Periodontal Disease Is Linked
to Heart Attacks and Strokes

If you have periodontal inflammation of the gums, do not do anything to stress your heart. A recent study has shown that your risk of heart attack is three times greater than if your gums were healthy.

Who is affected? Approximately 80% of all adults in the United States have experienced some degree of periodontitis, a chronic inflammatory disease of the gums and the bone and ligaments that support the teeth. It is usually preceded by gingivitis, an inflammation of the gums that can cause them to swell and bleed. Without treatment, gingivitis often progresses insidiously to periodontitis, which can result eventually in the loss of tissue and bone.

But periodontitis does not stop there. It can have profoundly negative effects on systemic health, particularly in terms of cardiovascular disease, cerebrovascular disease, diabetes, tissue-repair capacity, and immune-cell function.1

In a paper presented recently at the American Heart Association's annual meeting, Dr. Efthymios N. Deliargyris of the University of North Carolina, Chapel Hill, and colleagues compared 38 patients who had recently undergone a heart attack with 38 healthy volunteers.2 They found that 85% of the heart attack patients had periodontal disease, compared with only 29% of the healthy volunteers. Assuming that other relevant factors were properly controlled for, these results suggest strongly that periodontal disease is a problem worth solving if you value your health - and your life.

Dr. Deliargyris believes that a molecule called C-reactive protein may be a link between periodontal disease and heart attacks. The mechanism has to do with the inflammation caused by chronic infection. When infection is high, so are the levels of C-reactive protein in the blood. And once you've had a heart attack, your chances of having another one are increased if your levels of C-reactive protein are high.

Although this is not the first reported instance of a relationship between poor oral health and the risk of heart attack, the full implications are still not clear. And, to make things worse still, there is also the increased risk of stroke, or "brain attack."

The Mouth of the Gift Horse

"Never look a gift horse in the mouth." This obscure proverb - so old that its origins cannot be determined - refers to the bad manners displayed by one who receives a gift and then examines it for defects. Although a horse may appear to be young and frisky, its real age can be judged by looking at its teeth, the condition of which may show it to be fit for almost nothing but the glue-works. Horses get periodontal disease too.

Until recently, human oral bacteria were rarely suspected of causing major disease, but now we have strong evidence that they do. Our mouths harbor a variety of bacteria that, if not controlled, could precipitate disease and even death. So it behooves us to look our own "gift horse" - ourselves - in the mouth. By having an introspective look (literally), we can take one important step toward the gift of good health.

The mythical Trojan horse was a ruse, disguised as a gift to the besieged citizens of ancient Troy. Planned by the Greek King of Ithaca - none other than Odysseus - the huge wooden horse was left outside the city gates. When the Trojans deemed it innocuous and brought it into the city, they celebrated what they presumed to be a gift from the gods, and then they slept. In the night, Greek soldiers hidden in the belly of the horse released themselves to slit the throats of the sleeping guards and open the city gates to their waiting army, thus ending the siege of Troy.

If the Trojans had looked their gift horse in the mouth, metaphorically speaking, they would not have discounted its power to injure them, and the history of Western civilization would be written differently.

At the School of Dental Medicine at the State University of New York at Buffalo, recent studies suggest that chronic infections, including those associated with periodontitis, increase the risk for coronary heart disease (CHD) and stroke.3 Specimens obtained from 50 people undergoing carotid endarterectomy (the surgical removal of the inner lining of the carotid artery when it is clogged with atherosclerotic plaque) were examined for the presence of bacteria. Forty of the specimens were found to have a variety of bacteria and other microbes, including cytomegalovirus and C. pneumoniae. Twenty-two specimens (44%) had at least one periodontal pathogen (disease-causing microbe), and 13 (26%) had P. gingivalis, the bacterium associated with gingivitis. Of the 22 specimens with at least one periodontal pathogen, 13 (59%) had two or more.

Periodontal disease is a problem
worth solving if you value your
health - and your life.

The researchers hypothesize that oral microorganisms enter the bloodstream and become viable during transient bacteremia (a surge in microbial activity). Like other infectious microorganisms, such as C. pneumoniae, these periodontal pathogens may play a role in the development and progression of atherosclerosis, leading to both cardiovascular and cerebrovascular disease.

Until recently, the only ways to deal with periodontal disease were to brush, floss, have your teeth cleaned regularly, and submit to deep scrapings, antibiotic treatments, and possibly surgery. But there is now an additional choice that can help make a difference. It entails the use of the legendary antibacterial resin mastic gum, from the Mediterranean tree Pistacia lentiscus. Mastic is deadly to Helicobacter pylori, the ulcer-causing bacterium, as well as to a wide variety of other oral bacteria, and it is now available in both a toothpaste and a mouthwash.

H. pylori is now generally accepted as playing a key role in the development of ulcers and tumors of the stomach and duodenum. Although it is not generally recognized as a factor in other diseases, data are accumulating to show otherwise. Some studies have pointed to the connection between H. pylori and heart disease, and other diseases as well, including adult-onset diabetes and diseases of the nervous system (see Publisher's Commentary - May 99). There may even be a link with rosacea: treat the H. pylori, and the rosacea seems to fade, according to one study.

