Title	Periodontal Disease Possible Risk Factor For Ischemic Stroke
Clinical Question	In an adult patient, does chronic periodontitis increase one’s risk for an ischemic stroke in contrast to a periodontally healthy patient?
Clinical Bottom Line	Due to the large range of data, diagnostic methods, subgroups, and confounding factors, more studies must be conducted to support the suggestion that periodontitis is a risk factor for ischemic stroke. (See Comments on the CAT below)
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 15086623 Dorfer/2004 Acute cerebral ischemia patients (n=303) Representative population controls (n=300) Case Control Study Key results Patients who experienced acute cerebral ischemia had significantly more attachment loss than the representative population of controls, with a p-value of less than 0.001. It was concluded that individuals with a mean clinical attachment loss of more than 6 mm had a 7.4 odds ratio, a 95% confidence interval of 1.55-15.03, and a p-value of 0.007. Those with radiographic bone loss of more than 5.5 mm had a 3.6 odds ratio, a 95% confidence interval of 1.58-8.28, and a p-value of 0.001. There was not a significant association for radiographic bone loss ranging from more than 2.5 mm to 4.0 mm, and a p-value of 0.230 for those who had clinical attachment loss more than 3.0 mm to 4.5 mm. 19778330 Pradeep/2010 Acute cerebral ischemia patients (n=100) Representative population controls (n=100) Case Control Study Key results When comparing the probing depth and clinical attachment loss, patients who experienced a cerebrovascular accident had higher values than those of the control group with a statistically significant p-value less than 0.05. Plaque index and gingival index were reported as well. It was concluded in this study that the most significant factor for stroke was a probing depth of more than 4.5 mm. The statistics for this measurement include an odds ratio of 8.5 and a 95% confidence interval of 1.1-68.2. 19847898 Jimenez/2009 Dentate Men (n=1,137) Prospective Cohort Study Key results Out of 1,137 men the study followed for up to 34 years, there were 80 incidents of stroke or transient ischemic attacked (TIA). Periodontal bone loss was found to be the main link to stroke or TIA, as it had a hazard rate (HR) of 3.52, a 95% Confidence interval (CI) of 1.59 to 7.81, and a statistically significant p-value of less than 0.001. Interestingly, the association between periodontal bone loss and stroke/ TIA was stronger in men less than 65 years of age (HR: 5.81, 95% CI: 1.63-20.7) than in men 65 years or older (HR: 2.39, 95% CI: 0.91-6.25).
Evidence Search	Search "Cerebrovascular Disorders"[Mesh] Search "Periodontitis"[Mesh]
Comments on The Evidence	Dorfer: Study conducted on patients that experienced acute cerebral ischemia. Follow-up was not applicable as patients were examined 3 days after ischemia. Objective outcome criteria were not applied in a blind fashion. Adjustments were made for important prognostic factors, but there was no validation in independent test-set group. No competing interests noted.Pradeep: A homogenous population of Indian origin was assembled at a common point in the course of their disease. Patients were examined 5 days after ischemia. Objective outcome criteria were not applied in a blind fashion. Adjustments were made for important prognostic factors, but there was no validation in independent test-set group. There did not appear to be any competing interests.Jimenez: This prospective study was limited to a large population of males, who were of different ages and at different points in their disease. Follow up was sufficiently long and complete for up to 34 yrs (mean 24 yrs). Objective criteria were not applied in a blind fashion. Adjustments were made for important prognostic factors, but there was no validation in independent test-set group. There did not appear to be any competing interests.
Applicability	Because there are no conclusive results and more research with unified parameters must be conducted, there is no clinical application at the present time for this data.
Specialty	(General Dentistry) (Periodontics) (Dental Hygiene)
Keywords	Periodontitis, Cerebrovascular Disorders, Stroke, Periodontal Diseases, Transient Ischemic Attack
ID#	785
Date of submission	03/21/2011
E-mail	balderasv@livemail.uthscsa.edu
Author	Victoria Balderas
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Yong-Hee Patricia Chun, DDS, MS, PhD
Faculty mentor e-mail	ChunY@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) by Saad Al-Otaibi & Saad Al-Mujel (Riyadh) on 06/25/2014 We searched PubMed and Trip database for this topic in June 2014 and we found more recent publications: A meta-analysis study by Sfyroeras et. al. , 2012 , PMID#: 22244863 and a case-control study by Lafona A , 2014 , PMID#: 24720864. Both articles supports the conclusion of this CAT.