Denture-Related Stomatitis Is Associated with
Joanna Macidg,1Grzegorz Osmenda,2Daniel Nowakowski,1Grzegorz Wilk,2Anna Macidg,3
Tomasz MikoBajczyk,2Ryszard Nosalski,2Agnieszka Sagan,2,4 Magdalena Filip,2
MirosBaw Dróhdh,2Jolanta Loster,5Tomasz J. Guzik,2,4 and Marta CzeVnikiewicz-Guzik1,4
1Department of Prophylaxis and Experimental Dentistry, Institute of Dentistry,
Jagiellonian University Medical College, Cracow, Poland
2Department of Internal and Agricultural Medicine, Jagiellonian University Medical College, Cracow, Poland
Zak Voivodeship Dental Clinic, Cracow, Poland
4Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
5Department of Dental Prosthetics, Institute of Dentistry at Jagiellonian University Medical Collage, Cracow, Poland
Correspondence should be addressed to Marta Cze´
Received March ; Revised May ; Accepted May ; Published June
Academic Editor: Grant Drummond
Copyright © Joanna Maciąg et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Oral inammation, such as periodontitis, can lead to endothelial dysfunction, accelerated atherosclerosis, and vascular dysfunction.
e relationship between vascular dysfunction and other common forms of oral infections such as denture-related stomatitis (DRS)
is unknown. Similar risk factors predispose to both conditions including smoking, diabetes, age, and obesity. Accordingly, we aimed
to investigate endothelial function and major vascular disease risk factors in consecutive patients with dentures with clinical and
microbiological features of DRS (𝑛=20)andwithoutDRS(𝑛=24). While there was a tendency for higher occurrence of diabetes
and smoking, groups did not dier signicantly in respect to major vascular disease risk factors. Groups did not dier in main
ambulatory blood pressure, total cholesterol, or even CRP. Importantly, ow mediated dilatation (FMD) was signicantly lower in
DRS than in non-DRS subjects, while nitroglycerin induced vasorelaxation (NMD) or intima-media thickness (IMT) was similar.
Interestingly, while triglyceride levels were normal in both groups, they were higher in DRS subjects, although they did not correlate
with either FMD orNMD. Conclusions. Denture related stomatitis is associated with endothelial dysfunct ion in elderly patients with
dentures. is is in part related to the fact that diabetes and smoking increase risk of both DRS and cardiovascular disease.
Oral inammation is an important element in the patho-
genesis of vascular disease. In particular, large body of
evidence has accumulated recently that chronic periodon-
titis is a potential novel risk factor for atherosclerosis and
endothelial dysfunction [–]. Indeed, intensive treatment
of chronic periodontitis alleviates endothelial dysfunction
in a long-term follow-up, with clinical benet lasting up
to months aer intensive treatment . e mechanisms
of this association are not clearly dened but are most
likely dependent on systemic inammatory response, involv-
ing increased levels of IL-, CRP, TNF-alpha, and other
cytokines, which accompany periodontitis [,]. Moreover,
cellular immunity is also activated in periodontitis, including
overproduction of interferon gamma and IL- .
While numerous studies have focused on the links
between periodontitis and endothelial dysfunction, little
is known about the links between other forms of oral
infection and inammation in the context of cardiovascular
risk. In particular, denture-related stomatitis (DRS) is an
inammatory process of the oral mucosa in contact with a
denture and is one of the most common diseases in elderly
patients, aecting up to % of patients in the course of life
[,]. It is most common in complete prosthesis wearers,
Hindawi Publishing Corporation
BioMed Research International
Volume 2014, Article ID 474016, 9 pages
BioMed Research International
edentulous subjects [–]. e potential links are particularly
worth addressing, as major risk factors for DRS include
smoking, diabetes, age, and obesity, which coincide with risk
of atherosclerosis and vascular disease [,,]. us it
is even more surprising that this problem of concomitant
incidence of both conditions has not been studied up to
date. Interestingly, the relationship of DRS to dyslipidemia is
not known and female sex appears to predispose to higher
occurrence . Clinical symptoms of DRS include erythema
and swelling of palatal mucosa, sometimes combined with
subjective symptoms, such as dysgeusia or burning sensation.
and continuous use of dentures and poor denture and oral
hygiene habits promote the development of a biolm, called
denture plaque, on the surface of the prosthesis [,].
