## 4 Interaction between Periodontitis and AMI
### Pathophysiology and Effect of Periodontitis on AMI  
It is well known that periodontitis raises inflammatory markers such as CRP and fibrinogen. These proteins lead to the release of cytokines, such as tumor necrosis factor-\(\alpha\) and interleukin-6, through certain processes [72]. Moreover, bacteria in the oral cavity that induce periodontitis can cause local and systemic inflammation, causing the liver to respond and enter an acute phase [66; 72]. [PERSON] et al. showed a strong relationship between periodontitis patients and pathogens from AMI patients. They found a high association between periodontitis and heart disease and concluded that pathogens such as _P. gingivalis_ could be considered risk factors for AMI [73]. Furthermore, _P. gingivalis_ can reportedly evade innate immune detection by toll-like receptor 4, favoring chronic vascular inflammation [69; 74]. According to [PERSON] et al., the levels of immunoglobulin A against _P. gingivalis_ were risk factors for AMI [75]. Likewise, [PERSON] et al. reported that the levels of immunoglobulin G against _P. gingivalis_ increased upon deterioration in patients with AMI [76]. The search for bacteria associated with periodontitis continues. Through immunofluorescence microscopy, pathogens such as _Tamerella forythensis_ and _P. intermedia_ have been demonstrated to be associated with a greater risk of AMI [77]. Moreover, a more recent study of _P. intermedia_ placed its relationship with periodontitis and AMI closer to the spotlight [78]. A meta-analysis by [PERSON] et al. of five cohort studies showed that people with periodontal disease had a 1.14 times higher risk of developing CAD compared to controls independent of confounding factors [79]. Some relevant sample studies are shown in Table 2.  
Other studies reported that a small dental intervention such as the removal of tartar (a form of hardened dental plaque) could increase the risk of periodontitis in patients presenting with bacteremia. This would cause pro-inflammatory mediator activation by these microorganisms within the bloodstream, increasing the inflammation of atheroma plaques and the risk of their detachment or fragmentation [87]. Figure 3 shows a diagram of the microbial components of atherogenesis. \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Bacteria** & **Pathology** & **Findings** & **Reference** \\ \hline Porphromonas gingivalis (Pg). & Oral diseases Atherosclerosis & \(Pg\) can influence the malfunction of the endothelium, it is considered a promoter of foam cells, it stimulates the calcification of the smooth muscle cells of the vessels, it alters the regulatory and auxiliary T lymphocytes. & [80] \\ Aggregatibacter actinomycetemcomitans (Aa) & & Periodontal bacterial DNA was found in a high percentage in atheromatous plaques. & [81] \\ Porphromonas gingivalis (Pg) & Coronary artery disease & \(Pg\) can influence the representation of periodontal pathogens. & [73] \\ Prevotella intermedia (Pi) & & \(Pg\) can influence the representation of periodontal pathogens. & [74] \\ Prevotella nigrescens (Pn) & & \(Pg\) can influence the representation of periodontal pathogens. & [75] \\ Tannerella forsythia (Tf) & & \(Pg\) can influence the representation of periodontal pathogens. & [75] \\ Provtoplasc Gingivalis (Pg) & & \(Pg\) can influence the representation of periodontal pathogens. & [75] \\ Aggregatibacter actinomycetemcomitans (Aa) & & Periodontal status in patients with AMI is characterized by unsatisfactory and poor hygiene, increased indices of bleeding on probing, and periodontal pocket depth compared to patients without cardiovascular pathology. & [76] \\ Tannerella forsythia (Tf) & & \(Pg\) can influence the representation of periodontal pathogens. & [76] \\ Campylobacter rectus (Cr) & & \(Pg\) can influence the representation of periodontal pathogens in & [77] \\ Eikenella corrodens (Ec) & & \(Pg\) can influence the representation of periodontal pathogens. & [76] \\ Porphromonas gingivalis (Pg) & & \(Pg\) can influence the representation of periodontal pathogens.