|Year : 2022 | Volume
| Issue : 4 | Page : 370-374
Assessment of periodontal disease severity in patients with cardiovascular disease: A cross-sectional study
Amita Rao1, K Subramanyam2, Ballamoole Krishna Kumar3, Neevan D'Souza4
1 Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Department of Periodontics, Deralakatte, Mangaluru, India
2 Nitte (Deemed to be University), KS Hegde Medical Academy (KSHEMA), Department of Cardiology, Deralakatte, Mangaluru, India
3 Nitte (Deemed to be University), Nitte University Centre for Science Education and Research (NUCSER), Division of Infectious Diseases, Deralakatte, Mangaluru, India
4 Nitte (Deemed to be University), KS Hegde Medical Academy (KSHEMA), Department of Biostatistics, Deralakatte Mangaluru, India
|Date of Submission||11-Aug-2021|
|Date of Decision||21-Jul-2022|
|Date of Acceptance||19-Sep-2022|
|Date of Web Publication||19-Dec-2022|
Department of Periodontics, AB Shetty, Memorial Institute of Dental Sciences, Deralakatte, Mangaluru - 575 018, Karnataka
Ballamoole Krishna Kumar
Division of Infectious Diseases, Nitte University Centre for Science Education and Research, Nitte (Deemed to be University), Mangaluru - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Periodontitis is a biofilm-induced chronic inflammatory disease that affects the tooth-supporting structures. Transient bacteremia during periodontal infection may lead to direct bacterial invasion of endothelial cells. Aim: To observe if the patient's periodontal status has an influence on the severity of the cardiac disease. Materials and Methods: Subgingival and atherosclerotic plaques were extracted from patients with coronary artery disease in this cross-sectional analytical study. Based on the nested polymerase chain reaction results, 44 patients were age- and gender-matched and divided into two groups based on the presence or absence of periodontal pathogens belonging to the red complex in the atherosclerotic plaque samples. Version 20.0 of IBM SPSS Statistics for the Windows was used to analyze the data. The Pearson Chi-square test was done to investigate the association between periodontal status and pathogen detection, as well as determine the relationship between periodontal severity and cardiac severity. P < 0.05 was considered to be statistically significant. Results: Statistically insignificant association was observed between periodontal severity and the detection of the periodontal pathogens Porphyromonas gingivalis and Tannerella forsythia in the subgingival and atherosclerotic plaques in Group A; however, a significant association was observed for the pathogen Treponema denticola in the subgingival plaque for both Groups A (P = 0.039) and B (P = 0.005). No significant association was observed between the periodontal severity and cardiac severity for Groups A (P = 0.40) and B (P = 0.277). A weak positive but statistically insignificant (P = 0.097) correlation was observed for overall periodontal and cardiac severity. Conclusion: A higher percentage of patients had generalized chronic periodontitis in the group that tested positive for the pathogens in the atherosclerotic plaques, indicating a possible influence of periodontal status on cardiac outcomes.
Keywords: Atherosclerosis, coronary artery disease, periodontitis, Porphyromonas gingivalis
|How to cite this article:|
Rao A, Subramanyam K, Kumar BK, D'Souza N. Assessment of periodontal disease severity in patients with cardiovascular disease: A cross-sectional study. J Indian Assoc Public Health Dent 2022;20:370-4
| Introduction|| |
Cardiovascular diseases, including peripheral artery disease, stroke, and congestive heart failure, are among the leading causes of chronic disease morbidity. Even if traditional cardiovascular risk factors are taken into consideration, patients with periodontal diseases such as chronic periodontitis (CP) have a higher risk of developing systemic diseases such as coronary artery disease (CAD).,
Atherosclerosis is a vascular condition where subintimal thickening of medium-to-large-sized muscular arteries is observed. It is one of the primary causes of CAD, characterized by chronic inflammation, lipid deposition in the vasculature, and endothelial dysfunction. Numerous atherosclerotic risk factors have been recognized; however, the stimulus that initiates or promotes chronic inflammation is still unclear. Inflammation and infection are known to be risk factors for atherosclerosis, and they can either directly or indirectly contribute to chronic inflammatory processes. Periodontitis can be clinically characterized by deep pockets, clinical attachment loss (CAL), or apical shift of epithelium along the root surface and bone loss. In patients with periodontitis, the pockets may exist as reservoirs for the pathogens that evade the host defense mechanism and spread to other parts of the body, as the plaque biofilm is found in close vicinity to the gingival blood vessels., Certain invasive strains of periodontal pathogens may invade endothelial cells triggering inflammatory cells, resulting in cytokine overproduction leading to endothelial dysfunction., In the infected endothelial, there is an upregulation of toll-like receptors and adhesion molecules such as vascular cell adhesion molecule-1, which play a vital role in the onset of atherosclerosis.
