PDF《disease》

14S JADA, Vol.

137 http://jada.ada.org October

2006 Background. Oral infection models have emerged as useful tools to study the hypothesis that infection is a cardiovascular disease (CVD) risk factor. Periodontal infections are a leading culprit, with studies reporting associations between periodontal disease and CVD. The results, however, have varied, and it often is unclear what conclusions can be drawn from these data. Summary. An association exists between periodontal disease and CVD. It is unknown, however, whether this relationship is causal or coincidental. Early studies predominantly used nonspecific clinical and radiographic defi- nitions of periodontal disease as surrogates for infectious exposure. While most studies demonstrated positive associations between periodontal dis- ease and CVD, not all studies were positive, and substantial variations in results were evident. More recent studies have enhanced the specificity of infectious exposure definitions by measuring systemic antibodies to selected periodontal pathogens or by directly measuring and quantifying oral micro- biota from subgingival dental plaque. Results from these studies have shown positive associations between periodontal disease and CVD. Conclusions. Evidence continues to support an association among peri- odontal infections, atherosclerosis and vascular disease. Ongoing observa- tional and focused pilot intervention studies may inform the design of large- scale clinical intervention studies. Recommending periodontal treatment for the prevention of atherosclerotic CVD is not warranted based on scientific evidence. Periodontal treatment must be recommended on the basis of the value of its benefits for the oral health of patients, recognizing that patients are not healthy without good oral health. However, the emergence of peri- odontal infections as a potential risk factor for CVD is leading to a conver- gence in oral and medical care that can only benefit the patients and public health. Key Words. Cardiovascular;

infection;

periodontitis;

epidemiology. JADA 2006;

137(10 supplement):14S-20S. A fter two decades of research, it has been firmly established that an association exists between periodontal disease and cardiovascular disease (CVD). The pertinent question, however, is about the nature and relevance of this association. Specifically, does the infectious and inflammatory periodontal dis- ease process contribute causally to heart attacks and strokes, or are these two conditions coincidentally associated? Although the evidence of a potentially contributory role of periodontal infections in the nat- ural history of CVD continues to mount, there are well-founded rea- sons for skepticism. With this in mind, we provide a state-of-the- science article regarding the asso- ciation between periodontal dis- ease and CVD. TRADITIONAL STUDIES OF PERIODONTAL DISEASE AND CARDIOVASCULAR DISEASE In 1989, two Scandinavian reports revived a century-old hypothesis relating chronic infections with vascular disease that originally was proposed by French and German scientists.1 Mattila and colleagues2 found higher combined levels of caries, periodontitis, peri- apical lesions and pericoronitis (all serving as surrogate markers of oral infections) more frequently in patients with recent myocardial A B S T R A C T A RTICLE

2 Dr. Demmer is a postdoctoral research scientist, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City. Dr. Desvarieux is a faculty member, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City;

chair of excellence, Unité Mixte de Recherche, Site 707, Institut National de la Santé et de la Recherche Médicale, Université Pierre et Marie Curie-Paris. Address reprint requests to Dr. Desvarieux at Department of Epidemiology, Mailman School of Public Health, Columbia University,

722 W. 168th St., Suite 1704, New York, N.Y. 10032, e-mail [email protected] . J A D A C O N T I N U I N G E D U C A T I O N ? ? ? Periodontal infections and cardiovascular disease The heart of the matter Ryan T. Demmer, PhD;

Mo?se Desvarieux, MD, PhD JADA, Vol.

137 http://jada.ada.org October

2006 15S infarction than in healthy control patients from the same population. Syrjanen and colleagues3 observed relatively poor oral health among patients who had experienced a recent stroke compared with control patients who had not experienced stroke. These authors drew careful conclusions, pri- marily because of the substantial overlap noted between risk factors for both periodontal disease and CVD―being older, being male, cigarette smoking, diabetes and low socioeconomic status. If periodontal disease and CVD simply share common risk factors, a correlation between the two would be expected even if a causal link did not exist. This epidemiologic phenomenon is referred to as confounding.

4 These studies enrolled patients when they came to a hospital with a heart attack or stroke, which meant that measures of oral health were taken after the cardiovascular event had occurred, raising the possibility that the cardiovascular event might have influenced oral health nega- tively. The geographical homo- geneity and small number of par- ticipants enrolled in these studies precluded any reliable generaliza- tions beyond the specific study population. Subsequently, studies addressing many of these limitations have made substantial contributions to our understanding of periodontal disease and CVD associations.5,6 These studies collectively included more than 100,000 adult men and women from diverse populations, which has enhanced the consistency and generalizability of the proposed association between periodontal disease and CVD. Because many of these studies were prospective or retrospective,7-13 the assessment of periodontal disease often was done before the occurrence of cardiovascular events, thus better establishing the temporality of the association. Several authors also rigorously tested whether periodontal disease was associated with CVD independent of risk factors common to both con- ditions. Specifically, most studies reported posi- tive associations after accounting for the effects of multiple risk factors such as age, sex, diabetes, cholesterol levels, blood pressure, obesity, smoking status, dietary patterns, race/ethnicity, education and socioeconomic status.7-11,13 These results have particular importance in the case of smoking, as some have postulated that the asso- ciation between periodontal disease and CVD is due to smoking-related bias.14 While smoking status was assessed in most studies, the level of adjustment varied, with some studies providing a more detailed smoking assessment. For example, Morrison and colleagues10 observed that partici- pants with periodontal disease had more risk of developing fatal coronary heart disease and expe- riencing stroke even after controlling for smoking status by classifying current smokers according to the number of cigarettes smoked per day. Others have controlled for smoking by restricting their analyses to never-smokers. Joshipura and col- leagues13 reported an

80 percent elevation in stroke risk for people with zero to

24 teeth compared with those who had

25 or more teeth among never-smokers. Desvarieux and colleagues15 reported similar findings between tooth loss and carotid atherosclerosis, unmodified by smoking sta........