Over the years, there has been a substantial effort to improve patient health and reduce healthcare costs through preventive medicine. Regular dental care prevents tooth decay; published research shows how oral health can impact other organs, such as the heart. Heart disease is the leading cause of death in Mississippi, with almost 8,000 people dying from it each year. Problems that affect oral health are also common in Mississippi. The purpose of this study was to test if a relationship exists between oral and heart health in Mississippi patients. De-identified patient data from 2012 through 2020 was gathered by using a data warehouse from an electronic health record at a Medical Center in Mississippi and was analyzed with SAS. The results from this study identified a strong association between oral and heart health, which suggests there may be opportunities for improvements in healthcare in Mississippi through improvements in dental health.
Keywords: Preventive medicine, dental health, cardiovascular disease, social determinants of health, Mississippi
In the United States, heart disease is the current leading cause of death; in the state of Mississippi, almost 8,000 people die each year from heart disease.1 Many published research studies indicate an association between oral and heart health, which may pose opportunities to improve overall health by focusing on dental care.2–7 Problems that affect oral health, such as periodontal disease, cavities, and tooth loss, are very common in Mississippi. Frequent visits to the dentist can help reduce these problems and improve oral health; however, there are barriers to dental care in Mississippi.
In a 2016 study by the Mississippi Behavioral Risk Factor Surveillance System (MS BRFSS), Mississippi residents were asked how often they visited the dentist and how many teeth they have lost from gum disease or tooth decay. The national goal for the year 2020 was for 68.8 percent of adults aged 45 to 64 to report no permanent tooth loss due to dental decay or periodontal disease.8 According to the study, Mississippi has room for improvement; 57 percent of Mississippi residents reported having lost one or more permanent teeth due to poor oral health. The percent of residents that have lost teeth due to poor oral health has remained the same since the 2014 MS BRFSS. The study also found that 43 percent of respondents reported they had not seen a dentist in the last 12 months, which contributes to poor oral hygiene.9 By 2018, that percentage had risen to 45.9 percent, indicating that oral health is worsening, not improving.10 The results of both the 2016 and 2018 MS BRFSSs indicate there are socioeconomic factors that impact the likelihood of respondents visiting the dentist. The rate of visiting the dentist within the last year double between individuals with less than a high school diploma and those who are college graduates. Additionally, individuals with a higher annual income visit the dentist more frequently than those that earn less per year. The socioeconomic group that went to the dentist more frequently was respondents that had an annual income of $75,000 or more.11,12
There have been tremendous of changes in the United States healthcare system in the last decade to shift toward a prospective payment system, with preventive medicine as a focus to improve the health of the nation. The Affordable Care Act focuses on preventive care to improve quality of care, keep Americans healthy, and reduce the cost of healthcare. Heart disease is a significant issue in the United States, especially in the state of Mississippi where the death rate is the highest in the nation accounting for over one-third of all deaths.13 In regards to prevention, there are several risk factors associated with heart disease that are well known in the medical community, such as smoking, obesity, and high cholesterol. There are also other factors, such as oral health, that are established but not usually considered by the medical professionals. Over the years, many studies have investigated different aspects surrounding the importance of oral health and its impact on the heart. In a compelling systematic review by Blaizot, Vergnes, Nuwwareh, Amar, and Sixou, 215 epidemiological studies about the relationship between cardiovascular disease and periodontal disease were reviewed to determine consistency and strength of their results. In these studies, individuals with exposure to periodontitis and cardiovascular disease outcomes were examined. The studies included in the review were original, observational studies including cross-sectional, case-control, or cohort studies. Seventy percent of the studies included in this systematic review did not have an odds ratio or relative risk less than 1.00, demonstrating great consistency among the studies. The results of the systematic review indicated a significant strength of association between periodontal disease and cardiovascular disease. Patients with periodontal disease had a 34 percent increase in risk of development of cardiovascular diseases (relative risk=1.34).14
Research suggests that the link between oral health and heart health has to do with chronic infection or inflammation and atherosclerosis. Atherosclerosis is defined as a buildup of plaque, which is caused from cholesterol and other products found in the arteries. When a blockage of plaque occurs, oxygen is deprived from the heart, which ultimately causes a heart attack. Atherosclerosis is the cause of the most common type of heart disease in the United States, which is coronary artery disease, or CAD.15 Research by Friedewald et al. suggests that atherosclerosis is caused by inflammation and chronic infections. When inflammation and chronic infections are present, this contributes to the amount of atherosclerosis that is present within blood vessels. Periodontal disease is a chronic inflammation or infection of the gums due to the presence of dental plaque and bacteria along the gum line. Some people can have unresolved periodontal disease for years, even decades. Signs of periodontal disease include swollen gums that decompress, bleeding gums, pus between teeth and gums, and receding gums.16 Additional research by Beck and Offenbacher specifically investigates data regarding measures of infection caused by periodontal pathogens. The results of their research corroborate supporting evidence of an association between periodontal infection and cardiovascular disease. Individuals included in the survey who had presence of periodontal pathogens and antibody response had a higher rate of chronic systemic disease, including cardiovascular disease.17
