Abstract
Background/purpose
The relationship between Vitamin D (VD) and periodontitis in patients with metabolic syndrome (MetS) was unclear. This study was to investigate the relationship between VD and periodontitis in MetS patients.
Materials and methods
This cross-sectional study collected the data of 2165 MetS patients from the National Health and Nutrition Examination Survey (NHANES). The weighted univariate and multivariable Logistic regression models were applied to identify covariates and evaluate the association between 25-hydroxy vitamin D (25(OH)D) [25(OH)D]2 + 25(OH)D3 and periodontitis in patients. Odds ratio (OR) [95% confidence interval (CI)] was effect size. Subgroup analysis was performed in people with or without diabetes, dyslipidemia, hypertension, cardiovascular disease (CVD) and central obesity groups.
Results
In the unadjusted model, compared with patients with 25(OH)D2 + 25(OH)D3 < 50 nmol/L, those with 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L might be associated with decreased risk of periodontitis in MetS patients (OR = 0.70, 95% CI: 0.57–0.85). After adjusting for confounders including age, gender, race, education, poverty income ratio (PIR), smoking, diabetes, VD intake and supplement and number of missing teeth, 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was correlated with reduced risk of periodontitis in MetS patients (OR = 0.76, 95% CI: 0.60–0.97). Subgroup analysis revealed that in patients with CVD (OR = 0.60, 95% CI: 0.37–0.98), dyslipidemia (OR = 0.75, 95% CI: 0.57–0.97), and patients with central obesity (OR = 0.73, 95% CI: 0.57–0.95), decreased risk of periodontitis was identified in 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L.
Conclusion
VD was associated with the risk of periodontitis in patients with MetS, which suggest the importance of VD supplement in patients with MetS and provide a reference for the management of periodontitis in patients with MetS.
Keywords: Vitamin D, Periodontitis, Metabolic syndrome
Introduction
Periodontitis is the most prevalent disease of the oral cavity, and has emerged as a significant public health concern with an estimated global prevalence rate of 27%.1 Patients with periodontitis are at an increased risk of tooth loss and masticatory dysfunction, which may negatively affect their quality of life.2 Metabolic syndrome (MetS) is one of the non-communicable diseases known to be associated with periodontitis.3 Han et al. reported a 48.8% prevalence of periodontitis in individuals with MetS.4 The risk of periodontitis was significantly increased in patients with MetS compared with those without,5,6 and the risk was elevated gradually with the number of MetS components.7 To explore related factors that may affect the occurrence and development of periodontitis in patients with MetS is necessary.
Vitamin D (VD) level was recognized to be associated with the occurrence and development of a variety of inflammation-related chronic diseases.8 There was evidence identified that serum 25-OH-vitamin D3 (25(OH)D3) levels were significantly reduced in patients with chronic periodontitis,9 but the findings were not conducted in patients with MetS. Another study also found that insufficient VD supplement was associated with increased inflammation levels in patients with MetS.10 In diabetic patients with periodontitis, serum 25(OH)D3 levels were negatively correlated with the levels of inflammatory cytokines and the severity of periodontitis.11 The relationship between VD levels and the risk of periodontitis in patients with MetS was still unclear.
This study aimed to investigate the relationship between VD levels and the risk of periodontitis in patients with MetS based on the data from the National Health and Nutrition Examination Survey (NHANES) database. Subgroup analysis was performed according to the complications including diabetes, dyslipidemia, hypertension, and cardiovascular disease (CVD) and people with or without central obesity.
Materials and methods
Study design and population
This cross-sectional study collected the data of 2173 patients diagnosed of MetS from NHANES database between 2009 and 2014. The NHANES is a major program of the National Center for Health Statistics (NCHS), which evaluated the health and nutritional status of adults and children in the United States. The survey is unique in that it included interviews, physical examinations, and laboratory evaluations and obtained a large amount of quantitative and qualitative data.12 In our study, patients without VD information, periodontal status information from oral health exam, and those with the number of missing teeth of 28 were excluded. Finally, 2165 samples were included.
