Professional Documents
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PERIODONTOLOGY 2000
ISSN 0906-6713
Periodontitissystemic disease
associations in the presence of
smoking causal or
coincidental?
P. P. H, M. D, C. S & T. A. DR
No current issue in periodontal research is more visible or controversial than the relationship between
periodontitis and systemic diseases. Although there
is some awareness that the observed associations
could be coincidental, as a result of confounders
such as age and smoking, the full impact such confounding can have, especially without adequate statistical adjustment, does not seem to be appreciated.
Four lines of evidence suggests that the observed
periodontitissystemic disease associations are, in
part, a result of confounding by smoking the inability to distinguish the effect of smoking on periodontitis from the effect of smoking on systemic diseases. First, no periodontitissystemic disease associations have been identified among neversmokers. Second, periodontitis and smoking mimic
one another with respect to the types of diseases
with which they are associated (e.g. lung cancer and
Parkinsons disease). Third, only studies with inadequate adjustment for smoking report significant
periodontitissystemic disease associations. Lastly,
elimination of dental infection, unlike smoking cessation, does not reduce coronary heart disease risk.
A systematic evaluation of the periodontitissystemic associations among healthy never-smokers
would help to indicate in which direction, if any, periodontitissystemic disease research should progress.
without periodontitis (11). Therefore, when individuals with and without periodontitis are compared it
is to be expected that individuals with periodontitis
will have more smoking-related diseases, such as
coronary heart disease, lung cancer, low-birthweight babies etc., than individuals without periodontitis. The comparison between individuals with
and without periodontitis with respect to the occurrence of systemic diseases is said to be biased because of the unequal distribution of smoking in the
two groups. In epidemiological terminology, smoking is referred to as a confounder; smoking spuriously inflates the association between periodontitis
and smoking-related diseases because it is causally
related to both, regardless of whether periodontitis
and the systemic diseases are causally related to
each other.
Statistical adjustment or control for confounding
is possible using different statistical methods such as
stratification or covariance adjustment in statistical
models. Such statistical adjustment can be used to
eliminate some but (and this is a critical point) not
all of the bias caused by the higher prevalence of
smokers among individuals with periodontitis. The
goal of statistical adjustment is to make the two
compared groups (individuals with and without
periodontitis) similar with respect to the true lifelong exposure to any form of tobacco smoking. This
true life-long exposure requires detailed information
on many variables such as the dose (amount of tobacco used), chemical composition of smoke (use of
filter, type of tobacco) and smoking intensity
(amount of smoke inhaled) during a persons entire
lifetime.
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Hujoel et al.
52
ment for smoking history), and never-smokers exclusively. The association between periodontitis and
the systemic disease is reported using hazards ratios.
A hazards ratio of 1.0 indicates a lack of association,
a value above 1.0 indicates an elevated risk and a
value below 1.0 indicates a protective effect of periodontitis. If smoking is the driving factor behind the
periodontitissystemic disease associations, the
magnitude of the associations should decrease as
the control for smoking increases and the prevalence
of smoking decreases.
Table 1. Adjustment for tobacco smoking and the magnitude of periodontitissystemic disease associations
Excellenta
Goodb
Poorc
1.24 (0.901.72)
1.42 (1.161.72)
1.52 (1.211.91)
Lung cancer
0.58 (0.122.78)
1.48 (0.882.50)
1.94 (1.143.30)
1.11 (0.791.57)
1.09 (0.821.45)
1.19 (0.841.73)
1.04 (0.821.32)
1.13 (0.951.34)
1.26 (1.021.56)
Disease
COPDd
e
Stroke
g
CHD
a
Excellent control for smoking refers to analyses limited to never-smokers (duration of smoking 0 years).
b
Good control for smoking was obtained by including smokers in the analyses (50% of the population) and adjusting the analyses for the logarithm of smoking
duration and the number of cigarettes per day
c
Poor control for smoking was obtained by limiting the analyses to smokers and not adjusting the analyses for smoking duration or dose.
d
COPD, chronic obstructive pulmonary disease (analyses were adjusted for age, age squared, race, poverty index, education, smoking duration and dose, and
vitamins A and C).
e
Lung cancer (analyses adjusted for the same variables as COPD analyses).
f
Stroke (analyses were adjusted for same variables as CHD analyses).
g
CHD, coronary heart disease [analyses adjusted for age, age squared, gender, race (two indicator variables for African American and other), poverty index,
marital state, education, and an interaction term for marital state and gender, diastolic blood pressure, systolic blood pressure, serum cholesterol, diabetes,
log (height), log (weight), log (number of glasses per day), physical activity (indicator variable for heavy recreational or nonrecreational physical activity), and
nervous breakdown and sampling design]. No adjustment for sampling weights was performed. The results differ by 1% from a previous report (11) (1.13 vs.
