Association of Oral Health Practices and Cardiovascular Disease Among Patients Ages 40-79 in Quirino Memorial Medical CenterAssociation of Oral Health Practices and Cardiovascular Disease Among Patients Ages 40-79 in Quirino Memorial Medical Center

A Case-Control Study on the Association of Oral Health Practices and Cardiovascular Disease Among Patients Ages 40-79 in Quirino Memorial Medical Center

Group # 10

Authors:

Nicole B. Bautista

Bryan Edward A. Devanadera

Lisa Denise A. Encarnacion

Shiela Mariz S. Magnaye

Peter Paul R. Pascual

Angelica Grace S. Soriano

Audren Allen T. Wong

Adviser: Wendell Asuncion, M.D.

Abstract Oral health care refers to practices undertaken for the maintenance of ones oral health. As oral health practices contribute to the development of severe gum infection, which may subsequently lead to cardiovascular disease, possible associations in the results of this study could contribute to lowering the incidence of cardiovascular disease, which continues to be a leading cause of death among Filipinos. It is the lack of current information in the Philippine setting on oral health practices in relation to cardiovascular disease that gave rise to this study. This was accomplished in a case-control study on a population of patients aged 40-79 in Quirino Memorial Medical Center. Key tools to gather information were based on similar studies on oral health practices. Responses of participants were analyzed through SPSS in order to establish associations between specific variables and the occurrence of cardiovascular disease. The study found that while cases and controls share similar oral health practices, the use of toothbrushes when practicing oral hygiene has a significant association with likelihood of having cardiovascular disease suggesting increased likelihood of having cardiovascular disease among those who do not use toothbrushes in practicing oral hygiene. In logistic regression, diabetes is found to be a significant confounding variable, and this confirms the association of diabetes and the presence of cardiovascular disease.Keywords: Oral health practices, oral hygiene, cardiovascular disease

Introduction

Oral health is a state of being free from diseases and disorders that limit a persons capacity the following functions: biting, chewing, smiling, speaking, and psychosocial wellbeing which are essential to general health and quality of life. Poor oral hygiene is one of the risk factors of oral diseases and disorders (World Health Organization, 2012). On the other hand, cardiovascular diseases (CVDs) are the leading cause of mortality in the Philippines, accounting for 30% of deaths in the country. This is a group of disorders of the heart and blood vessels, and the main distinguishing characteristic of these disorders is the blockage of a major blood vessel that supplies a specific organ or system, ultimately leading to infarction and necrosis of the said tissue or organ (World Health Organization, 2013 & Bonow et. al, 2012). People within the age range of 40-79 have the highest occurrence of CVDs based on a study by the American Heart Association study from 2007 up to 2010 (Go, et al, 2013).

Poor oral health practices, e.g., inadequate and improper tooth brushing, cleaning of the tongue, inadequate flossing, could lead to poor oral health, and was shown to predispose individuals to CVDs, e.g., stroke, myocardial infarction and hypertension (Holmlund, 2008). Improper practices could result in plaque and calculus accumulation around teeth that can lead to gingivitis --- the inflammation and ulceration of the gingival tissues --- which progress to periodontitis leading to tooth loss (Lockhart et. al, 2009). Tooth loss has shown a consistent relationship with CVD (Holmlund, 2008). Less frequent tooth brushing was associated with increased concentrations of both C-reactive protein and fibrinogen, which are markers for certain CVDs (Oliveira, 2010). It is also associated with the formation of a carotid artery plaque, which increases the risk for stroke (Desvarieux, 2003). Myocardial infarction was shown to occur more frequently among people with poor periodontal conditions (Parkar et al., 2013). Poor oral hygiene could lead to infection which adds to the inflammatory burden of an individual resulting to increased risk for CVDs (Libby et al., 2002).

