The role of the oral microbiome, host response, and periodontal disease treatment in Alzheimer's disease: A primer

BACKGROUND: Alzheimer's disease (AD) is the leading cause of cognitive impairment and dementia in elderly patients worldwide. There is increasing evidence that periodontal disease may have an important role in the complex, multifactorial pathogenesis of AD. AIM: This narrative review aims to (1) highlight the current understanding of the role of periodontal disease in AD, including molecular and immunological evidence, epidemiological studies, and biological mechanisms linking periodontal disease to AD; and (2) explore the potential impact of periodontal therapy as part of an individualized, multitherapeutic approach to AD. MATERIALS AND METHODS: A literature search of the PubMed database was conducted using Boolean search strategies to identify publications related to the potential connections between periodontal disease and AD. RESULTS: Most of the evidence for a link between periodontal disease and AD is limited to preclinical research and epidemiological investigations. A direct causal link has not yet been demonstrated in human clinical studies, but periodontal pathogenic bacteria have been detected in brain tissue and cerebrospinal fluid of patients with AD. Further, colocalization of gingipain proteases secreted by Porphyromonas gingivalis has been found in AD pathological lesions. Epidemiological studies support associations between periodontal disease and increased risk/prevalence of cognitive decline, AD, and AD mortality. Two mechanistic theories have been proposed to explain the connection between periodontitis and AD: the "microbial involvement" theory focuses on periodontal disease-associated pathogenic bacteria, whereas the "inflammatory cascade" theory focuses on proinflammatory mediators as drivers of neuroinflammation that may exacerbate pathologic lesions associated with AD. Preclinical studies of periodontal therapies targeting oral microbiota or their byproducts have investigated small-molecule gingipain inhibitors and novel therapeutics that restore oral microbial homeostasis (e.g., probiotic bacteriocin nisin). In animal models, gingipain inhibitors and nisin showed inhibitory effects on formation of pathological lesions of AD or neuroinflammation and microbiome changes, respectively; however, no impact on cognition was found with use of gingipain inhibitors in patients with mild-to-moderate AD. CONCLUSIONS: Additional studies are needed to better understand the potential causal relationship between periodontal disease and AD, including further exploration of therapies targeting the oral-brain axis.