In another systematic review by Humphrey, Fu, Buckley, Freeman, and Hefland, periodontal disease was investigated to determine if it is independently associated to heart disease considering other traditional risk factors common with heart disease. There are traditional factors that providers can look for to determine risk of cardiovascular disease, but this research aimed to provide supporting evidence to the US Preventative Services Task Force for consideration of other non-traditional risk factors. The results of this systematic review suggested that there was an association between periodontal disease and heart disease that was independent of traditional risk factors and socioeconomic factors. Study participants that exhibited different measures of periodontal disease were at a 24-35 percent increased risk of cardiovascular disease.18
Another study by Larvin and colleagues analyzed 32 longitudinal cohort studies and determined that those with periodontal disease have a relative risk of 1.20 for cardiovascular disease.19 Recent literature has been focused on determining a causal relationship between periodontal disease and cardiovascular health.20,21 These results have indicated that there may be a causal relationship, but at the moment the results indicate that it is not causal. In order to ascertain if a causal relationship is indeed present, a large, randomized control study is needed. In addition, other studies have focused on if periodontal treatments can lower cardiovascular risk, and the results are mixed.22
The evidence showing an association between periodontal disease and cardiovascular disease in previous studies suggests it may be beneficial to also focus on dental health when population health is being considered to keep patients healthy. Given the need to make improvements in preventive health brought on by legislative changes and the need to improve oral health in Mississippi,23 a study was needed to specifically look at data from Mississippi patients and determine what kind of relationship exists between oral and heart health.
To learn more about how oral health can affect heart health in Mississippi, data was gathered by using de-identified patient diagnosis information from a data warehouse, the Patient Cohort Explorer.24 The data is presented in a Qlik application that allows for searching de-identified patient data originating from the medical center’s electronic healthcare record (EHR), which includes patient encounters from seven Mississippi hospitals and more than 30 outpatient clinics throughout the state of Mississippi. Data can be rapidly queried to discover a multitude of trends, inferences, and other beneficial information about the medical center’s patient population. Patient data can be searched at the patient or the encounter level, and then additional filtering, such as age, gender, or smoking status can be added to the criteria.
The search criteria included adult (18 years and older) patients seen at hospitals and clinics between January 14, 2013, and September 2, 2021. Rather than search at the encounter level, the patient level of the query was utilized to find data for the study. The ICD-10 (International Classification of Disease, version 10) diagnoses ‘chronic periodontal disease,’(K05.3), ‘Aggressive periodontitis,’ (K05.2) and ‘periodontal disease, unspecified’ (K05.6) were used to search for patients with periodontal disease, and an ICD-10 diagnosis grouper for ‘chronic heart disease’ (B37.6, I05-I09, I11, I13, I20, I25, I27, I33, I35, I38, I40, I47-I51, T86.2) was used to search for patients diagnosed with heart disease. Chronic heart disease was selected to eliminate purely acute illnesses, as chronic illnesses have had time to affect their overall health. There were 797,220 total adult patients included in the population for the date range. With the filters set to include patients with periodontal disease, the search returned 3,040 patients. After finding the first set of patients, the diagnosis grouper of chronic heart disease was added with the periodontal disease diagnosis to find all patients diagnosed with both heart and periodontal disease, which resulted in 253 patients. Finally, the filter for chronic periodontal disease was removed from the search criteria, which resulted in 26,266 patients diagnosed only with heart disease. Patients with a diagnosis of periodontal disease and heart disease were the cases, while the patients without heart disease or periodontal disease were the controls (see Table 1). After gathering the number of patients for the cases and controls, the data was analyzed through SAS version 9.425 using the chi-square analysis to determine if there is an association between the periodontal diagnoses and heart disease diagnoses. A power analysis was performed for both a chi square and relative risk analysis. The chi-square analysis is powered at 80 percent, and the relative risk analysis is powered at over 90 percent.
The data used in this study included adult patients seen between the years 2013 and September 2021 and was not limited by gender. For patients diagnosed with periodontal disease, the mean age was 58 years old, and 61 percent were male while 39 percent were female. The mean age for patients diagnosed with chronic heart disease was 61 years of age, and 58 percent were male while 42 percent were female (see Table 2). The results of the chi-square analysis gave a probability of <0.0001, which indicates a strong association between periodontal disease and heart disease. The relative risk for the study was 2.64 (CI: 2.33, 3.01), which is significant and indicates that there is an increased risk of heart disease for patients diagnosed with periodontal disease. An odds ratio was also included in the SAS procedure, which indicated the odds of Mississippi patients having heart disease when they have periodontal disease is 2.66 (CI: 2.34, 3.03) times higher compared to patients not diagnosed with periodontal disease.
