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J Clin Feriodoniol I99S: 25: 297-305 Copyright © Munksgaard I<^<JH

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JIUMUlOf
Clinical periodcntology
/.S.V,V OJ

Relationship between smoking p. Axelsson' 2, J.


and J. Lindhe^
'Department of Periodontology. Faculty of
Odontology, Goteborg University, Sweden;

and dental status in 35-, 50-, 65-, ^Department of Preventive and Community
Dentistry, Public Dental Health Service,
Karlstad, Varmland. Sweden

and 75-year-old individuals


A.xels.san P. PauUtiuler J. Limlhe J: Relatiomhip between smoking and dental .statu.s
in 35-. 50-, 65-, ami 75-year-okl individuals. J Clin Periodontol 1998: 25: 297-305.
© Munksgaard. 1998.

Abstract. The aim ofthe present study was to examine the dental status and
smoking habits in randomized samples of 35-, 50-, 65-, and 75-year-old subjects
(n=1093), recruited tor a cross-sectional epidemiological study in the County of
Varmland. Sweden. The following clinical variables were recorded by 4 well-
calibrated dentists: number of edentuolous subjects, number ol' missing teeth,
probing attachment level, furcation involvement, CPITN scores, DMF surfaces,
plaque and .stimulated salivary secretion rate (SSSR). In addition, the subjects
reported in a questionnaire their tobacco habits, orai hygiene habits, dietary
habits etc. The percentage of smokers in 35-, 50-, 65-. and 75-year-olds was 35%,
35'K), 24% and 12%, respectively. In 75-year-olds, 41"/) ofthe smokers were eden-
tulous compared to i5"/« of non-smokers. The difference in number of missing
teeth between smokers and non-smokers was 0.6 (p^0.\5). 1.5 (;?^O.OI3). 3.5 {p^
0.00Q7) and 5.8 (/?^0.005) in the 4 age groups. Smokers had the largest mean
probing attachment loss in all age groups. The ditTerences between smokers and
non-smokers in mean attachment level were 0.37 (/j^O.OOl), 0.88 (;)=O.OOI), 0.85
(p-0.001) and 1.33 mm ( ; J - 0 . 0 0 3 ) in the 35-. 50-, 65-, and 75-year-olds, respec-
tively. Treatment need assessed by CPITN was in al! age groups greatest among
smokers. The number of intact tooth surfaces was fewer in 35-, 50-, and 75-year-
old smokers than in non-smokers. The number of missing surfaces (MS) was
higher in 50-, 65-. and 75-year-old smokers than in non-smokers. In addition. 35-
year-old smokers exhibited a significantly larger number of decayed and filled
tooth surfaces (DFS) than non-smokers. Male smokers had significantly higher
SSSR than non-smoking males (;?=0.012). Plaque index and oral hygiene were
similar in smokers and non-smokers. Smokers reported a more frequent intake of
sugar containing soft drinks (yj=O.OOO) and snacks (/f=0.003) than non-smokers. Key words: analytic epidemiology; smoking;
tooth loss: attachment loss; CPITN; caries
The opposite was reported for consumption of fruit (/;^0.003). It was con- prevalence; plaque; salivary secretion rate;
cluded that smoking is a significant risk indicator for tooth loss, probing attach- oral hygiene habits; dietary habits
ment loss and dental caries.
Accepted for publication 21 July 1997

The main objective of epidemiological Findings from a number of cross-sec- study has been published in which the
surveys of a cross section design is to tional studies have indicated that effect of smoking on both caries and
provide important information about smokers have more missing teeth and periodontal diseases was evaluated in a
the distribution of e.g. oral diseases in more advanced periodontal disease randomized sample of adults belonging
a population, but the data generated than non-smokers (Table 1). Most of to well defined age groups (indicator
can also be used to assess the relative the studies referred to were carried out age groups).
importance of indicators for a given in selected groups of adults stratified The aim ol" the present study was to
disease or group of diseases (Beck et into age intervals. Such a selection may assess the prevalence and severity of
al. 1990, Hansen et al. 1990, Horning result in a scewed distribution of indi- periodontal disease and dental caries in
et al. 1992, Grossi et al. 1994. Beck viduals recruited to the study, and this smokers and non-smokers in a ran-
1994, Wolff et al. 1994, Wiktorsson may influence the interpretation of the domized sample of 35-, 50-. 65-. and 75-
1995). data obtained. To our knowledge, no year-old subjects.
298 A.xels.';on et al.

was based on both age and urban/ru- categories 11, 64. 45 and 72 subjects, re-
Material and Methods ral living - 5O'!^p of the subjects lived spectively, failed to appear for the
An epidemiological oral survey was in an urban area (>50,000 inhabi- examination. The main reasons for not
perlbrtned on 35-, 50-, 65-. and 75- tants) and 50% lived in 4 rural areas attending were (!) "no longer living at
year-old subjects in the Coiinty of (<8,000 inhabitants in the major mu- the official address" (tnostly 50-year-
Varmland, Sweden. The age groups nicipality). It should be observed that olds), (2) "illness", particularly among
were selected according to the recom- Ihe number of 50 year old individuals 65-, and 75- year-olds and (3) "refusal
mendations of the Swedish National included in the present study is con- to participate".
Board of Health and Welfare (Sund- siderably larger than the number of Before the clinical examination, all
berg 1989). A randomized, stratified subjects in the 3 remaining age cate- subjects signed informed, written con-
sample of 35-yecir-olds (/j=155), 50- gories. The reason for this is that the sent regarding participation. Individ-
year-olds (H^510), 65-year-olds («= 50 year old subjects were intended to uals reporting "no smoking" habits and
310) and 75-year-olds (/j-310) was be included also in a 10 year longi- "smoking" habits were selected for the
tudinal epidemiological survey. present study while "former smokers"
drawn from approximately 220,000 in-
habitants in the county. Stratification In the 35-, 50-. 65-. and 75-year age were excluded. The resulting distri-

Table 1. Review of cross-sectional orai epidemiology studies related to smoking habits


