Effect of Yoga Exercise on Circulatory System - Juniper Publishers

 Yoga and Physiotherapy - Juniper Publishers

Abstract

Yoga and mindfulness improve the blood circulation and thereby reduces the causes of hypertension hearth attack or stroke. Complete yoga breathing has the role in oxygenating the blood and therefore assists fresh nutrients to reach all peripheral vessels and capillaries. Yoga helps to prevent various circulatory ailments and illnesses such as high blood pressure, shallow breathing, muscle tension and coronary heart disease. During moderate to intense yoga exercise hearth rate increases and as a result hearth pumps more blood, systolic blood pressure rise and blood volume increases. It provides better circulation and formation of new capillaries. The purpose of this review is to investigate the efficacy of yoga exercise on circulatory system, pulse and hearth rate, systolic and diastolic blood pressure and cardiovascular function. A review of literature was conducted from Pubmed, Research Gate, Medline and Google Scholar.

Keywords: Yoga Asana; Circulatory System; Pulse Rate; Hearth Rate; Systolic And Diastolic Blood Pressure; Cardiovascular Function

Introduction

Yoga is a mind-body technique, which combines set of physical exercises (asana) and techniques (pranayama), relaxation and meditation, and it is practiced in India for thousands of years [1]. Throughout the world, scientists have extensively studied yogasanas and have concluded that yoga increases longevity of life and has therapeutic and rehabilitative effects [2]. Namely, it has been reported that yoga exercise has an positive impact on serum lipid profile [3], heart rate variability [4], decrease in blood pressure, and even regression of atherosclerosis when combined with dietary and other lifestyle modifications [5]. Also, many studies have shown that yoga can be a very effective as a non-invasive way of reducing high blood pressure [6]. A healthy circulatory system is important for a healthy living. Yoga helps to prevent various circulatory ailments and illnesses such as high blood pressure, shallow breathing, muscle tension and coronary heart disease [7].

The blood circulatory system (cardiovascular system) delivers nutrients and oxygen to all cells in the body. The circulatory system includes the heart, blood vessels and the blood. It transports the nutrients and oxygen to the tissues and removes carbon dioxide and other waste products of metabolism from the tissues. For this purpose the blood is continuously circulated in the body by rhythmic pumping action of the heart and through a complex network of the blood vessels. The blood acts as a vehicle that carries the products of digestion from the alimentary canal and the oxygen from the lungs to the tissues. While returning to the heart, the blood brings the toxic substances or the waste products back to the heart. The kidneys, lungs and the skin eliminate these substances when the blood circulates through them. The blood, thus, communicates with all the systems and organs, regulates the water level and the temperature of the body [7,8].

Yoga’s impact on cardiovascular health is multi-dimensional. While not all yoga movements raise the heart rate to suggested aerobic levels, yoga has a positive impact on how efficiently blood moves. An asana practice can increase blood circulation and decrease levels of cortisol, a stress hormone, in the body [2]. In fact, a study conducted by Kaviraja Udupa et al.in 2003 on 24 healthy young subjects showed significant reduction in basal heart rate and systolic and diastolic blood pressure following 3 months of yoga training [9]. The lower levels of stress enjoyed by yogis has a significant impact on creating healthier blood pressure. Yoga has also been shown to reduce cholesterol levels, thus reducing the interference of blood flow. Low-impact, meditative poses can also reduce potentially artery-clogging stress hormones. Examples of such poses are like Sukhasana (Easy Pose) or Child’s Pose (Balasana). Several poses and postures in Yoga have an different effect on circulatoy system [10].

