Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto

Antecedentes: Las enfermedades cardiovasculares, incluido el síndrome coronario agudo (SCA), son responsables de una gran proporción de muertes a nivel mundial. La periodontitis, una enfermedad inflamatoria crónica de las encías, se ha asociado con un mayor riesgo de enfermedades cardiovasculares, e...

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Autores:
Cardona Rodríguez, María José
Giraldo Mantilla, Caroline Johana
Vargas Sánchez, Daniela Alejandra
Tipo de recurso:
https://purl.org/coar/resource_type/c_7a1f
Fecha de publicación:
2025
Institución:
Universidad El Bosque
Repositorio:
Repositorio U. El Bosque
Idioma:
spa
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oai:repositorio.unbosque.edu.co:20.500.12495/14014
Acceso en línea:
https://hdl.handle.net/20.500.12495/14014
Palabra clave:
Periodontitis
Síndrome coronario agudo
Citoquinas proinflamatoria
Inflamación sistémica
Relación periodontal-cardiovascular
Periodontitis
Acute coronary syndrome
Pro-inflammatory cytokines
Systemic inflammation
Periodontal-cardiovascular relationship
WU 240
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License
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dc.title.none.fl_str_mv Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
dc.title.translated.none.fl_str_mv Effectiveness of two periodontal care modalities for controlling microbial dysbiosis and pro- inflammation in patients with acute coronary syndrome: a pilot study
title Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
spellingShingle Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
Periodontitis
Síndrome coronario agudo
Citoquinas proinflamatoria
Inflamación sistémica
Relación periodontal-cardiovascular
Periodontitis
Acute coronary syndrome
Pro-inflammatory cytokines
Systemic inflammation
Periodontal-cardiovascular relationship
WU 240
title_short Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
title_full Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
title_fullStr Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
title_full_unstemmed Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
title_sort Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio piloto
dc.creator.fl_str_mv Cardona Rodríguez, María José
Giraldo Mantilla, Caroline Johana
Vargas Sánchez, Daniela Alejandra
dc.contributor.advisor.none.fl_str_mv Lafaurie Villamil, Gloria Inés
Vargas Sánchez, Paula Katherine
Castillo Perdomo, Diana Marcela
Díaz Báez, David
dc.contributor.author.none.fl_str_mv Cardona Rodríguez, María José
Giraldo Mantilla, Caroline Johana
Vargas Sánchez, Daniela Alejandra
dc.subject.none.fl_str_mv Periodontitis
Síndrome coronario agudo
Citoquinas proinflamatoria
Inflamación sistémica
Relación periodontal-cardiovascular
topic Periodontitis
Síndrome coronario agudo
Citoquinas proinflamatoria
Inflamación sistémica
Relación periodontal-cardiovascular
Periodontitis
Acute coronary syndrome
Pro-inflammatory cytokines
Systemic inflammation
Periodontal-cardiovascular relationship
WU 240
dc.subject.keywords.none.fl_str_mv Periodontitis
Acute coronary syndrome
Pro-inflammatory cytokines
Systemic inflammation
Periodontal-cardiovascular relationship
dc.subject.nlm.none.fl_str_mv WU 240
description Antecedentes: Las enfermedades cardiovasculares, incluido el síndrome coronario agudo (SCA), son responsables de una gran proporción de muertes a nivel mundial. La periodontitis, una enfermedad inflamatoria crónica de las encías, se ha asociado con un mayor riesgo de enfermedades cardiovasculares, en parte debido a la inflamación sistémica y la presencia de bacterias periodontales que pueden entrar al torrente sanguíneo y contribuir al daño cardiovascular. Objetivo: Este estudio se centra en evaluar y comparar dos protocolos de tratamiento periodontal en pacientes con antecedentes de síndrome coronario agudo (SCA) que asisten a un programa de rehabilitación cardíaca para establecer los cambios en los parámetros clínicos, los cambios microbianos en el biofilm subgingival y la reducción de la inflamación sistémica en pacientes con SCA. Métodos: Se comparan 12 pacientes asignados aleatoriamente a dos modalidades de tratamiento periodontal (instrumentación subgingival) y detartraje ultrasónico con antibioterapia adjunta de Amoxicilina-Metronidazol con un diseño experimental para establecer la reducción de los índices clínicos periodontales, los microorganismos periodontopatógenos por técnica de qPCR y las citocinas proinflamatorias séricas en un período de 6 meses. Resultados: Ambos protocolos disminuyeron los índices de inflamación clínica, la carga bacteriana y los niveles de inflamación (p<0.05). Sin embargo, la instrumentación subgingival mostró una mayor eficacia en la reducción de Tannerella forsythia y Treponema denticola. La instrumentación subgingival mostró mayor efectividad para reducir la IL6 y la IL1b con un incremento de MCP-1. Los índices clínicos no mostraron diferencias entre los grupos p>0.05. Conclusiones: La instrumentación subgingival y el ultrasonido supragingival con antibióticos adjuntos impactan los índices clínicos de los pacientes con SCA en un período de 6 meses. Sin embargo, la instrumentación subgingival favorece la reducción de patógenos y de la proinflamación sistémica generando un impacto sistémico de la terapia periodontal que puede impactar el riesgo cardiovascular.
