*Bartłomiej Górski1, Ewa Nargiełło2, Grzegorz Opolski2, Ewa Grabowska1, Renata Górska1
Correlation between tooth loss and an increased risk of myocardial infarction in adult Polish population below 70 years of age – a case-control study
Korelacja pomiędzy utratą zębów a podwyższonym ryzykiem wystąpienia zawału mięśnia sercowego w grupie dorosłych Polaków poniżej 70. roku życia – badanie kliniczno-kontrolne
1Department of Periodontology and Oral Diseases, Medical University of Warsaw
Head of Department: prof. Renata Górska, MD, PhD
2I Chair and Clinic of Cardiology, Public Central Teaching Hospital, Medical University of Warsaw
Head of Chair and Clinic: prof. Grzegorz Opolski, MD, PhD
Streszczenie
Wstęp. W krajach rozwiniętych choroby układu sercowo-naczyniowego stanowią główną przyczynę zgonów. Jednym z ich czynników ryzyka jest podwyższone stężenie ogólnoustrojowych markerów stanu zapalnego. Ponieważ próchnica zębów i choroby przyzębia są głównymi infekcyjnymi przyczynami utraty zębów, mała liczba zębów może świadczyć o długotrwałym narażeniu na procesy zapalne w jamie ustnej.
Cel pracy. Analiza zależności pomiędzy liczbą utraconych zębów a ryzykiem wystąpienia zawału mięśnia sercowego (MI).
Materiał i metody. Do grupy badanej włączono 151 pacjentów (35 kobiet, 116 mężczyzn) hospitalizowanych z powodu MI, o średniej wieku 55,1 ± 8,0 lat. Do grupy kontrolnej włączono 82 osoby bez przebytego MI w wywiadzie oraz w wieku poniżej 70 lat (19 kobiet, 63 mężczyzn; średnia wieku 54,2 ± 9,9 roku).
Wyniki. W grupie badanej pacjenci mieli przeciętnie 17 zębów, w grupie kontrolnej 24 zęby (p < 0,0001). Odsetek osób bezzębnych w grupie badanej i kontrolnej wyniósł 11,3 i 1,6% (p = 0,0401). Po uwzględnieniu wieku, płci, cukrzycy, nadciśnienia tętniczego, nikotynizmu i BMI wykazano istotną zależność między liczbą utraconych zębów a zwiększeniem ryzyka wystąpienia MI (OR = 1,09; 95% CI = 1,02-1,16; p = 0,0095).
Wnioski. Wśród dorosłych Polaków poniżej 70. roku życia liczba utraconych zębów koreluje z podwyższonym ryzykiem wystąpienia MI, niezależnie od klasycznych czynników ryzyka: wieku, płci, cukrzycy, nadciśnienia tętniczego, hipercholesterolemii, palenia tytoniu i otyłości.
Summary
Introduction. Cardio-vascular diseases (CVD) are the main cause of death in developed countries. High systemic levels of inflammatory markers are one of the risk factors for CVDs. Dental caries and periodontitis, which represent infectious diseases, are the main causes of tooth loss. Thus the small number of teeth can suggest chronic oral inflammatory processes in the past.
Aim. The analysis of a relationship between the number of lost teeth and the risk of myocardial infarction (MI).
Material and methods. The study group comprised 151 patients (35 females, 116 males) aged 55.1 ± 8.0 years, hospitalised due to MI. The control group included 82 patients blow 70 years of age, who had no history of MI (19 females, 63 males; mean age 54.2 ± 9.9 years).
Results. Patients in the study group had less teeth than subjects in the control group (17 vs. 24, p < 0.0001). Edentulousness rate was higher in the study group (11.3%) compared to the controls (1.6%, p = 0.0401). There was a significant correlation between the number of lost teeth and risk of MI after adjusting for age, gender, diabetes, hypertension, nicotine addiction and BMI (OR = 1.09; 95% CI = 1.02-1.16; p = 0.0095).
