The incidence of stroke and heart attack in patients with periodontitis – In the last three decades, increasing attention has been directed towards studying the relationship between periodontitis and cardiovascular diseases, especially episodes of stroke and myocardial infarction.
This link between oral health and cardiovascular health has generated a fertile field of research, aiming to understand how the presence of periodontitis can influence the incidence of such critical events.
The fact that these diseases share several common risk factors has raised the question of whether the chronic inflammation present in periodontitis could contribute to the development of stroke and heart attack.
The incidence of stroke and heart attack in patients with periodontitis.
A Periodontal Disease It encompasses two forms of the disease according to the severity of the problem: Gingivitis and Periodontitis. Thus, gingivitis only affects the marginal gum tissue around the tooth. However, periodontitis destroys the gum tissue, the ligaments that attach the tooth to the bone tissue, and the bone tissue itself that supports the tooth.
Periodontitis, also known as periodontosis, has been associated with an increased risk of vascular events, such as stroke, for several reasons. These associations are supported by a number of research studies and include the following mechanisms:
The incidence of stroke and heart attack in patients with periodontitis.
A- Systemic inflammation
Periodontitis is a chronic inflammatory disease that affects the gums and supporting tissues of the teeth. Chronic inflammation is known to play a key role in the development of cardiovascular diseases, including stroke. It is believed that the inflammatory substances released into the bloodstream due to periodontitis may contribute to the process of atherosclerosis, which is the hardening and narrowing of the arteries that can lead to a stroke.
There are several inflammatory substances released into the bloodstream that can increase blood clotting factors. These substances play a role in the body's response to inflammation, but they can also contribute to clotting disorders. Examples include:
1. Interleukin-6 (IL-6):
IL-6 is an inflammatory cytokine that plays a central role in the inflammatory response. It can stimulate the production of fibrinogen, a protein that plays an important role in blood clotting.
2. Tumor necrosis factor alpha (TNF-alpha):
TNF-alpha is another pro-inflammatory cytokine that can affect blood clotting. It can activate endothelial cells, which line the inside of arteries, contributing to clot formation.
3. C-reactive protein (CRP):
CRP is a protein produced by the liver in response to inflammation. Elevated levels of CRP in the blood are associated with an increased tendency for clotting.
4. Tissue Factor or Prothrombin:
Tissue factor is a protein released in response to tissue injury. It plays a crucial role in activating the coagulation cascade, leading to clot formation.
5. Platelet-activating factor:
During inflammation, platelets in the blood can be activated, becoming more sticky and prone to clot formation.
All of these substances can contribute to a state of hypercoagulability in the blood, increasing the risk of thrombosis (formation of unwanted clots in blood vessels) and thrombotic events, such as myocardial infarction and stroke. Therefore, chronic inflammation and coagulation disorders are interconnected and can have significant implications for cardiovascular health and other body systems.
The incidence of stroke and heart attack in patients with periodontitis.
B- Oral bacteria in the bloodstream:
A periodontal pocket is an abnormally deepened space between the tooth and the gum that develops as a result of periodontitis. Therefore, this condition is a manifestation of the loss of support of the periodontal tissues surrounding the teeth.
A periodontal pocket forms when chronic inflammation and bacterial infection in the gums damage the tissues that normally attach the tooth to the surrounding bone. As the tissues deteriorate, the pocket begins to deepen, creating a space where bacteria can proliferate. The depth of this pocket is measured clinically using a professional instrument – the Willis Millimeter Probe – which assesses the severity of periodontal disease.
In advanced cases, these bacteria can enter the bloodstream during chewing, brushing, or even during invasive dental procedures. This can then lead to the spread of bacteria to other parts of the body through the bloodstream. Finally, the presence of bacteria in the bloodstream can trigger a systemic inflammatory response, which can increase the risk of cardiovascular disease.
The incidence of stroke and heart attack in patients with periodontitis.
C- Endothelial damage (inner lining of blood vessels)
The presence of bacteria and inflammation-promoting toxins in the bloodstream due to periodontitis can damage the inner lining of the arteries, called the endothelium. This can lead to endothelial dysfunction, which in turn contributes to the development of atherosclerotic plaques. These plaques can rupture and cause blockages in the arteries, predisposing to vascular events such as stroke.
It is important to note that the association between periodontitis and stroke risk is still being studied, and more research is needed to determine the exact extent of this relationship. However, the mechanisms mentioned above highlight the importance of oral health in preventing cardiovascular disease, emphasizing the need for regular dental care and proper treatment of periodontitis.
The incidence of stroke and heart attack in patients with periodontitis.