Candida albicans is fungal component of the physiological
microora of the human oral cavity [,]; however, factors
mentioned above may promote its excessive growth and,
consequently, the development of infection and DRS.
While in periodontitis systemic activation of the immune
system is very important in mediating increased cardiovas-
cular risk, the extent of systemic response to DRS is poorly
characterized. Systemic inammation may aect vascular
dysfunction in number of ways, which include activation of
monocytes and T cells with overproduction of cytokines such
as interferon 𝛾, TNF-alpha, interleukin , or , sub-
sequently leading to atherosclerosis and hypertension [–
] and increased cardiovascular risk. Interestingly, increased
cardiovascular risk has been shown also for caries [–],
as well as endodontic infection [–]. ese diseases are
all caused by bacterial infections, but, other microorganisms
are also able to infect oral tissues. Relationship between
fungal infection in oral cavity and systemic inammatory
response in context of vascular risk has not yet been studied.
erefore, the aim of this study was to determine whether
the presence of DRS coincides with the clinical measures of
vascular dysfunction, such as impaired endothelial function
or elevated blood pressure.
2.1. Patients. Using consecutive patients with dental pros-
theses for at least months were included in this study.
eir oral mucosa was examined by the dentist to clinically
identify inammation and DRS. e clinical signs of oral
mucosa inammation in DRS include erythema and swelling
of palatal mucosa, sometimes combined with subjective
symptoms, such as dysgeusia or burning sensation. ese
observations were conrmed by routine microbiological
laboratory diagnostic tests for Candida species presence.
Based on clinical and microbiological investigations, patients
were divided into DRS (𝑛=20)groupandnon-DRS
(𝑛=24) group. Diagnosis was conrmed by an independent
observer. Control, non-DRS patients had clinically healthy
oral mucosa and negative oral Candida swabs. Clinically
healthy oral mucosa was a pale pink, smooth mucosal
membrane without redness or swelling and with no pain or
discomfort reported by patient. Exclusion criteria included
acute inammatory disorders other than DRS, neoplastic
disease relapses or chemotherapy courses less than years
before the enrolment, and using antibiotics in less than
weeks or anti-inammatory drugs (steroids and nonsteroidal,
excluding aspirin in doses less than mg) in less than
months before the enrolment. Patients with history of
myocardial infarction, acute coronary incident or vascular
inammation in weeks or less before the enrolment, chronic
haematological disorders, and immunodeciency or major
during study were also excluded. e study was approved by
local ethics committee of Jagiellonian University. Informed
consent was obtained from all patients and all work was
conducted in accordance with the Declaration of Helsinki
2.2. Microbiological Investigations. Swabs were taken from
the hard palate (between the second and third palatal fold).
Samples were collected aer an overnight fast and aer
at least hours of continous denture usage, without the
use of adhesives or rinsing the mouth with disinfectants.
e material was collected in accordance with the general
principles of microbial material collection.
2.3. Clinical Data. Patients’ blood pressure (systolic, dias-
tolic) was monitored for hours using ambulatory blood
pressure monitoring system (ABPM; SpaceLabs , Ultra-
lite device). Systolic diastolic and mean arterial pressures
were recorded every minutes for hours. Day and night
averages were calculated. One patient in control group did
not agree to wear the ABPM monitor. Major risk factors
for both atherosclerosis and DRS were recorded based on
patient medical records and detailed patient history. Clinical
risk factors were dened as follows: hyperlipidemia (total
plasma cholesterol level > mmol/L and/or triglycerides level
>, mmol/L), diabetes (fasting glucose level ≥ mmol/L
or HbAc >.% or current treatment with insulin or
oral hypoglycemic agents), hypertension (blood pressure ≥
/ mmHg or current treatment with antihypertensive
agents), and smoking (current or within last months) based
on . Blood samples were obtained from antecubital vein
and lipoprotein prole was assessed by routine diagnostic
measurements of triglycerides, total cholesterol, low-(LDL),
and high-(HDL) density lipoprotein cholesterol fractions. C-
reactive protein (CRP) concentration was also assessed as in
2.4. Endothelial Function Measurement. Flow-mediated dil-
atation (FMD) method was used to determine the vascular
endothelial function and NMD (nitroglycerine-mediated
dilatation) for measuring endothelial-independent vasodi-
latation. Measurements were conducted using Toshiba Xario
Diagnostic Ultrasound System aer , , and - minutes
aer manometer cu deation or sublingual administration
of nitroglycerine and presented as percentage of the diameter
of the artery before intervention. Method validation in our
laboratory has been described elsewhere . Observers were
blinded regarding oral status of the patients.
