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 outpatients 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 pretested 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 selfadministered 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
Variable
N
%
N
%
Presence of
Cases
Controls
Cardiovascu
99
47.4 110 52.6
lar Disease
Hypertensio
Myocardial
CVD
n
Infarction
Classificatio
107
97.3
6
5.5
n (Among
Stroke
Angina
Cases)
22
20
5
4.5
Male
Female
Gender
73
34.9 136 65.1
Single
Married
32
15.3 147 70.3
Civil Status
Separated
Widowed
9
4.3
21
10.0
Never
Ever Been
Civil
Married
Married
Status2
32
15.3 177 84.7
Not
Widowed
Civil
Widowed
Status3
188
89.9
21
10.1
No
Yes
Currently
Working
122
58.4
87
41.6

Religion

Educational
Attainment

Educational
Attainment
2
Family Size

Roman
Catholic
185
88.5
Iglesia ni
Cristo
5
2.4
Others
12
5.7
No
educational
attainment
3
1.4
High school
113
54.1
Not a High
school
Graduate
44
21.1
1 to 5
Family Size
140
67.0

Protestant
6

2.9

Muslim
1

0.5

Elementary
41
19.6
College
52
24.9
At Least a
High
School
Graduate
165 78.9
6+ Family
Size
69
33.0

Table 2. Frequency table for oral health

practices.
Oral Health Practices
Variable
N
%
N
%
<1x/day
1x/day
10.
Frequency
5
2.4
22
5
Tooth brushing/
Practicing Oral
2x/day
>2x/day
Health
46.
40.
97
85
4
7
No
Yes
Uses
98.
Toothbrush
3
1.4
206
6
No
Yes
Uses
99.
Toothpaste
2
1.0
207
0
No
Yes
Uses
73.
26.
Mouthwash
154
55
7
3
No
Yes
Uses Dental
90.
Floss
189
20
9.6
4
No
Yes
Uses
79.
20.
Toothpicks
166
43
4
6
No
Yes
Uses Other
Oral Health
99.
207
2
1.0
Products
0
Timing of Toothbrushing, Flossing, and/or
use of Mouthwash and Other Health
Products
No
Yes
Pagkagisin
92.
g
15
7.2
194
8

Pagkatapos
Kumain

No
110

Yes
52.
6

99

Yes
12.
87.
27
182
9
1
<1 min
1 min
18.
29.
39
61
7
2
2 mins
>2 mins
Duration of
Toothbrushing
28.
20.
59
43
2
6
Others
7
3.3
Oral Health Practices
Variable
N
%
N
%
No
Yes
Visits the
90.
Dentist
20
9.6
189
4
Regular
Occasionall
every 6-12
y
months
12.
27
15
7.2
9
When I
have
As needed
Dental Visits
dental pain
19.
37.
40
78
1
3
Never
23.
48
0
No
Yes
Dental
Treatment
38.
61.
81
128
(Check Teeth)
8
2
No
Yes
Dental
Treatment (X98.
206
3
1.4
Ray)
6
No
Yes
Dental
Treatment
97.
203
6
2.9
(Check Gums)
1
Dental
No
Yes
Treatment
41.
58.
Tooth
86
123
1
9
Extraction
No
Yes
Dental
Treatment
85.
14.
178
31
(Tooth Filling)
2
8
No
Yes
Dental
Treatment
64.
35.
134
75
(Dentures)
1
9
Bago
Matulog

daily

47.
4

No

Table 3. Frequency table for the

confounding factors.
Confounding Factors
Variable
N
%
N
%
No
Yes
Alcohol
Consumption
138
66.0
71
34.0
Frequency of
<1 drink
1 drink

Drinking
Alcohol

Smoking (
Ever-smoked)
Diabetes
Mellitus
Type of
Diabetes
Mellitus
(among
diabetics)

34
47.9
>=2 drinks
daily (heavy
drinker)
25
35.2
No
145
69.4
No
181
86.6
Type 1
0

0.0

daily
(light
drinker)
12
16.9

Yes
30.6
Yes
28
13.4
Type 2
64

28

100.
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.
Variable
Gender
Civil Status
Civil Status2 (Never Married or
Ever Been Married)
Civil Status3 (Not Widowed
or Widowed)
Currently Working
Type of Occupation
Religion
Educational Attainment
Family Size
Frequency of Tooth brushing
Products used for Oral
Hygiene (Toothbrush)
Products used for Oral Hygiene
(Toothpaste)
Products used for Oral Hygiene
(Mouthwash)
Products used for Oral Hygiene
(Dental Floss)
Products used for Oral Hygiene
(Toothpick)

pvalue
0.454
0.080
0.139
0.023
0.056
0.240
0.698
0.914
0.698
0.864
0.098
0.178
0.112
0.823
0.417

Products used for Oral Hygiene

(Others)
Time of Oral Health Practices
(Toothbrushing,
Flossing, and/or use of
Mouthwash)
Duration of Toothbrushing
Visits the Dentist
Last Dental Visit
Dental Visits
Dental Treatments or
Procedures Availed
Uses Dentures
Frequency of Denture
Cleaning
Frequency of Denture
Cleaning2
(once a day or less or twice
a day or more)
Chewing Sugarless Gum
Frequency of Chewing Sugarless
Gum
Presence of Dental Problems
Specific Dental Problems
Smoking
Alcohol Consumption
Frequency of Drinking
Presence of Diabetes
Mellitus

0.178
0.288
0.348
0.472
0.593
0.684
0.182
0.378
0.092
0.079
0.448
0.236
0.637
0.152
0.924
0.689
0.434
0.003

(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.
Civil Status 3
Occupation
Toothbrush
Presence of
DM

Sig.

.858
-.468
21.325

.122
.111

Exp.
(B)
2.359
.626

.999

.000

1.236

.013

3.443

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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