J Periodont Res 2014

All rights reserved

2014 John Wiley & Sons A/S.

Published by John Wiley & Sons Ltd
JOURNAL OF PERIODONTAL RESEARCH
doi:10.1111/jre.12191

Use of floss/interdental
brushes is associated with
lower risk for new
cardiovascular events
among patients with
coronary heart disease

S. Reichert1, A. Schlitt2,
V. Beschow1, A. Lutze1,3,
S. Lischewski1, T. Seifert1,3,
T. Dudakliewa3, R. Gawe3,
K. Werdan3, B. Hofmann4,
H.-G. Schaller1, S. Schulz1
1
Department of Operative Dentistry and
Periodontology, Martin Luther University HalleWittenberg, Halle, Germany, 2Department of
Cardiology, Paracelsus-Harz-Clinic Bad
Suderode, Quedlinburg, Germany, 3Department
of Internal Medicine III, Heart Centre of the
University Clinics Halle (Saale), Martin Luther
University Halle-Wittenberg, Halle, Germany
and 4Department of Cardiothoracic Surgery,
Heart Centre of the University Clinics Halle
(Saale), Martin Luther University HalleWittenberg, Halle, Germany

Reichert S, Schlitt A, Beschow V, Lutze A, Lischewski S, Seifert T, Dudakliewa T,

Gawe R, Werdan K, Hofmann B, Schaller H-G, Schulz S. Use of floss/interdental
brushes is associated with lower risk for new cardiovascular events among patients
with coronary heart disease. J Periodont Res 2014; doi: 10.1111/jre.12191 . 2014
John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Background and Objective: Periodontitis has been found to be associated with
coronary heart disease (CHD) and stroke. However, only little is known about
whether periodontitis and associated confounders are associated with new cardiovascular events among patients with CHD.
Material and Methods: A total of 942 inpatients with CHD were examined
regarding periodontitis, oral care habits, bacteria in the subgingival biolm and
the expression of interleukin-(IL)-6 c. (coding DNA)174 genotypes (rs 1800793)
to determine whether these confounders are associated with new cardiovascular
events within a 1-year follow-up period. Adjusted hazard ratios (HR) with
respect of age, gender, smoking, body mass index, use of aids for interdental
hygiene, plaque index, occurrence of severe periodontitis and further internal
diseases such as diabetes, hypertension, dyslipoproteinemia, number of missing
teeth, serological parameters and IL-6 genotypes were generated with Cox
regression.
Results: In all, 941 cardiovascular patients completed the 1-year follow up and
7.3% of the patients achieved the primary endpoint (myocardial infarction:
2.1%, stroke/transient ischemic attack: 1.8%, cardiovascular deaths: 3.4%).
Patients who reported practicing interdental cleaning were younger, less likely to
be male or to have severe periodontitis, had a reduced tobacco exposure, had
fewer missing teeth, less indices for plaque and bleeding on probing and a
signicant decreased adjusted risk for new cardiovascular events (HR = 0.2, CI
0.060.6, p = 0.01) than those patients with CHD who did not report practicing
interdental cleaning. We did not obtain signicant increased HR for patients
with severe periodontitis (HR = 1.2, CI 0.72.1, p = 0.53), carriers of the IL-6
genotypes GC or CC (HR = 1.4, CI 0.82.5, p = 0.24) and did not nd a signicant association between the number of detected various oral species and the
incidence of the combined endpoint (HR = 0.9, CI 0.81.01, p = 0.07).

Dr Stefan Reichert, PD, Department of

Operative Dentistry and Periodontology, Martin
Luther University Halle-Wittenberg, Groe
Steinstrasse 19, 06108 Halle (Saale), Germany
Tel: +49 345 557 3772
Fax: +49 345 557 3773
e-mail: stefan.reichert@uk-halle.de
Key words: coronary heart disease; gene

polymorphism; interleukin-6; periodontitis;

prognostic marker
Accepted for publication March 26, 2014

Reichert et al.

Conclusions: These ndings suggest that ossing and brushing of interdental

spaces might reduce the risk for new cardiovascular events among patients with
CHD. The hypothesis that interdental cleaning per se reduces the risk of new
cardiovascular events should be examined in an interventional study.

In the last years numerous studies

were carried out to investigate
whether periodontitis is a putative
risk factor for atherosclerosis (1,2)
and subsequent diseases such as coronary heart disease (CHD) (3) and
stroke(4). Indeed, meta-analyses have
shown that periodontal disease is an
independent risk factor for CHD
(57) and cerebrovascular disease (8).
Furthermore, the occurrence of periodontopathogens in the subgingival
plaque was found to be associated
with the occurrence of CHD (9).
Interleukin (IL)-6 is a proinammatory cytokine, which stimulates hepatic production of acute phase proteins
such as C-reactive protein (CRP),
modulates adhesion of monocytes on
endothelial cells and promotes coagulation of platelets (10). Therefore,
IL-6 might be involved in the pathogenesis of both periodontitis (1113)
and CHD (1416). It has been
reported that IL-6 c.174G/C polymorphisms inuenced IL-6 serum levels (17). The genotype GG was
identied as a high-producer genotype
whereas carriers of the GC and CC
genotypes showed lower IL-6 serum
levels.
The IL-6 c.174G/C polymorphism
was found to be associated to both
chronic (18) and aggressive periodontitis (19) as well as to the subgingival
colonization with periodontopathogens (20). Furthermore, this polymorphism was found associated with
CHD (2123). Hence, IL-6 genotypes
at promoter position 174 may be
prognostic markers for CHD and
periodontitis and should be considered in multivariate risk factor
analyses.
So far, only one study from Finland has investigated the role of dental infection for new coronary events
among patients with proven coronary
artery disease (24). Therefore, the aim