In standing poses, the lateral wall of the heart is exercised is such a manner that it becomes flexible and toned up. Standing poses helps in improving the flow of blood along the walls of the heart thus preventing heart diseases. Inverted postures in Yoga helps to prevent muscles and cell tissue degeneration due to the benefits of that the inverted poses have on the body. Inverted postures help in effective blood circulation to the brain. Moreover the lymph system in the legs and the muscles are properly rested in exercises involving inverted poses. On the other hand. blood pressure in horizontal poses is effective brought under control as the performance of horizontal postures helps in resting and rejuvenating the heart and lungs. In bending postures the body experiences improved blood supply to the cardiac muscles. This leads to a toning up of the myocardium or the heart muscles [7]. Yoga exercise benefits the entire circulatory system, beginning with the production of blood, which takes place in the marrow of the long bones in the thighs. It has been showed that daily yoga stretching exercises are helping to rejuvenate the blood. Yoga exercises stretch the body’s major blood vessels, keeping them free-flowing and elastic [11]. Furthermore, improved circulation will improve the alertness, memory, and mood. Vital organs are by yoga receiving a steady supply of the nutrients they need for optimal functioning [2]. However, studies on the effect of yoga training on circulatory system are limited. In view of this, the present study was planned with an objective to determine the effect of yoga training on healthy circulatory system in the body.

Methods

Authors independently conducted literature searches to identify studies on the effect of yoga exercise on circulatory system. The databases searched included Pubmed, Research Gate, Medline and Google Scholar. The following search terms were used: yoga asana, circulatory system, systolic and diastolic blood pressure, cardiovascular function.

Inclusion criteria were:

a. randomized control trial (RCT); the study contained at least two groups where there are two different intervention groups or a meditation group and a control.

b. studies that were published in English.

c. Studies with 30 participants and more.

d. Studies with participants above the age of 35 years and less than 75 years old.

e. Studies are excluded if they:

I. They were not written in English.

II. Non-RCT study.

III. Studies with less than 30 participants and with adolescents.

A total of 118 articles were originally found through the database searches. Of those, 102 were excluded based on review of the title and abstract. The remaining 16 articles were carefully evaluated against the inclusion and exclusion criteria through detailed readings. Ten of 16 articles were excluded, leaving 6 to be included in the final analysis.

Result

The cardiovascular diseases are much on a rise ever since the past few decades in developing countries. In our study we have analyzed the effect of yoga on circulatory system and cardiovascular function in normal adult person above the age of 40 years. Five studies examined correlation between yoga exercise and decrease in heart rate and blood pressure. Krishna et al. in their study found a significant decrease in heart rate, blood pressure and rate pressure product in yoga group compared to control group. Out of 130 heart failure patients recruited for the study, 65 patients were randomly selected to receive 12 week yoga therapy along with standard medical therapy (yoga group). Other patients have received only standard medical therapy (control group). The authors came to conclusion that twelve-week yoga therapy can significantly improve the parasympathetic activity and decrease the sympathetic activity in heart failure patients [12] Singh has in his study found that yoga practice can be used as an intervention in ageing persons to reduce the morbidity and mortality from heart circulatory diseases. This study included 50 healthy men above the age of 40 years which are performing yoga regularly.

The heart circulatory status was assessed by recording the blood pressure and pulse rate, before and after 6 months of regular yogic practice. Results have shown that mean resting systolic blood pressure (mm Hg) was lowered to a highly significant level of 120.05±3.40. The mean resting diastolic blood pressure (mm Hg) before yoga was 83.6±6.10 and reduced significantly (p<0.001) to 76.4±6.35. Stress was measured with the Stress Assessment Questionnaire, and blood pressure information was taken from medical records. The study found a significant difference between the stress scores of the experimental and control group at the conclusion of the study even though there was no baseline difference from the second to the eighth week.

Bharshankar et al. [6] have examined examine the effect of yoga on cardiovascular function in 100 subjects above 40 years of age both sexes. Pulse rate, systolic and diastolic blood pressure and Valsalva ratio were studied in 50 control subjects (not doing any type of physical exercise) and 50 study subjects who had been practicing yoga for 5 years. The mean value of pulse rate was lower in study than control group statistically to the significant extent (p<0.001). The statistical difference in the mean systolic and diastolic blood presure in between study and control group was significant (p<0.01, p<0.001 respectively) [13].

