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Research Article
Originally Published 19 February 2013
Free Access

Dental Prophylaxis and Periodontal Treatment Are Protective Factors to Ischemic Stroke

Ya-Ling Lee, DDS, Hsiao-Yun Hu, PhD, Nicole Huang, PhD, De-Kuang Hwang, MD, Pesus Chou, DrPH, and Dachen Chu, MD, PhDAuthor Info & Affiliations
Stroke
Volume 44, Number 4
https://doi.org/10.1161/STROKEAHA.111.000076
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Abstract

Background and Purpose—

A correlation has been found between periodontal disease (PD) and stroke. This study was conducted to investigate whether dental prophylaxis and periodontal treatment reduce the incidence rate (IR) of ischemic stroke.

Methods—

We identified 510 762 PD cases and 208 674 non-PD subjects from January 1, 2000, to December 31, 2010. The PD cases were divided into dental prophylaxis, intensive treatment, and no treatment groups. The stroke IRs were assessed among groups during follow-up. Cox regression analysis was used after adjustment for age, sex, and comorbidities to determine the relationship between periodontal treatment and incidence of ischemic stroke.

Results—

The stroke IR of the non-PD subjects was 0.32%/year. In the PD group, subjects who received dental prophylaxis had the lowest stroke IR (0.14%/year); subjects with intensive treatment or tooth extraction had a higher stroke IR (0.39%/year); and subjects without PD treatment had the highest stroke IR (0.48%/year; P<0.001). After adjustment for confounders, the dental prophylaxis and intensive treatment groups had a significant lower hazard ratios for stroke than the non-PD group (hazard ratio=0.78 and 0.95; 95% confidence interval=0.75–0.81 and 0.91–0.99, respectively), whereas the PD without treatment group had a significant higher hazard ratio for stroke (1.15; 95% confidence interval=1.07–1.24), especially among the youngest (20–44) age group (hazard ratio=2.17; 95% confidence interval=1.64–2.87) after stratifying for age.

Conclusions—

Maintaining periodontal health by receiving dental prophylaxis and PD treatment can help reduce the incidence of ischemic stroke.

Introduction

The prevalence of periodontal disease (PD) is high but varies widely. Approximately ≥90% of the world population have mild to advanced PD.1 Recent studies have estimated that ≈50% of the American population ≥30 years of age have moderate to severe PD,2,3 and 10% to 15% of adults worldwide experience advanced PD with severe alveolar bone loss.4
PD is caused by specific bacterial biofilm, also known as dental plaque, that accumulates around the teeth, and dental calculus (calcified plaque). This plaque induces periodontal tissue inflammation and causes further destruction of the periodontal connective tissue and alveolar bone. In adults, PD is also a major cause of tooth loss.1
Chronic inflammation induces atherosclerosis and certain types of systemic disease, such as type 2 diabetes mellitus and cardiovascular and cerebrovascular disease, whereas PD is a prevalent chronic inflammatory disease.5–8 Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis that colonize in the periodontal pocket are the main disease-causing bacterial strains of PD. Previous studies have shown that A, actinomycetemcomitans, P, gingivalis, and other microbes are also present in atherosclerotic plaques.9–11 These pathogens induce macrophages to secrete cytokines that play important roles in atherothrombogenesis.12
Several observational studies have shown that poor periodontal health status is associated with an increased risk for stroke.13–17 The first National Health and Nutrition Examination Survey further showed that PD is one of the risk factors of nonhemorrhagic stroke.18 In their 12-year cohort study, Holmlund et al19 reported that people with ≤10 teeth had higher coronary heart disease or cardiovascular disease mortality rates than those who had >25 teeth remaining in their mouth. Previous meta-analysis studies have shown that PD and poor oral health increase the risk of cardiovascular disease and stroke.5,20,21 Other studies have suggested a significant association between poor periodontal condition, or lack of dentition, and the rise of C-reactive protein or fibrinogen.22–26 High-sensitivity C-reactive protein is an independent predictor of coronary heart disease/cardiovascular disease in intermediate-risk individuals.27–29
PD is a preventable and treatable disease because poor oral hygiene is a major cause of PD. An increase in the self-reported tooth-brushing frequency decreases the concentrations of C-reactive protein and fibrinogen in the serum.30 Chen et al31 found that tooth scaling decreases the incidences of stroke and total cardiovascular events of people ≥50 years of age. However, previous research has not studied the influences of different treatments among different age status of PD on stroke.
This study conducts a retrospective cohort study based on the Taiwanese National Health Insurance (NHI) Research Database administrative data to estimate the incidence rate (IR) and hazard ratio (HR) for ischemic stroke among different treatments of PDs and age groups during a 10-year follow-up period.