publishDate 2025
dc.date.accessioned.none.fl_str_mv 2025-02-21T19:54:53Z
dc.date.available.none.fl_str_mv 2025-02-21T19:54:53Z
dc.date.issued.none.fl_str_mv 2025-01
dc.type.coar.fl_str_mv http://purl.org/coar/resource_type/c_7a1f
dc.type.local.spa.fl_str_mv Tesis/Trabajo de grado - Monografía - Especialización
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dc.type.driver.none.fl_str_mv info:eu-repo/semantics/bachelorThesis
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dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional Universidad El Bosque
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dc.relation.references.none.fl_str_mv 1. World Health Organization-WHO [Web Site]. Washington DC: WHO; 2019. Cardiovascular diseases. Available in: https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1
2. Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol [Internet]. 2020;47(3):268–88. DOI: http://dx.doi.org/10.1111/jcpe.13189
3. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions: Classification and case definitions for periodontitis. J Periodontol [Internet]. 2018;89 Suppl 1:S173–82. DOI: http://dx.doi.org/10.1002/JPER.17-0721
4. Dietrich T, Sharma P, Walter C, Weston P, Beck J. The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease. J Clin Periodontol [Internet]. 2013;40 Suppl 14(s14):S70-84. DOI: http://dx.doi.org/10.1111/jcpe.12062
5. Izawa H, Yoshida T, Ikegame T, Izawa KP, Ito Y, Okamura H, et al. Standard cardiac rehabilitation program for heart failure. Circ J [Internet]. 2019;83(12):2394–8. DOI: http://dx.doi.org/10.1253/circj.CJ-19-0670
6. Ortega Castillo HF, Piedra Cosíos JC, Tito HD. Diagnóstico y tratamiento del síndrome coronario agudo: actualización. Revista Eugenio Espejo. 2018;12:76–100.
7. Suárez LJ, Garzón H, Arboleda S, Rodríguez A. Oral dysbiosis and autoimmunity: From local periodontal responses to an imbalanced systemic immunity. A review. Front Immunol [Internet]. 2020;11:591255. DOI: http://dx.doi.org/10.3389/fimmu.2020.591255
8. Horliana ACRT, Chambrone L, Foz AM, Artese HPC, Rabelo M de S, Pannuti CM, et al. Dissemination of periodontal pathogens in the bloodstream after periodontal procedures: a systematic review. PLoS One [Internet]. 2014;9(5):e98271. DOI: http://dx.doi.org/10.1371/journal.pone.0098271
9. Castillo DM, Sánchez-Beltrán MC, Castellanos JE, Sanz I, Mayorga-Fayad I, Sanz M, et al. Detection of specific periodontal microorganisms from bacteraemia samples after periodontal therapy using molecular-based diagnostics: Bacteraemia by molecular diagnostics. J Clin Periodontol [Internet]. 2011;38(5):418–27. DOI: http://dx.doi.org/10.1111/j.1600-051X.2011.01717.x
10. Gualtero DF, Lafaurie GI, Buitrago DM, Castillo Y, Vargas-Sanchez PK, Castillo DM. Oral microbiome mediated inflammation, a potential inductor of vascular diseases: a comprehensive review. Front Cardiovasc Med [Internet]. 2023;10:1250263. DOI: http://dx.doi.org/10.3389/fcvm.2023.1250263
11. Figuero E, Lindahl C, Marín MJ, Renvert S, Herrera D, Ohlsson O, et al. Quantification of periodontal pathogens in vascular, blood, and subgingival samples from patients with peripheral arterial disease or abdominal aortic aneurysms. J Periodontol [Internet]. 2014;85(9):1182–93. DOI: http://dx.doi.org/10.1902/jop.2014.130604
12. Hu X, Li H, Zhao X, Zhou R, Liu H, Sun Y, et al. Multi-omics study reveals that statin therapy is associated with restoration of gut microbiota homeostasis and improvement in outcomes in patients with acute coronary syndrome. Theranostics [Internet]. 2021;11(12):5778–93. DOI: http://dx.doi.org/10.7150/thno.55946
13. Moscoso SB, Mendoza F, Gómez LA, Londoño A, Marín JS, Sarmiento JM, Cortes F, Vargas-Sanchez PK, Díaz-Báez D, Lafaurie GI. Incidence of bleeding during and after two non-surgical periodontal therapy schemes in patients with recent acute coronary syndrome on dual antiplatelet therapy: A pilot study. J Clin Exp Dent. 2024;16(12):e1495-e1502. DOI: https://doi.org/10.4317/jced.61758
14. Kimura K, Kimura T, Ishihara M, Nakagawa Y, Nakao K, Miyauchi K, et al. JCS 2018 guideline on diagnosis and treatment of acute coronary syndrome. Circ J [Internet]. 2019;83(5):1085–196. DOI: http://dx.doi.org/10.1253/circj.CJ-19-0133
