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					                      Periodontal disease and smoking to age 32: a cohort study
                      WM Thomson, JM Broadbent, R Poulton, D Welch, JD Beck                                                                                                                         (Universities of Otago and North Carolina)

Abstract                                                                 At ages 26 and 32, systematic periodontal exams were conducted using                                                                                           Periodontal disease and smoking exposure
While smoking has been shown to be the primary                           an NIDR probe at 3 sites/tooth (mesiobuccal, midbuccal, distolingual),    30                                                                                   The prevalence and incidence of periodontitis were higher among current
behavioural risk factor for periodontal attachment loss                  with gingival recession (GR) and probing depth (PD) measured at each                                                                                           smokers than among former or never smokers (Figure 2). When the more
                                                                         site. These were added at the analysis stage to give an estimate of       25
                                                                                                                                                                                                                                        detailed exposure categories from Table 1 were used, it was apparent that
(AL), a lack of longitudinal exposure data from people
                                                                         combined attachment loss (CAL) for each site. At 26, diagonal half-                                                                                            there were some clear differences among those groups (Figure 3). A higher
aged in their 20s and 30s means that information is                      mouth exams were done; at 32, full-mouth exams were done. Age-32
                                                                                                                                                   20

lacking on smoking‟s role as a risk factor for AL through a                                                                                                                                                                             proportion of those who had smoked for longer (or more recently) were cases
                                                                         prevalence data reported here use full-mouth exam data, while age-26-                                                                                          or had experienced increases in CAL. When the 61 individuals who had given




                                                                                                                                               %
                                                                                                                                                   15
key period in the condition‟s development. Aim: to                       32 incidence data are based on half-mouth comparisons.                                                                                                         up smoking since age 26 were compared with the remainder, their disease
describe the association between long-term smoking and                   Measurement of smoking exposure                                           10
                                                                                                                                                                                                                                        experience was comparable to that of the “never-smokers” (Figure 4).
age-32 periodontitis, and to determine the effects of                    This took two forms: first, a categorical approach was used, whereby      5
recent smoking cessation. Methods: In a longstanding                     the smokers were determined for each age, and then each participant
prospective cohort study of all individuals born in 1972/73              was allocated to one of 32 possible smoking history categories; and       0
                                                                                                                                                        1+ sites with 5+mm CAL at age 32   1+ sites with 3+mm increase in CAL
                                                                         second, the number of pack-years was calculated. The pack-years data
in Dunedin (NZ), systematic periodontal examinations                                                                                                                             Smoking status
                                                                         were used to validate the categorical approach to smoking history. At
conducted at age 26 were repeated at age 32. Smoking                     age 15, smoking was determined using the question “Have you smoked                                 Never     Former    Current

exposure had been documented at ages 15, 18, 21, 26                      in the last 4 weeks?”. At age 18, we used “Have you been smoking
and 32. Results: Of the 810 individuals assessed: 51.1%                  every day for the last month?”. At ages 21, 26 and 32, we used “Have           Figure 2. Age-32 CAL prevalence and
had never smoked; 37.2% had smoked at 1+ of those                        you smoked every day for one month or more of the previous 12                  26-32 incidence of CAL, by smoking
                                                                         months?”. Each participant was then allocated a categorical code where,        status at age 32
ages; and 11.7% were smokers at all 5 ages. In those
groups, prevalence estimates for 1+ sites with 5+mm AL                   for example someone who had smoked at none of ages 15 through 32
were 4.3%, 16.9% and 29.5% respectively (P<0.01).                        was coded as “00000‟, while someone who had smoked at each of them
                                                                         was coded as „11111‟. Thus, a participant who had smoked at ages
Similar patterns were seen with the extent and severity of
                                                                         15,18 and 32 but not at ages 21 and 26 was coded as „11001‟.
AL. Among the 25 (3.1%) who had ceased smoking
between ages 26 and 32, AL prevalence and severity were
similar to the never-smokers. Those “recent quitters” had                Results
the highest proportion of individuals categorised as                     Periodontal exam data from ages 26 and 32 were available for 882               Table 1. Exposure groups
“periodontally healthy” according to criteria based on                   individuals (86.9% of the surviving 1015), and complete smoking-
probing depth and bleeding on probing (Moss et al, 2005).                history and periodontal data were available for 810 (91.8%) of those               Smoking
                                                                                                                                                         exposure group
                                                                                                                                                                                N          Mean pack-
                                                                                                                                                                                           years (sd)
Multivariate    modeling    confirmed      these    findings.            (50.7% males).                                                                                                                                                       Figure 3. Age-32 CAL prevalence and 26-32 incidence of CAL,
                                                                         Smoking status                                                                       00000            414          0.1 (0.4)
Conclusion: While smoking through adolescence and                                                                                                                                                                                             by smoking exposure category (those with N = 10+). * indicates
                                                                         Just under half (396, or 48.9%) had ever smoked, and there was
                                                                                                                                                                                                                                              those who gave up after age 26
                                                                                                                                                              10000             33          0.2 (0.6)
adulthood is associated with poorer periodontal health by                considerable intra-individual fluctuation in smoking between ages 15
the early 30s, smoking cessation after the mid-20s
                                                                                                                                                              10001              1           0.3 (—)
                                                                         and 32 (Figure 1). 750 (92.6%) Study members were distributed over 13
appears to increase the likelihood of a return to                        smoking exposure categories with N > 9 (Table 1), while the remaining
                                                                                                                                                              01000              6          1.8 (1.6)                                              %
                                                                                                                                                                                                                                                   25
periodontal health by age 32. Supported by the Health                    60 participants were distributed over 16 other combinations.                         01010              1           2.4 (—)

Research Council of New Zealand and NIDCR grant R01                                                                                                           00001              9          2.9 (2.0)                                              20

DE-015260-01A1.                                                                                                                                               11000              1           3.1 (—)                                               15

Introduction                                                                                                                                                  10010              3          3.1 (2.8)
                                                                                                                                                                                                                                                   10
It is now well-established that smoking is the primary behavioural                                                                                            00100             10          3.2 (2.4)
                                                                                                                                                                                                                                                     5
risk factor for periodontitis1,2, but a number of unanswered                                                                                                  10100              1           4.0 (—)

questions remain, largely because of the scarcity of information on                                                                                           00010             11          4.4 (4.3)                                                0
the natural history of periodontitis and its risk factors among adult                                                                                                                                                                                                     Never                            Ceased by 32                           Everyone else
                                                                                                                                                              11100             11          4.9 (2.3)
populations. Until very recently3,4, the only available information on                                                                                                                                                                                                                   Prevalence 5+mm                   Incidence 3+mm
periodontal disease in population-based samples of people in their                                                                                            00110             12          4.9 (2.8)

third and fourth decades of life has come from cross-sectional                                                                                                10011              6          5.4 (2.5)                                            Figure 4. Age-32 CAL prevalence and 26-32 incidence of CAL
studies (surveys). There were no reports from cohort studies,                                                                                                 00101              4          5.6 (0.1)                                            by smoking exposure group
meaning that information is lacking on the nature of smoking‟s role
as a risk factor for periodontal attachment loss (AL) through what is                                                                                         01100              6          5.8 (3.0)

arguably a key period in the condition‟s development. Bergstrom4                                                                                              10110              6          6.2 (2.1)               The Population Attributable Risk from smoking for new cases of 5+mm CAL was 67.1%,
has recently highlighted the need for longitudinal data on the                                                                                                00011             16          6.2 (3.7)
                                                                                                                                                                                                                    indicating that two-thirds of new cases of periodontitis were due to smoking.
relationship, not only to determine the effects of continued
                                                                                                                                                              01110             13          7.5 (2.4)               Conclusions
smoking, but also to quantify the positive effects of smoking                                                                                                                                                       Patterns of smoking through the life course are complex. Smoking is confirmed as a risk
cessation, for which there is a steadily accumulating body of                                                                                                 11110             25          8.3 (4.8)
                                                                                                                                                                                                                    factor for AL among younger adults: the greater the duration of smoking, the greater
evidence2,5.                                                                                                                                                  11010              2          8.8 (6.5)
                                                                                                                                                                                                                    the disease. Giving up smoking after the mid-20s is associated with improved
Study aim: to describe and quantify the association between                                                                                                   00111             38         10.0 (4.6)               periodontal health by the early 30s.
long-term smoking and periodontitis by age 32, and to determine                                                                                               10111             16         10.3 (5.0)
the effects of smoking cessation after age 26 upon age-32                                                                                                                                                          Acknowledgments
                                                                            Figure 1. Changes in smoking status from ages 15                                  11101              3         10.8 (3.2)              This work was supported by Grant R01 DE-015260-01A1 from the National Institute of Dental and Craniofacial
periodontitis.
                                                                            through to 32                                                                                                                          Research, National Institutes of Health, Bethesda, Maryland, 20892, USA, and a programme grant from the Health
Methods
                                                                                                                                                              01101              1          13.0 (—)
                                                                                                                                                                                                                   Research Council of New Zealand. The Study members, their families and their friends are thanked for their continuing
                                                                                                                                                                                                                   support. The Dunedin Multidisciplinary Health and Development Research Unit is supported by the Health Research
The Dunedin Multidisciplinary Health and Development Study
                                                                                                                                                              01111             56         13.3 (4.6)
                                                                                                                                                                                                                   Council of New Zealand.
(DMHDS) is a longitudinal study of a birth cohort of 1037 children        Periodontal disease incidence and prevalence                                        11111             95         13.9 (5.3)

who were born Dunedin (NZ) between 1/4/72 and 31/3/73. Periodic                                                                                                                                                    References
                                                                          Overall, 27.9% had 1+ sites with 4+mm CAL, and 12.0% had 1+ sites                   01011              4         15.0 (6.6)              1.   Gelskey SC. Cigarette smoking and periodontitis: methodology to assess the strength of evidence in support of a causal association. Comm Dent Oral Epidemiol 1999; 27:16-24.
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                                                                                                                                                                                                                   2.
                                                                                                                                                                                                                   3.
                                                                                                                                                                                                                        Johnson GK, Hill M. Cigarette smoking and the periodontal patient. J Perio 2004; 75:196-209.
                                                                                                                                                                                                                        Thomson WM et al. Changes in periodontal disease experience from age 26 to 32 in a birth cohort. J Perio 2006; 77: 947-954.
                                                                                                                                                              11011              6         17.8 (5.0)
examinations) have been undertaken since age 3. The current               26 and 32 was experienced by 12.7% (“incident cases”).
                                                                                                                                                                                                                   4.
                                                                                                                                                                                                                   4.
                                                                                                                                                                                                                        Hashim R et al. Smoking in adolescence as a predictor of early loss of periodontal attachment. Comm Dent Oral Epidemiol 2001; 29:130-135.
                                                                                                                                                                                                                        Bergstrom J et al. A 10-year prospective study of tobacco smoking & periodontal health. J Perio 2000; 71:1338-47.
study uses data collected from assessments at ages 15, 18, 21, 26                                                                                         All combined         810          4.5 (6.3)              5.   Bergstrom J. Tobacco smoking and risk for periodontal disease. J Clin Perio 2003; 30:107-13.

and 32.
                                                                                                                                                                                                                                                                                      84th General Session of the IADR, Brisbane, June 2006

				
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