Periodontal disease and risk of subsequent cardiovascular disease in U.S. male physicians

Association between toothbrushing and cardiovascular risk factors: a cross-sectional study using Korean National Health and Nutrition Examination Survey 2015-2017

BACKGROUND

Previous studies have suggested that frequent toothbrushing is associated with a lower risk of future cardiovascular events. We sought to investigate further the relationship between toothbrushing, cardiovascular risk factors, and lifestyle behaviours.

METHODS

We analysed a cross-sectional survey including 13,761 adults aged 30 years or older without a history of cardiovascular diseases from the Korean National Health and Nutritional Examination Survey. Conventional cardiovascular risk factors (blood pressure, lipid profiles, and fasting glucose), and inflammatory markers (high-sensitivity C-reactive protein [hsCRP], and white blood cell counts [WBC]) were investigated in relation to the frequency of toothbrushing.

RESULTS

The estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk, calculated using the pooled cohort equations was 13.7%, 9.1%, and 7.3% for participants who reported toothbrushing 0-1, 2, and ≥ 3 times a day, respectively. Both conventional risk factors and inflammatory markers were significantly associated with frequent toothbrushing. However, after adjusting potential confounding factors such as age, sex, comorbidities, and lifestyle behaviours, only inflammatory markers were remained as significant factors.

CONCLUSIONS

Oral hygiene behaviours are closely linked to cardiovascular risk factors. This study suggests that reduced systemic inflammatory burden may explain the benefit of improved oral hygiene in terms of cardiovascular risk.

Periodontitis and systemic inflammation as independent and interacting risk factors for mortality: evidence from a prospective cohort study

BACKGROUND

Recent studies have highlighted the role of low-grade systemic inflammation in linking periodontitis to cardiovascular disease (CVD) outcomes, but many aspects remain unclear. This study examines the independent and reciprocal associations of periodontitis and low-grade systemic inflammation with all-cause and CVD mortality in a large-scale cohort.

METHODS

A total of 3047 participants from the prospective, population-based Study of Health in Pomerania (SHIP-START) were followed for a period of 13.0 ± 2.4 years. For the association between various inflammation/periodontitis measures and mortality, hazard ratios (HRs) were obtained from covariate-adjusted Cox proportional hazards models. Interactions were analysed in joint models: on the multiplicative scale, HRs were reported and on the additive scale, relative excess risks due to interaction (RERI) were calculated. Subject and variable-specific interval records were used to account for time-varying exposures and covariates.

RESULTS

During the observation period, 380 (12.5%) individuals died from CVD (n = 125) or other causes (n = 255). All markers of periodontitis and inflammation showed apparent associations with all-cause mortality (HRs per SD-increase: mean PPD: 1.068 (95% confidence interval (CI): 0.988-1.155), mean CAL: 1.205 (95% CI: 1.097-1.323), missing teeth: 1.180 (95% CI: 1.065-1.307), periodontitis score: 1.394 (95% CI: 1.202-1.616), leukocytes: 1.264 (95% CI: 1.163-1.374), fibrinogen: 1.120 (95% CI: 1.030-1.218), CRP: 1.231 (95% CI: 1.109-1.366), inflammation score: 1.358 (95% CI: 1.210-1.523)). For CVD mortality, all PPD related variables showed significant associations. Interaction modelling revealed some variation with respect to mortality type and exposure combinations. On the additive scale, RERIs for periodontitis score and inflammation score implied 18.9% and 27.8% excess mortality risk for all-cause and CVD mortality, respectively. On the multiplicative scale, the HRs for interaction were marginal.

CONCLUSIONS

Both periodontitis and inflammation were significantly associated with all-cause mortality and CVD mortality. On the additive scale, a substantial excess risk was observed due to the interaction of periodontitis and inflammation, suggesting that the greatest treatment benefit may be achieved in patients with both periodontitis and high systemic inflammation. As periodontal therapy has been reported to also reduce systemic inflammation, the possibility of a reduction in CVD mortality risk by anti-inflammatory treatments, including periodontal interventions, seems worthy of further investigation.

Periodontal disease and subsequent risk of cardiovascular outcome and all-cause mortality: A meta-analysis of prospective studies

Studies reported periodontal disease (PD) periodontal disease is associated with many systemic diseases, including cardiovascular outcomes and all-cause mortality. However, the precise mechanistic link for these relationship remained unclear. We therefore performed a meta-analysis of cohort studies to investigate the association of PD with the risk of cardiovascular outcomes and all-cause mortality. We systematically searched the databases of PubMed, EmBase, and the Cochrane library to identify eligible studies until April 2023. The investigated outcomes included major adverse cardiovascular events (MACEs), coronary heart disease (CHD), myocardial infarction (MI), stroke, cardiac death, and all-cause mortality. The summary relative risk (RR) with 95% confidence interval (CI) were calculated using the random-effects model. Thirty-nine cohort studies with 4,389,263 individuals were selected for final meta-analysis. We noted PD were associated with elevated risk of MACEs (RR: 1.24; 95%CI: 1.15-1.34; P<0.001), CHD (RR: 1.20; 95%CI: 1.12-1.29; P<0.001), MI (RR: 1.14; 95%CI: 1.06-1.22; P = 0.001), stroke (RR: 1.26; 95%CI: 1.15-1.37; P<0.001), cardiac death (RR: 1.42; 95%CI: 1.10-1.84; P = 0.007), and all-cause mortality (RR: 1.31; 95%CI: 1.07-1.61; P = 0.010). Sensitivity analyses indicated the pooled conclusions for cardiovascular outcomes and all-cause mortality are robustness. The associations of PD with the risk of ardiovascular outcomes and all-cause mortality could affected by region, study design, PD definition, follow-up duration, and study quality. This study found the risk of cardiovascular outcomes and all-cause mortality were elevated in PD patients, and the intervention for PD should be applied to prevent the risk of cardiovascular outcomes.

Association of poor oral health with increased incidence of dysphagia and impaired improvement in nutritional status among patients with acute heart failure: a prospective cohort study

AIMS

This study aimed to clarify the association between oral health and the incidence of dysphagia as well as the recovery of nutritional status and improvement of dysphagia in hospitalized patients with acute heart failure.

METHODS

Hospitalized patients with AHF were prospectively enrolled. Oral health was evaluated using the Japanese Version of the Oral Health Assessment Tool (OHAT-J) after circulation dynamics improved (defined as baseline), and participants were classified into good and poor oral health groups (OHAT-J 0-2 and ≧ 3, respectively). The primary outcome measure was the incidence of dysphagia evaluated using the Food Intake Level Scale (FILS) at baseline. Secondary outcome measures were nutritional status and FILS score at discharge. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF). Univariate and multivariate logistic regression analyses were used to determine the association between oral health and the study outcomes.

RESULTS

Of the 203 recruited patients (mean age, 79.5 years; 50.7% female), 83 (40.9%) were in the poor oral health group. Participants with poor oral health were significantly older, had lower skeletal muscle mass and strength, lower nutrient intake and nutritional status, worse swallowing status, as well as lower cognitive level, and physical function than those with good oral health. In multivariate logistic regression analyses, baseline poor oral health was significantly associated with the incidence of dysphagia (odds ratio = 1.036, P = 0.020), as well as with the improvement in nutritional status (odds ratio = 0.389, P = 0.046) and dysphagia (odds ratio = 0.199, P = 0.026) at discharge.

CONCLUSIONS

Poor baseline oral health was associated with the incidence of dysphagia, as well as with the lack of improvement in nutritional status and dysphagia in patients with acute heart failure.

Association between cardiovascular diseases and periodontal disease: more than what meets the eye

Cardiovascular diseases (CVDs) are inflammatory diseases of coronary arteries accompanying atheroma formation that can spawn impairment and, in severe cases, death. CVDs are the leading cause of death in the world. In recent decades, investigators have focused their impact on CVD by periodontal disease (PD). PD is a risk factor that can trigger the formation, maturation, and instability of atheroma in the arteries. Two mechanisms have been proposed to explain this relationship: periodontopathic pathogens explicitly invade the circulation or indirectly increase systemic levels of inflammatory mediators. It has been suggested that improvement in disease state has a positive effect on others. This review summarizes evidence from epidemiological studies as well as researches focusing on potential causation channels to deliver a comprehensive representation of the relationship between PD and CVD.

