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Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 40-45

Link between tooth loss, cardiovascular disease and periodontitis: A review

Department of Periodontics, VSPM Dental College and Research Centre, Nagpur, Maharashtra, India

Date of Submission26-Oct-2019
Date of Acceptance12-Dec-2019
Date of Web Publication11-Mar-2020

Correspondence Address:
Dr. Surekha Rathod
Department of Periodontics and Implantology, VSPM Dental College and Research Centre, Digdoh Hills, Hingna Road, Nagpur - 440 017, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_75_19

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It is increasingly common to hear that oral health is vital for overall health. Oral diseases may be the risk factor for many of the systemic diseases. Some of the common oral conditions include dental caries, periodontitis, and tooth loss. These conditions may have a negative effect on health. Cardiovascular diseases (CVDs) are one of the common systemic diseases. Some of the common risk factors are shared by CVDs, periodontitis, and tooth loss. Hence, the review was based on the purpose to study the link between tooth loss, periodontitis, and CVDs. The search was based on population, intervention, comparison, and outcome to decide the parameters to study the link between CVDs, periodontitis, and tooth loss for the search methodology, and relevant articles were searched from various databases such as PubMed and Google Scholar. These articles were assessed by investigators. By assessing the articles, we found that tooth loss, periodontitis, and CVDs share some risk factors and may be linked with each other. Further studies should be carried to prove this association.

Keywords: Cardiovascular diseases, periodontitis, tooth loss

How to cite this article:
Rathod S, Ghoderao D, Gonde N. Link between tooth loss, cardiovascular disease and periodontitis: A review. SRM J Res Dent Sci 2020;11:40-5

How to cite this URL:
Rathod S, Ghoderao D, Gonde N. Link between tooth loss, cardiovascular disease and periodontitis: A review. SRM J Res Dent Sci [serial online] 2020 [cited 2023 Jun 3];11:40-5. Available from:

  Introduction Top

The common chronic conditions such as dental caries and periodontal diseases which have a noteworthy effect on quality of life requires long-lasting treatment.[1] Periodontitis is one of the most common diseases which is characterized by the obliteration of connective tissue and supporting bone, resulting an inflammatory host response secondary to infection by periodontal bacteria.[2] Bacteria colonizing on surfaces of tooth, margins of gingiva, and in subgingival locations are the main causative factor for destructive periodontal diseases. The existence of bacterial strains, which are pathogenic for the periodontium and the deficient or least amount of the beneficial microorganism in a susceptible host is associated with the commencement and succession of the inflammatory and destructive periodontal lesion. There are many host factors involved in determining the individual susceptibility to periodontal diseases, as these conditions are polymicrobial and multifactorial.[3] Swelling and redness of the tissues, loss of architecture, and compromised function are the common signs and symptoms of chronic inflammation which are observed in periodontal disease. If the condition is left untreated and the inflammatory response is not balanced by the host, then the effects can be so severe that it puts the teeth at risk and tooth loss can be the ultimate outcome.[4]

Tooth loss in an individual can be considered an oral health hazard. It not only gets in the way with work activities but also has negative outcome on quality of life. Missing teeth can affect person's chewing ability, improper pronunciation, and appearance. Low confidence related to tooth loss can leads to inability of an individual to socialize and also affects the performance of work and daily activities.[5] Okoje VN et al. recognized that total loss of teeth is a serious life event.[6] The main reasons for tooth loss in adults are caries and periodontal disease. Another factors which are related with tooth loss, such as the demographic factors, socioeconomic factors, dental facilities used, since the last visit to the dentist, reason for seeking treatment, and lifestyle.[5]

It is reported in many previous studies that the higher occurrence of tooth loss is significantly associated with cardiovascular disorders.[7] Based on chronic oral infections, such as caries, periodontal diseases, and the process of tooth extraction, tooth loss has been reported to link with cardiovascular diseases (CVDs). CVDs are considered one of the major health problems in developing countries. CVDs are considered among most common medical problems in the general population. CVDs are considered an epidemic rising in developing countries, and it is expected to be a main reason of death by the year 2020.[8]

CVDs are a group of heart and vascular disorders and they include (given by the World Health Organization):

  • Coronary heart disease (CHD) – disease of the blood vessels supplying the heart muscle
  • Cerebrovascular disease – disease of the blood vessels supplying the brain
  • Peripheral arterial disease – disease of blood vessels delivering to the arms and legs
  • Rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever produced by streptococcal bacteria
  • Congenital heart disease – deformities of heart structure present at birth
  • Deep-vein thrombosis and pulmonary embolism – blood clots in the veins of the leg that may be dislodge and transfers to the heart and lungs.

