J Clin Periodontol 2012; 39: 3844 doi: 10.1111/j.1600-051X.2011.01802.

Periodontal disease: a new

factor associated with the
presence of multiple complex
coronary lesions

Christine Romagna1, Laurie Dufour2,

Odile Troisgros3, Luc Lorgis2
Carole Richard2, Philippe Buffet2,
Gilles Soulat2, Jean Marie Casillas3,
Gilles Rioufol4, Claude Touzery2,
Marianne Zeller5, Yves Laurent3 and
Yves Cottin2
1

CHU, Odontologie, Dijon France; 2CHU,

Cardiologie, Dijon; 3CHU, ReeducationReadaptation, Dijon Cedex; 4CHU Hopital
Louis Pradel, Cardiologie, Bron Cedex; 5IFR
sante-STIC, Laboratoire de Physiopathologie
et Pharmacologie Cardiovasculaire
Experimentale, Dijon, France

Romagna C, Dufour L, Troisgros O, Lorgis L, Richard C, Buet P, Soulat G,

Casillas JM, Rioufol G, Touzery C, Zeller M, Laurent Y, Cottin Y. Periodontal
disease: a new factor associated with the presence of multiple complex coronary
lesions. J Clin Periodontol 2012; 39: 3844. doi: 10.1111/j.1600-051X.2011.01802.x.
Abstract
Background and Aim: Periodontal disease, including bone loss, is thought to be
involved in coronary artery disease. Multiple complex coronary lesions relate to
multifocal destabilization of coronary plaques. We investigated whether bone loss
could be associated with the presence of multiple complex coronary lesions.
Methods: This cross-sectional study included 150 patients with recent myocardial
infarction (<1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss >50% was
performed. Patients with no or simple complex lesions were compared to patients
with multiple complex lesions.
Results: Over 20% of patients had multiple complex coronary lesions. Patients
with multiple complex lesion were less likely to be women and more likely to
have multivessel disease or elevated C-reactive protein (CRP) than patients with
no or single complex lesion. Bone loss >50% tended to be more frequent in
patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion.
Bone loss >50% increased the risk of multiple complex lesion.
Conclusion: Bone loss was associated with complex multiple coronary lesions,
beyond systemic inammation. These ndings may bear important clinical implications for the prevention and treatment of coronary artery disease.

Traditional cardiovascular risk factors are now well known (Kannel

1976, Yusuf et al. 2004), and the
scientic community is now investi-

gating new biological mechanisms

implicated in the development of
atheroma, in particular in relation
to inammation. Recent data from

Conflict of interest and source of funding statement

This work was supported by the Federation Francaise de Cardiologie (FFC) and
the Societe Francaise de Cardiologie (SFC), the University Hospital of Dijon, the
Association de Cardiologie de Bourgogne and by grants from the Union Regionale
des Caisses dAssurance Maladie de Bourgogne (URCAM), the Agence Regionale
dHospitalisation (ARH) de Bourgogne, and Agence Regionale de Sante (ARS).
The authors declare that they have no conict of interests to disclose.

38

Key words: bone loss; complex multiple

coronary lesion; coronary artery disease;
inflammation; multifocal coronary plaque
destabilization; periodontal disease
Accepted for publication 2 September 2011

epidemiological studies suggest an

association between oral infections,
in particular periodontal disease and
the risk of myocardial infarction
(MI) (Kinane et al. 2010, Sanz et al.
2010). Periodontal diseases are the
most frequent chronic infections in
humans and are therefore a potential
target for prevention strategies with
important clinical implications. Coronary plaque with complex morphological features in patients with acute
MI is characterized by eccentric ste 2011 John Wiley & Sons A/S

Periodontal disease and coronary lesions

nosis with a narrow neck and/or irregular borders. They are linked to
occlusive coronary artery thrombosis
at sites of plaque ssure, rupture or
supercial erosion, which are frequently involved in the pathogenesis
of such acute events (Ambrose et al.
1985a, b, 1988). Complex coronary
lesions are also strongly associated
with the presence of unstable atheromatous plaque in histological or
angioscopic analysis (Levin & Fallon
1982, Waxman et al. 2003). In
patients with acute MI, multiple
complex coronary lesions (MCL) at
coronary angiography are associated
with an increased incidence of nonfatal cardiovascular events at 1 year
follow up (Rioufol et al. 2007).
Recent data from small populations
have also suggested a correlation
between elevated inammatory markers and MCL (Zairis et al. 2002,
Avanzas et al. 2004a, b, Rioufol
et al. 2007). The aim of our crosssectional study was to determine if
the severity of the periodontal disease relates with the multiple and
complex nature of coronary lesions
in patients who have suered a
recent acute MI.
Patients and Methods