In another study by Harinath et al. the aim was to evaluate effects of Hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. Hypertensive patients were randomly divided in two groups. Group 1 was conducted of 15 subjects served as control and performed body flexibility exercises for 40 minutes and slow running for 20 minutes during morning hours and played sports for 60 minutes during evening hours daily for 3 months and group 2 subjects, 15 of them, practiced selected yogic asanas (postures) for 45 minutes and pranayama. The benefit of yoga practice in terms of blood pressure reduction was modest, but statistically significant; in contrast the control group had no significant change in blood pressure. Furthermore, the results showed that yoga exercise for 3 months can result in an improvement in cardiorespiratory performance and psychologic profile.

The systolic blood pressure, diastolic blood pressure and mean arterial pressure did not show any significant correlation with plasma melatonin [14]. Patel and North conducted a randomized trial of yoga practice in 34 subjects who were less than 75 years old and had a diastolic blood pressure of 110mm Hg or higher. Patients were randomized to yoga practice or to general relaxation exercises, and all were evaluated every 2 weeks for 3 months. Patients in both groups had a significant drop in systolic and diastolic blood pressures (from 168/100 to 141/84 mm. Hg in the treated group and from 169/101 to 160/96 mm Hg in the control group). The difference was highly significant. The control group was then trained in yoga relaxation, and their blood pressure fell to that of the other group (now used as controls). Murugesan et al. [15] in their study have evaluated the effect of yogic practices on the management of hypertension. The study included 33 hypertensive patients, age 35 and 65 years. The subjects were randomly assigned into three groups. The group I underwent selected yoga practices, group II received medical treatment by the physician and the control group (group III) did not participate in any of the treatment stimuli. Patients in the yoga group performed breathing exercises, Asanas as well as meditation for 1 hour every day for 11 weeks. There was a significant decrease in systolic blood pressure, heart rate and body weight and these changes were greater in subjects who practiced yoga than in the subjects who received medications alone [16]. (Table 1) is the description of included studies.

It is obvious that the regular practice of yoga, particularly when combined with other life-style modifications, can induce biochemical alterations that have a salutary effect of cardiac hemodynamics, blood lipids, blood pressure and cardiovascular function [17].

Discussion

Yoga has three elements- exercise, brathing and meditation. Experts believe that the yoga asanas are the best way to keep it fit naturally. The heart is an involuntary muscle that contracts and relaxes around 70 times a minute within a healthy individual. With asanas, the expansion and contraction of the heart is made even faster and thorough. However, overdoing yoga asanas is never preferred for it may cause damage to the heart. Padmasana considerably improves blood circulation. In this case, the pelvic region receives larger blood supply from the bifurcations of the abdominal aorta. Each drop of blood travels twice, once through the pulmonary circulation and then through the systemic circulation in the body. During the systemic circulation, pure (oxygenated) blood is pumped out forcefully from the left ventricle into the aorta. It is then carried to parts of the body [7]. During yoga session the massaging effect on the internal organs improve blood circulation. During moderate to intense yoga exercise hearth rate increases and as a result hearth pumps more blood, systolic blood pressure rise and blood volume increases. It provides better circulation and formation of new capillaries [8].

Many research studies have documented the usefulness of yoga in the treatment of various lifestyle related diseases, especially heart circulatory disease. Singh has in his study concluded that yoga has significant and healthy impact on our life style [6]. Many studies show that yoga can be a very effective and non-invasive way of reducing high blood pressure. It is particularly effective in reducing the diastolic number – which is the most important. It is suggested that people with high blood pressure should only practice certain asanas (postures), whilst acknowledging that there are other asanas that are not suitable for them. The yogic practices of meditation and pranayama (breathing exercises) are also particularly beneficial for people who suffer from high blood pressure [18].

Additionaly, environmental conditions and variety of behavioural factors such as stress, anxiety, affective and attitudinal dispositions of the individual influence the cardiovascular responses. Yogic exercise involves physical, mental and spiritual task in a comprehensive manner. It brings about the behavioural changes. Yoga in long duration affects hypothalamus and brings about decrease in the systolic and diastolic blood pressure through its influence on vasomotor centre, which leads to reduction in sympathetic tone and peripheral resistance [7]. Bharshankar and associets came to conclusion that the correlation of age with blood pressure, both systolic and diastolic is stronger in the control group than in the study group. This suggests that rise in blood pressure is not an inevitable consequence of increase in age, but is a result of the aging process which may be slower in practitioners of yoga. Also, cardiovascular parameters alters with age but these alterations are slower in persons aging with yoga [13].

