Evaluation the Role of Periodontitis as a Putative

Risk Factor for Cardiovascular Disease

Walid Altayeb DDS, MDS, PhD

Dep. Of Periodontology
Faculty of Dentistry
Damascus University
The Fourth Libyan Dental Congress April 2008
Evaluation the Role ofPeriodontitis as a Putative
Risk Factor forCardiovascular Disease
Periodontitis Affect in Systemic
Health

The Fourth Libyan Dental Congress April 2008

 ? What Risk
 Risk factor is defined as an exposure that
increases the probability that disease will
occur.
 Risk indicator is a suspected risk factor
that is correctly identified through cross-
sectional case control study designs but
there are not yet longitudinal cohort study
data available.
The Fourth Libyan Dental Congress April 2008
Periodontitis

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Atherosclerosis =
CVD

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 FACTOIDS
FACTORS  Smoking
 Age  Cholesterol
 Sex  Blood Pressure
 Heredity  Physical Inactivity
 Obesity
 Diabetes Mellitus
 Stress
 Socioeconomic
The Fourth Libyan Dental Congress April 2008

Status
 ? Numbers…Numbers
 Cardiovascular disease is the number
one cause of death globally.
 WHO estimates that more than 17
million people died of CVD in 2005
 Around 80% of these deaths occurred in
low- and middle-income countries.
 by 2015, an estimated 20 million people
will die from cardiovascular disease
every year.
 approximately 10% to 15% of the
world’s population is affected by
advanced periodontal disease.
 more than 50% of adults 55 or older
have Periodontitis. The Fourth Libyan Dental Congress April 2008
 Are There Clinical
?Evidences
 To date, a number of investigators have
reported that an association between
periodontitis and Cardiovascular disease
may exist.
– (Matilla et al. 1989-1995, Beck et al. 1996, 1998, Garcia &
Vokonas 1996,Genco et al. 1997, Loesche et al. 1998, Mendez et
al. 1998, Morrison et al. 1999, Valtonen et al. 1999, Wu et al.
2000, Grau 2004, Dietrich 2005, Holmlund 2006 Schillinger 2006,
Briggs 2006 ).
 AAP Systematic Review Findings 2003 4/5 case control studies
found a positive association between Periodontitis and
CVD. 11/15 studies found a modest association between
periodontitis and CVD
The Fourth Libyan Dental Congress April 2008
 possible mechanisms

Common Risk
Genetics
Factors

Systemic
inflammatory
Bacteremia response

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 possible explanations
 First, it may merely reflect confounding
by common risk factors that cause both
periodontal disease and atherosclerosis,
such as:
– smoking
– Diabetes
– stress
– obesity

The Fourth Libyan Dental Congress April 2008

 possible explanations
 Second, the association may reflect an
individual tendency to predisposes to both
periodontal disease and atherosclerosis.
(Genetic)

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 possible explanations
 Third, Periodontitis may potentate the
atherosclerotic process by stimulation of
systemic inflammatory response (Acute-
Phase Response) as evidenced by increases
in C-reactive protein.
Loos 2000, Noack 2001, Craige 2003, Altayeb 2004

The Fourth Libyan Dental Congress April 2008

 possible explanations
 Fourth, bacteremia Bacteria
from the mouth
directly/indirectly infect blood
vessel walls and contribute to
development of plaques and
atherosclerosis.

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?Why Periodontitis

I. Specialty of Oral
Cavity.
II. Pathogenic Bacteria.
III. Inflammatory
response.
IV. Silent nature of
periodontitis.

The Fourth Libyan Dental Congress April 2008

 Epidemiological Study
•581 patients aged between (30-
70 years), were diagnosed for
Atherosclerosis
angiographically in department
of cardiology, Alasad Hospital,
Damascus University.