Materials Variables
Periodontal disease Life style
Studies n Age SEL RAN AG MT AB VAL HAL CPITN GI PD CAR PI PP CP SSR DC OH DH OTH
Herulf (I95II 535 19-25 X mt
Massler
et al. (1952)2577 17-21 mt NS
Arno et al. (195K)1246 25-55 mt S
Arno et al. (19591 728 21-45 mt S
Heruir (19681 700 20-85 int s s
Bergstrom
et al, (1983) 328 39-78 X int S s -s NS
Feldman
et ai. (1983) 862 7 all s NS NS -s
Preber et al. (1986) 369 18 70 int -s NS NS
Osterberg
et a!. (1986)1377 70 X ind
Bergstrom
et al. (1987) 235 21-60 int NS
Beck et al. int
Hansen (1990) 690 65 +
et al. ind NS
Goultscliin (1990) 144 35
et al. int
Bergstrom (1990) 344 20-70
et al. all
Horning (1991) 210 24-60
et al. 13 84 all
Preber et al. (1992)1783 32 74 all NS
Stoltenberg (1992) 145
et al, (1993) 189 28-73 all NS S NS
Haber et al. (1993) 227 int S
Linden et al. (1994) 82 20-33 all S S -S NS NS
Grossi et al. (1994)1426 25-74 all
Martine?-
Canut et al. (1995) 889 21-76 all
Wictorsson (1995) 236 44-56 all NS
Sakki et al. (1995) 527 55 ind S
Soder et al. (1995) 144
s
all s s NS S NS
Mtillally
et al. (1996) 100 35 + all NS NS
SELT: study on selected material; RAN: study on randomized material; .4G: agegroup (statistics performed on: ini: age interval; ind: indicator
age group(s); all: all ages simultaneously): MT: number of missing teeth; AB: alveolar bone; VAL: vertical attachment level: HAL: horizontal
attachment level; CPIT!^: community periodontal index of treatment needs; GI: gingival index; PD: pocket depth; CAR: dental caries; PI:
plaque index; PP: periopathogens; CP: caries pathogens; SSR: stimulated saliva secretion rate; DC: dental care habits; OH: oral hygiene
habits; DH: dietary habits; OTH: other important features. NS: non significant difference; S: significant difference, non smokers beeing
healthier; —S: reversed significant difference.
Smoking and dental health .status 299

Table 2. The primary sample, former smokers, smokers and non smokers according lo age and gender
Age (years) 35 50 65 75 TOT
Primary n 11 n
sample 155 510 310 310 1285
Examined 144 446 265 238 1093
male I "M female ("•''<•) m a l e ( "'il) female {"Al) male ( %) female {"/ '•<) male ( "/•i) female ("A,) male i1*!'") female ("/,)
72 72 215 231 128 137 117 121 536 557
Smoking
unknown 0 (0) 1 (l.4| 1 (0.5) 0 (0) 4 (3.1) I (0.7) 6 (5.0) 8 (6.8) ll (2.1) 10 {1.8)
Former
smokers 7 (9.7) 9 (12.5) 36 (6.7) 22 (9.5) 15 (11.7) 9 (6.6) 26 (21.5) 7 (6.0) 84 (15.7) 47 (8.4)
Smokers 21 (29.2) 23 (31.9) 65 (30.2) 71 (30.7) 37 (28.9) 19 (13.9) 14 (11.6) 8 (6.8) 137 (25.6) !21 (21.7)
Non-
smokers 44 (61.1) 39 (54-2) 113 (52.6) 138 (59.7) 72 (56.3) 108 (78.8) 75 (62.0) 94 (80.3) 304 (56.7) 379 (68.0)

bution of subjects in the diita base is was recorded when the curette did not lets), was scored on all mesial, buccal,
shown in Table 2. "catch" at the furcation entrance and distal and lingual tooth surfaces in 50-
score 1 as soon as the tip of the curette year old subjects. The % of surfaces
reached the furcation area by gentle with plaque was calculated.
Oral examination
probing. Thus the furcations were Stimulated saliva secret ioti rate
The examiniilion was performed in a dichotomized into healthy (score-0) iSSSRj: the volume (ml) of saliva,
public dental health clinic, using a con- and involved (score=l). For extracted sampled per minute and produced by
ventional dental unit and illumination. teeth, the furcations were recorded as paraflin chewing was measured in 50-.
Contamination with saliva was pre- missing. 65-. and 75-year old subjects.
vented by the use of saliva ejectors and Periodontal trealment needs: meas- Frequeney of orai hygiene measures:
cotton roils. The teeth were dried with urements were made according to the ihe use oi' toothbrush, dental Hoss.
compressed air and examined wiih the Community Periodontal Index of Treat- interdental toothpicks and interdental
aid of dental mirrors and explorers. A ment Needs - CPITN - (Ainamo 1984). brushes was reported on an ordinal as-
set of full mouth radiographs was taken All mesial, buccal. distal and lingual cending scale from 1-"never" to 7 -
in the 50-, 65-, and 75-year-olds, and surfaces were defined according to score "every day, morning, evening and after
bite-wings were taken in the 35-year- 0, 1, 2. 3. 4 or missing. every meal".
olds. Caries prevalence: clinically visible Frequeney of jood consumption: the
primary and secondary (recurrent) actual number of intakes was recorded.
caries lesions, radiographic caries and The intake of sugar containing items
Variables
filled surfaces were registered in accord- (sweets, confectionary, soft drinks,
The following variables were recorded: ance with Axelsson & Lindhe (1978). jam), snacks and fruit was reported on
(1) number of teeth, (2) probing attach- Clinical examination was carried out an ordinal ascending scale from 1 =
ment level. (3) furcation involvement. using a WHO double-ended probe. "never" to 5 = "more than seven times
(4) CPITN, (5) prevalence of dental Dental bitewing radiographs, 2 or 4, de- per week".
caries and fillings. (6) plaque index (PU) pending on the width ofthe dental arch, Feeling of "dry mouth": was recorded
and (7) stimulated salivary secretion were used to detect decayed and filled as l^"never", 2^"seldom", 3^"often"
rate (SSSR). Each participant com- approximal surfaces. The number of de- and 4="always".
pleted a questionnaire on ongoing or cayed-, missitig- and filled (DMF) teeth The data from the clinical examin-
former tobacco use, "dry mouth", oral and surfaces was calculated. ation were transferred to a specially de-
hygiene and dietary habits. Plaque (PIl): the presence of plaque signed computer program. Data rel-
Number of teeth: roots with lack of (after disclosure with erythrosin pel- evant for the studv were retrieved, re-
crown substance were reported as ab-
sent. Third molars were excluded.
Probing attachment level: measure-
ments were performed aecording to Tahle 3. Mean number of missing teeth according lo ;ige and smoking habits; dentate subjects
Ramfjord (1959) using a double-ended only (/( = 808)
WHO probe. All measurements were Age (years) 35 50 65 75
made in millimetres. All mesial surfaces Smoking I + +
were measured. /; 83 44 242 127 145 45 109 13
Furcation involvement score 0, 1 and mean 1.4 2.0 4. 8 6.3 10.3 13.8 13.0 18.8
missing: Only molars were evaluated. SD 1.82 1.98 5. 13 5.44 6,51 7.63 6.89 6.44
The measurements were made at each difference -0. 6 -1.5 -3.5 -5.8
furcation entrance using a double-end- p=0. 15 /T=0.013 /) = 0.007 p=0.005
ed curette (Goldman-Fox #3). Score 0 95 % CI -1.343; 0.207 - 2 . 570; -0.311 -6.026: -0.995 -9.772; -1.821
300 A.xels.son et al.