Furtermore, mechanisms by which yoga might may influence hearth rate, blood pressure and heart rate variability are stil speculative. In addition to hemodynamic derangements, an increased neuro-hormonal activation through the sympathetic nervous system and the renin-angiotensin system has been implicated in the progression of heart failure [19]. Murlidhara & Ranganathan reported an improvement in cardiac recovery index after 10 weeks of yoga training in 50 young subjects [20]. A study carried out by Ray et al on the effect of yoga exercises on physical and mental health of 54 young fellowship course trainees showed significant reduction in hearth rate and systolic and diastolic blood pressure after 5 months of yoga training [21]. Tulpule and Tulpule also considered yoga as a method of relaxation after myocardial infarction [22].

Results of many studies have shown that most of the yoga asanas like Sarvangasana, Viparita karni, Hahsana, Mayurasana, few pranayamas like Ujjayi and Bhastrika Pranayama as well as uddiyan, nauli, Jalandhar bandha specially influence the blood circulation. But, the ost important thing is to learn them from an expert in order to practice them safely, without taxing the circulatory system. When the body and mind are properly relaxed, mental peace is achieved and the muscle tone is reduced. The blood vessels are also relaxed which are otherwise constricted due to tension. The heart rate is reduced and blood pressure comes to the normal level.

Further, it is through veins that the impure blood is brought back and there are such troubles as vericose veins, which cause obstructions in blood circulation. However, practising yoga asanas, the body is placed in upside-down position which enables veins to drain themselves into the heart without any effort. Finally, asanas decrease the sympathetic tone, rate pressure product and double product (DoP), and improve cardiovascular endurance and anaerobic threshold [2].

Although yoga has been associated with serious adverse events in single case reports, population-based surveys as well as clinical trials indicate that yoga is a relatively safe intervention and there is no associations with more adverse events than other forms of physical activity. Yoga can thus be considered a safe and effective intervention for managing hypertension [17].

Conclusion

A healthy circulatory system is important for a healthy living. Yoga exercise helps to prevent various circulatory ailments and illnesses such as high blood pressure, shallow breathing, muscle tension and coronary heart disease. Our findings suggest that specific poses of Yoga directly benefit and enhance the circulation of blood and body fluids throughout the body. The different organs of the body are also positively impacted due to the effective flow circulation to the various parts.

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Periodontitis in a Group of Patients with Cardiovascular Disease-Juniper Publishers

Anatomy Physiology & Biochemistry International Journal

The association between periodontal disease and cardiovascular disease is based on the systemic inflammation which also involves the periodontopathogenic bacteria. Our research study investigated the prevalence of periodontal disease in a group of 20 patients with cardiovascular disease, divided into 2 groups according to the presence of periodontal disease, demographic and environmental factors. Periodontal and cardiovascular disease were established according to the current international classifications. The systemic inflammation was assessed by the following markers: leukocytes number, C-Reactive Protein, ESR and fibrinogen. The periodontal disease was assessed based on the bacterial plaque index, gingival bleeding index and clinical attachment loss.

Our results indicated that the prevalence of periodontal disease in patients with cardiovascular disease was 55%, and higher in females than males. Among patients with cardiovascular disease, those in the rural area had a poor oral hygiene. Patients with hypertension showed a higher number of teeth with periodontal pockets compared with patients with other cardiovascular diseases. There were no significant changes in systemic inflammatory markers related to the presence of periodontal disease.

