The possible Connection of periodontal diseases (PD) with cardiovascular disease (CVD) and prostatitis in sample of Iraqi patients

Periodontitis is a chronic inflammation that effect the tissue that surround and support the teeth, and this is prevalent cause of teeth loss in adults while prostatitis is a comparatively common issue affecting about 12 percent of men, and it’s the most common prostate-related health issue in men under age fifty. Researches showed that the heart diseases spread in the persons that have periodontitis about 25-50% higher than healthy persons. Recent studies have connected periodontal disease with plenty of systemic health risks, including heart disease and prostatitis but their results were varied. The recent study aimed to explore the linking of gum diseases with heart diseases and prostate inflammations. In total, 150 serum samples of four age groups of participants distributed as 100 (66.7%) samples of patients with periodontitis and other 50 (33.3%) samples of control, All patients were attending to Ibn alBitar hospital, teaching laboratories – Medical city and Specialized Dental Center \ AL-Alwiya and the diagnosis of all cases based up on patients medical history that evaluated by qualified physicians and some other laboratory investigations. As (38.0%) patients with heart diseases history and (58.6%) patients with prostatitis. Sample were analyzed for Triglycerides, Prostatespecific antigen (PSA) and CRP levels. The abnormal Triglycerides level estimated by (37.3%), while the elevated level of (PSA) was determined by (40.0%). Furthermore, the prevalence of CRP seropositivity in individuals increased by (43.3%). The incidence of periodontal disease (PD) was paralleled with the positivity of tested biochemical markers of cardiovascular disease (CVD) history and prostatitis respectively with high significant differences (P= 0.000). Finally, there is significant connection of PD with CVD and prostatitis, but further studies are needed, and the outcomes of this study have limitations, also the current finding encourages to review a large sample size with different age groups in order to clarify this issue.


Introduction
Periodontitis (PD) is a chronic inflammation that influence the tissue that surround and support the teeth, and this is prevalent cause of teeth loss in adults. The spread of periodontitis is high and the moderate type influence about 50% of the adults and progressive type influence 5-15% of the adults that caused by multi factors, so in addition to, the presence of bacteria and immune system, there is also the genetic predisposition of the persons [1]. For this reason, scientists saying the bacteria that cause periodontal diseases does not effects on the mouth only but also participate in the development of other systemic diseases in the body like heart diseases which some researchers noticed it spread in the persons that have periodontitis about 25¬-50% higher than healthy persons [2][3].
Lack the care to the oral health (which is risk factor of periodontitis) and falling of the teeth (which is the result of periodontitis) associated with increased incidence of heart diseases.
The investigation illustrates the relationship between heart diseases and periodontal diseases since more than century also it was concluded there were a link between heart problems and viral infections [4]. Prostatitis is Inflammation of the prostate a fairly common problem affecting about 12 percent of males of under age 50 [5]. Numerous reports have connected gum disease or gum inflammation with many of systemic health life-threating diseases, including heart stroke or even prostatitis, additional current studies launched a clear association between PD and prostatitis [2][3].The PD progresses when adhesive plaque forms on tooth surfaces turns to hard tartar formation, giving an ultimate residence for bacterial infection to hide and reproduce also, due to tartar forms along gum lines where it's hard for teeth brushing, that's permits bacterial agents to move underneath the gum and then into the blood and maybe to the whole body and its organs or tissues, such as the prostate tissues and heart tissues [6][7]. Report from Case Western Reserve University School of Dental Medicine and University Hospitals Case Medical Center supported the hypothesis of controlling and treating the gum disease it may minimize the symptoms of prostate inflammation as some of previous studies that's support this issue [8].  Marketed By: Euro Diagnostic Systems kit Pvt. Ltd.,) and CRP level was determined by using "diagnostic automation \ Cortez diagnostics, Inc., CRP Latex test kit and demonstrate the level of antibody specific for Human PSA (ab113327 -PSA (KLK3 \ abcam).

Statistics
The Chi-square used to detect the degree of significance differences among the studied variables of the recent study. By using SPSS ver.18.0. The significance differences among variables (p-value) in any test was: S\ Significant difference (p <0.05), NS\ Non -significant difference (p>0.05), HS\ highly significant difference (p <0.0001).   (1) showed the distribution of study groups according to the studied Clinicopathological characters as 50 (33.3%) of controls and 100 (66.7%) of PD patients as cases of the recent study, the age categories of the selective study groups were with higher percentage about 50 (33.3 %) of (≤ 30 years) followed by (31 -40 years) as 40 (26.7 %) of age groups. Furthermore, the heart diseases history it was in 57 (38%) of them and 93 (62%) individuals without it, while 88 (58.6%) of patients had prostatitis which distributed clinically into mild 40 (26.6%), moderate 25 (16.7%) and sever scales 23 (15.3%). Table 2.

Results
Results of Biochemical Tests among study groups    (4%) abnormal level of triglyceride respectively with high significant difference (p< 0.001).

