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Year : 2013  |  Volume : 17  |  Issue : 2  |  Page : 210-213  

Evaluation of the association between chronic periodontitis and acute coronary syndrome: A case control study

Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Derelakatte, Mangalore, Karnataka, India

Date of Submission30-Aug-2011
Date of Acceptance24-Feb-2013
Date of Web Publication6-Jun-2013

Correspondence Address:
Amita Rao
Department of Periodontics, A B Shetty Memorial Institute of Dental Sciences, Derelakatte, Mangalore - 575 018, Karnataka
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Source of Support: NITTE University, Conflict of Interest: None

DOI: 10.4103/0972-124X.113073

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Background: The periodontal tissues mount an immune inflammatory response to bacteria and their products and the systemic challenge with these agents also induce a major vascular response. Although many studies have found a correlation between chronic periodontitis and cardiovascular diseases, the role of infection in acute coronary syndrome is disputed. The aim of this study is to investigate whether there is an association between chronic periodontitis and acute coronary syndrome. Materials and Methods: A total of 30 patients, ages ranging from 30 -80. 15 patients from A. B. Shetty Memorial Institute of Dental Sciences and 15 patients admitted to Coronary Care Unit of Justice K. S. Hegde Charitable Hospital Deralakatte Mangalore were included in the study. Variables age more than 40 and gender were also analyzed. Results: Of the 30 patients analyzed in this study, periodontitis was recognized in 11 patients of the acute coronary syndrome group and 10 patients in the healthy group. Fisher's exact test yielded a p value of 0.4539 with an odds ratio of 0.727(95% confidence interval 0.151 to 3.493). Conclusion: No significant association was found between periodontal disease and acute coronary syndrome. Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.

Keywords: Acute coronary syndrome, periodontal disease, risk factors

How to cite this article:
Ramesh A, Thomas B, Rao A. Evaluation of the association between chronic periodontitis and acute coronary syndrome: A case control study. J Indian Soc Periodontol 2013;17:210-3

How to cite this URL:
Ramesh A, Thomas B, Rao A. Evaluation of the association between chronic periodontitis and acute coronary syndrome: A case control study. J Indian Soc Periodontol [serial online] 2013 [cited 2021 Dec 9];17:210-3. Available from:

   Introduction Top

Cardiovascular disease comprises a variety of heart and vascular conditions including ischemia, atherosclerosis, peripheral artery disease, infective endocarditis, and acute myocardial infarction. [1] Evidence suggests that an association between inflammatory markers such as interleukins, C-reactive proteins, [2] protease activated receptors, and matrix metalloproteinase-9 [3] for atherogenesis and acute ischemic events. It has been hypothesized that coronary artery disease (CAD) may be triggered by systemic mechanisms, in addition to local inflammatory factors, and chronic periodontal infection is one of the possibilities to be considered. [4],[5],[6],[7] Taking this into account studies suggest an association between periodontal disease and CAD.

The sub gingival micro biota in patients with periodontitis provides a significant and persistent gram-negative bacterial challenge to the host. These organisms and their products such as lipopolysaccharide have a ready access to the periodontal tissues and to the circulation via the sulcular epithelium which is frequently ulcerated. [8] Several studies assessing the presence of bacteria associated with periodontitis in specimens collected from the aorta or other blood vessels have identified bacteria associated with periodontitis in samples from aorta and heart valves. [1]

Risk-factors for atherosclerosis and thereby for CAD have been identified in epidemiological studies linking their presence with the incidence of clinically overt disease. [9] Foremost among modifiable risk-factors associated with increased incidence of coronary disease are hyperlipidemia, systemic arterial hypertension, smoking, and diabetes mellitus. [10] Age, gender, and family history are among the major non-modifiable risk-factors associated with ischemic heart disease. [11],[12],[13]

The aim of this study was to see if there is an association between chronic periodontitis and acute coronary syndrome (ACS).

   Materials and Methods Top

The present clinical study was carried out in the Department of Periodontology and Implantology, A B Shetty Memorial Institute of Dental Sciences and K. S. Hegde Superspecialty Hospital, Mangalore after obtaining approval from the ethical committee. This was a case control study and all patients were enrolled after signing an informed consent.

