Association of chronic periodontitis with metabolic syndrome: A cross-sectional study
Identifieur interne : 003182 ( Pmc/Corpus ); précédent : 003181; suivant : 003183Association of chronic periodontitis with metabolic syndrome: A cross-sectional study
Auteurs : Naresh Kumar ; Ashu Bhardwaj ; Prakash Chand Negi ; Pravesh Kumar Jhingta ; Deepak Sharma ; Vinay Kumar BhardwajSource :
- Journal of Indian Society of Periodontology [ 0972-124X ] ; 2016.
Abstract
Prevalence of metabolic syndrome (MeS) is high among Asians, including Indians and is rising, particularly with the adoption of modernized lifestyle. Various studies have reported a significant relationship between periodontal status and MeS. The objective of this study is to investigate the association between periodontitis and MeS.
The study included 259 subjects (130 cases with chronic periodontitis, 129 controls without chronic periodontitis) who underwent medical and periodontal checkup. Five components (obesity, high blood pressure, low- and high-density lipoproteins, cholesterol, hypertriglyceridemia, and high plasma glucose) of MeS were evaluated, and individuals with ≥3 positive components were defined as having MeS. The periodontal parameter was clinical attachment level (CAL) on the basis of which cases were selected with moderate (CAL loss 3–4 mm) and severe (CAL loss ≥5 mm) generalized chronic periodontitis. The association between chronic periodontitis and MeS components was investigated using odds ratios (ORs) and 95% confidence intervals (CIs).
The association of MeS and chronic periodontitis was strong and significant with OR: 2.64, 95% CI: 1.36–5.18, and
The results of this study suggest that there is a strong association between chronic periodontitis and MeS. The association was independent of the various potential confounding risk factors affecting the chronic periodontitis such as age, sex, residential background, and tobacco consumption.
Url:
DOI: 10.4103/0972-124X.183096
PubMed: 27563208
PubMed Central: 4976555
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Association of chronic periodontitis with metabolic syndrome: A cross-sectional study</title><author><name sortKey="Kumar, Naresh" sort="Kumar, Naresh" uniqKey="Kumar N" first="Naresh" last="Kumar">Naresh Kumar</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Bhardwaj, Ashu" sort="Bhardwaj, Ashu" uniqKey="Bhardwaj A" first="Ashu" last="Bhardwaj">Ashu Bhardwaj</name><affiliation><nlm:aff id="aff2"><italic>Department of Periodontology, Dental Faculty, Jamia Millia Islamia, New Delhi, India</italic></nlm:aff></affiliation></author><author><name sortKey="Negi, Prakash Chand" sort="Negi, Prakash Chand" uniqKey="Negi P" first="Prakash Chand" last="Negi">Prakash Chand Negi</name><affiliation><nlm:aff id="aff3"><italic>Department of Cardiology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Jhingta, Pravesh Kumar" sort="Jhingta, Pravesh Kumar" uniqKey="Jhingta P" first="Pravesh Kumar" last="Jhingta">Pravesh Kumar Jhingta</name><affiliation><nlm:aff id="aff4"><italic>Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Sharma, Deepak" sort="Sharma, Deepak" uniqKey="Sharma D" first="Deepak" last="Sharma">Deepak Sharma</name><affiliation><nlm:aff id="aff4"><italic>Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Bhardwaj, Vinay Kumar" sort="Bhardwaj, Vinay Kumar" uniqKey="Bhardwaj V" first="Vinay Kumar" last="Bhardwaj">Vinay Kumar Bhardwaj</name><affiliation><nlm:aff id="aff5"><italic>Department of Public Health Dentistry, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27563208</idno><idno type="pmc">4976555</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976555</idno><idno type="RBID">PMC:4976555</idno><idno type="doi">10.4103/0972-124X.183096</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">003182</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">003182</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Association of chronic periodontitis with metabolic syndrome: A cross-sectional study</title><author><name sortKey="Kumar, Naresh" sort="Kumar, Naresh" uniqKey="Kumar N" first="Naresh" last="Kumar">Naresh Kumar</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Bhardwaj, Ashu" sort="Bhardwaj, Ashu" uniqKey="Bhardwaj A" first="Ashu" last="Bhardwaj">Ashu Bhardwaj</name><affiliation><nlm:aff id="aff2"><italic>Department of