Bokhari SA et al. stated that the number of teeth loss is directly proportional to the extent of severe periodontal disease which is associated with the increased risk CHD.[8] One of the possible cause is that tooth loss can cause dietary changes and other behavioral changes, which ultimately increases the risk for CVDs.[9] Previous studies have also found relations among the tooth loss and carotid and aortic intima-media thickness and also aortic valve sclerosis. In an additional study, tooth loss was linked with inflammatory markers and stroke.[10]

Numerous possible pathways for the relationship between periodontal disease and CVD have been put forward.[11] The upregulation and release of inflammatory cytokines in immune response and inflammatory cascade exert their effect on the local tissues. Mediators of inflammation such as nuclear factor-kappa B, interleukin (IL)-1, tumor necrosis factor-alpha, matrix metalloproteinases (MMPs), C-reactive protein, IL-6, and interferon-gamma are found to be significant. The cellular sources of these inflammatory mediators are almost same in periodontal disease and CVD. In both diseases, these inflammatory mediators are released by monocytes/macrophages, lymphocytes, polymorphonuclear leukocytes, mast cells, fibroblasts, and endothelial cells. In periodontal disease, inflammatory mediators are released by epithelial cells and osteoblasts, whereas in CVD, these mediators are produced by smooth muscle cells. Connective tissue degradation, especially, destruction of collagen is the main characteristics of periodontal and CVDs. The prime enzyme that causes collagen breakdown is MMPs. These enzymes in periodontitis lead to the obliteration of the periodontal connective tissue, which eventually causes tooth loss. Similarly, these enzymes also degrade the fibrous cap in atherosclerosis, which can leads to myocardial infarction.[12]

In CVDs, matrix metalloproteinases may lead to the destabilization of atheromas, heart failure and also causes destructive changes in extracellular matrix in the myocardium. The inhibition of MMPs revealed to be efficient for the reduction of periodontal attachment loss and can also decreases the risk of the development of cardiac failure. Another mechanism that could relate the periodontal and CVDs is that the Streptococcus sanguis may contribute directly to platelet aggregation and the thrombi formation, which may be part of the cause of acute myocardial infarct. Some of the studies have shown that the occurrence of a combined antibody response to Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans has been associated with CHD.[12] Pussinen et al. observed that the host response contrary to periodontal infection might play a part in the pathogenesis of CHD.[13] Genetic susceptibility to inflammation systemically can exhibit increased oral inflammation in the form of gingivitis or periodontal disease along with increased risk of CVD.[11]

The two groups of diseases that is periodontitis and CVD share many risk factors.[12] Therefore, our review attempts to evaluate the relationship between the CVDs and tooth loss.

  Materials and Methods Top

A schematic search was conducted to obtain appropriate articles for critical appraisal. Population, intervention, comparison, outcome (PICO) was determined to appropriately decide the parameters to check the effect of CVDs on tooth loss for the search methodology, and relevant articles were searched from various databases such as PubMed and Google Scholar. Then, the searches from the various databases were combined, and duplicate articles were subsequently removed. By examining the bibliographies of retrieved articles, additional articles were identified and using the inclusion and exclusion, the titles of the retrieved articles were read independently by three authors. Articles were eliminated if two of the three authors deemed, it was inappropriate for inclusion. Finally, at the full-text stage, two investigators read and assessed each of the articles based on the criteria used in previous stages [Flow Chart 1].


  • PubMed
  • Google Scholar
  • Hand research of reference list of archived articles.

Search methodology

Search methodology was based on PICO [Table 1].
Table 1: Search methodology (population, intervention, comparison, and outcome)

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  • The searches from the various database were combined and duplicate articles subsequently removed
  • By examining the bibliographies of retrieved articles, additional articles were identified.

Inclusion criteria

  • In vivo study
  • English
  • Human studies
  • Studies with CVDs, tooth loss, and periodontal diseases
  • Studies between 2000 and 2016 were included in the study.

