Periodontal Disease and Coronary Heart Disease Incidence: A Systematic Review and Meta-analysis

  • Linda L. HumphreyEmail author
  • Rongwei Fu
  • David I. Buckley
  • Michele Freeman
  • Mark Helfand
Clinical Review



Periodontal disease is common among adults in the US and is a potential source of chronic inflammation. Recent data have suggested an important role for chronic inflammation in the development of coronary heart disease (CHD).


To aid the United States Preventive Services Task Force (USPSTF) in evaluating whether periodontal disease is an independent novel risk factor for incident CHD.


Studies were identified by searching Medline (1966 through March 2008) and reviewing prior systematic reviews, reference lists, and consulting experts. Prospective cohort studies that assessed periodontal disease, Framingham risk factors, and coronary heart disease incidence in the general adult population without known CHD were reviewed and quality rated using criteria developed by the USPSTF. Meta-analysis of good and fair quality studies was conducted to determine summary estimates of the risk of CHD events associated with various categories of periodontal disease.


We identified seven articles of good or fair quality from seven cohorts. Several studies found periodontal disease to be independently associated with increased risk of CHD. Summary relative risk estimates for different categories of periodontal disease (including periodontitis, tooth loss, gingivitis, and bone loss) ranged from 1.24 (95% CI 1.01–1.51) to 1.34 (95% CI 1.10–1.63). Risk estimates were similar in subgroup analyses by gender, outcome, study quality, and method of periodontal disease assessment.


Periodontal disease is a risk factor or marker for CHD that is independent of traditional CHD risk factors, including socioeconomic status. Further research in this important area of public health is warranted.


Coronary Heart Disease Periodontal Disease Tooth Loss Coronary Heart Disease Event Gingivitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Miranda Walker, Tanya Weeks and Craig Fleming, MD, for their contributions on this project, and Andrew Hamilton, MLS, MS, for conducting the literature searches.

Conflicts of Interest

None disclosed.