Potential covariates and definitions
Age, gender (males or females), race (Mexican American, non-Hispanic Black, non-Hispanic White, other Hispanic and other races-including multi-racial), education level [9-11th grade (Includes 12th grade with no diploma), college graduate or above, high school graduate/general equivalent diploma (GED) or equivalent, less than 9th grade and some college or Associate of Arts degree (AA) degree], poverty income ratio (PIR), smoking (never smoking, former smoking, and continuous smoking), drinking consumption (high level, low level, median level, never drinking, or unknown), physical activity (high level, or low level), energy, VD intake and supplement, dental implants (no or yes), CVD (no or yes), diabetes (no or yes), hypertension (no or yes), dyslipidemia (no or yes), body mass index (BMI), waist circumference (cm), number of missing teeth (0, 1–5 or ≥6), and anti-periodontitis drug (no or yes) were potential covariates analyzed in this study.
Never smoking was defined based on the answer of “no” to SMQ020 (Smoked 100 cigarettes at further in life), former smoker was those answered “yes” to SMQ020 (Smoked 100 cigarettes at further in life) and “no” to SMQ040 (Do you now smoke Cigarettes choice). Current smoker was defined based on the answer of “yes” to SMQ040 (Do you now smoke Cigarettes choice). Those answered “no” to ALQ101 were defined as never drinking. People answered “yes” to ALQ101 were drinkers, and were divided into <1 glass (low level), 1–8 glasses (median level), and ≥8 glasses (high level) with ALQ120U was unified as weekly × times (days) and ALQ120Q × ALQ130 (alcoholic drink volume per day). High level of physical activity was defined based on the answer of “yes” to any one of the items of high intensity PAQ605 or PAQ650, or “yes” to any two of the items of moderate intensity PAQ620, PAQ635 or PAQ665. CVD was defined based on self-reported answer to MCQ160D (Ever told you had angina or heart failure), MCQ160E (Ever told you had heart attack, MCQ160C (Has a doctor or other health professional ever told you that you had coronary heart disease), MCQ160B (Ever told you had a stroke), MCQ160F (Ever told had congestive heart failure), or CVD drug codes: First Level Category ID-Name or 40-CARDIOVASCULAR AGENTS-41, 43, 44, 45, 46, 50, 51, 52, 53, 54, 56, 303, 340, 342, 430, 433 or 483. BMI = weight (kg)/height (cm2). Central obesity was defined as a waist circumference of ≥88 cm for women and ≥102 cm for men.13
Main and outcome variables
VD level was the main variable in this study, which was calculated based on serum 25(OH)D2 + 25(OH)D3. 25(OH)D2 + 25(OH)D3 < 50 nmol/L was defined as VD deficiency group and 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was defined as the normal group.14,15
Periodontitis was defined based on the Centers for Disease Control and Prevention (CDC)/American Academy of Periodontology case definitions for surveillance of periodontitis.16 Severe periodontitis was defined as having ≥2 interproximal sites with ≥6 mm of attachment loss (AL), and (not on the same tooth) and ≥1 interproximal site with ≥5 mm of probing depth (PD). Moderate periodontitis was defined as ≥2 interproximal sites with ≥4 mm of clinical AL (not on the same tooth) or ≥2 interproximal sites with PD ≥ 5 mm, also not on the same tooth. Mild periodontitis was defined as ≥2 interproximal sites with ≥3 mm of AL and ≥2 interproximal sites with ≥4 mm of PD or 1 site with ≥5 mm (not on the same tooth). Patients with no and mild periodontitis were combined into the non-periodontitis group, and patients with moderate and severe periodontitis were combined into the periodontitis group to reduce the risk of bias due to the possible excessive prevalence of mild periodontitis in the population.17
Statistical analysis
Kolmogorov-Smirnov was used to test the normality of quantitative data. Normally distributed measurement data were described as Mean (standard error) [Mean (SE)]. Independent sample t-test was used for comparisons between the two groups. The non-normally distributed measurement data were described by median and quartiles [M (Q1, Q3)], and the Mann-Whitney U rank sum test was used for comparisons between groups. Enumeration data were described as number and percentages n (%), and Chi-square test and Wilcoxon rank sum test were used for comparisons between groups. The weighted univariate Logistic regression model was established and variable with P < 0.05 were identified. Potential confounding factors were screened out by backward stepwise regression method and identified as covariates. Model 1 was the univariate Logistic regression model without any adjustment. Model 2 adjusted for covariates including age, gender, race and education. In Model 3, covariates including age, gender, race, education, PIR, smoking, diabetes and number of missing teeth were adjusted. Odds ratio (OR) [95% confidence interval (CI)] was effect size for evaluating the association between 25(OH)D2 + 25(OH)D3 and risk of periodontitis in patients. Missing value interpolation were performed using Python 3.9.12 (Python Software Foundation, Delaware, DE, USA). Difference comparison was performed by SAS 9.4 (SAS Institute Inc., Cary, NC, USA). Statistical modeling and subgroup analysis were performed by R version 4.2.2 (2022-10-31 ucrt) (R Foundation for Statistical Computing, Vienna, Austria).
