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ORIGINAL ARTICLE
Ahead of print publication  

Assessment of Periodontal Status in the Patients with Chronic Obstructive Pulmonary Disease (COPD)


1 Consultant Periodontist and Implantologist, D-98/18, Rohini, New Delhi, India
2 Department of Respiratory Medicine, Muzaffarnagar Medical College, Muzaffarnagar, Uttar Pradesh, India
3 Department of Otorhinolaryngology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
4 Department of Respiratory Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
5 Department of Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India

Date of Submission04-Mar-2022
Date of Acceptance11-Jul-2022
Date of Web Publication08-Aug-2022

Correspondence Address:
Devendra Kumar Singh,
Professor, Department of Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_17_22

  Abstract 


Background: Oral infections, especially periodontal diseases, may affect the course and pathogenesis of a number of systemic diseases including respiratory diseases. The current study aimed to determine the periodontal status in the patients with chronic obstructive pulmonary disease (COPD). Materials and Methods: The study consisted of 65 COPD patients (case) and 65 healthy individuals (non-COPD). Individuals in the case group were well-functioning, ambulatory patients having COPD as determined by their history, clinical examination, and spirometry. Periodontal status was evaluated by the indices, namely, simplified oral hygiene index (OHI-S), plaque index (PI), gingival index (GI), pocket probing depth (PPD), and clinical attachment level (CAL) in both the groups. Results: In the studied population, the mean (± standard deviation, SD) age was higher in COPD group (50.3 ± 11.4) compared to the control group (41.9±8.1; P < 0.0001). In the COPD group, average smoking index was 369.3 ± 167.2, while in control group, it was 323.88 ± 132.8 (P = 0.889). Our data show that individuals in the COPD group had significantly higher OHI-S, PI, GI, PPD, and CAL (P < 0.0001) compared with the control group. The mean score of OHI-S, PI, GI, PPD, and CAL was higher in moderate and severe COPD patients compared to mild COPD patients; however, this difference was not statistically significant. Conclusion: The patients with COPD showed poor oral hygiene and a higher prevalence of periodontal disease. Prevention and treatment of periodontal disease could be included in the planned intervention campaigns designed to help patients with COPD.

Keywords: chronic periodontitis, oral hygiene, respiratory diseases, smoking



How to cite this URL:
Shree S, Khan R, Pathak V, Pandey AK, Verma AK, Singh DK. Assessment of Periodontal Status in the Patients with Chronic Obstructive Pulmonary Disease (COPD). MAMC J Med Sci [Epub ahead of print] [cited 2023 Jan 28]. Available from: https://www.mamcjms.in/preprintarticle.asp?id=353658




  Introduction Top


The mouth is a reflection of the lungs. Periodontitis is a chronic devastating disease of gums which occurs due to the bacterial interactions in the host. Chronic obstructive pulmonary disease (COPD) is a chronic lung disease which is the third leading cause of death globally.[1] Subgingival biofilm, common risk factors, and periodontium − cytokine reservoir are major players associated with severity of periodontal diseases. Oral colonization by respiratory pathogens seems to be a risk factor for respiratory disease development.

Recent evidences have suggested that there is an association between periodontal disease and COPD. Scannapieco et al.[2] were among the first researchers to find that both periodontal disease and COPD have similar pathogenic mechanism. Both the diseases are chronic inflammatory diseases with common risk factors such as age, smoking, pathogenic bacteria (e.g., Porphyromonas gingivalis), genetic factors, and socioeconomic factors. Smoking is a major risk factor in COPD as well as periodontal diseases. Increased neutrophils (responsible for inflammation) are found in both the diseases. It has also been suggested that dental plaque may serve as a reservoir for the respiratory pathogens.[3] Bacteria that colonize the supra or subgingival dental plaque are shed into the saliva, which can get aspirated into the lower respiratory tract, where an infection can ensue. Cytokines from periodontal tissues can enter the saliva from gingival crevicular fluid and contribute to the initiation and/or progression of infection in the lung.[4] Hence, it may be possible that periodontal disease activity may contribute to the progression of COPD. However, there is a paucity of sufficient literature in this regard; hence, the present study was conducted to determine the association between periodontal disease and COPD.


  Materials and Methods Top


Study population and design

In the present case–control study, we had screened 157 participants. In which, 65 COPD patients (case), and 65 healthy individuals (control) were selected randomly from the outpatient department (OPD) of the Department of Respiratory Medicine. Study protocol was approved from the ethical committee of the institution. The nature of the study was explained to the each participants and verbal as well as written consent was taken from all the participants. Schematic representation of work is represented in [Figure 1].
Figure 1 Schematic representation of study design.

