Periodontitis and invasive oral treatment in relation to myocardial infarction : epidemiological studies

Abstract: Background: Cardiovascular disease and periodontitis are major global health problems that are a large burden for the individual and society. During the last 30 years, it has been discussed whether there is an association between the two diseases. One explanation of a possible association between these conditions is systemic low-grade inflammation derived from periodontitis or acute inflammation from invasive dental procedures and which initiates or accelerates the development of atherosclerosis. It has not yet been established whether the relation is causal or only an expression of shared risk factors. Aims: To investigate the relation between oral health and cardiovascular disease by exploring the association between: 1. Periodontitis and myocardial infarction. 2. Periodontitis and myocardial infarction by gender. 3. Invasive dental treatment and incidence of myocardial infarction. Association between periodontitis and a first myocardial infarction in the PAROKRANK study The PAROKRANK study, a prospective case-control study, recruited 805 cases and 805 controls from 17 Swedish hospitals. Cases were patients <75 years with a first myocardial infarction, which were examined including a dental examination and panorama radiograph 6 to 10 weeks after the index infarction. Disease and health-preserving risk variables were queried at the time of the examination. Similar investigations were performed in controls matched for age, gender, and geographic area. Periodontitis was defined by bone loss: healthy (≥80% remaining bone), mild-to-moderate (79−66%), or severe (<66%). Moderate-tosevere periodontitis was more common in cases (43 vs. 33%, p<0.001). Moderate-to-severe periodontitis significantly increased the risk of a first myocardial infarction after adjusting for diabetes, smoking habits, education level, and marital status (OR 1.28; 95% CI: 1.03−1.60). In 785 cases (19% women) and 792 controls (19% women), severe periodontitis increased the risk of a first myocardial infarction in women (adjusted OR 3.72; 95% CI: 1.24−11.16), especially below age 65 years (adjusted OR 5.26; 95% CI: 1.03−26.76). Association between periodontitis and a first myocardial infarction in a nation-wide setting Merging data from The National Board of Health and Welfare with data from Statistics Sweden identified cases (n=51,884) with a first myocardial infarction (ICD 10 code I.21) and controls (n=246,978) during 2011-2013. Controls were matched 5:1 by age, gender and geographic area and free from prior myocardial infarction. Periodontal treatment derived from The Dental Health Register three years before the index date was used as a surrogate marker for periodontitis: (i) No record of dental treatment, (ii) No record of periodontal treatment, (iii) One or more non-advanced periodontal treatments, or (iv) One or more advanced periodontal treatments. No association between advanced periodontal treatment and incident myocardial infarction was found after adjustments (OR 1.02; 95% CI: 1.00−1.05), or in subjects with a high yearly frequency of advanced periodontal treatment, including periodontal surgery (OR 1.14; 95% CI: 1.00−1.29). Association between invasive dental treatment and a first myocardial infarction In the nation-wide case-control study population, the association between invasive dental treatment (defined by procedure and codes for sub-gingival curettage, dento-alveolar surgery, tooth extractions, implant surgery, apical surgery or periodontal surgery) and a first myocardial infarction (ICD 10 code I.21) within 4 weeks was investigated. Invasive dental treatment before a first myocardial infarction was not associated with an increased risk of a myocardial infarction (adjusted OR 0.98; 95% CI: 0.91−1.06). Conclusions: In nationwide contemporary populations periodontitis slightly increased the risk for experiencing a first myocardial infarction with even stronger risks in women, particular in those 65 years or younger. However, when using periodontal treatment as a surrogate marker for periodontitis there was no evidence that an association to a first myocardial infarction was of any significance in the general Swedish population. Invasive dental treatment, including dental surgery and tooth extractions, was not associated with an increased risk of a first myocardial infarction.