Is poor oral health a risk marker for incident cardiovascular disease hospitalisation and all-cause mortality? Findings from 172 630 participants from the prospective 45 and Up Study

Grace Joshy, Manish Arora, Rosemary J Korda, John Chalmers, Emily Banks, Grace Joshy, Manish Arora, Rosemary J Korda, John Chalmers, Emily Banks

Abstract

Objective: To investigate the relationship between oral health and incident hospitalisation for ischaemic heart disease (IHD), heart failure (HF), ischaemic stroke and peripheral vascular disease (PVD) and all-cause mortality.

Design: Prospective population-based study of Australian men and women aged 45 years or older, who were recruited to the 45 and Up Study between January 2006 and April 2009; baseline questionnaire data were linked to hospitalisations and deaths up to December 2011. Study exposures include tooth loss and self-rated health of teeth and gums at baseline.

Setting: New South Wales, Australia.

Participants: Individuals aged 45-75 years, excluding those with a history of cancer/cardiovascular disease (CVD) at baseline; n=172 630.

Primary outcomes: Incident hospitalisation for IHD, HF, ischaemic stroke and PVD and all-cause mortality.

Results: During a median follow-up of 3.9 years, 3239 incident hospitalisations for IHD, 212 for HF, 283 for ischaemic stroke and 359 for PVD, and 1908 deaths, were observed. Cox proportional hazards models examined the relationship between oral health indicators and incident hospitalisation for CVD and all-cause mortality, adjusting for potential confounding factors. All-cause mortality and incident CVD hospitalisation risk increased significantly with increasing tooth loss for all outcomes except ischaemic stroke (ptrend<0.05). In those reporting no teeth versus ≥20 teeth left, risks were increased for HF (HR, 95% CI 1.97, 1.27 to 3.07), PVD (2.53, 1.81 to 3.52) and all-cause mortality (1.60, 1.37 to 1.87). The risk of IHD, PVD and all-cause mortality (but not HF or ischaemic stroke) increased significantly with worsening self-rated health of teeth and gums (ptrend<0.05). In those reporting poor versus very good health of teeth and gums, risks were increased for IHD (1.19, 1.03 to 1.38), PVD (1.66, 1.13 to 2.43) and all-cause mortality (1.76, 1.50 to 2.08).

Conclusions: Tooth loss and, to a lesser extent, self-rated health of teeth and gums, are markers for increased risk of IHD, PVD and all-cause mortality. Tooth loss is also a marker for increased risk of HF.

Keywords: cardiovascular disease epidemiology; mortality; oral health.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Age-standardised rates per 1000 person-years of all-cause mortality and incident cause-specific CVD hospitalisation since baseline, directly age-adjusted to 2006 New South Wales population. Male: ; female: .
Figure 2
Figure 2
HR (95% CI) for incident hospitalisation for cardiovascular disease (CVD) and all-cause mortality by number of natural teeth left. Events, number of events; rate, crude rate per 1000 person years; CVD, cardiovascular disease; IHD, ischaemic heart disease; PVD, peripheral vascular disease. HR1, adjusted for age and sex; HR2, additionally adjusted for tobacco smoking, alcohol consumption, Australian born status, region of residence, education, health insurance, physical activity and body mass index, with missing values in covariates were coded as a separate categories (0.3%, 1.7%, 0%, 0.03%, 1.3%, 0%, 4% and 7%, respectively). There were no missing values in age or sex. HR2s are plotted on a log scale and are represented with squares, with areas inversely proportional to the logarithm of events; 95% CIs are indicated by horizontal lines.
Figure 3
Figure 3
HR (95% CI) for incident hospitalisation for CVD and all-cause mortality by self-rated health of teeth and gums. Events, number of events; rate: crude rate per 1000 person years; CVD, cardiovascular disease; IHD, ischaemic heart disease; PVD, peripheral vascular disease. HR1, adjusted for age and sex. HR2, additionally adjusted for tobacco smoking, alcohol consumption, Australian born status, region of residence, education, private health insurance, physical activity and body mass index; missing values in covariates were coded as a separate category (0.3%, 1.7%, 0%, 0.03%, 1.3%, 0%, 4%, 7%, respectively). There were no missing values in age or sex. HR2s are plotted on a log scale and are represented with squares with areas inversely proportional to the logarithm of events; 95% CIs are indicated by horizontal lines.
Figure 4
Figure 4
HR for incident hospitalisation for IHD by number of natural teeth left (≥10 vs 1, adjusted for age and sex. HR2, additionally adjusted for tobacco smoking, alcohol consumption, Australian born status, region of residence, education, private health insurance, physical activity and body mass index, where appropriate. HR2, HRs are plotted on a log scale and are represented with squares with areas inversely proportional to the variance of logarithm of HR2s; 95% CIs are indicated by horizontal lines. The vertical dotted line represents the overall HR of incident hospitalisation for IHD.