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Inclusion and exclusion criteria of participants

Inclusion criteria for the COPD group (case) included well-functioning, ambulatory, COPD patients with ≥35 years of age and ≥20 remaining teeth in the oral cavity. For the non-COPD group (control) inclusion criteria included smokers, ≥35 years of age, and not having COPD. Exclusion criteria for the COPD group included patients with an inability to perform pulmonary function test, patients with a history of acute exacerbation of COPD in the previous month, lobectomy, or pneumonectomy, history of periodontal treatment in the past 6 months, patients with systemic diseases or conditions that can modify periodontal disease (e.g., type 1 and type 2 diabetes), and patients using any medication (e.g., antibiotic, corticosteroid, etc.) known to influence periodontal tissue.

Demographic and clinical assessment

Demographic profile including age, sex, address, occupation, thorough medical history, past dental history, and smoking history were recorded for both the groups. Smokers were stratified according to their smoking index.

A detailed medical history of duration, exacerbations, and symptoms of COPD was recorded by the chest physician to diagnose COPD. Chest radiographs were taken as a part of diagnosis. Spirometry was then used to confirm the diagnosis and classify the COPD patients as mild, moderate, severe, and very severe.[5]

Measurement of periodontal parameters was performed by using indices such as simplified oral hygiene index (OHI-S), plaque index (PI), gingival index (GI), pocket probing depth (PPD), and clinical attachment level (CAL) in both the groups. OHI-S was calculated as recommended by Green and Vermillion.[6] Full mouth PI was recorded at four sites of each tooth using Loe.[7] For full mouth GI was determind by Loe[7] at four sites. PPD is the distance from the free gingival margin to the bottom of the pocket/sulcus. CAL is the distance from the cementoenamel junction to the bottom of the pocket/sulcus. PPD and CAL were measured at six sites per tooth by using a graduated Williams’ periodontal probe.

Data analysis

The statistical analysis was performed using Statistical Package for the Social Sciences Version 21.0 (SPSS, Version 21.0 Chicago, SPSS Inc.) software. All the variables were continuous variables which were summarized as mean and standard deviation (SD). The normalities of the data were checked by the Shapiro–Wilk test. Keeping in view the nature (continuous) and distribution (normal) of data, inferential statistics using chi-square test, independent t test, and one-way analysis of variance test were performed.


  Results Top


Detailed demographics and clinical characteristics are depicted in [Table 1]. In the present study, COPD group comprised of 45 (69.2%) males and 20 (30.8%) females while control group had 47 (72.3%) males and 18 (27.7%) females. The mean (± SD) age was higher in case group (50.3 ± 11.4) compared to non-COPD group (41.9 ± 8.1). In the COPD group, average smoking index was 369.3 ± 167.2, while in control group, it was 323.9 ± 132.8.
Table 1 Clinicodemographic profile of COPD and non-COPD group

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The mean OHI-S score, PI score, and GI score were higher in COPD group compared to control group. However, test of significance of the mean values showed that the case group had significantly higher values of PI score compared to control group (P < 0.0001). The mean PPD score and CAL score were significantly higher in case group compared to control group (P < 0.0001) [Table 2] and [Figure 2].
Table 2 Comparison of periodontal parameters of COPD and non-COPD group

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Figure 2 Periodontal parameters of studied population.

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The COPD intragroup comparison was done to evaluate the effect of the periodontal status on severity of the disease condition. The mean score of OHI-S, PI, GI, PPD, and CAL was higher in moderate and severe COPD patients compared to mild COPD patients; however, this difference was not statistically significant [Table 3].
Table 3 Intragroup comparison of periodontal parameters

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  Discussion Top


There has been a growing interest regarding the interaction between periodontal disease and respiratory diseases over the past years. COPD is a ubiquitous disease and is responsible for a significant number of deaths and considerable suffering in humans. The findings of the present study are in accordance with previous studies by Sharma and Shamsuddin[8] and Peter et al.[9] suggesting that patients with COPD had worse periodontal health status.

In this study, the mean age of subjects in the case group was significantly higher than that of the control group, with no significant difference in the smoking status of both groups. Similar results with smoking status as confounding factors were also obtained in a study conducted by Peter et al.[9]

In our study, higher mean OHI-S score and PI score were found in case group compared to control group. These results are similar to the studies by Sharma and Shamsuddin, Peter et al., and Prasanna.[8],[9],[10] The supragingival plaque accumulation may favor respiratory pathogen colonization, making patients more prone to develop respiratory diseases.

