Oral Medicine
Meta-analysis of periodontal disease and risk of coronary heart disease and stroke*,**,*,**,*,**,

Abstract presented at the conference of The International Association for Dental Research, Chiba, Japan, Jun 28, 2001; won second place in the Morita Junior Investigator Award in Geriatric Oral Research.
https://doi.org/10.1067/moe.2003.107Get rights and content

Abstract

Objective. The purpose of this study was to analyze published studies and abstracts in order to provide a quantitative summary of periodontal disease as a risk factor for cardiovascular disease and to explore the possible causes for conflicting results in the literature. Study Design. We searched all published literature on the Medline literature search engine since 1980. An additional search was performed with bibliographic citations from each article. Nine cohort studies (8 prospective and 1 retrospective), in which relative risks (RRs), CIs, and P values were reported or could be calculated were included. Four researchers independently extracted RRs, CIs, and P values from each study and evaluated the degree of confounding adjustment. The combined result was calculated with weighted average, and sources of disparity were tested with regression analyses. Results. The summary RR was 1.19 (95% CI, 1.08 1.32), indicating a higher risk of future cardiovascular events in individuals with periodontal disease compared with those without. In an analysis stratified to individuals of ≤65 years of age, the RR was 1.44 (95% CI, 1.20 to 1.73). When the outcome was restricted to stroke only, the RR was 2.85 (95% CI, 1.78 to 4.56). In the metaregression analysis, the effects of residual confounding caused an overestimate of the results by 12.9% and, with a proxy for periodontal disease, caused an underestimate of 29.7%. Conclusion. Periodontal disease appears to be associated with a 19% increase in risk of future cardiovascular disease. This increase in RR is more prominent (44%) in persons aged ≤65 years. Although the increment of risk between subjects with or without periodontal disease in the general population is modest, at around 20% because nearly 40% of population has periodontal disease, this modest increase may have a profound public health impact. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:559-69)

Section snippets

Literature search

A search of Medline for all the published articles in the English language with coronary heart disease (CHD) or stroke or both as the outcome and periodontal disease as the predictor variable was performed in February 2001. The CVD search terms used were cerebrovascular disorders, cerebrovascular accident or stroke, cardiovascular diseases, or coronary heart disease. We combined these terms with periodontal diseases. Nine cohort studies were identified. In addition, several studies cited in the

Results

The details of the 9 studies involving 7035 cardiovascular events from the cohort of 107,011 individuals are shown in Table III.The test of publication bias was not significant (Begg's test, P =.18), suggesting that it is unlikely that some studies might have been chosen preferentially. Interreviewer reliability of data extraction was tested with percent agreement. The average correlation coefficient between the reviewers was 0.9. Quality evaluation was described by the percent of the maximum

Discussion

Our results suggest that periodontal disease may be significantly associated with CVD, although the increment of risk between subjects with or without periodontal disease in the general population is modest, at around 20%. However, because nearly 40% of the population has periodontal disease,6 this modest increase may have a profound public health impact. A significant and stronger association of periodontal disease with the incidence of CVD was observed among subjects aged 65 years or younger

Conclusion

Our results suggest that periodontal disease is associated with the increased risk of development of subsequent CVD by approximately 19% in the general population. However, this summary result might still underestimate the true risk increase. Because in some studies inadequate confounding adjustment resulted in an overestimate of the RR by 12.9% and use of questionnaires resulted in an underestimate of the RR by 29.7%, the net result is still lower than the true RR. Further research is needed

Acknowledgements

We thank Dr David Bellinger, The Children's Hospital, Harvard Medical School, Boston, Mass, for input into and comments on epidemiologic interpretations.

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    *

    Reprint requests: Sok-Ja Janket, DMD, MPH, Division of Preventive Medicine, Harvard Medical School, 900 Commonwealth Ave East, Boston, MA 02215-1204, [email protected]

    **

    Views expressed in this article are those of the authors and do not represent those of the Department of Veterans Affairs.

    *

    aFellow, VA Medical Center, Dental Service, Bedford, Mass; Harvard School of Public Health, Boston, Mass.

    **

    bChief, Stroke Neuroscience Unit, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Md.

    *

    cInstructor, Harvard School of Public Health, Boston, Mass; Harvard School of Dental Medicine, Boston, Mass.

    **

    dChief, Outcomes Section, VA Center for Health Quality, Outcomes, & Economic Research, Bedford, Mass; Associate Professor and Chair of General Dentistry, Boston University Goldman School of Dental Medicine and School of Public Health, Boston, Mass.

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