The cases were 15 patients admitted with ACS to the Coronary Care Unit of K. S. Hegde Hospital, who met the ACS diagnostic criteria.

ACS comprised of patients with either ST segment elevation which was defined as acute myocardial infarction characterized by: Chest pain, radiating or not to the upper extremities, lower jaw, upper back or epigastrium lasting 30 min or more: Presence of ST segment elevation of 1 mm in two or more peripheral contiguous leads or 2 mm in two or more contiguous precordial leads on electrocardiogram: And elevation in serum markers of myocardial injury and necrosis (Creatine phospho kinase/creatinin kinase-MB, cardiac troponin) 3 times their reference value. [14]

Non-ST segment elevation ACS on, Electrocardiogram was defined as a clinical condition similar to that mentioned above but with chest pain lasting less than 30 min, with or without elevation of serum enzyme markers of myocardial injury and necrosis. [14]

Inclusion criteria

  • The control group comprised of patients with no history of CAD and systemically healthy aged between 30 and 80 years reporting to the Department of Periodontology were selected randomly
  • The cases were patients with ACS aged between 30 and 80 years
  • Those who had not taken any vitamins or mineral supplements for the past 3 months
  • Presence of minimum 15 natural teeth
  • Patients with any of the following conditions were excluded from the study
  • Patients who were completely edentulous.Neoplasias, liver cirrhosis, chronic inflammatory diseases like arthritis. Those who have undergone any periodontal treatment in the last 3 months. Pregnant and lactating women.
Screening examination

The severity of chronic periodontitis was determined by clinical attachment loss (CAL) more than 4 mm in more than 30% of sites. CAL was assessed using a Williams's graduated periodontal probe in both arches, examining all the teeth on six surfaces [Figure 1]. The severity of gingivitis was determined by gingival index as given by Loe and Silness, in 1963. Scores 1-3 were recorded with four scoring points on each teeth.
Figure 1: Measurement of clinical attachment level in a healthy patient with chronic Periodontitis

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All measurements and readings were done before the collection of blood sample.

Blood reports and blood pressure recording were also taken.

Statistical analysis

It was performed with Fishers exact test. P ≤ 0.05 was considered significant.

   Results Top

Thirty subjects were analyzed in this study, 15 patients were evaluated in the ACS group of whom chronic periodontitis was diagnosed in 11 patients. In the control group, 15 patients were evaluated of whom ten members had chronic periodontitis.

The results translated into an odds ratio (OR) of 0.727 (95% confidence interval (CI) =0.151-3.493) as shown in [Table 1].
Table 1: Chronic periodontitis in patients with acute coronary syndrome compared with control group

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P value calculated by Fisher's exact test was 0.4539, which was statistically insignificant.

The cluster bar graph for the two groups with the percentage of patients with and without periodontitis is shown in [Figure 2].
Figure 2: Cluster bar graph ‑ Comparing chronic periodontitis between the two groups

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Nine patients out of 15 in the ACS group were aged more than 40 years and eight in the control group were more than 40 years which translated into a total of 17 patients and an OR of 1.889. 95% CI (1.207-2.957) as shown in [Table 2].
Table 2: Chronic periodontitis in cases and controls more than 40 years of age

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17 (85%) patients age more than 40 years had periodontitis and 3 (15%) patients age more than 40 years did not have periodontitis.

The mean age for the ACS group was 57 years with a standard deviation (SD) of 12.7. The mean age for the control group was 42 years with a SD of 8.75 as shown in [Table 3] and [Figure 3].
Figure 3: Mean age of the patients in the two groups

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Table 3: Mean age of cases and controls

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In both the group, 15 men were diagnosed with chronic periodontitis compared to only six females with chronic periodontitis. The Fisher's exact test showed a P value of 0.331 which was statistically insignificant as shown in [Table 4].
Table 4: Fisher's test showing P value of males and females with and without chronic periodontitis

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All these were comparative results with no statistical significance.

