Is periodontal therapy an effective treatment modality for preventing or managing cardiovascular disease in patients with periodontitis?

Abstract

Data sources

Cochrane Oral Health Information specialist searched databases: Cochrane Oral Health’s Trials Register, Cochrane Central Register of Controlled Trials in the Cochrane diary, MEDLINE Ovid, Embase Ovid, CINAHL EBSCO and Open Grey up to 17 November 2021 without language, publication status or year restriction. Additionally, Chinese Bio Medical Literature Database, China National Knowledge Infrastructure and VIP database were searched up to 4 March 2022. For ongoing trials, the US National Institutes of Health Trials Register, the World Health Organization (WHO) Clinical Trials Registry Platform (up to 17 November 2021), and Sciencepaper Online (up to 4 March 2022) were also searched. A reference list of included studies, hand searching for important journals, and Chinese professional journals in the relevant field was performed until March 2022.

Study selection

Authors screened the articles on the basis of their titles and abstracts. Duplicates were removed. Full-text publications were evaluated. Any disagreement was resolved by discussion amongst themselves or in consultation with a third reviewer. Only randomised controlled trials assessing the effects of periodontal treatment on participants having chronic periodontitis with cardiovascular disease (CVD) (secondary prevention) or without cardiovascular disease (primary prevention) with minimum follow-up of one year were considered. Patients having known genetic or congenital heart defects, other sources of inflammation, aggressive periodontitis, or were pregnant and/or lactating were excluded. Subgingival scaling and root planning (SRP) with or without combination of systemic antibiotics with or without active remedies were compared with supragingival scaling, mouth rinse, or no periodontal treatment.

Data extraction and synthesis

Data extraction was performed by two independent reviewers in duplicate. A formal, customised pilot-based data extraction form was used to capture data. Overall risk of bias for each study was categorised as low, medium, and high. For trials having missing data or unclear data, clarification from the authors were sought by mail. Testing for heterogeneity was planned by I² test. For dichotomous data, fixed-effect model (Mantel-Haenszel) was used; and for continuous data, mean difference and 95% confidence intervals were used as measures of treatment effect. For time-to-event data, Peto or inverse variance method was used. Sensitivity and subgroup analysis was planned to test the stability of conclusion.

Results

Following initial electronic and hand search, 1690 articles were screened for title and abstract and 82 articles were considered for full-text eligibility. Finally, two studies out of the reported six articles were included in this review for qualitative synthesis of results, and no study was included in the quantitative analysis. Publication bias was determined using funnel plots which were further assessed using dichotomous and continuous outcome. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low certainty evidence. Scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio [OR] 7.48, 95% confidence interval [CI] 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). The possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up was observed. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, the data was not sufficiently robust for inclusion in the review. The study did not evaluate all-cause death and all CVD-related death. Conclusions about the effects of periodontal therapy on secondary prevention of CVD were not drawn.

Conclusions

There is very limited evidence assessing the impact of periodontal therapy on the prevention of cardiovascular disease, and it is insufficient to generate any implications for practice. Further trials are needed before reliable conclusions can be drawn.