Association between Periodontitis and Myocardial Infarction: Systematic Review and Meta-Analysis

Periodontal disease and cardiovascular disease: umbrella review

BACKGROUND

Periodontal disease (PD) is an infectious and inflammatory condition that affects the tissues surrounding and supporting the teeth. It has been suggested that PD may be associated with cardiovascular disease (CVD), one of the leading causes of mortality worldwide. Our study aimed to investigate the association between PD and CVD through an umbrella review.

METHODS

A comprehensive search was conducted until April 2024 across various electronic databases, including PubMed, Cochrane Library, Scopus, SciELO, Web of Science, Google Scholar, ProQuest Dissertations and Theses, and OpenGrey. Systematic reviews with or without meta-analysis were considered for inclusion, without any limitations on time or language, provided they examined primary studies linking PD with CVD. The AMSTAR-2 tool was employed to assess the quality and overall confidence of the included studies.

RESULTS

After the initial search, a total of 516 articles were identified. Following the application of selection criteria, 41 articles remained for further consideration. All these studies indicated an association between PD and CVD, with odds ratios and risk ratios ranging from 1.22 to 4.42 and 1.14 to 2.88, respectively.

CONCLUSIONS

Systematic reviews with high overall confidence support the association between PD, tooth loss, and cardiovascular diseases. However, it is crucial to interpret these results with caution due to methodological limitations. The potential public health relevance justifies preventive and corrective oral health strategies. Additionally, the need for rigorous future research is highlighted to strengthen the evidence and guide effective public health strategies.

Periodontal disease as a non-traditional risk factor for acute coronary syndrome: a systematic review and meta-analysis

OBJECTIVES

Previous observational studies have suggested an association between periodontal disease (PD) and cardiovascular and cerebrovascular diseases. Nonetheless, evidence linking PD with coronary heart disease (CHD) and acute coronary syndrome (ACS) is still contradictory. We aim to systematically review the role of PD as a risk factor for ACS (myocardial infarction and unstable angina).

METHODS

The protocol was registered in PROSPERO (CRD42021286278) and we followed the recommendations of the PRISMA and AMSTAR 2 guidelines. We systematically searched for 7 databases and electronic thesis repositories from inception to February 2022. We included articles without language restriction following the PECO strategy (population: "adult participants"; exposure: "periodontal disease"; comparator: "no periodontal disease"; outcome: "acute coronary syndrome" OR "acute myocardial infarction" OR "unstable angina"). Odds ratios (OR) with 95% confidence intervals (95% CI) were pooled using random effects and heterogeneity was quantified by Cochran's Q and Higgins' I² statistics. Subgroup analyses were carried out according to the participants' sex, type of diagnosis of PD, type of study, and continent of origin of studies.

RESULTS

We included 46 papers (17 cohort, 25 case-control, and 4 cross-sectional studies) that met the inclusion criteria. This meta-analysis includes a total of 6,806,286 participants and at least 68,932 ACS events, mainly myocardial infarction (MI). In accordance with our results, PD is associated with a higher risk of ACS (OR 1.35; 95% CI 1.25-1.45). However, clinical and methodological heterogeneity was significant (I²=86%, p<0.05). In the sensitivity analysis, the exclusion of some studies with "extreme" results (outliers) did not significantly affect the overall estimate or heterogeneity. In subgroup analysis, we found no statistically significant differences between men and women according to subgroup difference tests (I²=0%, p=0.67). Conversely, there were differences according to the type of diagnosis of PD (clinical or self-reported diagnosis), type of study (cohort, case-control, or cross-sectional study), and the continent of origin (North America, South America, Asia, or Europe) of the studies (I²=79%-96%, p<0.10). Of the 46 studies, only 4 had a high risk of bias. Additionally, the funnel plot suggested publication bias.

CONCLUSION

PD may be an important non-traditional risk factor for ACS. Although, this meta-analysis brings together more studies, and therefore more evidence, than any other previous similar study, its results should be interpreted with caution due to the great heterogeneity and the potential presence of bias.