Relationship between carotid intima-media thickness and periodontal disease in a Japanese urban population with and without hypertension: The Suita Study

AIM

To investigate the association between periodontal disease and atherosclerosis and to examine whether the association is modified by hypertension status.

MATERIALS AND METHODS

In this cross-sectional study, 1472 Japanese individuals aged 50-79 years who underwent a medical check-up, dental examination, and carotid ultrasonography were studied. Carotid atherosclerosis was expressed as the maximum and mean carotid intima-media thickness (max-IMT, mean-IMT) and the presence of stenosis (≥75%). Periodontal status was examined by the Community Periodontal Index (CPI, codes 0-4). The participants were divided into three groups according to the periodontal status (CPI0-2, CPI3, CPI4).

RESULTS

A positive correlation was found between mean-IMT and periodontal disease after adjustment for cardiovascular risk factors in the entire cohort (mean-IMT in hypertensives: CPI0-2: 0.848 mm, CPI3: 0.857 mm, CPI4: 0.877 mm; normotensives: 0.782, 0.802, 0.826). In the entire cohort, the multivariable-adjusted odds ratio of stenosis based on mean-IMT significantly increased according to periodontal status in normotensives (odds ratio; CPI0-2: 1, CPI3: 1.39, CPI4: 2.53; p-value for trend = .004) but showed only marginal significant increase in hypertensives (1, 1.15, 1.55; p-value for trend = .063). No significant relationships were observed for max-IMT in all analyses.

CONCLUSION

We observed an association between periodontal disease and atherosclerosis in normotensive and hypertensive participants.

Periodontal disease is associated with the risk of cardiovascular disease independent of sex: A meta-analysis

Objectives

Studies have established a link between periodontal disease and cardiovascular disease (CVD), but it is unclear whether there is a sex difference in their association.

Methods

The PubMed, Embase, and Cochrane databases were searched until June, 21 2022. Cardiovascular outcomes included any CVD, myocardial infarction (MI), coronary heart disease (CHD), or stroke. Studies reported the prevalence of CVD in patients with periodontal disease and the relationship between periodontal disease and CVD. The study is registered with PROSPERO (CRD42022333663). The level of evidence and recommendations is assessed by the Grading of Recommendations for Assessment, Development and Evaluation (GRADE).

Results

Twenty-six studies were included. In patients with periodontal disease, the prevalence of CVD was 7.2% [9 studies; 95% confidence interval (CI): 2.7-13.6%], and prevalence for CHD, hypertension, stroke, and heart failure was 6.6, 25.3, 1, and 1.1%, respectively. There was a significant association between periodontal disease and CVD in men [odds ratio (OR) = 1.22; 95% CI: 1.12-1.34] and women (OR = 1.11; 95% CI: 1.05-1.17), with no significant sex difference (P > 0.05).

Conclusion

Cardiovascular disease is relatively common in patients with periodontal disease, and an increased risk of CVD is associated with periodontal disease independent of sex. Interventions targeting periodontal disease may be beneficial for CVD.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333663.

Periodontal disease as a non-traditional risk factor for acute coronary syndrome: a systematic review and meta-analysis

OBJECTIVES

Previous observational studies have suggested an association between periodontal disease (PD) and cardiovascular and cerebrovascular diseases. Nonetheless, evidence linking PD with coronary heart disease (CHD) and acute coronary syndrome (ACS) is still contradictory. We aim to systematically review the role of PD as a risk factor for ACS (myocardial infarction and unstable angina).

METHODS

The protocol was registered in PROSPERO (CRD42021286278) and we followed the recommendations of the PRISMA and AMSTAR 2 guidelines. We systematically searched for 7 databases and electronic thesis repositories from inception to February 2022. We included articles without language restriction following the PECO strategy (population: "adult participants"; exposure: "periodontal disease"; comparator: "no periodontal disease"; outcome: "acute coronary syndrome" OR "acute myocardial infarction" OR "unstable angina"). Odds ratios (OR) with 95% confidence intervals (95% CI) were pooled using random effects and heterogeneity was quantified by Cochran's Q and Higgins' I² statistics. Subgroup analyses were carried out according to the participants' sex, type of diagnosis of PD, type of study, and continent of origin of studies.

RESULTS

We included 46 papers (17 cohort, 25 case-control, and 4 cross-sectional studies) that met the inclusion criteria. This meta-analysis includes a total of 6,806,286 participants and at least 68,932 ACS events, mainly myocardial infarction (MI). In accordance with our results, PD is associated with a higher risk of ACS (OR 1.35; 95% CI 1.25-1.45). However, clinical and methodological heterogeneity was significant (I²=86%, p<0.05). In the sensitivity analysis, the exclusion of some studies with "extreme" results (outliers) did not significantly affect the overall estimate or heterogeneity. In subgroup analysis, we found no statistically significant differences between men and women according to subgroup difference tests (I²=0%, p=0.67). Conversely, there were differences according to the type of diagnosis of PD (clinical or self-reported diagnosis), type of study (cohort, case-control, or cross-sectional study), and the continent of origin (North America, South America, Asia, or Europe) of the studies (I²=79%-96%, p<0.10). Of the 46 studies, only 4 had a high risk of bias. Additionally, the funnel plot suggested publication bias.

CONCLUSION

PD may be an important non-traditional risk factor for ACS. Although, this meta-analysis brings together more studies, and therefore more evidence, than any other previous similar study, its results should be interpreted with caution due to the great heterogeneity and the potential presence of bias.

The Link between Stroke Risk and Orodental Status-A Comprehensive Review

One of the primary causes of disability and mortality in the adult population worldwide is stroke. A person's general health is significantly impacted by their oral and dental health. People who have poor oral health are more susceptible to conditions such as stroke. Stroke risk has long been linked to oral and dental conditions. The risk of stroke and its cost impact on the healthcare systems appear to be significantly reduced as a result of the decline in the incidence and prevalence of oral and dental illnesses. Hypothetically, better management of oral hygiene and dental health lead to reduced stroke risk. To the authors' best knowledge, for the first time, the potential link between dental health and stroke were cross-examined. The most typical stroke symptoms, oral and dental illnesses linked to stroke, and the role of oral healthcare professionals in stroke prevention are revealed. The potential mediating processes and subsequent long-term cognitive and functional neurological outcomes are based on the available literature. It must be noted that periodontal diseases and tooth loss are two common oral health measures. Lack of knowledge on the effects of poor oral health on systemic health together with limited access to primary medical or dental care are considered to be partially responsible for the elevated risk of stroke. Concrete evidence confirming the associations between oral inflammatory conditions and stroke in large cohort prospective studies, stratifying association between oral disease severity and stroke risk and disease effects on stroke survival will be desirable. In terms of clinical pathology, a predictive model of stroke as a function of oral health status, and biomarkers of systemic inflammation could be useful for both cardiologists and dentists.

Risk of coronary heart disease in patients with periodontitis among the middled-aged and elderly in China: a cohort study

BACKGROUND

Convincing evidence of the periodontitis as a risk factor for coronary heart disease (CHD) is lacking due to shared risk factors, and no cohort study has investigated the association between CHD and periodontitis in Chinese populations.

METHODS

This study used a prospective cohort study design. The analysis included 4591 participants aged 40 years and older (3146 men and 1445 women). The association between CHD and periodontitis was estimated using relative risk (RR) calculated using modified Poisson regression. Multiple mediation analysis was used to differentiate the relative effects (RE) from different risk factors on the effect of periodontitis on CHD.

RESULTS

In the analysis using the imputed dataset and fully adjusted model, participants with periodontitis at baseline had 37% increased risk of CHD overall compared to those without periodontitis at baseline (RR 1.37; 95% CI 0.96-1.95). Most of the association can be explained by age, sex, history of diabetes, history of hypertension, uric acid and education (RE 0.76; 95% CI 0.41-1.02).

