Oral health and cardiovascular disease risk in a cohort of periodontitis patients


      • Oral health was associated to fatal and non-fatal cardiovascular disease.
      • Number of teeth was related to myocardial infarction and heart failure but none of the oral health parameters were related to stroke.
      • Oral health was not uniformly associated to myocardial infarction and heart failure and stroke in the present study.


      Background and aims

      The aim of this study was to determine whether oral health is uniformly associated with three different cardiovascular diseases (CVDs), including myocardial infarction (MI), stroke, and heart failure (HF), which has not been studied previously.


      A full mouth investigation was performed in 8999 individuals referred to a specialized periodontology clinic between 1979 and 2012. The number of deepened pockets (NDP), number of teeth (NT), and bleeding on probing (BOP) were investigated. Incident CVD diagnosis was obtained from the Swedish cause of death and the hospital discharge registers.


      During a median follow-up time of 15.8 years (153,103 person years at risk), 1338 incident cases of fatal/non-fatal CVD occurred (672 fatal/non-fatal MI, 545 stroke and 302 HF). When NT, BOP and NDP were all included in the same model with age, sex, smoking, calendar time, and education level, NT and NDP, but not BOP, were significantly related to future CVD (combined end-point, p = 0.0003 for NT and p = 0.007 for NDP).
      In similar analyses of 3 separate CVD outcomes, NT was significantly related to MI, with an incidence rate ratio (IRR) for a given interquartile range change of 0.90 (95% CI 0.82–0.99) and to HF, with an IRR of 0.87 (95% CI 0.77–0.99). However, NT was not significantly related to stroke. BOP and NDP were not significantly related to any of the three separate CVD outcomes.


      Oral health, mainly represented by NT, was related to incident MI and HF, but not to incident stroke. Therefore, oral health does not seem to relate to all major CV disorders in a similar fashion.


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      1. Kebschull M, Demmer RT, Papapanou PN. “Gum bug, leave my heart alone!“— epidemiologic and mechanistic evidence linking periodontal infections and atherosclerosis. J. Dent. Res.; 89(9): 879–902.

