Cardiovascular disease and dental implants – Mr. Matthieu Dupui – TBR Marketing Product Manager

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  Posted by: Dental Design      13th July 2019

There is a considerable body of research establishing that cardiovascular disease (CVD) is associated with periodontal disease and tooth loss. While evidence for a causal relationship between the two conditions is still contested, both diseases feature common risk factors making comorbidity more likely.[1],[2],[3] While inroads have been made, CVD remains the world’s biggest killer.[4]Within the UK alone, an estimated 7 million people are living with CVD, and a quarter of all deaths are attributed to heart and circulatory diseases.[5]

CVD is a systemic disease that has wide-ranging effects throughout the body, directly impacting blood supply and circulation system-wide through various mechanisms. As blood circulation is essential for supplying oxygen at a tissue level, this aspect alone is sufficient to interfere with healing, growth and basic function. This has implications for any surgical procedure and can adversely affect osseointegration. Furthermore, the vascular system is integral to immune function and nutrient delivery, so when it is compromised, we can expect to see adverse effects on the body’s ability to repair and defend itself from pathogens.[6]However, in spite of this, clinical studies and reviews generally seem to indicate that the success rate for dental implants for patients with CVD is essentially in line with the general population.[7],[8]

One proposed mechanism for how periodontal disease can exacerbate other inflammatory conditions, including CVD, is that the inflammation caused within the oral cavity results in the increased production and dissemination of C-reactive proteins (CRP), interleukin-1 beta (1L-1b) and interleukin-6 (1L-6), and TNF-alpha – proinflammatory cytokines. These provoke an inflammatory response, which under normal circumstances is a cornerstone of the body’s immune response, but when chronic can result in a wide variety of inflammatory diseases and negative effects throughout the body.[9],[10]Another theorised mechanism is that the bacteria involved in gingivitis and periodontitis – namely Tannerella forsythiaand Porphyromonas gingivalis– produce proteins (e.g. heat-shock protein-60), which may contribute to autoimmune problems or atheroma formation.[11]It is not unlikely that there are multiple mechanisms at play, given the potential for complex interactions between bacteria, proteins and the immune system.

Diabetes is a common risk factor for both CVD and periodontitis/edentulism. Where all three are present, there is an increased risk of micro and macrovascular complications, and a significantly elevated risk of mortality from CVD.[12],[13]The relationship between periodontitis and diabetes is bidirectional, so to a certain extent treating periodontitis can help improve the patient’s glycaemic condition.[14]There is currently some controversy over the relationship between hyperlipidemia and periodontitis, with some experts proposing that high lipid levels in the blood lead to increased production of proinflammatory cytokines (the same mechanism proposed to increase the risk of CVD).[15]Untangling these complex factors is a challenging area of active and ongoing research, but it is safe to say that the appearance of one systemic inflammatory condition predisposes a patient to further health problems.

Patients with valvular heart disease are particularly vulnerable to infective endocarditis, which is potentially fatal. During dental surgery, transient bacteremia occurs (bacteria temporarily enters the blood stream), which in most patients clears within 15 minutes. However, patients with valvular heart disease have abnormal or damaged cardiac tissue, and in some cases replacement heart valves. Bacteria more readily find refuge in such anatomy, putting the patient at increased risk of infection. Valvular heart disease is not thought to affect implant success and is not necessarily a contraindication to treatment, but great care does need to be taken. Where dental implant infection does occur, but is not quickly resolved with antibiotics, it is advisable to remove the implant as soon as possible.[16]

Patients with diagnosed CVD are likely to be on one or more medications that can affect clotting or interfere with other medications and analgesics, or prohibit their use entirely. Getting a complete understanding of the patient’s prescriptions and the potential effects of these is vital, and coordination with the patient’s cardiologist is recommended. It should also be remembered that many patients turn to other products for various reasons, such as herbal supplements, which in some cases could affect healing or interact with medication or anaesthetics (Saint John’s Wart, for example). A patient can easily overlook mentioning something that doesn’t require a prescription (such as high dose vitamin C supplements), so care must be taken when assessing patients before any procedures in order to get a complete picture of their overall health and pharmacological state.

Reducing the risk of infection is critical to minimising complications from dental implant therapy, and this is especially important for patients who already have systemic health issues. Selecting a high quality implant solution is essential to ensuring the overall success of treatment. TBR’s Z1 implant features an innovative zirconia collar that acts as an antibacterial shield to minimise the risk of infection. Indeed, zirconia surfaces demonstrate a lower affinity to bacteria compared to titanium.[17]This helps to protect the crestal bone and the gingiva from iatrogenic inflammation, encouraging the soft tissue to heal around the implant in a manner that closely resembles natural gingival growth.

With careful case selection, and a clear understanding of the patient’s health status and potential risk factors, dental implants are a viable treatment option for many patients. Cardiovascular disease need not preclude a patient from receiving the benefits of dental implants.

