Of periodontitis and the nonbiological and biological variables are presented in Table 2. Table 3 indicates that severe periodontitis 58-49-1 status was positively associated with the plasma levels of orosomucoid (p = 0.04) in the adjusted logistic regression model A (with adjustment for age, gender and smoking) but without reaching statistical significance (p 25033180 = 0.053) in Model B (with adjustment for age, gender, smoking and diabetes).DiscussionThe data of the present study indicate that morbidly obese patients are prone to chronic periodontitis, and that disease severity is significantly associated with the circulating concentration of orosomucoid. Regarding the poor periodontal condition in obese patients, our results are consistent with others showing that poor oral health is related to high BMI. Two meta-analyses have shown an association between BMI and periodontitis, although the magnitude of the relationship remains unclear [13,15]. In an adult French population, it has been found that BMI was statistically associated with buy 374913-63-0 missing teeth, pocket depth and plaque index, independently of dietary patterns and insulin resistance [26]. Our results indicate a median missing tooth value of 4, which is similar to the median number of missing teeth in the general French population i.e. 3.8 (95 confidence interval: 1.6?.6) [27]. Nevertheless, it has been demonstrated that the chewing patternswere affected in patients with morbid obesity as compared with controls, whatever the number of teeth present [28]. Consequently, it cannot be excluded that periodontitis, and not edentulism, negatively impacts the chewing ability and the quality of life of morbidly obese subjects. On the other hand, in the present study the Gingival Index, a clinical marker of local periodontal inflammation, did not significantly differ between mild to moderate periodontitis and severe periodontitis patients. It cannot be excluded that low grade inflammation associated with obesity obscures the clinical expression of local inflammation in the development of periodontitis. A recent study using a proteomic approach has shown an increased level of antimicrobial peptides (defensins) in the saliva of morbidly obese patients suffering from periodontitis [29]. A two-way relationship between obesityinduced and periodontitis-induced inflammation cannot be ruled out. Moreover, among the various adipokines and inflammatory markers studied here, only the orosomucoid level was associated with periodontal inflammation severity after adjustment for age, gender and smoking. In 
a comparative study on systemic inflammation in cardiovascular and periodontal disease, higher levels of orosomucoid were observed in subjects with both these conditions [30] compared to subjects with neither disease, or with only PD or CVD. Indeed, an increased level of orosomucoid is characteristic of subjects with both cardiovascular and periodontal diseases. Orosomucoid or Alpha (1)-acid glycoprotein is an inflammation-sensitive plasma protein. This protein is a typical marker of inflammation, which increases by a factor of 3? after an inflammatory stimulus [31,32]. The synthesis of orosomucoid takes place in the liver and is induced by IL-1, TNFa and IL-6. Neutrophils and monocytes can also synthesize orosomucoid and thus contribute to the elevation of this protein in the serum of patients with sepsis. Interestingly, C reactive protein is an acute phase inflammatory marker whereas orosomucoid is a chronic phase ma.Of periodontitis and the nonbiological and biological variables are presented in Table 2. Table 3 indicates that severe periodontitis status was positively associated with the plasma levels of orosomucoid (p = 0.04) in the adjusted logistic regression model A (with adjustment for age, gender and smoking) but without reaching statistical significance (p 25033180 = 0.053) in Model B (with adjustment for age, gender, smoking and diabetes).DiscussionThe data of the present study indicate that morbidly obese patients are prone to chronic periodontitis, and that disease severity is significantly associated with the circulating concentration of orosomucoid. Regarding the 
poor periodontal condition in obese patients, our results are consistent with others showing that poor oral health is related to high BMI. Two meta-analyses have shown an association between BMI and periodontitis, although the magnitude of the relationship remains unclear [13,15]. In an adult French population, it has been found that BMI was statistically associated with missing teeth, pocket depth and plaque index, independently of dietary patterns and insulin resistance [26]. Our results indicate a median missing tooth value of 4, which is similar to the median number of missing teeth in the general French population i.e. 3.8 (95 confidence interval: 1.6?.6) [27]. Nevertheless, it has been demonstrated that the chewing patternswere affected in patients with morbid obesity as compared with controls, whatever the number of teeth present [28]. Consequently, it cannot be excluded that periodontitis, and not edentulism, negatively impacts the chewing ability and the quality of life of morbidly obese subjects. On the other hand, in the present study the Gingival Index, a clinical marker of local periodontal inflammation, did not significantly differ between mild to moderate periodontitis and severe periodontitis patients. It cannot be excluded that low grade inflammation associated with obesity obscures the clinical expression of local inflammation in the development of periodontitis. A recent study using a proteomic approach has shown an increased level of antimicrobial peptides (defensins) in the saliva of morbidly obese patients suffering from periodontitis [29]. A two-way relationship between obesityinduced and periodontitis-induced inflammation cannot be ruled out. Moreover, among the various adipokines and inflammatory markers studied here, only the orosomucoid level was associated with periodontal inflammation severity after adjustment for age, gender and smoking. In a comparative study on systemic inflammation in cardiovascular and periodontal disease, higher levels of orosomucoid were observed in subjects with both these conditions [30] compared to subjects with neither disease, or with only PD or CVD. Indeed, an increased level of orosomucoid is characteristic of subjects with both cardiovascular and periodontal diseases. Orosomucoid or Alpha (1)-acid glycoprotein is an inflammation-sensitive plasma protein. This protein is a typical marker of inflammation, which increases by a factor of 3? after an inflammatory stimulus [31,32]. The synthesis of orosomucoid takes place in the liver and is induced by IL-1, TNFa and IL-6. Neutrophils and monocytes can also synthesize orosomucoid and thus contribute to the elevation of this protein in the serum of patients with sepsis. Interestingly, C reactive protein is an acute phase inflammatory marker whereas orosomucoid is a chronic phase ma.