Complications related to oral health, such as periodontal disease, dental caries, and tooth loss, have been suggested to be associated with an increased risk of cardiovascular disease (CVD). Cardiovascular disease is the leading cause of death worldwide, while periodontal disease (PD) ranks as the sixth most common disease in humans. Both conditions share common risk factors, including smoking, poor oral hygiene, diabetes, obesity, stress, sedentary lifestyle, and advanced age. 

The connection between oral health and cardiovascular health:

Research suggests that PD can trigger the formation, maturation, and instability of atheroma in the arteries. Evidence from epidemiological studies shows a positive association between PD and coronary heart disease, cerebrovascular disease (stroke), and peripheral artery disease. Simple oral hygiene practices, such as brushing teeth, may potentially alter a person’s CVD risk. 

In a nationwide population-based cohort study in Korea (n = 247,696), researchers aimed to evaluate whether oral hygiene behavior could influence CVD associated with oral health status. The subjects were healthy adults aged 40 or older with no history of major cardiovascular events. After a 9.5-year median follow-up, it was concluded that the risk of cardiovascular events (including cardiovascular death, acute myocardial infarction, heart failure, and stroke) was higher when a subject was diagnosed with PD, a higher number of dental caries, or had a higher number of tooth loss. The researchers concluded that just one additional tooth-brushing episode per day was associated with a significantly lower (9%) risk of cardiovascular events after multivariable adjustment. Furthermore, regular dental visits (once a year or more) for professional cleaning reduced cardiovascular risk by 14%. 

These conclusions align with various other extensive studies. A cross-sectional study (n = 11,869) concluded that participants who brushed less than once a day had a higher incidence of atherosclerotic CVD events compared to those who brushed twice daily. Additionally, a retrospective, nationwide, population-based study in Taiwan (n = 511,630) observed consistent reductions in the incidence of ischemic stroke in those receiving dental prophylaxis and intensive treatment. 

Recent research suggests that poor oral health may negatively influence cardiovascular health in multiple ways: 

• Increasing local and systemic inflammation: Oral dysbiosis causes the release of proinflammatory mediators both locally and systemically, which may contribute to the development of atheroma and endothelial dysfunction. PD and CVD both increase similar inflammatory pathways, including increased levels of white blood cells, C-reactive protein, fibrinogen, intercellular adhesion molecule-1, and proinflammatory cytokines. Inflamed periodontium may also increase inflammatory mediators such as interleukin (IL)-6, IL-8, IL-1, tumor necrosis factor, and other immunologic cells, such as T cells, B cells, and monocytes/macrophages. “These immune cells may recruit perivascular adipose tissue, leading to inflammation and damage of the blood vessel walls, consequentially causing vascular dysfunction and hypertension.” Local and systemic inflammation due to PD can disrupt the proper function of endothelial cells, increase oxidative stress, and negatively affect normal lipid metabolism. 
• Promoting unhealthy oral microbial environments: Periodontal disease increases the risk of bacteremia – pathogenic oral bacteria entering the bloodstream. These pathogenic bacteria may be deposited in atheromatous plaques. Various bacterial strains linked to the oral microbiome have been detected in human atherosclerotic plaques, where certain bacterial strains have an increased capability to adhere to and enter the human coronary artery endothelial cells. Streptococcus mutans was found to be the most common bacteria in cardiovascular specimens containing thrombus tissues, followed by Aggregatibacter actinomycetemcomitans. Certain pathogens, such as P. gingivalis, have been shown in experimental models (in vivo and in vitro) to induce the formation of foam cells or atherothrombotic lesions, resulting in inflammation and endothelial dysfunction.
  Moreover, there is some evidence that HSPs (heat shock proteins used for survival) from certain periodontal pathogens, such as Porphyromonas gingivalis, Tannerella forsythia, Aggregatibacter actinomycetemcomitans, and Fusobacterium nucleatum, can generate antibodies that can cross-react with human HSPs. These antibodies have been shown to activate cytokine production, plus monocyte and endothelial cell activation.
• Lowering healthy nitric oxide (NO) production: Poor oral health and oral dysbiosis have been shown to negatively impact normal NO production and metabolism. A healthy oral microbiome is necessary for proper NO production through the enterosalivary pathway, which converts dietary intake of nitrates through food or supplements into NO.
  Without sufficient NO production, healthy, regulated blood flow and circulation to every organ is lost. This results in dysfunctions in inflammatory responses, oxidative stress, and immune function. Moreover, the functional loss of NO production is termed “endothelial dysfunction.” It is considered the earliest stage in the development of hypertension. This may help to explain why epidemiological studies show that patients with PD exhibit significant endothelial dysfunction measured by flow-mediated dilation, arterial stiffness, and a significantly greater thickness of the carotid intima-media and elevated arterial calcification scores.

Clinical insights: 

It is advised that patients with PD or compromised oral health be educated on their potential increased risk for CVD. Similarly, those diagnosed with CVD should receive a thorough oral examination by a dental care professional. 

In addition to regularly brushing, flossing, and attending their annual dental examinations, patients must consider their nutritional status. Inadequate nutrition can be associated with PD, dental caries, and oral mucosal diseases. Conversely, compromised oral health, such as difficulty chewing or swallowing, may negatively influence a person’s daily food intake. This may result in suboptimal nutritional status, energy deficits, or malnutrition, which may increase the risk of chronic diseases like CVD. 

Encouraging a whole‐food diet emphasizing protein, vegetables, and antioxidant‐rich foods can support oral health. Additionally, reducing or eliminating soft drinks and refined sugar intake can be supportive. High sucrose intake, in particular, is associated with high plaque volume and gingivitis, and high sugar consumption, in general, has been associated with dental caries.

Explore more ways to promote oral health: 

Purified Silver for Oral Health 

MCT Oil and Periodontal Wellness 

The Latest on Probiotics and Periodontal Health 

Bromelain’s Unique Role in Oral Wellness 

By Danielle Moyer Male, MS, CNS, LDN