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RESEARCH REPORT |
1 Medical School, University of Tampere and Research Unit of Clinical Chemistry, Tampere University Hospital, Finland;
2 Institute of Dentistry, University of Helsinki, and Department of Oral and Maxillofacial Diseases, Helsinki University Central Hospital, Helsinki, Finland;
3 Oral and Maxillofacial Department, Tampere University Hospital, Finland;
4 Department of Forensic Medicine, University of Helsinki, Finland;
5 Department of Molecular Medicine, National Public Health Institute, Helsinki, Finland;
6 Department of Biometrics, Institute of Health, University of Tampere, Finland; and
7 Department of Clinical Pathology and Forensic Medicine, University of Kuopio, Finland
* corresponding author, Päivionkatu 21, FIN-74100 Iisalmi, Europe; vesa.karhunen{at}fimnet.fi
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: dental • panoramic tomography • sudden cardiac death • myocardial infarction • coronary heart disease • middle-aged • male • autopsy
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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65 yrs (Janket et al., 2003). Today, most (> 50%) cardiovascular deaths are sudden, and take place out-of-hospital. Among men aged < 50–55 yrs, as many as 90% of deaths due to coronary heart disease belong in this category (Huikuri et al., 2001; Mikkelsson et al., 2001). The risk factors of pre-hospital sudden cardiac death are mainly unresolved, because sudden death is often the first manifestation of coronary heart disease, and most victims have not been examined by a physician prior to death. Knowledge about risk factors is difficult to obtain after death, and laboratory values or dental records are rarely available. This background explains why the possible association between pre-hospital sudden cardiac death and dental infections has not been studied.
The dental data used in the earlier epidemiological studies on the association between dental infections and cardiovascular disease were obtained from questionnaires (Joshipura et al., 1996; Howell et al., 2001) or clinical examinations (DeStefano et al., 1993; Paunio et al., 1993; Beck et al., 1996; Hujoel et al., 2000; Wu et al., 2000; Tuominen et al., 2003). Panoramic tomography supported by clinical examination has seldom been applied (Mattila et al., 1989, 2000), although it gives a more comprehensive view of oral health. Post mortem panoramic tomography has previously been used for the assessment of marginal bone loss in a small series of cadavers (Soikkonen et al., 1990).
In this paper, we report on our use of panoramic tomography to study the dental health of middle-aged males who died suddenly out-of-hospital, to test the hypothesis that poor oral health may be a risk factor for sudden cardiac death.
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MATERIALS & METHODS |
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Methods
Interview on Risk Factors of Coronary Heart Disease
We obtained data on risk factors and other background factors or diseases (e.g., smoking, hypertension, diabetes, education level) by interviewing the spouses or other close relatives or close friends of the deceased. An informant was available for 165 (55%) of the cases, and data on risk factors could be obtained for 128 men (Table 1
). There were no statistically significant differences in age, body mass index, cause of death, or any of the measures related to the severity of coronary artery disease between those with and those without post mortem interview (Ilveskoski et al., 1999; Mikkelsson et al., 2001). The Helsinki Sudden Death Study (HSDS) protocol was approved by the Ethics Committee of the Department of Forensic Medicine, University of Helsinki.
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Scoring of Dental Status
The panoramic x-rays with only the autopsy case number were assessed independently by a board-certified dentist (VK) and a dental radiologist (HF) without knowledge of the age or any other data of the subjects. For every x-ray picture, 12 parameters of dental findings were scored. Altogether, 2964 values were assessed for the 247 panoramic radiographs.
The number of teeth was recorded (including third molars), and edentulous cases (no visible sign of teeth or residual roots) were identified. Dental osseous lesions (periapical lesions Ø 1–4 mm and cysts Ø > 4 mm) and signs of caries (caries lesions and residual roots) were assessed, and pericoronal lesions and impacted teeth recorded. Moreover, signs of dental care, e.g., number of fillings and root canal treatments, were recorded. We assessed periodontal health by measuring horizontal bone loss (with a ruler with a millimeter scale, the distance between the dentin-enamel junction and marginal alveolar bone at the root surface), as well as by scoring vertical bony pockets (> 3 mm) and furcation lesions (III grade).
