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Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 174-180

Risk of having myocardial infarction in periodontal disease patients: A systematic review

1 Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
2 Department of Public Health Dentistry, Amrita School of Dental Sciences, Kochi, Kerala, India

Date of Submission11-Feb-2019
Date of Acceptance24-Jul-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. Monika Kumari
Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_15_19

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Introduction: Periodontal disease is a common inflammatory disease of the teeth. There is mounting evidence that poor dental health, especially the occurrence of periodontal disease, increases the probability of the occurrence of cardiovascular disease (CVD) which, in turn, is the leading cause of mortality and morbidity throughout the world. Objectives: The study objective was to systematically review the literature and check the risk factors of myocardial infarction (MI) in periodontal disease patients. Materials and Methods: A literature published in PubMed/Medline, PubMed Central, Scopus, Complementary index, Ebscohost, SciELO, Open DOAR, Science Citation Index, and Web of Science was evaluated. Cross-sectional studies assessing the prevalence of periodontal disease among MI patients searched above were included. The methodological quality was assessed using a 10-item ordinal scale for cross-sectional studies. Two authors extracted the information and assessed the methodological quality of the included studies. The search was performed from 1990 till date for all the mentioned databases. There was no lower limit for the analyzed time frame and no language restrictions. The primary outcome measure was the proportion of MI in periodontal disease patients of each study. Results: Out of the total 46 titles appeared, 11 articles fulfilled the criteria and were selected for the review; most of the literature showed an association between MI and periodontal disease. There is a statistically significant increase in MI in periodontal disease patients. CVDs are associated with an increased incidence of periodontal disease, but the association is weak when adjusted with other potential cofounders. The lack of good-quality studies is a major limitation to assess the association between MI and periodontal diseases. Conclusion: Periodontal disease is mostly associated with MI and CVD. The association between periodontal disease and CVD may be confounded by other cofactors such as age, diabetes mellitus, and smoking. However, the association remains weak, and the quality of study is low.

Keywords: Gum disease, myocardial infarction, parodontosis, periodontal disease, tooth disease

How to cite this article:
Kumari M, Patthi B, Jankiram C, Singla A, Malhi R, Rajeev A. Risk of having myocardial infarction in periodontal disease patients: A systematic review. J Indian Assoc Public Health Dent 2019;17:174-80

How to cite this URL:
Kumari M, Patthi B, Jankiram C, Singla A, Malhi R, Rajeev A. Risk of having myocardial infarction in periodontal disease patients: A systematic review. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2022 May 23];17:174-80. Available from: https://www.jiaphd.org/text.asp?2019/17/3/174/266751

  Introduction Top

Periodontal diseases are a group of provocative diseases in which bacteria and their by-products are the main etiological agents for local as well as systemic disease in humans. There is mounting indication that reduced dental health, particularly the event of periodontal disease, increases the probability of the incidence of cardiovascular disease (CVD). Periodontal disease may be linked with CVDs which are the significant cause of mortality and morbidity worldwide. Mattila et al. in their study confirmed that there is a bidirectional association between CVD and periodontal diseases.[1] Stein et al. also reported an epidemiologic survey on clinical periodontal and microbiologic limits in patients with acute myocardial infarction (AMI), in which a relationship between CVD and periodontal disease was found.[2]

Many studies have been published in the past 20 years, with even a positive or negative relation between periodontal disease and various systemic diseases. Some researchers hypothesized that the pathogenesis of CVD is influenced by the etiologic role of periodontitis. Therefore, patients with diagnosed periodontal disease might be at greater risk of CVD because of their compromised immune system. Studies also suggest that periodontal pathogens or their lipopolysaccharides are systemically distributed via the blood flow and infect the vascular endothelium, producing an atherosclerotic lesion and following myocardial ischemia.[3],[4],[5],[6],[7],[8]

Focused question

Is there an association between MI and periodontal disease?


The study objective was to review the association between periodontal disease and MI in adults.