The present study also showed significantly higher scores of mean GI in case group. This observation was in line with a study done by Katancik et al.[11] The possible reason for significant positive relationship between GI score and COPD patients could be due to lack of oral hygiene awareness in this population, owing to their low socioeconomic status. However, Scannapieco and Ho[12] reported no significant relationship between gingival bleeding and respiratory disease.A similar observation of increased values of PPD and CAL in case group has been reported by Zeng et al.[13] Ghani and Bhattacharya[14] also observed that subjects with more clinical attachment loss had a higher prevalence of COPD. Here, all periodontal parameters have been observed to increase as severity of lung function impairment increased. Yan et al.,[15] in their study, found a similar strong association between periodontitis and severity of COPD.[16]

The strength of this study includes the factor that individuals enrolled in the case group were those having only COPD and no other systemic disease which could influence periodontal status. Full-mouth examination was done, and patients having <20 teeth were excluded from the study. This eliminated the probability of underestimating the true extent of periodontal disease.

However, the study has some limitations, also. This study cannot completely exclude the possibility of residual confounding by other healthy lifestyle variables. Sample size was lower and single center study was performed. Second, the mean age was statistically significant in case group compared to the control group years. This may be the reason for higher periodontal parameter as periodontal disease is more prevalent in older age group.

Our data concluded that the COPD patients showed poor oral hygiene and a higher prevalence of periodontal diseases. Prevention and treatment of periodontal disease could be included in the planned intervention to help the patients with COPD.

Financial support and sponsorship

Nil.Conflicts of interest

There are no conflicts of interest.









[17]

 
  References Top

1.
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2022 Report). Global Initiative for Chronic Obstructive Lung Disease, Inc; 2022. https://goldcopd.org/2021-gold-reports/. [Assessed on January 19, 2022].  Back to cited text no. 1
    
2.
Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease in a national sample survey population. Ann Periodontol 1998;3:251-6.  Back to cited text no. 2
    
3.
Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol 1996;(Suppl 10S);67:1114-22.  Back to cited text no. 3
    
4.
Linden GJ, Herzberg MC, Working Group 4 of Joint EFP/AAP Workshop. Periodontitis and systemic diseases: a record of discussions of working group 4 of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013;40(Suppl 14);S20-3.  Back to cited text no. 4
    
5.
Jiang S, Shan F, Zhang Y, Jiang L, Cheng Z. Increased serum IL-17 and decreased serum IL-10 and IL-35 levels correlate with the progression of COPD. Int J Chron Obstruct Pulmon Dis 2018;13:2483-94.  Back to cited text no. 5
    
6.
Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7-13.  Back to cited text no. 6
    
7.
Loe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:610-6.  Back to cited text no. 7
    
8.
Sharma N, Shamsuddin H. Association between respiratory disease in hospitalized patients and periodontal disease: a cross-sectional study. J Periodontol 2011;82:1155-60  Back to cited text no. 8
    
9.
Peter KP, Mute BR, Doiphode SS, Bardapurkar SJ, Borkar MS, Raje DV. Association between periodontal disease and chronic obstructive pulmonary disease: a reality or just a dogma? J Periodontol 2013;84:1717-23.  Back to cited text no. 9
    
10.
Prasanna SJ. Causal relationship between periodontitis and chronic obstructive pulmonary disease. J Indian Soc Periodontol 2011;15:359-65.  Back to cited text no. 10
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11.
Katancik JA, Kritchevsky S, Weyant RJ et al. Periodontitis and airway obstruction. J Periodontal 2005;76:2161-7.  Back to cited text no. 11
    
12.
Scannapieco FA, Ho AW. Potential associations between chronic respiratory disease and periodontal disease: analysis of National Health and Nutrition Examination Survey III. J Periodontol 2001;72:50-6.  Back to cited text no. 12
    
13.
Zeng XT, Tu ML, Liu DY, Zheng D, Zhang J, Leng W. Periodontal disease and risk of chronic obstructive pulmonary disease: a meta-analysis of observational studies. PLoS One 2012;7:e46508.  Back to cited text no. 13
    
14.
Ghani B, Bhattacharya HS. To evaluate association between periodontal disease and chronic obstructive pulmonary disease. Indian J Dent Sci 2014;6:41-5.  Back to cited text no. 14
    
15.
Yan Si, Fan H, Song Y, Zhou X, Zhang J, Wang Z. Association between periodontitis and chronic obstructive pulmonary disease in a Chinese population. J Periodontol 2012;83:1288-96.  Back to cited text no. 15
    
16.
Deo V, Bhongade ML, Ansari S, Chavan RS. Periodontitis as a potential risk factor for chronic obstructive pulmonary disease: a retrospective study. Indian J Den Res 2009;20:466-70.  Back to cited text no. 16
    
17.
Verma AK, Pandey AK, Singh A, Kant S, Mahdi AA, Prakash V, Ansari KM, Dixit RK, Chaudhary SC. Increased Serum Levels of Matrix-metalloproteinase-9, Cyclo-oxygenase-2 and Prostaglandin E-2 in Patients with Chronic Obstructive Pulmonary Disease (COPD). Indian J Clin Biochem 2022;37(2):169-177.  Back to cited text no. 17
    


    Figures

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    Tables

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