European Heart Journal (2019) 40, 1138–1145 CLINICAL RESEARCH

doi:10.1093/eurheartj/ehy836 Prevention and epidemiology

Improved oral hygiene care attenuates the

cardiovascular risk of oral health disease: a
population-based study from Korea

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Shin-Young Park1,2, Sun-Hwa Kim3, Si-Hyuck Kang3,4*, Chang-Hwan Yoon3,4,
Hyo-Jung Lee1, Pil-Young Yun5, Tae-Jin Youn3,4, and In-Ho Chae3,4
1
Department of Periodontology, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-Do 13620, Korea; 2Clinical Dental Education,
Department of Dentistry, Dental Research Institutes, School of Dentistry, Seoul National University, Seoul 03080, Korea; 3Cardiovascular Center, Department of Internal
Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Korea; 4Department of Internal Medicine,
Seoul National University, 101 Daehak-ro, Chong No Gu, Seoul, 03080, Korea; and 5Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National
University Bundang Hospital, Seongnam-si, Gyeonggi-Do 13620, Korea

Received 24 May 2018; revised 3 September 2018; editorial decision 22 November 2018; accepted 22 November 2018; online publish-ahead-of-print 18 December 2018

See page 1146 for the editorial comment on this article (doi: 10.1093/eurheartj/ehz060)

Aims Oral health problems such as periodontal disease, dental caries, and tooth loss have been suggested to have associ-
ations with cardiovascular disease. This study aimed to evaluate whether oral hygiene behaviour can alleviate car-
diovascular risk associated with oral health status using a nationwide population-based cohort.
...................................................................................................................................................................................................
Methods The data of 247 696 healthy adults aged 40 years or older who underwent an oral health screening programme
and results and had no history of major cardiovascular events were extracted from the National Health Insurance System-
National Health Screening Cohort. After a median follow-up of 9.5 years, 14 893 major cardiovascular events
occurred including cardiac death, myocardial infarction, stroke, and heart failure. The risk of cardiovascular events
was higher when a subject had periodontal disease, a higher number of dental caries, or more tooth loss.
Performing one more tooth brushing a day was associated with a 9% significantly lower risk of cardiovascular
events after multivariable adjustment. Regular dental visits (once a year or more) for professional cleaning were
also shown to reduce cardiovascular risk by 14%. Improved oral hygiene behaviours were shown to attenuate the
cardiovascular risk originating from periodontal disease, dental caries, and tooth loss.
...................................................................................................................................................................................................
Conclusion Oral hygiene care such as frequent tooth brushing and regular dental visits for professional cleaning reduced the
risk of future cardiovascular events in healthy adults. This study also suggests that improved oral hygiene behaviour
may modify the association between oral health and cardiovascular diseases.
䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏

Keywords Oral health • Risk factors • Epidemiology • Atherosclerotic cardiovascular disease

..
.. cardiovascular disease is yet unclear.7,8 The two diseases share com-
Introduction .. mon risk factors such as smoking, diabetes, and advanced age. The
..
The link between oral health and cardiovascular disease has been .. issue has potential impact because both the conditions have a high in-
debated.1,2 Observational studies have shown a positive association .. cidence; while cardiovascular disease is the leading cause of death
..
between the two diseases.3–5 Periodontal disease causes transient .. worldwide, oral health disease is one of the most common diseases
bacteraemia, systemic inflammation, and endothelial dysfunction, .. and is closely linked to daily activities.9–11
..
which are possible mechanisms underlying atherogenesis.6 However, .. Periodontal diseases are preventable.12 Bacterial plaque on the
limited evidence supports a causal relationship between the two dis-
.. dental surface is the main cause of gingivitis and periodontitis,
..
eases, and the therapeutic benefit of periodontal treatment for . which may result in dental caries and tooth loss.13 Daily personal