        • Lu B.
        • Parker D.
        • Eaton C.B.
        Relationship of periodontal attachment loss to peripheral vascular disease: an analysis of NHANES 1999-2002 data.
        Atherosclerosis. 2008; 200: 199-205
        • Mattila K.J.
        • Nieminen M.S.
        • Valtonen V.V.
        • et al.
        Association between dental health and acute myocardial infarction.
        BMJ. 1989; 298: 779-781
        • Volzke H.
        • Schwahn C.
        • Hummel A.
        • et al.
        Tooth loss is independently associated with the risk of acquired aortic valve sclerosis.
        Am. Heart J. 2005; 150: 1198-1203
        • Beck J.
        • Garcia R.
        • Heiss G.
        • Vokonas P.S.
        • Offenbacher S.
        Periodontal disease and cardiovascular disease.
        J. Periodontol. 1996; 67: 1123-1137
        • Buhlin K.
        • Gustafsson A.
        • Ahnve S.
        • et al.
        Oral health in women with coronary heart disease.
        J. Periodontol. 2005; 76: 544-550
        • Holmlund A.
        • Holm G.
        • Lind L.
        Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects.
        J. Periodontol. 2006; 77: 1173-1178
        • Wu T.
        • Trevisan M.
        • Genco R.J.
        • et al.
        Periodontal disease and risk of cerebrovascular disease: the first national health and nutrition examination survey and its follow-up study.
        Arch. Intern Med. 2000; 160: 2749-2755
        • Humphrey L.L.
        • Fu R.
        • Buckley D.I.
        • Freeman M.
        • Helfand M.
        Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis.
        J. general Intern. Med. 2008; 23: 2079-2086
        • Soder P.O.
        • Soder B.
        • Nowak J.
        • Jogestrand T.
        Early carotid atherosclerosis in subjects with periodontal diseases.
        Stroke. 2005; 36: 1195-1200
        • Bui A.L.
        • Horwich T.B.
        • Fonarow G.C.
        Epidemiology and risk profile of heart failure.
        Nat. Rev. Cardiol. 2011; 8: 30-41
        • Damman K.
        • Voors A.A.
        • Navis G.
        • van Veldhuisen D.J.
        • Hillege H.L.
        The cardiorenal syndrome in heart failure.
        Prog. Cardiovasc. Dis. 2011; 54: 144-153
        • Dhingra R.
        • Vasan R.S.
        Diabetes and the risk of heart failure.
        Heart Fail. Clin. 2012; 8: 125-133
        • Kaya Z.
        • Leib C.
        • Katus H.A.
        Autoantibodies in heart failure and cardiac dysfunction.
        Circ. Res. 2012; 110: 145-158
        • Holmlund A.
        • Holm G.
        • Lind L.
        Number of teeth as a predictor of cardiovascular mortality in a cohort of 7,674 subjects followed for 12 years.
        J. Periodontol. 2010; 81: 870-876
        • Borrell L.N.
        • Crawford N.D.
        Socioeconomic position indicators and periodontitis: examining the evidence.
        Periodontol 2000. 2012; 58: 69-83
        • Carstensen B.
        Demography and Epidemiology: Practical Use of the Lexis Diagram in the Computer Age, or: Who Needs the Cox-model Anyway?.
        • Papapanou P.N.
        Epidemiology of periodontal diseases: an update.
        J. Int. Acad. Periodontology. 1999; 1: 110-116
        • Holmlund A.
        • Hulthe J.
        • Lind L.
        Tooth loss is related to the presence of metabolic syndrome and inflammation in elderly subjects: a prospective study of the vasculature in Uppsala seniors (PIVUS).
        Oral health & Prev. Dent. 2007; 5: 125-130
        • Holmlund A.
        • Lind L.
        Number of teeth is related to atherosclerotic plaque in the carotid arteries in an elderly population.
        J. Periodontol. 2012; 83: 287-291
        • Syrjala A.M.
        • Ylostalo P.
        • Hartikainen S.
        • Sulkava R.
        • Knuuttila M.L.
        Number of teeth and myocardial infarction and stroke among elderly never smokers.
        J. Negat. Results Biomed. 2009; 8: 6
        • Tu Y.K.
        • Galobardes B.
        • Smith G.D.
        • et al.
        Associations between tooth loss and mortality patterns in the Glasgow Alumni Cohort.
        Heart. 2007; 93: 1098-1103
        • Emdin C.A.
        • Anderson S.G.
        • Salimi-Khorshidi G.
        • et al.
        Usual blood pressure, atrial fibrillation and vascular risk: evidence from 4.3 million adults.
        Int. J. Epidemiol. 2017; 46: 162-172
        • Ito H.
        • Ishii K.
        • Kihara H.
        • et al.
