Non-Surgical Periodontal Therapy Reduces Coronary Heart Disease Risk Markers: A Randomized Controlled Trial Bokhari SAH, Khan AA, Butt AK, Azhar M, Hanif M, Izhar M, Tatakis DN Journal of Clinical Periodontology 2012

 Periodontal Disease is a chronic inflammatory and infectious disease  Systematic Reviews and Meta- analysis have provided evidence for an association of Periodontal disease and CHD and PD has been found to be associated with higher risk of CHD Background

PD also induces production of proinflammatory cytokines and acute- phase proteins. A positive association between CRP, fibrinogen levels, and peripheral leukocyte count with periodontitis has been documented by various studies Background

 This link of PD and Systemic Inflammatory markers is further strengthened by intervention studies where PT has shown reduction in inflammatory markers associated with CHD risk Background

Investigate the effect of conventional, mechanical, non-surgical periodontal treatment on serum levels of hsCRP, fibrinogen and white blood cells in CHD patients with periodontitis. Aim of study

 Observe changes in clinical periodontal parameters of BOP, PPD, and CAL and Serum levels of hsCRP, Fibrinogen and WBCs following Periodontal therapy  Compare these changes to corresponding levels in periodontally untreated CHD patients  Determine the effect of PT on the reduction of CHD risk marker Objectives of study

Study Design A single-blind, parallel-arm, Randomized Controlled Intervention Trial Subjects Angiographically confirmed CHD patients with moderate to severe periodontitis

CHD was defined as having  >50% stenosis of ≥1 coronary artery Oral /Periodontal Status was defined as  ≥ 14 periodontally evaluable natural teeth  > 20% of sites BOP+  ≥ 4 teeth with ≥ 1 site with PPD ≥ 4 mm and CAL ≥ 3 mm at same site

Exclusion Criteria Diseases or conditions affecting or potentially confounding Periodontal status or systemic Inflammatory Biomarker levels

Sample Size  Based on primary endpoint (serum CRP), Sample Size was calculated for 317 CHD patients with periodontitis to be randomized into intervention and control group at 2:1 ratio with 90% power to detect significant difference between groups.

Based on the observations of our pilot study 1. Reduction in BOP sites to ≤20% 2. Reduction in Sites with PPD ≥ 4 mm by 50% 3. Reduction in Serum inflammatory marker levels by 20% Level of Achievement after Periodontal Treatment

All CHD Subjects were on cardiac medications that included Antiplatelets, betablockers, ARBs, ACE inhibitors, calcium channel antagonists, statins, diuretics and nitrates. Subjects were monitored for change in status of medications during follow-up visits Cardiac medications

RESULTS Based on 317 recruited subjects ITT Analysis was carried out A comparison of Intervention and Control groups at baseline revealed NO Significant Differences with respect to Demographic and Medical parameters Periodontal and systemic Inflammatory variables

Changes in Periodontal Parameters E1, E2, E3 indicate 1 st, 2 nd, and 3 rd Examination stages

E1 and E3 indicate 1 st and 3 rd Examination Stages Changes in Periodontal Parameters

E1 and E3 indicate 1 st and 3 rd Examination Stages Changes in Periodontal Parameters

E1, E2 and E3 indicate 1 st, 2 nd and 3 rd Examination Stages Changes in Inflammatory Parameters

E1, E2 and E3 indicate 1 st, 2 nd and 3 rd Examination Stages Changes in Inflammatory Parameters

E1, E2 and E3 indicate 1 st, 2 nd and 3 rd Examination Stages Changes in Inflammatory Parameters

Effect of Periodontal Therapy on CRP ( > 3mg/L) based CHD Risk Category ARR = 48.5%-36% = 12.5% (χ 2 =4.381, p=0.036) Relative Risk Ratio = 1.34 Relative Risk Reduction= 26% Periodontal therapy may reduce high-risk CRP levels by 26% in CHD patients NNT = 1 out of 8 CHD Patients with Moderate-Severe periodontitis may benefit from PT and lower serum CRP levels to mild risk (

Conclusion Treatment of periodontitis by conventional non-surgical periodontal therapy in CHD patients contributes to significant reduction in serum levels of systemic inflammatory markers associated with CHD Risk

This reduction in systemic markers of CHD risk might lead to CHD risk reduction. Periodontal screening of CHD patients might help identify individuals who may benefit from periodontal therapy. Conclusion

 Evidence suggests an association of PD and CHD and CHD risk markers of CRP, Fibrinogen and WBCs are raised in patients with Periodontitis. Treatment studies provide conflicting results regarding the systemic effects of mechanical periodontal therapy. This trial lends further evidence to such researches. Clinical Relevance/ Rationale of Study

 In the absence of any change in systemic medication, mechanical periodontal therapy significantly reduces serum levels of C- reactive protein, fibrinogen and white blood cells in CHD patients Principal Findings

 Treatment of CHD patients with periodontitis using mechanical periodontal therapy can result in significant reduction of CHD risk markers Practical Implications