  Materials and Methods Top

Search method for identification of studies

The search strategy used a combination of controlled vocabulary and free-text terms, as follows: (((((“myocardial infarction” [MeSH Terms] OR (“myocardial” [All Fields] AND “infarction” [All Fields]) OR “myocardial infarction” [All Fields]) AND (“periodontitis” [MeSH Terms] OR “periodontitis” [All Fields])) AND (“epidemiology” [Subheading] OR “epidemiology” [All Fields] OR “prevalence” [All Fields] OR “prevalence” [MeSH Terms])) AND (“association” [MeSH Terms] OR “association” [All Fields])) AND periodontal [All Fields]) AND (“disease” [MeSH Terms] OR “disease” [All Fields]). The main databases searched were PubMed, PubMed Central, Cochrane Review, Embase, and Google Scholar [Figure 1]. All the articles which were published in English, dated from March 1990 to October 2017, were included in this review.
Figure 1: Search strategy

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Data analysis and extraction

Two authors (MR and PB) independently eliminated any duplicates from the gathered results and examined the remaining articles by title and abstract. Subsequently, the full texts were obtained and analyzed for further inclusion/exclusion. Studies that did not meet the inclusion criteria were excluded. The full-text articles of those identified after the title and abstract were screened. All the included studies were assessed independently and in duplicate by two review authors (MR and PB) for study design characteristics and features of internal validity. An instrument was developed to assess the quality of the eligible studies. Each study was assessed in terms of study settings, sampling strategy, measurement tools, analysis method, and generalizability of findings. For cross-sectional and longitudinal studies, there are seven and five indicators respectively for quality assessment, which were assessed using the BSA Medical Sociology Group and the Quality Assessment Tool for Systematic Reviews of Observational studies.[9]

For every included study, using Microsoft Excel sheet, the study definition, risk-of-bias assessment, total length of study, unit of randomization, unit of analysis, participants' characteristics, interventions, outcomes, results, and other items were collected by two reviewers. The review authors were not blinded to author and source institution. Any disagreement was resolved by discussion or by third-party adjudication.

Synthesis of findings

The absence of significant clinical heterogeneity in terms of patient demographic characteristics and the measures used to record periodontal diseases, along with the quality of the studies, led to the decision to pool the study data. Because clinical heterogeneity was high, the summarized findings were depicted qualitatively only without meta-analysis.

  Results Top

By following the described strategy, the electronic search yielded 47 articles, and texts of the 43 articles which seemed to be relevant were obtained and reviewed after removal of duplicates. Based on the title of the study, seven articles were excluded and the remaining 36 were screened. After abstract evaluation, 14 full-text articles got eligible for the review. According to the inclusion criteria, a total of 11 studies, which attempted to assess the association of periodontal disease to MI, were selected for the review [Table 1]. The overall summary of all the cross-sectional, longitudinal, and case–control study is described in [Table 2].
Table 1: Characteristics of included studies

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Table 2: Synthesis of results

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The three cross-sectional studies which were selected for the study with a total of 6244 participants revealed that CVDs are associated with increased severity of periodontitis. The results became more evident through the six longitudinal studies, conducted with a total of 133,258 participants, which support the fact that periodontal disease is a risk factor for CVDs. In the two case–control studies which analyzed 1214 patients (211 cases + 1003 controls), hypercholesteremia was found out to be a possible link between periodontal diseases and MI. The quality assessment of the each included study was made using appropriate tools and is presented in [Table 3]a and [Table 3]b. Among the six longitudinal studies, two studies scored good and four scored fair interpretation. The quality assessment indicator of the three cross-sectional studies was found to be moderate. [Table 3]b describes the way through which the quality of cross-sectional studies was analyzed. All of these studies were appropriate with respect to research design, recruitment, response rate and statistical analysis, but power of calculation and ability of the representative sample were not mentioned.

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Relationship of periodontal diseases and cardiovascular diseases