Results
The baseline characteristics of patients in periodontitis group and non-periodontitis group
In total, the data of 2173 patients diagnosed of MetS were extracted from NHANES database. Patients without VD information (n = 8), those without periodontal status information from oral health exam (n = 0) and participants with the number of missing teeth of 28 (n = 0) were excluded. Finally, 2165 samples were included. All participants were divided into the periodontitis group (n = 1272) and the non-periodontitis group (n = 893). The screen process of the participants was shown in Fig. 1.
Figure 1.
The screen process of the participants in our study.
The mean age in the periodontitis group was higher than the non-periodontitis group (56.49 years vs 51.28 years). The percentage of participants in different numbers of missing teeth groups were statistically different between the periodontitis group and non-periodontitis group. The mean 25(OH)D2 + 25(OH)D3 in the periodontitis group was lower than the non-periodontitis group (63.56 nmol/L vs 68.85 nmol/L). The percentages of participants with 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L in the periodontitis group was lower than the non-periodontitis group (68.02% vs 75.27%) (Table 1).
Table 1.
Comparisons of the characteristics in the periodontitis group and non-periodontitis group.
| Variables | Total (n = 2165) | Non-periodontitis group (n = 893) | Periodontitis group (n = 1272) | Statistics | P |
|---|---|---|---|---|---|
| Age, years, Mean (S.E) | 53.84 (0.35) | 51.28 (0.48) | 56.49 (0.49) | t = −7.11 | <0.001 |
| Gender, n (%) | χ2 = 6.524 | 0.011 | |||
| Female | 1106 (48.84) | 510 (51.97) | 596 (45.59) | ||
| Male | 1059 (51.16) | 383 (48.03) | 676 (54.41) | ||
| Race, n (%) | χ2 = 70.499 | <0.001 | |||
| Mexican American | 371 (9.51) | 111 (6.49) | 260 (12.66) | ||
| Non-Hispanic Black | 417 (9.98) | 140 (7.84) | 277 (12.20) | ||
| Non-Hispanic White | 962 (69.39) | 489 (77.34) | 473 (61.14) | ||
| Other Hispanic | 246 (5.68) | 88 (4.44) | 158 (6.98) | ||
| Other races-including multi-racial | 169 (5.43) | 65 (3.89) | 104 (7.03) | ||
| Education level, n (%) | χ2 = 95.000 | <0.001 | |||
| 9–11th grade (Includes 12th grade with no diploma) | 372 (13.00) | 124 (9.42) | 248 (16.71) | ||
| College graduate or above | 359 (21.34) | 207 (28.17) | 152 (14.25) | ||
| High school graduate/GED or equivalent | 517 (24.40) | 189 (21.44) | 328 (27.49) | ||
| Less than 9th grade | 266 (6.82) | 56 (3.14) | 210 (10.63) | ||
| Some college or AA degree | 651 (34.44) | 317 (37.83) | 334 (30.92) | ||
| PIR, ratio, Mean (S.E) | 2.84 (0.06) | 3.13 (0.06) | 2.54 (0.07) | t = 9.25 | <0.001 |
| Smoking, n (%) | χ2 = 39.873 | <0.001 | |||
| Continuous smoking | 438 (17.98) | 132 (12.37) | 306 (23.81) | ||
| Former smoking | 602 (29.65) | 233 (27.70) | 369 (31.67) | ||
| Never smoking | 1125 (52.37) | 528 (59.94) | 597 (44.52) | ||
| Drinking consumption, n (%) | χ2 = 14.431 | 0.006 | |||
| High drinking | 238 (13.03) | 91 (12.23) | 147 (13.86) | ||