Vasoangiography

The Fourth Libyan Dental Congress April 2008

Periodontal Examination

The Fourth Libyan Dental Congress April 2008

 Prevelance of CVD Accordiong to periodontal
Disease

100.0 82.3
62.0
38.0
50.0
17.7

0.0
None Periodontitis Periodontitis

None Atherosclerosis Athesclerosis Patients

The Fourth Libyan Dental Congress April 2008

 Prevelance of CVD According to Diabetes mellitus

100.0 80.1
80.0 64.2
60.0 35.8
40.0 19.9
20.0
0.0
None Diabetes Diabetes

None Atherosclerosis Athesclerosis Patients

The Fourth Libyan Dental Congress April 2008

•subjects with severe periodontitis had
a 2.5 fold higher risk for CVD
Odds Ratio
Odds Ratio Risk Factors
After Statistical Exclusion

(0.76) (1.04) Family History

(1.40) 1.52 Smoking
1.83 2.25 Diabetes Mellitus
(1.18) 1.75 Blood Pressure

(1.6) 2.46 Physical Inactivity

2.59 2.56 Stress

(1.07) 1.64 Cholesterol

2.23 3.10 Obesity

2.50 2.85 Periodontitis

Periodontitis is independent risk

The Fourth Libyan Dental Congress April 2008
? Is it sufficient
 Overall, the observational studies support
but
a strong link with atherosclerosis,

cannot prove causation.

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Samakh, Palestine

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THE PLAYERS

 Recurrent P gingivalis bacteremia

induces aortic and coronary lesions
consistent with atherosclerosis in
animal. Li 2002, Lalla 2003, Brodala
2005

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 Group With Periodontitis Group Without Periodontitis P level (t
variable ((N=10 ((N=9 (test
Mean ± SD Mean ± SD Significance
Age 7.4 ± 51 5.8 ± 55.8 0.06
BMI 1.76 ± 24.09 1.59 ± 25.28 0.143
N teeth 4.20 ± 21.10 3.63 ± 22.22 0.544
Plaque Index 0.26 ± 2.15 0.52 ± 0.69 **0.000
(%) Bleeding Index 15.82 ± 43.20 7.42 ± 20 **0.001
(Pocket Depth (mm 0.55 ± 4.69 0.30 ± 1.96 **0.000
(%) PD>5.0 mm 12.36 ± 45.60 5.67 ± 5.78 **0.000
(%)CAL >5.0 mm 15.09 ± 57.30 7.63 ± 10.56 **0.000
WBCs (×109(/µl 7.30±3.80 2.19 ± 6.83 0.372
Triglycerides 100.47 ± 260.25 96.05 ± 247.90 0.450
Cholesterol 45.19 ± 235.06 49.24 ± 232.98 0.792
HDL 7.27 ± 40.39 7.81 ± 42.13 0.257
LDL 34.55 ± 135.91 34.14 ± 136.11 0.972

The Fourth Libyan Dental Congress April 2008

Material & Methods

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Bacteriological examination

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Comparison the Frequency of periodontopathic bacterial
DNA insubgingival plaque between patients with and
.without Periodontitis

10
9
8
7
N. Patients

6
5
4
3
2
1
0
Aa Pg Tf Pi Td Cr Fn Ec Cs En Pm

Periodontitis No Periodontitis

The Fourth Libyan Dental Congress April 2008

Comparison the Frequency of periodontopathic bacterial DNA in
Atheromatous plaque between patients with and without
Periodontitis
10
9
8
7
N. Patients

6
5
4
3
2
1
0
Aa Pg Tf Pi Td Cr Fn Ec Cs En Pm

Periodontitis No Periodontitis

 Ishihara 2004, Okuda 2005, Pucar 2007, Zaremba 2007

detected periodontopathogenic bacteria in arterial
walls. The Fourth Libyan Dental Congress April 2008
 explanation
• oral organisms are introduced into the bloodstream multiple
times daily in individuals with periodontitis the periodontal
tissue such as tooth brushing, mastication, periodontal
treatment.
• Tooth brushing 40%, Extractions 60%, Periodontal surgery
88%. Sabine et al 2002

 Therefore, the oral cavity represents a potentially large

reservoir of Gram-negative pathogenic organisms that could
readily interact with cardiovascular tissues.