Studies done by various researchers like Beck et al.,[10] Joshipura et al.,[11] Morrison et al.,[12] Arbes et al.,[13] Emingil et al.,[15] Katz et al.,[16] Jansson et al.,[17] Gundala et al.,[18] Oberoi et al.,[19] and LaMonte et al.[20] indicated a positive relationship between periodontal diseases and MI. The study by Beck et al. found that people with high bone loss at baseline had almost three times the odds of developing stroke as those with low bone loss.[10] During the same year, the study of Joshipura et al. showed an association of tooth loss with increased coronary heart disease (CHD) risk. After adjusted for age and smoking status, the study revealed that a relative risk of 1.40 (95% confidence interval, 1.04–1.87) was found in men with 0–10 teeth, as compared with men with 25 or more teeth.[11] Morrison et al. enrolled 10,368 individuals in the National Canada Survey, and the data showed that poor dental health is associated with an increased risk of CVD.[12] In the same year, Arbes et al. conducted the National Health and Nutrition Examination Survey in 5633 samples and provided support for the hypothesis of an association between periodontal disease and CHD in the United States population.[13] The number of sites with probing depth ≥4 mm, subjects exhibiting bleeding on probing, smoking status, and total cholesterol level was found to be statistically different between AMI and chronic CHD in the study by Emingil et al., which proposed a possible relation of periodontal disease with AMI.[15] In 2001, Katz et al. conducted a longitudinal study (14 years) on a large cohort and proposed hypercholesterolemia as a possible link between chronic periodontal inflammation and atherosclerosis.[16] Dental health was found to be a risk indicator of death due to CVD in the study by Jansson et al.[17] In 2014, Gundala et al. found a strong correlation of serum leptin concentration to body mass index (BMI), generalized chronic periodontitis, and AMI.[18] In 2016, Oberoi et al. concluded that diabetes mellitus, CVD, and respiratory diseases are associated with a higher severity of periodontal disease.[19] A recent study by LaMonte et al. suggests that improving periodontal condition of the general population could reduce overall mortality due to CVD.[20]

  Discussion Top

Among oral diseases, periodontal disease is a common disease that affects about 90% of the adult population.[1],[2],[3] There is a clear evidence that most of the people who died of CVDs had a poor periodontal health, which provokes to agree with the fact that periodontitis is an etiological cause of several diseases including MI and thus becoming the major cause of death in developing countries like India.[4],[5],[6],[7],[8]

Several studies have been conducted to determine the link between periodontal diseases and CVDs, which revealed a positive association between both conditions. Beck et al.[10] and Joshipura et al.[11] in their respective studies conducted in 1996 claimed an association between periodontal diseases and CVDs. The studies by Morrison et al.[12] and Arbes et al.[13] in 1999 also support that poor dental health has an increased risk of association with chronic heart diseases. In 2000, the study by Hujoel et al. failed to find out a convincing evidence of even a casual association between periodontal disease and chronic heart disease risk. This epidemiologic follow-up study was conducted on 8032 adults in the age group of 25–74 years, which claimed that there is no association between periodontal diseases and future MI.[14] However, in the same year, Emingil et al. claimed through their study that there is a strong association between periodontal diseases and MI.[15] The study revealed that rise in serum leptin in generalized chronic periodontitis and increased BMI may be considered as risk markers for AMI. Katz et al. proposed that higher blood cholesterol levels can be a possible link between AMI and periodontal diseases.[16] A study done by Jansson et al. revealed a major association of smoking with AMI as smoking is the major cause of periodontal diseases.[17] The study done by Gundala et al.[18] indicated that periodontal disease may be associated with AMI. In 2016, a study by Oberoi et al. revealed a significant fact that the relationship between periodontal and systemic diseases is a two-way process and can have common risk factors.[19] Another study by LaMonte et al.[20] found a positive association between periodontal diseases and CVDs.

Although MI shares common risk factors with periodontal diseases, there is no risk quantification between these diseases for pooled estimate. The wide clinical and methodological heterogeneity between the studies is a major concern to estimate the pooled value of proportion. Due to this, the qualitative findings are summarized in the table. Lack of good-quality studies is a major limitation to assess the association between MI and periodontal diseases. Further high-quality studies with less bias which estimate the relationship between these two would strengthen the evidence. From patients' and health-care providers' perspective, even though evidence remains ambiguous for the association between MI and PD, it is a valid strategy to promote oral hygiene or improve periodontal treatment outcomes to avoid the risk of MI. This is on the account serious consequences (mortality) of MI and morbidity of PD.

Considering the increased prevalence of both periodontitis and CVDs across the world and their significant association, it is evident that there is a relationship between both of them which cannot be neglected. However, there is a necessity of further large-scale longitudinal studies to reveal the extent of association and also to dissect the independent role of periodontal disease from lifestyle factors on cardiovascular conditions.