 

For more information on the Z1 implant, visit tbr.dental, email support@denkauk.comor call 0800 707 6212

 

 

References

[1]Stewart R., West M. Increasing evidence for an association between periodontitis and cardiovascular disease. Circulation. 2016; 133(6): 549-551. https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.115.020869April 18, 2019.

[2]Leng W., Zeng X., Kwong J., Hua X. Periodontal disease and risk coronary heart disease: an updated meta-analysis of prospective cohort studies. International Journal of Cardiology. 2015; 201: 469-472. https://www.internationaljournalofcardiology.com/article/S0167-5273(15)30209-6/fulltextApril 18, 2019.

[3]Cheng F., Zhang M., Wang Q., Xu H., Dong X., Gao Z., Chen J., Wei J., Qin F. Tooth loss and risk of cardiovascular disease and stroke: A dose-response meta analysis of prospective cohort studies. PLoS ONE. 2018; 13(3): e0194563. https://doi.org/10.1371/journal.pone.0194563April 18, 2019.

[4]World Health Organization. The top 10 causes of death.WHO.2018. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death

 April 18, 2019.

[5]British Heart Foundation. UK factsheet. British Heart Foundation. 2018. https://www.bhf.org.uk/what-we-do/our-research/heart-statisticsApril 18, 2019.

[6]Patil P., Patil A. Dental implant complications – systemic diseases – part I. Journal of Dentistry and Oral Care Medicine. 2017; 3(1): 103. https://doi.org/10.15744/2454-3276.3.103. April 18, 2018.

[7]Schimmel M., Srinivasan M., McKenna G., Müller F. Effects of advanced age and/or systemic medical conditions on dental implant survival: a systematic review and meta-analysis.Clinical Oral Implants Research. 2018; 29(Suppl. 16): 311-339. https://doi.org/10.1111/clr.13288April 18, 2019.

[8]Akay A., Arisan V. Dental implants in the medically compromised patient population.  IntechOpen. 2017. https://www.intechopen.com/books/clinical-trials-in-vulnerable-populations/dental-implants-in-the-medically-compromised-patient-populationApril 18, 2019.

[9]Chaudhry S., Jaiswal R., Sachdeva S. Dental considerations in cardiovascular patients: a practical perspective. Indian Heart Journal. 2016; 68: 572-575.http://dx.doi.org/10.1016/j.ihj.2015.11.034April 18, 2019.

[10]Delange N., Lindsay S., Lemus H., Finlayson T., Kelley S., Gottlieb R. Periodontal disease and its connection to systemic biomarkers of cardiovascular disease in young American Indian/Alaskan natives. Journal of Periodontology. 2018; 89(2): 219-227. https://aap.onlinelibrary.wiley.com/doi/full/10.1002/JPER.17-0319April 18, 2019.

[11]Chaudhry S., Jaiswal R., Sachdeva S. Dental considerations in cardiovascular patients: a practical perspective. Indian Heart Journal. 2016; 68: 572-575.http://dx.doi.org/10.1016/j.ihj.2015.11.034April 18, 2019.

[12]British Heart Foundation. UK factsheet. British Heart Foundation. 2018. https://www.bhf.org.uk/what-we-do/our-research/heart-statisticsApril 18, 2019.

[13]Sanz M., Ceriello A., Buysschaert, M., Chapple I., Demmer R., Graziani F., Herrera D., Jepsen S., Lione L., Madianos P., Mathur M., Montanya E., Shapira L., Tonetti M., Vegh D. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. Journal of Clinical Periodontology. 2017; 45(2): 138-149. https://doi.org/10.1111/jcpe.12808April 18, 2018.

[14]Zhou X., Zhang W., Liu X., Zhang W., Li Y. Interrelationship between diabetes and periodontitis: role of hyperlipidemia. Archives of Oral Biology. 2015; 60(4): 667-674. https://www.sciencedirect.com/science/article/pii/S0003996914002921April 18, 2019.

[15]Shivakumar T., Patil V., Desai M. Periodontal status in subjects with hyperlipidemia and determination of association between hyperlipidemia and periodontal health: a clinicobiochemical study. The Journal of Contemporary Dental Practice.2013; 14(5): 785-789.

[16]Patil P., Patil A. Dental implant complications – systemic diseases – part I. Journal of Dentistry and Oral Care Medicine. 2017; 3(1): 103. https://doi.org/10.15744/2454-3276.3.103. April 18, 2019.

[17]Rimondini, L., Cerroni, L., Carrassi, A., Torricelli, P. Bacterial colonisation of zirconia ceramic surfaces: an in vitro and in vivo study. Int. J. Oral Maxillofac. Implants. 2002; 17(6): 793-798. Link: https://www.researchgate.net/publication/10969412_Bacterial_Colonization_of_Zirconia_Ceramic_Surfaces_An_in_Vitro_and_in_Vivo_Study. April 23, 2019.

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