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The Link Between Periodontal Disease and Cerebrovascular Accident

By

Julia Nguyen

In partial fulfillment

of the requirements for

Seattle Central College

AHE 401: Research Methods

Ms. Gina Dunn, RDH, BSDH, MSDH

June 9, 2023
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Periodontal disease and cerebral vascular accidents (CVA) are two prevalent health

concerns worldwide. Cerebral vascular accident, also known as stroke, is a leading cause of

death and disability worldwide. The classification of CVA is based on the type of blood vessel

damage that occurs in the brain, with a hemorrhagic stroke being the result of a blood vessel

rupture, while an ischemic stroke is caused by a blocked blood vessel in the brain (Donkor,

2018). Moreover, periodontal disease is an infection caused by bacteria in dental biofilm that

affects the tooth supporting structures (Rathee & Jain, 2022). Periodontal disease manifests

inflammation in these areas and could result in tooth loss and contribute to systemic

inflammation. Several risk factors have been identified for stroke including hypertension,

smoking, and diabetes. In more recent years, periodontal disease has emerged as a potential risk

factor (U.S. Department of Health and Human Services, n.d.). Several studies have suggested

there may be a link between periodontal disease and stroke. This paper explores the link between

these diseases by analyzing research articles of meta-analysis reviews and systematic reviews.

Periodontal disease, commonly known as gum disease, is a common oral health condition

that affects the periodontium: gingiva, periodontal ligament, cementum, and alveolar bone. There

are two types of periodontal disease: gingivitis and periodontitis. Dental biofilm and calculus can

initiate gingivitis, which is the milder form of periodontal disease. Gingivitis is a bacterial

infection causing an inflammation of the gums (Rathee & Jain, 2022). The bacteria trigger an

inflammatory response showing clinical signs and symptoms of redness, swelling, tenderness,

and enlarged gingiva. In periodontal charting, the numbers are often 4mm due to pseudo

pocketing, also known as a false pocket due to the enlargement of the gums. When looking at the

dental radiographs, bone loss does not occur. Therefore, gingivitis is reversible with regular

dental visits, cleanings, and adequate home care. Furthermore, periodontitis is a chronic
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inflammatory disease affects not only the gums, but the bone surrounding the teeth. This is also

caused by bacteria in dental plaque and biofilm that ultimately leads to non-reversible alveolar

bone loss and can further lead to tooth loss if not treated. According to Centers for Disease

Control and Prevention (CDC), “about one out of every two American adult or 64.7 million

American adults, aged 30 and have mild, moderate, or severe periodontitis. Moreover, in adults

65 and older, prevalence rates increased to 70.1 percent” (Hegde & Awan, 2019, para. 1). It is

important for dental health care providers to educate patients on the importance of maintaining

good oral hygiene and seeking regular dental care to prevent and manage periodontal disease.

A cerebral vascular accident (CVA), also known as a stroke, occurs when there is a

sudden cessation of blood flow to a specific region of the brain, resulting in a sudden death of

brain cells. According to the Centers for Disease Control and Prevention (CDC, 2023), stroke is

one of the leading causes of death in the US, resulting in about 130,000 fatalities each year.

About 795,000 Americans experience a stroke each year. Among these cases, approximately 87%

are ischemic strokes (Gulli & Nasser, 2020). There are two types of ischemic stroke: cerebral

thrombosis and cerebral embolism. Cerebral thrombosis occurs when a thrombus forms within

the brain itself. This usually occurs due to atherosclerosis of the brain arteries due to a buildup of

fatty deposits. On the other hand, cerebral embolisms form when a blood clot from the

circulatory system breaks free and becomes lodged in a brain or neck vessel. The conditions

atherosclerosis and hypertension are often contributing factors in these types of strokes (Gulli &

Nasser, 2020).

Inflammation can increase the risk of stroke in which certain markers of inflammation,

such as C-Reactive protein, IL-6, and lipoprotein-associated phospholipase A2, have been linked

to stroke risk. Some of these markers, including IL-6 and C-Reactive protein, are also
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biomarkers of periodontitis and can be found in the bloodstream, which may contribute to the

aggravation of stroke (Fagundes et al., 2019). The systematic review and meta-analysis of 11

studies from Fagundes et al., (2019) observed the association between stroke and periodontal

disease. According to the results of three separate meta-analyses, individuals with periodontitis

were twice as likely to experience a stroke, specifically ischemic stroke. Nevertheless, the

qualitative and quantitative results were mixed with only cohort studies showing a significant

association between stroke and periodontitis, while others had high variation among the studies.

The studies in this meta-analysis and systematic review had limitations, flaws, sampling

problems, and blinding problems, therefore, a solid conclusion in this study cannot be

established. Although there is evidence of a strong association between both diseases, more

robust studies are needed for a reliable conclusion (Fagundes et al., 2019).

In another similar study by Palm et al. (2014), targets to investigate the salivary levels of

four periodontal pathogens and local and systemic inflammatory markers in patients with acute

ischemic stroke and healthy controls. This study included 98 patients and 100 healthy controls

who were randomly selected and were matched by age, gender, dental and medical history.

