Oral health in childhood as a predictor of future cardiovascular risk

There is an increasing amount of evidence supporting the role of the immune system in aetiopathogenesis of cardiovascular diseases, ranging from atherosclerosis, through heart failure and hypertension.1,2 Periodontal disease is one of the most common chronic inflammation in the world population and has been associated with atherosclerosis and hypertension.2 Moreover, the effective treatment of periodontitis leads to decreased blood pressure in hypertensive and pre-hypertensive patients.2–4 Other oral cavity pathologies, such as caries or periapical lesions, are also associated with cardiovascular risk.5,6 In this context, oral cavity could represent a critical culprit of lifetime or long-lasting exposure to inflammation,7 that is likely initiated already in childhood, but exerts its effects in adulthood. This aspect is particularly important for primordial and primary prevention strategies that can bring substantial benefits through inexpensive oral hygiene education and encouragements. Unfortunately, there is a limited number of prospective, cohort studies of children and their follow-up through adulthood. The National Longitudinal Study of Adolescence to adult health followed-up 11 556 participants from baseline of 12–19 years of age until participants were 24–32 years old.8 Deferred dental care was associated with increased systolic [beta = 0.9; 95% confidence interval (CI) 0.4–1.5; P = 0.002] and diastolic (beta = 1.0; 95% CI 0.5–1.5; P < 0.001) blood pressure values and an increased likelihood of being hypertensive (odds ratio = 1.2; 95% CI 1.0–1.3; P = 0.03).8 Kelishadi et al.9 showed data of nationwide population-based study conducted on 5258 Iranian students, aged 10–18 years. Unfortunately, the cohort was not followed prospectively but cardiometabolic risk factors were measured at the baseline. Higher frequency of tooth brushing was associated with lower mean levels of low-density lipoprotein cholesterol (LDL-C) (P < 0.0001) and lower frequency of elevated LDL-C in girls (P = 0.03). The frequency of elevated blood pressure decreased with higher tooth brushing frequency in boys (P = 0.03). After adjustment for potential cofounders such as age, gender, anthropometric indexes, socioeconomic status, and family history of non-communicable diseases, participants who brushed their teeth at least once a day had lower risk of high LDL-C and low high-density lipoprotein cholesterol levels in comparison to those who reported lower frequency of tooth brushing. These interesting studies open an area for further research how the oral heath can impact our cardiovascular risk factors and what mechanisms would be responsible for this causal association. Most likely there are a number of aspects we need to consider (see Figure 1). Firstly, oral cavity may be an important source of low-grade inflammation that may lead to generation of specific immune,10 as well as unspecific inflammatory responses.11 These, while targetable pharmacologically,10 may be modified by appropriate oral hygiene and lifestyle changes, especially in young individuals. At the same time, some systemic cytokines, particularly important in periodontitis or oral inflammation, such as interleukin-33 have multiple effects in the vasculature and metabolism.12 These overlaps and links to fibrosis were proposed in selected vascular therapeutic approaches focusing on therapeutic use of gingival fibroblasts in the vasculature.13 Not only low-grade systemic inflammation driven by the oral cavity pathologies as caries, periapical lesions, and periodontal disease needs to be investigated, but also effect of diet should be taken into account. Children with painful oral cavity disease or with limited number of teeth due to tooth loss have different diet compering to healthy children being able to chew hard vegetables and meats. This hypothesis goes in line with the recently highly debated links between effects of diet and development of hypertension via gut microbiota driven immunometabolism.7,14 The gut microbiome interacts with the immune system—commensal bacteria induce tolerance and soothe the inflammatory responses. At the same time, pathogenic microbes which develop in the presence of high salt, or high fat without sufficient fibre content diet support activation of the immune system which then may contribute to cardiovascular pathologies. This effect is exerted through induction of Th17 cell generation and their subsequent migration to perivascular space and the kidneys, where they can modify vascular function as well as sodium and water balance.14,15 In summary, recent epidemiological evidence provides sufficient proof of concept linking lifetime exposure to oral inflammatory burden with cardiovascular risk, justifying the development and further testing of orally focused therapeutic strategies in the prevention of cardiovascular disease.3 Conflict of interest: none declared. Multiple pathways linking childhood oral heath status and its risk factors to cardiovascular endpoints. Created with BioRender as part of Academic License. Multiple pathways linking childhood oral heath status and its risk factors to cardiovascular endpoints. Created with BioRender as part of Academic License. Biography: Professor Marta Czesnikiewicz-Guzik (BDS PhD) is a specialist in dental surgery and periodontology with a particular interest in the cardiovascular consequences of oral inflammation. Her PhD defined links between oral Helicobacter pylori and gastric infection by this bacterium. After her postdoctoral fellowship at Lowance Centre for Human Immunology, Emory University School of Medicine, Atlanta, USA, in the laboratory of Prof. Jorg Goronzy and Prof. Cornelia Weyand, she turned her research passion to studying immune mechanisms in periodontal disease and its influences on systemic health. She published more than 100 papers in high-impact journals such as the European Heart Journal, Journal of Experimental Medicine, Cardiovascular Research, British Journal of Pharmacology, Clinical Immunology, and the Journal of Prosthodontics. She is an advocate for the use of evidence-based dentistry as a pillar of the dental profession. She collaborates with other international centres: The Eastman Dental Institute of University College London (UK), University of Florence Dental School (Italy), Stanford University (USA), Vanderbilt University (USA), Oxford University (UK), and Dresden University (Germany). She is a member of the Polish Dental Society, Polish Society of Periodontology, British Society of Periodontology, and Royal College of Physicians and Surgeons of Glasgow. Biography: Professor Renata Górska is a graduate of the First Medical Faculty of the Dental School of the Medical Academy in Warsaw. Immediately after graduation, as a scholarship holder of the Kosciuszko Foundation, she took a 1-year and 2-month scientific internship at the Sloan Kettering Cancer Center in New York. In 1995, she obtained a specialization in periodontology, in 1998, the degree of habilitated doctor, in 2007, the title of Professor in medicine. Since 2008, Professor Górska has become the National Consultant in the field of periodontology. In the years 2006–2012, she was Vice-Dean for the Dental School of the First Faculty of Medicine at the University of Warsaw. From 2012 to 2016, she was the Vice-Rector of the First Faculty of Medicine at the University of Warsaw. Professor Górska has in her achievements 380 works printed in Poland and abroad, including 250 original research papers in Polish and English published in many respected journals such as the Journal of Periodontology, Journal of Clinical Periodontology and Clinical Dental Research, Clinical Experimental Immunology, European Journal of Immunology, American Journal Hypertension, Oral Disease, Clinical Oral Investigations, Advances in Clinical Experimental Medicine, Journal of Cardiology, Journal of Dentistry, as well as in Dental Medical Problems. She is the author or co-author of 36 chapters in specialist books and monographies. Professor Renata Górska is the supervisor of 18 doctoral dissertations and of 5 habilitation theses. In the years 2001–2003, she was the Vice President, and from 2004, the President, of the Polish Dental Association of the Warsaw Decision. She has been a member of the American Periodontological Society (AAP) since 1998 and since 2013, she has been the President of the Periodontology Section of the Polish Periodontological Society (PTP) in addition to being was in the 2017/2018 term as a member of the Main Board of the European Federation of Periodontology.