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Cited by 394Oral microbiology and periodontitis researchBlood Pressure and Hypertension StudiesPeriodontal Regeneration and Treatments

Periodontitis is associated with hypertension: a systematic review and meta-analysis

Open access
Muñoz Aguilera, Eva, Suvan, Jean, Buti, Jacopo, Czesnikiewicz-Guzik, Marta, Barbosa Ribeiro, Aline, Orlandi, Marco, Guzik, Tomasz J, Hingorani, Aroon D +2 more·2020·Cardiovascular Research
DOI 10.1093/cvr/cvz201
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Abstract

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10–1.35] and severe PD (OR = 1.49; 95% CI: 1.09–2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85–3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88–6.11] and DBP (2.03 mmHg; 95% CI: 1.25–2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis found that periodontitis is associated with higher odds of hypertension and higher mean systolic and diastolic blood pressure, though evidence that periodontal therapy reduces blood pressure is inconclusive. The authors conclude that oral health assessment and periodontitis management may be relevant in hypertension management, while calling for larger and longer studies.

Key findings

  • Moderate-to-severe periodontitis was associated with hypertension (OR = 1.22; 95% CI: 1.10–1.35), and severe periodontitis was also associated with hypertension (OR = 1.49; 95% CI: 1.09–2.05 in the abstract; the results text reports 1.09–2.50).
  • Prospective studies showed periodontitis diagnosis increased the likelihood of hypertension occurrence, but this was not statistically significant (OR = 1.68; 95% CI: 0.85–3.35; P = 0.14).
  • Patients with periodontitis had higher mean systolic blood pressure (WMD = 4.49 mmHg; 95% CI: 2.88–6.11) and diastolic blood pressure (WMD = 2.03 mmHg; 95% CI: 1.25–2.81) than those without periodontitis.
  • Only 5 of 12 interventional studies confirmed blood pressure reduction after periodontal therapy, ranging from 3 to 12.5 mmHg for SBP and 0 to 10 mmHg for DBP.

Methods

  • Systematic review and meta-analysis registered in PROSPERO (CRD42017081455), reported with PRISMA; searches covered five electronic databases plus manual searching up to December 2018.
  • From 5,574 records after duplicate removal, 182 full texts were screened, 81 publications met inclusion criteria, and 40 were included in quantitative meta-analyses; meta-analysis A pooled odds ratios for hypertension, and meta-analysis B pooled mean SBP/DBP differences.
  • Random-effects models were used because of significant heterogeneity; risk of bias was assessed with ROB-2.0, ROBINS-I, and Newcastle-Ottawa tools, and strength of evidence was graded with SORT.

Limitations

  • The paper states that systematic reviews of observational studies have limited value for ascertaining causality, and that observational studies carry intrinsic selection and information biases.
  • The paper reports high heterogeneity in case definitions for both periodontitis and hypertension, unclear direction of association in some studies, mostly office rather than ambulatory blood pressure measurement, and suspected publication bias in the moderate-to-severe periodontitis and mean DBP meta-analyses.
  • The paper notes that only one RCT primarily addressed whether non-surgical periodontal therapy reduces blood pressure, and that a pilot study in refractory hypertension included only 26 patients; the text also makes evident a discrepancy between the abstract and results for the severe periodontitis confidence interval.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1093/cvr/cvz201

Cites

88 of 88 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 49 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    Reductions in inflammatory biomarkers were observed in 11 interventional studies following periodontal therapy.

    “Reductions in inflammatory biomarkers were observed in 11 interventional studies following periodontal therapy.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Publication bias was suspected in the mean diastolic blood pressure meta-analysis because Egger's test showed a statistically significant difference (P = 0.0224).

    “Egger's test estimated for meta-analyses B revealed a not statistically significant result (P = 0.5582) for the mean SBP meta-analysis and a statistically significant difference (P = 0.0224) for the mean DBP meta-analysis.On this basis, publication bias was suspected in the mean DBP meta-analysis.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Severe periodontitis is associated with increased odds of hypertension (OR = 1.49; 95% CI: 1.09-2.05 in the abstract and 1.09-2.50 in the Results).

