Two Journals Publish Editors' Consensus on Periodontitis and Atherosclerotic Cardiovascular Disease
The American Journal of Cardiology and the Journal of Periodontology have jointly published an Editors' Consensus on periodontitis and atherosclerotic cardiovascular disease (CVD).1 The document, including a range of clinical recommendations, was prepared by a designated expert panel from the fields of cardiology and periodontology. The document is intended to provide health professionals with a better understanding of the relationship between periodontal disease and atherosclerotic CVD.
The Editors' Consensus cites numerous studies that have investigated potential correlations between periodontitis and atherosclerotic CVD, two prevalent diseases that share similar risk factors and the common, complex link of chronic inflammation. While the consensus paper indicates that no "direct causal link" between periodontitis and atherosclerotic CVD has been confirmed to date, the authors describe an "indirect relation" due to the "many shared risk factors" common to the two diseases, especially cigarette smoking.
The consensus paper authors propose 18 clinical recommendations, and rate each with a level of evidence and confidence.* One recommendation is presented with a high level of confidence and supporting evidence (i.e., level 1A):
- all patients with periodontitis and elevated blood pressure should undertake lifestyle changes (e.g., weight reduction, physical activity, moderation of alcohol intake).
The remaining clinical recommendations are presented with varying levels of confidence and either "C" or "D" evidence levels. These lower evidence levels are consistent with the research conducted to date in this area. Though moderate to severe periodontitis reportedly increases the level of systemic inflammation (a characteristic of all chronic inflammatory diseases and not unique to CVD), the authors note that study findings related to periodontitis and atherosclerotic CVD vary widely. They attribute the variance to different study designs, definitions and/or measures of periodontal disease, and the impact of other confounders such as smoking history.
Other recommendations from the authors include the following: patients with periodontitis and elevated blood pressure be treated to target blood pressure levels identified by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (confidence/evidence level 1C); medical evaluation of patients with periodontal disease should include a blood lipid profile (e.g., LDL/HDL cholesterol), as well as blood glucose measurement (confidence/evidence level 2D); patients with atherosclerotic CVD and no previous diagnosis of periodontitis should be considered for periodontal evaluation if they show signs of gingival disease, significant tooth loss, and elevated levels of high-sensitivity C-reactive protein (hs-CRP) or other inflammatory biomarkers (confidence/evidence level 2D).
Importantly, the consensus panel encourages further research to better define the relationship between periodontal disease and atherosclerotic CVD, and to evaluate the overall influence of intensive periodontal interventions on long-term cardiovascular health. A series of 10 specific research questions are proposed by the authors. The consensus panel also notes that no prospective periodontitis intervention studies have evaluated CVD outcomes. A stronger body of evidence is also required to determine if the relationship between periodontitis and atherosclerotic CVD is bidirectional, as has been previously demonstrated in some studies of diabetes mellitus.
As explained in the consensus paper, "[a]lthough the inflammation hypothesis provides a plausible and attractive explanation for the relationship of periodontal disease to cardiovascular disease, further research is needed to define the mechanisms linking the two diseases and how patients with periodontitis should best be managed to reduce their risk for CVD." The consensus panel also emphasizes that greater collaborative efforts should be taken by dental professionals and cardiologists "to optimize CVD risk reduction and periodontal care." To fulfill a primary objective of the 2008-2009 ADA Research Agenda, the research community is encouraged to investigate the relationships between oral diseases and systemic conditions, such as atherosclerotic CVD, in order to determine whether clinical outcomes for systemic diseases can be improved by treating oral conditions.
*Confidence levels are categorized from 1 to 4, ranging from 1=very confident to 4=not confident. Levels of evidence are identified as: A=well-designed randomized controlled trial (RCT); B=single RCT with highly statistically significant result, well-conducted case-control studies, or managed care claims database analysis with highly statistically significant result; C=multiple case studies, reports to regulatory agencies, and/or well-conducted prospective cohort study; D=expert opinion, poorly controlled/uncontrolled studies, or nondefinitive evidence from regulatory agencies/managed care claims databases; U=unknown).
1. Friedewald VE, Kornman KS et al. The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease. Am J Cardiol 2009;104:000–000. Available online at: http://www.ajconline.org/webfiles/images/journals/ajc/AJC16740final.pdf. Accessed June 2, 2009.
Document Posted June 2009