15. Nakano K, Nemoto H, Nomura R, Inaba H, Yoshioka H, Taniguchi K, et al. Detection of oral bacteria in cardiovascular specimens. Oral Microbiol Immunol [Internet]. 2009;24(1):64–8. DOI: http://dx.doi.org/10.1111/j.1399-302X.2008.00479.x
16. Raffaelli L, Santangelo R, Falchetti P, Galluccio F, Luciani N, Anselmi A, et al. Examination of periodontal pathogens in stenotic valve specimens and in whole blood samples in patients affected by aortic valve stenosis and chronic periodontitis. Int J Immunopathol Pharmacol [Internet]. 2010;23(2):561–6. DOI: http://dx.doi.org/10.1177/039463201002300218
17. Yamazaki Y, Morita T, Nakai K, Konishi Y, Goto A, Yamamoto T, et al. Impact of dental health intervention on cardiovascular metabolic risk: a pilot study of Japanese adults. J Hum Hypertens [Internet]. 2024;38(6):500–9. DOI: http://dx.doi.org/10.1038/s41371-021-00551-2
18. Skaar D, O’Connor H, Lunos S, Luepker R, Michalowicz BS. Dental procedures and risk of experiencing a second vascular event in a Medicare population. J Am Dent Assoc [Internet]. 2012;143(11):1190–8. DOI: http://dx.doi.org/10.14219/jada.archive.2012.0063
19. Mendoza F, Lafaurie GI, Moscoso S, Sarmiento JM, Morales K, Castro M, et al. Prevalencia de la enfermedad periodontal en pacientes con antecedente de síndrome coronario agudo en un programa de rehabilitación cardiaca. Rev Colomb Cardiol [Internet]. 2020;27(4):276–82. DOI: http://dx.doi.org/10.1016/j.rccar.2019.02.009
20. Wojtkowska A, Zapolski T, Wysokińska-Miszczuk J, Wysokiński AP. The inflammation link between periodontal disease and coronary atherosclerosis in patients with acute coronary syndromes: case-control study. BMC Oral Health [Internet]. 2021;21(1):5. DOI: http://dx.doi.org/10.1186/s12903-020-01356-4
21. Gotsman I, Lotan C, Soskolne WA, Rassovsky S, Pugatsch T, Lapidus L, et al. Periodontal destruction is associated with coronary artery disease and periodontal infection with acute coronary syndrome. J Periodontol [Internet]. 2007;78(5):849–58. DOI: http://dx.doi.org/10.1902/jop.2007.060301
22. Morillo JM, Lau L, Sanz M, Herrera D, Martín C, Silva A. Quantitative real-time polymerase chain reaction based on single copy gene sequence for detection of periodontal pathogens. J Clin Periodontol [Internet]. 2004;31(12):1054–60. DOI: http://dx.doi.org/10.1111/j.1600-051x.2004.00608.x
23. Yoshida A, Kawada M, Suzuki N, Nakano Y, Oho T, Saito T, et al. TaqMan real-time polymerase chain reaction assay for the correlation of Treponema denticola numbers with the severity of periodontal disease. Oral Microbiol Immunol [Internet]. 2004;19(3):196–200. DOI: http://dx.doi.org/10.1111/j.0902-0055.2004.00142.x
24. Romero-Sanchez C, Rodríguez C, Santos-Moreno P, Mesa AM, Lafaurie GI, Giraldo-Q S, et al. Is the treatment with biological or non-biological DMARDS a modifier of periodontal condition in patients with rheumatoid arthritis? Curr Rheumatol Rev [Internet]. 2017;13(2):139–51. DOI: http://dx.doi.org/10.2174/1573397113666170407161520
25. Cross KL, Chirania P, Xiong W, Beall CJ, Elkins JG, Giannone RJ, et al. Insights into the evolution of host association through the isolation and characterization of a novel human periodontal pathobiont, Desulfobulbus oralis. MBio [Internet]. 2018;9(2). DOI: http://dx.doi.org/10.1128/mBio.02061-17
26. Lafaurie GI, Castillo DM, Iniesta M, Sanz M, Gómez LA, Castillo Y, et al. Differential analysis of culturable and unculturable subgingival target microorganisms according to the stages of periodontitis. Clin Oral Investig [Internet]. 2023;27(6):3029–43. DOI: http://dx.doi.org/10.1007/s00784-023-04907-5
27. Castillo Y, Delgadillo NA, Neuta Y, Iniesta M, Sanz M, Herrera D, et al. Design and validation of a quantitative polymerase chain reaction test for the identification and quantification of uncultivable bacteria associated with periodontitis. Arch Oral Biol [Internet]. 2023;154(105758):105758. DOI: http://dx.doi.org/10.1016/j.archoralbio.2023.105758
