Sci-Afric Journal of Scientific Issues, Research and Essays Vol. 3(8), Pp. 746-754, August, 2015.

(ISSN 2311-
2311-6188)
http://www.sci-africpublishers.org

Research Article

Prevalence of Periodontal Disease in Patients with

Chronic Obstructive Pulmonary Disease

Lúcio Hélio Pereira de Almeida1, Maria Vieira de Lima Saintrain2*, Paulo César de Almeida3, Danilo
Lopes Ferreira Lima4, Francisco Rogério Rodrigues Costa4, Walda Viana Brígido de Moura5

1
University of Fortaleza (UNIFOR), Av. Washington Soares, 1321 Bloco S–Sala 1-Bairro Edson Queiroz, Fortaleza – CE, Brazil.
E-mail: luciohpalmeida@yahoo.com.br
*2Center of Health Sciences, University of Fortaleza (UNIFOR). Av. Washington Soares, 1321 Bloco S – Sala 1- Bairro Edson
Queiroz, Fortaleza – CE, Brazil. E-mail: mvlsaintrain@yahoo.com.br
3
State University of Ceará (UECE), Av. Paranjana, 1700, Campus do Itaperi, Fortaleza–CE, Brazil. E-mail:
pc49almeida@gmail.com
4
Dentistry Department of Center of Health Sciences, University of Fortaleza (UNIFOR). Av. Washington Soares, 1321 Bloco S –
Sala 1- Bairro Edson Queiroz, Fortaleza – CE, Brazil. E-mail: lubbos@uol.com.br
4
Dentistry Department of Center of Health Sciences, University of Fortaleza (UNIFOR). Av. Washington Soares, 1321 Bloco S –
Sala 1- Bairro Edson Queiroz, Fortaleza – CE, Brazil. E-mail: rogerio_rodrigues@hotmail.com
5
Dentistry School, Federal University of Ceará (UFC) Rua Alexandre Baraúna, 949 - Rodolfo Teófilo. E-mail: walda@ufc.br

*Corresponding Author’s e-mail: mvlsaintrain@yahoo.com.br

th
Accepted August 11 , 2015
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ABSTRACT

The objective of this study is to assess the prevalence of periodontal disease in patients with COPD as
Northeastern Brazil ranks third in the number of hospitalizations for this pathology. Quantitative cross-
sectional research was conducted with 61 patients with COPD of a hospital specialized in heart and lung
diseases in Northeastern Brazil. A semi-structured questionnaire with sociodemographic data and past medical
history was used. Two clinical examinations were applied: Community Periodontal Index (CPI) and Clinical
Attachment Loss (CAL). Chi-squared test and likelihood-ratio test were used to check for association between
variables. Significance level was set at p<0.05. The results show that there was a prevalence of periodontal
disease in 98.3% of the patients, with a predominance of gingival bleeding (91.8%), dental calculus (98.4%),
periodontal pocket (60.7%), attachment loss (63.9%). There was a prevalence of patients with very severe
(16.4%), severe (50.8%) and moderate (32.8%) COPD. Hypertension was the most prevalent systemic disease
(33.1%). Deleterious habits such as long-term smoking and drinking have been reported (13.8±5.6 years;
10.0±5.2 years, respectively). There was an association between CPI and CAL considering moderate COPD
(p=0.014). In conclusion, severe periodontal disease was observed in a high percentage of patients with COPD,
suggesting the implementation of a Dental Care Protocol in hospitals and outpatient care centers.

Key words: Oral Health. Periodontitis. Periodontal Index. Chronic Obstructive Pulmonary Disease
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 Almeida et al 746