Periodontology, Dental Faculty, Jamia Millia Islamia, New Delhi, India</italic></nlm:aff></affiliation></author><author><name sortKey="Negi, Prakash Chand" sort="Negi, Prakash Chand" uniqKey="Negi P" first="Prakash Chand" last="Negi">Prakash Chand Negi</name><affiliation><nlm:aff id="aff3"><italic>Department of Cardiology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Jhingta, Pravesh Kumar" sort="Jhingta, Pravesh Kumar" uniqKey="Jhingta P" first="Pravesh Kumar" last="Jhingta">Pravesh Kumar Jhingta</name><affiliation><nlm:aff id="aff4"><italic>Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Sharma, Deepak" sort="Sharma, Deepak" uniqKey="Sharma D" first="Deepak" last="Sharma">Deepak Sharma</name><affiliation><nlm:aff id="aff4"><italic>Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author><author><name sortKey="Bhardwaj, Vinay Kumar" sort="Bhardwaj, Vinay Kumar" uniqKey="Bhardwaj V" first="Vinay Kumar" last="Bhardwaj">Vinay Kumar Bhardwaj</name><affiliation><nlm:aff id="aff5"><italic>Department of Public Health Dentistry, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Indian Society of Periodontology</title><idno type="ISSN">0972-124X</idno><idno type="eISSN">0975-1580</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background:</title><p>Prevalence of metabolic syndrome (MeS) is high among Asians, including Indians and is rising, particularly with the adoption of modernized lifestyle. Various studies have reported a significant relationship between periodontal status and MeS. The objective of this study is to investigate the association between periodontitis and MeS.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>The study included 259 subjects (130 cases with chronic periodontitis, 129 controls without chronic periodontitis) who underwent medical and periodontal checkup. Five components (obesity, high blood pressure, low- and high-density lipoproteins, cholesterol, hypertriglyceridemia, and high plasma glucose) of MeS were evaluated, and individuals with ≥3 positive components were defined as having MeS. The periodontal parameter was clinical attachment level (CAL) on the basis of which cases were selected with moderate (CAL loss 3–4 mm) and severe (CAL loss ≥5 mm) generalized chronic periodontitis. The association between chronic periodontitis and MeS components was investigated using odds ratios (ORs) and 95% confidence intervals (CIs).</p></sec><sec id="st3"><title>Results:</title><p>The association of MeS and chronic periodontitis was strong and significant with OR: 2.64, 95% CI: 1.36–5.18, and <italic>P</italic> < 0.003. Comparison of mean values of components of MeS between cases and controls reveals that the mean waist circumference (mean difference: −4.8 [95% CI: 7.75–−1.84], <italic>P</italic> < 0.002) and mean triglycerides level (mean difference: −25.75 [95% CI: −49.22–−2.28], <italic>P</italic> < 0.032) were significantly higher in cases than in control groups. Although mean systolic blood pressure, diastolic blood pressure, and fasting blood sugar level were higher in cases (125.77, 82.99 and 86.38, respectively) compared with control (122.81, 81.3 and 83.68, respectively), it was statistically insignificant.</p></sec><sec id="st4"><title>Conclusion:</title><p>The results of this study suggest that there is a strong association between chronic periodontitis and MeS. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Indian Soc Periodontol</journal-id><journal-id journal-id-type="iso-abbrev">J Indian Soc Periodontol</journal-id><journal-id journal-id-type="publisher-id">JISP</journal-id><journal-title-group><journal-title>Journal of Indian Society of Periodontology</journal-title></journal-title-group><issn pub-type="ppub">0972-124X</issn><issn pub-type="epub">0975-1580</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27563208</article-id><article-id pub-id-type="pmc">4976555</article-id><article-id pub-id-type="publisher-id">JISP-20-324</article-id><article-id pub-id-type="doi">10.4103/0972-124X.183096</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Association of chronic periodontitis with metabolic syndrome: A cross-sectional study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Kumar</surname><given-names>Naresh</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Bhardwaj</surname><given-names>Ashu</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib><contrib