Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.

150682

Associations Between Periodontitis and Chronic Obstructive

Pulmonary Disease; the 2010-2012 Korean National Health and
Nutrition Examination Survey (KNHANES)

Jae Ho Chung,* Hee-Jin Hwang, Sun-Hyun Kim, Tae Ho Kim

*Department of Internal Medicine, International St. Mary`s Hospital, Catholic Kwandong

University College of Medicine, Incheon, Republic of Korea.

Department of Family Medicine, International St. Mary`s Hospital, Catholic Kwandong
University College of Medicine, Incheon, Republic of Korea.

Department of Internal Medicine, Seoul Medical Center, Seoul, Republic of Korea.
Objectives: To examine whether the oral hygiene and self care especially in periodontal health are
associated with chronic obstructive pulmonary disease (COPD) in a Korean population.
Methods: Using data from the Korean National Health and Nutrition Examination Survey
(KNHANES) between 2010 and 2012, we included 5,878 participants (normal lung function: 5181, obstructive
spirometric pattern: 697) aged 40 years who underwent spirometry and assess the community periodontal
index (CPI).
Results: Participants with COPD brushed their teeth less frequently, used less frequently dental floss
and / or interdental brush, mouthwash and electric toothbrush (p<0.001). The prevalence of periodontitis in
COPD (58.1%) was significantly higher than without COPD (34.0%, p<0.001). The number of teeth was
significantly lower in COPD patients when compared to the controls. DMF (decayed+missing+filled teeth)
index is significantly lower in COPD patients. Table 3 showed risk of COPD by periodontal severity.
Periodontitis (CPI 3 and 4) was associated in male COPD after adjustment for age, income, education, smoking,
alcohol consumption, exercise, BMI, tooth brushing frequency, diabetes and number of teeth (CPI 3, RR 1.38;
95% confidence interval [CI], 1.122.05: CPI 4, RR 1.23; 95% CI, 1.06-1.56) .
Conclusions: Findings of this cross-sectional study suggest that male COPD may be associated with
the severe periodontitis and indicate the importance of promoting dental care in COPD patients.

KEYWORDS:
oral hygiene, pulmonary disease, chronic obstructive, respiratory function tests, periodontitis.
1
Periodontitis is a common infectious disease affecting tissues supporting the teeth. Risk
factors for periodontal disease include poor oral hygiene, diabetes, smoking, low
2
socioeconomic status, age, and stress. Diabetes increases susceptibility to oral infections
3
such as periodontitis and progresses more rapidly in poorly controlled diabetics. Smoking is
4
a well-established risk factor for periodontal disease. Smoking tobacco is destructive effect
5
on the periodontal system and increases the rate of periodontal disease aggravation.
6
Periodontal disease is also associated with socioeconomic status. Gingival helath is better in
those who received the more education and higher incomes. The prevalence and severity of
7 7
periodontal disease increase with age. Papapanou et al , demonstrated that the mean annual
rate of dental bone loss was 0.07 mm in 25-year-olds and 0.28 mm in 70-year-olds. Stress is
8
associated with increased risk of periodontitis. Men who reported being angry had a 43%
8
higher risk of periodontitis than did not. Although chronic obstructive pulmonary disease
(COPD) is primarily a pulmonary disease characterized by airflow limitation, it is also often
9, 10
associated with a significant systemic inflammatory response. Poor periodontal status was
11
also been associated with COPD. Several studies suggested an association between poor

1
oral health (alveolar bone injury, periodontal attachment loss, oral hygiene index, and oral
12-14
plaque colonization) and lung diseases. Casecontrol studies also found that poor
15,16
periodontal health was significantly associated with increased risk of COPD. A meta-
analysis of 14 studies suggested that periodontal disease was a significant risk factor for
17
COPD. However, other studies showed uncertain associations between periodontal disease
18,19
and COPD. A recent review of research on the relationship between COPD and
18 19
periodontitis found only a weak relationship, at best. Another study found no significant
difference in periodontal variables between COPD and non-COPD groups.
Because of this inconsistent data, we examined the relation of periodontal health status
and oral health-related behaviors such as self-care, smoking, alcohol consumption with
COPD in a representative sample of adults who were involved in the fifth Korean National
20
Health and Nutrition Examination Survey (KNHANES).

