Tooth Loss Patterns in Hypertensive Patients with Chronic Periodontitis

Aim: The aim of the study is to study the tooth loss pattern in patients with chronic periodontitis and hypertension. Study Design: Retrospective cohort study. Materials and Methods: The case sheet records (DIAS data) of tooth loss pattern in hypertensive patients with chronic periodontitis were extracted. A total of 1318 case sheets were analysed for the study. Age, gender and tooth loss pattern with respect to the region were collected and statistically analysed. Descriptive statistics (Percentage, Mean, Standard deviation) and Inferential test (Chisquare test) were performed to determine the association between age, gender and tooth loss pattern in patients with chronic periodontitis and hypertension. Results: The results showed that that females were affected more with tooth loss with hypertension with chronic periodontitis when compared to males. According to age, patients between 50 to 70 years with chronic periodontitis and hypertension were more affected by tooth loss (p value = 0.001 (p<0.05; Statistically significant)). Original Research Article Ravichandran et al.; JPRI, 33(60B): 3856-3862, 2021; Article no.JPRI.78097 3857 Conclusion: The present study highlighted a possible relationship between hypertension and tooth loss due to chronic periodontitis. Loss of mandibular posterior teeth were more common and females were more prone to tooth loss than males with hypertension due to chronic periodontitis. However, the underlying mechanism has to be further investigated in a different study design, thus more conclusive findings would be elucidated.


INTRODUCTION
A beautiful smile is due to the harmonious relationship between the components of the oral cavity such as lips, teeth, and gingiva for all Individuals. Factors hindering this smile among the population is generally tooth loss. Tooth loss is a multifactorial process involving dental caries, periodontal disease, a variety of socio environmental factors, educational levels, access to care and insurance status and general health status.
Hypertension is a major global health disorder affecting about 972 million adults in 2000 and expected to increase to 1.56 billion by the year 2025 [1]. Meanwhile periodontal disease is a group of chronic inflammatory diseases involving soft tissues and bone surrounding the teeth, known as periodontium. It is characterized by inflammation of tooth supporting tissues caused by bacterial infection [2]. Gingivitis is a reversible condition manifested as redness, gum swelling and may progress to periodontitis if left untreated [3].
Hypertension and periodontitis share some common risk factors, such as increased age, smoking, stress and socioeconomic factors. These risk factors may confound the association of the two diseases [4].

MATERIALS AND METHODS
The study group included in the study were local population of Chennai, Tamil Nadu, India. The data comprising of demographic details and tooth loss pattern in hypertensive patients with chronic periodontitis were collected from the duration of June 2019 to April 2020. A total of 1318 case sheets were analysed. The samples were collected by simple random sampling method. Cross verification of data was done. FDI tooth numbering system was followed in this study. Periodontal assessment used a standardized protocol. Baseline data on full-mouth periodontal assessment was retrieved from the case records for all participants. The periodontal examination & diagnosis data of the patients which includes probing depth, clinical loss of attachment, furcation involvement and tooth mobility were analysed.
The inclusion criteria for the Periodontitis patients include moderate to severe periodontitis not >2 teeth missing in each quadrant; greater than or equal to 30% of periodontal sites with periodontal pocket depth greater than or equal to 4 mm; greater than or equal to 20% of periodontal sites with interproximal clinical attachment loss >2 mm; greater than or equal to 30% of sites showing bleeding on probing; tooth mobility and furcation involvement and radiographic evidence of bone loss visible in posterior vertical bitewing films. Exclusion criteria for periodontitis group were individuals who had undergone periodontal treatment in the last 6 months. Inclusion criteria for hypertension are values of systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg, or; the use of antihypertensive medication.
Incomplete and censored data were excluded. The analysis was done using SPSS version 19. The dependent variables were the number of missing teeth. The independent variables were age and gender. The data was statistically analysed using the Chi-square test. The level of significance was set at 0.05.

RESULTS AND DISCUSSION
The result showed that the majority of the hypertensive patients with chronic periodontitis were with missing posterior teeth, in which mandibular first molars were most commonly followed by maxillary first molars and mandibular and maxillary second molars. The results indicated that female patients with hypertension and chronic periodontitis were affected more with tooth loss than males [ Fig. 1]. And also, patients between the age group of 50 to 70 years old were affected more with tooth loss than other age groups [ Fig. 2 Recent evidence suggests a possible causal link between periodontitis and hypertension. Patients with periodontitis often present with higher arterial BP values and a 30% to 70% higher chance to also present with hypertension, especially when there is active gingival inflammation (i.e., with gingival bleeding). The etiological bacterial burden of chronic periodontitis has also been positively associated with blood pressure (BP) and prevalent hypertension. Several studies have reported an association between tooth loss and hypertension [33,34]. Mustafa Al-Ahmad BE et al. in a cross-sectional study found that tooth loss is significantly associated with hypertension in postmenopausal women [35]. A study in Korean population found interaction between tooth loss and ischemic stroke [36]. In a short-term prospective cohort study, a significant association was found between the presence of periodontal disease and hypertension in Japanese university students. But, the risk of prehypertension was not associated with presence of periodontal disease [37]. A recent systematic review reported that the evidence suggesting that the treatment of inflammatory diseases like periodontitis could reduce blood pressure is inconclusive [38]. The authors opinioned that oral health assessment and management of periodontal disease could not only improve oral and overall health and quality of life but also be of relevance in the management of patients with hypertension [32]. A systematic review assessing evidence from Mendelian randomization and a randomized controlled trial of nonsurgical periodontal therapy reported a causal relationship between periodontitis and BP was observed. The authors suggested that this provides proof of concept for the development of clinical trials in a large cohor The bar graph represents the comparison of age of the patients and the number of missing teeth. The X-axis represents the number of missing teeth and the Y-axis represents the number of patients. The colour blue represents the age group of less than 30 years old, Green colour represents the age group of 31 to 50 years old, Yellow colour represents the age group of 51 to 70 years old and the purple colour represents the age group of more than 70 years old of hypertensive patients [39]. Several studies reported that hypertensive subjects exhibited a more detrimental periodontal status compared to control subjects [40,41,42].
The limitations of this study was small sample size and it is a single centered study. It does not represent all ethnic groups or populations. The future scope is to study a larger population and comparison among different ethnic groups. The study further aims at creating awareness and special preventive therapeutic measures for hypertensive patients.

CONCLUSION
The present study highlighted a possible relationship between hypertension and periodontal status. Within the limitations of the study it was seen that mandibular posterior teeth were most commonly missing followed by maxillary posterior teeth. It was also seen that the females were more prone to tooth loss than males with hypertension and chronic periodontitis.
However, the underlying mechanism has to be further investigated in a different study design, thus more conclusive findings would be elucidated.

CONSENT
It is not applicable.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).