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Relationship between Periodontal Diseases and Essential Hypertension: A

Cross-Sectional Comparative Study Association entre maladies p arodontales
et hypertension essentielle: une...

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Periodontal diseases and essential hypertension in Yaounde : a cross-sectional comparative study Ndongo Amougou et al
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Original Article

Relationship between Periodontal Diseases and Essential

Hypertension: A Cross-Sectional Comparative Study
Association entre maladies p arodontales et hypertension essentielle: une étude
comparative.

Sylvie Ndongo Amougou1,3,4*, Karl Guy Grégoire Kwedi2, Marie Elvire Nokam Abena 2, Jingi Musa
Ahmadou1, Elise Marie Eya’ane Mendomo2, Charles Messanga Bengondo2, 3,4

ABSTRACT

1
Background. Periodontal disease is a multifactorial inflammatory disease affecting the
Department of Medicine and support tissues of the teeth. Numerous studies have investigated the relationship between
Specialties. Faculty of Medicine oral diseases and Essential Hypertension. There is a paucity of data on the relationship
and Biomedical Sciences. between periodontal disease and essential hypertension in Cameroon. Methods. We carried
University of Yaounde 1. this cross-sectional comparative study in adults ≥ 21 years, of both sex. Participants were
Cameroon. hypertensive (test group), and non-hypertensive (comparison group). The different
2
Department oral and maxillo- periodontal indices (plaque index, bleeding index, loss of attachment) were measured during
facial surgery, and the periodontal examination. Student's test, Chi-square test, and linear regression models
Parodontology. Faculty of were used in the statistical analyses. Results. A total of 80 participants (40 hypertensives
Medicine and Biomedical and 40 controls) were enrolled. Their mean ages were 53.3 ± 11.4 years and 42.8 ± 8.2 years
Sciences. University of Yaounde respectively. Mean plaque index was 1.54 ± 0.7 in the hypertensives, and 1.36 ± 0.5 in non-
1. Cameroon. hypertensives (p<0.05). Mean bleeding index was 1.88 ± 0.3 in hypertensives and 1.38 ± 0.4
3
University Teaching Hospital, in non-hypertensives (p<0.05). Mean attachment loss was 1.58 ± 0.22 in hypertensive
Yaounde. Cameroon. patients and 1.26 ± 0.27 in controls with p <0.05. Conclusion. Our studies suggest a link
4
Hospital Center and University between periodontal disease and essential hypertension. Further studies matching the control
of Yaounde (CHU-Y) group in confounding variables are mandatory because of the significant difference in age
*
Corresponding author: email: between the two groups.
ndongoamougou@yahoo.fr
mobile: (237) RÉSUMÉ
699 818 207
Introduction. La parodontite est une pathologie inflammatoire multifactorielle affectant les
Key words : Periodontal disease, tissus de soutien de la dent. De nombreuses études se sont penchées sur les rapports entre les
essential hypertension, maladies bucco-dentaires et. Au Cameroun, peu d’études ont examiné la relation entre la
periodontal indices, Yaoundé. maladie parodontale et L’Hypertension artérielle essentielle. Méthodes. Il s’agit d’une étude
transversale comparant un groupe patients (les hypertendus), et un groupe contrôle constitué
Mots clés : maladies de patients sans Hypertension. Tous avaient un âge au moins égal à 21 ans. Les différents
parodontales, hypertension indices parodontaux (indice de plaque, de saignement, perte d’attache) ont été mesurés au
artérielle essentielle, indices cours de l’examen parodontal. Le test de Student, le test de Chi-carré et les modèles de
parodontaux, Yaoundé. régression linéaire ont été utilisés pour les analyses statistiques. Résultats. La population
d’étude était constituée de 80 sujets repartis en deux groupes de 40 sujets chacun: un groupe
d’étude (hypertendus) et un groupe contrôle de 40 patients. L’âge moyen de la population
d’étude était respectivement de 53,28 ans± 11,4 chez les hypertendus et de 42,8 ans ± 8,2
Received : Novembrer 27, 2017 chez les contrôles. L’indice de plaque moyen était plus élevé chez les hypertendus 1,54 ±
Accepted : December 3, 2017 0,69 contre 1,36 ± 0,51 chez les contrôles (p<0,05). L’indice de saignement moyen lui aussi
était plus élevé pour les hypertendus 1,88 ± 0,34 contre 1,38 ± 0,42 pour les contrôles
(p<0,05). La perte d’attache moyenne était de 1,58 ± 0,22 chez les hypertendus et de 1,26 ±
0,27 chez les contrôles avec p<0,05. Conclusion. Nos résultats suggèrent l’existence d’un
lien entre la MP et l’Hypertension essentielle. Toutefois, la différence d’âge entre les
groupes est notable, des études complémentaires avec appariement du groupe contrôle au
groupe d’étude sont nécessaires.

