Periodontitis and COVID-19 complications

periodontitis and covidThe European Federation of Periodontology explores a new study that has found a link between gum disease and COVID-19 complications.

COVID-19 patients are at least three times more likely to experience complications if they also have gum disease, according to research by Marouf and colleagues (2021) published in the Journal of Clinical Periodontology.

The case-control study of more than 500 patients with COVID-19 found that those with gum disease were 3.5 times more likely to be admitted to intensive care. They were 4.5 times more likely to need a ventilator. Also, they were almost nine times more likely to die compared to those without gum disease.

Blood markers indicating inflammation in the body were significantly higher in COVID-19 patients who had gum disease compared to those who did not. This suggests that inflammation may explain the raised complication rates.

‘The results of the study suggest that the inflammation in the oral cavity may open the door to the coronavirus becoming more violent,’ said Professor Lior Shapira, EFP president-elect.

‘Oral care should be part of the health recommendations to reduce the risk for severe COVID-19 outcomes.’

Association between periodontitis and severity of COVID‐19 infection – abstract

Aim

COVID‐19 is associated with an exacerbated inflammatory response that can result in fatal outcomes. Systemic inflammation is also a main characteristic of periodontitis. Therefore, we investigated the association of periodontitis with COVID‐19 complications.

Materials and methods

A case-control study was performed using the national electronic health records of the State of Qatar between February and July 2020. Cases were defined as patients who suffered COVID‐19 complications (death, ICU admissions or assisted ventilation), and controls were COVID‐19 patients discharged without major complications. Periodontal conditions were assessed using dental radiographs from the same database. Associations between periodontitis and COVID-19 complications were analysed using logistic regression models adjusted for demographic, medical and behaviour factors.

Results

In total, 568 patients were included. After adjusting for potential confounders, periodontitis was associated with COVID‐19 complication including death (OR = 8.81, 95% CI 1.00-77.7), ICU admission (OR = 3.54, 95% CI 1.39-9.05) and need for assisted ventilation (OR = 4.57, 95% CI 1.19-17.4). Similarly, blood levels of white blood cells, D‐dimer and C Reactive Protein were significantly higher in COVID‐19 patients with periodontitis.

Conclusion

Periodontitis was associated with higher risk of ICU admission, need for assisted ventilation and death of COVID‐19 patients, and with increased blood levels of biomarkers linked to worse disease outcomes.

Investigating the relationship

Periodontitis, a serious form of gum disease, affects up to half of all adults worldwide (Nazir, 2017). Periodontitis causes inflammation of the gums and, if left untreated, inflammation can spread throughout the body. COVID-19 is associated with an inflammatory response that may be fatal. This study investigated the relationship between periodontitis and COVID-19 complications.

This was a nationwide case-control study conducted in Qatar, which has electronic health records containing medical and dental data. The study included 568 patients diagnosed with COVID-19 between February and July 2020. Of these, 40 had complications (intensive care unit [ICU] admission, ventilator requirement, or death) and 528 did not.

Information was collected on gum disease and other factors that might be associated with COVID-19 complications including:

  • Body mass index (BMI)
  • Smoking
  • Asthma
  • Heart disease
  • Diabetes
  • High blood pressure.

Data were also obtained on blood levels of chemicals related to inflammation in the body.

Of 568 COVID-19 patients in the study, 258 (45%) had gum disease. After adjusting for age, sex, BMI, smoking status, and other conditions, the odds ratios for COVID-19 complications in patients with gum disease, compared to those without gum disease, were 3.67 (95% confidence interval [CI] 1.46-9.27) for all COVID-19 complications, 3.54 (95% CI 1.39-9.05) for ICU admission, 4.57 (95% CI 1.19-17.4) for ventilator requirement, and 8.81 (95% CI 1.00-77.7) for death.

The authors stated: ‘If a causal link is established between periodontitis and increased rates of adverse outcomes in COVID-19 patients, then establishing and maintaining periodontal health may become an important part of the care of these patients.’

Further evidence

One of the study’s authors, Professor Mariano Sanz of the Complutense University of Madrid, Spain, noted that patients with periodontitis can inhale oral bacteria and infect the lungs, particularly in those using a ventilator.

‘This may contribute to the deterioration of patients with COVID-19 and raise the risk of death,’ he said. ‘Hospital staff should identify COVID-19 patients with periodontitis and use oral antiseptics to reduce transmission of bacteria.’

Professor Shapira said that the association between periodontitis and lung diseases including asthma, pneumonia, and chronic obstructive pulmonary disease (COPD) is well established (Gomes-Filho et al, 2020).

He said: ‘This study adds further evidence to the links between oral health and respiratory conditions. Periodontitis is a common disease but can be prevented and treated.’

Professor Nicola West, European Federation of Periodontology (EFP) secretary general, added: ‘This study highlights another association between gum disease and our systemic health and reiterates the need for ongoing, lifelong dental care for people susceptible to gum disease and a strong preventive approach to periodontitis for populations as a whole.’

The study can be found at bit.ly/2Q0KN5o

Preventing periodontitis

  • Brush teeth carefully, more than once a day, using a manual or powered toothbrush
  • Clean between teeth daily using an interdental brush (or floss if the gaps are too tight)
  • Specific mouth rinses or toothpastes can be used on top of cleaning to reduce inflammation
  • Do not smoke, maintain a healthy weight, eat a balanced diet, exercise, reduce stress
  • If you have diabetes, control your blood sugar.

References

Gomes-Filho IS, Cruz SSD, Trindade SC, Passos-Soares JS, Carvalho-Filho PC, Figueiredo ACMG, Lyrio AO, Hintz AM, Pereira MG, Scannapieco F (2020) Periodontitis and respiratory diseases: A systematic review with meta-analysis Oral Dis 26: 439-446

Marouf N, Cai W, Said KN, Daas H, Diab H, Chinta VR, Hssain AA, Nicolau B, Sanz M, Tamimi F (2021) Association between periodontitis and severity of COVID-19 infection: A case-control study J Clin Periodontol 00: 1-9. doi.org/10.1111/jcpe.13435

Nazir MA (2017) Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim) 11(2): 72-80

This article first appeared in Dentistry magazine. You can read the latest issue here.

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