Can periodontal treatment reduce CV events in stroke patients?

The first randomized trial to investigate whether periodontal treatment can reduce future risk of cardiovascular events or stroke shows promise with this strategy.

The PREMIERS study, which was conducted in patients with recent stroke or transient ischemic attack (TIA) who also had gum disease, did not show a statistically significant difference between intensive periodontal treatment and treatment standard in the rate of stroke recurrence, myocardial infarction (MI) or death in the one-year follow-up, although there was a strong trend towards benefit in the intensive group.

Both groups had a much lower event rate compared to a historical control group of similar patients.

Additionally, the number of dental visits was significantly correlated with a reduction in the rate of composite events in the study.

“My take-home message from this study is that periodontal treatment appears to impact cardiovascular outcomes in stroke/TIA patients,” said lead author Souvik Sen, MD, MPH, professor of neurology at the University of South Carolina Medical School. lecoeur.org | Medscape Cardiology.

“Even standard periodontal care – a dental cleaning every 3 months – was beneficial.”

Sen presented the study Feb. 9 at the International Stroke Conference (ISC), which is taking place in New Orleans and virtually.

“It was a very ambitious study, and it turned out to be very insufficient for the comparisons involved, but I was impressed that we saw such a trend towards benefits in the intensive group,” he said. .

Sen explained that they originally planned to compare periodontal treatment to no treatment, but could not have a control group that received no treatment for ethical reasons, so they ended up by comparing standard treatment with intensive treatment.

“We probably needed a study twice as large for this comparison. But our results are encouraging and we are now planning to do a larger study,” he said.

Sen reported that gum disease (periodontitis) is extremely common, occurring in about half of the US population. It is particularly prevalent in the southeastern part of the United States, known as the “Stroke Belt” due to a much higher incidence of stroke compared to the rest of the country. Gum disease is known to be associated with an increased risk of cardiovascular events and strokes.

For the study, 280 patients from the Stroke Belt region with recent stroke or TIA and periodontal disease were randomly assigned to standard periodontal treatment or intensive periodontal treatment and followed for 1 year.

The standard treatment consisted of regular supragingival removal (every 3 months) of plaque and tartar; patients also received a regular toothbrush and advice on dental care.

The intensive group received supragingival and subgingival plaque and calculus removal (also every 3 months), hopeless tooth extraction, locally administered antibiotics, and patients received an electric toothbrush, oral rinse -mouth and a dental floss for dental care.

All patients received full conventional therapy for stroke risk factors.

The study had an adaptive randomization design to ensure that the two groups were balanced in terms of age, stroke causes, race, socioeconomic status and stroke risk factors.

The results showed that after 1 year of follow-up, the primary outcome (stroke/myocardial infarction/death) occurred in 7.7% of the intensive treatment group compared to 12.3% of the standard care group, which which gives a relative risk of 0.65 (95% CI, 0.30 – 1.38; P = 0.26).

But both groups had a much lower rate of recurrent events compared to a historical control group that had a 1-year stroke/MI/death rate of 24%. The historical controls were part of an observational study that the same group of researchers previously conducted in a similar population.

In the standard treatment and intensive treatment groups, the combined number of dental visits was strongly correlated with a reduction in cardiovascular events. Of the study participants, 65% attended all five visits, 25% attended two to four, and 10% did not attend any after the baseline assessment.

Those who attended all visits within a year had a 1-year stroke/MI/death rate of 8%. And those who did not attend further visits after the baseline visit had a 25% event rate at one year of follow-up, which Sen said was very similar to historical controls. the P the value of this trend was “very significant” (P = 0.0017), he said.

Secondary outcomes showed reduced blood pressure, A1c levels, carotid intima-media thickness, and better lipid profiles in all patients who received treatment – ​​both on standard treatment and on intensive treatment.

“Previous data on the relationship between gum disease and periodontal treatment and cardiovascular outcomes have all come from observational studies. They have shown that regular dental care is associated with a reduced incidence of future cardiovascular events. now we haven’t had randomized data,” Sen noted.

He believes oral care advice should be part of routine clinical practice for patients who have had a stroke. “It’s not something we’re currently thinking about, but it could make a big difference to future event rates.”

Sen said the ongoing study has sparked interest in the topic and his presentation has been enthusiastically received by the public.

“We are in South Carolina in the Stroke Belt. Previous studies have shown that gum disease is very common in this area. People in this area have a high risk of stroke, but we don’t know all the factors. of attributable risk. The traditional risk factors for stroke don’t seem to explain all of the excess risk,” Sen said. “Periodontal disease may be one of the additional risk factors that explain the increased risk of stroke in this population.

“I think doctors treating stroke patients should advise them to pay special attention to oral care and to visit the dentist frequently for periodontal treatment if they have gum disease. It is very unusual for people to have their teeth cleaned regularly. They don’t understand that they need to do it,” he said.

But he acknowledges that larger studies are needed to show statistically significant results so that a strong recommendation can be made in clinical guidelines for secondary prevention.

“Even in people who have not had a stroke or cardiovascular event, population-based observational studies clearly show that gum infection is related to future risk of myocardial infarction and stroke, and that regular dental care (one or more visits per year) can reduce this risk. I don’t think we can do a randomized trial in the general population – that would require huge numbers. We’ll have to rely on the observational studies here,” he added.

Commenting on the ongoing study for lecoeur.org | Medscape CardiologyLouise McCullough, MD, chair of the ISC 2022 program, said she thought the results were promising.

“There was no difference between the intensive cleaning group and the standard cleaning, but the number of events was low, so it was not powerful enough to see the differences. I think the main takeaway is that the two groups that came in for dental visits had a much lower risk of another event than the group that did not show up for follow-up,” said McCullough, chair of the neurology department. , McGovern Medical School, University of Texas Health Science Center, Houston “Obviously seeing a provider made a difference. It is likely that contacting a dentist, checking blood pressure, etc., made a dramatic difference.”

The study was funded by the National Institute of Minority Health Disparity, Phillips Oral Healthcare, and Orapharma (which provided the antibiotic drug for the study).

International Stroke Conference 2022. LBS3 Abstract. Presented February 9, 2022.

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