There has long been conflicting data on the association between oral health (namely periodontal disease/periodontitis) and cardiovascular disease (CVD). A number of chronic infectious, inflammatory and immune diseases are associated, with significantly higher risk of adverse CVD events including periodontitis.
Periodontitis is a non-communicable disease with high prevalence of about 50% affecting the gingival and periodontal supporting oral tissues that anchor teeth into the jaw. It is the sixth most common human disease.
Traditional risk factors for CVD (inclusive of atherosclerotic diseases, coronary heart disease, cerebrovascular disease and peripheral vascular disease) remain lifestyle factors, principally tobacco smoking, dyslipidaemia, hypertension and altered glucose metabolism. However, there is a significant body of evidence to support an independent association between periodontitis and CVD, as well as diabetes, COPD and chronic kidney disease.
Patients with periodontitis have a higher prevalence of CVD, a higher prevalence of coronary artery disease and risk of myocardial infarction, higher prevalence of cerebrovascular disease and risk of stroke, higher prevalence and incidence of peripheral artery disease, and higher risk of heart failure and atrial fibrillation. There is limited evidence that CVD is a risk factor for the onset or progression of periodontitis.
Benefits of oral hygeine
There have been no randomised controlled trials on the effect of periodontal intervention on primary prevention of CVD, but there is some evidence from observational studies of oral health interventions such as tooth brushing, dental prophylaxis, increased dental visits and periodontal treatment which have produced a reduction in the incidence of these events.
There is, however, insufficient evidence to support or refute the potential benefit of the treatment of periodontitis in preventing or delaying a cardiovascular event. There is some limited evidence that systemic statin intake may have a positive impact on periodontal health, but insufficient evidence that statin intake may enhance the outcomes of periodontal therapy.
Non-surgical treatment of periodontitis involving supra- and sub-gingival debridement of the affected teeth is often delivered in several short sessions, or in one full-mouth treatment. Delivering periodontal debridement in one full-mouth session triggers an acute systemic inflammatory response associated with transient impairment of endothelial function.
There is no evidence for specific effects of periodontal treatment on increasing ischemic cardiovascular risk. Similarly, periodontal treatment is safe with regard to cardiovascular risk in patients with established CVD. There is no evidence to support discontinuation of antiplatelet therapy, vitamin K antagonists, or novel oral anticoagulant (NOAC) therapy before periodontal debridement procedures. Delayed post-operative bleeding may occur but local haemostatic agents are effective in controlling this.
Patients with CVD should be advised that periodontitis may have a negative impact on their CVD and may also increase the risk of a CVD event and that effective periodontal therapy may have a positive impact on cardiovascular health. All patients with newly diagnosed CVD should be referred to their dental professional for a periodontal examination and cleaning.
Patients should be advised of the need to clean teeth and gums carefully at home and to have personalised advice and care from a dental professional to minimise the potential negative effects of periodontitis on CVD.
Oral hygiene procedures should include twice daily tooth brushing with either a manual or electric toothbrush (for a minimum of two minutes each time), cleaning between the teeth and around the gums with floss or an interdental brush, use of specific antibacterial toothpastes to control plaque accumulation, and having regular dental check-ups.
Long-term mouth rinsing with most commercial products has not been shown to be effective in managing periodontal disease and is not encouraged as part of a regular oral hygiene regime.
About the author
Professor Camile S. Farah
BDSc MDSc (OralMed OralPath) PhD GCEd GCExLead FRACDS (OralMed) MAICD AFCHSM FOMAA FIAOO FICD FPFA FAIM
Professor Farah is a Consultant Oral Pathologist at Australian Clinical Labs. In addition to practising at Perth Oral Medicine & Dental Sleep Centre, Camile holds a hospital appointment as Consultant in Oral Medicine & Pathology at Fiona Stanley Hospital, and is a member of its Head and Neck Cancer Multidisciplinary Team. In 2019 he was named the Australian Research Field Leader in Oral & Maxillofacial Surgery for his research on oral cancer and premalignant pathology.
See Sanz et al. J Clin Periodontal 2020;47:268-288 and “Contemporary Oral Medicine” at https://www.springer.com/gp/book/9783319723013