CONCLUSION

Periodontitis was weakly associated with an increased risk of CHD among the middled-aged and elderly in China. Further studies are required to identify more mediators and elucidate the mechanisms of how periodontitis increases the risk of CHD.

Associations of toothbrushing behaviour with risks of vascular and nonvascular diseases in Chinese adults

Accumulating evidence has shown that poor oral hygiene is associated with increased risk of cardiometabolic diseases in Western populations. However, its relevance about the relationships in Chinese adults remains unclear. The China Kadoorie Biobank enrolled 512 715 adults aged 30-79 years in China during 2004-2008. Cox regression was used to estimate adjusted hazard ratios (HRs) for each disease associated with measures of oral hygiene. Overall 9.3% of the participants reported rarely or never brushing teeth at baseline. Participants who rarely or never brushed teeth had adjusted HR of 1.12 (95% CI: 1.09, 1.15) for MVE, with similar HRs for stroke (1.08, 1.05-1.12), intracerebral haemorrhage (1.18, 1.11-1.26) and pulmonary heart disease (1.22, 1.13-1.32) compared with those who brushed teeth regularly. Those who did not brush teeth also had increased risk of cancer (1.09, 1.04-1.14), chronic obstructive pulmonary disease (COPD) (1.12, 1.05-1.20), liver cirrhosis (1.25, 1.09-1.44) and all-cause death (1.25, 1.21-1.28) but not type 2 diabetes (0.94, 0.86-1.03) and chronic kidney disease (0.98, 0.81-1.18). Among Chinese adults, we found that poor oral hygiene is associated with higher risks of major vascular disease, cancer, COPD, liver cirrhosis and all-cause deaths, but not type 2 diabetes and chronic kidney disease.

The traditional and modifiable risk factors of coronary artery disease - a community-based cross-sectional study among 2 populations

A community-based cross-sectional study was undertaken by the Cardiology Society of India (Kerala Chapter) to determine the prevalence of coronary artery disease (CAD) and its risk factors. The periodontal health status of the rural and urban participants in the Thiruvananthapuram district of Kerala was evaluated to document any association between periodontal disease (PD) and CAD and to describe any shared risk factors.The participants were selected using a multistage cluster random sampling method. Socio-demographic data and personal histories were collected using a structured interview schedule and validated tools. Body mass index, blood pressure, electrocardiogram, and biochemical investigations were recorded and analyzed using standard protocols. A modification of the Ramfjord periodontal disease index was used to assess periodontal health.PD was more frequent among rural (61.4%) than in the urban population (35.5%). The frequencies of CAD associated with PD in the rural and urban populations were 82.6% and 40.5%, respectively. PD was not found to be a significant risk factor for CAD in the univariate regression analysis of urban populations. In the rural population, the odds of PD as a risk factor for CAD were found to be 3.08 (95% CI [1.38-8.38]) and significant (P = .043) in univariate regression analysis and 1.54 (95% CI: 0.44-5.4) and non-significant (P = .503) in the multivariate regression analysis.In rural areas, male sex and dyslipidemia demonstrated borderline significance as risk factors for CAD. PD was not found to be an independent risk factor after adjusting for age, sex, tobacco use, hypertension, sedentary lifestyle, and dyslipidemia. Male sex and dyslipidemia were identified as shared risk factors between PD and CAD, which could have confounded the significant association between the latter. In urban areas, age, male sex, and dyslipidemia demonstrated an independent association with CAD. This study could not establish an independent association between PD and CAD in either community. Future epidemiological studies should identify and recruit novel environmental factors to understand the interrelationships between PD and CAD and focus on the role of effect modifiers that may have a protective role against PD colluding with CAD.

Periodontitis and Number of Teeth in the Risk of Coronary Heart Disease: An Updated Meta-Analysis

Background

A positive link between periodontitis and chronic systemic disease has been indicated. However, few studies focused on the loss of teeth. Our analysis aims to analyze the relationship of periodontitis and number of teeth with the risk of coronary heart disease (CHD).

Material/Methods

A meta-analysis was conducted on qualified data extracted from the PubMed, Embase, and Cochrane Library databases. Only cohort studies were included in this study. We screened articles that assessed the periodontal condition and teeth number as well as the incidence or mortality of CHD. Hazard ratio (HR) and relative risk (RR) were calculated by Stata SE software.

Results

A total of 11 prospective studies with over 200 000 total participants were analyzed. Ten studies reported on periodontitis and CHD, and 4 studies included data on number of teeth. After adjusting for multivariate factors, there was a significant association between periodontitis and the risk of CHD (RR, 1.18; 95% confidence interval [CI], 1.10–1.26); the RR of CHD in the edentulous population was 1.20 (95% CI, 1.08–1.34). Moreover, results on the RR values for number of teeth were as follows: 24–17 teeth (RR, 1.12; 95% CI, 1.05–1.19); 16–11 (RR, 1.28; 95% CI, 1.15–1.42); and ≤10 (RR, 1.55; 95% CI, 1.43–1.69).

Conclusions

Our study showed that periodontitis is a risk factor for CHD and that the number of removed teeth is positively correlated with the risk of CHD. During clinical assessment, both factors need to be considered as factors associated with cardiovascular risks.

Periodontal disease and myocardial infarction risk: A meta-analysis of cohort studies

INTRODUCTION

The objective of this meta-analysis was to systematically assess the association between periodontal disease (PD) and myocardial infarction (MI).

METHODS

We searched the EMBASE, PubMed, and Cochrane Library databases for eligible cohort studies from inception to August 31st, 2020 that reported the association between PD and MI. Data extraction was conducted after screening the literature. The risk of bias of the included studies was evaluated by using the Newcastle-Ottawa Scale (NOS). The combined OR value and 95% confidence interval (CI) were calculated by using STATA 11.0 software, and the source of any heterogeneity was determined by performing subgroup analysis and sensitivity analysis.

RESULTS

A total of 10 cohort studies involving 5,369,235 participants fulfilled the inclusion criteria. The meta-analysis showed an increased risk for MI in patients with PD [RR = 1.13, 95% CI (1.04, 1.21), P = 0.004], and this result was robust according to sensitivity analysis. Subgroup analyses indicated that the results were affected by sex, effect value, study quality, survey form and investigation type.

DISCUSSION

This meta-analysis suggests that PD is modestly associated with MI, especially in women, which is similar to the conclusions of earlier meta-analyses of case-control or observational studies. PD may be an untraditional risk factor for cardiovascular diseases, including MI; thus, maintaining periodontal health may be an effective measure to prevent MI. More cohort studies are still needed to further explore the relationship between the incidence of MI and PD.

Association between dental diseases and history of stroke in the United States

Objective

This study aimed to determine the potential association between the dental diseases and self‐reported history of stroke in the United States based on data from the Third National Health and Nutrition Examination Survey (NHANES III).

Methods

Data were extracted from NHANES III. Dental variables were carious tooth surfaces, number of missing teeth, gingival bleeding, and periodontal pockets. Multiple logistic regression modeling was used to estimate the effect of these dental diseases on the self‐reported history of stroke with intent to adjust for the other potential determinants: age, sex, race, marital status, health insurance, education, exercise, body mass index, smoking, alcohol, hypertension, high serum cholesterol, and diabetes.

Results

Number of missing teeth was found to be significantly associated with the self‐reported history of stroke. Associations between the self‐reported history of stroke and caries, gingival bleeding, or periodontal pockets were not statistically significant.

Conclusions

Number of missing teeth was an independent determinant of the self‐reported history of stroke.

Periodontal Pathogens and Neuropsychiatric Health

Increasing evidence incriminates low-grade inflammation in cardiovascular, metabolic diseases, and neuropsychiatric clinical conditions, all important causes of morbidity and mortality. One of the upstream and modifiable precipitants and perpetrators of inflammation is chronic periodontitis, a polymicrobial infection with Porphyromonas gingivalis (P. gingivalis) playing a central role in the disease pathogenesis. We review the association between P. gingivalis and cardiovascular, metabolic, and neuropsychiatric illness, and the molecular mechanisms potentially implicated in immune upregulation as well as downregulation induced by the pathogen. In addition to inflammation, translocation of the pathogens to the coronary and peripheral arteries, including brain vasculature, and gut and liver vasculature has important pathophysiological consequences. Distant effects via translocation rely on virulence factors of P. gingivalis such as gingipains, on its synergistic interactions with other pathogens, and on its capability to manipulate the immune system via several mechanisms, including its capacity to induce production of immune-downregulating micro-RNAs. Possible targets for intervention and drug development to manage distal consequences of infection with P. gingivalis are also reviewed.

