The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 89

Scientia et Humanitas: A Journal of Student Research

88 Spring 2014

The Link between Cardiovascular Disease and Periodontal 
Disease: A Literature Review

Holly Plemons

Abstract 
Cardiovascular disease is the leading cause of death in the United States.  According to the 
American Academy of Periodontology, one half of people over the age of thirty, approximately 
64.7 million Americans, have periodontal disease.  The purpose of this literature review is to 
examine existing studies that document a link between cardiovascular disease and periodontal 
disease in order to determine if the connection extends beyond shared risk factors.  To further 
support the relationship of the heart and oral environment, research was reviewed to 
determine if the treatment and subsequent improvement of periodontal status would improve 
cardiovascular health.  Research supports the relationship between the two conditions, although 
there is no evidence that has established a causal connection.  Patients with periodontal disease 
have higher serum levels of inflammatory markers implicated in cardiovascular disease as 
compared to patients who are periodontally healthy.  Elevated salivary amounts of periodontal 
pathogens have been found in patients with coronary artery disease when compared to patients 
without cardiovascular concerns.  Nonsurgical treatment of periodontal disease has been shown 
to decrease the amount of inflammatory markers circulating in the bloodstream and to reduce 
the thickness of the coronary arteries.  The systemic improvement from periodontal therapy is 
not permanent and supports the current standard of care, calling for long-term interventions.  
The established link between systemic and oral health adds urgency to the prevention, diagnosis, 
treatment, and maintenance of periodontal disease. 

Works Cited

Bly, Mary. “Bawdy Puns and Lustful Virgins: The Legacy of Juliet’s Desire in Comedies 
of the Early 1600s.” Shakespeare Survey 49 (1996): 97-109. Rpt. in Shakespeare and 
Sexuality as “The Legacy of Juliet’s Desire in Comedies of the Early 1600s.” Ed. 
Catherine M. S. Alexander and Stanley Wells. Cambridge: Cambridge UP, 2001. 
52-71. Print.

Brode, Douglas. “Star Crossed Lovers: Romeo and Juliet.” Shakespeare in the Movies: From 
the Silent Era to Shakespeare in Love. Oxford: Oxford UP, 2000. 41-59. Print.

Buchanan, Judith. “Leaves of Brass and Gads of Steel: Cinema as Subject in Shakespeare 
Films, 1991-2000.” Shakespeare on Film. Harlow: Pearson Education, 2005. 220-60. 
Print.

Butler, Judith. Gender Trouble. 1990. New York: Routledge, 1999. E-book. 

Hunter, Lynette and Peter Lichtenfels. Negotiating Shakespeare’s Language in Romeo and 
Juliet: Reading Strategies from Criticism, Editing and the Theatre. Farnham: Ashgate, 
2009. Print.

Jackson, Russell. “Introduction: Shakespeare, Films, and the Marketplace.” The Cambridge 
Companion to Shakespeare on Film. Ed. Russell Jackson. Cambridge: Cambridge UP, 
2000. 1-12. Print.

Luhrmann, Baz, dir. William Shakespeare’s Romeo + Juliet. Perf. Leonardo DiCaprio, Claire 
Danes, John Leguizamo, and Pete Postlethwaite. 20th Century Fox, 1996. DVD.

Luhrmann, Baz, Catherine Martin, Craig Pearce, and Don McAlpine. Audio Commentary. 
William Shakespeare’s Romeo + Juliet: Special Edition. Dir. Luhrmann. Perf. Leonardo 
DiCaprio, Claire Danes, John Leguizamo, and Pete Postlethwaite. 20th Century Fox, 
2002. DVD.

Moisan, Thomas. “‘O Any Thing, of Nothing First Create!’: Gender and Patriarchy and the 
Tragedy of Romeo and Juliet.” In Another Country: Feminist Perspectives on Renaissance 
Drama. Ed. Dorothea Kehler and Susan Baker. Metuchen: Scarecrow, 1991. 113-36. 
Print.

Pearson, Lu Emily. Elizabethan Love Conventions. U of California P, 1933. Print.

Shakespeare, William. Romeo and Juliet. Ed. René Weis. London: Bloomsbury, 2012. Print.

Tatspaugh, Patricia. “The Tragedies of Love on Film.” The Cambridge Companion to 
Shakespeare on Film. Ed. Russell Jackson. Cambridge: Cambridge UP, 2000. 135-59. 
Print.



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 91

Scientia et Humanitas: A Journal of Student Research

90 Spring 2014

Introduction

According to the Centers for Disease Control and Prevention, cardiovascular disease is the leading cause of death in the United States. Many of the patients 
seen in dental offices have some type of cardiovascular disease, which require consideration 
in determining appropriate treatment.  In recent years the interrelationship between the 
environment in the oral cavity and systemic diseases has become more heavily disputed in 
an effort to give patients the best chance at controlling both conditions.   This established 
link is of great importance to healthcare providers and patients and influences the standard 
of care that is currently accepted.  The significance of this topic is that by discovering 
how diseases affect each other, scientists may be able to develop treatment protocols that 
improve the prognosis for these conditions.  

For the purposes of this research, cardiovascular disease will include any conditions that 
affect the heart or blood vessels.   Periodontal disease is defined as “The inflammation and 
tissue destruction result in degradation of the attachment apparatus of the teeth, causing 
tooth loss” (Berent et al.. 2009, p. 127).  Periodontal disease is thought to be initiated by 
bacterial plaque and is impacted by the host immune response.  

The purpose of this review is to examine the existing research on the relationship 
between periodontal disease and cardiovascular disease.  The following research questions 
will be addressed:

•   Does the evidence support a connection that is more than shared risk factors? 
•    Is there research that identifies a connection between the management of periodontal 
disease and improvements in the cardiovascular health of the subjects? 

The independent variable in this study is periodontal disease.  It will be evaluated for an 
effect, if any, on cardiovascular disease.  Cardiovascular disease is the dependent variable 
as the research will indicate to what extent it is modified by the treatment of periodontal 
disease.  The review will be organized first to address studies that provide data on the link 
between the conditions.  Research that identifies the management of periodontal disease as 
a factor in the improvement of conditions that affect the heart and blood vessels will then 
be evaluated and listed to support the conclusions that a link does exist. 

Discussion
In a study conducted by Kodovazenitis et al.. (2011), the connection between 

periodontal disease and cardiovascular disease was investigated.  The purpose of the study 
was to analyze the effect that periodontal disease had on C-reactive protein (CRP) levels 
found in patients with acute myocardial infarctions.  CRP is an inflammatory marker 
that is not found in healthy individuals, circulates in the bloodstream, and appears in 
response to inflammation, infection, or injury.  Increased levels of CRP lead to a greater 
risk of cardiovascular complications.  The study subjects were selected from a group of 
204 consecutive patients diagnosed with acute myocardial infraction (AMI) and 102 
consecutive subjects without AMI at the First Cardiology Clinic of the Hippokration 
Hospital, University of Athens.  The researchers excluded participants based on:

• diabetes mellitus
• hepatitis or HIV infection
• immunosuppressive therapy
• current pregnancy or lactation
• periodontal therapy in the preceding 6 months
• antibiotic therapy for 3 months prior to study entry 
• tobacco use

The use of these exclusion criteria adds validity to the research by limiting the effect of 
common risk factors for cardiovascular disease. The state of the patients’ periodontiums was 
evaluated by one periodontist using criteria accepted widely across the dental profession.   
Using one specialist to examine patients provides measurements that are considerably more 
reliable when being compared.  The subjects were required to complete questionnaires with 
regard to their medical and dental history.  Periodontal disease was identified as being 
systemic in exposure when more than 30% of the sites examined had both clinical attachment 
loss greater than 3mm and probing depths above 4mm, these measurements illustrate how 
much damage has occurred to the supporting structures of the teeth.  The data relating to 
the presence and amount of inflammatory markers for cardiovascular disease was gathered 
from blood samples collected from patients when they were admitted.  The results showed 
that the contribution of periodontal disease to CRP elevations was strong, independent 
of other risk factors and consistent amongst a spectrum of PD measures evaluated.  A 
strong correlation between the presence of periodontal disease and elevated levels of CRP 
was found in the analysis portion of the results.  The findings showed that AMI patients 
had significantly higher mean CRP levels.  The conclusions drawn by the researchers in 
this study support a connection between periodontal disease and inflammatory markers, 
specifically CRP.

The sampling method used provided a random way of selecting the study group and 
eliminated participants with risk factors that could have produced conflicting results.  
The analysis of the data showed definite significance in the relationship between the two 
variables and effectively supports a connection between the conditions.