The objective of this study was to determine the association of oral health practices and cardiovascular diseases among 40-79 year-old patients of Quirino Memorial Medical Center (QMMC). Specifically, to determine the oral health practices among patients with and without CVDs and to measure the association of identified specific oral health practices to CVDs. The cardiovascular status of suggested controls was determined using QRISK2-2014 cardiovascular disease risk calculator (www.qrisk.org) which objectively determines the risk of an individual developing a CVD over the next 10 years. The results provide information on the current oral health practices of patients in QMMC and their correlation with the presence of cardiovascular diseases.

Methodology

The research team partnered with QMMC as its study location. It is a 42,000-sq. meter tertiary hospital located at Quezon City which caters to nearby residents as well as neighboring towns of Marikina, Antipolo, San Mateo, Montalban, Caloocan, Novaliches, and neighboring provinces of Laguna, Bulacan, and Cavite. The team was

under the supervision of the Internal Medicine Division as instructed by the Research Department of QMMC. With their endorsements, surveyors were able to accommodate in-patients and out-patients of the specific wings of the Internal Medicine Division, Emergency Division and Central Nervous System Division of the hospital. Interviews for out-patients were done at the waiting area shortly before or after their consultations, while in-patients were interviewed at their respective wards. Materials used for data collection were 5-page, 39-item survey forms, printed and photocopied to satisfy the targeted number of cases and controls to be interviewed. Before data collection, participants were asked for their voluntary participation with a brief introduction on the process and study. Once participants agreed, they were read and given the consent form to sign before proceeding with the interview. An adapted survey that assessed the association of health practices and cardiovascular diseases was used. The survey questionnaire utilized was pre-tested and was worded in both English and Filipino. The questionnaire may be self-administered, but for this research, it was employed by having the surveyor interview the participant with the questionnaire as a guide, for the interest of saving time and also to allow hospital inpatients an easier time in answering. This study utilized a case-control research design. See figure 1 for the conceptual framework to determine the oral health practices associated to the presence or absence of CVD. Cases were set as: male and female patients of QMMC, aged 40-79 with conditions that fit or have been diagnosed with a cardiovascular disease. Controls were set as: male and female patients of QMMC, aged 40-79 with conditions that do not fit or have not been diagnosed with a cardiovascular disease. If a patient was identified as a control, an additional self-administered checklist based on the QRISK tool was performed to formally confirm their cardiovascular function. QRISK was designed to estimate the risk of an individual developing a cardiovascular disease over the next 10 years by incorporating potential risk factors such as: age, sex, smoking, systolic blood pressure, total cholesterol, high density lipoprotein, fasting blood sugar, antihypertensive, BMI, family history, townsend, rheumatoid arthritis, chronic renal disease, atrial fibrillation and ethnicity in their calculations. A score of 20% is considered high risk of developing CVD (Hippisley-Cox et al., 2008). Figure 1. Conceptual framework to determine the oral health practices associated to the presence or absence of CVD. However, the QRISK calculator, a validated tool used to determine the cardiovascular status, was only employed to confirm control status after the actual collection of data. This was due to the limited internet accessibility during data gathering. Patients who were calculated with results below 20% risk were the only control participants included, while the rest were excluded. In total, 99 controls and 110 cases were included in the study. The data gathered was encoded using Microsoft Excel and SPSS. Quantitative data was evaluated through SPSS univariate, bivariate and logistic regression analysis. Results

The study included variables that were classified as either patients sociodemographic factors (Table 1), oral health practices (Table 2) or confounding factors (Table 3). Data were collected and analyzed from a total sample size of 209 patients aged 40-79 in QMMC, with 99 controls and 110 cases. Among all the variables included in the study, civil status, currently working status, the use of toothbrush, frequency of denture cleaning and the presence of type 2 diabetes mellitus are seen to have a significant association with the presence of CVD. Table 1. Frequency table for sociodemographic factors.Sociodemographic Factors