of the present, prospective, longitudinal study was to investigate whether

oral hygiene habits, severe periodontitis, presence of periodontopathogens
in the subgingival biolm, or certain
IL-6 c.174 genotypes represent independent risk factors for the incidence
of new cardiovascular events (combined endpoint: myocardial infarction,
stroke/transient ischemic attack [TIA],
myocardial death) among inpatients
suering from CHD.

Material and methods

Study population

At baseline, 942 consecutive German

patients of Caucasian origin from central Germany admitted to the Department of Internal Medicine III or
Department of Cardiothoracic Surgery of the Martin Luther University
Halle-Wittenberg with angiographically proven CHD were prospectively
included from October 2009 to February 2011. The investigations were carried out in accordance with the
ethical guidelines of the Declaration
of Helsinki and its amendment in
Tokyo and Venice. The study was
approved by the ethics committee of
the Martin Luther University HalleWittenberg. Informed written consent
was obtained from each patient.
Inclusion
criteria
were
age
18 years and known CHD as
dened by a stenosis of 50% of a
main coronary artery by coronary
angiography or percutaneous coronary intervention or coronary artery
bypass surgery. At least four own
teeth except for the third molars
needed to be present. Exclusion criteria were pregnancy, antibiotic therapy
during the last 3 mo, subgingival scaling and root planing during the last
6 mo or psychological reasons that
rendered study participation impracti-

cal. Patients with current alcohol or

drug abuse might be not completely
able to understand the aim of the
study and the necessity of an additional dental examination. If a drug
or alcohol abuse was known from
patients le or a patient reported
during the interview about a current
drug or alcohol abuse s/he was not
included in the study.
Ages, body mass index, current or
past diseases (e.g. diabetes mellitus,
hypertension and dyslipoproteinemia)
were assessed as part of the patients
medical history. Diabetes mellitus
was diagnosed when it was known
from the history and/or the patients
were receiving dietary or antidiabetic
drug therapy in the hospital, or had
a fasting blood glucose of 7 mM.
Dyslipoproteinemia was assumed if
this had been prediagnosed, a therapy with lipid-lowering agents was
being administered or a fasting cholesterol of > 5.2 mM or low-density
lipoprotein cholesterol > 3.9 mM was
present. Arterial hypertension was
dened as hypertension that was
diagnosed before the current hospitalization and/or the patient was taking
antihypertensive medication or when
a blood pressure of > 140/90 mmHg
was measured. Furthermore, patients
were asked about their smoking
behaviors. A person who smoked a
minimum of one cigarette per day
at the time of questioning was
considered a current smoker. For
quantication of cigarette smoking,
pack-year of each current smoker
was calculated. When calculating the
pack-year, former smokers were not
considered. Furthermore, all patients
underwent detailed clinical and biochemical investigation. For instance,
serum parameters, including hemoglobin (mM), IL-6 (pg/mL), CRP
(mg/dL) and creatinine (lM) were
recorded.

Periodontitis and cardiovascular events

During the periodontal examination, patients were asked about the
frequency of tooth brushing per day
and whether they use dental oss or
interdental brushes to clean the interdental spaces. The clinical assessment
involved determining the plaque index
(PI) (25) and assessing bleeding on
probing (BOP) (26). In both indexes,
four sites around each tooth (mesiobuccal, mid-buccal, disto-buccal and
mid-lingual) were examined. The measurements for both maximal clinical
probing depth (distance between gingival margin and bottom of the
pocket) and maximum clinical attachment loss (distance between cementoenamel junction and bottom of the
pocket) were taken using a pressuresensitive probe (DB764R; Aesculap
AG & Co. KG, Tuttlingen, Germany)
at six sites around each tooth (mesiobuccal, mid-buccal, disto-buccal, mesio-lingual mid-lingual, disto-lingual).
For the diagnosis of periodontitis, we
used the published criteria for a twolevel periodontitis case denition for
risk factor research. Periodontitis was
dened as the presence of proximal
attachment loss of 3 mm in 2
nonadjacent teeth. Severe periodontitis was dened as the presence of
proximal attachment loss of 5 mm
in at least 30% of the teeth (27).
A 1-year follow-up was performed
and the incidence of the combined
endpoint dened as myocardial infarction, stroke/TIA and death from cardiovascular causes was calculated.
For acquiring follow-up data, a standardized questionnaire was sent out.
If patients did not return the
questionnaires, a telephone interview
was conducted with the patient or
patients relatives and physician, when
the patient was dead. At an unknown
current address or telephone number,
we contacted civil registration oces
and requested information about current address or date of death. If the
patients death was already known,
for instance for individuals who died
in our hospital, we did not send out a
questionnaire. Instead, the information about the cause and date of
death was obtained from electronic
patient les.