An earlier study attempted to assess if a patient’s perception of their oral health status 
could be useful in determining if indicators for cardiovascular disease were present.  A 
cross-sectional baseline sub study was conducted by Mochari et al.. (2008).  The purposes of 
this study were to “determine if self-reported oral health status is independently associated 
with inflammatory markers and if oral health assessment as part of CVD (cardiovascular 
disease) risk screening can identify at-risk individuals without traditional CVD risk 
factors” (Mochari et al., 2008, p.1509).  The participants were already taking part in a study 
conducted by the National Heart, Lung, and Blood Institute’s Family Intervention Trial for 
Heart Health. The participants were eligible if they were  family members or cohabitants of 
patients hospitalized with CVD, were aged 20-79 years, did not have CVD or diabetes, and 
spoke either English or Spanish.  There were 421 subjects in this study whose oral health 
condition was evaluated based on the answers they provided to questionnaires with regard 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 91

Scientia et Humanitas: A Journal of Student Research

90 Spring 2014

Introduction

According to the Centers for Disease Control and Prevention, cardiovascular disease is the leading cause of death in the United States. Many of the patients 
seen in dental offices have some type of cardiovascular disease, which require consideration 
in determining appropriate treatment.  In recent years the interrelationship between the 
environment in the oral cavity and systemic diseases has become more heavily disputed in 
an effort to give patients the best chance at controlling both conditions.   This established 
link is of great importance to healthcare providers and patients and influences the standard 
of care that is currently accepted.  The significance of this topic is that by discovering 
how diseases affect each other, scientists may be able to develop treatment protocols that 
improve the prognosis for these conditions.  

For the purposes of this research, cardiovascular disease will include any conditions that 
affect the heart or blood vessels.   Periodontal disease is defined as “The inflammation and 
tissue destruction result in degradation of the attachment apparatus of the teeth, causing 
tooth loss” (Berent et al.. 2009, p. 127).  Periodontal disease is thought to be initiated by 
bacterial plaque and is impacted by the host immune response.  

The purpose of this review is to examine the existing research on the relationship 
between periodontal disease and cardiovascular disease.  The following research questions 
will be addressed:

•   Does the evidence support a connection that is more than shared risk factors? 
•    Is there research that identifies a connection between the management of periodontal 
disease and improvements in the cardiovascular health of the subjects? 

The independent variable in this study is periodontal disease.  It will be evaluated for an 
effect, if any, on cardiovascular disease.  Cardiovascular disease is the dependent variable 
as the research will indicate to what extent it is modified by the treatment of periodontal 
disease.  The review will be organized first to address studies that provide data on the link 
between the conditions.  Research that identifies the management of periodontal disease as 
a factor in the improvement of conditions that affect the heart and blood vessels will then 
be evaluated and listed to support the conclusions that a link does exist. 

Discussion
In a study conducted by Kodovazenitis et al.. (2011), the connection between 

periodontal disease and cardiovascular disease was investigated.  The purpose of the study 
was to analyze the effect that periodontal disease had on C-reactive protein (CRP) levels 
found in patients with acute myocardial infarctions.  CRP is an inflammatory marker 
that is not found in healthy individuals, circulates in the bloodstream, and appears in 
response to inflammation, infection, or injury.  Increased levels of CRP lead to a greater 
risk of cardiovascular complications.  The study subjects were selected from a group of 
204 consecutive patients diagnosed with acute myocardial infraction (AMI) and 102 
consecutive subjects without AMI at the First Cardiology Clinic of the Hippokration 
Hospital, University of Athens.  The researchers excluded participants based on:

• diabetes mellitus
• hepatitis or HIV infection
• immunosuppressive therapy
• current pregnancy or lactation
• periodontal therapy in the preceding 6 months
• antibiotic therapy for 3 months prior to study entry 
• tobacco use

The use of these exclusion criteria adds validity to the research by limiting the effect of 
common risk factors for cardiovascular disease. The state of the patients’ periodontiums was 
evaluated by one periodontist using criteria accepted widely across the dental profession.   
Using one specialist to examine patients provides measurements that are considerably more 
reliable when being compared.  The subjects were required to complete questionnaires with 
regard to their medical and dental history.  Periodontal disease was identified as being 
systemic in exposure when more than 30% of the sites examined had both clinical attachment 
loss greater than 3mm and probing depths above 4mm, these measurements illustrate how 
much damage has occurred to the supporting structures of the teeth.  The data relating to 
the presence and amount of inflammatory markers for cardiovascular disease was gathered 
from blood samples collected from patients when they were admitted.  The results showed 
that the contribution of periodontal disease to CRP elevations was strong, independent 
of other risk factors and consistent amongst a spectrum of PD measures evaluated.  A 
strong correlation between the presence of periodontal disease and elevated levels of CRP 
was found in the analysis portion of the results.  The findings showed that AMI patients 
had significantly higher mean CRP levels.  The conclusions drawn by the researchers in 
this study support a connection between periodontal disease and inflammatory markers, 
specifically CRP.

The sampling method used provided a random way of selecting the study group and 
eliminated participants with risk factors that could have produced conflicting results.  
The analysis of the data showed definite significance in the relationship between the two 
variables and effectively supports a connection between the conditions.

An earlier study attempted to assess if a patient’s perception of their oral health status 
could be useful in determining if indicators for cardiovascular disease were present.  A 
cross-sectional baseline sub study was conducted by Mochari et al.. (2008).  The purposes of 
this study were to “determine if self-reported oral health status is independently associated 
with inflammatory markers and if oral health assessment as part of CVD (cardiovascular 
disease) risk screening can identify at-risk individuals without traditional CVD risk 
factors” (Mochari et al., 2008, p.1509).  The participants were already taking part in a study 
conducted by the National Heart, Lung, and Blood Institute’s Family Intervention Trial for 
Heart Health. The participants were eligible if they were  family members or cohabitants of 
patients hospitalized with CVD, were aged 20-79 years, did not have CVD or diabetes, and 
spoke either English or Spanish.  There were 421 subjects in this study whose oral health 
condition was evaluated based on the answers they provided to questionnaires with regard 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 93

Scientia et Humanitas: A Journal of Student Research

92 Spring 2014

to their oral health status which were designed to be predictive of clinical attachment loss 
and periodontitis.  Questionnaires addressing dietary assessments and physical health 
were included further to screen the participants.  BMI and blood pressure screenings 
were conducted by trained examiners using automated equipment.  Blood specimens were 
taken and analyzed at the Columbia University Clinical and Translational Science Award 
Center.  The data was collected using standardized forms and double entered, to prevent 
contamination based on human error, into a Microsoft Access Database.  The results 
showed a statistically-significant difference in the amount of inflammatory markers for 
CVD, particularly Lp-Pla2 in patients with periodontal disease.  According to Mochari et 
al. (2008),“The data supports a possible independent association between oral health and 
inflammation, suggesting that inflammation may be the factor in the relationship between 
oral health and CVD” (p. 1512).  This association is shown by the increased amount of 
inflammatory markers found the blood samples obtained from patients with periodontal 
disease.  The research showed that women were more likely than men to have increased 
levels of Lp-Pla2, while men had a higher likelihood of having elevated amounts of CRP.  
The research also disproved a connection between age, education level, and having health 
insurance with elevated levels of either inflammatory marker studied.  

The results of this study are dependent on self-reported periodontal disease.  This is a 
noteworthy limitation, as the true state of the participants’ oral health is not documented or 
quantified by any measurable standard.  The participants in this study may not be indicative 
of the population as they were volunteers and may have characteristics unlike those of the 
rest of the population, such as an increased access to care.

The identification of shared risk factors for cardiovascular disease and periodontal 
disease has allowed researchers to eliminate or attempt to reduce the impact of these factors 
in the design of their studies.  The ability to limit these variables, such as smoking and 
diabetes, provides research that more accurately measures the link between the conditions 
being evaluated.   Berent et al.. (2009), conducted a prospective epidemiologic study of 
patients undergoing coronary angiography, which is a procedure used to assess cardiovascular 
disease (CVD), including 466 patients in the research.  The participants were admitted 
to the General Hospital in Wels by recommendation of their physicians to evaluate the 
presence and extent of CVD using scores to measure the amount of vascular stenosis, the 
narrowing of blood vessels that can restrict blood flow.  Blood samples were collected from 
the participants and analyzed for inflammatory markers, specifically CRP.  The periodontal 
health of the participants was evaluated using radiographs, and an examination by a dentist 
using the Community Periodontal Index of Treatment Needs (CPITN).  This screening 
index was designed by the World Health Organization to assess the treatment needs of a 
community; scores of three (3) or above indicate the presence of periodontal disease.  The 
participants were also interviewed with regard to their oral health behaviors at home by the 
dentist conducting the screenings.  The results confirmed a significant association between 
periodontal disease and CVD, although it did not draw a correlation between measurable 
signs of periodontal disease and the severity of CVD.  The results showed that the number 

of patients with confirmed CVD showed a higher prevalence of periodontal disease than 
those participants without CVD.   According to Berent et al (2009), “CPITN scores of at 
least 3 were observed in 38% of patients with CHD and 27% of patients without CHD”(p. 
130). 

