non-surgical periodontal therapy reduces coronary heart disease risk markers: a randomized...

Non-Surgical Periodontal Therapy Reduces

Coronary Heart Disease Risk Markers: A Randomized

Controlled TrialBokhari SAH, Khan AA, Butt AK, Azhar M,

Hanif M, Izhar M, Tatakis DNJournal of Clinical Periodontology 2012

Periodontal Disease is a chronic inflammatory and infectious disease

Systematic Reviews and Meta-analysis have provided evidence for an association of Periodontal disease and CHD and PD has been found to be associated with higher risk of CHD

Background

• PD also induces production of proinflammatory cytokines and acute-phase proteins. A positive association between CRP, fibrinogen levels, and peripheral leukocyte count with periodontitis has been documented by various studies

Background

This link of PD and Systemic Inflammatory markers is further strengthened by intervention studies where PT has shown reduction in inflammatory markers associated with CHD risk

Background

Investigate the effect of conventional, mechanical, non-surgical periodontal treatment on serum levels of hsCRP, fibrinogen and white blood cells in CHD patients with periodontitis.

Aim of study

Observe changes in clinical periodontal parameters of BOP, PPD, and CAL and Serum levels of hsCRP, Fibrinogen and WBCs following Periodontal therapy

Compare these changes to corresponding levels in periodontally untreated CHD patients

Determine the effect of PT on the reduction of CHD risk marker

Objectives of study

Study Design

A single-blind, parallel-arm, Randomized

Controlled Intervention Trial

Subjects

Angiographically confirmed CHD patients

with moderate to severe periodontitis

CHD was defined as having >50% stenosis of ≥1 coronary arteryOral /Periodontal Status was defined as ≥ 14 periodontally evaluable natural teeth > 20% of sites BOP+ ≥ 4 teeth with ≥ 1 site with PPD ≥ 4

mm and CAL ≥ 3 mm at same site

Exclusion Criteria

Diseases or conditions affecting or

potentially confounding

Periodontal status or systemic

Inflammatory Biomarker levels

Sample Size

Based on primary endpoint (serum CRP), Sample Size was calculated for 317 CHD patients with periodontitis to be randomized into intervention and control group at 2:1 ratio with 90% power to detect significant difference between groups.

Based on the observations of our pilot study

1. Reduction in BOP sites to ≤20%

2. Reduction in Sites with PPD ≥ 4 mm

by 50%

3. Reduction in Serum inflammatory

marker levels by 20%

Level of Achievement after Periodontal

Treatment

All CHD Subjects were on cardiac medications that includedAntiplatelets, betablockers, ARBs, ACE inhibitors, calcium channel antagonists, statins, diuretics and nitrates. Subjects were monitored for change in status of medications during follow-up visits

Cardiac medications

RESULTS

Based on 317 recruited subjects ITT Analysis was carried outA comparison of Intervention and Control groups at baseline revealed NO Significant Differences with respect to •Demographic and Medical parameters •Periodontal and systemic Inflammatory variables

Changes in Periodontal Parameters

E1, E2, E3 indicate 1st, 2nd , and 3rd Examination stages

a.

cb

a

****P>0.05

0

510

1520

25

3035

4045

50

E1 E2 E3

BO

P (

perc

en

tag

e)

Intervention group Control groupn=212 n=105

E1 and E3 indicate 1st and 3rd Examination Stages

Changes in Periodontal Parameters

b.

a

b

P>0.05

P>0.05

2.8

2.93

3.13.2

3.3

3.43.5

3.63.7

3.8

E1 E3

PP

D (

mm

)

Intervention group Control groupn=212 n=105

E1 and E3 indicate 1st and 3rd Examination Stages

Changes in Periodontal Parameters

c.

aa

P>0.05P>0.05

2.9

3

3.1

3.2

3.3

3.4

3.5

3.6

E1 E3

CA

L (

mm

)

Intervention group Control groupn=212 n=105

E1, E2 and E3 indicate 1st , 2nd and 3rd Examination Stages

Changes in Inflammatory Parameters

d.

a

b

c

***P>0.05

2.5

3

3.5

4

4.5

5

E1 E2 E3

CR

P (

mg

/L)

Intervention group Control groupn=212 n=105

E1, E2 and E3 indicate 1st , 2nd and 3rd Examination Stages

Changes in Inflammatory Parameters

e.

bb

a

*P>0.05

P>0.05

200

220240

260280

300

320340

360380

400

E1 E2 E3

FIB

(m

g/L

)

Intervention group Control groupn=212 n=105

E1, E2 and E3 indicate 1st , 2nd and 3rd Examination Stages

Changes in Inflammatory Parameters

f.

c

b

a

***P>0.05

5

5.5

6

6.5

7

7.5

8

8.5

E1 E2 E3

WB

C (

x109/L

)

Intervention group Control groupn=212 n=105

Effect of Periodontal Therapy on CRP ( > 3mg/L) based CHD Risk Category

ARR = 48.5%-36% = 12.5% (χ2=4.381, p=0.036)

Relative Risk Ratio = 1.34

Relative Risk Reduction= 26%Periodontal therapy may reduce high-risk CRP levels by 26% in CHD patients

NNT = 1 out of 8 CHD Patients with Moderate-Severe periodontitis may benefit from PT and lower serum CRP levels to mild risk(www.nottingham.ac.uk)

Conclusion

Treatment of periodontitis by conventional non-surgical periodontal therapy in CHD patients contributes to significant reduction in serum levels of systemic inflammatory markers associated with CHD Risk

• This reduction in systemic markers of CHD risk might lead to CHD risk reduction.

• Periodontal screening of CHD patients might help identify individuals who may benefit from periodontal therapy.

Conclusion

Evidence suggests an association of PD and CHD and CHD risk markers of CRP, Fibrinogen and WBCs are raised in patients with Periodontitis. Treatment studies provide conflicting results regarding the systemic effects of mechanical periodontal therapy. This trial lends further evidence to such researches.

Clinical Relevance/ Rationale of Study

In the absence of any change in systemic medication, mechanical periodontal therapy significantly reduces serum levels of C-reactive protein, fibrinogen and white blood cells in CHD patients

Principal Findings

Treatment of CHD patients with periodontitis using mechanical periodontal therapy can result in significant reduction of CHD risk markers

Practical Implications