By Michael H. Crawford, MD
Professor of Medicine, Lucy Stern Chair in Cardiology, University of California, San Francisco
SYNOPSIS: Researchers used data from the 2013 to 2014 period of the National Health and Nutrition Examination Survey to study possible connections between poor oral health and the likelihood of developing cardiovascular disease.
SOURCE: Ngamdu KS, Mallawaarachichi I, Dunipace EA, et al. Association between periodontal disease and cardiovascular disease (from the NHANES). Am J Cardiol 2022;178:163-168.
The purported association of periodontal disease (PD) with cardiovascular disease (CVD) might be related to chronic inflammation — or it might just share risk factors for CVD, such as smoking, lower socioeconomic status, and diabetes. Investigators studied this association using data collected during the 2013-2014 period of the National Health and Nutrition Examination Survey (NHANES). For this purpose, CVD was defined as coronary artery disease (CAD) and stroke. This survey included an in-person examination by a dentist. Characterization of any PD detected followed the latest criteria established by the American Academy of Periodontology. The authors excluded subjects with conditions requiring antibiotic prophylaxis for dental work because the periodontal examination required probing the gums.
Complete data were available for 2,830 subjects, of whom 17% were diagnosed with stage I PD, 57% with stage II PD, and 26% with stages III and IV PD. Those diagnosed with stage III or IV PD were older, more likely to be men, more likely to have attained less education than others, and more likely to make less money than those with stage I or II PD (P < 0.0001). Also, traditional CVD risk factors were significantly higher in the stages III/IV group, except for high body mass index. In addition, chronic kidney disease and alcohol consumption were not different across the PD groups.
Stages III and IV PD subjects recorded a 3.6-fold higher incidence of PD than stage I subjects (95% CI, 1.12-11.54; P = 0.03). Self-reported poor to fair oral health was associated with a 2.17-fold higher incidence of CVD compared to those who self-reported good to excellent oral health (95% CI, 0.98-4.79). However, this was not statistically significant (P = 0.055). The authors concluded data from the NHANES 2013-2014 period showed PD severity established by a dental examination was associated with higher CVD risk and is more reliable than self-reported oral health information.
COMMENTARY
When researchers build their studies around self-administered questionnaires, the validity of the results, along with the sensitivity, can be called into question. In this investigation, Ngamdu et al used in-person dental exams, administered by credentialed dentists, to which the most recent American Academy of Periodontology classification system for PD was applied. This led the authors to report a strong association between PD and CVD. Another strength of this work was the use of the NHANES database, which is a sample of subjects representative of the entire U.S. population.
Still, there were some limitations to the Ngamdu et al paper. It was a cross-sectional study; the risk factors for PD and CVD overlapped. Also, the authors did not assess the adequacy of risk factor control. Thus, causality cannot be firmly established. The association of PD and CVD likely is mediated by a systemic inflammatory response to bacteria released through oral manipulation, such as mastication or teeth brushing. This precipitates the release of proinflammatory cytokines, which are known to promote atherosclerosis.
In addition, common oral bacteria have been found in atherosclerotic plaques, so there may be a direct toxic effect of this bacteremia as well. Finally, despite effective pharmacological treatments for hypertension, dyslipidemia, and diabetes, the CVD mortality rate has plateaued in developed countries. Therefore, clinicians must focus more attention on other treatable risk factors for CVD, such as maintaining good oral health.
Researchers used data from the 2013 to 2014 period of the National Health and Nutrition Examination Survey to study possible connections between poor oral health and the likelihood of developing cardiovascular disease.
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