This study made adjustments for shared risk factors, namely diabetes, smoking, and 
age.  These confounding variables had the potential to interfere with the data, adjusting 
for them strengthens the validity of the findings.  The extensive data collection process and 
standardized tests and indices used to quantify the presence and extent of disease also add 
a measure of reliability to the study.  The aim of this study was to determine a correlation 
between CVD and PD, the method and treatment succeeded in demonstrating a link.  The 
authors’ suggestion that further research be done to determine the effect of periodontal 
therapy on CVD status was a logical next step and increases the usefulness of this research.

Periodontal pathogens, microbes implicated in periodontal disease, have been identified 
and studied.  Research to determine if these microbes are involved in cardiovascular disease 
helped to strengthen the link between oral and systemic health.  Hyvarinen et al..  (2012), 
described the purpose of the study they conducted at the Helsinki University Central 
Hospital, as investigating the “association between angiographically verified coronary 
artery disease (CAD) and salivary levels of four major periodontal pathogens” (p. 478). 
Periodontal pathogens are a group of bacteria with disease-causing potential and when 
present are the primary etiologic factors for the loss of supporting structures in the oral 
cavity.  The participants were randomly selected from a group of patients enrolled in the 
Parogene study between June 2006 and March 2008.  These participants were having a 
procedure, coronary angiography, done to diagnose coronary artery disease and the study 
group was made up of 492 patients.  The methods used to acquire the necessary data 
included: coronary angiography to determine coronary artery disease; detailed periodontal 
evaluation including radiographs and full mouth probing with bleeding points to assess 
the extent of periodontal involvement; salivary sample and blood samples to evaluate for 
the presence and prevalence of major periodontal pathogens.   According to Hyvarinen 
et al (2012), the results showed “that high salivary A. actinomycetemcomitans (Aa) levels 
are strongly associated with the risk of angiographically confirmed stable CAD” (p.482).   
Aa has been shown to be strongly associated with moderate-severe periodontal disease, 
and this study supported those findings. This study was not able to show a significant 
relationship between the other three major periodontal pathogens and CAD.  

This research supports the theory that oral health is connected to cardiovascular status 
beyond shared risk factors because the bacteria responsible for periodontal disease were 
evaluated and measured.   The results have an added measure of validity as they confirm 
previously-documented connections between periodontal pathogens and the severity of 
destruction clinically visible in the oral environment.  This study has implications for the 
clinical management of periodontal disease as it supports the need to treat the condition 
to improve systemic health.  The treatment of periodontal disease decreases the number of 
pathogens present, which leads to a suppression of the inflammatory response; the reduction 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 93

Scientia et Humanitas: A Journal of Student Research

92 Spring 2014

to their oral health status which were designed to be predictive of clinical attachment loss 
and periodontitis.  Questionnaires addressing dietary assessments and physical health 
were included further to screen the participants.  BMI and blood pressure screenings 
were conducted by trained examiners using automated equipment.  Blood specimens were 
taken and analyzed at the Columbia University Clinical and Translational Science Award 
Center.  The data was collected using standardized forms and double entered, to prevent 
contamination based on human error, into a Microsoft Access Database.  The results 
showed a statistically-significant difference in the amount of inflammatory markers for 
CVD, particularly Lp-Pla2 in patients with periodontal disease.  According to Mochari et 
al. (2008),“The data supports a possible independent association between oral health and 
inflammation, suggesting that inflammation may be the factor in the relationship between 
oral health and CVD” (p. 1512).  This association is shown by the increased amount of 
inflammatory markers found the blood samples obtained from patients with periodontal 
disease.  The research showed that women were more likely than men to have increased 
levels of Lp-Pla2, while men had a higher likelihood of having elevated amounts of CRP.  
The research also disproved a connection between age, education level, and having health 
insurance with elevated levels of either inflammatory marker studied.  

The results of this study are dependent on self-reported periodontal disease.  This is a 
noteworthy limitation, as the true state of the participants’ oral health is not documented or 
quantified by any measurable standard.  The participants in this study may not be indicative 
of the population as they were volunteers and may have characteristics unlike those of the 
rest of the population, such as an increased access to care.

The identification of shared risk factors for cardiovascular disease and periodontal 
disease has allowed researchers to eliminate or attempt to reduce the impact of these factors 
in the design of their studies.  The ability to limit these variables, such as smoking and 
diabetes, provides research that more accurately measures the link between the conditions 
being evaluated.   Berent et al.. (2009), conducted a prospective epidemiologic study of 
patients undergoing coronary angiography, which is a procedure used to assess cardiovascular 
disease (CVD), including 466 patients in the research.  The participants were admitted 
to the General Hospital in Wels by recommendation of their physicians to evaluate the 
presence and extent of CVD using scores to measure the amount of vascular stenosis, the 
narrowing of blood vessels that can restrict blood flow.  Blood samples were collected from 
the participants and analyzed for inflammatory markers, specifically CRP.  The periodontal 
health of the participants was evaluated using radiographs, and an examination by a dentist 
using the Community Periodontal Index of Treatment Needs (CPITN).  This screening 
index was designed by the World Health Organization to assess the treatment needs of a 
community; scores of three (3) or above indicate the presence of periodontal disease.  The 
participants were also interviewed with regard to their oral health behaviors at home by the 
dentist conducting the screenings.  The results confirmed a significant association between 
periodontal disease and CVD, although it did not draw a correlation between measurable 
signs of periodontal disease and the severity of CVD.  The results showed that the number 

of patients with confirmed CVD showed a higher prevalence of periodontal disease than 
those participants without CVD.   According to Berent et al (2009), “CPITN scores of at 
least 3 were observed in 38% of patients with CHD and 27% of patients without CHD”(p. 
130). 

This study made adjustments for shared risk factors, namely diabetes, smoking, and 
age.  These confounding variables had the potential to interfere with the data, adjusting 
for them strengthens the validity of the findings.  The extensive data collection process and 
standardized tests and indices used to quantify the presence and extent of disease also add 
a measure of reliability to the study.  The aim of this study was to determine a correlation 
between CVD and PD, the method and treatment succeeded in demonstrating a link.  The 
authors’ suggestion that further research be done to determine the effect of periodontal 
therapy on CVD status was a logical next step and increases the usefulness of this research.

Periodontal pathogens, microbes implicated in periodontal disease, have been identified 
and studied.  Research to determine if these microbes are involved in cardiovascular disease 
helped to strengthen the link between oral and systemic health.  Hyvarinen et al..  (2012), 
described the purpose of the study they conducted at the Helsinki University Central 
Hospital, as investigating the “association between angiographically verified coronary 
artery disease (CAD) and salivary levels of four major periodontal pathogens” (p. 478). 
Periodontal pathogens are a group of bacteria with disease-causing potential and when 
present are the primary etiologic factors for the loss of supporting structures in the oral 
cavity.  The participants were randomly selected from a group of patients enrolled in the 
Parogene study between June 2006 and March 2008.  These participants were having a 
procedure, coronary angiography, done to diagnose coronary artery disease and the study 
group was made up of 492 patients.  The methods used to acquire the necessary data 
included: coronary angiography to determine coronary artery disease; detailed periodontal 
evaluation including radiographs and full mouth probing with bleeding points to assess 
the extent of periodontal involvement; salivary sample and blood samples to evaluate for 
the presence and prevalence of major periodontal pathogens.   According to Hyvarinen 
et al (2012), the results showed “that high salivary A. actinomycetemcomitans (Aa) levels 
are strongly associated with the risk of angiographically confirmed stable CAD” (p.482).   
Aa has been shown to be strongly associated with moderate-severe periodontal disease, 
and this study supported those findings. This study was not able to show a significant 
relationship between the other three major periodontal pathogens and CAD.  

This research supports the theory that oral health is connected to cardiovascular status 
beyond shared risk factors because the bacteria responsible for periodontal disease were 
evaluated and measured.   The results have an added measure of validity as they confirm 
previously-documented connections between periodontal pathogens and the severity of 
destruction clinically visible in the oral environment.  This study has implications for the 
clinical management of periodontal disease as it supports the need to treat the condition 
to improve systemic health.  The treatment of periodontal disease decreases the number of 
pathogens present, which leads to a suppression of the inflammatory response; the reduction 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 95

Scientia et Humanitas: A Journal of Student Research

94 Spring 2014

of inflammation has a positive effect on cardiovascular health.  Treatment protocols for 
periodontal disease should be implemented with an eye to the systemic benefit.

