Based on the results of studies conducted over the past 25 years, oral health is increasingly recognized as an important factor in cardiovascular health.1 Although causal evidence remains elusive, researchers have linked various oral health issues with an elevated risk of cardiovascular disease and myocardial infarction.
“Poor oral health, particularly gingivitis and periodontal disease, have been associated with the development of atherosclerotic cardiovascular disease,” according to Tamara Horwich, MD, MS, health sciences clinical professor of medicine/cardiology at the David Geffen School of Medicine at the University of California, Los Angeles, medical director of the UCLA Cardiac Rehabilitation Program.2 “Studies of the general population in different countries have also shown that people with periodontitis are more likely to experience a heart attack.”3
Emerging research on the oral-CV health connection
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Results of several recent studies have generated further insights regarding the connection between oral health and cardiovascular disease. A study published in August 2021 in Scientific Reports found that tooth loss, dry mouth, and the presence of 3 or more oral problems were associated with all-cause mortality in a sample of 3075 older adults in the United States.4 In addition, periodontal disease was linked to higher rates of cardiovascular disease-related mortality (subdistribution hazard ratio (SHR), 1.49; 95% CI,1.01-2.20).
In a nationwide Korean cohort study published in February 2022 in the Journal of Hypertension, Kim et al investigated the presence of cardiovascular disease in 52,677 patients with hypertension who received oral checkups at baseline, with a mean follow-up period of roughly 11 years.5 Analyses revealed an independent association between the presence of 5 or more dental caries and the occurrence of stroke or myocardial infarction (adjusted HR [aOR], 1.37; 95% CI, 1.10–1.72; P =.006], and brushing teeth at least twice daily was associated with a lower risk of these outcomes (aOR, 0.88; 95% CI, 0.81–0.96; P =.002).
A study reported in May 2022 in the Journal of Dental Research analyzed prospective data from 5294 participants in France who underwent full oral and physical examinations and were subsequently assessed every 2 years over a median follow-up period of approximately 8 years.6 The authors examined the risk of coronary heart disease (CHD) associated with varying states of oral health status: optimal oral health and preserved masticatory capacity (cluster 1), moderate oral health and moderately impaired masticatory capacity (cluster 2), and poor oral health and severely impaired masticatory capacity (cluster 3).
The findings demonstrated a higher CHD risk in cluster 2 compared to cluster 1(HR, 1.45; 95% CI, 0.98-2.15), and in cluster 3 vs cluster 2 (HR, 2.47; 95% CI, 1.34-4.57; P <.05). “To conclude, middle-aged individuals with poor oral health and severely impaired masticatory capacity have more than twice the risk of incident CHD than those with optimal oral health and preserved masticatory capacity,” as stated in the paper.6
Dr Horwich described 2 main hypotheses regarding the proposed mechanisms driving the link between oral health and cardiovascular disease. “When there is infection in the oral cavity, bacteria can translocate from the mouth into the blood and blood vessels, triggering an immune response which may damage the blood vessel lining and initiate the development of atherosclerotic plaque formation,” she explained. “Alternatively, an oral infection such as gingivitis or periodontitis may increase general inflammation in the body, which contributes to the process of plaque formation in the coronary arteries.”
In a 2021 review published in the American Journal of Preventive Cardiology, the authors discuss associations between periodontal disease and atherosclerotic cardiovascular disease, noting that both are inflammatory diseases with overlapping mechanisms and risk factors.2 This connection is especially concerning given the high prevalence (46%) of periodontal disease among US adults. They emphasized that the current lack of causal evidence should not impede efforts to promote awareness and prevention of periodontal disease with the aim of reducing the risk of atherosclerotic cardiovascular disease.