The Fourth Libyan Dental Congress April 2008

The Eyes of the
Hippopotamus
 Asymptomatic bacteremia due
to periodontopathic bacteria
may be an etiologic factor in
cardiovascular plaque
accumulation.

The Fourth Libyan Dental Congress April 2008

 Recommendations

1. Regular dental examinations for all

dentate patients and more work in
prevention.

The Fourth Libyan Dental Congress April 2008

 Recommendations

1. Work more collaboratively in

interdisciplinary relationships with
other health professionals.

• DENTIST, A magician who, putting metal

into your mouth, pulls coins out of your
pocket.
Ambrose Bierce (1911), U.S. writer and journalist.

The Fourth Libyan Dental Congress April 2008

 Recommendation
1. Full periodontal therapy for infections
especially high risk persons for CVD.
 Periodontal treatment lowered the outcome of
CVD in 50-75%. Iwamoto 2003

 National Institutes of Health has agreed to

support of periodontal treatment in patients with
both Atherosclerosis and Periodontitis with
doxycycline (20 mg twice a day) . Caton 2000

 Recommendations for perio treatment on the

basis of potential CVD outcomes remains
premature. Maas 2005 The Fourth Libyan Dental Congress April 2008
 Let us learn from
History
 Miller 1891, Belling 1912 (Focal
Infection).

 Removing the teeth will cure something,

including the foolish belief that removing
the teeth will cure everything.
– Anonymous.

The Fourth Libyan Dental Congress April 2008

 Prevention of infective Endocarditis:
Guidelines from the American Heart
Association
 A guideline from the American Heart Association Rheumatic Fever,
Endocarditis and Kawasaki Disease Committee, Council on
Cardiovascular Disease in the Young, and the Council on Clinical
Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the
Quality of Care and Outcomes Research Interdisciplinary Working
Group.
 JADA, June 2007; Vol. 138: 739-760. http://jada.ada.org

The Fourth Libyan Dental Congress April 2008

 Message
 Periodontal disease can affect
general health...and it can be
affected by general health.

 WITHOUT GOOD
PERIODONTAL HEALTH,
YOU CAN’T HAVE GOOD
GENERAL HEALTH

The Fourth Libyan Dental Congress April 2008

 ‫خصوصية المعالجة اللثوية لمرضى‬
‫الصابات القلبية الوعائية‬
‫تتطلب سلمة وفعالية المعالجة اللثوية عند مرضى الصابات‬
‫القلبية الوعائية‪:‬‬
‫‪ ‬فهماً لطبيعة المرض القلبي والتاريخ الطبي للمريض والحاجة‬
‫للستشارة الطبية التخصصية التي تقرر إمكانية إجراء‬
‫المعالجة اللثوية‪.‬‬
‫‪ ‬معرفة التأثيرات الجانبية للدوية القلبية وخاصة على النسج‬
‫حول السنية والتأثيرات غير المرغوبة للمعالجات اللثوية‬
‫الدوائية‪.‬‬
‫‪ ‬نوع المعالجة اللثوية وتوقيتها وتقدير الحاجة للتحضيرات‬
‫الدوائية الوقائية‪.‬‬
‫‪ ‬المعرفة بالختلطات الممكن حدوثها أثناء المعالجة اللثوية‬
‫وطرق تدبيرها‪.‬‬
‫‪The Fourth Libyan Dental Congress April 2008‬‬
 ‫خطوط عامة‬

‫‪ ‬الحالت القلبية غير المستقرة‪:‬‬

‫– استشارة طبية‬
‫– معالجات محافظة (المسكنات والمضادات الحيوية)‬
‫– تأجيل العمل اللثوي لمدة ‪ 6‬أشهر بعد جراحات زرع القلب‬
‫والصمامات و احتشاء العضلة القلبية‪.‬‬