The indirect mechanism of infection varies depending on factors such as host-microbial interaction, the virulence of the pathogens, and the host's genetic susceptibility. Patients with chronic and aggressive periodontitis have a higher systemic level of acute-phase reactants and inflammatory cytokines., A positive association between periodontitis and cardiovascular diseases has been reported by the European Federation of Periodontology and the World Heart Federation. However, the mechanism underlying this association or the process by which periodontal pathogens may promote the onset or progression of atherosclerosis is still unclear.
In a recent study, periodontal pathogens comprising the red complex triad of Tannerella forsythia, Porphyromonas gingivalis, and Treponema denticola were detected in the atherosclerotic plaques of patients with CAD suggesting their systemic dissemination from periodontal pockets. As a result, this study was designed to further investigate if the periodontal status of the patient had an influence on the detection of periodontal pathogens in atherosclerotic plaques and cardiac disease severity.
| Materials and Methods|| |
The study included patients diagnosed with CAD based on the classic symptoms at presentation and confirmed by electrocardiograms, echocardiography, cardiac biomarkers, and coronary angiograms in this cross-sectional analytical study. Only those consenting to participate were enrolled in the study. The study was reviewed and approved by the Central Ethics Committee of the University (NU/CEC/2017-2018/0121, NU/CEC/2017-2019/0213). The research protocol was according to the ethical guidelines of the 1975 Declaration of Helsinki involving human subjects.
Subgingival and atheromatous plaque samples were collected from patients with CAD undergoing angioplasty or coronary artery bypass grafting (CABG) at a tertiary health care center. Patients with <12 teeth or those who gave a history of periodontal therapy in the previous 6 months were excluded. Data on smoking, tooth loss, gingival index (GI), probing depth (PD), and CAL were recorded by a single periodontist. PD and CAL measurements were recorded on six sites per tooth using a calibrated periodontal probe. Periodontal disease severity was graded, according to the working group's guidelines of the Center for Disease Control and Prevention, into three levels: mild, moderate, and severe periodontitis. Sterile paper points were inserted into the deepest subgingival sulcus area of each quadrant for obtaining subgingival plaque samples.
The cardiac severity of the patient was graded by a senior cardiologist based on a Syntax score. The syntax score is the sum of the points allocated to each lesion located in the coronary tree with a diameter narrowing of more than 50% in vessels more than 1.5 mm in diameter. The syntax score was divided into tertiles with scores ranging from 0 to 16 indicating low severity, above 16–22 representing intermediate severity, and scores >22 denoting high severity. Atherosclerotic plaque samples were retrieved from the balloon catheter in patients undergoing angioplasty or from the coronary arteries recovered during the CABG procedure. Plaque samples were then transferred to sterile microcentrifuge tubes and stored at minus 20° centigrade for DNA extraction.
Polymerase chain reaction analysis for the detection of the periodontal pathogen
Genomic DNA extraction was done for the subgingival and atheromatous plaque samples using the QIAamp DNA Mini Kit (Qiagen, Germany), and 4 μl of the extracted DNA was used as a template for the first step nested polymerase chain reaction (PCR) targeting the conserved region of the 16S rDNA. This was followed by the second step PCR using specific primers for pathogens T. forsythia, T. denticola, and P. gingivalis with the first step PCR product as a template.
A sample size of 96 patients was calculated based on an anticipated proportion of 50% presence of dominant microorganisms with a 5% level of significance and a precision of 10%. Further, based on the nested PCR results, 44 patients were then gender- and age-matched and divided into two main groups on the basis of the presence or absence of periodontal bacterial DNA in the atherosclerotic plaques. Patients in Group A tested positive for one or more periodontal pathogens in the atherosclerotic plaque samples. On the other hand, Group B patients had patients whose atherosclerotic plaque samples were negative for any of the three periodontal pathogens. The subgingival plaque samples of all the patients in both groups were positive for one or more pathogens belonging to the red complex.