Discussion
This study was subject to numerous restrictions. First, selection bias of study sample which include study design and selected patients who visited restricted hospitals and dental clinics and who were diagnosed with periodontitis with prostatitis and heart problems. Moreover, this study did not investigate follow-up period of periodontitis and prostatitis in cohort dental records or even heart diseases, which limited the ability to diagnose the outcomes and severity of the selected cases. Lastly, since the documents were collected from a varied Our study tested the influence of the periodontitis on the heart diseases also and the consequence showed that the periodontitis may have strong impact on heart health as shown in table 2 and table 3. There is a lot of proofs that highlight on this strong relationship.
For instance, the ischemic heart disease. There are sharing risky issues between heart diseases and periodontitis that increase the happening of these diseases include: age, male sex, diabetes, hypercholesterolemia, tobacco, obesity, and chronic infection [9]. Another signal is the inflammation caused by bacteria of dental plaque can cause inflammation in any part of the body as confirmed by increase in the C -reactive protein (CRP) as shown in table 2. This information makes the link between periodontitis and heart health more clear, since there are a lot of revisions tell that there is individual with high cholesterol and triglyceride levels and heart diseases also have periodontitis. It is clear that the periodontitis effect on the heart diseases but it is not clear if the periodontitis is the crucial cause of heart diseases as noticed in table 2b [10].
Atherosclerosis it a serious condition that makes blood flowing hard to reach the heart and causes heart attack or stroke. Inflammation as a sure sign of periodontitis that's may raises the concern for heart problems because it permits bacteria and other bacterial toxins to extent underneath the gum lines [11]. Inflammation also cause damage to blood vessels, including those of the heart, in addition to, gums are very vascular, filled of blood vessels as mouth too. If it disrupts the gum layer even a little bit, that's make more bacteria in the bloodstream, and trigger inflammation throughout any part of the body [10][11].
Several Studies demonstrate that the bacteria found in periodontitis including Streptococcus sanguis that takes a part in strokes which disseminate to the heart.
In the lack of periodontal diseases, there is significantly less amount of these bacteria in the heart [12]. Research proposes that the more bacteria get from periodontal diseases, the thicker carotid arteries formed then prevent the blood flow into the brain which can cause a stroke consequently [13].
Somewhat, the more bacterial load in the body, the more the chance of the heart will be affected. If it can decrease the long-existing of bacteria in bodies, it will lower the risk cofactors to heart problems [12][13]. Periodontitis is obviously linked with immune dysregulation and systemic inflammation, which are both etiological Co-factors in systemic inflammation maybe [14]. Nevertheless, the etiological agents and bidirectional causes relations between periodontitis and prostatitis persist as unclear association, with slight knowing about their fundamental mechanisms. Consequently, further researches of the biological probability and the gathering of clinical and epidemiological proofs are needed to both reinforce and comprehend the association between periodontitis with prostatitis and consequences of heart risk factors as shown in table 3 [15,25].
Periodontitis may interfere with elevated PSA level in patients with prostatitis as explored in table 2. In our research, it examined 100 males, most of them had prostate inflammation i.e, either mild, moderate or a severe form as confirmed and evaluated by qualified clinical urological physician. Furthermore, some laboratory tests such as prostate-specific antigen (PSA) levels. Those studied had not continuously received dental care with obvious dental problems based on gum examination. The studied groups divided into two populations, including high PSA levels group and limited PSA levels group. It's established that in patients with both severe prostatitis problem and PD issues, their PSA levels after estimation were significantly higher than those with only periodontal issues or prostatitis alone [15-16-17].
Our data tells, patients with periodontal disease that have high PSA levels in the bloodstreams were higher than the normal range in those of controls group. Depend up on this observation, its established that PSA levels is not a a screening or indicative marker or for prostatitis only, but perhaps also its action like an inflammatory marker like others common markers in the body, such as cytokines (ILs) and C-reactive proteins (CRP), which are both of them good markers for the existence of systemic inflammatory diseases in the whole body [17][18].
A recent assessment established a noteworthy connection between erectile dysfunction with periodontal disease. The attack of oral pathogenic-bacteria, particularly Porphyromonas gingivalis, may convince irritation of the epithelium and mucosa with traumatic injury and subsequent inflammations [19]. This study found a strong relationship between PD and vasculogenic erectile dysfunction in a nationwide population-based NHIS-HEC. Though the indication is not definitive, these outcomes recommend that a diagnosis of periodontal disease is connected into high risk of prostatitis [20].
Recently, researches have finger out that cardiovascular diseases (CVD) connected to prostate-specific antigen (PSA) [18], many researches have exposed that PSA is correspondingly expressed outside of prostate glands such as many of female tissues including; ovarian, breast tissue and endometrial tissues) in addition to, body fluids like; breast milk, amniotic fluids and breast cyst fluids). Reviews displayed that many heart diseases elevated PSA levels. Also, a fresh study by Durmaz et al in Turkey, determined that, there may be a link between PSA of serums and free PSA levels and diagnosis of extent of coronary artery disease (CAD) and acute coronary syndrome (ACS) [21].
Insufficient revisions have noticed the connection of prostate cancer PC with PD with heart problems. One study based on (Follow-Up) of prospective-cohort module of the health professionals it was establish that periodontitis was linked with a minor but significant increase in the risk of systemic cancer of the body, but PD was also inversely correlated with PC. Hiraki et al. presented a case-control large-scale revision of Japanese patients that revealed of increased tooth loss linked with a diminished risk of prostate cancer after modifying for potential confounding factors and teeth treatment [22][23][24][25][26][27][28].
Further studies are needed to conclude interconnection by determination of which one comes first: prostatitis or PD? Or a study delivers more actual answers regarding to the relation between prostatitis and inflammation of mouth periodontia and significances of heart diseases consequences, and treating for chronic periodontal disease, would this have an influence on (1) reducing the signs and symptoms of the prostatitis (2) lowering the PSA level (3) does that effect of the heart heath or not?

Conclusions
According to the resent study results, it was a possible the connection of periodontal disease (PD) with cardiovascular disease (CVD) and prostatitis.

Ethical Approval
The study was approved by the Ethical Committee.

Conflicts of Interest
The authors declare that they have no competing interests.