Cardiovascular and periodontal diseases have an inflammatory component.  During 
periods of active periodontal disease, inflammation exists in the oral tissues, which triggers 
a systemic reaction.  Blum et al.. (2007) investigated the connection between periodontal 
conditions and systemic inflammation as it relates to cardiovascular disease using 
a prospective case-controlled pilot study.  The purpose of this study as stated by Blum 
(2007) was, “to determine whether periodontitis could be an infectious trigger to systemic 
inflammation, and whether conservative treatment could cure the local infection and 
reverse systemic inflammation”(p. 114).  Participants were selected from patients referred 
to the Outpatient Dental Clinic of the Hospital where the study took place in Galilee, 
Israel.  The study group was comprised of nine out of fifty patients who met the criteria of 
the study.  Exclusion criteria included: 

• history of smoking
• risk factors for cardiovascular disease particularly hypertension
• diabetes
• family history of cardiovascular conditions
• chronic inflammatory conditions
• cancer  
The study group underwent a medical history review and physical examination by a 

team comprised of a periodontist and cardiologist.   This information served as the baseline 
for the experiment and follow-up measurements were made after intervention with 
systemic antibiotics, Amoxicillin and Metronidazole, advanced oral hygiene instruction, 
and two to four sessions of scaling and root planing.  Scaling and root planing is a 
nonsurgical procedure that employs manual and power instruments to free tooth and root 
surfaces from debris and bacteria.  A control group of nine participants was used in this 
study and included participants not diagnosed with periodontal disease and deemed to 
be healthy.  The results of this research showed that there were elevated levels of CRP in 
participants with periodontal disease as compared to those without evidence of periodontal 
disease.  According to Blum et al.. (2007), “periodontitis was improved in all 9 patients 
that completed 3 months of treatment” (p.114).   The results also showed a reduction in 
the levels of CRP post-treatment.  Although there was a reduction in the inflammatory 
markers for cardiovascular disease with the treatment, the levels seen are still higher than 
those seen in healthy patients such as those in the control group.   Blum et al.. (2007), also 
drew the conclusion that treating periodontal disease, “may inhibit systemic inflammation 
and could be used as an important prevention tool” (p. 116).   The results of this study help 
to support current treatment regimes that include oral hygiene instruction, instrumentation 
and chemotherapeutics to improve periodontal health.

This study used methods to increases the significance of the results by testing both 
a study and a control group and by using the same demographics and exclusion criteria 
for each.  The results agree with previous research supported by the American Dental 

Association.  The clinical application of this study supports the treatment of periodontal 
disease using nonsurgical interventions.  Improvements seen in the periodontal status and 
systemic health of participants receiving treatment supports current treatment protocols. 

Dental professionals believe that improving oral care practices will improve patients’ 
health.  If these improvements impact systemic health as well as the oral cavity, then 
motivation and urgency to treat and maintain oral health will be increased.   Frisbee et al.. 
(2010), conducted a cross sectional convenience sample study of 115 subjects. The research 
hypothesis stated that better dental hygiene practices and more frequent preventive dental 
care would be associated with more favorable levels of systemic inflammation.  The data 
for the analysis of inflammatory markers for cardiovascular disease was collected via blood 
samples taken from the subjects.  The participants were required to complete a structured 
questionnaire that detailed their health and lifestyle focusing on their oral hygiene practices, 
dental health, and routine preventive dental care.  Those participants who indicated better 
general oral health showed lower levels of CRP according to Frisbee (2010).  Interestingly, 
the study also found a correlation between specific oral hygiene practices and cardiovascular 
disease risk factors.  The statistics showed, “Less frequent brushing was associated with 
elevated total cholesterol and less frequent flossing was associated with elevated mean 
arterial pressure” (Frisbee, 2010, p.179).  Self-reported oral hygiene practices demonstrated 
an impact on important markers for cardiovascular disease and the analysis of the data 
provided support for the hypothesis.  According to Frisbee et al.. (2010), “Better self-
reported, overall dental health was associated with lower levels of CRP” (p.180).   The 
conclusions drawn support from previous studies that have documented a relationship 
between CRP, aggressive, and localized periodontitis.  It is also interesting to note that 
this study dealt with the non-clinical aspects of periodontal disease and that the increased 
levels of cardiovascular inflammatory markers were present at that point, before the clinical 
signs and symptoms of the disease were evident. Further research to pinpoint the stage at 
which cardiovascular health becomes affected may help develop better preventive strategies 
to reduce the negative systemic influence of periodontal disease.

This study used methods to analyze the data, specifically a multiple linear ordinary least 
squares regression, to allow the correlation strength of the data to be tested.  One significant 
limitation of this study is that the oral hygiene status and practices were self-reported.  The 
reliability of the participants’ responses on the questionnaires was assumed to be accurate 
and true with no criteria in place to test the amount or extent of their periodontal disease 
status.  The volunteers used as the participants in this study are a possible source of bias 
as they may have characteristics unlike the rest of the population, such as increased health 
literacy.  Further research is necessary to determine whether the systemic inflammation 
related to periodontal disease begins before the onset of clinically detectable disease, and if 
so at what point.

Further research conducted by Xu, F. and Lu, B. (2011), attempted to determine if 
periodontal disease had a higher prevalence in patients with cardiovascular disease.  The 
research technique was a multistage cluster design study of 3,661 participants over the 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 95

Scientia et Humanitas: A Journal of Student Research

94 Spring 2014

of inflammation has a positive effect on cardiovascular health.  Treatment protocols for 
periodontal disease should be implemented with an eye to the systemic benefit.

Cardiovascular and periodontal diseases have an inflammatory component.  During 
periods of active periodontal disease, inflammation exists in the oral tissues, which triggers 
a systemic reaction.  Blum et al.. (2007) investigated the connection between periodontal 
conditions and systemic inflammation as it relates to cardiovascular disease using 
a prospective case-controlled pilot study.  The purpose of this study as stated by Blum 
(2007) was, “to determine whether periodontitis could be an infectious trigger to systemic 
inflammation, and whether conservative treatment could cure the local infection and 
reverse systemic inflammation”(p. 114).  Participants were selected from patients referred 
to the Outpatient Dental Clinic of the Hospital where the study took place in Galilee, 
Israel.  The study group was comprised of nine out of fifty patients who met the criteria of 
the study.  Exclusion criteria included: 

• history of smoking
• risk factors for cardiovascular disease particularly hypertension
• diabetes
• family history of cardiovascular conditions
• chronic inflammatory conditions
• cancer  
The study group underwent a medical history review and physical examination by a 

team comprised of a periodontist and cardiologist.   This information served as the baseline 
for the experiment and follow-up measurements were made after intervention with 
systemic antibiotics, Amoxicillin and Metronidazole, advanced oral hygiene instruction, 
and two to four sessions of scaling and root planing.  Scaling and root planing is a 
nonsurgical procedure that employs manual and power instruments to free tooth and root 
surfaces from debris and bacteria.  A control group of nine participants was used in this 
study and included participants not diagnosed with periodontal disease and deemed to 
be healthy.  The results of this research showed that there were elevated levels of CRP in 
participants with periodontal disease as compared to those without evidence of periodontal 
disease.  According to Blum et al.. (2007), “periodontitis was improved in all 9 patients 
that completed 3 months of treatment” (p.114).   The results also showed a reduction in 
the levels of CRP post-treatment.  Although there was a reduction in the inflammatory 
markers for cardiovascular disease with the treatment, the levels seen are still higher than 
those seen in healthy patients such as those in the control group.   Blum et al.. (2007), also 
drew the conclusion that treating periodontal disease, “may inhibit systemic inflammation 
and could be used as an important prevention tool” (p. 116).   The results of this study help 
to support current treatment regimes that include oral hygiene instruction, instrumentation 
and chemotherapeutics to improve periodontal health.

This study used methods to increases the significance of the results by testing both 
a study and a control group and by using the same demographics and exclusion criteria 
for each.  The results agree with previous research supported by the American Dental 

Association.  The clinical application of this study supports the treatment of periodontal 
disease using nonsurgical interventions.  Improvements seen in the periodontal status and 
systemic health of participants receiving treatment supports current treatment protocols. 

