Periodontitis in Patients With Coronary Artery Disease: An 8-Year Follow-Up

• Autores: Carin Starkhammar Johansson, Nils Ravald, Christos Pagonis, Arina Richter
• Localización: Journal of periodontology, ISSN 0022-3492, Nº. 3, 2014, págs. 417-425
• Idioma: inglés
• Texto completo no disponible (Saber más ...)
• Resumen

  • Background: This study examines whether preceding assessment of periodontal status in patients with established coronary artery disease (CAD) can predict future CAD endpoints (myocardial infarction, new revascularization procedure, or CAD-related death) during 8-year follow-up and whether the changes in periodontal status over time differ in patients with CAD compared with healthy controls.

    Methods: In 2003, periodontal status was examined in 161 patients with CAD who underwent percutaneous coronary intervention or coronary artery bypass graft due to significant stenosis in the coronary arteries and 162 controls without CAD. Eight years later, 126 patients with CAD (102 males and 24 females, mean age: 68 ± 8.9 years) and 121 controls (101 males and 20 females, mean age: 69 ± 9.0 years) were reexamined periodontally. A standard classification of periodontal disease in three groups (mild, moderate, and severe) was used. CAD endpoints during follow-up were obtained by review of medical records. CAD as cause of death was confirmed from the Swedish Cause of Death Register.

    Results: No significant differences were found among patients with CAD, with or without CAD-related endpoints at 8-year follow-up, and severity of periodontitis at baseline (P = 0.7). CAD did not influence the incidence or severity of periodontitis. Significant differences were found at the final examination in periodontitis prevalence and severity (P = 0.001), number of teeth (P = 0.006), probing depth 4 to 6 mm (P = 0.016), bleeding on probing (P = 0.001), and radiographic bone level (P = 0.042) between CAD patients and controls, all in favor of controls.

    Conclusions: The study results did not show a significant association during 8 years among CAD endpoints and periodontal status at baseline. The progression of periodontitis was low in both groups, although the higher proportion of individuals with severe periodontitis among patients with CAD compared with controls remained unchanged over the 8-year follow-up. Further long-term prospective studies are needed to show whether periodontitis can be considered a risk or prognostic factor for CAD, in terms of endpoints including myocardial infarction, new revascularization procedure, and CAD-related death.

    Coronary artery disease (CAD) is one of the main causes of death in developed countries.1-3 This chronic disease forms atherosclerotic plaque in coronary vessels.4 Endothelium inflammation triggers plaque formation that slowly leads to vessel lumen narrowing.4 Consequently, blood supply is reduced to the heart muscle, which leads to angina pectoris and myocardial infarction and, in worst cases, sudden death.4 Other diseases based on inflammation or infections, such as periodontitis, might exacerbate inflammatory actions in vessels.4 The chronic inflammatory burden from periodontal disease might be a factor of importance for additional cardiovascular problems.5,6 In 1999, Arbes et al.7 reported cross-sectional data from the Third National Health and Nutrition Study (NHANES III) describing periodontal attachment loss (AL) associated with self-reported heart attack, with the highest relative risk (RR) of 3.8 (95% confidence interval [CI]: 1.5 to 9.7) for individuals with >67% sites with ?3 mm AL, compared with individuals with no sites with AL. The findings remained after adjusting for other risk factors for CAD; i.e., age, sex, smoking, and diabetes (DM). During the past 10 years, an increasing number of epidemiologic studies including systematic reviews5,8-11 have investigated the possible association between periodontitis and atherosclerotic vascular disease. An increased risk for CAD by 1.15 (95% CI: 1.01 to 1.27, P = 0.032) among patients with periodontal disease was described by Khader et al..12 Meurman et al.8 showed that periodontitis increases the risk for CAD by 20% (95% CI: 1.08 to 1.32). Severe periodontal bone loss, defined as ?50% sites with bone loss >3 mm on panoramic oral radiographs, has been associated with an increase in risk for the presence of carotid artery plaque (adjusted odds ratio [OR]: 3.64; 95% CI: 1.37 to 9.65).13 In a meta-analysis, periodontitis increased the risk for CAD in cohort studies with an RR of 1.14 (95% CI: 1.074 to 1.213), case-control studies with an OR of 2.22 (1.59 to 3.117), and cross-sectional studies with an OR of 1.59 (1.329 to 1.907).9 In a recent longitudinal study, periodontitis was found to be a risk factor for future acute coronary syndrome events (crude OR: 3.6, 95% CI: 2.0 to 6.6, P <0.001) in patients with known CAD14 which is in accordance with results reported by Vettore,15 who showed periodontitis as a factor of risk for future cardiovascular events (RR: 1.19, 95% CI: 1.08 to 1.32).

    On an epidemiologic basis, tooth loss is associated with decreased life span and increased mortality risk due to heart disease and stroke.16-18 A dose-dependent relationship between number of teeth and CAD mortality has been described.19 In addition, periodontal therapy has been suggested as intervention in secondary cardiac event prevention.20,21 Even though observational studies support an association between CAD and periodontitis, not all study results were positive; substantial variations in results were evident,22,23 and no causative relationship has been proven.24 In a previous study, the present authors found severe periodontitis (in terms of alveolar bone loss [ABL] and gingival inflammation) to be significantly more pronounced among patients with established CAD than healthy controls.25 Periodontitis was associated with CAD (OR: 5.74, 95% CI: 2.07 to 15.90). The authors hypothesize that in the patients with CAD and periodontitis, the periodontitis might be a factor negatively influencing the outcome in CAD, and, on the other hand, that CAD may worsen periodontal status over time.

    The objective of the present case-control follow-up study is to evaluate whether preceding assessment of periodontal status in patients with CAD can predict future CAD endpoints (myocardial infarction, new revascularization procedure, or CAD-related death) over an 8-year follow-up and whether the changes in periodontal status over time differ in patients with CAD compared with healthy controls.