Determination of interleukin-6 c.174

G/C genotypes

The genomic DNA was obtained

from leukocytes in venous EDTA
blood using a commercial DNA
extraction kit (QIAamp; Qiagen,
Hilden, Germany) in accordance with
the manufacturers instructions.
Genotype analyses were carried out
using a commercial available polymerase chain reaction (PCR)-SSP kit
(CTS-PCR-SSP Tray kit, Collaborative Transplant Study, Department of
Transplantation Immunology of the
University Clinic of Heidelberg,
Germany) as described previously (28).
After agarose gel electrophoresis, the
results were evaluated visually. Bands
of 430 bp correspond to the various
IL-6 alleles. According to db single
nucleotide polymorphism, the identication number of the single nucleotide
polymorphism was rs 1800793.
Molecular biological assessment of
periodontal bacteria in subgingival
pockets

Microbial samples were taken from

the deepest pocket of each quadrant
by inserting one sterile paper point
for 20 s. The four bacterial plaque
samples taken from each patient were
pooled in one tube. Aggregatibacter
actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia,
Tannerella forsythia, Treponema denticola,
Peptostreptococcus
micros,
Fusobacterium nucleatum, Campylobacter rectus, Eubacterium nodatum,
Eikenella corrodens and a combination of Capnocytophaga sputigena,
Capnocytophaga gingivalis and Capnocytophaga ochracea were specically
assessed by PCR in a commercial laboratory (micro-Ident plus test; HAINDiagnostica, Nehren, Germany). The
procedure for detecting bacterial
DNA can be divided into three steps:
isolation of bacterial DNA, multiplex
amplication
with
biotinylated
species-specic primers by PCR, and
reverse hybridization. These steps
have been described in detail in a previously published paper of our group
(29). The detection limit for all bacte-

ria was 104 genome equivalents with

the exception of Aggregatibacter
actinomycetemcomitans with 103 genome equivalents. The numbers of
detected bacterial species per individual that were over the detection limit
were counted.
Statistical evaluation

Statistical analyses were carried out

using commercially available software
(SPSS v.19.0 package; IBM, Chicago,
IL, USA). Values of p 0.05 were
considered signicant. The distribution of the IL-6 c.174GG, GC and
CC among the inpatients with CHD
was tested according to the Hardy
Weinberg equilibrium.
Metric demographic, clinical and
serological data were checked for
normal
distribution
using
the
KolmogorovSmirnov test and the
ShapiroWilk test. As all metric values
were not normally distributed, they
were plotted as median and 25th/75th
percentiles. For statistical evaluation,
the MannWhitney U test was used.
Pack-year was calculated by multiplying the number of packs (one
pack = 20 cigarettes) of cigarettes
smoked per day by the number of
years the person has smoked.
To evaluate adjusted odds ratios
for occurrence of severe periodontitis
among patients with CHD, a logistic
regression analysis was conducted
with respect of the cofactors age, gender, body mass index, pack-year,
number of detected dierent bacterial
species per individual, frequency of
tooth brushing per day, use of oss/
interdental brushes and expression of
IL-6 c.174 G/C genotypes.
For survival evaluation, Kaplan
Meier analyses with the log-rank test
were applied. Adjusted hazard ratios
were generated with Cox regression
and with respect of the variables age
gender, body mass index, pack-year,
hypertension, dyslipoproteinemia, diabetes, serum levels for IL-6, CRP,
hemoglobin and creatinine, IL-6 c.
174 genotypes (GC+CC vs. GG),
number of missing teeth, number of
detected dierent bacterial species per
individual,
frequency
of
tooth

Reichert et al.

Table 1. Periodontal conditions, prevalence of internal diseases, biochemical parameters,

distribution of c.174 interleukin-6 genotypes among inpatients with coronary heart disease
Stationary patients
with coronary
heart disease
n = 942

Variables
Demographic parameters
Age (years), median (25th/75th percentiles)
Males (%)
Pack-years, mean (SD)
Body mass index (kg/m2), median (25th/75th percentiles)
Prevalence of internal diseases
Diabetes (%)
Hypertension (%)
Dyslipoproteinemia (%)
Oral care habits and periodontal conditions
Frequency of tooth brushing per day (%)
Once a day
More than once a day
Use of interdental oss/brush (%)
No periodontitis (%)
All periodontitis cases (%)a
Severe periodontitis cases (%)b
Plaque index (%), median (25th/75th percentiles)
Bleeding index (%), median (25th/75th percentiles)
Number of missing teeth, median (25th/75th percentiles)
Number of detected oral species, median
(25th/75th percentiles)
Serological parameters
C-reactive protein (mg/dL), median (25th/75th percentiles)
Reference: < 0.5
Interleukin 6 (pg/mL)
Median (25th/75th percentiles)
Reference: < 6.4
Creatinine (lM), median (25th/75th percentiles)
Reference: males: < 102; females: < 88
Hemoglobin (mM)
Median (25th/75th percentiles)
Reference: males 8.711.2; females: 7.39.9
IL-6 c.174 G>C genotypes (rs 1800793) (%)
GG
GC
CC