Keywords: Periodontitis; Cardiovascular disease; Prevalence; Periodontal pockets; Systemic inflammatory markers

Abbrevations: AC: Anticoagulants; AHA: American Heart Organization; CAL: Clinical Attachment Loss; CHF: Chronic Heart Failure; CI: Calculus Index; CIHD: Chronic Ischemic Heart Disease; CRP - C Reactive Protein; CVD: Cardiovascular Disease; CVE: Cerebrovascular Event; DI: Debris Index; DSR: Digital Subtraction Radiography; ESR: Erythrocyte Sedimentation Rate; GBI: Gingival Bleeding Index; GDPR: General Data Protection Regulation; HBP: High Blood Pressure; IL-1β: Interleukin -1 Beta; IHD: Ischemic Heart Disease; MI: Myocardial Infarction; OHI-S: Oral Hygiene Index-Simplified; PA: Platelet Antiaggregants; PD: Periodontal Disease; TNF-α: Tumor Necrosis Factor Alpha; US: United States; WBC: Leukocyte; WHO: World Health Organization

Introduction

Periodontal disease (PD) is a chronic inflammation that occurs in response to the periodontopathogenic bacteria and causes the progressive and irreversible destruction of the periodontal tissues and eventually, leads to tooth loss [1]. Numerous studies have demonstrated the association between PD and CVDs [2] such as arteriosclerosis [3], dyslipidemia [4] and hypertension [5]. According to prospective observational studies, this association is based on the systemic inflammation initiated by the microorganisms in the biofilm on the dental surfaces. However, a clear link has not been yet established [6]. PD and heart disease could have simultaneous onset, but singularly, one disease cannot induce the another [7]. This blurring persisted for several decades until several important studies established the influence of periodontal disease treatment on cardiovascular disease outcomes [8]. Since periodontal disease does not induce pain in the early stages and has a slow evolution, it is often left untreated [9,10].

According to the WHO, cardiovascular diseases are the number one cause of death globally [11]. In 2012, there were 17.5 million deaths globally, accounting for 31% of the total deaths [12]. Among cardiovascular diseases, IHD and cerebrovascular disease are the most common causes of death worldwide. According to the AHA, 795,000 people suffer a stroke annually [13].

The oral cavity is a reflection of a patient’s overall health, harmful habits and nutritional status. It is the entry as well as the site of microbial infections that also alter the general health [14]. Several theories explain the link between periodontal disease and heart disease. One theory is that oral bacteria entering the blood stream could affect the heart by attaching to the atherosclerotic plaques in the coronary arteries and leading to clot formation. Coronary artery disease is characterized by thickening and hardening of the coronary arteries walls due to the formation of plaques. Blood clots may obstruct the normal blood flow, restricting the amount of nutrients and oxygen required for the heart to function properly. This may lead to heart attacks. Another possibility is that the systemic inflammation caused by periodontal disease increases plaque formation, which may contribute to inflammation of the arteries walls. Researchers have found that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease [15].

The inflammatory potential of periodontal disease is manifested at macromolecular level through systemic dissemination of local mediators such as CRP, IL-1β, IL-6 and TNF-α. According to Chambers et al., this goal together with the increased number of inflammatory molecules could be involve in cardiovascular disease [16]. There is strong relationship between the periodontal and cardiovascular diseases and two directions have been the focus of delineating this relationship: bacteria from the oral cavity directly exacerbate cardiovascular disease or alter the systemic risk factors of cardiovascular disease; the chronic periodontal inflammation at the focus of infection increase circulating levels of inflammatory mediators, and/or bacteria disseminated into the circulation elicit elevations in systemic host inflammatory mediators that exacerbate cardiovascular disease directly or alter other systemic risk factors for cardiovascular disease [17].

The purpose of this study was to assess the prevalence of periodontal disease in a group of patients with cardiovascular disease and to establish the correlation between serum levels of inflammatory markers and periodontal status in these patients. The specific objectives of the present study were:

a. Evaluation of the prevalence of periodontal disease in a group of patients with cardiovascular disease.

b. Assessment of clinical parameters and severity of periodontal disease (bacterial plaque index, gingival bleeding index, clinical attachment loss) and the form of cardiovascular disease according to current international classifications.

c. Evaluation of systemic inflammatory markers (leukocytes, CRP, ESR, fibrinogen).