contrib-type="author"><name><surname>Negi</surname><given-names>Prakash Chand</given-names></name><xref ref-type="aff" rid="aff3">2</xref></contrib><contrib contrib-type="author"><name><surname>Jhingta</surname><given-names>Pravesh Kumar</given-names></name><xref ref-type="aff" rid="aff4">3</xref></contrib><contrib contrib-type="author"><name><surname>Sharma</surname><given-names>Deepak</given-names></name><xref ref-type="aff" rid="aff4">3</xref></contrib><contrib contrib-type="author"><name><surname>Bhardwaj</surname><given-names>Vinay Kumar</given-names></name><xref ref-type="aff" rid="aff5">4</xref></contrib></contrib-group><aff id="aff1"><italic>Department of Periodontology, Maharaj Ganga Singh Dental College and Research Centre, Sri Ganganagar, Rajasthan, India</italic></aff><aff id="aff2"><label>1</label><italic>Department of Periodontology, Dental Faculty, Jamia Millia Islamia, New Delhi, India</italic></aff><aff id="aff3"><label>2</label><italic>Department of Cardiology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India</italic></aff><aff id="aff4"><label>3</label><italic>Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></aff><aff id="aff5"><label>4</label><italic>Department of Public Health Dentistry, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India</italic></aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Naresh Kumar, Department of Periodontology, Maharaj Ganga Singh Dental College and Research Centre, Sri Ganganagar, Rajasthan, India. E-mail: <email xlink:href="jnishu.naresh@gmail.com">jnishu.naresh@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>May-Jun</season><year>2016</year></pub-date><volume>20</volume><issue>3</issue><fpage>324</fpage><lpage>329</lpage><history><date date-type="received"><day>06</day><month>1</month><year>2015</year></date><date date-type="accepted"><day>19</day><month>4</month><year>2016</year></date></history><permissions><copyright-statement>Copyright: © Journal of Indian Society of Periodontology</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p></license></permissions><abstract><sec id="st1"><title>Background:</title><p>Prevalence of metabolic syndrome (MeS) is high among Asians, including Indians and is rising, particularly with the adoption of modernized lifestyle. Various studies have reported a significant relationship between periodontal status and MeS. The objective of this study is to investigate the association between periodontitis and MeS.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>The study included 259 subjects (130 cases with chronic periodontitis, 129 controls without chronic periodontitis) who underwent medical and periodontal checkup. Five components (obesity, high blood pressure, low- and high-density lipoproteins, cholesterol, hypertriglyceridemia, and high plasma glucose) of MeS were evaluated, and individuals with ≥3 positive components were defined as having MeS. The periodontal parameter was clinical attachment level (CAL) on the basis of which cases were selected with moderate (CAL loss 3–4 mm) and severe (CAL loss ≥5 mm) generalized chronic periodontitis. The association between chronic periodontitis and MeS components was investigated using odds ratios (ORs) and 95% confidence intervals (CIs).</p></sec><sec id="st3"><title>Results:</title><p>The association of MeS and chronic periodontitis was strong and significant with OR: 2.64, 95% CI: 1.36–5.18, and <italic>P</italic> < 0.003. Comparison of mean values of components of MeS between cases and controls reveals that the mean waist circumference (mean difference: −4.8 [95% CI: 7.75–−1.84], <italic>P</italic> < 0.002) and mean triglycerides level (mean difference: −25.75 [95% CI: −49.22–−2.28], <italic>P</italic> < 0.032) were significantly higher in cases than in control groups. Although mean systolic blood pressure, diastolic blood pressure, and fasting blood sugar level were higher in cases (125.77, 82.99 and 86.38, respectively) compared with control (122.81, 81.3 and 83.68, respectively), it was statistically insignificant.</p></sec><sec id="st4"><title>Conclusion:</title><p>The results of this study suggest that there is a strong association between chronic periodontitis and MeS. The association was independent of the various potential confounding risk factors affecting the chronic periodontitis such as age, sex, residential background, and tobacco consumption.