| Low drinking | 515 (25.81) | 244 (27.90) | 271 (23.65) | ||
| Median drinking | 402 (21.10) | 195 (24.02) | 207 (18.06) | ||
| Never drinking | 615 (24.07) | 234 (23.14) | 381 (25.03) | ||
| Unknown | 395 (16.00) | 129 (12.72) | 266 (19.40) | ||
| Physical activity, n (%) | χ2 = 10.771 | 0.001 | |||
| High level | 864 (42.48) | 393 (46.99) | 471 (37.80) | ||
| Low level | 1301 (57.52) | 500 (53.01) | 801 (62.20) | ||
| Energy, kcal, Mean (S.E) | 2126.42 (25.55) | 2158.94 (34.65) | 2092.65 (31.57) | t = 1.55 | 0.128 |
| VD intake and supplement, mcg, Mean (S.E) | 15.77 (1.04) | 17.84 (1.78) | 13.62 (0.82) | t = 2.28 | 0.027 |
| Dental implants, n (%) | χ2 = 3.686 | 0.055 | |||
| No | 2124 (98.06) | 865 (97.27) | 1259 (98.88) | ||
| Yes | 41 (1.94) | 28 (2.73) | 13 (1.12) | ||
| CVD, n (%) | χ2 = 7.559 | 0.006 | |||
| No | 1561 (72.65) | 684 (76.81) | 877 (68.34) | ||
| Yes | 604 (27.35) | 209 (23.19) | 395 (31.66) | ||
| Diabetes, n (%) | χ2 = 33.252 | <0.001 | |||
| No | 1360 (68.04) | 636 (75.36) | 724 (60.45) | ||
| Yes | 805 (31.96) | 257 (24.64) | 548 (39.55) | ||
| Hypertension, n (%) | χ2 = 3.586 | 0.058 | |||
| No | 356 (16.96) | 173 (19.03) | 183 (14.81) | ||
| Yes | 1809 (83.04) | 720 (80.97) | 1089 (85.19) | ||
| Dyslipidemia, n (%) | χ2 = 1.025 | 0.311 | |||
| No | 179 (7.55) | 76 (6.70) | 103 (8.42) | ||
| Yes | 1986 (92.45) | 817 (93.30) | 1169 (91.58) | ||
| Height, cm, Mean (S.E) | 169.15 (0.39) | 169.98 (0.46) | 168.29 (0.51) | t = 2.78 | 0.008 |
| Weight, kg, Mean (S.E) | 95.95 (0.59) | 97.81 (0.85) | 94.01 (0.90) | t = 2.99 | 0.004 |
| BMI, kg/m2, Mean (S.E) | 33.42 (0.22) | 33.79 (0.34) | 33.04 (0.22) | t = 1.98 | 0.053 |
| Waist circumference, cm, Mean (S.E) | 111.43 (0.46) | 111.62 (0.70) | 111.24 (0.61) | t = 0.39 | 0.695 |
| Central obesity n(%) | χ2 = 4.288 | 0.038 | |||
| No | 218 (8.92) | 62 (7.50) | 156 (10.39) | ||
| Yes | 1947 (91.08) | 831 (92.50) | 1116 (89.61) | ||
| Number of missing teeth, n (%) | χ2 = 143.377 | <0.001 | |||
| 0 | 504 (29.49) | 330 (42.15) | 174 (16.33) | ||
| 1–5 | 862 (41.73) | 365 (40.36) | 497 (43.15) | ||
| ≥6 | 799 (28.78) | 198 (17.48) | 601 (40.51) | ||
| Anti-periodontitis drug, n (%) | χ2 = 1.353 | 0.245 | |||
| No | 2111 (96.90) | 864 (96.20) | 1247 (97.63) | ||
| Yes | 54 (3.10) | 29 (3.80) | 25 (2.37) | ||
| 25(OH)D2 + 25(OH)D3, nmol/L, Mean (S.E) | 66.26 (1.07) | 68.85 (1.39) | 63.56 (1.08) | t = 3.63 | <0.001 |
| 25(OH)D2, nmol/L, Mean (S.E) | 4.81 (0.61) | 4.92 (0.84) | 4.69 (0.56) | t = 0.31 | 0.760 |
| 25(OH)D3, nmol/L, Mean (S.E) | 61.45 (1.18) | 63.93 (1.63) | 58.87 (1.09) | t = 3.10 | 0.003 |
| 25(OH)D2 + 25(OH)D3, n (%) | χ2 = 14.939 | <0.001 | |||
| <50 | 738 (28.29) | 266 (24.73) | 472 (31.98) | ||
| ≥50 | 1427 (71.71) | 627 (75.27) | 800 (68.02) |
S.E: standard error; GED: general equivalent diploma; PIR: poverty income ratio; VD: vitamin D; CVD: cardiovascular disease; BMI: body mass index; 25(OH)D: 25-OH-vitamin D.
Potential covariates associated with the risk of periodontitis in MetS patients
