Science in the News
"New" Periodontal Disease and Cardiovascular Disease
October 21, 2015
Periodically, there are news stories claiming to demonstrate an association between periodontal disease and one or more forms of cardiovascular disease. Epidemiologic studies have found an association between periodontal disease and functional or morphological markers of coronary heart disease, and that those with periodontal disease have higher coronary heart incidence than those without periodontal disease.1,2 However, both periodontal disease and cardiovascular disease are complex conditions that share common risk factors.
The mechanism by which periodontal disease affects coronary heart disease has not been established, though there are numerous theories, ranging from the actions of periodontal pathogens in the coronary arteries or endothelium to periodontal pathogens leading to systematic inflammation, with subsequent detrimental effects on cardiovascular health. The current position of the American Heart Association and the American Dental Association is that while periodontal disease and heart health have an association, additional research is needed to establish whether one causes the other.1,3
A recent doctoral thesis publicized in the ADA’s Morning Huddle analyzed data from the STABILITY trial.4 This was a randomized, prospective, placebo-controlled, double-blind, multi-center trial designed to test the efficacy of darapladib (an inhibitor of the proinflammatory enzyme Lp-PLA2) in adults with chronic coronary artery disease. The study assessed known risk factors for cardiovascular disease as well as two factors of interest to dentists: self-reports of subjects’ number of teeth and how frequently their gums bleed during toothbrushing or other activities. All study subjects had coronary artery disease, and they reported a high overall prevalence of tooth loss (16.4% reported having no teeth, and 40.9% had less than 15 remaining teeth) and gum bleeding (25.6% reported that their gums bled during teethbrushing or other activities at least some of time). For every five teeth lost, the risk of cardiovascular death within the study period (median of 3.7 years) rose 17%, risk of all-cause death rose 16%, and stroke rose 14%.
Subjects with no teeth had the highest risks of stroke, cardiovascular death, and all-cause death. Additionally, higher levels of tooth loss were accompanied by progressively higher levels of inflammatory biomarkers (hs-CRP, IL-6, and Lp-PLA2) and higher levels of biomarkers of cardiovascular events (growth differentiation factor 15, high sensitivity troponin T, and N-terminal pro B-type natriuretic peptide). Statistical models that adjusted for these biomarkers still found a significant association between tooth loss and cardiovascular death, which may indicate that tooth loss does not lead to cardiovascular death via the pathways related to these biomarkers. Also, there did not appear to be a significant association between tooth loss and risk of heart attack.
Overall, this analysis found mixed results with respect to tooth loss as a risk factor for cardiovascular outcomes. Higher levels of tooth loss were associated with the highest risk of stroke, cardiovascular death or all-cause death, but the pathway by which tooth loss led to these outcomes remains unclear, since inflammation, myocardial injury, or heart attack did not appear to lie in the causal pathway between tooth loss and cardiovascular death.
Similar to previous studies, this study presents evidence that tooth loss and adverse cardiovascular health are associated with each other. It is important to note that this study does not demonstrate that tooth loss causes poor cardiovascular health, nor that periodontal treatment improves cardiovascular health.
1. Lockhart PB, Bolger AF, Papapanou PN, et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circulation 2012;125(20):2520-44.
2. 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 2013;40 Suppl 14:S70-84.
3. ADA Oral-Systemic Health. Available at: "http://www.ada.org/en/member-center/oral-health-topics/oral-systemic-health”. Accessed October 20, 2015.
4. Vedin O. Prevalence and Prognostic Impact of Periodontal Disease and Conventional Risk Factors in Patients with Stable Coronary Heart Disease. [Doctoral Thesis]: Uppsala University; 2015.
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