68.8 (59.5/74.9)
74.0
3.0 (9.7)
28.1 (25.3/30.8)
34.2
87.6
58.7

23.9
74.9
20.1
2.1
97.9
47.7
0.8
5.6
10.0
7.0

(0.5/1.4)
(1.8/12.1)
(5.0/18.0)
(5.0/8.0)

8.9 (3.6/32.1)
7.4 (3.6/15.7)

87.0 (72.0/106.3)
8.3 (7.2/9.1)

29.8
49.3
20.95

Attachment loss of 3 mm in at least two non-adjacent teeth.

Attachment loss of 5 mm in 30% of teeth present.

brushing per day and use of oss/

interdental brushes were included in
one model.

Results
Periodontal, microbial and serologic
conditions in inpatients with
coronary heart disease

All baseline data are presented in

Table 1. The overall prevalence of
severe periodontitis among our
patients with CHD was almost 50%.

A median of 10 missing teeth (exception third molars) was recorded. The

median for the number of detected
bacterial species was 7. The majority
of patients with CHD (74.9%)
brushed their teeth more than once a
day but only 20.1% used oss and/or
interdental brushes. The overall median values for CRP and IL-6 were
above the reference values for healthy
persons.
The distribution of the IL-6 c.-174
genotypes GG, GC and CC fullled
the criteria of the HardyWeinberg

equilibrium. Of the patients, 70%

were carriers of IL-6 c.174 genotypes
GC or CC.
Factors associated to the
occurrence of a severe periodontitis
among patients with coronary heart
disease

The age, male gender, the number of

detected oral species, and occurrence
of IL-6 c.174 GC or CC genotypes
were associated with an increased
adjusted odds ratio for severe periodontitis whereas the use of oss/
interdental brushes was associated
with a lower adjusted odds ratio
(Table 2). Patients who used oss
and/or interdental brushes were significantly younger, more often females,
and had lower values for pack-years,
occurrence of a severe periodontitis,
missing teeth, PI and BOP in comparison to patients with CHD, who did
not use any aids for interdental
hygiene (Table 3).
Association of severe periodontitis,
periodontal and microbial
conditions and IL-6 c.174
genotypes with the incidence of the
combined endpoint within the 1-year
follow-up period

A total of 942 patients with CHD

were prospectively included in the
longitudinal cohort study. For one
patient (0.1% dropout rate) we did
not obtain 1-year follow-up data.
During the mean follow-up of
54  11 wk, 20 (2.1%) myocardial
infarctions, 17 (1.8%) strokes/TIAs
and 32 (3.4%) cardiovascular deaths
were recorded. The total incidence of
the combined endpoint was 7.3%.
Bivariate analyses The
Kaplan
Meier plot (Fig. 1) showed a signicantly lower incidence for the
combined endpoint among patients
who used dental oss/interdental
brushes than among individuals who
did not use these aids for oral hygiene
(1.6% vs. 8.8%, log-rank p = 0.001).
Moreover, patients with CHD who
had only 010 missing teeth showed a
signicantly lower incidence of the
combined endpoint than individuals

Periodontitis and cardiovascular events

Table 2. Logistic regression analysis for the occurrence of a severe periodontitisa among
patients with cardiovascular heart disease

Confounding variables
Age
Male gender
Body mass index
Pack-years
Frequency of tooth brushing per day
Use of oss/interdental brushes
Number of detected bacterial various
species per individual
Diabetes
IL-6 c.174 GC or CC vs. GG
a

Odds
ratio

95%
lower

CI
upper

p values

1.02
1.42
0.99
1.03
0.87
0.50
1.14

1.01
1.03
0.96
1.01
0.68
0.35
1.08

1.04
1.95
1.02
1.05
1.11
0.71
1.21

0.002
0.03
0.44
0.002
0.26
< 0.001
< 0.001

1.22
1.11

0.91
0.83

1.64
1.49

0.18
0.009

Attachment loss of 5 mm in 30% of teeth present.

Table 3. Demographic, general and periodontal conditions in patients with coronary heart
diseases in depending on the use of aids for approximal hygiene

Variable
Age (years), median
(25th/75th percentiles)
Males (%)
Pack-years, mean (SD)
Body mass index (kg/m2), median
(25th/75th percentiles)
Severe periodontitis (%)a
Missing teeth (exception third
molars), median (25th/75th
percentiles)
Plaque index (%), median
(25th/75th percentiles)
Bleeding upon probing (%),
median (25th/75th percentiles)
Number of bacterial species per
individual, median (25th/75th
percentiles)

No use of oss/
interdental brushes
n = 753

Use of oss/
interdental brushes
n = 189

69.2 (59.7/75.5)

67.3 (59.2/72.0)

0.006c

74.0
3.3 (10.4)
28.1 (25.2/30.8)

30.7
1.5 (5.9)
27.9 (25.4/30.5)

< 0.001b
0.045c
0.649c

51.9
12.0 (6.0/20.0)

30.7
7.0 (3.1/10.0)

< 0.001b
< 0.0001c

0.9 (0.6/1.6)

0.6 (0.4/0.8)

< 0.0001c

6.3 (2.2/12.5)

3.5 (0.9//6.9)

< 0.0001c

7 (5.0/8.0)

7 (4.0/8.0)

0.963c

Severe periodontitis: Attachment loss of 5 mm in 30% of teeth present.