Periodontitis Treatment
Treatment of periodontal pockets typically involves deep cleaning of the affected area through a procedure known as scaling and root planing. In severe cases, periodontal surgery may be necessary to eliminate the pocket and promote tissue healing.
Tooth extraction is also a treatment to consider when it is not possible to eliminate the periodontal pocket or when bone destruction has exceeded the capacity for masticatory support.
Treatment is essential to prevent the progression of the disease. periodontal disease, ...to avoid tooth loss and reduce the risk of systemic complications. These complications include those mentioned in the paragraphs above, which discuss the increased risk of cardiovascular disease.
The incidence of stroke and heart attack in patients with periodontitis.
Well, so far we've only highlighted the theoretical reasons that suggest this possible relationship between periodontitis and the risk of strokes. But what about in practice? What clinical data supports this possibility?
Clinical and patient follow-up studies have provided substantial evidence linking periodontitis to an increased risk of vascular events, such as stroke. Here are some examples of clinical data and figures that reinforce this relationship:
Clinical study 1
This study evaluated the prevalence of periodontal disease in 100 patients, 50 of whom had ischemic stroke and 50 were controls without stroke. Patients were matched for age, gender, ethnicity, smoking, alcohol consumption, and diabetes. The study found that 621% of stroke patients had moderate or severe periodontal disease, compared to 321% in the control group. The analysis showed a significant correlation between moderate periodontal disease and gingival discoloration in the case/control group. The results suggest a strong association between periodontal disease and stroke.
This study can be found at the following address: Association between periodontal disease and ischemic stroke: preventive alert – epidemiological analysis of periodontal disease in individuals who have had ischemic stroke | RGO (Porto Alegre);53(4): 291-295, Oct.-Dec. 2005. tab | LILACS | BBO (bvsalud.org)
Clinical Study 2
In this large case-control study of periodontal disease (PD), verified by radiographic bone loss and with careful consideration of potential confounding factors, the risk of a first myocardial infarction (MI) was significantly increased in patients with PD, even after adjusting for confounding factors. These findings strengthen the possibility of an independent relationship between PD and MI.
Clinical Study 3
Another study conducted at Harvard demonstrated that if you have periodontitis, your risk of having a heart attack or stroke can be two to three times higher. However, this does not necessarily mean that one disease causes the other. Conversely, there are people with healthy hearts who have gum disease, and not all people with gum disease have heart problems. In short, some habits, such as smoking or having a poor diet, may be the real cause of these problems. But there are still suspicions that gum disease may be an independent risk factor for heart disease.
Since this link is too long, you can check it out here:
Clinical Study 4
A 2020 Swedish study analyzed over 1.1 million participants over 24 years and found that the presence of periodontitis was associated with a 9% increased risk of stroke, especially in individuals under 65 years of age.
Clinical Study 5
Another study from the National Library of Medicine concluded that periodontal disease is quite common in patients with ischemic heart disease. Many studies have shown a link between these two conditions, although we still don't know exactly how one might influence the other.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035434/
The incidence of stroke and heart attack in patients with periodontitis.
The five studies we listed above are just some of the most recent. There is a wealth of accumulated reports over the past 30 to 40 years that reinforce the reality of this problem. The simplest way to explain what these studies say is as follows:
Let's consider a group of 600 individuals between 40 and 70 years old followed over several years. Within this group, 300 individuals have experienced a stroke at some point. The remaining 300 individuals have not reported any strokes.
Upon periodontally examining both groups, the researchers discovered that in the group with a history of stroke, the incidence of individuals with periodontitis was much higher than in the group without a history of stroke.
Similarly, it is important to highlight that some studies suggest an increase in the number of these strokes in young patients, in the 40-50 age range. I myself occasionally treated a patient in his 40s who played football and didn't smoke. However, he suffered a stroke at age 40. I met him in a wheelchair when he came for treatment with me. He reported that after the incident, he had a checkup and apparently the only health problem was advanced periodontitis. .
The incidence of stroke and heart attack in patients with periodontitis.
Finally, all these examples highlight that statistically significant clinical data support the relationship between periodontitis and an increased risk of stroke. Although the numbers may vary depending on the population studied and other risk factors, these large-scale studies consistently show that periodontitis is associated with an increased risk of vascular events such as stroke and myocardial infarction.
It is important to note that research in this field continues to evolve, but this clinical evidence provides a solid foundation for understanding the relationship between oral health and cardiovascular health.
Therefore, studies cannot prove a direct link, but they do raise very strong suspicions. So, if you have periodontitis or know of a relative or friend with this disease, be warned. In short, don't let time pass without treatment.
Author: Nivaldo Pinho, Periodontist CROSC 9696
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A strong association has been discovered between periodontitis and stroke.