Conclusions. The number of lost teeth correlated with an increased risk of myocardial infarction among Poles under 70 years old, regardless of classic CVD risk factors, such as age, gender, diabetes, hypertension, smoking and obesity.
Introduction
Cardiovascular diseases (CVD) belong to social diseases and are the leading cause of death worldwide (1). The etiopathogenesis of CVDs is multifactorial, and the cardiovascular risk factors, such as diabetes, hypertension, hypercholesterolaemia, smoking and body weight disorders, have been widely known since the Framingham Heart Study (2). However, the coexistence of conventional CVD risk factors does not fully explain the total cardiovascular risk in a given patient (3).
Periodontal disease was for the first time included in the group of chronic diseases associated with an increased cardiovascular risk in the European Guidelines on cardiovascular prevention in clinical practice (2012). It was also considered that the treatment of periodontal tissues has beneficial effects on endothelial dysfunction, which represents one of the earliest signs of atherosclerosis.
Odontogenic infections and dental extractions were linked with the etiopathogenesis of infectious pericarditis already in the last century (4). The issue of odontogenic focal infections has evolved over the years. Various oral health parameters, the loss of hard dental tissue as well as periodontal indices were investigated. The number of present and missing teeth were also considered as potential variables in studies on the relationship between the state of oral cavity and CVDs. Advanced periodontal diseases as well as complications of dental caries and pulp diseases are the main causes of dental extraction. Both of these groups of diseases involve chronic inflammation with all its systemic consequences.
Previously published studies were inconclusive. Some of them supported the relationship between the number of lost teeth and the risk of coronary heart disease (CHD) (5, 6), myocardial infarction (MI) (7-9) and stroke (10, 11). On the other hand, other authors have not observed any relationship between the number of teeth and CHD (12) or MI (13-15). There are at least several theories aimed to explain the biological aspects of the relationship between local inflammatory processes of the oral cavity and the increased cardiovascular risk (16, 17). It is increasingly postulated that these correlations have immune-inflammatory causes. However, the existence of independent and clinically relevant relationship between the number of lost teeth and the risk of MI is still a dubious and controversial issue.
From the perspective of public health, this issue is of great social importance due to the high incidence of MI and missing teeth in the population as well as the burden on healthcare systems, which is associated with the treatment of the consequences of both these diseases. The number of edentulous individuals aged 65-74 years ranges between 5.3 and 76.9% in different regions of Poland (18). The mean number of preserved teeth is 21.1 in people aged 35-44 years and 6.6 in those aged 65-74 years (18). The divergence of the scientific reports and the lack of consensus among the experts on the relationship between the number of teeth and MI requires further research on the subject, the more that such an assessment has not been performed in Poland, and it could contribute to a more effective primary and secondary prevention of MI.
Aim
The aim of the study was to assess the relationship between the number of lost teeth and the risk of MI in the population of adult Poles below the age of 70 years.
Material and methods
The study was conducted in the First Department of Cardiology of the First Faculty of Medicine at the Medical University of Warsaw as well as in the Department of Periodontal and Oral Mucosa Diseases of the Faculty of Medicine and Dentistry at the Medical University of Warsaw between 2011 and 2013. The research was conducted in accordance with ethical standards from the Declaration of Helsinki. All participants in the study gave their informed consent to participate in the project by signing the informed consent form. The study was approved by the Bioethics Committee at the Medical University of Warsaw (approval no. KB-145/2011).
A total of 151 patients (35 females and 116 males) hospitalised in the First Department of Cardiology of the Medical University of Warsaw due to myocardial infarction were included in the study group. The mean age was 55.1 (± 8.0) years. Inclusion criteria were as follows: 1) a history of MI; 2) age below 70 years. Control group included 82 patients (19 females and 63 males) selected by the Ministry of Internal Affairs from an adult population of Poles who reported at the Department of Periodontal and Oral Mucosa Diseases of the Medical University of Warsaw, and then were subject to a stratified sampling to obtain age and gender structure corresponding to the study group (76.8% males, 23.2% females). The mean age in this group was 54.2 (± 9.9) years. Control group inclusion criteria were as follows: 1) no medical history of MI and 2) age below 70 years. Exclusion criteria were as follows: 1) cancer; 2) rheumatic disease; 3) autoimmune disease; 4) chronic liver disease; 5) chronic kidney disease stage 4 and 5; 6) a history of stroke.
