J Clin Periodontol 2003; 30: 107–113 Copyright r Blackwell Munksgaard 2003

Printed in Denmark. All rights reserved

Tobacco smoking and risk for Jan Bergström

Institute of Odontology, Karolinska Institutet,
Stockholm, Sweden

periodontal disease
Bergström J: Tobacco smoking and risk for periodontal disease. J Clin Periodontol
Blackwell 2003; 30: 107–113. r Blackwell Munksgaard, 2003.

Abstract
Objective: The magnitude of risk for periodontal disease associated with smoking
was investigated by exploring the interrelationships between definition of disease,
prevalence and relative risk in a population of dentally aware individuals.
Materials and Methods: A total of 133 smokers and 242 non-smokers in the age
range 20–69 years served as the database. Criteria based on clinical probing of pocket
depth and radiographic measurement of bone height were used for the purpose of
disease definition. Various pocket frequency cutoff points for two probing depth
levels, X5 and X6 mm, and, in addition, the 30th, 25th, and 20th percentiles of the
bone height distribution were alternately selected as criteria.
Results: Disease definition had an impact on the prevalence, and the relative risk
varied as a function of the prevalence. For a broad definition of disease such as 1% of
pockets X5 mm, the prevalence for smokers was approximately twice the prevalence
for non-smokers and the odds ratio (OR) was 3.0. A narrower definition such as 15%
of pockets X5 mm resulted in decreased prevalences for both smokers and non-
smokers and an OR of 12.1. Increasing exposures correlated with greater magnitudes
of risk. Heavy exposure was associated with greater risk than light exposure. For the
combination of a narrow disease definition and heavy exposure, the relative risk was
considerable (OR 9.8–20.3).
Conclusion: Smoking-associated relative risk is dependent on definition of disease Key words: periodontitis; relative risk; risk
and prevalence. Given other factors, a narrow definition will result in a low prevalence assessment; smoking; tobacco
and a high risk and, vice versa, for a broader definition, prevalence will be high and
the risk moderate. Accepted for publication 2 July 2001

The risk of attracting periodontal dis- for the large variation may be found variation in magnitude of the risk
ease in association with tobacco smok- in the type of study and character and estimate. We have previously reported
ing has been estimated in several studies size of the population studied. An on the influence of smoking on the
over the years. The variation in magni- additional factor may be the definition periodontal health in subjects with
tude of the risk estimates reported, of disease. The wide variation among regular dental care habits (Bergström
however, is considerable. Risk estimates studies regarding diagnostic criteria for & Eliasson 1987a, b, Bergström et al
found from cross-sectional and case– the determination and classification of 2000a, b). To further explore the impact
control studies vary between 1.4 and disease is striking. Among commonly of smoking on the periodontal health,
11.8 (Markkanen et al. 1985, Preber & used determinants are, e.g., probing the purpose of the present study was to
Bergström 1986, Bergström 1989, Ha- depth, attachment level, bone height, investigate the relations between defini-
ber & Kent 1992, Horning et al. 1992, furcation involvement, tooth loss, as tion of disease, prevalence and relative
Haber et al. 1993, Hansen et al. 1993, well as composite indices. There is, risk associated with smoking in this
Locker & Leake 1993, Stoltenberg et al. furthermore, a wide variation regarding population.
1993, Grossi et al. 1994, 1995, Linden the choice of boundary or cutoff border-
& Mullally 1994, Mullally & Linden line for the discrimination of disease
1996, Dolan et al. 1997, Norderyd & from nondisease, e.g., one pocket of Materials and Methods
Study population
Hugoson 1998, Moore et al. 1999, Paidi 5 mm probing depth; one tooth with an
et al. 1999, Wakai et al. 1999) and attachment loss of 7 mm; a majority of Two samples drawn from the same
those found from the few cohort teeth exhibiting alveolar bone loss population with a 10-year interval were
studies available vary between 4.6 exceeding one-third of the root length, used as the database of the present
and 6.3 (Ismail et al. 1990, Holm etc. Apparently, therefore, the definition investigation. The population is char-
1994, Norderyd et al. 1999, Skaleric & of the disease is an important factor that acterized by a high standard of dental
Kovac-Kavcic 2000). Some reasons can be expected to contribute to the awareness as seen from, e.g., regular
108 Bergström