Methods

Data Source

The NHI program in Taiwan is a compulsory and universal health insurance program that includes all inpatient and outpatient medical benefit claims. Up to 99% of the inhabitants of Taiwan are enrolled. The National Health Research Institute cooperates with the Bureau of NHI to establish an NHI research database. The National Health Research Institute guards the privacy and confidentiality of all beneficiaries and provides health insurance data to researchers who have obtained ethical approval. The Longitudinal Health Insurance Database contains all the original claim data of 1 000 000 beneficiaries, randomly sampled from the beneficiaries of the NHI Research Database in 2000. The sex and age distribution of the sampled subjects in the Longitudinal Health Insurance Database 2000 are similar to those of all beneficiaries. These data include details of medical orders, procedures, and medical diagnoses with codes based on the International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD9-CM). The identification of all patients in the Longitudinal Health Insurance Database is encrypted and protects patient privacy. The National Health Research Institutes provides access to the database for analysis.

Study Samples

This study conducts a retrospective cohort study retrieved from the Taiwanese NHI Research Database administrative data from January 1, 2000, to December 31, 2010. The study cohort included 723 024 beneficiaries who were followed up between 2000 and 2010 after excluding patients <20 years of age because PD occurs less commonly in children and adolescents. The index date for the study cohort is the date of the first ambulatory care visit between 2000 and 2010, which resulted in a diagnosis code for PD (ICD9-CM code 523.0–523.5). Other excluded criteria were individuals who had stroke before being diagnosed with PD (n=2973) and unknown sex (n=615). A total of 719 436 subjects were included in the analysis, and the total person-years of follow-up were 5 985 121. The study cohort was divided into 3 different groups according to the different periodontal treatment they received: (1) PD patients who only received dental prophylaxis (n=343 944; person-years=2 801 625); (2) PD patients who received intensive periodontal treatments, such as subgingival curettage and root planning or periodontal flap operation or tooth extraction (n=121 552; person-years=784 344); and (3) PD patients who received no treatments (n=45 296; person-years=168 525). Individuals who were never diagnosed with PD during the study period were included as a control group (n=208 674; person-years=2 230 628).
Starting from the cohort entry date, the study subjects were followed until the occurrence of hospitalization with ischemic stroke (ICD-9-CM 433–434) or death, whichever came first, or at the end of the study (December 31, 2010) if no stroke or death.
The comorbidities of risk factors include hypertension (ICD-9-CM 401–405), diabetes mellitus (ICD-9-CM 250), atrial fibrillation (ICD-9-CM 437.3), subclinical atherosclerosis (ICD-9-CM 440,437.0), chronic kidney diseases (ICD-9-CM 580–589), and dyslipidemia (ICD-9-CM 272). To increase the validity of diagnoses in the administrative data set, we only included outpatients who received ≥3 diagnoses of the above comorbidities during the period between January 1, 2000, and December 31, 2010.

Statistical Analysis

This study uses the SAS statistical package, version 9.2 (SAS Institute, Cary, NC) to perform all statistical analysis. Ages were categorized into 3 groups: 20 to 44 years, 45 to 64 years, and ≥65 years. Basic characteristics were presented as a percentage. The incidence of stroke among PD patients and controls was compared using the IR. The χ2 test was used to compare the IR estimates of stroke among subsamples. The Cox proportional hazards model was used to calculate the HR and 95% confidence interval (CI) to determine whether PD is a risk factor for the development of stroke. The variables in the model were age, sex, hypertension, diabetes mellitus, and atrial fibrillation.