* Corresponding author. Tel: 182 31 787 7027, Fax: 182 31 787 4290, Email: eandp303@snu.ac.kr
Published on behalf of the European Society of Cardiology. All rights reserved. V
C The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
Oral health disease, oral hygiene, and cardiovascular outcomes 1139

oral hygiene such as tooth brushing is key to preventing peri-

Table 1 Baseline characteristics of the study
odontal disease.14 While tooth brushing is limited to the removal
population
of dental deposits below the gingival margin alone, professional
cleaning (also known as supragingival scaling or professional mech- Characteristics Total (n 5 247 696)
.................................................................................................
anical plaque removal) by a dentist or dental hygienist removes
Age (years) 52 (46–60) (247 696)
mineralized plaques (tartar).15 Regular tooth brushing and profes-
Male sex 58.0% (144 437/247 696)
sional cleaning have been proven to reduce periodontal diseases,
Income levels, % (n)
dental caries, and tooth loss.14,16 Current guidelines recommend
Fifth quintile (highest) 38.1% (94 306/247 696)
tooth brushing twice or more daily and regular dental visits for
Fourth quintile 20.1% (49 799/247 696)
professional cleaning.12,17
Third quintile 14.5% (35 863/247 696)
However, there is limited evidence regarding whether improved
Second quintile 12.8% (31 656/247 696)
oral hygiene care reduces cardiovascular events.2,18 In addition, it is

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First quintile (lowest) 14.4% (35 676/247 696)
unknown how oral hygiene care interacts with oral health diseases
Covered by medical aid 0.2% (396/247 696)
including periodontal disease, dental caries, and tooth loss in terms
Regular physical activity 18.9% (46 716/247 696)
of primary cardiovascular prevention. Thus, we performed a
Anthropometric measurements
population-based study using a large nationwide database to assess
Body mass index (kg/m2) 23.9 (22.0–25.8) (247 547)
the impact of self-reported oral hygiene behaviour on the occurrence
Systolic blood pressure (mmHg) 125 (113–137) (245 417)
of cardiovascular disease stratified by oral health status.
Diastolic blood pressure (mmHg) 80 (70–86) (245 396)
Comorbidities (%)
Hypertension 19.9% (49 351/247 696)
Methods Diabetes mellitus 6.0% (14 580/247 696)
Dyslipidaemia 24.0% (59 936/247 696)
Data sources Current smoker 21.8% (51 410/235 610)
Subjects aged 40 years or older with no previous history of cardiovascular
Renal disease 0.7% (1749/247 696)
diseases were chosen from the National Health Insurance System-
History of malignancy 7.0% (17 899/247 696)
National Health Screening Cohort (NHIS-HEALS).19 The National
Health Insurance Service is the sole insurance provider in Korea and cov- Laboratory findings (mg/dL)
ers almost all citizens. Enrolees of the insurance system are entitled to Total cholesterol 197 (174–222) (247 318)
standardized medical examinations biennially that include questionnaires HDL cholesterol 52 (44–61) (221 762)
on lifestyle and medical history, height, weight, and blood pressure meas- LDL cholesterol 117 (95–140) (221 548)
urements, and laboratory tests. The cohort contains the data of 514 866 Triglyceride 115 (81–165) (221 031)
subjects who received routine check-ups between 2002 and 2003 and Serum creatinine 0.90 (0.80–1.10) (223 287)
includes demographic data, eligibility status, income levels, claims, and Oral health status
death records by the end of 2013. Periodontal disease 30.5% (75 653/247 696)
The oral health screening programme is provided to enrolees aged Number of dental caries 0.4 ± 1.1 (247 696)
40 years or older. It is composed of a self-reported survey and oral exam-
0 79.4% (79 578/247 696)
ination by professional dentists. The oral health survey includes questions
1–5 17.1% (42 372/247 696)
regarding dental visits, dental symptoms, and oral hygiene care.
>_6 0.9% (2274/247 696)
Participants are examined by dentists for periodontal status and for the
number of decayed, filled, and missing teeth. Recommendations for den- Number of missing teeth 0.8 ± 2.5 (247 696)
tal treatments such as caries control or periodontal surgery are provided 0 75.6% (187 160/247 696)
to the participants. 1–7 21.5% (53 366/247 696)
Subjects with a previous history of myocardial infarction, heart failure, 8–14 1.9% (4743/247 696)
and stroke were excluded from the analysis. Variables such as anthropo- 15–21 0.6% (1505/247 696)
metric measurements, physical and dental examination, and laboratory 21–28 0.4% (922/247 696)
tests were obtained from the health screening database. The insurance Gum bleeding 21.3% (51 655/242 957)
eligibility database was linked to death certificate records from the Oral hygiene care
National Death Index to extract information on vital status, date of death, Dental visit for any reasons 44.3% (107 896/243 402)
and cause of death. This study was exempt from review by the Seoul
Tooth brushing (time/day)
National University Bundang Hospital Institutional Review Board (I-2017-
0–1 14.7% (36 417/247 669)
9037), and the need to obtain informed consent from the participants
2 44.8% (111 038/247 669)
was waived because the database was anonymized by the NHIS for re-
search purposes. >_3 40.5% (100 241/247 669)
Dental visit for professional cleaning 25.9% (63 266/244 314)