METHODS
Study Participants
The present study was conducted using data acquired from Korean National Health and
Nutrition Examination Surveys (KNHANES). The KNHANES analyses are periodically
conducted to assess the health and nutritional status of Korea. These investigations are
composed of a health interview survey, health examination survey, and nutrition survey, and
are conducted by well-trained investigators. Annually, 10,00012,000 individuals from 4,600
households are selected by a panel to represent Koreans that are 18 years of age and older
using a multistage clustered and stratified random sampling method based on National
Census Data. The sampling frame was developed based on the 2005 population and housing
census in Korea, and the household units were selected by a stratified multistage probability
sampling design created for the South Korean population. Thus, the KNHANES were
nationally representative cross-sectional surveys conducted by the Division of Chronic
Disease Surveillance of the Korea Centers for Disease Control and Prevention, and included
data from approximately 260,000 primary sampling units that were each composed of
approximately 60 households. Of these participants, 8,145 participants (normal lung function:
5181, obstructive spirometric pattern: 697) aged 40 years who underwent spirometry and
assess the community periodontal index (CPI)21 were analyzed.

Baseline Physical Health

Self-reported smoking, alcohol, and physical activity were calculated from questionnaire, and
education status, household income were categorized. Smokers were classified as current,
former, or non-smokers. Risky alcohol drinking is defined as consuming 5 standard drinks
22
consecutively on one occasion Regular exercise was defined as walking exercise (5 times
per week for at least 30 min), or moderate exercise (5 times per week for at least 30 min) or
strenuous exercise (3 times per week for at least 20 min), as defined by the American College
23
of Sports Medicine Guidelines , during the survey period. The height and weight of the
participants were measured and used to calculate body mass index (BMI) with the following
2
formula: (weight [kg]/height [m ]). Diabetes mellitus (DM) was determined in self-
administration questionnaires as follows: Have you ever been diagnosed with diabetes
mellitus by doctor? Yes or no?.
Lung Function Measurement
Spirometry was performed by well-trained technicians according to the 1994 American
24
Thoracic Society recommendations .
Airway obstruction was defined according to the Global Initiative for Chronic
25
Obstructive Lung Disease (GOLD) criteria (GOLD Stage I) as FEV1/ FVC <70%. The
severity of airway obstruction was based on the percentage predicted FEV1 in accordance
with the GOLD criteria (FEV1 80% predicted, mild; FEV1 = 5079% predicted, moderate;
FEV1 = 3049% predicted, severe; FEV1 <30% predicted, very severe).

Oral Hygiene and Self Care

This study checked both time of day when tooth brushing (before or after breakfast, lunch,
dinner, after snacks, or before bedtime) occurred and use of dental floss, mouthwash,
interdental brush, and electric toothbrush. We calculated the frequency of daily toothbrushing
by the sum of tooth brushing per day, use of dental floss, mouthwash, interdental brush, and
electric toothbrush.

Periodontitis
Dentists conducted an oral health examination in the survey. The World Health Organization
21
(WHO) community periodontal index (CPI) was used to assess periodontitis. CPI code is
categorized as normal (CPI 0), gingival bleeding (CPI 1), calculus (CPI 2), shallow
periodontal pocket (CPI 3), deep periodontal pocket (CPI 4). The index tooth numbers were
11, 16, 17, 26, 27, 31, 36, 37, 46 and 47 according to the Federation Dentaire Internationale
26 27
(FDI) system. A CPI probe that met the WHO guidelines was used (World Health
Organization 1997). Periodontitis was defined as a CPI 3 ( >3.5 mm pocket) or CPI4 (>5.5
mm pocket). The mean of Kappa value of inter-examiner was 0.89 (0.551.00). Number of
teeth (28 except for the wisdom teeth) was measured.

Ethical Issues
Korea Centers for Disease Control and Prevention approved the study protocol (nos. 2010
02CON-21-C, 201102CON-06-C, 2012-01EXP-01-2C), and all of the participants signed
informed consent forms.