   Discussion Top

Cardiovascular diseases rank among the leading causes of death and thereby have an important clinical and epidemiological role. [15],[16] Results from studies relating periodontal disease to cardiovascular disease have been mixed. A study carried out by Emingil et al. suggests that the presence of periodontal disease may induce a systemic inflammatory response, [7] resulting in elevated serum levels of inflammatory makers, such as tumor necrosis factor, interleukin and C-reactive protein that contribute to plaque instability and atherosclerotic events. [2],[3]

Meta-analysis of prospective and retrospective follow-up studies have shown that periodontal disease may only slightly increase the risk of cardiovascular disease. [17],[18],[19] In contrast, some studies have found a significant relationship between periodontal status (based on clinical measures of probing pocket depth/CAL) and acute myocardial infarction.

Most studies provide an OR of periodontitis (defined by clinical measures of probing pocket depth and clinical attachment levels) as a risk for cardiovascular disease at levels less than a ratio of 3:1. Studies resulting in higher OR have commonly used alveolar bone loss as a definition of periodontitis rather than CAL level. [20],[21] Disparities in prevalence rates of periodontitis in study populations with different age groups, ethnicity, and geographic location makes it difficult to assess the likelihood of an association between periodontitis and cardiovascular diseases.

Age is an important factor associated with both periodontitis and cardiovascular diseases. Available studies suggest that periodontitis prevalence in older subjects is high. [22] In the study done by Persson et al. approximately 50% of subjects older than 60 years of age had periodontitis. In addition, approximately 55% had either a diagnosis of atherosclerosis, or a history of stroke, or ACS. [23] In this study, mean age of the patients with ACS was greater than that of the control group. It is known that the age factor also accounts for increased cardiovascular risk, and this finding may have reduced both the significance and magnitude of the results. [17]

Another subset analysis with gender in this study did not show any association of ACS with chronic periodontitis in either males or females. There is evidence to suggest that the extent of atheroma assessed by intravascular ultrasound in women is less severe and prevalent than in men and independent of other traditional cardiovascular risk-factors. [24] Whereas in another study, investigators failed to identify gender differences in the association between periodontitis and cardiovascular diseases. [25]

Hujoel et al. published a prospective cohort study involving patients with periodontal and medical evaluation who were followed for 10 years. The endpoints evaluated were coronary death, ACS, or need for myocardial revascularization. After adjusting for risk-factors, no association was found either between gingivitis or CAD or between periodontitis and CAD. [26]

The limitations of this study however, were that, the sample size taken was also too small to come to any definitive conclusion and it was not possible to accesses the amount of bone loss by radiographic evaluation due to the non-ambulatory condition of the patients with ACS.

   Conclusion Top

The aim of our study was to emphasize the hypothesis that oral infectious processes may be implicated in inflammatory and thrombotic phenomena, leading to the development of acute coronary events. Such processes may induce cytokine release in the presence of lipopolysaccharide. It is believed that these substances act systemically from the periodontal vascular complex, or are released from coronary endothelial cells, promoting platelet aggregation and thrombus formation. [6],[7]

In this study, however, no independent association was found between chronic periodontitis and ACS. More multicenter properly powered longitudinal case-control trials are needed to specifically assess the prevalence and distribution of periodontitis in relation to cardiovascular disease. Interventional trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular disease.

   Acknowledgments Top

The authors would like to thank Ms. Sharada, Bio Statistician of NITTE University and Dr. K. Subramanyam, Cardiologist at K.S. Hegde Hospital, Mangalore for their support.