VariableN%N%

Presence of Cardiovascular DiseaseCasesControls

9947.411052.6

CVD Classification (Among Cases)HypertensionMyocardial Infarction

10797.365.5

StrokeAngina

222054.5

GenderMaleFemale

7334.913665.1

Civil StatusSingleMarried

3215.314770.3

SeparatedWidowed

94.32110.0

Civil Status2Never MarriedEver Been Married

3215.317784.7

Civil Status3Not WidowedWidowed

18889.92110.1

Currently WorkingNoYes

12258.48741.6

ReligionRoman CatholicProtestant

18588.562.9

Iglesia ni CristoMuslim

52.410.5

Others

125.7

Educational AttainmentNo educational attainmentElementary

31.44119.6

High schoolCollege

11354.15224.9

Educational Attainment2Not a High school GraduateAt Least a High School Graduate

4421.116578.9

Family Size1 to 5 Family Size6+ Family Size

14067.06933.0

Table 2. Frequency table for oral health practices.Oral Health Practices

VariableN%N%

Frequency Tooth brushing/ Practicing Oral Health2x/day

9746.48540.7

Uses ToothbrushNoYes

31.420698.6

Uses ToothpasteNoYes

21.020799.0

Uses MouthwashNoYes

15473.75526.3

Uses Dental FlossNoYes

18990.4209.6

Uses ToothpicksNoYes

16679.44320.6

Uses Other Oral Health ProductsNoYes

20799.021.0

Timing of Toothbrushing, Flossing, and/or use of Mouthwash and Other Health Products

PagkagisingNoYes

157.219492.8

Pagkatapos KumainNoYes

11052.69947.4

Bago MatulogNoYes

2712.918287.1

Duration of Toothbrushing2 mins

5928.24320.6

Others

73.3

Oral Health Practices

VariableN%N%

Visits the DentistNoYes

209.618990.4

Dental VisitsRegular every 6-12 monthsOccasionally

2712.9157.2

When I have dental painAs needed

4019.17837.3

Never

4823.0

Dental Treatment (Check Teeth)NoYes

8138.812861.2

Dental Treatment (X-Ray)NoYes

20698.631.4

Dental Treatment (Check Gums)NoYes

20397.162.9

Dental Treatment Tooth ExtractionNoYes

8641.112358.9

Dental Treatment (Tooth Filling)NoYes

17885.23114.8

Dental Treatment (Dentures)NoYes

13464.17535.9

Table 3. Frequency table for the confounding factors.Confounding Factors

VariableN%N%

Alcohol ConsumptionNoYes

13866.07134.0

Frequency of Drinking Alcohol=2 drinks daily (heavy drinker)

2535.2

Smoking (

Ever-smoked)NoYes

14569.46430.6

Diabetes MellitusNoYes

18186.62813.4

Type of Diabetes Mellitus (among diabetics)Type 1Type 2

00.028100.0

Among those with cardiovascular diseases, hypertension is found to be the most prevalent CVD, occurring in 97.3% of the cases (107/109). A number of those found to have hypertension also have other concomitant CVDs. Other CVDs reported in the study include the following: 20% had at least one episode of stroke (22/109), 5.5% have had myocardial infarction (6/109); and 4.5% have had chest pains or angina (5/109). The ages of the cases surveyed ranged from 40-79 years old. The control group also had the same age range. The mean age among cases is 58 years old, which is higher compared to mean age among controls, which is 51 years. There are more females who participated in the study than males, with females totaling 136 and males totaling 73 respondents. However, cases (37% males and 63% females) and controls (32% males and 68% females) are similar in proportion in terms of gender and found to have no significant difference between the two groups (p = 0.454). After running a bivariate analysis, it was found that those with CVD tend to be widowed compared to those who do not have CVD (p = 0.023). See table 4 for the bivariate analysis. Those with CVD are less likely to be currently working as compared to those without CVD (p = 0.056). Religion, family size and educational attainment were found to have no significant association with the presence of CVD. Smoking and alcohol consumption were likewise not significant. In terms of oral health practices, the study found that tooth brushing has a significant association with likelihood of having CVD (p= 0.098). The study found that only 3 respondents do not use a toothbrush in practicing oral hygiene. These respondents were all cases (with CVD) and were not diabetic. Frequency of denture cleaning is also found have a significant relationship with the presence of CVD among patients who use dentures (p = 0.092). The results are analyzed from the 79 cases and 77 controls in our study that use dentures. Those with CVD are found to more likely clean their dentures twice a day or more compared to those without CVD (p = 0.079). Table 4. Bivariate table of analysis. Variablep-value

