Abstract
Background
Smoking is associated with tooth loss. However, smoking's relationship to the specific reason for tooth loss in postmenopausal women is unknown.
Methods
Postmenopausal women (n = 1,106) who joined a Women's Health Initiative ancillary study (The Buffalo OsteoPerio Study) underwent oral examinations for assessment of the number of missing teeth, as well as the self-reported reasons for tooth loss. The authors obtained information about smoking status via a self-administered questionnaire. The authors calculated odds ratios (ORs) and 95 percent confidence intervals (CIs) by means of logistic regression to assess smoking's association with overall tooth loss, as well as with tooth loss due to periodontal disease (PD) and with tooth loss due to caries.
Results
After adjusting for age, education, income, body mass index (BMI), history of diabetes diagnosis, calcium supplement use and dental visit frequency, the authors found that heavy smokers (≥ 26 pack-years) were significantly more likely to report having experienced tooth loss compared with never smokers (OR = 1.82; 95 percent CI, 1.10-3.00). Smoking status, packs smoked per day, years of smoking, pack-years and years since quitting smoking were significantly associated with tooth loss due to PD. For pack-years, the association for heavy smokers compared with that for never smokers was OR = 6.83 (95 percent CI, 3.40-13.72). The study results showed no significant associations between smoking and tooth loss due to caries.
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 in tooth loss due to caries. Further study is needed to explore the etiologies by which smoking is associated with different types of tooth loss. Dentists should counsel their patients about the impact of smoking on oral health, including the risk of tooth loss due to PD.
Keywords: Tooth loss, periodontal diseases, caries, smoking, menopause, women's health
Partial or total tooth loss has been associated with onset of disability and mortality in the elderly.1 Although tooth loss in U.S. adults has decreased during the past few decades,2 tooth loss without replacement has been associated with a poor physical function index, as measured by the SF-36 Health Survey (QualityMetric, Lincoln, R.I.).3 Tooth loss also has been associated with chronic systemic conditions such as ischemic stroke,4 cancer,5 rheumatoid arthritis6 and diabetes.7 As a result, both partial and total tooth loss remain significant public health concerns in the United States. Understanding the reasons for tooth loss will facilitate the development of prevention strategies that may, in turn, benefit oral health and function and have a favorable effect on associated morbidities.
The U.S. Centers for Disease Control and Prevention, Atlanta, estimated the prevalence of current smoking among U.S. adults in 2007 to be 17.4 percent in women and 22.3 percent in men.8 Smoking has been associated with chronic illnesses such as respiratory ailments,9 cancer10 and heart disease.11 A positive association between smoking status and tooth loss has been indicated in several,12-27 but not all,28,29 published observational studies. Limitations in study design, including small sample size and incomplete adjustment for confounding variables, may explain in part the disparate findings between studies. In addition, few investigators have explored different reasons for tooth loss in relation to smoking habits, which also may explain inconsistencies in published results.30,31 Tooth loss can be a consequence of caries, periodontal disease (PD), accidents or trauma, previous root canal treatment, orthodontic procedures and other reasons. Caries and PD account for a large proportion of missing teeth in adult populations.32,33 Although caries is a major reason for tooth loss across all age groups, PD is a particularly important reason among older adults,34,35 Many studies pertaining to smoking and tooth loss were conducted in men, and fewer data are available regarding this association in women. Study results show that women often experience more tooth loss than men36,37 despite having better oral health practices and a lower smoking prevalence.8 Women older than 65 years have an average of 18.77 teeth, and the number of remaining teeth is 4.52 fewer among current smokers than it is among never smokers.38
In this study, we collected detailed information about cigarette smoking via self-administered questionnaires, and we evaluated the extent of and reasons for tooth loss as part of a comprehensive oral examination in a large, well-characterized cohort of postmenopausal women. We then assessed the association between smoking and tooth loss and examined whether this association varied according to reasons for tooth loss in this study group.
Methods
This cross-sectional study consisted of postmenopausal women enrolled in the Buffalo Osteoporosis and Oral Bone Loss (OsteoPerio) Study, which is ancillary to the Women's Health Initiative Observational Study (WHI OS)39,40 conducted at the Buffalo, N.Y., clinical center. Details about participant recruitment and selection have been described elsewhere.41 A total of 1,362 women completed the OsteoPerio visit. We restricted the current analyses to the 1,106 women for whom all information pertaining to the key study variables was available; these included a detailed smoking history, reason for tooth loss and the major confounding variables of interest. In addition, we excluded women from these analyses who had lost teeth owing to reasons other than caries or PD (Figure). The health sciences institutional review board at the University at Buffalo, N.Y., approved this study, and we obtained written informed consent from all participants before completing study assessments.
Figure 1. Flowchart of participants.
Exclusion criteria (n = 166) included incomplete questionnaires (n = 5), missing alveolar crestal height (ACH) information (n = 16), missing reasons for tooth loss (n = 2), missing teeth due only to reasons other than periodontal disease or caries (n = 113), and missing information about pack-years of smoking (n = 30).
