Abbas Kharal, MD, MPH, and Richa Sharma, MD, MPH
Sen S, Giamberardino LD, Moss K, Morelli T, Rosamond WD, Gottesman RF, et al. Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke. Stroke. 2018
This is a well-designed study exploring the relationship of dental disease, a prevalent and modifiable condition, and the incidence of ischemic stroke. The authors sought to investigate whether an association was present between the two conditions given significant prior retrospective studies suggesting a correlation.
The study population is the ARIC (Atherosclerosis Risk in Communities) cohort who also had a dental examination during the fourth visit, resulting in a total of 6,736 patients. Utilization of regular dental visits was assessed by self-report. The degree of periodontal disease was determined by classifying each patient by aggregating data on the tooth level involving 7 dental parameters. The diagnosis of ischemic stroke and stroke subtype from visit 4 onwards was documented as the outcome of interest. Covariates that were accounted for included demographic data and history of vascular risk factors. Education level was used as a proxy for economic status of the participants as data about income level and insuredness were not included. Hazard ratios were obtained to assess the risk of incident stroke based on degree of dental disease and usage of dental care. Compared to those with dental health, participants with any dental disease, as categorized by periodontal profile class, had a higher risk of incident ischemic stroke, both in unadjusted and adjusted regressions (see Figure below). There was a trend towards increase in stroke risk with each periodontal profile class severity increment, suggesting a possible dose response. Furthermore, the increased hazard of ischemic stroke was noted only in patients with cardioembolic and thrombotic strokes, not lacunar strokes. The authors have also implicated that this association may be biologically plausible since periodontal disease induces systemic inflammation, which may lead to atherosclerosis and atrial fibrillation. Another possibility is that these patients may be transiently bacteremic and the burden of endocarditis was not assessed.
Figure. Risk for incident ischemic stroke in the dental ARIC (Atherosclerosis Risk in Communities) cohort depicted as crude (A) and adjusted (B) hazard ratios (HRs) for the various classes of periodontal disease periodontal profile classes (PPC)-A or reference healthy group without periodontal disease, PPC-B or mild periodontal disease, PPC-C or high gingival index (GI) score, PPC-D or tooth loss, PPC-E or posterior disease, PPC-F or severe tooth loss, and PPC-G or severe periodontal disease.