Definitions
Periodontal disease was defined as the presence of the following
..
International Statistical Classification of Diseases and Related Health Problems, .. chronic periodontitis (K053), periodontosis (K054), other periodontal
Tenth Revision (ICD-10) codes more than two times or a periodontal .. disease (K055), and unspecified periodontal disease (K056). Dental caries
treatment with the following ICD-10 codes: acute periodontitis (K052),
.. and tooth loss were ascertained by dentists during the oral examination.
1140
Figure 1 Kaplan–Meier survival curves associated with oral health diseases and oral hygiene behaviours. (A) Periodontal disease, (B) number of
dental caries, (C) number of tooth loss, (D) frequency of tooth brushing a day, and (E) frequency of professional dental cleaning.
The number of dental caries was categorized as 0, 1–5, and >_6. The num- ..
..
ber of lost teeth was categorized as 0, 1–7, 8–14, 15–21, and 22–28. ..
Personal oral hygiene behaviour was classified by the number of tooth ..
brushings a day: 0–1, 2, and >_3 times a day. Regular dental visits for pro-
..
..
fessional cleaning were classified as <1 and >_1 time a year. ..
The main study outcome was the occurrence of major cardiovascular
..
..
events, which was defined as a composite of cardiovascular death, acute ..
myocardial infarction, heart failure, and stroke. Cardiovascular mortality ..
..
was defined using specific causes of death according to the ICD-10 codes ..
(I00–I99). Acute myocardial infarction was defined as a hospitalization ..
with ICD-10 codes I21–23 as the primary or secondary diagnosis. Heart
..
..
failure was defined based on discharge diagnosis (ICD-10 codes: I11.0, ..
I13.0, I13.2, I25.5, I42, I50, and O90.3) after a hospitalization. Stroke was ..
..
defined by a discharge diagnosis (ICD-10 codes: I60–64) among patients ..
who had been hospitalized and had undergone brain imaging studies such
as computed tomography and magnetic resonance imaging.20
Statistical analysis
Baseline characteristics are reported using numbers (%) for categorical
variables and means ± standard deviation for continuous variables. The
v2 test was performed for categorical variables and Student’s t-test or
analysis of variance test was used for continuous variables. Kaplan–Meier
survival curves were constructed to determine the effects of oral health
diseases and oral hygiene behaviours on the incidence of cardiovascular
events. The 10-year events were calculated by dividing the number of
patients with major cardiovascular events by the sum of the follow-up
duration. Age- and sex-adjusted event rates were estimated using stand-
ardized incidence ratio. Cox proportional hazard models were used to
evaluate the associations between the independent variables and the
S.-Y. Park et al.
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occurrence of major cardiovascular events. Hazard ratios (HRs) and 95%
confidence intervals (CIs) were calculated. Multivariable regression mod-
els were constructed with adjustment for (i) age and sex; (ii) age, sex,
hypertension, diabetes, dyslipidaemia, renal disease, body mass index, sys-
tolic blood pressure, malignancy, income level, regular physical activity,
and current smoking status; and (iii) for the variables listed above, as well
as for oral health and hygiene variables. The assumption of proportional
hazards was tested on the basis of scaled Schoenfeld residuals. When the
assumption was violated, an interaction term between covariates and a
function of time was included. Variance inflation factors were used to de-
tect multi-collinearity in the regression models.
Next, we assessed whether the associations between oral hygiene
care and cardiovascular risk differed according to the presence of oral
health diseases. The cardiovascular effect of oral hygiene was stratified by
.. oral health status. Interactions of oral health status and oral hygiene be-
.. haviour regarding cardiovascular outcomes were calculated. Significance
..
.. of the unadjusted and adjusted effects of each independent variable on
.. major cardiovascular events was judged by Bonferroni-corrected a levels
.. of 0.0025 (=0.05/20). Statistical analyses were conducted using STATA
..
.. (STATA/SE14 software, Stata Corp, College Station, TX, USA) and R
.. programming version 3.2.4 (http://www.R-project.org; The R Foundation
..
.. for Statistical Computing, Vienna, Austria).
..
..
..
.. Results
..
..
.. The study population comprised 247 696 healthy adults who had no
.. history of major cardiovascular events. The median participant
..
. age was 52 years; 58.0% were men, 19.9% had hypertension, and
Table 2 Risk of composite cardiovascular events according to oral health disease and oral hygiene care

Events/n Event rate (%) Unadjusted model Age, sex-adjusted model Multivariable adjusted (1) Multivariable adjusted (2)
..................................... .......................................... ............................................ ............................................
HR (95% CI) P-value HR (95% CI) P-value HR (95% CI) P-value HR (95% CI) P-value
................................................................................................................................................................................................................................................................................................
Periodontal disease
Absent 10 098/172 043 6.6 Reference <0.001 Reference 0.031 Reference 0.228 Reference 0.964
Present 4594/75 653 7.6 1.17 (1.13–1.21) 1.04 (1.00–1.08) 0.98 (0.94–1.01) 1.00 (0.96–1.04)
Number of dental caries
0 12 001/203 050 6.7 Reference <0.001 Reference <0.001 Reference <0.001 Reference -<0.001
1–5 2686/42 372 7.1 1.04 (1.00–1.09) 1.10 (1.06–1.15) 1.09 (1.04–1.14) 1.07 (1.02–1.12)
>_6 206/2274 10.6 1.56 (1.36–1.79) 1.32 (1.15–1.51) 1.28 (1.11–1.48) 1.22 (1.06–1.42)
Number of missing teeth
0 10 183/187 160 6.2 Reference <0.001 Reference <0.001 Reference <0.001 Reference <0.001
Oral health disease, oral hygiene, and cardiovascular outcomes

1–7 3670/53 366 7.9 1.29 (1.25–1.34) 1.12 (1.07–1.16) 1.05 (1.01–1.09) 1.04 (0.99–1.08)
8–14 598/4743 15.3 2.49 (2.29–2.70) 1.30 (1.20–1.41) 1.20 (1.10–1.31) 1.16 (1.06–1.27)
15–21 258/1505 21.7 3.54 (3.13–4.00) 1.45 (1.28–1.64) 1.30 (1.14–1.48) 1.27 (1.11–1.45)
22–28 184/922 26.0 4.24 (3.66–4.90) 1.42 (1.22–1.64) 1.44 (1.24–1.67) 1.43 (1.23–1.66)
Number of tooth brush (times/day)
0–1 3282/36 417 10.4 Reference <0.001 Reference <0.001 Reference <0.001 Reference <0.001
2 7149/111 038 7.3 0.70 (0.67–0.73) 0.86 (0.82–0.89) 0.86 (0.82–0.90) 0.87 (0.83–0.91)
>_3 4462/100 241 5.1 0.49 (0.46–0.51) 0.74 (0.70–0.77) 0.78 (0.74–0.82) 0.79 (0.75–0.83)
Professional dental cleaning
<1/year 3115/181 048 7.3 Reference <0.001 Reference <0.001 Reference <0.001 Reference <0.001
>_1/year 11 580/63 266 5.6 0.78 (0.75–0.81) 0.90 (0.86–0.93) 0.89 (0.86–0.93) 0.90 (0.87–0.94)

Event rates were reported in 10-year event rates (%). Multivariable model (1) was adjusted for age, sex, income levels, regular exercise, body mass index (kg/m2), systolic blood pressure (mmHg), hypertension, diabetes, dyslipidaemia, cur-
rent smoker, renal disease, and malignancy history. Multivariable model (2) was adjusted for the variables listed above as well as periodontal disease, dental caries, missing teeth, tooth brushing, and professional dental cleaning. P-values indi-
cate P-values for trend.
CI, confidence interval; HR, hazard ratio.
1141

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1142 S.-Y. Park et al.

