|Year : 2023 | Volume
| Issue : 1 | Page : 15-21
Periodontitis as a risk factor for stroke: A hospital-based case–control study
Mayank Kalpdev1, Rashmi Gupta2, Kusum Singh3, Veer Bahadur Singh1, Saranshi Singh4, Harish Kumar5
1 Department of Medicine, Jawahar Lal Medical College, Ajmer, India
2 Department of Community Medicine, Jawahar Lal Medical College, Ajmer, India
3 Department of Dentistry, Sardar Patel Medical College, Bikaner, India
4 Department of Medicine, Intern, Rajasthan University of Health Sciences, Jaipur, India
5 Department of Emergency Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India
|Date of Submission||25-Nov-2022|
|Date of Decision||12-Jan-2023|
|Date of Acceptance||13-Feb-2023|
|Date of Web Publication||17-May-2023|
Department of Dentistry, Sardar Patel Medical College, PBM Hospital, Bikaner 334001, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Stroke is the second most common cause of mortality worldwide. Identification of the association between stroke and its risk factor is essential. Objective: Our aim was to study the relationship between gum infections such as periodontitis as a risk factor for cerebral ischemic stroke and its correlation of periodontitis staging for stroke. Methods: This prospective hospital-based case–control study involved 100 cases with their first episode of stroke compared with 100 controls without stroke. Clinical parameterswere recorded—such as “periodontal index,” radiographic bone loss, tooth loss, probing pocket depth, and clinical attachment loss (CAL), all important parameters for assessing periodontal destruction loss of connective tissue attachment to the tooth root surface. Results: Groups were comparable according to age and sex. Statistically significant differences were observed according to associated diseases and investigations, with all the parameters higher for the case group compared to the controls (P < 0.001). There were no significant differences between the groups regarding a family history of cerebral vascular attack. A significant difference was observed for carotid intima-medial thickness, whereas there was no significant difference regarding side. No statistically significant differences were observed according to the total number of teeth lost, interdental CAL, carotid artery atherosclerosis, and 2D echocardiography. Conclusion: There is a strong relationship between periodontal disease and ischemic stroke. Periodontitis is an independent risk factor for cerebral ischemia and is a treatable and preventable disease. Adequate treatment can reduce the incidence of stroke.
Keywords: Periodontotal disease, risk, severity, stroke, tooth
|How to cite this article:|
Kalpdev M, Gupta R, Singh K, Singh VB, Singh S, Kumar H. Periodontitis as a risk factor for stroke: A hospital-based case–control study. Sci Dent J 2023;7:15-21
|How to cite this URL:|
Kalpdev M, Gupta R, Singh K, Singh VB, Singh S, Kumar H. Periodontitis as a risk factor for stroke: A hospital-based case–control study. Sci Dent J [serial online] 2023 [cited 2023 Jun 9];7:15-21. Available from: https://www.scidentj.com/text.asp?2023/7/1/15/377192
| Background|| |
The burden of stroke has increased in the past two decades in India due to increased life expectancy and an aging population. This is currently a major health problem in developing and low- and middle-income countries. Seventy percent of strokes occur in low- and middle-income countries. Due to increased life expectancy in India (over 60 years), the morbidity and mortality estimates for stroke have also increased., Stroke is the fourth-leading cause of death and fifth-leading cause of disability in India.
Periodontitis is a treatable condition, and its identification contributes to a new pathway in stroke prevention. Because of limited age and sex matching with hospital controls, selection bias, a small sample size, and retrospective data analyses, knowledge of the role of periodontal disease in stroke is still limited. Hence, this study was conducted to determine the independent association of periodontal disease with acute or transient ischemic attack.
| Materials and Methods|| |
This prospective hospital-based case–control study involved patients who presented to the Department of Medicine, Jawahar Lal Medical College, Ajmer, Rajasthan, India. Approval was obtained from the ethical committee. The study had a total of 200 sex-matched participants (18–70 years): 100 cases exposed recently to their first episode of stroke and 100 without stroke. For each patient, a clinico-demographic profile with a detailed history was obtained, including a family history of stroke, diabetes, hypertension (HTN), diet, smoking and alcohol consumption, clinical examination, as well as routine investigation liver and renal function tests, and a lipid profile. Special investigations and clinical parameters were recorded for eligible patients. A dental examination to assess periodontitis was conducted according to criteria. chronic periodontitis and aggressive periodontitis.
In this study, periodontitis was classified according to severity (the measurable amount of destroyed and/or damaged tissue) and specific factors that may attribute to the complexity of long-term case management. Clinical attachment loss (CAL) determined the initial stage, and if unavailable, radiographic bone loss (RBL) was used. Stage modification was effected if there was tooth loss due to periodontitis, and one or more complexity factors shifted the stage to a higher level. Mild periodontitis was defined as a mean CAL of 3 mm. Other categories had increases of 1.5 mm (mean CAL 3–4.5, 4.5–6, and 6 mm), with a mean CAL of 6 mm defined as severe periodontitis. RBL was measured as the distance from the cementoenamel junction to the most apical extension of the bony defect at two sites per tooth (mesial and distal).