To screen out potential confounding factors associated with the risk of periodontitis in MetS patients, a weighted univariate Logistic regression model was established. The results delineated that age, gender, race, education, PIR, smoking, physical activity, VD intake and supplement, CVD, diabetes, BMI, and number of missing teeth might be potential covariates associated with the risk of periodontitis in MetS patients. These variables were included in the weighted multivariable Logistic regression model, and covariates were screened out via the backward stepwise regression method. The data delineated that age (OR = 1.03, 95% CI: 1.02–1.05), gender (OR = 0.51, 95% CI: 0.40–0.65), race (OR = 0.46, 95% CI: 0.32–0.65), education, PIR (OR = 0.90, 95% CI: 0.83–0.97), smoking (OR = 2.55, 95% CI: 1.82–3.56), diabetes (OR = 1.50, 95% CI: 1.12–1.99), VD intake and supplement (OR = 0.76, 95% CI: 0.60–0.97) and the number of missing teeth were associated with the risk of periodontitis in MetS patients (Table 2).
Table 2.
Potential covariates associated with the risk of periodontitis in patients with MetS.
| Variables | OR (95% CI) | P |
|---|---|---|
| Age | 1.03 (1.02–1.04) | <0.001 |
| Gender | ||
| Male | Ref | |
| Female | 0.77 (0.64–0.94) | 0.012 |
| Race | ||
| Mexican American | Ref | |
| Non-Hispanic Black | 0.80 (0.58–1.09) | 0.164 |
| Non-Hispanic White | 0.41 (0.30–0.54) | <0.001 |
| Other Hispanic | 0.81 (0.60–1.08) | 0.151 |
| Other races-including multi-racial | 0.93 (0.53–1.61) | 0.788 |
| Education level | ||
| 9–11th grade (Includes 12th grade with no diploma) | Ref | |
| College graduate or above | 0.29 (0.19–0.43) | <0.001 |
| High school graduate/GED or equivalent | 0.72 (0.50–1.05) | 0.097 |
| Less than 9th grade | 1.91 (1.19–3.07) | 0.011 |
| Some college or AA degree | 0.46 (0.33–0.64) | <0.001 |
| PIR | 0.78 (0.74–0.82) | <0.001 |
| Smoking | ||
| Never smoking | Ref | |
| Former smoking | 1.54 (1.19–1.98) | 0.002 |
| Continuous smoking | 2.59 (1.95–3.45) | <0.001 |
| Drinking consumption | ||
| High drinking | Ref | |
| Low drinking | 0.75 (0.51–1.10) | 0.149 |
| Median drinking | 0.66 (0.42–1.05) | 0.090 |
| Never drinking | 0.95 (0.56–1.62) | 0.863 |
| Unknown | 1.34 (0.85–2.12) | 0.211 |
| Physical activity | ||
| High level | Ref | |
| Low level | 1.46 (1.15–1.85) | 0.003 |
| Energy | 1.00 (1.00–1.00) | 0.128 |
| VD intake and supplement | 1.00 (0.99–1.00) | 0.040 |
| Dental implants | ||
| No | Ref | |
| Yes | 0.40 (0.15–1.07) | 0.074 |
| CVD | ||
| No | Ref | |
| Yes | 1.53 (1.13–2.09) | 0.009 |
| Diabetes | ||
| No | Ref | |
| Yes | 2.00 (1.54–2.60) | <0.001 |
| Hypertension | ||
| No | Ref | |
| Yes | 1.35 (0.99–1.84) | 0.064 |
| Dyslipidemia | ||
| No | Ref | |
| Yes | 0.78 (0.48–1.26) | 0.319 |
| BMI | 0.98 (0.97–1.00) | 0.042 |
| Circumference | 1.00 (0.99–1.01) | 0.694 |
| Number of missing teeth | ||
| ≥6 | Ref | |
| 0 | 0.17 (0.12–0.24) | <0.001 |
| 1–5 | 0.46 (0.37–0.58) | <0.001 |
| Anti-periodontitis drug | ||
| No | Ref | |
| Yes | 0.62 (0.27–1.41) | 0.258 |