After the assessment procedure was completed, the observers (VK, HF) held a consensus meeting in which the x-ray pictures with scores that differed between the observers were jointly assessed. The original inter-observer accordance was 95.4%, and 135 values (4.6%) were reviewed.
To be able to describe the overall oral health status of dentate victims in one figure to be used in statistical analyses, we formed a "Panoramic Tomography Index" by summing the number of residual roots, vertical bony pockets, periapical, cystic, furcation, caries, and pericoronitis lesions. A similar approach has been used in previous studies (Mattila et al., 1989; Janket et al., 2004).
There were no significant differences in the number of teeth, the panoramic tomography index, or individual dental parameters between men with and men without interview data, with the exception of slightly more caries lesions (p = 0.058) and horizontal bone loss (p = 0.032) in men without interview data.
Data Analysis
The differences in the medians of panoramic tomography scores between cases of sudden cardiac death and controls were tested by the Mann-Whitney Two-independent-samples test, and the differences in medians of dental variables between different age groups were tested by the Kruskall-Wallis Several Independent Samples test, due to non-normal distribution of the dental parameters. Confirmatory analyses were performed by Binary Logistic Regression analysis, with age, body mass index, smoking status (smokers or ex-smokers vs. never-smokers), hypertension, diabetes, education level (Primary school level, Secondary school level, and University level), and number of teeth as covariates, along with the panoramic tomography index. Missing values were treated as "own categories" in each covariate variable, for maximum statistical power. The level of significance was set equal to 0.05, but the exact p-values are displayed where appropriate. The computation was carried out with SPSS/Win (Version 12.0.1, SPSS Inc., USA).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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). Most victims (98.4%) had lost one or more teeth, and the number of remaining teeth varied from edentulous (17.4%) to a full dentition (32 teeth, 1.6%). The mean number of teeth was 15.2 (SD 10.6, median 16, range 32).
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Of all teeth (n = 3759), 34.7% (n = 1306) had fillings, the mean number being 6.4 (SD 5.7) per subject. Signs of severe periodontal infection—vertical bony pockets or furcation lesions—were found in 36.8% of dentate victims (n = 75).
Age-dependency of Dental Pathological Findings
To assess the validity of the post mortem dental pathological findings obtained from the panoramic tomographies, we studied the age-dependency of the findings (Table 3). In univariate analysis using the Kruskall-Wallis test, we found a significant and strong age-dependent decrease in the number of remaining teeth (p < 0.0001) and fillings (p < 0.0001), whereas we observed an age-dependent increase in horizontal bone loss (p < 0.0001), number of residual roots (p = 0.001), periapical lesions (p = 0.046), and number of vertical bony pockets (p = 0.013). The panoramic tomography index also showed a strong (p < 0.0001) age-dependency.
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) (mean 5.1 vs. 3.5, median 4 vs. 2, p = 0.015), compared with controls (unnatural sudden deaths and non-cardiac natural deaths). In binary logistic regression analysis with age, body mass index, smoking, hypertension, diabetes, education level, number of teeth, and the panoramic tomography index as covariates, body mass index (p = 0.005), age (p = 0.010), smoking (p = 0.016), and the panoramic tomography index (p = 0.053) remained in the model as the most significant explanatory factors for sudden cardiac death.
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In age groups 50–59 yrs and > 60 yrs, the panoramic tomography index was no longer a significant risk factor (p = 0.941 and p = 0.177, respectively).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS & METHODSRESULTSDISCUSSIONREFERENCES |
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The Mini-Finland survey, a nationwide comprehensive study on general and dental health in the adult population in 1980, provided epidemiological data on the oral health of Finnish adults (Vehkalahti et al., 1991). According to the survey, the mean number of teeth remaining in males aged 30 to 69 yrs from this area (including the Helsinki area) was 17.7, and 15% of the men were edentulous. These numbers do not greatly deviate from those in our study, in which the mean number of teeth was 15.2, and 17.4% of the men were edentulous.
