Jurnal Periodonsia Merokok Terhadap Tanggalnya Gigi

2013;144(3):252-265JADA Mine Tezal and Robert J. GencoM. Hovey, Michael J. LaMonte, Chaoru Chen, Xiaodan Mai, Jean Wactawski-Wende, KathleenBuffalo OsteoPerio Studyaccording to the reason for tooth loss: The Associations between smoking and tooth loss

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252 JADA 144(3) http://jada.ada.org March 2013

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Partial or total tooth loss has beenassociated with the onset of dis-ability and mortality in the elderly.1Although tooth loss in U.S. adults

has decreased during the past fewdecades,2 tooth loss without replacementhas been associated with a poor physicalfunction index, as measured by the SF-36Health Survey (QualityMetric, Lincoln,R.I.).3 Tooth loss also has been associated

with chronic systemicconditions such asischemic stroke,4 cancer,5rheumatoid arthritis6and diabetes.7 As aresult, both partial andtotal tooth loss remainsignificant public healthconcerns in the UnitedStates. Understanding

the reasons for tooth loss will facilitate thedevelopment of prevention strategies that,in turn, may benefit oral health and func-tion and have a favorable effect on asso-ciated morbidities.

Dr. Mai is a doctoral student in epidemiology, Department ofSocial and Preventive Medicine, School of Public Health andHealth Professions, University at Buffalo, The State University ofNew York.Dr. Wactawski-Wende is a professor, Department of Social andPreventive Medicine, School of Public Health and Health Profes-sions, University at Buffalo, The State University of New York,270 Farber Hall, Buffalo, N.Y. 14214, e-mail [email protected] reprint requests to Dr. Wactawski-Wende.Ms. Hovey is a data analyst, Department of Social and PreventiveMedicine, School of Public Health and Health Professions, Uni-versity at Buffalo, The State University of New York.Dr. LaMonte is an assistant professor, Department of Social andPreventive Medicine, School of Public Health and Health Profes-sions, University at Buffalo, The State University of New York.Dr. Chen is a former research support specialist, Department ofSocial and Preventive Medicine, School of Public Health andHealth Professions, University at Buffalo, The State University ofNew York.Dr. Tezal is an assistant professor, Department of Oral Biology,School of Dental Medicine, University at Buffalo, The State Uni-versity of New York.Dr. Genco is Distinguished Professor of Oral Biology and Microbi-ology, Department of Oral Biology, School of Dental Medicine,University at Buffalo, The State University of New York.

Associations between smoking and toothloss according to the reason for tooth lossThe Buffalo OsteoPerio Study

Xiaodan Mai, MBBS; Jean Wactawski-Wende, PhD; Kathleen M. Hovey, MS; Michael J.LaMonte, PhD, MPH; Chaoru Chen, PhD; Mine Tezal, DDS, PhD; Robert J. Genco, DDS, PhD

Background. Smoking is associatedwith tooth loss. However, smoking’s rela-tionship to the specific reason for tooth lossin postmenopausal women is unknown.Methods. Postmenopausal women (n =1,106) who joined a Women’s Health Initiative ancillarystudy (The Buffalo OsteoPerio Study) underwent oralexaminations for assessment of the number of missingteeth, and they reported the reasons for tooth loss. Theauthors obtained information about smoking status via aself-administered questionnaire. The authors calculatedodds ratios (ORs) and 95 percent confidence intervals (CIs)by means of logistic regression to assess smoking’s associa-tion with overall tooth loss, as well as with tooth loss dueto periodontal disease (PD) and with tooth loss due tocaries.Results. After adjusting for age, education, income, bodymass index, history of diabetes diagnosis, calcium supple-ment use and dental visit frequency, the authors foundthat heavy smokers (≥ 26 pack-years) were significantlymore likely to report having experienced tooth loss com-pared with never smokers (OR = 1.82; 95 percent CI, 1.10-3.00). Smoking status, packs smoked per day, years ofsmoking, pack-years and years since quitting smokingwere significantly associated with tooth loss due to PD.For pack-years, the association for heavy smokers com-pared with that for never smokers was OR = 6.83 (95 per-cent CI, 3.40-13.72). The study results showed no signifi-cant associations between smoking and tooth loss due tocaries.Conclusions and Practical Implications.Smoking may be a major factor in tooth loss due to PD.However, smoking appears to be a less important factor intooth loss due to caries. Further study is needed to explorethe etiologies by which smoking is associated with dif-ferent types of tooth loss. Dentists should counsel theirpatients about the impact of smoking on oral health,including the risk of experiencing tooth loss due to PD.Key Words. Tooth loss; periodontal diseases; caries;smoking; menopause; women’s health.JADA 2013;144(3):252-265.

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Copyright © 2013 American Dental Association. All rights reserved.

JADA 144(3) http://jada.ada.org March 2013 253

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The U.S. Centers for Disease Control andPrevention, Atlanta, estimated the prevalence ofcurrent smoking among U.S. adults in 2007 tobe 17.4 percent in women and 22.3 percent inmen.8 Smoking has been associated with chronicillnesses such as respiratory ailments,9 cancer10and heart disease.11 A positive associationbetween smoking status and tooth loss has beenindicated in several,12-27 but not all,28,29 publishedobservational studies. Limitations in studydesign, including small sample size and incom-plete adjustment for confounding variables, mayexplain in part the disparate findings betweenstudies. In addition, few investigators haveexplored different reasons for tooth loss in rela-tion to smoking habits, which also may explaininconsistencies in published results.30,31 Toothloss can be a consequence of caries, periodontaldisease (PD), accidents or trauma, previous rootcanal treatment, orthodontic procedures andother reasons. Caries and PD account for a largeproportion of missing teeth in adult popula-tions.32,33 Although caries is a major reason fortooth loss across all age groups, PD is a particu-larly important reason among older adults.34,35Many studies pertaining to smoking and toothloss were conducted in men, and fewer data areavailable regarding this association in women.Study results show that women often experiencemore tooth loss than men36,37 despite havingbetter oral health practices and a lower smokingprevalence.8 Women older than 65 years have anaverage of 18.77 teeth, and the number ofremaining teeth is 4.52 fewer among currentsmokers than it is among never smokers.38In this study, we collected detailed informa-

tion about cigarette smoking via self-administered questionnaires, and we evaluatedthe extent of and reasons for tooth loss as partof a comprehensive oral examination in a large,well-characterized cohort of postmenopausalwomen. We then assessed the associationbetween smoking and tooth loss and examinedwhether this association varied according toreasons for tooth loss in this study group.

METHODSThis cross-sectional study consisted of post-menopausal women enrolled in the BuffaloOsteoporosis and Oral Bone Loss (OsteoPerio)Study, which is ancillary to the Women’s HealthInitiative Observational Study (WHI OS)39,40conducted at the Buffalo, N.Y., clinical center.Details about participant recruitment and selec-tion have been described elsewhere.41 A total of1,362 women completed the OsteoPerio visit. Werestricted the current analyses to the 1,106

women for whom all information pertaining tothe key study variables was available; theseincluded a detailed smoking history, reason fortooth loss and the major confounding variablesof interest. In addition, we excluded womenfrom these analyses who had lost teeth owing toreasons other than caries or PD (Figure). Thehealth sciences institutional review board at theUniversity at Buffalo approved this study, andwe obtained written informed consent fromall participants before completing studyassessments.Participants underwent a comprehensive oral

examination administered by trained and cali-brated dental examiners (M.T. and others) whoused standardized protocols. We scheduled theOsteoPerio study visit to correspond approxi-mately with the participant’s three-year WHI OSclinical visit. On examination, the dental exam-iner assessed the number of teeth present, theparticipant reported the reason for each missingtooth (excluding third molars) and the dentalexaminer recorded the reason for each missingtooth. Reasons for missing teeth included caries,PD, accident or trauma, orthodontic procedure,congenital absence, eruption problems, previousroot canal treatment or unable to determine. Thedental examiner classified participants as havingno tooth loss if they had retained all 28 naturalteeth (excluding third molars).Tooth loss. Among participants who were

missing at least one tooth, the examiner catego-rized each missing tooth according to thewoman’s self-reported reason it was missing.For these analyses, we defined those whoreported at least one tooth missing as a result ofPD as having tooth loss due to PD. We definedthose reporting at least one tooth missing as aresult of caries and no tooth loss as a result ofPD as having tooth loss due to caries. Weexcluded from these analyses participantswhose tooth loss was due only to reasons otherthan caries or PD (n = 113). We classified thosewithout tooth loss as such. We conducted a vali-dation study among a subsample of theOsteoPerio study population (n = 70), in whichwe contacted the participants’ personal dentistsand asked them to report the reason for eachmissing tooth. We asked the dentists to refer totheir patients’ dental records. They were notmade aware of the participants’ self-reportedreasons as part of the OsteoPerio study.

ABBREVIATION KEY. AP: Anteroposterior. BMI: Bodymass index. PD: Periodontal disease. SES: Socioeco-nomic status.WHI OS:Women’s Health InitiativeObservational Study.



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Smoking.We obtainedinformation about partici-pants’ smoking habits from astandardized self-adminis-tered questionnaire completedduring the OsteoPerio clinicvisit. We categorized smokingstatus as “never,” “former” or“current” smokers on the basisof participants’ responses tothis question: “Do you use orhave you used cigarettes nowor in the past?” We computedthe number of years ofsmoking by subtracting theparticipant’s age at smokinginitiation from her age atsmoking cessation for formersmokers, and we subtractedthe participant’s age atsmoking initiation from hercurrent age for currentsmokers. We computedsmoking pack-years by multi-plying the number of packssmoked per day (obtainedfrom participants’ responses toquestions about packs smokedper day) by the number ofyears the participant smoked.We then classified partici-pants into one of fourcategories:dnever smokers;dlight smokers (first tertile,< eight pack-years)dmoderate smokers (secondtertile, eight to 25 pack-years);dheavy smokers (third ter-tile, ≥ 26 pack-years).In this study, cigarette

smoking was the predominantsource of tobacco exposure.Nine women reported usingcigars, pipes or chewing tobacco, but thesewomen also reported smoking cigarettes. Nodata were available about the intensity or dura-tion of use of tobacco products other than ciga-rettes, and, therefore, we did not explore thisinformation further in our analyses.Participants’ characteristics.At the time of

the study visit, we measured height and weightaccording to standardized protocols. We calcu-lated body mass index (BMI) by dividing weight(in kilograms) by the square of height in meters.In addition, we obtained data pertaining to otherkey variables fromWHI OS questionnaires. We

determined the participant’s age by using thedate of birth. Participants described their race aswhite (not of Hispanic origin), black or AfricanAmerican (not of Hispanic origin), AmericanIndian or Alaskan Native, Asian or PacificIslander (ancestry is Chinese, Indo-Chinese,Korean, Japanese, Pacific Islander, Vietnamese),Hispanic/Latino (ancestry is Mexican, Cuban,Puerto Rican, Central American or SouthAmerican) or other, and we then categorized themas white or other. We categorized educationallevel into high school, college and graduateschool. We categorized current annual family

Figure. Flowchart of participants. Exclusion criteria (n = 166) included incomplete ques-tionnaires (n = 5), missing alveolar crestal height information (n = 16), missing reasons fortooth loss (n = 2), missing teeth due only to reasons other than periodontal disease orcaries (n = 113) and missing information about pack-years of smoking (n = 30).

Women Completing OsteoPerio Visit(n = 1,362)

Exclusion Criteria Applied(n = 1,196)

Participants for Whom InformationAbout Confounding Variables

Was Available(n = 1,106)

No Tooth Loss(n = 206)

Any Tooth Loss(n = 900)

Tooth LossDue to

Periodontal Disease(n = 108)

Tooth LossDue toCaries

(n = 792)



S T O R YC O V E R

income as less than $35,000 or $35,000 or more.Questions regarding additional potential con-

founders included those pertaining to a historyof diabetes diagnosis and medication use, hor-mone therapy, calcium and vitamin D supple-ment use and history of gingival surgery. Weassessed participants’ oral health behaviors byusing three variables: frequency of dental visits(> one per year versus ≤ one per year), fre-quency of toothbrushing (≥ two times per dayversus < two times per day) and frequency offlossing (every day versus not every day). Weassessed bone mineral density by means ofdual-energy x-ray absorptiometry with use of adensitometer (QDR2000 densitometer, Hologic,Waltham, Mass.) at several body sites includingthe anteroposterior (AP) spine, femoral neck,total hip, wrist and total body. We convertedbone mineral density values into T-scores foreach of the skeletal sites.42 (The T-score is acomparison of a person’s bone density with thatof a healthy young adult [20 to 30 years old] ofthe same sex. It is a calculation of the standarddeviations from the young adult mean value forthat site.) We used the worst T-score from themeasured sites, including the total hip, femoralneck, wrist, AP spine or total body to charac-terize a participant’s osteoporosis status. Wefurther classified participants’ overall osteo-porosis status as normal, low bone mass orosteoporosis according to World Health Organi-zation diagnostic criteria.42,43Data analysis.We compared characteristics

of women retaining all 28 teeth with those ofwomen who lost at least one tooth by using a ttest for continuous variables and a χ2 test forcategorical variables. We selected confoundingvariables for the final models after assessing thecontribution of each factor by itself after firstadjusting for age. Our final adjusted modelsincluded age, education, BMI, history of dia-betes diagnosis, calcium supplement use anddental visit frequency.We conducted logistic regression analyses to

estimate the OR and 95 percent CI for the asso-ciation between smoking history and overall toothloss. To investigate whether the association dif-fered according to the reason for tooth loss, weconducted separate logistic regression analysesstratified by those who lost any teeth due to PDand by those who lost any teeth due to caries (butnone due to PD). In addition, we conductedanalyses to assess whether the associations dif-fered according to the severity of tooth loss (stratainclude loss of one to three teeth and more thanthree teeth specifically as a result of PD orcaries). We examined the influence of smoking

intensity and duration by using the P for trendfor continuous measures of packs smoked, yearsof smoking, pack-years of smoking, age at whichparticipant started smoking, and years since par-ticipant quit smoking. We conducted sensitivityanalyses that included only those women whohad lost teeth due to PD exclusively (that is,excluding those with any tooth loss due to caries)(n = 47). In addition, we assessed effect modifica-tion by calcium supplement intake, vitamin Dsupplement intake and hormone therapy byadding cross-product interaction terms in logisticregression models. For the logistic regressionanalyses, we considered two-sided P values ≤ .05to be statistically significant. We performed allanalyses by using a statistical software package(SAS Version 9.2, SAS Institute, Cary, N.C.).

RESULTSCharacteristics. Participants’ characteristicsare summarized in Table 1. Overall, the numberof missing teeth ranged from 0 to 22. Two hun-dred six women retained all 28 teeth; 257, 297and 346 women lost one to two teeth, three tofive teeth and six or more teeth, respectively.The majority of study participants were whiteand had completed some college education.About one-half of participants reported neverhaving smoked during their lifetime, whereas16.5 percent were heavy smokers when classi-fied according to pack-years of smoking. Two-thirds of study participants reported havingreceived menopausal hormone therapy, withslightly less than one-half reporting current use.More than two-thirds of women reported cur-rent use of a calcium supplement and more thanone-half reported current use of a vitamin Dsupplement. When classified according to WorldHealth Organization42,43 criteria, 48.6 percent ofwomen had low bone mass and 25.5 percent hadosteoporosis.Table 1 also presents selected characteristics

according to tooth loss status. Factors signifi-cantly different according to tooth loss were ageat the OsteoPerio clinic visit, BMI, educationallevel, annual family income, history of diabetesdiagnosis, calcium supplement use, vitamin Dsupplement use, history of gingival surgery anddental visit frequency. Race, toothbrushing fre-quency and flossing frequency did not differaccording to tooth loss status. We did notobserve any significant differences for mostsmoking characteristics, including smokingstatus, packs smoked per day, years of smoking,pack-years of smoking, age at which participantstarted smoking and years since participantquit smoking.



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Smoking andtooth loss. Table 2(page 258) presentsresults for crude,age-adjusted andmultivariable-adjustedlogistic regressionanalyses of smokingexposures and overalltooth loss. In thecrude analyses, heavysmokers had signifi-cantly elevated oddsof experiencingoverall tooth losscompared with neversmokers. This asso-ciation was somewhatstronger after we con-trolled for age. Fur-ther adjustment foreducation, income,BMI, history of dia-betes diagnosis, cal-cium supplementintake and dentalvisit frequency didnot change the pointor interval estimatesappreciably. Packssmoked per day andpack-years ofsmoking, when meas-ured as continuousvariables, showed sig-nificant trends inmultivariable-adjusted models.When we measuredthem as categoricalvariables, the resultsshowed no statisti-cally significant asso-ciations betweensmoking status,packs smoked perday, years of smoking,age at which partici-pant started smokingor years since quit-ting smoking andoverall tooth loss.Reason for tooth

loss. Next, we per-formed separatelogistic regressionanalyses to relate

TABLE 1

Characteristics of 1,106 postmenopausal womenoverall and according to tooth loss status.CHARACTERISTIC OVERALL

(N = 1,106)*NO TOOTH LOSS

(n = 206)*ANY TOOTH LOSS

(n = 900)*P VALUE†

Missing Teeth, Mean(SD‡), No. 5.1 (5.6) —§ 6.2 (5.6) —

Missing Teeth,No. (%)

0 206 (18.6) — 01-2 257 (23.2) — 257 (28.6)3-5 297 (26.9) — 297 (33.0) —≥ 6 346 (31.3) — 346 (38.4)Range — — 1-22

Age at Visit, Mean(SD), in Years 66.9 (7.1) 63.8 (6.4) 67.6 (7.0) < .001

Smoking Status,No. (%)

Never 593 (53.6) 117 (56.8) 476 (52.9).541Former 473 (42.8) 81 (39.3) 392 (43.6)

Current 40 (3.6) 8 (3.9) 32 (3.6)

Packs Smoked perDay, No. (%)

Never 593 (53.6) 117 (56.8) 476 (52.9)

.441< 1 270 (24.4) 52 (25.2) 218 (24.2)1 to < 2 188 (17.0) 30 (14.6) 158 (17.6)≥ 2 55 (5.0) 7 (3.4) 48 (5.3)

Years of Smoking,No. (%)

Never 593 (53.6) 117 (56.8) 476 (52.9)

.359< 16 163 (14.7) 34 (16.5) 129 (14.3)16-30 173 (15.6) 29 (14.1) 144 (16.0)≥ 31 177 (16.0) 26 (12.6) 151 (16.8)

Pack-Years, No. (%)Never 593 (53.6) 117 (56.8) 476 (52.9)

.142Light (< 8 ) 161 (14.6) 34 (16.5) 127 (14.1)Moderate (8-25) 170 (15.4) 32 (15.5) 138 (15.3)Heavy (≥ 26) 182 (16.5) 23 (11.2) 159 (17.7)

Age Started Smoking,Mean (SD), in Years¶ 18.3 (4.2) 17.7 (3.3) 18.5 (4.3) .063

Age Started Smoking,No. (%), in Years¶

< 20 378 (73.7) 71 (79.8) 307 (72.4).151≥ 20 135 (26.3) 18 (20.2) 117 (27.6)

Years Since QuittingSmoking#, Mean (SD) 25.1 (13.1) 25.0 (12.2) 25.2 (13.3) .907

Years Since QuittingSmoking,# No. (%)

≥ 30 182 (38.5) 30 (37.0) 152 (38.8)

.72220-29 117 (24.7) 24 (29.6) 93 (23.7)10-19 105 (22.2) 16 (19.8) 89 (22.7)< 10 69 (14.6) 11 (13.6) 58 (14.8)

* Not all percentages total 100 percent because of rounding.† P value calculated from a t test for continuous variables or a χ2 test for categorical variables.‡ SD: Standard deviation.§ Dash indicates not applicable.¶ Restricted to former and current smokers (n = 513).# Restricted to former smokers (n = 473).** Included sites of total hip, femoral neck, wrist, anteroposterior spine or total body.†† Sources: World Health Organization42; Kanis and colleagues.43‡‡ kg/m2: Kilograms per square meter.



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smoking exposureswith tooth loss due toPD and tooth loss dueto caries as distinctoutcome variables(Table 3, pages 260-261). Of 900 womenreporting loss of atleast one tooth, 108(12 percent) wereclassified as havingexperienced tooth lossdue to PD and 792(88 percent) wereclassified as havingexperienced tooth lossdue to caries. In thecrude analyses, eversmokers, packssmoked per day,duration of smoking,pack-years ofsmoking and yearssince quittingsmoking all showedsignificantlyincreased odds ofexperiencing toothloss due to PD whencompared with find-ings in neversmokers. Afteradjusting for age andother confoundingvariables, we foundthat these increasedodds remained statis-tically significant. Inthe multivariable-adjusted analyses,women who smokedtwo or more packs perday and those withthe heaviest pack-years of smokingexhibited a 10-foldand sevenfold ele-vated odds of experi-encing tooth loss dueto PD, respectively,when compared withfindings in neversmokers.We did not observe

any clear relationshipbetween age at whichthe participant

TABLE 1 (CONTINUED)

CHARACTERISTIC OVERALL(N= 1,106)*

NO TOOTH LOSS(n = 206)*

ANY TOOTH LOSS(n = 900)*

P VALUE*

Worst-Site T-Score,**††

No. (%)

Normal 287 (26.0) 63 (30.6) 224 (24.9)

.096Low bone mass 537 (48.6) 101 (49.0) 436 (48.4)Osteoporosis 282 (25.5) 42 (20.4) 240 (26.7)

Race, No. (%)

Other 34 (3.1) 5 (2.4) 29 (3.2).548White 1,070 (96.9) 201 (97.6) 869 (96.8)

Body Mass Index,Mean (SD), kg/m2‡‡ 26.8 (5.2) 26.0 (4.5) 26.9 (5.4) .015

Education, No. (%)

High School 252 (22.8) 22 (10.7) 230 (25.6)

< .001College 493 (44.6) 101 (49.0) 392 (43.6)Graduate school 361 (32.6) 83 (40.3) 278 (30.9)

Annual FamilyIncome, No. (%), $

< 35,000 466 (42.1) 51 (24.8) 415 (46.1)< .001≥ 35,000 640 (57.9) 155 (75.2) 485 (53.9)

History of DiabetesDiagnosis, No. (%)

No 1,050 (94.9) 202 (98.1) 848 (94.2).024Yes 56 (5.1) 4 (1.9) 52 (5.8)

Ever Use HormoneTherapy, No. (%)

No 370 (33.5) 58 (28.2) 312 (34.7).074Yes 736 (66.6) 148 (71.8) 588 (65.3)

Current Use ofHormone Therapy,No. (%)

No 608 (55.0) 105 (51.0) 503 (55.9).201Yes 498 (45.0) 101 (49.0) 397 (44.1)

Use CalciumSupplement, No. (%)

No 324 (29.3) 47 (22.8) 277 (30.8).024Yes 782 (70.7) 159 (77.2) 623 (69.2)

Use Vitamin DSupplement, No. (%)

No 476 (43.0) 76 (36.9) 400 (44.4).048Yes 630 (57.0) 130 (63.1) 500 (55.6)

History of GingivalSurgery, No. (%)

No 866 (79.1) 173 (84.4) 693 (77.9).038Yes 229 (20.9) 32 (15.6) 197 (22.1)

Brush Teeth

< 2 times/day 259 (23.4) 43 (20.9) 216 (24.0).339≥ 2 times/day 847 (76.6) 163 (79.1) 684 (76.0)

Floss Teeth, No. (%)

Not every day 626 (57.0) 119 (58.1) 507 (56.7).727Every day 473 (43.0) 86 (42.0) 387 (43.3)

Dental Visit

≤ 1 per year 271 (24.5) 35 (17.0) 236 (26.2).006> 1 per year 835 (75.5) 171 (83.0) 664 (73.8)



S T O R YC O V E R

started smoking and tooth loss due to PD. Wedid find a significant inverse trend betweenyears since quitting smoking and reported toothloss due to PD (P trend < .01). There was noclear association between smoking variablesand tooth loss due to caries in crude, age-adjusted or multivariable-adjusted models.

Increasing numbers of packs smoked per dayand duration of cigarette smoking showedslightly increased odds of experiencing toothloss due to caries; however, neither of theseassociations reached statistical significance.We further assessed whether the association

between cigarette smoking and tooth loss dif-

TABLE 2

Association between cigarette smoking and any tooth loss for 1,106postmenopausal women.CHARACTERISTIC NO TOOTH LOSS

(n = 206),NO. (%)*

ANY TOOTH LOSS (n = 900)

No. (%) ofParticipants*

Crude OR†

(95% CI‡)Age-AdjustedOR (95% CI)

Multivariable-Adjusted§

OR (95% CI)

Smoking StatusAnalysis 1Never 117 (56.8) 476 (52.9) 1.0 1.0 1.0Former 81 (39.3) 392 (43.6) 1.19 (0.87-1.63) 1.32 (0.96-1.83) 1.34 (0.96-1.86)Current 8 (3.9) 32 (3.6) 0.98 (0.44-2.19) 1.29 (0.57-2.93) 1.11 (0.47-2.58)Analysis 2Never 117 (56.8) 476 (52.9) 1.0 1.0 1.0Ever 89 (43.2) 424 (47.1) 1.17 (0.86-1.59) 1.32 (0.97-1.81) 1.32 (0.95-1.82)