MetS: metabolic syndrome; OR: odd ratio; CI: confidence interval; Ref: reference; GED: general equivalent diploma; PIR: poverty income ratio; VD: vitamin D; CVD: cardiovascular disease; BMI: body mass index.
The association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in MetS patients
As exhibited in Table 3, in the unadjusted model, compared with patients with 25(OH)D2 + 25(OH)D3 < 50 nmol/L, those with 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L might be associated with decreased risk of periodontitis in MetS patients (OR = 0.70, 95% CI: 0.57–0.85). After adjusting for confounding factors including age, gender, race, education, PIR, smoking, diabetes, VD intake and supplement and number of missing teeth, 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was correlated with reduced risk of periodontitis in MetS patients (OR = 0.76, 95% CI: 0.60–0.97).
Table 3.
The association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in patients with MetS.
| 25(OH)D2 + 25(OH)D3 |
||||
|---|---|---|---|---|
| Periodontitis | <50 (n = 738) | ≥50 (n = 1427) | ||
| OR (95% CI) | P | OR (95% CI) | P | |
| Model 1 | Ref | 0.70 (0.57–0.85) | 0.001 | |
| Model 2 | Ref | 0.68 (0.53–0.87) | 0.004 | |
| Model 3 | Ref | 0.76 (0.60–0.97) | 0.038 | |
25(OH)D: 25-OH-vitamin D; MetS: metabolic syndrome; OR: odd ratio; CI: confidence interval; Ref: reference.
Model 1: Unadjusted.
Model 2: Adjusted for age, gender, race, and education level.
Model 3: Adjusted for age, gender, race, education level, PIR, smoking, diabetes, number of missing teeth.
Subgroup analysis on the association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in MetS patients
Subgroup analysis revealed that in patients complicated with CVD (OR = 0.60, 95% CI: 0.37–0.98), dyslipidemia (OR = 0.75, 95% CI: 0.57–0.97), and central obesity (OR = 0.73, 95% CI: 0.57–0.95), decreased risk of periodontitis was identified in those with 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L. In patients with diabetes, or hypertension, or those without CVD, diabetes, hypertension or central obesity, no significant association was observed between 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L and the risk of periodontitis in MetS patients (all P > 0.05) (Fig. 2).
Figure 2.
Forest plot showing the subgroup analysis of the association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in MetS patients.
Discussion
The present study assessed the association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in patients with MetS based on the data of 2165 participants from NHANES database. The results delineated that 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was associated with decreased risk of periodontitis in MetS patients. Subgroup analysis revealed that in MetS patients complicated with CVD, dyslipidemia, and central obesity, decreased risk of periodontitis was observed in 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L group. The findings might provide a reference for the prevention and treatment of periodontitis in patients with MetS.
