relaÇÃo entre a doenÇa periodontal e as...
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UNIVERSIDADE DE LISBOA
FACULDADE DE MEDICINA DENTÁRIA
RELAÇÃO ENTRE A DOENÇA PERIODONTAL E AS
PATOLOGIAS CARDIOVASCULARES
Catarina Maria da Silva Bernardes
MESTRADO INTEGRADO
2012
ii
UNIVERSIDADE DE LISBOA
FACULDADE DE MEDICINA DENTÁRIA
RELAÇÃO ENTRE A DOENÇA PERIODONTAL E AS
PATOLOGIAS CARDIOVASCULARES
Catarina Maria da Silva Bernardes
Dissertação orientada pela Sra. Dra. Susana Noronha
MESTRADO INTEGRADO
2012
ii
AGRADECIMENTOS
À Dr.ª Susana Noronha pela sua disponibilidade, ajuda e confiança, sem as quais
a elaboração desta dissertação não seria possível.
iii
DEDICATÓRIA
Em primeiro lugar aos meus pais por toda a sua dedicação e esforço em me
educar da melhor forma possível e por me terem transmitido os valores que permitiram
ser o que sou hoje. Tenho ainda a agradecer-lhes todo o apoio e a presença constante
nos bons e maus momentos, mostrando-me sempre qual o melhor caminho a seguir e
estimulando-me a tomar as melhores decisões.
A toda a minha família pelo esforço em compreender as minhas ausências, em
alguns momentos, e que sempre me transmitiram confiança necessária para ultrapassar
algumas adversidades.
Em jeito especial ao meu avô que, infelizmente, não pode estar presente para
assistir ao início da minha vida profissional, mas que sempre se mostrou muito
orgulhoso com os seus netos.
A todos os meus amigos que me acompanharam na minha vida académica e que
sempre me proporcionaram bons momentos, permitindo-me abstrair de alguns menos
bons.
À minha dupla de trabalho da FMDUL, Rita Reis pela sua amizade e pelo apoio
incondicional que sempre me prestou.
À Rita Moio por estes seis anos de amizade que fizeram toda a diferença na
minha vida.
Ao Manel por tudo o que fez e faz por mim e por ser o pêndulo da balança
necessário para alcançar o equilíbrio.
iv
RESUMO
A doença periodontal e as patologias cardiovasculares apresentam uma etiologia
complexa e multifatorial, sendo parte desta causada por fatores de risco.
A relação entre estas duas patologias tem sido especulada há aproximadamente
três décadas, contudo, esta eventual relação permanece controversa entre os diversos
estudos epidemiológicos realizados até à data.
Com o objetivo de procurar esclarecer uma eventual relação, entre as duas
patologias, foram propostas e descritas três teorias: teoria infeciosa ou bacteriana, teoria
inflamatória e a teoria imunológica.
No entanto, a associação causal entre a doença periodontal e os eventos
cardiovasculares continua a ser posta em causa visto alguns fatores de risco tradicionais
para as patologias cardiovasculares serem comuns aos da doença periodontal, bem
como, devido à presença de modificadores do efeito, dos próprios fatores de risco, e de
uma eventual relação bidirecional.
A influência do tratamento da doença periodontal na melhoria, ou agravamento,
do estado inflamatório sistémico e na prevenção de futuros eventos cardiovasculares é
igualmente controversa.
Os estudos realizados nesta temática apresentam diversas limitações e grande
heterogeneidade, nomeadamente, quanto à sua metodologia e amostras analisadas
carecendo de evidência científica. Deste modo, são necessários mais estudos futuros, a
longo prazo, nomeadamente estudos longitudinais, que permitam esclarecer o
mecanismo concreto responsável por esta relação, bem como, a postura mais correta
para o médico dentista adotar aquando do tratamento de pacientes com patologia
cardiovascular ou com risco de vir a desenvolvê-la futuramente.