Chi-squared test with Yates correction.
c
MannWhitney U-test.
a

who had 1124 missing teeth (4.9%

vs. 9.8%, log-rank p = 0.004) (Fig. 2).
The incidence for the combined endpoint tended to be higher in patients
with severe periodontitis than in individuals who did not have severe periodontitis (8.9% vs. 5.9%, log-rank
p = 0.095). There was no signicant
dierence regarding the incidence of
the combined endpoint in patients
where none to ve various bacterial
species were detected in comparison
to those with six to 11 bacteria (7.9%
vs. 7.0%, log-rank p = 0.515). IL-6
c.174 genotypes were not signi-

cantly associated with dierent incidence rates of the combined endpoint

(GG 6.1%, GC 7.1%, CC 9.6%,
log-rank p = 0.340).
Multivariate analysis To generate
adjusted hazard ratios the inuence of
severe periodontitis, oral hygiene habits, number of missing teeth and
expression of IL-6 c.174 genotypes
on the cardiovascular endpoint, was
investigated with Cox regression with
respect to known confounders for
both, periodontitis and CHD. Only
the use of dental oss/interdental

brushes was associated with a signicantly decreased adjusted hazard ratio

for the combined endpoint (Table 4).

Discussion
Periodontitis,
periodontopathogens,
oral hygiene habits, number of missing teeth and polymorphisms in genes
of cytokines such as IL-6 might be
indicative for new cardiovascular
events among patients who suer
from CHD. If such associations were
identied, the diagnosis and therapy
of periodontal diseases would need to
be regularly integrated into cardiac
rehabilitation programs to reduce the
risk for such events.
The purpose of the present study
was to evaluate the impact of these
periodontal and genetic conditions on
further cardiovascular events (combined endpoint: myocardial infarction,
stroke/TIA, myocardial death) within
a 1-year follow-up period among
inpatients with proven CHD. The
hazard ratios should be controlled for
known confounders for both periodontitis and CHD.
Both the overall prevalence of periodontitis (97.9%) and prevalence of a
severe periodontitis (47.7%) among
our patients with CHD (Table 1) were
slightly higher than the epidemiologic
data obtained in the fourth German
Dental Health Survey (DMS IV). In
that study, the overall prevalence of
periodontitis was 87.8% (Community
Periodontal Index [CPI] Code 3 or 4)
among individuals aged from 65 to
74 years and 39.9% had a severe periodontitis (CPI Code 4) (30). In contrast, the number of missing teeth
(except for the third molars) was not
higher among our patients with CHD
(14.0 vs. 14.2) (31).
The dierences regarding the prevalence of periodontitis among patients
with CHD in comparison to the DMS
IV data should be interpreted with
caution, however, and we cannot conclude from these data that the prevalence of periodontal disease is higher
among patients with CHD in general.
For instance, CPI codes were only
recorded on index teeth and a pocket
depth on 45 mm (Code 3) was
dened as periodontitis. In the present

Reichert et al.
1.0

Combined endpoint

0.8

0.6

0.4

0.2

Use of dental
floss/interdental
brushes
No
Yes

0.0
0

20

40
60
Wk of follow up

80

100

Fig. 1. KaplanMeier plot for combined endpoint (stroke/transient ischemic attack, cardiovascular death, myocardial infarction) according to the use of aids for interdental
hygiene (use of oss/interdental brushes vs. no use of oss interdental brushes).

1.0

Combined endpoint

0.8

0.6

0.4

0.2
010 missing teeth
1124 missing teeth

0.0
0

20

40
60
Wk of follow up

80

100

Fig. 2. KaplanMeier plot for combined endpoint (myocardial infarction, stroke/transient

ischemic attack, myocardial death) according to the number of missing teeth (010 missing
teeth vs. 1124 missing teeth).

study, the threshold for diagnosis of a

periodontitis case was a clinical
attachment loss of at least 3 mm in at
least two nonadjacent teeth. Moreover, all teeth were investigated.
As only 20 (2.1%) of our study
patients with CHD did not have peri-

odontitis, a separate statistical evaluation for this cohort would not be

meaningful. Therefore, this group was
added to patients who had no severe
periodontitis.
Our main results showed a signicantly decreased adjusted HR for the

