Periodontal Disease And Cardiovascular Disease Pdf

periodontal disease and cardiovascular disease pdf

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Arch Intern Med.

Metrics details. 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.

Gum disease and the connection to heart disease

Bichat Hospital, Paris France,. In Europe cardiovascular disease CVD is responsible for 3. There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations.

The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation WHF , which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes.

This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices. Risk Factors Collaborators, Senate Committee on Health, In Europe, CVD is responsible for 3. In this consensus report, the term CVD is used as a general term for atherosclerotic diseases, principally coronary heart disease, cerebrovascular disease and peripheral vascular disease.

A number of chronic infectious, inflammatory and immune diseases are associated with significantly higher risks of adverse cardiovascular events, including rheumatoid arthritis, psoriasis, systemic lupus erythematosus and periodontitis Roth et al.

The latter correlate strongly with diets high in saturated fats, salt and refined sugars and contribute to obesity and type 2 diabetes mellitus, major attributable risk factors for myocardial infarction Joseph et al. The workshop concluded that there was consistent and strong epidemiological evidence that periodontitis imparts increased risk for future atherosclerotic cardiovascular disease.

The present workshop was jointly organized by the EFP and the World Heart Federation WHF to include global experts in both periodontal and cardiovascular disciplines and was held in Madrid on 18th and 19th February Four technical reviews updating the evidence base from the workshop were prepared and supplemented by additional studies discussed at the workshop.

Furthermore, section 4. Finally, following the review of the presented evidence, recommendations for both medical and dental teams, as well as patients and the public, were elaborated. There is robust evidence from epidemiological studies for a positive association between periodontitis and coronary heart disease. A systematic review Dietrich et al. Relative risk estimates vary between studies, depending on population characteristics and periodontitis case definitions.

There are two cohort studies reporting an association between periodontitis and higher cardiovascular mortality due to coronary heart disease and cerebrovascular disease. There is evidence from epidemiologic studies for a positive association between periodontitis and cerebrovascular disease.

Furthermore, a recent analysis of data from the ARIC study demonstrated an association between periodontal profile class and incident ischaemic stroke. In this cohort, patients with periodontitis had more than double the risk of cardioembolic and thrombotic stroke compared with periodontally healthy individuals Sen et al.

In addition, as previously documented, there are two cohort studies reporting an association between periodontitis and higher cardiovascular mortality due to coronary heart disease and cerebrovascular disease Dietrich et al.

There is limited but consistent evidence that individuals with periodontitis have a higher prevalence and incidence of PAD compared to individuals without periodontitis Yang et al. Several studies report positive associations between periodontitis and heart failure. There is currently limited scientific evidence that CVD is a risk factor for the onset or progression of periodontitis.

From three studies investigating the association between periodontitis and secondary cardiovascular events, two large studies did not find a significant association Dorn et al. There is evidence that oral bacterial species can enter the circulation and cause bacteremia, which has been demonstrated following daily life activities toothbrushing, flossing, chewing or biting an apple , although it has been studied more frequently following professional interventions tooth polishing, scaling, tooth extraction, surgical extraction of third molars and periodontal probing.

A recent randomized clinical trial RCT concluded that periodontal therapy by means of scaling and root planing, SRP induced bacteremia in both gingivitis and periodontitis patients, but the magnitude and frequency were greater among periodontitis patients Balejo et al. Whilst there are methodological limitations in some of the reported studies, the overall picture supports the contention that bacteremia results from daily life activities and oral interventions, and it is more frequent of longer duration and involves more virulent bacteria in periodontitis patients.

There is evidence through traces of DNA, RNA or antigens derived from oral bacterial species, mainly periodontal pathogens, that have been identified in atherothrombotic tissues. Studies have attempted to correlate the presence of these bacteria in atherothrombotic tissues, with other sample sources subgingival plaque, serum, etc.

At least two studies have demonstrated viable P. Different animal models have been employed to provide evidence that periodontal pathogens can promote atheroma formation. Recently, further evidence has emerged using hyperlipidemic ApoEnull mice after infection with P. There is also in vitro evidence of intracellular entry by periodontal pathogens P.

Reyes et al. In vivo and in vitro studies demonstrate the importance of the fimbriae of P. In vitro experiments have shown that certain bacterial strains expressing P. The effect of periodontal therapy has been shown to associate with a significant decrease in CRP levels, along with improvements in surrogate measurements of cardiovascular health Demmer et al.

