You are on page 1of 8

[Downloaded free from http://www.jdrntruhs.org on Thursday, March 05, 2015, IP: 36.84.11.

183] || Click here to download free Android application for this journal

Original Article

Association between chronic periodontal


disease and cardiovascular risk factor
hyperlipidemia
Akkaloori Anitha, Peddireddy Parthasarathi1, Mohammad Shakeel
Anjum1, Gadde Praveen2, Mocherla Monica1, Yadav Rao1
Departments of Public Health Dentistry, Mamata Dental College, Khammam, 1Sri Sai College of Dental
Surgery, Vikarabad, 2Department of Public Health Dentistry, Vishnu Dental College, Bhimavaram, Andhra
Pradesh, India

ABSTRA
CT
Background: Periodontal disease is one of the major reasons for tooth loss. Accumulating
evidence suggests that chronic infections, such as periodontitis, are associated with increased
risk for cardiovascular diseases (CVD) possibly through providing a systemic inflammation and
found that 25% to 50% increase in risk of CVD for those with periodontitis when compared to
those with no or minimal periodontitis.
Aim: To evaluate the association between chronic periodontal disease and cardiovascular
risk factor such as hyperlipidemia.
Materials and Methods: A hospital-based study was conducted among the patients who came
to the out-patient department. Fifty subjects including both males and females were selected by
systematic random method, and community periodontal index was recorded on all subjects.
Subjects were divided in to healthy group (controls) and chronic periodontitis group (cases)
based on presence/ absence of loss of attachment. Blood samples were collected from all subjects
for the measurement of lipid profile in the serum.
Results: Mean total cholesterol values in controls and cases were 190.44 and 200.64, which were
not statistically significant between the groups. Mean LDL cholesterol values in controls and cases
were 110.96 and 136.64, which were statistically increased in cases (P = 0.003). Mean HDL
cholesterol values in controls and cases were 61.60 and 49.28, which were statistically higher in
controls (P = 0.041).
Conclusion: Chronic periodontitis patients may have high risk of getting cardiovascular diseases
since cardiovascular risk factors such as total cholesterol and LDL are associated with
periodontitis.
Key words: Chronic periodontitis, cardiovascular diseases,
and cholesterol levels

INTRODUCTION
Periodontitis is a chronic inflammatory disease, which
destroys connective tissue and bone that support the
teeth. Periodontal disease is one of the major reasons
for tooth loss and impaired oral health. Poor oral
Address for correspondence
Dr. Anitha,
Department of Public Health Dentistry, Mamata Dental
College, Khammam - 507001, Andhra Pradesh, India.
E-mail: anithareddy176@gmail.com

health may have a profound effect on general health,


and the experience of pain, problems with eating,
chewing, smiling, and communication due to missing
teeth have a major impact on peoples daily lives and
well-being. Severe periodontitis, which may result in
tooth loss, is found in 5-20% of most adult population
worldwide.[1]
India is experiencing a rapid health transition, with
large and rising burden of chronic diseases, and the
Global Burden of Disease Study, estimated that the

Access this article online

[Downloaded
from http://www.jdrntruhs.org
on Thursday, March 05, 2015, IP: 36.84.11.183] || Click here to download free Android application for this journal
Quickfree
Response
Code:

number of deaths Website:


attributable to
www.jdrntruhs.org
chronic diseases would
rise from 378
million in 1990 (404%
of all deaths)
DOI:
10.4103/2277-8632.146628

Journal of Dr. NTR University of Health Sciences 2014;3(4) 249253

to 763 million in 2020 (667% of all deaths).[1]


Among all the chronic diseases, cardiovascular
diseases are the most prevalent diseases, which are
249