Results

Among the total of 719 436 subjects, 15 141 patients developed ischemic stroke between 2000 and 2010. The total person-years of follow-up were 5 985 121, and the IR of ischemic stroke was 0.25%/year (Table 1). The stroke IR increased as age increased (P<0.001). The stroke IR of people 20 to 40 years of age was only 0.03%/year, that of people 45 to 64 years of age was 0.36%/year, and that of people ≥65 years of age increased to 1.0%/year. Men had a higher stroke IR than women (0.29%/year versus 0.22%/year; P<0.001). There was also a significantly higher stroke IR among subjects with comorbidities, such as hypertension, diabetes mellitus, and atrial fibrillation, with stroke IR values of 0.78, 0.84, and 1.55, respectively (P<0.001).
Table 1. Baseline Characteristics of the Study Subjects
VariablesTotal
nStroke, nPerson-yIR (%/y)P Value
Total719 43615 1415 985 1210.25 
Age at baseline, y    <0.001
 20–44436 39010593 621 9820.03 
 45–64186 52554071 497 6260.36 
 ≥6596 5218675865 5131.00 
Sex    <0.001
 Women351 79763712 911 6420.22 
 Men367 63987703 073 4800.29 
Comorbidity
 Hypertension173 72310 8141 380 9320.78<0.001
 Diabetes mellitus81 2605398643 7820.84<0.001
 Atrial fibrillation596674648 0081.55<0.001
 Atherosclerosis10 94182987 0100.95<0.001
 Chronic kidney diseases29 4951701240 6930.71<0.001
 Dyslipidemia113 7824061890 8020.46<0.001
Periodontal disease    <0.001
 No periodontal disease208 67472232 230 6280.32 
 Dental prophylaxis343 94440232 801 6250.14 
 Intensive treatment or extraction121 5223081784 3440.39 
 PD without treatment45 296814168 5250.48 
IR indicates incidence rate; and PD, periodontal disease.
There were 208 674 subjects (29%) who never received PD diagnosis and periodontal treatment. Among them, 7223 people developed ischemic stroke (stroke IR=0.32%/year). Of the remaining 510 762 subjects who were diagnosed with PD, 7918 people developed ischemic stroke. Among the PD group, subjects who received dental prophylaxis had the lowest stroke IR (0.14%/year); subjects with intensive treatment or tooth extraction had a higher stroke IR (0.39%/year); and subjects without PD treatment had the highest stroke IR (0.48%/year) among all subjects (P<0.001).
When comparing stroke IRs after being stratified by age, sex, and comorbidity variables (Table 2), the lowest stroke IR of the PD population always appeared in the dental prophylaxis group, followed by intensive treatment or tooth extraction group, and the highest stroke IR appeared in PD without treatment group (P for trend test <0.001 or =0.006).
Table 2. The Stroke Prevalence Among Study Subjects by Periodontal Disease Types
VariablesNo Periodontal DiseasePeriodontal Disease
Dental ProphylaxisIntensive Treatment or ExtractionPD Without TreatmentP for Trend Test
n=208 674n=343 944n=121 522n=45 296
nStroke, nPerson-yIR (%/y)nStroke, nPerson-yIR (%/y)nStroke, nPerson-yIR (%/y)nStroke, nPerson-yIR (%/y)
Age at baseline, y
 20–44107 5593681 162 9550.03246 4154412 025 0350.0256 602190350 2820.0525 8146083 7100.07<0.001
 45–6447 9352093514 9080.4177 8071728621 2090.2847 2471308310 2850.4213 53627851 2230.54<0.001