There is evidence of significantly higher levels of fibrinogen in periodontitis patients versus healthy controls, and in CVD and periodontitis patients compared with either condition alone Chandy et al.

Periodontal therapy appears to result in a significant decrease in fibrinogen levels Lopez et al. These antibodies have been shown to activate cytokine production, as well as monocyte and endothelial cell activation. This is consistent with data from Boillot et al. These levels are reversed after periodontal therapy Teeuw et al.

There is strong mechanistic evidence that peripheral blood neutrophils PBNs from periodontitis patients produce higher levels of total and extracellular reactive oxygen species ROS than healthy controls, under various conditions of priming and stimulation and from unstimulated cells Ling et al. There is scientific evidence of pleiotropy between periodontitis and cardiovascular diseases Aarabi et al. Its function appears to be related to the regulation of gene expression Hubberten et al.

There is evidence for plasminogen PLG as a shared genetic risk factor for coronary artery disease and periodontitis Schaefer et al. The 4th pleiotropic locus between coronary artery disease and periodontitis is a haplotype block at the VAMP8 locus Munz et al. These shared genetic factors suggest a mechanistic link or immunological commonalities between coronary artery disease and periodontitis.

The impairment of the regulatory pathways by genetic factors may be a common pathogenic denominator of at least coronary artery disease and periodontitis. There have been no prospective randomized controlled periodontal intervention studies on primary prevention of cardiovascular diseases including first ischaemic events or cardiovascular death since the last consensus report Tonetti et al. The Group questioned the feasibility of performing adequately powered RCTs in primary prevention at a population level due to important ethical, methodological and financial considerations.

In summary, progression of ACVD may be influenced by successful periodontal treatment independent of traditional CVD risk factor management. Thus, there is insufficient evidence to support or refute the potential benefit of the treatment of periodontitis in preventing or delaying ACVD events Li et al. Summary of the evidence on the effect of periodontal therapy on surrogate markers of cardiovascular diseases. Statins are medications prescribed to decrease LDL cholesterol. Interestingly, statins possess various additional properties relevant to the pathogenesis and treatment of periodontitis Estanislau et al.

Statin use was not found to be associated with decreased tooth loss in adults with chronic periodontitis when analysing administrative health plan data Saver et al. Furthermore, patients on statin medication were reported to exhibit significantly fewer signs of periodontal inflammatory lesions than patients without a statin regimen Lindy et al. This distant effect is not observed when periodontal treatment is delivered across several separate sessions Graziani et al. This is achieved by limiting the number of teeth involved and the time devoted to completing the dental instrumentation.

There is no evidence for specific effects of periodontal treatment procedures on increasing ischaemic cardiovascular risk. Chen et al. Minassian et al. In summary, the Group concluded that delivering periodontal treatment is safe with regard to cardiovascular risk. In the PAVE feasibility randomized secondary prevention trial, provision of periodontal scaling and root planing treatment in patients with established CVD did not increase the incidence of cardiovascular events compared to the control group community treatment within 6 months Beck et al.

In summary, the Group concluded that delivering periodontal treatment is safe with regard to cardiovascular risk in patients with established CVD. Periodontal treatment consists of numerous procedures with different levels of bleeding risk.

This risk of bleeding is however low in the vast majority of procedures, and it can be easily controlled with local haemostatic measures. Perioperative bleeding risk varies according to the extent and invasiveness of the periodontal procedure performed. Appendix S1 summarized the main recommendations for patients with antithrombotic therapy when performing periodontal therapy.

Limited trials and evidence are available on the management of patients on novel oral anticoagulant NOAC therapy undergoing dental treatment; hence, the Group concluded that further studies regarding dental procedures in these patients are strongly encouraged.

It appears there is no need for interruption of NOAC therapy in most dental treatments, due to a low incidence of bleeding complications, which can be successfully managed with local haemostatic measures when comparing groups continuing NOAC and groups discontinuing NOAC therapy Kwak et al. When comparing NOAC patients with healthy individuals, there seems to be a higher incidence of delayed bleeding 2 days and later in those patients who do not discontinue NOAC therapy Miclotte et al.