modelled and transferred into ti The outcome of the reliability study in- involvetnent, however, the level of
statistical database package (SPSS^) dicated that the 4 examiners could be agreement was low (intra class corre-
together with answers from the qttes- used interchangeably for: caries preva- lation coefficient=0.682 and 0.745;
tionnaire. lence (intra class correlation coef- variation due to difference between the
4 teams of dctital examiners were tieient=0.996/().996 and 0.980/0.990; examiners was not significant and vari-
trained and calibrated. An ititer- and variance due to examiners O.l/O.OI'Mi ance due to examiners in relation to
intra- examiner reliability study was and 0.06/0.02'/<) for total and approxi- total variance was negligible in both age
performed on 20. 35-50-year-old sub- ma! DFS in 35-50- and 65-75-year- groups).
jects, and 20 subjects 65-75-years old. olds, respectively) and probing atlach-
Each of the 40 subjects was examined ^ tnent level tiieasiirenient (intra-class
Statistics
times. The reliability study included the correlation coefficient 0.924 and 0.933;
foliowing variables: caries prevalence variance due to examiners l.3/3.O'/<p in Analysis was performed on a personal
(DFS). probing attachment level (tnm) 35-50 and 65-75 year olds, respec- computer using the SPSS® system.
and furcation involvement (score 0 1). tively). For the assessement of furcation Non-parametric variables were tested

100 100

50 -

100 100
17/47 15/45 13/43 11/41 22/32 24/34 26/36 17/47 21,5 13/43 11/41 22/32 24/34 26/36
16/46 14/44 12/42 21/31 23/33 25/35 27/37 16/46 14/44 12/42 21/31 23/33 25/35 27/37
smokers non-smokers smokers non-smokers

100 100

50

100 100
17/47 15/25 13/43 11/41 22/32 24/34 26/36 17/47 15/25 13/43 11/41 22/32 24/34 26/36
16/46 14/44 12/42 21/31 23/33 25/35 27/37 16/46 14/44 12/42 21/31 23/33 25/35 27/37
u ^ smokers
smoKers non-smokers
non-smoKers a • smokers
smokers non-smokers
Fig. L Percentage of missing teeih. (a) 35-year-olds; (b) 50-year-olds; (c) 65-year-olds; (d) 75-year-olds
Smoking and dental hccilth .status 301

mm jects, there was only a minor difference


in the "pattern" of missing teeth between
smokers and non-smokers: except for
the first molars, which were more often
missing in smokers. The 65- and 75-year-
old age category smokers exhibited a
much higher percentage of missing
maxillary anterior teeth than non-
smokers, but in both groups the molars
were the most frequently missing teeth.
The mean probing attachment level at
mesial surfaces increased with age in all
age categories. Smokers displayed a
higher probing attachment loss (PAL)
value than non-smokers. The differences
regarding PAL between smokers and
non-smokers (0.37, 0.88, 0.85 and L33
mm) in the 4 age groups (Fig, 2) were
statistically significant (/t=0,001. p=
0.0000. /j-0,0000 and /)-0,002) in the
35-. 50-. 65-, and 75-year-olds respec-
35 yrs 50 yrs 65 yrs 75 yrs tively.
~ non-smokers • smokers The "/<• of molars with furcation in-
Fig. 2. Mean mesial loss of probing attachment. volvement was in all age groups greater
in smokers than in non-smokers, and the
difference increased with age; 3.6, 13.8,
using the Mann-Whitney U - Wilcoxon category were smokers 33.9'^ versus 19.3 and 26.5 % for 35-. 50-, 65-. and 75-
rank sum test and the y~ test. Para- 15.0% (77=0.0006). ycar olds respectively. The / - test showed
metric tests were performed by the Stu- There were no edentulous subjects these differences to be statistically sig-
dent /-test. Although some data are rep- among the 35-year-olds, The '/^J of eden- nificant in 3 age groups: 35-. 50-, and 65-
resented in the Tables and Figures as tulou.s subjects in non-smokers versus year old subjects (Table 4).
'^s. all statistical calculations were smokers increased with age from 3.6/ The mean "/.s of different CPITN
based on raw data. 6.6. 19,4/19,6 to 35.5/40,9% in 50-, 65-. scores is reported in Fig, 3, The % of
and 75-year-oids. but there were no score 0 in non-smokers versus smokers
statistically significant differences be- was 71/54. 55/43. 37/27 and 30/17 and
Results tween groups. for missing surfaces 5/7, 18/23, 37/49
The overall frequency of smokers was Tooth loss was on the average greater and 46/67 in the 35-. 50-. 65-. and 75-
27.4%. Approximately 32-37'^ of the in smokers than in non-smokers. The year-olds, respectively. In all age
35-50- and 65-year-old males were differences regarding the number of groups, the "A> of sites with CPITN
smokers but only 15,7"'ti of the 75-year missing teeth were statistically signifi- score 1 was lower in smokers than in
olds. In females, the highest frequency cant in the 50-, 65-, and 75-year age non-smokers. The differences between
of smokers was found among Ihe 35- groups(/?-0.013,/»-0.007./)-0.005),as smokers and non-smokers regarding the
year-olds (37,r'/i) and the lowest in the reported in Table 3. The distribution of mean number of missing surfaces were
75-year olds (7.8'KJ). Significantly more missing teeth in the dentition ("pattern") 2.2 (/;-O.I58), 5.8 (/?-0?013). 14.0 (p=
males than females in the 65-vear-old is presented in Fig. I. In 35-year-old sub- 0.0007) and 23.1 (/?-0.005) in the 35-.