28. Gómez LA, De Avila J, Castillo DM, Montenegro DA, Trujillo TG, Suárez LJ, et al. Porphyromonas gingivalis placental atopobiosis and inflammatory responses in women with adverse pregnancy outcomes. Front Microbiol [Internet]. 2020;11:591626. DOI: http://dx.doi.org/10.3389/fmicb.2020.591626
29. Park S-Y, Kim S-H, Kang S-H, Yoon C-H, Lee H-J, Yun P-Y, et al. Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea. Eur Heart J [Internet]. 2019;40(14):1138–45. DOI: http://dx.doi.org/10.1093/eurheartj/ehy836
30. Chang Y, Lee JS, Lee K-J, Woo HG, Song T-J. Improved oral hygiene is associated with decreased risk of new-onset diabetes: a nationwide population-based cohort study. Diabetologia [Internet]. 2020;63(5):924–33. DOI: http://dx.doi.org/10.1007/s00125-020-05112-9
31. Larvin H, Kang J, Aggarwal VR, Pavitt S, Wu J. Multimorbid disease trajectories for people with periodontitis. J Clin Periodontol [Internet]. 2021;48(12):1587–96. DOI: http://dx.doi.org/10.1111/jcpe.13536
32. Reichert S, Schlitt A, Beschow V, Lutze A, Lischewski S, Seifert T, et al. Use of floss/interdental brushes is associated with lower risk for new cardiovascular events among patients with coronary heart disease. J Periodontal Res [Internet]. 2015;50(2):180–8. DOI: http://dx.doi.org/10.1111/jre.12191
33. Hada DS, Garg S, Ramteke GB, Ratre MS. Effect of non‐surgical periodontal treatment on clinical and biochemical risk markers of cardiovascular disease: A randomized trial. J Periodontol [Internet]. 2015;86(11):1201–11. DOI: http://dx.doi.org/10.1902/jop.2015.150249
34. Renvert S, Pettersson T, Ohlsson O, Persson GR. Bacterial profile and burden of periodontal infection in subjects with a diagnosis of acute coronary syndrome. J Periodontol [Internet]. 2006;77(7):1110–9. DOI: http://dx.doi.org/10.1902/jop.2006.050336
35. Lee HR, Jun HK, Choi BK. Tannerella forsythia BspA increases the risk factors for atherosclerosis in ApoE(-/-) mice. Oral Dis [Internet]. 2014;20(8):803–8. DOI: http://dx.doi.org/10.1111/odi.12214
36. Samulak R, Suwała M, Dembowska E. Nonsurgical periodontal therapy with/without 980 nm diode laser in patients after myocardial infarction: a randomized clinical trial. Lasers Med Sci [Internet]. 2021;36(5):1003–14. DOI: http://dx.doi.org/10.1007/s10103-020-03136-6
37. Frangogiannis NG, Dewald O, Xia Y, Ren G, Haudek S, Leucker T, et al. Critical role of monocyte chemoattractant protein-1/CC chemokine ligand 2 in the pathogenesis of ischemic cardiomyopathy. Circulation [Internet]. 2007;115(5):584–92. DOI: http://dx.doi.org/10.1161/CIRCULATIONAHA.106.646091
38. Widén C, Holmer H, Coleman M, Tudor M, Ohlsson O, Sättlin S, et al. Systemic inflammatory impact of periodontitis on acute coronary syndrome. J Clin Periodontol [Internet]. 2016;43(9):713–9. DOI: http://dx.doi.org/10.1111/jcpe.12540
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spelling Lafaurie Villamil, Gloria InésVargas Sánchez, Paula KatherineCastillo Perdomo, Diana MarcelaDíaz Báez, DavidCardona Rodríguez, María JoséGiraldo Mantilla, Caroline JohanaVargas Sánchez, Daniela Alejandra2025-02-21T19:54:53Z2025-02-21T19:54:53Z2025-01https://hdl.handle.net/20.500.12495/14014instname:Universidad El Bosquereponame:Repositorio Institucional Universidad El Bosquerepourl:https://repositorio.unbosque.edu.coAntecedentes: Las enfermedades cardiovasculares, incluido el síndrome coronario agudo (SCA), son responsables de una gran proporción de muertes a nivel mundial. La periodontitis, una enfermedad inflamatoria crónica de las encías, se ha asociado con un mayor riesgo de enfermedades cardiovasculares, en parte debido a la inflamación sistémica y la presencia de bacterias periodontales que pueden entrar al torrente sanguíneo y contribuir al daño cardiovascular. Objetivo: Este estudio se centra en evaluar y comparar dos protocolos de tratamiento periodontal en pacientes con antecedentes de síndrome coronario agudo (SCA) que asisten a un programa de rehabilitación cardíaca para establecer los cambios en los parámetros clínicos, los cambios microbianos en el biofilm subgingival y la reducción de la inflamación sistémica en pacientes con SCA. Métodos: Se comparan 12 pacientes asignados aleatoriamente a dos modalidades de tratamiento