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Correlation between the severity of periodontitis and coronary artery stenosis in a Chinese population. Only subjects that were >=60 years old, had >=50% stenosis in at least one coronarartery, and did not have diabetes or a history of smoking were included.
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Yang 2013 Correlation Between the Severity of Periodontitis and Coronary Artery Stenosis in a Chinese Population
Correlation between the severity of periodontitis and coronary artery stenosis in a Chinese population. Only subjects that were >=60 years old, had >=50% stenosis in at least one coronarartery, and did not have diabetes or a history of smoking were included.
Correlation between the severity of periodontitis and coronary artery stenosis in a Chinese population. Only subjects that were >=60 years old, had >=50% stenosis in at least one coronarartery, and did not have diabetes or a history of smoking were included.
Correlation between the severity of periodontitis and
coronary artery stenosis in a Chinese population
J Yang,* L Feng,* J Ren,* G Wu, S Chen,* Q Zhou,* Z Du, S Zhang,* C Hu, X Wu, L Ling *Department of Stomatology, First Afliated Hospital of Sun Yat-sen University, China. Department of Cardiovascular Medicine, First Afliated Hospital of Sun Yat-sen University, China. Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, China. ABSTRACT Background: The aim of this study was to evaluate the relationship between the severity of periodontitis and the extent and degree of coronary artery stenosis in a Chinese population. Methods: Patients (n = 853) with coronary artery stenosis conrmed by coronary angiography were eligible to take part in the study. Only subjects that were 60 years old, had 50% stenosis in at least one coronary artery, and did not have diabetes or a history of smoking were included (n = 115). After periodontal examination, including bleeding index, prob- ing depth calculus index, plaque index and periodontal attachment loss, four groups were dened based on the severity of periodontitis: no periodontitis/gingivitis (M0, n = 19); mild periodontitis (M1, n = 27); moderate periodontitis (M2, n = 31); and severe periodontitis (M3, n = 38). The extent and degree of coronary artery stenosis was obtained by calcu- lating the Gensini score (GS). Results: The GS was signicantly greater in the M3 group compared with the M0 group. Multiple linear regression anal- ysis revealed that probing depth and plaque index were signicantly correlated with the GS. Conclusions: The extent and severity of coronary artery stenosis in Chinese patients 60 years old is positively correlated with the severity of periodontitis. Keywords: Coronary artery disease, periodontitis, coronary artery stenosis, Gensini score, clinical attachment loss. Abbreviations and acronyms: BI = bleeding index; CAG = coronary angiography; CAL = clinical attachment loss; CHD = coronary heart disease; CI = calculus index; GS = Gensini score; HDL-C = high density lipoprotein cholesterol; LAD = left anterior descending; LDL-C = low density lipoprotein cholesterol; PB = probing depth; PLI = plaque index. (Accepted for publication 12 October 2012.) INTRODUCTION Coronary heart disease (CHD) is a life-threatening disease that has a serious impact on physical and emotional well-being. CHD is also one of the major causes of death worldwide. In-depth studies on the aetiology, pathogenesis and clinical treatment of CHD have identied other important pathogenic factors in addition to the traditional risk factors of smoking, hypertension, diabetes and dyslipidaemia. 1 Since the 1990s, researchers have provided evidence that infec- tion is one of the risk factors for atherosclerosis and thrombus formation and that systemic inammation due to infection promotes and accelerates the initia- tion and progression of atherosclerosis. 25 There are several similarities between CHD and peri- odontitis. In particular, infection and inammation are common mechanisms in both diseases. 6,7 Periodontitis is one of the main causes of tooth loss in humans. Recur- rent infection of the periodontium results in higher lev- els of inammatory factors in the serum. As the severity of periodontitis increases, there is a greater systemic inammatory response. 810 Previous studies showed that periodontitis leads to atherosclerosis through periodon- tal pathogens and their by-products, or through the release of inammatory mediators from periodontal tis- sue that induce endothelial dysfunction. 11,12 Pathologi- cal studies of atherosclerotic plaques have identied the presence of periodontal pathogens. 