Recruited respondents reflect well the demographic profile of visitors to the dental care specialists
Figure 1 demonstrates stratification of 706 patients by age and gender recruited for the study and underwent the specialised survey.
The stratified age groups differ significantly (P < 0.001) regarding the frequency of their visits to the dental care specialists that reflects well general statistics monitored by dental care centres in St. Petersburg, Russia. To this end, the most frequent visitors were young people aged between 18 and 24 years old (35.9% women and 45.8% men). In contrast, the rarest visitors were people aged between 61 to 75 years old (5.7% women and 2.3% men). Regularity and reasons of dental visits by patients in different age groups are outlined in Table 1. One third of the respondents within the participating groups visited a dentist twice a year. Patients aged between 61 to 75 years old visited dentists less than once a year.
Table 1
Frequencyandreasonsofdentalvisitsby patients stratified by age; PAB –level of significance of difference between group A and B; PAC – level of significance of difference between group A and C; PAD– level of significance of difference between group A and D; PBC– level of significance of difference between group B and C; PBD– level of significance of difference between group B and D; PCD– level of significance of difference between group C and D
No | Indicator | | 18 to 24 years old, N = 271 | 25 to 44 years old, N = 226 | 45 to 60 years old, N = 175 | 61 to 75 years old, N = 34 | Significance P |
| Group | | A | B | C | D | |
1 | Frequency of dental visits | Less than once a year | 34(12.5%) | 39(17.3%) | 46(26.3%) | 12(35.3%) | PAB>0,05 PAC<0,01 PAD<0,01 PBC>0,05 PBD>0,05 PCD>0,05 |
Less than twice a year | 54(19.9%) | 34(15.0%) | 27(15.4%) | 3(8.8%) |
Once a year | 84(31.0%) | 76(33.6%) | 53(30.3%) | 7(20.6%) |
twice a year | 99(36.5%) | 77(34.1%) | 49(28.0%) | 12(35.3%) |
2 | Reason for dental visits | Routine oral cavity treatment | 72(26.6%) | 92(40.7%) | 65(37.1%) | 13(38.2%) | PAB>0,05 PAC>0,05 PAD>0,05 PBC<0,001 PBD<0,01 PCD<0,01 |
Acute pain | 24(8.9%) | 20(8.8%) | 35(20.0%) | 6(17.6%) |
Preventive check-up | 175(64.6%) | 114(50.4%) | 75(42.9%) | 15(44.1%) |
Table 1 shows that the routine oral cavity treatment is more often taken by patients between 25 and 44 years old (40.7%). Therefore, in this group, the number of visits to a dentist with acute pain is lower than in other groups. Young people (between 18 and 24 years old) less often than other groups undergo this procedure; however they are most frequent visitors for preventive check-up.
The largest portion of respondents who used to seek medical treatment of acute toothache was registered for groups between 45 and 60 (20%) and between 61 and 75 (17.6%) years old, that corresponds well with the fact that only one third of them take routine oral cavity treatments.
Chronic disorders in stratified patient groups
Responders have been analysed towards their collateral chronic disorders such as cardiovascular diseases, diabetes, gastrointestinal diseases, chronic kidney disease, and liver disease, amongst others. Figure 2 summarises collected data.
Respondents in the oldest group (between 61 and 75 years old) demonstrate the highest level of chronic diseases, namely 87.5% followed by the group between 45 and 60 years old (75.8%).
Oral care preferences in stratified patient groups
Collected statistics demonstrated that 80.2% of respondents considered in all groups taken together clean their teeth twice a day. However, a significant difference (P < 0.05) has been observed between the oldest and youngest groups of patients, namely 29.4% versus 11.1%, respectively. More than a half of respondents replace the toothbrush every two months. However some of them replace the toothbrush only if it wears out, that is more typical for the oldest group (38.1%). The stratified patient groups differ significantly in their preferences towards oral care approach and products as demonstrated in Fig. 3.
Only a toothbrush and toothpaste are used by 10%, 14.2%, 12% and 35.3% of responders in groups A, B, C, and D, respectively, and only toothbrush is used by 15.5 %, 8.4%, 17.1%, 2.9% in corresponding groups. Floss is more frequently used by younger responders in contrast to the mouthwash preferred rather by the oldest group. Noteworthy, 0.6 % of responders in group C do not make any use of the oral hygiene measures.
