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. 2021 Dec 12;12(12):CD009409.
doi: 10.1002/14651858.CD009409.pub2.

Effect of periodontal treatments on blood pressure

Yuxue Luo  1 , Huilin Ye  1 , Wei Liu  1 , Zongkai Lv  2 , Yuanyuan Jia  3 , Chunjie Li  4 , Yifan Zhang  5
Affiliations

Effect of periodontal treatments on blood pressure

Yuxue Luo et al. Cochrane Database Syst Rev. .

Abstract
in English, Persian

Background: An association has been hypothesized between periodontitis and hypertension. Periodontal therapy is believed to reduce systemic inflammatory mediators and increase endothelial function, thus having the potential to prevent and treat hypertension.

Objectives: To assess the effect and safety of different periodontal treatment modalities on blood pressure (BP) in people with chronic periodontitis.

Search methods: The Cochrane Hypertension Information Specialist searched for randomized controlled trials (RCTs) up to November 2020 in the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, seven other databases, and two clinical trials registries. We contacted the authors of relevant papers regarding further published and unpublished work.

Selection criteria: RCTs and quasi-RCTs aiming to detect the effect of periodontal treatment on BP were eligible. Participants should have been diagnosed with chronic periodontitis and hypertension (or no hypertension if the study explored the preventive effect of periodontal treatment). Participants in the intervention group should have undergone subgingival scaling and root planing (SRP) and any other type of periodontal treatments, compared with either no periodontal treatment or alternative periodontal treatment in the control group.

Data collection and analysis: We used standard methodological procedures expected by Cochrane for study identification, data extraction, and risk of bias assessment. We used a formal pilot-tested data extraction form for data extraction, and the Cochrane risk of bias tool for risk of bias assessment. We planned the meta-analysis, test for heterogeneity, sensitivity analysis, and subgroup analysis. We assessed the certainty of evidence using GRADE. The primary outcome was change in systolic BP (SBP) and diastolic BP (DBP).

Main results: We included eight RCTs. Five had low risk of bias, one had unclear risk of bias, and two had high risk of bias. Four trials compared periodontal treatment with no treatment. We found no evidence of a difference in the short-term change of SBP and DBP for people diagnosed with periodontitis and other cardiovascular diseases except hypertension (very low-certainty evidence). We found no evidence of a difference in long-term changes in SBP (mean difference [MD] -2.25 mmHg, 95% confidence interval [CI] -9.41 to 4.92; P = 0.54; studies = 2, participants = 108; low-certainty evidence) and DBP (MD -2.55 mmHg, 95% CI -6.90 to 1.80; P = 0.25; studies = 2, participants = 103; low-certainty evidence). Concerning people diagnosed with periodontitis, in the short term, two studies of low certainty reported no changes in SBP (MD -0.14 mmHg, 95% CI -4.05 to 3.77; P = 0.94; participants = 294) and DBP (MD -0.15 mmHg, 95% CI -2.47 to 2.17; P = 0.90; participants = 294), and we found no evidence of a difference in SBP and DBP over a long period based on low certainty of evidence. Three studies compared intensive periodontal treatment with supra-gingival scaling. We found no evidence of a difference in changes in SBP and DBP for any length of time in people diagnosed with periodontitis (very low-certainty evidence). In people diagnosed with periodontitis and hypertension, we found one study reporting a significant reduction in the short term in SBP (MD -11.20 mmHg, 95% CI -15.40 to -7.00; P < 0.001; participants = 101; moderate-certainty evidence) and DBP (MD -8.40 mmHg, 95% CI -12.19 to -4.61; P < 0.0001; participants = 101; moderate-certainty evidence).

Authors' conclusions: We found no evidence of a difference of an impact of periodontal treatments on BP in most comparisons assessed in this review, and given the low certainty of evidence and the lack of relevant studies we could not draw conclusions about the effect of periodontal treatment on BP in people with chronic periodontitis. We found only one study suggesting that periodontal treatment may reduce SBP and DBP over a short period in people with hypertension and chronic periodontitis, but the certainty of evidence was moderate.

