Association between periodontal inflamed surface area and cardiovascular disease: a cross-sectional study based on the NHANES database_Chinese Journal of Evidence-Based Medicine

Authors：

ZHAO Lin , TAN Jianshu , KANG Lunwei , HUANG Xinyan ,  LIAO Ga

State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, P. R. China;

Corresponding?author：

LIAO Ga, Email: liaoga@hotmail.com

Keywords：

Periodontal inflamed surface area; Cardiovascular disease; National health and nutrition examination survey

DOI：

10.7507/1672-2531.202604175

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective Periodontal disease may increase the risk of cardiovascular disease(CVD). Periodontal inflammation can contribute to CVD through both local and systemic inflammatory pathways. The Periodontal Inflamed Surface Area (PISA) quantifies the extent of periodontal inflammation; however, evidence based on large, representative populations remains limited. This study aimed to evaluate the association between PISA and CVD using data from the National Health and Nutrition Examination Survey (NHANES). Methods This study utilized data from six cycles of NHANES, including a total of 8 925 participants. Three machine learning algorithms—Random Forest, XGBoost, and Boruta—were used for key feature selection. A logistic regression model was constructed to assess the association between PISA and CVD prevalence, and further machine learning prediction models were developed to explore the additional predictive value of PISA in identifying CVD status. Results Participants in the highest quartile of PISA showed a higher prevalence of CVD. Multivariable logistic regression analysis and restricted cubic spline analysis demonstrated that PISA score was positively associated with CVD in a linear fashion (OR=2.85, 95%CI 1.75 to 4.62, P<0.001). Conclusion In individuals with periodontitis, the PISA index is linearly associated with the prevalence of cardiovascular disease events and their subtypes. As a continuous measure of periodontal inflammatory burden, PISA may help identify people at higher risk of CVD.

Citation： ZHAO Lin, TAN Jianshu, KANG Lunwei, HUANG Xinyan, LIAO Ga. Association between periodontal inflamed surface area and cardiovascular disease: a cross-sectional study based on the NHANES database. Chinese Journal of Evidence-Based Medicine, 2026, 26(7): 821-826. doi: 10.7507/1672-2531.202604175 Copy