Data interpretation in the context of 3P Medicine
Periodontal and systemic diseases – the functional link
Periodontal diseases (PDs) are widespread in both – developed and developing countries and affect about 20-50% of world populations. PDs are prevalent through entire age spectrum from adolescence to elderly challenging therefore global public healthcare systems [35]. Periodontal disease is characterised by the destruction of connective tissues of the periodontium and alveolar bone, which may lead not only to local symptoms, but also to systemic diseases, such as cardiovascular diseases, diabetes, liver disease, chronic obstructive pulmonary disease, and several types of cancer [36]. Proposed mechanisms include bacteraemia and concomitant systemic inflammation, elevated C-reactive protein patterns and imbalanced oxidative stress [36, 37]. Risk factors such as poor oral hygiene, irregular dental care, diabetes mellitus, smoking, aging, medication, and stress overload – individually and synergistically promote PDs development in populations [35]. Further, robust evidence demonstrates a reciprocal relationship between PDs development and systemic diseases including but not restricted to systemically altered microbiome and inflammation[37], chronic kidney disease [36, 37], neurodegenerative pathologies [38], bacterial superinfections, pneumonia and sepsis characteristic for viral epidemics such as the actual COVID-19 pandemic condition (see the dedicated subchapter provided below). PDs significantly increase risks of cardiovascular diseases and mortality rates in patients with co-incidence of diabetic history and severe PD forms compared to no or mild PD [39]. Periodontitis is highly relevant for maternal infections, preterm birth, low birth weight, and preeclampsia [35].
Although PDs are characterised by a local inflammatory process, several studies have shown that inflammatory mediators produced during this process, as well as subgingival species and bacterial components, can disseminate from the oral cavity, leading therefore, to various extra-oral diseases including systemic inflammation and cancer [39]. To this end, carcinogenesis associated with periodontal species has been observed in both the oral cavity and in extra-oral sites known as the “oro-digestive” cancer types: oral, esophageal, gastric, colonic, and pancreatic malignancies [39].
Association between periodontal diseases, bacterial overload and poor outcomes of viral infections: Lessons for protective measures under pandemics
Experience collected in the past with influenza outbreaks
During influenza outbreaks, it has been observed that respiratory viruses were associated with bacterial superinfections as the common feature for particularly severe disease course and the primary cause of death opposed to the virus itself as evident, for example, for influenza in 1918, H1N1 influenza in 2009 [40] and others. Periodontopathic microflora has been demonstrated as being implicated in imbalanced microbiome alterations, systemic inflammation and pneumonia development, in severe cases leading to sepsis and death. Contextually, the most optimal treatments utilise the dual antiviral and antibiotic medication [41]. This rich experience actually promotes extensive research activities to explore a potential association between disease course severity and oral hygiene in COVID-19 infected individuals. Preliminary results have been reported during the year 2020.
Association between disease course severity and oral hygiene in COVID-19 infected individuals
Clear association between diagnosed periodontitis and high risk of admission to intensive care units (ICU), need for assisted ventilation and increased COVID-19 related death has been demonstrated [42]. In consensus, the study performed in UK has reported over 50% of deaths in COVID-19 infected patients exhibiting bacterial superinfections and severe disease course [41]. High levels of Prevotella, Staphylococcus and Fusobacterium representing periodontopathic bacteria have been demonstrated specifically for this patient cohort with poor COVID-19 outcomes. To this end, for 80% of patients treated at intensive care units, a particularly high oral bacterial load has been recorded.
Noteworthy, the prominent risk factors and comorbidities linked to the severe disease course and poor outcomes in COVID-19 infected individuals, such as elderly, diabetes mellitus, hypertension and cardiovascular disease, are frequently associated with significantly altered oral microbiome profiles, systemic inflammatory processes and poor oral health [43].
Suggested pathomechanisms consider potential preferences in the interaction between the viral particles and the host microbiota including oral cavity, the respiratory and gastrointestinal tracts [44]. Since an aspiration of periodontopathic bacteria induces the expression of angiotensin-converting enzyme 2 – the receptor for SARS-CoV-2, and production of inflammatory cytokines in the lower respiratory tract, poor oral hygiene and periodontal disease has been proposed as leading to COVID-19 aggravation [45].
Consequently, the issue-dedicated expert recommendations are focused on the optimal oral hygiene as being crucial for improved individual outcomes and reduced morbidity under the COVID-19 pandemic condition [41; 46]. For an effective prevention, an application of oral probiotics have been proposed connecting the gut-lung axis with viral and microbial pathogenesis, inflammation, secondary infections and severe complications linked to COVID-19 [47].