Gender0.454

Civil Status 0.080

Civil Status2 (Never Married or Ever Been Married) 0.139

Civil Status3 (Not Widowed or Widowed)0.023

Currently Working0.056

Type of Occupation0.240

Religion0.698

Educational Attainment0.914

Family Size0.698

Frequency of Tooth brushing0.864

Products used for Oral Hygiene (Toothbrush)0.098

Products used for Oral Hygiene (Toothpaste)0.178

Products used for Oral Hygiene (Mouthwash)0.112

Products used for Oral Hygiene (Dental Floss)0.823

Products used for Oral Hygiene (Toothpick)0.417

Products used for Oral Hygiene (Others)0.178

Time of Oral Health Practices (Toothbrushing,

Flossing, and/or use of Mouthwash)0.288

Duration of Toothbrushing0.348

Visits the Dentist0.472

Last Dental Visit0.593

Dental Visits0.684

Dental Treatments or Procedures Availed0.182

Uses Dentures0.378

Frequency of Denture Cleaning0.092

Frequency of Denture Cleaning2(once a day or less or twice a day or more)0.079

Chewing Sugarless Gum0.448

Frequency of Chewing Sugarless Gum0.236

Presence of Dental Problems0.637

Specific Dental Problems0.152

Smoking0.924

Alcohol Consumption0.689

Frequency of Drinking0.434

Presence of Diabetes Mellitus0.003

(p-value cut-off = 0.1), 90% confidence interval Timing of oral health practices as well as duration of toothbrushing was not significant. Using toothpaste, mouthwash, dental floss, and toothpick as products for oral hygiene were not significant. Visits to the dentist and frequency of visits were not significant. Presence of dental problems and type of dental problems were not significant. 62 cases and 59 controls reported to have dental problems. It is interesting to note that among the cases, 90% (56/62) also had dental caries and 6.5% (4/62) have periodontal disease. Among controls with dental problems, 98% (58/59) reported to have dental caries and one patient had periodontal disease. Periodontal disease seemed to be more prevalent among those with CVD, but its difference among controls is not statistically significant (p = 0.152).

It is worth mentioning that in terms of most common products used for oral health practices, the use of toothpaste ranks number 1 among the respondents of the study (99.0%, 207/209), followed by toothbrush (98.6%, 206/209), mouthwash (26.3%, 55/209), then toothpick (9.6%, 20/209) and dental floss (9.6%, 20/209) respectively. Two respondents (1%) use other health products. In terms of frequencies in tooth brushing, 92.8 % of the respondents brush their teeth in the morning (194/209) and 87.1% brush at night (182/209). Only 47.4% brush their teeth after meals (99/209). Duration of tooth brushing is almost equal among cases and controls, approximating 51% brushing less than 2 minutes and 49% brushing for 2 minutes and above. Running a binary logistic regression (Table 5), the study found that only the presence of diabetes mellitus proved to be significant (p = 0.003), with a directly proportional relationship to the presence of CVD (OR= 3.443).