VD is a generic name comprising Vitamin D2 and D3, and Vitamin D2 is manufactured through ultraviolet irradiation of ergosterol from yeast while Vitamin D3 results from ultraviolet irradiation of 7-dehydrocholesterol from lanolin.18 A widely accepted biomarker analysis for VD status is to measure the serum 25[OH]D.19 Recently, VD levels have been gaining growing attention in oral health especially periodontitis. There was evidence identified the association of VD deficiency with a myriad of acute and chronic illnesses including periodontitis.20 A comprehensive review depicted that VD deficiency was associated with higher prevalence of periodontitis.21 Another randomized double-blind placebo-controlled study revealed that 6-month VD supplement improved the treatment of periodontitis in patients with initial 25(OH) vitamin D3 < 30 ng/mL.22 In the current study, 25(OH)D2 + 25(OH)D3 was evaluated to identity the association between VD levels and risk of periodontitis in patients with MetS. We found that 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was associated with reduced risk of periodontitis in patients with MetS. We suspected that the potential mechanism might be that VD could participate in the inflammation processes, decrease the inflammatory levels including RANKL, TNF-α, IL-1, MMP-9, and IL-6 and stimulate the healing of periodontal tissues, which played a vital part in maintaining healthy periodontal tissues.23 VD was reported to exhibite apparent fine-tuning, anti-inflammatory and mineralization effects on the periodontium, and may decrease the number of live porphyromonas gingivalis through active autophagy.24 Other studies also revealed that VD participated in the oxidative stress,25,26 and systemic inflammation in patients with MetS,27 and these might also help decrease the risk of periodontitis. Bone metabolism might be another mechanism that VD has impact on oral health.28 Subgroup analysis showed that in MetS patients complicated with CVD, dyslipidemia, and central obesity, 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was correlated with decreased risk of periodontitis. Inflammation exerted significant roles in CVD, dyslipidemia, and central obesity.29, 30, 31 VD was identified to be a potential anti-inflammatory mediator of CVD.32 A previous study demonstrated the beneficial effects of VD supplementation in anti-inflammation in overweight and obese paediatric populations.33
Our study showed the association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in patients with MetS based on data from a large sample size using multi-stage complex sampling, and the representativeness was good. The evaluation of periodontitis covered 28 teeth with 6 locations per tooth, and the results might be more comprehensive. Additionally, VD level was evaluated based on the detection of 25-(OH)-D, which could more objectively reflect the VD level of the body. We found that 25(OH)D2 + 25(OH)D3 ≥ 50 nmol/L was associated with decreased risk of periodontitis in MetS patients. The findings suggested the potential importance of VD in MetS patients. VD is a steroid hormone obtained mainly from exposure to sunlight, but also from diet and dietary supplements.34 Foods naturally containing VD is rare, and it can be found in oily fish including salmon, mackerel, and herring and oils from fish.35 Both metabolic syndrome and periodontitis are urgent issues for the global burden of disease, and to identify more reliable biomarkers that might help better manage patients with these diseases are important. Considering the association of VD with periodontal health, nutritional advice might be given for the management of periodontal diseases. Regular and timely VD during dental practice might help improve the quality of life, hence benefitting the MetS patients. In the case of a deficiency of any micronutrients, dietary sources, exposure to sunlight, or 25(OH)D3 supplement must be considered.
There were limitations in this study. Firstly, this was a cross-sectional study, and only the association between 25(OH)D2 + 25(OH)D3 and the risk of periodontitis in patients with MetS could be identified, while the causal relationship between them could not be inferred. Secondly, the information on certain dental diseases of participants was not reported in the database, such confounding factors could not be included in the analysis. Thirdly, the underlying mechanisms between VD and the risk of periodontitis in patients with MetS could not be verified in our study, and in the future, more well-designed studies were required to verify the results in the present study.
The current study identified that VD level was associated with the risk of periodontitis in patients with MetS, which might suggest the importance of VD supplement in patients with MetS and provide a reference for the prevention and treatments of periodontitis in patients with MetS.
Declaration of competing interest
The authors have no conflicts of interest relevant to this article.
Acknowledgments
None.
References
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