Periodontitis is associated with cardiovascular diseases: A 13-year study

AIM

To prospectively evaluate the association between periodontitis and the incidence of cardiovascular diseases (CVDs) in Thai adults.

MATERIALS AND METHODS

Medical data from the questionnaires and physical examinations of 1850 participants aged 47-73 years from EGAT study were gathered. Random half-mouth periodontal examination of each participant was performed by calibrated periodontists, and periodontal status was defined. The incidence of new CVD events, including coronary heart disease (CHD) and stroke, was verified by cardiologists. The Cox proportional hazard regression model was used to estimate hazard ratios (HRs).

RESULTS

The prevalence of no/mild, moderate and severe periodontitis in the study participants was 11.7%, 52.7% and 35.6%, respectively. During the 13-year follow-up, CVD events occurred in 110 (5.9%) participants, with 82 (4.4%) from CHD and 28 (1.5%) from stroke. After adjusting for cardiovascular risk factors, a significant association between severe periodontitis and the incidence of CHD was found compared with the no/mild periodontitis group with an HR of 4.53 (95% confidence intervals: 1.08-19.02). However, no significant association was seen when considering total CVD events and stroke outcome.

CONCLUSIONS

This study demonstrates that severe periodontitis is associated with an increased incidence of CHD, independent of established cardiovascular risk factors.

Risk of incident cardiovascular disease in people with periodontal disease: A systematic review and meta-analysis

OBJECTIVES

Cardiovascular disease (CVD) is a major cause of mortality; periodontal disease (PD) affects up to 50% of the world's population. Observational evidence has demonstrated association between CVD and PD. Absent from the literature is a systematic review and meta-analysis of longitudinal cohort studies quantifying CVD risk in PD populations compared to non-PD populations. To examine the risk of incident CVD in people with PD in randomised controlled trials and longitudinal cohort studies.

MATERIAL AND METHODS

We searched Medline, EMBASE and Cochrane databases up to 9th Oct 2019 using keywords and MeSH headings using the following concepts: PD, CVD, longitudinal and RCT study design. CVD outcomes included but were not restricted to any CVD, myocardial infarction, coronary heart disease (CHD) and stroke. Diagnosis method and severity of PD were measured either clinically or by self-report. Studies comparing incident CVD in PD and non-PD populations were included. Meta-analysis and meta-regression was performed to determine risk of CVD in PD populations and examine the effects of PD diagnosis method, PD severity, gender and study region.

RESULTS

Thirty-two longitudinal cohort studies were included after full text screening; 30 were eligible for meta-analysis. The risk of CVD was significantly higher in PD compared to non-PD (relative risk [RR]: 1.20, 95% CI: 1.14-1.26). CVD risk did not differ between clinical or self-reported PD diagnosis (RR = 0.97, 95% CI: 0.87-1.07,). CVD risk was higher in men (RR: 1.16, 95% CI: 1.08-1.25) and severe PD (RR: 1.25, 95% CI: 1.15-1.35). Among all types of CVD, the risk of stroke was highest (RR = 1.24; 95% CI:1.12-1.38), the risk of CHD was also increased (RR = 1.14; 95% CI:1.08-1.21).

CONCLUSION

This study demonstrated modest but consistently increased risk of CVD in PD populations. Higher CVD risk in men and people with severe PD suggests population-targeted interventions could be beneficial.

Association between Carotid Artery Calcification and Periodontal Disease Progression in Japanese Men and Women: A Cross-Sectional Study

Objective: To evaluate the association between alveolar bone loss (ABL) detected on panoramic radiographs and carotid artery calcification (CAC) detected on computed tomography (CT). Methods: The study subjects included 295 patients (mean age ± SD: 64.6 ± 11.8 years) who visited the Matsumoto Dental University Hospital. The rate of ABL and the number of present teeth were measured on panoramic radiographs. Univariate analyses with t-tests and chi-squared tests were performed to evaluate the differences in age, gender, history of diseases, number of present teeth, and the ABL between subjects, with and without CAC. Moreover, multivariate logistic regression analysis, with forward selection and receiver operating characteristic curve (ROC) analysis, was performed. Results: The number of subjects without and with CAC was 174 and 121, respectively. Univariate analyses revealed that CAC was significantly associated with age, hypertension, osteoporosis, number of present teeth, and ABL. Multivariate logistic regression analysis adjusted for covariates revealed that the presence of CAC was significantly associated with ABL (OR = 1.233, 95% CI = 1.167–1.303). In the ROC analysis for predicting the presence of CAC, the the area under the ROC curve was the highest at 0.932 (95% CI = 0.904–0.960) for ABL, which was significant. Conclusions: Our results suggest that the measurement of ABL on panoramic radiographs may be an effective approach to identifying patients with an increased risk of CAC.

Effects of occlusal disharmony on susceptibility to atrial fibrillation in mice

Tooth loss or incorrect positioning causes occlusal disharmony. Furthermore, tooth loss and atrial fibrillation (AF) are both risk factors for ischemic stroke and coronary heart disease. Therefore, we hypothesized that occlusal disharmony-induced stress increases susceptibility to AF, and we designed the present study to test this idea in mice. Bite-opening (BO) was done by cementing a suitable appliance onto the mandibular incisor to cause occlusal disharmony by increasing the vertical height of occlusion by 0.7 mm for a period of 2 weeks. AF susceptibility, evaluated in terms of the duration of AF induced by transesophageal burst pacing, was significantly increased concomitantly with atrial remodeling, including fibrosis, myocyte apoptosis and oxidative DNA damage, in BO mice. The BO-induced atrial remodeling was associated with increased calmodulin kinase II-mediated ryanodine receptor 2 phosphorylation on serine 2814, as well as inhibition of Akt phosphorylation. However, co-treatment with propranolol, a non-selective β-blocker, ameliorated these changes in BO mice. These data suggest that improvement of occlusal disharmony by means of orthodontic treatment might be helpful in the treatment or prevention of AF.

Relationship of periodontitis and edentulism to angiographically diagnosed coronary artery disease: A cross-sectional study

OBJECTIVE

The objective of the study is to examine the connection between oral status and the extent of coronary artery disease (CAD), which is diagnosed by angiography.

BACKGROUND

Periodontitis and tooth loss have been linked to atherosclerosis and CAD in previous studies. However, no distinct connection was revealed due to the diversity of the results and the variety of diagnostic methods. To provide a more consistent data pool and stronger evidence, there is a need for studies with standard measurements and diagnostic criteria.

METHODS

309 patients, who consulted to Ankara University, Faculty of Medicine, Department of Cardiology and had coronary angiography, were enrolled to this study. Individuals were grouped based on their coronary angiography results, as CAD (+) (n = 233) and CAD (-) (n = 76). Studied parameters included cardiovascular risk factors, plaque index (PI), remaining teeth count, bleeding on probing (BOP), and probing pocket depth (PPD). Periapical radiographs were taken from teeth with ≥4 mm PPD. Oral status was categorized as periodontally healthy subjects/patients with gingivitis (Group 1), patients with periodontitis (Group 2), and edentulous subjects (Group 3).

RESULTS

PI (P < 0.001), PPD (P = 0.001), BOP (P = 0.004), the number of patients with less than 10 teeth (P = 0.014), and edentulism (P = 0.009) were significantly higher in CAD (+) patients, who were mostly older (P < 0.001) and male (P < 0.001). Multivariate logistic regression analysis revealed that Group 2 (odds ratio = 2.48, 95% confidence interval = 1.24-4.95, P = 0.010) and Group 3 (odds ratio = 2.01, 95% confidence interval = 1.14-5.17, P = 0.040) were highly associated with CAD. Two and three stenosed vessels were significantly higher in Groups 2 and 3 compared to Group 1 (P = 0.003).