</p></sec></abstract><kwd-group><title>Key words</title><kwd>Chronic periodontitis</kwd><kwd>hypertriglyceridemia</kwd><kwd>metabolic syndrome</kwd><kwd>obesity</kwd><kwd>plasma glucose</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>Periodontitis is a chronic infectious disease of the supporting tissues of the teeth, with multiple related factors.[<xref rid="ref1" ref-type="bibr">1</xref>] In recent years, interest has grown regarding the relationship with other systemic conditions to identify some new aspects to improve diagnostic tools and treatment outcomes.[<xref rid="ref2" ref-type="bibr">2</xref>]</p><p>Metabolic syndrome (MeS) consists of a combination of impaired glucose regulation, abdominal obesity, dyslipidemia, and high blood pressure.[<xref rid="ref3" ref-type="bibr">3</xref>] It is estimated that approximately one-fourth of the world's adult population is affected by MeS.[<xref rid="ref4" ref-type="bibr">4</xref>] It is generally accepted that the origin is a pro-inflammatory state derived from excessive calorie intake and over nutrition and other chronic inflammatory diseases. Oxidative stress has been proposed as a potential common link to explain relationship among each component of MeS and periodontitis.[<xref rid="ref5" ref-type="bibr">5</xref>]</p><p>A cross-sectional study conducted by Shimazaki <italic>et al</italic>., in 2007, showed that individuals exhibiting more components of MeS had a higher odds ratio (OR) for a greater periodontal probing depth (PD) and clinical attachment level (CAL).[<xref rid="ref6" ref-type="bibr">6</xref>] In addition, other cross-sectional studies revealed that individuals with MeS had a higher risk for poor periodontal status,[<xref rid="ref7" ref-type="bibr">7</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref12" ref-type="bibr">12</xref>] and those individuals with poor periodontal status had a higher risk for MeS.[<xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref14" ref-type="bibr">14</xref><xref rid="ref15" ref-type="bibr">15</xref><xref rid="ref16" ref-type="bibr">16</xref>]</p><p>Elevated blood levels of inflammatory markers, such as C-reactive protein (CRP) and interleukin (IL)-6, were reported in patients with periodontal disease,[<xref rid="ref17" ref-type="bibr">17</xref><xref rid="ref18" ref-type="bibr">18</xref>] suggesting that periodontal disease is a mild chronic inflammatory disease affecting the systemic conditions.[<xref rid="ref19" ref-type="bibr">19</xref><xref rid="ref20" ref-type="bibr">20</xref>] Aggravation of glucose tolerance in people with deep periodontal pockets was also shown epidemiologically, suggesting that infection with periodontal disease pathogens enhance tumor necrosis factor-alpha (TNF-α) production, induces the prediabetic condition, and leads to abnormal glucose tolerance.[<xref rid="ref21" ref-type="bibr">21</xref>]</p><p>Furthermore, negative influences by lipopolysaccharide and cytokines produced by inflammation, such as TNF-α and IL-1 on lipid metabolism, were reported,[<xref rid="ref22" ref-type="bibr">22</xref>] suggesting that Gram-negative anaerobe-induced periodontal disease has some influence on lipid metabolism. Considering these findings, it is possible that periodontal disease increases the risk of developing MeS as a Gram-negative anaerobe-induced mild chronic inflammatory disease.[<xref rid="ref23" ref-type="bibr">23</xref>] Prevalence of MeS is high among Asians including Indians and is rising, particularly with the adoption of modernized lifestyle.[<xref rid="ref23" ref-type="bibr">23</xref>] However, little information is available on the possible association between periodontitis and MeS as a sole clinical entity in Indian population; this study was carried out to assess the association between MeS and chronic periodontitis.</p></sec><sec sec-type="materials|methods" id="sec1-2"><title>MATERIALS AND METHODS</title><p>The total percentage of rural population in Himachal Pradesh 90.20% of the total population residing in 17,495 inhabited villages. The rural population has limited access to health-care facility as compared to the urban population. Himachal Pradesh has the highest percentage of rural population among all the states of the country with poor socioeconomic status as compared to those residing in urban areas. Per capita income at current prices is Rs. 82,611 as per the recent survey conducted by the Department of Economics and Statistics.