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Figure 2 Additive benefit of frequent tooth brushing and regular dental visits for professional cleaning procedures. The numbers in the box plot in-
dicate (A) unadjusted and (B) age- and sex-adjusted 10-year event rates of major cardiovascular events (a composite of cardiac death, myocardial in-
farction, stroke, and heart failure).

..
21.8% were current smokers (Table 1). The medians of body ..
mass index, blood pressure, and total cholesterol were 23.9 kg/m2, ..
..
125/80 mmHg, and 197 mg/dL, respectively. Approximately 30%, ..
20%, and 25% of the participants had periodontal disease, at least one ..
..
dental caries, and had lost one or more teeth, respectively. ..
According to the self-reported questionnaires, 40.5% of the study ..
..
subjects brushed their teeth three times or more a day, 44.8% twice ..
a day, and 14.7% once or less a day. More than one-fourth (25.9%) ..
..
reported having dental visits for professional cleaning at least once a ..
year. Supplementary material online, Tables S1–S5 compare the base- ..
..
line characteristics of the study subjects according to their dental ..
health status, tooth brushing habits, and number of dental visits for ..
..
professional cleaning procedures. ..
After a median follow-up of 9.5 years, 14 893 major cardiovascu- ..
..
lar events occurred (10-year event rate of 6.84%). The estimated ..
10-year event rates were 5.31% for all-cause mortality, 1.01% for
..
..
cardiac death, 1.48% for acute myocardial infarction, 2.21% for ..
heart failure, and 3.58% for stroke. Figure 1 shows the survival
..
..
curves free from cardiovascular events according to oral health ..
disease and oral hygiene behaviour. The risk for cardiovascular
..
..
events was higher when a subject was diagnosed as having peri-
odontal disease, had a higher number of dental caries, and had lost
a higher number of teeth. In contrast, healthy oral hygiene behav-
iours including frequent tooth brushing and regular dental visits for
professional cleaning procedures were associated with significantly
better cardiovascular outcomes.
Table 2 shows the multivariable-adjusted analysis for the impact of
dental health and behavioural variables on composite cardiovascular
events. The effects of the independent variables were largely attenu-
ated after adjustment for age and sex. While the effect of periodontal
disease lost statistical significance after adjustment, the number of
missing teeth and dental caries, tooth brushing, and professional
cleaning remained significant. Brushing teeth one more time a day
was associated with a 9% lower risk of cardiovascular events (HR:
0.91; 95% CIs: 0.89–0.93; P < 0.001), while regular professional
cleaning reduced the risk by 14%, independent of potential confound-
ing factors or oral health problems (HR: 0.86; 95% CIs: 0.82–0.90;
P < 0.001). Frequent tooth brushing and regular professional cleaning
provided additive benefits (Figure 2). Analyses for each component of
cardiovascular events are shown in Supplementary material online,
Tables S6–S10.
The interplay between oral health status and oral hygiene is shown
in Figure 3 (see Supplementary material online, Tables S11–S13).
Frequent tooth brushing and regular professional cleaning were asso-
ciated with improved cardiovascular outcomes even in subjects with
poor oral conditions. However, the benefit of tooth brushing was
more remarkable when periodontal disease was absent, and the
number of dental caries was low. The favourable effect of tooth
brushing was not modified by the number of tooth loss. The advan-
tage of professional cleaning was consistent across all stratified
analyses.
Discussion
.. In this study, we found that periodontal disease, an increased number
..
.. of dental caries, and greater tooth loss were associated with future
.. adverse cardiovascular events. In contrast, better oral hygiene care
..
.. such as frequent tooth brushing and regular dental visits for profes-
.. sional cleaning procedures were associated with a lower cardiovascu-
..
.. lar risk. The benefit of oral hygiene was independent of potential
.. confounding factors and oral health status. This study suggests that
..
.. better oral hygiene behaviour may modify the risk associated with
.. periodontal disease, dental caries, and tooth loss.
..
.. Previous observational studies have reported the association of
.. oral health problems such as periodontal disease, dental caries, and
..
.. tooth loss with atherosclerotic cardiovascular disease.21,22 However,
.. as stated by the American Heart Association, evidence supporting a
..
.. causal relationship is weak.1 The present study also found that the as-
.. sociation between periodontal disease and adverse cardiovascular
Oral health disease, oral hygiene, and cardiovascular outcomes 1143