INTRODUCTION

Oral diseases are major public health problems worldwide. In addition to being associated with social inequalities, the high
prevalence and consequences of oral diseases, as a result of pain, suffering and impairment of function, have a major influence
on people’s quality of life.
Evidence suggests a strong correlation between oral diseases and non-communicable diseases (NCDs), sometimes
sharing common risk factors. Moreover, many general pathological states have oral manifestations and can increase the risk of
pathologies like cardiovascular diseases (atherosclerosis, acute myocardial infarction, cerebrovascular accident), pneumonias,
diabetes mellitus, osteoporosis, preterm birth and low birth weight [1,2,3].
There is evidence that individuals with early onset of periodontal disease may have systemic diseases like diabetes,
hypertension and lung diseases or present immune system alterations [4,5,6]. Thus, the oral cavity may be an important source
of bacteria that cause infections of the lungs as dental plaque, a tooth-borne biofilm that initiates periodontal disease, may
influence the initiation and progression of pneumonia because of relocalization of the bacteria from the biofilm into the respiratory
tract [7]. There is a host inflammatory response to the infectious agent: bacteria, in cases of periodontal disease, and cigarette
smoke, in cases of COPD. In this context, Carranza (2011, p.370) [8] confirms that the Chronic Obstructive Pulmonary Disease
(COPD) shares similar pathogenic mechanisms with periodontal disease.
COPD is characterized by the obstruction of lung airflow resulting from chronic bronchitis or emphysema. It is a major public
health problem that mainly affects people over the age of 40. It is believed to be one of the main causes of chronic morbidity and
mortality, and it is projected to rank seventh as a worldwide burden of disease by 2030 [8,9]. The most common symptoms of
COPD complications include: shortness of breath (dyspnea), increased volume and altered color of sputum, coughing, fever, and
wheezing. The treatment of stable COPD mainly includes smoking cessation, drug treatment (bronchodilators, systemic
corticosteroids and antibiotics) and non-drug treatment, which includes regular physical activity in order to improve physical
fitness, dyspnea and reduce the risks of comorbidities. Therefore, health services should be prepared to care for patients with
more severe symptoms who often need oxygen support, monitoring and sometimes noninvasive positive pressure ventilation
[10,11]. One of the difficulties in assessing the prevalence of COPD is the late diagnosis of the disease, which is performed when
the disease is clinically apparent and moderately advanced. It has been estimated to range from 4% to up to 20% in adults over
40 years of age, with a considerable increase by age, particularly among smokers [9].
Prospective studies conducted by Murray and Lopez [12] (1997) have already pointed COPD as one of the diseases that
will contribute to increasing mortality rate to 49.7 million people worldwide in 2020. Recent epidemiologic data from Brazil show
that there were 9,086 cases of hospitalization from COPD in 2012, with the Northeastern region ranking third in number of cases
after Southeastern and Southern regions, respectively [13].
Given the above, the present study aimed to analyze the prevalence of periodontal disease in patients with Chronic
Obstructive Pulmonary Disease in a public hospital specializing in lung diseases located in the municipality of Fortaleza, Ceará,
Brazil.

METHODS

This is a quantitative, descriptive and analytical cross-sectional study conducted at the Hospital de Messejana Dr. Carlos Alberto
Studart Gomes (HM), in Fortaleza – CE, Brazil.
The hospital specializes in the diagnosis and treatment of heart and lung diseases. It performs all the high complexity
procedures related to these problems and has become a reference in heart transplantation in Latin America. It became the first
hospital to perform lung transplantation in Northern and Northeastern Brazil since June 2011. The institution is managed by the
Ceará State Health Secretariat (SESA) and receives patients from all the 184 municipalities of Ceará, and also from the Northern
and Northeastern regions of the country. It counts on multi-professional teams to provide care and treatment to patients with
severe diseases like lung cancer, pneumonia, COPD, asthma, and others. It provides lung rehabilitation services since 1999, and
in 2002 it started to offer a smoking control program (the first public service for the treatment of smokers in Fortaleza) and an
asthma control program to provide patients with a better quality of life [14].
In the State of Ceará, with regard to the protocol for the management of patients with COPD, it is compulsory to check for
items included in the action plan of the tertiary care network (reference centers). The items include the enrollment of patients
referred for differential diagnosis and confirmation of disease; the availability of long-acting bronchodilators provided by SESA to
these centers; the adequate functioning of the oxygen therapy program for hypoxemia cases; and the establishment of a
pulmonary rehabilitation program in these centers [15]. The HM is a reference center in which these two services are fully
available.
Given that the outpatient center receives an average of 60 patients weekly, it took three months to collect data from patients
treated at the COPD outpatient center. This amount of time was considered sufficient to obtain an adequate number of patients.
Therefore, the target population comprised patients diagnosed with COPD who attended the outpatient center of the HM in the
period from August to October 2013 and agreed to participate in the research, regardless of whether they were attending their first
consultation or receiving outpatient care.
 Almeida et al 747

