Associação entre parâmetros de saúde bucal e desfechos cardiovasculares : série de estudos observacionais e análise crítica da medicina periodontal e endodôntica

Abstract

Introduction: The relationship between oral health parameters and cardiovascular outcomes increased in the scientific community over the last decades; however, there are several lacks in the knowledge about this topic. The present thesis aimed to evaluate the association between oral health parameters and cardiovascular outcomes and was divided into six articles: 1- a literature review, updating the knowledge on the association between oral health parameters (periodontitis, AP and tooth loss (TL)) and the occurrence of ischemic stroke (IS); 2- an observational study evaluating the association between TL, carotid atherosclerotic burden (CAB) and functional status in patients with IS or transient ischemic attack (TIA); 3- a case-control study evaluating the association between TL and the occurrence of IS or TIA; 4- an observational study evaluating the association between oral inflammatory burden (OIB) and CAB in patients with IS or TIA; 5- a critical and systematic review of the periodontal and endodontic medicine literature; 6- evaluation of the level of knowledge of internal medicine trainees toward the relationship between oral health and systemic diseases. Methods: In article 1, the PubMed / MEDLINE, LILACS, Scielo, ISI Web of Science and Scholar Google databases were searched, as well as manual searches without language or date restrictions. Animal or in vitro studies, reports and case series were excluded. In article 2, 418 patients diagnosed with IS or TIA were included. TL and CAB were measured through a head and neck agiotomography. The modified Rankin scale (mRS) was used to assess the patient's functional status at discharge. Socio-demographic and medical variables were taken from medical records. The association between TL and CAB and between TL and IS subtypes were estimated by Poisson regression. Cox regression was used to evaluate the association between TL and mRS (α = 5%). In article 3, 458 individuals were included, 229 patients diagnosed with IS or TIA (cases) and 229 patients with no history of cardiovascular disease (CVD) (controls). TL was measured by head and neck agiotomography (cases) and panoramic radiographs (controls). The groups were matched for age and sex, socio-demographic and medical confounding variables were obtained from medical records and by a structured questionnaire. Poisson regression was used to estimate the association between TL and IS or TIA (α = 5%). In article 4, 240 patients diagnosed with IS or TIA were included. Oral parameters (AP, root canal treatment and bone loss) and CAB were measured through a head and neck agiotomography. Confounding variables were taken from medical records. Multivariate analyses were performed to estimate the association between OIB and CAB. In article 5, the PubMed / MEDLINE, EMBASE and COCHRANE databases, as well as manual searches in the bibliographies of the relevant articles and textbooks, were searched, identifying studies on periodontal and endodontic medicine associated with CVD. Based on the inclusion and exclusion criteria, two reviewers identified and extracted data in the articles selected for future analysis. In article 6, a structured questionnaire with 20 questions was applied in 05 scholar hospitals with residency service in Porto Alegre- RS. The questions were elaborated based on previous articles and structured with dichotomous answers or following the Likert scale. Statistical analyses were performed using descriptive statistics and chi-square statistical test, with α = 5%. Results: In article 01, 11 observational clinical studies evaluating the association between different oral health indicators and stroke, as well as a meta-analysis on the subject, were included. No intervention studies were identified. In article 02, multivariate analyses revealed an independent association between severe TL (> 23 missing teeth) with CAB ≥50% (PR = 2.86, 95% CI = 1.19-6.89) and mRS scores (> 2) (HR = 1.97 95% CI = 1.10-3.75). In article 03, the occurrence of IS or TIA was independently associated with hypertension (PR = 2.35, 95% CI = 1.83- 3.02), smoking (PR = 1.60, 95% CI = 1.37-1.88), TL (≥1 & ≤ 8 teeth) (PR = 1.62, 95% CI = 1.19-2.21) and edentulism (PR = 1.91, 95% CI = 1.41-2.58). In article 04, the OIB was independently associated with CAB ≥50% (PR = 2.47, 95% CI = 1.04-5.87). In article 05, of the 2172 articles identified, 155 were selected. The most evidence relating oral health with CVD came from studies evaluating periodontal parameters (n = 100) or TL (n = 31). Most studies (n = 17) evaluating endodontic parameters adjusted the results for buccal confounding variables, in contrast, only 10 studies where the main exposure was the periodontal variable, were adjusted for others buccal covariates. In article 6, 59 questionnaires were applied. Most respondents knew about periodontitis (78%), but are unaware of AP (88%). Only 15.8% of respondents are comfortable with performing a clinical dental examination. Second and 3rd-year residents advise their patients to find dental care more than first-year students (p <0.05). Most respondents agree that physicians should receive more information about the association between oral health and general health. Conclusions: The results of article 01 showed that a causal relationship cannot be confirmed or rejected, considering the lack of interventional studies on the area. In articles 02 and 03, the number of permanent teeth present was inversely and independently associated with a higher level of CAB and the occurrence of IS or TIA respectively. In article 04, OIB was independently associated with CAB ≥50% in patients with IS or TIA. Article 05 has shown that there is consistent evidence on the association between oral health parameters and cardiovascular disease. None of the studies that evaluated periodontitis as the main exposure adjusted for endodontic variables. Futures, interventional trials are necessary to evaluate the impact of the effect of the global oral inflammatory burden as a risk indicator or a potential causal risk factor for CVD. In article 06, the results revealed that the level of knowledge of internal medicine trainees about the relationship between oral health and systemic outcomes is limited. However, there is space for the inclusion of specific oral health education for these professionals, promoting greater interdisciplinarity among health professionals. This thesis contributed to elucidate some gaps existing in the literature regarding the association between oral parameters and cardiovascular outcomes, such as the relation between PD and poorer functional outcome after IS, besides reinforcing the role of endodontic variables in the association between oral health and CVD. Finally, although this epidemiologic field is in evidence in the scientific community, doctors in training still have limited knowledge on the subject.