Health Sci. Dis: Vol 19 (1) January – February – March 2018 88

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Periodontal diseases and essential hypertension in Yaounde : a cross-sectional comparative study Ndongo Amougou et al
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INTRODUCTION both arms with a standard sized cuff, using an electronic

BP recorder (OMRON® M2 Basic). Two measures were
Periodontal disease (PD) is a multifactorial inflammatory
taken for each arm. The arm with the higher average was
disease affecting the support tissues of the teeth. It is
considered in diagnosing hypertension. We defined
characterized by the progressive destruction of the
hypertension as a resting systolic BP > 140 mmHg, and
periodontal tissues resulting in the loss of the dental
or diastolic BP > 90 mmHg in untreated hypertensive
organ [1]. The World Health Organization (WHO)
patients. The various periodontal indices (plaque index,
estimated that 15 to 20% of the population have severe
bleeding index and loss of attachment) were measured
PD [2]. The prevalence of PD in Africa is one of the
during the periodontal examination.
highest in the world [3]. There are many risk factors that
Statistical analysis : Data were analyzed using the
allow each individual to react differentl y such as;
software IBM SPSS version 20. Student t-test was used
smoking, alcohol, stress, poor nutrition, obesity, diabetes
to compare the means, and Chi squared test was used to
mellitus, and dyslipidemia. These are also risk factors for
compare proportions. Linear logistic regression models
cardiovascular diseases (CVD), a public health problem
were used to study the factors associated with
worldwide accounting for 17.3 million deaths yearly, of
hypertension. A p value <0.05 was considered
which 9.4 million are attributed to hypertension [4, 5].
statistically significant for the observed associations or
Hypertension has reached epidemic proportions, with
differences.
greatest burden in low-income settings in sub-Saharan
Ethical considerations : Ethical clearance for this work
Africa (SSA) [5]. It affects about 30% of the population
was obtained from the institutional review board of the
of Cameroon [6]. Numerous studies have examined the
Faculty of medicine and Biomedical sciences of the
relationship between oral diseases and cardiovascular
University of Yaounde 1. We report this work in
disease [7]. Studies have suggested a link between
accordances with the declarations of Helsinki. We report
periodontal disease and hypertension. In Italy in 2003, a
this work following the STROBE checklist.
study of the relationship between the severity of
Results
periodontitis and left ventricular mass in subjects with
Participants : A total of 80 participants (40
essential hypertension reveals a direct link between PD
hypertensives and 40 normotensives) were included.
and hypertension [8].
There were 16 (40%) males in the hypertension group,
There is a paucity of data on the association of
and 11 (27.5%) males in the normotensive group. Their
periodontal disease and hypertension in our setting.
mean age was 53.3 ± 11.4 years in the hypertensive
These pathologies directly affect the quality of life. and
group, and 42.8 ± 8.2 years in the normotensive group
have a considerable impact on the well-being of the
(Table I).
individual [2, 9]. The aim of this cross-section
comparative study was to investigate the association of Table I: Baseline characteristics of
periodontal disease and hypertension in Yaounde. the study population.
METHODS Variables Hypertensives Controls p
(n=40) (n=40) value
Study design and setting : In 2017, we carried out a
cross-sectional comparative study in the Internal Age (years), mean ± SD 53.3 ± 11.4 42.8 ± 8. <0.05
Male (%) 40 27.5 <0.05
medicine units of the Yaounde University Teaching Alcohol (%) 37.5 40 0.49
Hospital, and the Yaounde central Hospital. Yaounde is Obesity (%) 27.5 10 <0.05
the political capital of Cameroon, with a population of Systolic blood pressure 162 ± 21 116 ± 13 <0.05
about 2 million inhabitants. (mmHg)
Diastolic blood pressure 93 ± 11 75 ± 8 <0.05
Participants : These were consenting adults aged ≥ 21 (mmHg)
years, of both sex, with newly diagnosed and untreated Family history of 72.5 42.5 0.06
hypertension (test group), and without hypertension Hypertension (%)
(comparator group). We excluded those with other heart Plaque index 1.54 ± 0.7 1.36 ± 0.5 <0.05
Bleeding index 1.88 ± 0.3 1.38 ± 0.4 <0.05
conditions, thyroid diseases, chronic kidney disease, Loss of attachment 1.58 ± 0.2 1.26 ± 0.3 <0.05
respiratory disorders, rheumatic disorders, diabetes,
tobacco users, and pregnant women. We also excluded
those with less than 50% of their teeth, or had undergone Outcome data: The mean plaque index was 1.54 ± 0.7 in
dental cleaning within the last 6 months. the hypertensive group, and 1.36 ± 0.5 in the
Variables and measurements: We prospectively normotensive group (p<0.05). The mean bleeding index
collected data on socio-demography (age and sex), past was 1.88 ± 0.3 in the hypertensives, and 1.38 ± 0.4 in the
medical history, and anthropometry (weight and height). normotensives (p<0.05) (Table II).
Their weight (kg) was measured in light clothing and no Table II shows a cross analysis of bleeding index and
shoes on using an electronic scale balance (OMRON® attachment loss as a function of plaque index average of
HN289), and their height (m) with a stadiometer. We between 1.25 – 1.5. This was to minimize the impact of
calculated their Body Mass Index (BMI) as their weight / bacterial plaque on the periodontium at the expense of
(height) 2. High adiposity was considered when the BMI hypertension. This range was the most representative
was ≥ 25 kg/m2. We measured their blood pressure (BP) with 9 hypertensives and 26 controls for a total of 35
after at least 10 minutes of rest in the sitting position in (Table II).