  1. 1.
    Kochanek KD, Murphy SL, et al. Final Data for 2002. National Statics Reports. Vol 53. Hyattsville, Maryland: National Center for Health Statistics; 2004.Google Scholar
  2. 2.
    Mackay J, Mensah GA. The Atlas of Heart Disease and Stroke. Geneva: WHP; 2004.Google Scholar
  3. 3.
    Anonymous. Heart Disease and Stroke Statistics. American Heart Association; 2006.Google Scholar
  4. 4.
    Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Eng J Med. 2000;342(12):836–43.CrossRefGoogle Scholar
  5. 5.
    Brown LJ, Brunelle JA, Kingman A. Periodontal status in the United States. J Dent Res. 1996;75:672–83. In 5/5/2005.PubMedGoogle Scholar
  6. 6.
    Douglass CW, Jette AM, Fox CH, et al. Oral health status of the elderly in New England. J Gerontol. 1993;48:M39–46. In 65/6/05.PubMedGoogle Scholar
  7. 7.
    Papapanou PN. Periodontal diseases: epidemiology. Annals of Periodontology. 1996;1:1–36. In 5/5/2005.PubMedGoogle Scholar
  8. 8.
    D’Aiuto F, Parkar M, Andreou G, Brett PM, Ready D, Tonetti MS. Periodontitis and atherogenesis: causal association or simple coincidence? J Clin Periodontol. 2004;31(5):402–11.PubMedCrossRefGoogle Scholar
  9. 9.
    Ebersole JL, Machen RL, Steffen MJ, Willmann DE. Systemic acute-phase reactants, C-reactive protein and haptoglobin, in adult periodontitis. Clin Exp Immunol. 1997;107(2):347–52, Feb.PubMedCrossRefGoogle Scholar
  10. 10.
    Kweider M, Lowe GD, Murray GD, Kinane DF, McGowan DA. Dental disease, fibrinogen and white cell count; links with myocardial infarction. Scott Med J. 1993;38:73–4. In 5/6/05.PubMedGoogle Scholar
  11. 11.
    Noack B, Genco RJ, Trevisan M, Grossi S, Zambon JJ, De Nardin E. Periodontal infections contribute to elevated systemic C-reactive protein level. J Periodontol. 2001;72(9):1221–7, Sep.PubMedCrossRefGoogle Scholar
  12. 12.
    Slade GD, Offenbacher S, Beck JD, Heiss G, Pankow JS. Acute-phase inflammatory response to periodontal disease in the US population. J Dent Res. 2000;79(1):49–57, Jan.PubMedGoogle Scholar
  13. 13.
    Wu T, Trevisan M, Genco R, et al. Examination of the relation between periodontal health status and cardiovascular risk factors: serum total and high-density lipoprotein cholesterol, C-reactive protein, and plasma fibrinogen. Am J Epidemiol. 2000;151:273–82. In 5/6/05.PubMedGoogle Scholar
  14. 14.
    Janket SJ, Baird AE, Chuang SK, Jones JA. Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endo. 2003;95(5):559–69.CrossRefGoogle Scholar
  15. 15.
    Khader YS, Albashaireh ZS, Alomari MA. Periodontal diseases and the risk of coronary heart and cerebrovascular diseases: a meta-analysis. J Periodontol. 2004;75(8):1046–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force. A review of the process. Am J Prev Med. 2001;30(3S):21–35.CrossRefGoogle Scholar
  17. 17.
    Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34, Sep 13.PubMedGoogle Scholar
  18. 18.
    Ajwani S, Mattila KJ, Tilvis RS, Ainamo A. Periodontal disease and mortality in an aged population. Spec Care Dent. 2003;23(4):125–30.CrossRefGoogle Scholar
  19. 19.
    Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol. 1996;67(10 Suppl):1123–37.PubMedGoogle Scholar
  20. 20.
    DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell CM. Dental disease and risk of coronary heart disease and mortality. BMJ. 1993;306(6879):688–91.PubMedCrossRefGoogle Scholar
  21. 21.
    Howell TH, Ridker PM, Ajani UA, Hennekens CH, Christen WG. Periodontal disease and risk of subsequent cardiovascular disease in U.S. male physicians. J Am Coll Cardiol. 2001;37(2):445–50.PubMedCrossRefGoogle Scholar
  22. 22.
    Hung HC, Joshipura KJ, Colditz G, et al. The association between tooth loss and coronary heart disease in men and women. J Public Health Dent. 2004;64(4):209–15.PubMedGoogle Scholar
  23. 23.