dental care habits, and a high standard 6 mm, were used. For a critical level of height or combinations of pocket fre-
of oral health as seen from, e.g., a great 5 mm, i.e., a probing depth of 5 mm or quency and bone height, respectively, as
number of retained teeth. A detailed greater, a pocket frequency of 1%, 5%, the dependent dichotomous variable.
description of the characteristics of the 10%, and 15%, respectively, was se- Pocket frequency was dichotomized
population has been reported elsewhere lected as a cutoff point. For a critical according to o1% (0) and X1% (1);
(Bergström & Eliasson 1985, Bergström level of 6 mm, i.e., a probing depth of o5% (0) and X5% (1); o10% (0) and
et al. 2000a). The first sample included 6 mm or greater, pocket frequencies of X10% (1), etc. These steps were
83 smokers and 110 non-smokers in the 1%, 5%, and 10% were the selected labelled 1%, 5%, 10%, etc., cutoff
age range 20–69 years (median 41 cutoff points. With regard to bone points. Following the percentile distri-
years, IR 31–50 years), and the second height, the 30th, 25th, and 20th percen- butions of the cohorts, bone height level
sample included 50 smokers and 132 tiles of the distribution were used as was dichotomized according to 430th
non-smokers in the same age range cutoff points. These cutoff points corre- percentile (0) and 430th percentile (1);
(median 38 years, IR 31–51 years). In sponded to a mean bone height level of 425th percentile (0) and 425th per-
addition, to increase statistical power 82%, 80%, and 76%, respectively, in centile (1); 420th percentile (0) and
and estimate precision, analyses were cohort 1, and 83%, 82%, and 80%, 420th percentile (1). These bone height
also performed for both samples respectively, in cohort 2. levels were labelled 30th percentile,
combined. The latter analyses included Probing depth was assessed at four 25th percentile, and 20th percentile
63 individuals (17 smokers and 46 non- positions of all teeth, and bone height cutoff points, respectively. The possible
smokers) who were part of both sam- was measured as a percentage of the confounding of other factors such as
ples. All smokers were current smokers, root length mesially and distally to all age, plaque, calculus, gingival bleeding,
since for the purpose of the present teeth and the average across all single and number of teeth was tested in
study former smokers were excluded. measurements formed the bone height preliminary analyses. It was revealed
The mean cigarette consumption and level of the individual (Eliasson & that age exerted influence on the
smoking duration of smokers in sample Bergström 1986). dependent variables, whereas the effects
1 was 14.0 (95% CI 12.4–15.5) cig/day The smoking exposure was expressed of the others were marginal, if any. Age,
and 21.7 (95% CI 19.4–24.0) years, in terms of consumption (cigarettes per therefore, was regarded as a confounder
respectively. The corresponding means day), duration (number of years of and included in all regression analyses.
in sample 2 were 13.3 (95% CI 11.2– smoking), and lifetime exposure, i.e., If not otherwise explained, therefore, all
15.4) cig/day and 20.4 (95% CI 16.7– the product of consumption and dura- results are valid after adjustment for
24.0) years, respectively. The study tion (cigarette-years). Analyses regard- age. Statistical significance was ac-
samples, referred to as cohorts ing exposure were performed for both cepted at po0.05.
1 and 2, respectively, according to cohorts combined only, with exposure
gender and smoking are presented in variables stratified into three subgroups.
Table 1. The mean (SD) number of The subgroups regarding consumption Results
retained teeth in smokers and non- were 1–9 cig/day (n 5 28, mean 5 3.8 The prevalence according to pocket
smokers was 27.0 (3.8) and 28.0 (2.8), cig/day), 10–19 cig/day (n 5 57, frequency cutoff point for a critical
respectively, in cohort 1, and 28.0 (2.5) mean 5 12.1 cig/day), 20 or more cig/ level of 5 mm together with the age-
and 28.7 (2.6), respectively, in cohort 2. day (n 5 47, mean 5 21.5 cig/day); re- adjusted smoking-associated ORs is
Although slightly lower in smokers, garding duration 1–15 years (n 5 39, presented in Table 2. Regarding cohort
these means were not statistically sig- mean 5 7.9 years), 16–30 years (n 5 53, 1, a 1% cutoff resulted in a prevalence
nificantly different when controlling mean 5 20.4 years), more than 30 years of 70% for smokers and 41% for
for age. The study was approved by (n 5 41, mean 34.9 years); regarding non-smokers and an OR of 2.5 (95% CI
the local ethical committee of the lifetime exposure 1–170 cigarette-years 1.3–5.0). At a 5% cutoff the prevalence
Karolinska Institute. (n 5 46, mean 5 74.5 cigarette-years), decreased to 41% for smokers and 15%
171–350 cigarette-years (n 5 44, for non-smokers and the OR increased to
Clinical registration and classification
mean 5 264.4 cigarette-years), more 3.1 (95% CI 1.4–6.6). At 10% and 15%
than 350 cigarette-years (n 5 42, cutoffs, the prevalence further de-
Several criteria based on clinical prob- mean 5 614.3 cigarette-years). creased to 29% and 20%, respectively,
ing of pocket depth and radiographic for smokers and 6% and 4%, respec-
measurement of bone height were Statistics tively, for non-smokers, the ORs being
alternately used for the purpose of 4.9 (95% CI 1.9–12.9) and 5.5 (95% CI
disease definition and case identifica- The relative risk was estimated from the 1.7–17.7), respectively. The overall
tion. With regard to pocket probing odds ratio (OR) following logistic prevalence related to these cutoff points
depth two levels (critical levels), 5 and regression with pocket frequency, bone decreased from 53% to 11%. The risk
estimates were throughout statistically
Table 1. Study cohorts; frequency distributions by gender and smoking significant (po0.01). A similar trend of
Cohort 1 Cohort 2 Cohorts combined Total (%) decreasing prevalence and increasing
risk with increasing cutoff point was
men women men women men women observed for cohort 2. As the cutoff
was shifted from 1% to 10%, the
smoker 72 11 40 10 112 21 133 (35) prevalence decreased from 30% to
non-smoker 86 24 92 40 178 64 242 (65)
12% for smokers and from 16% to
total 158 35 132 50 290 85 375 (100)
2% for non-smokers, whereas the OR
 Smoking-associated risk 109