CONCLUSIONS

It was found that both edentulism and periodontitis were related to CAD.

Periodontal disease classifications and incident coronary heart disease in the Atherosclerosis Risk in Communities study

BACKGROUND

Periodontal disease has been linked to coronary heart disease (CHD), but studies have been inconclusive. This study investigates the link between periodontal disease and incident CHD.

METHODS

Baseline periodontal data from a full-mouth periodontal exam (N = 6,300) and CHD outcomes through 2017 were obtained from the Atherosclerosis Risk in Communities Study. Periodontitis was defined by the Periodontal Profile Class System adapted to Stages (PPC stages) and the Centers for Disease Control/American Academy of Periodontology (CDC/AAP) index. Competing risk models were used to determine hazard ratios (HR) for incident CHD, congestive heart failure (CHF), and other causes of death. Secondary analysis included myocardial infarction (MI) and fatal CHD.

RESULTS

Females comprised 56% of participants and males 44% with a combined mean age of 62.3 years (range: 52 to 74). Participants were followed for an average of 16.7 (SD: 5.5) years. In a fully adjusted model, PPC stage VII (Severe Tooth Loss) was moderately significantly related to incident CHD, (HR 1.51 [1.11 to 2.09]). PPC stage V (Mild Tooth Loss/High Gingival Inflammation) was significant for fatal CHD (HR, 5.27 [1.80 to 15.4]) and PPC stage VII was significant for incident MI (HR, 1.59 [1.13 to 2.23]). The CDC/AAP definition was not significantly associated with incident CHD.

CONCLUSIONS

Incident CHD was moderately significantly associated with a specific stage of periodontal disease characterized by severe tooth loss, while none of the categories of the CDC/AAP were significantly associated. Thus, while periodontal therapy may improve oral health, it may be effective at impacting CHD incidence in only certain groups of people.

Improved oral hygiene care attenuates the cardiovascular risk of oral health disease: a population-based study from Korea

AIMS

Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associations with cardiovascular disease. This study aimed to evaluate whether oral hygiene behaviour can alleviate cardiovascular risk associated with oral health status using a nationwide population-based cohort.

METHODS AND RESULTS

The data of 247 696 healthy adults aged 40 years or older who underwent an oral health screening programme and had no history of major cardiovascular events were extracted from the National Health Insurance System-National Health Screening Cohort. After a median follow-up of 9.5 years, 14 893 major cardiovascular events occurred including cardiac death, myocardial infarction, stroke, and heart failure. The risk of cardiovascular events was higher when a subject had periodontal disease, a higher number of dental caries, or more tooth loss. Performing one more tooth brushing a day was associated with a 9% significantly lower risk of cardiovascular events after multivariable adjustment. Regular dental visits (once a year or more) for professional cleaning were also shown to reduce cardiovascular risk by 14%. Improved oral hygiene behaviours were shown to attenuate the cardiovascular risk originating from periodontal disease, dental caries, and tooth loss.

CONCLUSION

Oral hygiene care such as frequent tooth brushing and regular dental visits for professional cleaning reduced the risk of future cardiovascular events in healthy adults. This study also suggests that improved oral hygiene behaviour may modify the association between oral health and cardiovascular diseases.

Oral health and cardiovascular disease risk factors and mortality of cerebral haemorrhage, cerebral infarction and unspecified stroke in elderly men: A prospective cohort study

Background: Stroke mortality comprises different specific diagnoses as cerebral infarction, different haemorrhagic conditions and unspecified stroke. This study seeks to explore the prediction of oral health indicators versus known cardiovascular disease risk factors for stroke mortality. Methods: Altogether, 12,764 men aged 58 to 77 years were invited to the health screening Oslo II in the year 2000. It included general medical measurements and questionnaire information. Mortality data were supplied by Statistics Norway for the 6530 attending men. Cox proportional hazards regression analyses were used to establish prediction models for mortality. Results: Oral health by number of tooth extractions >10 was found to be an independent predictor for cerebral infarction hazard ratio = 2.92, 95% confidence interval (1.24-6.89). This was independent of HDL-Cholesterol (inversely) hazard ratio = 0.21, 95% confidence interval (0.06-0.76), frequent alcohol consumption (drinking 4-7 times per week) hazard ratio = 3.58, 95% confidence interval (1.40-9.13) and diabetes hazard ratio = 4.28, 95% confidence interval (1.68-10.89). Predictors for cerebral haemorrhage were age, hs-C-reactive protein and body mass index (inversely). Age and total cholesterol (inversely) were predictors for unspecified stroke. Conclusions: Oral health measured by number of tooth extractions >10 was an independent predictor for cerebral infarction in addition to age, HDL-C, hs-C-reactive protein and diabetes. The pattern of risk factors varied between the specific stroke diagnoses.

Distal Consequences of Oral Inflammation

Periodontitis is an incredibly prevalent chronic inflammatory disease, which results in the destruction of tooth supporting structures. However, in addition to causing tooth and alveolar bone loss, this oral inflammatory disease has been shown to contribute to disease states and inflammatory pathology at sites distant from the oral cavity. Epidemiological and experimental studies have linked periodontitis to the development and/or exacerbation of a plethora of other chronic diseases ranging from rheumatoid arthritis to Alzheimer's disease. Such studies highlight how the inflammatory status of the oral cavity can have a profound impact on systemic health. In this review we discuss the disease states impacted by periodontitis and explore potential mechanisms whereby oral inflammation could promote loss of homeostasis at distant sites.

Association Between Toothbrushing and Behavioral Risk Factors of Non-communicable Diseases: A population Based Survey of 4500 adults in China

Non-communicable Disease (NCD) related behavioral risk factors (BRF) plays a crucial role in NCD prevention, as does oral hygiene behavior in oral health promotion. We examined the association between NCD BRF and toothbrushing using data from a population-based survey, which recruited 4485 adults aged 18+ years, in Chongqing city, China. Prevalence of five NDC BRF and their clustering within individual were determined by toothbrushing frequency. Ordinal logistic regression examined the association between toothbrushing and BRF clustering. Prevalence of current smoking, insufficient intake of vegetable and fruit, and harmful use of alcohol increased significantly with toothbrushing frequency. Respondents who brushed teeth ≥2 times daily consumed more red meat than those with less frequent toothbrushing. Relative to those with no BRF, the adjusted cumulative odds ratio of brushing teeth less frequently was 2.1 (95% CI: 1.4-3.1) for respondents with 3+ BRF. The adjusted cumulative odds ratio was 1.5 (1.1-2.1) and 1.4 (1.0-1.8) for those who had two BRF and those who had one, respectively. Significant correlation between toothbrushing and NCD BRF implied that integrated intervention strategy involving the both may be beneficial in public health programs targeting at either oral health or NCDs, or both.

Periodontal Disease: A Risk Factor for Diabetes and Cardiovascular Disease

Periodontitis is a chronic inflammatory disease, initiated by the presence of a bacterial biofilm, called dental plaque, which affects both the periodontal ligaments and bone surrounding teeth. In the last decades, several lines of evidence have supported the existence of a relationship between periodontitis and systemic health. For instance, as periodontitis acts within the same chronic inflammatory model seen in cardiovascular disease (CVD), or other disorders, such as diabetes, several studies have suggested the existence of a bi-directional link between periodontal health and these pathologies. For instance, people with diabetes are more susceptible to infections and are more likely to suffer from periodontitis than people without this syndrome. Analogously, it is now evident that cardiac disorders are worsened by periodontitis, both experimentally and in humans. For all these reasons, it is very plausible that preventing periodontitis has an impact on the onset or progression of CVD and diabetes. On these grounds, in this review, we have provided an updated account on the current knowledge concerning periodontal disease and the adverse effects exerted on the cardiovascular system health and diabetes, informing readers on the most recent preclinical studies and epidemiological evidence.