Akkaloon, et al.: Chronic periodontal disease and hyperlipidemia

responsible for high morbidity and mortality among


young adults. Compared with all other countries, India
suffers the highest loss in potentially productive years
of life, due to deaths from cardiovascular disease in
people aged 35-64 years (92 million years lost in
2000). By 2030, this loss is expected to rise to 179
million years940% greater than the corresponding
loss in the USA, which has a population a third the
size of Indias population.[2]
Accumulating evidence suggests that chronic
infections, such as periodontitis, are associated with
increased risk for cardiovascular diseases (CVD)
possibly through providing a systemic inflammation
and found that 25% to 50% increase in risk of CVD
for those with periodontitis when compared to those
with no or minimal periodontitis.[3]
Recent studies have shown that there is an association
between the dyslipidemia, chronic periodontitis, and
atherosclerosis, which can lead to mortality and
morbidity because of cardiovascular diseases.[4,5]
Hyperlipidemia is a state of abnormal lipid
profile, which is characterized by elevated blood
concentrations of triglycerides (TG), elevated levels
of total cholesterol (TC) and low-density lipoproteincholesterol (LDL), and decreased levels of highdensity lipoprotein-cholesterol (HDL).
Higher incidence of poor oral hygiene and periodontal
disease are associated with increased risk of
cerebrovascular, coronary, and peripheral vascular
atherosclerotic diseases.[6]
And, most of the risk factors for cardiovascular
diseases are also regarded as risk factors for
periodontal diseases.[7]
Studies have been conducted to know the association
between chronic periodontitis and cardiovascular
diseases,[8-10] but the mechanism of the association is
not yet clearly understood.
Chronic periodontitis is also associated with increased
levels of cholesterol levels in blood. Very few
studies[11] have been conducted to know the association
between hypercholesterolemia, cardiovascular disease,
and periodontal disease, but the exact mechanism
behind the association is not clear.
250

Hence, the aim of the present study is to evaluate


the association between chronic periodontal disease
and cardiovascular risk factors like hyperlipidemia in
blood.

MATERIALS
METHODS

AND

A cross-sectional survey was conducted on a sample


of patients who came to the out-patient department of
Sri Sai College of Dental Surgery, Vikarabad, Andhra
Pradesh over a period of 6 months from March to
August 2011. The age group of the study subjects
ranged from 30 to 60 years old. Ethical clearance
was obtained from the Ethical Committee of Sri Sai
College of Dental Surgery, Vikarabad. Participants
were explained about the study, and written consent
was taken from every subject who participated in the
study.
Pilot study was conducted on 6 cases and 6 controls
(convenience sample) to know the feasibility of
the study and for sample size calculation, and total
sample size was determined as 25 in each group.
Systemically healthy subjects were selected by
systematic random sampling technique (every 3rd
person).
Inclusion criteria
Systemically healthy subjects
Exclusion criteria
Chronic smokers, chronic alcoholics, BMI > 25 kg/m2
After the selection of subjects based on inclusion and
exclusion criteria, periodontal examination was done
to all subjects. Community periodontal index was
recorded for all subjects. According to community
periodontal index, those subjects who are having
loss of attachment of less than 4 mm in all sextants
were considered as healthy group (Controls). Those
subjects who are having loss of attachment of more
than 4 mm for at least one sextant were considered as
chronic periodontitis group (Cases). Both the groups
were matched for age and sex, and all the subjects
were referred to clinical pathology laboratory for
collection of blood samples and for the analysis of
lipid profile in serum. ECG was taken to all subjects
to know whether they have any abnormalities in ECG,
and body mass index (BMI) of each subject was also
measured. Subjects who had BMI more than 25 kg/m2
were excluded from the study.
Journal of Dr. NTR University of Health Sciences 2014;3(4)

Akkaloon, et al.: Chronic periodontal disease and hyperlipidemia

The collected data was entered in to Microsoft excel


2007 and subjected to statistical analysis using SPSS
version 16.0. The quantitative data was summarized
using means and standard deviations. Multivariate
analysis was done to compare the dependent variable
with independent variables. The statistical tests used
were t-test and multivariate analysis. In the present
study, level of significance was considered as < 0.05.

RESULT
S
A total number of 50 subjects with the age range
between 30 and 60 years participated in the study.
The mean age of the subjects in control was 39.88
+ 8.16 years and cases were 42.92 + 10.11 years

also contribute to acute thromboembolic events in


susceptible persons.[15]
Periodontal diseases are a group of inflammatory
diseases, in which bacteria and their byproducts are
the principal etiologic agents. [16] There is growing
evidence that poor dental health, especially the
presence of periodontal disease, increases the risk of
cardiovascular diseases.[16,17]
In this study, there was an increased levels of total
cholesterol in chronic periodontitis patients, but
there was no statistical significant difference between
TABLE 1: DISTRIBUTION OF STUDY
SUBJECTS ACCORDING TO AGE

(Tables 1 and 2 show the distribution of study


subjects according to age and gender respectively).

