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22 September 2020

EFP Perio Talks session highlighted how periodontists and cardiologists should work together

Categories:Clinical Practice, Communication, Science

The latest EFP Perio Talks session on Instagram put the spotlight on the Perio & Cardio campaign recently launched by the EFP in partnership with the World Heart Federation (WHF).

The need to increase awareness among cardiologists of the potential role of periodontal care in preventing and treating cardiovascular disease was one of the key issues addressed in the 45-minute session by Filippo Graziani (chair of the EFP’s European project committee) and Álvaro Marco del Castillo (a Spanish cardiologist representing the WHF).

Other topics covered included joint protocols for dentists and cardiologists on referring patients, the risks of periodontal surgery for cardiovascular patients, and the importance of including periodontal care in the rehabilitation of patients with cardiovascular disease.

Prof Graziani, the EFP’s immediate past president, asked how cardiologists viewed the idea that dentists wanted to be more involved in the systemic management of their patients, given the volume of evidence on the links between periodontal and systemic diseases.

Dr Marco del Castillo cited studies that showed how treating systemic inflammation can improve the overall health of these patients and reduce the burden of cardiovascular events during follow-up. “So probably if we reduce systemic inflammation by treating periodontitis, we can help these patients, because it has been shown that periodontitis generates this kind of systemic inflammation,” he observed. “I think we need to look closer at this and start collaborating between each other.”

But the WHF representative admitted that cardiologists had not been quick off the mark on this issue. “I see a lot of interest from your side, but I don’t see the same level of interest from our side, because we are so focused on other things that we are not paying attention to it,” he said.

“As cardiologists, we have been extremely focused on just one organ and we have omitted the rest of the body. Cardiologists don’t routinely check for systemic inflammation before treating cardiovascular diseases, and that’s an important mistake.”

In this context, the Perio & Cardio campaign – which includes separate recommendations for medics, oral-health professionals, and patients – could be useful in raising awareness among cardiologists, noted Graziani.

Asked about how else periodontists could help their cardio colleagues, Dr Marco del Castillo highlighted two areas. “You can help us learn about periodontitis – how can I assess it in my clinic? Should I regularly check the gums of my patients or should I send them to you? And another thing that would be good for both of us would be to establish protocols of collaboration: when patients need to see dentists and when patients should see the cardiologist – when should each one be referred.”


One key issue for periodontists when treating patients with cardiovascular disease concerns whether anti-platelet or anti-coagulation therapy needs to be suspended temporarily ahead of surgery to prevent the risk of bleeding. Current guidelines – such as those of the UK’s National Institute for Health and Care Excellence (NICE) – suggest not suspending this treatment.

Dr Marco del Castillo cautioned: “Whenever they are on two medications, I would really encourage you to be careful because the risk of bleeding increases exponentially. They should be referred to the cardiologist just to make sure they need them, because most of the time they only need one of them.”

Graziani asked whether periodontal surgery might expose cardiovascular patients to an increased risk of cardiovascular events.

“The problem is spikes of systemic inflammation, which are extremely dangerous, especially if we know that there are some unstable atherosclerosis plaques going on – for example a recent myocardial infarction,” explained Marco del Castillo. “If you want to treat a patient for periodontitis in the 12 months after the myocardial infarction, he’s going to be on two antiplatelet therapies and – even though he can undergo it – you don’t really want that spike of acute inflammation.”

When performing periodontal surgery on patients with cardiovascular disease, clinicians should be aware of signs of discomfort and stress as “being nervous increases heart rate and raises the blood pressure and those two factors combined in a patient with a cardiovascular disease can sometimes lead to fatal consequences,” said the cardiologist. He added that in longer surgical procedures, periodontists might check the patient’s blood pressure every 30 minutes and give a mild sedative if it rises above 160-180.

Dr Marco del Castillo said that there were questions a periodontist could ask patients with cardiovascular disease ahead of surgery, such as whether they feel pain in their chest or legs, if they have trouble breathing, or if they have palpitations and an irregular pulse.

“There is a question that anaesthesiologists do in their clinics which is: Can you go up one flight of stairs? If they can go up a flight of stairs without any chest pain or any extreme exhaustion it means their cardiovascular fitness should tolerate almost any intervention,” he said.

The campaign

Turning to the Perio & Cardio campaign, Prof Graziani asked how dentists and cardiologists should use the material.

“From our side, we cardiologists have to study more – how to recognise the early signs of periodontitis so we can refer patients to you,” replied Marco del Castillo. “It is also important to use all that knowledge to start cooperating – maybe establishing liaison between cardiac and dental clinics to create early referral transfers or protocols.”

Finally, he suggested that adding periodontal care to cardiac rehabilitation, along with instructions on diet and exercise, would be useful.

“Cardiovascular diseases are all about prevention. I don’t know how many lives we would save by improving gum health in patients with cardiovascular disease. Imagine we save only five lives, is it less important? No. They need to take care of their mouth either way. So, let’s just go with it – if its five, good; if it’s 2,000 or 10,000 even better.”

Graziani said it was crucial that the campaign raised awareness in “every possible stakeholder” and thanked the WHF for endorsing the project, which has been sponsored by Dentaid.

Some of the comments from this live Instagram EFP Perio Talks session have been edited for clarity and concision.