Statistical analysis was done using SPSS trial version 23.0 to analyze the association of periodontitis with cerebral ischemic stroke. This edition applies to IBM® SPSS® Amos™ 23 and to all subsequent releases and modifications. Mean and standard deviation (SD) were used for qualitative and quantitative data. A chi-square test and t test were used between the groups, with a 5% probability level was considered statistically significant.
| Results|| |
From the distribution of cases according to different parameters, we found nonsignificant differences between the groups regarding gender, socioeconomic status, blood pressure, pulse rate, and respiratory rate [Table 1]. As per blood investigations—white blood cell count, erythrocyte sedimentation rate, and serum creatinine—no significant differences were found between the groups, and for parameters such as hemoglobin, hematocrit, platelet, and blood urea.
|Table 1: Primary goals in staging and grading a patient with periodontitis|
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Regarding serum glutamic oxaloacetic transaminase (SGOT) and total cholesterol, there were significant differences between the groups. The mean ± SD values of hemoglobin and platelet were lower for the cases compared to the controls, whereas values for blood urea, SGOT, and total cholesterol were higher for the cases compared to the controls [Table 2].
There were significant differences for C-reactive protein (CRP; P < 0.001) and electocardiography (ECG) between the groups, being higher for cases. There were no significant differences according to the thyroid profile and chest X-ray [Table 3].
From the distribution of cases as per associated diseases, we found significant differences between the groups for all parameters, such as diabetes mellitus (DM), HTN, and ischemic heart diseases. About 26% of the case group had DM, a value higher than that of the control group. There was no significant difference between the groups regarding a family history of cerebral vascular attack (78% and 75% for the case and control groups, respectively, P = 0.270) [Table 4].
According to the carotid color Doppler ultrasound, 88% patients of the case group had carotid artery atherosclerosis, compared to 82% of the control group, implying a nonsignificant difference [95% confidence interval (CI) 0.731–3.547, P = 0.322]. No significant difference was observed according to hypertensive fundus changes. Regional wall motion abnormality (RWMA) was observed in 11% of the cases group as compared to 3% of controls (P = 0.063). The mean ± SD of carotid intima-medial thickness was significantly higher for cases than controls for the left side (P < 0.001) but was nonsignificant for the right side (P = 0.348) [Table 5].
|Table 5: Distribution of the cases according to carotid artery atherosclerosis carotid color Doppler fundus exam and carotid intima-medial thickness|
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RBL was significantly higher for cases (79% vs. 21%; mean ± SD for the case group was 3.57 ± 1.57 and for the control group was 3.48 ± 1.75). The mean ± SD values of interdental CAL and tooth loss were also significantly higher for cases [P < 0.001; [Table 6], [Figure 1]].
|Table 6: Distribution of the cases according to periodontal index, radiographic bone loss, interdental clinical attachment loss and tooth loss (no. of teeth)|
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|Figure 1: Periodontal index, radiological bone loss, inter dental CAL and tooth loss|
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| Discussion|| |
New technologies and therapeutic approaches to periodontitis management are now available such that clinicians with advanced training can manage patients with moderate and severe periodontitis to achieve clinical outcomes that were not previously possible [Table 7].
Staging a periodontitis patient
To classify the severity and extent of an individual based on currently measurable extent of destroyed and damaged tissue attributable to periodontitis.
To assess specific factors that may determine the complexity of controlling the current disease and managing long-term function and aesthetics of the patient’s dentition.
Grading a periodontitis patient
To estimate future risk of periodontitis progression and responsiveness to standard therapeutic principles to guide the intensity of therapy and monitoring.
To estimate the potential health impact of periodontitis on systemic disease and the reverse to guide systemic monitoring and cotherapy with medical colleagues.
Hypersensitive C-reactive protein (hs-CRP) and lipoprotein-associated phospholipase A2 are the serum inflammatory biomarkers associated with the pathogenesis of periodontitis. Periodontitis is associated with these elevated inflammatory biomarkers for the indicators of atherosclerotic plaque for stroke risk; however, the epidemiologic association between periodontitis and stroke is still questionable.
In our study, statistically significant increases in CRP levels (inflammatory marker) initiated a cascade of biochemical reactions, caused endothelial damage, and facilitated cholesterol plaque attachment in cases with periodontal disease when compared to healthy controls (P = 0.036) [Table 3].
Moderate elevation of CRP is a predictor of increased risk for cardiovascular diseases and stroke. Elevated CRP levels are also seen in patients with periodontitis. Periodontitis initiates systemic inflammation—leading to endothelial damage, which can be monitored by inflammatory markers such as CRP and fibrinogen levels.