Health Sci. Dis: Vol 19 (1) January – February – March 2018 89

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Periodontal diseases and essential hypertension in Yaounde : a cross-sectional comparative study Ndongo Amougou et al
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Table II : Distribution of the plaque index. periodontium. This was significantly higher in
Range of Plaque Hypertensives Controls p value hypertensives. Our finding was similar to that reported
index N % N % by Iwashima et al. [12] in Japan, and Leye et al. [10] in
1 – 1.25 5 13,2 7 17,5 <0.001 Senegal. In a nationwide study by Tsakos et al. [13] in
1.26 – 1.5 9 23,7 26 65,0 <0.001 the USA, there was a significant association between
1.51 – 1.75 20 52,6 6 15,0 <0.001 gum bleeding and hypertension in adults. However, our
1.76 – 2.0 4 10,5 1 2,5 <0.001 findings were not similar to that reported by Ollikainen
et al. [14] in 2014. The mean attachment loss was greater
Hypertensives had a higher mean gingival index and in hypertensive patients. This was similar to that reported
higher mean attachment loss (p <0.05). The mean plaque by Ollikainen et al. [14].
index and mean bleeding index increased with the We observed that plaque index and bleeding index
severity of hypertension (Table IV). increased with the severity of hypertension. On the other
hand, this distribution was not the same for the loss of
attachment where the lowest mean score was seen in
Table III: Gingival index and loss of those with grade 2 hypertension. Our findings are similar
attachment as a function of plaque index to that reported by Aworojolu et al. in Nigeria in 2016.
Variable Hypertensives Controls p value Hypertension causes modifications in the blood vessels.
Gingival index 1.89 ± 0.2 1.39 ± 0.3 <0.05 In the gum, theses microvascular modifications render it
Loss of attachment 1.56 ± 0.3 1.26 ± 0.4 <0.05 fragile, thus vulnerable to bacterial infections [15]. Some
studies have reported that periodontal pathogens
especially Porphyromonas gingivalis and Actinobacillus
Logistic analysis using hypertension as the dependent actinomycetemcomitans can be found in atheromatous
variable showed that, family history (OR: 6.7, [95% CI: plaques. Concerning P. gingivalis, its role has been
6.5 – 6.9), p = 0.03]), the plaque index (OR: 1.5, [95% recognized in the induction of the expression of cell
CI: 1.3 – 1.97), p = 0.042]), the bleeding index (OR: adhesion molecules including ICAM-1, VCAM-1 and p-
1.11, [95% CI: 1.1 – 2.3), p = 0.001]), and attachment selectin. Thus, the endothelial cells are activated, and
loss (OR: 1.5, [95% CI: 1.2 – 3.1), p = 0.<001]) were smooth muscle cell proliferation is triggered with
determinants, and could be associated with hypertension resultant alteration of vasomotor function [15]. Knowing
(Table IV). the harmful effect of atheroma plaques on the evolution
Table IV: Distribution of periodontal indices of hypertension, this could explain the increase in blood
according to the severity of hypertension pressure values concomitant with plaque index and
Variable Hypertension p gingival index. The loss of attachment is a chronic
Grade 1 Grade 2 Grade 3 value process of multifactorial etiology. In addition to the
Plaque index 1.51 ± 0.2 1.58 ± 0.2 1.59 ± 0.2 0.3 gingival inflammation involved, there is an inter human
