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Three New Reports on Heart Attack Risk associated with Tooth Scaling

If anyone questions the value of regular dental care….read on…

Three New Reports on Heart Attack Risk: Tooth Scaling Decreases Risk, Periodontal Disease Predicts Type of Risk, Stopping Aspirin Increases Risk.

First report – Professional tooth scaling appears to decrease the risk of heart attack and stroke.

This report was presented at the annual meeting of the American Heart Association 2011 in Orlando, FL and is cited as the following:

Chen Z., & Leu H. The association of tooth scaling and decreased cardiovascular disease — a nationwide population-based study. Circulation 124:21 suppl:A17704.

The study investigated the association between preventive dentistry and cardiovascular risk reduction. To do this, the authors investigated the effect of mouth scaling on cardiovascular disease and stroke risk. The study was conducted in Taiwan using information from the Taiwan National Health Institute.

The authors selected 51,108 adults with no history of myocardial infarction or stroke who had received full or partial mouth scaling at least once, and compared them with another 51,512 matched subjects according to age, gender and co-morbidities with no history of myocardial infarction and stroke and did not receive mouth scaling. Standard statistical methods were used to compare the cardiovascular events rate between the two groups.

During an average follow-up period of 7 years, a total of 102,620 patients enrolled, of which 51,108 had received tooth mouth scaling, had a 24% lower risk of heart attack and a 13% lower risk of stroke compared with those who had never had a tooth mouth scaling. The statistics showed that patients with tooth scaling have significantly higher acute myocardial infarction-free and higher stroke-free survival rates. The study statistics also showed that tooth scaling was the independent factor associated with less risk of developing future heart attacks and stroke. The frequency of tooth scaling correlated with the degree of risk reduction of heart attack and stroke. Tooth scaling was considered frequent if it was performed at least twice or more within two years; occasional tooth scaling was once or fewer times in two years. This study did not take into account other potential risk factors for cardiovascular disease such as weight and smoking.

The conclusion of this study was that tooth scaling was associated with decreased risk for cardiovascular disease and stroke.

Second report – The type of periodontal disease appears to predict the risk for heart attack, heart failure and stroke in different ways.

This study was conducted in Sweden by Dr. Anders Holmlund, Periodontology, Specialized dentistry, Gavle and Dr. Lars Lind, Acute Medicine, Uppasal Academic Hospital.

The purpose of this study was to investigate if different markers of periodontal disease relate to the three most common cardiovascular disorders: heart failure, myocardial infarction and stroke.

The study evaluated 7,999 subjects referred to the dental clinic for periodontal treatment between 1976 and 2008. Adjustments were made for age, gender, smoking and education. The number of remaining teeth, periodontal severity index, number of deepened periodontal pockets and bleeding on probing were then evaluated in relation to fatal/nonfatal myocardial infarction, heart failure and stroke

Over a median follow-up time of 13.6 years, 414 events occurred involving fatal/nonfatal myocardial infarction; 204 events occurred involving heart failure; and 438 events occurred involving stroke. Participants who had fewer than 21 teeth had a 69% higher risk of heart attack compared to those with the most teeth. Participants with the highest number of deepened periodontal pockets around the base of the teeth had a 53% higher risk of heart attack compared to those with the fewest number of pockets. Participants with the fewest number of teeth had 2.5 times the risk of congestive heart failure compared to those with the most teeth. Those with the highest incidence of gum bleeding had 2.1 times the risk of stroke compared to subjects with the lowest incidence.

The study authors suggested that markers of periodontal disease predict cardiovascular events in different ways, thus, suggesting that they could be used as risk indicators for the three most common cardiovascular disorders.

The study citation is the following:

Holmlund A., & Lind L. Markers of periodontal disease predict myocardial infarction, stroke and heart failure differently in a cohort of 7999 subjects. Circulation 124:21 suppl:A10576.

Third report – Discontinuation of aspirin by cardiovascular patients can lead to increased risk of ischemic events and death.

Patients with a history of heart disease, who stopped taking aspirin, had a 60% increased risk of having a heart attack over the three year follow-up, compared with patients who continued the daily aspirin. This study by Garcia Rodriquez et al. used a validated primary care database to evaluate the risk of non-fatal myocardial infarction and death from coronary heart disease after discontinuation of low dose aspirin in primary care patients taking it as secondary prevention for cardiovascular disease.