ECG changes and/or typical symptoms. The patients included underwent panoramic radiography during
their stay in cardiac rehabilitation
unit. The present study complied
with the Declaration of Helsinki,
was approved by the ethics committee of university hospital of Dijon.
Clinical and ultrasonography

Clinical and epidemiological data as

well as cardiovascular risk factors
were collected for each patient.
Smoking was dened as current
smoking or stopped within 3 months.
Maximal VO2 was the VO2 estimated during the initial stress test
performed at the admission for cardiac rehabilitation. The left ventricular ejection fraction was estimated
using transthoracic ultrasonography
and calculated using the Simpson
method in four chambers and then
in two chambers.
Biological data

A blood sample was taken at admission to the Intensive Care Unit to

determine the biological parameters.
Fasting lipids were assessed on the
morning after admission.

Methods

Coronary angiography

One hundred and fty consecutive

patients admitted for cardiac rehabilitation, after suering MI <1 month
earlier, and who had undergone coronary angiography were included.
Briey, data were prospectively collected at each site by a trained study
coordinator using a standardized
case report form. Cases were ascertained by prospective collection of
consecutive
admissions.
Eligible
patients were identied during the
index admission and medical records
were reviewed on an ongoing basis
after appropriate consent has been
obtained. Patients with ST-segment
elevation or suspected new left bundle branch block on the admission
ECG were dened as having ST-segment
elevation
MI
(STEMI).
Patients were enrolled if they were
>18 years of age and admitted with
a suspected diagnosis of MI. A nal
diagnosis of MI was made in the
presence of serial increases in serum
biochemical markers of cardiac
necrosis, associated with typical

The coronary angiography was performed via the femoral or radial

approach. The tapes were analysed
by two experts blinded to the clinical, biological and dental data. The
lesions were analysed as previously
described (Goldstein et al. 2000,
Rioufol et al. 2007). A complex
lesion was dened by stenosis >50%,
and at least two of the following criteria: chronic occlusion, ow impairment, the presence of a thrombus,
irregularity, or ulceration. Patients
without complex lesions or with a
single complex lesion were included
in the simple complex lesion group
(SCL) and patients presenting more
than one complex lesion were
included in the MCL group.

2011 John Wiley & Sons A/S

39

biological and coronary angiographic data. The level of interobserver agreement was at 82% for
bone loss. In cases of disagreement,
the nal decision was taken by consensus. Five radiographic scores for
the state of dental and periodontal
health were established:
(1) Caries score was 0 if the patient
had no caries and 1 if there was
at least one caries.
(2) Inammation score was 0 if the
patient had no latent infectious
foci and 1 if there was at least
one latent infectious focus.
Images of peri-apical periodontitis,
images of lateral bone loss related to
cracked or fractured roots or for
which the endodontic treatment was
defective, impacted teeth, teeth worn
down to residual roots, and broken
and/or decayed teeth with suspect
vitality were considered latent infectious foci.
(3) Tooth loss score corresponded to
the number of missing teeth. A
tooth loss score of 0 corresponded to a patient with no
missing teeth and a tooth loss
score of 32 corresponded to a
patient with no natural teeth.
(4) Mastication score corresponded
to the number of pairs of occluding cuspid teeth. The score 0 was
given if more than ve pairs of
cuspid teeth were still in occlusal
contact and a score of 1 was
given if fewer than ve pairs of
cusped teeth were in occlusal
contact. Occluding cuspid teeth
were considered functional.
(5) Bone loss score. Bone loss
greater than 50% corresponded
to inter-dental septa situated
below half of the height of the
roots, below the amelocementary
junction.
Previous studies have reported
the use of panoramic radiography as
a useful tool for assessment of periodontitis, especially for bone loss
(Kaimenyi & Ashley 1988, Rushton
& Horner 1996).

