Graziani and Shapira discuss impact of research showing association between periodontitis and Covid-19 complications

“A very important paper” with “very striking data” that had implications for the healthcare of people with Covid-19 and key messages on prevention for the public and medical professionals.

These were among the comments made by Filippo Graziani (University of Pisa and EFP past president) and Lior Shapira (Hebrew University–Hadassah of Jerusalem and EFP president-elect) in an Instagram Live session on the EFP’s Instagram page (@perioeurope) on Wednesday 3 February to discuss new research showing an association between periodontitis and Covid-19 complications.

Despite having been announced only a few hours earlier, the session was well attended with more than 1,400 people viewing the 30-minute conversation about the research either live or within the next 24 hours. By Sunday 7 February, it has been viewed nearly 2,200 times.

The case-control study, published by the EFP’s Journal of Clinical Periodontology (JCP) on February 1, found that Covid-19 patients with periodontitis were 3.5 times more likely to be admitted to intensive care, 4.5 times more likely to need a ventilator, and almost nine times more likely to die compared to those without periodontitis.

“This is a striking paper,” said Prof Shapira. “This is new data, and it has opened the door to new investigations. We need to confirm these findings with other centres and maybe with longitudinal studies too. However, the fact that there is an association between Covid-19 and periodontitis is important.”

The experts suggested some biologically plausible explanations for why periodontitis might lead to Covid-19 complications.

Prof Shapira suggested two possibilities. First, that periodontitis involves inflammation of the gums and can affect systemic inflammation, while the complications of Covid-19 are connected to the so-called “cytokine storm”, a form of inflammatory response.  “The combination of these two – inflammation from Covid-19 and inflammation from the gum – may be synergistic and cause a lot of damage for the patient,” he said.

The second hypothesis was that inflammation in periodontitis is related to bacterial infection in the periodontal pockets, and these bacteria can easily go down into the lungs where Covid-19 is causing pulmonary infection. “So, the combination is like a super-infection, with the virus and the periodontal pathogens acting in a synergistic way to produce the inflammatory response,” he suggested.

Reacting to this, Prof Graziani said that while these possibilities were “very plausible” and did not exclude each other, the limitations of a case-control study meant that “we don’t know whether it is the periodontitis inflammatory effect that triggers death or whether it is just an inflammatory tendency of the subject that is expressed whether in periodontitis or in the lung.”

Prevention messages

Professors Graziani and Shapira discussed possible prevention messages for both the public and medical practitioners based on the research.

“The public and the dentists have to be aware that if we prevent the infection of the gums and prevent periodontitis, we might also help the patient to survive if he gets infected by Covid 19,” said Shapira.

He added that it was important that Covid-19 patients in hospitals receive oral healthcare, whether through cleaning the teeth or mouth rinses, and warned of the dangers of neglecting this: “Let’s say, if you get to a position where you need ventilation. It’s a direct infection site from the mouth to the lung – so if the mouth is loaded with bacteria it might cause a lot of problems during the ventilation process.”

Graziani added that there was often “a complete absence of dental care within the ICU – and that is a general health issue which I think is extremely important.”

He cautioned that these were all inferences that could not be proved based on the data from the study: “It’s just one centre, it’s a case-control study, and even the diagnosis of periodontitis is just done with x-rays, so there are some complications.”

Nonetheless, argued Prof Shapira, “there is no harm in going to the public and the medical profession and explaining the possibility that keeping your gums healthy will affect your health if you are infected with Covid-19.”

Note: The comments from Filippo Graziani and Lior Shapira have been edited for clarity and concision.

VIEW the conversation on Instagram