Data Analysis
All sampling and weight variables used in the present study were stratified to ensure
appropriate estimates and standard errors. In addition, survey sample weights were used to
produce non-biased estimates for the descriptive and analytical data analyses. Descriptive
statistical methods were used to describe the basic characteristics of the study population, and
the numbers and percentages were reported for each variable. All of the characteristics were
compared using student's t- tests for continuous variables and the Chi-squared test or Fishers
exact test for categorical variables. A multivariate logistic regression analysis that was
adjusted for sex, age, exercise, family income, education, alcohol, smoking, BMI and DM
were also used to assess the data.
RESULTS
Clinical characteristics of the study population are shown in Table 1. COPD patients were
more likely to be older, less educated, more regular exercise and more likely to earn a lower
income and to more current smoking and more alcohol intake.
Table 2 showed the relationship between oral hygiene and self-care with COPD. Shallow
(39.3% vs 24.5%) and deep periodontal pocket (18.7% vs 9.6%) were significantly increased
in COPD patients than non-COPD patients (p<0.001). Despite of more prevalent periodontitis
defined as a CPI 3 in COPD patients (58.1%) than non-COPD patients (34.0%, p<0.001),
dental visit in last year in COPD were only 27.6% and 49% of COPD patients think their oral
health status is in good condition. Participants who tooth brushed more than three times per
day were 35.8% in the COPD patients and 44.4% in the non-COPD patients (p<0.001). The
COPD patients also used dental floss, mouthwash, interdental brush, and electric toothbrush
less frequently than non-COPD patients. The number of teeth was significantly lower in
COPD patients when compared to the controls. DMF (decayed+missing+filled teeth) index is
significantly lower in COPD patients.
Table 3 showed risk of COPD by periodontal severity. After adjustment for age, income,
education, smoking, alcohol, exercise, BMI, tooth brushing frequency, diabetes, number of
teeth, periodontitis (CPI 3, CPI4) were associcated in male COPD (CPI 3, RR 1.38; 95%
confidence interval [CI], 1.122.05: CPI 4, RR 1.23; 95% CI, 1.06-1.56).

DISCUSSION
In this representative sample of Koreans aged 40 years and older, we found that the severe
periodontitis was closely associated with COPD in males after adjusting for confounding
12, 14, 28
factors. The findings of the present study consistent with other studies. , support an
12
association between periodontitis and COPD. Hayes et al found that, for every 20%
increase in alveolar bone loss, there was a 60% increase in the risk of COPD. A cross-
14
sectional retrospective study found that lung function was lower with poor periodontal
health, and the most periodontitis scores was 1.45-fold greater odds ratio of concurrent
COPD. There is a relationship between more severe periodontal status and severity of COPD.
28
However, other studies have shown uncertain associations between periodontal disease and
COPD.
18
Azarpazhooh could showed only a weak association between COPD and periodontitis,
and another study found no significant difference in periodontitis between COPD and non-
19
COPD patients. Some periodontal status may be significantly worse in COPD, but such as
29
clinical attachment level is not significant . These inconsistent findings may result from
differences in assessments of periodontal status and the use of different diagnostic
12
criteria. The Hayes study used a COPD criterion of FEV1 <65% instead of the GOLD
14
criteria. In the Scannapieco study, COPD was defined by a questionnaire rather than by
spirometry. Our study included only those who underwent spirometry and met the GOLD
COPD criteria.
Our study showed that the prevalence of periodontitis, defined as community periodontal
index code (CPI) 3, was significantly higher in those with than in those without COPD.
Some mechanisms have been proposed to explain the association between periodontitis and
COPD. COPD and periodontitis have a similar pathophysiology, specifically, inflammation
of the local connective tissue. Neutrophils also play an important role in both COPD and
periodontitis, as their proteases and ROS can promote inflammation and destroy connective
tissue.
30
Similar to Oztekin study , our study showed that the number of teeth was significantly
lower in COPD patients than in controls. Furthermore, periodontal health was associated with
dental loss, may have contributed to systemic inflammation, and was associated with COPD.
30
The Oztekin study also showed that serum and gingival crevicular fluid high-sensitive C-
reactive protein levels were significantly higher in COPD patients than in controls.
Periodontitis may be linked to COPD through microbial species, by supporting colonization
29
of respiratory pathogens in dental plaque or by airway inflammation and exacerbation by
periodontal organisms. COPD inflammatory status may be modified by dental plaque and/or
hematogenous dissemination of inflammatory mediators and plaque microbials from
31
periodontal pockets. Pavord et al. suggested that multiple inflammations in the airway may
32
be a key factor leading to the development of severe airway disease .
The present study has several limitations. First, because it was a cross-sectional study, it
is not possible to determine a cause-and-effect relationship between COPD and periodontitis.
Second, periodontal status was assessed by CPI only. Although CPI can assess the
periodontitis and has been adopted as an index for periodontitis on the association between
33, 34
systemic disease and periodontal disease, the limitations of CPI should be considered
because it can overestimate or underestimate the prevalence of periodontitis due to the use of
35
representative teeth and pseudo pockets. Our study only used CPI and only measured index
teeth to diagnose periodontal disease. In an adult population, CPI should be measured for all
teeth; it can be measured from index teeth in population-based surveys only in patients under
18 years, where periodontitis (CPI 3 and 4) is not as prevalent as in older patients. Consensus
and uniformity in the definition of periodontitis are lacking in epidemiological studies, as is
uniformity of methods used. The consequence is that data from studies using differing case
definitions and differing survey methods are not readily interpretable or comparable. In 2003,
the American Association of Periodontology developed methods for assessing periodontal
disease. This classification defines severe and moderate periodontitis in terms of probing
depth (PD) and clinical attachment level (CAL) to enhance case definitions; this approach
also stresses the importance of thresholds of PD and CAL and the number of affected sites
36
when defining periodontitis. In Europe, two threshold criteria for the diagnosis of
th
periodontitis were proposed during the 5 European Workshop in Periodontology: 1. the
presence of proximal attachment loss of 3 mm in 2 non-adjacent teeth, and 2. the presence
37
of proximal attachment loss of 5 mm in 30% of teeth.
Finally, a limitation of KNHANES is that the participants in the survey generally have
mild comorbidities. Thus, the small number of COPD patients in GOLD stages III and IV
may influence the analysis of risk for periodontitis.
Despite these limitations, our study is important for clinical practice. Strengths of our
study were that the data were obtained from a nationwide population, which made higher
precision and could multiple statistical adjustments. Second, the natural teeth numbers and
oral condition were objectively assessed by dentists using the same criteria. Additionally,
several confounding variables were precisely recorded by well-trained examiners.
 Survey participants with COPD reported more periodontitis than did participants in the
general population. Thus, it is important for practicing general physicians to be aware that
patients with COPD are at risk of significant periodontitis. In our study, only 27.6% of COPD
patients visited dental clinics in the last year, and 49% of COPD patients reported that their
oral health status was good, despite the high prevalence of periodontitis.