periodontal (instrumentación subgingival) y detartraje ultrasónico con antibioterapia adjunta de Amoxicilina-Metronidazol con un diseño experimental para establecer la reducción de los índices clínicos periodontales, los microorganismos periodontopatógenos por técnica de qPCR y las citocinas proinflamatorias séricas en un período de 6 meses. Resultados: Ambos protocolos disminuyeron los índices de inflamación clínica, la carga bacteriana y los niveles de inflamación (p<0.05). Sin embargo, la instrumentación subgingival mostró una mayor eficacia en la reducción de Tannerella forsythia y Treponema denticola. La instrumentación subgingival mostró mayor efectividad para reducir la IL6 y la IL1b con un incremento de MCP-1. Los índices clínicos no mostraron diferencias entre los grupos p>0.05. Conclusiones: La instrumentación subgingival y el ultrasonido supragingival con antibióticos adjuntos impactan los índices clínicos de los pacientes con SCA en un período de 6 meses. Sin embargo, la instrumentación subgingival favorece la reducción de patógenos y de la proinflamación sistémica generando un impacto sistémico de la terapia periodontal que puede impactar el riesgo cardiovascular.Grupo de investigación UIBO - Unidad de Investigación Básica OralFUndación Clínica SHAIOEspecialista en periodoncia y medicina oralEspecializaciónBackground: Cardiovascular diseases, including acute coronary syndrome (ACS), are among the leading causes of death worldwide. Periodontitis, a chronic inflammatory gum disease, has been linked to an increased risk of cardiovascular diseases, partly due to systemic inflammation and the presence of periodontal bacteria that can enter the bloodstream and contribute to cardiovascular damage. Objective: This study aims to evaluate and compare two periodontal treatment protocols in patients with a history of ACS attending a cardiac rehabilitation program. The goal is to assess changes in clinical parameters, microbial composition of the subgingival biofilm, and reductions in systemic inflammation. Methodology: Twelve patients were randomly assigned to two periodontal treatment modalities: subgingival instrumentation and ultrasonic supragingival debridement with adjunctive antibiotic therapy (Amoxicillin-Metronidazole). The experimental design evaluated the reduction in clinical periodontal indices, periodontopathogenic microorganisms using qPCR, and serum pro- inflammatory cytokines over six months. Results: Both protocols reduced clinical inflammation indices, bacterial load, and levels of systemic inflammation (p<0.05). However, subgingival instrumentation demonstrated greater efficacy in reducing Tannerella forsythia and Treponema denticola. Subgingival instrumentation was also more effective in lowering IL-6 and IL1b levels while increasing MCP-1. Clinical indices showed no significant differences between groups (p>0.05). Conclusions: Subgingival instrumentation and ultrasonic supragingival debridement with adjunctive antibiotics positively impact clinical indices in patients with ACS over six months. However, subgingival instrumentation is more effective in reducing pathogens and systemic pro-inflammatory markers, potentially lowering cardiovascular risk through the systemic impact of periodontal therapy.application/pdfAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://creativecommons.org/licenses/by-nc-sa/4.0/Acceso abiertohttps://purl.org/coar/access_right/c_abf2http://purl.org/coar/access_right/c_abf2PeriodontitisSíndrome coronario agudoCitoquinas proinflamatoriaInflamación sistémicaRelación periodontal-cardiovascularPeriodontitisAcute coronary syndromePro-inflammatory cytokinesSystemic inflammationPeriodontal-cardiovascular relationshipWU 240Efectividad de dos modalidades de atención periodontal para control de la disbiosis microbiana y la proinflamación en pacientes con síndrome coronario agudo. Estudio pilotoEffectiveness of two periodontal care modalities for controlling microbial dysbiosis and pro- inflammation in patients with acute coronary syndrome: a pilot studyEspecialización en periodoncia y medicina oralUniversidad El BosqueFacultad de OdontologíaTesis/Trabajo de grado - Monografía - Especializaciónhttps://purl.org/coar/resource_type/c_7a1fhttp://purl.org/coar/resource_type/c_7a1finfo:eu-repo/semantics/bachelorThesishttps://purl.org/coar/version/c_970fb48d4fbd8a851. World Health Organization-WHO [Web Site]. Washington DC: WHO; 2019. Cardiovascular diseases. Available in: https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_12. Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol [Internet]. 2020;47(3):268–88. DOI: http://dx.doi.org/10.1111/jcpe.131893. Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions: Classification and case definitions for periodontitis. J Periodontol [Internet]. 2018;89 Suppl 1:S173–82. DOI: http://dx.doi.org/10.1002/JPER.17-07214. Dietrich T, Sharma P, Walter C, Weston P, Beck J. The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease. J Clin Periodontol [Internet]. 2013;40 Suppl 14(s14):S70-84. DOI: http://dx.doi.org/10.1111/jcpe.120625. Izawa H, Yoshida T, Ikegame T, Izawa KP, Ito Y, Okamura H, et al. Standard cardiac rehabilitation program for heart failure. Circ J [Internet]. 2019;83(12):2394–8. DOI: http://dx.doi.org/10.1253/circj.CJ-19-06706. Ortega Castillo HF, Piedra Cosíos JC, Tito HD. Diagnóstico y tratamiento del síndrome coronario agudo: actualización. Revista Eugenio Espejo. 2018;12:76–100.7. Suárez LJ, Garzón H, Arboleda S, Rodríguez A. Oral dysbiosis and autoimmunity: From local periodontal responses to an imbalanced systemic immunity. A review. Front Immunol [Internet]. 2020;11:591255. DOI: http://dx.doi.org/10.3389/fimmu.2020.5912558. Horliana ACRT, Chambrone L, Foz AM, Artese HPC, Rabelo M de S, Pannuti CM, et al. Dissemination of periodontal pathogens in the bloodstream after periodontal procedures: a systematic review. PLoS One [Internet]. 2014;9(5):e98271. DOI: http://dx.doi.org/10.1371/journal.pone.00982719. Castillo DM, Sánchez-Beltrán MC, Castellanos JE, Sanz I, Mayorga-Fayad I, Sanz M, et al. Detection of specific periodontal microorganisms from bacteraemia samples after periodontal therapy using molecular-based diagnostics: Bacteraemia by molecular diagnostics. J Clin Periodontol [Internet]. 2011;38(5):418–27. DOI: http://dx.doi.org/10.1111/j.1600-051X.2011.01717.x10. Gualtero DF, Lafaurie GI, Buitrago DM, Castillo Y, Vargas-Sanchez PK, Castillo DM. Oral microbiome mediated inflammation, a potential inductor of vascular diseases: a comprehensive review. Front Cardiovasc Med [Internet]. 2023;10:1250263. DOI: http://dx.doi.org/10.3389/fcvm.2023.125026311. Figuero E, Lindahl C, Marín MJ, Renvert S, Herrera D, Ohlsson O, et al. Quantification of periodontal pathogens in vascular, blood, and subgingival samples from patients with peripheral arterial disease or abdominal aortic aneurysms. J Periodontol [Internet]. 2014;85(9):1182–93. DOI: http://dx.doi.org/10.1902/jop.2014.13060412. Hu X, Li H, Zhao X, Zhou R, Liu H, Sun Y, et al. Multi-omics study reveals that statin therapy is associated with restoration of gut microbiota homeostasis and improvement in outcomes in patients with acute coronary syndrome. Theranostics [Internet]. 2021;11(12):5778–93. DOI: http://dx.doi.org/10.7150/thno.5594613. Moscoso SB, Mendoza F, Gómez LA, Londoño A, Marín JS, Sarmiento JM, Cortes F, Vargas-Sanchez PK, Díaz-Báez D, Lafaurie GI. Incidence of bleeding during and after two non-surgical periodontal therapy schemes in patients with recent acute coronary syndrome on dual antiplatelet therapy: A pilot study. J Clin Exp Dent. 2024;16(12):e1495-e1502. DOI: https://doi.org/10.4317/jced.6175814. Kimura K, Kimura T, Ishihara M, Nakagawa Y, Nakao K, Miyauchi K, et al. JCS 2018 guideline on diagnosis and treatment of acute coronary syndrome. Circ J [Internet]. 2019;83(5):1085–196. DOI: http://dx.doi.org/10.1253/circj.CJ-19-013315. Nakano K, Nemoto H, Nomura R, Inaba H, Yoshioka H, Taniguchi K, et al. Detection of oral bacteria in cardiovascular specimens. Oral Microbiol Immunol [Internet]. 2009;24(1):64–8. DOI: http://dx.doi.org/10.1111/j.1399-302X.2008.00479.x16. Raffaelli L, Santangelo R, Falchetti P, Galluccio F, Luciani N, Anselmi A, et al. Examination of periodontal pathogens in stenotic valve specimens and in whole blood samples in patients affected by aortic valve stenosis and chronic periodontitis. Int J Immunopathol Pharmacol [Internet]. 