Inclusion criteria were: patients diagnosed with COPD in the outpatient center of the HM and being 20 years old or older. The
latter criterion aimed to ensure greater autonomy to choose whether or not to participate in the research and suit the WHO
guidelines for basic oral health surveys on Community Periodontal Index – CPI and Clinical Attachment Loss - CAL. Additionally, it
aimed to avoid the scoring of deepened sulcus associated with eruption of molars as periodontal pockets [16]. Patients who
needed antibiotic prophylaxis for periodontal probing (valvulopathy, decompensated diabetes, and others) and fully edentulous
individuals were excluded from the research. Informing the hospital staff about the study, its relevance and objectives was of
utmost importance for having them collaborate on the referral of patients with COPD to the dental office. After being examined by
a doctor and having their records in hand, patients were taken to the Dentistry Department of the HM by an assistant.
The researcher received each patient in the office and informed about the research objectives and types of procedures to
be carried out. Patients who agreed to participate signed a Free Informed Consent Form. All the patients agreed to participate in
the research. This was made possible due to educational work previously performed by a multi-professional team of the hospital
through a support group for patients with COPD. These patients are informed about their rights and duties and feel empowered to
participate in activities and research involving the improvement of their health and quality of life. The documentary research was
performed using medical records. The research was authorized by the Chief of the Archives Department through a Trustee
Statement and allowed the researcher to know the past medical history of a patient and also obtain information about the general
state of health and use of medications.
Data were collected using a semi-structured questionnaire for sociodemographic data and the transcription of past medical
history in addition to the records of the clinical examination of periodontal condition. The researcher, a dentist-surgeon who has
specialized in Periodontics, performed the examination in the office of the HM. Biosafety criteria were met, and probing was
performed using the WHO-621 periodontal probe. The periodontal evaluation was performed according to the WHO guidelines for
periodontal examination using CPI and CAL. The CPI gives greater emphasis to the evaluation of periodontal conditions and uses
three indicators: gingival bleeding, calculus, and periodontal pockets. To evaluate the CAL, it is recommended to probe pocket
depths to verify the extent of loss of attachment [16). The codes used to record the CPI are as follows: 0 – Healthy; 1 – Bleeding
observed, directly or by using a mouth mirror, after probing; 2 – Calculus detected during probing, with the black band on the
probe fully visible; 3 – Periodontal pocket is 3.5-5.5mm (gingival margin within the black band on the probe); 4 – Periodontal
pocket is 5.5mm or more (black band on the probe not visible); X – Excluded sextant (less than two teeth present); 9 – Not
recorded [16].
The severity of the attachment loss is generally but not always correlated with the depth of the pocket. This is because the
degree of attachment loss depends on the location of the base of the pocket on the root surface until the Cementoenamel
Junction (CEJ), whereas pocket depth is the distance between the base of the pocket and the crest of the gingival margin [8].
The extent of loss of attachment is recorded applying the following codes: 0 – Loss of attachment is 0-3.5mm (CEJ not
visible and CPI value is 0-3.5) or (CEJ not visible and CPI is 3..5-5.5mm); 1 – loss of attachment is 3.5-5.5mm (CEJ within black
band); 2 – loss of attachment is 5.5-8.5mm (CEJ between upper limit of the black band and 8.5mm ring); 3 – loss of attachment is
8.5-11.5mm (CEJ between 8.5mm and 11.5 mm ring); 4 – loss of attachment is 11.5mm or more (CEJ beyond 11.5mm ring); X –
excluded sextant (less than two teeth present); 9 – not recorded (CEJ not visible and not detectable) [16].
The clinical examination allowed diagnosing the periodontal condition and evaluating the forms and frequencies of the
disease. After the clinical examinations, patients were scheduled to start the treatment by the researcher in the Dentistry
Department of the HM from November 2013. Data were consolidated by the Statistical Package for Social Science for Windows
19.0 (SPSS Inc., Chicago, IL, USA) and then presented in tables for analysis and discussion. The chi-squared test and likelihood-
ratio test were used to check for potential associations between variables. In all analyses, the significance level was set at p<0.05.
The research was approved by the Ethics Committee of the University of Fortaleza (UNIFOR) under Opinion No. 332.870 and by
the Ethics Committee of the HM under Opinion No. 338.260 as required by the Brazilian legislation [17].