Dental analyses

Statistical analysis

Every patient had digital panoramic

dental radiography at admission for
cardiac rehabilitation. The panoramic radiographs were analysed by
two experts blinded to the clinical,

Continuous variables were expressed

as the median (rst and third quartile) and dichotomous variables as
percentages and numbers. The characteristics of patients with and with-

40

Romagna et al.

out MCL were compared using a

chi test for dichotomous data and a
standard Mann and Whitney test for
continuous variables. Logistic regression analysis was used to determine
factors associated with MCL. Only
factors associated with MCL with a
threshold of 10% in univariate analysis were included in the multivariate model. The following variables
were thus included: female sex, multivessel lesions, C-reactive protein
(CRP) > 10, in addition to bone loss
>50%. Given that smoking is a
known shared risk factor between
periodontitis and atherosclerosis, this
variable was entered into the model
as forced variable. Given the importance of assessing confounding variables
in
analysis
involving
periodontal and cardiovascular diseases (Hyman 2006), we have tested
all the interactions that could potentially interfere and we have entered
these interaction as a variable in the
logistic regression models. We
applied the recommended (i.e. Bonferroni correction) 2% cut o to
take into account the multiple comparisons. This value is based on two
criteria (1) the inclusion cut o
(10%) and (2) the number of covariates in the multivariate model (i.e.
ve variables, including interaction
term). The incremental value of bone
loss >50% was tested by comparing
the -2log likelihood of the two multivariate models using a chi test. The
analyses were performed using SPSS
software (IBM SPSS statistics 12.0).
Results

There were 118 patients (79%) in the

SCL group and 32 patients (21%) in
the MCL group (Table 1). The cardiovascular risk factors in the two
groups were similar. Concerning the
angiographic characteristics, patients
in the MCL group were more likely
to have multivessel disease than were
patients in the SCL group (88% versus 46%, p < 0.001). There was a
greater proportion of women in the
SCL group than in the MCL group,
but the dierence was not signicant
(21% versus 6%, p = 0.051). Patients
in the MCL group were more likely
to have taken beta blockers in their
pre-infarction treatment than were
those in the SCL group (34% versus
13%, p = 0.004). A greater proportion of patients in the MCL group

Table 1. Demographic, clinical and angiographic characteristics of patients and treatments

before admission
Total population
n = 150
Patients characteristics
Women
27
Age, years
59
LVEF, %
56
VO2 max, ml/kg/min 22.0
Multivessel
82
LVEF<40%
9
Cardiovascular risk factors
AHT
60
Diabetes
15
Dyslipidemia
63
Family history
49
of CAD
Current smoking
61
History of MI
6
Weight, kg
80
Size, cm
171
26.0
BMI, kg/m2
Waist
96
circumference, cm
Treatment before MI
Aspirin
9
Beta blockers
26
ACE inhibitors
20
Statins
30

(18)
(5065)
(5063)
(16.428.0)
(55)
(6)
(40)
(10)
(42)
(33)
(41)
(4)
(7091)
(166178)
(23.529.0)
(88102)

(6)
(17)
(13)
(20)

SCL
n = 118 (79)
25
58
57
22.0
54
5
45
11
46
37
50
4
80
170
26.0
95

6
15
14
22

(21)
(5065)
(5265)
(16.028.0)
(46)
(5)
(38)
(9)
(39)
(31)

2
59
56
23.0
28
4
15
4
17
12

(42)
(3)
(6991)
(166177)
(23.029.0)
(88102)

(5)
(13)
(12)
(19)

MCL
n = 32 (21)

11
2
84
173
27.0
98

3
11
6
8

(6)
(5266)
(5060)
(15.928.0)
(88)
(13)

0.051
0.626
0.199
0.841
<0.001
0.107

(47)
(13)
(53)
(38)

0.371
0.595
0.151
0.511

(34)
(6)
(7390)
(169180)
(23.729.0)
(89104)

0.414
0.464
0.644
0.169
0.930
0.399

(9)
(34)
(19)
(25)

0.365
0.004
0.309
0.425

Data are expressed as n (%) and medians (rst and third quartile).
LVEF, left ventricular ejection fraction; MI, myocardial infarction; MCL, multiple complex
coronary lesions, SCL, simple complex lesion group.

had a high level of CRP (>10 mg/l)

