In this study 33 patients with acute coronary syndrome (ACS-group) were matched in terms of age, gender, and smoking behavior with a proven generally healthy group of blood donors (H-group) and studied with regard to their oral health status. The majority of participants in both groups showed good oral hygiene behavior and control-oriented behavior in relation to the use of dental care and treatment. For the parameter DMF-T, no difference was found between the two groups. Although, in the ACS-group the average loss of teeth (M-T) was higher than in the H-group, the difference was not significant. Regarding the total number of tooth loss the difference between the ACS-group and the H-group was significant. In relation to oral hygiene status (PI) no difference was found between the two groups. In contrast, the ACS patients showed significantly more signs of gingival inflammation (GI) than the H subjects. In the assessment of the periodontal status (PSR®/PSI as well as AL), there were no differences between the groups. Nevertheless, two-third of the ACS-group and approximately one half of the H-group had moderate to severe periodontitis, a finding which was confirmed by the AL.
The finding that the ACS patients showed a higher rate of tooth loss than the H subjects confirmed some previous studies [39
]. Other studies were unable to find a significant difference in the number of missing teeth [19
]. Moreover, a large prospective study in Sweden showed a close relationship between number of missing teeth and cardiovascular and coronary heart diseases (and even cardiovascular mortality), indicating a link between coronary artery disease and oral health [42
]. One participant of each group was toothless. In other studies, the number of toothless individuals with ACS was higher (6–35
In this study the reasons for tooth loss could not be definitely determined but was mainly attributed to destruction by caries. Only in 22
% of the cases periodontitis was given as the reason for tooth loss.
A comparison of the DMF-T of the ACS patients investigated in this study with other studies in CHD patients is limited by the fact that only the number of missing teeth and/or the number of remaining teeth were given. However, the results for DMF-T in the present study (ACS: 18.7
6.8; H: 19.4
5.1) are between the findings for the age group 35 to 44
14.5) and age group 65 to 74
22.1) in the DMS IV (German Study on Oral Health, part IV) [32
Considering the results for PI the differences between the groups were not significant, but oral hygiene in the ACS-group tended to be worse. This finding has been obtained by two other studies [24
]. In the case of ACS patients, however, gingival inflammation was increased significantly versus H subjects. It should be taken into account that 18
% of the ACS patients in the studies mentioned above had diabetes mellitus[44
], and in addition, there were differences in smoking behavior between the ACS patients and the control subjects [24
]. This could possibly have influenced (confounder) the results. In the present study these factors were taken into account by matching procedure and exclusion criteria, and can be excluded as a possible confounder.
Other research groups used other indices for assessing the state of gingival inflammation, e. g., bleeding on probing (BOP); they observed that the ACS patients showed a worse gingival status than control subjects [40
]. These findings could be confirmed by the results of this study. Only one investigation established no difference between the groups [20
In the present study no difference was found between ACS-group and H-group with regard to the periodontal situation (PSR®/PSI and AL). However, two-third of the ACS patients had an increased periodontal treatment need, despite regular visits to the dentist. In contrast, Willershausen et al.[41
] found a significant higher amount of PSI score 4 in their ACS patients, however, it is to mention that there were clearly (significantly) more smokers and diabetics in their ACS-group than in the corresponding control group. Whereas, Katz et al.[45
] were unable to find a significant difference, but instead a tendency of a correlation between CPITN 4 in CHD patients. An association between moderate periodontitis and cardiac disease was likewise not found by this research group [45
]. Spahr et al.[46
], however, reported higher amount of CPITN values (3 and 4) in their CHD patients than in controls. Moreover, a number of authors observed deeper (probing) pocket depths in CHD/ACS patients than in corresponding controls [20
]. The millimetre measurements ranged between 1.8
mm and 5
]. Converted into PSR®/PSI, these values correspond to the scores 0 to 3 and reflect rather moderate periodontitis. In contrast to this, some studies have indicated that in ACS patients significantly more measurement points with increased probe depths of >4
mm or >5
mm were present than in control subjects [19
]. These findings correspond to PSI scores 3 and 4 and are comparable with the results presented here.
Likewise, in the present study, no statistically significant difference was found in relation to loss of attachment (AL). In contrast to this, other studies showed a significant correlation between CHD/ACS and an increased loss of attachment [24
]. Thus, an association between a high loss of attachment and CHD/ACS diagnosis with an OR of 1.5 or 3.8, respectively, has been reported [21
A number of authors established a correlation between a poor state of oral hygiene and CHD/ACS [20
]; according to a meta-analysis, there is an OR of 2.35 for ACS with poor oral hygiene [23
]. Other authors reported there is no association between oral hygiene and CHD/ACS [26
]. This largely agrees with the results of this study. Although the ACS patients in this study had poor oral hygiene, the differences in relation to the healthy control group were marginal. Only in relation to signs of gingival inflammation there were significant differences.
Limitation of the study: Only 33 patients/subjects were included per group. However, they were carefully controlled for confounder such as age and smoking behavior. In addition, for the first time in a case control study, a control group with healthy subjects confirmed by a physician was included. PSR®/PSI was used to assess the periodontal situation. This index provides sufficient information on the condition of the periodontium and allows a comprehensive evaluation of the periodontal situation [35
]. However, it is a screening index to assess the periodontal treatment need. In contrast, there is no information on the actual situation regarding the periodontal destruction. For this reason, AL was used additionally, in order to provide meaningful results. However, it should be noted that, in the pathogenesis of PD and with regard to the consequences for the general state of health, the composition of the biofilm (microbial plaque) plays a decisive role. This point was not taken into account in the study presented here.