Cardiovascular prevention starts from your mouth

Abstract

Atherosclerosis remains the leading cause of cardiovascular disease worldwide and recent clinical evidence has confirmed that inflammation plays a significant role in its complications. Diseases characterized by a chronic inflammatory exposure (including rheumatoid arthritis, psoriasis, oral inflammatory diseases, chronic bowel diseases, etc.) have been associated with raised risk of future cardiovascular events, and have been studied to explore the potential impact of anti-inflammatory drugs or procedures on mitigating the cardiovascular risk. The ability to modulate inflammation in these conditions has also enabled identification of inflammatory pathways potentially involved in the regulation of vascular homeostasis. The association between parameters of poor oral health and risk of cardiovascular diseases has been repeatedly reported by observational (cross-sectional, case controls, and prospective) studies in humans, leading to the inclusion of periodontitis (a common oral inflammatory disease) in the group of potential conditions increasing the risk of cardiovascular disease in the most recent European Guidelines for cardiovascular disease prevention. The interest around the potential link between oral health and cardiovascular disease is explained by its potential benefits in term of cardiovascular disease prevention. Indeed, oral diseases are highly prevalent in the general population, collectively affecting 3.9 billion people worldwide. This prevalence is significantly higher than other common cardiovascular risk factors (i.e. diabetes) and if a causal link with atherosclerosis could be demonstrated, the proportion of individuals in the general population who might obtain cardiovascular benefits from improved oral health could be substantial, with a significant reduction of the costs for the public health systems. In this issue of the European Heart Journal, Kang et al. report the results of a large, prospective, population-based study exploring the potential influence of oral health care on the future risk of cardiovascular disease. Using data from the National Health Insurance System-National Health Screening Cohort, including almost the entire population in Korea, the authors documented that an increased number of dental caries, the presence of periodontitis, and a greater loss of teeth were associated with an increased risk of future major cardiovascular events (MACEs), including cardiovascular death, acute myocardial infarction, heart failure, and stroke. Importantly, frequent tooth brushing and regular dental visits were associated with a lower cardiovascular disease risk, and mitigated the risk of cardiovascular events in participants with oral diseases. While, the association between periodontitis and adverse cardiovascular events lost statistical significance after multivariable adjustments, including age, hypertension, diabetes, and tobacco smoking, measures of dental caries and tooth loss remained significantly associated with the risk of MACEs in the fully adjusted model. Based on these results, the authors concluded that oral health promotion strategies (i.e. better dental hygiene behaviour) could modify the cardiovascular risk associated with poor oral health. The results by Kang et al. confirm previous studies suggesting a potential impact of oral inflammatory diseases on the risk of cardiovascular events, over and above the contribution of traditional cardiovascular risk factors. They also provide clinical evidence for a potential benefit in cardiovascular protection achieved by the simple adoption of better oral health behaviours in a large prospective study. This is important as current guidelines recognize the general lack of knowledge on the potential cardiovascular benefits obtained with active treatment of oral health diseases. The biological pathways accounting for the results presented by Kang et al. remain to be clarified. We have previously documented that periodontitis and an intensive treatment regimen able to improve gingival health can alter systemic inflammation, and have profound effects on endothelial cell function and biology. More recently, we confirmed that the same treatment improves metabolic control and endothelial function, and prevents renal deterioration in