Orofacial Features and Their Correlation in Cardiovascular Diseases.

Background: The association between cardiovascular diseases and periodontitis had different pathophysiological mechanisms involved. These mechanisms are both inflammatory and microbial. Furthermore, the possible association between two diseases can be explained by common risk factors. Aims: The present trial was carried out to establish a relation between coronary artery disease and periodontitis. Materials and
Methods: One hundred and twenty-six participants advised for the angiography were included. Periodontists determined the presence of periodontitis in all participants followed by lipid profile, C-reactive protein (CRP) levels, and blood coronary angiography was then performed. The collected data were subjected to the statistical analysis, and the results were formulated.
Results: The level of CRP in participants with and without coronary artery disease was 0.66 ± 1.52 and 0.53 ± 1.01, respectively, which was nonsignificant with a P = 0.63. Nonstatistically significant difference was seen in values of cholesterol and blood glucose in participants with and without coronary artery disease (P = 0.28 and P = 0.53). The mean tooth loss in participants with coronary artery disease was 14.2 ± 6.4 and in participants with no coronary artery disease was 11.8 ± 6.5, and such difference was statistically significant (P = 0.05).
Conclusion: The present study establishes an association between poor oral health, periodontitis, and coronary artery disease. This study demonstrates that tooth loss which is an important feature of periodontitis is significantly associated with coronary artery disease. Copyright:

INTRODUCTION

Among all the cardiovascular diseases (CVDs), atherosclerosis resulting from coronary heart disease accounts for the maximum number of deaths. Coronary heart diseases result from various factors and involve responses to the injury caused and resulting mechanisms such as lipogenic, infectious, and immunoinflammatory mechanisms.[1] Atherosclerosis and its complications have been linked in the literature to various factors such as hypertension, diabetes mellitus, male gender, obesity, increased age, family history of the disease, smoking, and/or dyslipidemia. Few cases of the participants with cardiac disease have not been linked to the mentioned factors.[2]

Chronic periodontitis is one of the most common infections affecting a large population globally and is encountered in participants with poor oral hygiene. Dental plaque is the main etiological factor causing periodontitis. Plaque is deposited on the tooth surface in subjects with less brushing and flossing leading to gingival inflammation.[3] In participants who have genetic predilection, gingival inflammation proceeds to chronic periodontitis with the apical shift of the epithelium on the root. This apical migration results in loss of teeth supporting tissues such as alveolar bone and periodontal ligament leading to tooth loss.[4]

Periodontal pockets seen in periodontitis are seen to be inhabited by Gram-negative microorganisms which cause periodontitis. The association between CVDs and periodontitis had different pathophysiological mechanisms involved. These mechanisms are both inflammatory and microbial. Furthermore, the possible association between two diseases can be explained by common risk factors.[5]

Recently, the focus has shifted greatly in establishing the link between oral diseases, CVDs, and other inflammatory conditions. The part of inflammatory mediators in CVDs is reported in the literature previously where periodontitis in systemic inflammation is a modifiable factor with C-reactive protein levels increased in both.[6] C-reactive protein (CRP) is an important prognostic factor for CVDs. However, the association between CVDs and periodontitis is still controversial and inconclusive owing to the lack of confounding factor assessment like smoking.[7]

Owing to the high prevalence of periodontitis and atherosclerosis in a large population globally along with an easy diagnosis of coronary artery disease and periodontitis, there is a need to clarify and establish the association between the two. Hence, the present trial was carried out to establish the relationship between coronary artery disease and periodontitis.

MATERIALS AND METHODS

The present trial was carried out to establish the relationship between coronary artery disease and periodontitis after obtaining the ethical clearance by the Institutional Ethical forum. The study included a total of 126 participants including both males and females within the age group of 18–77 years with a mean age of 43.4 years. The participants visiting the outpatient departments and were advised for the angiography were included in the study after obtaining informed consent. For participation, the participants had to be of 18 years or more. The pregnant and lactating females and the participants on immunosuppressive drugs were excluded from the study. Furthermore, participants with previous endocarditis, having carcinoma, or autoimmune disease were also refrained from participating in the study.