پیشینه: تصور می‌شود ارتباطی بین پریودونتیت (periodontitis) و هیپرتانسیون وجود دارد. اعتقاد بر این است که درمان پریودونتال واسطه‌های التهابی سیستمیک را کاهش داده و عملکرد اندوتلیال را افزایش می‌دهد، بنابراین پتانسیل پیشگیری و درمان هیپرتانسیون را دارد. اهداف: ارزیابی تاثیر و بی‌خطری (safety) روش‌های مختلف درمان پریودونتال بر فشار خون (BP) در افراد مبتلا به پریودونتیت مزمن. روش‌های جست‌وجو: متخصص اطلاعات گروه هیپرتانسیون در کاکرین تا نوامبر 2020 به دنبال کارآزمایی‌های تصادفی‌سازی و کنترل شده (randomised controlled trials; RCTs) در پایگاه ثبت تخصصی گروه هیپرتانسیون در کاکرین، CENTRAL؛ MEDLINE؛ Embase؛ هفت بانک اطلاعاتی دیگر، و دو پایگاه ثبت کارآزمایی‌های بالینی جست‌وجو کرد. در رابطه با کارهای منتشر شده و منتشر نشده با نویسندگان مقالات مرتبط تماس گرفتیم. معیارهای انتخاب: RCTها و شبه‐RCTهایی واجد شرایط بودند که هدف آنها شناسایی تاثیر درمان پریودونتال بر BP بود. شرکت‌کنندگان باید مبتلا به پریودونتیت مزمن و هیپرتانسیون (یا بدون هیپرتانسیون، اگر مطالعه مذکور تاثیر پیشگیرانه درمان پریودونتال را بررسی کرد) بودند. شرکت‌کنندگان در گروه مداخله باید تحت جرم‌گیری زیر لثه و پلانینگ ریشه (subgingival scaling and root planing; SRP) و هر نوع دیگری از درمان پریودونتال قرار گرفته، و با عدم درمان پریودونتال یا درمان جایگزین پریودونتال در گروه کنترل مقایسه شده باشند. گردآوری و تجزیه‌وتحلیل داده‌ها: از روش‌های استاندارد روش‌شناسی مورد انتظار کاکرین برای شناسایی مطالعات، استخراج داده‌ها، و ارزیابی خطر سوگیری (bias) استفاده کردیم. از یک فرم رسمی استخراج اطلاعات که به صورت پایلوت تست شد، برای استخراج داده‌ها و از ابزار خطر سوگیری کاکرین برای ارزیابی خطر سوگیری استفاده شد. برای انجام متاآنالیز، تست ناهمگونی، آنالیز حساسیت، و تجزیه‌وتحلیل زیر‐گروه، برنامه‌ریزی کردیم. قطعیت شواهد را با استفاده از رویکرد درجه‌‏بندی توصیه‏، ارزیابی، توسعه و ارزشیابی (GRADE) ارزیابی کردیم. پیامد اولیه، تغییر در BP سیستولیک (SBP) و BP دیاستولیک (DBP) بود. نتایج اصلی: هشت RCT وارد شدند. پنج کارآزمایی با خطر پائین سوگیری، یک کارآزمایی با خطر نامشخص سوگیری، و دو کارآزمایی با خطر بالای سوگیری روبه‌رو بودند. چهار مطالعه، درمان پریودونتال را با عدم درمان مقایسه کردند. هیچ شواهدی را مبنی بر تفاوت در تغییر کوتاه‐مدت SBP و DBP برای افراد مبتلا به پریودونتیت و دیگر بیماری‌های قلبی عروقی، به جز هیپرتانسیون (شواهد با قطعیت بسیار پائین)، پیدا نکردیم. هیچ شواهدی را دال بر تفاوت در تغییرات طولانی‐مدت در SBP (تفاوت میانگین (MD): 2.25‐ میلی‌متر جیوه، 95% فاصله اطمینان (CI): 9.41‐ تا 4.92؛ P = 0.54؛ مطالعات = 2، شرکت‌کنندگان = 108؛ شواهد با قطعیت پائین) و DBP (MD؛ 2.55‐ میلی‌متر جیوه؛ 95% CI؛ 6.90‐ تا 1.80؛ P = 0.25؛ مطالعات = 2، شرکت‌کنندگان = 103؛ شواهد با قطعیت پائین) نیافتیم. در مورد افراد مبتلا به پریودونتیت، در کوتاه‐مدت، دو مطالعه با قطعیت پائین هیچ تغییری را در SBP (MD؛ 0.14‐ میلی‌متر جیوه؛ 95% CI؛ 4.05‐ تا 3.77؛ P = 0.94؛ شرکت‌کنندگان = 294) و DBP (MD؛ 0.15‐ میلی‌متر جیوه؛ 95% CI؛ 2.47‐ تا 2.17؛ P = 0.90؛ شرکت‌کنندگان = 294) گزارش نکردند، و هیچ شواهدی را مبنی بر تفاوت در SBP و DBP در یک دوره طولانی بر اساس شواهدی با قطعیت پائین پیدا نکردیم. سه مطالعه درمان فشرده پریودونتال را با جرم‌‌گیری بالای لثه مقایسه کردند. هیچ شواهدی را مبنی بر وجود تفاوت در تغییرات SBP و DBP برای هر مدت زمانی در افراد مبتلا به پریودونتیت (شواهد با قطعیت بسیار پائین) پیدا نکردیم. در افراد مبتلا به پریودونتیت و هیپرتانسیون، مطالعه‌ای را یافتیم که کاهش قابل توجهی را در کوتاه‐مدت در SBP (MD؛ 11.20‐ میلی‌متر جیوه؛ 95% CI؛ 15.40‐ تا 7.00‐؛ P < 0.001؛ شرکت‌کنندگان = 101؛ شواهد با قطعیت متوسط) و DBP (MD؛ 8.40‐ میلی‌متر جیوه؛ 95% CI؛ 12.19‐ تا 4.61‐؛ P < 0.0001؛ شرکت‌کنندگان = 101؛ شواهد با قطعیت متوسط) گزارش کرد. نتیجه‌گیری‌های نویسندگان: ما هیچ شواهدی را مبنی بر تفاوت در تاثیر درمان‌های پریودونتال بر BP در اکثر مقایسه‌های ارزیابی‌ شده در این مرور پیدا نکردیم، و با توجه به قطعیت پائین شواهد و فقدان مطالعات مرتبط در این زمینه، نتوانستیم در مورد تاثیر درمان پریودونتال بر BP در افراد مبتلا به پریودونتیت مزمن نتیجه‌گیری کنیم. فقط یک مطالعه را پیدا کردیم که نشان می‌دهد درمان پریودونتال ممکن است SBP و DBP را در مدت کوتاهی در افراد مبتلا به هیپرتانسیون و پریودونتیت مزمن کاهش دهد، اما قطعیت شواهد در حد متوسط بود.