Dental professionals believe that improving oral care practices will improve patients’ 
health.  If these improvements impact systemic health as well as the oral cavity, then 
motivation and urgency to treat and maintain oral health will be increased.   Frisbee et al.. 
(2010), conducted a cross sectional convenience sample study of 115 subjects. The research 
hypothesis stated that better dental hygiene practices and more frequent preventive dental 
care would be associated with more favorable levels of systemic inflammation.  The data 
for the analysis of inflammatory markers for cardiovascular disease was collected via blood 
samples taken from the subjects.  The participants were required to complete a structured 
questionnaire that detailed their health and lifestyle focusing on their oral hygiene practices, 
dental health, and routine preventive dental care.  Those participants who indicated better 
general oral health showed lower levels of CRP according to Frisbee (2010).  Interestingly, 
the study also found a correlation between specific oral hygiene practices and cardiovascular 
disease risk factors.  The statistics showed, “Less frequent brushing was associated with 
elevated total cholesterol and less frequent flossing was associated with elevated mean 
arterial pressure” (Frisbee, 2010, p.179).  Self-reported oral hygiene practices demonstrated 
an impact on important markers for cardiovascular disease and the analysis of the data 
provided support for the hypothesis.  According to Frisbee et al.. (2010), “Better self-
reported, overall dental health was associated with lower levels of CRP” (p.180).   The 
conclusions drawn support from previous studies that have documented a relationship 
between CRP, aggressive, and localized periodontitis.  It is also interesting to note that 
this study dealt with the non-clinical aspects of periodontal disease and that the increased 
levels of cardiovascular inflammatory markers were present at that point, before the clinical 
signs and symptoms of the disease were evident. Further research to pinpoint the stage at 
which cardiovascular health becomes affected may help develop better preventive strategies 
to reduce the negative systemic influence of periodontal disease.

This study used methods to analyze the data, specifically a multiple linear ordinary least 
squares regression, to allow the correlation strength of the data to be tested.  One significant 
limitation of this study is that the oral hygiene status and practices were self-reported.  The 
reliability of the participants’ responses on the questionnaires was assumed to be accurate 
and true with no criteria in place to test the amount or extent of their periodontal disease 
status.  The volunteers used as the participants in this study are a possible source of bias 
as they may have characteristics unlike the rest of the population, such as increased health 
literacy.  Further research is necessary to determine whether the systemic inflammation 
related to periodontal disease begins before the onset of clinically detectable disease, and if 
so at what point.

Further research conducted by Xu, F. and Lu, B. (2011), attempted to determine if 
periodontal disease had a higher prevalence in patients with cardiovascular disease.  The 
research technique was a multistage cluster design study of 3,661 participants over the 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 97

Scientia et Humanitas: A Journal of Student Research

96 Spring 2014

age of thirty who had received a periodontal examination from NHANES III mortality 
follow-up sample. The participants were classified as having moderate or severe periodontal 
disease using examination procedures obtained on the CDC website which are based on a 
numeric value for the amount of attachment loss present in the mouth.  The stated purpose 
of the study was to evaluate the relationship of periodontal disease to cardiovascular disease.  
The study used data collected from the National Death Index records to determine the 
cause of death.  The results of the data analysis showed that “men with severe PD still have 
an increased risk for CVD and all-cause mortality compared to men without PD in the 
younger group” (Xu & Lu, 2011, p.539).  The results failed to show a relationship between 
periodontal disease and cardiovascular disease in older men and women.  

The information gained through this study is limited as it was taken from post-mortem 
examinations of the participants.  Periodontal disease has periods of activity and remission, 
the use of information from death certificates does not permit the distinction between 
current disease activity and the damage to the periodontium seen from disease potentially 
in a state of remission.  The data contained in death certificates is also subject to error and 
this may impact the results of this study.  The findings listed by Xu and Lu (2011), support 
the results of many other studies.  The validity of this work is supported by comparison to 
research conducted by Kodovazenitis et al..(2011), which also documented an increase in 
the amount of CRP in participants with periodontal disease. 

Current research has not proven that the connection between cardiovascular disease 
and periodontal disease encompasses all aspects of the disease process.  Sridhar et al.. 
(2009), conducted a study to evaluate the relationship between periodontitis, cardiovascular 
disease and serum lipid levels.  The study included 120 participants who were divided into 
4 groups sharing common traits.  Group A were periodontally healthy patients without a 
diagnosed cardiovascular condition and served as the control group for the study.  Group 
B consisted of participants with chronic periodontitis and no documented cardiovascular 
concerns.  Group C participants displayed chronic periodontitis and coronary heart disease 
(CHD).  Group D included those participants with CHD but no measurable signs of 
periodontitis.  The inclusion criteria used for this study included subjects between 40 and 
60 years of age, a minimum of 14 natural teeth present, clinical attachment of at least 1mm 
on 30% of teeth present, and CHD diagnosed with a coronary angiogram.  Sridar et al.. 
(2009), listed the exclusion criteria as: 

• other systemic diseases
• non-ambulatory CHD patients
• use of drugs for hyperlipidemia(high cholesterol) 
• antibiotic treatment for 4 weeks before the start of the study
• dental treatment 6 months before the start of the study
• tobacco use

Serum levels were measured from blood samples taken at fasting levels for all participants 
and evaluated for total cholesterol, low and high density lipoprotein, as well as triglyceride 
levels.  The periodontal status was evaluated by an intra-oral examination which included 

Gingival Index, Oral Hygiene Index, Periodontal Disease Index scores, and attachment 
loss measurements.  The results did not show a correlation between periodontitis and serum 
lipid levels, and the presence of elevated levels of triglycerides did not have an adverse effect 
on the attachment levels of the subjects.  The results also concluded that there was not a 
significant difference in the serum levels of LDL levels in periodontally healthy patients as 
compared with patients with documented disease.

The use of indices accurately to diagnose participants used in this study adds to the 
validity of the results and the use of standard tests to measure serum levels of lipids also 
contributes to the reliability of the data collected by providing consistency.  While this study 
did not show a correlation between periodontitis and serum lipid levels it did not disprove 
a link between cardiovascular disease and periodontitis.  The use of a greater number of 
participants and evaluating other aspects of cardiovascular disease could further document 
the correlation between the two conditions.

During dental procedures, oral tissues are manipulated and bleeding frequently occurs. 
The impact that treating dental disease has on the systemic health has been studied.  
Minasslan et al.. (2010), conducted a self-controlled case series to investigate whether 
invasive dental treatment affected the number of vascular events.   Minasslan et al.. (2010), 
stated the null hypothesis, which implies that two aspects in a study are not related, as 
“rates of vascular events remain constant from day to day and are not affected by exposure 
to invasive dental treatment” (p. 500).   Stating a research goal in terms of a null hypothesis, 
encourages the study design to attempt to prove that theory.  The participants were selected 
from the Medicaid database and included 1,152 patients admitted for hospitalization for 
ischemic stroke or myocardial infarction over the age of twenty years.  The database listed 
the disease conditions using the International Classification of Diseases, Ninth Revision, 
Clinical Modification, classification system.  The study collected data for twenty-four weeks 
before the first cardiovascular event and included only those subjects that had invasive 
dental treatment and a cardiovascular event during the observation period.  Exclusion 
criteria used for this study included:

• history of diabetes
• hypertension 
• coronary artery disease
• participants with prescriptions for antiplatelet or salicylate drugs

The information regarding invasive dental treatment was collected based on the Current 
Dental Terminology coding system and included procedures such as, periodontal therapy, 
invasive dental surgery, simple extractions, and complicated extractions.  Each procedure 
was followed by twenty-four weeks of observation.  The results demonstrated a significant 
increase in the number of vascular events in the four weeks following invasive dental 
procedures.  The results also showed that the increased risk of cardiovascular complications 
following invasive dental procedures declined and reached baseline levels within six 
months.  The data supports findings that periodontal therapy has the potential to increase 
the systemic inflammatory response, which can impair the function of the blood vessels for 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 97

Scientia et Humanitas: A Journal of Student Research

96 Spring 2014

age of thirty who had received a periodontal examination from NHANES III mortality 
follow-up sample. The participants were classified as having moderate or severe periodontal 
disease using examination procedures obtained on the CDC website which are based on a 
numeric value for the amount of attachment loss present in the mouth.  The stated purpose 
of the study was to evaluate the relationship of periodontal disease to cardiovascular disease.  
The study used data collected from the National Death Index records to determine the 
cause of death.  The results of the data analysis showed that “men with severe PD still have 
an increased risk for CVD and all-cause mortality compared to men without PD in the 
younger group” (Xu & Lu, 2011, p.539).  The results failed to show a relationship between 
periodontal disease and cardiovascular disease in older men and women.  