Table 2. Prevalence (%) and odds ratio (OR) according to pocket frequency cutoff point and cohort
Power Cohort 1 Cohort 2 Cohorts combined
frequency
cutoff (%) prevalence OR 95% CI p prevalence OR 95% CI p prevalence OR 95% CI p

S NS total S NS total S NS total

1 70 41 53 2.5 1.3–5.0 0.009 30 16 20 2.3 1.1–5.5 0.049 55 27 37 3.0 1.8–4.6 o0.001

5 41 15 26 3.1 1.4–6.6 0.003 16 04 07 5.8 1.6–21.4 0.008 30 08 16 4.7 2.5–9.0 o0.001
10 29 06 16 4.9 1.9–12.9 0.001 12 02 04 9.6 1.7–52.8 0.009 23 04 10 7.3 3.2–15.5 o0.001
15 20 04 11 5.5 1.7–17.7 0.004 08 00 02 — — — 17 02 07 12.1 3.9–37.1 o0.001
Critical probing depth level 5 mm. Adjusted for age. S 5 smoker, N 5 non-smoker.

Table 3. Prevalence (%) and odds ratio (OR) according to pocket frequency cutoff point and cohort
Power Cohort 1 Cohort 2 Cohorts combined
frequency
cutoff (%) prevalence OR 95% CI p prevalence OR 95% CI p prevalence OR 95% CI p

S NS total S NS total S NS total

1 51 27 37 2.1 1.1–4.0 0.033 20 08 12 3.0 1.1–8.6 0.036 39 17 25 2.9 1.7–4.9 o0.001

5 26 06 15 4.3 1.6–11.3 0.003 12 02 05 6.6 1.4–30.4 0.015 19 04 09 5.6 2.4–13.0 o0.001
10 17 03 09 5.7 2.0–21.5 0.010 10 00 03 — — — 14 01 06 12.7 3.5–45.0 o0.001
Critical probing depth level 6 mm. Adjusted for age. S 5 smoker, N 5 non-smoker.

Table 4. Prevalence (%) and odds ratio (OR) according to bone height cutoff point and cohort
Bone Cohort 1 Cohort 2 Cohorts combined
height
cutoff (%) prevalence OR 95% CI p prevalence OR 95% CI p prevalence OR 95% CI p

S NS total S NS total S NS total

30th percentile 49 15 30 4.2 1.8–9.6 0.001 45 26 31 2.8 1.1–7.0 0.031 48 21 30 4.3 2.3–8.2 o0.001
25th percentile 45 13 27 5.1 1.9–13.9 o0.001 40 19 25 4.2 1.5–11.8 0.005 45 14 25 7.5 3.7–15.3 o0.001
20th percentile 32 09 19 6.0 2.4–14.8 0.001 34 11 17 9.3 2.8–31.5 o0.001 35 09 18 8.1 3.8–17.5 o0.001
Adjusted for age. S 5 smoker, N 5 non-smoker.

increased from 2.3 (95% CI 1.0–5.5) 6 mm are presented in Table 3. Regard- was 49% and 15% for smokers and non-
to 9.6 (95% CI 1.7–52.8). At a 15% ing cohort 1, the OR increased from 2.1 smokers, respectively, and the OR was
cutoff, no disease was present in non- (95% CI 1.1–4.0) to 5.7 (95% CI 2.0– 4.2 (95% CI 1.8–9.6). At the 25th and
smokers and the OR could not be 21.5) at 1% through 10% cutoff. 20th percentile cutoffs, the prevalence
estimated. The overall prevalence Regarding cohort 2 the OR increased dropped for both smokers and non-
decreased from 20% to 2% with from 3.0 (95% CI 1.1–8.6) to 6.6 (95% smokers, whereas the OR increased to
increasing cutoff point. The risk esti- CI 1.4–30.4) as the cutoff was shifted 5.1 (95% CI 1.9–13.9) and 6.0 (95% CI
mates were throughout statistically sig- from 1% to 5%. At a 10% cutoff, the 2.4–14.8), respectively. Similar obser-
nificant (po0.05 to po0.01), but OR could not be estimated since no vations held true for cohort 2. For both
confidence intervals around those re- disease was present in non-smokers. For cohorts combined, the ORs related to
lated to the greater cutoff points were both cohorts combined, the OR at 1%, these percentile cutoffs were 4.3 (95%
wide. The observed pattern became 5%, and 10% cutoffs gradually in- CI 2.3–8.2), 7.5 (95% CI 3.7–15.3), and
even more evident for both cohorts creased from 2.9 (95% CI 1.7–4.9) to 8.1 (95% CI 3.8–17.5), respectively.
combined. The smoking-associated 12.7 (95% CI 3.5–45.0) along with The risk estimates were throughout
OR increased from 3.0 (95% CI 1.8– decreasing prevalence rates in both statistically significant (po0.05 to
4.6) at a 1% cutoff to 12.1 (95% CI 3.9– smokers and non-smokers. The risk o0.001).
37.1) at a 15% cutoff in parallel with estimates were throughout statistically The age-adjusted smoking-associated
decreasing prevalence rates. The risk significant (po0.05 to o0.001). OR according to combinations of bone
estimates were throughout highly sig- The prevalence and smoking-asso- height and 5 mm critical level pocket
nificant (po0.001). ciated ORs according to bone height frequency cutoff points is demonstrated
The prevalence and smoking-asso- criteria are presented in Table 4. in Table 5 for both cohorts combined.
ciated ORs according to pocket fre- Regarding cohort 1, the prevalence at At the 30th percentile cutoff in combi-
quency cutoff point for a critical level of the 30th percentile bone height cutoff nation with gradually increasing pocket
110 Bergström