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Conflict of interest statement

LY: nothing to declare.

YH: nothing to declare.

LW: nothing to declare.

LZL: nothing to declare.

JY: nothing to declare.

LC: nothing to declare.

ZY: nothing to declare.

Figures

1
1
Flow diagram of study inclusion. RCT: randomized controlled trial.
2
2
Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 1: Short‐term change of systolic blood pressure (mmHg)
1.2
1.2. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 2: Long‐term change of systolic blood pressure (mmHg)
1.3
1.3. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 3: Short‐term change of diastolic blood pressure (mmHg)
1.4
1.4. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 4: Long‐term change of diastolic blood pressure (mmHg)
1.5
1.5. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 5: Long‐term change of heart rate (beats per minute)
1.6
1.6. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 6: Short‐term change of high‐sensitivity C‐reactive protein (hs‐CRP) (mg/L)
1.7
1.7. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 7: Long‐term change of hs‐CRP (mg/L)
1.8
1.8. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 8: Short‐term change of interleukin (IL)‐6 (pg/mL)
1.9
1.9. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 9: Long‐term change of IL‐6 (pg/mL)
1.10
1.10. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 10: Long‐term change of forearm blood flow (FBF) (mL/(min 100 mL tissue))
1.11
1.11. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 11: Short‐term change of pocket probing depth (PPD) (mm)
1.12
1.12. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 12: Long‐term change of PPD (mm)
1.13
1.13. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 13: Short‐term change of clinical attachment level (CAL) (mm)
1.14
1.14. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 14: Long‐term change of CAL (mm)
1.15
1.15. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 15: Short‐term change of bleeding on probing (BOP) (%)
1.16
1.16. Analysis
Comparison 1: Periodontal treatment versus no treatment, Outcome 16: Long‐term change of BOP (%)
2.1
2.1. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 1: Short‐term change of systolic blood pressure (mmHg)
2.2
2.2. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 2: Long‐term change of systolic blood pressure (mmHg)
2.3
2.3. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 3: Short‐term change of diastolic blood pressure (mmHg)
2.4
2.4. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 4: Long‐term change of diastolic blood pressure (mmHg)
2.5
2.5. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 5: Short‐term change of high‐sensitivity C‐reactive protein (hs‐CRP) (mg/L)
2.6
2.6. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 6: Long‐term change of hs‐CRP (mg/L)
2.7
2.7. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 7: Short‐term change of interleukin (IL)‐6 (pg/mL)
2.8
2.8. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 8: Long‐term change of IL‐6 (pg/mL)
2.9
2.9. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 9: Short‐term change of endothelial microparticles (EMPs) (μL)
2.10
2.10. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 10: Long‐term change of EMPs (μL)
2.11
2.11. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 11: Short‐term change of flow‐mediated dilation (%)
2.12
2.12. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 12: Long‐term change of flow‐mediated dilation (%)
2.13
2.13. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 13: Short‐term change of pocket probing depth (PPD) (mm)
2.14
2.14. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 14: Long‐term change of PPD (mm)
2.15
2.15. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 15: Short‐term change of clinical attachment level (CAL) (mm)
2.16
2.16. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 16: Long‐term change of CAL (mm)
2.17
2.17. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 17: Short‐term change of bleeding on probing (BOP) (%)
2.18
2.18. Analysis
Comparison 2: Periodontal treatment versus supra‐gingival scaling, Outcome 18: Long‐term change of BOP (%)
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References