Materials and Methods

The study was conducted on 20 patients diagnosed with cardiovascular disease, 12 women and 8 men aged between 42 and 82 years, hospitalized in the Cardiology 1st Clinic, County Emergency Clinical Hospital Cluj-Napoca. All the patients signed the informed consent and the protection of personal data GDPR for participating to this study.

The patients were enrolled based on exclusion and inclusion criteria. The inclusion in the study was based on two criteria:

a. Minimum 6 teeth present in the oral cavity.

b. The diagnosis of cardiovascular disease.

The exclusion criteria were:

a. Complete edentation or presence of less than 5 teeth.

About half of all-American adults-117 million individuals— have one or more preventable chronic diseases, many of which are related to poor quality eating patterns and physical inactivity with more than two-thirds of adults and nearly one-third of children and youth being overweight or obese [8]. With the dietary link of diet and disease in mind, one must consider the application of diet upon biochemical processing overall and in particular for this work, with that of ADZ progression. Dietary demographics may play a pivotal role in the radically reduced rates of progression between the United States and that of other countries such as Singapore. It may be a point to consider that, although certain fish and shellfish contain greater levels of mercury content, they also contain essential fatty acids and are a rich protein resource that is needed to promote neuro-physiological processing through normal biochemical pathway processing [20,21].Research is now more than ever asking the question whether diet could play a substantial role in ADZ progression as well as many other dementias when considering the population demographics between East and West.

b. Severe general conditions that didn’t allow patient’s examination.

c. Other general diseases that could increase the levels of systemic inflammatory markers.

Using the Excel program, all data obtained in this study were organized in frequency tables, sectorial graphs (pie charts) and contingency tables. Information on the type of edentation according to the Kennedy classification, the appearance of the dental units, the presence of the dental fillings, their aspect and the material used, the aspect of the periodontium, the presence of gingival inflammation, bacterial plaque and tartar were recorded and compared. The major drawback in this study was the lack of periodontometry because this examination was performed in the hospital environment, not in the dental office. The periodontal clinical examination assessed the gingival bleeding, periodontal pockets depth, gingival retractions and tooth mobility.

To evaluate oral hygiene, we calculated the OHI-S index (Greene and Vermillion, 1964) in patients with cardiovascular disease. Plaque examination was performed by inspection without staining solutions. The following dental surfaces were examined: the vestibular surface of teeth 1.6, 1.1, 2.6 and 3.1, and the lingual surfaces of teeth 3.6 and 4.6. The values of the debris index (DI) were registered as follows: 0 = absence of the bacterial plaque; 1 = supragingival plaque in the cervical 1/3 of the tooth, on the parcel; 2 = plaque in the middle 1/3 of the tooth; 3 = plaque in the occlusal or incisal 1/3 of the tooth. The values of the CI index were as follows: 0 = absence of the tartar; 1 = supragingival tartar in the cervical 1/3 of the crown; 2 = supragingival tartar in middle 1/3 of the crown and islands of subgingival tartar; 3 = tartar and in occlusal or incisal 1/3 of the tooth and a band of subgingival tartar. The values obtained in the assessment of the above areas were collected and divided by the total number of assessed areas for both DI and CI. Values obtained for DI and CI were collected and the OHI-S value was obtained. Interpretation of OHI-S index values was the following: between 0 and 1.2 = good oral hygiene; between 1.3 and 3 = satisfactory oral hygiene; between 3.1 and 6 = poor oral hygiene.