</p><sec id="sec2-1"><title>Patients and study design</title><p>The study approved by the Ethics Committee of the H.P. Government Dental College, Shimla, India, had a cross-sectional design. The cases and controls were screened on the basis of CAL according to the American Academy of Periodontology classification system. Subjects meeting the inclusion/exclusion criteria were invited to take part in the study and were provided with the subject information sheet and consent form. Three hundred and seventy-eight subjects were enrolled for the study of duration 22 months. Among all the consecutive patients population referred for care to the outpatient Department of Periodontology and services of H.P. Government Dental College and Hospital, Shimla, India, 119 (out of 378 subjects) patients did not complete the study. The sample used was a convenient sample. Therefore, among the 259 subjects who completed the study, 130 individuals diagnosed with moderate/severe periodontitis were enrolled in the periodontal clinic, whereas 129 patients without periodontitis were invited to participate while attending the oral surgery or restorative clinics and served as nonaffected controls. All subjects gave a written informed consent. Thus, patients with moderate/severe chronic periodontitis formed the study population and those without periodontitis on clinical evaluation formed the control group.</p><p>The cases were screened from individuals who presented with clinical signs of periodontal disease. Periodontal disease was assessed by a comprehensive examination. However, screening of cases, i.e., individuals with moderate/severe periodontitis, was based on mean clinical attachment loss measured at four sites per tooth (mesiobuccal, buccal, distobuccal, and lingual) of the entire dentition except for third molars. Inclusion criteria for the cases were diagnosis of moderate/severe periodontitis based on the 1999 Consensus Classification of Periodontal Disease by Armitage and Thomas F. Flemmig (1999).[<xref rid="ref24" ref-type="bibr">24</xref>]</p><p>Inclusion criteria for cases with moderate/severe chronic periodontitis: (1) Patients with at least 20 teeth and more than 30% of sites exhibiting 3–4 mm of mean clinical attachment loss for moderate chronic periodontitis and more than 30% of sites ≥5 mm of mean clinical attachment loss for severe chronic periodontitis, (2) Minimum age of 20 years, and (3) Patients consenting to participate. Inclusion criteria for controls: (1) The absence of the clinical and radiographic manifestations of periodontal disease, (2) At least, 20 teeth present in the oral cavity and no history of periodontal treatment in the past, (3) Minimum age of 20 years, and (4) Patients consenting to participate.</p><p>Exclusion criteria: (1) Patients not willing to participate in the study, (2) pregnant patients, (3) patients of rheumatic heart disease, congenital heart disease and/or with prosthetic valves who were at high risk for endocarditis, and (4) all patients medically unfit to participate in the study. Nearly 50.19% cases and 49.80% controls participated in the study.</p><p>MeS was diagnosed based on the presence of three of the five following components using modified Adult Treatment Panel III criteria:[<xref rid="ref25" ref-type="bibr">25</xref>] (1) Abdominal/central obesity (as indicated by increased waist circumference or markedly increased body mass index [BMI] and defined as waist circumference with ethnicity-specific values): Waist circumference ≥90 cm in men and ≥80 cm in women (based on a Chinese, Malay, and Asian–Indian population), (2) Hypertriglyceridemia: ≥150 mg/dL (1.69 mmol/L), (3) Low- and high-density lipoprotein cholesterol: <40 mg/dL (1.04 mmol/L) in men; <50 mg/dL (1.29 mmol/L) in women, (4) High blood pressure: ≥130/≥85 mmHg, and (5) High fasting glucose: ≥100 mg/dL (6.1 mmol/L).