The information gained through this study is limited as it was taken from post-mortem 
examinations of the participants.  Periodontal disease has periods of activity and remission, 
the use of information from death certificates does not permit the distinction between 
current disease activity and the damage to the periodontium seen from disease potentially 
in a state of remission.  The data contained in death certificates is also subject to error and 
this may impact the results of this study.  The findings listed by Xu and Lu (2011), support 
the results of many other studies.  The validity of this work is supported by comparison to 
research conducted by Kodovazenitis et al..(2011), which also documented an increase in 
the amount of CRP in participants with periodontal disease. 

Current research has not proven that the connection between cardiovascular disease 
and periodontal disease encompasses all aspects of the disease process.  Sridhar et al.. 
(2009), conducted a study to evaluate the relationship between periodontitis, cardiovascular 
disease and serum lipid levels.  The study included 120 participants who were divided into 
4 groups sharing common traits.  Group A were periodontally healthy patients without a 
diagnosed cardiovascular condition and served as the control group for the study.  Group 
B consisted of participants with chronic periodontitis and no documented cardiovascular 
concerns.  Group C participants displayed chronic periodontitis and coronary heart disease 
(CHD).  Group D included those participants with CHD but no measurable signs of 
periodontitis.  The inclusion criteria used for this study included subjects between 40 and 
60 years of age, a minimum of 14 natural teeth present, clinical attachment of at least 1mm 
on 30% of teeth present, and CHD diagnosed with a coronary angiogram.  Sridar et al.. 
(2009), listed the exclusion criteria as: 

• other systemic diseases
• non-ambulatory CHD patients
• use of drugs for hyperlipidemia(high cholesterol) 
• antibiotic treatment for 4 weeks before the start of the study
• dental treatment 6 months before the start of the study
• tobacco use

Serum levels were measured from blood samples taken at fasting levels for all participants 
and evaluated for total cholesterol, low and high density lipoprotein, as well as triglyceride 
levels.  The periodontal status was evaluated by an intra-oral examination which included 

Gingival Index, Oral Hygiene Index, Periodontal Disease Index scores, and attachment 
loss measurements.  The results did not show a correlation between periodontitis and serum 
lipid levels, and the presence of elevated levels of triglycerides did not have an adverse effect 
on the attachment levels of the subjects.  The results also concluded that there was not a 
significant difference in the serum levels of LDL levels in periodontally healthy patients as 
compared with patients with documented disease.

The use of indices accurately to diagnose participants used in this study adds to the 
validity of the results and the use of standard tests to measure serum levels of lipids also 
contributes to the reliability of the data collected by providing consistency.  While this study 
did not show a correlation between periodontitis and serum lipid levels it did not disprove 
a link between cardiovascular disease and periodontitis.  The use of a greater number of 
participants and evaluating other aspects of cardiovascular disease could further document 
the correlation between the two conditions.

During dental procedures, oral tissues are manipulated and bleeding frequently occurs. 
The impact that treating dental disease has on the systemic health has been studied.  
Minasslan et al.. (2010), conducted a self-controlled case series to investigate whether 
invasive dental treatment affected the number of vascular events.   Minasslan et al.. (2010), 
stated the null hypothesis, which implies that two aspects in a study are not related, as 
“rates of vascular events remain constant from day to day and are not affected by exposure 
to invasive dental treatment” (p. 500).   Stating a research goal in terms of a null hypothesis, 
encourages the study design to attempt to prove that theory.  The participants were selected 
from the Medicaid database and included 1,152 patients admitted for hospitalization for 
ischemic stroke or myocardial infarction over the age of twenty years.  The database listed 
the disease conditions using the International Classification of Diseases, Ninth Revision, 
Clinical Modification, classification system.  The study collected data for twenty-four weeks 
before the first cardiovascular event and included only those subjects that had invasive 
dental treatment and a cardiovascular event during the observation period.  Exclusion 
criteria used for this study included:

• history of diabetes
• hypertension 
• coronary artery disease
• participants with prescriptions for antiplatelet or salicylate drugs

The information regarding invasive dental treatment was collected based on the Current 
Dental Terminology coding system and included procedures such as, periodontal therapy, 
invasive dental surgery, simple extractions, and complicated extractions.  Each procedure 
was followed by twenty-four weeks of observation.  The results demonstrated a significant 
increase in the number of vascular events in the four weeks following invasive dental 
procedures.  The results also showed that the increased risk of cardiovascular complications 
following invasive dental procedures declined and reached baseline levels within six 
months.  The data supports findings that periodontal therapy has the potential to increase 
the systemic inflammatory response, which can impair the function of the blood vessels for 



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 99

Scientia et Humanitas: A Journal of Student Research

98 Spring 2014

a significant (approximately one week) period of time before returning to baseline levels as 
previously documented.  

One notable limitation of this study is the use of the Medicaid population as these 
participants may have characteristics that may not be representative of the entire population, 
such as low socioeconomic status and a heavy proportion of disabilities.  Another concern 
for the reliability of this study is that the use of over-the-counter medications with the 
potential to affect the cardiovascular system was not considered or addressed.  The validity 
of the study is strengthened by the large number of participants, the length of the study, 
the uniform coding of the disease status for the participants as well as the outcome of their 
events.  

The effect that treating periodontal disease has on cardiovascular disease is an important 
aspect of this link that has been evaluated.  This research is significant because it attempts to 
justify the current treatment protocols accepted as standard of care in the dental profession.   
Piconi et al..(2009), attempted to “verify possible correlations between periodontal disease 
and atherosclerosis in the clinical setting” (p. 1197).  The participants of this longitudinal 
study were thirty-five otherwise healthy subjects, with a mean age of 46.21 years, who 
were diagnosed with mild to moderate periodontal disease.  The study took place at the 
Dental Clinic of the Luigi Sacco University Hospital in Milan, Italy.  All participants were 
screened for medical conditions that could be confounding variables.  Exclusion criteria for 
this group included:

• acute infectious diseases
• respiratory disease
• cardiovascular disease
• metabolic conditions
• kidney disease
• tumors
• antibiotic treatment in the previous 6 months

Baseline data was collected to determine the amount of inflammatory markers for 
cardiovascular disease present using blood samples and Echo-Doppler cardiography of 
the carotid artery.  Periodontal status was evaluated using the Periodontal Screening and 
Recording Index (PSR), plaque scores, and bleeding points.  The numbers and types of 
periodontal pathogens were measured by collecting and analyzing the crevicular fluid using 
paper points inserted into four sites per participant.  The participants underwent periodontal 
therapy that included anti-infectives and non-surgical debridements that were completed 
by the fourth week.   Data was then collected again at one, six, and twelve month intervals 
and compared.  The results showed that the treatment applied to the participants caused a 
significant reduction in the total number of periodontal pathogens present.  The treatment 
also resulted in a decrease in the amount of inflammatory markers for cardiovascular disease 
in the blood as well as the adhesion and activation proteins.  The thickness of the intima-
media, a measurement of the innermost two layers of the arterial wall, was also decreased 

after treatment.  A reduction is a positive finding because the thicker the arterial wall, the 
more blood flow is reduced which contributes to cardiovascular complications. 

This research further supports the link between periodontal pathogens that cause 
inflammation in the oral cavity and increased systemic inflammation that contributes to 
cardiovascular disease.  Of concern is that the positive effects of treating periodontal disease 
are time-limited, as the levels of periodontal pathogens gradually increase within the 
twelve month period studied and indicate the necessity to provide continuous treatment 
to maintain improvements. The longitudinal method used in this research is verified by 
repeated observation of the variable over a long period of time.  Using exclusion criteria 
to limit confounding variables strengthens the validity and the applied therapy was 
standardized and the measurements taken were reliable.  This is notable because limiting 
the effect of shared risk factors for these diseases strengthens their relationship beyond 
common characteristics.

Conclusion
While a causal relationship between periodontal disease and cardiovascular disease has 

not been documented, a relationship does exist.   Helfand et al.. (2009) state, “Our review and 
meta-analyses suggest that periodontal disease is an independent, though relatively weak, 
risk factor for CHD” (p. 502).   Cardiovascular and periodontal disease are both prevalent 
conditions with multifactorial etiologies.  The value of assessing and treating periodontal 
disease is supported by this literature review as the correlation between periodontal disease 
and cardiovascular disease needs to be of concern for patients and healthcare practitioners.  
Luciak et al.. (2007), suggest that early treatment might have a positive effect on the 
health of those at risk for periodontal conditions.  The use of screening methods to detect 
periodontal conditions was found to be beneficial in this study.   Nonsurgical treatment 
of periodontal disease has been shown to improve not only the oral health of patients but 
also their systemic health.  According to Pickett (2012), treatment can reduce the clinical 
signs of the disease and decrease the systemic inflammatory response.   The alteration of 
inflammatory markers with periodontal therapy is a significant finding and supports the 
need to address the condition.  Lockhart et al.. (2012), state that several cohort studies 
and randomized clinical trials have reported improvements in endothelial function and 
associated markers for inflammation among subjects who have undergone nonsurgical 
periodontal therapy, with or without systemic antibiotics.   Of great concern for dental 
providers is the return to baseline levels of the bacterial burden and inflammatory markers 
over time.  Long-term interventions need to be incorporated into treatment protocols to 
maintain the improvements seen with initial therapies.  Kuo et al.. (2007), support the 
treatment of periodontal diseases to improve systemic health.  According to Kuo et al.. 
(2007), prevention and management of periodontal diseases can have a significant impact 
on the improvement of cardiovascular function at a public health level.  