Packs Smoked perDayNever 117 (56.8) 476 (52.9) 1.0 1.0 1.0< 1 52 (25.2) 218 (24.2) 1.03 (0.72-1.48) 1.11 (0.77-1.62) 1.14 (0.78-1.67)1 to < 2 30 (14.6) 158 (17.6) 1.30 (0.83-2.01) 1.53 (0.97-2.40) 1.49 (0.94-2.35)≥ 2 7 (3.4) 48 (5.3) 1.69 (0.74-3.82) 2.05 (0.89-4.71) 1.90 (0.82-4.50)P for trend¶ — — .141 .026 .050P for trend# — — .271 .135 .210

Years of SmokingNever 117 (56.8) 476 (52.9) 1.0 1.0 1.0< 16 34 (16.5) 129 (14.3) 0.93 (0.61-1.43) 1.18 (0.76-1.83) 1.16 (0.74-1.83)16-30 29 (14.1) 144 (16.0) 1.22 (0.78-1.91) 1.35 (0.85-2.13) 1.40 (0.88-2.24)≥ 31 26 (12.6) 151 (16.8) 1.43 (0.90-2.27) 1.47 (0.91-2.35) 1.41 (0.87-2.29)P for trend¶ — — .099 .102 .123P for trend# — — .158 .628 .757

Pack-yearsNever 117 (56.8) 476 (52.9) 1.0 1.0 1.0Light (< 8) 34 (16.5) 127 (14.1) 0.92 (0.60-1.41) 1.08 (0.70-1.68) 1.10 (0.70-1.72)Moderate (8-25) 32 (15.5) 138 (15.3) 1.06 (0.69-1.64) 1.18 (0.75-1.84) 1.18 (0.75-1.87)Heavy (≥ 26) 23 (11.2) 159 (17.7) 1.70 (1.05-2.75) 1.87 (1.14-3.05) 1.82 (1.10-3.00)P for trend¶ — — .041 .020 .039P for trend# — — .063 .088 .158

Age StartedSmoking#

< 20 71 (79.8) 307 (72.4) 1.0 1.0 1.0≥ 20 18 (20.2) 117 (27.6) 1.50 (0.86-2.63) 1.11 (0.62-1.99) 1.12 (0.62-2.04)P for trend# — — .114 .517 .545

Years Since QuittingSmoking**

≥ 30 30 (37.0) 152 (38.8) 1.0 1.0 1.020-29 24 (29.6) 93 (23.7) 0.77 (0.42-1.39) 0.90 (0.48-1.65) 0.89 (0.47-1.67)10-19 16 (20.0) 89 (22.7) 1.10 (0.57-2.13) 1.24 (0.63-2.44) 1.22 (0.61-2.45)< 10 11 (13.6) 58 (14.8) 1.04 (0.49-2.21) 1.24 (0.57-2.68) 1.24 (0.56-2.73)P for trend# — — .906 .452 .503

* Not all percentages total 100 percent because of rounding.† OR: Odds ratio.‡ CI: Confidence interval.§ Adjusted for age, education, income, body mass index, history of diabetes diagnosis, calcium supplement use and dental visit frequency.¶ Included all participants.# Restricted to former and current smokers (n = 513).** Restricted to former smokers (n = 473).



S T O R YC O V E R

fered according to the severity of tooth loss, asindicated by the reported number of teeth lostdue to PD and the reported number of teeth lostdue to caries as separate outcomes (Table 4,page 262). The patterns of association betweensmoking exposures and severity of tooth loss foreither reason (PD or caries) were similar tothose in Table 3. The results of additionalanalyses showed that there was no evidence ofeffect modification of the association betweensmoking and tooth loss according to calciumsupplement intake, vitamin D supplementintake or hormone therapy (data not shown).Last, we conducted sensitivity analyses for PDrestricted to participants with tooth loss dueexclusively to PD. The point estimates and pat-terns of association with smoking exposureswere similar to those presented in Table 3 (datanot shown).

DISCUSSIONTo our knowledge, this study is the first to eval-uate the association between several smokingexposure variables and tooth loss prevalenceaccording to the specific reason for tooth lossamong a cohort of postmenopausal women. Theavailability of smoking exposure variables inthe OsteoPerio study was more extensive thanthat in most previous studies. In our cohort,heavy smokers (≥ 26 pack-years of smoking) hadsignificantly higher odds of experiencing toothloss compared with never smokers (OR = 1.82;95 percent CI, 1.10-3.00) after we controlled forage, education, income, BMI, history of diabetesdiagnosis, calcium supplement use and fre-quency of dental visits. This result is in accor-dance with those of previous studies in whichinvestigators observed a dose-response relation-ship between cigarette smoking and toothloss.12,13,44-48Moreover, former smokers were at higher

odds of experiencing tooth loss compared withnever smokers, although this association was ofborderline statistical significance in our study(OR = 1.34; 95 percent CI, 0.96-1.86). Investiga-tors in other studies have reported inconsistentassociations between former smoking andoverall tooth loss.12,14-21 In our study, currentsmokers did not have higher odds of experi-encing tooth loss compared with never smokers,which is in contrast with the results of themajority of reports in the literature, which showa wide range (from 1.7 to 4.7) in effect size esti-mates (OR or risk ratio).12-27 However, it isimportant to note that the prevalence of currentsmoking in our study tended to be lower thanthat reported in other cohorts of women, and

this could account in part for the discrepantfindings.Differences in study populations and in

methodologies for defining key variables mayprovide a partial explanation of the disparateresults. Our sample consisted entirely of post-menopausal women who generally were healthyand reported practicing good oral hygiene. Menare more likely than women to smoke and to beheavy smokers, and the effect of smoking ontooth loss may be stronger in men than it is inwomen.27 The prevalence of current smokerswas relatively low (3.6 percent) in our cohort,and all participants were required to have atleast six teeth at study entry.41 Some previousstudies22-26 have included edentulous partici-pants, who also were more likely than partici-pants in our study to have been heavy smokers.The small proportion of current and heavysmokers may have limited the statistical powerof our study to detect stronger and more consis-tent associations between smoking status andtooth loss.When stratified according to reason for tooth

loss, nearly all of the smoking exposure vari-ables were strongly and consistently associatedwith tooth loss due to PD. In contrast, none ofthe smoking exposure variables were associatedwith tooth loss due to caries. Thus, a null rela-tionship between smoking and overall tooth lossin postmenopausal women may be explained bythe limited effect of smoking on tooth loss due tocaries in previous studies. The etiology of theeffect of smoking on tooth loss may explain fur-ther the large range of effect sizes that havebeen reported in the literature.12-27 Althoughcaries is a common reason for tooth loss in allage groups, the frequency of tooth loss due toPD increases with age.35,49 Hence, the effect ofsmoking on tooth loss due to PD may be weakerin studies consisting mostly of young adults,which could further attenuate the point esti-mate between smoking exposures and overalltooth loss, PD and caries combined.To our knowledge, researchers in only one

study conducted in Bangladesh investigatedsmoking as a risk factor for tooth loss due to PDand caries separately, and they reported similarresults.31 However, tooth extraction practices inBangladesh may differ from those in the UnitedStates, which might result in systematically dif-ferent reasons for tooth loss across studies. Inaddition, data in the Bangladesh study were col-lected only for tooth loss occurring in popula-tions of low socioeconomic status (SES) within45 days of the dental visit, so these resultsshould be interpreted with caution.



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Cigarette smoking could accelerate the courseof PD. The results of previous studies suggestthat the chemicals found in smoke select forplaque-forming anaerobic bacteria that may

modify the oral microflora50 and decrease theantioxidative capacity of saliva.51 Free radicalsproduced by the host during the immuneresponse to bacterial stimulation then damage

TABLE 3

Association between cigarette smoking and tooth loss due toperiodontal disease and caries for 1,106 postmenopausal women.CHARACTERISTIC NO TOOTH LOSS,

NO. (%) OFPARTICIPANTS

(n = 206)*

TOOTH LOSS DUE TO PERIODONTAL DISEASE (n = 108)

No. (%) ofParticipants*

Crude OR†

(95% CI‡)Age-AdjustedOR (95% CI)

Multivariable-AdjustedOR§ (95% CI)

Smoking StatusAnalysis 1Never 117 (56.8) 36 (33.3) 1.0 1.0 1.0Former 81 (39.3) 63 (58.3) 2.53 (1.54-4.16) 2.83 (1.66-4.80) 2.99 (1.70-5.23)Current 8 (3.9) 9 (8.3) 3.66 (1.31-10.17) 5.33 (1.82-15.61) 4.07 (1.27-13.03)Analysis 2Never 117 (56.8) 36 (33.3) 1.0 1.0 1.0Ever 89 (43.2) 72 (66.7) 2.63 (1.62-4.27) 3.02 (1.80-5.06) 3.09 (1.78-5.34)

Packs Smokedper DayNever 117 (56.8) 36 (33.3) 1.0 1.0 1.0< 1 52 (25.2) 29 (26.9) 1.81 (1.01-3.26) 1.98 (1.06-3.69) 2.24 (1.15-4.37)1 to < 2 30 (14.6) 31 (28.7) 3.36 (1.80-6.28) 3.81 (1.96-7.43) 3.17 (1.56-6.45)≥ 2 7 (3.4) 12 (11.1) 5.57 (2.04-15.21) 8.64 (2.98-25.10) 10.39 (3.41-31.68)P for trend¶ — — < .001 < .001 < .001P for trend# — — .015 .005 .006

Years ofSmokingNever 117 (56.8) 36 (33.3) 1.0 1.0 1.0< 16 34 (16.5) 8 (7.4) 0.77 (0.33-1.80) 1.02 (0.42-2.50) 1.17 (0.46-2.96)16-30 29 (14.1) 26 (24.1) 2.91 (1.52-5.57) 3.15 (1.60-6.20) 3.31 (1.60-6.82)≥ 31 26 (12.6) 38 (35.2) 4.75 (2.55-8.56) 4.98 (2.59-9.58) 4.64 (2.34-9.23)P for trend¶ — — < .001 < .001 < .001P for trend# — — < .001 .001 .008

Pack-YearsNever 117 (56.8) 36 (33.3) 1.0 1.0 1.0Light (< 8) 34 (16.5) 13 (12.0) 1.24 (0.59-2.61) 1.50 (0.69-3.29) 1.60 (0.70-3.66)Moderate (8-25) 32 (15.5) 16 (14.8) 1.63 (0.80-3.30) 1.68 (0.80-3.56) 1.71 (0.77-3.80)Heavy (≥ 26) 23 (11.2) 43 (39.8) 6.08 (3.24-11.40) 7.15 (3.66-13.97) 6.83 (3.40-13.72)P for trend¶ — — < .001 < .001 < .001P for trend# — — < .001 < .001 < .001

Age StartedSmoking,# Years< 20 71 (79.8) 52 (72.2) 1.0 1.0 1.0≥ 20 18 (20.2) 20 (27.8) 1.52 (0.73-3.15) 1.12 (0.51-2.46) 1.16 (0.48-2.78)P for trend# — — 0.452 0.963 0.838

Years SinceQuittingSmoking**

≥ 30 30 (37.0) 13 (20.6) 1.0 1.0 1.020-29 24 (29.6) 15 (23.8) 1.44 (0.58-3.61) 2.04 (0.76-5.48) 2.11 (0.73-6.06)10-19 16 (19.8) 19 (30.2) 2.74 (1.08-6.95) 3.48 (1.27-9.51) 3.08 (1.02-9.29)< 10 11 (13.6) 16 (25.4) 3.36 (1.23-9.18) 4.36 (1.48-12.81) 4.55 (1.43-14.42)P for trend# — — .009 .002 .008

* Not all percentages total 100 percent because of rounding.† OR: Odds ratio.‡ CI: Confidence interval.§ ORs adjusted for age, education, income, body mass index, history of diabetes diagnosis, calcium supplement use and dental visitfrequency.

¶ Included all participants.# Restricted to former and current smokers (n = 513).** Restricted to former smokers (n = 473).



S T O R YC O V E R

the periodontium, increasing the person’s sus-ceptibility to tooth loss due to PD. Anothermechanism by which cigarette smoking mayaffect PD progression is toxic effects on bone.Study results have shown that nicotine reducesbone density and bone mineral content throughan increased secretion of bone-resorbing factors52or a decreased intestinal uptake of calcium.53Estrogen may attenuate osteoporotic bone loss.54Estrone and estradiol levels have been shown to

be lower in smokers than in non-smokers,55 and this effect may beparticularly deleterious amongpostmenopausal women.In this study, we did not observe

an association between smokingand tooth loss due to caries. Pre-vious research findings suggestthat smoking may increase the riskof developing dental caries byimpairing salivary function andsalivary buffering capacity.56 How-ever, tooth loss due to caries maynot be directly related to smoking,but may be influenced by factorssuch as SES and access to, and uti-lization of, dental care.57 Teeth withdental caries are restorable giventhat dental care is accessible andutilized. Therefore, tooth loss maynot be the end result. On the otherhand, periodontitis, once devel-oped, tends to be persistent. Effec-tive treatment of periodontitis,which is based on control of bothdental biofilm and inflammation, ismore difficult to achieve.58 Thus,periodontitis may lead to tooth lossmore often in older populations.Smoking cessation and PD.

Smoking cessation may prevent PDfrom progressing to tooth loss.Researchers in several studies haveinvestigated the associations ofsmoking cessation with PD59,60 andtooth loss.61,62 However, to ourknowledge, investigators have notstudied the influence of smokingbehavior on specific reasons fortooth loss (caries or PD), and pub-lished findings specifically in post-menopausal women are not avail-able, to our knowledge. Someresearchers have addressed the roleof smoking cessation. Investigatorsconducting a study with use ofNational Health and Nutrition

Examination Survey III data reported that theodds of periodontitis’ developing declined with thereported number of years since smoking cessa-tion.59 The findings of the U.S. Health Profes-sionals’ Follow-Up Study showed that risk of self-reported tooth loss among middle-aged and oldermen decreased after smoking cessation, though itremained elevated by 20 percent even 10 or moreyears after participants quit smoking comparedwith the risk among never smokers.61 Consistent

TABLE 3 (CONTINUED)

TOOTH LOSS DUE TO CARIES (n = 792)

No. (%) ofParticipants

Crude OR(95%CI)

Age-AdjustedOR (95% CI)

Multivariable-Adjusted

OR (95% CI)

440 (55.6) 1.0 1.0 1.0329 (41.5) 1.08 (0.79-1.48) 1.21 (0.87-1.67) 1.22 (0.87-1.70)23 (2.9) 0.76 (0.33-1.75) 1.02 (0.44-2.39) 0.91 (0.38-2.18)

440 (55.6) 1.0 1.0 1.0352 (44.4) 1.01 (0.77-1.33) 1.19 (0.87-1.64) 1.19 (0.86-1.65)

440 (55.6) 1.0 1.0 1.0189 (23.9) 0.97 (0.67-1.40) 1.04 (0.71-1.51) 1.05 (0.72-1.55)127 (16.0) 1.13 (0.72-1.76) 1.38 (0.87-2.19) 1.38 (0.86-2.21)36 (4.6) 1.37 (0.59-3.15) 1.57 (0.67-3.68) 1.41 (0.59-3.39)

— .503 .141 .220— .528 .300 .428

440 (55.6) 1.0 1.0 1.0121 (15.3) 0.95 (0.62-1.46) 1.19 (0.76-1.85) 1.15 (0.72-1.81)118 (14.9) 1.08 (0.69-1.71) 1.19 (0.75-1.90) 1.25 (0.78-2.01)113 (14.3) 1.16 (0.72-1.85) 1.20 (0.74-1.94) 1.17 (0.71-1.92)

— .556 .540 .537— .586 .736 .729

440 (55.6) 1.0 1.0 1.0114 (14.4) 0.89 (0.58-1.38) 1.04 (0.66-1.62) 1.05 (0.66-1.65)122 (15.4) 1.01 (0.65-1.57) 1.13 (0.72-1.78) 1.14 (0.72-1.81)116 (14.7) 1.34 (0.82-2.19) 1.49 (0.90-2.47) 1.46 (0.87-2.44)

— .326 .189 .273— .317 .386 .522

255 (72.4) 1.0 1.0 1.097 (27.6) 1.50 (0.85-2.65) 1.14 (0.63-2.05) 1.16 (0.63-2.13)

— 0.08 0.36 0.35

139 (42.3) 1.0 1.0 1.078 (23.7) 0.70 (0.38-1.28) 0.83 (0.45-1.55) 0.82 (0.43-1.55)70 (21.3) 0.94 (0.48-1.85) 1.06 (0.54-2.11) 1.08 (0.53-2.19)42 (12.8) 0.82 (0.38-1.78) 0.99 (0.45-2.20) 1.01 (0.45-2.29)

— .418 .962 .913



S T O R YC O V E R

with these results, our findings of moderate tostrong positive associations between smokingexposures and tooth loss due to PD suggest thatsmoking cessation and smoking prevention pro-grams potentially could reduce tooth loss due toPD in the growing population of postmenopausal

women in theUnited States.Study limita-

tions. Our studyhad several limita-tions that oneshould considerwhen interpretingits findings. First,causal relation-ships cannot beinferred from thecross-sectional datareported here.However, althoughwe could not deter-mine whether alltooth loss occurredafter smoking expo-sure, we measuredthe duration ofsmoking cessationand our findingssuggest thatsmoking cessationis associated withsignificantly lowerodds of experi-encing tooth lossdue to PD. A secondlimitation is thatthe study cohortconsisted mostly ofwhite women ofhigher SES whohad good oralhygiene; the per-centage of currentsmokers was low.This could limitgeneralizabilityand comparison ofour results withthose in cohortsthat included morecurrent smokers orgroups of greaterethnic or SESdiversity.Validation

study. The reasonsfor tooth loss in this study were self-reported.We conducted a validation study in a subset ofthe OsteoPerio cohort (n = 70) in which theactual prevalence of tooth loss due to PD andthat due to caries was 34 and 54 percent,respectively, as determined by a review of the

TABLE 4

Adjusted* ORs† and 95 percent CIs‡ for the associationsbetween cigarette smoking and severity of tooth lossdue to periodontal disease and caries.VARIABLE ADJUSTED OR (95% CI)

Tooth Loss Dueto Periodontal Disease

Tooth Loss Due to Caries

1 to 3 teeth(n = 53)

More than 3teeth (n = 55)

1 to 3 teeth(n = 394)

More than 3teeth (n = 398)

Smoking StatusNever 1.0 1.0 1.0 1.0Former 3.05 (1.51-6.19) 3.13 (1.49-6.57) 1.28 (0.89-1.84) 1.13 (0.76-1.68)Current 5.04 (1.29-19.77) 3.00 (0.62-14.40) 0.56 (0.18-1.71) 1.50 (0.56-4.00)

Packs Smokedper DayNever 1.0 1.0 1.0 1.0< 1 2.67 (1.19-5.99) 1.70 (0.66-4.30) 1.13 (0.75-1.72) 0.98 (0.62-1.56)1 to < 2 3.00 (1.19-7.57) 4.00 (1.65-9.70) 1.36 (0.82-2.27) 1.36 (0.79-2.34)≥ 2 10.80 (2.88-40.50) 11.26 (2.66-47.71) 1.33 (0.50-3.52) 1.68 (0.63-4.51)P for trend§ < .001 < .001 .341 .186P for trend¶ .022 .024 .697 .217

Years of SmokingNever 1.0 1.0 1.0 1.0< 16 0.78 (0.20-3.11) 1.67 (0.52-5.36) 1.45 (0.90-2.35) 0.76 (0.42-1.36)16-30 3.72 (1.55-8.91) 2.95 (1.14-7.64) 1.16 (0.69-1.95) 1.35 (0.78-2.33)≥ 31 4.98 (2.18-11.39) 4.53 (1.82-11.24) 1.00 (0.57-1.75) 1.44 (0.82-2.53)P for trend§ < .001 < .001 .926 .167P for trend¶ .009 .126 .134 .190

Pack-yearsNever 1.0 1.0 1.0 1.0Light (< 8) 1.19 (0.38-3.72) 2.08 (0.73-5.95) 1.23 (0.76-2.00) 0.82 (0.46-1.43)Moderate (8-25) 2.44 (0.96-6.19) 1.10 (0.33-3.63) 1.12 (0.68-1.85) 1.16 (0.68-1.99)Heavy (≥ 26) 7.07 (3.04-16.41) 7.59 (3.05-18.90) 1.36 (0.77-2.39) 1.65 (0.93-2.95)P for trend§ < .001 < .001 .621 .115P for trend¶ .001 .004 .887 .133

Age StartedSmoking,¶ Years< 20 1.0 1.0 1.0 1.0≥ 20 0.69 (0.22-2.18) 2.19 (0.74-6.50) 1.13 (0.58-2.19) 1.17 (0.58-2.35)P for trend¶ .295 .068 .326 .534

Years Since QuittingSmoking#

≥ 30 1.0 1.0 1.0 1.020-29 2.13 (0.58-7.86) 2.14 (0.52-8.79) 0.58 (0.29-1.20) 1.23 (0.57-2.64)10-19 2.80 (0.72-10.94) 3.58 (0.84-15.13) 0.78 (0.36-1.69) 1.86 (0.79-4.38)< 10 4.95 (1.25-19.59) 4.97 (1.08-22.95) 0.81 (0.34-1.93) 1.46 (0.53-3.92)P for trend# .018 .044 .414 .213

* Adjusted for age, education, income, body mass index, history of diabetes diagnosis, calcium supplementuse and dental visit frequency. The reference group was women who retained all 28 natural teeth(excluding third molars).

† OR: Odds ratio.‡ CI: Confidence interval.§ Included all participants.¶ Restricted to former and current smokers (n = 513).# Restricted to former smokers (n = 473).



S T O R YC O V E R

participant’s dental record by her personal den-tist (via a mailed questionnaire). Results of thisvalidation study showed that most self-reportsof not having experienced tooth loss due to PDwere confirmed by the participants’ personaldentists (43 of 59 dentists; negative predictivevalue = 72.9 percent). Likewise, the majority ofself-reports of having experienced tooth loss dueto PD were confirmed by participants’ personaldentists (eight of 11 dentists; positive predictivevalue = 72.7 percent). Given the relatively smallnumber of false-positive reports of tooth lossdue to PD, the findings of this validation studyalso indicated that the reason for tooth loss wasself-reported with high specificity (93.5 percent).Conversely, we observed low sensitivity (33.3percent) of self-reported tooth loss due to PD,owing to a relatively high proportion of false-negative values. This finding indicates thatwomen in our study underreported PD as thereason for their tooth loss, perhaps in partbecause caries also affected the tooth, and thediscussion about caries with the dentist, thetreatment of caries or both may have beenrecalled more clearly by participants than wasa diagnosis of PD in the same tooth.As a result, our findings regarding the asso-

ciation between smoking habits and PD could beunderestimated, and findings pertaining to therole of smoking in tooth loss due to caries maybe overestimated because they include sometooth loss due to PD. Most self-reports of toothloss due to caries were confirmed by partici-pants’ personal dentists (37 of 58 dentists; posi-tive predictive value = 63.8 percent). Nonethe-less, there were a sizable number of false-positive findings, resulting in low specificity(34.4 percent) of reported tooth loss due tocaries. Among women who reported no toothloss due to caries, the number of false-negativefindings was small (one of 12), which resulted inhigh values for both sensitivity (97.4 percent)and negative predictive value (91.7 percent).Collectively, the validation study findings indi-cate that the reported associations betweensmoking habits and tooth loss may be biasedtoward the null hypothesis. Thus, the strongassociation between smoking and tooth lossspecifically due to PD would not be expected tobe changed in the study.Several study strengths add relevance to the

current literature pertaining to smoking andtooth loss. These include the following:da relatively large study group compared withthose of previous studies;dan entirely postmenopausal cohort of olderwomen in whom the burden of poor oral health

and the need for improved prevention and con-trol opportunities will challenge public healthand clinical periodontology increasingly incoming years;ddental assessment information collectedduring comprehensive standardized oral exami-nations by trained dental examiners who couldverify which teeth were missing;devaluation of several smoking exposure vari-ables typically not available in previous epi-demiologic studies of this issue;dthe availability of information about severalindividual and clinical factors that could beevaluated as potential confounding effects onthe observed association between smoking andtooth loss.To our knowledge, this is one of the most com-

prehensive examinations of smoking and toothloss; these are the only available findings in alarge, well-characterized cohort of post-menopausal women who were not selected onthe basis of PD or through clinical periodontalcatchments.

CONCLUSIONSThese study findings suggest that there is anassociation between cigarette smoking andtooth loss in postmenopausal women, and thisassociation primarily is the result of tooth lossdue to PD. Investigators in previous studies whodid not examine the role of smoking according tothe reason for tooth loss may have underre-ported the importance of smoking in tooth loss,especially tooth loss due to PD. Researchers infuture studies should investigate the reasons fortooth loss in older adults when consideringsmoking as a risk factor. Our findings suggestthat smoking prevention and control could beimportant facets of comprehensive targetedstrategies to control PD and its oral health com-plications in the growing population of post-menopausal women in the United States. �

Disclosure. None of the authors reported any disclosures.

This study was supported by grant R01DE013505 from theNational Institute of Dental and Craniofacial Research, NationalInstitutes of Health (NIH), Bethesda, Md., to Dr. Wactawski-Wende,U.S. Army, Medical Research and Materiel Command, Fort Detrick,Md., grant OS950077 and NIH/National Heart Lung and Blood Insti-tute contracts N01WH32122 and HHSN268201100001C (Women’sHealth Initiative) to Dr. Wactawski-Wende.

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