The Association Between Periodontal Disease and Cardiovascular Health Explored
Robert J. Ostfeld, MD, MSc; Nitasha Sarswat, MD; Marc B. Kapner, MD; and Lisa Bienstock, DMD
Emerging research is demanding greater attention be paid to the association between cardiovascular and periodontal diseases. One of the studies presented indicates that physicians may not be receiving adequate training to screen for periodontal diseases. Another indicates that co-existent periodontal disease appears to worsen endothelial function in patients with cardiovascular disease and treatment of periodontal disease may improve endothelial dysfunction in such patients. This review also discusses a study that the presence of coronary disease (CAD) was associated with an increased periodontal risk score, providing additional evidence about the association between periodontal disease and CAD. The last study analyzed the association between periodontal disease and stroke, including potential racial discrepancies.
Quijano A, Shah AJ, Schwarcz AI, Evanthia L, Ostfeld RJ. Knowledge and orientations of internal medicine trainees toward periodontal disease [published online ahead of print November 26, 2009]. J Periodontol. doi:10.1902/jop.2009.090475.
Given the association between periodontal disease and systemic health, physicians have compelling reasons to become involved in screening for periodontal disease. However, few studies have examined the physician’s role in discussing, identifying, or preventing this condition. With the aim of assessing oral health knowledge and orientations of physicians in training, Quijano et al surveyed internal medicine trainees about their general attitudes, knowledge, and behaviors/practices in regard to periodontal health and disease.
A survey was given to incoming internal medicine trainees during orientation at an urban teaching hospital in New York City. A total of 115 of the 125 trainees responded, of whom 96% were medical interns. The median age was 27 years; 39% were male and 61% were female. The questionnaire included five true/false statements about general periodontal knowledge. Thirty-five percent of respondents answered all five correctly. Furthermore, 90% reported receiving no periodontal disease training in medical school, and 82% do not ask their patients if they have periodontal disease. Most said they were uncomfortable performing basic periodontal examinations. Many (46%) “felt that discussing/evaluating the periodontal status of their patients is peripheral to their role as physicians,” and only 17% “agreed that physicians should discuss/screen for periodontal disease.”
Incoming medical trainees appear to have received suboptimal training regarding periodontal disease. Quijano et al recommended offering oral health education in both medical school and the postgraduate setting.
Higashi Y, Goto C, Hidaka T, Soga J, Nakamura S, Fujii Y, et al. Oral infection-inflammatory pathway, periodontitis, is a risk factor for endothelial dysfunction in patients with coronary artery disease. Atherosclerosis. 2009;206(2):604-610.
Endothelial dysfunction is an initial step in the development of atherosclerosis and may predate by decades overt vascular disease. Endothelial dysfunction may be caused, in part, by inflammation. By promoting systemic inflammation, periodontal disease may lead to endothelial dysfunction and cardiovascular disease. However, a causal link between these diseases has not been identified.
The treatment of periodontal disease has been reported to improve endothelial function in those without overt CAD. However, limited information is available regarding how both periodontal disease and its treatment impact endothelial function in patients with CAD.
Higashi et al measured endothelial function in 101 people with CAD (48 with co-existing periodontitis) and then randomized those 48 participants to periodontal treatment or no periodontal treatment groups. Prior and current smokers were excluded.
Changes in endothelial function were measured by both an endothelium-dependent (acetylcholine) and endothelium-independent (sodium nitroprusside) vasodilator. These separate measures were performed to evaluate whether any degree of vasodilation could be attributed specifically to the endothelium.
At baseline, the researchers found that patients with CAD and no periodontal disease (compared with those with both CAD and periodontal disease) had significantly greater vasodilation with acetylcholine treatment. This finding suggests reduced endothelial health in patients with both CAD and periodontal disease. No difference in vasodilation with the use of sodium nitroprusside was evident between the groups, implying the previous difference was mediated by the endothelium.
Participants with both CAD and periodontal disease randomized to receive periodontal treatment had increased vasodilation with acetylcholine vs those who received no treatment. Serum markers of inflammation also decreased in patients who were given therapy for periodontal disease.
In participants with CAD, co-existent periodontal disease appears to worsen endothelial function and treatment for periodontal disease seems to improve endothelial function. However, more studies are needed to elucidate the mechanisms of endothelial dysfunction reported above and to evaluate whether periodontal disease treatment improves outcomes in patients with CAD.
Oe Y, Soejima H, Nakayama H, Fukunaga T, Sugamura K, Kawano H, et al. Significant association between score of periodontal disease and coronary artery disease. Heart Vessels. 2009;24(2):103-107.