Periodontal, metabolic, and cardiovascular disease: Exploring the role of inflammation and mental health

Previous evidence connects periodontal disease, a modifiable condition affecting a majority of Americans, with metabolic and cardiovascular morbidity and mortality. This review focuses on the likely mediation of these associations by immune activation and their potential interactions with mental illness. Future longitudinal, and ideally interventional studies, should focus on reciprocal interactions and cascading effects, as well as points for effective preventative and therapeutic interventions across diagnostic domains to reduce morbidity, mortality and improve quality of life.

Associations between self-reported periodontal disease, assessed using a very short questionnaire, cardiovascular disease events and all-cause mortality in a contemporary multi-ethnic population: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Periodontal disease (PD) is believed to be associated with cardiovascular disease (CVD) events. Nevertheless, the additive prognostic value of PD for the prediction of CVD events beyond traditional risk factors is unclear, particularly when self-reported using a short questionnaire.

METHODS

In the community-based, multicenter, prospective, Multi-Ethnic Study of Atherosclerosis (MESA), PD was assessed at baseline using a two-item questionnaire. We used Cox proportional hazards regression models to evaluate the independent associations between self-reported PD and coronary heart disease (CHD), CVD events, and all-cause death. In addition, the area under the receiver-operator characteristic curve (AUC) was calculated for each of the study endpoints, for models including traditional CVD risk factors alone and models including traditional CVD risk factors plus information on PD. Subgroup analyses were performed stratifying by age and tobacco use.

RESULTS

Among the 6640 MESA participants, high education level, high income, and access to healthcare were more frequent among individuals who self-reported PD. In multivariable analyses, null associations were observed between self-reported PD and incident CVD events, CHD events, and all-cause mortality; and self-reported PD did not improve risk prediction beyond traditional CVD risk factors in terms of AUC, for any of the three study endpoints. Subgroup analyses were consistent with the overall results.

CONCLUSIONS

Our findings suggest that the prevalence of self-reported PD may be strongly influenced by educational status and other socioeconomic features. In this context, self-reported PD does not improve CVD risk assessment when evaluated using a brief questionnaire. Future studies should prioritize objective, dental health-expert assessments of PD.

Poor oral health and risk of incident myocardial infarction: A prospective cohort study of Swedish adults, 1973-2012

Previous studies provide conflicting evidence as to whether there is an association between poor oral health and an increased risk of myocardial infarction. The aim of the study was to deepen knowledge of the association between oral health and myocardial infarction risk using a large (n = 20,133), prospective, and population-based cohort in Uppsala, Sweden. Oral health was determined during a clinical dental examination at entry into the cohort in 1973/74. Individuals were followed through linkage with the Swedish National Patient Register, Cause of Death Register and Emigration Register. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) for total, non-fatal and fatal myocardial infarction events. Increased risks of total, non-fatal and fatal myocardial infarction events among individuals with fewer reference teeth at examination, more dental plaque and a borderline significant increased risk among individuals with oral lesions were observed. Adjustment for multiple potential confounding factors did not change the results appreciably. However, the observed HRs generally decreased towards one when the analysis was confined to non-tobacco users only. The results from this study indicate that poor oral health is associated with a slightly increased risk of myocardial infarction; however, these results may be partly explained by residual confounding.

Tooth loss and risk of cardiovascular disease and stroke: A dose-response meta analysis of prospective cohort studies

Conflicting results identifying the association between tooth loss and cardiovascular disease and stroke have been reported. Therefore, a dose-response meta-analysis was performed to clarify and quantitatively assess the correlation between tooth loss and cardiovascular disease and stroke risk. Up to March 2017, seventeen cohort studies were included in current meta-analysis, involving a total of 879084 participants with 43750 incident cases. Our results showed statistically significant increment association between tooth loss and cardiovascular disease and stroke risk. Subgroups analysis indicated that tooth loss was associated with a significant risk of cardiovascular disease and stroke in Asia and Caucasian. Furthermore, tooth loss was associated with a significant risk of cardiovascular disease and stroke in fatal cases and nonfatal cases. Additionally, a significant dose-response relationship was observed between tooth loss and cardiovascular disease and stroke risk. Increasing per 2 of tooth loss was associated with a 3% increment of coronary heart disease risk; increasing per 2 of tooth loss was associated with a 3% increment of stroke risk. Subgroup meta-analyses in study design, study quality, number of participants and number of cases showed consistent findings. No publication bias was observed in this meta-analysis. Considering these promising results, tooth loss might provide harmful health benefits.

Nut Consumption and Risk of Cardiovascular Disease

BACKGROUND

The associations between specific types of nuts, specifically peanuts and walnuts, and cardiovascular disease remain unclear.

OBJECTIVES

The authors sought to analyze the associations between the intake of total and specific types of nuts and cardiovascular disease, coronary heart disease, and stroke risk.

METHODS

The authors included 76,364 women from the Nurses' Health Study (1980 to 2012), 92,946 women from the Nurses' Health Study II (1991 to 2013), and 41,526 men from the Health Professionals Follow-Up Study (1986 to 2012) who were free of cancer, heart disease, and stroke at baseline. Nut consumption was assessed using food frequency questionnaires at baseline and was updated every 4 years.

RESULTS

During 5,063,439 person-years of follow-up, the authors documented 14,136 incident cardiovascular disease cases, including 8,390 coronary heart disease cases and 5,910 stroke cases. Total nut consumption was inversely associated with total cardiovascular disease and coronary heart disease after adjustment for cardiovascular risk factors. The pooled multivariable hazard ratios for cardiovascular disease and coronary heart disease among participants who consumed 1 serving of nuts (28 g) 5 or more times per week, compared with the reference category (never or almost never), were 0.86 (95% confidence interval: 0.79 to 0.93; p for trend = 0.0002) and 0.80 (95% confidence interval: 0.72 to 0.89; p for trend <0.001), respectively. Consumption of peanuts and tree nuts (2 or more times/week) and walnuts (1 or more times/week) was associated with a 13% to 19% lower risk of total cardiovascular disease and 15% to 23% lower risk of coronary heart disease.

CONCLUSIONS

In 3 large prospective cohort studies, higher consumption of total and specific types of nuts was inversely associated with total cardiovascular disease and coronary heart disease.

Association between missing tooth count and mortality: A systematic review

PURPOSE

The purpose of this review was to analyze existing literature on the relationship between tooth count and mortality by evaluating the findings in the context of methodological variations. We aimed at addressing the question of whether preserving natural teeth can impact mortality.

STUDY SELECTION

PubMed, Web of Science and CINAHL databases were systematically searched using various combinations of related and synonymous keywords for "tooth count" and "mortality". The references of included articles were also evaluated for inclusion. Overall 49 studies found to be eligible were critically evaluated and their key findings were summarized.

RESULTS

Studies were conducted in various continents and differed substantially in regards to their sample size, population, methodology, the definition of the tooth count variable, the confounders as well as the mediators accounted for in the analysis. Follow-up period ranged from 1 to 56 years.

CONCLUSIONS

Although high variability in the studies precludes a definite conclusion about the relationship between number of teeth and mortality, the overall finding from this review is that reduced tooth count is associated with higher mortality. However the impact of factors such as smoking, health-care access, baseline co-morbidity and risk profile, dental and periodontal health, the presence of dental prosthesis as well as socio-economic status, in mediating whole or part of the association cannot be overlooked and needs further investigation using more standard methodologies. Any differences in males vs. females, as well as among different age groups, will also need further consideration in the future studies.

History of Periodontitis Diagnosis and Edentulism as Predictors of Cardiovascular Disease, Stroke, and Mortality in Postmenopausal Women

BACKGROUND

Few studies have reported associations between periodontitis and cardiovascular disease (CVD) risk in older women, which is the objective of the present investigation.

METHODS AND RESULTS

Participants were 57 001 postmenopausal women ages 55 to 89 years (mean 68 years; >85% 60 and older) who were enrolled (1993-1998) in the Women's Health Initiative Observational Study, and were without known CVD when history of periodontitis and edentulism was assessed by questionnaire at study Year-5 (1998-2003). There were 3589 incident CVD events and 3816 total deaths during a mean follow-up of 6.7 years. In multivariable analysis, periodontitis was not associated with CVD events, but was associated with higher total mortality (hazard ratio (HR)=1.12, 95% CI: 1.05-1.21). Edentulism was associated with higher age- and smoking-adjusted risks of CVD (HR=1.42, 95% CI: 1.27-1.59) and mortality (HR=1.47, 95% CI: 1.32-1.63). Further adjustment eliminated the association with CVD, but mortality remained significantly increased (HR=1.17, 95% CI: 1.02-1.33). Stratification on age, race-ethnicity, smoking, and diabetes mellitus yielded comparable results; however, edentulism was more strongly associated with CVD in women reporting ≥1 dental visit (HR=1.57) compared with <1 visit (HR 1.03, interaction P=0.004) annually.