Patients with periodontitis should be advised that there is a higher risk for cardiovascular diseases, such as myocardial infarction or stroke, and as such, they should actively manage all their cardiovascular risk factors smoking, exercise, excess weight, blood pressure, lipid and glucose management, and sufficient periodontal therapy and periodontal maintenance.

Patients with periodontitis and a diagnosis of CVD should be informed that they may be at higher risk for subsequent CVD complications, and therefore, they should regularly adhere to the recommended dental therapeutic, maintenance and preventive regimes. Patients collect a careful history to assess for CVD risk factors, such as diabetes, obesity, smoking, hypertension, hyperlipidaemia and hyperglycaemia.

If no periodontitis is diagnosed initially, patients with CVD should be placed on a preventive care regime and monitored regularly at least once a year for changes in periodontal status.

In people with CVD, if periodontitis is diagnosed, they should be managed as soon as their cardiovascular status permits. Surgical periodontal and implant therapy when indicated should be provided in a similar manner as in patients without CVD. Medication with antiplatelet and anticoagulant drugs.

Consideration should also be given to the local management of bleeding complications that may arise. However, if the INR internationalized normalized ratio is 3. The expert group, however, strongly recommends that the dental clinician should consult with the responsible medical professional.

Lastly, in cases of combined antiplatelet and anticoagulant therapies that pertain patients with the highest thrombotic and ischaemic risk i.

In elective periodontal procedures, the operation should be delayed until after treatment stabilization and appropriate consultation with the medical specialist.

In cases of triple therapy dual antiplatelet and one anticoagulant or one anticoagulant plus one antiplatelet, such patients need individualized management by the responsible medical professional according to their thrombotic and haemorrhagic risk Valgimigli et al.

It is important to highlight that local haemostatic agents such as oxidized cellulose, absorbable gelatin sponges, sutures, tranexamic acid mouthwashes, compressive gauze soaked in tranexamic acid should be used and dental clinicians should consider the confounding effect of local anaesthetic with vasoconstrictors.

Patients with a risk of endocarditis should be premedicated with antibiotics following current guidelines such as the European or the American guidelines. People with cardiovascular disease who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition. Because of the potential negative impact of periodontitis on CVD complications, the following recommendations are made:. Patients should be advised that effective periodontal therapy may have a positive impact upon CV health.

For people with CVD, physicians should ask about a prior diagnosis of periodontitis. If a positive diagnosis has been made, the physician should seek to ascertain that appropriate periodontal care and maintenance are being provided. In the case of a negative history, people with CVD should be advised to check for the above symptoms, and if a positive sign appears, they should visit their dentist at least once per year.

Periodontitis and cardiovascular diseases: Consensus report

Bichat Hospital, Paris France,. In Europe cardiovascular disease CVD is responsible for 3. There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation WHF , which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices. Risk Factors Collaborators,


Several epidemiologic studies have examined the association between dental health status and the risk of cardiovascular disease, or CVD, events. A series of.


Global report published on links between periodontal and cardiovascular diseases

The role of oral bacteremia and periodontal inflammation driving atherosclerosis is still under investigation. This review article highlights the role of periodontal inflammation and oral microorganisms in the development and progression of atherosclerosis and cardiovascular diseases. Association between periodontal and cardiovascular diseases has been well characterized, but causal correlation is yet to be established. For instance, untreated gingivitis can progress to periodontitis.

Periodontitis and cardiovascular disease have a complex etiology and genetics and share some common risk factors i. In recent years, the relationship between periodontal disease and cardiovascular disease has been investigated extensively. This research mostly focused on the fact that periodontitis is an independent risk factor for cardiovascular disease. Our aim in this article is to investigate the etiological relationship between periodontal disease and cardiovascular disease and the mechanisms involved in this association.

Periodontal Inflammation and the Risk of Cardiovascular Disease

REFERENCES

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Cardiovascular and periodontal diseases

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Background. Oral infection models have emerged as useful tools to study the hypothesis that infection is a cardiovascular disease (CVD) risk factor. Periodontal.

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Cardiovascular diseases, especially those associated with atherosclerosis, are still one of the main causes of death worldwide.

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For me, it's been one of the more surprising observations in recent years: study after study has shown that people who have poor oral health such as gum disease or tooth loss have higher rates of cardiovascular problems such as heart attack or stroke than people with good oral health.

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