Periodontitis, dental plaque, and atrial fibrillation in the Hamburg City Health Study

Abstract

Background/Aim Atrial fibrillation (AF) is a major health problem and causes heart failure and stroke. Pathophysiological mechanisms indicate a link with oral health including periodontitis (PD), but supporting data are scarce. The aim was to investigate the link between features of oral health and the prevalence of AF. Methods This cross-sectional analysis of the Hamburg City Health Study included 5,634 participants with complete data on their PD and AF status. AF was assessed via self-reported questionnaire or medically diagnosed by standard 12-lead resting ECG. The oral health examination included full-mouth measurements of the dental plaque index (PI), the clinical attachment loss (CAL) at 6 sites per tooth, the bleeding on probing (BOP) and the decayed, missing and filled teeth (DMFT) index. Descriptive analyses for all variables stratified by the status of PD were performed. To test for an association between prevalent PD and prevalent AF, multivariable logistic regression models were used. Mediation analysis was used to test if interleukin-6 (IL-6) and/or C-reactive protein (CRP) mediated the association between PD and AF. Results Atrial fibrillation (prevalence: 5.6%) and the severity of PD (prevalence: moderate: 57.7%, severe: 18.9%) increased with age in men and women. Prevalent severe PD, CAL ≥3 mm, PI, and BOP were all associated with prevalent AF in unadjusted regression analysis. However, no association except for PI (odds ratio (OR): 1.22, 95% confidence interval (CI): 1.1–1.35, p<0.001) could be observed after adjusting for age, sex, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), body mass index, diabetes, smoking, and educational level. Participants brushing their teeth at least twice daily had a lower AF prevalence compared with those brushing only once daily. Hs-CRP, IL-6, and the odds of AF increased as a function of PD severity grades in unadjusted analysis. However, neither the DMFT index nor IL-6 or CRP was associated with AF after adjusting for age and sex. Mediation analyses could not provide support for the hypothesis that IL-6 or CRP acted as mediator of the association between prevalent PD and prevalent AF. Conclusion The study shows an association between prevalent AF and increased dental plaque levels indicated by a higher PI. In contrast, an association of prevalent PD with prevalent AF after adjustments for several confounders could not be demonstrated. Further studies are necessary to investigate the mechanisms underlying poor oral hygiene and AF as well as the influence of improved oral hygiene on AF onset.

Effects of Oral Inflammatory Diseases and Oral Hygiene on Atrial Fibrillation: A Systematic Review

“…The sample sizes of the abovementioned study population ranged from 227 to 3,056,291, with follow-up periods ranging from 18 months to 17 years. A cross-sectional study, including 5,634 participants with complete data on periodontitis and atrial fibrillation, was conducted to assess the relationship between periodontitis and its severity and atrial fibrillation [ 19 ]. Specific baseline data included in the literature are shown in Table 1 .…”

“…Two studies reported the different effects of PD severity on the occurrence risk of atrial fibrillation [ 12 , 19 ], involving healthy patients and mild PD patients (4,588 patients), moderate PD patients (5,197 patients), and severe PD patients (2,382 patients). The prospective cohort study [ 12 ] by Sen et al included healthy individuals, mild PD, moderate PD, and severe PD patients.…”

“…Univariate analysis found that the severity of periodontitis was associated with a dose-response relationship with atrial fibrillation, but only severe PD significantly increased the risk of new-onset AF (HR 1.31, 95% CI 1.06–1.62) after adjusting for confounding factors. Struppek et al [ 19 ] included healthy/mild PD, moderate PD, and severe PD patients in a cross-sectional study, and only severe PD was associated with new-onset atrial fibrillation (OR 1.66, 95% CI 1.16–2.36) in univariate analysis, and there was no significant correlation between various degrees of periodontitis and atrial fibrillation after adjusting for confounding factors.…”

“…Two studies reported the effect of tooth brushing frequency on the occurrence of atrial fibrillation [ 13 , 19 ], of which a cross-sectional study by Struppek [ 19 ] reported that the incidence of atrial fibrillation was 25%, 7.53%, and 7.12% in patients with different tooth brushing frequencies of once a week, once a day, and twice a day, respectively, and the advantage of ≥2/d tooth brushing to reduce the occurrence risk of atrial fibrillation was more significant in people aged ≥65 years. A retrospective cohort study by Chang [ 13 ] reported that the incidence of atrial fibrillation was 3.99%, 3.22%, and 2.51% in patients with different tooth brushing frequencies of 0-1/d, 2/d, and 3/d, respectively.…”

Screening of Atrial Fibrillation in Dental Practices: a qualitative feasibility study

“…A recent study that monitored patients for 17 years found an increased incidence of AF and stroke with periodontitis, 21 and another study in Hamburg assessed 5,634 participants with AF for severity of periodontitis had found an increased association before adjusting for confounders. 22 Current reviews have suggested the importance of prospective clinical studies to investigate a possible link further. 23,24 Recently, there has been evidence that opportunistic screening for AF may prove bene cial.…”