Palavras-chave: doença periodontal, doenças cardiovasculares, aterosclerose,
fator de risco e indicador de risco.
v
ABSTRACT
Periodontal disease and cardiovascular diseases have a complex and
multifactorial etiology, being part of this, caused by risk factors.
The relationship between these two diseases has been postulated for nearly three
decades, however, this possible relationship remains controversial among several
epidemiological studies conducted to date.
In order to seek to clarify a possible relationship between the two diseases it has
been proposed and described three theories: the bacterial or infectious theory, the
inflammatory theory and the immunological theory.
However, a causal association between periodontal disease and cardiovascular
events continues to be challenged because some traditional risk factors for
cardiovascular diseases are common to periodontal disease, as well as due to the
presence of effect modification of their own risk factors, and a possible bidirectional
relationship.
The influence of the treatment of periodontal disease in improving or worsening,
the systemic inflammatory state and in the prevention of the future cardiovascular
events is also controversial.
Studies on this topic have several limitations and heterogeneity, in particular,
regarding its methodology and samples lacking scientific evidence. Thus, further long
term studies are needed, namely longitudinal studies, to clarify the mechanism
responsible for this particular relationship, as well as the correct posture for the dentist
to adopt when treating patients with cardiovascular disease or risk of developing it in
the future.
Key-words: periodontal disease, cardiovascular diseases, atherosclerosis, risk
factor and risk indicator.
vi
LISTA DE ABREVIATURAS
Aa Aggregatibacter actinomycetemcomitans
ADN Ácido desoxirribonucleico
AR Alisamento radicular
AVC Acidente vascular cerebral
CBS Células brancas sanguíneas
CV Cardiovascular
DAC Doença arterial coronária
DCC Doença cardíaca coronária
DCV Doenças cardiovasculares
DP Doença periodontal
EAM Enfarte agudo do miocárdio
EIM Espessura íntima média
Fn Fusubacterium nucleatum
HbA1C Hemoglobina A1C
HDL Lipoproteína de elevada densidade
HTA Hipertensão arterial
ICAM Molécula de adesão intercelular
Ig Imunoglobulina
IL Interleucina
LDL Lipoproteína de baixa densidade
Lp-PLA2 Lipoproteína associada à fosfolipase A2
LPS Lipopolissacárido
MCP Proteína quimiotática dos monócitos
M-CSF Fator de estimulação de colónias de macrófagos
MMP Metaloproteínase de matriz
PA Plasminogénio ativado
vii
PAF Fator ativador de plaquetas
PCR Proteína C reativa
Pg Porphyromonas gingivalis
PGE-2 Prostanglandina E2
Pi Prevotella intermedia
PMN Polimorfonucleares
PS Pressão sanguínea
SCA Síndrome coronário agudo
Td Treponema denticola
Tf Tannerella forsythia
TNF Fator de necrose tumoral
TP Tratamento periodontal
UD Ultrassonografia Duplex
VCAM Molécula de adesão vascular
VIH Vírus da Imunodeficiência Humana
VLDL Lipoproteína de muito baixa densidade
viii
ÍNDICE
RESUMO ........................................................................................................................ iv
ABSTRACT .................................................................................................................... v
1. Introdução.................................................................................................................. 1
2. Doença Periodontal ................................................................................................... 3
3. Doenças Cardiovasculares......................................................................................... 6
4. Relação entre DP e DCV ........................................................................................... 8
4.1.Teoria bacteriológica/ infeciosa .............................................................................. 8
4.2.Teoria inflamatória ............................................................................................... 10
4.3.Teoria Imunológica ............................................................................................... 12
5. Fatores de risco comuns, modificadores do efeito e relação bidirecional ............... 13
6. Parâmetros bioquímicos e auxiliares de diagnóstico............................................... 19
7. Efeitos do tratamento periodontal na patologia cardiovascular .............................. 22
8. Discussão ................................................................................................................. 27
9. Conclusão ................................................................................................................ 31
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