</p></sec><sec id="sec2-2"><title>Statistical analysis</title><p>SPSS package version 16 (SPSS Inc., Chicago, IL, USA) was used. The value of continuous variables was expressed as mean ± standard deviation. The distribution of discrete variables in patients and control group was expressed as percentages. The significance of difference in mean values of continuous variables between study and control group was estimated by Student's <italic>t</italic>-test. The significance of the difference in the distribution of discrete variables between the groups was estimated with Chi-square test. Association between chronic periodontitis and MeS was estimated by calculating OR with 95% confidence interval (CI). <italic>P</italic> < 0.05 was considered statistically significant.</p></sec></sec><sec sec-type="results" id="sec1-3"><title>RESULTS</title><p>The study is attempted to evaluate the association between MeS and chronic periodontitis in case–control study design. The cases and controls were well matched with insignificant difference for age (mean age: 39.06 vs. 37.9, <italic>P</italic> < 0.475), sex (male: 46.9% vs. 58.9%, <italic>P</italic> < 0.070), residential background (rural: 60.8% vs. 55.8%, <italic>P</italic> < 0.494), educational status (illiterate: 6.2% vs. 3.9%, <italic>P</italic> < 0.578), occupation (employed: 45.39% vs. 41.86%, <italic>P</italic> < 0.655), and tobacco consumption status (current tobacco consumers: 14.6% vs. 11.6%, <italic>P</italic> < 0.597). The prevalence of diabetes (3.1% vs. 0.8%, <italic>P</italic> < 0.37), hypertension (15.4% vs. 13.2%, <italic>P</italic> < 0.741), and coronary artery disease/myocardial infarction (0.8% vs. 1.6%, <italic>P</italic> < 0.622) was also similar in both the two groups [Tables <xref ref-type="table" rid="T1">1</xref>–<xref ref-type="table" rid="T3">3</xref>].</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Clinical characteristics of the study population</p></caption><graphic xlink:href="JISP-20-324-g001"></graphic></table-wrap><table-wrap id="T2" position="float"><label>Table 2</label><caption><p>Clinical characteristics of the study population</p></caption><graphic xlink:href="JISP-20-324-g002"></graphic></table-wrap><table-wrap id="T3" position="float"><label>Table 3</label><caption><p>Risk factors and atherovascular disease distribution among the study population</p></caption><graphic xlink:href="JISP-20-324-g003"></graphic></table-wrap><p>However, the association of MeS and chronic periodontitis was strong and significant with OR: 2.64, 95% CI: 1.36–5.18, and <italic>P</italic> < 0.003 [<xref ref-type="table" rid="T3">Table 3</xref>]. Comparison of mean values of components of MeS and lipid parameters between cases and controls reveals that the mean waist circumference (mean difference: −4.8 [95% CI: −7.75–−1.84], <italic>P</italic> < 0.002), mean total cholesterol level (mean difference: −9.43 [95% CI: −18.72–−0.14], <italic>P</italic> < 0.047), mean triglycerides level (mean difference: −25.75 [95% CI: −49.22–−2.28], <italic>P</italic> < 0.032), and mean LDL level (mean difference: −7.6 [−14.2–−0.99], <italic>P</italic> < 0.024) were significantly higher in cases than in control groups. There was no significant difference in the mean systolic blood pressure (−2.9 [95% CI: −6.7–0.83], <italic>P</italic> < 0.126), diastolic blood pressure (−1.69 [95% CI: −3.87–0.48], <italic>P</italic> < 0.127), and HDLs levels (0.05% [95% CI: −2.43–2.54], <italic>P</italic> < 0.963) in the two groups. Although mean systolic blood pressure, diastolic blood pressure, and fasting blood sugar level were higher in cases (125.77, 82.99, and 86.38, respectively) compared with control (122.81, 81.3, and 83.68, respectively), it was statistically insignificant [<xref ref-type="table" rid="T4">Table 4</xref>]. The observed strong association between chronic periodontitis and MeS is unlikely to be influenced by the tobacco consumption pattern in the study and control groups as comparison of the distribution of tobacco consumption index in two groups was statistically insignificant [<xref ref-type="table" rid="T5">Table 5</xref>].</p><table-wrap id="T4" position="float"><label>Table 4</label><caption><p>Frequency and distribution of biological variables among the study population</p></caption><graphic xlink:href="JISP-20-324-g004"></graphic></table-wrap><table-wrap id="T5" position="float"><label>Table 5</label><caption><p>Frequency and distribution of tobacco consumption index of current tobacco consumers among the subjects with or without metabolic syndrome</p></caption><graphic xlink:href="JISP-20-324-g005"></graphic></table-wrap></sec><sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title><p>The results of this study suggest that there is a strong association of MeS and chronic periodontitis was strong and significant with OR: 2.64, 95% CI: 1.36–5.18, and <italic>P</italic> < 0.003. The association was independent of the various potential confounding risk factors affecting the chronic periodontitis such as age, gender, residential background, and tobacco consumption.