Cardiac Health & the Mouth

doctor and patient exam

A well-established link has been documented between periodontal disease and cardiovascular diseases like atherosclerosis, coronary heart disease, and acute coronary events including myocardial infarction.1-5 Meta-analyses have associated periodontal disease with elevated bacterial exposure, coronary heart disease, and early atherogenesis;5 a groundbreaking study in 2019 showed—for the first time—the common presence of bacterial DNA from viridans streptococci in aspirated thrombi of patients with acute ischemic stroke.6 The authors of this latter study conclude that Streptococcal bacteria, mostly of oral origin, may contribute to the progression and thrombotic events of cerebrovascular diseases.6 Other evidence suggests that oral health and systemic disease are indeed linked—what’s healthy for the mouth is also healthy for the rest of the body, and vice versa.7-10

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According to the 2000 US Surgeon General’s report, Oral Health in America, oral examination can reveal signs and symptoms of more than 90% of systemic diseases.10 However, in spite of these associations, some researchers feel there is a lack of awareness in the healthcare community on their possible importance.11 Nutrition-oriented physical exams, as taught in Functional Medicine, can help clinicians to identify early warning signs. This can enable personalized interventions for patients at risk. In the following video, IFM educator Michael Stone, MD, MS, identifies the signs to look for inside of the mouth during the patient physical exam:

IFM educator Michael Stone, MD, MS, is a board-certified family physician who practices in Ashland, Oregon. His interests and lectures have covered a wide range of topics—bezoars, neonatal hypocalcemia, exposure to vitamin D and chronic disease—and many subjects in between.

There are approximately 800 species of bacteria that have been identified in the oral cavity, and periodontal disease is the most common oral condition in the population.13 In 2008, a systematic review found that periodontitis is a risk factor for coronary heart disease.14 One meta-analysis found that periodontal disease causes a 19% increase in the risk of cardiovascular disease.15 This increase in relative risk rises to 44% among individuals aged 65 years and over.15

In addition to cardiovascular diseases, some studies suggest that infections in the oral cavity are contributing factors to systemic inflammatory diseases such as diabetes.7-9 New data suggest that this association is not indicated by traditional clinical signs of periodontal disease but rather by a cluster of host immune and inflammatory mediators.8 A 2015 study examining the relationship between periodontal microbiota and early diabetes risk found that higher levels of four species (A. actinomycetemcomitans, P. gingivalis, T. denticola, and T. forsythia) were associated with a two- to three-fold higher prevalence of prediabetes.16 The study speculates that if bacterial dysbiosis can contribute to prediabetes development in susceptible individuals, it may be possible that periodontitis and prediabetes (or diabetes) are comorbid conditions due to shared microbial risk factors.16

Researchers are calling for further studies into the possible casual associations between oral conditions and systemic disease.17 In 2018, the largest study to date of nearly one million people experiencing more than 65,000 cardiovascular events (including heart attack) found that after accounting for age, there was a moderate correlation between tooth loss (a measure of poor oral health) and coronary heart disease, and when smoking status was considered, the connection between tooth loss and cardiovascular disease largely disappeared. The researchers concluded that the modest tooth loss–coronary heart disease gradient appeared to be explained by cigarette smoking.18

In a 2014 study, participants with excellent oral hygiene had a significantly lower cardiovascular disease risk compared to those with poor oral hygiene.19 Encouraging healthy oral hygiene (including daily brushing and flossing) and supporting a healthy microbiome are just two ways practitioners can help prevent oral microbial imbalances that may contribute to systemic disease. In fact, the Journal of the American Medical Association recently published a report on the importance of oral health in comprehensive health care, stating that “a 5-minute oral examination could help physicians not only recognize poor oral health but also detect clues to seemingly unrelated health issues.”20

What does this mean for clinicians? Oral health in the physical exam can be easily assessed. Modifiable risk factors that contribute to periodontal diseases include smoking, poor oral hygiene, hormonal changes in females, diabetes mellitus, medications, and stress.13

The Functional Medicine model recognizes that everything in the body is connected, and that conquering heart disease is not simply a matter of driving serum cholesterol down. More information about how to perform an oral exam during a routine physical screening can be found in IFM’s free N Sight course. Follow the links below for more of a Functional Medicine perspective about cardiometabolic health.

