periodontitis as a potential risk factor for cardiovascular diseases

1. DEPARTMENT OF PERIODONTICS, YENEPOYA DENTAL COLLEGE, MANGALORE.

2. GUMS AND HEARTS: PERIODONTITIS –
A POTENTIAL RISK FACTOR FOR
CARDIOVASCULAR DISEASES
A REVIEW
Dr. A A MOHAMED JIYAD

3. INTRODUCTION
• The oral cavity is a major entry point to the body with mechanisms to
defend against toxins or invading pathogens.
• If integrity of oral tissues is breached, the oral cavity can become a source
of disease affecting other parts of the body

4. • Oral cavity may be the site for transmission of infectious microbes
• 700 strains of bacteria have been identified in the mouth
• Bacteria have been found to migrate from the mouth to the heart or
other organs
• Periodontal disease has links to systemic disease, and affects 3 out of 4
people at some point in their life

5. What is Periodontal Disease?
“An inflammatory disease of the supporting tissues of the teeth caused by
specific microorganisms or groups of specific microorganisms, resulting in
progressive destruction of the periodontal ligament and alveolar bone with
pocket formation, recession, or both”.
Newman MG, Carranza FA, Takei H, Klokkevold PR. Carranzas clinical
Periodontology. 10th ed. Elsevier health sciences; 2006.

6. Periodontitis is very common, and is widely regarded as the second most
common dental disease worldwide, after dental decay, and in the United
States has a prevalence of 30–50% of the population.
Fuster V, Badimon L, Badimon JJ, et al. The pathogenesis of coronary artery disease and the acute
coronary syndromes. N Engl J Med. 1992;326:242–50

7. CARDIOVASCULAR DISEASE
• The Guidelines of the European Society of Cardiology (ESC) include
periodontitis as a risk factor
• Cardiovascular disease (CVD) caused by atherosclerosis have been proven
to be associated with periodontal disease.
Vedin O, Hagstro¨m E, Gallup D, et al. Periodontal disease in patients with chronic coronary heart disease:
Prevalence and association with cardiovascular risk factors. Eur J Prevent Cardiol 2014

8. ATHEROSCLEROSIS
Atherosclerosis is an inflammatory disease characterised by an alteration of the
vascular endothelium and the formation of atherosclerotic plaques that decrease the
lumen of blood vessels, narrowing them progressively.
These plaques are formed by a LDL cholesterol core and a fibrous capsule, and may be
pathologic in two ways:
Blood vessel stenosis
Rupture of the atherosclerotic plaque

9. ATHEROSCLEROSIS
 Blood vessel stenosis
• The narrowing of the blood vessel due to the formation of atherosclerotic
plaque may allow passage of enough blood flow under basal conditions,
but this blood flow can not increase when necessary like during exercise
 Rupture of the plaque
• The content of the plaque core has, among other components,
thrombogenic material which can cause the formation of a thrombus
when it comes in contact with the blood, thereby completely occluding the
blood vessel lumen.

10. • Bacterial plaque
• Smoking/tobacco use
• Genetics
• Stress
• Medications
• Poor nutrition
Thomas E. Van Dyke. Et al. J Int Acad Periodonto 2006

11. • Periodontal pathogens which include P gingivalis, P intermedia,
and AA
• Circulating lipoproteins (hypercholesterolemia),
V. V. Valtonen, “Role of infections in atherosclerosis,” The American Heart Journal, vol. 138,
no. 5, part 2, pp. S431–S433, 1999

12. CARDIOVASCULAR DISEASE – PERIODONTAL DISEASE
• EPIDEMIOLOGICAL EVIDENCE
Individuals with periodontitis:
Are 25% more likely to develop coronary heart disease
As periodontitis severity increases, so does the probability of CVD
Exhibit increased serum biomarkers and clinical markers (mediators of
inflammation) of endothelial dysfunction and of atherosclerosis:
30% increase in C-reactive protein (CRP) levels
- 11% increase in cholesterol (LDL)
J. D. Beck and S. Offenbacher, “The association between periodontal diseases and cardiovascular diseases:
a state-of-the-science review,” Annals of Periodontology, vol. 6, no. 1, pp. 9–15, 2001.

13. CARDIOVASCULAR DISEASE –PERIODONTAL DISEASE
• MICROBIOLOGICAL EVIDENCE
Direct association between an increased risk of atherosclerosis and the
presence of periodontal pathogens such as:
- C. rectus
- P. micros
- A. actinomycetemcomitans
- P. gingivalis
- T. denticola
- T. forsythia
Jirina Bartova, et al. Periodontitis as a Risk Factor of Atherosclerosis: a review. Journal of Immunology
Research 2014

14. ETIOPATHOGENESIS
Atheromatous plaque
Periodontal disease
Blood vessel
Blood vessel Atheromatous plaque formation Atheromatous plaque maturation
Vascular subendothelium
Periodontal bacteria (P. gingivalis, F.nucleatum…)
Proinflammatory signals (Cytokines IL6, IL8, etc.)

15. PERIODONTAL TREATMENT
• The initial aim of treatment is to control the infection to stop disease progression:
 Mechanical biofilm control:
• Oral hygiene at home: brushing, interproximal hygiene, oral irrigation
• Supragingival plaque removal
• Subgingival scaling and root planing
• Periodontal surgery
 Chemical biofilm control:
• Use of daily-use antiseptics as an adjunctive therapy

16. BENEFITS FROM PERIODONTAL TREATMENT
• Locally:
 Restores health of gums and teeth
Systemically:
 Reduces systemic inflammation: by lowering levels of C-reactive
protein
 Improves clinical levels of endothelial function
• Both parameters are related to an increased risk for future
cardiovascular episodes.

17. In patients with periodontal disease, the use of antiseptics such
as Chlorhexidine (CHX) combined with Cetylpyridinium
chloride (CPC) are recommended for controlling the level of
periodontal pathogens.
• Maintenance (up to 6 months):
CHX 0.05% + CPC 0.05%
• Treatment (2-4 weeks):
CHX 0.12% + CPC 0.05%

18. Prevention of periodontitis
• Adequate plaque removal has been shown to prevent gingivitis
as well as substantially limit the progression of periodontitis.
• Regular and thorough removal of plaque by dental
professional can successfully control periodontal disease.
• Oral hygiene practices involves the daily removal of dental
plaque and other debris by tooth brushing and flossing.

19. RECOMMENDATIONS
- Teaching oral hygiene (brushing technique, interproximal
hygiene, etc.)
Motivation: long-term treatment success depends on patient
compliance
Dentists should form part of a multidisciplinary team, in which
primary care doctors and/or cardiologists are also participating,
to ensure safe and effective treatment for patients suffering from
periodontal diseases.

20. CONCLUSION
• When solving the question whether periodontitis is the cause or
consequence of developing atherosclerosis, we may conclude that
circulating microorganisms or their products may promote pathogenesis
and enhance local inflammatory changes in vessel walls that may promote
clotting and clot formation

21. • The relationship between periodontitis and atherosclerosis has been
a subject of many research activities with the number of publications
focusing on this relationship rapidly increasing in recent years
• Thus, the prevention and treatment of periodontal disease reduces
the risk of cardiovascular disease.

22. THANK YOU