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PAVE 2008 {published data only}
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    1. Couper DJ, Beck JD, Falkner KL, Graham SP, Grossi SG, Gunsolley JC, et al. The Periodontitis and Vascular Events (PAVE) pilot study: recruitment, retention, and community care controls. Journal of Periodontology 2008;79(1):80-9. - PubMed
    1. Offenbacher S, Beck JD, Moss K, Mendoza L, Paquette DW, Barrow DA, et al. Results from the Periodontitis and Vascular Events (PAVE) study: a pilot multicentered, randomized, controlled trial to study effects of periodontal therapy in a secondary prevention model of cardiovascular disease. Journal of Periodontology 2009;80(2):190-201. - PMC - PubMed
    1. Dyke TE, Maupome G, Madden T, Grossi S, Gunsolley JC, Offenbacher S, et al. Periodontal Intervention for Cardiac Events: a pilot trial [Periodontitis and Cardiovascular Events or "PAVE"]. clinicaltrials.gov/ct2/show/NCT00066053 (first received 5 August 2003).
Perio‐Hyperten 2016 {published data only}
    1. NCT03122990. Acute-phase response & periodontal treatment in patients with hypertension (Perio-Hyperten). clinicaltrials.gov/ct2/show/NCT03122990 (first received 21 April 2017). [clinicaltrials.gov/show/nct03122990]
Ramírez 2011 {published data only}
    1. Jaramillo A, Contreras A, Ramirez JH. Periodontal Infection and Endothelial Dysfunction. www.clinicaltrials.gov/ct2/show/NCT00681564 (first received 21 May 2008).
    1. Ramírez JH, Arce RM, Contreras A. Periodontal treatment effects on endothelial function and cardiovascular disease biomarkers in subjects with chronic periodontitis: protocol for a randomized clinical trial. Trials 2011;12:46. [DOI: 10.1186/1745-6215-12-46] - DOI - PMC - PubMed
Torumtay 2016 {published data only}
    1. Torumtay G, Kırzıoglu FY, Ozturk Tonguc M, Kale B, Calapoglu M, Orhan H. Effects of periodontal treatment on inflammation and oxidative stress markers in patients with metabolic syndrome. Journal of Periodontal Research 2016;51(4):489-98. - PubMed
Tüter 2007 {published data only}
    1. Tüter G, Kurtiş B, Serdar M, Aykan T, Okyay K, Yücel A, et al. Effects of scaling and root planing and sub-antimicrobial dose doxycycline on oral and systemic biomarkers of disease in patients with both chronic periodontitis and coronary artery disease. Journal of Clinical Periodontology 2007;34(8):673-81. - PubMed
Tüter 2010 {published data only}
    1. Tüter G, Serdar M, Kurtiş B, Walker SG, Atak A, Toyman U, et al. Effects of scaling and root planing and subantimicrobial dose doxycycline on gingival crevicular fluid levels of matrix metalloproteinase-8, -13 and serum levels of HsCRP in patients with chronic periodontitis. Journal of Periodontology 2010;81(8):1132-9. - PubMed
Ushida 2008 {published data only}
    1. Koshy G, Kawashima Y, Kiji M, Nitta H, Umeda M, Nagasawa T, et al. Effects of single-visit full-mouth ultrasonic debridement versus quadrant-wise ultrasonic debridement. Journal of Clinical Periodontology 2005;32(7):734-43. - PubMed
    1. Ushida Y, Koshy G, Kawashima Y, Kiji M, Umeda M, Nitta H, et al. Changes in serum interleukin-6, C-reactive protein and thrombomodulin levels under periodontal ultrasonic debridement. Journal of Clinical Periodontology 2008;35(11):969-75. - PubMed

References to studies awaiting assessment

Vidal 2009 {published data only}
    1. Vidal F, Figueredo CM, Cordovil I, Fischer RG. Periodontal therapy reduces plasma levels of interleukin-6, C-reactive protein, and fibrinogen in patients with severe periodontitis and refractory arterial hypertension. Journal of Periodontology 2009;80(5):786-91. - PubMed

References to ongoing studies

PERIOTENSION 2020 {published data only}
    1. Periodontal management in hypertensive patients (PERIOTENSION trial I). clinicaltrials.gov/show/NCT04328389 (first received 31 March 2020). [clinicaltrials.gov/show/NCT04328389]

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References to other published versions of this review

Li 2011
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Publication types