Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Is periodontal inflammation associated with raised blood pressure? Evidence from a National US survey Georgios Tsakos a , Wael Sabbah a , Aroon D. Hingorani a , Gopalakrishnan Netuveli b , Nikos Donos c , Richard G. Watt a and Francesco D’Aiuto c There is incomplete and inconclusive evidence for the association between periodontal disease markers and arterial blood pressure, particularly from large national epidemiological studies. This study assessed the relationship between different markers of periodontal inflammation and disease with arterial blood pressure in people aged 17 years and over in USA. We analysed data from the Third National Health and Nutrition Examination Survey on 6617 men and 7377 women who received a periodontal examination. Blood pressure was analysed in both a continuous format and a binary variable for case definition of hypertension. Periodontal disease markers (extent of gingival bleeding, pocket depth, and loss of attachment, and a case definition of periodontitis) were associated on the arterial blood pressure outcomes through a series of regression models, incrementally adjusting for confounders (demographic, inflammation markers, chronic conditions, smoking, BMI, socio-economic status). All periodontal measures had significant crude associations with SBP and hypertension. Gingival bleeding, a marker of current periodontal inflammation, was the only measure consistently and significantly associated with raised SBP and an increased odds of hypertension in the US adult population throughout the adjustment process. For a 10% greater extent of gingival bleeding, the average SBP was higher by 0.5 (0.3, 0.6) mmHg in the fully adjusted model. By referring to the general population and the whole distribution of blood pressure, not only to those at higher risk for hypertension, this association might have some important implications for clinical practice and public health strategies. J Hypertens 28:2386–2393 Q 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Hypertension 2010, 28:2386–2393 Keywords: adult, blood pressure, epidemiology, health survey, hypertension, inflammation, periodontal diseases Abbreviations: BP, blood pressure; CRP, C-reactive protein; CVD, cardiovascular diseases; HBP, high blood pressure/hypertension; NHANES III, Third National Health and Nutrition Examination Survey a Department of Epidemiology and Public Health, UCL, b Department of Primary Care and Social Medicine, Imperial College London and c Periodontology Unit, UCL Eastman Dental Institute, London, UK Correspondence to Dr Georgios Tsakos, Department of Epidemiology and Public Health, UCL, 1-19 Torrington Place, London WC1E 6BT, UK Tel: +44 2076795614; fax: +44 2078130280; e-mail: g.tsakos@ucl.ac.uk Received 25 November 2009 Revised 18 June 2010 Accepted 30 June 2010 See editorial comment on page 2382 Introduction Low-grade systemic inflammation indexed by levels of inflammatory markers has been linked to risk of coronary heart disease and stroke [1,2]. A number of noninfective auto-immune disorders are also associated with increased cardiovascular risk [3–5]. Moreover blood levels of inflammation markers are associated with greater risk of cardiovascular diseases (CVDs) in later life [6,7]. Periodontitis is one potential chronic infectious stimulus for systemic inflammation linked to CVD [8–10]. Sever- ity of periodontitis correlates with systemic inflammation markers and periodontal therapy reduces systemic inflammation [11–14]. Furthermore, acute inflammation, chronic inflammation and individual inflammatory cyto- kines have been shown to cause endothelial dysfunction. The latter may provide a link between inflammation and CVD risk. This could be mediated through consequent alterations in vascular resistance and blood pressure (BP). Studies have suggested a possible association between periodontal disease and high blood pressure (HBP) [11,15 – 22]. This may be partly attributed to the fact that periodontal disease is associated with higher levels of inflammatory markers such as C-reactive protein (CRP), fibrinogen and white blood cells [23,24]. These inflam- matory markers, in turn, are known to be related to HBP and coronary heart disease [2,25–27]. However, the evi- dence has been inconclusive as there are also studies refuting such an association [28–31]. Even when indi- cating an association, most research has either been conducted in smaller-scale clinical studies [11,15,16,18] or focussed on the association between periodontal disease and HBP using only case definitions without considering the continuous nature of the measurements [16,17,20]. In addition, when large-scale studies were used, the role of potential confounders (such as demo- graphic factors, socioeconomic position, smoking, obesity, general health conditions and biological markers) has not been fully investigated [19]. To date, there has not been a large epidemiological study on a nationally representative sample that provided 2386 Original article 0263-6352 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/HJH.0b013e32833e0fe1