References

    1. Murray CJL, Vos T, Lozano R et al. . Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2197–223. 10.1016/S0140-6736(12)61689-4
    1. Helfand M, Buckley DI, Freeman M et al. . Emerging risk factors for coronary heart disease: a summary of systematic reviews conducted for the U.S. Preventive Services Task Force. Ann Intern Med 2009;151:496–507.
    1. Lockhart PB, Bolger AF, Papapanou PN et al. . Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circulation 2012;125:2520–44. 10.1161/CIR.0b013e31825719f3
    1. Watt RG, Tsakos G, de Oliveira C et al. . Tooth loss and cardiovascular disease mortality risk--results from the Scottish Health Survey. PLoS ONE 2012;7:e30797 10.1371/journal.pone.0030797
    1. Mucci LA, Hsieh CC, Williams PL et al. . Do genetic factors explain the association between poor oral health and cardiovascular disease? A prospective study among Swedish twins. Am J Epidemiol 2009;170:615–21. 10.1093/aje/kwp177
    1. Fisher MA, Taylor GW, Papapanou PN et al. . Clinical and serologic markers of periodontal infection and chronic kidney disease. J Periodontol 2008;79:1670–8. 10.1902/jop.2008.070569
    1. Pitiphat W, Garcia RI, Douglass CW et al. . Validation of self-reported oral health measures. J Public Health Dent 2002;62:122–8. 10.1111/j.1752-7325.2002.tb03432.x
    1. Axelsson G, Helgadóttir S. Comparison of oral health data from self-administered questionnaire and clinical examination. Community Dent Oral Epidemiol 1995;23:365–8. 10.1111/j.1600-0528.1995.tb00264.x
    1. Fisher MA, Borgnakke WS, Taylor GW. Periodontal disease as a risk marker in coronary heart disease and chronic kidney disease. Curr Opin Nephrol Hypertens 2010;19:519–26. 10.1097/MNH.0b013e32833eda38
    1. Humphrey LL, Fu R, Buckley DI et al. . Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med 2008;23:2079–86. 10.1007/s11606-008-0787-6
    1. Asai K, Yamori M, Yamazaki T et al. . Tooth loss and atherosclerosis: the Nagahama Study. J Dent Res 2015;94(3 Suppl):52S–8S. 10.1177/0022034514559127
    1. Liljestrand JM, Havulinna AS, Paju S et al. . Missing teeth predict incident cardiovascular events, diabetes, and death. J Dent Res 2015;94:1055–62. 10.1177/0022034515586352
    1. Janket SJ, Baird AE, Chuang SK et al. . Meta-analysis of periodontal disease and risk of coronary heart disease and stroke. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:559–69. 10.1067/moe.2003.107
    1. Holmlund A, Holm G, Lind L. Number of teeth as a predictor of cardiovascular mortality in a cohort of 7,674 subjects followed for 12 years. J Periodontol 2010;81:870–6. 10.1902/jop.2010.090680
    1. Ando A, Tanno K, Ohsawa M et al. . Associations of number of teeth with risks for all-cause mortality and cause-specific mortality in middle-aged and elderly men in the northern part of Japan: the Iwate-KENCO study. Community Dent Oral Epidemiol 2014;42:358–65. 10.1111/cdoe.12095
    1. Bahekar AA, Singh S, Saha S et al. . The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis. Am Heart J 2007;154:830–7. 10.1016/j.ahj.2007.06.037
    1. Li Q, Chalmers J, Czernichow S et al. . Oral disease and subsequent cardiovascular disease in people with type 2 diabetes: a prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial. Diabetologia 2010;53:2320–7. 10.1007/s00125-010-1862-1