 ≥6553 1804762552 7640.8619 7221854155 3811.1917 6731583123 7761.28594647633 5911.42<0.001
Sex
 Women88 5503185942 2880.34187 27617541 542 8820.1154 4841073347 3500.3121 48735979 1220.45<0.001
 Men120 12440381 288 3390.31156 66822691 258 7430.1867 0382008436 9940.4623 80945589 4030.51<0.001
Comorbidity
 Hypertension45 1024775468 6251.0271 3262996564 9090.5343 6152403288 5430.8313 68064058 8551.09<0.001
 Diabetes mellitus20 1182259207 9251.0932 0681492255 2520.5823 0711360154 1310.88600328726 4751.08<0.001
 Atrial fibrillation184928918 9471.53211523716 4741.44155916910 3031.644435122842.230.006
 Atherosclerosis271530828 2901.09425826734 0130.78311620720 7331.008524739741.18<0.001
 Chronic kidney disease795369883 7790.8312 02247397 3760.49728341549 0550.85223711510 4831.10<0.001
 Dyslipidemia19 2761325206 0570.6455 8791431452 9020.3230 7121084200 7610.54791522131 0820.71<0.001
Follow-up time, y (mean±SD)10.6±1.68.1±2.46.4±2.63.7±3.4
IR indicates incidence rate; and PD, periodontal disease.
In Cox regression analysis (Table 3) after adjustment of age, sex, and comorbidity, the dental prophylaxis group and the intensive treatment group had a significant lower HR for stroke than the non-PD group (HR=0.78 and 0.95; 95% CI=0.75–0.81 and 0.91–0.99, respectively). For the PD without treatment group, the HR was significantly higher than the non-PD group (1.15; 95% CI=1.07–1.24). When stratified by age, dental prophylaxis was associated with significantly lower risk of stroke among the 20 to 44 and 45 to 64 age groups (HR=0.74 and 0.68; 95% CI=0.64–0.86 and 0.64–0.73, respectively). However, intensive treatment or tooth extraction was associated with significantly higher risk of stroke for 20 to 44 years of age (HR=1.35; 95% CI=1.12–1.62) and significantly lower risk of stroke for 45 to 64 years of age (HR=0.89; 95% CI=0.83–0.96). Subjects with PD but without treatment had a higher risk of stroke among all age groups, especially that of the youngest group (HR=2.17, 1.19, and 1.13; 95% CI=1.64–2.87, 1.05–1.35, and 1.03–1.25, respectively).
Table 3. Cox Regression Model for Predictor of Stroke
VariablesTotalAge 20–44 yAge 45–64 yAge ≥65 y
HR95% CIHR95% CIHR95% CIHR95% CI
Age, y
 20–441.00       
 45–547.046.58–7.54      
 ≥6515.9814.92–17.11      
Sex
 Women1.00 1.00 1.00 1.00 
 Men1.331.29–1.371.861.63–2.131.631.55–1.731.071.03–1.12
Comorbidity
 Hypertension3.133.00–3.266.745.84–7.783.433.21–3.662.452.32–2.58
 Diabetes mellitus1.731.67–1.802.662.24–3.152.071.94–2.191.481.41–1.56
 Atrial fibrillation1.691.57–1.824.782.91–7.862.021.74–2.351.591.45–1.73
 Atherosclerosis1.091.02–1.172.221.42–3.471.251.10–1.431.040.95–1.13
 Chronic kidney disease0.950.90–1.001.981.57–2.491.111.02–1.210.860.80–0.91
 Dyslipidemia0.760.73–0.790.730.61–0.860.670.63–0.720.780.74–0.83
Periodontal disease
 No periodontal disease1.00 1.00 1.00 1.00 
 Dental prophylaxis0.780.75–0.810.740.64–0.860.680.64–0.730.990.94–1.05
 Intensive treatment or extraction0.950.91–0.991.351.12–1.620.890.83–0.961.020.96–1.08
 PD without treatment1.151.07–1.242.171.64–2.871.191.05–1.351.131.03–1.25
CI indicates confidence interval; HR, hazard ratio; and PD, periodontal disease.

