Intended for healthcare professionals


Periodontal disease and poor health outcomes

BMJ 2010; 340 doi: (Published 17 June 2010) Cite this as: BMJ 2010;340:c2735
  1. Peter N Galgut, clinical periodontist
  1. 1Lotus Clinic, London NW11 7PE
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    Clinicians must recognise the risks and refer patients for periodontal care

    Periodontal diseases are localised gingival infections that affect most adults at some time in their lives. They are broadly divided into two groups. Gingivitis is related to dental plaque and manifests as superficial redness, swelling, and bleeding of the gums. Periodontitis occurs when the infection spreads into the deeper tissues surrounding the roots of the teeth, and it causes breakdown of the gingival tissues and alveolar bone resorption.

    Evidence shows that periodontal diseases can have systemic effects.1 2 3 Oral infection can result in the formation of sites that favour colonisation by blood borne microbes—a locus minoris resistentiae. A well known example of this phenomenon is heart valves that are damaged by rheumatic fever, which are more susceptible to bacterial infection from blood borne bacteria.

    In the linked survey (doi:10.1136/bmj.c2451), de Oliveira and colleagues report that poor oral hygiene (measured by self reported toothbrushing) is associated with a higher risk of cardiovascular disease (hazard ratio 1.7, 95% confidence interval 1.3 to 2.3) and low grade inflammation (C reactive protein and fibrinogen).1 A prospective cohort study of 9760 people who participated in the National Health and Nutrition Examination Surveys (NHANES I and III) found that people with active periodontitis had a significantly higher risk of coronary heart disease (adjusted relative risk 1.25, 96% confidence interval 1.06 to 1.48).4 In men under 50 years at baseline, the risk of dying from coronary heart disease was even higher (1.72, 1.10 to 2.68).4 Periodontitis and poor oral hygiene were associated with total mortality more than with coronary heart disease itself. Similar results were reported in the Health Professionals Follow-up Study,2 5 and in a recent meta-analysis of observational studies.6 Other studies report that cardiovascular disease is the most commonly found systemic condition in people with periodontitis.3

    The nature and direction of the association is unclear because periodontitis and cardiovascular disease share similar risk factors. However, it is now accepted that periodontitis has effects beyond the oral cavity, and its treatment and prevention may contribute to the prevention of vascular diseases such as atherosclerosis.7

    Periodontal diseases are also associated with other systemic diseases including rheumatoid arthritis,7 8 9 glomerulonephritis, inflammatory bowel disease,8 diabetes, and obesity.3 7 8 Septic pulmonary emboli involving Streptococcus intermedius and Actinobacillus actinomyctemcomitans from periodontal lesions have been found in infective endocarditis and brain abscesses.2

    Mothers with a history of preterm delivery and low birthweight babies have worse periodontal disease than mothers with normal sized, full term babies, even after adjustment for confounding factors such as age, smoking, drug use, nutrition, and systemic disease.2 10 11 It seems that a combination of high levels of periodontal pathogens and a low maternal IgG antibody response to periodontal bacteria during pregnancy is associated with an increased risk of preterm delivery.11 12

    What are the implications for what clinicians should do in practice? A key shared risk factor in cardiovascular disease and periodontal disease is smoking. Smokers are six to seven times more likely to have alveolar bone loss and three to five times more likely to have severe periodontal disease than non-smokers.2 3 Consequently, doctors should explain the risks of smoking for both diseases and encourage and support their patients to stop.

    Young adults with premature and multiple loss of teeth and patients with systemic diseases who are resistant to medical treatment warrant particular attention. They should be referred for periodontal assessment and treatment to eliminate oral foci of infection that may be adversely affecting treatment.

    In addition, it has been suggested that eliminating active infection from the oral cavity before surgical procedures, especially prosthetic surgery, may help prevent postoperative infection.


    Cite this as: BMJ 2010;340:c2735


    • Research, doi:10.1136/bmj.c2451
    • Competing interests: The author has completed the Unified Competing Interest form at (available on request from the corresponding author) and declares: (1) No financial support for the submitted work from anyone other than his employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouse, partner, or children with relationships with commercial entities that might have an interest in the submitted work; (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Not commissioned; externally peer reviewed.