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Figure 3 Interaction between oral health disease and oral hygiene behaviours. Periodontal disease with (A) tooth brushing and (B) professional
dental cleaning. The number of dental caries with (C) tooth brushing and (D) professional dental cleaning. The number of tooth loss with (E) tooth
brushing and (F) professional dental cleaning. The squares and vertical lines indicate the hazard ratio and 95% confidence intervals, respectively. The
models were adjusted for age, sex, hypertension, diabetes, dyslipidaemia, renal disease, body mass index, systolic blood pressure, malignancy, and cur-
rent smoking status. Int P, interaction P-values.
1144
Take home figure Proposed pathophysiology linking oral health status and dental hygiene care with atherosclerotic cardiovascular diseases.
events lost statistical significance after multivariable adjustment.
..
..
Advanced age, hypertension, diabetes, and tobacco smoking were ..
shown to be strong confounders of this association, being common
..
..
risk factors for both conditions. However, more advanced oral health ..
problems such as dental caries and tooth loss remained significant
..
..
after adjusting for the potential confounding factors. ..
The role of periodontal intervention has not been established in
..
..
cardiovascular prevention for patients with chronic periodontitis.2,23 ..
..
Earlier trials with systemic antibiotic treatment targeting Chlamydia in
patients with stable coronary artery disease failed to demonstrate a
cardiovascular benefit.24–26 Of note, systemic antibiotics may prevent
systemic bacteraemia but are not expected to ameliorate chronic
periodontitis, in which bacteria reside in a biofilm.1 Small-sized
randomized trials have evaluated the effect of periodontal therapy,
with inconsistent results.8,27,28 Notably, substantial heterogeneity
was present in the method, extent, and duration of periodontal
therapy.
This study suggests that a simple behavioural change in oral hy-
giene may help prevent future cardiovascular events, and the benefit
was notable. Tooth brushing three times a day or more was associ-
ated with a 19% reduction in cardiovascular events compared with
tooth brushing once or less a day. Regular professional cleaning once
a year or more was shown to reduce cardiovascular risk by 14%. The
study findings are in line with previous observational studies that
S.-Y. Park et al.
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showed the cardiovascular benefit of tooth brushing and scaling.18,29
Several mechanisms have been proposed to explain this benefit. First,
periodontal disease causes chronic inflammation. A reduction in in-
flammatory markers such as C-reactive protein and interleukins have
been reported in association with regular tooth brushing as well as
periodontal treatment.18,27 Recently, a therapeutic approach target-
ing interleukin-1b using canakinumab showed benefits in preventing
recurrent cardiovascular events.30 Second, oral hygiene has been sug-
.. gested to modify major risk factors such as diabetes and dyslipidae-
.. mia.31 Third, oral hygiene alters the oral microbiota.32 Increasing
..
.. evidence suggests the human microbiota play a role in the pathogen-
.. esis of atherosclerotic cardiovascular disease and heart failure.33
..
.. Various bacteria have been detected in human atherosclerotic pla-
.. ques, which are linked with oral microbiota.34,35
..
.. The novel finding of this study was that improved oral hygiene care
.. modified adverse cardiovascular outcomes associated with poor oral
..
.. health (Take home figure). The interaction was limited to periodontal
.. disease and dental caries, but not present in tooth loss. Periodontal
..
.. disease reflects the present inflammatory burden and, thus, may be
.. reversed by proper oral hygiene to a certain extent. Dental caries
..
.. and tooth loss are the results of past severe dental infections destroy-
.. ing mineralized bone and are mostly irreversible. The present study’s
..
.. findings suggest the importance of early intervention. One may ex-
.. pect the largest benefit from improved oral care before development
Oral health disease, oral hygiene, and cardiovascular outcomes 1145

..
of periodontal disease or dental caries. In contrast, if the subject has .. Funding
already lost a significant number of teeth, an improvement in personal .. This work was supported by the Seoul National University Bundang
..
oral health behaviour would be insufficient to reduce cardiovascular .. Hospital Research Grant (18-2018-012).
risk. However, we still believe higher-quality evidence is required to ..
.. Conflict of interest: none declared.
establish the role of oral hygiene in cardiovascular prevention. ..
..
.. References
Limitations .. 1. Lockhart PB, Bolger AF, Papapanou PN, Osinbowale O, Trevisan M, Levison ME,
..
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