Oral Hygiene and Metabolic Syndrome: History
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Subjects: Endocrinology & Metabolism
Contributor:
Nagy Attila
,
Cornelia Melinda Adi Santoso

Poor oral hygiene is the primary cause of common oral diseases. Accumulation of dental plaque allows bacterial growth that may lead to inflamed periodontal tissues and eventually create bacteremia and systemic inflammation. Invading bacteria from severe caries or endodontic infections is also thought to provoke similar mechanisms.

  • oral hygiene
  • dental plaque
  • oral bacteria
  • tooth brushing
  • interdental cleaning
  • dental visit
  • metabolic syndrome

1. Introduction

Metabolic syndrome (MetS), a clustering of abdominal obesity, hyperglycemia, hypertension, and dyslipidemia, represents a growing public health concern globally [1]. Although the prevalence of MetS differs depending on diagnostic criteria, age group, and ethnicity [1][2], it is estimated to affect around 25% of the world population [2][3]. MetS raises the risk of type 2 diabetes mellitus (T2DM) and cardiovascular diseases [1] and is associated with a 20% increase in healthcare costs [4].

Several risk factors for MetS have been identified. Besides socioeconomic status (SES) [5], smoking [6], diet [7], and physical activity [8], oral diseases, such as periodontal diseases and dental caries, are associated with MetS [9][10][11]. The link between oral and systemic diseases is suggested due to common risk factors, subgingival biofilm harboring Gram-negative bacteria, and periodontium serving as a cytokine reservoir [12].

Tooth brushing and interdental cleaning, which are the main forms of oral self-care, together with regular professional care, are important measures for plaque control or removal and maintaining optimal oral health [13][14][15]. Poor oral hygiene care is associated with low-grade inflammation [16], suggesting its potential link to MetS [17]. The association of poor oral hygiene care with a higher risk of the components of MetS, such as obesity [18], diabetes [19][20], hypertension [20][21], and dyslipidemia [20][22], as well as with cardiovascular disease [23][16], has been demonstrated.

Although several epidemiological studies have reported the association of oral hygiene status [24] and care [17][25] with MetS, some studies found no such association [26][27]. To date, there has not been a systematic review conducted on the topic. A summary of evidence can provide a better understanding of the potential relationship and help healthcare practitioners deliver more targeted care. It can provide more substance for the formulation of public health programs and policies, especially strategies for the prevention and management of MetS.

2. Association between Oral Hygiene Status, Care, and MetS

Figure 1 shows the results of the meta-analysis of associations of oral hygiene status, tooth-brushing frequency, and interdental cleaning with MetS. Good oral hygiene (OR = 0.30; 95% CI = 0.13–0.66), frequent tooth brushing (OR = 0.68; 95% CI = 0.58–0.80), and frequent interdental cleaning (OR = 0.89; 95% CI = 0.81–0.99) were associated with a lower risk of MetS. While heterogeneity was minimal for interdental cleaning (I2 = 27%), there was substantial heterogeneity for oral hygiene status (I2 = 91%) and tooth-brushing frequency (I2 = 89%).
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Figure 1. Meta-analysis of the associations of (a) oral hygiene status, (b) tooth-brushing frequency, and (c) interdental cleaning with metabolic syndrome.
The association between dental visits and MetS was evaluated only in a study by Tanaka et al. It was found that dental visits were not significantly associated with MetS (OR = 1.10; 95% CI = 0.77–1.55) [17].

3. Subgroup Analyses

Table 2 displays the results of subgroup analysis by study design for the association between oral hygiene status and MetS. The inverse association between oral hygiene status and MetS was only observed in the subgroup of case–control studies. Subgroup analysis by study design reduced heterogeneity to less than 50%.
Table 2. Subgroup analysis by study design for the association between oral hygiene status and MetS.
Subgroup Number of Studies OR (95% CI) I2 (%) p
Cross-sectional 2 0.72 (0.41–1.26) 46 0.17
Case–control 3 0.11 (0.06–0.20) 39 0.19
Cohort 1 0.83 (0.59–1.15) - -
MetS, metabolic syndrome; OR, odds ratio; CI, confidence interval; I2, percentage of variation due to heterogeneity; p, p-value for heterogeneity.
Table 3 shows the results of subgroup analyses for the association between tooth-brushing frequency and MetS. Frequent tooth brushing was consistently associated with a lower risk of MetS in all subgroup analyses. However, high heterogeneity was still observed among studies with a cross-sectional design. While subgroup analysis by country reduced heterogeneity, it remained above 50%.
Table 3. Subgroup analyses for the association between tooth-brushing frequency and MetS.
Subgroup Number of Studies OR (95% CI) I2 (%) p
Study design        
Cross-sectional 5 0.67 (0.55–0.81) 93 <0.001
Cohort 2 0.74 (0.62–0.89) 0 0.64
Country        
Japan 5 0.61 (0.52–0.70) 55 0.06
Korea 2 0.85 (0.78–0.93) 73 0.06
MetS, metabolic syndrome; OR, odds ratio; CI, confidence interval; I2, percentage of variation due to heterogeneity; p, p-value for heterogeneity.

4. Conclusion

The association between dental visits and MetS was not demonstrated in the study by Tanaka et al. [17]. This finding was similar to another study demonstrating no associations between dental visits, professional dental cleaning, and diabetes. It was argued that other confounders had more important roles in the development of diabetes than professional dental cleaning [19]. However, an earlier review has demonstrated the benefit of scaling and root planing on metabolic control and systemic inflammation reduction in patients with T2DM [28].
This entry and meta-analysis was the first to explore the association of oral hygiene status and care with MetS. The topic is seen as recent in the scientific literature, with the earliest identified studies published in 2009. It is also related to an emerging interest in the interrelationships between oral pathogens, oral microbiome dysbiosis, and systemic conditions [29]. Exploring this topic is relevant considering the importance of formulating policies with common risk factors approach to address both oral and general health [30]. Another strength of our review was the quality of the studies, which was moderate to high.
The result might be limited by the methodological weakness of the included studies with a cross-sectional design. The number of cohort studies was also limited. Moreover, the restriction of studies to those published in English and the exclusion of a grey literature search might introduce bias. The risk of publication bias could not be ruled out and was not assessed in the current study due to an inadequate number of studies and high heterogeneity. Besides study design and country, the potential source of heterogeneity might be from the variability in measurement methods of oral hygiene status (e.g., the use of different indices) and the reporting of tooth-brushing frequency and interdental cleaning between studies. Moreover, the criteria used to define MetS varied.
Information on tooth-brushing frequency and interdental cleaning was self-reported, which might be prone to bias. However, it might only be the type of nondifferential misclassification, leading to the underestimation of true effect estimates. Regular brushing does not necessarily reflect effective brushing, as the studies did not adjust for the duration and method of tooth brushing and the type of dentifrice used.
Finally, most of the included studies in our review were conducted among an Asian population, which may influence the generalizability of the findings worldwide. Further research conducted among other populations is warranted to provide more evidence. Using a uniform protocol for reporting oral hygiene (e.g., tooth-brushing frequency) may also facilitate better comparison.

This entry is adapted from the peer-reviewed paper 10.3390/jcm10132873

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