RESULTS

A total of 61 patients aged 36-85 years, mean age 63.2 (SD± 10.19 years), were examined. Table 1 show the occurrence of
systemic diseases and deleterious habits in addition to the distribution of the number of patients according to the degree of COPD
and time elapsed between diagnosis in the HM and first dental consultation. It highlights patients without systemic diseases
[19(31.1%), patients with hypertension [20(32.8%), ex-smokers [52(85.25), patients with severe COPD [31(50.8%) and time
elapsed after diagnosis from 13 to 60 months [34(55.7%).
 Almeida et al 748

Table 1: Frequency distribution for systemic diseases, deleterious habits, degree of Chronic Obstructive Pulmonary Disease and
time elapsed after diagnosis. Fortaleza - Ceará, 2013

Variables Frequency Percentage

Systemic Diseases
None 19 31.1
Hypertension 20 32.8
Cardiopathy 4 6.6
Arthritis
3 4.9
Asthma
3 4.9
Diabetes
3 4.9
Other 9 1.6

Deleterious Habits

Smoker 2 3.3

Ex-smoker 52 85.2
2
Alcoholic 3.3

Ex-alcoholic 23 37.7

Degree of COPD
Moderate
20 32.7
Severe 31 50.8
Very severe
10 16.4
Mean ± SD
2.8 ± 0.7

Time elapsed after COPD diagnosis (months)

Up to 12 15 24.6

13 to 60 34 55.7

61 to 120 10 16.4

More than 120 2 3.3

Mean ± SD 45.4 ± 57.5

Source: Research data

Table 2 shows the results of sociodemographic factors inferred from COPD data and highlights the prevalence of COPD in
individuals aged 60 and older [25(64.1%)] and the prevalence of severe and very severe COPD. There was a prevalence of males
26 (72.2%) and elementary education 26(72.2%). The majority of interviewees sleep accompanied by a person 25(80%) and there
is a predominance of ex-smokers 37(71.2%), non-smokers 40(67.8%) and non-alcoholics 26(68.4%). There was a prevalence of
monthly income of R$501.00-R$ 1500.00, which is equivalent to 1-2 minimum wages – MW (one MW ± 265 US$ in December
2012) [18].
 Almeida et al 749

Table 2: Inference of sociodemographic data versus Degree of Chronic Obstructive Pulmonary Disease. Fortaleza-Ceará, 2013

Severe or very Mild or

Variables severe moderate OR CI 95% p-value
N % N %
Age
36-47 04 80.0 01 20.0 2.24 0.23 - 22.05 0.761
48-59 12 70.6 05 29.4 1.34 0.39 - 4.60
60 or older 25 64.1 14 35.9 1.00 -
Sex
Male 26 72.2 10 27.8 1.73 0.59 - 5.12 0.317*
Female 15 60.0 10 40.0 1.00 -
Education
Illiterate 06 85.7 01 14.3 2.31 0.17 - 30.85 0.266*
Elementary 26 72.2 10 27.8 2.17 0.41 - 11.45
High school 06 54.5 05 45.5 1.60 0.24 - 10.81
Higher Education 03 42.9 04 57.1 1.00 -
Income
Up to 500 03 75.0 01 25.0 2.67 0.25 - 28.28 0.021*
501 to 1500 20 87.0 03 13.0 5.93 1.48 - 23.74
More than 1500 18 52.9 16 47.1 1.00 -
Sleeps
Alone 11 61.1 07 38.9 1.26 0.25 - 6.36 0.481*
Accompanied by one person 25 80.0 09 26.5 2.22 0.49 - 10.16
Accompanied by more than one
05 55.6 04 44.4
person 1.00 -
Smoker
Yes 01 50.0 01 50.0 1.00 - 1.000*
No 40 67.8 19 32.2 2.11 0.12 - 35.5
Ex-smoker
Yes 37 71.2 15 28.8 3.08 0.73 - 13.08 0.139*
No 04 44.4 05 55.6 1.00 -
Alcoholic
Yes 01 50.0 01 50.0 1.00 -
No 40 67.8 19 32.2 2.11 0.12 - 35.5 1.000*
Ex-alcoholic
Yes 15 65.2 08 34.8 1.00 - 0.796
No 26 68.4 12 31.6 1.16 0.39 - 3.46
Source: Research data. *Fisher’s test.