In the Mini-Finland study, the mean number of teeth with fillings was 8.8, and 42% of teeth in dentate males had fillings. Corresponding numbers from our study are 6.4 and 34.7%, respectively. Similarly, 38% of males in the survey had severe destruction of the periodontium (pockets > 6 mm), compared with 36.8% (vertical pockets or furcation lesions) in our study. For other dental pathological findings, no comparable data are available for Finland or other countries. Analysis of these data suggests that the dental health in our study sample does not deviate much from that observed in the general male population living in Southern Finland at the time of the collection of the autopsy series.
In our study, younger victims of sudden cardiac death (< 50 yrs) had more oral pathology compared with men in the control group, measured by the panoramic tomography index, after adjustment for the conventional coronary heart disease risk factors. Our results are in line with those from another Finnish study (Mattila et al., 1989), where pantomography indices were also used as a measure of total oral infection load. In that study, patients with acute myocardial infarction had poorer dental health than controls matched for age and sex.
The mechanisms behind the association between dental pathological findings and different phenotypes of coronary heart disease are not known at present and should be the focus of further research. The main phenotypes of coronary heart disease are angina pectoris, myocardial infarction, and sudden cardiac death. Our results support the hypothesis that ongoing dental infections might play a role as one of the triggering factors of sudden cardiac death, possibly leading to activation of thrombogenic factors or contributing to the inflammatory process within the unstable coronary plaque.
The use of panoramic tomography has been advocated in some studies (Walsh et al., 1997), whereas other studies have preferred periapical radiographs (Pepelassi et al., 2000). The reliability of panoramic tomography in the assessment of marginal alveolar bone loss has previously been studied in cadaver material (Soikkonen et al., 1990). Those investigators concluded that the method is sufficiently reliable, but that radiographic bone loss values were found to be about 27% less than clinical values. Other reports on clinical patients have agreed with this and have suggested that underestimation of bone loss ranges from 13 to 32% (Akesson et al., 1992). Thus, except for slight underestimation, the assessment of periodontal pathology can be made with sufficient confidence by the use of panoramic tomography in dentate areas. From edentulous areas, the measurement of bone loss would be too uncertain, because of lack of a reference point (dentin-enamel junction).
The main problem in the scoring of the radiographs was that, in many cases, the quality of the routinely taken x-rays was not as good as that of x-rays taken in normal dental practice. Because the subjects were cadavers with rigor mortis, the chin might be tipped up or down, and the head turned toward either side, both resulting in distorted x-rays. However, the number of teeth, periapical lesions, horizontal bone loss, and number of fillings showed age associations typical of those reported in many previous studies (Kelly, 1967; Pilot et al., 1992; Holm, 1994; Kirkevang et al., 2001). This speaks for the validity of the post mortem panoramic tomography method.
The main weakness of the present study is the lack of information on coronary heart disease risk factors for 45% of the sample. Sudden death is often the first symptom of heart disease, especially among middle-aged men (Huikuri et al., 2001; Mikkelsson et al., 2001). Since, in most cases, no hospital records were available, the only way to gather data on risk factors was by interviewing spouses, children, and other close relatives and, in some cases, a close friend of the deceased. For many cases, there was nobody to provide detailed information. Although there were no significant differences in the demographic characteristics or in the severity of coronary stenosis, number of teeth, or the panoramic tomography index between deceased with and those without interview data, our results should be interpreted with caution. Although the dental health of our cases does not differ from that observed in the general male population living in Southern Finland, our victims may not be representative of the general middle-aged male population as such.
In conclusion, the present results indicate that men who suffer sudden cardiac death in early middle age seem to exhibit greater dental pathology compared with men who die of other causes. This suggests that infections of dental origin may be among the risk factors for sudden cardiac death. Post mortem panoramic tomography seems to be a valid method for the assessment of dental health in victims of sudden cardiac death, giving a comprehensive view of dental pathology. Since the victims of sudden cardiac death show heterogeneous cardiac pathology, more detailed studies on the contributions of different dental pathological processes are needed.
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ACKNOWLEDGMENTS |
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Received June 15, 2004; Last revision September 14, 2005; Accepted September 29, 2005
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REFERENCES |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| IADR Journals | Advances in Dental Research ® |
| Journal of Dental Research ® | Critical Reviews (1990-2004) |
1 findings in panoramic tomography]