1.	Yang X, Liu P, Fan X, et al. Distribution and influencing factors on residual pockets of the teeth in patients with periodontitis following non-surgical periodontal treatment: a retrospective observational study. BMC Oral Health, 2023, 23(1): 736.
2.	Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res, 2012, 91(10): 914-920.
3.	Nascimento GG, Alves-Costa S, Romandini M. Burden of severe periodontitis and edentulism in 2021, with projections up to 2050: the global burden of disease 2021 study. J Periodontal Res, 2024, 59(5): 823-867.
4.	Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nat Rev Immunol, 2015, 15(1): 30-44.
5.	Arbildo-Vega HI, Cruzado-Oliva FH, Coronel-Zubiate FT, et al. Periodontal disease and cardiovascular disease: umbrella review. BMC Oral Health, 2024, 24(1): 1308.
6.	Emecen-Huja P, Li HF, Ebersole JL, et al. Epidemiologic evaluation of nhanes for environmental factors and periodontal disease. Sci Rep, 2019, 9(1): 8227.
7.	Nesse W, Abbas F, van der Ploeg I, et al. Periodontal inflamed surface area: quantifying inflammatory burden. J Clin Periodontol, 2008, 35(8): 668-673.
8.	Mance Kristan R, Jurgec S, Poto?nik U, et al. The association between periodontal inflamed surface area (PISA), inflammatory biomarkers, and mitochondrial DNA copy number. J Clin Med, 2024, 14(1): 24.
9.	Kumari R, Banerjee A, Verma A, et al. Assessing the correlation of periodontal inflamed surface area (PISA) with systemic inflammatory markers. Cureus, 2024, 16(6): e62389.
10.	Meeker KL, Luckett PH, Barthélemy NR, et al. Comparison of cerebrospinal fluid, plasma and neuroimaging biomarker utility in Alzheimer's disease. Brain Commun, 2024, 6(2): fcae081.
11.	Lee Y, Cappellato M, Di Camillo B, et al. Machine learning-based feature selection to search stable microbial biomarkers: application to inflammatory bowel disease. Gigascience, 2022, 12: giad083.
12.	Abbas Z, Rehman MU, Tayara H, et al. XGBoost framework with feature selection for the prediction of RNA N5-methylcytosine sites. Mol Ther, 2023, 31(8): 2543-2551.
13.	Tao S, Yu L, Li J, et al. Association between the triglyceride-glucose index and 1-year major adverse cardiovascular events in patients with coronary heart disease and hypertension. Cardiovasc Diabetol, 2023, 22(1): 305.
14.	Eke PI, Page RC, Wei L, et al. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol, 2012, 83(12): 1449-1454.
15.	Beck J, Garcia R, Heiss G, et al. Periodontal disease and cardiovascular disease. J Periodontol, 1996, 67(10 Suppl): 1123-1137.
16.	Gomes-Filho IS, Coelho JMF, Miranda SS, et al. Severe and moderate periodontitis are associated with acute myocardial infarction. J Periodontol, 2020, 91(11): 1444-1452.
17.	Rydén L, Buhlin K, Ekstrand E, et al. Periodontitis increases the risk of a first myocardial infarction: a report from the PAROKRANK study. Circulation, 2016, 133(6): 576-583.
18.	Sanghvi MM, Ramírez J, Chadalavada S, et al. The association between periodontal disease and cardiovascular disease: insights from imaging, observational, and genetic data. JACC Adv, 2024, 3(10): 101241.
19.	Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol, 2002, 29(5): 400-410.
20.	Sanz M, Marco Del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: consensus report. J Clin Periodontol, 2020, 47(3): 268-288.
21.	Bruno JS, Heidrich V, Knebel FH, et al. Commensal oral microbiota impacts ulcerative oral mucositis clinical course in allogeneic stem cell transplant recipients. Sci Rep, 2022, 12(1): 17527.
22.	Holmlund A, Lampa E, Lind L. Poor response to periodontal treatment may predict future cardiovascular disease. J Dent Res, 2017, 96(7): 768-773.
23.	Susanto H, Nesse W, Dijkstra PU, et al. Periodontal inflamed surface area and C-reactive protein as predictors of HbA1c: a study in Indonesia. Clin Oral Investig, 2012, 16(4): 1237-1242.
24.	Iwasaki M, Shirobe M, Ohara Y, et al. Periodontal inflammation and serum inflammatory markers in community-dwelling older adults in Japan: the otassha study. J Clin Periodontol, 2025, 52(8): 1099-1107.
25.	Botelho J, Machado V, Leira Y, et al. Periodontal inflamed surface area mediates the link between homocysteine and blood pressure. Biomolecules, 2021, 11(6): 875.
26.	Latorre Uriza C, Roa NS, Velosa-Porras J, et al. Relationship between carotid intima-media thickness, periodontal disease, and systemic inflammation biomarkers in an adult population. Biomedicines, 2024, 12(7): 1425.
27.	Forner L, Larsen T, Kilian M, et al. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. J Clin Periodontol, 2006, 33(6): 401-407.
28.	Martínez-García M, Hernández-Lemus E. Periodontal inflammation and systemic diseases: an overview. Front Physiol, 2021, 12: 709438.
29.	Zhang J, Xie M, Huang X, et al. The effects of porphyromonas gingivalis on atherosclerosis-related cells. Front Immunol, 2021, 12: 766560.
30.	Kozarov EV, Dorn BR, Shelburne CE, et al. Human atherosclerotic plaque contains viable invasive actinobacillus actinomycetemcomitans and porphyromonas gingivalis. Arterioscler Thromb Vasc Biol, 2005, 25(3): e17-e18.