    Morrison HI, Ellison LF, Taylor GW. Periodontal disease and risk of fatal coronary heart and cerebrovascular diseases. J Cardiovasc Risk. 1999;6(1):7–11.PubMedGoogle Scholar
  24. 24.
    Tuominen R, Reunanen A, Paunio M, Paunio I, Aromaa A. Oral health indicators poorly predict coronary heart disease deaths. J Dent Res. 2003;82(9):713–8.PubMedGoogle Scholar
  25. 25.
    Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal disease and coronary heart disease risk. JAMA. 2000;284(11):1406–10.PubMedCrossRefGoogle Scholar
  26. 26.
    Mattila KJ, Nieminen M, Valtonen V, et al. Association between dental health and acute myocardial infarction. Br Med J. 1989;298:779–81. In 5/6/05.Google Scholar
  27. 27.
    Mattila KJ, Valtonen V, Nieminen M, Huttunen JK. Dental infection and the risk of new coronary events: prospective study of patients with coronary artery disease. Clin Infect Dis. 1995;20:588–92. In 5/6/05.PubMedGoogle Scholar
  28. 28.
    Persson RG, Ohlsson O, Pettersson T, Renvert S. Chronic periodontitis, a significant relationship with acute myocardial infarction. Eur Heart J. 2003;24(23):2108–15.CrossRefGoogle Scholar
  29. 29.
    Mattila KJ, Rasi V, Nieminen M, et al. von Willebrand factor antigen and dental infections. Thomb Res. 1989;56:325–9. In 5/6/05.CrossRefGoogle Scholar
  30. 30.
    Pearson TA, Mensah GA, Alexander RW, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003;107(3):499–511, Jan 28.PubMedCrossRefGoogle Scholar
  31. 31.
    Deliargyris EN, Marron I, Kadoma W, et al. Periodontal disease and acute myocardial infarction. Circulation. 2000;460(Suppl. II):II–710 (Abstr. 3436), In 5/6/05.Google Scholar
  32. 32.
    Arbes SJ, Slade GD, Beck J. Association between extent of periodontal attachment loss and self-reported history of heart attack: an analysis of NHANES III data. J Dent Res. 1999;78:1777–82. In 5/6/05.PubMedGoogle Scholar
  33. 33.
    Buhlin K, Gustaffson A, Hakansson J, et al. Oral health and cardiovascular disease in Sweden. J Clin Periodontol. 2002;29:254–9. In 5/6/05.PubMedCrossRefGoogle Scholar
  34. 34.
    Loesche WJ, Shork A, Terpenning MS, Chen Y-M, Dominguez BL, Grossman N. Assessing the relationship between dental disease and coronary heart disease in elderly US veterans. J Am Dent Assoc. 1998;129:301–11. In 5/6/05.PubMedGoogle Scholar
  35. 35.
    Mattila KJ, Valle MS, Nieminen M, Valtonen V, Hietaniemi KL. Dental infections and coronary atherosclerosis. Atherosclerosis. 1993;103:205–11. In 5/6/05.PubMedCrossRefGoogle Scholar
  36. 36.
    Glurich I, Grossi S, Albini B, et al. Systemic inflammation in cardiovascular and periodontal disease: comparative study. Clin Diagn Lab Immunol. 2002;9(2):425–32, Mar.PubMedCrossRefGoogle Scholar
  37. 37.
    Joshipura KJ, Wand HC, Merchant AT, Rimm EB. Periodontal disease and biomarkers related to cardiovascular disease. J Dent Res. 2004;83(2):151–5.PubMedGoogle Scholar
  38. 38.
    Sahingur SE, Sharma A, Genco RJ, De Nardin E. Association of increased levels of fibrinogen and the -455G/A fibrinogen gene polymorphism with chronic periodontitis. J Periodontol. 2003;74(3):329–37, Mar.PubMedCrossRefGoogle Scholar
  39. 39.
    D’Aiuto F, Ready D, Tonetti MS. Periodontal disease and C-reactive protein-associated cardiovascular risk. J Periodontal Res. 2004;39(4):236–41.PubMedCrossRefGoogle Scholar
  40. 40.
    Tonetti MS, D’Aiuto F, Nibali L, et al. Treatment of periodontitis and endothelial function. N Eng J Med. 2007;356(9):911–20, Mar 1.CrossRefGoogle Scholar
  41. 41.
    Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ. Identification of periodontal pathogens in atheromatous plaques. J Periodontol. 2000;71(10):1554–60, Oct.PubMedCrossRefGoogle Scholar
  42. 42.
    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(11):1816–22.PubMedCrossRefGoogle Scholar
  43. 43.