    “and severe PD (OR = 1.49; 95% CI: 1.09-2.05)were associated with hypertension.”
    • Also stated in: § 3.1 Primary outcome · boosted
      “A meta-analysis of eight cross-sectional and case-control studies confirmed that patients with severe periodontitis had increased odds (1.49, 95% CI: 1.09-2.50;P = 0.01) of diagnosis of hypertension”
    • Also stated in: § 4. Discussion · plain
      “the more severe periodontitis is, the higher the likelihood (49%) of having hypertension.”
    Quote in the paperSubstantial claim
  • Findingcitation

    Six interventional studies reported no changes in blood pressure measures following non-surgical and/or surgical periodontal therapy.

    “Six studies reported no changes in blood pressure measures following non-surgical and/or surgical periodontal therapy”
    Quote in the paperNot a substantial claim
  • Findingown data

    Eight studies with a non-confident case definition of periodontitis confirmed higher odds of hypertension (OR = 1.33; 95% CI: 1.14-1.55; P = 0.003).

    “compared to a meta-analysis of eight studies with a non-confident definition of periodontitis (1.33, 95% CI: 1.14-1.55;P = 0.003)”
    Quote in the paperNot a substantial claim
  • May combine two claims. 16
  • Classified as probably not a substantial claim. 30
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingcitation

    Platelet count, fibrinogen, vWF:Ag, and D-Dimer levels increased after 48 h of treatment and decreased after 6 weeks in hypertensive patients with periodontitis, with no significant differences between groups.

    “Platelet count, fibrinogen, Von Willebrand factor antigen (vWF:Ag), and D-Dimer levels increased after 48 h of treatment (scaling of the teeth including subgingival root debridement for half of the patients and surgical periodontal therapy for the other 20) and decreased after 6 weeks (P < 0.05), with no significant differences between groups (P > 0.05).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [57] Albush, 2013, Effect of surgical and non-surgical periodontal debridement on vascular thrombotic markers in hypertensives, J Indian Soc Periodontol source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    In three cohort studies, periodontitis diagnosis predicted occurrence of hypertension (OR = 1.68; 95% CI: 0.85-3.35), but this was not statistically significant (P = 0.14).

    “Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35).”
    • Also stated in: § 3.1 Primary outcome · plain
      “The analysis of three cohort studies predicted the occurrence of hypertension (OR = 1.68; 95% CI: 0.85-3.35),but this was not statistically significant (P = 0.14)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Only 5 of 12 interventional studies confirmed a reduction in systolic blood pressure following periodontal therapy (range 3-12.5 mmHg), with inconsistent reduction in diastolic blood pressure (range 0-10 mmHg).

    “Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP.”
    • Also stated in: § 3.2.4 Mean blood pressure (interventional evidence) · plain
      “Five of the 12 interventional studies included in the analysis confirmed a reduction in SBP following periodontal therapy (range = 3-12.5mmHg), and an inconsistent reduction of DBP (range = 0-10 mmHg).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    One RCT reported an absolute difference of SBP = 12.57 mmHg (95% CI 10.45-14.69, P < 0.05) and DBP = 9.65 mmHg (95% CI 7.06-12.24, P < 0.05) after periodontal therapy.

    “They included 107 pre-hypertensive participants and reported an absolute difference of SBP = 12.57mmHg 95% CI: 10.45-14.69,P < 0.05 and of DBP = 9.65 mmHg 95% CI: 7.06-12.24,P < 0.05 after periodontal therapy.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [65] Zhou, 2017, Effect of intensive periodontal therapy on blood pressure and endothelial microparticles in patients with prehypertension and periodontitis: a randomized controlled trial, J Periodontol source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Circulating levels of MMP-8, MMP-9, myeloperoxidase and neutrophil elastase were increased in patients with hypertension and periodontitis but not in controls.