Table 3 shows the distribution and percentage of patients according to periodontal condition (CPI) and Clinical Attachment Loss
(CAL). The results obtained from the six sextants did not reveal any association between these variables (p=0.508 and p=0.221,
respectively).
 Almeida et al 750

Table 3: Distribution of patients with COPD according to the correlation between index teeth, periodontal condition and loss of
attachment (clinical exams). Fortaleza- Ceará, 2013

Index teeth
17/16 11 26/27 36/37 31 46/47 p
Nº % Nº % Nº % Nº % Nº % Nº %
Periodontal 0.508
Condition
Bleeding 16 26.2 27 44.3 18 29.5 15 24.6 48 78.7 21 4.4
Calculus 16 26.2 27 44.3 18 29.5 17 27.9 54 88.5 23 7.7
Pocket (3.5-5.5 11 18.0 10 16.4 09 14.7 08 13.1 19 31.1 13 21.3
mm)
Pocket (> 5.5mm) 01 1.7 03 4.9 03 4.9 - - - - 01 1.7

Loss of 0.221
Attachment

3.5-5.5mm 06 9.8 07 11.5 06 9.8 07 11.5 07 11.5 10 16.4

5.5-8.5mm 04 6.5 03 4.9 03 4.9 01 1.7 08 13.1 03 4.9
8.5-11.5mm 01 1.7 04 6.5 03 4.9 - - 02 3.3 - -
≥ 11.5mm 01 1.7 - - - - - - 01 1.7 - -
Source: research data

Table 4 shows the correlation between patients with COPD and periodontal disease. Periodontal disease was present in almost all
the patients, with a prevalence of dental calculus [60(98.4%). Periodontal pocket was observed in 60.7% of the patients, but no
association was found between CPI variables (bleeding, dental calculus, and periodontal pocket) and CAL (p=0.189).

Table 4: Distribution of the number of patients with COPD according to the presence of periodontal disease. Fortaleza- Ceará,
2013

Periodontal condition Nº % p-value

Bleeding 56 91.8 0.189

Dental calculus 60 98.4
Periodontal pocket 37 60.7
Loss of Attachment 39 63.9

Table 5 shows the correlation between the periodontal condition and the degree of COPD (CPI and CAL).

Periodontal Condition
Degree of COPD CPI CAL
1 2 3 4 1 2 3 4 p(1)
Moderate (II) 19 20 12 02 10 02 02 01 0.014
Severe (III) 30 32 20 02 10 14 04 01 0.582
Very severe (IV) 08 08 05 01 02 03 01 01 0.789
p(2) 0.997 0.175
Source: research data. p(1): comparison of the proportions of the degree of COPD between CPI and Loss of Attachment p(2): comparison of the
proportions of the degree of COPD within each index: CPI and CAL

DISCUSSION

The present research, conducted with patients with COPD, presents significant results. According to the sociodemographic
characteristics, there is a prevalence of males, and the majority of individuals receiving care are at the age of 60 and older. These
findings are corroborated by studies showing that elderly people with chronic respiratory diseases are at increased risk for
 Almeida et al 751