The results of the study alone were significant and confirm the association between heart and periodontal disease in this population. In addition, taking into account that medical providers, rather than dental providers, were performing most of the periodontal disease diagnosis coding for the time frame of the data makes the results even more significant. About two years prior to this study, the dental areas of the medical center adopted the medical center’s EHR to begin documenting dental visits. The true number of patients with periodontal disease may be even higher, as medical providers do not routinely document dental diagnoses. It is possible that as more dental information is documented in patients’ medical records there will be more data to compare oral health to other diagnoses for future studies.
The relative risk for this study was different compared to other studies investigating the relationship between periodontal and heart disease. Many of the studies included in the systematic review by Humphrey, Fu, Buckley, Freeman, and Hefland had a relative risk that fell between 1.24 and 1.34.26 The relative risk for this study involving Mississippi patients doubles that of the systematic review at 2.64, which indicates Mississippi patients are at higher risk of developing heart disease when compared to similar studies.
The odds ratio was comparable to other studies, such as the study by Blaizot, Vergnes, Nuwwareh, Amar, and Sixou, where the odds ratio observed was 2.35.27 Although it is comparable due to its significance, the odds ratio for the study involving Mississippi patients is higher, indicating the odds of developing heart disease when patients also have periodontal disease is higher in Mississippi. It is possible this is due to the higher numbers of patients with poor oral health in Mississippi, as well as the different socioeconomic factors present in the state.28
There are many interesting statistics regarding health and socioeconomic status that makes Mississippi unique when compared to other states. Many of these statistics impact Mississippi residents’ likelihood of visiting a dentist regularly to prevent oral health issues, but they also impact general health issues. For example, the median household income is lower than the national average, and Mississippi also leads the nation in rates of obesity, diabetes, and lower levels of education.29,30 The age-adjusted mortality is also higher in Mississippi when compared nationally.31 There are issues in Mississippi in regards to access to care, which includes both health care and dental care, and there is a dentist shortage in many counties within Mississippi.32 Interestingly, in a survey from the MS Department of Health where Mississippi residents were asked how they would rate their health, only 8 percent rated themselves in the categories of unhealthy or very unhealthy.33 The results from the personal health rating suggest there are misconceptions about health and that there is a need for additional education about health prevention and living healthy lifestyles. All these issues together create a unique scenario, which may contribute to the more significant associations seen in this study.
The Mississippi State Department of Health recognizes the need to improve both overall well-being and oral health in Mississippi. In the 2016-2021 MS State Oral Health Plan, the connection between oral health and general health is referenced as an important part of keeping Mississippi healthy. Furthermore, oral health is mentioned as an essential component needed in the state’s health programs and policies. The unique problems that Mississippi faces requires a structured plan to remedy, and the MS Department of Health’s Oral Health Plan targets each of the unique problems that are present in Mississippi.34
Only one organization’s data is included and does not represent all of Mississippi. However, University of Mississippi Medical Center is a large hospital and provides dental care with numerous clinics throughout the state. In addition, the dental clinic has only been entering diagnoses into the EHR for the last two years. It is unknown what percentage of these diagnoses were from dental or health providers. Periodontal disease is estimated to affect roughly 47 percent of the population35, and yet only 0.4 percent of this patient population has a diagnosis of periodontal disease. This is in part due to the dentists only recently starting to use the EHR and not all health patients being seen at the dental clinic.
This study indicated a strong association between oral health and heart health, which helps bring attention to the importance of dental health being considered with existing preventive medicine efforts. There are increased opportunities for future research into the impact of oral health on patients’ overall health in Mississippi with the recent integration of dentistry with the medical center’s EHR. Mississippians have double the relative risk as other studies have shown, perhaps due to the low level of dental health within the state. This study demonstrates an association between heart and periodontal health; however, there is more work to be done to determine if poor oral health is causative of heart disease.
The data warehouse from which the information for this study is derived has been de-identified and date-shifted so that it does not include any protected health information (PHI). Pursuant to 45 CFR 46, use of this database does not meet the definition of human subjects’ research and does not require IRB review.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The authors would like to thank the Center for Informatics and Analytics at the University of Mississippi Medical Center for the Patient Cohort Explorer.
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Priscilla Nordan (firstname.lastname@example.org) is a senior Epic application analyst at Cook Children’s Healthcare System in Fort Worth, Texas.
Shamsi Daneshvari Berry (email@example.com) is an assistant professor in the Department of Biomedical Informatics at the Western Michigan University Homer Stryker MD School of Medicine.
Mary E. Morton (firstname.lastname@example.org) is a professor and health information management program director in the Department of Health Sciences at the University of Mississippi Medical Center.