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Introduction
Over the past two decades, there has been an increasing interest in the possible link between dental disease, specifically periodontal disease, and cardiovascular disease. 1 Inflammation plays an important role in the pathogenesis of atherosclerosis, and markers of low grade inflammation have been consistently associated with a higher risk of cardiovascular disease. 2 Consequently, contributing factors associated with inflammation and chronic infections, including oral infections such as periodontal disease, have been investigated to explain the relation between dental disease and cardiovascular disease.
Poor oral hygiene is the major cause of periodontal disease, a chronic infection of the tissue surrounding the teeth. It is one of the most common chronic infections and is associated with a moderate systemic inflammatory response, 3 such as raised concentrations of C reactive protein and other inflammatory biomarkers. 4 5 6 7 Systemic inflammation could represent the underlying mechanism that links oral health and cardiovascular disease. Thus, oral infections might add to the inflammatory burden of the individual and result in increased levels of cardiovascular risk based on serum C reactive protein and fibrinogen concentrations as a consequence of the systemic inflammatory response subsequent to low grade chronic infections. 8 C reactive protein and fibrinogen are sensitive markers used to evaluate the inflammatory status of an individual, and the results of prospective longitudinal studies indicate that these markers might be useful predictors for future cardiovascular events in various populations. 9 10 Preliminary intervention trials showed a significant effect of treatment with systemic antibiotics in reducing systemic inflammatory markers. 11 12
Previous smaller epidemiological studies that have examined the association between oral health and cardiovascular disease have generally used clinical assessments to identify periodontal disease. Such assessments might not be feasible in large scale population studies. Self reported measures of oral hygiene have been associated with clinically confirmed periodontal disease. 13 The association between self reported oral hygiene behaviour and incident cardiovascular disease has not been previously examined in a large population study. We investigated whether a single item self reported measure of frequency of toothbrushing (as a proxy of periodontal disease) was associated with risk of cardiovascular disease events in a sample of adults from the Scottish Health Survey. In addition, we examined the association between frequency of toothbrushing and...