(42% versus 15%, p = 0.001). The
rest of the biological parameters were
similar in the two groups (Table 2).
With regard to the dental lesions
(Table 3), patients in the MCL
group were more likely than patients
in the SCL group to have bone loss
>50%, but the dierence was not
signicant (50% versus 32%, p =
0.063). There was no signicant difference between the SCL and MCL
groups for other dental parameters
(caries, inammation, tooth loss,
mastication).
The results of the multivariate
analysis are presented in Table 4.
According to Bonferroni correction,
the alpha value has been lowered
at 0.02 to account for the number
of comparisons being performed.
Among these three interactions, only
multivessel 9 smoking had an incremental value when added to the
model 1. Patients with multivessel
disease (OR (95% CI):6.519(2.078
20.449)), and CRP > 10 mg/l (OR
(95% CI): 3.952(1.47110.621) were
independent factors associated with
the presence of MCL. Female sex

and smoking failed to be independently associated with MCL (p =

0.128 and p = 0.362, respectively).
Bone loss >50% was independently
associated with MCL [OR (95% CI):
3.524(1.2519.928)] even after adjustment for the other confounding
factors, notably CRP, and after Bonferroni correction. In addition, when
bone loss >50% was included in the
previous model the likelihood of the
model (model 2 versus model 1, 2
log likelihood 116.171 versus 122.261,
respectively, p = 0.01) increased signicantly, showing the incremental
value of bone loss >50% to determine the multiple and complex nature of coronary lesions. Analysis of
the performance of the nal model
(model 2) showed that sensitivity
was 23%, specicity was 97%, and
that 82% of patients were correctly
classied.
Given the importance of assessing
confounding variables in analysis
involving both periodontal and cardiovascular diseases (Hyman 2006),
we have tested all the interactions
that could potentially interfere with
the model. Among all the six interac 2011 John Wiley & Sons A/S

Periodontal disease and coronary lesions

Table 2. Biological data
Total population
n = 150
CRP > 10 mg/l
Haemoglobin, g/dl
Haematocrit, %
Leucocytes, 109/l
Plaquettes, 109/l
ESR, mm
Fibrinogen, g/l
Creatinine, lmol/l
HBA1c, %
Total cholesterol,
mmol/l
LDL cholest, mmol/l
HDL cholest, mmol/l
Triglycerides, mmol/l
Nt proBNP, pg/ml

SCL
n = 118

MCL
n = 32

31
14.6
42.9
10.2
228
10
3.3
89
5.6
5.4

(21)
(13.515.2)
(40.245.0)
(8.212.8)
(196278)
(520)
(3.04.2)
(78100)
(5.35.8)
(4.76.1)

18
14.6
42.9
10.4
228
10
3.2
89
5.6
5.4

(15)
(13.515.2)
(40.245.0)
(8.412.8)
(197282)
(516)
(3.04.1)
(79100)
(5.35.8)
(4.86.1)

13
14.5
42.9
9.4
225
14
3.6
91
5.6
5.3

(42)
(13.615.3)
(40.545.1)
(8.012.0)
(190273)
(622)
(2.94.6)
(78100)
(5.06.1)
(4.06.1)

0.001
0.863
0.781
0.385
0.613
0.644
0.981
0.364
0.594
0.400

3.5
1.2
1.3
536

(2.94.1)
(1.01.4)
(0.91.9)
(2301403)

3.5
1.2
1.3
527

(3.04.1)
(1.01.4)
(0.91.9)
(2301326)

3.5
1.2
1.3
576

(2.44.1)
(1.01.4)
(0.92.0)
(2622857)

0.331
0.514
0.744
0.221

41

both periodontal disease and coronary artery disease, we also performed

stratied analysis limited to non-smokers (n = 89). Again, bone loss >
50% was associated with MCL, in
multivariate analysis, with an OR
similar to that found in the whole
study population (OR = 3.52, p =
0.045), further strengthens the conclusion of our works on the relation
between periodontal disease and coronary artery disease, even in a nonsmoker.
Discussion

Data are expressed as n (%) and medians (rst and third quartile).
CRP, C-reactive protein; MI, myocardial infarction; MCL, multiple complex coronary
lesions, SCL, simple complex lesion group.

Our work showed that bone loss, a

simple and objective evaluation of
the severity of periodontal disease, is
associated with complex and/or multiple nature of coronary lesions.