Participants underwent a comprehensive oral examination administered by trained and calibrated dental examiners (M.T. and others) who used standardized protocols. We scheduled the OsteoPerio study visit to correspond approximately with the participant's three-year WHI OS clinical visit. On examination, the dental examiner assessed the number of teeth present, the patient reported the reason for each missing tooth (excluding third molars) and the dental examiner recorded the reason for each missing tooth. Reasons for missing teeth included caries, PD, accident or trauma, orthodontic procedure, congenitally missing, eruption problems, previous root canal treatment or unable to determine. The dental examiner classified participants as having no tooth loss if they had retained all 28 natural teeth (excluding third molars).
Tooth loss
Among participants who were missing at least one tooth, the examiner categorized each missing tooth according to the reason why it was missing. For these analyses, we defined those who reported at least one tooth missing as a result of PD as having tooth loss due to PD. We defined those reporting at least one tooth missing as a result of caries and no tooth loss as a result of PD as having tooth loss due to caries. We excluded from these analyses participants whose tooth loss was due only to reasons other than caries or PD (n = 113). We classified those without tooth loss as such. We conducted a validation study among a subsample of the OsteoPerio study population (n = 70), in which we contacted the participants' current dentists and asked them to report the reason for tooth loss for each missing tooth. We asked the dentists to refer to their patients' dental records. They were not made aware of the participants' self-reported reasons as part of the OsteoPerio study.
Smoking
We obtained information about participants' smoking habits from a standardized self-administered questionnaire completed during the OsteoPerio clinic visit. We categorized smoking status as “never,” “former” or “current” smokers on the basis of participants' responses to this question: “Do you use or have you used cigarettes now or in the past?” We computed the number of years smoked by subtracting the participant's age at smoking initiation from her age at smoking cessation for former smokers, and we subtracted the participant's age at smoking initiation from her current age for current smokers. We computed smoking pack-years by multiplying the number of packs smoked per day (obtained from participants' responses to questions about packs smoked per day) by the number of years the participant smoked. We then classified participants into one of four categories:
never smokers;
light smokers (first tertile, < eight pack-years)
moderate smokers (second tertile, eight to 25 pack-years);
heavy smokers (third tertile, ≥ 26 pack-years).
In this study, cigarette smoking was the predominant source of tobacco exposure. Nine women reported using cigars, pipes or chewing tobacco, but these women also reported smoking cigarettes. No data were available about the intensity or duration of use of tobacco products other than cigarettes, and, therefore, we did not explore this information further in our analyses.
Participants' characteristics
At the time of the study visit, we measured height and weight according to standardized protocols. We calculated body mass index by dividing weight (in kilograms) by the square of height in meters. In addition, we obtained data pertaining to other key variables from WHI OS questionnaires. We determined the participant's age by using the date of birth. Participants described their race as white (not of Hispanic origin), black or African American (not of Hispanic origin), American Indian or Alaskan Native, Asian or Pacific Islander (ancestry is Chinese, Indo-Chinese, Korean, Japanese, Pacific Islander, Vietnamese), Hispanic/Latino (ancestry is Mexican, Cuban, Puerto Rican, Central American or South American)or other, and we then categorized them as white or other. We categorized educational level into high school, college and graduate school. We categorized current annual family income as less than $35,000 or $35,000 and more.
Questions regarding additional potential confounders included those pertaining to a history of diabetes diagnosis and medication use, hormone therapy, calcium and vitamin D supplement use and history of gingival surgery. We assessed participants' oral health behaviors by using three variables: frequency of dental visits (> 1per year versus ≤ 1per year), frequency of toothbrushing (≥ two times per day versus < two times per day) and frequency of flossing (every day versus not every day). We assessed bone mineral density by means of dual-energy x-ray absorptiometry with use of a densitometer (QDR2000 densitometer, Hologic, Waltham, Mass.) at several body sites including the anteroposterior (AP) spine, femoral neck, total hip, wrist and total body. We converted bone mineral density values into T-scores for each of the skeletal sites.42 (The T-score is a comparison of a person's bone density with that of a healthy young adult [20 to 30 years old] of the same sex. It is a calculation of the standard deviations from the young adult mean value for that site.)We used the worst T-score from the measured sites, including the total hip, femoral neck, wrist, AP spine or total body to characterize a participant's osteoporosis status. We further classified participants' overall osteoporosis status as normal, low bone mass or osteoporosis according to World Health Organization diagnostic criteria.42, 43
Data analysis
We compared characteristics of women retaining all 28 teeth with those of women who lost at least one tooth by using a t test for continuous variables and a χ2 test for categorical variables. We selected confounding variables for the final models after assessing the contribution of each factor by itself after first adjusting for age. Our final adjusted models included age, education, BMI, history of diabetes diagnosis, calcium supplement use and dental visit frequency.
We conducted logistic regression analyses to estimate the OR and 95 percent CI for the association between smoking history and overall tooth loss. To investigate whether the association differed according to the reason for tooth loss, we conducted separate logistic regression analyses stratified by those who lost any teeth due to PD and those who lost any teeth due to caries (but none due to PD). In addition, we conducted analyses to assess whether the associations differed according to the severity of tooth loss (strata include loss of one to three teeth and more than three teeth specifically as a result of PD or caries). We examined the influence of smoking intensity and duration by using the P for trend for continuous measures of packs smoked, years of smoking, pack-years of smoking, age at which participant started smoking, and years since participant quit smoking. We conducted sensitivity analyses that included only those women who had lost teeth due to PD exclusively (that is, excluding those with any tooth loss due to caries) (n = 47). In addition, we assessed effect modification by calcium supplement intake, vitamin D supplement intake and hormone therapy by adding cross-product interaction terms in logistic regression models. For the logistic regression analyses, we considered two-sided P values ≤.05 to be statistically significant. We performed all analyses by using a statistical software package (SAS Version 9.2, SAS Institute, Cary, N.C.).
Results
Characteristics
Participants' characteristics are summarized in Table 1. Overall, the number of missing teeth ranged from 0 to 22. Two hundred six women retained all 28 teeth; 257, 297 and 346 women lost one to two teeth, three to five teeth and six or more teeth, respectively. The majority of study participants were white and had completed some college education. About one-half of participants reported never having smoked during their lifetime, whereas 16.5 percent were heavy smokers when classified according to pack-years of smoking. Two-thirds of study participants reported having received menopausal hormone therapy, with slightly less than one-half reporting current use. More than two-thirds of women reported current use of a calcium supplement and more than one-half reported current use of a vitamin D supplement. When classified according to World Health Organization42, 43 criteria, 48.6 percent of women had low bone mass and 25.5 percent had osteoporosis.
Table 1.
Characteristics of 1,106 postmenopausal women overall 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) | — | 0 | |
| 1-2 | 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), 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) | |
| Former | 473 (42.8) | 81 (39.3) | 392 (43.6) | |
| Current | 40 (3.6) | 8 (3.9) | 32 (3.6) | .541 |
|
| ||||
| Packs Smoked per Day, No. (%) | ||||
| None | 593 (53.6) | 117 (56.8) | 476 (52.9) | |
| < 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) | .441 |
|
| ||||
| Years of Smoking, No. (%) | ||||
| None | 593 (53.6) | 117 (56.8) | 476 (52.9) | |
| < 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) | .359 |
|
| ||||
| Pack-Years, No. (%) | ||||
| Never | 593 (53.6) | 117 (56.8) | 476 (52.9) | |
| Light (<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) | .142 |
|
| ||||
| Age Started Smoking, Mean (SD), Years§ | 18.3 (4.2) | 17.7 (3.3) | 18.5 (4.3) | .063 |
|
| ||||
| Age Started Smoking, No. (%), Years§ | ||||
| <20 | 378 (73.7) | 71 (79.8) | 307 (72.4) | |
| ≥20 | 135 (26.3) | 18 (20.2) | 117 (27.6) | .151 |
|
| ||||
| Years Since Quitting Smoking¶, Mean (SD) | 25.1 (13.1) | 25.0 (12.2) | 25.2 (13.3) | .907 |
|
| ||||
| Years Since Quitting Smoking,¶ No. (%) | ||||
| ≥30 | 182 (38.5) | 30 (37.0) | 152 (38.8) | |
| 20-29 | 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) | .722 |
|
| ||||
| Worst-Site T-Score,# No. (%) | ||||
| Normal | 287 (26.0) | 63 (30.6) | 224 (24.9) | |
| Osteopenia | 537 (48.6) | 101 (49.0) | 436 (48.4) | |
| Osteoporosis | 282 (25.5) | 42 (20.4) | 240 (26.7) | .096 |
|
| ||||
| Race, No. (%) | ||||
| Other | 34(3.1) | 5 (2.4) | 29 (3.2) | |
| White | 1,070 (96.9) | 201 (97.6) | 869 (96.8) | .548 |
|
| ||||
| 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) | |
| College | 493 (44.6) | 101 (49.0) | 392 (43.6) | |
| Graduate school | 361 (32.6) | 83 (40.3) | 278 (30.9) | <.001 |
|
| ||||
| Annual Family Income, No. (%), $ | ||||
| <35,000 | 466 (42.1) | 51 (24.8) | 415 (46.1) | |
| ≥35,000 | 640 (57.9) | 155 (75.2) | 485 (53.9) | <.001 |
|
| ||||
| History of Diabetes Diagnosis, No. (%) | ||||
| No | 1,050 (94.9) | 202 (98.1) | 848 (94.2) | |
| Yes | 56 (5.1) | 4 (1.9) | 52 (5.8) | .024 |
|
| ||||
| Ever Use Hormone Therapy, No. (%) | ||||
| No | 370 (33.5) | 58 (28.2) | 312 (34.7) | |
| Yes | 736 (66.6) | 148 (71.8) | 588 (65.3) | .074 |
|
| ||||
| Current Use of Hormone Therapy, No. (%) | ||||
| No | 608 (55.0) | 105 (51.0) | 503 (55.9) | |
| Yes | 498 (45.0) | 101 (49.0) | 397 (44.1) | .201 |
|
| ||||
| Use Calcium Supplement, No. (%) | ||||
| No | 324 (29.3) | 47 (22.8) | 277 (30.8) | |
| Yes | 782 (70.7) | 159 (77.2) | 623 (69.2) | .024 |
|
| ||||
| Use Vitamin D Supplement, No. (%) | ||||
| No | 476 (43.0) | 76 (36.9) | 400 (44.4) | |
| Yes | 630 (57.0) | 130 (63.1) | 500 (55.6) | .048 |
|
| ||||
| History of Gingival Surgery, No. (%) | ||||
| No | 866 (79.1) | 173 (84.4) | 693 (77.9) | |
| Yes | 229 (20.9) | 32 (15.6) | 197 (22.1) | .038 |
|
| ||||
| Brush Teeth | ||||
| < 2 times/day | 259 (23.4) | 43 (20.9) | 216 (24.0) | |
| ≥ 2 times/day | 847 (76.6) | 163 (79.1) | 684 (76.0) | .339 |
|
| ||||
| Floss Teeth, No. (%) | ||||
| Not everyday | 626 (57.0) | 119 (58.1) | 507 (56.7) | |
| Everyday | 473 (43.0) | 86 (42.0) | 387 (43.3) | .727 |
|
| ||||
| Dental Visit | ||||
| ≤ 1 per year | 271 (24.5) | 35 (17.0) | 236 (26.2) | |
| >1 per year | 835 (75.5) | 171 (83.0) | 664 (73.8) | .006 |
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.
kg/m2: Kilograms per square meter.
Table 1 also presents selected characteristics according to tooth loss status. Factors significantly different according to tooth loss were age at the OsteoPerio clinic visit, BMI, educational level, annual family income, history of diabetes diagnosis, calcium supplement use, vitamin D supplement use, history of gingival surgery and dental visit frequency. Race, toothbrushing frequency and flossing frequency did not differ according to tooth loss status. We did not observe any significant differences for most smoking characteristics, including smoking status, packs smoked per day, years smoked, pack-years of smoking, age at which participant started smoking and years since participant quit smoking.
Smoking and tooth loss
Table 2 presents results for crude, age-adjusted and multivariable-adjusted logistic regression analyses of smoking exposures and overall tooth loss. In the crude analyses, heavy smokers had significantly elevated odds of overall tooth loss compared with never smokers. This association was somewhat stronger after we controlled for age. Further adjustment for education, income, BMI, history of diabetes diagnosis, calcium supplement intake and dental visit frequency did not change the point or interval estimates appreciably. Packs smoked per day and pack-years of smoking, when measured as continuous variables, showed significant trends in multivariable-adjusted models. When we measured them as categorical variables, the results showed no statistically significant associations between smoking status, packs smoked per day, years of smoking, age at which participant started smoking or years since quitting and overall tooth loss.
Table 2.
Association between cigarette smoking and any tooth loss for 1,106 postmenopausal women.
| Characteristic | No tooth loss (n = 206), No. (%) | Any tooth loss (n = 900) | |||
|---|---|---|---|---|---|
|
| |||||
| No. (%) of Participants | Crude OR*(95% CI†) | Age-Adjusted OR (95% CI) | Multivariable-Adjusted‡ OR (95% CI) | ||
|
| |||||
| Smoking Status | |||||
| Never | 117 (56.8) | 476 (52.9) | 1.0 | 1.0 | 1.0 |
| Former | 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) |
|
| |||||
| Smoking Status | |||||
| Never | 117 (56.8) | 476 (52.9) | 1.0 | 1.0 | 1.0 |
| Ever | 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 per Day | |||||
| Never | 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 | .050 |
| P for trend¶ | — | — | .271 | .135 | .210 |
|
| |||||
| Years of Smoking | |||||
| Never | 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 | .123 |
| P for trend¶ | — | — | .158 | .628 | .757 |
|
| |||||
| Pack-years | |||||
| Never | 117 (56.8) | 476 (52.9) | 1.0 | 1.0 | 1.0 |
| Light(<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 | .039 |
| P for trend¶ | — | — | .063 | .088 | .158 |
|
| |||||
| Age Started Smoking¶ | |||||
| <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 Quitting Smoking# | |||||
| ≥30 | 30 (37.0) | 152 (38.8) | 1.0 | 1.0 | 1.0 |
| 20-29 | 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 |
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).
Reason for tooth loss
Next, we performed separate logistic regression analyses to relate smoking exposures with tooth loss due to PD and tooth loss due to caries as distinct outcome variables (Table 3). Of 900 women reporting loss of at least one tooth, 108 (12 percent) were classified as having experienced tooth loss due to PD and 792 (88 percent) were classified as having experienced tooth loss due to caries. In the crude analyses, ever smokers, packs smoked per day, duration of smoking, pack-years of smoking and years since quitting smoking all showed significantly increased odds of tooth loss due to PD when compared with findings in never smokers. After adjusting for age and other confounding variables, we found that these increased odds remained statistically significant. In the multivariable-adjusted analyses, women who smoked two or more packs per day and those with the heaviest pack-years of smoking showed a 10-fold and sevenfold elevated odds of tooth loss due to PD, respectively, when compared with findings in never smokers.
Table 3.
Association between cigarette smoking and tooth loss due to periodontal disease and caries for 1,106 postmenopausal women.
| Characteristic | No tooth loss, No. (%) of Participants (n = 206) | Tooth loss due to Periodontal disease(n = 108) | Tooth loss due to caries(n = 792) | ||||||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| No. (%) of Participants | Crude OR*(95% CI†) | Age-Adjusted OR (95% CI) | Multivariable-Adjusted OR‡(95% CI) | No. (%) of Participants | Crude OR(95% CI) | Age-Adjusted OR (95% CI) | Multivariable- Adjusted OR (95% CI) | ||
|
| |||||||||
| Smoking Status | |||||||||
| Never | 117 (56.8) | 36 (33.3) | 1.0 | 1.0 | 1.0 | 440 (55.6) | 1.0 | 1.0 | 1.0 |
| Former | 81 (39.3) | 63 (58.3) | 2.53(1.54-4.16) | 2.83 (1.66-4.80) | 2.99 (1.70-5.23) | 329 (41.5) | 1.08(0.79-1.48) | 1.21 (0.87-1.67) | 1.22(0.87-1.70) |
| 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) | 23 (2.9) | 0.76(0.33-1.75) | 1.02 (0.44-2.39) | 0.91(0.38-2.18) |
|
| |||||||||
| Smoking Status | |||||||||
| Never | 117 (56.8) | 36 (33.3) | 1.0 | 1.0 | 1.0 | 440 (55.6) | 1.0 | 1.0 | 1.0 |
| Ever | 89 (43.2) | 72 (66.7) | 2.63 (1.62-4.27) | 3.02 (1.80-5.06) | 3.09 (1.78-5.34) | 352(44.4) | 1.01 (0.77-1.33) | 1.19 (0.87-1.64) | 1.19 (0.86-1.65) |
|
| |||||||||
| Packs Smoked per Day | |||||||||
| Never | 117 (56.8) | 36 (33.3) | 1.0 | 1.0 | 1.0 | 440 (55.6) | 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) | 189 (23.9) | 0.97 (0.67-1.40) | 1.04 (0.71-1.51) | 1.05 (0.72-1.55) |
| 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) | 127 (16.0) | 1.13 (0.72-1.76) | 1.38 (0.87-2.19) | 1.38 (0.86-2.21) |
| ≥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) | 36 (4.6) | 1.37 (0.59-3.15) | 1.57 (0.67-3.68) | 1.41 (0.59-3.39) |
| P for trend§ | — | — | <.001 | <.001 | <.001 | — | .503 | .141 | .220 |
| P for trend¶ | — | — | .015 | .005 | .006 | — | .528 | .300 | .428 |
|
| |||||||||
| Years of Smoking | |||||||||
| Never | 117 (56.8) | 36 (33.3) | 1.0 | 1.0 | 1.0 | 440 (55.6) | 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) | 121 (15.3) | 0.95 (0.62-1.46) | 1.19 (0.76-1.85) | 1.15 (0.72-1.81) |
| 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) | 118 (14.9) | 1.08 (0.69-1.71) | 1.19(0.75-1.90) | 1.25 (0.78-2.01) |
| ≥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) | 113 (14.3) | 1.16 (0.72-1.85) | 1.20 (0.74-1.94) | 1.17 (0.71-1.92) |
| P for trend§ | — | — | <.001 | <.001 | <.001 | — | .556 | .540 | .537 |
| P for trend¶ | — | — | <.001 | .001 | .008 | — | .586 | .736 | .729 |
|
| |||||||||
| Pack-Years | |||||||||
| Never | 117 (56.8) | 36 (33.3) | 1.0 | 1.0 | 1.0 | 440 (55.6) | 1.0 | 1.0 | 1.0 |
| Light (<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) | 114 (14.4) | 0.89 (0.58-1.38) | 1.04 (0.66-1.62) | 1.05 (0.66-1.65) |
| 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) | 122 (15.4) | 1.01 (0.65-1.57) | 1.13 (0.72-1.78) | 1.14 (0.72-1.81) |
| 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) | 116 (14.7) | 1.34 (0.82-2.19) | 1.49 (0.90-2.47) | 1.46(0.87-2.44) |
| P for trend§ | — | — | <.001 | <.001 | <.001 | — | .326 | .189 | .273 |
| P for trend¶ | — | — | <.001 | <.001 | <.001 | — | .317 | .386 | .522 |
|
| |||||||||
| Age Started Smoking,¶ Years | |||||||||
| <20 | 71 (79.8) | 52 (72.2) | 1.0 | 1.0 | 1.0 | 255 (72.4) | 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) | 97 (27.6) | 1.50 (0.85-2.65) | 1.14 (0.63-2.05) | 1.16 (0.63-2.13) |
| P for trend¶ | — | — | 0.452 | 0.963 | 0.838 | — | 0.08 | 0.36 | 0.35 |
|
| |||||||||
| Years Since Quitting Smoking# | |||||||||
| ≥30 | 30 (37.0) | 13 (20.6) | 1.0 | 1.0 | 1.0 | 139 (42.3) | 1.0 | 1.0 | 1.0 |
| 20-29 | 24 (29.6) | 15 (23.8) | 1.44(0.58-3.61) | 2.04(0.76-5.48) | 2.11 (0.73-6.06) | 78 (23.7) | 0.70(0.38-1.28) | 0.83(0.45-1.55) | 0.82 (0.43-1.55) |
| 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) | 70 (21.3) | 0.94(0.48-1.85) | 1.06 (0.54-2.11) | 1.08 (0.53-2.19) |
| <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) | 42 (12.8) | 0.82(0.38-1.78) | 0.99 (0.45-2.20) | 1.01(0.45-2.29) |
| P for trend# | — | — | .009 | .002 | .008 | — | .418 | .962 | .913 |
OR: Odds ratio.
CI: Confidence interval.
ORs 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).
We did not observe any clear relationship between age at which the participant started smoking and tooth loss due to PD. We did find a significant inverse trend between years since quitting smoking and reported tooth loss due to PD (P trend < .01). There was no clear association between smoking variables and tooth loss due to caries in crude, age-adjusted or multivariable-adjusted models. Increasing number of packs smoked per day and duration of cigarette smoking showed slightly increased odds of tooth loss due to caries; however, neither of these associations reached statistical significance.
We further assessed whether the association between cigarette smoking and tooth loss differed according to the severity of tooth loss, as indicated by the reported number of teeth lost due to PD and the reported number of teeth lost due to caries as separate outcomes (Table 4). The patterns of association between smoking exposures and severity of tooth loss for either reason (PD or caries) were similar to those in Table 3. The results of additional analyses showed that there was no evidence of effect modification of the association between smoking and tooth loss according to calcium supplement intake, vitamin D supplement intake or hormone therapy (data not shown). Last, we conducted sensitivity analyses for PD restricted to participants with tooth loss due exclusively to PD. The point estimates and patterns of association with smoking exposures were similar to those presented in Table 3 (data not shown).
Table 4.
Adjusted* OR† and 95% CI‡ for the associations between cigarette smoking and severity of tooth loss due to periodontal disease and caries.
| Variable | Adjusted or (95% CI) | |||
|---|---|---|---|---|
|
| ||||
| Tooth Loss Due to Periodontal Disease | Tooth Loss Due to Caries | |||
|
| ||||
| 1 to 3 teeth(n=53) | More than 3 teeth(n=55) | 1 to 3 teeth(n=394) | More than 3teeth(n = 398) | |
|
| ||||
| Smoking Status | ||||
| Never | 1.0 | 1.0 | 1.0 | 1.0 |
| Former | 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 Smoked per Day | ||||
| Never | 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 | .186 |
| P for trend¶ | .022 | .024 | .697 | .217 |
|
| ||||
| Years of Smoking | ||||
| Never | 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 | .167 |
| P for trend¶ | .009 | .126 | .134 | .190 |
|
| ||||
| Pack-years | ||||
| Never | 1.0 | 1.0 | 1.0 | 1.0 |
| Light (<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 | .115 |
| P for trend¶ | .001 | .004 | .887 | .133 |
|
| ||||
| Age Started Smoking,¶ 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 Quitting Smoking# | ||||
| ≥30 | 1.0 | 1.0 | 1.0 | 1.0 |
| 20-29 | 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 supplement use 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).
Discussion
To our knowledge, this study is the first to evaluate the association between several smoking exposure variables and tooth loss prevalence according to the specific reason for tooth loss among a cohort of postmenopausal women. The availability of smoking exposure variables in the OsteoPerio study was more extensive than that in most previous studies. In our cohort, heavy smokers (≥ 26 pack-years of smoking) had significantly higher odds of experiencing tooth loss compared with never smokers (OR = 1.82, 95 percent CI = 1.10-3.00) after we controlled for age, education, income, BMI, history of diabetes diagnosis, calcium supplement use and frequency of dental visits. This result is in accordance with those of previous studies in which investigators observed a dose-response relationship between cigarette smoking and tooth loss.12,13,44-48
Moreover, former smokers were at higher odds of experiencing tooth loss compared with never smokers, although this association was of borderline statistical significance in our study (OR = 1.34, 95 percent CI = 0.96-1.86). Investigators in other studies have reported inconsistent associations between former smoking and overall tooth loss.12,14-21 In our study, current smokers did not have higher odds of experiencing tooth loss compared with never smokers, which is in contrast with the results of the majority of reports in the literature, which show a wide range (from 1.7 to 4.7) in effect size estimates (OR or risk ratio).12-27 However, it is important to note that the prevalence of current smoking in our study tended to be lower than that reported in other cohorts of women, and this could account in part for the discrepant findings.
Differences in study populations and in methodologies for defining key variables may provide a partial explanation of the disparate results. Our sample consisted entirely of postmenopausal women who generally were healthy and reported practicing good oral hygiene. Men are more likely than women to smoke and to be heavy smokers, and the effect of smoking on tooth loss may be stronger in men than it is in women.27 The prevalence of current smokers was relatively low (3.6 percent) in our cohort, and all participants were required to have at least six teeth at study entry.41 Some previous studies22-26 have included edentulous participants, who also were more likely than participants in our study to have been heavy smokers. The small proportion of current and heavy smokers may have limited the statistical power of our study to detect stronger and more consistent associations between smoking status and tooth loss.
When stratified according to reason for tooth loss, nearly all of the smoking exposure variables were strongly and consistently associated with tooth loss due to PD. In contrast, none of the smoking exposure variables were associated with tooth loss due to caries. Thus, a null relationship between smoking and overall tooth loss in postmenopausal women may be explained by the limited effect of smoking on tooth loss due to caries in previous studies. The etiology of the effect of smoking on tooth loss may explain further the large range of effect sizes that have been reported in the literature.12-27 Although caries is a common cause of tooth loss in all age groups, the frequency of tooth loss due to PD increases with age.35,49 Hence, the effect of smoking on tooth loss due to PD may be weaker in studies consisting mostly of young adults, which could further attenuate the point estimate between smoking exposures and overall tooth loss, PD and caries combined.
To our knowledge, researchers in only one study conducted in Bangladesh investigated smoking as a risk factor for tooth loss due to PD and caries separately, and they reported similar results.31 However, tooth extraction practices in Bangladesh may differ from those in the United States, which might result in systematically different reasons for tooth loss across studies. In addition, data in the Bangladesh study were collected only for tooth loss occurring in populations of low socioeconomic status (SES) within 45 days of the dental visit, so these results should be interpreted with caution.
Cigarette smoking could accelerate the course of PD. The results of previous studies suggest that the chemicals found in smoke select for plaque-forming anaerobic bacteria that may modify the oral microflora50 and decrease the antioxidative capacity of saliva.51 Free radicals produced by the host during the immune response to bacterial stimulation then damage the periodontium, increasing the person's susceptibility to tooth loss due to PD. Another mechanism by which cigarette smoking may affect PD progression is via toxic effects on bone. Study results have shown that nicotine reduces bone density and bone mineral content through an increased secretion of bone-resorbing factors52 or a decreased intestinal uptake of calcium.53 Estrogen may attenuate osteoporotic bone loss.54 Estrone and estradiol levels have been shown to be lower in smokers than in nonsmokers,55 and this effect may be particularly deleterious among postmenopausal women.
In this study, we did not observe an association between smoking and tooth loss due to caries. Previous research findings suggest that smoking may increase the risk of developing dental caries by impairing salivary function and salivary buffering capacity.56 However, tooth loss due to caries may not be directly related to smoking, but may be influenced by factors such as SES and access to, and utilization of, dental care.57 Teeth with dental caries are restorable given that dental care is accessible and utilized. Therefore, tooth loss may not be the end result. On the other hand, periodontitis, once developed, tends to be persistent. Effective treatment of periodontitis, which is based on control of both dental biofilm and inflammation, is more difficult to achieve.58 Thus, periodontitis may lead to tooth loss more often in older populations.
Smoking cessation and PD
Smoking cessation may prevent PD from progressing to tooth loss. Researchers in several studies have investigated the associations of smoking cessation with PD59,60 and tooth loss.61,62 However no previous studies, to our knowledge, have studied the influence of smoking behavior on specific reasons for tooth loss (caries or PD), and published findings specifically in postmenopausal women are not available, to our knowledge. Some researchers have addressed the role of smoking cessation. Investigators conducting a study with use of National Health and Nutrition Examination Survey III data reported that the odds of periodontitis's developing declined with the reported number of years since smoking cessation.59 The findings of the U.S. Health Professionals' Follow-Up Study showed that risk of self-reported tooth loss among middle-aged and older men decreased after smoking cessation, though it remained elevated by 20 percent even 10 or more years after participants quit smoking compared with the risk among never smokers.61 Consistent with these results, our findings of moderate to strong positive associations between smoking exposures and tooth loss due to PD suggest that smoking cessation and smoking prevention programs potentially could reduce tooth loss due to PD in the growing population of postmenopausal women in the United States.
Study limitations
Our study had several limitations that one should consider when interpreting its findings. First, causal relationships cannot be inferred from the cross-sectional data reported here. However, although we could not determine whether all tooth loss occurred after smoking exposure, we measured the duration of smoking cessation and our findings suggest that smoking cessation is associated with significantly lower odds of tooth loss due to PD. A second limitation is that the study cohort consisted mostly of white women of higher SES who had good oral hygiene; the percentage of current smokers was low. This could limit generalizability and comparison of our results with those in cohorts that included more current smokers or groups of greater ethnic or SES diversity.
Validation study
The reasons for tooth loss in this study were self-reported. We conducted a validation study in a subset of the OsteoPerio cohort (n = 70) in which the actual prevalence of tooth loss due to PD and that due to caries was 34 and 54 percent, respectively, as determined by a review of the participant's dental record by her personal dentist (via a mailed questionnaire). Results of this validation study showed that most self-reports of not having experienced tooth loss due to PD were confirmed by the participants' personal dentists (43 of 59 dentists; negative predictive value = 72.9 percent). Likewise, the majority of self-reports of having experienced tooth loss due to PD were confirmed by participants' personal dentists (eight of 11 dentists, positive predictive value = 72.7 percent). Given the relatively small number of false-positive reports of tooth loss due to PD, the findings of this validation study also indicated that the reason for tooth loss was self-reported with high specificity (93.5 percent). Conversely, we observed low sensitivity (33.3 percent) of self-reported tooth loss due to PD, owing to a relatively high proportion of false-negative values. This finding indicates that women in our study underreported PD as the reason for their tooth loss, perhaps in part because caries also affected the tooth, and the discussion about caries with the dentist, the treatment of caries or both may have been recalled more clearly by participants than was a diagnosis of PD in the same tooth.
As a result, our findings regarding the association between smoking habits and PD could be underestimated, and findings pertaining to the role of smoking in tooth loss due to caries may be overestimated because they include some tooth loss due to PD. Most self-reports of tooth loss due to caries were confirmed by participants' personal dentists (37 of 58, positive predictive value = 63.8 percent). Nonetheless, there were a sizable number of false-positive findings, resulting in low specificity (34.4 percent) of reported tooth loss due to caries. Among women who reported no tooth loss due to caries, the number of false-negative findings was small (one of 12), which resulted in high values for both sensitivity (97.4 percent) and negative predictive value (91.7 percent). Collectively, the validation study findings indicate that the reported associations between smoking habits and tooth loss may be biased toward the null hypothesis. Thus, the strong association between smoking and tooth loss specifically due to PD would not be expected to be changed in the study.
Several study strengths add relevance to the current literature on smoking and tooth loss. These include the following:
a relatively large study group compared with that of previous studies;
an entirely postmenopausal cohort of older women in whom the burden of poor oral health and the need for improved prevention and control opportunities will challenge public health and clinical periodontology increasingly in coming years;
dental assessment information collected during comprehensive standardized oral examinations by trained dental examiners who could verify which teeth were missing;
evaluation of several smoking exposure variables typically not available in previous epidemiologic studies of this issue;
the availability of information about several individual and clinical factors that could be evaluated as potential confounding effects on the observed association between smoking and tooth loss.
To our knowledge, this is one of the most comprehensive examinations of smoking and tooth loss; these are the only available findings in a large, well-characterized cohort of postmenopausal women who were not selected on the basis of PD or through clinical periodontal catchments.
Conclusions
These study findings suggest that there is an association between cigarette smoking and tooth loss in postmenopausal women, and this association primarily is the result of tooth loss due to PD. Investigators in previous studies who did not examine the role of smoking according to the reason for tooth loss may have underreported the importance of smoking in tooth loss, especially tooth loss due to PD. Researchers in future studies should investigate the reasons for tooth loss in older adults when considering smoking as a risk factor. Our findings suggest that smoking prevention and control could be important facets of comprehensive targeted strategies to control PD and its oral health complications in the growing population of postmenopausal women in the United States.
Acknowledgments
This study was supported by grant R01DE013505 from the National Institute of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, Md., to Dr. Wactawski-Wende, U.S. Army, Medical Research and Materiel Command, Fort Detrick, MD., grant OS950077and NIH/National Heart Lung and Blood Institute contracts N01WH32122 and HHSN268201100001C (Women's Health Initiative) to Dr. Wactawski-Wende.
Abbreviation Key
- AP
Anteroposterior
- BMI
Body mass index
- PD
Periodontal disease
- SES
Socioeconomic status
- WHI OS
Women's Health Initiative Observational Study
Footnotes
Disclosure. None of the authors reported any disclosures.
Contributor Information
Dr. Xiaodan Mai, Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, The State University of New York.
Dr. Jean Wactawski-Wende, Email: jww@buffalo.edu, Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, The State University of New York, 270 Farber Hall, Buffalo, N.Y. 14214.
Ms. Kathleen M. Hovey, Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, The State University of New York.
Dr. Michael J. LaMonte, Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, The State University of New York.
Dr. Chaoru Chen, Department of Social and Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, The State University of New York.
Dr. Mine Tezal, Department of Oral Biology, School of Dental Medicine, University at Buffalo, The State University of New York.
Dr. Robert J. Genco, Department of Oral Biology, School of Dental Medicine, University at Buffalo, The State University of New York.
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