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T : Patient clinical characteristics.
𝑛=20 Control group
Gender (M : F) : 𝑃>, :
Age [mean (SD)] , (,) 𝑃>, , (,)
BMI [median (𝑄1;𝑄2)] , (,; ,) 𝑃>, , (,; ,)
Smoking (%) (%) 𝑃>, (,%)
Diabetes mellitus (%) (%) 𝑃>, (,%)
Hypertension (%) (%) 𝑃>, (,%)
Hyperlipidemia (%) (%) 𝑃>, (%)
ACE inhibitor (%) 𝑃>, (%)
Acetylsalicylic acid (%) 𝑃>, (%)
𝛽-blocker (%) 𝑃>, (%)
Ca antagonist (%) 𝑃>, (%)
Diuretic (%) 𝑃>, (%)
Statin (%) 𝑃>, (%)
Insulin (%) 𝑃>, (,%)
Oral antidiabetic agents (%) 𝑃>, (,%)
ACE: angiotensin converting enzyme, BMI: body mass index, DM: diabetes mellitus, SD: standard deviation.
2.5. Subclinical Atherosclerosis Assessment. e measure-
ments of intima-media thickness were performed in
dierent points (cm below common carotid arteries bulbs,
ca. every cm, omitting visible coronary plaques), on right
and le common carotid artery, measuring the distance
between the border between artery lumen and carotid artery
intima and second bright line-m (border between media and
adventitia) as described previously .
2.6. Statistical Analysis. Analysis was performed using Stat-
so Statistica soware. Compliance of the distribution of
variables with normal distribution was tested by Shapiro-
Wilk test. Most of the variables did not have normal distri-
and th (Q), th (Q) percentiles. For those variables
nonparametric statistical tests were used, Mann-Whitney 𝑈
test for continuous variables or, for dichotomous variables, 𝜒2
for the expected frequencies >or𝜒2with Yates’ correction
for the expected frequencies < with conrmation of Fisher’s
exact test and Spearman correlation. For variables with
normal distribution Student’s 𝑡-test was applied and data are
presentation of results is given for each variable in the text.
Values of 𝑃 < 0, 05 were considered statistically signicant.
3.1. Clinical Risk Factors in Studied Groups. Both groups
were balanced in terms of age, sex, body mass index (BMI)
value, and antihypertensive treatment. ere were more
smokers and patients with diabetes mellitus (DM) in DRS
group than in control group, although these dierences were
not statistically signicant. Higher prevalence of DM and
pressure Diastolic blood
pressure Mean arteria l
Blood pressure (mmHg)
F : Ambulatory blood pressure parameters in control and
DRS patients. Blood pressure parameters were assessed by h
measurement with ambulatory blood pressure monitoring system.
Results are presented as mean (SD); 𝑛control group = , 𝑛DRS
group = .
smoking in DRS group is consistent with epidemiologic data
and is understandable, as both are recognized as a risk factor
for developing DRS . e proportion of males in both
study groups was lower than expected for general population,
which is consistent with the epidemiology of DRS, which
is more common in females . Patients characteristics are
summarized in Tab l e .
3.2. Blood Pressure in Denture Related Stomatitis. Ambula-
tory blood pressure monitoring has shown no signicant
dierences in both mean systolic and mean diastolic blood
pressure in DRS and control non-DRS group (Figure ).
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Vascular function (% of artery dilation)
F : Vascular dysfunction in control and DRS. Vascular
endothelium-dependent ow-mediated dilatation (FMD) and en-
dothelium-independent nitroglycerin-mediated dilatation (NMD)
parameters were assessed by ultrasonography. Results presented as
median (Q; Q); ∗𝑃 < 0,005;𝑛control group = , 𝑛DRS group =
Moreover, subsequent analysis of blood pressures during
activity and rest periods did not show signicant dierences
either (data not shown).
3.3. Vascular Function. Flow-mediated dilatation measure-
ments showed a signicantly reduced median percentage of
arterial dilation in response to ow in the DRS group in
comparison with control patients (Figure ). At the same
time there was no dierence between groups in endothelium-
independent vasodilatation, NMD (Figure ). ere was no
dierence in baseline vessel diameter between control and
DRS group (3, 7 ± 0, 8mm versus 3, 8 ± 0,7 mm; 𝑃=0,4).