Table 4. Dentate subjects (« = 8O8}; number of molars uiih iLirciition involvement related to total number of molars; dilTerence in mean number
of molars with furcation involvement related lo smoking habits. (/; = 679}
35 50 65 75
Age (years) ("•") (%) ( (%)
Smoking - 4- - + - + - +
subjects without molars 0(0) 0(0) 16(7) 8(6) 35 (25) 15 (33) 43 (39) 11 (85)
subjects with molars 83 (100) 44(100) 226 (93) 119(94) 109 (75) 30 (67) 66(61) 2(15)
total number of molars 636 314 1287 590 395 88 203 5
mean 7,7 7.1 5.7 5,0 3,6 29 3,1 2,5
SD 0,887 1,424 2.066 2.164 2,004 2 116 1,739 0.707
furcation involved molars 17(2,7) 20 (6,3) 186(14.5) 167(28,3) 88 (22,3) 37 (42,0) 68 (33.5) 3 (60.0)
not furcation involved
molars 6!9(97,3) 294 (95,7) itOl (85.5) 423(71.7) 307 (77.7) 51 (68.0) 135(66,5) 2 (40.0)
/ - test 7.67 50.84 14.66 1.52
P /XO.OOl /XO.OOI
302 Axelsson et al.

The mean number and the differ-


ences in Intact, Decayed. Filled, and
Missing surfaces in dentate subjects
were calculated (Table 5). The 35-,5Q-.
30 and 75-year-old non-smokers had sig-
nificantly larger numbers of intact sur-
faces than the smokers. Significantly
more filled surfaces were recorded in 35-
year-old smokers than in non-smokers,
but the 65-year-old non-smokers had
more filled surfaces than smokers.
Smokers had significantly more missing
surfaces than non-smokers in the 50-,
65-. and 75-year-old age groups. In the
50-year-olds, there was no significant
difference between non-smokers and
smokers with respect to the % ' > of sur-
faces with plaque.
•10 The SSSR in a combined group of
50-, 65-, and 75-year-old males and fe-
males was calculated. Male smokers
and non-smokers had a mean secretion
rate of 2.1 and 1.8 ml/min. respectively.
so
The difference, 0.3 ml/min, was statisti-
cally significant (p=O.OI2, 95% CI
0.575; 0.073). For females, there was no
statistically significant difference in sali-
35 yrs 50 yrs B5 yrs 75 yrs vary secretion rate between smokers
l ^ l missing | I score 0 Y//A score 1 ^ ^ score 2 l_ ! score 3 ^ H score 4 and non-smokers. Smokers more fre-
quently reported a feeling of "dry
Fig. i. Percentage of CPITN scores and missing surfaces. "-"" refers to non-smokers and "• + " mouth" (/.'^0.004). There were no stat-
to smokers.
istically significant differences in the
frequency of using different oral hy-
giene measures (toothbrush, inlerdental
floss, interdental toothpicks and inter-
50-, 65-. and 75-year-o!d age groups. In ( —). Statistically significant differences
dental brushes) between smokers and
35-year-olds, there were stalislically sig- in the 50-year-olds were found for
non-smokers. Concerning dietary
nificant differences between non- CPITN score 0 (+), 3 ( - ) and 4 ( - ) .
habits there were no significant differ-
smokers and smokers in the mean num- In the 65- and 75-year-oIds, statistically
ences between smokers and non-
ber of CPITN score 0 - positive differ- significant differences were found for
smokers in the mean number oi' meals
ence ( + ). 2 and 3 negative differences CPITN score 0 (+) and 1 ( + ).

Table 5. Mean number of inlacl. decayed, filled and missing surfaces in dentate subjects (« = 808)
35 50 65 75
Age (years) *(=127 n=369 n=[90 n = 122
smoking - + + + +
n 83 44 242 127 145 45 109 13
mean inlacI 89.9 79. t 51.3 43.6 35.0 29.2 27.8 13.4
SD 1S.91 18.66 21.50 22.71 23.27 19.48 22.12 13.74
mean decayed 0.3 1.5 0.4 0.6 0.2 0.5 0.2 0.15
SD 0.61 5.68 1.90 2.00 0.86 f.O4 0.71 0.56
mean filled 30.9 37.8 52.7 53.4 43.5 33.1 38.2 26.5
SD 16.50 14.65 18.77 21.27 20.68 24.52 22.30 19.40
mean missing 6.9 9.7 23.6 30.4 49.3 65.2 61-8 87.9
SD 8.87 12.28 24.20 25.64 30.14 34.79 31.51 28.75
diff intact 10.8/7=0.002 7.7/1=0.002 5.877=0.130 14.5/7=0.003
95% CI 3.90f; f7.794 2.944; 12.391 -1.734; 13.372 5.375; 23.544
diff decayed -I.2/J=O.183 -O.\ p=0.5\6 -0.3/7=0.122 0.07 /7=0.746
95% CI -2.894; 0.569 -0.554; 0.279 -0.606; 0.073 -0.339; 0.472
diff filled -6.9/-=0-02l -0.7/7=0.732 10.4/7=0.012 11.6/7=0.075
95% CI -12.769: -1.042 -4.975; 3.498 2.344; 18.474 -1.172; 24.425
difi" missing -2.8/j=0.145 -6.8/7=0.013 -16.0/7=0.007 -26.2/>=0.005
95"^ C! -6.534; 0.975 -12.ff5; - L 4 6 8 -27,459; -4.464 -44.304; -8.001
Smoking and dental health status 303

(4.1/4.0). intake of sweets or sugar con- in a longitudinal study (3 years) showed a case control study in a selected group
taining confectionary. Sugar containing that smokers (>50-years-old) lost 0.8 of referred periodontal patients, re-
soft drinks and snacks were consumed teeth / individual, compared to 0.4 lost ported that smokers had on average 1.9
more often by smokers than by non- teeth in non-smokers {p<0.05). molars with furcation involvement com-
smokers (/j^O.OOO and / J = 0 . 0 0 3 respec- The 65- and 75-year-o!d smokers pared to 0.9 in non-smokers.
tively) whereas fruit intake was more (Fig. lc. d) had a higher % of missing In all age groups, the "/.>s, of healthy
frequent in non-smokers (/J=0.003). maxillary incisors than non-smokers. sites (CPITN score^O) were lower in
The 75-year-old smokers had also more smokers than in non-smokers, but the
missing maxillary premolars and mo- "Al of sites with gingivitis and shallow
Discussion lars than non-smokers (Fig. Id). This pockets (CPITN score- 1) was higher in
Approximately 30% of the subjects re- may indicate that smoking has a local non-smokers than in smokers. These
cruited for the study were smokers, but deleterious effect in the maxillary den- findings are in agreement with data
the distribution was tinequal with re- tition and in particularly on the front from other studies showing that
spect to age group and gender; 37% of tooth region. In all four age groups smokers experience less gingivitis than
35-year-old females were smokers, but smokers exhibited significantly more non-smokers (Bergstrom & Floderus-
only 8'/o of 75-year-olds. TKe corre- probing attachment loss than non- Myrhed 1983, Preber & Bergstrom
sponding values for mates were 'i2% smokers (Fig. 2). This difference in PAL 1985. 1986. Bergstrom 1990, Gouldtsh-
and 16'/o respectively. Overall, the distri- increased with age. Thus the present re- in et al. 1990). One reason for lower
bution of smokers related to age and sults indicated that loss of periodontal gingivitis scores in smokers than in
gender was found to be in agreement attachment was correlated with the non-smokers is that smoking appears to
with data for Sweden previously re- number of years the subjects had been suppress the vascular reaction in the
ported (Swedish National Board of smokers. The current findings are thus marginal gingiva. In a study by Dani-
Health and Wellfare Report 1991). in agreement with data from other elsen et al. (1990) the rate of plaque ac-
cross-sectional studies showing that cumulation was similar in smokers and
In the current study, the "A> of edentu- smoking is a powerful risk indicator tor non-smokers, but the increase in gingi-
lous subjects among non-smokers and loss of periodontal tissue support (Beck val vascuiarity in smokers was only half
smokers was similar in the four age et al. 1990. Linden & Muilally 1994. of that in non-smokers. The proportion
groups. In 75-year-old males, however. Grossi et al. 1994. Martinez-Canut et of CPITN scores i-4- among the re-
43'yii of the smokers were edentulous, al. 1995). maining sites in the present material,
compared to 35"/i of non-smokers. This however, was higher in smokers than in
difference between smokers and non- In the baseline data collected for a non-smokers. The findings of the pres-
smokers is in agreement with findings longitudinal epidemiological study on ent study further showed that smokers
by Osterberg & Mellstrom (1986) who older adults (50-64 and 65- 75 years), had significantly fewer intact tooth sur-
found that in 70-year-old males almost Locker & Leake (1993) found that faces in all age groups than non-
50% of smokers were edentulous com- smokers had significantly more loss of smokers, and more missing surfaces
pared to only 20'!^) 0*1 non-smokers. probing attachment than non-smokers. (MS) in 50-. 65-. and 75-year olds. Al-
The difference in the mean number In a recent 3-year prospective study. though it may be argued that most MS
of missing teeth between smokers and Beck et al. (1995) showed that among were lost due to periodonta! disease in
non-smokers increased from the age of older adults, smokers were significantly these age groups, it is interesting to note
35 to 75. This may indicate that the more susceptible to loss of periodontal that in the 35-year olds, smokers had
longer the subjects had been smokers attachment than non-smokers. Machtei significantly more DFS and fewer intact
the more extensive was the relative et al. (1997) also showed in a longitudi- surfaces than non-smokers. This is in
tooth loss. This conclusion is in agree- nal study that smokers had three times agreement with Wictorsson (1995) who
ment with results from a longitudinal more attachment loss and twice more found significantly higher caries preva-
study by Holm (1994). In this study 20 alveolar bone loss than non-smokers. lence among smokers than in non-
40-year-old non-smokers lost, over a 10 Tobacco smoking also seems to play an smokers in a randomized sample of 30-
year period, only 13 teeth per 1000 indi- important role in refractory peri- 40-year old Swedes living in an area
viduals, compared to 121 teeth in age odontitis (Adams 1992, MacFarlane et with low water fluoride concentration.
matched smokers (>15 cigarettes/day). al. 1992). Compared to the % of The above findings indicate that smok-
During the same time interval. 50 70- smokers in the general population ing may indeed also be associated with
year-old smokers lost as many as 543 (<3O'/o) smokers comprised an unusu- increased risk for dental caries. This
teeth per 1000 individuals. Finding by ally high '^ (>90"A<) of refractory peri- hypothesis is supported by finding by
Osterberg & Mellstrom (1986) also con- odontitis cases (MaeFarlane et al. Ravald et al. (1993). In a twelve year
firmed that a correlation exists between 1992). longitudinal study they observed that
the number of lost teeth and the total smokers after periodontal treatment de-
The current data showed that
exposure to smoking. In the Oster- veloped significantly more new root
smokers had a greater prevalence of
berg & Mellstrom material the 70-year- caries lesions than non-smokers.
molars with furcation involvement than
old male smokers had 7 more missing
non-smokers. This difference between
teeth than age matched non-smokers.
the groups increased with age. Al- Plaque was measured only in the ex-
Even in a selected group of young
though no other cross-sectional epide- panded group of 50-year old subjects.
adults (20-35-ycar olds) Linden &
miological studies have compared the No differences in plaque scores were
Mullally (1994) found that smokers had
prevalence of molars with furcation in- observed between smokers and non-
lost 2.2 (p<Q.(i5) teeth more than non-
volvement in smokers and non- smokers. This oberservation is in agree-
smokers. Recently Locker et al. (1996)
smokers, Mullally & Linden (1996), in ment with results from other cross-sec-
304 A.xelssoit et al.

lionai studies (Bcrgslroni & Floderus- 0.001), 0.85 (;j = O.OOI) und 1.33 mm (;>= ge. Le nombre de faces dentaires intactes
Myrhcd 1983, Preber & Bergstrom 0.002) bei den 35-. 50-. 65-, und 75j;ihrigen. etait plus bas chez les fumeurs de 35, 50, ct
1986. Berg.strom & Eliasson 1987. Lin- Der Behandlungsbedarf, gemessen mJltels 75 ims que chez les non-fumeurs. Le nombre
den & Muilally 1994, see Table I). We CPITN. lag in alien Aitersgruppen bei den dc faces dentaires absentes (missing surfaces)
Rauchern am hochstcn. Die Anzahl von in- eliiit plus eleve chez les fumeurs de 50, 65 et
found significantly higher SSSR in male 75 ans quc chez les non fumeurs. Dc plus, les
laklen Zahnfliicben war bei den 35-, 50-. und
smokers than in non-smoking males 75j;ihrigen Rauchern gerlngcr ais bei den fumeurs dc 35 ans presentaient un nombre
and no differences between female Niehlrauchern. Die Anzahl der lehlenden significativcment plus grand de faces carices
smokers and non-smokers. In spite of Zahnflachen (MS) war bei den 35-, 50-, und (decayed) ct obturccs (filled) que les non-t^i-
this smokers more frequently reported 75jahrigen Rauchern boher als bei den meurs. Chez les fumeurs du sexc masculin.
a feeling of ""dry mouth". It has been Nichiranchern. Des weiteren zciglen 35-jahr- SSSR etait significaiivement plus elevee que
ige Raucher eine signifikant groBere Anzahl chez les non-fumeurs du sexe maseulin (/; =
proposed (Sheiham 1971. Ismail et al.
an karioscn und geftillten Zahnfliichen 0.012). L'indice de plaque et I'hygiene bucco-
1983. Sakki et al. 1995) that the poorer dentaire etaient semblables chez les fumeurs
dental health of smokers may be attri- (DFS) als Nichiraucher. Miinnliche Raucbcr
batten eine signifikatil hohere SSSR als et les non-fumeurs. Les fumeurs rendaient
buted in part to different life style comple d'une consommation plus frequente
mannliche Nicbiraucher (/>=0.0]2). Plaque-
habits. In the present study, however, no de boissons rafraichissantes (/'=0.000) et
Index und Mundhygiene waren bei Rau-
differences were found between smokers snacks (/! = 0.003) conlenant du sucre que les
chern und Nichtraiicbern vergleicbbar. Rau-
and non-smokers with respect to oral non-fumeurs. Pour la consommation de frui-
cher bericliteten iibcr cine hiiufigere Aufnah- ts, c'etail le contraire (/' = ().003). En conclu-
hygiene habits, which are known to in- me von zuckcrballigen Erl'rischungsgelran- sion, le tabagisme rcpresente un indicaleur si-
fluence dental health status. The mean ken (77=0.000) und Snacks (/)=0.003) als gnificatif du risque dc perte de dents, de per-
number of meals, the consumption of Nicliiraucher. Das Gegenteil war bcini Ver- le d'attachc au sondage et de caries denlaires.
sweets and sugar containing confection- zchr von Friicblen (/J = 0.003) bcrichtct. Es
ary were similar in smokers and non- wurde die SchluBfolgerung gczogen, daC
Raucben ein signifikantcr Risikoindikalor
smokers. The frequency of intakes of References
fur Zahnverlust, Attachment verlust und
sugar containing soft drinks, possibly Zahnkaries ist. Adams. D. F (iy92) Diagnosis and Ireatmenl
due to a feeling of "dry mouth", and of refractory periodontitis. Current Opin-
snacks was higher in smokers, which ions in Dentistry 2. 33-38.
Resume
may result in a higher risk for caries. Ainamo, J. (1984) Assessment of periodontal
In eonelusion. the present study docu- Relation eiiirc le tahac el I'elat ilcniciire ehez treatment needs. Adaptation ofthe WHO
mented that smoking is a significant dfs sujets d^es de 35. 50. 65 et 75 ans Community I'eriodontal Index of Treat-
risk indicator for tooth loss, probing Le preseni Iravait avait pour but d'examiner ment Needs (CPITN) to European con-
I'etat dentaire et les liabiiudes eonceinani le ditions. In A. Frandsen Ed.: Public health
attachment loss and dental caries. tabac dans des echaniillons randomises dc aspects of periodontal tlisect.se in Europe.
sujets iige.s de 35. 50. 65, et 75 ans («= 1 093), Berlin: Quintessenz Vcrlag.
recrutcs pour une elude epidemiologique Arno. A., Schei, O,, Lovdal, A. & Waerhaug.
Zusammenfassung Iransversale dans lecomte de Varmlaud, Sue- J. (1959) Alveolar bone loss as a function
Beziehung zwischen Riiiichen und Zahustatus de. Les variables eliniques suivantes ont ete of tobbaco consumption. Acta Oilontohg-
bei 35-. 50-. 65-. und 75 Jahrigen Iiulividtten enregistrecs par 4 dentisies calibres pour as- ica Sctindiiuivica 17. 3-10.
Das Ziel der vorliegenden Sludic war es. den surer une bonne concordance des resultats: Arno, A.. Waerhaug, J., Lovdal. A. & Schei,
Zahnstatus und die Rauciigewohtiheiten in ei- nombre de sujets edentes, nombre de dents O. (1958) Incidence of gingivitis as related
ner randomisierten Stichprobe von 35-, 50-, abscnics, niveau de ['attache au sondage. at- to sex, occupation, tobacco consumption,
65-, und 75 jiihrigen Individuen ( = 1093) zu teinte de la furcation, scores du CPITN (indi- loothbrushing. and age. Oral Surgery Oral
unlersuchen. Die Personen wurden anhand ce parodontal dc bcsoin en traitements du Medicine and Oral Pathology I I . 587-595.
einer epideniiologischen Querschnitlsstudie public), faces CAO (cariecs, absentes, obtu-
rees) et vitesse de la secretion salivaire stimu- Axelsson, P & Lindhe, J. (1978) Effect of
im Bezirk Varmland, Schweden rekruticrt. controlled oral hygiene procedures on
Durch vier gut kalibrierle Zahnarzle wurden lee (SSSR). De plus, les sujets onl dans un
questionnaire rendu compte de leurs habitu- caries and periodontal disease in adults.
die folgendcn klinischen Parameter erhoben: Jotirnul of Clinical Pcriodontologv S. 133
Anzahl der zahnlosen Personen. Anzalil der des concernant lc tabac. I'hygiene bucco-den-
taire, I'alimentation, elc. Les proportions de 151.
fehlenden Zahne, klinisches Atlachmcntnive-
fumeurs chez les sujets de 35, 50. 65 et 75 ans Beck, J. D. (19941 Methods of assessing risk
au, Furkationsbefiill, CPITN-Werte, DMF-
etaient respectivement de 35'Mi. 35"/;,, 24"/;i et for periodontitis and developing multifac-
Flachen, Plaque sowie slimuliertc Speichelse-
12'^ii. Chez les sujets dc 75 ans, AV'Ai des fu- toriai models. Journal of Periodontologv.
kretionsrate (SSSR). Zusiilzlich gaben die
meurs etaient edentes, a comparer a 35'i^i des 65, 468^78.
Personen in einem Fragebogen ihre Ranch-,
die Mundhygiene- und die EBgewohnhcilen non-fumeurs. Les diflerences entre les nom- Beck, J. D . Koch, G. G.. & Offenbacher, S.
usw. an. Der Anieil der Raucher bei den 35-, bres dc denis absentes chez les fumeurs et Ies (1995) Incidence of attacbment loss over 3
50-, 65- und 75jahrigen lag bei entsprechend non-fumeurs etaienl rcspectivement de 0.6 years in older adults - new and pro-
35%. 35%, 24"/" und 12'^.. Bei den 7?jahrigen (;!=0.l5), 1.5 (;'=0.013K 3.5 {p^Q.imi) et gressing lesions. Coimnunily Dentistrv and
waren A\% der Raucher verglichen mil 35'^! 5.8 (/7-O.Ofl5) dans les 4 groupes d'agcs. Oral Epidemiology 23, 291-296.
der Nicliiraucher zahnlos. Die Unlerscliiede Dans lous les groupes d"ages, les fumeurs Beck, J. D , Koch, G. G., Rozier, R. G. &
in der fehlendcn Ziihne zwischen Riiuchern avaicni la perte d'attacbe au sondage moyen- Tudor, G. E. (1990) Prevalence and risk in-
und Nichtrauchcrn bctrugen in den vier ne la plus grande. Les differences entre les dicators forpeiiodonlal aitacbment loss in
Aitersgruppen 0.6 (/)^O.I5}. 1.5 (/)=0.0I3). niveaux moycns d'altache chez les fumeurs et a population of older community-dwelling
3.5 (/)=0.0007) und S.S (/> = 0.005). Raucher les non-fumeurs etaient respectivement de blacks and whites. Journal of Periodonio-
hatten in alien Aitersgruppen den groUten 0.37 (/) = 0.00l), 0.88 (/J = O.OO1), 0.85 {p = logy b\. 521 528.
miltleren klinischen All;ichmentverlusl. Die 0.001) ct 1.33 mm/) = 0.002) chez ies sujets dc Bergstrom, J. (1990) Oral hygiene compli-
Unterschiede im mitlleren Auachmcniniveau 35. 50, 65 et 75 ans. Les besoins en traitement ance and gingivitis expression in cigarette
zwischen Rauchern un Nichtriiuchcrn betru- mesure.s par CPITN etaient les plus grands smokers. Scandinavian J<nirnal of Denial
gen entsprechend 0.37 (;) = O.OOI), 0.88 (/?= parmi les fumeurs dans lous les groupes d"a- Researeh 98. 497-503.
Bergstrom, J. & Eliasson. S. (1987) Cigarette
Smoking ami dental health status 305

smoking and alveolar bone hcighl in sub- in a military treatment population. Journal of non-surgical treattnent on periodontal
jects with a high standard of oral hygiene. of Periodontology 63. 297-302. pockets in smokers and non-smokers.
Journal of Clinical Periodontology. 14. Ismail. A. I.. Btirt, B. A. & Eklund. S. A. Journal of Clinical Periodontolof^y. 13.
466-469. (1983) Epidemiologic patterns of smoking 319-323.
Bergstrom. J.. Elia.sson, S. & Preber, H. and periodontal disease in the United Preber, H. & Bergstrom, J. (1986) Cigarette
(1991) Cigarette smoking and periodontal Slates. Journal of the .American Dental As- smoking in patients referred for peri-
bone loss [published erratum appears in J sociation 106. 617-623. odonta! treatment, Scandinavian Journal
Periodontol 1991 Dec; 62(12): 809]. Linden, G. J, & Mullally. B. H. (1994) Ciga- of Dental Research 94. 102-108.
Journal of Periodoniology 62. 242-246. rette smoking and periodontal destruction Preber. H.. Bergstrom. J. & Linder. L. E.
Bergstrom, J. & Floderus-Myrhed. B. (1983) in young adults. Journal ol Fi'iicdomolo^y (1992) Occurrence of periopathogens in
Co-twin control study of the relationship 65,'718-723. smoker and non-smoker patients. Journal
between smoking and some periodontal Locker, D, Ford, J. & Leake. J. L. (1996) of Clinical Periodoniolo^y. 19, 667 67!.
disease factors. Comnmnity Dentistry and Incidence of and risk factors for tuoih Ramljord. S, P (1959) Indices for prevalence
Oral Epidemiology 11. 113-116. loss in a population of older Canadians. and incidence of periodontal disease.
Danielsen, B.. ManjI. F, Nagelkerke, N.. Journal of Dental Research 75, 783 789. Journal oJ Periodontolof^y. 30. 51-59.
Fejerskov. O.. & Baelum, V (1990) Effect Locker. D. & Leake. J. L. (1993) Risk indi- Ravald. R . Birkhed. D. & Hamp. S. E.
of cigarelte smoking on the transition dy- cators and risk markers for periodontal (1993) Root caries susceptibility in peri-
namics in experimental gingivitis. Journal disease experience in older adults living in- odontally treated patients. Results after 12
of Clinical Periodontology 17. 159-164. dependently in Ontario. Canada. Journal years. Journal of Clinical Periodontology
Feldman. R. S.. Bravacos. J. S. & Rose, L. of Dental Research 11. 9 17. 20. 124-129,
(1983) Association between smoking and MacFarlane. G. D., Herzberg. M. C . Wolff. Sakki. T, K,, Knuuttila. M. L.. Vimpari. S.
different tobacco products and peri- L. F & Hardie. N. A. (1992) Refractory S.. & Hartikainen, M. S. (1995) Associ-
odonial disease indexes. Journal of Period- periodontitis associated with abnormal ation of lifestyle with periodontal health.
ontology S. 4ii[^iil. polymorphoniiclear leukocyte phago- Community Dentistry and Oral Epidemi-
Goultschin. J.. Cohen, H. D., Donchin, M., cytosis and cigarette smoking. Journal of ology 23, 155-158.
Brayer. L. & Soskolne, W. A. (1990) As- Periodontology 63, 90K-913. Sheiham. A.. (1971) Periodontal disease and
sociation of smoking with periodontal Machtei, F. E.. Dunford. R.. Hausmann. oral cleanliness in tobaeco smokers.
treatment needs. Journal of PeriodoiUolo^y E., Grossi. S. G.. Powell. J.. Cummins. Journal of Periodonrology 42. 259-263.
61, 364-367. D., Zambon. J. J. & Genco. J. (1997) Soder. B., Jin. L. J.. Soder. P O. & Wikner.
Grossi, S. G.. Zambon. J. J.. Ho. A. W. Longitudinal study of prognostic factors S. (1995) Clinical characteristics of de-
Koch. G.. Dunford. R. G., Machtei, E. E-. in established periodontitis patients. structive periodontitis in a risk group of
Norderyd, O. M. & Genco, R. J. (1994) Journal of Clinical PerioJontology 24, Swedish urban aduhs. Swedish Dental
Assessment of risk for periodontal disease. 102 109. Journal 19, 9 15.
I. Ri^k indicators for attachment loss. Martinez-Canut. P. Lorca. A. & Magan. R. Stoltenberg, J. L.. Osborn. J. B.. Pihlstrom.
Journal of Periodontology 65. 260-267. (1995) Smoking and periodonlal disease B. L.. Herzberg. M. C , Aeppli. D, M..
Haber. J.. Wattles. J.. Crowley. M,. Mandell. severity. Journal of Clinical Periodontology Wolff, L. F & Fischer. G, E. (1993) As-
R,, Joshipura. K. & Kent. R. L. (1993) 22. 734 749. sociation between cigarette smoking, bac-
Evidence for cigarette smoking as a major Massler. M. & Ludwick. W. (1952) Relation terial pathogens, and periodontal status.
risk factor tor periodontitis. Journal of of dental caries experience and gingivitis Journal of Periodontaiogy. 12. 1225-1230.
Periodontology 64. 16-23, to cigarette smoking in males 17 to 21 Sundberg. H. (1989) Dnr 5501 348,
Hansen. B. F . Bjertness. E. & Gjermo, P. years old. Journal oj Denial Research 31. Wiktorsson. A, M, (1995) Dental caries and
(1990) Changes in periodontal disease in- 319-322. dental fluorosis among adults in two
dicators in 35-year-old Oslo citizens from Mullally. B. H. & Linden. G. J. (1996) Molar Swedish communities with optimal and
1973 to 1984. Journal of Clinical Pcriodon- furcation involvement associated with low water fluoride concentrations. Thesis,
tohgv 17. 249 254. cigarette smoking in periodontal referrals. Faculty of Odontology. Karolinska Insti-
Herulf. G. (1951) On the margin;tl alveolar Journal of Clinical Periodontology 23. 658 tute. Sweden,
ridge in students. A roentgenografic study. 661. Wolff, L,. Dahlen. G. & Aeppli. D, (1994)
Acta Genetiea et Staiistica Medica. II, Osterberg. T & Mellsirom. D. (1986) To- Bacteria as risk markers for periodontitis.
(Abstract). bacco smoking; a major risk factor for los.s Journal of Periodontology 65. 498 510,
Herulf. G. (1968) On the marginal alveolar of teeth in lliree 70-year-old cohorts. Com-
ridge in adults. Swedish Dental Journal f}\. munity Dentistry ami Oral Epidemiology
675 703. 14, 367-370. Address;
Holm. G, (1994) Smoking as an additional Preber, H. & Bergstrom, J. (1985) Occurrence Per A.\cls.son
risk for tooth loss. Journal of Periodonio- of gingival bleeding in smoker and non- Deparimeni of Preveniive Dentistry
/»i;,i 65. 996-1001. smoker patients. Aeta Odontolo^ica Scan- Alvgatan 47
Homing. G. M.. Hatch. C. L., & Cohen, M. dinavica 43. 315-320. S-65: 30 Karlstad
E. (1992) Risk indicators for periodontitis Preber. H. & Berastrom. J, (1986) The effect Stye den