Exclusion criteria

The exclusion criteria are as follows:

  • In vitro studies
  • Nonhuman studies
  • Non-English
  • Case reports
  • Case series
  • Retrospective studies
  • Animal studies and review.

The included studies are summarized in [Table 2]. Studies evaluated periodontal parameters are summarized in [Table 3]. Methods of evaluation of tooth loss are given in [Table 4].
Table 2: Characteristics of the included studies

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Table 3: Studies evaluated periodontal parameters

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Table 4: Studies evaluated tooth loss

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  Discussion Top

In this review, we found some of the studies which investigated about the relationship between CVDs, tooth loss, and periodontitis. Watt et al. noted that edentate participants had 2.97 times increased risk of mortality associated with stroke.[1]

A study by Bokhari et al. in 2012 found a positive relation between tooth loss and CHD. Elter et al. in 2004 found that individuals with both high attachment loss and high tooth loss had increased prevalence of CHDs compared to individuals with low attachment loss and tooth loss.[9] Gomes et al. observed that self-reported oral hygiene status and also the number of teeth were independently linked to coronary atherosclerotic burden.[10] Pussinen et al. evaluated the association of CHD and serology of periodontitis. They found that missing teeth and serum antibodies to major periodontal pathogens were correlated with CHDs, suggesting that periodontal infection or response of the host's response to the infection could be responsible for the pathogenesis of CHDs.[13]

Joshipura et al. conducted a study to evaluate the periodontal disease and tooth loss as a risk factor for ischemic stroke. They found that periodontal disease and less number of teeth might be associated with a higher risk of stroke.[16] Another study by Willershausen et al. noted that within the CHDs group, the periodontal chart showed a mean probing depth of 3.4 ± 1.1 mm for all examined teeth, describing the relationship between an existing CHD and the presence of periodontitis.[17]

In a survey involving 41,891 adults aged 40–79 years old, it was found that there was a strong association between the degree of tooth loss and the incidence of heart disease. Participants who had a few missing teeth or edentulous were significantly more likely to have heart disease than those without tooth loss.[18] Bahekar et al. conducted meta-analysis in 2007, and they found that the risk of developing CHDs was 1.14 times higher for individuals with periodontal disease. It was also found that both the prevalence and incidence of developing CHDs are noticeably increased in periodontal diseases.[19]

Choe et al. found that a graded association between higher tooth loss and higher risk of total stroke was observed in men and women in a multivariable model that accounted for selected covariates.[20] In a questionnaire study done by Senba et al. observed that there was a significant association in between the loss of 5 or more teeth and history of CHD.[21]

Asai et al. observed in 2015 that there was a linear relationship exists between tooth loss and degree of arterial stiffness in 8124 participants who undergone comprehensive dental investigation and extensive in-person assessments of CVD risk factors, the and that the association varied depending on sex.[22]

Some studies showed that there is no relation among these conditions. Zanella et al., in 2016, found that periodontal disease was not related to CHD which was evaluated by angiography, whereas tooth loss was found to be a risk factor for CHD.[2] In contrast, a study done by Hujoel et al. in 2000 observed that there is no association between periodontal disease and CHD. Another study by Malthaner et al., in 2002, found that there is no significant relation between periodontitis and coronary artery disease.[14],[15]

  Conclusion Top

This study concluded that there is a relationship between CVDs, periodontal diseases, and tooth loss. Included studies in our review suggested a positive correlation between heart diseases and oral conditions. As these conditions are prevalent in the general population and public health concern, further studies should be carried out in future [23].

