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How Periodontitis and Cardiovascular Disease Are Intricately Linked

New insights into the interplay between periodontitis and cardiovascular disease reveal direct and indirect pathways.


A causal link between periodontitis and cardiovascular disease has long been difficult to establish. They share common risk factors, such as male gender, age, cigarette smoking, type 2 diabetes mellitus, and low socioeconomic status. And, after adjusting for confounders, most studies report a positive association between these disease processes. This is due to the direct and indirect pathways that connect the pathogenesis of periodontitis to cardiovascular disease, and vice versa.1

Oral bacteria and their byproducts can enter the bloodstream, damaging the vascular endothelium and increasing oxidative stress. In fact, periopathogens were found in 30% of resected human carotid plaques, with 44% containing at least one or more oral pathogens.2 Local oxidation attracts macrophages to the site of injury. As these cells ingest various lipoproteins and lipids that accumulate along the vascular wall, they become pathogenic foam cells. A release in platelet-derived growth factor then causes collagen deposition and fibrous encapsulation. This fatty plaque or atheroma increases tunica intima-media wall thickness, which is a preclinical measure of atherosclerosis associated with coronary heart disease and stroke.1

Indirectly, periodontitis increases systemic inflammation and alters macrophage activity to promote atheroma formation.3 Nonsurgical and surgical periodontal treatment, however, can reduce proinflammatory markers over time. A clinical trial of 65 healthy subjects showed a significant decrease in C-reactive protein and interleukin-6 (IL-6) two months after prophylaxis and scaling and root planing.4 In another interventional study, three months after full-mouth tooth extractions, inflammatory and thrombotic markers decreased when severe periodontitis was eliminated.5

Periodontal patients should be informed of the comorbidities associated with cardiovascular disease. In the nationwide Atherosclerosis Risk in Communities Study, the odds of carotid artery intima-media wall thickness ≥ 1 mm were 1.4 to 2.09 times higher for patients with moderate to severe periodontitis compared to healthy controls.6 A meta-analysis later revealed the prevalence and incidence of coronary heart disease were significantly increased in periodontitis, especially for subjects with less than 10 teeth.7 Periodontal treatment will not guarantee reduced risk for cardiovascular disease, but instead should be seen as a means to offset the body’s inflammatory burden, thereby improving overall health.


  1. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc. 2006;137(Suppl):14S–20S.
  2. Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ. Identification of periodontal pathogens in atheromatous plaques. J Periodontol. 2000;71:1554–1560.
  3. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men.N Engl J Med. 1997;336:973–979.
  4. D’Aiuto F, Nibali L, Parkar M, Suvan J, Tonetti MS. Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol. J Dent Res.2005;84:269–273.
  5. Taylor BA, Tofler GH, Carey HM, et al. Full-mouth tooth extraction lowers systemic inflammatory and thrombotic markers of cardiovascular risk. J Dent Res. 2006;85:74–78.
  6. Beck JD, Elter JR, Heiss G, Couper D, Mauriello SM, Offenbacher S. Relationship of periodontal disease to carotid artery intima-media wall thickness: the atherosclerosis risk in communities (ARIC) study. Arterioscler Thromb Vasc Biol. 2001;21:1816–1822.
  7. Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis. Am Heart J.2007;154:830–837.

This information originally appeared in Saltz A. Periodontal medicine: from teeth to total body health. Decisions in Dentistry. 2021;7(3):25–31.

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