1. Yang X, Liu P, Fan X, et al. Distribution and influencing factors on residual pockets of the teeth in patients with periodontitis following non-surgical periodontal treatment: a retrospective observational study. BMC Oral Health, 2023, 23(1): 736.
2. Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res, 2012, 91(10): 914-920.
3. Nascimento GG, Alves-Costa S, Romandini M. Burden of severe periodontitis and edentulism in 2021, with projections up to 2050: the global burden of disease 2021 study. J Periodontal Res, 2024, 59(5): 823-867.
4. Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nat Rev Immunol, 2015, 15(1): 30-44.
5. Arbildo-Vega HI, Cruzado-Oliva FH, Coronel-Zubiate FT, et al. Periodontal disease and cardiovascular disease: umbrella review. BMC Oral Health, 2024, 24(1): 1308.
6. Emecen-Huja P, Li HF, Ebersole JL, et al. Epidemiologic evaluation of nhanes for environmental factors and periodontal disease. Sci Rep, 2019, 9(1): 8227.
7. Nesse W, Abbas F, van der Ploeg I, et al. Periodontal inflamed surface area: quantifying inflammatory burden. J Clin Periodontol, 2008, 35(8): 668-673.
8. Mance Kristan R, Jurgec S, Poto?nik U, et al. The association between periodontal inflamed surface area (PISA), inflammatory biomarkers, and mitochondrial DNA copy number. J Clin Med, 2024, 14(1): 24.
9. Kumari R, Banerjee A, Verma A, et al. Assessing the correlation of periodontal inflamed surface area (PISA) with systemic inflammatory markers. Cureus, 2024, 16(6): e62389.
10. Meeker KL, Luckett PH, Barthélemy NR, et al. Comparison of cerebrospinal fluid, plasma and neuroimaging biomarker utility in Alzheimer's disease. Brain Commun, 2024, 6(2): fcae081.
11. Lee Y, Cappellato M, Di Camillo B, et al. Machine learning-based feature selection to search stable microbial biomarkers: application to inflammatory bowel disease. Gigascience, 2022, 12: giad083.
12. Abbas Z, Rehman MU, Tayara H, et al. XGBoost framework with feature selection for the prediction of RNA N5-methylcytosine sites. Mol Ther, 2023, 31(8): 2543-2551.
13. Tao S, Yu L, Li J, et al. Association between the triglyceride-glucose index and 1-year major adverse cardiovascular events in patients with coronary heart disease and hypertension. Cardiovasc Diabetol, 2023, 22(1): 305.
14. Eke PI, Page RC, Wei L, et al. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol, 2012, 83(12): 1449-1454.
15. Beck J, Garcia R, Heiss G, et al. Periodontal disease and cardiovascular disease. J Periodontol, 1996, 67(10 Suppl): 1123-1137.
16. Gomes-Filho IS, Coelho JMF, Miranda SS, et al. Severe and moderate periodontitis are associated with acute myocardial infarction. J Periodontol, 2020, 91(11): 1444-1452.
17. Rydén L, Buhlin K, Ekstrand E, et al. Periodontitis increases the risk of a first myocardial infarction: a report from the PAROKRANK study. Circulation, 2016, 133(6): 576-583.
18. Sanghvi MM, Ramírez J, Chadalavada S, et al. The association between periodontal disease and cardiovascular disease: insights from imaging, observational, and genetic data. JACC Adv, 2024, 3(10): 101241.
19. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol, 2002, 29(5): 400-410.
20. Sanz M, Marco Del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: consensus report. J Clin Periodontol, 2020, 47(3): 268-288.
21. Bruno JS, Heidrich V, Knebel FH, et al. Commensal oral microbiota impacts ulcerative oral mucositis clinical course in allogeneic stem cell transplant recipients. Sci Rep, 2022, 12(1): 17527.
22. Holmlund A, Lampa E, Lind L. Poor response to periodontal treatment may predict future cardiovascular disease. J Dent Res, 2017, 96(7): 768-773.
23. Susanto H, Nesse W, Dijkstra PU, et al. Periodontal inflamed surface area and C-reactive protein as predictors of HbA1c: a study in Indonesia. Clin Oral Investig, 2012, 16(4): 1237-1242.
24. Iwasaki M, Shirobe M, Ohara Y, et al. Periodontal inflammation and serum inflammatory markers in community-dwelling older adults in Japan: the otassha study. J Clin Periodontol, 2025, 52(8): 1099-1107.
25. Botelho J, Machado V, Leira Y, et al. Periodontal inflamed surface area mediates the link between homocysteine and blood pressure. Biomolecules, 2021, 11(6): 875.
26. Latorre Uriza C, Roa NS, Velosa-Porras J, et al. Relationship between carotid intima-media thickness, periodontal disease, and systemic inflammation biomarkers in an adult population. Biomedicines, 2024, 12(7): 1425.
27. Forner L, Larsen T, Kilian M, et al. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. J Clin Periodontol, 2006, 33(6): 401-407.
28. Martínez-García M, Hernández-Lemus E. Periodontal inflammation and systemic diseases: an overview. Front Physiol, 2021, 12: 709438.
29. Zhang J, Xie M, Huang X, et al. The effects of porphyromonas gingivalis on atherosclerosis-related cells. Front Immunol, 2021, 12: 766560.
30. Kozarov EV, Dorn BR, Shelburne CE, et al. Human atherosclerotic plaque contains viable invasive actinobacillus actinomycetemcomitans and porphyromonas gingivalis. Arterioscler Thromb Vasc Biol, 2005, 25(3): e17-e18.

Chinese Journal of Evidence-Based Medicine

Association between periodontal inflamed surface area and cardiovascular disease: a cross-sectional study based on the NHANES database

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content