The quantitative data were analyzed using an unpaired t-test. Pearson Chi-square test was done to look into an association between periodontal status and detection of pathogens. Pearson Chi-square test was also done to look into an association between periodontal severity and cardiac severity. Spearman's correlation was done to look into the overall relation between periodontal severity and cardiac severity. P < 0.05 was considered to be statistically significant. Version 20.0 of IBM SPSS Statistics for Windows statistical software (Armonk, NY, USA: IBM Corp.) was used to analyze the data.
| Results|| |
A total of 44 patients with CAD (7 females and 15 males in each group) with an average age of 58 years (range from 40 to 77 years) were analyzed. The presence or absence of periodontal bacterial DNA in atherosclerotic plaques was used to divide the participants into two groups. Statistically, no significant association was observed between the two groups A and B for GI score (P = 0.425), syntax score (P = 0.617), and mean PD (P = 1.00) [Table 1]. Forty-three patients exhibited either localized or generalized CP with varying degrees of severity, while one patient did not show any clinical sign of periodontitis. In Group A 72.7% had moderate, 13.6% had mild, and 9.1% had severe periodontitis. In Group B, 40.9% of patients were in the mild periodontitis category with only isolated areas of deep pockets or CAL and 9.1% of the patients had severe periodontitis [Table 2].
In Group A patients, P. gingivalis, T. forsythia, and T. denticola were detected in 72.7%, 100%, and 86.4% of the subgingival plaque samples and in 45.5%, 63.6%, and 4.5% of the atherosclerotic plaques, respectively [Table 2]. P. gingivalis and T. denticola were found in 68.2% and 95.5% of the subgingival plaque samples in Group B. Both groups tested positive for T. forsythia in all the subgingival plaque samples. Statistically, no significant association was found between periodontal severity and the detection of the periodontal pathogens P. gingivalis (P = 0.319) and T. forsythia in the subgingival and atherosclerotic plaque samples (P = 0.702), (P = 0.551), respectively, for Group A patients. No significant association was observed for periodontal severity and detection of periodontal pathogens P. gingivalis (P = 0.428) and T. forsythia in the subgingival plaque of Group B patients. A significant association was, however, observed for periodontal severity and the detection of T. denticola in the subgingival plaques for both Group A (P = 0.039) [Figure 1] and Group B (P = 0.005) patients. The periodontal severity between the two groups was found to be nonsignificant (P = 0.177).
|Figure 1: Percentage of periodontal pathogens in the subgingival and atherosclerotic plaques of Group A patients with varying degrees of periodontal severity. Pg: Porphyromonas gingivalis, Tf: Tannerella forsythia, Td: Treponema denticola, S: Subgingival, A: Atherosclerotic|
Click here to view
For the Group A patients, the overall syntax score ranged from 2 to 40, with a mean of 18.91 ± 10.7, whereas the syntax score of Group B patients ranged from 4 to 42 with a mean of 17.23 ± 11.43. Group A (41%) had high syntax scores of more than 22 compared to Group B patients (31.8%). Based on the syntax scores, no significant association was observed between the periodontal severity and cardiac severity for Group A (P = 0.40) and Group B (P = 0.277). A weak positive correlation was observed when overall periodontal severity and cardiac severity were analyzed; it was statistically insignificant (P = 0.097).
| Discussion|| |
The purpose of this study was to investigate if the cardiac disease severity and the detection of periodontal pathogens in atherosclerotic plaques are influenced by a patient's periodontal status. Based on the results of the study, we observed that a higher percentage of patients in Group A had a clinical finding of a moderate degree of CP compared to Group B and studies have shown that untreated moderate-to-severe CP cases have higher systemic levels of key cardiovascular risk markers (like E-selectin, myeloperoxidase, and intercellular adhesion molecule-1) and red-complex bacteria. These markers have been found to be associated with endothelial dysfunction, a key event in the progression of atherosclerosis.