CONCLUSIONS

In community-dwelling older women, edentulism was associated with increased risks of CVD and total mortality, and presence of periodontitis, which is more prevalent than edentulism, was associated with 17% higher mortality rate. These findings suggest that improving periodontal condition of the general population could reduce overall mortality.

The association between periodontal disease and the risk of myocardial infarction: a pooled analysis of observational studies

Background

Several meta-analyses have indicated that periodontal disease (PD) are related to cardiovascular diseases (CVDs). However, the association between PD and myocardial infarction (MI) remains controversial. Here we aimed to assess the association between PD and MI by meta-analysis of observational studies.

Methods

PubMed, EMBASE and the Cochrane Library were searched through July, 2016. Observational studies including cohort, cross-sectional and case–control studies reporting odds ratio (OR) or relative risk (RR) with 95% confidence intervals (CIs) were included in the analysis. Either fixed or random-effects model were applied to evaluate the pooled risk estimates. Sensitivity and subgroup analyses were also carried out to identify the sources of heterogeneity. Publication bias was assessed by the Begg’s, Egger’s test and funnel plot.

Results

We included 22 observational studies with 4 cohort, 6 cross-sectional and 12 case–control studies, including 129,630 participants. Patients with PD have increased risk of MI (OR 2.02; 95% CI 1.59-2.57). Substantial heterogeneity in risk estimates was revealed. Subgroup analyses showed that the higher risk of MI in PD patients exists in both cross-sectional studies (OR 1.71; 95% CI 1.07-2.73) and case–control studies (OR 2.93; 95% CI 1.95-4.39), and marginally in cohort studies (OR 1.18; 95% CI 0.98-1.42). Further, subgroup meta-analyses by location, PD exposure, participant number, and study quality showed that PD was significantly associated with elevated risk of MI.

Conclusion

Our meta-analysis suggested that PD is associated with increased risk of future MI. However, the causative relation between PD and MI remains not established based on the pooled estimates from observational studies and more studies are warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0480-y) contains supplementary material, which is available to authorized users.

Relationship of Periodontal Disease and Edentulism to Stroke/TIA

Periodontitis has been shown to increase the systemic inflammatory response, which has been implicated in atherosclerosis and cerebrovascular events. We hypothesized an association between periodontitis or edentulism and Stroke/TIA in the ARIC Study. Data on 9415 dentate and 1491 edentulous adults included demographics, cardiovascular outcomes, lifestyle, laboratory measures, and, for 6436 of the dentate, a dental examination. The dependent variable was Stroke/TIA, and the exposure was extent (%) of attachment level 3+ millimeters (AL). Quartiles of AL and edentulism were compared for Stroke/TIA using odds ratios (OR) and 95% confidence intervals (CI), and confounders were controlled by logistic regression. Stroke/TIA was prevalent in 13.5% of periodontal examinees, 15.6% of dentate non-examinees, and 22.5% of edentulous persons. The highest quartile of AL (OR 1.3, CI 1.02-1.7) and edentulism (OR 1.4, CI 1.5-2.0) were associated with Stroke/TIA.

Radiographic Assessment of Dental Health in Middle-aged Men Following Sudden Cardiac Death

Poor oral health has been suggested to be a risk factor for myocardial infarction. To study if dental pathology might predispose to pre-hospital sudden cardiac death, and using a sum index of panoramic tomography findings, we compared the oral health of middle-aged (33–69 yrs) male victims (Helsinki Sudden Death Study) of sudden cardiac death (n = 117) with that of controls, who died of non-cardiac diseases (n = 63) or suffered unnatural sudden death (n = 120). The mean number of teeth was 15.2, and 17.4% of the men were edentulous. Frequent age-associated findings in dentate victims were fillings (79.9%), horizontal bone loss (72.1%), periapical lesions (45.6%), residual roots (38.2%), and vertical pockets (30.9%). In multivariate analysis with coronary heart disease risk factors and number of teeth as covariates, poor oral health was associated (p = 0.053) with the risk of sudden cardiac death along with age, smoking, and body mass index. This association was especially strong (p = 0.009) among victims < 50 yrs.

Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk

Prior studies of a link between periodontal and cardiovascular disease have been limited by being predominantly observational. We used a treatment intervention model to study the relationship between periodontitis and systemic inflammatory and thrombotic cardiovascular indicators of risk. We studied 67 adults with advanced periodontitis requiring full-mouth tooth extraction. Blood samples were obtained: (1) at initial presentation, immediately prior to treatment of presenting symptoms; (2) one to two weeks later, before all teeth were removed; and (3) 12 weeks after full-mouth tooth extraction. After full-mouth tooth extraction, there was a significant decrease in C-reactive protein, plasminogen activator inhibitor-1 and fibrinogen, and white cell and platelet counts. This study shows that elimination of advanced periodontitis by full-mouth tooth extraction reduces systemic inflammatory and thrombotic markers of cardiovascular risk. Analysis of the data supports the hypothesis that treatment of periodontal disease may lower cardiovascular risk, and provides a rationale for further randomized studies.

Low frequency of toothbrushing practices is an independent risk factor for diabetes mellitus in male and dyslipidemia in female: A large-scale, 5-year cohort study in Japan

BACKGROUND

We previously reported the association between toothbrushing practices and diabetes mellitus (DM) and dyslipidemia (DL) in a cross-sectional study. This study was conducted to clarify whether low frequency of toothbrushing practices is an independent risk factor for DM and DL using a follow-up design.

METHODS

This study was a 5-year retrospective cohort study at St. Luke's International Hospital, Tokyo, Japan. We analyzed study subjects between 30 and 85 years old in 2004, who underwent annual medical examination both in 2004 and 2009. We compared the cumulative incidences of developing DM, DL, hypertension (HT), and hyperuricemia (HUA) between 2004 and 2009 among 3 groups: toothbrushing practices 'after every meal,' 'at least once a day,' and 'less than once a day'. Furthermore, we analyzed odds ratios (ORs) of risk for developing DM and DL by sex after making adjustments for age, obesity, DM, DL, HT, and HUA between two groups: 'after every meal' and 'not after every meal.'

RESULTS

The number of study subjects was 13,070. Of 13,070 study subjects, 575 had DM, 5118 had DL, 2599 had HT, and 1908 had HUA in 2004. We excluded the subjects with each disease in 2004. The cumulative incidences (rates) of DM, DL, HT, and HUA between 2004 and 2009 were 318 (2.5%), 1454 (18.3%), 1108 (10.6%), and 489 (4.4%), respectively. Toothbrushing practices 'not after every meal' was a significant risk factor for developing DM in male [OR: 1.43; 95% confidence interval (CI), 1.040-1.970] and developing DL in female (OR: 1.18; 95% CI, 1.004-1.383) compared with toothbrushing practices 'after every meal.'

CONCLUSION

Toothbrushing practices 'after every meal' prevented developing DM in males and DL in females significantly. Toothbrushing practices may be beneficial to reduce developing risk factors for cardiovascular disease.

Association between Myocardial Infarction and Periodontitis: A Meta-Analysis of Case-Control Studies

Background and Objective: Many clinical researches have been carried out to investigate the relationship between myocardial infarction (MI) and periodontitis. Despite most of them indicated that the periodontitis may be associated with an increased risk of MI, the findings and study types of these studies have been inconsistent. The goal of this meta-analysis was to critically assess the strength of the association between MI and periodontitis in case-control studies.