2010;23(2):561–6. DOI: http://dx.doi.org/10.1177/03946320100230021817. Yamazaki Y, Morita T, Nakai K, Konishi Y, Goto A, Yamamoto T, et al. Impact of dental health intervention on cardiovascular metabolic risk: a pilot study of Japanese adults. J Hum Hypertens [Internet]. 2024;38(6):500–9. DOI: http://dx.doi.org/10.1038/s41371-021-00551-218. Skaar D, O’Connor H, Lunos S, Luepker R, Michalowicz BS. Dental procedures and risk of experiencing a second vascular event in a Medicare population. J Am Dent Assoc [Internet]. 2012;143(11):1190–8. DOI: http://dx.doi.org/10.14219/jada.archive.2012.006319. Mendoza F, Lafaurie GI, Moscoso S, Sarmiento JM, Morales K, Castro M, et al. Prevalencia de la enfermedad periodontal en pacientes con antecedente de síndrome coronario agudo en un programa de rehabilitación cardiaca. Rev Colomb Cardiol [Internet]. 2020;27(4):276–82. DOI: http://dx.doi.org/10.1016/j.rccar.2019.02.00920. Wojtkowska A, Zapolski T, Wysokińska-Miszczuk J, Wysokiński AP. The inflammation link between periodontal disease and coronary atherosclerosis in patients with acute coronary syndromes: case-control study. BMC Oral Health [Internet]. 2021;21(1):5. DOI: http://dx.doi.org/10.1186/s12903-020-01356-421. Gotsman I, Lotan C, Soskolne WA, Rassovsky S, Pugatsch T, Lapidus L, et al. Periodontal destruction is associated with coronary artery disease and periodontal infection with acute coronary syndrome. J Periodontol [Internet]. 2007;78(5):849–58. DOI: http://dx.doi.org/10.1902/jop.2007.06030122. Morillo JM, Lau L, Sanz M, Herrera D, Martín C, Silva A. Quantitative real-time polymerase chain reaction based on single copy gene sequence for detection of periodontal pathogens. J Clin Periodontol [Internet]. 2004;31(12):1054–60. DOI: http://dx.doi.org/10.1111/j.1600-051x.2004.00608.x23. Yoshida A, Kawada M, Suzuki N, Nakano Y, Oho T, Saito T, et al. TaqMan real-time polymerase chain reaction assay for the correlation of Treponema denticola numbers with the severity of periodontal disease. Oral Microbiol Immunol [Internet]. 2004;19(3):196–200. DOI: http://dx.doi.org/10.1111/j.0902-0055.2004.00142.x24. Romero-Sanchez C, Rodríguez C, Santos-Moreno P, Mesa AM, Lafaurie GI, Giraldo-Q S, et al. Is the treatment with biological or non-biological DMARDS a modifier of periodontal condition in patients with rheumatoid arthritis? Curr Rheumatol Rev [Internet]. 2017;13(2):139–51. DOI: http://dx.doi.org/10.2174/157339711366617040716152025. Cross KL, Chirania P, Xiong W, Beall CJ, Elkins JG, Giannone RJ, et al. Insights into the evolution of host association through the isolation and characterization of a novel human periodontal pathobiont, Desulfobulbus oralis. MBio [Internet]. 2018;9(2). DOI: http://dx.doi.org/10.1128/mBio.02061-1726. Lafaurie GI, Castillo DM, Iniesta M, Sanz M, Gómez LA, Castillo Y, et al. Differential analysis of culturable and unculturable subgingival target microorganisms according to the stages of periodontitis. Clin Oral Investig [Internet]. 2023;27(6):3029–43. DOI: http://dx.doi.org/10.1007/s00784-023-04907-527. Castillo Y, Delgadillo NA, Neuta Y, Iniesta M, Sanz M, Herrera D, et al. Design and validation of a quantitative polymerase chain reaction test for the identification and quantification of uncultivable bacteria associated with periodontitis. Arch Oral Biol [Internet]. 2023;154(105758):105758. DOI: http://dx.doi.org/10.1016/j.archoralbio.2023.10575828. Gómez LA, De Avila J, Castillo DM, Montenegro DA, Trujillo TG, Suárez LJ, et al. Porphyromonas gingivalis placental atopobiosis and inflammatory responses in women with adverse pregnancy outcomes. Front Microbiol [Internet]. 2020;11:591626. DOI: http://dx.doi.org/10.3389/fmicb.2020.59162629. Park S-Y, Kim S-H, Kang S-H, Yoon C-H, Lee H-J, Yun P-Y, et al. Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea. Eur Heart J [Internet]. 