing with most other studies investigating these impacts. These results are also in general agreement with other authors, who also linked chronic diseases to lower functional capacity, as well as causing emotional insecurity and instability on the mental status.[468]

The results of the systemic metabolic levels in the healthy group showed that the rates of total cholesterol, for 30% of the group, were on the borderline (200–239 mg/dL), but LDL cholesterol in the CP group was high. It was reported that the level of anxiety and stress associated with a high-calorie diet can lead to increased cholesterol levels.[20] This is in agreement with the findings of this study. In fact, excessive intakes of fat can cause increases in uric acid, triglycerides, and cholesterol.[21] It seems that chronic diseases are related to a liver block. When high serum uric acid levels persist, there may be urate precipitation in the synovial fluid of the temporomandibular joint and periodontal tissue due to the liver block mentioned above.[222324]

Glycemic assessment levels are altered in the CP group compared to the healthy group; these results confirm other studies[2526] which reported that when glycemic decomposition is associated with collagen synthesis and maturation changes of the connective tissue, it promotes the development of periodontal disease and impairs QoL in the physical domain, leading to energy loss, fatigue, dry mouth, and halitosis.

This study, therefore, confirms some previous findings regarding the effects of CP on people's QoL and systemic health, indicating that it is necessary to develop specific programs with strategies that minimize the negative effects of CP. A different philosophical approach, with co-participation of the patient in the therapeutic process, may be the best way to raise responsibility awareness to obtain healing, as well as developing the perceived need to change the patient's perspective on health in all domains (physical, social/familiar, emotional, and functional).

Concluding, CP negatively affected the overall well-being and systemic condition of a group of Brazilian individuals.