Age group

Difference between age groups was not statistically


significant (P = 0.124).
Table 3 shows the comparison of different cholesterol
levels between the groups. Table 4 shows the
multivariate comparison between the dependent
variable (presence/absence of periodontitis) and
independent variables.

DISCUSSION
A cross-sectional study was conducted to evaluate the
association between chronic periodontal disease and
cardiovascular risk factor such as hyperlipidemia.
In the present study, total cholesterol, high density
lipoprotein, low density lipoprotein, very low density
lipoprotein, and triglycerides in serum were measured
for subjects with chronic periodontitis and without
chronic periodontitis.

Controls

Cases

30-40
41-50

10
14

40
56

08
15

32
60

51-60

01

02

Total

25

100.0

25

100.0

TABLE 2: DISTRIBUTION OF STUDY SUBJECTS


ACCORDING TO GENDER
Gender

Controls

Cases

Male
Female

7
18

28
72

5
20

20
80

Total

25

100.0

25

100.0

TABLE 3: COMPARISON OF DIFFERENT


CHOLESTEROL LEVELS BETWEEN THE GROUPS
Cases
(mean value)

Controls
P-value
(mean value)

Total cholesterol

190.44

200.64

0.173

HDL cholesterol

61.60

49.28

0.041*

LDL cholesterol

110.96

136.64

0.003*

VLDL cholesterol

15.28

18.32

0.05*

88.76

0.156

Triglyceride cholesterol

77.46

*P-value < 0.05

Cardiovascular diseases are the leading cause of


adult mortality and morbidity throughout the world.
The development of cardiovascular diseases can
result from genetic and several environmental risk
factors such as age, abnormal serum lipids, diabetes,
smoking, and hypertension.[12,13]
These well-known risk factors independently or
combined are involved in atherosclerosis, which is
responsible for cardiovascular diseases.[14,15] Not only
these risk factors, viral and bacterial infections may

TABLE 4: MULTIVARIATE COMPARISON BETWEEN


THE DEPENDENT VARIABLE (PRESENCE /
ABSENCE OF PERIODONTITIS) AND INDEPENDENT
VARIABLES
Dependent variable

Independent variables

Presence/Absenc
e of Periodontitis

Sex

P-value
0.657

ECG

0.104

Total cholesterol

0.517

LDL

0.474

HDL

0.674

VLDL

0.839

Triglycerides

0.910

Journal of Dr. NTR University of Health Sciences


2014;3(4)

251

Akkaloon, et al.: Chronic periodontal disease and hyperlipidemia

chronic periodontitis subjects and healthy subjects


related to total cholesterol levels (P = 0.173), and
this finding was similar to a study conducted by
Saxlin T et al.[18] in 2008 and Aiuto et al.,[19] in 2005,
in which they have compared the cholesterol levels
in chronic periodontitis patients and healthy group;
the results showed that there was an increase in total
cholesterol levels in cases. This finding in the present
study might be due to chronic localized inflammation
may cause systemic inflammation, which results in
increased cholesterol level in chronic periodontitis
patients.
In the present study, HDL cholesterol levels were
significantly higher (P = 0.041) in healthy subjects
when compared to chronic periodontitis subjects;
this finding in the present study was comparable to
a study conducted by Buhlin et al. [20] in 2003, in
which HDL cholesterol levels were lower in subjects
with chronic periodontitis. This finding in the present
study was in contrast to a study done by Tiejian Wu
et al.[21] in 2000, in which the authors analyzed the
relationship between blood serum lipids, CRP levels,
and periodontal condition, and the study findings
showed that there was no difference in the blood
serum concentration of HDL cholesterol between
the people with healthy periodontium and those with
chronic periodontitis.
In the present study, there was a significant increase
in LDL cholesterol levels (P = 0.003) in chronic
periodontitis subjects when compared to healthy
subjects, which was in agreement with a study
done by Losche et al. [22] in 2005. This finding in
the present study might be due to the fact that the
chronic periodontitis subjects may have systemic
inflammation through periodontitis, which results in
increased LDL cholesterol in the serum.
This finding in the present study was in contrast to
a study conducted by P. J. Pussinen[23] in 2004, in
which authors evaluated whether periodontal treatment
affects proatherogenic properties of low-density
lipoprotein (LDL) and, thus, macrophage activation,
and that study results showed that the number of sites
with bleeding on probing correlated negatively with
LDL cholesterol (r = 0.497).
There was a significant increase in VLDL cholesterol
levels (P = 0.05) in chronic periodontitis subjects
when compared to healthy subjects, and this finding
252