2019;40(14):1138–45. DOI: http://dx.doi.org/10.1093/eurheartj/ehy83630. Chang Y, Lee JS, Lee K-J, Woo HG, Song T-J. Improved oral hygiene is associated with decreased risk of new-onset diabetes: a nationwide population-based cohort study. Diabetologia [Internet]. 2020;63(5):924–33. DOI: http://dx.doi.org/10.1007/s00125-020-05112-931. Larvin H, Kang J, Aggarwal VR, Pavitt S, Wu J. Multimorbid disease trajectories for people with periodontitis. J Clin Periodontol [Internet]. 2021;48(12):1587–96. DOI: http://dx.doi.org/10.1111/jcpe.1353632. Reichert S, Schlitt A, Beschow V, Lutze A, Lischewski S, Seifert T, et al. Use of floss/interdental brushes is associated with lower risk for new cardiovascular events among patients with coronary heart disease. J Periodontal Res [Internet]. 2015;50(2):180–8. DOI: http://dx.doi.org/10.1111/jre.1219133. Hada DS, Garg S, Ramteke GB, Ratre MS. Effect of non‐surgical periodontal treatment on clinical and biochemical risk markers of cardiovascular disease: A randomized trial. J Periodontol [Internet]. 2015;86(11):1201–11. DOI: http://dx.doi.org/10.1902/jop.2015.15024934. Renvert S, Pettersson T, Ohlsson O, Persson GR. Bacterial profile and burden of periodontal infection in subjects with a diagnosis of acute coronary syndrome. J Periodontol [Internet]. 2006;77(7):1110–9. DOI: http://dx.doi.org/10.1902/jop.2006.05033635. Lee HR, Jun HK, Choi BK. Tannerella forsythia BspA increases the risk factors for atherosclerosis in ApoE(-/-) mice. Oral Dis [Internet]. 2014;20(8):803–8. DOI: http://dx.doi.org/10.1111/odi.1221436. Samulak R, Suwała M, Dembowska E. Nonsurgical periodontal therapy with/without 980 nm diode laser in patients after myocardial infarction: a randomized clinical trial. Lasers Med Sci [Internet]. 2021;36(5):1003–14. DOI: http://dx.doi.org/10.1007/s10103-020-03136-637. Frangogiannis NG, Dewald O, Xia Y, Ren G, Haudek S, Leucker T, et al. Critical role of monocyte chemoattractant protein-1/CC chemokine ligand 2 in the pathogenesis of ischemic cardiomyopathy. Circulation [Internet]. 2007;115(5):584–92. DOI: http://dx.doi.org/10.1161/CIRCULATIONAHA.106.64609138. Widén C, Holmer H, Coleman M, Tudor M, Ohlsson O, Sättlin S, et al. Systemic inflammatory impact of periodontitis on acute coronary syndrome. J Clin Periodontol [Internet]. 2016;43(9):713–9. DOI: http://dx.doi.org/10.1111/jcpe.12540spaCC-LICENSElicense_rdflicense_rdfapplication/rdf+xml; charset=utf-81160https://repositorio.unbosque.edu.co/bitstreams/4634d673-8521-4b88-9922-0388dccc6ef6/download5643bfd9bcf29d560eeec56d584edaa9MD56TEXTTrabajo de grado.pdf.txtTrabajo de grado.pdf.txtExtracted texttext/plain96423https://repositorio.unbosque.edu.co/bitstreams/93ff5103-dd80-41a7-87e5-aa45a3b08f86/download1c81104739cceeec77643b4b8fa0980cMD510THUMBNAILTrabajo de grado.pdf.jpgTrabajo de grado.pdf.jpgGenerated Thumbnailimage/jpeg3066https://repositorio.unbosque.edu.co/bitstreams/a86c717b-8f31-416b-a8d8-155723b03da8/downloadbdb9b2be3596caab3dffbb43a8f3ae46MD511ORIGINALTrabajo de grado.pdfTrabajo de grado.pdfapplication/pdf1507274https://repositorio.unbosque.edu.co/bitstreams/d06cc350-06c3-4bfa-b805-e7cd75b42e8f/download33e6f927d1d12eca16e21104e73e7882MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-82000https://repositorio.unbosque.edu.co/bitstreams/b11e3538-aa21-469f-b156-15ee91ca899c/download17cc15b951e7cc6b3728a574117320f9MD55Carta de autorizacion.pdfapplication/pdf488787https://repositorio.unbosque.edu.co/bitstreams/893a6aa1-a368-4e03-991f-6adc5c133a4f/downloadeb9f997efbecf9078621457445c97adaMD57Anexo 1 acta de aprobacion.pdfapplication/pdf208551https://repositorio.unbosque.edu.co/bitstreams/d74c643f-073b-461e-a0fa-4d998bd66fec/downloadf8b47f33ec86e3304c113adfd32e8129MD58Anexo 2.pdfapplication/pdf256726https://repositorio.unbosque.edu.co/bitstreams/d571e091-366c-446e-bd26-582ef6c0f228/download6415da48e4a0288c39f2069dea283525MD5920.500.12495/14014oai:repositorio.unbosque.edu.co:20.500.12495/140142025-02-22 05:04:03.118http://creativecommons.org/licenses/by-nc-sa/4.0/Attribution-NonCommercial-ShareAlike 4.0 Internationalopen.accesshttps://repositorio.unbosque.edu.coRepositorio Institucional Universidad El Bosquebibliotecas@biteca.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