How common is H. pylori in the mouth? A study conducted in Pakistan found dental plaque to be an important "reservoir" for the bacteria.4 When 125 males and 53 females who were selected for having bad dental hygiene were examined for H. pylori colonization, 173 of them (97%) were found to be infected. Of these, 140 had what were identified as heavy plaque deposits. By contrast, in the control group of 30 healthy volunteers with good hygiene (17 males and 13 females), 20 had some dental plaque, but only 7 (23%) tested positive for H. pylori.

In India, another study examined the relationship between two reservoirs of H. pylori: dental plaque and the stomach.5 In 43 subjects with indigestion, the bacteria were detected in: dental plaque (98% of the subjects); the antrum (lower portion) of the stomach, which produces gastrin (67%); and throughout the stomach's lining, known as the gastric mucosa, which produces acid (70%). Surprisingly, H. pylori levels were found to be highest in the dental plaque and lowest in the antrum.

Administration of conventional triple-drug therapy (bismuth, tinidazole, and amoxycillin or doxycycline) to 24 of the subjects for 15 days resulted in the elimination of H. pylori from the gastric mucosa of all of them. However, the infection persisted in the dental plaque in all of them. Thus it seems clear that H. pylori infection in dental plaque is not affected by the conventional therapy and represents a likely source of rapid reinfection of the rest of the gastrointestinal tract.

Don't Forget Calcium for Periodontal Disease

The role of calcium in periodontal disease was examined through the data of the Third National Health and Nutrition Examination Survey (NHANES III), which is representative of the U.S. civilian noninstitutionalized population.8 When dietary calcium intake (which was determined from the subjects' recall of their food consumption during a 24-hour period) was compared with the loss of teeth, a clear correlation between lower calcium intake and periodontal disease was found for young males and females (20 to 39 years of age), and for older males (40 to 59 years of age).

For all women, the risk of periodontal disease was 54% greater for the lowest level of daily calcium intake (2 to 499 mg), and 27% greater for a moderate level (500 to 799 mg), than in those who took 800 mg or more per day. A statistically significant correlation between low total serum calcium and periodontal disease was found in the young females, aged 20 to 39, and, to a lesser degree, in the older ones as well. These results suggest that low dietary intake of calcium results in more severe periodontal disease.

Gum disease, apart from being unsightly and uncomfortable, might significantly increase a person's risk of stroke, according to the results of a nationwide study conducted in the United States. Dr. Tiejian Wu and colleagues examined the link between periodontitis and the risk of stroke in nearly 10,000 adults who participated in a large health survey between the early 1970s and 1992.6,7 What they found during a 21-year follow-up period was a significantly increased risk of stroke.

What sets the process in motion is the presence of certain bacteria that, according to Dr. Wu, enter the bloodstream and help stimulate clotting. At the same time, these bacteria may damage the lining of blood vessels, increasing the risk of stroke even more. Stroke is characterized by either bleeding in the brain because of a ruptured vessel or impaired blood flow to a part of the brain when a vessel is blocked by a clot.

While Dr. Wu and colleagues were not able to identify the guilty bacteria, they expect that future research will answer this question, and they caution that oral bacteria are but the tip of the iceberg, the unseen bulk of which can tear the hull out of our systemic health.

Hundreds of millions of people worldwide suffer from peptic ulcers, and even more suffer from other gastrointestinal problems, such as indigestion and heartburn. H. pylori is now blamed for many of these conditions, as well as some of their graver consequences, such as stomach cancer.

An amazing 75% of patients with gastric (stomach) ulcers and more than 95% of those with duodenal (intestinal) ulcers are infected with H. pylori, which the World Health Organization now considers to be a carcinogen. If only the word could get out more widely: There is an affordable and convenient way to prevent (and treat, if necessary) problems of the stomach, the mouth, and, for all we know, the heart, the brain, the insulin system, the immune system, and more. That way is to supplement one's diet with mastic and to brush one's teeth with it and gargle with it.

Dr. Barry J. Marshall, the Australian researcher who discovered the role of H. pylori in the development of ulcers, refers visitors to his Web site ( - home of The Helicobacter Foundation since 1994.


  1. Iacopino AM, Cutler CW. Pathophysiological relationships between periodontitis and systemic disease: recent concepts involving serum lipids. J Periodontol 2000 Aug;71(8):1375-84.
  2. Anon. Gum disease linked to heart attack risk. Nov 13, 2000.
  3. Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ. Identification of periodontal pathogens in atheromatous plaques. J Periodontol 2000 Oct;71(10):1554-60.
  4. Butt AK, Khan AA, Bedi R. Helicobacter pylori in dental plaque of Pakistani. J Int Acad Periodontol 1999 Jul;1(3):78-82.
  5. Desai HG, Gill HH, Shankaran K, Mehta PR, Prabhu SR. Dental plaque: a permanent reservoir of Helicobacter. Scand J Gastroenterol 1991 Nov;26(11):1205-8.
  6. Stern P. Gum disease raises stroke risk. October 27, 2000;
  7. Wu T, Trevisan M, Genco RJ, Dorn JP, Falkner KL, Sempos CT. Periodontal disease and risk of cerebrovascular disease: the first national health and nutrition examination survey and its follow-up study. Arch Intern Med 2000 Oct 9;160(18):2749-55.
  8. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ. Calcium and the risk for periodontal disease. J Periodontol 2000 Jul;71(7):1057-66.

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