Public Health Implications of Chronic Periodontal Infections in Adults

Difficulties in Evaluating the Relationships between Periodontal Disease and Cardiovascular Diseases
John Gunsolley, DDS, Chair, Departments of Periodontics and Endodontics, University of Maryland Dental School, Baltimore, Maryland

A great deal of controversy exists about whether periodontal disease is associated with the severity or incidence of cardiovascular disease. To date, there have been multiple cross-section, cohort, and case-control studies with conflicting results.

Some studies have reported a moderate relationship, and others have reported no relationship at all. It has been difficult to compare these studies because of a lack of consistency in study designs, outcome measures of cardiovascular disease, and outcome measures of periodontal disease. This inconsistency is especially evident in measurement of periodontal disease and could be a major source of inconsistent findings. If there is a relationship between cardiovascular disease and periodontal disease, there must be an adequate exposure of periodontal disease to create cardiovascular disease. It is even difficult, however, to determine criteria for classifying an individual as having periodontal disease. In general, numerous criteria have been used in studies of periodontal disease; no consistent criteria separate individuals who have disease from those who are periodontally healthy. Further complicating this problem is that periodontal disease is measured at multiple places on multiple teeth, so criteria are usually stated as extent and severity of disease (i.e. 3 mm of attachment loss at four or more sites). Thus, both threshold and number of sites or teeth may vary.

Moreover, complicating the problem of defining criteria for periodontal disease is the variety of measures of periodontal disease that have been used at these multiple locations. In studies relating periodontal disease to cardiovascular disease, authors have used probing measurements (attachment level and pocket depth), radiographic measurements, a combination of bony defect and deep pocket measurements, a combination of periodontal and gingivitis measurements, and nonprobing indices (Russell’s Index). Almost all of the studies investigating this relationship have used different criteria for periodontal disease.

Studies based on nonprobing measures such as Russell’s Index have generally failed to find a relationship between periodontal disease and cardiovascular disease. Half the studies that used self-reported history of periodontal disease failed to show a relationship between periodontal disease and cardiovascular disease. In contrast, among studies that have used probing periodontal measurements (such as attachment level), a larger percentage have found a relationship between periodontal disease and cardiovascular disease. In some of these studies, the authors used progressively more severe criteria for periodontal disease; they found a stronger relationship between periodontal disease and cardiovascular disease as the criteria became more severe. In contrast, using varying extent criteria with the Russell Index another author could not find the same relationship.

In summary, the lack of consistent results in these studies makes it difficult to determine if an association exists between the two diseases. The types of measurements used in these studies may have contributed to this problem. Lack of consistency has also made it difficult to combine the results of these studies in meta-analysis to further determine the strength of the potential association of these diseases.

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Historical Document
Page last reviewed: February 2, 2005
Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion