Periodontal inflammation: A clinically significant and underrecognized cardiovascular risk factor—The Endothelial Risk Score (ERS)

Abstract

Periodontitis is a chronic inflammatory disease affecting the tooth-supporting structures and has been consistently associated with endothelial dysfunction, the earliest detectable stage of atherosclerosis. This article is a narrative review with conceptual framework development – not a systematic review or meta-analysis. We synthesize evidence from key studies to propose a hypothesis-generating heuristic: the Endothelial Risk Score (ERS). Despite robust biological plausibility and supportive clinical evidence, a critical translational gap persists: no quantitative framework integrates continuous periodontal inflammation with established cardiovascular risk factors. Clinicians cannot answer: “How much endothelial dysfunction is explained by periodontal inflammation?” This review synthesises evidence from mechanistic studies, clinical association studies, intervention trials, and established cardiovascular risk frameworks to propose the ERS. The ERS is a hypothesis-generating heuristic that integrates Periodontal Inflamed Surface Area (PISA) with age, sex, systolic blood pressure, smoking pack-years, diabetes status, and hs-CRP into a four-strata scoring system (Low, Moderate, High, Very High vascular burden). All point assignments are evidence-informed heuristics, not empirically derived coefficients. The proposed ERS is not a validated prediction tool; it is a conceptual framework to structure existing evidence, guide patient education, foster interdisciplinary collaboration, and define testable hypotheses for future empirical validation. A detailed validation blueprint is provided.