Editors' consensus
The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease

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Acknowledgment

This Editors' Consensus is supported by an educational grant from Colgate-Palmolive, Inc., New York, New York, and is based on a meeting of the authors held in Boston, Massachusetts, on January 9, 2009.

Disclosure

Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Kornman is a full-time employee and shareholder of Interleukin Genetics, Waltham, Massachusetts, which owns patents on genetic biomarkers for chronic inflammatory diseases. Dr. Genco is a consultant to Merck. Dr. Ridker has received research support from AstraZeneca, Wilmington, Delaware; Novartis; Pfizer, New York, New York; Roche, Nutley, New Jersey; Sanofi-Aventis, Bridgewater, New Jersey; and

Inflammation and Atherosclerotic Cardiovascular Disease

The dietary ingestion of low-density lipoprotein (LDL), mainly from animal fat, with subsequent lipid oxidation and accumulation of lipid products within the arterial vascular wall is essential for atherogenesis. Thus, the most important current strategies for preventing atherosclerotic CVD are dietary fat restriction and pharmacologic measures that lower serum levels of LDL cholesterol. A number of risk factors also relate closely to the development of atherosclerotic disease and risk for

Periodontitis and Atherosclerotic Cardiovascular Disease

The association between periodontitis and atherosclerotic CVD has received considerable attention.58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91 The findings of these studies, however, have varied greatly, ranging from determinations of no causative relation between periodontitis and CVD to strong causative connections between the 2 conditions. Reasons for the discrepancies in the results of these studies

Mechanisms for an Association Between Periodontitis and Atherosclerotic Cardiovascular Disease

A direct causal relation between periodontitis and atherosclerotic CVD is not established. Multiple studies, however, support 2 biologically plausible mechanisms98, 99, 100, 101: (1) Moderate to severe periodontitis increases the level of systemic inflammation, a characteristic of all chronic inflammatory diseases, and periodontitis has been associated with increased systemic inflammation as measured by hsCRP and other biomarkers. Treatment of moderate to severe periodontitis sufficient to

Clinical Recommendations: Patients With Periodontitis

Although the treatment of periodontitis reduces systemic markers of inflammation and endothelial dysfunction, no prospective periodontitis intervention studies have evaluated CVD outcomes. It seems reasonable, however, on the basis of current data, to acknowledge that because untreated or inadequately controlled moderate to severe periodontitis increases the systemic inflammatory burden, periodontitis may independently increase the risk for CVD. (See Table 1 for confidence and evidence level

Clinical Recommendations: Patients With Atherosclerotic Cardiovascular Disease With or Without a Previous Diagnosis of Periodontitis

I. Patients With Atherosclerotic CVD and Previous Diagnosis of Periodontitis

Recommendation: Periodontists and physicians managing patients with CVD should closely collaborate to optimize CVD risk reduction and periodontal care.

Confidence and evidence level: 1D

II. Patients With Atherosclerotic CVD and No Previous Diagnosis of Periodontitis

Recommendation A: Periodontal evaluation should be considered in patients with atherosclerotic CVD who have signs or symptoms of gingival disease, significant

Recommendations for Future Research

Although the inflammation hypothesis provides a plausible and attractive explanation for the periodontitis-atherosclerosis relation, further research is needed to define the mechanisms linking the 2 diseases and how patients with periodontitis should best be managed to reduce their risk for CVD. Specific questions that the consensus panel believes should be addressed in future research include the following: (1) Is periodontitis an independent risk factor for atherosclerotic CVD? (2) If

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