13,14 Although not all studies have shown a signicant association between periodontitis and CHD, 15 the majority of studies, as summarized in a meta-analysis by Bahekar et al., 16 demonstrated a signicant associ- ation between periodontal disease and CHD even after adjusting for traditional risk factors such as smoking, blood lipids, race, gender and obesity. 2013 Australian Dental Association 333 Australian Dental Journal 2013; 58: 333338 doi: 10.1111/adj.12087 Australian Dental Journal The ofcial journal of the Australian Dental Association A limitation of previous studies that investigated the relationship between periodontal disease and CHD was that the denition of periodontitis was highly vari- able and not always based on a clinical examination. Furthermore, the denition of CHD was variable, and the presence of coronary artery occlusion or stenosis was not always documented by coronary angiography (CAG). Only a few studies have examined the relation- ship between periodontitis and the presence of CHD assessed by CAG. 1720 Although the results of these studies suggested that there was a positive association between periodontitis and coronary arterial stenosis, these studies did not assess the severity and extent of stenosis throughout the entire coronary arterial tree. Because of limitations in the denitions of periodontitis and CHD in previous studies, we performed a retro- spective analysis to systemically evaluate the relation- ship between periodontitis and CHD in a Chinese population with coronary stenosis (50%) documented by CAG. We used a standardized scoring method, the Gensini method, 21 to evaluate the extent and severity of coronary artery stenosis throughout the entire coro- nary arterial tree. In addition, a standardized grading method, the Armitage method, 22 was used to grade the severity of periodontitis. MATERIALS AND METHODS Subjects There were 853 patients with CHD disease who were admitted to our hospital from January 2011 to Febru- ary 2012 that were eligible for the study. The study was approved by the medical ethics committee at the First Afliated Hospital of Sun Yat-sen University. All examinations were acknowledged and consented by the patients, and consent forms were signed. All patients that were included in the study met the following inclusion criteria: age 60 years old, steno- sis >50% in at least one branch of a major coronary artery conrmed by CAG, and at least 14 natural teeth in full denture. Patients were excluded if they met any of the following criteria: periodontal treat- ment; antibiotic administration, or medications induc- ing gingival overgrowth within six months of the study; pregnancy; a history of smoking or alcoholism; acute cerebrovascular disease, peripheral vascular dis- ease or severe infection; systemic diseases including diabetes, respiratory diseases, malignant tumours, or liver or kidney dysfunction. Study design Although the study design was retrospective, the peri- odontal examiners had no previous knowledge of the coronary angiography results, and the physicians that interpreted the coronary angiograms had no informa- tion about the patients periodontal condition. All subjects completed a questionnaire for general infor- mation, that included gender, age, height, family his- tory of periodontitis, history of smoking, blood pressure, the degree of stenosis by coronary angiogra- phy, history of systemic disease, triglycerides, total serum cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and habit and status of oral hygiene (number, time and method of daily toothbrushing, bleeding condi- tions and regularity of oral examinations). Diagnosis of CHD CHD was diagnosed by CAG using Judkins tech- nique with projections in multiple views. All angio- grams were evaluated by experienced physicians from visual assessment, and the degree of coronary stenosis was determined. The extent and severity of coronary artery stenosis was based on the Gensini score (GS). 21 To obtain the GS, the coronary arterial tree was divided into 14 segments, and the degree of stenosis evaluated in each segment. A score of 1 was given for 125% stenosis, 2 for 2650% stenosis, 4 for 5175% stenosis, 8 for 7690% stenosis, 16 for 9199% and 32 for total occlusion. The score of each segment was then multiplied by a weighting factor that represented the importance of a lesion in that segment. The weighting factor was 5 for a left main lesion; 2.5 for a proximal left anterior descending (LAD) or left circumex (LCx) lesion; 1.5 for a mid- segment LAD or LCx lesion, 1 for a lesion in the distal LAD, LCx, rst diagonal branch, rst obtuse marginal branch, right coronary artery, posterior descending artery or septal artery; and 0.5 for a lesion in the second diagonal or obtuse marginal branches. The products in each of the 14 segments were then summed to obtain the nal GS. The GS values ranged from 2 to 190. A higher GS score indicated a greater extent and severity of coronary stenosis. Diagnosis of periodontitis According to the diagnostic standard from Armit- age, 22 the grouping of periodontitis severity was based on clinical attachment loss (CAL) to determine sever- ity. In the group with no periodontitis/gingivitis (M0), the average CAL was 0.5 mm, the number of loci (with proximal CAL 3 mm) was zero and the num- ber of teeth lost was 2 (excluding the third molar, orthodontic teeth, tooth extraction due to trauma or injury, tooth loss due to severe caries and congenital tooth loss). In the group with mild periodontitis (M1), the average CAL 0.6 mm but 1.5 mm, the number of loci (with proximal CAL 3 mm) was zero, and 334 2013 Australian Dental Association J Yang et al. the number of teeth lost was 3. In the moderate peri- odontitis group (M2), the average CAL was 1.6 but 2.4 mm, loci (with proximal CAL 3 mm) were dis- tributed in three different areas or the total number was 6 and the number of teeth lost was 5. In the severe periodontitis group (M3), the average CAL was 2.5 mm, loci (with proximal CAL 5 mm) were dis- tributed in three to four different areas and the num- ber of teeth lost was 14. All patients received an oral examination by the same physician with a Hu-Friedy periodontal probe. The complete intercuspal position was examined, and six loci were probed in each tooth (buccal surface, and the distal, central and proximal lingual surfaces of the tooth) for the examination of CAL, probing depth (PD), bleeding index (BI), calcu- lus index (CI) and plaque index (PLI). The average values of individual indexes were used as the corre- sponding values for each patient. Blood sampling and assays On the morning (67 am) of the second day of hospital- ization, a blood sample was collected by drawing 3 ml of fasting venous blood. After storing at low tempera- ture for 1 hour, the blood sample was delivered to the medical laboratory at the First Afliated Hospital of Sun Yat-sen University. The blood sample was centri- fuged at 3600 rpm for 5 minutes (KDL-1044, USTC Chuangxin Co. Ltd., Zonkia Branch, China). Total cho- lesterol and triglycerides was determined with ELISA kits, whereas HDL-C and LDL-C were detected by the direct method. Normal ranges of blood lipid were as follows: total cholesterol, 3.105.18 mmol/L; triglyce- rides 0.331.7 mmol/L; HDL-C, 1.091.63 mmol/L; and LDL-C, 1.943.61 mmol/L. Statistical analysis All statistical analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA). Continuous vari- ables were expressed as mean SD; categorical vari- ables were presented as the number (percentage) of patients. The Chi-square test was used to detect any difference in severity of periodontitis; the Mann Whitney U test was used to detect any difference in age, total cholesterol, triglyceride, HDL-C, LDL-C, BMI, GS, CAL, PD, BI, CI, and PLI among the male and female groups. The KruskalWallis test was used to detect any difference among M0, M1, M2 and M3 groups, and when a signicant difference was detected, the MannWhitney U test and Bonferroni adjustment of critical p-values were used for between- group comparisons. Multiple linear regression analysis was used to examine the correlations between the GS and CAL, PD, BI, CI and PLI. The signicance level a was set at 0.05. RESULTS Patient demographic characteristics are shown in Table 1. A total of 115 patients with CHD were included in this study; 82 males and 33 females. There were 19 patients in the M0 group, 27 in the M1 group, 31 in the M2 group and 38 in the M3 group. The total cholesterol, triglycerides, HDL-C and LDL-C were in the normal range in all patients. The demo- graphic characteristics of the M0, M1, M2 and M3 groups are shown in Table 2. The four groups were similar with respect to age, total cholesterol, triglycer- ide, LDL-C and BMI (all p > 0.05). Compared with the M0 group, the M1 and M3 groups had lower HDL-C, although the values were still within the nor- mal range. The GS was signicantly greater in the M3 group compared with that in M0 group. For the sever- ity of periodontitis, the M1, M2 and M3 groups had signicantly increased CAL and CI compared with the M0 group. Furthermore, compared with the M1 group, the M2 and M3 groups had signicantly increased CAL and the M3 group had a signicantly increased CI. In addition, the M3 group had signi- cantly increased CAL and CI compared with the M2 group. The PD, BI and PLI were signicantly higher in the M2 and M3 groups compared with the M0 group, and the BI in the M3 group showed a signicant increase compared with that in the M1 group. The GS among all the patients stratied according to the sever- ity of periodontitis is shown in Fig. 1. The correlation between the severity of CHD and CAL, PD, BI, CI and PLI are shown in Table 3. Mul- tiple regression analysis revealed that PD and PLI were signicantly correlated with the GS. After adjust- ing for CAL, PD, BI, CI and PLI, an increase in PD of Table 1. Clinical characteristics Variable Mean SD Age (years) 65.0 3.6 Total cholesterol (mmol/l) 4.2 1.1 Triglyceride (mmol/l) 1.5 0.9 HDL-C (mmol/l) 1.1 0.3 LDL-C (mmol/l) 2.7 1.2 BMI (kg/m 2 ) 23.8 4.0 Gender, n (%) Male 82 (71.3%) Female 33 (28.7%) Severity of periodontitis, n (%) M0 19 (16.5%) M1 27 (23.5%) M2 31 (27.0%) M3 38 (33.0%) Continuous variables are presented as mean standard deviation; categorical variables are presented as number (percentage). HDL-C = high density lipoprotein cholesterol; LDL-C = low density lipoprotein cholesterol; GS = Gensini score; CAL = clinical attach- ment loss; PD = probing depth; BI = bleeding index; CI = calculus index; PLI = plaque index. 2013 Australian Dental Association 335 Periodontitis correlated to coronary heart disease 1 unit was associated with an increase in the GS of 0.62 points. Furthermore, an increase in PLI of 1 unit was associated with an increase in the GS of 0.57 points. DISCUSSION This is the rst study that combined the Armitage method for the evaluation of periodontitis with the Gensini scoring system to assess the extent and sever- ity of CHD. The results showed that the GS was sig- nicantly higher in the M3 group with the most severe periodontitis compared with the M0 group with no peridontitis/gingivitis. Furthermore, multiple linear regression analysis using all patients showed that PD and PLI were positively correlated with the GS. These results indicate that periodontitis might be an independent risk factor for the severity of CHD. An important aspect of the present study was that it was conducted in a relatively homogenous popula- tion. All patients were 60 years old and patients with risk factors common for both periodontitis and CHD such as smoking and diabetes were excluded as these factors might confound the relationship between periodontitis and CHD. 16,23 Furthermore, the Armit- age method was used to classify the results of the periodontal examination. Full-denture teeth were examined, and six loci were taken for each tooth. These approaches avoided data loss and selection bias. The Armitage method employs CAL as the index of the severity of periodontitis. Although previous studies have used CAL to dene peridontitis, other studies have used pocket (probing) depth. There is a lack of consensus on the best denition. 24 When patients in the present study were stratied into four groups using the Armitage method to dene the severity of periodontitis, the M3 group with the most severe peri- odontitis had a signicantly higher GS than the M0 group with no periodontitis/gingivitis. However, in Table 2. Clinical characteristics among all patients stratied according to the severity of periodontitis Variable M0 (n = 19) M1 (n = 27) M2 (n = 31) M3 (n = 38) p-value Age (years) 64.2 3.1 64.4 3.3 64.5 3.2 66.1 4.0 0.171 Total cholesterol (mmol/l) 4.3 1.2 4.1 0.8 4.2 1.1 4.1 1.2 0.585 Triglyceride (mmol/l) 1.8 1.4 1.5 0.8 1.6 1.0 1.4 0.6 0.924 HDL-C (mmol/l) 1.2 0.2 1.0 0.2* 1.1 0.2 1.1 0.4* 0.004 LDL-C (mmol/l) 2.6 0.8 2.7 0.8 2.6 1.0 2.9 1.8 0.998 BMI (kg/m 2 ) 22.9 6.3 24.8 4.2 23.2 3.3 24.1 2.5 0.552 GS 10.9 12.8 15.2 17.8 31.2 35.0 36.0 36.7* 0.006 Periodontitis Index CAL 0.5 0.2 1.2 0.2* 2.0 0.2* 3.1 0.3* <0.0001 PD 2.8 0.3 3.2 0.5 3.3 0.7* 3.7 0.8* <0.0001 BI 1.2 0.7 1.6 0.6 1.9 0.6* 2.2 0.7* <0.0001 CI 0.8 0.5 1.7 1.0* 1.9 0.7* 2.6 0.8* <0.0001 PLI 1.6 1.0 2.3 0.9 2.5 0.5* 2.7 0.5* <0.0001 Data are presented as mean standard deviation and were tested by the KruskalWallis test; the MannWhitney U test and Bonferroni adjust- ment of critical p-values were used for multiple comparisons. Signicant difference among the four periodontitis groups. *Signicant difference between M0 and M1/M2/M3. Signicant difference between M1 and M2/M3. Signicant difference between M2 and M3. HDL-C = high density lipoprotein cholesterol; LDL-C = low density lipoprotein cholesterol; GS = Gensini score; CAL = clinical attachment loss; PD = probing depth; BI = bleeding index; CI = calculus index; PLI = plaque index. M0 G e n s i n i
s c o r e 0 20 40 60 80 100 120 140 160 M1 M2 M3 Fig. 1 Gensini score among all the patients stratied according to the severity of periodontitis. Table 3. Multiple regression analysis for the association between the Gensini score and severity of periodontitis Variable Regression coefcient Standard error p-value Intercept 0.82 0.72 0.259 CAL 0.19 0.17 0.280 PD 0.62 0.19 0.002 BI 0.33 0.22 0.129 CI 0.02 0.22 0.945 PLI 0.57 0.25 0.024 CAL = clinical attachment loss; PD = probing depth; BI = bleeding index; CI = calculus index; PLI = plaque index. 336 2013 Australian Dental Association J Yang et al. multivariate linear regression analysis, the average CAL was not correlated with the GS (p = 0.28). Only the PD and PLI were correlated with the GS. Although the mechanism for this is not clear, there may have been complex relationships among these three variables that were important in the multivariate regression model. A major strength of this study was that the degree of coronary artery stenosis was assessed in 14 differ- ent segments of the coronary arterial tree using CAG. The Gensini scoring system assigned different weight- ing factors to the 14 segments and generated a single score that reected the overall extent and severity of coronary stenosis in each patient. Although other studies have used CAG to document the presence of coronary artery stenosis in patients with periodonti- tis, 1720 our study is the rst to show a relationship between the extent and severity of coronary stenosis throughout the coronary arterial tree and the severity of periodontitis. An interesting nding in the present study was that 17% of patients with CHD documented by CAG had no periodontitis/gingivitis. Furthermore, the GS in this group (M0) was not signicantly different from that in the M1 group with mild periodontitis. These results indicate that there are multiple factors that lead to CHD and this may well account for the lack of a strong association between periodontitis and CHD that has been observed in some previous studies. 16 Alternatively, our results may have been inuenced by the inclusion/exclusion criteria used in the study and the analytical methods. An important variable that was not controlled in the present was gender. When regression analysis was conducted separately in each gender, there was no sig- nicant association between the severity of periodonti- tis and CHD (data not shown). This may well have been due to the reduction in statistical power due to a decrease in sample size. It is possible that gender has an inuence on the association between periodontitis and CHD, but this will need to be evaluated in a lar- ger population. The results of our study indicated that periodontitis might be an independent risk factor for CHD in the population 60 years old. Persson et al. 25 showed a correlation between alveolar bone loss (assessed by radiography) and calcium accumulation in the carotid arterial wall in 1064 subjects that ranged in age from 6075 years old. The same study also showed that alveolar bone loss was associated with a self-reported history of heart attack. Thus, the results of our study tend to conrm these previous ndings that there is an important association between periodontitis and CHD in patients 60 years old. This study has several important limitations. The number of volunteers recruited in this study without receiving medication for CHD (e.g. antilipaemic agents) was small, the design was retrospective and there was no control group. Furthermore, our study population was limited to Chinese patients 60 years old with CHD who did not have diabetes, a history of smoking or a history of cerebral or peripheral vas- cular disease. The relationship between periodontitis and CHD may be different in more ethnically diverse populations or younger patients or patients with more risk factors. To clearly establish the relationship between periodontitis and CHD, unied standards should be formulated and a larger sample number should be included. In addition, to further clarify the effect of periodontitis on coronary artery stenosis, CHD patients with periodontitis should receive peri- odontal treatment and be followed in a longitudinal manner to determine whether periodontitis treatment improves the prognosis of CHD patients. CONCLUSIONS The extent and severity of coronary artery stenosis in Chinese patients 60 years old with CHD is positively correlated with the severity of periodontitis. Periodon- titis might be an independent risk factor for CHD. ACKNOWLEDGEMENTS This study was supported by the Science and Technol- ogy Planning Project of Guangdong Province, China; project number: 2007B031500018; 2009B060700042. 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Address for correspondence: Jun-ying Yang MD Department of Stomatology First Afliated Hospital of Sun Yat-sen University No. 58 Zhongshan Road 2 Guangzhou 510080 China Email: yangjuny@mail.sysu.edu.cn 338 2013 Australian Dental Association J Yang et al.