Discussion

This is the first nationwide, population-based study to examine the strength of association between periodontal treatment and the incidence of ischemic stroke. Results show that PD is an important risk factor for ischemic stroke, and PD patients who received treatment have a lower risk of stroke, especially among young subjects.
PD was reported to be a significant risk factor for total cerebrovascular accident and nonhemorrhagic stroke after adjustment for known cerebrovascular accident risk factors by the first National Health and Nutrition Examination Survey cohort study, which compared the IRs of cerebrovascular accident between the PD and non-PD subjects based on the baseline records.18 The age-adjusted IRs were reported to be increased with poor periodontal status (non-PD<PD), especially in nonhemorrhagic stroke. PD and <25 teeth at baseline are also reported to be associated with increased risk of ischemic stroke by another 12-year follow-up study that documented 349 ischemic stroke cases from 41 380 men who were free of cardiovascular disease at baseline.32
Our study classified the PD subjects based on their treatment. The significant trend of stroke IR was found among different PD groups (dental prophylaxis<intensive treatment<without treatment). Those who were diagnosed with PD but not treated had the greatest risk for ischemic stroke among all PD and non-PD groups. This finding suggests that PD must be treated to reduce the risk of stroke. The PD patients who needed intensive treatment or tooth extraction had more severe irreversible PD, and the stroke IRs were higher than those of dental prophylaxis group among all different age, sex, and comorbidity groups.
The PD patients who received only dental prophylaxis during the 10-year follow-up period had the lowest stroke IRs among all age and comorbidity groups and even lower than those of the non-PD group (except the 65+ age group). These patients might have mild periodontitis or relatively healthy periodontal tissue. The Taiwan NHI provides free dental checkups and prophylaxis twice a year to promote the prevention of PD. Therefore, those who received dental prophylaxis on a regular basis are likely to have healthier periodontal conditions and are less likely to have systemic chronic inflammatory reaction.
Chen et al31 also found that tooth scaling decreases the incidence of stroke, but their population was restricted in those ≥50 years of age. However, Grau et al33 reported that severe PD is a risk factor in younger (<60 years of age), but not older, subjects. In our study, the preventive effect of dental prophylaxis to stroke is found among all age groups and better among the younger population.
Our findings suggest that age is an important risk factor for stroke. The risk of stroke dramatically increases after 65 years of age. However, the HRs of the youngest subjects were the highest in the fully adjusted models among intensive treatment and without-treatment groups. This might be because the effect of aging superseded the influence of periodontal health condition on stroke. Therefore, young people should pay more attention to maintaining their oral hygiene and periodontal health to reduce the risk of stroke coming from the influence of PD.
The incidence of stroke in men was significantly higher than that of women in the total population and among the PD groups. A meta-analysis studying the sex disparities in stroke concluded that men had more atherothrombotic strokes and women were older than men at stroke onset with a mean difference of 5.2 years.34 The sex differences in the relationship among PD, tooth loss, and atherosclerosis were reported by Desvarieux et al.35 They concluded that tooth loss and PD were related to subclinical atherosclerosis in men but not women, and the influence of sex on carotid artery plaque prevalence was most evident in the age group <59 years. A case–control study33 reported that severe PD is a risk factor in men but not women. They checked the dental conditions of 303 patients within 7 days after acute ischemic stroke or transient ischemic attack. Subjects with severe PD had a 4.3× more risk of cerebral ischemia than subjects with mild PD or without PD. Our study shows that the HRs to stroke of male subjects at 20 to 44, 45 to 64 years, or >65 years of age were all higher than that of women. The sex disparity of the risk of PD to ischemic stroke decreased while age increased.
Several limitations must also be considered. First, the accuracy of diagnosis based on administrative data is an issue of concern, and a potential for misclassification of PD and stroke outcomes is inevitable. However, the Bureau of NHI routinely samples patient charts randomly to cross-check the quality of claims from all medical institutions, and bias from miscoding or misclassification could be minimized. In addition, when we included PD patients using the ICD-9 diagnosis codes, we also collected treatment codes for PD. When we collected ischemic stroke cases, we selected inpatient cases because of ischemic stroke. For other comorbidity cases, we selected those who had outpatient visits >3×. We strictly ruled out other patients to lower the nondifferential misclassification bias. Second, the database could not provide information for some other risk factors of stroke, such as body mass index, family history, and smoking, and some comorbidities, such as inflammatory diseases. Smoking is proven to be one of the important risk factors for PD and will influence the outcome of PD treatments. A clinical trial showing the effect of PD treatment (or prophylaxis) on the ischemic stroke outcome in individuals with PD is needed in the future.
The results of this study show that PD increases the incidence of ischemic stroke, especially among the younger population. Because PD can be prevented and treated as long as people improve their oral hygiene and attend regular dental checkups and prophylaxis, those who already have PD should seek treatment to alleviate tissue inflammation and thereby reduce the incidence of ischemic stroke.

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Published In

Go to Stroke
Stroke
Volume 44 • Number 4 • April 2013
Pages: 1026 - 1030
PubMed: 23422085

Copyright

© 2013 American Heart Association, Inc.

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History

Received: 7 November 2012
Accepted: 7 January 2013
Published online: 19 February 2013
Published in print: April 2013

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Keywords

  1. dental prophylaxis
  2. ischemic stroke
  3. periodontal disease

Subjects

  1. Cognitive Impairment

Authors

Affiliations

Ya-Ling Lee, DDS
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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Hsiao-Yun Hu, PhD
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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Nicole Huang, PhD
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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De-Kuang Hwang, MD
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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Pesus Chou, DrPH
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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Dachen Chu, MD, PhD
From the Department of Dentistry, Taipei City Hospital, Taipei, Taiwan (Y.-L.L.); Institute of Public Health and Community Medicine Research Center (Y.-L.L., H.-Y.H., D.-K.H., P.C., D.C.) and Institute of Hospital and Health Care Administration (N.H.), National Yang-Ming University, Taipei, Taiwan; Department of Neurosurgery (D.C.) and Department of Education and Research (H.-Y.H., N.H.), Taipei City Hospital, Taipei, Taiwan; and Department of Ophthalmology, Taipei Veterans General Hospital—Taoyuan Branch, Taoyuan, Taiwan (D.-K.H.).
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Notes

Correspondence to Dachen Chu, MD, PhD, Superintendent, Taipei City Hospital, Zhongxing Branch No 145, Zheng Zhou Rd, Datong District, Taipei City, Taiwan. E-mail [email protected]

Disclosures

None.

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Dental Prophylaxis and Periodontal Treatment Are Protective Factors to Ischemic Stroke
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