Pocket formation results from periodontal tissue destruction that occurs due to the host's response to the subgingival spread of periodontal pathogens under impaired defense conditions. As the pocket depth increases, there is a shift toward a more anaerobic flora. The host response to these microorganisms can trigger an inflammatory reaction and cause the destruction of the periodontal tissues. The epithelial barrier is ulcerated in sites with active periodontal disease, allowing oral bacteria to infiltrate into the underlying connective tissue and capillaries and subsequently into the systemic circulation.,, In patients with severe-to-moderate degrees of CP, blood myeloid dendritic cells play a role in periodontal pathogen transmission by harboring and disseminating the pathogens from the oral mucosa to atherosclerotic plaques. Studies in vitro have also shown that P. gingivalis, one of the keystone pathogens in CP can invade, spread, and replicate in gingival epithelial cells, endothelial cells, and macrophages., This could partially explain the detection of periodontal pathogens in the atherosclerotic plaque samples of Group A patients, given that this group had a higher percentage of patients with generalized CP in comparison to Group B.
The syntax score, an angiographic grading method for determining the intricacy of CAD, was used to rate the cardiac severity. The syntax score can predict significant cardiac outcomes after percutaneous coronary intervention in patients with three-vessel disease. A higher syntax score indicates a more complex CAD and may indicate a worse prognosis. Group A had a higher percentage of patients with high syntax scores as compared to group B patients, demonstrating the severity of the cardiac condition. We observed statistically insignificant results when overall periodontal severity and cardiac severity were analyzed. Statistically insignificant results have also been observed when the relationship between periodontal disease and the incidence of new cardiovascular events in post-CABG patients was evaluated. Interestingly, we noted that the patients who had a severe degree of periodontitis in Group A also had high syntax scores hinting toward a possible influence of periodontal status on cardiac outcomes. Research done has shown that each millimeter increase of mean PD and periodontal attachment loss is linked to a higher risk of arterial stiffness and maximal carotid intima-media thickness.
Although an association between periodontitis and cardiovascular disease studies has been demonstrated in various studies, the mechanism underlying this relationship and the extent of the impact of periodontal disease on the onset and progression of CAD are unclear at this juncture and needs to be further examined., However, given the high prevalence of periodontitis, even low-to-moderate risk is significant from a public health perspective; hence, dentists should inform patients diagnosed with periodontitis that they are at a higher risk for developing cardiovascular diseases. Diagnosis and treatment of periodontal diseases at an early stage may help reduce the complications associated with it.
This study did not quantify the periodontal pathogens nor were the levels of systemic inflammatory markers analyzed. It would have given us a better understanding of the extent of involvement of the periodontal pathogens and helped us correlate the severity of the cardiac disease with the total bacterial count. It is also difficult to generalize the study's findings due to the limited sample size.
| Conclusion|| |
We observed that the group that tested positive for the periodontal pathogens in the atherosclerotic plaques had a higher percentage of patients with generalized CP. The results of this research point out a potential role periodontal pathogens P. ginigvalis, T. forsythia, and T. denticola may play in the development of atherosclerosis either directly or indirectly by a host-mediated immunologic response.
The financial support from the University toward faculty research is gratefully acknowledged. The authors are grateful to all the patients included in this study.
Financial support and sponsorship
The study was funded by Nitte University for faculty research (NUFR2/2018/10/11).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Beck JD, Elter JR, Heiss G, Couper D, Mauriello SM, Offenbacher S. Relationship of periodontal disease to carotid artery intima-media wall thickness: The atherosclerosis risk in communities (ARIC) study. Arterioscler Thromb Vasc Biol 2001;21:1816-22.
Gotsman I, Lotan C, Soskolne WA, Rassovsky S, Pugatsch T, Lapidus L, et al.
Periodontal destruction is associated with coronary artery disease and periodontal infection with acute coronary syndrome. J Periodontol 2007;78:849-58.
O'Connor S, Taylor C, Campbell LA, Epstein S, Libby P. Potential infectious etiologies of atherosclerosis: A multifactorial perspective. Emerg Infect Dis 2001;7:780-8.
Sessa R, Pietro MD, Filardo S, Turriziani O. Infectious burden and atherosclerosis: A clinical issue. World J Clin Cases 2014;2:240-9.
Kinane DF. Causation and pathogenesis of periodontal disease. Periodontol 2000 2001;25:8-20.
Paju S, Scannapieco FA. Oral biofilms, periodontitis, and pulmonary infections. Oral Dis 2007;13:508-12.
Han YW, Wang X. Mobile microbiome: Oral bacteria in extra-oral infections and inflammation. J Dent Res 2013;92:485-91.
Kinjo K, Sato H, Sato H, Shiotani I, Kurotobi T, Ohnishi Y, et al.
