Clinical Studies

Assessing the Relationship Between Dental Disease and Coronary Heart Disease in Elderly U.S. Veterans

  • Walter J. Loesche, D.M.D., Ph.D.
  • Anthony Schork, Ph.D.
  • Margaret S. Terpenning, M.D.
  • Yin-Miao Chen, M.S.
  • B. Liza Dominguez, D.D.S., M.S.
  • Natalie Grossman, R.D.H., M.A.




Several recent studies have shown a link between dental disease and coronary heart disease. The authors studied 320 U.S. veterans in a convenience sample to assess the relationship between oral health and systemic diseases among older people. They present cross-sectional data confirming that a statistically significant association exists between a diagnosis of coronary heart disease and certain oral health parameters, such as the number of missing teeth, plaque benzoyl-DL-arginine-naphthylamide test scores, salivary levels of Streptococcus sanguis and complaints of xerostomia. The oral parameters in these subjects were independent of and more strongly associated with coronary heart disease than were recognized risk factors, such as serum cholesterol levels, body mass index, diabetes and smoking status. However, because of the convenience sample studied, these findings cannot be generalized to other populations.

In 1989, Mattila and colleagues1 reported that poor dental health could be associated with both an acute myocardial infarction and a cerebral vascular accident.2 The investigators developed two measurements of dental disease, one based on radiographs of the teeth and jaws, called the pantomographic index, and the second, based on clinical examination findings, which they termed the Total Dental Index, or TDI.

In a subsequent seven-year prospective study, the TDI, the number of previous myocardial infarctions and, to a lesser extent, diabetes and the pantomographic index were associated with a risk of developing a new and often fatal myocardial infarction.3 Traditional risk factors such as hypertension, smoking, total cholesterol levels, high-density lipoprotein cholesterol levels, triglycerides levels, socioeconomic status, sex and age were not significant predictors of a coronary event when included in a model that contained the dental variables.

Other studies have generally confirmed this link between dental disease and coronary heart disease, or CHD. A prospective, cohort-designed study, involving data from 9,760 American men who were examined three times between 1971 and 1987, found a significant relationship between either periodontitis or edentulism and CHD, even after adjusting for 13 known risk factors.4 A study of 1,384 Finnish men, aged 45 to 64 years, showed that the number of missing teeth, along with hypertension, geographical area and educational level were independent explanatory factors for the presence of ischemic heart disease.5

In a longitudinal aging study of U.S. veterans, Beck and colleagues6 found a significant association between periodontal disease, as measured by the extent of alveolar bone loss, and CHD and stroke after adjusting for various cardiovascular risk factors. In a case-control study of hospitalized patients, people with acute cerebrovascular ischemia had a higher TDI than did age- and sex-matched controls.7

These associations indicate that there may be some type of linkage between dental disease and cardiovascular disease. Because dental caries and periodontal disease are chronic infections that are often asymptomatic, they could be the source of the increased levels of C-reactive protein that have been suggested as a predictor of myocardial infarction and stroke.8

Since 1990, we have been recording information for a large number of oral health variables in a group of elderly veterans to study the relationship between oral health and systemic diseases among older people.9 We present cross-sectional data confirming that a statistically significant association exists between a diagnosis of CHD and certain oral health parameters, such as the level of gingival bleeding; number of missing teeth; benzoyl-DL-arginine-naphthylamide, or BANA, test scores; and complaints of xerostomia.

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