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Watt RG, Tsakos G, de Oliveira C, Hamer M. Tooth loss and cardiovascular disease mortality risk – Results from the Scottish Health Survey. PLoS One 2012;7:e30797.  Back to cited text no. 1
AlJehani YA. Risk factors of periodontal disease: review of the literature. Int J Dent. 2014;2014:182513.  Back to cited text no. 2
Popova C, Panova VD, Panov V. Microbiology of periodontal diseases. Biotechnol Biotechnol Equip 2013;27:3754-9.  Back to cited text no. 3
Shewale AH, Gattani DR, Bhatia N, Mahajan R, Saravanan SP. Prevalence of periodontal disease in the general population of india-a systematic review. J Clin Diagn Res 2016;10:ZE04-9.  Back to cited text no. 4
Batista MJ, Rihs LB, Sousa Mda L. Risk indicators for tooth loss in adult workers. Braz Oral Res 2012;26:390-6.  Back to cited text no. 5
Okoje VN, Dosumu OO, Alonge TO, Onyeaso C. Tooth loss: Are the patients prepared? Niger J Clin Pract 2012;15:172-5.  Back to cited text no. 6
  [Full text]  
Dhadse P, Gattani D, Mishra R. The link between periodontal disease and cardiovascular disease: How far we have come in last two decades? J Indian Soc Periodontol 2010;14:148-54.  Back to cited text no. 7
  [Full text]  
Bokhari SA, Khan AA, Khalil M, Abubakar MM, Rehaman MU, Azhar M. Oral health status of CHD and non-CHD adults of Lahore, Pakistan. J Indian Soc Periodontol 2011;15:51-4.  Back to cited text no. 8
[PUBMED]  [Full text]  
Elter JR, Champagne CM, Offenbacher S, Beck JD. Relationship of periodontal disease and tooth loss to prevalence of coronary heart disease. J Periodontol 2004;75:782-90.  Back to cited text no. 9
Gomes MS, Chagas P, Padilha DM, Caramori P, Hugo FN, Schwanke CH, et al. Association between self-reported oral health, tooth loss and atherosclerotic burden. Braz Oral Res 2012;26:436-42.  Back to cited text no. 10
Joshipura K, Zevallos JC, Ritchie CS. Strength of evidence relating periodontal disease and atherosclerotic disease. Compend Contin Educ Dent 2009;30:430-9.  Back to cited text no. 11
Second in a Series of Research Articles Delivered at the RCDSO Symposium, Oral Health: A Window To Systemic Disease; 2005.   Back to cited text no. 12
Pussinen PJ, Jousilahti P, Alfthan G, Palosuo T, Asikainen S, Salomaa V. Antibodies to periodontal pathogens are associated with coronary heart disease. Arterioscler Thromb Vasc Biol 2003;23:1250-4.  Back to cited text no. 13
Hujoel PP, Drangsholt M, Spiekerman C, DeRouen TA. Periodontal disease and coronary heart disease risk. JAMA 2000;284:1406-10.  Back to cited text no. 14
Malthaner SC, Moore S, Mills M, Saad R, Sabatini R, Takacs V, et al. Investigation of the association between angiographically defined coronary artery disease and periodontal disease. J Periodontol 2002;73:1169-76.  Back to cited text no. 15
Joshipura KJ, Hung HC, Rimm EB, Willett WC, Ascherio A. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 2003;34:47-52.  Back to cited text no. 16
Willershausen B, Krahwinkel T, Valentinis L, Todt M. Correlation between inflammatory periodontal diseases and cardiovascular diseases. Eur J Med Res 2003;8:499-504.  Back to cited text no. 17
Okoro CA, Balluz LS, Eke PI, Ajani UA, Strine TW, Town M, et al. Tooth loss and heart disease: Findings from the behavioral risk factor surveillance system. Am J Prev Med 2005;29:50-6.  Back to cited text no. 18
Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: A meta-analysis. Am Heart J 2007;154:830-7.  Back to cited text no. 19
Choe H, Kim YH, Park JW, Kim SY, Lee SY, Jee SH. Tooth loss, hypertension and risk for stroke in a Korean population. Atherosclerosis 2009;203:550-6.  Back to cited text no. 20
Senba T, Kobayashi Y, Inoue K, Kaneto C, Inoue M, Toyokawa S, et al. The association between self-reported periodontitis and coronary heart disease – From MY health up study. J Occup Health 2008;50:283-7.  Back to cited text no. 21
Asai K, Yamori M, Yamazaki T, Yamaguchi A, Takahashi K, Sekine A, et al. Tooth loss and atherosclerosis: The Nagahama Study. J Dent Res 2015;94:52S-8.  Back to cited text no. 22
Zanella SM, Pereira SS, Barbisan JN, Vieira L, Saba-Chujfi E, Haas AN, et al. Periodontal disease, tooth loss and coronary heart disease assessed by coronary angiography: A cross-sectional observational study. J Periodontal Res 2016;51:221-7.  Back to cited text no. 23


  [Table 1], [Table 2], [Table 3], [Table 4]


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