CONCLUSIONS
We found that COPD in males may be associated with the periodontitis. Thus, healthcare
workers should be screen for and promptly diagnose these problems and refer patients to
appropriate oral health professionals, who may be able to prevent periodontitis and arrest the
progression of periodontitis in COPD. However, it will require randomized controlled trials
to investigate cause-and-effect relationship and understand the pathological basis and
correlates of the disease.

CONFLICT OF INTEREST:
The authors declare no conflict of interest.

ACKNOWLEDGMENTS:
The authors declare no acknowledgement.

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Corresponding Authors: Sun-Hyun Kim, MD and Tae Ho Kim, MD , Address: Sun Hyun
Kim, MD, PhD; Department of Family Medicine, International St. Mary`s Hospital, Catholic
Kwandong University College of Medicine, Simgokro 100gil 25 Seo-gu, Incheon, Republic
of Korea, Tel +82 32 290 2932 fax: +82 32 290 2660. E-mail:sunhyun@yahoo.com, Tae Ho
Kim, MD; Department of Internal Medicine, Seoul Medical Center, 156 Sinnae-ro,
Joongrang-gu, Seoul, Republic of Korea, 131-795 Tel.: +82 2 2276 8864; fax: +82 2 2276
8504. E-mail: drtaeho76@gmail.com
Submitted November 16, 2015; accepted for publication February 19, 2016.
Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150682