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 99

Scientia et Humanitas: A Journal of Student Research

98 Spring 2014

a significant (approximately one week) period of time before returning to baseline levels as 
previously documented.  

One notable limitation of this study is the use of the Medicaid population as these 
participants may have characteristics that may not be representative of the entire population, 
such as low socioeconomic status and a heavy proportion of disabilities.  Another concern 
for the reliability of this study is that the use of over-the-counter medications with the 
potential to affect the cardiovascular system was not considered or addressed.  The validity 
of the study is strengthened by the large number of participants, the length of the study, 
the uniform coding of the disease status for the participants as well as the outcome of their 
events.  

The effect that treating periodontal disease has on cardiovascular disease is an important 
aspect of this link that has been evaluated.  This research is significant because it attempts to 
justify the current treatment protocols accepted as standard of care in the dental profession.   
Piconi et al..(2009), attempted to “verify possible correlations between periodontal disease 
and atherosclerosis in the clinical setting” (p. 1197).  The participants of this longitudinal 
study were thirty-five otherwise healthy subjects, with a mean age of 46.21 years, who 
were diagnosed with mild to moderate periodontal disease.  The study took place at the 
Dental Clinic of the Luigi Sacco University Hospital in Milan, Italy.  All participants were 
screened for medical conditions that could be confounding variables.  Exclusion criteria for 
this group included:

• acute infectious diseases
• respiratory disease
• cardiovascular disease
• metabolic conditions
• kidney disease
• tumors
• antibiotic treatment in the previous 6 months

Baseline data was collected to determine the amount of inflammatory markers for 
cardiovascular disease present using blood samples and Echo-Doppler cardiography of 
the carotid artery.  Periodontal status was evaluated using the Periodontal Screening and 
Recording Index (PSR), plaque scores, and bleeding points.  The numbers and types of 
periodontal pathogens were measured by collecting and analyzing the crevicular fluid using 
paper points inserted into four sites per participant.  The participants underwent periodontal 
therapy that included anti-infectives and non-surgical debridements that were completed 
by the fourth week.   Data was then collected again at one, six, and twelve month intervals 
and compared.  The results showed that the treatment applied to the participants caused a 
significant reduction in the total number of periodontal pathogens present.  The treatment 
also resulted in a decrease in the amount of inflammatory markers for cardiovascular disease 
in the blood as well as the adhesion and activation proteins.  The thickness of the intima-
media, a measurement of the innermost two layers of the arterial wall, was also decreased 

after treatment.  A reduction is a positive finding because the thicker the arterial wall, the 
more blood flow is reduced which contributes to cardiovascular complications. 

This research further supports the link between periodontal pathogens that cause 
inflammation in the oral cavity and increased systemic inflammation that contributes to 
cardiovascular disease.  Of concern is that the positive effects of treating periodontal disease 
are time-limited, as the levels of periodontal pathogens gradually increase within the 
twelve month period studied and indicate the necessity to provide continuous treatment 
to maintain improvements. The longitudinal method used in this research is verified by 
repeated observation of the variable over a long period of time.  Using exclusion criteria 
to limit confounding variables strengthens the validity and the applied therapy was 
standardized and the measurements taken were reliable.  This is notable because limiting 
the effect of shared risk factors for these diseases strengthens their relationship beyond 
common characteristics.

Conclusion
While a causal relationship between periodontal disease and cardiovascular disease has 

not been documented, a relationship does exist.   Helfand et al.. (2009) state, “Our review and 
meta-analyses suggest that periodontal disease is an independent, though relatively weak, 
risk factor for CHD” (p. 502).   Cardiovascular and periodontal disease are both prevalent 
conditions with multifactorial etiologies.  The value of assessing and treating periodontal 
disease is supported by this literature review as the correlation between periodontal disease 
and cardiovascular disease needs to be of concern for patients and healthcare practitioners.  
Luciak et al.. (2007), suggest that early treatment might have a positive effect on the 
health of those at risk for periodontal conditions.  The use of screening methods to detect 
periodontal conditions was found to be beneficial in this study.   Nonsurgical treatment 
of periodontal disease has been shown to improve not only the oral health of patients but 
also their systemic health.  According to Pickett (2012), treatment can reduce the clinical 
signs of the disease and decrease the systemic inflammatory response.   The alteration of 
inflammatory markers with periodontal therapy is a significant finding and supports the 
need to address the condition.  Lockhart et al.. (2012), state that several cohort studies 
and randomized clinical trials have reported improvements in endothelial function and 
associated markers for inflammation among subjects who have undergone nonsurgical 
periodontal therapy, with or without systemic antibiotics.   Of great concern for dental 
providers is the return to baseline levels of the bacterial burden and inflammatory markers 
over time.  Long-term interventions need to be incorporated into treatment protocols to 
maintain the improvements seen with initial therapies.  Kuo et al.. (2007), support the 
treatment of periodontal diseases to improve systemic health.  According to Kuo et al.. 
(2007), prevention and management of periodontal diseases can have a significant impact 
on the improvement of cardiovascular function at a public health level.  



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 101

Scientia et Humanitas: A Journal of Student Research

100 Spring 2014

The diseases reviewed here are complex and have many shared characteristics and 
a connection between periodontal disease and cardiovascular disease is supported.  The 
data does not infer a causal relationship, merely a relationship that extends beyond shared 
risk factors.  The treatment and management of periodontal disease has been shown to 
improve both systemic and oral health, having an impact on inflammatory markers for 
cardiovascular disease and decreasing the destructive bacteria that is harbored in periodontal 
pockets.  The value of properly identifying and treating periodontal disease should not be 
understated, as it is a significant factor in the progression of cardiovascular disease, which 
is the leading cause of death in the United States.   Current standards of treatment aim to 
reduce the presence and extent of periodontal disease and need to be continually updated 
with evidence based protocols.  The management of periodontal disease needs to include 
long-term and continuous interventions to maintain improvements.

References
Berent, R., Auer, J., Schmid, P., Krennmair, G., Crouse, S., Green, J., ...von Duvillard, S. (2009).  Periodontal 

and coronary heart disease in patients undergoing coronary angiography.  Metabolism Clinical and 
Experimental, 60, 127-133. doi:10.1016/j.metabol.2009.12.016

Blum, A., Frnoy, E., Peleg, A. (2007). Periodontal care may improve systemic inflammation.  Clinical & 
Investigative Medicine, 30 (3), E114-E117.

Frisbee, S., Chambers, C., Frisbee, J., Goodwill, A., Crout, R. (2010). Association between dental hygiene, 
cardiovascular disease risk factors and systemic inflammation in rural adults.  Journal of Dental 
Hygiene, 84(4), 177-184. 

Helfand, M., Buckley, D., Freeman, M., Fu, R., Rogers, K., Fleming, C., Humphrey, L. (2009).  Emerging 
risk factors for coronary heart disease: a summary of systemic reviews conducted for the U. S. 
Preventive Services Task Force.  Annals of Internal Medicine, 151 (7), 496-507. 

Hyvarinen, K., Mantyla, P., Buhlin, K., Paju, S., Nieminen, M., Sinisalo, J., Pussinen, P. (2012). A common 
periodontal pathogen has an adverse association with both acute and stable coronary artery disease.  
Atherosclerosis, 223, 478-484.  doi:10.1016/j.atherosclerosis.2012.05.021

Kodovazenitis, G., Pitsavos, C., Papadimitriou, L., Deliargyris, E., Vrotsos, I., Stefanadis, C., Madianos, 
P. (2011). Periodontal disease is associated with higher levels of C-reactive protein in non-diabetic, 
non-smoking acute myocardial infarction patients.  Journal of Dentistry, 39, 849-854.  doi:10.1016/j.
jdent. 2011.09.005

Kuo, L., Polson, A., Kang, T. (2007). Associations between periodontal diseases and systemic diseases: A 
review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular 
diseases and osteoporosis.  Journal of The Royal Institute of Public Health, 122, 417-433.  doi:10.1016/j.
puhe.2007.07.004

Lockhart, P., Bolger, A., Papapanou, P., Osinbowale, O., Trevisan, M., Levison,  M., Baddour, 
L.   (2012).  Periodontal disease and athersclerotic vascular disease: does the evidence support an 
independent association?  Circulation, 125, 2520-2544.  doi:10.1161/CIR.0b013e31825719f3

Luciak-Donsberger, C., Piribauer, F. (2007).  Evidence-based rational supports a national periodontal 
disease screening program.  Journal of Evidence-Based Dental Practice, 7, 51-59. doi:10.1016/j.
jebdp.2007.02.001

Minasslan, C., D’Aiuto, F., Hingorani, A., Smeeth, L. (2010).  Invasive dental treatment and risk for 
vascular events.  Annals of Internal Medicicne, 53 (8), 499-506.

Mochari, H., Grbic, J., Mosca, L.  (2008).  Usefulness of self-reported periodontal disease to identify 
individuals with elevated inflammatory markers at risk of cardiovascular disease.  The American 
Journal of Cardiology, 102, 1509-1513. doi:10.1016/j.amjcard.2008.07.047

Pickett, F. (2012). State of evidence: Chronic periodontal disease and stroke.  Canadian Journal of Dental 
Hygiene, 46 (2), 124-128.  

Piconi, S., Trabattoni, D., Luraghi, C., Perilli, E., Borelli, M., Pacei, M., ...Clerici, M. (2009).  Treatment of 
periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid 
intima-media thickness.  The Federation of American Societies for Experimental Biology Journal, 23, 
1196-1204. doi:10.1096/fj.08-119578



The Link between Cardiovascular Disease and Periodontal Disease:  A Literature Review

Middle Tennessee State University 101

Scientia et Humanitas: A Journal of Student Research

100 Spring 2014

The diseases reviewed here are complex and have many shared characteristics and 
a connection between periodontal disease and cardiovascular disease is supported.  The 
data does not infer a causal relationship, merely a relationship that extends beyond shared 
risk factors.  The treatment and management of periodontal disease has been shown to 
improve both systemic and oral health, having an impact on inflammatory markers for 
cardiovascular disease and decreasing the destructive bacteria that is harbored in periodontal 
pockets.  The value of properly identifying and treating periodontal disease should not be 
understated, as it is a significant factor in the progression of cardiovascular disease, which 
is the leading cause of death in the United States.   Current standards of treatment aim to 
reduce the presence and extent of periodontal disease and need to be continually updated 
with evidence based protocols.  The management of periodontal disease needs to include 
long-term and continuous interventions to maintain improvements.

References
Berent, R., Auer, J., Schmid, P., Krennmair, G., Crouse, S., Green, J., ...von Duvillard, S. (2009).  Periodontal 

and coronary heart disease in patients undergoing coronary angiography.  Metabolism Clinical and 
Experimental, 60, 127-133. doi:10.1016/j.metabol.2009.12.016

Blum, A., Frnoy, E., Peleg, A. (2007). Periodontal care may improve systemic inflammation.  Clinical & 
Investigative Medicine, 30 (3), E114-E117.

Frisbee, S., Chambers, C., Frisbee, J., Goodwill, A., Crout, R. (2010). Association between dental hygiene, 
cardiovascular disease risk factors and systemic inflammation in rural adults.  Journal of Dental 
Hygiene, 84(4), 177-184. 

Helfand, M., Buckley, D., Freeman, M., Fu, R., Rogers, K., Fleming, C., Humphrey, L. (2009).  Emerging 
risk factors for coronary heart disease: a summary of systemic reviews conducted for the U. S. 
Preventive Services Task Force.  Annals of Internal Medicine, 151 (7), 496-507. 

Hyvarinen, K., Mantyla, P., Buhlin, K., Paju, S., Nieminen, M., Sinisalo, J., Pussinen, P. (2012). A common 
periodontal pathogen has an adverse association with both acute and stable coronary artery disease.  
Atherosclerosis, 223, 478-484.  doi:10.1016/j.atherosclerosis.2012.05.021

Kodovazenitis, G., Pitsavos, C., Papadimitriou, L., Deliargyris, E., Vrotsos, I., Stefanadis, C., Madianos, 
P. (2011). Periodontal disease is associated with higher levels of C-reactive protein in non-diabetic, 
non-smoking acute myocardial infarction patients.  Journal of Dentistry, 39, 849-854.  doi:10.1016/j.
jdent. 2011.09.005

Kuo, L., Polson, A., Kang, T. (2007). Associations between periodontal diseases and systemic diseases: A 
review of the inter-relationships and interactions with diabetes, respiratory diseases, cardiovascular 
diseases and osteoporosis.  Journal of The Royal Institute of Public Health, 122, 417-433.  doi:10.1016/j.
puhe.2007.07.004

Lockhart, P., Bolger, A., Papapanou, P., Osinbowale, O., Trevisan, M., Levison,  M., Baddour, 
L.   (2012).  Periodontal disease and athersclerotic vascular disease: does the evidence support an 
independent association?  Circulation, 125, 2520-2544.  doi:10.1161/CIR.0b013e31825719f3

Luciak-Donsberger, C., Piribauer, F. (2007).  Evidence-based rational supports a national periodontal 
disease screening program.  Journal of Evidence-Based Dental Practice, 7, 51-59. doi:10.1016/j.
jebdp.2007.02.001

Minasslan, C., D’Aiuto, F., Hingorani, A., Smeeth, L. (2010).  Invasive dental treatment and risk for 
vascular events.  Annals of Internal Medicicne, 53 (8), 499-506.

Mochari, H., Grbic, J., Mosca, L.  (2008).  Usefulness of self-reported periodontal disease to identify 
individuals with elevated inflammatory markers at risk of cardiovascular disease.  The American 
Journal of Cardiology, 102, 1509-1513. doi:10.1016/j.amjcard.2008.07.047

Pickett, F. (2012). State of evidence: Chronic periodontal disease and stroke.  Canadian Journal of Dental 
Hygiene, 46 (2), 124-128.  

Piconi, S., Trabattoni, D., Luraghi, C., Perilli, E., Borelli, M., Pacei, M., ...Clerici, M. (2009).  Treatment of 
periodontal disease results in improvements in endothelial dysfunction and reduction of the carotid 
intima-media thickness.  The Federation of American Societies for Experimental Biology Journal, 23, 
1196-1204. doi:10.1096/fj.08-119578



Faith-based Aviation: An Ethnographic Study of Missionary Flights International

Middle Tennessee State University 103

Scientia et Humanitas: A Journal of Student Research

102 Spring 2014

Skilton, M., Maple-Brown, L., Kapellas, K., Celermajer, D., Bartold, M., Brown, A.,...Jamieson, L.  (2011). 
The effect of a periodontal intervention on cardiovascular risk markers in Indigenous Australians with 
periodontal disease:  the PerioCardio study.  BioMed Central Public Health, 11:729, 1-8. 

Sridhar, R., Byakod, G., Pudakalkatti, P., Patil, R. (2009). A study to evaluate the relationship between 
periodontitis, cardiovascular disease and serum lipid levels.  International Journal of Dental Hygiene, 
7(2), 144-150.  doi:10.1111/j.1601-5037.2008.00318.x

Xu, F., Lu, B. (2011). Prospective association of periodontal disease with cardiovascular and all-
cause mortality: NHANES III follow-up study. Athersclerosis, 218, 536-542. doi:10.1016/j.
athersclerosis.2011.07.091

Faith-based Aviation: An Ethnographic Study of Missionary 
Flights International

Joseph Cooper

Abstract
The development of faith-based missionary aviation is a post-World War II phenomenon. The 

war effort demonstrated the value, utility, and global reach of aviation to remote, underdeveloped 
areas of the world. With the beginnings of a worldwide infrastructure for aviation, Christian 
aviators realized aviation could increase the range and effectiveness of their efforts to reach the 
world for Christ (Mellis, 2006).   

A qualitative, ethnographic study was conducted to document the activities of one faith-based 
aviation organization to gain an understanding of this little known-aspect of civilian aviation. 
The study was conducted with Missionary Flights International (MFI) of Fort Pierce, Florida, 
which has been involved in faith-based missionary aviation since its inception in 1964. 

A constant comparative method was utilized to identify common elements, themes and patterns; 
common threads woven throughout the fabric of the organization and its culture. With the use of 
triangulation, three sides of input data from interviews, questionnaires and observations, two 
general phenomena, aviation and missions, each with six related categories emerged, describing the 
organization.  MFI provides twice a week service to the island of Hispaniola and the Republic of 
Haiti. In this in-depth study, insight and understanding were gained into the purpose of MFI, its 
daily routines and operations, and the challenges it faces in maintaining its flight services to Haiti.