    “The authors observed that circulating levels of matrix metalloproteinases (MMP)-8, MMP-9, myeloperoxidase and neutrophil elastase (NE) were increased in patients with hypertension and periodontitis but not in the controls.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55] Türkoğlu, 2014, Evaluation of systemic levels of neutrophilic enzymes in patients with hypertension and chronic periodontitis, J Periodontol source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    One study only confirmed higher prevalence of hypertension in men.

    “and one study only confirmed higher prevalence in men.50”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [50] Tuominen, 2003, Oral health indicators poorly predict coronary heart disease deaths, J Dent Res source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Findingreasoning

    A lack of consistent case definitions for periodontitis contributed to difficulty in assessment and interpretation of the retrieved data.

    “Regarding the exposure, multiple case definitions for periodontitis were found.A lack of consistent case definitions contributed to the difficultly in assessment and interpretation of the data retrieved.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The interventional studies comprised a varied sample of individuals, including medically healthy people in six studies, pre-hypertension, refractory hypertension, hypertension, metabolic syndrome, coronary artery disease, and Type 2 diabetes.

    “These studies comprised a varied sample of individuals, including people medically healthy in six studies 22,28,44,58,59,62 pre-hypertension, 65 refractory hypertension, 29 hypertension, 59 metabolic syndrome, 63 coronary artery disease, 60 and Type 2 diabetes.64”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The meta-analysis B of mean SBP/DBP of 26 studies resulted in statistically significant heterogeneity, with I2 ranging from 96 to 98%.

    “The meta-analysis B, of mean SBP/DBP of 26 studies was performed resulting in statistically significant heterogeneity, confirmed with a Tau-squared test (ranging from 14.38 to 2.92), v 2 test ranging from (<0.00001), and I2 test (ranging from 96 to 98%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Some included studies reported lower cut-offs for hypertension (e.g., SBP >130 mmHg and/or DBP >85 mmHg) or based hypertension prevalence on medical records, self-report, or national classification codes.

    “Nevertheless, some studies reported lower cut offs for hypertension (i.e.SBP > _130mmHg and/or DBP > _85 mmHg) 42 or hypertension prevalence was based on medical records, self-report, or national classification codes for disease.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] Grundy, 2005, Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute scientific statement, Circulation source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Different methods for measuring blood pressure were described in the included studies.

    “Similarly, different methods for measuring blood pressure were described in the studies included”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Among the 12 interventional studies, eight were RCTs, three were non-RCTs, and one was a pilot study.

    “Eight studies were RCTs, three were non-RCT, and one was a pilot study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Eligibility assessment of titles/abstracts and full reports was performed independently and in duplicate by two reviewers, with almost perfect agreement (97.24%; Cohen's k: 0.94).

    “The eligibility assessment of titles and abstracts (when available) of all reports identified were independently screened by two reviewers based on inclusion/exclusion criteria (E.M.A. and J.S.).”
    • Also stated in: § 3. Results · plain
      “Reviewers (E.M.A. and J.S.) achieved an almost perfect agreement with 97.24%; Cohen's k: 0.94.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Periodontitis is associated with increased odds of hypertension (SORT C) and higher systolic/diastolic blood pressure levels.

    “PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels.”
    • Also stated in: § 3.4 Reporting on strength of recommendation · plain
      “we conclude that diagnosis and treatment of periodontitis is positively associated with hypertension (SORT C).”
    • Also stated in: § 4. Discussion · plain
      “The results of this systematic review support a positive association between periodontitis and hypertension.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Quality assessment of all included studies was undertaken independently and in duplicate by two reviewers using ROB-2.0, ROBINS-I, and Newcastle-Ottawa tools.

    “Quality assessment of all included studies was undertaken independently and in duplicate by two reviewers as part of the data extraction process.For bias assessment of randomized controlled trials, non-randomized studies of interventions, and observational studies we used the revised Cochrane tool (ROB-2.0tool), 35 the ROBINS-I tool, 36 and the Newcastle-Ottawa (NOS) tool, 37 respectively.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [35] Higgins, 2016, A revised tool for assessing risk of bias in randomized trials, Cochrane Database Syst Rev

      Not checked in the free run.

    • cites [36] Sterne, 2016, ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions, BMJ source

      Not checked in the free run.