Table 5. Logistic regression results.BSig.Exp. (B)

Civil Status 3.858.1222.359

Occupation-.468.111.626

Toothbrush-21.325.999.000

Presence of DM1.236.0133.443

Discussion

The study aimed to discover the association of oral health practices and the presence of cardiovascular disease among patients aged 40-79 in QMMC. In the binary logistic regression test performed, only one factor showed significance in determining the presence or absence of cardiovascular disease among the patients aged 40-79 in QMMC. Among the different parameters used, having Diabetes Mellitus showed a significant association with the presence of cardiovascular disease. The different parameters on oral hygiene are not significantly associated to the presence or absence of CVD among the patients. Only one product used for oral hygiene, which is the toothbrush, was significant in the study with a 90% confidence interval p-value of 0.098. In the current study the p-value obtained with regards to the products used for oral hygiene (toothbrush) is significant, which means that there is an association with the presence of cardiovascular disease and the products used for oral hygiene. The mechanism by which the use of oral health practices may lead to presence of CVDs may be follow what was found in previous studies. As previously mentioned, improper oral hygiene practices increase the risk for infection and inflammation in the cardiovascular system leading to a rise in the levels of C-reactive proteins and fibrinogen, which are markers of systemic inflammatory processes (Oliveira et al., 2010). Another study done by Hartzell et al., (2005), showed that the incidence of bacteremia is reduced in people who have undergone proper tooth brushing. A definitive study by Lockhart et al., 2008, reported that improper tooth brushing leads to a positive bacterial culture for about 60 minutes, which is the same when a person undergoes dental extraction. They confirmed that the risk for bacteremia and infection is the same for dental extraction and improper usage and practice of different oral hygiene protocols. Improper usage of the tooth brush by the respondents in the our current study may have lead to the increase in the incidence of bacteremia in the patients blood which could have promoted the systemic inflammatory responses that are implicated as the main cause of cardiovascular disease. The current study also confirms the findings of other researchers such as Desvarieux et al., 2003, which also showed that improper oral health practice due to improper usage of oral health products, promote the incidence of bacteremia in the mouth which leads to cardiovascular diseases. The bacteria growing in the mouth promotes systemic inflammation, which again serves as a risk factor that promotes coronary artery disease. The detailed mechanism of how the systemic inflammation caused by bacteria or any other inflammatory process has not yet been elucidated. The American Heart Association in a study by Pearson et al., 2003, suggest that the inflammation seen in cardiovascular diseases is part of an atherogenic response, which along with other risk factors promotes the development and progression of cardiovascular diseases such as coronary artery disease and stroke. They argue that reduction in the inflammation promoted by different processes could very well decrease the incidence and progression of different cardiovascular diseases such as myocardial infarction and stroke. The current study corroborates with the findings of other studies, but instead looks at a different perspective if ones oral health practices can be used as a predictive marker for the presence of cardiovascular diseases. Even though some of the parameters used in the current study did not result as significant, our finding with regards to the oral products used associates the improper and inadequate usage of oral products in the development of cardiovascular diseases as found out in the other studies. Diabetes is a significant confounding factor in the presence of cardiovascular disease in this study. The American Heart Association and other researchers have always diabetes to be a major and independent risk factor for CVD for both men and women. In this study, diabetes still proves to be a major risk factor to the presence of cardiovascular disease. A study by Griffin, 2009, established that dental disease has been associated with diabetes and other chronic diseases, along with cardiovascular disease. The same study also reports that when patients with diabetes develop clinical cardiovascular disease, they are expected to have the worse prognosis.Conclusions The study found that while cases and controls share very similar oral health practices, the use of toothbrushes when practicing oral hygiene has a significant association with likelihood of having CVD suggesting increased likelihood of having CVD among those who do not use toothbrushes in practicing oral hygiene. The study was able to confirm the correlation between diabetes and presence of CVD and proves that it is a stronger confounder to the variables involved in this study. Oral health practices among the patients aged 40-79 in QMMC were also elucidated.Acknowledgements The research group would like to express their gratitude to the members of Ateneo School of Medicine and Public Health for granting this research approval for execution, our preceptor, Dr. Wendell Asuncion, and Dr. Lou Querubin who helped make the study possible. The group would also like to thank the members of the Research and Ethics Board of Quirino Memorial Medical Center, headed by Dr. Evelyn Reside.

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4 (p-value cut-off = 0.1), 90% confidence interval1