combined endpoint among patients

who used dental oss/interdental
brushes for oral hygiene (Table 4).
According to our results this association might be due to the favorable
eect of proper oral hygiene in the
plaque and bleeding index, number of
missing teeth and prevalence of severe
periodontitis (Table 3). The inverse
association between use of oss/interdental brushes and prevalence of a
severe periodontitis was additionally
conrmed in a binary logistic regression model (Table 2). The long-term
eect of eective plaque control on
periodontitis and tooth mortality has
already been demonstrated (32). The
use of aids for cleaning interdental
spaces as an adjunct to brushing was
found to remove more dental plaque
than brushing alone (33). In contrast
to our results, a Scottish health survey
(34) obtained (Table 4) an inverse
association between the frequency of
dental brushing and the risk of CHD.
The use of oss/interdental brushes,
however, was not evaluated.
Although our data suggest a direct
link between oral hygiene and the
incidence of the combined endpoint,
further confounders should be discussed. For instance, patients who
used aids for interdental hygiene were
signicantly younger, more often were
females and had a lower smoke
exposure than their counterparts who
did not clean the interdental spaces
(Table 3). These confounders might
inuence the risk for further cardiovascular events. It is also conceivable
that patients with a proper interdental
hygiene were in better general health
and more motivated and/or able to
use oss/interdental brushes regularly.
Furthermore, good oral care habits
such as use of aids for interdental
hygiene might reect a higher health
consciousness in general. Despite this
uncertainty regarding the underlying
biologic eect of oral hygiene to the
incidence of new cardiovascular
events, the use of interdental brushes/
dental oss might be recommended,
in particular, to patients with CHD.
The hypothesis that interdental
cleaning per se reduces the risk of
new cardiovascular events should be
examined in an interventional study.

Periodontitis and cardiovascular events

Hazard
ratio

95%
lower

CI
upper

p values

0.99
0.65
0.95
0.99
0.96
0.86
0.97
1.51
1.00
1.00
1.00
1.20
1.41
0.99
1.25
0.91

0.97
0.37
0.89
0.96
0.45
0.53
0.78
0.90
0.99
0.99
1.00
0.68
0.79
0.96
0.89
0.82

1.02
1.16
1.00
1.02
2.02
1.41
1.20
2.56
1.01
1.00
1.00
2.09
2.49
1.03
1.77
1.01

0.52
0.15
0.07
0.43
0.91
0.55
0.77
0.12
0.29
0.71
0.13
0.53
0.24
0.74
0.20
0.07

(cross-sectional vs. longitudinal) or

the dierent methods for detecting
periodontopathogens and thus dierent detection limits.
There was trend for a positive association between the individual expression of the genotypes IL-6 c.-174 GC
or CC and the prevalence of a severe
periodontitis among patients with
CHD (Table 2). However, although
our patients who were carriers of IL-6
c.174 CC or GC genotypes usually
met the combined endpoint, this was
not signicant after both log-rank test
and Cox regression. Therefore, our
results did not support previous crosssectional studies and meta-analyses,
which identied the IL-6 c.174 G/C
polymorphism as indicative for cardiovascular diseases (2123,36).

1.14
0.19

0.74
0.06

1.78
0.63

0.56
0.01

Limitations of the study

Table 4. Cox regression for the incidence of the combined endpoint (myocardial infarction,
stroke/transient ischemic attack, myocardial death) within the 1-year follow-up period
among patients with coronary heart disease. Signicant data are highlighted in bold print.

Confounding variables
Age
Male gender
Body mass index
Pack-years
Hypertension
Dyslipoproteinemia
Hemoglobin
Diabetes
IL-6
C-reactive protein
Creatinine
Severe periodontitisa
IL-6 c.174 GC or CC vs. GG
Missing teeth
Plaque index
Number of detected various bacterial
species per individual
Frequency of tooth brushing per day
Use of oss/interdental brushes

CI, condence interval; IL, interleukin.

a
Severe periodontitis: Attachment loss of 5 mm in 30% of teeth present.

Although oral hygiene habits were

associated to both, the prevalence of
a severe periodontitis (Table 2) and
incidence of the cardiovascular endpoint (Table 4) we found only a trend
but not a signicant association
between severe periodontitis and the
incidence of the combined endpoint at
all. In contrast to our result, a previous study (24) showed a signicant
positive association between dental
infection and the risk of new coronary
events among patients with proven
coronary artery disease. In particular,
dierences in the study design (e.g.
number of studied individuals, followup intervals and denition of the endpoint, including cofactors) might be
responsible for these inconsistent
results. For instance, in a previous
study (24) only 214 individuals were
investigated but the follow-up period
was 7 years. The endpoint was
dened as incidence of fatal and nonfatal coronary events and overall
mortality but incidence of TIA/stroke
was not investigated. Moreover, in
comparison to our multivariate Cox
regression the socioeconomic status,
the number of previous myocardial
infarctions, and serum lipids were
included as confounding variables.