Male Female
Controls (n = Controls (n = Controls (n =
COPD (n = COPD (n = COPD (n =
a 5181 P-value a 2086 P-value a 3095 P-value
697 n =0.68) a 524 n =0.48) a 173 n =0.21) a
n =5.24) n =2.12) n =3.07)
Age (years) 64.3 0.2 54.60.1 <0.001 64.0 0.2 53.6 0.3 <0.001 65.3 0.2 55.4 0.4 <0.001
GOLD classification
Stage 1 318 (45.6) 237 81
Stage 2 355 (50.9) 270 85
Stage 3 19 (2.7) 14 5
Stage 4 5 (0.7) 3 2
FEV1 (l) 2.310.23 2.780.32 <0.001 2.500.15 3.320.23 <0.001 1.730.15 2.400.24 <0.001
FEV1(% predicted) 77.91.43 94.41.14 <0.001 78.11.44 93.11.09 <0.001 77.51.47 95.31.15 <0.001
Smoking status <0.001 <0.001 <0.001
Never 196 (28.8) 3203 (63.3) 196 (28.8) 3003 (63.3) 145 (85.8) 2831 (93.0)
Ex-former 270 (39.6) 995 (19.7) 270 (39.0) 995 (19.7) 5 (3.0) 101 (3.3)
Current 215 (31.6) 864 (17.1) 215 (31.6) 864 (17.1) 19 (11.2) 112 (3.7)
Alcohol drinking 385 (56.7) 2599 (51.5) 0.011 345 (67.6) 1526 (75.7) <0.001 40 (23.7) 1073 (35.4) <0.001
Regular exercise 342 (49.1) 2359 (45.5) 0.043 271 (51.7) 975 (46.7) 0.023 71 (41.0) 1384 (44.7) 0.001
Family income <0.001 <0.001 0.061
Low 218 (31.7) 909 (17.7) 152 (29.3) 273 (13.2) 66 (38.8) 636 (20.8)
Moderate-low 186 (27.0) 1282 (25.0) 143 (27.6) 509 (24.7) 43 (25.3) 773 (25.3)
Moderate-high 134 (19.5) 1338 (26.1) 103 (19.9) 596 (28.9) 31 (18.2) 742 (24.2)
High 150 (21.8) 1595 (31.1) 120 (23.2) 685 (33.2) 30 (17.6) 910 (29.7)
Education <0.001 <0.001 <0.001
Elementary 289 (42.3) 1334 (26.3) 173 (33.7) 287 (14.2) 116 (68.6) 1047 (34.4)
Middle school 132 (19.3) 723 (14.3) 113 (12.2) 265 (13.1) 19 (11.2) 458 (15.0)
High school 175 (25.6) 1738 (34.3) 151 (29.4) 734 (36.3) 24 (14.2) 1004 (33.0)
College 87 (12.7) 1272 (25.1) 77 (15.0) 734 (36.3) 10 (5.9) 538 (17.7)
BMI 23.70.1 24.30.2 <0.001 23.70.1 24.50.2 0.753 23.80.1 24.20.2 0.234
DM 58 (16.8) 238 (8.6) <0.001 46 (18.0) 107 (9.5) <0.001 12 (13.3) 131 (8.0) 0.193

Table 1.
Clinical characteristics of study participants.

