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Taking oral health to heart: An overview

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reproduce this article in whole or in part can be found at: 2010 American Dental Association. The sponsor and its products are not endorsed by the ADA. A B S T R A C T
Background. This article is an introduc-
tion to the 2001 ADA symposium, “Taking
Oral Health to Heart,” which focused on the and cardiovascular disease. This overview Taking oral health
used in discussions of epidemiologic studies Conclusions.
disease, medication or condition is a riskfactor for another entity, one must carefullyevaluate and analyze the data, weigh the SEBASTIAN G. CIANCIO, D.D.S.
various other contributing risk factors and
then determine the mechanism of interac-
tion if an association is established.
Clinical Implications. This sympo-
sium provided practitioners with variousconcepts regarding the role of periodontaldisease as a risk factor for cardiovascular Several authors have suggested that periodontal
disease increases the risk of myocardial infarct,stroke and other systemic conditions.1-5 TheADA symposium “Taking Oral Health to Heart” disease, and the data presented represent (held July 26-27, 2001, in Chicago) focused on the relationship between oral and cardiovascular disease,and presented the basis on which this relationship can beevaluated. Serving as an overview, this introduction highlights some of the terminology, databases and epidemiologic studies that were discussed at the symposium.
same number of cases without the condi-tion; these cases are randomly selected TERMINOLOGY
It is important to understand the various terms associ- ated with the potential relationships between oral and cardiovascular disease. Risk factors are defined as some- thing that increases the likelihood of an This symposium
increasing age as a risk factor for death.
practitioners that can be changed, thereby—we
with various hope—decreasing the chance that a dis-
yses. Cross-sectional studies can lead to concepts ease will occur. A good example is
regarding smoking, a modifiable risk factor for cer-
the role of
of an increased risk of stroke), which are Hierarchy of studies. Case reports.
reasonable or plausible correlates of dis- periodontal Risk factors can be identified by ana-
disease as a lyzing a hierarchy of studies.6 The
Longitudinal studies. Longitudinal risk factor for weakest studies are anecdotes, case his-
studies generally are useful in providing cardiovascular tories and case reports; they are helpful
disease. because they provide the basis for gener-
as risk factors in longitudinal studies.
strongest form of evidence is provided by case-control studies, which often can identify risk indicators, but are not often able to assess the role of important confounding risk indicators identified in lower-level factors. (In case-control studies, researchers match case Copyright 2002 American Dental Association. All rights reserved.
examine the data regarding the relationship ofsmoking to oral cancer. If the incidence of oral CARDIOVASCULAR DISEASE
cancer in a smoking population is 0.002, and in a RISK FACTORS.
nonsmoking population it is 0.0004, than the oddsratio is calculated as follows: From this calculation, we can conclude that the odds of developing oral cancer among smokers is dAlcohol Use
five times as high as that among nonsmokers.
Also, one can calculate the increase in the odds dHypertension
ratio by subtracting the ratio for “no association” dCholesterol Level
(that is, 1) from 5, which equals 4, and multi- dSmoking
plying the result by 100 percent. This equals 400 percent; therefore, the odds of developing oral dEducation
cancer among smokers increased by 400 percent.
dHeight and Weight
The data for a number of the longitudinal studies dMarital Status
discussed in this supplement were obtained from dPhysical Activity
the National Health and Nutrition Epidemiolog- dHistory of Cardiovascular Disease
ical Survey I, or NHANES I, which studied31,973 men and women from 1971 through 1975.8 This study was followed by the NHANES Epi- dPoverty Level
demiological Follow-up Study carried out from dInfection
1982 through 1984, which studied 11,348 peoplewho had participated in NHANES I.8 In 1984, a Intervention studies. The strongest evidence of subset of these subjects (3,980) who were 55 the benefit of reducing or eliminating a risk factor through 74 years of age at baseline in 1971 is found in intervention studies. These studies use through 1975 were re-evaluated.8 Researchers re- a random, controlled, masked design and evaluate evaluated all subjects in 1987 and again in 1992.8 the effect of therapy on the outcome or outcomes Evaluations included various measures of general being measured. Intervention studies are in their health, history of cardiovascular diseases and early stages and, when completed, should provide convincing evidence for or against the existence of Russell’s Periodontal Index. The NHANES
a relationship between periodontal disease and researchers used Russell’s Periodontal Index,9 as described below, to determine the periodontal The highest form of data obtained to date regarding an association between periodontal dis- ease and cardiovascular disease has been from longitudinal studies. In these studies, researchers d6 = gingivitis with pocket formation, tooth firm; have evaluated epidemiologic data that have been d8 = advanced destruction of periodontium with Odds ratios. In epidemiologic studies, the
Using this index, researchers sum all scores measures of association have been presented as and calculate the mean. The disadvantages of this odds ratios. An odds ratio greater than 1 indicates system are that it gives heavy weight to the a positive association; less than 1 indicates a neg- destructive stages of periodontal disease and has ative association. An odds ratio equal to 1 indi- no provision for distinguishing between slight and cates no association. Some investigators have extreme pocketing. In addition, a periodontal questioned the meaning of an odds ratio between probe is not used to determine pocketing.
