Are postmenopausal women with periodontitis or edentulism at greater risk of cardiovascular disease and death? A large prospective study examined the risk of cardiovascular disease and death in this population, with the results suggesting that improving oral health could lengthen life.
Lead study author Michael LaMonte, PhD, MPH. Image courtesy of the University of Buffalo.Researchers examined the relationship between periodontitis and cardiovascular disease in a large cohort of postmenopausal women who participated in the Women's Health Initiative Observational Study. The results suggest an association between periodontitis and higher mortality and also between edentulism and both cardiovascular disease and mortality, they reported in a study published online in the Journal of the American Heart Association (March 29, 2017).
"Our findings suggest that older women may be at higher risk for death because of their periodontal condition and may benefit from more intensive oral screening measures," stated lead study author Michael LaMonte, PhD, MPH, a research associate professor of epidemiology and environmental health at the University at Buffalo, in a university news release.
Living longer
Periodontitis is a chronic inflammatory condition that is a major cause of tooth loss in adults, the authors noted. Around 64% of adults age 60 and older have moderate to severe periodontitis, and 33% of this age group are edentulous. These conditions have been associated with atherosclerotic cardiovascular disease and mortality, but few studies have included older adults and women, and the results have been inconsistent.
The researchers of the current study examined these relationships using data from 57,001 postmenopausal women who were 55 to 89 years old when they enrolled in the Women's Health Initiative Observational Study from 1993 to 1998. The participants were also without known cardiovascular disease when they completed a questionnaire after five years in the study.
Covering a broad range of health- and mood-related topics, the questionnaire included the following items designed to assess periodontal status and edentulism:
- "Has a dentist or dental hygienist ever told you that you had periodontal or gum disease?"
- "During the past three years, how often have you gone to the dentist or dental hygienist for routine checkups or cleaning?"
- "Have you lost all of your permanent teeth (edentulism), both upper and lower?"
The investigators used data on demographics, health behaviors, medical conditions, and medication use collected from each participant when they enrolled in the study. In some cases, the data were updated at year 5 of the study. The primary study end point was newly diagnosed cardiovascular disease, such as nonfatal myocardial infarction, cardiac death, stroke, pulmonary embolism, or heart failure. The researchers separately evaluated coronary heart disease, such as myocardial infarction and cardiac death, and ischemic stroke. Follow-up time was from when the year 5 questionnaire was completed through the date of cardiovascular disease diagnosis, death, loss to follow-up, or the end of follow-up in 2010.
The mean age of the study participants was 68.1 years, and the majority of participants were non-Hispanic whites with at least some college education. About half were overweight or obese. Two-thirds had used hormone therapy at some point. They had the following major cardiovascular disease risk factors: 4.1% were cigarette smokers, 5.0% had diabetes mellitus, 36.7% had hypertension, and 11.9% had hypercholesterolemia.
During the study, the researchers recorded 3,816 deaths, of which 819 were due to cardiovascular disease, and 3,589 total cardiovascular disease events.
Of the study participants, 26% reported having been diagnosed with periodontitis. They had the following significant differences compared with women without periodontitis:
- Younger age
- More education
- Greater consumption of alcohol
- Higher frequency of dental visits
- Lower frequency of edentulism
- Lower frequency of hypertension
- Higher frequency of current smoking
- Higher mean age at menopause
Over a mean follow-up of 6.7 years, the researchers found a 12% higher risk of death from any cause in women with a history of periodontitis, but they found no significant difference between the groups in the rate of cardiovascular disease events. The authors noted that 1 in 4 study participants reported a history of periodontitis that was not associated with elevated risks of cardiovascular disease events or mortality.
Edentulous women had a 17% higher risk of death from any cause and significantly higher risks of cardiovascular disease, coronary heart disease, and mortality due to cardiovascular disease. Additionally, edentulous women who visited the dentist at least once a year had higher risks of cardiovascular disease and mortality, compared with those who reported doing so less often.
Edentulous women had the following significant differences compared with nonedentulous women:
- Older age
- Less education
- Less physically active
- Lower consumption of alcohol
- Less healthy diet
- Less frequent dental visits
- Lower frequency of periodontitis
The cardiovascular disease risk factors in edentulous women are listed in the table below.
| Cardiovascular disease risk factors in edentulous women | |
| Risk factor | Percentage of edentulous women |
| Hypertension | 46.7% |
| Obesity | 36.4% |
| Hypercholesterolemia | 14.5% |
| Diabetes | 10.8% |
| Current smoking | 10.5% |
Women who reported having both periodontitis and edentulism had the highest mortality rate.
"Because edentulism may be a more objective reflection of periodontal health than self-reported periodontal diagnosis, and because tooth loss at older ages occurs predominantly due to periodontitis, the present findings are consistent with the hypothesis that dental inflammatory processes and resulting periodontitis may be relevant to atherosclerotic cardiovascular disease risk in older adults," the authors wrote.
Self-report is limiting
The use of self-reports for noting whether a study participant had been diagnosed with periodontitis or was edentulous was a major study limitation, according to the authors. Another limitation was the reliance on a single assessment of periodontitis in the study. The method of data collection also did not allow for the study of whether there was a dose-response association.
Nonetheless, the study authors noted that the stronger and more consistent adverse findings associated with edentulism, which is a more reliable marker of periodontitis history than self-reported diagnosis, increases confidence in the results. Additionally, women who reported both periodontitis and edentulism had the highest disease risks, as would be expected.
"Edentulism was associated with increased risks of [cardiovascular disease] and total mortality, and presence of periodontitis, which is more prevalent than edentulism, was associated with 17% higher mortality rate," the authors wrote. "These findings suggest that improving periodontal condition of the general population could reduce overall mortality."
"However, studies of interventions aimed at improving periodontal health are needed to determine whether risk of death is lowered among those receiving the intervention compared to those who do not. Our study was not able to establish a direct cause and effect," LaMonte noted.
Other studies are also needed to confirm whether periodontitis and tooth loss are possible modifiable risk factors for preventing cardiovascular disease or prolonging life at later ages, the authors concluded.