Blood samples were also taken from patients, and saliva samples were taken from both patients

and controls. The results displayed higher saliva matrix metallopretinase-8 (MMP-8),

myeloperoxidase (MPO), IL-1β, A. actinomycetemcomitans, and serum LPS activity levels. This

shows current periodontal infections have a high periodontal pathogen amount, endotoxemia,

localized inflammation, and tissue destruction. In ischemic stroke patients, they had a higher

MMP-8 and MPO as well as were more often carried several periodontal pathogens in the saliva,

especially A. actinomycetemcomitans. As a result, there may be a link to chronic inflammation

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caused by periodontal disease leading to the development of systemic inflammation and stroke

(Palm et al., 2014).

In the study by Sen et al. (2018), “ Periodontal Disease, Regular Dental Care Use, and

Incident Ischemic Stroke,” studies the association between periodontal disease and incident

stroke risk. The study included 10,362 participants between 45 to 64 years old in biracial cohort

from four different US communities. The evidence from randomized controlled trials found that

intensive periodontal treatments improve “systemic inflammation, high blood pressure, improves

lipid profile, and endothelial dysfunction” (Sen et al., 2018, para. #20). Therefore, there is a link

between periodontal disease and stroke, however the treatment of periodontal disease reducing

stroke incidence has not been tested in a randomized clinical trial yet.

In a meta-analysis by Zeng et al. (2016) of 17,330 participants, the association between

periodontal disease and carotid atherosclerosis was reviewed. There were fifteen observational

studies of 17,330 participants and the overall pool resulted in that periodontal disease is

associated with atherosclerosis. Previously stated, atherosclerosis is a common contributing

factor for ischemic strokes. Therefore, there may be a link between periodontal disease and

ischemic stroke.

In conclusion, the available evidence suggests a potential association between periodontal

disease and ischemic stroke. While several studies have reported a positive link between the two,

there are limitations, flaws, and inconsistencies observed in the articles. Thus, more studies are

needed for a reliable conclusion. It is important for dental healthcare providers to understand the

link between periodontal disease and ischemic stroke to develop effective prevention, diagnosis,

and treatment strategies. By addressing the connection between oral health and systemic
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conditions like stroke, dental health care professionals can strive for better healthcare outcomes

and improve the quality of life for patients.

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References

Donkor E. S. (2018). Stroke in the 21st Century: A snapshot of the burden, epidemiology, and

quality of life. Stroke Research and Treatment, 2018, 3238165.

https://doi.org/10.1155/2018/3238165

Fagundes, N. C. F., Almeida, A. P. C. P. S. C., Vilhena, K. F. B., Magno, M. B., Maia, L. C., &

Lima, R. R. (2019). Periodontitis as a risk factor for stroke: A systematic review And

meta-analysis. Vascular Health and Risk Management, 15, 519–532.

https://doi.org/10.2147/VHRM.S204097

Gulli, L. F., & Nasser, B. (2020). Stroke. In J. L. Longe (Ed.), The Gale Encyclopedia of

Medicine (6th ed., Vol. 8, pp. 4929-4935). Gale. https://link-gale-

com.seattlecentral.idm.oclc.org/apps/doc/CX7986601805/GVRL.encylopedias?

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Hegde, R., & Awan, K. H. (2019). Effects of periodontal disease on systemic health. Disease-A

Month: DM, 65(6), 185–192. https://doi.org/10.1016/j.disamonth.2018.09.011

Marroquin, T. Y., & Guauque-Olarte, S. (2023). Integrative analysis of gene and protein

expression in atherosclerosis-related pathways modulated by periodontal pathogens.

Systematic review. The Japanese Dental Science Review, 59, 8–22.

https://doi.org/10.1016/j.jdsr.2022.12.001

Palm, F., Lahdentausta, L., Sorsa, T., Tervahartiala, T., Gokel, P., Buggle, F., Safer, A., Becher,

H., Grau, A. J., & Pussinen, P. (2014). Biomarkers of periodontitis and inflammation in

ischemic stroke: A case-control study. Innate Immunity, 20(5), 511–518.

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Rathee, M., & Jain, P. (2022, June 15). Gingivitis. StatPearls. Retrieved from

https://pubmed.ncbi.nlm.nih.gov/32491354/

Sen, S., Giamberardino, L. D., Moss, K., Morelli, T., Rosamond, W. D., Gottesman, R. F., Beck,

J., & Offenbacher, S. (2018). Periodontal disease, regular dental care use, and incident

ischemic stroke. Stroke, 49(2), 355–362. https://doi.org/10.1161/strokeaha.117.018990

U.S. Department of Health and Human Services. (n.d.). Periodontal (gum) disease. National

Institute of Dental and Craniofacial Research. Retrieved from

https://www.nidcr.nih.gov/health-info/gum-disease

https://doi.org/10.1161/STROKEAHA.117.018990

Zeng, X. T., Leng, W. D., Lam, Y. Y., Yan, B. P., Wei, X. M., Weng, H., & Kwong, J. S. (2016).

Periodontal disease and carotid atherosclerosis: A meta-analysis of 17,330

participants. International Journal of Cardiology, 203, 1044–1051.

https://doi.org/10.1016/j.ijcard.2015.11.092