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Heart Health Explained

Tooth Loss: Does tooth loss in older women lead to heart disease?

A study published online March 29, 2017 in the Journal of the American Heart Association found that tooth loss and gum disease in older women was associated with higher rates of cardiovascular disease and death.

It was reported March 29, 2017 by CNN.

Tooth Loss, Gum Disease, and Heart Health

Does tooth loss in older women lead to heart disease?

Team Specialist

Jennifer Dickerson, MD, Cardiology, Advanced Imaging, OhioHealth Health System, Columbus, Ohio

Tooth Loss, Gum Disease, and Heart Health

What’s the most important thing I should know about this study related to my health?

Women who had complete tooth loss as an adult (edentulism) had a higher risk of heart and vascular disease as well as a higher risk of dying compared to women who had not lost all their teeth, even when accounting for traditional cardiovascular risk factors such as age, smoking and diabetes. So the bottom line is: the better the health of your teeth and gums, the better your overall health and cardiovascular health will tend to be. And the lower your risk of dying.

Did the researchers offer an explanation for the results?

The self-reported nature of the study in terms of periodontitis may be less robust than studies that would be based on an objective clinical exam. And the complete loss of teeth may be a more objective reflection of overall oral health than the self-reported periodontitis. Frequency of dental visits may better reflect the severity of the condition as well.

What conclusions, if any, can be made about cause and effect?

There are several theories that explore the link between poor dental health and increased risk of cardiovascular disease and death. Inflammation and bacteria that get into the bloodstream can trigger inflammation in other parts of the body besides the mouth. This inflammation can affect the lining of blood vessels in the circulatory system and lead to hardening of the arteries and heart attacks. There may also be something about the low estrogen hormone state after menopause that may promote periodontitis as well as heart and vascular disease. However, the design of the study was not intended to establish a cause and effect relationship.

What, if anything, should people and health care professionals do differently in the face of these findings? What are the challenges to addressing this issue?

Health care providers need to stress the importance of good dental care, with routine cleanings and exams, and consider poor oral health as a risk factor for cardiac disease that the patient can control. As with other things, patient compliance with the recommendation of their health care professionals and the resources available to promote good health are always challenges to doing the right things to live a long and healthy life.

What are common risk factors for developing cardiovascular disease? Are they different for men and women?

The most common risk factors for developing cardiovascular disease are smoking, diabetes, age, high blood pressure, high cholesterol, and obesity. In general, women have different considerations with cardiac risk factors than men. For example, before menopause, women typically have higher “good” cholesterol (HDL) that is protective to the heart. After menopause, their “bad” cholesterol (LDL) as well as triglycerides increase, and the “good” cholesterol lowers. All these changes are unique to women. In addition, women are more likely to have metabolic syndrome, which is a combination of a large waist size, elevated blood sugar, and high triglycerides that increase risk factors for hardening of the arteries. Smoking as a risk factor is also worse for women for both their heart and lungs. And once women have a heart attack, they are more likely to suffer heart failure.

What was this study seeking to determine? Has this been done before?

This study wanted to better understand the link between tooth loss and inflammation of the tissue around the teeth known as periodontitis with cardiovascular disease risk and overall death rate. This has been looked at in prior studies, but they were less likely to include older adults and less likely to include women. The Women’s Health Initiative Observational Study population used in this new study provided an ideal patient population to better understand this association. This population included 57,001 women who were 55 years of age or older. So this study is the largest study of its kind with a focus specifically on post-menopausal women.

How were the data obtained for this study? How long were the subjects followed?

Women who were participants in the Women’s Health Initiative Observational Study were sent a questionnaire at the five year follow-up mark to probe details about dental health and gum disease. Questions included “Has a dentist or dental hygienist every told you had periodontal or gum disease?” The researchers also asked how often in the last three years had the patient visited the dentist or had a routine check-up. The average amount of time a subject was followed was 6.7 years.

Who were the subjects, and how were they categorized?

The subjects were taken from a group of participants from the 57,001 postmenopausal women who were enrolled in the Women’s Health Initiative Observational Study and who were without cardiovascular disease at the time when the five year follow-up questionnaire was completed. They were categorized as having “self-reported” periodontitis described as none or mild, moderate or severe, or reaching edentulous (complete loss of adult teeth).

What did the researchers measure, and how did they measure it? What was the primary outcome they looked for?

The researchers looked at primary endpoint for total cardiovascular disease. This is defined as heart attacks that are not fatal, death related to a heart cause, stroke, blood clot to the lung, or heart failure. They also looked at the rate of stroke as a separate clinical finding. Within this population of study participants, they knew a lot about other important measures such as how many of the participants smoked and for how long and how much they smoked. The researchers also looked at the race and ethnicity of the group, the level of education achieved, the level of physical activity, the use of hormone therapy, and the presence of diabetes, high blood pressure, high cholesterol and other factors known to increase risk of heart disease.

What were the results?

Among those studied, 26 percent had periodontitis and 5.9 percent had lost all of their adult teeth but had a lower prevalence of periodontitis. Overall, higher risk of total cardiovascular disease as well as total mortality was higher in women without teeth, and this group tended to visit the dentist more frequently. Total mortality was also higher for both groups with periodontitis as well as the group without teeth. Those with periodontal disease had a 12 percent higher risk of death from any cause, and the study participants who had lost all their teeth had a 17 percent higher risk of death from any cause.

Did the study reveal any differences concerning subgroups?

There was a stronger association between loss of teeth and cardiovascular disease regardless of how frequently they visited the dentist. The women who were in the group with complete tooth loss were more likely to be older, have more traditional cardiac risk factors, and less education.

Does this research fall in line with previous studies? Was anything surprising?

There is evidence to support the associated risk between periodontitis and cardiovascular disease, but the study subgroup without teeth proved to be at higher risk. There was no association evident between periodontitis and stroke. And women without teeth who had more reported dental visits had a higher likelihood of dying from a heart-related cause.

What were the strengths of this study’s design and execution?

One of the strengths of this study design is the large numbers of older women who are postmenopausal that participated. And the overall study design allowed for many specifics about the details of the risk factors of the group to be collected. Cardiovascular disease is the number one killer of women in the United States, and this article helps to focus on another potential risk factor to consider in the fight against cardiovascular disease.

Were there any shortcomings in the study design and execution? What could have helped achieve more accurate or useful data?

One of the shortcomings was that the study design relied on the study participants to self-report the status of their tooth and gum status. So the study depended on what the individual thought the condition of their gum tissues and oral health was and not what a doctor or dentist reported.

Q&A Editor

Teresa Caulin-Glaser, MD, FACC, FAACVPR System Vice President, Heart & Vascular Services OhioHealth Healthcare System, Columbus, Ohio

Heart Health Explained is a collaboration of Women’s Health Research at Yale and the OhioHealth Healthcare System, a nationally recognized not-for-profit organization with providers across 46 counties, offering a holistic approach to prevention, treatment and rehabilitation of heart disease. OhioHealth is staffed by physicians, psychologists, nutritionists and nurses who answer the questions of the moment on heart and vascular health.

The information provided here may help you make more informed choices. However, it is not a substitute for an individualized medical opinion or diagnosis, and everyone should always consult with their personal physicians to make decisions about their condition or treatment.