Sociodemographic data were collected using a properly constructed questionnaire. Education was classified as primary, secondary and higher. Income was determined based on the income per family member: < 800 PLN, 800-1500 PLN, > 1500 PLN. The following terms were used to define nicotine addiction: current smoker (more than 10 cigarettes per day, continuously for at least 5 years), past smoker, non-smoker.
The clinical evaluation was conducted by one cardiologist (E.N.). MI was diagnosed based on typical ECG changes and increased plasma levels of myocardial damage markers. Diabetes was diagnosed if fasting blood glucose levels exceeded 126 mg/dL, random glycaemia level above 200 mg/dL or if the patient received medications due to previously diagnosed diabetes. Hypertension was diagnosed in patients with systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or if the patient received hypotensive medications. Body mass index (BMI) was determined based on body weight and height (by dividing the body weight (kg) by height (m2)). Overweight was diagnosed if BMI was 25-29.9 kg/m2, and obesity was diagnosed if BMI ≥ 30 kg/m2. Dental examination was performed by one dentist (B.G.). The number of teeth and the edentulousness rate were determined. The third molars were not included in the study. Data on the causes of tooth loss were also collected.
Statistical analysis of the collected data was performed using PQStat v. 1.4.4. The χ2 test was used for categorical variables, the U-Mann-Whitney test was used for continuous variables. Models taking into account the most important MI risk factors, such as age, gender, diabetes, hypertension, smoking, BMI and the number of lost teeth, were constructed. Multivariate analysis was performed using logistic regression, by calculating the odds ratio (OR) of MI and 95% confidence interval (CI) depending on the number of lost teeth. P ≤ 0.05 was considered statistically significant.
Results
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Piśmiennictwo
1. World Health Organization: World Health Statistics. 2014. http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1. World Health Organization. Geneva, France. 2. Wilson PW, Castell WP, Kannel WB: Coronary risk prediction in adults: the Framingham Heart Study. Am J Cardiol 1987; 59: 91-94. 3. Hackam DG, Anand S: Emerging risk factors for atherosclerotic vascular disease: a critical review of the evidence. JAMA 2003; 290: 932-940. 4. Miller WD: The human mouth as a focus of infection. Dent Cosmos 1891; 33: 689-713. 5. Morrison HI, Ellison LF, Taylor GW: Periodontal disease and risk of fatal coronary heart and cerebrovascular diseases. J Cardiovasc Risk 1999; 6: 7-11. 6. Medina-Solis CE, Pontigo-Loyola AP, Pèrez-Campos E et al.: Association between edentulism and angina pectoris in Mexican adults aged 35 years and older: a multivariate analysis of a population-based survey. J Periodontol 2013; 85: 406-416. doi: 10.1902/jop.2013.130186. 7. Andriankaja OM, Genco RJ, Dorn J et al.: The use of different measurements and definitions of periodontal disease in the study of the association between periodontal disease and risk of myocardial infarction. J Periodontol 2006; 77: 1067-1073. 8. Holmlund A, Holm G, Lind L: Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects. J Periodontol 2006; 77: 1173-1178. 9. Dietrich T, Jimenez M, Krall Kaye EA et al.: Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease. Circulation 2008; 117: 1668-1674. doi: 10.1161/CIRCULATIONAHA.107.711507. 10. AbnetCC, Qiao YL, Dawsey SM et al.: Tooth loss is associated with increased risk of total death and death from upper gastrointestinal cancer, heart disease, and stroke in a Chinese populatio