After final inclusion, the demographic characteristics and other relevant information from the subjects were recorded including family history and disease history. Following which an expert periodontist determined the presence of periodontitis in all subjects using visual and tactile examinations. The periodontal assessment included the evaluation of bleeding, calculus, plaque, inflammation, and/or exudation. After the periodontal assessment, lipid profile, CRP levels, and blood glucose were determined in laboratory examination in all participants. Coronary angiography was then performed for all participants by an expert cardiologist not aware of laboratory results and periodontal examination results.

The collected data were subjected to the statistical analysis, and the results were formulated.

RESULTS

The present trial was carried out to establish the relationship between coronary artery disease and periodontitis. Of the included 126 participants, 4 participants did not turn for follow-up and hence were excluded from the study leaving a final sample size of 122 participants with the age range of 18–77 years and a mean age of 43.4 years.

Out of the total of 122 participants that completed the study, 38 had no coronary artery disease after angiography, and 84 were found to have coronary artery disease. The risk factors and demographic characteristics of the study participants are listed in Table 1. It was seen that BMI in participants with coronary artery disease and with no disease was 27.4 ± 4.0 and 28.7 ± 4.6 kg/m2, respectively. Fifty-one participants with coronary artery disease were alcoholics, whereas 13 were smokers. Diabetes mellitus and hypertension were seen in 29 and 73, respectively, in participants with coronary artery disease. Seventy-one participants with coronary artery disease had a familial history of CVDs. It was seen that male gender, higher age, and less education were associated with coronary artery disease.

Table 1

Characteristics of the study subjects

Characteristics	Positive coronary artery disease (n=84)	Negative coronary artery disease (n=38)	P
Age (years)
≤40	6	12	0.0007
41-50	24	12
51-60	38	7
≥61	16	7
Gender
Female	23	22	0.0074
Male	61	16
Education
Uneducated	8	4	-
Primary	57	21
Graduation or above	19	13
BMI	27.4±4.0	28.7±4.6	0.115
Alcohol intake
Never consumed	19	25	0.56
Quitted	14	2
Alcoholic	51	11
Smoking
Former smoker	28	9	0.61
Current smoker	13	1
Nonsmoker	43	28
Diabetes mellitus	29	12	0.62
Hypertension	73	26	0.07
Familial history of CVDs	71	17	0.36

BMI: Body mass index, CVD: Cardiovascular diseases

The present study also assessed the laboratory examination for lipid profile and blood glucose levels in subjects with or without CVDs. The results showed that a nonsignificant difference was seen in subjects with or without coronary artery disease with elevated inflammatory markers [Table 2]. The level of CRP in subjects with and without coronary artery disease was 0.66 ± 1.52 and 0.53 ± 1.01 respectively which was nonsignificant with a P = 0.63. Mean blood glucose levels in participants with and without coronary artery disease were 124.1 ± 56.2 and 113.2 ± 39.6 mg/dL respectively which were also nonsignificant (P = 0.28). Nonstatistically significant difference was seen in values of cholesterol in subjects with and without coronary artery disease (P = 0.53).

Table 2

Laboratory findings in study subjects

Parameter	Positive coronary artery disease (n=84)	Negative coronary artery disease (n=38)	P
CRP (mg/dL)	0.66±1.52	0.53±1.01	0.63
Blood glucose level (mg/dL)	124.1±56.2	113.2±39.6	0.28
LDL	118.1±50.7	112.4±32.5	0.52
HDL	42.6±11.8	47±13.5	0.07
Triglycerides	138.8±86.2	118.5±62.1	0.19
Total cholesterol	186.4±58.4	180±37.8	0.53

CRP: C- reactive protein, LDL: Low-density lipoprotein, HDL: High-density lipoprotein

The present study also assessed the association between cardiovascular health and oral health. The results are described in Table 3. It was seen that presence of gingival inflammation and bacterial plaque had no association with the presence of coronary artery disease. The mean values for gingival inflammation in subjects with and without coronary artery disease were 0.86 ± 0.16 and 0.84 ± 0.19 respectively which showed a nonsignificant difference (P = 0.54). However, the absence of teeth was seen to be associated with coronary artery disease detected on angiography. The mean tooth loss in subjects with coronary artery disease was 14.2 ± 6.4 and in subjects with no coronary artery disease was 11.8 ± 6.5, and such difference was statistically significant (P = 0.05).

Table 3

Correlation of cardiovascular health and oral health in study subjects

Parameter	Positive coronary artery disease (n=84)	Negative coronary artery disease (n=38)	P
Missing teeth	14.2±6.4	11.8±6.5	0.05
Plaque	0.86±0.16	0.85±0.17	0.75
Gingival inflammation	0.86±0.16	0.84±0.19	0.54

DISCUSSION

The present trial was carried out to establish the relationship between coronary artery disease and periodontitis. Of the included 126 subjects, 4 subjects did not turn for follow-up and hence were excluded from the study leaving a final sample size of 122 subjects with the age range of 18 years to 77 years and a mean age of 43.4 years. The study showed that chronic periodontitis showed a higher prevalence. This prevalence was contradictory to the findings of Bokhari et al.[8] in 2011 where the prevalence of periodontitis was threefold lesser than the present study. This difference can be attributed to the study sample of the present study which was of higher age and poor background.

The present study showed that the presence of gingival inflammation and bacterial plaque had no association with the presence of coronary artery disease. The mean values for gingival inflammation in subjects with and without coronary artery disease were 0.86 ± 0.16 and 0.84 ± 0.19 respectively which showed a nonsignificant difference (P = 0.54). However, the absence of teeth was seen to be associated with coronary artery disease detected on angiography. The mean tooth loss in subjects with coronary artery disease was 14.2 ± 6.4 and in subjects with no coronary artery disease was 11.8 ± 6.5, and such difference was statistically significant (P = 0.05). These findings of the present study were in agreement with the findings of Accarini and de Godoy[9] in 2006 where authors showed that participants having <15 teeth had a 1.24 times higher risk of coronary artery disease.

The study showed that nonsignificant difference was seen in subjects with or without coronary artery disease with elevated inflammatory markers. The level of CRP in participants with and without coronary artery disease was 0.66 ± 1.52 and 0.53 ± 1.01, respectively, which was nonsignificant with a P = 0.63. Mean blood glucose levels in participants with and without coronary artery disease were 124.1 ± 56.2 and 113.2 ± 39.6 mg/dL, respectively which were also nonsignificant (P = 0.28). Nonstatistically significant difference was seen in values of cholesterol in participants with and without coronary artery disease (P = 0.53). These findings were in contrast with the findings of Accarini and de Godoy[9] in 2006 where authors found a correlation of inflammatory markers and coronary artery disease.

The association between CVDs and periodontitis is inconclusive, where studies by Beck et al. in 2005 and Humphrey found no such association, whereas Nonnenmacher et al.[10] in 2007 found an association. These studies had biases and small samples and hence were not considered conclusive. However, controlling periodontal factors have resulted in improved cardiac events. This was supported by the findings of de Oliveira et al.[11] in 2010 were brushing twice reduced CRP levels and cardiac disease events.

The present study utilized the gold standard angiography to diagnose coronary artery disease. Confounding factors were also ruled out. These findings were in contrast to the study of Danesh J et al.[12] in 2004, as in the present study diabetes mellitus, hypertension, and smoking were excluded risk factors as no difference was seen in participants having coronary artery disease and in participants with no event of coronary artery disease.

CONCLUSION

Within its limitations, the present study establishes an association between poor oral health, periodontitis, and coronary artery disease. This study demonstrates that tooth loss which is an important feature of periodontitis is significantly associated with coronary artery disease. The study had few limitations including a smaller sample size, study carried out at a single center, geographical area biases, noninclusion of edentulous subjects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.