        Adding thiazide to a renin-angiotensin blocker improves left ventricular relaxation and improves heart failure in patients with hypertension.
        Hypertens. Res. official J. Jpn. Soc. Hypertens. 2012; 35: 93-99
        • Kalogeropoulos A.P.
        • Georgiopoulou V.V.
        • Butler J.
        From risk factors to structural heart disease: the role of inflammation.
        Heart Fail. Clin. 2012; 8: 113-123
        • Wrigley B.J.
        • Lip G.Y.
        • Shantsila E.
        The role of monocytes and inflammation in the pathophysiology of heart failure.
        Eur. J. heart Fail. 2011; 13: 1161-1171
        • Liljestrand J.M.
        • Havulinna A.S.
        • Paju S.
        • et al.
        Missing teeth predict incident cardiovascular events, diabetes, and death.
        J. Dent. Res. 2015; 94: 1055-1062
        • Jimenez M.
        • Krall E.A.
        • Garcia R.I.
        • Vokonas P.S.
        • Dietrich T.
        Periodontitis and incidence of cerebrovascular disease in men.
        Ann. Neurol. 2009; 66: 505-512
        • Pussinen P.J.
        • Alfthan G.
        • Jousilahti P.
        • Paju S.
        • Tuomilehto J.
        Systemic exposure to Porphyromonas gingivalis predicts incident stroke.
        Atherosclerosis. 2007; 193: 222-228
        • Mustapha I.Z.
        • Debrey S.
        • Oladubu M.
        • Ugarte R.
        Markers of systemic bacterial exposure in periodontal disease and cardiovascular disease risk: a systematic review and meta- analysis.
        J. Periodontol. 2007; 78: 2289-2302
        • Chambless L.E.
        • Folsom A.R.
        • Sharrett A.R.
        • et al.
        Coronary heart disease risk prediction in the Atherosclerosis Risk in Communities (ARIC) study.
        J. Clin. Epidemiol. 2003; 56: 880-890
        • Danesh J.
        • Whincup P.
        • Walker M.
        • et al.
        Low grade inflammation and coronary heart disease: prospective study and updated meta-analyses [see comments].
        BMJ. 2000; 321: 199-204
        • Ridker P.M.
        • Silvertown J.D.
        Inflammation, C-reactive protein, and atherothrombosis.
        J. Periodontol. 2008; 79: 1544-1551
        • Ridker P.M.
        • Hennekens C.H.
        • Buring J.E.
        • Rifai N.
        C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women.
        N. Engl. J. Med. 2000; 342: 836-843
        • Kweider M.
        • Lowe G.D.
        • Murray G.D.
        • Kinane D.F.
        • McGowan D.A.
        Dental disease, fibrinogen and white cell count; links with myocardial infarction?.
        Scott Med. J. 1993; 38: 73-74
        • Montebugnoli L.
        • Servidio D.
        • Miaton R.A.
        • et al.
        Poor oral health is associated with coronary heart disease and elevated systemic inflammatory and haemostatic factors.
        J. Clin. Periodontol. 2004; 31: 25-29
        • Slade G.D.
        • Offenbacher S.
        • Beck J.D.
        • Heiss G.
        • Pankow J.S.
        Acute-phase inflammatory response to periodontal disease in the US population.
        J. Dent. Res. 2000; 79: 49-57
        • Bokhari S.A.
        • Khan A.A.
        • Butt A.K.
        • et al.
        Non-surgical periodontal therapy reduces coronary heart disease risk markers: a randomized controlled trial.
        J. Clin. Periodontol. 2012; 39: 1065-1074
        • D'Aiuto F.
        • Ready D.
        • Tonetti M.S.
        Periodontal disease and C-reactive protein-associated cardiovascular risk.
        J. Periodontal Res. 2004; 39: 236-241
        • Giacona M.B.
        • Papapanou P.N.
        • Lamster I.B.
        • et al.
        Porphyromonas gingivalis induces its uptake by human macrophages and promotes foam cell formation in vitro.
        FEMS Microbiol. Lett. 2004; 241: 95-101
        • Naito M.
        • Sakai E.
        • Shi Y.
        • et al.
        Porphyromonas gingivalis-induced platelet aggregation in plasma depends on Hgp44 adhesin but not Rgp proteinase.
        Mol. Microbiol. 2006; 59: 152-167
        • Oorni K.
        • Kovanen P.T.
        Proteolysis of low density lipoprotein particles by Porphyromonas gingivalis microorganisms: a novel biochemical link between periodontitis and cardiovascular diseases?.
        J. Intern Med. 2008; 263: 553-557
        • Ravald N.
        • Johansson C.S.
        Tooth loss in periodontally treated patients: a long-term study of periodontal disease and root caries.
        J. Clin. Periodontol. 2012; 39: 73-79