    • cites [37] Wells, 2009

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Randomized controlled trials had low (five studies) to high (two studies) risk of bias, mainly due to randomization and blinding.

    “The assessment of randomized controlled trials with the Rob 2.0 tool revealed a low (five studies) to high (two studies) risk of bias for the studies included (Supplementary material online, Appendix S4).The main reasons for high risk of bias in randomized controlled trials arose from the randomization . . . . . . . . . . . . . . . . . . . . . . . . . . .process, blinding of participants and”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The systematic review protocol was registered in PROSPERO (ID: CRD42017081455).

    “The systematic review protocol was registered in PROSPERO on 28/11/ 2017 with ID: CRD42017081455.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A PRISMA statement is attached to follow the reporting of this systematic review.

    “A PRISMA statement is attached to follow the reporting of this systematic review (Supplementary material online, Appendix S1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Egger's test was only calculated for the meta-analysis A of moderate to severe periodontitis.

    “Egger's test was only calculated for the meta-analyses A of moderate to severe periodontitis (Supplementary material online, Appendix S8).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An ulcerated epithelial lining of the gingival pocket could amount to a sizeable area in patients with generalized periodontitis.

    “An ulcerated epithelial lining of the gingival pocket, subsequent to a local inflammatory response to the dental biofilm could amount to a sizeable area in patients with generalized periodontitis.21”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Hujoel, 2001, Examining the link between coronary heart disease and the elimination of chronic dental infections, J Am Dent Assoc source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Publication bias was examined using funnel plots for both meta-analyses A and B.

    “Study publication bias was examined using funnel plots for both metaanalyses A and B (Supplementary material online, Appendix S8).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The interplay between the bacterial burden and host response is the most plausible biological mechanism linking periodontitis to a number of chronic systemic diseases, such as diabetes mellitus, cardiovascular diseases, and neurological diseases such as Alzheimer.

    “The interplay between the bacterial burden and host response is the most plausible biological mechanism linking periodontitis to a number of chronic systemic diseases, such as diabetes mellitus, CVDs, and neurological diseases such as Alzheimer.17,19,20”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [17] Tonetti, 2013, Periodontitis and atherosclerotic cardiovascular disease: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases, J Clin Periodontol source

      Not checked in the free run.

    • cites [19] Southerland, 2013, Periodontitis may contribute to poor control of hypertension in older adults, J Evid Based Dent Pract source

      Not checked in the free run.

    • cites [20] Dominy, 2019, Porphyromonas gingivalis in Alzheimer’s disease brains: evidence for disease causation and treatment with small-molecule inhibitors, Sci Adv source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

    Interpretationcitation

    The magnitude of association between periodontitis and hypertension reported in this review (OR 1.22-1.53) is in agreement with that recently reported by Martin-Cabezas et al.

    “The magnitude of association between periodontitis and hypertension reported in this review (OR 1.22-1.53) is in agreement with that recently reported.27”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Martin-Cabezas, 2016, Association between periodontitis and arterial hypertension: a systematic review and meta-analysis, Am Heart J source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Patients with periodontitis often present with systemic inflammation and endothelial dysfunction, which improves following successful periodontal treatment.

    “These patients often present with systemic inflammation and endothelial dysfunction, 22 which improves following successful periodontal treatment.23”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] Tonetti, 2007, Treatment of periodontitis and endothelial function, N Engl J Med source

      Not checked in the free run.

    • cites [23] Orlandi, 2014, Association between periodontal disease and its treatment, flow-mediated dilatation and carotid intima-media thickness: a systematic review and meta-analysis, Atherosclerosis source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Possible publication bias was assessed for studies included in meta-analyses A and B using the methods described by Begg et al. and Egger et al.

    “Possible publication bias was assessed for studies included in the different meta-analyses A and B using the methods described by Begg et al. and Egger et al. 38,39”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [38] Begg, 1994, Operating characteristics of a rank correlation test for publication bias, Biometrics source

      Not checked in the free run.

    • cites [39] Egger, 1997, Bias in meta-analysis detected by a simple, graphical test, BMJ source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The significance of discrepancies in estimates from different trials was assessed by Cochran's test for heterogeneity and the I2 statistic.