3.4. Subclinical and Clinical Atherosclerosis. Intima-media
thickness evaluation showed no signicant dierences in
either maximal or mean IMT in studied groups. It is impor-
tant to point out that neither of the groups showed very
high values of mean IMT (Figure ). Moreover, presence of
the atherosclerotic lesions of common carotid artery was
equally distributed between groups; it was detected in .%
of patients from control group and in % of DRS group,
𝑃 = 0,86.
3.5. Plasma Lipid Prole and CRP. As the elevated blood
triglycerides, LDL and total cholesterol levels and low HDL
cholesterol levels are recognized as cardiovascular risk fac-
tors; we compared their concentrations in blood samples
collected from patients with oral fungal infection and with
LDL, and HDL cholesterol were similar in both groups;
however, triglycerides levels were signicantly elevated in
DRS group (Figure (a)). Surprisingly, CRP levels were sim-
ilar between studied groups, indicating lack of signicant
component of systemic inammation in DRS (Figure (b)).
As the level of triglycerides was dierent between groups and
this parameter may impact vascular function, we checked if
there is a correlation between FMD or NMD and triglycerides
levels. We found that these parameters were not correlated in
case of FMD (𝑅Spearman = −,, 𝑃 = 0, 42)andNMD(𝑅
Spearman = −,, 𝑃 = 0, 87)(Figure ).
3.6. Subgroup Analysis in Female Subpopulation Only. As
there was a much lower proportion of males in our study
population, we performed an additional subgroup analysis
in female population. It revealed that all studied vascular
phenomena were observed to the same extent as in total
studied population, including the dierence in endothelium
derived vasorelaxations (FMD (mean ±SD): 5,95 ± 3, 80%
in female DRS patients and 9,72 ± 3, 31%incontrolsubjects;
𝑃 = 0,0032) and TG levels (median [Q; Q]: , [,; ,]
in DRS versus , [,; ,]in non-DRS; 𝑃 = 0,01).
e oral health impact on the general health is evident.
Oral infections and inammation have been implicated in
many disease entities, such as rheumatoid arthritis ,
obesity , negative pregnancy outcomes , DM ,
andeveninepilepsy. In particular, the role of oral
inammation and infection in the modulation of the risk
of cardiovascular disorders has been well dened [–].
ese studies have, however, focused mainly on periodontal
inammation and gingival bleeding. In the present study
we investigated the relationships between denture-related
stomatitis, a common oral inammatory condition in elderly
patients with endothelial dysfunction, blood pressure, and
lipid prole. We observed that denture-related stomatitis
which occurs in ca. % of patients wearing dentures, is
associated with signicant reduction of endothelial function,
measured as nitric oxide bioavailability in a clinical ow-
mediated dilatation study. Importantly, control, nitroglycerin
induced endothelium-independent vasodilatation was not
changed. As it is known that the severity of endothelial dys-
function correlates with the development of coronary artery
disease and predicts future cardiovascular events , our
with negative cardiovascular outcomes. us, such patients
should be particularly carefully monitored in relation to their
cardiovascular risk. Considering that DRS is one of the most
common oral disorders in the elderly, occurring in –%
of subjects wearing dentures [,], our nding may have
important implications for clinical care of denture wearing
patients. It is important to note, however, that majority of
patients studied here were females which is consistent with
the epidemiology of DRS, that is, more common in females
. We have also performed an additional analysis in female
subpopulation only, which conrmed all major observations
of this study.
While numerous previous studies have shown increased
cardiovascular risk in subjects with oral inammatory condi-
tions such as periodontitis [–], endodontic infections [–
], and even caries [–], this is the rst study focusing
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Control group DRS group
Mean IMT value (mm)
Mean IMT value
Control group DRS group
Maximal IMT value (mm)
Maximal IMT value
F : IMT measurements in DRS and control group. (a) Mean common carotid artery intima-media thickness. Results are presented as
mean (SD); (b) maximal common carotid artery intima-media thickness. Results presented as median (Q; Q). (a) and (b): 𝑛control group
=,𝑛DRS group = .