   References Top

1.Persson GR, Persson RE. Cardiovascular disease and periodontitis: An update on the associations and risk. J Clin Periodontol 2008;35:362-79.  Back to cited text no. 1
2.Szmitko PE, Wang CH, Weisel RD, de Almeida JR, Anderson TJ, Verma S. New markers of inflammation and endothelial cell activation: Part I. Circulation 2003;108:1917-23.  Back to cited text no. 2
3.Szmitko PE, Wang CH, Weisel RD, Jeffries GA, Anderson TJ, Verma S. Biomarkers of vascular disease linking inflammation to endothelial activation: Part II. Circulation 2003;108:2041-8.  Back to cited text no. 3
4.Mackenzie RS, Millard HD. Interrelated effects of diabetes arteriosclerosis and calculus on alveolar bone loss. J Am Dent Assoc 1963;66:192-8.  Back to cited text no. 4
5.Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP, Kesäniemi YA, Syrjälä SL, et al. Association between dental health and acute myocardial infarction. BMJ 1989;298:779-81.  Back to cited text no. 5
6.Beck JD. Epidemiology of periodontal disease in older adults. In: Ellen RP, editor. Periodontal Care in Older Adults. Toronto: Canadian Scholars Press Inc.; 1992. p. 9-35.  Back to cited text no. 6
7.Emingil G, Buduneli E, Aliyev A, Akilli A, Atilla G. Association between periodontal disease and acute myocardial infarction. J Periodontol 2000;71:1882-6.  Back to cited text no. 7
8.Page RC. The pathobiology of periodontal diseases may affect systemic diseases: Inversion of a paradigm. Ann Periodontol 1998;3:108-20.  Back to cited text no. 8
9.Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: Final report of the pooling project. The pooling project research group. J Chronic Dis 1978;31:201-306.  Back to cited text no. 9
10.Ross R. The pathogenesis of atherosclerosis: A perspective for the 1990s. Nature 1993;362:801-9.  Back to cited text no. 10
11.Stern MP. The recent decline in ischemic heart disease mortality. Ann Intern Med 1979;91:630-40.  Back to cited text no. 11
12.Dzau VJ. Atherosclerosis and hypertension: Mechanisms and interrelationships. J Cardiovasc Pharmacol 1990;15:S59-64.  Back to cited text no. 12
13.Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA 1988;260:2259-63.  Back to cited text no. 13
14.Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: Executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina). Circulation 2000;102:1193-209.  Back to cited text no. 14
15.Mansur AP, Favarato D, Souza MF, Avakian SD, Aldrighi JM, César LA, et al. Trends in death from circulatory diseases in Brazil between 1979 and 1996. Arq Bras Cardiol 2001;76:497-510.  Back to cited text no. 15
16.Marinho de Souza MF, Timerman A, Serrano CV Jr, Santos RD, de Pádua Mansur A. Trends in the risk of mortality due to cardiovascular diseases in five Brazilian geographic regions from 1979 to 1996. Arq Bras Cardiol 2001;77:569-75.  Back to cited text no. 16
17.Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: A meta-analysis. Am Heart J 2007;154:830-7.  Back to cited text no. 17
18.Meurman JH, Janket SJ, Qvarnström M, Nuutinen P. Dental infections and serum inflammatory markers in patients with and without severe heart disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:695-700.  Back to cited text no. 18
19.Mustapha IZ, Debrey S, Oladubu M, Ugarte R. Markers of systemic bacterial exposure in periodontal disease and cardiovascular disease risk: A systematic review and meta-analysis. J Periodontol 2007;78:2289-302.  Back to cited text no. 19
20.Rutger Persson G, Ohlsson O, Pettersson T, Renvert S. Chronic periodontitis, a significant relationship with acute myocardial infarction. Eur Heart J 2003;24:2108-15.  Back to cited text no. 20
21.Geismar K, Stoltze K, Sigurd B, Gyntelberg F, Holmstrup P. Periodontal disease and coronary heart disease. J Periodontol 2006;77:1547-54.  Back to cited text no. 21
22.Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration pneumonia: Dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001;49:557-63.  Back to cited text no. 22
23.Persson RE, Hollender LG, Powell VL, MacEntee M, Wyatt CC, Kiyak HA, et al. Assessment of periodontal conditions and systemic disease in older subjects. II. Focus on cardiovascular diseases. J Clin Periodontol 2002;29:803-10.  Back to cited text no. 23
24.Nicholls SJ, Wolski K, Sipahi I, Schoenhagen P, Crowe T, Kapadia SR, et al. Rate of progression of coronary atherosclerotic plaque in women. J Am Coll Cardiol 2007;49:1546-51.  Back to cited text no. 24
25.Andriankaja OM, Genco RJ, Dorn J, Dmochowski J, Hovey K, Falkner KL, et al. Periodontal disease and risk of myocardial infarction: The role of gender and smoking. Eur J Epidemiol 2007;22:699-705.  Back to cited text no. 25
26.Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal disease and coronary heart disease risk. JAMA 2000;284:1406-10.  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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