Increasingly, studies support the hypothesis that infection and inflammation may be actively involved in atherogenesis. Dental infections have been implicated as a possible association for atherosclerosis and cardiovascular disease (CVD).
Three pathways have been hypothesised to explain the consequences of oral infections on such systemic diseases.
- Metastatic spread of infection from the oral cavity resulting from a transient bacteraemia. High salivary levels of A. actinomycetemcomitans and systemic exposure to the bacterium are associated with increased risk for CVD
- Metastatic injury by circulating oral microbial toxins
- Metastatic inflammation arising from an immune response to oral microorganisms.
These oral infectious diseases include periodontal disease and apical periodontitis. Periodontal disease is a chronic infection of the supporting tissues of the tooth that can lead to teeth loss. This inflammatory disease of the periodontal tissues is caused by groups of specific microorganisms, resulting in the progressive destruction of the periodontal ligament and the alveolar bone, with gingival pocket formation, recession of the gingiva, or both.
Dentists measure the depth of the pocket in millimetres using a periodontal probe as an indication of the severity of the destructive process. According to a recent CDC report, in the U.S, 47.2% of adults aged 30 years and older have some form of periodontal disease, and 70.1% of adults 65 years and older have periodontal disease.
Similarly, one-fifth of the overall Australian population has been found to have destructive periodontal disease, with a strong and consistent association between age and the prevalence of periodontal disease. Risk factors for periodontal disease include smoking, type 2 diabetes mellitus, poor oral hygiene, genetics, immunodeficiencies and other systemic conditions.
Signs and symptoms of periodontal disease include bleeding gums during tooth brushing, painful chewing, red, swollen, or tender gums, gums pulled away from the teeth (recession of the gingiva), persistent halitosis, suppuration between the teeth and gums, teeth mobility and subsequent loss of teeth, and changes in the occlusion due to teeth mobility.
Treatment of periodontal diseases ranges from non-surgical treatment involving a thorough debridement (cleaning) of the tooth root surfaces to periodontal surgery. Patients typically see their dentist, oral health therapist, and/or specialist dental periodontist on a regular basis to manage this condition.
Apical periodontitis (late consequence of an endodontic infection) is caused dental caries affecting the pulp of the tooth. Infection usually reaches the periapical region of a tooth root from infected, necrotic pulp in the crown of the tooth via the root canal and apical foramen. It is commonly a chronic infection.
People with untreated tooth infections have been reported to be almost three times more likely to have cardiovascular disease than patients who had dental infections treated.
Apical periodontitis clinical signs and symptoms may range from asymptomatic, to formation of a periapical abscess, presence of sinus tract, and pain when biting or palpating around the tooth.
If there is an acute exacerbation, symptoms can be severe. It is a chronic infection and, in some cases, is diagnosed by the radiographic observation of a radiolucent area around the root of the affected tooth by a dentist and absence of a pulp response to application of a cold test. Apical periodontitis can be treated by endodontic treatment (otherwise known as a root canal), periapical surgery or the extraction of the tooth by a dentist or specialist endodontist.
Dental disease such as periodontal disease or apical periodontitis may occur together with some forms of CVD or represent an oral manifestation of the same disease. While there are unknowns, an emerging body of evidence strongly supports an independent association between periodontitis and CVD, and there are reports of an association between CVD and apical periodontitis and dental caries status.
This association has been hypothesised to be attributable to a common inflammatory response trait. More studies are needed to establish if dental disease can directly damage the cardiovascular system, and if the association is casual.
Key messages
- Patients with CVD should be encouraged to maintain regular dental visits
- Patients with CVD should be urged to see their dentist, especially if experiencing toothache, sensitivity, or bleeding gums
- Good management of oral hygiene and dental health may reduce CVD risk.
Author competing interests – nil