Tot a l
F : Plasma lipid prole and C-reactive protein levels in control and DRS patients. (a) Comparison of lipid proles. Results are presented
as median (Q; Q); ∗𝑃 < 0,05; (b) comparison of plasma CRP concentrations. Results are presented as median (Q; Q). (a) and (b): 𝑛control
group = , 𝑛DRS group = .
on vascular dysfunction in elderly population of patients
wearing dentures. is is important, while previous studies
focused on bacteria-mediated, resulting from disturbances
of physiological oral microora diseases, we have primarily
studied fungal infection, as DRS is most commonly associ-
ated with Candida infection.
Previous studies focused on a positive association
between periodontitis and vascular endothelial dysfunction.
Amar et al. and Blum et al. observed that subjects with
advanced periodontal disease exhibit worse endothelial func-
tion when compared to the healthy controls [,]. Blum
et al. , along with others [,], reported also an
improvement of endothelial function as a long-term outcome
of periodontal treatment. Tonetti et al. inalandmark
that such improvement provides clinical benet for up to
months aer intensive treatment.
e mechanisms of increased cardiovascular risk in oral
inammatory conditions are multifactorial and range from
chronic systemic inammation (periodontitis) to the eects
of risk factors such as diabetes, hyperlipidemia, smoking,
and oral disorders, such as periodontitis [–], caries [–],
endodontic infections [–], or DRS [,,]. is coin-
cidence of risk factors is visible in the population of patients
we have studied. Although the dierence in occurrence of
smoking or diabetes did not reach statistical signicance,
we can clearly see increased occurrence of these factors
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0 4 8 12 16 20 24
FMD (% of artery dilation)
0 5 10 15 20 25 30
NMD (% of artery dilation)
F : Spearman correlation between parameters of vascular function parameters and triglycerides levels. (a) Spearman correlation
between FMD and triglycerides levels: 𝑅Spearman = −,, 𝑃=0,;(b)SpearmancorrelationbetweenNMDandtriglycerideslevels:
𝑅Spearman = −0,025,𝑃 = 0, 87;(a)and(b):𝑛=42.
in DRS. is can in part explain the increased degree of
endothelial dysfunction in DRS subjects. Measurement of
baseline FMD prior to developing DRS in a long-term follow-
up study would unquestionably strengthen the conclusions
of t h is stu dy. Alte rnat ivel y, a f utur e int e r vent iona l s tudy
in which the eect of treatment of DRS on endothelial
function could also help to address this issue in a more cause-
eect manner. Importantly, as the population we studied
was relatively young for denture carriers, no signicant
increase in intima-media thickness was detected yet. is is
in agreement with numerous cardiovascular studies which
show that endothelial dysfunction precedes the development
of severe atherosclerosis .
e role of systemic inammation, very well dened in
periodontitis, is not known in DRS. e mechanisms through
which DRS could aect endothelial dysfunction are unclear.
In periodontitis, bacteria lead to the activation of the local
immune response, leading to systemic inammation. Simi-
larly, immune stimulation of T cells and monocytes has been
reported in response to fungal C. albicans antigens [,].
However, in our study we did not nd signicantly increased
levels of total CRP, which could suggest that local Candida-
evoked oral mucosal inammation is not causing signicant
activation of systemic inammatory response. e CRP levels
among edentulous were assessed by Ajwani et al. at Helsinki
Aging Study involving over patients older than years
old . ey identied mucosal lesions in the edentulous as
an important factor associated with elevated CRP le vel among
elderly individuals and observed that it was signicantly more
common among the edentulous with complete dentures.
Importantly, patients having clinical signs of oral candidosis
or denture stomatitis also showed elevated levels of CRP,
and authors suggested that it may be the explanation of the
have also seen a trend toward higher CRP values in DRS
patients, but it did not reach statistical signicance, probably
because of small numbers of patients involved and the fact
that we have not measured high sensitivity hsCRP which
would better characterize cardiovascular risk . In the
light of our results, assessing other markers of the systemic
inammation becomes a very interesting aspect for further
studies. Taking into account our results, at present our data
is involved. Rather, the eect of concomitant risk factors on
DRS and vascular function is most likely.
De Oliveira et al. and Rodriguez-Archilla et al. have found
that oral Candida infection may impact peripheral blood
mononuclear cells state, measured by amount of cytokines
produced in vitro in response to Candida antigens [,].
