Association between periodontal disease and vulnerable plaque morphology in patients undergoing carotid endarterectomy

Abstract

Background: Periodontal disease (PD) is a chronic inflammatory oral condition with potentially important systemic sequelae. We sought to determine whether the presence of PD in patients with severe carotid disease was associated with morphological features consistent with carotid plaque instability.

Methods: A total of 52 dentate patients hospitalized for carotid endarterectomy (CEA) had standardized assessments of their periodontal status, including measurements of probing pocket depth (PPD), clinical attachment level (CAL) and bleeding on probing (BoP). Carotid plaque morphology was assessed by ultrasound using the gray scale median (GSM) score and by immunohistochemistry using anti-CD68 and anti-alpha-actin antibodies, markers for macrophages and smooth muscle cells (SMCs) respectively.

Results: In total 30/52 patients (58%) had PD. Significant associations were noted between low GSM on ultrasound and each mm in PPD (p = 0.001), each mm in CAL (p = 0.002) and with a 10% increase in BoP (p = 0.009). Using the standardized PERIO definition the association remained robust (aOR = 10.4 [95% CI:2.3-46.3], p = .002). Significant associations were also observed with high macrophage accumulation and each individual PD measure (p < 0.01 for PPD, CAL and BoP) and with the PERIO definition (aOR = 15 [95% CI:1.8-127.8], p = .01). Similarly, low SMC density was also significantly associated with individual measures of PD (p < 0.05 for PPD, CAL and BoP), but not with the PERIO definition (aOR 3.4 [95% CI:0.9-12.8], p = .07).

Conclusions: The presence of PD was significantly associated with both ultrasound and immunohistochemistry features of carotid plaque instability in patients undergoing CEA.

Keywords: Carotid endarterectomy; Inflammation; Periodontal disease; Vulnerable plaque.

Fig. 1

Demonstrative figure panel of the immunohistochemical evaluation of plaque stability. (a) Scanty macrophages assessed with low density of anti-CD68 staining (arrows). Plaque considered stable (Score 1). (b) Numerous macrophages around atheromatous core assessed with high density of anti-CD68 staining (arrows). Plaque considered unstable (Score 3). (c) Thick cellular cap assessed with high density of anti-alpha actin staining (arrows). Plaque considered stable (Score 1). (d) Collagenized cup with scanty SMCs, assessed with low density of anti-alpha actin staining (arrows). Plaque considered unstable (Score 3).

Supplementary figure 1

Clinical presentation of periodontal disease. (a) Gingivitis and (b) Periodontitis.

Supplementary figure 1

Clinical presentation of periodontal disease. (a) Gingivitis and (b) Periodontitis.

Supplementary figure 3

Demonstrative figure panel of the ultrasound evaluation of plaque stability. (a) Atherosclerotic lesion with gray scale median <25, predominantly echolucent. Plaque considered unstable. The boundaries of the plaque are depicted only on power Doppler image (marked area). (b) Atherosclerotic lesion with gray scale median >25, homogenous echogenic. Plaque considered stable.

Supplementary figure 3

Demonstrative figure panel of the ultrasound evaluation of plaque stability. (a) Atherosclerotic lesion with gray scale median <25, predominantly echolucent. Plaque considered unstable. The boundaries of the plaque are depicted only on power Doppler image (marked area). (b) Atherosclerotic lesion with gray scale median >25, homogenous echogenic. Plaque considered stable.

Supplementary figure 4

Linear regression analysis with grey scale median (GSM) score and number of remaining teeth as covariates.