Oral prophylaxis may reduce stroke risk factors

In individuals who had a recent stroke or transient ischaemic attack (TIA), a trip to the dentist might just spare them from a recurrence, findings from the PREMIERS* study suggest.

“Approximately 40 percent of stroke/TIA patients have moderate gum disease,” said Dr Souvik Sen from the University of South Carolina, Columbia, South Carolina, US at ISC 2022. “The identification of periodontal disease as a risk factor for stroke and MI raises the possibility that periodontal treatment may reduce vascular event rates in stroke/TIA patients.”

In one of the first trials to date that evaluated the effect of treating periodontal disease on major adverse cardiovascular events in recent stroke/TIA patients, the risk of the primary composite outcome of stroke, MI, or death was similarly low among individuals who had intensive and standard periodontal treatment (7.7 percent vs 12.3 percent; hazard ratio [HR], 0.65; p=0.26). [ISC 2022, abstract LB3]

“[The difference was not] statistically significant but in the hypothesized direction,” said Sen.

When compared against historical data** reflecting an event rate of about 25 percent, there was “quite a dramatic difference”, Sen noted.

“It is very interesting [to see] these results in a relatively short timeframe. [At] 1 year, you’re reducing the number of vascular events,” commented ISC 2022 Chair Dr Louise McCollough from the Memorial Herman Hospital, Houston, Texas, US, who was not affiliated with the study, during a video interview. “The numbers might be small, [but this] suggests that there is a benefit from aggressive [periodontal] treatment, at least in the right direction.”

More visits – less risk?

“It seems the biggest bang for our buck is getting people seen,” continued McCollough. Sen concurred and noted this to be “the interesting finding of the study”, as participants who had ≥4 dental visits were significantly more likely to have fewer composite events than those who only came for the baseline visit (p=0.0017).

When asked how a 3-month dental visit could make such a difference, Sen said, “Inflammation does increase the risk for atherosclerotic cardiovascular disease and stroke. The first mechanism we can think of is that treatment of gum disease lowers the inflammatory burden. These patients came back every 3 months [and the blood pressure (BP) and] medication compliance check [may] have a direct impact on lowering the recurrent vascular event rate.”

All secondary outcomes did improve in both arms. Of note were the significant drops in diastolic BP from baseline to 12 months, both in the intensive (from 89 to 85 mm Hg; p=0.04) and standard treatment arms (from 89 to 84 mm Hg; p=0.02), and the significant increase in high-density lipoprotein (HDL) level in the standard treatment arm (from 53 to 59 mg/dL; p=0.03).

Oral healthcare is important

Participants (n=280; mean age 60 years, 90 percent male) had minor, nondisabling ischaemic stroke/TIA within 3 months (median NIHSS*** 2) and moderate-to-severe^# periodontal disease. They were randomized 1:1 to receive standard or intensive^## periodontal treatment quarterly for a year.

Both intensive and standard arms had low rates of sepsis (n=3 vs 2) and dental bleeding (n=2 vs 0). “[T]he sepsis rate … goes along with what we notice in a general stroke population,” Sen noted.

The one case of infective endocarditis in the intensive treatment arm does not appear to be related to dental treatment, as cultures revealed that the bacterial pathogen was not present in the oral cavity. “With that, we were able to safely exclude the possibility that dental care in any way led to the infective endocarditis,” Sen said.

“[Overall, our findings suggest that] oral hygiene is important to cerebrovascular and cardiovascular health,” Sen concluded. “[W]e need more studies in this area.”