in the present study was similar to a study done by


Rao et al.,[24] in 2011. The present study finding might
be due to the fact that chronic inflammations like
periodontitis affects the VLDL levels in serum.
There was no significant difference between chronic
periodontitis subjects and healthy subjects related
to triglycerides (P = 0.156), and this finding in
this study was comparable to a study conducted by
Giedre et al.[4] in 2005, in which the authors analyzed
the relationship between blood serum lipids and
periodontal condition, as well as the relationship
between the left ventricular mass index and the
condition of periodontium, and the study findings
showed that there was no difference in the blood
serum concentration of triglycerides between people
with healthy periodontium and those with gingivitis
or periodontitis.
The present study demonstrated a significant
association between hypercholesterolemia and chronic
periodontal disease and a possible association between
cardiovascular diseases and chronic periodontal
disease. The present study was a cross-sectional
investigation and did not allow to interpret the results
in a causal context. Chronic periodontitis might be a
risk indicator for cardiovascular diseases.
In the present study, history regarding physical
activity and diet history of protein intake, coffee
consumption were not taken, which could alter the
different cholesterol levels. However, in the present
investigation, obese subjects were excluded from
the study, and BMI of the subjects were recorded to
eliminate the bias because of physical activity and diet.
However, while the evidence continues to accumulate,
it still does not establish periodontal disease as a
proven risk factor for CVD. Additional interventional
and follow up studies will be required with larger
sample to further define this relationship.

CONCLUSION
In the present study, there was an association between
chronic periodontitis and cardiovascular risk factors
like hyperlipidemia. LDL-cholesterol was significantly
increased in subjects with chronic periodontitis
than in healthy subjects, which is risk factor for
cardiovascular diseases. HDL-cholesterol levels were
significantly increased in healthy subjects than in
Journal of Dr. NTR University of Health Sciences 2014;3(4)

Akkaloon, et al.: Chronic periodontal disease and hyperlipidemia

subjects with chronic periodontitis. Total cholesterol


levels were increased in chronic periodontitis patients
than in healthy subjects, but there was no significant
difference between chronic periodontitis group and
healthy group related to total cholesterol levels.
Triglycerides and VLDL Cholesterol levels were
increased in subjects with chronic periodontitis than
in subjects without periodontitis, but there was no
significant difference between them. Hence, chronic
periodontitis patients may have high risk of getting
cardiovascular diseases like atherosclerosis and
angina pectoris, which can lead to high morbidity
and mortality among periodontitis patients. The
present study results suggest a potential effect
of periodontitis-driven systemic inflammation on
lipid metabolism. It was observed that there is an
association between periodontal disease and CVD.

8.

Suggestions
and
recommendations
There is a need to conduct the longitudinal
studies to know the causal association between
periodontitis and cardiovascular diseases.
Patients with periodontal diseases are advised to
monitor the cardiovascular risk factors like lipid
profile in the blood to prevent the cardiovascular
diseases among them.

16.
17.

REFERENCES
1.
2.
3.
4.
5.
6.
7.

Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C.


The global burden of oral diseases and risks to oral health. Bull
World Health Organ 2005;83:661-9.
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to
the threat of chronic diseases in India. Lancet 2005;366:1744-9.
Nakib SA, Pankow JS, Beck JD, Off enbacher S, Evans GW,
Desvarieux M, et al. Periodontitis and coronary artery calcification:
the atherosclerosis risk in communities (ARIC) study. J Periodontol
2004;75:505-10.
Valentaviciene G, Paipaliene P, Nedzelskiene I, Zilinskas J,
Anuseviciene OV. The relationship between blood serum lipids and
periodontal condition. Stomatologija 2005;8:96-100.
Lsche W, Karapetow F, Pohl A, Pohl C, Kocher T. Plasma lipid and
blood glucose levels in patients with destructive periodontal
disease. J ClinPeriodontol 2000;27:537-41.
DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell CM.
Dental disease and risk of coronary heart disease and mortality.
BMJ 1993:36;688-91.
Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal

9.
10.
11.
12.
13.
14.
15.