    Desvarieux M, Demmer RT, Rundek T, et al. Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke. 2003;34(9):2120–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Nakib SA, Pankow JS, Beck JD, et al. Periodontitis and coronary artery calcification: the Atherosclerosis Risk in Communities (ARIC) study. J Periodontol. 2004;75(4):505–10.PubMedCrossRefGoogle Scholar
  45. 45.
    Sharma A, Novak EK, Sojar HT, Swank RT, Kuramitsu HK, Genco RJ. Porphyromonas gingivalis platelet aggregation activity: outer membrane vesicles are potent activators of murine platelets. Oral Microbiol Immunol. 2000;15(6):393–6, Dec.PubMedCrossRefGoogle Scholar
  46. 46.
    Genco R, Offenbacher S, Beck J. Periodontal disease and cardiovascular disease: epidemiology and possible mechanisms. J Am Dent Assoc. 2002;133.Google Scholar
  47. 47.
    Grau AJ, Buggle F, Ziegler C, et al. Association between acute cerebrovascular ischemia and chronic and recurrent infection. Stroke. 1997;28:1724–9. In 5/6/05.PubMedGoogle Scholar
  48. 48.
    Syrjanen J, Peltola J, Valtonen V, et al. Dental infections in association with cerebral infarction in young and middle-ages men. J Intern Med. 1989;225:179–84. In 5/6/05.PubMedGoogle Scholar
  49. 49.
    Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation. 2005;111(5):576–82, Update Search 3/15/06.PubMedCrossRefGoogle Scholar
  50. 50.
    Soder PO, Soder B, Nowak J, et al. Early carotid atherosclerosis in subjects with periodontal diseases. Stroke. 2005;36(6):1195–200, Update Search 3/15/06.PubMedCrossRefGoogle Scholar
  51. 51.
    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(18):2749–55.PubMedCrossRefGoogle Scholar
  52. 52.
    Mendez MV, Scott T, LaMorte W, Vokonas P, Menzoian JO, Garcia R. An association between periodontal disease and peripheral vascular disease. Am J Surg. 1998;176(2):153–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Jansson L, Lavstedt S, Frithiof L. Relationship between oral health and mortality rate. J Clin Periodontol. 2002;29(11):1029–34.PubMedCrossRefGoogle Scholar
  54. 54.
    Gonzalez YM, De Nardin A, Grossi SG, Machtei EE, Genco RJ, De Nardin E. Serum cotinine levels, smoking, and periodontal attachment loss. J Dent Res. 1996;75(2):796–802, Feb.PubMedGoogle Scholar
  55. 55.
    Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Dietary vitamin C and the risk for periodontal disease. J Periodontol. 2000;71(8):1215–23, Aug.PubMedCrossRefGoogle Scholar
  56. 56.
    Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Calcium and the risk for periodontal disease. J Periodontol. 2000;71(7):1057–66, Jul.PubMedCrossRefGoogle Scholar
  57. 57.
    Becker A, Leber A, Becker C, Knez A. Predictive value of coronary calcifications for future cardiac events in asymptomatic individuals. Am Heart J. 2008;155(1):154–60, Jan.PubMedCrossRefGoogle Scholar
  58. 58.
    Couper DJ, Beck JD, Falkner KL, et al. The Periodontitis and Vascular Events (PAVE) pilot study: recruitment, retention, and community care controls. J Periodontol. 2008;79(1):80–9, Jan.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Linda L. Humphrey
    • 1
    • 2
    • 3
    • 4
    • 7
    • 8
    Email author
  • Rongwei Fu
    • 1
    • 4
    • 5
  • David I. Buckley
    • 1
    • 2
    • 6
  • Michele Freeman
    • 1
  • Mark Helfand
    • 1
    • 2
    • 3
    • 7
  1. 1.Oregon Evidence-based Practice CenterVeterans Affairs Medical CenterPortlandUSA
  2. 2.Department of Medical Informatics and Clinical EpidemiologyVeterans Affairs Medical CenterPortlandUSA
  3. 3.Department of MedicineVeterans Affairs Medical CenterPortlandUSA
  4. 4.Public Health and Preventive MedicineVeterans Affairs Medical CenterPortlandUSA
  5. 5.Emergency MedicineVeterans Affairs Medical CenterPortlandUSA
  6. 6.Family MedicineVeterans Affairs Medical CenterPortlandUSA
  7. 7.Oregon Health & Science University, Hospital and Specialty MedicineVeterans Affairs Medical CenterPortlandUSA
  8. 8.Oregon Health & Science UniversityPortlandUSA

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