</p><p>Chronic periodontitis has been associated with systemic alteration such as low-grade inflammation, dyslipidemia, a procoagulant state, glucose intolerance, and endothelial dysfunction.[<xref rid="ref13" ref-type="bibr">13</xref>] It leads to the state of the chronic systemic inflammatory state through the release of various inflammatory cytokines such as IL-6, IL-1, TNF-α, and CRP, which may worsen the insulin resistance.[<xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref>] Further, the production of oxidative stress-enhancing reactive oxygen species in affected periodontal tissues is a potential factor which could increase insulin resistance [<xref rid="ref5" ref-type="bibr">5</xref>] that may result in MeS. MeS is characterized by state of constellation of metabolic and biological risk factors presumed to be the result of insulin resistance which is thought to be the outcome of the complex interaction of acquired environmental factors related to lifestyle and genetic predisposition.[<xref rid="ref28" ref-type="bibr">28</xref><xref rid="ref29" ref-type="bibr">29</xref>]</p><p>MeS is an independent risk factor for diabetes and atherosclerotic vascular disease.[<xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref28" ref-type="bibr">28</xref><xref rid="ref29" ref-type="bibr">29</xref><xref rid="ref30" ref-type="bibr">30</xref>] The studies also suggested the association between MeS and chronic periodontitis but the exact mechanism is not known.[<xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref><xref rid="ref31" ref-type="bibr">31</xref>] MeS could also be a predisposing factor for chronic periodontitis [<xref rid="ref6" ref-type="bibr">6</xref>] and it can influence the periodontal disease process.[<xref rid="ref13" ref-type="bibr">13</xref>] MeS is known to affect normal vascular function and it may increase the vulnerability for infection because of its predisposition to glucodysregulation.[<xref rid="ref28" ref-type="bibr">28</xref>] Individual risk factors of MeS such as obesity can affect the levels of plasminogen activator inhibitor-1,[<xref rid="ref32" ref-type="bibr">32</xref>] alterations in T-cells and monocytes for macrophage and increased cytokine production, abnormally elevated cytokines IL-6 and -1 and TNF-α,[<xref rid="ref27" ref-type="bibr">27</xref>] all of which contribute to periodontitis. Adipose tissue can produce cytokines and prostaglandins,[<xref rid="ref33" ref-type="bibr">33</xref>] which play an important role in tissue destruction during periodontal disease.[<xref rid="ref34" ref-type="bibr">34</xref>] Lipids and glucose can also deeply affect the immune system. In obese, hypertensive rats, hyperplasia and hypertrophy of the walls of blood vessels supplying the periodontium was observed.[<xref rid="ref35" ref-type="bibr">35</xref>] Thus, all the individual risk factors for MeS either affect the normal periodontium or the periodontal disease process. Conversely, as an infectious process with a prominent inflammatory component, periodontal disease can adversely affect MeS.[<xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref>] Thus, associations between chronic periodontitis and MeS could be bidirectional.</p><p>Thus, observations in present case–control study strongly suggest the significant association between chronic periodontitis and MeS. The underlying cause-and-effect relationship needs to be explored in future interventional studies that would have important implications in management and preventive strategies of both these conditions more effectively. The association between chronic periodontitis and MeS has also been observed by various studies.