‫‪The Fourth Libyan Dental Congress April 2008‬‬

 ‫خطوط عامة‬

‫‪ ‬الحالت القلبية المستقرة‪:‬‬

‫– جلسات عمل قصيرة‬
‫– مواعيد الظهيرة‬
‫– اعطاء مهدئات للمرضى القلقين‬
‫– وضعية الكرسي بشكل قائم أو مائل قليلً‬
‫– وجود وسائل المعالجات السعافية (أكسجين‪ ،‬نتروغلسرين‪،‬‬
‫مورفين‪).....‬‬

‫‪The Fourth Libyan Dental Congress April 2008‬‬

 ‫خطوط عامة‬

‫‪ ‬مرضى جراحة الصمامات القلبية‪:‬‬

‫– إنهاء المعالجات السنية قبل أسبوعين على القل من‬
‫اجراء الجراحة‪.‬‬
‫– تأجيل العمل اللثوي لمدة ‪ 6‬أشهر بعد الجراحة‪.‬‬
‫– الجراءات العلجية اللثوية التي تعتمد على الشفاء‬
‫بالمقصد الثاني مضاد استطباب ( قطع اللثة ‪ ،‬الطعم‬
‫اللثوي الحر‪)...‬‬

‫‪The Fourth Libyan Dental Congress April 2008‬‬

 ‫خطوط عامة‬

‫‪ ‬التخدير‪:‬‬
‫– أن ل تتجاوز كمية الدرينالين المعطاة في الجلسة‬
‫الواحدة ‪ 0.054 –0.04‬ملغ‪.‬‬
‫– استبعاد التخدير في الرباط أو العظم‪.‬‬
‫– ل توجد فوائد أو مساوئ لستخدام الليفونورديفرين‬
‫‪ levonordefrine‬كبديل للدرينالين‪.‬‬

‫‪The Fourth Libyan Dental Congress April 2008‬‬

 ‫خطوط عامة‬

‫‪ ‬المرضى الذين يتناولون مضادات التخثر‪:‬‬

‫– قيمة ‪ INR‬الطبيعية ‪1‬‬
‫– تطيل مضادات التخثر من زمن البروترومبين وتجعل‬
‫قيمة ‪ INR‬بين ‪.3.5 – 2‬‬
‫– ل خطورة لحدوث نزف تالي بعد المعالجات اللثوية‬
‫عندما تكون قيمة ‪ INR‬بين ‪.3 – 1‬‬
‫– القيم أكبر من ‪ 3‬تتطلب تعديلً في بروتوكول اعطاء‬
‫الدواء قبل العمال الجراحية الفموية‪.‬‬
‫‪The Fourth Libyan Dental Congress April 2008‬‬
 ‫التأثيرات غير المرغوبة للمعالجات الدوائية‬
‫‪ ‬الدوية اللثوية‪:‬‬
‫– يزيد كل من (‪Tetracycline's, Metronidazole,‬‬
‫‪ )Erythromycin‬من زمن البروترومبين ‪ PT‬عند المرضى المعالجين‬
‫بمضادات التخثر‪.‬‬
‫– مضادات اللتهاب غير الستيروئيدية (‪Ibuprofen, Naproxan,‬‬
‫‪ )Indomitacine‬تخفض من فعالية اللدوية الخافضة للضغط الدموي‪.‬‬
‫الدوية القلبية‪:‬‬ ‫‪‬‬
‫– تؤدي حاصرات أقنية الكالسيوم (‪ )Nifidipin‬إلى ضخامة لثوية‪.‬‬
‫– يسبب ‪ Digoxin‬صداع ‪ ،‬دوار‪ ،‬تغير نظم القلب‪.‬‬
‫– تحرض مثبطات أنزيم ‪ )Angiotencin )Captopril‬منعكس‬
‫‪The Fourth Libyan Dental Congress April 2008‬‬
‫السعال‪.‬‬
 ‫التهاب شغاف القلب النتاني‬
Infective Endocarditis
‫ توجد علقة مثبتة بين النتانات الفموية وما يعرف بالتهاب‬
.Infective Endocarditis ‫شغاف القلب النتاني‬
‫ تشارك العديد من الجراثيم الفموية في هذا المرض مثل‬
streptococcus viridans , streptococcus aureus , A.a ,
capnocytophaga , Eikenella corrodense.
Karchmer 1999