According to Maurizio S. Tonetti & al, understanding the periodontitis stages, as well as the correct treatment applied in each of these stages is crucial for an immediate treatment at these patients [18]. In order to assess the periodontal health status, we evaluated the GBI [19]. This is a reliable, easy-to-use indicator that reveals the presence or absence of gingival inflammation [20]. After about 10-15 seconds, the occurrence or absence of bleeding was recorded. The number of registered positive units was divided by the number of gingival margins examined and the result was multiplied by 100 for the expression of the percentage indicator. It was shown that scores obtained with this index were statistically correlated with those obtained from the application of the gingival index GI [21,22]. Several studies showed that the absence of gingival bleeding was a good indicator of the healthy marginal periodontium. Other studies demonstrated that the surfaces that bled upon probing did not show extensive tissue destruction in all cases. Moreover, this parameter is not correlated with the degree of gingival inflammation in smokers. The diagnosis of periodontal disease has been established based on the clinical criteria: multiple gingival attachment loss, grade 2 or 3 dental mobility with tooth malposition, bone resorption that could be clinically observed, gingival and periodontal pathological changes (presence of periodontal pockets, gingival bleeding, ulcers). Since the patients were hospitalized, the radiological examination could not be performed, in order to validate and complete the clinical diagnosis. The biochemical parameters assessed as markers of systemic inflammation included: WBC, CRP, Plasma fibrinogen and ESR.

Results

In this study, 20 patients were enrolled: 63% were women aged between 65 and 77 years and 37% men aged between 43 and 82 years. Among patients from the rural area, 73% were women and 27% were men. Among patients from the urban area, 55% were men. In this study group, 11 patients with CVD had PD (55% of which 35% were females and 20% were males). As represented in Figure 1, OHI-S indicated that 40% of all the patients achieved values ranging from 3 to 6, suggesting poor oral hygiene. Of these, 75% were females coming from rural areas. Among patients with both CVD and PD, 64% had a poor oral hygiene at the time of OHI-S assessment. These results suggested that in patients with CVD, the poor oral hygiene was correlated with the oral status and could be a risk factor for the occurrence and/or worsening of PD. The neglected oral hygiene observed in these patients might be the result of the associated general diseases.

In Figure 2, 60% of patients with CVD were treated with AC (Acenocumarol or Apixaban) or PA (Acetylsalicylic acid, Clopidogrel or Ticagrelor) and 10% were administered drugs from both groups. This medication could be the explanation for the 85% of patients with CVD who experienced bleeding during periodontal examination.

Patients in this study presented different types of edentation according to the Kennedy classification. Most of the edentations were biterminal in both upper and lower jaws. Approximately 55% of the patients presented improper adaptation of prostheses on marginal profile, and 40% of them had no prosthetic crowns. Among patients with both PD and CVD, 45% had improper prostheses in terms of marginal closure, and the remaining 55% did not have prosthetic dentures. It is known that inappropriate prosthetic works are a local risk factor for PD, especially due to poor marginal adaptation that favors plaque retention on the prosthesis-tooth interface. Approximately 64% of patients with both CVD and PD had between 1 and 18 irrecoverable teeth that were either remnant roots or exhibited grade 2 or 3 dental mobility.

The CVDs diagnosed among the patients in this study included: HBP, CIHD, CHF, STD and MI (Figure 3). In patients with CVDs, the PD was found in 55% of patients with HBP, 40% in patients with CHF and 30% in patients with chronic CIHD.

Among patients with CVD and PD, 73% had between 1 and 12 teeth with inactive periodontal pockets, most of them with a depth of 2 to 4mm. As seen in Table 1, the largest number of teeth with periodontal pockets compared with the total number of teeth has been found in patients with HBP.

To evaluate the relationship between inflammatory markers and the presence of PD, the patients were divided into 2 groups. The first group included 11 patients with both CVD and PD, and the second group included 9 patients with CVD but without PD. There was no significant difference between the two groups regarding the inflammatory markers. However, as can be seen in Table 2, patients with both CVD and PD exhibited higher ESR and fibrinogen values compared with patients without PD.

There was no clear evidence if inflammation manifested by leukocytosis was the cause or the effect of atherosclerosis. Among patients with HBP, approximately 30% had leukocytosis. In the Table 3 can be seen the distribution of patients who had values of inflammatory markers evaluated above the normal range according to cardiovascular disease.