    “The significance of any discrepancies in the estimates from different trials was assessed by means of Cochran's test for heterogeneity and the I 2 statistic.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The pilot intervention trial had limited sample size and inclusion criteria.

    “We urge caution in interpreting these results especially in view of the limited sample size and inclusion criteria adopted by the authors.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Vidal, 2013, Non‐surgical periodontal treatment reduces cardiovascular risk in refractory hypertensive patients: a pilot study, J Clin Periodontol source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    An immune response to Porphyromonas gingivalis results in elevation of blood pressure, vascular inflammation, and endothelial dysfunction in experimental animals.

    “Emerging experimental animal evidence indicates that an immune response to a common periodontal pathogen: Porphyromonas gingivalis (Pg) results in elevation of BP, vascular inflammation, and endothelial dysfunction.78”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] Czesnikiewicz‐Guzik, 2019, Th1‐type immune responses to Porphyromonas gingivalis antigens exacerbate angiotensin II-dependent hypertension and vascular dysfunction, Br J Pharmacol source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Management of periodontitis could impact on the management of hypertension.

    “Further, management of periodontitis could impact on the management of hypertension.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Anti-hypertensives such as calcium channel blockers can cause gingival enlargement in 6.3-83% of patients.

    “Lastly, it has been reported that anti-hypertensives such as calcium channel blockers can cause gingival enlargement in 6.3-83% of patients, 84”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [84] Hallmon, 1999, The role of drugs in the pathogenesis of gingival overgrowth. A collective review of current concepts, Periodontol 2000 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    This challenge was mainly due to unclear description in the published manuscripts.

    “This was mainly due to unclear description in the published manuscripts.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The quality and strength of the evidence was assessed with the SORT (Strength of Recommendation Taxonomy).

    “The quality and strength of the evidence was assessed with The SORT (Strength of Recommendation Taxonomy).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    A systematic review yielded 9866 reports, and after removal of duplicates and application of inclusion and exclusion criteria, 46 studies were included in two different meta-analyses.

    “A systematic review yielded 9866 reports.After removal of duplicates and the application of inclusion and exclusion criteria, 46 studies were included in two different meta-analyses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Five electronic databases were searched up to 10 December 2018 with no year restrictions.

    “Five electronic databases were searched up to 10 December 2018 with no year restrictions [Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE, Web of Science and Latin American & Caribbean Health Sciences Literature (LILACS)]”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Our findings highlight the potential to improve CV outcomes by addressing poor oral health in the general population.

    “Our findings highlight the potential to improve CV outcomes by addressing poor oral health in the general population.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The quality, quantity, and consistency of the evidence from observational and interventional studies on the relationship between periodontitis and hypertension were thoroughly assessed for a SORT recommendation.

    “The quality, quantity, and consistency of the evidence from observational and interventional studies on the relationship between periodontitis and hypertension were thoroughly assessed for a SORT recommendation.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Study design and conductnone given

    Sensitivity analyses were planned to explore, quantify, and control for sources of heterogeneity between studies.

    “As alluded above, sensitivity analyses were also planned to explore, quantify, and control for sources of heterogeneity between studies.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Some data may have been missed in this systematic review due to difficulties in identifying outcomes within published reports.

    “but the authors acknowledge that some of the data may have been missed due to the difficulties in identifying the outcomes within the published reports.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    One challenge encountered in this systematic review was to establish the direction of association when studies were included in the quantitative analyses.

    “One of challenges encountered was to establish the direction of association when studies were included in the quantitative analyses (i.e.dependent and independent variables in the model).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    Prevention and management of periodontitis improves oral/overall health and quality of life and could prevent/improve hypertension.

    “Prevention and management of periodontitis improves oral/overall health and quality of life and could prevent/improve hypertension.”
    Quote in the paperNot a substantial claim
40 of 40

  • The paper relies on this without support.

    Periodontitis is associated with systemic inflammation, and mediators including CRP, IL-6, and TNF-α can affect endothelial function.