The authors of the study recognized the cardio-protective effects of aspirin in patients with a history of heart attacks. In fact, guidelines announced in 2006 and 2007 by the American Heart Association and the European Union (see references below) recommend long term use of low dose aspirin (75-150 mg/day) as an effective antiplatelet regimen for patients with cardiovascular disease unless contraindicated. Discontinuation of aspirin by cardiovascular patients can lead to increased risk of ischemic events and death.

Details of the Garcia Rodriquez Report

The Health Improvement Network database of the United Kingdom was used to conduct the study. The database contains recorded data on more than three million patients enrolled in primary care practices in the UK. According to the authors, 60-80% of UK patients taking aspirin for cardio-protection obtain their treatment by prescription rather than over the counter. Therefore, it was thought that the database is a representative source of low dose aspirin use in the UK.

The network was used to identify individuals aged 50-84 with a first ever prescription of low dose aspirin (75 – 300 mg/day) for the secondary prevention of angina, ischemic heart disease, myocardial infarction, cerebrovascular disease, stroke or transient ischemic attack from January 2000 through December 2007. The study population consisted of 39,513 subjects.

Individuals were followed up for a mean of 3.2 years to identify cases of non-fatal myocardial infarction or death from coronary heart disease. The data analysis assessed the risk of these events in those who had stopped taking low dose aspirin compared with those who had continued treatment.

Analysis used the occurrence of myocardial infarction and death from coronary heart disease as the dependent variables. The analyses assessed the risk of these events in those who had stopped taking aspirin compared to those who had continued treatment. Risk estimates were adjusted by age, sex, time to event, smoking status, ischemic heart disease (at start date), cerebrovascular disease (at start date), diabetes (at start date), chronic obstructive pulmonary disease (at start date), and use of clopidogrel, statins, anticoagulants, nitrates, antihypertensives, oral steroids or non-steroidal anti-inflammatory drugs.

Results

Over a mean follow-up of 3.2 years, the authors identified 876 individuals with new diagnosis of non-fatal myocardial infarction. They also identified 346 individuals that died from coronary heart disease, thus totaling 1,222 cases. Overall incidence of non-fatal myocardial infarction was 6.87 per 1000 person years. The overall incidence of death from coronary heart disease was 2.71 per 1000 person years. The combined incidence of non-fatal myocardial infarction or death from coronary heart disease was 9.58 per 1000 person years.

People who had stopped taking aspirin had a significantly increased risk (60%) of non-fatal myocardial infarction.

Based on an incidence of non-fatal myocardial infarction of about 6 per 1000 person years among current users of aspirin, the incidence among discontinuers was estimated to be 10 per 1000 patient years, an extra four cases of non-fatal myocardial infarction associated with discontinuation among 1000 aspirin users.

There was no increased risk between stopping aspirin and the risk of heart disease death alone.

Assessment of Discontinuation of Low Dose Aspirin

Current users were defined as those taking aspirin at the time of observation and who continually refilled their aspirin prescriptions. Discontinuers were defined as individuals within a period of over 30 days after the last prescription would have been finished, who did not refill their prescription during that time.

Reasons for discontinuation of aspirin usually were due to an adverse reaction such as gastrointestinal bleeding or simply non-adherence to daily aspirin.

Study Conclusion

Patients with a history of cardiovascular or cerebrovascular disease in primary care who stop taking aspirin are at significantly increased risk of non-fatal myocardial infarction compared with those who continue taking aspirin. The increased risk is present irrespective of the length of time the patient had previously been taking low dose aspirin.

An interesting finding in this study was that the cumulative incidence of non-fatal myocardial infarction or death from coronary heart disease in patients taking aspirin after having a heart attack was 4% during the mean follow-up of three years. This was consistent with data from earlier studies showing a cumulative incidence of non-fatal myocardial infarction or death from coronary heart disease in patients taking antithrombotic treatment after having a heart attack was 2-14% .

Full report can be found at:

Garcia Rodriquez L.A., Cea-Soriano L., Martin-Merino E., & Johansson S. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. British Medical Journal 2011; 343:d4094.

Guidelines for aspirin use can be found at:

AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006; 47:2130-9.

European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J 2007; 28:2375-414.