HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dietrich, T. Articles by Garcia, R.I. Search for Related Content PubMed PubMed Citation Articles by Dietrich, T. Articles by Garcia, R.I.

Tobacco Use and Incidence of Tooth Loss among US Male Health Professionals

¹ Dept. of Health Policy & Health Services Research and
² Dept. of Periodontology and Oral Biology, Boston University Goldman School of Dental Medicine, 715 Albany St., 560, 3rd floor, Boston, MA 02118, USA;
³ Dept. of Epidemiology, Harvard School of Public Health;
⁴ New England Research Institutes;
⁵ University of Puerto Rico, Division of Dental Public Health, School of Dentistry, Medical Science Campus; and
⁶ VA Normative Aging Study, VA Boston Healthcare System

^* corresponding author, tdietric{at}bu.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
Data on the dose-dependent effects of smoking and smoking cessation on tooth loss are scarce. We hypothesized that smoking has both dose- and time-dependent effects on tooth loss incidence. We used longitudinal data on tobacco use and incident tooth loss in 43,112 male health professionals, between 1986 and 2002. In multivariate Cox models, current smokers of 5 to 14 and 45+ cigarettes daily had a two-fold (HR, 1.94; 95% CI, 1.72, 2.18) and three-fold (HR, 3.05; 95% CI, 2.38, 3.90) higher risk of tooth loss, respectively, compared with never-smokers. Risk decreased with increasing time since cessation, but remained elevated by 20% (95% CI, 16%, 25%) for men who had quit 10+ years before. Current pipe/cigar smokers had a 20% (95% CI, 1.11, 1.30) increased risk of tooth loss compared with never- and former smokers of pipes/cigars.

KEY WORDS: periodontitis • smoking • tobacco • tooth loss

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
Cigarette smoking has emerged as the single most important modifiable behavioral risk factor for periodontal disease (Tomar and Asma, 2000; Hujoel et al., 2003; Palmer et al., 2005). In cross-sectional studies, cigarette smoking has also been associated with higher prevalence of edentulousness and fewer remaining teeth (Daniell, 1983; Gilbert et al., 1993; Linden and Mullally, 1994; Krall et al., 1997; Axelsson et al., 1998), and, in longitudinal studies, with increased rates of tooth loss (Ahlqwist et al., 1989; Eklund and Burt, 1994; Holm, 1994; Krall et al., 1997; Jansson and Lavstedt, 2002). However, many previous studies were relatively small or used broad categorizations of smoking history. Therefore, the dose-response relationship between cigarette smoking and tooth loss has not been well-characterized. Furthermore, little is known about the time-dependent effect of smoking cessation on risk of tooth loss. In a study of 1031 Swedish women, risk of tooth loss over 12 yrs was similar between never-smokers and former smokers who had quit any time before baseline (Ahlqwist et al., 1989). Krall et al. found an intermediate rate of tooth loss for male smokers who quit at any time during the 3 to 26 yrs of follow-up, and concluded that it may take decades for quitters to return to the tooth loss rate of never-smokers (Krall et al., 1997).

The use of other types of tobacco, such as cigar, pipe, and smokeless tobacco, is also likely to be related to tooth loss risk, but few studies have explored this hypothesis. A cross-sectional analysis of 705 participants in the Baltimore Longitudinal Study of Aging found that the number of missing teeth was higher among smokers of pipes and cigars (Copeland et al., 2004). Both pipe- and cigar-smoking were independently associated with increased tooth loss risk in a longitudinal study of 690 men (Krall et al., 1999). In a representative survey of the US population (NHANES III), history of smokeless tobacco use was associated with periodontal disease prevalence (Fisher et al., 2005). However, whether or not the use of smokeless tobacco increases the risk of tooth loss has not been investigated.

The purpose of the present study was to evaluate the associations between the various forms of tobacco use (cigarette smoking, pipe or cigar smoking, chewing tobacco) and smoking cessation and the incidence of tooth loss in a large, prospective study of US health professionals.

	MATERIALS & METHODS

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
The Health Professionals’ Follow-Up Study (HPFS) is an ongoing longitudinal cohort study of 51,529 male health professionals, including dentists (58%), veterinarians (20%), pharmacists (8%), optometrists (7%), osteopaths (4%), and podiatrists (3%). Participants were 40 to 75 yrs of age at the study baseline in 1986. Participants completed mailed questionnaires every 2 yrs to provide information on medical history and health behaviors. On average, over 90% of the baseline population responded to each follow-up questionnaire. This study was approved by the Human Subjects Committee at the Harvard School of Public Health.

For the present analysis, we excluded men if, at baseline, they had: missing data for cigarette smoking status, a cancer diagnosis by 1986, self-reported daily caloric intake outside the plausible range of 800 to 4200, or ^> 70 of the 131 dietary questions left blank. We also excluded 742 edentulous men (29% never, 57% former, and 15% current cigarette smokers). The final analytic sample included 43,112 men who contributed 569,366 person-years.

Exposure Assessment
The baseline HPFS questionnaire asked detailed questions on the history of cigarette smoking. Men who had smoked fewer than 20 packs of cigarettes in their lifetime were defined as ’never-smokers’. ’Ever-smokers’ of cigarettes reported the average number of cigarettes per day (0–4, 5–14, 15–24, 25–34, 35–44, 45+ cig/d) and, if former smokers, time since cessation (< 1 yr, 1–2 yrs, 3–5 yrs, 6–9 yrs, 10+ yrs). Information on cigarette and cigar or pipe smoking (current, yes/no) was updated biennially. Ever-use of chewing tobacco was ascertained in the 1996 questionnaire ("Have you ever chewed tobacco at least once a week for a year?").

Outcome Assessment
Participants reported baseline number of teeth in 1986 and incident tooth loss in two-year intervals thereafter. Missing values on incident tooth loss were assumed to represent no tooth loss during that follow-up period, because only 10% of participants experienced tooth loss biennially. Self-reported number of teeth and tooth loss have been found to be highly accurate in various populations (Douglass et al., 1991; Gilbert et al., 2002; Pitiphat et al., 2002). Thus, in this population of dentists and health professionals, self-reported number of teeth and tooth loss are likely to have high validity.

Assessment of Potential Confounders
Diet was assessed at baseline and every 4 yrs thereafter with an expanded semi-quantitative food frequency questionnaire (Willett et al., 1985). Every 2 yrs, questionnaires also assessed use of multivitamins and specific vitamin supplements. Validity of the dietary data has been documented by comparisons with multiple weighted dietary records (Rimm et al., 1992). Physical activity was assessed biennially and calculated as the sum of the activity-specific metabolic equivalent (MET) hrs/wk as a measure of total leisure-time physical activity.

Data Analysis
Person-time for each participant was calculated from the date of return of the 1986 questionnaire to the date of first incident tooth loss, death, or January 31, 2002, whichever occurred first.

We used Cox proportional-hazards models to obtain hazard ratios and 95% confidence intervals for the association between tobacco use and risk of tooth loss. Former smokers were categorized according to time since cessation (< 1, 1–2, 3–5, 6–9, and 10+ yrs ago), and current smokers were categorized according to intensity (< 5, 5–14, 15–24, 25–34, 35–44, 45+ cigarettes/day).

All models contained cigarette, cigar/pipe, and chewing tobacco variables, mutually adjusted for type of tobacco use. The basic model included age (mos) and race (Caucasian vs. other). A multivariable model further adjusted for other variables that were significantly associated with tooth loss (p < 0.05) in bivariate analyses, or that changed the effect estimates of the tobacco use/tooth loss association by ^> 5%. Cigarette smoking, pipe/cigar smoking, body mass index (BMI), physical activity, diabetes, use of multivitamins/vitamin supplements, and intakes of nutrients/food groups were modeled as time-dependent variables.

Sensitivity analyses restricted the cohort to dentists, because reasons for tooth loss and accuracy of self-reports may differ from those of non-dentists. Finally, because smoking increases the risk of various cancers and cancer treatment (i.e., radiotherapy and chemotherapy) that may be associated with increased tooth loss, a separate analysis censored person-time at the follow-up preceding a first report of a cancer diagnosis.

All statistical tests were two-sided and calculated by SAS 9.1.2 (SAS Institute Inc., Cary, NC, USA).

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
At baseline in 1986, 3765 (8.7%) men were current cigarette smokers, and 18,950 (44.0%) were former cigarette smokers. Age, race, BMI, profession, multivitamin use, and total caloric intake were similar among never, former, and current smokers (Table 1). Compared with never-smokers, current smokers and, particularly, current heavy smokers were more likely to be diabetic and physically inactive, less likely to have had a routine physical examination, less likely to take vitamin C supplements, and more likely to consume alcohol. Furthermore, smokers had lost more teeth prior to baseline.

Current pipe or cigar smoking was associated with a 20% (multivariate HR, 1.20; 95% CI, 1.11, 1.30) increased risk of tooth loss compared with never- or former smokers of pipes or cigars. Results were similar when the analysis was restricted to dentists. Ever-use of chewing tobacco was associated with incident tooth loss in the age- and race-adjusted analysis (HR, 1.27; 95% CI, 1.16, 1.39), as well as in the full multivariate model (HR, 1.14; 95% CI, 1.04, 1.24), although the association was attenuated when additional covariates were included. When analysis was restricted to dentists, however, no statistically significant association between chewing tobacco and tooth loss was observed (HR, 1.06; 95% CI, 0.90, 1.26).

Censoring of person-time prior to a first diagnosis of cancer did not change the results (data not shown).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
In this large, prospective cohort study of male health professionals, we found a strong, dose-dependent association between cigarette smoking and the risk of tooth loss, independent of other risk factors and potential confounders. The risk of tooth loss declined after smoking cessation as a function of time since cessation; however, compared with never-smokers, the risk of tooth loss remained elevated, even 10 yrs after smoking cessation. Current smokers of pipes or cigars also had increased risk of tooth loss. Ever-use of chewing tobacco seemed to increase risk as well, though estimates were not as robust as for other types of tobacco.

Important strengths of this study are its prospective design, large sample size, long follow-up, and detailed, biennially updated data on smoking, allowing for fine exposure categories and precise estimates. When one considers that tooth loss is the outcome of a complex process that may involve numerous factors that are also related to tobacco use (e.g., diet, health behaviors), another strength of this study is our ability to control adequately for such confounders. Furthermore, the cohort’s relative homogeneity minimizes potential confounding by factors such as socio-economic status and access to care.

The path by which cigarette smoking affects tooth loss is presumed to involve periodontitis. In addition to periodontitis, dental caries may also contribute to the increased risk of tooth loss among smokers (Ylostalo et al., 2004). Associations have been reported between cigarette smoking and root caries (Hahn et al., 1999; Fure, 2004; Phelan et al., 2004), coronal caries (Drake et al., 1997; Axelsson et al., 1998), endodontic treatment (Krall et al., 2006a), and periapical periodontitis (Kirkevang and Wenzel, 2003), although not consistently (Bergström et al., 2004).

We found that risk of tooth loss declines as early as 1 yr after smoking cessation. However, it may take more than 10 yrs of abstinence for the risk to decline to that of never-smokers. This is in agreement with results from the VA Dental Longitudinal Study, where, after 12 yrs of cessation, the risk of tooth loss approached that of never-smokers (Krall et al., 1997, 2006b).

These results suggest that, following smoking cessation, the effect of smoking on tooth loss declines less rapidly than the effect of smoking on periodontitis (Bolin et al., 1993; Bergström et al., 2000; Tomar and Asma, 2000). Using NHANES III data, we estimated the half-life of the effect of smoking on periodontal disease at 1.5 yrs (Dietrich and Hoffmann, 2004), suggesting that the risk for periodontal disease for former smokers should approach that of never-smokers approximately 6 yrs after quitting. This apparent difference in the half-life of the effects of smoking on periodontal disease vs. tooth loss may be explained by factors other than periodontitis, such as caries, that also mediate the effect of smoking on tooth loss risk.

Our finding that cigar or pipe smoking is associated with risk of tooth loss confirms results of earlier work. In a cross-sectional study, men who smoked pipes or cigars had a higher prevalence of moderate or severe periodontitis and fewer teeth remaining than did non-smokers (Albandar et al., 2000). In an earlier longitudinal study, we found that cigar smoking is associated with significantly higher rates of tooth loss (Krall et al., 1999). However, it is uncertain by exactly how much the risk increases, since we had only a dichotomous measure of current cigar or pipe smoking, i.e., the comparison group included both never- and former smokers.

We found a significant positive association between ever-use of chewing tobacco and risk of tooth loss only among the non-dentist health professionals. Previous studies of smokeless tobacco and tooth loss are lacking, and our results should be interpreted with caution. Multivariable adjustment resulted in a marked attenuation of the hazard ratio, and no association was evident when the analysis was restricted to dentists. Although residual or unknown confounding may explain the small association found, it is likely that our measure of chewing tobacco use was insufficient to estimate accurately an association with tooth loss. We did not have specific information on dose, duration, or timing (i.e., ages) of chewing tobacco use, and it may be that a great many ever-users were men who had used chewing tobacco in the distant past.

Our results provide evidence for a strong time- and dose-dependent association between tobacco smoking and risk of tooth loss among men. However, these results may not be directly generalizable to women. In a cross-sectional study of 8409 young Finnish adults, a somewhat stronger association between smoking and tooth loss was reported among women (Ylostalo et al., 2004). Last, since the majority of HPFS participants were Caucasian, generalizability of our findings to other racial/ethnic groups is uncertain.

In conclusion, there is a strong association between cigarette, pipe, or cigar smoking and subsequent tooth loss in men. Current heavy cigarette smokers have a three-fold greater risk of incident tooth loss, compared with never-smokers. The risk declines soon after cessation of cigarette smoking, but remains elevated for more than 10 yrs compared with risk in never-smokers.

	ACKNOWLEDGMENTS

 
This investigation was supported by NIDCR Grants R03 DE016357 and K24 DE00419, and by the US Dept. of Veterans’ Affairs.

Received April 1, 2006; Last revision September 19, 2006; Accepted December 5, 2006

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS & METHODS RESULTS DISCUSSION REFERENCES

 
Ahlqwist M, Bengtsson C, Hollender L, Lapidus L, Osterberg T (1989). Smoking habits and tooth loss in Swedish women. Community Dent Oral Epidemiol 17:144–147.[ISI][Medline]

Albandar JM, Streckfus CF, Adesanya MR, Winn DM (2000). Cigar, pipe, and cigarette smoking as risk factors for periodontal disease and tooth loss. J Periodontol 71:1874–1881.[ISI][Medline]

Axelsson P, Paulander J, Lindhe J (1998). Relationship between smoking and dental status in 35-, 50-, 65-, and 75-year-old individuals. J Clin Periodontol 25:297–305.[ISI][Medline]

Bergström J, Eliasson S, Dock J (2000). A 10-year prospective study of tobacco smoking and periodontal health. J Periodontol 71:1338–1347.[ISI][Medline]

Bergström J, Babcan J, Eliasson S (2004). Tobacco smoking and dental periapical condition. Eur J Oral Sci 112:115–120.[ISI][Medline]

Bolin A, Eklund G, Frithiof L, Lavstedt S (1993). The effect of changed smoking habits on marginal alveolar bone loss. A longitudinal study. Swed Dent J 17:211–216.[ISI][Medline]

Copeland LB, Krall EA, Brown LJ, Garcia RI, Streckfus CF (2004). Predictors of tooth loss in two US adult populations. J Public Health Dent 64:31–37.[ISI][Medline]

Daniell HW (1983). Postmenopausal tooth loss. Contributions to edentulism by osteoporosis and cigarette smoking. Arch Intern Med 143:1678–1682.[Abstract]

Dietrich T, Hoffmann K (2004). A comprehensive index for the modeling of smoking history in periodontal research. J Dent Res 83:859–863.[Abstract/Free Full Text]

Douglass CW, Berlin J, Tennstedt S (1991). The validity of self-reported oral health status in the elderly. J Public Health Dent 51:220–222.[ISI][Medline]

Drake CW, Beck JD, Lawrence HP, Koch GG (1997). Three-year coronal caries incidence and risk factors in North Carolina elderly. Caries Res 31:1–7.[ISI][Medline]

Eklund SA, Burt BA (1994). Risk factors for total tooth loss in the United States; longitudinal analysis of national data. J Public Health Dent 54:5–14.[ISI][Medline]