Prevalence of Helicobacter pylori
infection and its link to coronary risk factors in Japanese patients with acute myocardial infarction. Circ J 2002;66:805-10.
Yumoto H, Chou HH, Takahashi Y, Davey M, Gibson FC 3rd
, Genco CA. Sensitization of human aortic endothelial cells to lipopolysaccharide via regulation of toll-like receptor 4 by bacterial fimbria-dependent invasion. Infect Immun 2005;73:8050-9.
Yoshii S, Tsuboi S, Morita I, Takami Y, Adachi K, Inukai J, et al.
Temporal association of elevated C-reactive protein and periodontal disease in men. J Periodontol 2009;80:734-9.
De Nardin E. The role of inflammatory and immunological mediators in periodontitis and cardiovascular disease. Ann Periodontol 2001;6:30-40.
Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D'Aiuto F, Bouchard P, et al.
Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol 2020;47:268-88.
Rao A, D'Souza C, Subramanyam K, Rai P, Thomas B, Gopalakrishnan M, et al.
Molecular analysis shows the presence of periodontal bacterial DNA in atherosclerotic plaques from patients with coronary artery disease. Indian Heart J 2021;73:218-20.
Page RC, Eke PI. Case definitions for use in population-based surveillance of periodontitis. J Periodontol 2007;78 Suppl 7S: 1387-99.
Ashimoto A, Chen C, Bakker I, Slots J. Polymerase chain reaction detection of 8 putative periodontal pathogens in subgingival plaque of gingivitis and advanced periodontitis lesions. Oral Microbiol Immunol 1996;11:266-73.
Ramírez JH, Parra B, Gutierrez S, Arce RM, Jaramillo A, Ariza Y, et al.
Biomarkers of cardiovascular disease are increased in untreated chronic periodontitis: A case control study. Aust Dent J 2014;59:29-36.
Bosshardt DD. The periodontal pocket: Pathogenesis, histopathology and consequences. Periodontol 2000 2018;76:43-50.
Takeuchi H, Furuta N, Morisaki I, Amano A. Exit of intracellular porphyromonas gingivalis from gingival epithelial cells is mediated by endocytic recycling pathway. Cell Microbiol 2011;13:677-91.
Carrion J, Scisci E, Miles B, Sabino GJ, Zeituni AE, Gu Y, et al.
Microbial carriage state of peripheral blood dendritic cells (DCs) in chronic periodontitis influences DC differentiation, atherogenic potential. J Immunol 2012;189:3178-87.
Reyes L, Herrera D, Kozarov E, Roldán S, Progulske-Fox A. Periodontal bacterial invasion and infection: Contribution to atherosclerotic pathology. J Clin Periodontol 2013;40 Suppl 14:S30-50.
Lamont RJ, Chan A, Belton CM, Izutsu KT, Vasel D, Weinberg A. Porphyromonas gingivalis invasion of gingival epithelial cells. Infect Immun 1995;63:3878-85.
Wang M, Shakhatreh MA, James D, Liang S, Nishiyama S, Yoshimura F, et al.
Fimbrial proteins of porphyromonas gingivalis mediate in vivo
virulence and exploit TLR2 and complement receptor 3 to persist in macrophages. J Immunol 2007;179:2349-58.
Valgimigli M, Serruys PW, Tsuchida K, Vaina S, Morel MA, van den Brand MJ, et al.
Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention. Am J Cardiol 2007;99:1072-81.
Reichert S, Schulz S, Friebe L, Kohnert M, Grollmitz J, Schaller HG, et al.
Is periodontitis a predictor for an adverse outcome in patients undergoing coronary artery bypass grafting? A pilot study. J Clin Med 2021;10:818.
Hayashida H, Saito T, Kawasaki K, Kitamura M, Furugen R, Iwasaki T, et al.
Association of periodontitis with carotid artery intima-media thickness and arterial stiffness in community-dwelling people in Japan: The Nagasaki Islands study. Atherosclerosis 2013;229:186-91.
Pinho MM, Faria-Almeida R, Azevedo E, Manso MC, Martins L. Periodontitis and atherosclerosis: An observational study. J Periodontal Res 2013;48:452-7.
Zardawi F, Gul S, Abdulkareem A, Sha A, Yates J. Association between periodontal disease and atherosclerotic cardiovascular diseases: Revisited. Front Cardiovasc Med 2020;7:625579.
[Table 1], [Table 2]