Table 3. Characteristics of dental lesions in panoramic radiography

Multiple complex lesions

Total population
n = 150
Dental lesions
Presence of caries
Presence of inammation
Edentation score
Functional mastication
Bone loss >50%

63
111
8
58
54

SCL
n = 118

(42)
(74)
(416)
(39)
(36)

49
86
9
44
38

(42)
(73)
(418)
(37)
(32)

MCL
n = 32
14
25
8
14
16

(44)
(78)
(412)
(44)
(50)

0.821
0.549
0.295
0.506
0.063

Data are expressed as n (%) and medians (rst and third quartile).
Table 4. Factors associated with the presence of multiple complex coronary lesions in multivariate analysis
Model 1
OR (95% CI)
Female sex
Multivessel
CRP > 10 mg/l
Smoking
Bone loss > 50%
2LL

0.288
6.519
3.952
0.650

(0.0581.429)
(2.07820.449)
(1.47110.621)
(0.2581.639)

122.261

Model 2
p
0.128
0.001
0.006
0.362

OR (95% CI)
0.170
7.348
4.695
0.456
3.524
116.171

(0.0281.027)
(2.27023.786)
(1.60613.729)
(0.1631.281)
(1.2519.928)

p
0.054
0.001
0.005
0.136
0.017

Periodontal disease and coronary artery

disease

CRP, C-reactive protein.

tions tested from the four variables

of the model 1 (female, multivessel,
CRP > 10 and smoking), only three
were signicantly associated with
MCL in univariate analysis (i.e.
multivessel 9 smoking, multivessel 9
CRP > 10 and CRP > 10 9 smoking)
(p < 0.10). Both interactions including
multivessel (i.e. multivessel 9 smoking
and multivessel 9 CRP > 10) showed
concern of multicollinearity when
introduced as covariates in the four
variables model. Hence, they were
entered as covariates without smoking
2011 John Wiley & Sons A/S

During the year following the infarction, the presence of MCL is associated with an increased recurrence
of acute coronary syndromes, angioplasties and heart surgery for coronary artery bypass grafts (p < 0.001)
(Goldstein et al. 2000). In addition,
the risk of cardiovascular death is
higher in patients with MCL than
that in patients with SCL (14%
versus 3%, p = 0.0003) (Goldstein
et al. 2005). Patients with MCL also
carry a higher risk of cardiogenic
shock and death at 30 days. The
only known predictors of multiple
complex lesions so far identied are
CRP, and multivessel disease (Rioufol et al. 2007). Hence, bone loss, as
a new factor associated with MCL,
could be relevant to identify patients
with a high cardiovascular risk.

or without CRP > 10 in a three variables model. The interaction CRP >
10 9 smoking, which was devoid of
multicolinearity, has been added to
the model 1. In all these models that
tested the interactions, the performance to predict MCL was similar to
the model without interaction (p >
0.05). Hence, we have retained only
the model without interaction (model
2) to test the incremental value of
bone loss >50%. Given the signicant
interaction of smoking and since
smoking has a major aetiologic in

One of the underlying physiopathological mechanisms thought to

trigger the destabilisation of atheromatous plaque in periodontal disease
is the presence of oral bacteria in the
bloodstream. In clinical trials, bacteriemia has been reported after
preventive and curative dental treatment (Kinane et al. 2005). Several
studies have shown the presence of
certain strains of oral bacteria in
atherosclerotic plaques and in aneurysms of the abdominal aorta, in
particular strains implicated in the

42

Romagna et al.

pathogenesis of perodontitis (Ford

et al. 2006, Nakano et al. 2006,
Padilla et al. 2006). Recently, prospective studies have shown that infections
caused by periodontal pathogens such
as Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis
are associated with a risk of stroke
(Pussinen et al. 2007) and an increased
risk of MI (Pussinen et al. 2004 a, b)
and ACS (Renvert et al. 2006). Periodontitis has been known to increase
the risk of CAD by 25% and overall
death by 46% (DeStefano et al. 1993,
Genco et al. 2001). A systematic
review of seven cohort studies (Humphrey et al. 2008) showed that periodontal disease increased cardiovascular
risk by approximately 2435%.
Periodontal disease and CRP