A Swedish longitudinal study (35)

reported a dose-dependent relationship between number of teeth and
all-cause and cardiovascular disease
mortality. The authors assumed that
severe tooth loss might be an indicator for life-long dental infections,
which could represent an important
risk factor for atherosclerotic vascular
changes. The results of that study are
partially conrmed by our ndings
because, according to the log-rank
test (Fig. 2), the incidence of the combined endpoint was associated with
the number of missing teeth. However, this was not signicant in the
multivariate model (Table 4).
The positive association between
the periodontal pathogen burden and
the prevalence of CHD obtained in a
previous cross-sectional controlled
study (9) could not be conrmed by
our results. According to our ndings,
the number of detected bacterial species per individual was indeed associated to the prevalence of a severe
periodontitis (Table 2) but not to the
incidence of the combined endpoint
(Table 4).
This dierent result in comparison
to the preceding study (9) could be
due to dierences in study designs

The present study is a longitudinal

cohort study to investigate predictors
for new cardiovascular events among
patients with CHD. Therefore, a gender- and age-matched non-CHD control group was not included and the
prevalence of a severe periodontitis
among patients with CHD was compared with data obtained in the
fourth German Dental Health Survey
(DMS IV). Not surprisingly, the comparison of patients with CHD to
matched controls without CHD
would extend conclusions. The present study does not provide information about whether use of aids for
interdental hygiene among individuals
without CHD reduced the risk for
CHD events at all.
In the study 118 patients were
included who reported in the interview about a previous periodontitis
therapy earlier than 6 mo before dental examination. Previous periodontal
therapy might lower the risk for new
cardiovascular
events.
Moreover,
patients with CHD were heterogeneous regarding their status of internal diseases. For instance, patients
with diabetes who had not yet started
any diabetic control measures were
included.
It is feasible that patients with
CHD where the concomitant internal
diseases were well treated have a

Reichert et al.

lower risk for further CHD events

than patients with untreated internal
diseases.
We investigated Caucasian patients
from central Germany. As the distribution of gene polymorphisms is also
dierent with respect to ethnicity, our
results regarding the IL-6 polymorphism cannot be transferred to groups
with other ethnic aliations.
With multivariate analyses, we tried
to identify independent risk indicators
for the incidence of the cardiovascular
endpoint. However, the results depend
very strongly on the type and number
of included confounding variables and
duration of follow-up. This could
explain dierent results in comparison
to other investigations.
In summary, the use of dental oss
and/or interdental brushes was signicantly associated with an adjusted
decreased HR for new cardiovascular
events among patients with CHD
within a 1-year follow-up period
whereas severe periodontitis, number
of missing teeth, the amount of
detected bacterial species and certain
IL-6 c.174 genotypes were not.
Whether the use of aids for oral
hygiene actually reduces the incidence
of new cardiovascular events should be
investigated in an interventional study.

Acknowledgements
We would like to thank all patients
for their cooperation in this study.

Source of funding
The study was supported by a grant of
the Deutsche Herzstiftung, Frankfurt
am Main, Germany (F/34/08) and by
an unrestricted grant from HAINDiagnostica, Nehren, (Germany).

Conflict of interest
The authors declare that they have no
conict of interest.

References
1. Buhlin K, M
antyla P, Paju S et al. Periodontitis is associated with angiographically veried coronary artery disease.
J Clin Periodontol 2011;38:10071014.

2. Pinho MM, Faria-Almeida R, Azevedo

ao Manso M, Martins L. PeriE, Conceic~
odontitis and atherosclerosis: an observational
study.
J
Periodontal
Res
2013;48:452457.
3. Tonetti MS, van Dyke TE. Periodontitis
and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/
AAPWorkshop on periodontitis and systemic diseases. J Periodontol 2013;84:
(suppl 4):2429.
4. Straka M, Trapezanlidis M. Periodontitis
and stroke. Neuro Endocrinol Lett
2013;34:200206.
5. Janket SJ, Baird AE, Chuang SK, Jones
JA. Meta-analysis of periodontal disease
and risk of coronary heart disease and
stroke. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2003;95:559569.
6. Bahekar AA, Singh S, Saha S, Molnar J,
Arora R. The prevalence and incidence
of coronary heart disease is signicantly
increased in periodontitis: a meta-analysis. Am Heart J 2007;154:830837.
7. Humphrey LL, Fu R, Buckley DI, Freeman M, Helfand M. Periodontal disease
and coronary heart disease incidence: a
systematic review and meta-analysis.
J Gen Intern Med 2008;23:20792086.
8. Wu T, Trevisan M, Genco RJ, Dorn JP,
Falkner KL, Sempos CT. Periodontal
disease and risk of cerebrovascular disease: the First National Health and
Nutrition Examination Survey and its
follow-up study. Arch Intern Med
2000;160:27492755.
9. Spahr A, Klein E, Khuseyinova N et al.
Periodontal infections and coronary
heart disease: role of periodontal bacteria
and importance of total pathogen burden
in the coronary event and periodontal
disease (CORODONT) study. Arch
Intern Med 2006;166:554559.
10. Raman K, Chong M, Akhtar-Danesh G
et al. Genetic markers of inammation
and their role in cardiovascular disease.
Can J Cardiol 2013;29:6774.
11. Stefani FA, Viana MB, Dupim AC et al.
Expression, polymorphism and methylation pattern of interleukin-6 in periodontal tissues. Immunobiology 2013;218:
10121017.
12. Nakajima T, Honda T, Domon H et al.
Periodontitis-associated up-regulation of
systemic inammatory mediator level
may increase the risk of coronary heart
disease. J Periodontal Res 2010;45:
116122.
13. Trindade SC, Olczak T, Gomes-Filho IS
et al. P. gingivalis HmuY-induced production of interleukin-6 and IL-6 polymorphism in chronic periodontitis.
J Periodontol 2013;84:650655.
14. Haba D, Teslaru S, Ungureanu D et al.
Evaluation of serum and gingival crevicular uid C-reactive protein and IL-6