Fisher MA, Taylor GW, Tilashalski KR (2005). Smokeless tobacco and severe active periodontal disease, NHANES III. J Dent Res 84:705–710.[Abstract/Free Full Text]

Fure S (2004). Ten-year cross-sectional and incidence study of coronal and root caries and some related factors in elderly Swedish individuals. Gerodontology 21:130–140.[Medline]

Gilbert GH, Duncan RP, Crandall LA, Heft MW, Ringelberg ML (1993). Attitudinal and behavioral characteristics of older Floridians with tooth loss. Community Dent Oral Epidemiol 21:384–389.[ISI][Medline]

Gilbert GH, Chavers LS, Shelton BJ (2002). Comparison of two methods of estimating 48-month tooth loss incidence. J Public Health Dent 62:163–169.[ISI][Medline]

Hahn P, Reinhardt D, Schaller HG, Hellwig E (1999). Root lesions in a group of 50–60 year-old Germans related to clinical and social factors. Clin Oral Investig 3:168–174.[Medline]

Holm G (1994). Smoking as an additional risk for tooth loss. J Periodontol 65:996–1001.[ISI][Medline]

Hujoel PP, del Aguila MA, DeRouen TA, Bergström J (2003). A hidden periodontitis epidemic during the 20th century? Community Dent Oral Epidemiol 31:1–6.[ISI][Medline]

Jansson L, Lavstedt S (2002). Influence of smoking on marginal bone loss and tooth loss—a prospective study over 20 years. J Clin Periodontol 29:750–756.[ISI][Medline]

Kirkevang LL, Wenzel A (2003). Risk indicators for apical periodontitis. Community Dent Oral Epidemiol 31:59–67.[ISI][Medline]

Krall EA, Dawson-Hughes B, Garvey AJ, Garcia RI (1997). Smoking, smoking cessation, and tooth loss. J Dent Res 76:1653–1659.[Abstract/Free Full Text]

Krall EA, Garvey AJ, Garcia RI (1999). Alveolar bone loss and tooth loss in male cigar and pipe smokers. J Am Dent Assoc 130:57–64.[Abstract]

Krall EA, Abreu Sosa C, Garcia C, Nunn ME, Caplan DJ, Garcia RI (2006a). Cigarette smoking increases the risk of root canal treatment. J Dent Res 85:313–317.[Abstract/Free Full Text]

Krall EA, Dietrich T, Nunn ME, Garcia RI (2006b). Risk of tooth loss after cigarette smoking cessation. Prev Chronic Dis 3:A115. http://www.cdc.gov/pcd/issues/2006/oct/05_0243.htm.[Medline]

Linden GJ, Mullally BH (1994). Cigarette smoking and periodontal destruction in young adults. J Periodontol 65:718–723.[ISI][Medline]

Palmer RM, Wilson RF, Hasan AS, Scott DA (2005). Mechanisms of action of environmental factors—tobacco smoking. J Clin Periodontol 32(Suppl 6):180–195.

Phelan JA, Mulligan R, Nelson E, Brunelle J, Alves ME, Navazesh M, et al. (2004). Dental caries in HIV-seropositive women. J Dent Res 83:869–873.[Abstract/Free Full Text]

Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ (2002). Validation of self-reported oral health measures. J Public Health Dent 62:122–128.[ISI][Medline]

Rimm EB, Giovannucci EL, Stampfer MJ, Colditz GA, Litin LB, Willett WC (1992). Reproducibility and validity of an expanded self-administered semiquantitative food frequency questionnaire among male health professionals. Am J Epidemiol 135:1114–1126.[Abstract/Free Full Text]

Tomar SL, Asma S (2000). Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey. J Periodontol 71:743–751.[ISI][Medline]

Willett WC, Sampson L, Stampfer MJ, Rosner B, Bain C, Witschi J, et al. (1985). Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol 122:51–65.[Abstract/Free Full Text]

Ylostalo P, Sakki T, Laitinen J, Jarvelin MR, Knuuttila M (2004). The relation of tobacco smoking to tooth loss among young adults. Eur J Oral Sci 112:121–126.[ISI][Medline]

This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Dietrich, T. Articles by Garcia, R.I. Search for Related Content PubMed PubMed Citation Articles by Dietrich, T. Articles by Garcia, R.I.