Direct impact of Candida cells on the vascular system is
unlikely, since systemic fungal infections are characterized, in
contrast to the DRS, by extremely serious symptoms; more-
over, fungal DNA has not been detected in atherosclerotic
vascular risk factors such as diabetes, smoking, and hyper-
triglyceridemia in mediating vascular dysfunction. Although
no relationship was found between triglyceride levels and
endothelial dysfunction in a simple correlation analysis,
when multivariate linear regression was introduced including
diabetes, smoking, and/or triglyceride levels, the dierence
in endothelial function was no longer signicant (data not
shown). One has to however bear in mind that statistical
power of such analysis in the studied group was relatively
While the nding that classical risk factors may be
main mediators of endothelial dysfunction may not sound
exceptionally interesting, it is very important to show that
this is the case in DRS subjects, and therefore this group of
patients should be carefully studied in larger epidemiological
trials. is is particularly important in the light of ageing
Despite the lack of dierences in the levels of total, HDL,
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DRS, we observed signicantly higher levels of triglycerides
in patients with DRS. Our surprising nding that DRS is
wearing can change dietary habits. It could also suggest that
increased triglyceride levels could be a risk factor of DRS,
although our study was not powered to answer this question.
ere are no studies looking at lipid parameters in DRS, while
conicting data are available regarding periodontitis. Sandi et
al. and Penumarthy et al. observed higher concentrations of
total cholesterol and LDL cholesterol in the blood of patients
with periodontal disease than in healthy group, but the
dierences in the levels of triglycerides and HDL cholesterol
were shown only by Penumarthy et al., despite the smaller
sample sizes [,]. Simultaneously, Elter et al. did not
demonstrate changes in the total cholesterol and HDL levels
aer treatment of periodontitis . Altogether, these results
can point to a potential relationship between oral infection
We did not observe the tendency towards elevated blood
pressure in patients with DRS as compared to healthy
subjects. is shows potential important dierence in oral
inammatory conditions as periodontitis is potentially asso-
ciated with elevated blood pressure, which was frequently
observed . e relationship between the use of dental
prostheses and the prevalence of cardiovascular diseases,
et al. . ey found positive association between dentures
and all cardiovascular diseases but not for elevated blood
pressure, myocardial infarction, or stroke. However, the
group dened as “dentures” was very heterogeneous. e
authors gathered together edentulous and partially eden-
tulous denture wearers and edentulous without dentures.
is creates potential bias of the presence of periodontitis
in partially edentulous patients. Importantly, in our study
virtually all subjects were completely edentulous ( out of
In conclusion, our study shows that patients with denture-
related stomatitis are characterized by more pronounced
systemic endothelial dysfunction than denture subjects with-
out stomatitis. is dierence in vascular function is likely
linked with increased cardiovascular risk in DRS and indi-
cates that such patients should be carefully monitored for
cardiovascular disease. While our study identies certain
very interesting and potentially very important cardiovas-
cular aspects of denture-related stomatitis, a larger study is
warranted to nally conrm these observations. is may
be very important for clinical practice considering ageing
CRP: C-reactive protein
DM: Diabetes mellitus
DRS: Denture-related stomatitis
FMD: Flow-mediated dilatation
HDL: High density lipoprotein cholesterol
LDL: Low density lipoprotein cholesterol
NMD: Nitroglycerine-mediated dilatation
QandQ: th (Q) and th (Q) percentiles
SD: S tandard deviation.
Conflict of Interests
e authors declare that there is no conict of interests
regarding the publication of this paper.
Joanna Maciąg and Grzegorz Osmenda contributed equally
to this study.
is study was supported by Public Funds for Science
of Republic of Poland Grant no. /B/P// and
the Foundation for Polish Science Welcome Grant (FNP/
Welcome/) (TJG, TM, GO, AS).
 S. J. Arbes, G. D. Slade, and J. D. Beck, “Association between
extent of periodontal attachment loss and self-reported history
of heart attack: an analysis of NHANES III data,” Journal of
 K. Buhlin, A. Gustafsson, J. H˚
health and cardiovascular disease in Sweden: results of a
national questionnaire survey,” Journal of Clinical Periodontol-
B. Klinge, “Oral health in women with coronary heart disease,”
Journal of Periodontology, vol. , no. , pp. –, .
between periodontal disease, tooth loss, and carotid artery
plaque: the oral infections and vascular disease epidemiology
study (INVEST),” Stroke,vol.,no.,pp.–,.