In our study, the threshold of

CRP > 10 mg/l is based on previous
studies that demonstrated the predictive role of such threshold of CRP
in acute MI (Toss et al. 1997, Lindahl et al. 2000, Heeschen et al.
2000, Mueller et al. 2002, James
et al. 2003). Levels of CRP are also
associated with the severity of the
periodontal disease (Loos et al.
2000, Noack et al. 2001) and the
presence of periodontal pathogens in
patients with severe periodontitis. A
recent review of the literature studied
the association between levels of
CRP in the blood and destruction
due to periodontal disease (Paraskevas et al. 2008). A mean dierence
in CRP of 1.56 mg/l has been found
between patients with periodontal
disease and controls (p < 0.00001)
(Kinane et al. 2010). Other studies
showed that the smallest reduction
in CRP obtained by periodontal
treatment was of the order of
0.5 mg/l (Albandar & Rams 2002).
Bone loss as a new factor associated with
MCL

Our work suggest for the rst time

that bone loss could be a new parameter linked with the presence of
MCL in patients with recent MI
even after adjustment for other
known predictors of MCL. Bone
loss, a dental parameter simple and
easy to evaluate on a panoramic
radiograph, correlated signicantly
with the presence of MCL. It is thus
an additional parameter to be

assessed in CAD patients with MI,

as it may be linked to the risk of
adverse cardiovascular events in
both short and long term after MI.
Moreover, bone loss on a panoramic
radiograph can be easily assessed
not only by dental surgeons, but
also, with experience, by general
practitioners or specialists, and could
thus prove to be very useful from a
public health perspective.
Tooth loss

The impact of tooth loss on the presence of CAD and overall mortality
may be similar to that of periodontal
diseases (DeStefano et al. 1993).
Number of teeth remaining had an
impact on the risk of stroke, since
men with fewer than 24 teeth had an
increased risk of stroke (HR = 1.57;
95% CI, 1.241.98) compared with
men with 25 teeth or more
(HR = 1.33; 95% CI, 1.031.70)
(Joshipura et al. 1996). In patients
older than 60 years, tooth loss, more
than any other parameter of dental
evaluation, increased the risk of
CAD (Dietrich et al. 2008). In animals, it was shown that for the same
nutritional content, harder foods
could signicantly reduce weight and
the development of diabetes (Ueda
et al. 2000, Nojima et al. 2006)).
Edentulous patients require major
modications in their food, as softer
foods are needed.
Therapeutic perspectives

Therapeutic intervention have shown

that endothelial function in the brachial artery was improved after
treatment of periodontal lesions
(basic versus intensive periodontal
treatment) (Tonetti et al. 2007). As
early as 60 days after treatment,
vasodilatation was greater and levels
of soluble E-selectin lower in the
intensive treatment group than in
the control group. It was therefore
suggested that the treatment of periodontal lesions could have a benecial impact on the complications of
atheroma, by improving endothelial
function and decreasing levels of
E-selectin. A very recent study (Minassian et al. 2010) also showed that
patients who had undergone dental
treatment were at a greater risk of
stroke or MI in the weeks following
the procedure; this increased risk

was not maintained 6 months after

the procedure, and the long-term
benets of dental health on the vascular system outweigh the short-term
risks of dental treatment.
Conclusion

Our study showed for the rst time

that bone loss using panoramic
radiography could be a relevant and
simple criterion to assess the likelihood of MCL in patients with recent
MI. Our works bear major clinical
implications, and suggests that interventional studies are now needed to
investigate whether treatment of periodontal lesions could reduce cardiovascular risk in such patients.
Acknowledgement

We thank Philip Bastable for English assistance.

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Address:
Marianne Zeller
Laboratoire de Physiopathologie et
Pharmacologie Cardiovasculaires
Experimentales, IFR sante-STIC
UFR Medecine, 7Bd Jeanne dArc 21000
Dijon, France
E-mail: marianne.zeller@u-bourgogne.fr

44

Romagna et al.

Clinical Relevance

Scientic rationale for the study:

Periodontal disease, including bone
loss, may predispose to coronary
artery disease. We aimed to investigate the relationship between multiple complex coronary lesions, as
an index of multifocal plaque
instability, and periodontitis.

Principal ndings: This is the rst

study to provide direct evidence that
signicant bone loss is associated
with multiple complex coronary
lesions, beyond traditional factors
known to be linked with such
lesions, in particular inammation
markers such as CRP levels.

Practical implications: If conrmed,

these ndings could have major
public health implications because
they raise the possibility that plaque instability could be prevented
through therapeutic intervention of
periodontitis.

2011 John Wiley & Sons A/S