    1. Vedin O, Hagström E, Gallup D et al. . Periodontal disease in patients with chronic coronary heart disease: prevalence and association with cardiovascular risk factors. Eur J Prev Cardiol 2015;22:771–8. 10.1177/2047487314530660
    1. Banks E, Redman S, Jorm L et al. . Cohort profile: the 45 and up study. Int J Epidemiol 2008;37:941–7. 10.1093/ije/dym184
    1. National Centre for Classification in Health. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM). 5th edn Sydney: National Centre for Classification in Health, 2006.
    1. National Centre for Classification in Health. The Australian Classification of Health Interventions (ACHI). Tabular list of interventions and alphabetic index of interventions. 6th edn Sydney: National Centre for Classification in Health, 2007.
    1. Australian Institute of Health and Welfare. The Active Australia Survey: a guide and manual for implementation, analysis and reporting. Canberra: AIHW, 2003.
    1. Joshy G, Korda RJ, Abhayaratna WP et al. . Categorising major cardiovascular disease hospitalisations from routinely collected data. Public Health Res Pract 2015;25:e2531532 10.17061/phrp2531532
    1. Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: a method based on the gamma distribution. Stat Med 1997;16:791–801. 10.1002/(SICI)1097-0258(19970415)16:7<791::AID-SIM500>;2-#
    1. Lim SS, Vos T, Flaxman AD et al. . A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224–60. 10.1016/S0140-6736(12)61766-8
    1. Hicks LS, Fairchild DG, Cook EF et al. . Association of region of residence and immigrant status with hypertension, renal failure, cardiovascular disease, and stroke, among African-American participants in the third National Health and Nutrition Examination Survey (NHANES III). Ethn Dis 2003;13:316–23.
    1. Waters A, Moon L. Socioeconomic inequalities in cardiovascular disease in Australia. AIHW bulletin no. 37. Cat. no. AUS 74 2006. (accessed 17 December 2015).
    1. Howell TH, Ridker PM, Ajani UA et al. . Periodontal disease and risk of subsequent cardiovascular disease in U.S. Male physicians. J Am Coll Cardiol 2001;37:445–50. 10.1016/S0735-1097(00)01130-X
    1. Joshipura K. The relationship between oral conditions and ischemic stroke and peripheral vascular disease. J Am Dent Assoc 2002;133:23S–30S. 10.14219/jada.archive.2002.0373
    1. Lafon A, Pereira B, Dufour T et al. . Periodontal disease and stroke: a meta-analysis of cohort studies. Eur J Neurol 2014;21:1155–e67. 10.1111/ene.12415
    1. Hung HC, Joshipura KJ, Colditz G et al. . The association between tooth loss and coronary heart disease in men and women. J Public Health Dent 2004;64:209–15. 10.1111/j.1752-7325.2004.tb02755.x
    1. Joshipura KJ, Rimm EB, Douglass CW et al. . Poor oral health and coronary heart disease. J Dent Res 1996;75:1631–6. 10.1177/00220345960750090301
    1. Hung HC, Willett W, Merchant A et al. . Oral health and peripheral arterial disease. Circulation 2003;107:1152–7. 10.1161/01.CIR.0000051456.68470.C8
    1. Borgnakke WS, Ylöstalo PV, Taylor GW et al. . Effect of periodontal disease on diabetes: systematic review of epidemiologic observational evidence. J Clin Periodontol 2013;40(Suppl 40):S135–52. 10.1111/jcpe.12080
    1. Australian Institute of Health and Welfare. Cardiovascular disease, diabetes and chronic kidney disease—Australian facts: Morbidity–Hospital care. Cardiovascular, diabetes and chronic kidney disease series no. . no. CDK 3. Canberra: AIHW, 2014.
