Periodontitis negatively affects antihypertensive treatment success at high BP
Poor Oral Health and Blood Pressure Control Among US Hypertensive Adults
Literature - Pietropaoli D, Del Pinto R, Ferri C et al. - Hypertension 2018;72:00-00Introduction and methods
Periodontitis, a chronic inflammatory disorder of tissues surrounding the teeth [1], is associated with many CV risk factors and related diseases, such as endothelial dysfunction [2-4], hypertension [5,6], atherosclerosis [7,8] and major CV events [5,6,9-12]. Although some studies have shown beneficial effects of periodontal treatment on blood pressure (BP) [13,14], data on the effect of periodontitis on BP control in patients with antihypertensive treatment are lacking. Therefore, this study aimed to examine the relation between periodontitis and uncontrolled hypertension in treated hypertensive patients enrolled in the National Health and Nutrition Examination Survey (NHANES).
This retrospective cross-sectional analysis of the NHANES assessed arterial BP in hypertensive adults with (n=1,834) versus without (n=1,694) periodontitis, aged ≥30 years on prescribed medicine for high BP with at least one natural tooth. Subjects with a history of heart transplant, artificial heart valve, congenital heart disease not including mitral valve prolapse, or bacterial endocarditis were excluded for periodontal examination.
Disease severity was defined as mild, moderate or severe according to the gold standard full-mouth periodontitis surveillance protocol following suggested Centers for Disease Control and Prevention/American Academy of Periodontology case definitions [1]. Arterial BP was measured by trained and calibrated physicians using a mercury sphygmomanometer according to standardized BP measurement protocols [15].
Main results
- Treated hypertensive adults with periodontitis showed higher systolic BP (SBP) (133.43±19.7 mmHg) when compared to those without periodontitis (131.17±19.5 mmHg) (difference: 2.3 mmHg, P<0.001), which increased to a difference of 3.06 mmHg after progressive adjustment (P<0.001).
- Treated hypertensive adults with periodontitis had 20% higher risk of unsuccessful antihypertensive treatment compared to those without periodontitis, which was no longer statistically significant after adjustment for CRP (OR: 1.19, 95%CI: 0.91–1.54, P=0.205).
- Quartiles of periodontitis severity were identified at 1.07, 1.53, 2.01 and 6.03 mm for probing depth (PD) and 1.02, 1.56, 2.35 and 11.33 for clinical attachment loss (CAL). Treated hypertensive patients in the highest quartile of periodontal scores showed significantly higher ORs of uncontrolled BP, compared with those in the lowest quartile (both OR: 1.26, 95%CI: 1.04-1.52, P=0.018), which remained significant after multivariable adjustment, except when also adjusting for CRP.
- Poorer SBP was achieved across all age ranges in treated patients with periodontitis vs without periodontitis (ΔSBP between groups according to model 2: 30–44 years of age: 2.05 mmHg, P<0.0001; 45–64 years of age: 2.30 mmHg, P<0.0001; ≥65 years of age: 2.50 mmHg, P<0.0001).
- Periodontal disease severity analysis showed that participants with moderate disease had higher SBP (133.59±4.6) than those with mild disease (128.14±4.7, P<0.001) and those without periodontitis (131.08±5.0, P<0.001). Those with severe disease had significantly (Bonferroni-corrected for multiple comparisons) higher SBP (134.22±4.1) than all other disease severities.
- Cubic spline analysis of the relation between PD (a measure of acute disease) or CAL (chronic disease) and SBP across different age ranges, suggested that PD affected SBP more in younger participants and CAL had more effect on SBP in older subjects.
- Among untreated hypertensive patients (n=460) the mean SBP was 2.8-7.6 mmHg higher in those with periodontitis compared to those without periodontitis, depending on the adjustment model.
- When the prevalences of having BP below vs. above the BP threshold of 130/80 mmHg were assessed, no difference according to periodontitis was observed in untreated patients (with periodontitis: below vs. above 130/80 mmHg: 15.9% vs. 33.8%, vs. no periodontitis: 17.4% vs. 32.9%, P=0.552), in contrast to what was observed in treated patients (with periodontitis: 20.9% vs. 31%, vs. no periodontitis: 21.5% vs. 26.6%, P=0.007), of whom more participants with periodontitis had a BP above the threshold.
