Dental professionals have long known that oral and systemic health are inextricably linked. In this article, we discuss the growing body of evidence showing the link between cardiovascular disease (CVD) and periodontitis and how dental students can help to prevent and manage periodontitis in their patients.
CVD
CVD encompasses various types of atherosclerotic diseases, including coronary heart disease, cerebrovascular disease, and peripheral vascular disease.
According to a 2019 consensus report on periodontitis and cardiovascular diseases, CVD is responsible for 17.9 million deaths worldwide each year. That represents 45% of deaths from non-communicable diseases and a third of all total deaths, making CVD a burdensome global health condition.
CVD and periodontal disease
The 2019 consensus report was the result of a joint workshop between the European Federation of Periodontology (EFP) and the World Heart Federation (WHF), in which they examined evidence for the epidemiological association between periodontitis and CVD. It aimed to build upon the findings of a previous 2012 workshop, which concluded that there was “consistent and strong” evidence that periodontitis increases future CVD risk, but also that there was insufficient evidence to explain the biological mechanisms underlying the connection.
In reviewing research that had been conducted since the earlier workshop, the 2019 workshop found evidence for the following associations:
a. People with periodontitis show significant endothelial dysfunction in the arteries, including calcification and stiffness.
b. There is a strong positive association between periodontitis and coronary heart disease, cerebrovascular disease (e.g., stroke), heart failure, and atrial fibrillation.
c. There is a positive association between periodontitis and higher cardiovascular mortality due to coronary heart disease and cerebrovascular disease.
d. There is limited but consistent evidence that people with periodontitis have a higher prevalence and incidence of peripheral arterial disease. Two large studies demonstrated a positive association with the severity of attachment loss.
The 2019 workshop was also able to find evidence supporting the underlying mechanisms of this positive association, with some key findings outlined below.
a. Bacteremia (the introduction of bacteria into the blood) can occur due to everyday activities. In patients with periodontitis, there is evidence that bacteremia is more frequent, of longer duration and involves more virulent bacteria.
b. Some strains of oral bacteria associated with periodontal disease have been shown to accelerate atherosclerosis and induce arterial lesions in animal models. There is evidence that pathogenic oral bacteria are present in atherothrombotic tissues, where blood has clotted at the site of an arterial plaque.
c. There is evidence that levels of total cholesterol, low-density lipoproteins (LDL), triglycerides, and other blood lipid markers associated with CVD are elevated in periodontitis, while levels of protective lipid markers like high-density lipoprotein (HDL) are lowered. Treating periodontal leads to a direct, measurable reduction in CVD risk factors given that dyslipidemia reverses following periodontal therapy.
d. There is evidence of significantly higher levels of clotting factors (associated with atherothrombosis) in periodontitis patients than in healthy people, and in CVD and periodontitis patients compared with either condition alone. Again, levels decrease with periodontal therapy.
e. There is evidence of significantly higher levels of inflammatory markers (associated with CVD) in periodontitis patients than in healthy people, and in CVD and periodontitis patients compared with either condition alone. Again, periodontal therapy is associated with a decrease in these markers.
The value of prevention
Given the well-established link to CVD, as well as other systemic diseases like diabetes, it is clear that the value of preventing periodontal disease goes far beyond the teeth. This is supported by a study from United Concordia Dental, which found that biannual preventative dental check-ups reduced the need for later medical treatment related to 12 systemic conditions. These included asthma, anemia, immunity disorders and lower gastrointestinal disorders.
In reducing the risk of systemic illnesses like CVD, we play an important part in helping our patients to maintain their health, preserve their quality of life, and reduce their risk of mortality. According to the United Concordia study, it can also reduce the burden on the healthcare system and reduce medical insurance claims for the patient or their employer. With these benefits in mind, here are four steps dental students can take to help patients manage their risk.
Prevention and management of periodontal disease
- Actively screen for both conditions
- Make the patient aware of the connection
- Establish good oral health care
- Recommend appropriate home-use products
Gingivitis is reversible, but the soft tissue and bone loss associated with periodontitis is not. That, along with the progressive risk to the cardiovascular system, is why early detection is associated with positive oral and systemic health outcomes.
If a patient has diagnosed CVD, you should conduct a full periodontal evaluation and risk assessment, even if the patient does not report symptoms. If a patient presents with gingivitis or periodontitis, you should include CVD risk factors as part of your oral health screening. These risk factors include smoking, diabetes, obesity and hypertension.
Many patients are still unaware of the connection between periodontal and cardiovascular health, but you’re well-placed to educate them. Patients who present with any degree of periodontal disease should be made aware that this increases their risk of CVD, and patients with existing CVD should be made aware that periodontal disease can increase their risk of serious complications.
Whether you’re aiming to prevent periodontal disease or manage an active case, encouraging your patients to minimize oral biofilm through proper oral hygiene is essential. Advise your patients to brush thoroughly twice a day, coaching them on proper brushing technique, and recommend daily interdental cleaning and rinsing.
Finally, ensure that your patients are equipped to prevent or manage periodontal disease at home by recommending evidence-based products like Colgate Total SF Toothpaste. The patented stannous fluoride and zinc phosphate formulation creates a protective barrier on all mouth surfaces and proactively fights the bacteria that causes periodontal disease, offering superior reductions in biofilm, calculus and gingivitis. If a patient has gingivitis, you may want to complement your toothpaste recommendation with a prescription antimicrobial mouth rinse like Colgate PerioGard, which contains 0.12% chlorhexidine,. This mouth rinse is clinically proven to fight the bacteria associated with gingivitis, reducing certain bacteria counts by 54% to 97% with sustained clinical use over 6 months.
Thorough oral hygiene may help prevent cardiovascular-disease and it's important that our patients know this and take action.
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