1.14) because 14 individuals missed in the previous analyses were included in the current analyses.
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Hujoel et al.
Table 2. Smoking- and periodontitis-related systemic diseases; similarity of the pattern of the associations
Diseases
Periodontitis
associated
Smoking identified
as a causal factor
Periodontitissystemic
disease association
Smokingsystemic
disease association
Lung cancer
&
&
1.48 (0.882.50)
7.11 (3.3115.26)
COPD
&
&
1.42 (1.161.72)
2.63 (2.243.09)
CHD
&
&
1.13 (0.951.34)
1.41 (1.201.66)
Stroke
&
&
1.09 (0.821.45)
1.26 (0.961.67)
Parkinsons diseasea
&
&
0.62 (0.341.14)
0.72 (0.411.25)
&
&
Diabetes
&
&
54
Table 3. Control for smoking dose and the magnitude of the periodontitiscoronary heart disease association
Control
for smoking
dose
Study
referencea
Hazard ratio or
relative risk (95%
confidence interval)
No
(19)
1.21 (1.081.36)
No
(7)
2.68 (1.305.50)
No
(1)
1.50 (1.042.14)
No
(5)
1.25 (1.061.48)
Summary
1.25 (1.151.37)
Yes
(12)
0.97 (0.721.31)
Yes
(22)
1.37 (0.802.35)
Yes
(17)
1.04 (0.861.25)
Yes
(10)
1.01 (0.881.15)
Yes
(11)
1.13 (0.951.34)
Summary
1.05 (0.961.15)
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Hujoel et al.
Table 4. Hazard ratios (HRs) for coronary heart disease (CHD) events and CHD mortality associated with elimination of dental infectionsa
HR
95% CI
HR
95% CI
DMG/SES
CVR1
CVR2
1.52
1.351.70
1.61
1.351.92
1.08
0.951.22
1.10
0.911.33
1.04
0.901.20
0.99
0.791.25
1.02
0.871.19
1.02
0.791.31
1.02
0.861.21
1.02
0.811.29
Sample design
HRs larger than 1 indicate a harmful effect of dental infection elimination, less than 1 indicate that dental infection elimination reduces CHD risk.
a
Coronary heart disease (CHD) events include revascularization, nonfatal myocardial infarction, and fatal CHD. CI indicates confidence interval. Comparisons
are made to individuals with a chronic dental infection, periodontitis. Individuals with periodontitis had a periodontal pocket with attachment loss (i.e. not
merely a deepened gingival crevice because of swelling in the free gingiva).
DMG/SES: age, age squared, gender, race (two indicator variables for African American and other), poverty index, marital state, education, and an interaction
term for marital state and gender.
CVR1: log(smoking duration), number of cigarettes per day, diastolic blood pressure, systolic blood pressure, serum cholesterol, diabetes.
CVR2: height, weight, an interaction term for height and weight, log(number of glasses per day), physical activity (indicator variable for heavy recreational or
nonrecreational physical activity), nervous breakdown.
Sample Design: multistage cluster sampling without replacement.
56
event among edentulous individuals did not decrease when compared to individuals with periodontitis. If a complete, definitive and irreversible
elimination of dental infection through complete
tooth removal does not lower CHD risk, why would
an incomplete, imperfect and reversible decreasing
of the bacterial load by means of periodontal treatments decrease CHD risk? Some have offered the explanation that the risk, once established, is not reversible and therefore primary periodontitis prevention trials, rather than secondary prevention, should
be initiated (16). An alternative explanation of this
evidence is that, unlike smoking cessation, dental infection elimination has no impact on CHD incidence
(13).
The current intervention evidence is consistent
with the hypothesis that dental infections occur coincidentally with, but are not causal for, increased
cardiovascular risk. Periodontitis is known to be
strongly associated with smoking, which also elevates systemic disease risks. The elimination of dental
infections may not reduce cardiovascular disease
risk because the elimination of dental infections
does not necessarily have an effect on smoking
habits.
Periodontitissystemic disease
studies need to be limited to neversmokers
Substantial evidence indicates that periodontitis
systemic disease associations are inflated because
the effect of smoking on periodontitis cannot be separated from the effect of smoking on systemic diseases. The bias caused by smoking explains why the
complete elimination of dental infections does not
decrease CHD risk (12) and why no significant periodontitissystemic disease associations have been
identified among never-smokers. In addition, the
bias caused by smoking explains why in populations
with a high smoking prevalence, periodontitis behaves like a surrogate measure for smoking being
associated with an elevated risk for the smoking-related diseases, such as COPD, and with a decreased
risk for a disease against which smoking protects,
Parkinsons disease. It is obviously ludicrous to suggest inducing periodontitis to treat Parkinsons disease, but is the epidemiological evidence for treating
periodontitis to prevent secondary CHD events any
better? While methodological issues other than
smoking remain important (13), the next step in re-
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Hujoel et al.
References
1. Beck J, Garcia R, Heiss G, Vokonas PS, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol
1996: 67: 11231137.
2. Breslow RA, Wideroff L, Graubard BI, Erwin D, Reichman
ME, Ziegler RG, Ballard-Barbash R. Alcohol and prostate
cancer in the NHANES I epidemiologic follow-up study.
First National Health and Nutrition Examination Survey of
the United States. Ann Epidemiol 1999: 9: 254261.
3. Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW, Jr.
Body-mass index and mortality in a prospective cohort of
US adults. N Engl J Med 1999: 341: 10971105.
4. Cowley G. The Heart Attackers. Newsweek 1997: 130: 46
48.
5. DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell
CM. Dental disease and risk of coronary heart disease and
mortality [see comments]. BMJ 1993: 306: 688691.
6. Feskanich D, Ziegler RG, Michaud DS, Giovannucci EL,
Speizer FE, Willett WC, Colditz GA. Prospective study of
fruit and vegetable consumption and risk of lung cancer
among men and women. J Natl Cancer Inst 2000: 92: 1812
1823.
7. Genco R, Chadda S, Grossi S, Dunford R, Taylor G, Knowler W, Pettitt D. Periodontal disease is a predictor of cardiovascular disease in a Native American Population. J Dent
Res 1997: 76: 408 (Abstract 3158).
8. Graubard BI, Korn EL. Analyzing health surveys for cancer-related objectives. J Natl Cancer Inst 1999: 91: 1005
1016.
9. Hoffmann D, Djordjevic MV, Hoffmann I. The changing
cigarette. Prevent Med 1997: 26: 427434.
10. Howell TH, Ridker PM, Ajani UA, Hennekens CH, Christen
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2001: 37: 445450.
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Appendix
Statistical adjustment: over-, under-, and
appropriate adjustment for confounders and its
relationship to divergent results on the
periodontitisstroke association
An analysis is said to be under-adjusted when an important
confounding variable such as alcohol, which is causing
both periodontitis and stroke, is inadequately accounted
for in the analyses. Under-adjustment may be a common
problem in periodontitissystemic disease studies and may
result in an over-estimation of the true association between
periodontitis and systemic diseases (27). In contrast, an
analysis is said to be over-adjusted when adjustment is
made for a potentially confounding variable that is in the
etiological pathway. For instance, if periodontitis causes increased serum C-reactive protein (CRP) levels, and high
CRP causes systemic disease, adjustment for CRP leads to
over-adjustment. As a result of this over-adjustment, the
true impact of periodontitis on systemic disease is underestimated. While no analysis is perfectly adjusted (all
models are wrong), the ideal analyses would make the
comparison of stroke in individuals with and without periodontitis identical with respect to all confounding variables
except the periodontal status.
The impact of over- vs. under-adjustment on the reported risks depends on the population under study. If individuals with and without periodontitis are similar with
respect to potentially confounding variables, over- vs.
under- adjustment will have almost no impact on the periodontitissystemic disease association. For instance, in the
Physicians Health Study, severe under-adjustment (no adjustment for any potentially confounding variables) leads
to the conclusion that periodontitis increases the risk for
a nonfatal myocardial infarction (MI) by 12% (10). When
adjustment is made for a long list of confounding variables
in the analyses (age, aspirin- and b-carotene-assignment,
smoking, alcohol use, hypertension, body mass index, diabetes, physical activity and family history of heart disease),
periodontitis is associated with a 1% increased nonfatal MI
risk. In this homogeneous population, the difference between under-adjusted vs. potentially over-adjusted analyses is small (11%). In homogeneous populations the topic
of potential over- vs. under-adjustment is primarily of academic interest only, because either approach leads to almost identical conclusions. On the other hand, if individuals with and without periodontitis are dissimilar with respect to potentially confounding variables, over- vs. underadjustment can lead to different conclusions.
In heterogeneous populations, different research groups
can obtain different answers depending on how confounding variables are adjusted for in the analyses. We report in this study that the risk for stroke associated with
periodontitis is an insignificant hazard ratio of 1.09. Another study using the same data reported a significant
Sampling weights
Adjustment for sampling weights in the NHEFS sample
substantially increases periodontitissystemic disease associations. For stroke, the hazard ratio increases from 1.09
to 1.35. Because we do not understand how sampling
weights relate to the causal pathway and because no information is available on how sample weights were calculated,
we have presented both weighted and unweighted results
in all our work (11, 14). Statisticians working on the topic
of sampling weights have often elected to present the unweighted results (2, 8). In Table 1 of this report, unweighted
results are presented. Whether adjustment for sampling
weights is appropriate and represents over- or under-adjustment needs careful attention in periodontitissystemic
disease research because it influences the findings greatly.
Until information exists on how weights were calculated or
how they play a role in the causal pathway, we feel uncomfortable including them in our primary analyses.
Edentulous individuals
The inclusion of edentulous individuals inflates the periodontitissystemic disease associations. For stroke, the
hazard ratio changes from 1.09 to 1.15 (in the unweighted
analysis) or to 1.41 (in the weighted analyses). When the
primary goal of the analysis is to compare individuals with
periodontitis to individuals without gingivitis or periodontitis, the inclusion of edentulous individuals serves
only one purpose obtaining a more accurate estimate of
the impact of confounders. If such increased precision occurs at the cost of increased bias, it violates the principle
of first looking for a valid (unbiased) estimate, and only
then looking for ways to improve precision. Since the inclusion of edentulous individuals biases the comparison of
individuals with a healthy periodontium to individuals with
periodontitis, we believe that they should be deleted from
the analyses. For some diseases, such as lung cancer, the
inflation of the hazard ratio that results as a consequence
of including edentulous individuals is substantial.
Alcohol
A systematic review indicated the presence of a consistent
association between alcohol and stroke, with some evi-
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Hujoel et al.
dence for a linear association between alcohol and hemorrhagic stroke, and inconsistent information for establishing
a J-shaped association for alcohol and ischemic stroke (20).
As a result, adjustment for the number of alcoholic drinks
is important. In an analysis that adjusts for the typical
number of drinks per week, the risk for periodontitis associated with stroke is 1.09. If one adjusts for alcohol consumption by including an indicator variable that is positive
when an individual reports yes to the question During the
past year have you had at least one drink of beer, wine, or
liquor? the hazard ratio increases to 1.17. Not adjusting
for number of drinks leads to a higher periodontitisstroke
association. Since individuals with periodontitis drink significantly more alcohol than individuals with a healthy
periodontium, not adjusting for alcohol is an under-adjustment, which spuriously inflates the periodontitisstroke association.
These various analyses show how hazard ratios can
change significantly depending on how statistical adjustments are made. Including edentulous individuals, not including an estimate of alcohol consumption, and including
sampling weights provides one example of how the hazard
ratio can be changed from an insignificant 1.09 to a significant 1.53.
An analysis plan (i.e. which variables to adjust for in the
analysis) should be decided prior to conduct of the analysis, rather than in response to what is seen in the data, in
order to avoid data dredging (i.e. searching for the analysis
60
that maximizes the desired result). For reporting stroke results, we utilized our analysis plan for coronary heart disease (CHD), which we adopted prior to analyzing the CHD
data. We did not see any reason to change this plan for
stroke because CHD and stroke have similar risk factors.
Rigorous control for confounding variables through restriction of the sample to, for example, never-smokers or to
those individuals for whom alcohol consumption is known,
comes at a cost a decreased sample size. In a study on
the effect of body mass index and mortality, the decision
to limit the primary analysis to healthy never-smokers resulted in an elimination of 75% of the sample (3). Valid
(unbiased) estimates for periodontitissystemic disease associations come at a similar price a substantial decrease
in precision. In the NHEFS study, our analyses resulted in
the elimination of individuals who did not provide information on the number of alcoholic drinks consumed or
smoking duration and dose. To limit the analyses to neversmokers with no prior history of cardiovascular disease,
54% of the NHEFS sample would be eliminated. While this
price in terms of deleted sample size is high, it may be the
best approach available for obtaining valid estimates. It is
of critical importance that these differences in analytic
plans and their corresponding differences in estimated effects be fully understood because very few large well-controlled cohort studies on the periodontitissystemic disease
associations are available.