frequency cutoffs, the OR increased combined. At each frequency cutoff, the

o0.001
o0.001
o0.001
from 5.4 (95% CI 2.8–10.4) to 8.3 ORs associated with consumption levels

p
(95% CI 3.3–20.8) as the prevalence 1–9 cig/day, 10–19 cig/day, and more
decreased from 39% to 21% for smo- than 19 cig/day, respectively, gradually
kers and from 12% to 3% for non- increased from approximately 2 to a

20.8
36.5
48.1
smokers. At the 25th percentile bone maximum of 10.7 (95% CI 4.1–28.1)
CI
10% pocket frequency cutoff

height cutoff in combination with the (Fig. 1a). The ORs associated with
same pocket frequency cutoffs, the OR smoking duration levels 1–15 years,
increased from 6.8 (95% CI 3.7–15.3) to 16–30 years, and more than 30 years
95%

3.3
3.5
4.8 11.4 (95% CI 3.5–36.5), and at the 20th gradually increased from 1.2 (95% CI
percentile bone height cutoff it in- 0.6–2.9) to 5.3 (95% CI 2.1–13.2) at a
creased from 10.7 (95% CI 4.7–24.7) 1% cutoff, from 2.3 (95% CI 0.7–7.8) to
8.3
11.4
15.3

to 15.3 (95% CI 4.8–48.1). The pre- 7.9 (95% CI 3.5–17.9) at a 5% cutoff,

OR

valence rates decreased from 35% to and from 4.2 (95% CI 0.9–19.0) to 9.8
20%, and from 31% to 20%, respec- (95% CI 3.7–26.0) at a 10% cutoff (Fig.
NS total

09
09
08

tively, for smokers and from 8% to 3%, 1b). Similarly, a gradual elevation of the
prevalence

and from 6% to 2%, respectively, for OR was observed along with lifetime
03
03
02

non-smokers. All estimates were highly exposure levels 1–170 cigarette-years,

significant (po0.001). 170–350 cigarette-years, and more than
21
20
20
S

350 cigarette-years from 2.2 (95% CI

Table 5. Prevalence (%) odds ratio (OR), and 95% confidence interval (CI) according to bone height and pocket frequency cutoff points

Exposure-related risk
1.1–4.4) at a 1% cutoff and light
o0.001
o0.001
o0.001

exposure (o170 cigarette-years) to

p

The age-adjusted ORs associated with 11.4 (95% CI 4.5–29.0) at a 10% cutoff
gradients of cigarette consumption, and heavy exposure (4350 cigarette-
smoking duration, and lifetime exposure years) (Fig. 1c). The risk estimates
16.6
27.2
39.6

according to pocket frequency cutoff associated with light exposure levels

5% pocket frequency cutoff

CI

point for a critical level of 5 mm are were generally rather weak and not
illustrated in Figs. 1a–c for both cohorts always statistically significant, whereas
95%

3.3
4.4
4.0
Critical probing depth level 5 mm. Both cohorts combined. Adjusted for age. S 5 smoker, NS 5 non-smoker.
7.4
10.9
12.5
OR

NS total

13
11
10
prevalence

05
03
02
27
25
25
S

o0.001
o0.001
o0.001
p
1% pocket frequency cutoff

10.4
15.3
24.7
CI
95%

2.8
3.7
4.7
15 10.7
21 5.4
18 6.8
OR

NS total
prevalence

12
08
06
39
35
31
S

30th percentile
25th percentile
20th percentile
Bone height

Fig 1. Odds ratios (95% CI) according to smoking exposure and pocket frequency cutoff
point. Critical level of probing depth: 5 mm. Cutoff points: 1%, 5%, and 10%. Both cohorts
cutoff

combined. (a) Cigarette consumption (cig/day). (b) Smoking duration (years). (c) Lifetime
exposure (cigarette-years).
 Smoking-associated risk 111

estimates for moderate and heavy ex- together with more than 10% of 5 mm naturalness (MacMahon and Trichopou-
posures were highly significant, although or deeper pockets) was approximately los 1996). In the absence of knowledge
confidence intervals were wide. Similar 20-fold that of a nonsmoker. of causal criteria, manifestational criter-
results were obtained using 6 mm prob- ia provide the only basis for categoriza-
ing depth or bone height as a basis for tion. Although general acceptance of a
disease definition (data not shown). Discussion unanimous definition of periodontal
The relations between the smoking Under the presumption that smoking disease does not exist, there is wide
exposure-associated relative risk and constitutes a risk for periodontal dis- agreement that certain clinical and
combinations of bone height critical ease, the objective of the present radiographic manifestations such as
levels and 5 mm pocket frequency cut- investigation was to explore the rela- pocket probing depth, attachment loss,
off points are illustrated in Figs. 2a–c tions between the smoking-associated and bone loss beyond a given limit
regarding smoking duration and both relative risk, disease definition, and (critical level) are diagnostic for the
cohorts combined. For each level of prevalence of the disease. In the main, disease. However, once a decision has
bone height, the OR gradually increased the observations showed that the esti- been made on a critical level of the
with increases in exposure and pocket mated risk was moderate in correspon- criterion or set of criteria, the frequency
frequency cutoff. The risk estimates dence with a high prevalence and, vice of the criterion criteria to be required for
were normally highly significant, but versa, of considerable magnitude in the discrimination of disease from non-
as seen in the figures the confidence correspondence with a low prevalence, disease, i.e., for the classification of an
interval became wider as the OR suggesting that the relative risk was individual as a case or not, remains to
increased. The highest risk was ob- dependent on the prevalence, which, in be decided. In the present study, several
served for the combination of heavy turn, was dependent on disease definition. predetermined critical levels based on
exposure and great cutoff levels. The The classification of periodontal dis- various sets of diagnostic criteria were
risk run by a heavy smoker (more than ease like any disease is based on selected for the definition of disease.
30 years’ duration) of having severe arbitrary or artificial categories con- First, critical levels referring to pocket
disease (less than 76% bone height structed more for utility than for probing depths of 5 and 6 mm were
alternately used as the diagnostic criter-
ion. Then, for each critical level, several
cutoff points representing increasing
frequencies were selected for the final
definition of disease. In addition, a
certain fraction of the population with
regard to radiographic bone height
distribution, the 30th, 25th, and 20th
percentile, respectively, served the same
purpose. Although arbitrary, these cri-
teria largely concur with those reported
in the literature.
Using a broad definition of disease
such as a cutoff of 1% of pockets with a
probing depth of 5 mm or more, the
overall prevalence for both cohorts
combined was 37% with a prevalence
among smokers that was approximately
twice the prevalence of non-smokers.
This was reflected in an estimated OR
of about 3, suggesting a three-fold
elevated risk for smokers. Using a
narrower definition of disease such as
a cutoff of 15% of pockets with a
probing depth of 5 mm or more, or 10%
of pockets with a probing depth of 6 mm
or more, the overall prevalence de-
creased to approximately 7% and 6%,
respectively. Although the overall pre-
valence related to such a definition
of disease decreased considerably, the
prevalence was 10–15-fold greater
among smokers than non-smokers. This
Fig 2. Odds ratios (95% CI) according to smoking duration, bone height percentile cutoff was reflected in estimated ORs of about
point and pocket frequency cutoff point. Critical level of probing depth: 5 mm. Cutoff points 12, suggesting a 12-fold elevated risk
of pocket frequency: 1%, 5%, and 10%. Both cohorts combined. (a) Bone height cutoff point: for smokers, i.e., a four times greater
30th percentile. (b) Bone height cutoff point: 25th percentile. (c) Bone height cutoff point: risk than that estimated according to
20th percentile. the first condition. Thus, along with
112 Bergström

gradually more stringent criteria the regardless of the diagnostic criterion. increase the precision of the estimates
overall prevalence decreased whereas It seems highly likely, therefore, that the therefore, data from both cohorts were
the smoker to non-smoker relative risk estimates reported in the literature combined although collected from two
prevalence gradually increased, which also reflect the cutoff level selected for different points in time.
was reflected in gradually increasing disease definition and case identification. In conclusion, the present observa-
relative risk estimates. The same pattern The present observations suggest that tions suggest that the relative risk
held true regardless of whether the the magnitude of the smoking-asso- associated with smoking, among other
criterion was selected on the basis of ciated risk is dependent on the magni- factors, is dependent on definition of
probing depth, bone height, or combina- tude of exposure. A positive correlation disease and prevalence. Given other
tions of these. between increasing exposure and mag- factors, a narrow definition of disease,
Since the risk estimate catches the nitude of the risk estimate was observed including predominantly aggressive
relative prevalence of the exposed ver- irrespective of definition of disease and forms or severe cases, resulted in a
sus nonexposed subpopulations, a good measure of exposure. Whereas light low prevalence and a high risk. For a
estimate of the ‘‘true’’ prevalence is exposure was associated with low risk, broader definition, including also less
needed. It follows from the above that the risk associated with heavy exposure distinct forms of disease and borderline
since prevalence is related to disease was considerable (9.8–11.4 related to cases, the prevalence increased and the
definition, a ‘‘true’’ prevalence cannot probing depth alone or 10.7–20.3 re- risk decreased. It was, additionally,
be unambiguouly determined as long as lated to probing depth and bone height observed that heavy smoking consis-
the criteria for disease definition vary. combined). The observations are in tently was associated with high risk,
This problem is clearly evident from the accord with the few previous studies suggesting that for the combination of a
epidemiological literature (e.g., Pilot & that have estimated the relative risk narrow definition of disease and heavy
Miyazaki 1991, Brown et al. 1996) and associated with exposure gradients exposure, the smoking-associated risk
is further discussed by Burt (1996). A (Grossi et al. 1994, 1995, Haber and of attracting periodontal disease is
prevalence of periodontal disease greater Kent 1992, Haber et al. 1993, Wakai et considerable. The results provide at
than 10% in the normal adult population, al. 1999). The notion that the smoking- least in part an explanation to the great
however, does not seem reasonable and associated risk for periodontal disease variation reported in the literature con-
would imply an unnecessary large pro- is exposure dependent is important. cerning the magnitude of risk for perio-
portion of false positives. Applied to the Following the concept of causation dontal disease attributed to smoking.
present observations a ‘‘true’’ prevalence advocated by Rothman (1986), light
of 10% would result from a definition of smoking may not be a component cause
Zusammenfassung
disease based on pocket frequencies of of periodontal disease, whereas heavy
10–15% related to 5 mm probing depth, smoking in contrast is highly likely to Tabakrauchen und Risiko für parodontale
or 5–10% related to 6 mm probing be one. Counselling heavy smokers to Erkrankungen
Ziele: Die Stärke des Risikos für parodontale
depth. Based on such criteria, the mag- reduce smoking (become light smokers)
Erkrankungen in Verbindung mit Rauchen
nitude of the smoking-associated rela- rather than quit, therefore, may have wurde untersucht durch das Erforschen der
tive risk was in the range 5.6–12.7 substantial import in the context of Beziehungen zwischen der Definition der Erk-
(probing depth criteria alone) or 8.3–15.3 prevention. rankung, der Prävalenz und dem relativen
(probing depth and bone height criteria When estimating the magnitude of Risiko in einer Population von zahnbewu!ten
combined). Although, admittedly, the risk associated with tobacco smoking, Individuen.
confidence intervals around these esti- several limiting factors have to be Material und Methoden: Insgesamt 133 Rau-
cher und 242 Nichtraucher im Alter von 20
mates were wide, such a range would considered such as population charac- bis 69 Jahren dienten als Datanquelle. Kriterien,
most likely include more precise esti- teristics and sample size as well as die auf der klinischen Sondierungstiefe und
mates found from larger sample sizes. methodological limitations such as den radiographischen Messungen der Knochen-
The magnitude of smoking-asso- smoking misclassification and exposure höhe fu!ten, wurden für den Zweck der
ciated risk estimates reported in the inaccuracy. The present study was Krankheitsdefinition genutzt. Die verschiede-
literature varies considerably and so based on cross-sectional data from two nen Frequenzen der Taschen mit den zwei
Sondierungstiefen X5 mm und X6 mm sowie
do the diagnostic criteria. On the basis samples drawn from the same popula- zusätzlich das 30-, 25- und 20-Perzentil der
of criteria related to pocket probing tion with an interval of 10 years. The Verteilung von der Knochenhöhe waren alter-
depth and attachment loss, respectively, observations from both time points were native Selektionskriterien.
estimates in the range 1.4–5.3 (Markka- similar, increasing reliability and gen- Ergebnisse: Die Definition der Erkrankung hat
nen et al. 1985, Hansen et al. 1993, eralizability of the observations. Among Auswirkung auf die Prävalenz, und das relative
Stoltenberg et al. 1993, Wakai et al. the advantages of the study are the Risiko variiert als eine Funktion der Prävalenz.
1999) and 1.9–9.7 (Locker & Leake socioeconomical homogeneity of the Für eine umfassende Definition der Erkrankung
mit 1 % der Taschen X5 mm war die Prävalenz
1993, Grossi et al. 1995, Dolan et al. population and the high participation für Raucher ungefähr zweimal höher verglichen
1997, Paidi et al. 1999, Moore et al. rate (Bergström et al. 1986, 2000a, b). mit derjenigen von Nichtrauchern. Die Odds-
1999) have been reported. Studies based In addition, the clinical and radio- ratio betrug 3,0. Eine engere Defintion der
on bone height criteria or combinations graphic data were characterized by high Erkrankung mit 15 % der Taschen X5 mm
of criteria report estimates in the range methodological quality. Among the ergab eine Verringerung der Prävalenz sowohl
1.8–11.8 (Horning et al. 1992, Haber et limitations are noted the small sample für Raucher als auch für Nichraucher und eine
Odds-ratio von 12,1. Die vergrö!erte Exposi-
al. 1993, Linden & Mullally 1994, sizes. As a consequence, risk estimates tion korrelierte mit einer grö!eren Amplitude
Mullally & Linden 1996, Norderyd & were determined with comparably wide des Risikos. Schwere Expositionen waren
Hugoson 1998). From these studies it is confidence intervals, particularly when mit grö!erem Risiko verbunden als leichtere
apparent that the risk estimate varies related to exposure substrata. In order to Expositionen. Bei einer Kombination einer
 Smoking-associated risk 113

engen Definition der Erkrankung und einer Bergström, J. & Eliasson, S. (1987a) Noxious MacMahon, B. & Trichopoulos, D. (1996)
schweren Exposition war das relative Risiko effect of cigarette smoking on periodontal Epidemiology. Principles and methods, 2nd
beträchltich (Odds-ratio 9,8 – 20,3). health. Journal of Periodontal Research 22, edition, p. 32. Boston: Little, Brown.
Zusammenfassung: Das mit Rauchen verbun- 513–517. Markkanen, H., Paunio, I., Tuominen, R. &
dene relative Risiko ist abhängig von der Bergström, J. & Eliasson, S. (1987b) Cigarette Rajala, M. R. (1985) Smoking and period-
Definition der Erkrankung und der Prävalenz. smoking and alveolar bone height in subjects ontal disease in the Finnish population aged
Vorausgesetzt andere Faktoren wird eine enge with a high standard of oral hygiene. Journal 30 years and over. Journal of Dental
Defintion in einer niedrigen Prävalenz und of Clinical Periodontology 14, 466–469. Research 64, 932–935.
einem hohen Risiko resultieren und umgekehrt Bergström, J., Eliasson, S. & Dock, J. (2000a) Moore, P. A., Weyant, R. J., Mongeluzzo, M.
wird bei einer breiten Definition die Prävalenz Exposure to smoking and periodontal health. B., Mayers, D., Rossie, K., Guggenheimer, J.,
hoch und das Risiko moderat sein. Journal of Clinical Periodontology 27, 61–68. Block, H., Huber, H. & Orchard, T. (1999)
Bergström, J., Eliasson, S. & Dock, J. (2000b) Type 1 diabetes mellitus and oral health,
Résumé A 10-year prospective study of tobacco assessment of periodontal disease. Journal of
smoking and periodontal health. Journal of Periodontology 70, 409–417.
Tabagisme et risque de maladie parodontale
Periodontology 71, 1338–1347. Mullally, B. H. & Linden, G. J. (1996)
Objectif: L’amplitude du risque de souffrir de
Brown, L. J., Brunelle, J. A. & Kingman, A. Molar furcation involvement associated with
maladie parodontale associe au tabagisme a été
(1996) Periodontal status in the United cigarette smoking in periodontal referrals.
recherche en explorant les relations entre la
définition de la maladie, la prévalence et le States, 1988–91: prevalence, extent, and Journal of Clinical Periodontology 23,
risque relatif dans une population d’individus demographic variation. Journal of Dental 658–661.
intéressé par leur dents. Research 75, 672–683. Norderyd, O. & Hugoson, A. (1998) Risk
Matériel et Méthodes: 133 fumeurs et 242 Burt, B. A. (1996) Epidemiology of periodontal of severe periodontal disease in a Swedish
non-fumeurs âgés de 20 à 69 ans ont servi de diseases. Position Paper. Journal of Period- adult population. A cross-sectional study.
base de données. Des critères bases sur le ontology 67, 935–945. Journal of Clinical Periodontology 25,
sondage clinique de la poche et des mesures Dolan, T. A., Gilbert, G. H., Ringelberg, M., 1022–1028.
radiologiques de la hauteur osseuse ont été Legler, D., Antonson, D., Forster, U. & Heft, Norderyd, O., Hugoson, A. & Grusovin, G.
utilise pour définir la maladie. Des points M. W. (1997) Behavioral risk indicators of (1999) Risk of severe periodontal disease in a
limites variés de fréquence des poches pour attachment loss in adult Floridians. Journal Swedish adult population. A longitudinal
deux niveaux de profondeur de po- of Clinical Periodontology 24, 223–32. study. Journal of Clinical Periodontology
che,4 5 5 mm et4 5 6 mm, et en plus, 30%, Grossi, S. G., Genco, R. J., Machtei, E., Ho, A., 26, 608–615.
25%, et 20% de distribution de la hauteur Koch, G., Dunford, R., Zambon, J. & Haus- Paidi, S., Pack, A. R. & Thomson, M. W.
osseuse ont alternativement été utilise comme man, E. (1995) Assessment of risk for (1999) An example of measurement and
critère de sélection. periodontal disease. II. Risk indicators for reporting of periodontal loss of attachment
Résultats: La définition de la maladie a un alveolar bone loss. Journal of Periodontology (LOA) in epidemiological studies: smoking
impact sur la prévalence, et le risque relatif 66, 23–29. and periodontal tissue destruction. New
varie en fonction de la prévalence. Pour une Grossi, S. G., Zambon, J., Ho, A., Koch, G., Zealand Dental Journal 95, 118–123.
définition assez large de la maladie, comme 1% Dunford, R., Machtei, E., Norderyd, O. & Pilot, T. & Miyazaki, H. (1991) Periodontal
des poches4 5 5 mm, la prévalence pour les Genco, R. J. (1994) Assessment of risk for conditions in Europe. Journal of Clinical
fumeurs était approximativement le double de periodontal disease. I. Risk indicators for Periodontology 18, 353–357.
la prévalence chez les non-fumeurs et le odds attachment loss. Journal of Periodontology Preber, H. & Bergström, J. (1986) Cigarette
ratio était de 3.0. Une définition plus étroite 65, 260–267. smoking in patients referred for periodontal
comme 15% des poches4 5 5 mm résultait en
Haber, J. & Kent, R. L. (1992) Cigarette treatment. Scandinavian Journal of Dental
des prévalences diminuées pour les deux
smoking in a periodontal practice. Journal Research 94, 102–108.
groupes et un odds ratio de 12.1. Une exposition
of Periodontology 63, 100–106. Rothman, K. J. (1986) Modern epidemiology,
plus importante était corrélée avec une plus
Haber, J., Wattles, J., Crowley, M., Mandell, R., pp. 7–21. Boston: Little, Brown.
grande amplitude de risque. Une lourde exposi-
tion était associe avec un plus grand risque Joshipura, K. & Kent, R. L. (1993) Evidence Skaleric, U. & Kovac-Kavcic, M. (2000) Some
qu’une exposition légère. Pour une combinaison for cigarette smoking as a major risk factor risk factors for the progression of periodontal
d’une définition étroite de la maladie et une for periodontitis. Journal of Periodontology disease. Journal of the International Acad-
lourde exposition, le risque était considérable 64, 16–23. emy of Periodontology 2-1, 19–23.
(odds ratio 9.8-20.3). Hansen, B. F., Bjertness, E. & Gronnesby, J. K. Stoltenberg, J. L., Osborn, J. B., Pihlstrom, B.,
Conclusion: Le risque relatif associe au (1993) A socio-ecologic model for period- Herzberg, M., Aeppli, D., Wolff, L. &
tabagisme dépend de la définition de la maladie ontal diseases. Journal of Clinical Period- Fischer, G. E. (1993) Association between
et de la prévalence. D’autres facteurs étant ontology 20, 584–590. cigarette smoking, bacterial pathogens, and
déterminés, une étroite définition résultera en Holm, G. (1994) Smoking as an additional risk periodontal status. Journal of Periodontology
une prévalence basse et un risque important, et for tooth loss. Journal of Periodontology 65, 64, 1225–1230.
vice versa, pour une plus large définition, la 996–1001. Wakai, K., Kawamura, T., Umemura, O., Hara,
prévalence sera forte et le risque modéré. Ismail, A. I., Morrison, E. C., Burt, B. A., Y., Machida, J., Anno, T., Ichihara, Y.,
Cafesse, R. G. & Kavanagh, M. T. (1990) Mizuni, Y., Tamakoshi, A., Lin, Y., Nakaya-
References Natural history of periodontal disease in ma, T. & Ohno, Y. (1999) Associations of
adults: findings from the Tecumseh Period- medical status and physical fitness with
Bergström, J. (1989) Cigarette smoking as risk ontal Disease Study, 1959–87. Journal of periodontal disease. Journal of Clinical
factor in chronic periodontal disease. Com- Dental Research 69, 430–435. Periodontology 26, 664–672.
munity Dentistry and Oral Epidemiology 17, Linden, G. J. & Mullally, B. H. (1994) Cigarette
245–247. smoking and periodontal destruction in
Bergström, J. & Eliasson, S. (1985) Dental care young adults. Journal of Periodontology 65,
habits, oral hygiene, and gingival health in 718–723. Address:
Swedish professional musicians. Acta Odon- Locker, D. & Leake, J. L. (1993) Risk Jan Bergström
tologica Scandinavica 43, 191–197. indicators and risk markers for periodontal Odontologiska Institutionen
Bergström, J. & Eliasson, S. (1986) Alveolar disease experience in older adults living Box 4064
bone height in professional musicians. Acta independently in Ontario, Canada. Journal S-141 04 Huddinge
Odontologica Scandinavica 44, 141–147. of Dental Research 72, 9–17. Sweden