    “Firstly, periodontitis is associated with systemic inflammation, mediators of which, including CRP, IL-6; TNF-a can all affect endothelial function.”

  • The paper relies on this without support.

    Observational studies have intrinsic biases (mostly selection and information bias).

    “Moreover, observational studies have intrinsic biases (mostly selection and information bias), hence the results of this systematic review should be interpreted within the context of the methodology used.”

  • The paper relies on this without support.

    Studies looking at hypertension have inherent problems from the effect of blood pressure measurement technique on the outcome and variable degree of reporting of actual criteria of hypertension.

    “Moreover, studies looking at hypertension have inherent problem of the effect of blood pressure measurement technique on the outcome as well as variable degree of reporting of actual criteria of hypertension.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract calls the prospective association confirmed despite a nonsignificant result

    Major

    The abstract says prospective studies confirmed an increased likelihood of hypertension, but the results section explicitly says the same estimate was not statistically significant. Its 95% confidence interval also includes an odds ratio of 1.

  • Severe-periodontitis confidence interval has two different upper limits

    Minor

    The abstract reports an upper 95% confidence limit of 2.05 for the severe-periodontitis odds ratio, while the results section reports 2.50 for the same estimate.

  • Quantitative synthesis study count differs between abstract and figure caption

    Minor

    The abstract says 40 studies were included in quantitative meta-analyses, whereas the Figure 1 caption says 46 studies were included in the two meta-analyses.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Rivas-Tumanyan, 2012, Periodontal disease and incidence of hypertension in the health professionals follow-up study, 770

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Authors
Muñoz Aguilera, E., Suvan, J., Buti, J., Czesnikiewicz-Guzik, M., Barbosa Ribeiro, A., Orlandi, M., Guzik, T. J., Hingorani, A. D., Nart, J., & D’Aiuto, F.
Affiliations
  • Periodontology Unit, University College London Eastman Dental Institute, London WC1X 8LD, UK
  • University College London (GB)
  • Department of Periodontology and Oral Sciences Research Group, University of Glasgow Dental School, Glasgow G12 8QQ, UK
  • Jagiellonian University (PL)
  • Department of Periodontology, Faculty of Dentistry, Universitat Internacional de Catalonia, Sant Cugat del Vallès, Barcelona 08195, Spain
Corresponding author
D’Aiuto, Francesco
ORCID
Venue
Cardiovascular Research
Publisher
Oxford University Press (OUP)
Published
2019-09-24
Volume
116
Issue
1
Pages
28-39
ISSN
  • 0008-6363 (ISSN-L)
  • 1755-3245
DOI
10.1093/cvr/cvz201
OpenAlex
W2975445774
Semantic Scholar
3131211fe850558668122eb17c36c705f24f4cda
Cited by
394
References
88
Citations by year
2026: 44 · 2025: 58 · 2024: 59 · 2023: 78 · 2022: 55 · 2021: 56 · 2020: 37 · 2019: 7
FWCI
5.48
Type
journal article
Language
en
Open access
Licence
academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
Locations
  • Cardiovascular Research (publishedVersion)
  • PubMed (publishedVersion)
  • Jagiellonian University Repository (Jagiellonian University) (submittedVersion, cc-by-nc-nd)
  • ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (submittedVersion, cc-by-sa)
  • UCL Discovery (University College London) (submittedVersion)
Funders
  • UCLH
  • UCL
  • Department of Health’s NIHR Biomedical Research Centre
  • European Research Council
  • ERC
Topics
  • Health Sciences › Dentistry › Periodontics › Oral microbiology and periodontitis research
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
  • Health Sciences › Medicine › Urology › Periodontal Regeneration and Treatments
Keywords
periodontitis, hypertension, blood pressure, periodontal treatment, systemic inflammation, cardiovascular risk, oral health, biomarkers
MeSH terms
Blood Pressure, Dental Care, Female, Humans, Hypertension, Male, Oral Health, Oral Hygiene, Periodontitis, Prognosis, Quality of Life, Risk Factors, Severity of Illness Index, Prevalence, Risk Assessment

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