[<xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref10" ref-type="bibr">10</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref><xref rid="ref31" ref-type="bibr">31</xref>] The finding from this study is in agreement with the findings by Shimazaki <italic>et al</italic>.,[<xref rid="ref6" ref-type="bibr">6</xref>] which reported that MeS among 584 Japanese women was associated with an increased risk for periodontitis. Analysis of data from 13,710 participants in the NHANES III by D'Aiuto <italic>et al</italic>.[<xref rid="ref13" ref-type="bibr">13</xref>] showed a direct relationship between periodontitis and the prevalence of MeS. Khader <italic>et al</italic>.[<xref rid="ref26" ref-type="bibr">26</xref>] showed that the severity of periodontal disease, as measured by average PD and average CAL, and the extent of periodontal disease, as measured by the percentage of sites with CAL ≥3 mm and the percentage of sites with PD ≥3 mm, were significantly greater among patients with MeS compared to those without MeS.</p><p>Thus, the link between MeS and periodontitis could be bidirectional. Oxidative stress lies at the heart of the two-way association. It is generally accepted that the origin of metabolic disorders is in “pro-inflammatory” state derived from excessive caloric intake, over nutrition, and other chronic inflammatory conditions.[<xref rid="ref36" ref-type="bibr">36</xref><xref rid="ref37" ref-type="bibr">37</xref>] The pro-inflammatory status also leads to an increase in oxidative stress, which has potential to impair several crucial biological mechanisms.[<xref rid="ref38" ref-type="bibr">38</xref><xref rid="ref39" ref-type="bibr">39</xref>] A study has demonstrated an increase in the products of oxidative damage in peripheral blood from persons with periodontitis, which emphasized the influence of periodontitis on serum and/or plasma oxidative markers.[<xref rid="ref40" ref-type="bibr">40</xref>] Reduced antioxidant capacity was also found in persons with periodontitis.[<xref rid="ref41" ref-type="bibr">41</xref>] Pro/anti-oxidant capacity between periodontitis and MeS could add the evidence for elucidating the mechanism of the link between periodontitis and MeS. By removing all confounding potential risk factors for periodontitis and MeS, the strong association between the two diseases in our study was not by chance, thus disproving the null hypothesis which was also substantiated by the other previous studies.[<xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref13" ref-type="bibr">13</xref><xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref><xref rid="ref31" ref-type="bibr">31</xref>]</p><sec id="sec2-3"><title>Limitations and suggestions</title><p>The design of the study is such that the causal relationship between periodontal diseases and MeS cannot be identified. Attrition of 119 subjects from the study can lead to important loss of the information of the study. Multiple logistic regression and multivariate analysis were not done which would have helped in finding out the correlation of the different variables in the study. Other confounding variables, for example, in between snacking, lack of exercise, genetics, and hereditary were not included in the study. As the study is conducted in the individuals with more than “20” teeth, the relation between periodontal disease and MeS with <“20” teeth and among edentulous remains unknown. In future, a study should be carried out taking into considerations the above-mentioned facts.</p></sec></sec><sec sec-type="conclusions" id="sec1-5"><title>CONCLUSION</title><p>This study concludes a strong association between chronic periodontitis and MeS. The association was independent of the various potential confounding risk factors affecting the chronic periodontitis such as age, gender, residential background, and tobacco consumption. Keeping in mind this association, dental professionals in general and periodontists in particular should take MeS into consideration when evaluating periodontitis.</p><sec id="sec2-4"><title>Financial support and sponsorship</title><p>Nil.</p></sec><sec id="sec2-5"><title>Conflicts of interest</title><p>There are no conflicts of interest.</p></sec></sec></body><back><ack><title>Acknowledgement</title><p>We would like to thank all the patients who agreed to take part in the study, the administration of the dental college for granting permission to conduct the study, and the statistician for the statistical analysis.</p></ack><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group 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