Authors: Abigail Batten and Kimberly Brockenbrough, MD
The role that dentists play in their patient’s health can extend beyond the health of gums & teeth- numerous studies have established a clear association between periodontal disease and cardiovascular disease. According to the PAROKRANK study published by the American Heart Association in 2016, patients with periodontal disease are at a significantly higher risk of experiencing a first-time heart attack than those without periodontal disease. Inflammation caused by periodontitis could contribute to the acceleration of atherosclerosis (plaque build-up) in the coronary arteries; this inflammation also potentially increases the risk that plaque will rupture and cause a heart attack (Ryden et al., 2016).
Several other studies have likewise contributed evidence underscoring the relationship between periodontitis and cardiovascular disease. One such study revealed that stenosis of the coronary arteries 50% or greater, revealed by a coronary CT angiogram, has a significant positive association with poor periodontal health. This study also observed a linear association between severity of coronary artery disease and severity of periodontal disease parameters (Buhlin et al., 2011).
Oral bacteria associated with periodontitis have been identified in coronary artery plaques, contributing to the evidence that periodontitis could be an independent indicator of cardiovascular disease risk. Oral bacteria were present in 75% of plaque examined in one such study (Ford et al., 2006)
Why this matters in real-world practice
In our experience seeing patients at Cardia Vision, we are seeing something remarkable: even though many people lead very healthy lifestyles, coronary artery disease remains widespread. Among our first 100 patients in 2024, 83% had soft (non‐calcified) plaque in their coronary arteries. That’s 83%! To put it in perspective, less than 1% of mammograms and 1% of colonoscopies are positive for cancer. Soft plaque matters because it is more likely to rupture than calcified plaque, as demonstrated in the SCOT–HEART 2020 trial (Williams et al., 2020). Large plaque rupture can lead to heart attack or stroke; smaller amounts of soft plaque may lead to congestive heart failure or dementia.
What does this mean for your dental practice? When you identify significant periodontal disease- especially in patients with known cardiovascular risk factors (family history, diabetes, high cholesterol, etc)- this may represent a window of opportunity to refer to see the vessels of the heart with a Coronary CT Angiogram, potentially before a cardiovascular event, such as heart attack or sudden death, occurs.
What dentists should discuss with patients
Educating your patients that periodontal disease is not just about dental health- it may indicate cardiovascular risk. You can mention that a coronary CT angiogram may be beneficial. At Cardia Vision, we recommend a Coronary CT Angiogram for men at 40 and women at 50 with risk factors such as high cholesterol, family history, diabetes, pre-diabetes, high blood pressure, obesity, excessive alcohol consumption, working as a first responder, testosterone use, periodontal disease, etc., and 10 years older without any risk factors.
A coronary artery calcium scan can be used to identify calcified plaque in the arteries, but a coronary CT angiogram can reveal what a calcium scan alone can’t- non-calcified soft plaque. A coronary calcium score of zero is often considered reassuring- but in our 2024 sample, a coronary CT angiogram revealed soft plaque in 69.8% of patients who had a coronary calcium score of 0. That means a “zero” score doesn’t guarantee absence of disease, because only a coronary CT angiogram (or intravascular ultrasound) can reveal soft plaque which is more likely to rupture than calcified plaque. (Williams et al., 2020)
The good news is that it’s treatable- according to findings from the 2024 LOCATE trial, statins at low dose may reduce soft plaque a little, while high‐dose statins and PCSK9 inhibitors (for example, Repatha) can eliminate non-calcified plaque (Weichsel et al., 2024). Thanks to recent price reductions (Repatha now about $239/month at GoodRx), this is becoming more accessible.
As demonstrated by the current literature, including the studies mentioned, periodontal disease has a well-known association with coronary artery disease. If you diagnose periodontitis in a patient with cardiovascular risk, consider educating your patient about the potential benefit of a preventative coronary CT angiogram.
Patients do not need a referral to get a coronary CT angiogram done at Cardia Vision, and results will be sent to their primary care provider to arrange a treatment plan. Give us a call at 425-998-8627 or text us at 425-200-0548 and we can send you informative brochures to give to your patients.
Periodontal disease is more than a dental health issue-it is an indicator of cardiovascular disease risk. By educating patients with periodontal disease about preventative heart health screening and care, dentists may be able to save those patients from a heart attack or sudden death.
References
Buhlin, K., Mäntylä, P., Paju, S., Peltola, J. S., Nieminen, M. S., Sinisalo, J., & Pussinen, P. J. (2011). Periodontitis is associated with angiographically verified coronary artery disease. Journal of Clinical Periodontology, 38(11), 1007–1014. https://doi.org/10.1111/j.1600-051x.2011.01775.x
Ford, P. J., Gemmell, E., Chan, A., Carter, C. L., Walker, P. J., Bird, P. S., West, M. J., Cullinan, M. P., & Seymour, G. J. (2006). Inflammation, heat shock proteins and periodontal pathogens in atherosclerosis: An immunohistologic study. Oral Microbiology and Immunology, 21(4), 206–211. https://doi.org/10.1111/j.1399-302x.2006.00276.x
Rydén, L., Buhlin, K., Ekstrand, E., de Faire, U., Gustafsson, A., Holmer, J., Kjellström, B., Lindahl, B., Norhammar, A., Nygren, Å., Näsman, P., Rathnayake, N., Svenungsson, E., & Klinge, B. (2016). Periodontitis increases the risk of a first myocardial infarction. Circulation, 133(6), 576-583. https://doi.org/10.1161/circulationaha.115.020324
Weichsel, L., André, F., Renker, M., Breitbart, P., Overhoff, D., Beer, M., Giesen, A., Vattay, B., Buss, S., Marwan, M., Schlett, C. L., Giannopoulos, A. A., Kelle, S., Frey, N., Korosoglou, G., Giusca, S., Schütz, M., Weberling, L. D., Schmitt, R., … Stach, K. (2024). Effects of high- versus low-intensity lipid-lowering treatment in patients undergoing serial coronary computed tomography angiography: Results of the multi-center locate study. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-024-02502-6
Williams, M. C., Kwiecinski, J., Doris, M., McElhinney, P., D’Souza, M. S., Cadet, S., Adamson, P. D., Moss, A. J., Alam, S., Hunter, A., Shah, A. S. V., Mills, N. L., Pawade, T., Wang, C., Weir McCall, J., Bonnici-Mallia, M., Murrills, C., Roditi, G., van Beek, E. J. R., … Dey, D. (2020). Low-attenuation noncalcified plaque on coronary computed tomography angiography predicts myocardial infarction. Circulation, 141(18), 1452-1462. https://doi.org/10.1161/circulationaha.119.044720
