Resumen de Association Between Edentulism and Angina Pectoris in Mexican Adults Aged 35 Years and Older: A Multivariate Analysis of a Population-Based Survey
Carlo Eduardo Medina Solís, América Patricia Pontigo Loyola, Eduardo Pérez Campos, Leticia Avila-Burgos
Background: The possible association between oral infection and chronic inflammation and cardiovascular disease risk has been studied intensively. The present study is designed to determine the strength of association between edentulism and angina pectoris in Mexican adults aged 35 years and older.
Methods: Using the tools and sampling strategies of the World Health Survey of the World Health Organization, cross-sectional data were collected in Mexico in the National Performance Assessment Survey (probabilistic, multistage, and cluster sampling). Dental information was available for 20 of the 32 states of Mexico. Angina and edentulism are self-reported in this study. Statistical analysis was performed using binary logistic regression adjusting for complex samples.
Results: A total of 13,966 participants, representing a population of 29,853,607 individuals, were included. Of the complete study population, 3,052,263 (10.2%) were completely toothless, and 673,810 (2.3%) were diagnosed with angina pectoris. After adjusting for smoking, alcohol consumption, diabetes, body mass index, and sex, the effect of edentulism on angina was modified by age (interaction), being more marked in the younger age group (odds ratio [OR] = exp2.5597 =12.93) than in the older individuals surveyed (OR = exp2.5597 + (-0.0334) =12.51). Additionally, low physical activity (OR = 1.51; 95% confidence interval [CI] = 1.03 to 2.22) and higher socioeconomic status (OR = 1.37; 95% CI = 1.00 to 1.90) were more likely to be associated with angina pectoris.
Conclusions: Overall, the results of this study, conducted in a representative sample of Mexican adults, suggest that an association exists between edentulism and angina pectoris. Additional studies are necessary to elucidate the underlying mechanism for this association.
Dental caries and periodontitis are diseases intimately associated with bacteria and affect the hard and supporting tissues of teeth, respectively. If these chronic diseases are not controlled, they have the potential to cause tooth loss. Globally, they represent important oral health problems because of their elevated prevalence and incidence in populations with severe socioeconomic disadvantage. In terms of pain, suffering, diminished function, and impact on quality of life, the morbidity is considerable and costly.1 Adult dental caries and periodontal disease, in terms of global prevalence, have been designated the first and sixth most debilitating conditions.2 In addition, oral infections may have a negative impact at the systemic level.3-13 Given that cardiovascular diseases (CVDs) are the main cause of death globally, considerable attention has been devoted to investigating the hypothesis that the nearly ubiquitous oral cavity infections are associated with CVD risk and cardiac disease.7-13 Around the world, individuals may lose their natural teeth until complete toothlessness (edentulism); dental caries or periodontal disease are often implicated.14-17 In Mexico, these are the two main reasons for tooth extractions in the adult population.18 Both diseases may lead to chronic infection that can trigger systemic inflammatory mechanisms. Chronic inflammation plays an important role in the pathophysiology of atherosclerosis, which is involved in the initiation, progression, and final stages of infarction; thus, circulating inflammatory biomarkers have been consistently associated with a greater risk of CVD.19 Factors associated with chronic inflammation and oral infections have been studied in an attempt to explain the relationship between oral diseases and CVDs. Oral infections are associated with a moderate systemic inflammatory response, such as elevated concentrations of C-reactive protein and other inflammatory biomarkers.20-23 Angina pectoris is the main manifestation of symptomatic myocardial ischemia and is generally associated with coronary artery disease leading to insufficient blood reaching the heart. Although stable angina is a common initial presentation of coronary disease, and it greatly affects quality of life, work capacity, and costs to society, only a few large-scale epidemiologic studies have been undertaken to identify risk factors for angina pectoris.24 Some of those factors include the following: 1) antioxidant deficiencies; 2) aging; 3) obesity; 4) high cholesterol; 5) insulin resistance; 6) glycemic index; 7) inflammation; 8) stress; and 9) hypertension.25,26 Concerning the oral health status as an indicator of angina pectoris risk, Paunio et al.27 observed that ischemic heart disease (angina pectoris or previous myocardial infarction) was associated with tooth loss experience, in addition to age, clinical diagnosis of arterial hypertension, geographical area, and education level. Likewise, Frisk et al.28 explored the possible association between endodontic disease and coronary disease, specifically angina pectoris and a history of myocardial infarction. In their study, dental variables associated with infection included the following: 1) the number of teeth with root fillings; 2) number of teeth with periapical radiolucency; and 3) tooth loss. In the multivariate analysis of these factors, only tooth loss was positively associated with coronary disease and therefore presumably not necessarily associated with endodontic causes. Alternatively, using data from the 1966 Northern Finland Birth Cohort Study, Ylöstalo et al.29 found an association among self-reported gingivitis, dental caries, and tooth loss and the presence of angina pectoris. In the United States, Dietrich et al.12 found that edentulous males aged 60 years and older tended to have greater risk of coronary disease than dentate males, independent of other variables. Buhlin et al.30 studied the association of several periodontal clinical indicators and coronary disease in Finnish individuals, observing that losing eight to 17 teeth was associated with stable coronary disease and acute coronary syndrome. Using National Health and Nutrition Examination Survey (NHANES) data, Fedele et al.31 found that individuals with oral mucosal disease were 1.36 times (95% confidence interval [CI] = 1.02 to 1.80) more likely to have a history of myocardial infarction and 1.33 times (95% CI = 1.03 to 1.71) more likely to report angina than unaffected individuals. All associations were independent of common confounding factors. Arbes et al.32 used similar variables and found that, after adjusting for age, sex, race, poverty, smoking, diabetes, high blood pressure, body mass index (BMI), and serum cholesterol, the odds of heart attack increased with more severe attachment loss (AL). Lu et al.33 examined the relationship between AL and peripheral vascular disease using 1999 to 2002 NHANES data. After adjusting for age, sex, race, poverty, traditional risk factors of peripheral vascular disease, and other potential confounding factors, periodontal AL was significantly associated with peripheral vascular disease. Finally, Watt et al.34 used data from the Scottish Health Survey to confirm an association between edentulism and death because of cardiovascular conditions: edentate individuals had 2.97 times (95% CI = 1.46, 6.05) higher risk for stroke-related mortality. To expand the body of evidence that associates tooth loss with CVD beyond the existing literature primarily limited to industrialized countries, the objective of the present study is to quantify the association between edentulism and angina pectoris (both conditions self-reported) in Mexican adults who were aged 35 years and older.