  Conclusion Top

The evidence of the association between periodontal disease and CVDs remains low and is influenced by diabetes, smoking, etc., However, the association remains weak, and the quality of study is low.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mattila KJ, Asikainen S, Wolf J, Jousimies-Somer H, Valtonen V, Nieminen M. Age, dental infections, and coronary heart disease. J Dent Res 2000;79:756-60.  Back to cited text no. 1
Stein JM, Kuch B, Conrads G, Fickl S, Chrobot J, Schulz S, et al. Clinical periodontal and microbiologic parameters in patients with acute myocardial infarction. J Periodontol 2009;80:1581-9.  Back to cited text no. 2
Simonka M, Skaleric U, Hojs D. Condition of teeth and periodontal tissue in patients who had suffered a heart attack. Zobozdrav Vestn 1988;43:81-3.  Back to cited text no. 3
Cueto A, Mesa F, Bravo M, Ocaña-Riola R. Periodontitis as risk factor for acute myocardial infarction. A case control study of Spanish adults. J Periodontal Res 2005;40:36-42.  Back to cited text no. 4
Rutger Persson G, Ohlsson O, Pettersson T, Renvert S. Chronic periodontitis, a significant relationship with acute myocardial infarction. Eur Heart J 2003;24:2108-15.  Back to cited text no. 5
Pasupuleti MK, Nagireddy RR, Dinahalli R, Anumala D, Kishore Kumar A, Chavan V. Microbiological tests to identify a link between periodontitis and acute myocardial infarction-an original research. Iran J Microbiol 2013;5:391-5.  Back to cited text no. 6
Holmlund A, Lampa E, Lind L. Poor response to periodontal treatment may predict future cardiovascular disease. J Dent Res 2017;96:768-73.  Back to cited text no. 7
Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol 2003;8:38-53.  Back to cited text no. 8
Joanna Briggs Institute. The Joanna Briggs Institute Critical Appraisal Tools for use in JBI Systematic Reviews: Checklist for Qualitative Research. Australia: The Joanna Briggs Institute; 2016.  Back to cited text no. 9
Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-37.  Back to cited text no. 10
Joshipura KJ, Rimm EB, Douglass CW, Trichopoulos D, Ascherio A, Willett WC. Poor oral health and coronary heart disease. J Dent Res 1996;75:1631-6.  Back to cited text no. 11
Morrison HI, Ellison LF, Taylor GW. Periodontal disease and risk of fatal coronary heart and cerebrovascular diseases. J Cardiovasc Risk 1999;6:7-11.  Back to cited text no. 12
Arbes SJ Jr., Slade GD, Beck JD. 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.  Back to cited text no. 13
Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal disease and coronary heart disease risk. JAMA 2000;284:1406-10.  Back to cited text no. 14
Emingil G, Buduneli E, Aliyev A, Akilli A, Atilla G. Association between periodontal disease and acute myocardial infarction. J Periodontol 2000;71:1882-6.  Back to cited text no. 15
Katz J, Chaushu G, Sharabi Y. On the association between hypercholesterolemia, cardiovascular disease and severe periodontal disease. J Clin Periodontol 2001;28:865-8.  Back to cited text no. 16
Jansson L, Lavstedt S, Frithiof L, Theobald H. Relationship between oral health and mortality in cardiovascular diseases. J Clin Periodontol 2001;28:762-8.  Back to cited text no. 17
Gundala R, Chava VK, Ramalingam K. Association of leptin in periodontitis and acute myocardial infarction. J Clin Periodontol 2014;85:917-24.  Back to cited text no. 18
Oberoi SS, Harish Y, Hiremath S, Puranik M. A cross-sectional survey to study the relationship of periodontal disease with cardiovascular disease, respiratory disease, and diabetes mellitus. J Indian Soc Periodontol 2016;20:446-52.  Back to cited text no. 19
[PUBMED]  [Full text]  
LaMonte MJ, Genco RJ, Hovey KM, Wallace RB, Freudenheim JL, Michaud DS, et al. History of periodontitis diagnosis and edentulism as predictors of cardiovascular disease, stroke, and mortality in postmenopausal women. J Am Heart Assoc 2017;6. pii: e004518.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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