Treatment of Periodontal Diseases Reduces Chronic Systemic Inflammation in Maintenance Hemodialysis Patients

Abstract

Background: Evidences suggest that chronic systemic inflammation is associated with increasing mortality in maintenance hemodialysis patients due to atherosclerosis and malnutrition. Periodontal diseases are treatable sources of systemic inflammation in hemodialysis patients. We therefore evaluated the effect of periodontal treatment in maintenance hemodialysis patients. Method: Periodontal diseases were evaluated in 30 stable maintenance hemodialysis patients by using clinical periodontal status by plaque index (PI) and periodontal disease index (PDI). Hematologic, biochemical, nutritional, and dialysis-related parameters as well as highly sensitive C-reactive protein (hs-CRP), a sensitive systemic inflammatory marker, were analyzed before and after periodontal therapy. Result: Maintenance hemodialysis patients had high prevalence of periodontal disease (63%). At baseline, hs-CRP positively correlated with clinical periodontal status (PI, r = 0.74, p < 0.001; PDI, r = 0.66, p < 0.001), but negatively correlated with hemoglobin (r = −0.51, p < 0.001), serum albumin (r = −0.61, p = 0.002), and normalized protein catabolic rate (r = −0.42, p = 0.043). After completion of periodontal therapy (duration 6 ± 2 weeks), the PI and PDI significantly declined from 2.13 to 1.48 (p = 0.001) and 3.53 to 2.52 (p = 0.001), respectively, while hs-CRP significantly declined from 3.8 to 0.6 mg/L (p < 0.001). Moreover, erythropoietin dosage could be reduced from 8000 to 6000 unit/week (p = 0.03) after treatment. Pre-dialysis blood urea nitrogen increased from 66.18 to 79.54 mg/dL (p = 0.003) and serum albumin level increased from 3.15 to 3.38 mg/dL (p = 0.003), reflecting improved nutritional status of the patients after periodontal treatment. Conclusion: Periodontitis is an important source of chronic inflammation. Treatment of periodontal diseases can improve systemic inflammation, nutritional status, and erythropoietin responsiveness in the hemodialysis population.

Effect of Nonsurgical Periodontal Treatment on C-Reactive Protein Levels in Maintenance Hemodialysis Patients

“…These authors related their obtained results to the relatively small number of patients. The findings of their study were consistent with those of Idle et al 43 Siribamrungwong et al 39 found significant decrease in the serum levels of CRP 8 weeks after the completion of periodontal treatment in 30 maintenance hemodialysis patients. Vilela et al 37 also reported the reduction of CRP, IL-6, and prohepcidin levels in both CKD and control patients 12 weeks following periodontal treatment.…”

“…37 There are different studies that reveal the association between high serum levels of CRP and the severity of periodontitis in ESRD who are on hemodialysis. 7,38,39 Although there are numerous studies that have examined the effect of different periodontal treatment modalities on serum CRP levels in chronic periodontitis patients, this is scarcely performed on patients suffering from both periodontitis and CKD. From the first category, many treatment studies show an effect on CRP levels in favor of periodontal treatment.…”

“…This finding was in agreement with the results of some other publications. 37,39 During the study, patients were under observation and no important changes in the lifestyle, habits, medical health, or medications were noticed. So it can be proposed that different degrees of periodontal inflammation that were present in these patients and controlled by treatment, have contributed to their inflammatory burden.…”

Evidence that periodontal treatment improves biomarkers and CVD outcomes

“…Inflammatory serum biomarkers associated with the risk of coronary heart disease in prospective studies Acute-phase reactants High-sensitive C-reactive protein (Ridker et al 1998) Lipoprotein-associated phospholipase A2 (Madjid et al 2010 (Hwang et al 1997) sE-selectin (Hwang et al 1997) Vascular endothelial growth factor Placental growth factor (Lenderink et al 2006) White blood cell counts (Madjid et al 2004) periodontal therapy on WBC (Appendix S4). Christgau et al (1998) failed to show any differences in WBC in patients with diabetes and healthy controls 4 months after periodontal treatment; these findings were confirmed in other trials (Montebugnoli et al 2005, Seinost et al 2005, Marcaccini et al 2009a, Graziani et al 2010, Siribamrungwong & Puangpanngam 2012 (Rastogi et al 2012). That efficacy was further confirmed in three additional clinical trials (Fokkema et al 2003, Hussain Bokhari et al 2009, Piconi et al 2009).…”

The Malnutrition Inflammation Complex Syndrome-The Micsing Factor in the Perio-Chronic Kidney Disease Interlink

“…The recent years have witnessed an emerging evidence which has linked periodontitis to various systemic illnesses and it was confirmed that the periodontal health was poor in haemodialysis patients and that it correlated with the markers of malnutrition and inflammation [21]. The treatment of periodontal diseases reduces the chronic systemic inflammation in maintenance haemodialysis patients [22] by inducing a decline in the systemic inflammatory response [23]. Further studies could evaluate whether the treatment of periodontitis would translate into the amelioration of an inflammatory and protein depletion state and they could confirm a cause-effect relationship which leads to improved outcomes in the haemodialysis population.…”