As per ECG, a significant difference was found between the groups. Twelve percent of the case group had sinus tachycardia, a higher value than that of the control group. Grau et al. found similar ECG results, with 7% of cases and 2% of controls having atrial fibrillation.
Regarding associated diseases, there were significant differences between the groups for all parameters: DM, HTN, and ischemic heart diseases. About 26% of the case group had DM, a value higher than that of the control group [Table 4]. In Grau et al.’s study, 23.4% of the case group had DM compared to 11.9% of the control group, and 26.8% and 29% of the case and control groups, respectively, had HTN.
Regarding carotid artery atherosclerosis detected by carotid color Doppler ultrasound, no significant difference was found between the groups. This finding agrees with the research of Grau et al., who studied severe periodontitis as a risk factor for cerebral ischemia caused by large-artery atherosclerosis and cardioembolism and with cryptogenic etiology.
In the present study, for the case group, 88% had carotid artery atherosclerosis, compared to 82% of the control group [odd ratio (OD) 1.6, 95% CI 0.731–3.547, P = 0.322]. In this regard, only 9% and 2% of the case and control groups, respectively, had RWMA, implying no significant difference between the groups (P = 0.063). In addition, no significant difference was observed according to hypertensive fundus changes, with 11% of the case group having RWMA as compared to 3% of the controls (P = 0.063). The mean ± SD of carotid intima-medial thickness for the case group was significantly higher than that of the control group (1.19 ± 0.14 vs. 1.11 ± 0.13, P < 0.001) for the left side but nonsignificant for the right side.
Common risk factors, such as age, male gender, cigarette smoking, diabetes, and obesity, are associated with atherosclerosis, stroke, and periodontitis simultaneously. Using Grau et al.’s and Bodnar et al.’s studies, it can be concluded that hs-CRP and lipoprotein-associated phospholipase A2, inflammation markers existing in the periodontium can lead to biochemical reactions, tissue damage, and the development of atherosclerosis plaque, both directly and indirectly. Studies have confirmed that the severity of periodontal disease is associated with the thickness of the corresponding plaque. Fagundes et al. made similar observations. In contrast to our study, Bell et al. observed no significant association between periodontitis and subclinical atherosclerosis (β –0.002, 95% CI –0.004 to 0.001).,
In the current study, RBL was significantly higher in the case group (79% vs. 21% and mean ± SD: 3.57 ± 1.57 vs. 3.48 ± 1.75). The mean ± SD of interdental CAL was significantly higher in cases as compared to the control group (2.52 ± 0.70 vs. 2.16 ± 0.70, P < 0.001). The same applies to the number of teeth lost (5.15 ± 7.79 vs. 4.19 ± 1.86, P < 0.001).
Regarding RBL as periodontal index, 79% of cases belonged to the case group, which was far higher than 21% for the control group (P < 0.001) [Table 5] and [Table 6]. However, for one to six indexes, control group values were higher as compared to case group values. Here, the mean ± SD value for the case group was 3.57 ± 1.57and for the control group was 3.48 ± 1.75. This is in agreement with Grau et al.’s study findings, where the mean RBL was higher, indicating more severe periodontitis, in patients than in the control group. Severe periodontitis increased the by a factor of 4.3. Grau et al. observed that severe RBL was also independently associated with gingivitis, whereas caries was not associated with the risk of cerebral ischemia. Subjects with severe periodontitis have a higher risk of developing cerebral ischemia than those without periodontitis.
Periodontal bone loss was significantly associated with increased heart rate in cerebrovascular disease heart rate 3.52, 95% CI 1.59–7.81, comparing the highest to the lowest bone loss category; P for trend < 0.001). The moderate and severe periodontitis cases in the patient group were more than those in the control group (P = 0.003 and 0.001, respectively) [Table 5] and [Table 6]. The results of present study indicated a significant relationship between stroke and periodontal index. These meta-analyses showed statistically significant association between periodontitis and ischemic stroke in both cohorts, pooled relative risk at 2.52.
Regarding interdental CAL, there was no significant difference between the groups [Table 5] and [Table 6]. Other studies have presented similar observations. Present study indicated higher incidences of periodontal diseases, with increased severity, in patients with a positive perfusion scan, while Abolfazi et al. found that patients who had experienced an ischemic stroke had greater CAL than the control group.,
As per the number of teeth lost, there was no significant difference between the groups [Table 5]. Wu et al., Geerts et al., and Lafon et al. discovered that subjects with a lower number of teeth, mostly men, were more likely to suffer a stroke.
| Conclusion|| |
Periodontal disease is significantly associated with cerebral ischemic stroke independently. As periodontitis is a treatable and preventable disease, adequate prevention and treatment can reduce the incidence of stroke.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]