 H.-C. Hung, W. Willett, A. Merchant, B. A. Rosner, A. Ascherio,
Circulation, vol. , no. , pp. –, .
 M. S. Tonetti, F. D'Aiuto, L. Nibali et al., “Treatment of peri-
odontitis and endothelial function,” e New England Journal
IL- and TNF-𝛼levels in the gingival tissue of patients with
periodontitis,” Experimental and erapeutic Medicine,vol.,
 A. di Benedetto, I. Gigante, S. Colucci, and M. Grano, “Peri-
odontal disease: linking the primar y inammationto b oneloss,”
Clinical and Developmental Immunology,vol.,ArticleID
, pages, .
 L. Gendreau and Z. G. Loewy, “Epidemiology and etiology of
denture stomatitis,” Journal of Prosthodontics,vol.,no.,pp.
BioMed Research International
 A. E. Kossioni, “e prevalence of denture stomatitis and its pre-
disposing conditions in an older Greek population,” Gerodon-
 O. Abaci, A. Haliki-Uztan, B. Ozturk, S. Toksavul, M. Ulusoy,
and H. Boyacioglu, “Determining candida spp. incidence in
denture wearers,” My copatholog ia ,vol.,no.,pp.–,
 C. Salerno, M. Pascale, M. Contaldo et al., “Candida-associated
denture stomatitis,” Medicina Oral, Patologia Oral y Cirugia
 B. Dorocka-Bobkowska, D. Zozulinska-Ziolkiewicz, B.
Wierusz-Wysocka, W. Hedzelek, A. Szumala-Kakol, and E.
orgensen, “Candida-associated denture stomatitis in
type diabetes mellitus,” Diabetes Research and Clinical
 M. A. Ghannoum, R. J. Jurevic, P. K. Mukherjee et al., “Char-
acterization of the oral fungal microbiome (mycobiome) in
healthy individuals,” PLoS Pathogens,vol.,no.,ArticleID
 M. S. Campos, L. Marchini, L. A. S. Bernardes, L. C. Paulino,
and F. G. Nobrega, “Biolm microbial communities of denture
stomatitis,” Oral Microbiology and Immunology,vol.,no.,
 E. L. Schirin, “e immune system: role in hypertension,”
Canadian Journal of Cardiology,vol.,no.,pp.–,.
 A. P. Davel, C. F. Wenceslau, E. H. Akamine et al., “Endothelial
dysfunction in cardiovascular and endocrine-metabolic dis-
eases: an update,” Brazilian Journal of Medical and Biological
 T. J. Guzik, N. E. Hoch, K. A. Brown et al., “Role of the T cell in
the genesis of angiotensin II-induced hypertension and vascular
dysfunction,” e Journal of Experimental Medicine,vol.,
no. , pp. –, .
 B. Larsson, I. Johansson, L. Weinehall, G. Hallmans, and T.
Ericson, “Cardiovascular disease risk factors and dental caries
in adolescents: eect of a preventive program in Northern
Sweden (the Norsjo project),” Acta Paediatrica,vol.,no.,
 R. Kelishadi, S. Mortazavi, T. R. Hossein, and P. Poursafa,
“Association of cardiometabolic risk factors and dental caries
in a population-based sample of youths,” Diabetology and
 P. V. Yl¨
ostalo, M. R. J¨
arvelin, J. Laitinen, and M. L. Knuuttila,
“Gingivitis, dental caries and tooth loss: risk factors for cardio-
vascular diseases or indicators of elevated health risks,” Journal
of Clinical Periodontology,vol.,no.,pp.–,.
 E. Cotti, C. Dess, A. Piras et al., “Association of endodontic
infection with detection of an initial lesion to the cardiovascular
system,” Journal of Endodontics,vol.,no.,pp.–,
A. Colditz, and C. W. Douglass, “Pulpal inammation and
incidence of coronary heart disease,” Journal of Endodontics,vol.
endodontic origin and risk of coronary heart disease,” Journal
of Dental Research,vol.,no.,pp.–,.
“e relationship between self-reported history of endodontic
therapy and coronary heart disease in the Atherosclerosis
Risk in Communities study,” Journal of the American Dental
of chronic apical periodontitis and endodontic therapy with
atherosclerosis,” Clinical Oral Investigations,.