Other research has indicated that regular dental screening may reduce the risk of cardiovascular disease, including a 2021 retrospective cohort study described in the Journal of Clinical Periodontology. Investigators followed 478,245 adults for 11 years and observed a lower risk of major adverse cardiovascular events among participants who underwent dental screening compared to those who did not receive dental screening (aHR, 0.90; 95% CI, 0.87–0.93; P <.001).7
Clinical implications and remaining needs
“It is important to be aware of all the areas of residual risk that leave patients at risk for cardiovascular disease,” said the lead author of the 2021 review, Eugenia Gianos, MD, director of Women’s Heart Health at Lenox Hill Hospital and director of cardiovascular prevention for Northwell Health in New York.2 Notably, research has shown that cardiovascular disease can increase the risk for oral disease as well.8 “Making sure to ask patients about their dental health is important for cardiovascular care but also overall health.”
Despite the growing evidence supporting the broader implications of oral health, there remain substantial gaps in access to oral health care in the US.9 “One of the most important limitations to optimal oral care is inadequate dental coverage,” according to Dr Gianos, who says that greater legislative support is needed to address this disparity.
Although there is an ongoing need for randomized controlled trials to investigate whether improved dental care can reduce cardiovascular disease, Dr Horwich cites the importance of encouraging regular dental checkups and proper oral hygiene for all patients, such as brushing teeth twice daily and flossing once daily. Clinicians can educate patients about the connection between oral health and cardiovascular health and ask simple oral health screening questions such as, “Do your gums bleed when you brush?” and “How many teeth do you have?” with referral to dental practitioners for further assessment as warranted.8
“While more research is necessary to identify mechanisms that link cardiovascular disease and oral health, collaboration between dentists and physicians is recommended to reduce potential risk factors for systemic disease,” said 1 of Gianos’ co-authors, Kenneth Fleisher, DDS, FACS, clinical professor in the department of oral and maxillofacial surgery at the New York University College of Dentistry. Dr Gianos points to the need to integrate medical and dental electronic health records and to develop interdisciplinary conferences to increase collaboration between medical and dental providers.2
References
1. Aldossri M, Farmer J, Saarela O, Rosella L, Quiñonez C. Oral health and cardiovascular disease: Mapping clinical heterogeneity and methodological gaps. JDR Clin Trans Res. Published online September 4, 2020. doi:10.1177/2380084420953121
2. Gianos E, Jackson EA, Tejpal A, et al. Oral health and atherosclerotic cardiovascular disease: A review. Am J Prev Cardiol. 2021;7:100179. doi:10.1016/j.ajpc.2021.100179
3. Xu S, Song M, Xiong Y, Liu X, He Y, Qin Z. The association between periodontal disease and the risk of myocardial infarction: a pooled analysis of observational studies. BMC Cardiovasc Disord. Published online February 1, 2017. doi:10.1186/s12872-017-0480-y
4. Kotronia E, Brown H, Papacosta AO, et al. Oral health and all-cause, cardiovascular disease, and respiratory mortality in older people in the UK and USA. Sci Rep. Published online August 12, 2021. doi:10.1038/s41598-021-95865-z
5. Kim J, Kim HJ, Jeon J, Song TJ. Association between oral health and cardiovascular outcomes in patients with hypertension: a nationwide cohort study. J Hypertens. 2022;40(2):374-381. doi:10.1097/HJH.0000000000003022
6. Deraz O, Rangé H, Boutouyrie P, et al. Oral condition and incident coronary heart disease: A clustering analysis. J Dent Res. Published online December 7, 2022. doi:10.1177/00220345211052507
7. Kim KS, Kim T, Kang SH, Lee JR, Lee HJ, Lee H. Effect of dental screening on cardiovascular risk: A nationwide cohort study. J Clin Periodontol. Published online December 12, 2022. doi:10.1111/jcpe.13584
8. King S, Chow CK, Eberhard J. Oral health and cardiometabolic disease: understanding the relationship. Intern Med J. Published online February 20, 2022. doi:10.1111/imj.15685
9. D’Souza RN, Collins FS, Murthy VH. Oral health for all – Realizing the promise of science. N Engl J Med. Published online March 3, 2022. doi:10.1056/NEJMp2118478