1
Journal of Periodontology; Copyright 2016 DOI: 10.1902/jop.2016.150682

Table 2.
Relationship between oral health behaviors and COPD
Total Male Female
COPD Controls COPD Controls COPD Controls
P- P- P-
(n=697 (n=5181 (n=524 (n=2086 (n=173 (n=3095
a a value a a value a a value
n =0.68) n =5.24) n =0.48) n =2.12) n =0.21) n =3.07)
Dental visit 188 1374 0.418 148 599 0.373 40 (23.8) 775 0.354
in last year (27.6) (27.2) (28.8) (29.7) (25.5)
Perceived 0.131 0.305 0.625
oral health
status
Very Good 8 (1.1) 58 (1.1) 6 (1.1) 23 (1.1) 2 (1.2) 35 (1.1)
Good 88 (12.6) 643 60 (11.5) 267 28 (16.2) 376
(12.4) (12.8) (12.1)
Moderate 246 2081 180 799 66 (38.2) 1282
(35.3) (40.2) (34.4) (38.3) (41.4)
Bad 282 1945 219 794 63 (36.4) 1151
(40.5) (37.5) (41.8) (38.1) (37.2)
Very Bad 73 (10.5) 454 (8.8) 59 (11.3) 203 (9.7) 14 (8.1) 251 (8.1)
Frequency of <0.00 <0.00 <0.00
tooth 1 1 1
brushing
1 time 133 554 114 307 19 (11.7) 247 (8.2)
per day (20.0) (11.1) (22.7) (15.4))
2 times per 294 2228 227 873 67 (41.4) 1355
day (44.2) (44.5) (45.1) (43.9) (44.9)
3 times 238 2221 162 808 76 (46.9) 1413
per day (35.8) (44.4) (32.2) (40.6) (46.9)
Use of other
oral products
Dental 48 (6.1) 382 <0.00 31 (12.5) 293 <0.00 17 (3.2) 89 (5.7) 0.012
floss (13.3) 1 (22.3) 1
Mouthwas 60 (10.7) 370 0.214 44 (19.4) 280 0.321 16 (4.8) 90 (5.1) 0.465
h (11.9) (21.0)
Interdental 95 (8.8) 335 <0.00 66 (16.6) 2581 0.010 29 (4.2) 77 (5.4) 0.138
brush (13.0) 1 (22.2)
Electric 28 (11.5) 402 0.497 20 (16.9) 98 (21.1) 0.172 8 (6.3) 98 (5.0) 0.299
toothbrush (11.8)
Total teeth 20.86 24.45 <0.00 20.71 24.59 <0.00 21.32 24.36 <0.00
0.26 0.07 1 0.30 0.11 1 0.53 0.09 1
DMF 7.410.2 6.680.0 <0.00 7.170.2 5.540.1 <0.00 8.130.4 7.450.0 0.008
(decayed+ 3 7 1 7 0 1 4 9
missing+fille
d) teeth
Tooth loss 7.14 3.55 <0.00 7.29 3.41 <0.00 6.68 3.64 <0.00
0.26 0.07 1 0.30 0.11 1 0.53 0.09 1
Periodontitis 405 1764 <0.00 319 883 <0.00 86 (49.7) 881 <0.00
(58.1) (34.0) 1 (60.9) (42.3) 1 (28.5) 1
Periodontal <0.00 <0.00 <0.00
severity 1 1 1
Normal 96 (13.8) 1238 70 (13.4) 393 26 (15.0) 845
(23.9) (18.8) (27.3)
Gingival 31 (4.4) 311 (6.0) 19 (3.6) 101 (4.8) 12 (6.9) 210 (6.8)
bleeding

1
 Calculus 166 1868 117 709 49 (28.3) 1159
(23.8) (36.1) (22.3) (34.0) (37.4)
Shallow 274 1267 213 591 61 (35.3) 676
periodontal (39.3) (24.5) (40.6) (28.3) (21.8)
pocket
Deep 130 497 (9.6) 105 292 25 (14.5) 205
periodontal (18.7) (20.0) (14.0) (16.6)
pocket
a
n :unweighted sample size, n :weighted sample size in millions.
Table 3.
Risk of COPD on periodontal severity
Male Female
Gingival bleeding (CPI 1)
Model 1 1.17 (0.70-1.95) 1.53 (0.83-2.92)
Model 2 0.86 (0.49-1.52) 1.31 (0.70-2.43)
Model 3 1.00 (0.53-1.90) 1.11 (0.49-2.49)
Model 4 0.68 (0.20-2.29) 1.01 (0.21-4.92)
Calculus (CPI 2)
Model 1 0.64 (0.51-0.82) 0.73 (0.52-1.03)
Model 2 0.63 (0.49-0.79) 0.76 (0.54-1.08)
Model 3 0.66 (0.48-0.91) 0.87 (0.56-1.35)
Model 4 0.61 (0.33-1.10) 0.64 (0.26-1.57)
Shallow Periodontal Pocket (CPI 3)
Model 1 1.93 (1.57-2.38) 2.18 (1.57-3.03)
Model 2 1.76 (1.41-2.18) 1.67 (1.18-2.35)
Model 3 1.69 (1.28-2.24) 1.55 (1.02-2.40)
Model 4 1.38 (1.12-2.05) 3.89 (1.61-9.39)
Deep periodontal pocket (CPI 4)
Model 1 1.95 (1.51-2.52) 3.44 (2.19-5.44)
Model 2 1.73 (1.32-2.27) 2.50 (1.55-4/05)
Model 3 1.45 (1.22-2.05) 2.40 (1.29-4.46)
Model 4 1.23 (1.06-1.56) 2.17 (0.53-8.89)
Results represent risk ratio (95% confidence interval). Adjusted for age variable in model 1. Adjusted for age,
family income, education variables in model 2. Adjusted for age, family income, education, smoking, alcohol,
exercise, BMI, tooth brushing frequency variables in model 3. Adjusted for age, income, education, smoking,
alcohol, exercise, BMI, tooth brushing frequency, diabetes, number of natural teeth in model 4.