 J. Perk, G. de Backer, H. Gohlke et al., “European guidelines on
cardiovascular disease prevention in clinical practice (version
). e Fih Joint Task Force of the European Society
of Cardiology and Other Societies on Cardiovascular Disease
Prevention in Clinical Practice (constituted by representatives
of nine societies and by invited experts),” Atherosclerosis,vol.
assessment in atherosclerosis: comparison of brachial artery
owmediated vasodilation and peripheral arterial tonometry,”
Polskie Archiwum Medycyny Wewnetrznej,vol.,no.,pp.
 C. O. Bingham and M. Moni, “Periodontal disease and rheuma-
toid arthritis: the evidence accumulates for complex pathobio-
logic interactions,” Current Opinion in Rheumatology,vol.,
 C. C. Zeigler, G. R. Persson, B. Wondimu, C. Marcus, T. Sobko,
and T. Mod´
eer, “Microbiota in the oral subgingival biolm is
associated with obesity in adolescence,” Obesity,vol.,no.,
 A. J. Kim, A. J. Lo, D. A. Pullin, D. S. ornton-Johnson,
and N. Y. Karimbux, “Scaling and root planing treatment for
periodontitis to reduce preterm birth and low birth weight: a
systematic review and meta-analysis of randomized controlled
trials,” Journal of Periodontology,vol.,no.,pp.–,
II diabetes: a two-way relationship,” International Journal of
Evidence-Based Healthcare, vol. , no. , pp. –, .
 A. L. Costa, C. L. Yasuda, W. Shibasaki et al., “e association
between periodontal disease and seizure severity in refractory
epilepsy patients,” Seizure,vol.,no.,pp.–,.
 E. H. C. Tang and P. M. Vanhoutte, “Endothelial dysfunction:
a strategic target in the treatment of hypertension?” P¨
and J. A. Vita, “Periodontal disease is associated with brachial
artery endothelial dysfunction and systemic inammation,”
Arteriosclerosis, rombosis, and Vascular Biology,vol.,no.
 A. Blum, K. Kryuger, M. MashiachEizenberg et al., “Periodontal
care may improve endothelial function,” European Journal of
Internal Medicine, vol. , no. , pp. –, .
 J. R. Elter, A. L. Hinderliter, S. Oenbacher et al., “e eects
of periodontal therapy on vascular endothelial function: a pilot
trial,” American Heart Journal,vol.,no.,article,.
 T. J. Guzik, N. E. West, E. Black et al., “Vascular superoxide
production by NAD(P)H oxidase: association with endothelial
dysfunction and clinical risk factors,” Circulation Research,vol.
 M. A. M. de Oliveira, L. P. Carvalho, M. D. S. Gomes, O.
Bacellar, T. F. Barros, and E. M. Carvalho, “Microbiological and
immunological features of oral candidiasis,” Microbiology and
 A. Rodriguez-Archilla, M. Urquia, A. Cutando, and R. Asencio,
“Denture stomatitis: quantication of interleukin- production
by mononuclear blood cells cultured with Candida albicans,”
Journal of Prosthetic Dentistry,vol.,no.,pp.–,.
BioMed Research International
“Oral health status, C-reactive protein and mortality—a year
follow-up study,” Gerodontology,vol.,no.,pp.–,.
 P. Calabr`
atherosclerotic events,” Seminars in Immunopathology,vol.,
no. , pp. –, .
oc¸as, and J. F.
Siqueira Jr., “Molecular survey of atheromatous plaques for the
presence of DNA from periodontal bacterial pathogens, archaea
and fungi,” Journal of Periodontal Research,vol.,no.,pp.
 R. M. Sandi, K. G. Pol, P. Basavaraj, N. Khuller, and S. Singh,
“Association of Serum Cholesterol, Triglyceride, High and Low
Density Lipoprotein (HDL and LDL) levels in chronic peri-
odontitis subjects with risk for Cardiovascular Disease (CVD):
acrosssectionalstudy,”Journal of Clinical and Diagnostic
 S. Penumarthy, G. P. Penmetsa, and S. Mannem, “Assessment
of serum levels of triglycerides, total cholesterol, high-density
lipoprotein cholesterol, and low-density lipoprotein cholesterol
in periodontitis patients,” Journal of Indian Society of Periodon-
 X. F. Leong, C. Y. Ng, B. Badiah, and S. Das, “Association
between hypertension and periodontitis: possible mechanisms,”
e Scientic World Journal,vol.,ArticleID,