Oe et al provided further support for the association between periodontal disease and CAD. The authors enrolled 174 consecutive dentate patients with planned cardiac catheterizations and performed thorough periodontal examinations, including taking dental radiographs, during the admission for catheterization. Of the 174 patients, 99 were found to have CAD, as defined by > 50% stenosis in one or more coronary arteries, previous percutaneous coronary intervention, or previous coronary artery bypass grafting. Periodontal risk scores were established based on previous literature,1 including the proportion of bleeding on probing, number of sites with probing depth (≥ 6 mm), number of teeth lost, proportion of bone resorption, and smoking status.
At baseline, patients with CAD were more likely to be taking statins and have hypertension, diabetes mellitus or impaired glucose tolerance, as well as higher total periodontal risk scores. Furthermore, on multivariate analysis, an increased periodontal risk score was associated with increased odds of having CAD (OR, 2.3 [1.2 - 4.6]).
Among those younger than 60 years (n = 61), total periodontal risk score was higher in patients with CAD vs those without. Among those 60 years of age or older (n = 113), total periodontal risk score was not significantly higher in those with CAD vs those without the condition.
Oe et al found that the above periodontal risk score is increased in patients with CAD compared to those without it and provide additional evidence supporting the association between periodontal disease and CAD. Furthermore, they support the findings of Dietrich et al2 who found that “chronic periodontitis was associated with incidence of coronary artery disease among younger men,” suggesting periodontal disease may have a disproportionately deleterious impact on the coronary arteries of younger people.
The researchers found a trend toward reduced periodontal risk scores in patients using statins, supporting the retrospective findings of Lindy et al3 et al, who found statin use was associated with fewer pathologic periodontal pockets. However, additional research is needed to evaluate the potential impact of statins on periodontal disease.
You Z, Cushman M, Jenny NS, Howard G; REGARDS. Tooth loss, systemic inflammation and prevalent stroke among participants in the Reasons for Geographic and Racial Difference in Stroke (REGARDS) study. Atherosclerosis. 2009;203(2):615-619.
Although a substantial amount of literature supports an association between periodontal disease and CAD, data are sparse regarding the relationship between periodontal disease and stroke. Given that atherosclerosis is a systemic disease and periodontal disease may promote atherosclerosis, periodontal disease also may be associated with an increased risk of stroke.
You et al “hypothesized that tooth loss, as a surrogate for periodontal disease, would be associated with higher levels of inflammation markers and with stroke and would be more common in blacks than whites and in the Stroke Belt [southeastern United States] compared to the rest of the United States.” To achieve this end, You et al performed a cross-sectional analysis based on the Reasons for Geographic and Racial Difference in Stroke (REGARDS) study, a “national, population-based longitudinal study of black and white adults aged 45 years and over.” Data were collected from 30,101 patients via telephone interviews and in-home visits. Those with missing data were excluded.
On multivariate analysis, including demographics; socioeconomic status; the presence of diabetes, hypertension, and CAD; smoking status; and body mass index, increased tooth loss (17 to 32 vs zero teeth lost) was associated with both increased serum markers of inflammation and an increased prevalence of stroke. On similar multivariate analysis, blacks had higher odds of tooth loss compared to whites, whereas the association of tooth loss and area of residence (southeastern United States versus other regions) was not significant.
This study reinforces the association between periodontal disease (as measured by tooth loss) and inflammation and supports an association between periodontal disease and stroke. Furthermore, both periodontal disease and stroke were found to be more common in blacks than whites. Hence, given the association between periodontal disease and stroke, periodontal disease may, in part, mediate the racial discrepancy in stroke.
While this study is strengthened by its large sample size, it is limited by its cross-sectional design and methods of data ascertainment. Further epidemiologic and mechanistic research is needed.
1. Renvert S, Ohlsson O, Persson S, Lang NP, Persson GR. Analysis of periodontal risk profiles in adults with or without a history of myocardial infarction. J Clin Periodontol. 2004;31(1): 19-24.
2. Dietrich T, Jimenez M, Krall Kaye EA, Vokonas PS, Garcia RI. Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease. Circulation. 2008;117(13):1668-1674.
3. Lindy O, Suomaulainen K, Mäkelä M, Lindy S. Statin use is associated with fewer periodontal lesions: a retrospective study. BMC Oral Health. 2008;8:16.
About the Authors
Robert J. Ostfeld, MD, MSc
Associate Professor of Clinical Medicine
Albert Einstein College of Medicine
Bronx, New York
Montefiore Medical Center
Bronx, New York
Nitasha Sarswat, MD
UMDNJ/Cooper University Hospital
Camden, New Jersey
Marc B. Kapner, MD
Assistant Professor of Medicine
Albert Einstein College of Medicine
Bronx, New York
Montefiore Medical Center
Bronx, New York
Lisa Bienstock, DMD
Assistant Clinical Professor of Dental Medicine
New York, New York