Tooth Loss Tied to Stroke, CV Death in Stable CHD Cohort

Marlene Busko

December 24, 2015

UPPSALA, SWEDEN—In an almost 4-year international observational study of more than 15,000 patients with prior MI, prior revascularization, or multivessel coronary heart disease, increasing degrees of self-reported tooth loss—a surrogate for periodontal disease—was linked with a higher likelihood of adverse cardiac outcomes[1].

Specifically, every increase in five levels of greater tooth loss predicted a 6% increased risk of the primary outcome—a major adverse cardiovascular event (MACE), a composite of cardiovascular death, nonfatal MI, and nonfatal stroke. However, when researchers looked deeper, every worse level of tooth loss was associated with a 17% increase in risk of cardiovascular death and a 14% increase in stroke, but there was no increased risk of MI.

These findings, from Dr Ola Vedin (Uppsala University, Sweden) and colleagues, from the Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy (STABILITY) study, were published December 17, 2015 in the European Journal of Preventive Cardiology.

This was an observational study and cannot prove causality, Vedin and colleagues stress. Tooth loss might be the result of cavities, rather than an infection, which might partly explain the "puzzling" lack of an association between level of tooth loss and MI, they suggest.

Nevertheless, the study implies that "mechanisms leading to tooth loss, most importantly [periodontal disease], may contribute to a worse prognosis in CHD," and tooth loss "can be used to discriminate the risk of adverse events beyond that of established risk factors and socioeconomic status among patients with stable CHD," they conclude.

Does Gum Disease Predict Worse CV Outcomes?

As reported previously by heartwire from Medscape, STABILITY investigated the efficacy of darapladib (GlaxoSmithKline), an oral inhibitor of lipoprotein-associated phospholipase A2, compared with placebo and found that this agent did not reduce CVD risk. A subsequent analysis reported that substantial tooth loss was common, and patients with a higher degree of tooth loss also had more CV disease risk factors.

Researchers have proposed that gum disease and inflammation might lead to atherosclerosis progression and plaque instability. In the current study, Vedin and colleagues extended their previous work to determine whether oral health (specifically self-reported tooth loss) was associated with worse outcomes in this high-risk population. They analyzed data from 15456 patients who were enrolled in STABILITY in 39 countries on five continents.

At baseline, the patients were stratified into five levels of worsening tooth loss: 26 to 32 teeth (most teeth); 20 to 25 teeth (loss of seven to 12 teeth); 15 to 19 teeth; one to 14 teeth; and no teeth. Four in 10 were missing half their teeth, and almost two in 10 (16%) had no teeth.

Patients with greater tooth loss were more likely to be older, smokers, female, and less physically active and have diabetes, higher blood pressure, higher body-mass index (BMI), a lower education level, and worse kidney function.

After a median follow-up of 3.7 years, 1543 patients had MACE, 705 patients died from CV causes, 1120 patients died from all causes, 746 patients had a fatal or nonfatal MI, and 301 patients had a fatal or nonfatal stroke.

Compared with patients with the most teeth (no gum disease), those with no teeth had a 27% greater risk of MACE (HR 1.27, 95% CI 1.08–1.49), after adjustment for treatment or placebo, age, blood pressure, BMI, cholesterol, diabetes, prior MI, gender, smoking, waist-to-hip ratio, kidney function, family history of heart disease, alcohol consumption, education, physical activity, and country income level.

Similarly, compared with the patients with the most teeth, those with no teeth had an 85% increased risk of CV death and a 67% increased risk of stroke during follow-up.

There may be other confounders that they didn't account for, the authors acknowledge. Tooth loss may reflect poor access to dental care or a tendency for more tooth extraction and dentures in certain countries, and the study did not assess the role of diet or tooth implants.

STABILITY and the current study were funded by GlaxoSmithKline. Vedin received an institutional research grant from GlaxoSmithKline during the conduct of the study and receives lecture and consultancy fees from Fresenius and Novartis outside the submitted work. Disclosures for the coauthors are listed in the article.

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