Although a clear link between PD and CVDs has not been yet established, several studies focused on the analysis of the relationship between PD and HBP [5,23,24]. Numerous clinical and epidemiological studies reported that the leukocyte count is an independent risk factor for coronary heart disease. In our study, of patients with CIHD, only 11% had leukocytosis (Table 3). According to a study investigating the relationship between white blood cells counts and CIHD, increased leukocyte counts were associated with an increased risk of cardiovascular morbidity and mortality in a group of undiagnosed patients. Leukocytosis influences the severity of coronary heart disease through multiple pathological mechanisms that mediate inflammation, causes the destruction of endothelial cells through oxidative stress and proteolysis, affects microcirculation by clogging the capillaries, arterioles and venules, induces hypercoagulability and contributes to the expansion of infarcted areas. Moreover, leukocytosis is a risk factor independent of atherosclerotic disease status [25]. Leukocytes play a pivotal role in normal host resistance at dental-plaque biofilm level and its dysfunctions are involved in periodontitis development [26].

Recently, numerous epidemiological studies confirmed that patients with elevated basal plasma levels of CRP have an increased risk of coronary artery disease and myocardial infarction. Prospective studies in the European and US countries have provided reliable data regarding the predictive value of CRP determinations on cardiovascular risk in both men and women. Thus, CRP is an indirect risk factor for coronary artery disease, and elevated levels may reflect some of the followings: inflammation of the coronary arteries in response to infectious agents; severity of inflammatory response in atherosclerotic vessels; extension of inflammation associated with myocardial ischemia; extension of inflammation associated with myocardial necrosis; the levels and activity of circulating proinflammatory cytokines.

There are two types of CRP tests: one of these has a measurable range that includes values obtained in patients with infectious or inflammatory processes (generally 0.3-20mg/dL) and the other can detect lower CRP levels (analytical sensitivity in around 0.01mg/dL) to estimate the risk of acute CVE. For this reason, the second test is termed CRP with high sensitivity (CRP ultrasensitive, “high-sensitive” CRP) [27]. At present, the value of the highly sensitive C-protein (hs-CRP) appears to be the most reliable predictor of acute CVE and is successfully used for the clinical assessment of patients with cardiovascular risk. Decision intervals for cardiovascular risk assessment are established according to the AHA: <0.1mg/dL - low risk; 0.1-0.3mg/dL - moderate risk; >0.3mg/dL - increased risk. For values higher than 1mg/dL, a non-cardiovascular cause should be considered.

Although there is clear evidence of the role of inflammation in coronary artery disease, the precise mechanism underlying the relationship between plasma CRP levels and the cardiovascular risk has not been yet established. It is still unclear whether increased CRP levels are the cause or the consequence of the disease or both. The inflammatory response associated with atheromatous lesions may trigger cytokine production in an amount sufficient to induce a measurable increase in plasma CRP. In turn, CRP, due to pro-inflammatory effects, may increase the formation of the dental plaque, or may have other effect that aggravate the PD.

In our study, 30% of the patients with CVD had CRP values ranging between 0.1 and 0.3mg/dL, which were associated with moderate cardiovascular risk. Among patients with chronic heart failure, 47% had CPR values higher than 1mg/dL. It has been reported that people with CRP serum levels that consistently exceed 1mg/dL had an increased risk of myocardial infarction. The following circumstances could influence the CRP values: pregnancy, obesity, the presence of an intrauterine contraceptive device, or the use of medications such as oral contraceptives, menopausal hormone replacement therapy, statins (drugs used to lower blood cholesterol), and anti-inflammatory drugs. The PD was present in 64% of rural patients and in 44% of urban patients. A recent transversal study based on the simple randomized method performed on 470 rural subjects, showed a 73.62% prevalence of PD [28]. These findings could be explained by the fact that the rural population neglects the oral health and is unaware of the seriousness of the oro-dental conditions, and also by the low accessibility to dental services.

Conclusion

Future studies should focus on a better understanding of the common pathogenic mechanisms and the interactions between cardiovascular disease and periodontal disease. In order to demonstrate the causal relationship between periodontal disease and cardiovascular disease, further studies should be performed on a large population to provide data enabling statistically significant correlations.

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