18.
19.
20.
21.

22.
23.
24.

disease and cardiovascular disease. J Periodontol 1998;67:1123-37.


Katz J, Chaushu G, Sharabi Y. On the association between
hypercholesterolemia, cardiovascular disease and severe periodontal
disease. J ClinPeriodontol 2001;28:865-8.
Zaremba M, Grska R, Suwalski P, Czerniuk MR, Kowalski J.
Periodontitis as a risk factor of coronary heart diseases? Adv Med
Sci 2006;51:34-9.
Senba T, Kobayashi Y, Inoue K, Kaneto C, Inoue M, Toyokawa S, et
al.
The association between self reported periodontitis and coronary heart
diseases. J Occup Health 2008;50:283-7.
Cutler CW, Shinedling EA, Nunn M, Jotwani R, Kim BO, Nares S,
et al. Association between periodontal diseases and hyperlipidemia.
Cause or effect? J Periodontol 1999 70:1429-34.
Fuster V, Badminton L, Badminton JJ, Chesebro JH. The
pathogenesis
of coronary artery diseases and the acute coronary syndromes. New
Engl J Med 1992;326:242-50.
Hegele RA. The pathogenesis of coronary atherosclerosis.
ClinChimActa 1996;246:21-38.
Anderson KM, Castelli WP, Levy D. Cholesterol and mortality.
30 years of follow up from the Framingham study. JAMA
1987;257:2176-80.
Mattila KJ, Valtonen VV, Nieminen MS, Asikainen S. Role of
infection
as a risk factor for atherosclerosis, myocardial infarction. J Intern Med
1989;225:293-6.
Listgarten MA. Nature of periodontal diseases: Pathogenic
mechanisms. J Periodont Res 1987;22:172-8.
Joshipura KJ, Rimm EB, Douglass CW, Trichopoulos D, Ascherio A,
Willett WC. Poor oral health and coronary heart disease. J Dent Res
1996;75:1631-6.
Saxlin T, Suominen-Taipale L, Kattainen A, Marniemi J, Knuuttila
M,
Ylstalo P. Association between serum lipid levels and periodontal
infection. J Clin Periodontal 2008;35:1040-7.
DAiuto 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;84:269-73.
Buhlin K, Gustafsson A, Pockley AG, Frostegrd J, Klinge B. Risk
factors for cardiovascular disease in patients with periodontitis. Eur
Heart J 2003;24:2099- 107.
Wu T, Trevisan M, Genco RJ, Falkner KL, Dorn JP, Sempos CT.
Examination of the Relation between Periodontal Health Status
and Cardiovascular Risk Factors: Serum Total and High Density
Lipoprotein Cholesterol, C - reactive protein, and Plasma Fibrinogen.
Am J Epidemiol 2000;151:273-82.
Lsche W, Marshal GJ, Apatzidou DA, Krause S, Kocher T, Kinane
DF. Lipoprotein associated phospholipase A2 and plasma lipids in
patients with destructive periodontal disease. J Clin Periodontal
2005;32:640-4.
Pussinen PJ, Jauhiainen M, Vilkuna-Rautiainen T, Sundvall J,
Vesanen
M, Mattila K, et al. Periodontitis decrease the antiatherogenic potency
of high density lipoprotein. J Lipid Res 2004;45:139-47.
Rao NS, Bajaj P, Naik SB, Pradeep AR. Effect of non-surgical
periodontal therapy on serum lipid levels in chronic periodontitis.
AOSR 2011;1:60-4.

How to cite this article: Akkaloori A, Parthasarathi P, Anjum MS,


Gadde P, Mocherla M, Rao Y. Association between chronic
periodontal disease and cardiovascular risk factor hyperlipidemia. J
NTR Univ Health Sci 2014;3:249-53.
Source of Support: Nil. Conflict of Interest: None
declared.

Journal of Dr. NTR University of Health Sciences


2014;3(4)

253