Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke

Abstract

Background and purpose: Periodontal disease is independently associated with cardiovascular disease. Identification of periodontal disease as a risk factor for incident ischemic stroke raises the possibility that regular dental care utilization may reduce the stroke risk.

Methods: In the ARIC (Atherosclerosis Risk in Communities) study, pattern of dental visits were classified as regular or episodic dental care users. In the ancillary dental ARIC study, selected subjects from ARIC underwent fullmouth periodontal measurements collected at 6 sites per tooth and classified into 7 periodontal profile classes (PPCs).

Results: In the ARIC study 10 362 stroke-free participants, 584 participants had incident ischemic strokes over a 15-year period. In the dental ARIC study, 6736 dentate subjects were assessed for periodontal disease status using PPC with a total of 299 incident ischemic strokes over the 15-year period. The 7 levels of PPC showed a trend toward an increased stroke risk (χ² trend P<0.0001); the incidence rate for ischemic stroke/1000-person years was 1.29 for PPC-A (health), 2.82 for PPC-B, 4.80 for PPC-C, 3.81 for PPC-D, 3.50 for PPC-E, 4.78 for PPC-F, and 5.03 for PPC-G (severe periodontal disease). Periodontal disease was significantly associated with cardioembolic (hazard ratio, 2.6; 95% confidence interval, 1.2-5.6) and thrombotic (hazard ratio, 2.2; 95% confidence interval, 1.3-3.8) stroke subtypes. Regular dental care utilization was associated with lower adjusted stroke risk (hazard ratio, 0.77; 95% confidence interval, 0.63-0.94).

Conclusions: We confirm an independent association between periodontal disease and incident stroke risk, particularly cardioembolic and thrombotic stroke subtype. Further, we report that regular dental care utilization may lower this risk for stroke.

Keywords: atherosclerosis; dental care; gingivitis; risk factors; stroke.

Figure 1

Risk for incident ischemic stroke in the Dental ARIC cohort depicted as crude (A) and adjusted (B) Hazard Ratios for the various classes of periodontal disease: PPC-A or reference healthy group without periodontal disease, PPC-B, or mild periodontal disease, PPC-C or high GI score, PPC-D or tooth loss, PPC-E or posterior disease, PPC-F or severe tooth loss and PPC-G or severe periodontal disease. In panel B Hazard Ratios are adjusted for Race/Center, Age, Gender, BMI, Hypertension, Diabetes, LDL Level, Smoking (3-levels), Pack Years, Education (3-levels).

Figure 2

Risk reduction in incident ischemic stroke in the main ARIC cohort depicted as crude (A) and adjusted (B) Hazards Ratio for episodic and regular (reference group for comparison) dental care users, determined at visit 4. In panel B Hazards Ratio is adjusted for Race/Center, Age, Gender, BMI, Hypertension, Diabetes, LDL Level, Smoking (3-levels), Pack Years, Education (3-levels).

Figure 3

Kaplan Meier curves depicting 15 years’ outcome of (A) incident ischemic stroke (overall), (B) lacunar, (C) cardioembolic and (D) thrombotic stroke subtypes. Inset: Crude Hazard Ratios for ischemic stroke (overall) and stroke subtypes. Hazards Ratio adjusted for Race/Center, Age, Gender, BMI, Hypertension, Diabetes, LDL Level, Smoking (3-levels), Pack Years, Education (3-levels)