Lifestyle interventions to modify cardiovascular disease risk

Clinical pearls on cardiometabolic treatment


  1. Bochniak M, Sadlak-Nowicka J. Periodontitis and cardiovascular diseases—review of publications. Przegl Lek. 2004;61(5):518-522.
  2. Singer RH, Stoutenberg M, Feaster DJ, et al. The association of periodontal disease and cardiovascular disease risk: results from the Hispanic Community Health Study/Study of Latinos. J Periodontol. 2018;89(7):840-857. doi:10.1002/JPER.17-0549
  3. Delange N, Lindsay S, Lemus H, Finlayson TL, Kelley ST, Gottlieb RA. Periodontal disease and its connection to systemic biomarkers of cardiovascular disease in young American Indian/Alaskan natives. J Periodontol. 2018;89(2):219-227. doi:10.1002/JPER.17-0319
  4. Beck JD, Offenbacher S. Systemic effects of periodontitis: epidemiology of periodontal disease and cardiovascular disease. J Periodontol. 2005;76(11 Suppl):2089-2100. doi:10.1902/jop.2005.76.11-S.2089
  5. Mustapha IZ, Debrey S, Oladubu M, Ugarte R. Markers of systemic bacterial exposure in periodontal disease and cardiovascular disease risk: a systematic review and meta-analysis. J Periodontol. 2007;78(12):2289-2302. doi:10.1902/jop.2007.070140
  6. Patrakka O, Pienimäki JP, Tuomisto S, et al. Oral bacteria signatures in cerebral thrombi of patients with acute ischemic stroke treated with thrombectomy. J Am Heart Assoc. 2019;8(11):e012330. doi:1161/JAHA.119.012330
  7. Babu NC, Gomes AJ. Systemic manifestations of oral diseases. J Oral Maxillofac Pathol. 2011;15(2):144-147. doi:10.4103/0973-029X.84477
  8. Teng YT, Taylor GW, Scannapieco F, et al. Periodontal health and systemic disorders. J Can Dent Assoc. 2002;68(3):188-192.
  9. Masthan MK, Anitha N, Jacobina JJ, Babu NA. Oral infections causing systemic diseases. Biomed Pharmacol J. 2016;9(2). doi:10.13005/bpj/1019
  10. Evans CA, Kleinman DV, Maas WR, et al. Oral Health in America: A Report of the Surgeon General (Executive Summary). US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Accessed October 1, 2019.
  11. Bouchard P, Boutouyrie P, D’Aiuto F, et al. European workshop in periodontal health and cardiovascular disease consensus document. Eur Heart J Suppl. 2010;12(Suppl B):B13-B22. doi:10.1093/eurheartj/suq001
  12. Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci. 2017;11(2):72-80.
  13. Humphrey LL, Fu R, Buckley DI, Freeman M, Helfand M. Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23(12):2079-2086. doi:10.1007/s11606-008-0787-6
  14. Janket SJ, Baird AE, Chuang SK, Jones JA. Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(5):559-569. doi:10.1067/moe.2003.107
  15. Demmer RT, Jacobs DR, Singh R, et al. Periodontal bacteria and prediabetes prevalence in ORIGINS: the Oral Infections, Glucose Intolerance, and Insulin Resistance study. J Dent Res. 2015;94(9 Suppl):201S-211S. doi:10.1177/0022034515590369
  16. Joshipura K, Ritchie C, Douglass C. Strength of evidence linking oral conditions and systemic disease. Compend Contin Educ Dent Suppl. 2000;(30):12-23.
  17. Batty GD, Jung KJ, Mok Y, et al. Oral health and later coronary heart disease: cohort study of one million people. Eur J Prev Cardiol. 2018;25(6):598-605. doi:10.1177/2047487318759112
  18. VanWormer JJ, Acharya A, Greenlee R, Nieto FJ. Oral hygiene and cardiometabolic disease risk in the Survey of the Health of Wisconsin. Community Dent Oral Epidemiol. 2013;41(4):374-384. doi:10.1111/cdoe.12015
  19. Lee JS, Somerman MJ. The importance of oral health in comprehensive health care. JAMA. 2018;320(4):339-340. doi:10.1001/jama.2017.19777

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