colonization of dental plaque by respiratory pathogens and the total percentage of these bacteria in the mouth can be as high as
70% in the dental biofilm [19,20].
In this context, a study by Halbert et al.[21] (2006) conducted in 28 countries showed a higher prevalence of COPD in men
and individuals over 40 years old. Accordingly, research in the Global Initiative for Chronic Obstructive Lung Disease has also
found similar results [11]. Additionally, studies conducted in Portugal showed a prevalence of COPD in men and individuals aged
40-69 years and confirmed the findings of the present research [22,23].
Regarding family income, there was a greater statistical association between patients with moderate or severe COPD and
low family income, according to the value of the minimum wage in December 2012 [18].
The family income found in the present study corroborates the research by the Instituto Brasileiro de Geografia e Estatística
– IBGE (Brazilian Institute of Geography and Statistics). According to the list of socioeconomic classes, the study population
predominantly belongs to socioeconomic class D – 1-3 minimum wages and class E – less than one minimum wage, which are
considered low-income classes [24].
Some studies addressing the periodontal condition of the Brazilian population and the socioeconomic status of the
population assisted by dental services are important to highlight as they point the low income and low education levels as barriers
to health care access. Therefore, the low family income invokes a great deal of concern given it determines other factors that can
put both overall and oral health in jeopardy [20, 25,26,27].
There was a prevalence of severe and very severe COPD in the present research. It was possible to relate the odds ratio
for the severity detected to patients’ information regarding socioeconomic status, health and deleterious habits, such as smoking
and drinking. As for deleterious habits, only two participants of the present study smoke and drink; however, there was a majority
of ex-smokers and ex-alcoholics, which does not prevent the bad effects of these previous habits. According to Bascom [28], it is
difficult to dissociate the epidemiology of COPD from that of smoking, given this is its main and most frequent risk factor,
accounting for 42% of chronic respiratory diseases [29].
With regard to periodontal condition and COPD, there is also a great concern about patients who took a long time to attend
their first dental consultation for the clinical examination of periodontal disease after the diagnosis of COPD in HM. In this context,
some studies highlight that a shorter time elapsed between the diagnosis of COPD and the dental consultation is associated with
greater reduction in the risk of developing and/or aggravating periodontal disease, particularly the most severe forms. Therefore,
they show the importance of early preventive dental care to lower the rates of periodontal disease in patients with lung diseases
[2,30,31].
Regarding systemic diseases, hypertension appeared to be the most frequent disease as others have been cited less
frequently. Some studies show an association between COPD, periodontal disease and other pathologies, particularly
cardiovascular diseases. Authors like Scannapieco, Dasanayake and Chhun [32] have highlighted the risk of myocardial
infarction. Previously, in 1998, Hayes et al. [33] had already highlighted the association between periodontal disease and
cardiovascular diseases like coronary artery disease, CVA, and peripheral vascular disease.
According to Lowe [34], the risk of coronary heart disease and stroke in patients with periodontal disease is associated with
high white blood cell count and high fibrinogen levels in the blood. Other important data on the risk of associated diseases reveal
that patients with poorly controlled diabetes mellitus are three times more likely to have severe periodontal disease with loss of
attachment, accounting for 60% of these cases [32]. The presence of periodontal disease exacerbates COPD and hinders
patients’ quality of life, increasing the costs of the treatment. Although periodontal disease and COPD do not share the same
pathogens, they live harmoniously, and several researchers have found respiratory pathogens in dental biofilm [3, 35, 36].
Additionally, important periodontal pathogens have also been found in the sputum of patients with an acute exacerbation of
respiratory diseases - Fusobacterium nucleatum e Prevotella intermédia [37].
In the present study, the presence of periodontal disease was observed in the majority of patients examined. There was a
very high percentage of periodontal bleeding and dental calculus in teeth 11 and 31 of sextants two and five, respectively (upper
and lower anterior sextants). These results may be related to the fact that the study participants, for a cultural reason, may have
paid special attention to anterior teeth in order to preserve the smile or they may have sought dental care only in case of pain [26].
These findings have been corroborated by Brazilian research [38] that verified that adults (91.7%) and elders (84.0%) have used
dental services just a few times throughout life. However, 31.1% of adults and 35.3% of elders seek dental care only in case of
pain and tooth extraction. In the same research, the CPI revealed that 82.2% of adults and 98.2% of elders presented periodontal
problems; additionally, periodontal pocket and loss of attachment have also presented relevant results, accounting for more than
half of the interviewees.
Research on the association of COPD with periodontal diseases highlight that the respiratory distress in these patients
cause them to mouth breathe, leading to a dry mouth (xerostomia) and decreased saliva. As a consequence of xerostomia, there
is an accumulation of calculus on upper incisors and swelling of gums [39]. Regarding the relationship between COPD and
accumulation of calculus, Deo et al [40], in a research conducted with 150 patients from two rural hospitals of India aiming to
evaluate the potential association between respiratory diseases and periodontal health status and to co-relate the severity of
periodontal disease with that of COPD, corroborate these findings and report an increased gingival bleeding.
The statistical tests used to determine the degree of COPD and Periodontal disease revealed an association of CPI and
CAL with moderate COPD (p=0.014) when the proportion within periodontal conditions was much higher in the CPI. As both
 Almeida et al 752