    1. Quan H, Parsons GA, Ghali WA. Assessing accuracy of diagnosis-type indicators for flagging complications in administrative data. J Clin Epidemiol 2004;57:366–72. 10.1016/j.jclinepi.2003.01.002
    1. Teng TH, Finn J, Hung J et al. . A validation study: how effective is the Hospital Morbidity Data as a surveillance tool for heart failure in Western Australia? Aust N Z J Public Health 2008;32:405–7. 10.1111/j.1753-6405.2008.00269.x
    1. Ruigómez A, Martín-Merino E, Rodríguez LA. Validation of ischemic cerebrovascular diagnoses in the health improvement network (THIN). Pharmacoepidemiol Drug Saf 2010;19:579–85. 10.1002/pds.1919
    1. Boyle CA, Dobson AJ. The accuracy of hospital records and death certificates for acute myocardial infarction. Aust N Z J Med 1995;25:316–23. 10.1111/j.1445-5994.1995.tb01896.x
    1. Northridge ME, Chakraborty B, Kunzel C et al. . What contributes to self-rated oral health among community-dwelling older adults? Findings from the ElderSmile program. J Public Health Dent 2012;72:235–45. 10.1111/j.1752-7325.2012.00313.x
    1. Douglass CW, Berlin J, Tennstedt S. The validity of self-reported oral health status in the elderly. J Public Health Dent 1991;51:220–2. 10.1111/j.1752-7325.1991.tb02218.x
    1. Ramos RQ, Bastos JL, Peres MA. Diagnostic validity of self-reported oral health outcomes in population surveys: literature review. Rev Bras Epidemiol 2013;16:716–28. 10.1590/S1415-790X2013000300015
    1. Blicher B, Joshipura K, Eke P. Validation of self-reported periodontal disease: a systematic review. J Dent Res 2005;84:881–90. 10.1177/154405910508401003
    1. Eke PI, Dye BA, Wei L et al. . Self-reported measures for surveillance of periodontitis. J Dent Res 2013;92:1041–7. 10.1177/0022034513505621
    1. Eke PI, Dye B. Assessment of self-report measures for predicting population prevalence of periodontitis. J Periodontol 2009;80:1371–9. 10.1902/jop.2009.080607
    1. Gilbert GH, Chavers LS, Shelton BJ. Comparison of two methods of estimating 48-month tooth loss incidence. J Public Health Dent 2002;62:163–9. 10.1111/j.1752-7325.2002.tb03438.x
    1. Unell L, Söderfeldt B, Halling A et al. . Oral disease, impairment, and illness: congruence between clinical and questionnaire findings. Acta Odontol Scand 1997;55:127–32. 10.3109/00016359709115404
    1. Slade GD. Interim analysis of validity of periodontitis screening questions in The Australian population. J Periodontol 2007;78(7 Suppl):1463–70. 10.1902/jop.2007.060344
    1. CDC. Periodontal Disease Surveillance Project: Background, Objectives, and Progress Report. , 2007.
    1. Miller K, Eke PI, Schoua-Glusberg A. Cognitive evaluation of self-report questions for surveillance of periodontitis. J Periodontol 2007;78(7 Suppl):1455–62. 10.1902/jop.2007.060384
    1. Papapanou P, Lindhe J. Epidemiology of periodontal diseases. In: Lindhe J, Karring T, Lang N, eds. Clinical Periodontology and Implant Dentistry. Oxford, UK: Blackwell Munksgaard, 2008:129–79.
    1. Mealing NM, Banks E, Jorm LR et al. . Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs. BMC Med Res Methodol 2010;10:26 10.1186/1471-2288-10-26
    1. Rothman KJ, Gallacher JE, Hatch EE. Why representativeness should be avoided. Int J Epidemiol 2013;42:1012–14. 10.1093/ije/dys223

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren