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Contents lists available at ScienceDirect

Journal of Cardiology
journal homepage: www.elsevier.com/locate/jjcc

Original article

Association between dental caries and out-of-hospital cardiac arrests

of cardiac origin in Japan
Yasunori Suematsu (MD, PhD)a, Shin-ichiro Miura (MD, PhD, FACC, FJCC)a,b,
Bo Zhang (PhD)b,c, Yoshinari Uehara (MD, PhD, FJCC)a,b, Masahiro Ogawa (MD, PhD)a,b,
Naohiro Yonemoto (PhD)d, Hiroshi Nonogi (MD, PhD, FJCC)e, Ken Nagao (MD, PhD, FJCC)f,
Takeshi Kimura (MD, PhD, FJCC)g, Keijiro Saku (MD, PhD, FACP, FACC, FJCC)a,b,* on behalf of
the Japanese Circulation Society Resuscitation Science Study (JCS-ReSS) Group
a
Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Japan
b
The AIG Collaborative Research Institute of Cardiovascular Medicine, Fukuoka University, Fukuoka, Japan
c
Department of Biochemistry, Fukuoka University School of Medicine, Fukuoka, Japan
d
Department of Epidemiology and Biostatistics, National Center of Neurology and Psychiatry, Tokyo, Japan
e
Shizuoka General Hospital, Shizuoka, Japan
f
Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital, Nihon University School of Medicine,
Tokyo, Japan
g
Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Background: Oral infection contributes to atherosclerosis and coronary heart disease. We hypothesized
Received 3 April 2015 that dental caries may be associated with out-of-hospital cardiac arrests (OHCA) of cardiac origin, but
Received in revised form 8 June 2015 not non-cardiac origin.
Accepted 24 June 2015
Methods and results: We compared the age-adjusted incidence of OHCA (785,591 cases of OHCA: 55.4%
Available online xxx
of cardiac origin and 44.6% of non-cardiac origin) to the age-adjusted prevalence of dental caries between
2005 and 2011 in the 47 prefectures of Japan. In both the total population and males over 65 years, the
Keywords:
number of cases of dental caries was significantly associated with the number of OHCA of total and
Out-of-hospital cardiac arrest
Dental caries
cardiac origin from 2005 to 2011, but not those of non-cardiac origin. In the total population, the age-
Ecological study adjusted prevalence of dental caries was not significantly associated with the age-adjusted incidence of
Japan OHCA (total OHCA: r correlation coefficient = 0.22, p = 0.14; OHCA of cardiac origin: r = 0.25, p = 0.09;
OHCA of non-cardiac origin: r = 0.002, p = 0.99). Among male patients over 65 years, the age-adjusted
prevalence of dental caries was significantly associated with OHCA of total and cardiac origin, but not
non-cardiac origin (total OHCA: r = 0.47, p < 0.001; OHCA of cardiac origin: r = 0.37, p = 0.01; OHCA of
non-cardiac origin: r = 0.28, p = 0.054).
Conclusions: While oral hygiene is important in all age groups, it may be particularly associated with
OHCAs of cardiac origin in males over 65 years.
ß 2015 Published by Elsevier Ltd on behalf of Japanese College of Cardiology.

Introduction heart disease [6–9], atherosclerotic vascular disease [10], and

Oral infection may contribute to coronary heart disease [1]. Oral
infection and especially periodontal disease is associated with
carotid artery intima-media thickness [2–4], stroke [5], coronary
* Corresponding author at: Department of Cardiology, Fukuoka University School
of Medicine, 7-45-1 Nanakuma Jonan-ku, Fukuoka 814-0180, Japan.
Tel.: +81 92 801 1011; fax: +81 92 865 2692.
E-mail address: saku-k@fukuoka-u.ac.jp (K. Saku).
other cardiovascular disease [11–17]. Periodontal disease is also
associated with cardiovascular death [18–21]. It has been reported
that cardiovascular disease mortality was significantly higher
among dentate patients with periodontal disease [relative risk (RR)
1.97, confidence interval (CI) 1.01–3.85] than among those without
periodontal disease [20]. Ajwani et al. [18] reported that
periodontitis more than doubled the risk of cardiovascular
disease-related mortality among patients over 75 years old [hazard
ratio (HR) 2.28, CI 1.03–5.05]. In addition, Saremi et al. [21]
reported that severe periodontal disease had 3.2-fold risk (95% CI

http://dx.doi.org/10.1016/j.jjcc.2015.06.012
0914-5087/ß 2015 Published by Elsevier Ltd on behalf of Japanese College of Cardiology.

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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2 Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx

1.1–9.3) of cardiorenal mortality (ischemic heart disease and
diabetic nephropathy combined) compared with a reference group
after adjusting for risk factors, whereas it was not indicated that
periodontal interventions prevent the atherosclerotic vascular
disease or modify its outcomes [10]. Dental caries, as well as
periodontitis, has also been reported to be associated with
cardiovascular events [22–25], but the association in Japan has
not been studied to date.
The estimated number of patients with dental caries was
obtained from the Patient Survey published by the Ministry of
Health, Labor and Welfare of Japan [26]. Cardiac events include
various types such as coronary heart disease, arrhythmia, or
syncope [27]. In January 2005, the Fire and Disaster Management
Agency of Japan launched a prospective, nationwide, population-
based, cohort study in subjects who had had an out-of-hospital
cardiac arrest (OHCA) to evaluate the effect of the nationwide
dissemination of public-access automated external defibrillators
on the rate of survival among patients who had an OHCA [28–30],
and we have access to this database. Therefore, as a working
hypothesis, we assumed that dental caries would be associated
with OHCA of cardiac origin.
An ecological study is an epidemiologic analysis in which the
units of analysis are populations or groups of people rather than
individuals. Such studies are useful for generating a hypothesis,
and for comparing occupations, social classes, and generations.
With the use of two different large databases, we performed an
ecological study to investigate the association between dental
caries and OHCA of cardiac origin according to the age distribution
and sex.
Methods
Subjects
Patients who suffered from OHCA of cardiac or non-cardiac
origin (n = 435,064 and 350,527, respectively) and who were
enrolled in the All-Japan Utstein Registry of the Fire and Disaster
Management Agency between 2005 and 2011 were included in
this analysis. The estimated number of patients with dental caries
was obtained from the Patient Survey published by the Ministry
of Health, Labor and Welfare of Japan [26]. The populations in
the 47 prefectures of Japan were obtained from the Annual Report
on Current Population Estimates (2005–2011) published by the
Ministry of Internal Affairs and Communications of Japan [31].
The study protocol for analyses was approved by the Ethics
Committee of Fukuoka University (FU-#00000403), Japan.
this survey. We divided the estimated number of patients by the
population of the prefecture for each year and expressed the
results as the average prevalence of dental caries in 2005, 2008,
and 2011. In the 2011 survey, the number of patients was not
estimated in Fukushima prefecture or in part of Miyagi prefecture
because of the Great East Japan Earthquake, and we excluded
these two prefectures from the 2011 survey. The method for age-
standardization was as described above.
Statistical analysis
The statistical analysis was performed using SAS software,
version 9.4 (SAS Institute, Cary, NC, USA) at Fukuoka University.
We used a t-test for continuous variables and chi-squared tests for
categorical variables. The Pearson product-moment correlation
coefficient was used to evaluate associations between groups. The
values are expressed as the mean  standard deviation (SD).
Statistical significance was defined as a p-value of less than 0.05.
Results
Patient characteristics in the All-Japan Utstein Registry
There were 797,422 cases of OHCA in the All-Japan Utstein
registry between 2005 and 2011, including 11,831 cases that did
not receive resuscitation. Table 1 shows the patient characteristics
in the All-Japan Utstein Registry between 2005 and 2011,
excluding 11,831 in the no-resuscitation group: 785,591 cases
of OHCA; 435,064 (55.4%) of cardiac origin; and 350,527 (44.6%) of
non-cardiac origin. Non-cardiac origin included cerebrovascular
disease, respiratory disease, malignant tumor, and exogenous
disease (4.8%, 6.1%, 3.5%, and 18.9%, respectively). Patients with
OHCA of cardiac origin were significantly older, and had a lower
incidence of males and a higher incidence of 1-month survival,
cerebral performance category 1 or 2, and overall performance
category 1 or 2. The initial rhythms in OHCA of cardiac origin were
significantly more likely to be ventricular fibrillation and pulseless
ventricular tachycardia, and less likely to be pulseless electrical
activity and asystole.
Time trends for the number of patients with OHCA and dental caries in
the 47 prefectures of Japan between 2005 and 2011
Yearly changes in the number of patients with OHCA and dental
caries in Japan between 2005 and 2011 are shown in Fig. 1. The
number of patients with OHCA of total, cardiac origin, and

Age-adjusted incidence of OHCA Table 1

Patient characteristics.
Using the Utstein Registry, we calculated the crude incidence of
Total Cardiac origin Non-cardiac origin
OHCA by determining the raw number of cases of OHCA by (n = 785,591) (n = 435,064) (n = 350,527)
prefecture and then dividing these numbers by the population of
Age, years 72  18 75  16* 69  21
the prefecture from 2005 to 2011. The Japanese Model Population
Male, n (%) 458,105 (58.3) 251,554 (57.8)* 206,551 (58.9)
in 1985 was used as a standard population, and age-standardiza- ROSC, n (%) 52,955 (6.7) 29,214 (6.7) 23,741 (6.8)
tion was performed by a direct method. 1-month survival, 37,912 (4.8) 23,553 (5.4)* 14,359 (4.1)
n (%)
Age-adjusted prevalence of dental caries CPC1 or 2, n (%) 17,410 (2.2) 13,230 (3.0)* 4180 (1.2)
OPC1 or 2, n (%) 17,223 (2.2) 13,109 (3.0)* 4114 (1.2)
Initial rhythm
The estimated number of patients with dental caries was VF 55,192 (7.0) 47,606 (10.9)* 7586 (2.2)
obtained from the Patient Survey published by the Ministry of pulseless VT 1862 (0.2) 1219 (0.3)* 643 (0.2)
Health, Labor and Welfare of Japan. This survey is performed once PEA 166,976 (21.3) 87,158 (20.0)* 79,818 (22.8)
Asystole 528,193 (67.2) 282,336 (64.9)* 245,857 (70.1)
every three years in patients of medical care institutions across
Japan who are selected by random stratified sampling. The ROSC, return of spontaneous circulation; CPC, cerebral performance category;
estimated number of patients who received medical treatment OPC, overall performance category; VF, ventricular fibrillation; VT, ventricular
tachycardia; PEA, pulseless electrical activity.
in hospitals and general clinics on the dates surveyed was used. *
p < 0.05 vs. Non-cardiac origin.
The data were not recorded within 99 patients in the age group of

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx 3

a Total OHCA b OHCA of cardiac origin

(/1,000 people) (/1,000 people)
140 80
120 70

100 60
50
80
40
60 y = 3849x + 96822 y = 2535.5x + 52005
R² = 0.958 30 R² = 0.950
40 20
20 10
0 0
2005 2006 2007 2008 2009 2010 2011 2005 2006 2007 2008 2009 2010 2011
(year) (year)

c OHCA of non-cardiac origin d Dental caries

(/1,000 people) (/1,000 people)
60 350

50 300

40 250
200
30
y = 1313.5x + 44817 150 y = -700x + 301300
R² = 0.891 R² = 0.011
20
100
10 50

0 0
2005 2006 2007 2008 2009 2010 2011
2005 2006 2007 2008 2009 2010 2011
(year) (year)

2
Fig. 1. Yearly changes in the number of patients in Japan between 2005 and 2011. R = determination coefficient. OHCA, out-of-hospital cardiac arrests.

non-cardiac origin increased between 2005 and 2011. In contrast,
the number of patients with dental caries slightly decreased from
2005 to 2011.
Correlations between the number of patients with OHCA and dental
caries in the 47 prefectures of Japan
Fig. 2 shows the distributions of the number of patients with
OHCA and dental caries in the 47 prefectures of Japan from
2005 to 2011. Fig. 3 shows the associations between the number
of patients with OHCA and dental caries in the 47 prefectures of
Japan from 2005 to 2011. The prefectures of Fukushima and
Miyagi were excluded because of the data loss. The number of
patients with dental caries was significantly and positively
associated with the numbers of patients with OHCA of total and
cardiac origin, but not of non-cardiac origin (total OHCA, r:
correlation coefficient = 0.45, p = 0.002; OHCA of cardiac origin,
r = 0.59, p < 0.001; OHCA of non-cardiac origin, r = 0.05,
p = 0.73).
Time trends for the numbers of patients with OHCA and dental caries
among male patients over 65 years old in the 47 prefectures of Japan
between 2005 and 2011
Yearly changes in the number of patients with OHCA and dental
caries among male patients over 65 years old in Japan between
2005 and 2011 are shown in Fig. 4. The numbers of patients with
OHCA of total, cardiac origin, non-cardiac origin, and dental caries
increased between 2005 and 2011. Fig. 5 shows the associations
between the number of patients with OHCA and dental caries
among male patients over 65 years old in the 47 prefectures of
Japan from 2005 to 2011. The prefectures of Fukushima and Miyagi
were excluded because of the data loss. The number of patients
with dental caries was more significantly and positively associated
with the number of patients with OHCA of total and cardiac origin,
but not non-cardiac origin, than those in the total population
(total OHCA, r = 0.50, p < 0.001; OHCA of cardiac origin, r = 0.55,
p < 0.001; OHCA of non-cardiac origin, r = 0.09, p = 0.53). We also
analyzed the number of patients with OHCA and dental caries
among female patients over 65 years old in the 47 prefectures of
Japan from 2005 to 2011. In the female group, the number of
patients with dental caries did not increase year by year (data not
shown). There was a significant association between the number of
cases of dental caries and total OHCA (total OHCA, r = 0.33,
p = 0.02), but the association between the number of cases of
dental caries and OHCA of cardiac origin or non-cardiac origin from
2005 to 2011 did not have significance (OHCA of cardiac origin,
r = 0.19, p = 0.19; OHCA of non-cardiac origin, r = 0.26, p = 0.08).
Correlations between the age-adjusted incidence of OHCA and the age-
adjusted prevalence of dental caries in the 47 prefectures of Japan
between 2005 and 2011
In the total population, the average age-adjusted prevalence of
dental caries was not significantly associated with the age-adjusted
incidence of OHCA of total, cardiac origin, and non-cardiac origin in
the 47 prefectures of Japan between 2005 and 2011 (total OHCA,
r = 0.22, p = 0.14; OHCA of cardiac origin, r = 0.25, p = 0.09; OHCA of
non-cardiac origin, r = 0.002, p = 0.99) (Fig. 6).
The associations between the age-adjusted incidence of OHCA
and the average age-adjusted prevalence of dental caries in the
47 prefectures of Japan between 2005 and 2011 according to age
group (under 24 years, 25 to 64 years, and over 65 years) are shown
in Fig. 7A. In the under-24 years group, there was no significant
association between the average age-adjusted prevalence of
dental caries and the age-adjusted incidence of OHCA in the
47 prefectures of Japan between 2005 and 2011 (total OHCA,
r = 0.10, p = 0.51; OHCA of cardiac origin, r = 0.22, p = 0.14; OHCA of
non-cardiac origin, r = 0.05, p = 0.73). The 25–64 years group
showed a significant negative association between the average
age-adjusted prevalence of dental caries and the age-adjusted
incidences of OHCA of total (r = 0.29, p = 0.05) and non-cardiac

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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4 Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx

Fig. 2. Distribution of the number of patients with OHCA and dental caries in the 47 prefectures of Japan from 2005 to 2011. (a) Total OHCA; (b) OHCA of cardiac origin; (c)
OHCA of non-cardiac origin; (d) dental caries. OHCA, out-of-hospital cardiac arrests; *area of data loss.

origin (r = 0.37, p = 0.01), but not cardiac origin (r = 0.04,

p = 0.78), in the 47 prefectures of Japan between 2005 and
2011. The over-65 years group showed a significant positive
association between the average age-adjusted prevalence of dental
caries and the age-adjusted incidences of OHCA of total (r = 0.41,
p = 0.005), cardiac origin (r = 0.31, p = 0.04), and non-cardiac origin
(r = 0.30, p = 0.04) in the 47 prefectures of Japan between 2005 and
2011.
Fig. 7B shows the associations between the age-adjusted
incidence of OHCA and the average age-adjusted prevalence of
dental caries in the 47 prefectures of Japan between 2005 and
2011 by gender in the over-65 years group. Among male patients
over 65 years old, there was a significant positive association
between the average age-adjusted prevalence of dental caries and
the age-adjusted incidences of OHCA of total (r = 0.47, p < 0.001)
and cardiac origin (r = 0.37, p = 0.01), but not non-cardiac origin
(r = 0.28, p = 0.054), in the 47 prefectures of Japan between
2005 and 2011. On the other hand, among female patients over
65 years old, there were no significant associations (total OHCA,
r = 0.27, p = 0.07; OHCA of cardiac origin, r = 0.20, p = 0.18; OHCA of
non-cardiac origin, r = 0.22, p = 0.14).

Discussion

Our investigation revealed that the age-adjusted prevalence

Fig. 3. Correlations between the number of patients with OHCA and dental caries in
the 47 prefectures of Japan from 2005 to 2011. Orange, red, and blue lines and dots
indicate the correlations between the number of patients with dental caries and the
number of patients with OHCA in all patients, and OHCA of cardiac and non-cardiac
origin, respectively. OHCA, out-of-hospital cardiac arrest; r = correlation coefficient.
of dental caries was significantly and positively associated with
the age-adjusted incidence of OHCAs of cardiac origin among
males over 65 years old in the 47 prefectures of Japan between
2005 and 2011.

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx 5

a Total OHCA b OHCA of cardiac origin

(/1,000 people) (/1,000 people)
60 35
50 30

40 25

30 20
y = 1799.6x + 37611 15 y = 1179.4x + 21522
20 R² = 0.950
R² = 0.959
10
10
5
0
2005 2006 2007 2008 2009 2010 2011 0
(year) 2005 2006 2007 2008 2009 2010 2011
(year)
c OHCA of non-ca
- rdiac origin d Dental caries
(/1,000 people) (/1,000 people)
25 30

25
20
20
15
15
10 y = 620.21x + 16090 y = 1066.7x + 20067
R² = 0.931 10 R² = 0.94
5 5

0 0
2005 2006 2007 2008 2009 2010 2011 2005 2006 2007 2008 2009 2010 2011
(year) (year)

Fig. 4. Yearly changes in the number of patients with OHCA and dental caries among male patients over 65 years old in Japan between 2005 and 2011. R2, determination
coefficient; OHCA, out-of-hospital cardiac arrest.

In Japan, the number of OHCA of total and cardiac origin
increased yearly from 2005 to 2011. In both the total population
and in males over 65 years old, the number of OHCAs of total and
cardiac origin was significantly and positively associated with
the number of cases of dental caries from 2005 to 2011 in the
47 prefectures of Japan. In the female over-65 years old group, the
number of cases of dental caries was significantly associated with
the number of total OHCAs, but was not significantly associated
with the number of OHCAs of cardiac origin or non-cardiac origin.
The association of total OHCA was influenced by the association of
OHCA of non-cardiac origin. The data on OHCA of non-cardiac
origin will not be discussed in this report, because 66.7% of OHCA of
non-cardiac origin was of unknown causes. These results indicate

Fig. 5. Correlations between the number of patients with OHCA and dental caries
among male patients over 65 years old in the 47 prefectures of Japan from 2005 to
2011. Orange, red, and blue lines and dots indicate the correlations between the
number of patients with dental caries and the number of patients with OHCA in all
patients, and OHCA of cardiac and non-cardiac origin, respectively. OHCA, out-of-
hospital cardiac arrests. r = correlation coefficient.
Fig. 6. Correlations between the age-adjusted incidence of OHCA and the prevalence
of dental caries in the 47 prefectures of Japan between 2005 and 2011. Orange, red,
and blue lines and dots indicate the correlations between the age-adjusted
prevalence of dental caries and the age-adjusted incidence of OHCA in all patients,
and OHCA of cardiac and non-cardiac origin, respectively. OHCA, out-of-hospital
cardiac arrests.

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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6 Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx

Fig. 7. (A) Correlations between the age-adjusted incidence of OHCA and the prevalence of dental caries in the 47 prefectures of Japan between 2005 and 2011 according to the
age distribution. Orange, red, and blue lines and dots indicate the correlations between the age-adjusted prevalence of dental caries and the age-adjusted incidence of OHCA
in all patients, and OHCA of cardiac and non-cardiac origin, respectively. (a) In under-24 years old group, the number of total OHCA is 21,737, OHCA of cardiac origin is 5449,
and OHCA of non-cardiac origin is 16,288. (b) In 25–64 years old group, the number of total OHCA is 183,018, OHCA of cardiac origin is 84,789, and OHCA of non-cardiac origin
is 98,229. (c) In over-65 years old group, the number of total OHCA is 580,772, OHCA of cardiac origin is 344,792, and OHCA of non-cardiac origin is 235,980. (B) Associations
between the age-adjusted incidence of OHCA and the prevalence of dental caries among patients over 65 years old in the 47 prefectures of Japan between 2005 and 2011 by
sex. Orange, red, and blue lines and dots indicate the correlations between the age-adjusted prevalence of dental caries and the age-adjusted incidence of OHCA in all patients,
and OHCA of cardiac and non-cardiac origin, respectively. (a) In male over 65 years old group, the number of total OHCA is 313,669, OHCA of cardiac origin is 183,675, and
OHCA of non-cardiac origin is 129,994. (b) In female over 65 years old group, the number of total OHCA is 267,103, OHCA of cardiac origin is 161,117, and OHCA of non-cardiac
origin is 105,986. OHCA, out-of-hospital cardiac arrests.

that dental caries may be involved in OHCA of cardiac origin,
especially in males over 65 years old. The correlation between
dental caries and cardiovascular events has been reported
previously. Stein et al. reported that hygiene indexes were
significantly increased among patients with acute myocardial
infarction (plaque index, p = 0.0055 and gingival index, p = 0.0002)
[23]. Dental caries diagnostic criteria were determined in terms of
the decayed, missing, and filled teeth (DMFT) index of the World
Health Organization. Soto-Barreras et al. reported that there were
significant differences between the DMFT index (p = 0.0002) and
missing teeth (p = 0.0459) in patients with peripheral arterial
disease compared with a control group [25]. Kaneko et al. reported
that root caries is associated with an increased risk for
dysrhythmias in a non-smoking elderly population [odds ratio
(OR), 5.84; p = 0.04] [24]. It has been shown that dental caries is a
risk factor for cardiovascular events and our investigation
supported this association.
However, in the total population, the age-adjusted incidences of
OHCA of total and cardiac origin were not significantly associated
with the age-adjusted prevalence of dental caries in the 47 pre-
fectures of Japan between 2005 and 2011. The reason may be why
the investigation which was the number of patients with OHCA
and dental caries in the 47 prefectures of Japan from 2005 to
2011 in the total population had some outliers and this
might affect the associations. The results of age-adjusted analysis
would be a more correct analysis, because the rate of prevalence
or incidence is adjusted for the differences of populations and
the age-adjusted analysis is adjusted for the differences in

Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
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Y. Suematsu et al. / Journal of Cardiology xxx (2015) xxx–xxx
age-distributions in 47 prefectures. In an age-group analysis, in
both the under-24 years group and the 25–64 years group, there
were no significant correlations between the age-adjusted inci-
dence of OHCA of cardiac origin and the age-adjusted prevalence of
dental caries. In the 25–64 years group, the age-adjusted incidence
of total OHCA was significantly associated with the age-adjusted
prevalence of dental caries, but this is likely due to the effect of
the age-adjusted incidence of OHCA of non-cardiac origin. The
association between the age-adjusted incidence of total OHCA and
age-adjusted prevalence of dental caries could not be discussed,
since 66.7% of OHCA of non-cardiac origin was of unknown causes.
In the over-65 years group, the age-adjusted incidences of OHCA of
total and cardiac origin were significantly and positively associated
with the age-adjusted prevalence of dental caries in the 47 pre-
fectures of Japan between 2005 and 2011. These results indicate
that the correlation between the age-adjusted incidence of OHCA
of cardiac origin and the age-adjusted prevalence of dental caries
should be considered in terms of the age distribution. In the over-
65 years group, among males, but not females, there was a
significant positive correlation between the age-adjusted inci-
dence of OHCA of cardiac origin and the age-adjusted prevalence of
dental caries in the 47 prefectures of Japan between 2005 and
2011. Dietrich et al. reported age-dependent associations between
chronic periodontitis/edentulism and the risk of coronary heart
disease [8]. In their report, periodontitis was significantly
associated with coronary heart disease among subjects <60 years
of age, but not among men more than 61 years of age. In this study,
our results did not indicate a significant association between the
age-adjusted incidence of OHCA of cardiac origin and age-adjusted
prevalence of dental caries among patients <65 years of age. It
might be considered that the OHCA database included all causes of
OHCA of cardiac origin in Japan. While coronary artery disease and
acute myocardial infarction are the most common causes of
sudden cardiac death in older populations, some cases may have
been due to some other heart disease, such as arrhythmia or
congenital heart disease, which are often observed in younger
patients [32]. The differences of the patients might affect the
differences of the results. Among men more than 61 years of age,
those who were edentulous tended to have a higher risk of
coronary heart disease than dentate men, independent of
confounders [8]. The results also indicated that the age distribution
and sex affected the association between chronic oral infection and
the risk of coronary heart disease. Since they get teeth lost due to
periodontitis, it is difficult to investigate the association between
the periodontitis and cardiac events in elderly males. One possible
explanation is that older edentulous men may have systemic
inflammation and this may also apply to dental caries. Although
the data on gingivitis and periodontal diseases were based on the
Patient Survey, there was no significant correlation between
the age-adjusted incidence of OHCA of cardiac origin and the age-
adjusted prevalence of gingivitis and periodontal diseases in
elderly males in the 47 prefectures of Japan between 2005 and
2011 (data not shown). The number of teeth or dental caries may
be more associated with cardiac events than periodontitis in
elderly males. Our investigation also revealed that the age-
adjusted prevalence of dental caries was significantly and
positively associated with the age-adjusted incidence of OHCA
of cardiac origin in elderly males in the 47 prefectures of Japan.
While oral hygiene is important in all age groups, it may be
particularly associated with OHCAs in older males.
Limitations
Confounding factors such as age, smoking, and diabetes
mellitus are known to be correlated with OHCA of total and
cardiac origin, as well as with dental caries, and we could not
Please cite this article in press as: Suematsu Y, et al. Association between dental caries and out-of-hospital cardiac arrests of cardiac
origin in Japan. J Cardiol (2015), http://dx.doi.org/10.1016/j.jjcc.2015.06.012
7
exclude these factors. Since this is an ecological study and the
baseline characteristics in these surveys are different, we may need
to consider an ecological fallacy, and thus the results may not be
completely accurate, although the data from 780,000 individuals
could be suitable for discussing our hypothesis.
Conclusion
While oral hygiene is important in all age groups, it may be
particularly associated with OHCAs in males over 65 years old.
Funding
This work was supported by a grant-in-aid from the AIG
Collaborative Research Institute of Cardiovascular Medicine
(2011–2013) at Fukuoka University, the Baccalaureate Degree
Program ‘‘Learning that Life is Precious’’ of Fukuoka University
(2011–2013), and the JCS-ReSS group of the Japanese Circulation
Society.
Disclosures
Research and education grants, and consulting and promotional
speaking fees (YU, SM, KS) were obtained from MSD Co. KS and SM
are Directors of NPOClinical and Applied Science, Fukuoka, Japan.
KS and SM had a grant from the Public Interest Incorporated
Foundation of ‘‘Clinical Research Promotion Foundation’’in
Fukuoka, Japan, and the part of work was transferred into
NPO
Clinical and Applied Science, Fukuoka, Japan. KS has the
Endowed Department of Molecular Cardiovascular Therapeutics
(YU, SM), Fukuoka University, which is supported by MSD Co., Ltd,
the Endowed Department of Advanced Therapeutics for Cardio-
vascular Disease (MO), Fukuoka University, which is supported by
Boston Scientific Japan Co. LTD, Japan Medtronic Co. LTD, Japan
Lifeline Co. LTD, and St Jude Medical Japan Co. LTD, and the
Endowed Department of Community and Emergency Medicine
(KS), Fukuoka University, which is supported by Izumi City,
Kagoshima, Japan.
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