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

levels in patients with periodontitis and

transient ischemic attacks. Rom J Morphol Embryol 2011;52:12431247.
Lee KWJ, Hill JS, Walley KR, Frohlich
JJ. Relative value of multiple plasma
biomarkers as risk factors for coronary
artery disease and death in an angiography
cohort.
CMAJ
2006;174:
461466.
Nishida H, Horio T, Suzuki Y et al.
Interleukin-6 as an independent predictor
of future cardiovascular events in highrisk Japanese patients: comparison with
C-reactive protein. Cytokine 2011;53:
342346.
Fishman D, Faulds G, Jeery R et al.
The eect of novel polymorphisms in the
interleukin-6 (IL-6) gene on IL-6 transcription and plasma IL-6 levels, and an
association with systemic-onset juvenile
chronic arthritis. J Clin Invest 1998;102:
13691376.
Kalburgi NB, Bhatia A, Bilichodmath S,
Patil SR, Mangalekar SB, Bhat K. Interleukin-6
promoter
polymorphism
(-174 G/C) in Indian patients with
chronic periodontitis. J Oral Sci 2010;52:
431437.
Shao M, Huang P, Cheng R, Hu T.
Interleukin-6 polymorphisms modify the
risk of periodontitis:a systematic review
and meta-analysis. J Zhejiang Univ Sci B
2009;10:920927.
Nibali L, Ready DR, Parkar M et al.
Gene polymorphisms and the prevalence
of key periodontal pathogens. J Dent
Res 2007;86:416420.
Manginas A, Tsiavou A, Chaidaroglou
A et al. Inammatory cytokine gene variants in coronary artery disease patients
in Greece. Coron Artery Dis 2008;19:
575582.
Vakili H, Ghaderian SMH, Akbarzadeh
Najar R, Tabatabaei Panah AS, Azargashb E. Genetic polymorphism of interleukin-6 gene and susceptibility to acute
myocardial infarction. Coron Artery Dis
2011;22:299305.
Yin Y, Hu A, Sun Q et al. Association
between interleukin-6 gene -174 G/C
polymorphism and the risk of coronary
heart disease: a meta-analysis of 20 studies including 9619 cases and 10,919 controls. Gene 2012;503:2530.
Mattila KJ, Valtonen VV, Nieminen M,
Huttunen JK. Dental infection and the
risk of new coronary events: prospective
study of patients with documented coronary artery disease. Clin Infect Dis
1995;20:588592.
Loe H, Silness J. Periodontal disease in
pregnancy. I. Prevalence and severity.
Acta Odontol Scand 1963;21:533551.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque.
Int Dent J 1975;25:229235.

Periodontitis and cardiovascular events

27. Tonetti MS, Claey N. Advances in the
progression of periodontitis and proposal
of denitions of a periodontitis case and
disease progression for use in risk factor
research. Group C consensus report of
the 5th European Workshop in Periodontology. J Clin Periodontol 2005;32
(suppl 6):210213.
28. Schulz S, Machulla HKG, Altermann W
et al. Genetic markers of TNF-a in relation to aggressive and chronic periodontitis. J Clin Periodontol 2008;35:493500.
29. Reichert S, Altermann W, Stein JM,
Schaller H, Machulla HK, Schulz S.
Individual composition of human leukocyte antigens and periodontopathogens in the background of periodontitis.
J Periodontol 2013;84:100109.

30. Holtfreter B, Kocher T, Homann T, Desvarieux M, Micheelis W. Prevalence of periodontal disease and treatment demands
based on a German dental survey (DMS
IV). J Clin Periodontol 2010;37:211219.
31. Schiner U, Homann T, Kerschbaum
T, Micheelis W. Oral health in German
children, adolescents, adults and senior
citizens in 2005. Community Dent Health
2009;26:1822.
32. Axelsson P, Nystrom B, Lindhe J. The
long-term eect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after
30 years of maintenance. J Clin Periodontol 2004;31:749757.
33. Slot DE, D
orfer CE, van der Weijden
GA. The ecacy of interdental brushes

on plaque and parameters of periodontal

inammation: a systematic review. Int J
Dent Hyg 2008;6:253264.
34. de Oliveira C, Watt R, Hamer M.
Toothbrushing, inammation, and risk
of cardiovascular disease: results from
Scottish Health Survey. BMJ 2010;340:
c2451.
35. Holmlund A, Holm G, Lind L. Number
of teeth as a predictor of cardiovascular
mortality in a cohort of 7,674 subjects
followed for 12 years. J Periodontol
2010;81:870876.
36. Yang Y, Zhang F, Skrip L et al. IL-6
gene polymorphisms and CAD risk: a
meta-analysis. Mol Biol Rep 2013;40:
25892598.