Over the past two decades, several studies have shown a significant association between periodontitis and the occurrence of diverse cardiovascular events. 

Coronary heart disease and cerebrovascular diseases are the first and second causes, respectively, of death worldwide. Coronary heart disease causes 7.25 million deaths annually (12.8% of total deaths) and cerebrovascular diseases are responsible for 6.15 million deaths annually (10.8%), and are therefore considered a challenge for today's healthcare systems. 

Nevertheless, great difficulties exist for assessing cardiovascular risk, as well as for diagnosing cardiovascular diseases properly and early on. There is therefore a growing interest in identifying other underlying pathogenic biological mechanisms involved in cardiovascular disease and that may involve other risk factors that are less obvious than those already known, such as blood pressure, smoking, altered lipid metabolism, diabetes, poor diet or lack of physical exercise. 

Thus, it has been suggested that local or remote infections could lead to chronic inflammatory processes, which directly impact the physiopathology of atherosclerosis, thereby representing cardiovascular risk factors. 

Consistent Evidence 

Over the past two decades, several studies have shown a significant association between periodontitis and the occurrence of diverse cardiovascular events. Despite the fact that this link is small scale and depends on the severity of periodontal involvement, it is of great clinical significance. 

In studies that have evaluated cardiovascular episodes, a statistically significant excess risk has been observed for atherosclerotic cardiovascular disease in individuals with periodontitis. "Given the high prevalence of periodontitis, even with low to moderate excess risk, this fact is important from a public health perspective," explains Dr. Francisco Fernández-Avilés, Chief of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid. 

This fact calls for a comprehensive approach in these patients, as correct oral and periodontal health involves a decrease in the risk factors that are potentially dangerous for a patient with atherosclerotic disease. 

"As healthcare professionals we are able to reduce the risk of coronary heart disease and stroke in our patients by properly managing periodontal disease," states Dr. Fernández-Avilés. 

Better oral health, reduced cardiovascular risk 

Among other evidence of interest, healing periodontal disease has been shown to possibly improve significant alterations in the vessel wall. Intervention studies have revealed an improvement in the cardiovascular condition of patients with periodontitis after intense or long-term periodontal treatments have been performed. 

As pointed out by Dr. Mariano Sanz, Professor of Periodontics at the Universidad Complutense de Madrid, "Certain bacterial strains from the oral cavity have been detected in atheromatous plaques situated in different locations throughout the arterial and venous trees." The presence of these bacteria, along with inflammation mediators, can lead to rupture or alteration of the atheromatous plaque, and in turn, the occurrence of severe vascular events. 

It has been suggested that bacterial pathogens from the subgingival biofilm and the inflammatory response that these cause may be directly involved in the development of atherosclerotic lesions, leading to an increased risk of cardiovascular events in patients. 

Resolving doubts 

The placement of devices for keeping vascular lumen open (stents) or the progression of various diseases involving the need to place a prosthetic heart valve, make it so that these patients have special needs when planning and performing dental treatment. 

In particular, it is often controversial to manage patients undergoing antiplatelet or anticoagulant treatment. Experts recommend that the approach to these patients be done consensually between the dentist and the cardiologist to determine the overall state of their disease, "since the vast majority of dental procedures can be done without stopping medication that has already been initiated," says Dr. Mariano Sanz, who stresses the need to "make a correct clinical history of patients treated with antiplatelets or anticoagulants and to maintain regular contact with the cardiologist to know the patient's state before initiating any invasive treatment." 

Local haemostatic measures, with proper planning, allow treatments to be performed without discontinuing the patient's antiplatelet or anticoagulant medication, as the risk of thromboembolic phenomena is much greater than the potential risk of bleeding. 

Moreover, the usefulness of antibiotic prophylaxis in some cases is increasingly limited due to the lack of scientific evidence. Currently, panels of experts and scientific associations only recommend use in very limited cases involving high risk procedures and patients with vascular prostheses; generally these patients are advised to perform good oral hygiene and regular check-ups by dental professionals. 

Local or remote infections could lead to chronic inflammatory processes, which directly impact the physiopathology of atherosclerosis 

Certain bacterial strains from the oral cavity have been detected in atheromatous plaques situated in different locations throughout the arterial and venous trees