indices (CPI and CAL) are based on the depth of pockets (crest of gingival margin and cementoenamel junction, respectively) and
sometimes use the same teeth and sites of index teeth for its recording, they may be similar and therefore do not present
statistical significance.
However, if the periodontal pocket used to measure CPI or CAL is the same and located on the same site and surface of
the same index tooth for both CPI and CAL, higher CAL scores will result in lower CPI scores due to gingival recession and
exposed tooth roots and to the fact that most of the times the base of the pocket corresponds to the end of the root of the site
examined[8]. Therefore, the present study has been corroborated by this assumption and has presented similar results.
Importantly, the non-correlation found between severe and very severe COPD and Periodontal Condition may be related to the
fact that when patients get to oral health services seeking urgency care/hospitalization, the most serious sources of oral infections
(teeth with class II and III mobility, periodontal abscess and deep pockets with discharge) are immediately removed in order to
obtain a faster recovery of these patients.
Concerning cases of moderate COPD, the rate of periodontal conditions is higher in CPI because it shows the active
disease while CAL reveals the sequelae of the periodontal disease. As patients only seek dental services when there is an
exacerbation of pain, the only possible treatment is, most of the times, the tooth extraction. This fact makes it difficult to find teeth
in the mouth with sequelae of periodontal disease; therefore, it is easier to find teeth with active periodontal disease detected
using the CPI. On the other hand, in patients with severe and very severe COPD, there is not enough time for the dental
practitioner to choose conservative dental treatment (as in moderate COPD), which makes it necessary to use treatments that
cease any possibility of inflammation and infection [40]. The dental team of the hospital provides systematized care and follow-up
to patients with heart diseases. However, there is a need to extend this service to patients with lung diseases who only receive
care in urgency and emergency situations and patients under oxygen therapy. Moreover, these patients have a difficult access to
primary care. Therefore, one should notice the importance of health professionals in performing health education actions,
particularly the delivery of messages about quitting smoking when receiving patients, even if they seek care for reasons other than
COPD or respiratory problems. Quitting smoking is the key intervention for all patients with COPD and health care providers
should encourage all patients who smoke to quit [11].
The clinical examination allowed diagnosing the periodontal condition and evaluating the forms and frequencies of the
disease. All patients presented clinical manifestations of periodontal disease after the clinical examination and were then
scheduled to start the treatment in November 2013 by the researcher, who works in the Dentistry Department of the HM. In this
context and aiming to identify potential relationships between periodontal disease and the pulmonary disease, it was possible to
contribute to a faster recovery of patients through early and preventive diagnosis and treatment of periodontal disease. It is
important to highlight that the reference Institution does not provide routine dental actions for patients with COPD receiving care in
the outpatient care center. Thus, the present research was of utmost importance for it sought to provide information that is
relevant to the planning of actions for the treatment of the dental needs of these patients. Therefore, these patients could have
their quality of life improved by reducing some dental intercurrence that are preventable and by promoting and integrated
performance of the service. Additionally, there is a need for further research to prove the relationship between COPD and
periodontal disease as the literature about this issue is still scarce.

CONCLUSIONS

The presence of periodontal disease was observed in the majority of patients examined, with a very high percentage of gingival
bleeding, dental calculus, periodontal pocket and attachment loss. The prevalence of deleterious habits (current and previous) in
the interviewees and the predominance of severe and very severe COPD highlight clinical conditions that require concrete and
efficient preventive public policy actions targeted to this population. The occurrence of periodontal disease in patients with COPD
suggests the establishment of Dental Care Protocols for these patients. The findings highlight reasons for implementing health
care actions based on reference and counter-reference strategies of Health Systems in both hospitals and outpatient care centers.

AUTHORS CONTRIBUTIONS: LHPA, MVLM, PCAA and DLFL conceived and designed the research project. LHPA, FRRC performed data collection. PCAA,
DLFL and WVBM analyzed the data. LHPA, FRRC and DLFL contributed reagents/materials/analysis tools. LHPA, MVLM and WVBM wrote the paper. MVLS,
LHPA, PCAA, and WVBM reviewed the paper.

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