Conclusion
Hypertensive patients without periodontitis show a better SBP during antihypertensive treatment by about 2.3-3.0 mmHg and lower odds of treatment failure than hypertensives without periodontitis. The data suggest that antihypertensive therapy in the presence of periodontitis may be less effective as compared with good oral health. Dedicated studies may focus on the effect of periodontal therapy on BP in treated hypertensive patients.
References
1. Eke PI, Page RC, Wei L, Thornton-Evans G, Genco RJ. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol. 2012;83:1449–1454. doi: 10.1902/jop.2012.110664
2. Higashi Y, Goto C, Jitsuiki D, Umemura T, Nishioka K, Hidaka T, Takemoto H, Nakamura S, Soga J, Chayama K, Yoshizumi M, Taguchi A. Periodontal infection is associated with endothelial dysfunction in healthy subjects and hypertensive patients. Hypertension. 2008;51:446–453. doi: 10.1161/HYPERTENSIONAHA.107.101535
3. Amar S, Gokce N, Morgan S, Loukideli M, Van Dyke TE, Vita JA. Periodontal disease is associated with brachial artery endothelial dysfunction and systemic inflammation. Arterioscler Thromb Vasc Biol. 2003;23:1245–1249. doi: 10.1161/01.ATV.0000078603.90302.4A
4. Higashi Y, Goto C, Hidaka T, Soga J, Nakamura S, Fujii Y, Hata T, Idei N, Fujimura N, Chayama K, Kihara Y, Taguchi A. Oral infection-inflammatory pathway, periodontitis, is a risk factor for endothelial dysfunction in patients with coronary artery disease. Atherosclerosis. 2009;206:604–610. doi: 10.1016/j.atherosclerosis.2009.03.037
5. Martin-Cabezas R, Seelam N, Petit C, Agossa K, Gaertner S, Tenenbaum H, Davideau JL, Huck O. Association between periodontitis and arterial hypertension: a systematic review and meta-analysis. Am Heart J. 2016;180:98–112. doi: 10.1016/j.ahj.2016.07.018
6. Holmlund A, Holm G, Lind L. Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects. J Periodontol. 2006;77:1173–1178. doi: 10.1902/jop.2006.050233
7. Beck JD, Elter JR, Heiss G, Couper D, Mauriello SM, Offenbacher S. Relationship of periodontal disease to carotid artery intima-media wall thickness: the atherosclerosis risk in communities (ARIC) study. Arterioscler Thromb Vasc Biol. 2001;21:1816–1822.
8. Yu H, Qi LT, Liu LS, Wang XY, Zhang Y, Huo Y, Luan QX. Association of carotid intima-media thickness and atherosclerotic plaque with periodontal status. J Dent Res. 2014;93:744–751. doi: 10.1177/0022034514538973
9. Humphrey LL, Fu R, Buckley DI, Freeman M, Helfand M. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23:2079–2086. doi: 10.1007/s11606-008-0787-6
10. Wu T, Trevisan M, Genco RJ, Dorn JP, Falkner KL, Sempos CT. Periodontal disease and risk of cerebrovascular disease: the first national health and nutrition examination survey and its follow-up study. Arch Intern Med. 2000;160:2749–2755.
11. Lu B, Parker D, Eaton CB. Relationship of periodontal attachment loss to peripheral vascular disease: an analysis of NHANES 1999-2002 data. Atherosclerosis. 2008;200:199–205. doi: 10.1016/j.atherosclerosis. 2007.12.037
12. Holmlund A, Lampa E, Lind L. Oral health and cardiovascular disease risk in a cohort of periodontitis patients. Atherosclerosis. 2017;262:101– 106. doi: 10.1016/j.atherosclerosis.2017.05.009
13. D’Aiuto F, Parkar M, Nibali L, Suvan J, Lessem J, Tonetti MS. Periodontal infections cause changes in traditional and novel cardiovascular risk factors: results from a randomized controlled clinical trial. Am Heart J. 2006;151:977–984. doi: 10.1016/j.ahj.2005.06.018
14. Vidal F, Cordovil I, Figueredo CM, Fischer RG. Non-surgical periodontal treatment reduces cardiovascular risk in refractory hypertensive patients: a pilot study. J Clin Periodontol. 2013;40:681–687. doi: 10.1111/jcpe.12110
15. Ostchega Y, Prineas RJ, Paulose-Ram R, Grim CM, Willard G, Collins D. National Health and Nutrition Examination Survey 1999-2000: effect of observer training and protocol standardization on reducing blood pressure measurement error. J Clin Epidemiol. 2003;56:768–774.
Facebook Comments