1 and 2 in regard to the importance of the associa- Risk factors. The box lists the cardiovascular
disease risk factors that must be evaluated in To demonstrate the use of an odds ratio, let us these studies. Smoking is the single largest con- Copyright 2002 American Dental Association. All rights reserved.
founder in evaluating the data. Smoking factors researchers and clinicians must consider a variety to be considered include not only smoking fre- of factors in determining odds ratios, which, in quency, but also the time at smoking onset and turn, provide information relevant to the strength the time at cessation for subjects who stopped of a relationship between one condition and smoking before entering the study or during the Below are some questions that researchers CONCLUSION
The information presented above describes the dIs the relationship between periodontal disease databases and terminology used in discussions of epidemiologic topics presented in this supplement dIf there is a causal relationship between peri- and published in the literature. In determining if odontal disease and cardiovascular disease, is it a particular disease, condition or medication is a risk factor for another entity, one must carefully dDoes periodontal therapy reduce the risk of evaluate and analyze the data, weigh the various other contributing risk factors and then deter- dWhat is the incidence of cardiovascular disease mine the mechanism of the relationship, if any, dIf the relationship is shown to exist, what is variety of ways, different authors may obtain dif-ferent results from the same database. The ulti- RISK FACTOR EVALUATION
mate solution to determining if a causal relation- In determining if a certain disease, medication or ship exists between periodontal disease and condition is a risk factor for another entity, one cardiovascular disease will depend on the out- must carefully evaluate and analyze the data, come of intervention studies now under way. " weigh the various other contributing risk factors Dr. Ciancio is the Distinguished Service Professor and chairman, and determine the mechanism of action. For Department of Periodontics and Endodontics, a clinical professor of example, a recent study published in the Journal Pharmacology, and director, Center for Dental Studies, State Univer-sity of New York at Buffalo, Room 250, Squire Hall, 3435 Main St., of the American Medical Association reported Buffalo, N.Y. 14214. Address reprint requests to Dr. Ciancio.
that tetracyclines or quinolones may reduce the 1. Offenbacher S, Katz V, Ferrik G, et al. Periodontal infection as a incidence of a first myocardial infarct.10 This possible risk factor for preterm low birth weight. J Periodontol finding was based on an evaluation of data from a 2. Scannapieco FA, Mylotte JM. Relationships between periodontal longitudinal study that gave an odds ratio of less disease and bacterial pneumonia. J Periodontol 1996;67:1114-22.
than 1 for the incidence of myocardial infarct in 3. Morrison HI, Ellison LF, Taylor GW. Periodontal disease and risk of fatal coronary heart and cerebrovascular diseases. J Cardiovasc Risk patients who had a history of being medicated with tetracyclines or quinolones. However, when 4. Wu T, Trevisan M, Genco RJ, Dorn JP, Falkner KL, Sempos CT.
Periodontal disease and risk of cerebrovascular disease: the first another statistician ruled out confounding risk National Health and Nutrition Examination Survey and its follow-up factors not considered in the original analysis, an study. Arch Intern Med 2000;160:2749-55.
5. Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal association was found only for tetracycline and disease and cardiovascular disease. J Periodontol 1996;67:1123-37.
6. Ibrahim M. Epidemiology and health policy. Rockville, Md.: Aspen Subsequently, Golub and colleagues12 offered 7. Taubes G. Epidemiology faces its limits. Science 1995;269:164-9.
an explanation of the mechanism of this interac- 8. Eklund SA, Burt BA. Risk factors for total tooth loss in the United States: longitudinal analysis of national data. J Public Health Dent tion; they suggested that tetracycline may have been effective, not because of its antibacterial 9. Russell AL. A system of scoring for prevalence surveys of peri- odontal disease. J Dent Res 1956;35:350-9.
effect, but because of its ability to suppress vas- 10. Meier CR, Derby LE, Jick SS, Vasilakis C, Jich H. Antibiotics and cular inflammation owing to its inhibition of risk of subsequent first-time acute myocardial infarction. JAMA1999;281:427-31.
matrix metalloproteinases, or MMPs, such as col- 11. Glenn L. Antibiotic use and risk of myocardial infarction (letter).
lagenase and elastase. Their suggestion was sup- 12. Golub LM, Greenwald RA, Thompson RW. Antibiotic use and risk ported by an earlier study13 that showed that of myocardial infarction (letter). JAMA 1999;282:1997-8.
doxycycline and chemically modified tetracycline 13. Curci JA, Petrinec D, Liao S, Golub LM, Thompson RW. Pharma- cologic suppression and abdominal aortic aneurysms: a comparison of inhibit the development of aortic aneurysm in a doxycycline and four chemically modified tetracyclines. J Vasc Surg Copyright 2002 American Dental Association. All rights reserved.


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