Methods: PubMed and the Cochrane Library were searched for eligible case-control studies reporting relevant parameters that compared periodontal status between MI and control subjects. The odds ratios (ORs) and 95% confidence intervals (CIs) from each study were pooled to estimate the strength of the association between MI and periodontitis. The mean differences and 95% CIs for periodontal-related parameters were calculated to determine their overall effects.

Results: Seventeen studies including a total of 3456 MI patients and 3875 non-MI control subjects were included. The pooled OR for the association between MI and periodontitis was 2.531 (95% CI: 1.927–3.324). The mean differences (95% CIs) for clinical attachment loss, probing depth, bleeding on probing, plaque index, and the number of missing teeth were 1.000 (0.726–1.247), 1.209 (0.538–1.880), 0.342 (0.129–0.555), 0.383 (0.205–0.560), and 4.122 (2.012–6.232), respectively.

Conclusion: With the current evidence, the results support the presence of a significant association between MI and periodontitis. Moreover, MI patients had worse periodontal and oral hygiene status and fewer teeth than did control subjects. More high-quality and well-designed studies focusing on the casual relationship between MI and periodontitis should be conducted in the future.

Is poor oral health a risk marker for incident cardiovascular disease hospitalisation and all-cause mortality? Findings from 172 630 participants from the prospective 45 and Up Study

OBJECTIVE

To investigate the relationship between oral health and incident hospitalisation for ischaemic heart disease (IHD), heart failure (HF), ischaemic stroke and peripheral vascular disease (PVD) and all-cause mortality.

DESIGN

Prospective population-based study of Australian men and women aged 45 years or older, who were recruited to the 45 and Up Study between January 2006 and April 2009; baseline questionnaire data were linked to hospitalisations and deaths up to December 2011. Study exposures include tooth loss and self-rated health of teeth and gums at baseline.

SETTING

New South Wales, Australia.

PARTICIPANTS

Individuals aged 45-75 years, excluding those with a history of cancer/cardiovascular disease (CVD) at baseline; n=172 630.

PRIMARY OUTCOMES

Incident hospitalisation for IHD, HF, ischaemic stroke and PVD and all-cause mortality.

RESULTS

During a median follow-up of 3.9 years, 3239 incident hospitalisations for IHD, 212 for HF, 283 for ischaemic stroke and 359 for PVD, and 1908 deaths, were observed. Cox proportional hazards models examined the relationship between oral health indicators and incident hospitalisation for CVD and all-cause mortality, adjusting for potential confounding factors. All-cause mortality and incident CVD hospitalisation risk increased significantly with increasing tooth loss for all outcomes except ischaemic stroke (ptrend<0.05). In those reporting no teeth versus ≥20 teeth left, risks were increased for HF (HR, 95% CI 1.97, 1.27 to 3.07), PVD (2.53, 1.81 to 3.52) and all-cause mortality (1.60, 1.37 to 1.87). The risk of IHD, PVD and all-cause mortality (but not HF or ischaemic stroke) increased significantly with worsening self-rated health of teeth and gums (ptrend<0.05). In those reporting poor versus very good health of teeth and gums, risks were increased for IHD (1.19, 1.03 to 1.38), PVD (1.66, 1.13 to 2.43) and all-cause mortality (1.76, 1.50 to 2.08).

CONCLUSIONS

Tooth loss and, to a lesser extent, self-rated health of teeth and gums, are markers for increased risk of IHD, PVD and all-cause mortality. Tooth loss is also a marker for increased risk of HF.

Association between periodontitis and ischemic stroke: a systematic review and meta-analysis

Several observational studies have suggested an association between periodontitis and cerebral ischemia. This meta-analysis aimed to investigate whether this link exists, and if so, the degree to which it is significant. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline for systematic review was used. The search strategy included using electronic databases and hand searching works published up to March 2015. MEDLINE via PubMed, EMBASE, Proceedings Web of Science and Current Contents Connect were searched by two independent reviewers. Case-control, cross-sectional or cohort studies including patients with measures of periodontitis and ischemic stroke were eligible to be included in the analysis. Quality assessments of selected studies were performed. From a total of 414 titles and abstracts, 57 potentially relevant full text papers were identified. After inclusion criteria were applied, 8 studies were included in the present systematic review (5 case-control and 3 cohort studies). Although it was not the intention, cross-sectional studies were excluded due to eligibility criteria were not accomplished. Therefore, meta-analyses were conducted with data retrieved from the 8 studies included. These meta-analyses showed statistically significant association between periodontitis and ischemic stroke in both cohort pooled relative risks at 2.52 (1.77-3.58), and case-control studies pooled relative risks at 3.04 (1.10-8.43). In conclusion, the present meta-analysis demonstrated an association between periodontitis and ischemic stroke. However, well-designed prospective studies should be carried out to provide robust evidence of the link between both diseases. In regards to ischemic stroke subtypes, further case-control studies should be carried out to investigate whether there is any association between the different subtypes of cerebral infarcts and periodontitis.

Association between toothbrushing and risk factors for cardiovascular disease: a large-scale, cross-sectional Japanese study

OBJECTIVES

To clarify the association between toothbrushing and risk factors for cardiovascular disease--namely, hypertension (HT), diabetes mellitus (DM), dyslipidaemia (DL), hyperuricaemia (HUA) and chronic kidney disease (CKD).

DESIGN

A large-scale, single-centre, cross-sectional study.

SETTING

St Luke's International Hospital, Center for Preventive Medicine, Tokyo, Japan, between January 2004 and June 2010.

PARTICIPANTS

This study examined the toothbrushing practices of 85,866 individuals according to the 3-category frequency criterion: 'after every meal', 'at least once a day' and 'less than once a day'. The ORs by frequency were calculated for the prevalences of HT, DM, DL, HUA and CKD according to binominal logistic regression analyses adjusted for age, gender, body mass index and lifestyle habits--smoking, drinking, walk time and sleep time.

RESULTS

The prevalences of the risk factors were as follows: HT ('after every meal': 13.3%, 'at least once a day': 17.9% and 'less than once a day': 31.0%), DM (3.1%, 5.3% and 17.4%, respectively), DL (29.0%, 42.1% and 60.3%, respectively), HUA (8.6%, 17.5% and 27.2%, respectively) and CKD (3.8%, 3.1% and 8.3%, respectively). The prevalences were significantly higher in the 'less than once a day' group than in the 'after every meal' group for DM (OR=2.03; 95% CI 1.29 to 3.21) and DL (OR=1.50; 95% CI 1.06 to 2.14), but not for HT, HUA and CKD.

CONCLUSIONS

Even taking into account lifestyle habits, a lower frequency of toothbrushing was associated with high prevalences of DM and DL. Toothbrushing practices may be beneficial for oral health improvement and also for prevention of certain systemic diseases.

Association between dental caries and out-of-hospital cardiac arrests of cardiac origin in Japan

BACKGROUND

Oral infection contributes to atherosclerosis and coronary heart disease. We hypothesized that dental caries may be associated with out-of-hospital cardiac arrests (OHCA) of cardiac origin, but not non-cardiac origin.

METHODS AND RESULTS

We compared the age-adjusted incidence of OHCA (785,591 cases of OHCA: 55.4% of cardiac origin and 44.6% of non-cardiac origin) to the age-adjusted prevalence of dental caries between 2005 and 2011 in the 47 prefectures of Japan. In both the total population and males over 65 years, the number of cases of dental caries was significantly associated with the number of OHCA of total and cardiac origin from 2005 to 2011, but not those of non-cardiac origin. In the total population, the age-adjusted prevalence of dental caries was not significantly associated with the age-adjusted incidence of OHCA (total OHCA: r correlation coefficient=0.22, p=0.14; OHCA of cardiac origin: r=0.25, p=0.09; OHCA of non-cardiac origin: r=-0.002, p=0.99). Among male patients over 65 years, the age-adjusted prevalence of dental caries was significantly associated with OHCA of total and cardiac origin, but not non-cardiac origin (total OHCA: r=0.47, p<0.001; OHCA of cardiac origin: r=0.37, p=0.01; OHCA of non-cardiac origin: r=0.28, p=0.054).

CONCLUSIONS

While oral hygiene is important in all age groups, it may be particularly associated with OHCAs of cardiac origin in males over 65 years.