The Fourth Libyan Dental Congress April 2008

 :Prevention of Bacterial Endocarditis

High-risk category
Prosthetic valves 

Previous endocarditis 

Complex cyanotic congenital heart 

disease
Surgically constructed systemic 
pulmonary shunts

AHA Recommendations 1997 

The Fourth Libyan Dental Congress April 2008
 :Prevention of Bacterial Endocarditis

:Moderate –risk
Acquired valvular dysfunction such as 
rheumatic heart disease
Hypertrophic cardiomyopathy 

mitral valve prolapse with valvular 

regurgitation

AHA Recommendations 1997 

The Fourth Libyan Dental Congress April 2008
 :Prevention of Bacterial Endocarditis
Prophylaxis Not Recommended
Isolated secundum atrial septal defect 
Surgically repaired atrial septal defect 
Previous coronary artery bypass graft surgery 
Mitral valve prolapse without valvular regurgitation 
Physiologic, functional or innocent heart murmurs 
Cardiac pacemakers 
Previous Kawasaki disease or rheumatic fever without 
valvular dysfunction

AHA Recommendations 1997 The Fourth Libyan Dental Congress April 2008

 Dental Procedures and Endocarditis
 Prophylaxis
:Prophylaxis recommended
Dental extractions 

Periodontal procedures 

Dental implant placement 

Endodontic instrumentation or surgery only beyond the 
apex
Subgingival placement of antibiotic fibers and strips 

Initial placement of orthodontic bands but not brackets 

Intraligamentary local anesthetic injections 

Prophylactic cleaning of teeth where bleeding is 
anticipated

AHA Recommendations 1997  The Fourth Libyan Dental Congress April 2008
 Dental Procedures and Endocarditis
 Prophylaxis
Prophylaxis not recommended :((AHA 1997
restorative dentistry 

Nonligamentary local anesthetic injections 

Intracanal endodontic treatment; post placement and 
buildup
Placement of rubber dams 
Postoperative suture removal 
Taking of oral impressions 
Fluoride treatments 

Placement of removable prosthodontic or orthodontic 

appliances
Taking of oral radiographs 
The Fourth Libyan Dental Congress April 2008

AHA Recommendations 1997
 Endocarditis Prophylaxis
Regimens
:I. Standard 
Amoxicillin: Adults: 2 g (children 50 mg/kg) orally 1 hr –
prior to procedure

II .:Penicillin allergic patients 

clindamycin: Adults: 600mg (children 20 mg/kg) orally –

1 hr before procedure
Cephalexin orcefadoxil: Adults 2.0 gr (children 50 –
mg/kg) orally 1 hr prior to procedure
Azithromycin orclarithromycin: Adults 500 mg –
(children: 15 mg/kg) orally 1 hr prior to procedure

AHA Recommendations 1997  The Fourth Libyan Dental Congress April 2008
 Endocarditis Prophylaxis
Regimens
I. :Standard non-oral 
Ampicillin: Adults: 2.0 g intramuscularly or intravenously –
(within 30 min of procedure (children: 50 mg/kg IM or IV

:II. Penicillin allergic patients 

Clindamycin: Adults: 600 mg, children 20 mg/kg IV 30 –

min. prior to procedure, or
Cefazolin: Adults: 1.0 gr; children: 25 mg/kg IM or IV –
within .30 min before procedure

AHA Recommendations 1997 The Fourth Libyan Dental Congress April 2008

 Endocarditis Prophylaxis
  :Specific Situations
.Rheumatic fever 

Patients coming in more than once 

.per week

Periodontitis patient associated with 

Tetracycline . sensitive organisms
AHA Recommendations 1997
The  Fourth Libyan Dental Congress April 2008