Caries risk, pulpal inflammation, and cardiovascular disease in a dental clinical population: a cohort study

Background While periodontitis is well established as a risk factor for cardiovascular disease (CVD), the role of dental caries remains underexplored. Traditional measures such as number of carious lesions may not adequately capture the dynamic risk status of caries, potentially obscuring its association with systemic conditions. Caries Management by Risk Assessment (CAMBRA) offers a more comprehensive evaluation by incorporating biological, behavioral, and clinical factors. It is primarily designed as a clinical tool to estimate an individual’s future risk of developing caries and to guide preventive and management strategies. Additionally, pulpal inflammation may serve as a more direct indicator of active infection and systemic inflammatory burden. This cohort study aimed to assess the association between caries risk and CVD. It also examined whether pulpal inflammation was associated with CVD and described CAMBRA profiles according to CVD status. Methods This retrospective cohort study included 39,837 patients from the BigMouth Dental Data Repository (January 2011 to December 2024). Baseline caries risk was evaluated as low, moderate, or high/extreme using the CAMBRA assessment form, and pulpal inflammation was identified using the Systematized Nomenclature of Dentistry Dental Diagnostic System (SNODDS). CVD was identified from the self-reported medical history form during follow-up. Baseline characteristics were summarized and compared across different caries risk levels. Adjusted logistic regression was performed to estimate the association between caries risk, pulpal inflammation and CVD. Missing values were imputed using a probability random forest with the ranger package. E-values were calculated for the point estimates and confidence interval limits to assess the robustness of the observed associations to unmeasured confounding. Results Among 39,837 patients without CVD at baseline, 1,934 (4.9%) patients had newly recorded CVD during the follow-up period. Patients with moderate (adjusted OR = 2.27, 95% CI: 1.75 to 2.95) or high/extreme caries risk (adjusted OR = 2.32, 95% CI: 1.80 to 2.98) had significantly higher odds of newly recorded CVD compared to those at low risk. In contrast, pulpal inflammation was not associated with newly recorded CVD (adjusted OR = 1.06, 95% CI: 0.86 to 1.31). Patients with newly recorded CVD demonstrated a higher burden of oral disease indicators such as noncavitated approximal enamel lesions, cavitated lesions, and tooth extraction due to caries within three years. In addition, they also had fewer protective factors, such as lower exposure to fluoride and reduced use of antiseptic or antimicrobial rinse. Conclusions Within the limitations of this cohort study, elevated caries risk was associated with higher odds of newly recorded CVD, whereas pulpal inflammation was not. Further prospective studies are needed to elucidate underlying mechanisms and evaluate potential causal pathways.