Gingival 1.86 ± 0.2 1.88 ± 0.2 1.93 ± 0.2 0.62 variability in their response [16]. This could explain this
index divergence of evolution according to the severity of
Loss of 1.58 ± 0.3 1.53 ± 0.3 1.58 ± 0.3 0.24 hypertension. Periodontal disease was assessed using
attachment periodontal indices. Oral hygiene was assessed by plaque
index, inflammation of the gum was assessed by
bleeding index, and the involvement of the deep
DISCUSSION periodontium was evaluated by the loss of attachment.
This study may suggest an association between
We carried out this cross-sectional comparative study to
periodontal disease and hypertension. However, the two
assess the association of periodontal indices and
groups were significantly different in terms of age, sex
hypertension in a group of patients. The mean plaque
and weight, and this may have biased our findings.
index was significantly higher in hypertensives. This is
comparable with that reported by Leye et al. [10] in 2014 CONCLUSION
in Senegal. There is evidence that hypertension is Periodontal diseases are characterized by the presence of
associated with microvascular dysfunction. This will plaques, gingival bleeding, periodontal pocket and / or
result in a reduction in blood supply to the salivary loss of attachment. Hypertensive patients seem to be
glands. Constituents of blood are important in the more affected by periodontal disease than
production of saliva. Changes in blood constituent will normotensives, but we cannot draw a definite conclusion
thus lead to the modification in the flow of saliva. of a cause and effect relationship. Further studies are
Masood et al. [11] showed that the flow of salivar was needed to better assess this issue and to see if treating
lower in those with hypertension than healthy controls. periodontal disease will improve on blood pressure
This condition of low salivary flux favours an increase in control in our setting.
bacterial activity, thus the formation of plaques.
However, this difference was not statistically significant.
The first reaction of periodontal tissues to bacterial
plaque is inflammation of the gum. The bleeding index is
indicative of the inflammatory activity of the

Health Sci. Dis: Vol 19 (1) January – February – March 2018 90

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 Periodontal diseases and essential hypertension in Yaounde : a cross-sectional comparative study Ndongo Amougou et al
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RESEARCH IN CONTEXT DISCLOSURE

 What is known about this subject : Periodontal Acknowledgement : We thank the participants for
disease and Hypertension are very frequent in accepting to take part in this study.
our setting suggesting an association. Conflict of interest : We declare no conflict of interest.
 What this study adds : There is an association of Authors’ contribution : All the authors contributed in
periodontal disease and essential hypertension. the conception, design, data collection, data analysis, and
The severity of periodontal disease increases drafting of the manuscript. All the authors approved of
with the severity of hypertension. the final version for publication.
Funding : None.

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