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J Dent Res. Author manuscript; available in PMC 2008 November 11.

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Published in final edited form as:

J Dent Res. 2007 April ; 86(4): 373377.

Tobacco use and incidence of tooth loss among US male health

professionals
T. Dietrich1,2, N. N. Maserejian3,4, K. J. Joshipura5, E.A. Krall1, and R. I. Garcia1,6
1 Dept of Health Policy & Health Services Research, Boston University Goldman School of Dental Medicine
2 Dept of Periodontology and Oral Biology, Boston University Goldman School of Dental Medicine
3 Dept of Epidemiology, Harvard School of Public Health
4 New England Research Institutes
5 University of Puerto Rico, Division of Dental Public Health, School of Dentistry, Medical Science Campus

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6 VA Normative Aging Study, VA Boston Healthcare System

Abstract
Data on the dose dependent effect of smoking and smoking cessation on tooth loss are scarce. We
hypothesized that smoking has a dose and time dependent effect on tooth loss incidence. We used
longitudinal data on tobacco use and incident tooth loss in 43,112 male health professionals between
1986 and 2002. In multivariate Cox models, current smokers of 5 to 14 and 45+ cigarettes daily had
a two-fold (HR: 1.94; 95% CI: 1.72, 2.18) and three-fold (HR: 3.05; 95% CI: 2.38, 3.90) higher risk
of tooth loss, respectively, compared to never-smokers. Risk decreased with increasing time since
cessation, but remained elevated by 20% (95% CI: 16%, 25%) for men who had quit 10+ years before.
Current pipe/cigar smokers had a 20% (95% CI: 1.11, 1.30) increased risk of tooth loss compared to
never and former smokers of pipes/cigars.

Keywords
Periodontitis; Smoking; Tobacco; Tooth loss

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INTRODUCTION
Cigarette smoking has emerged as the single most important modifiable behavioral risk factor
for periodontal disease (Hujoel et al., 2003; Palmer et al., 2005; Tomar and Asma, 2000).
Cigarette smoking has also been associated with higher prevalence of edentulousness and fewer
remaining teeth in cross-sectional studies (Axelsson et al., 1998; Daniell, 1983; Gilbert et
al., 1993; Krall et al., 1997; Linden and Mullally, 1994), and with increased rates of tooth loss
in longitudinal studies (Ahlqwist et al., 1989; Eklund and Burt, 1994; Holm, 1994; Jansson
and Lavstedt, 2002; Krall et al., 1997). However, many previous studies were relatively small
or used broad categorizations of smoking history. Therefore, the dose-response relationship
between cigarette smoking and tooth loss is not well characterized. Furthermore, little is known
about the time-dependent effect of smoking cessation on risk of tooth loss. In a study of 1,031
Swedish women, risk of tooth loss over 12 years was similar between never smokers and former
smokers who had quit any time before baseline (Ahlqwist et al., 1989). Krall et al. found an

Corresponding author: Thomas Dietrich, DMD, MD, MPH Dept of Health Policy & Health Services Research Boston University School
of Dental Medicine 715 Albany St, 560, 3rd floor Boston, MA 02118 USA T: +1-617-414-1130 F: +1-617-638-6381 [email protected].

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intermediate rate of tooth loss for male smokers who quit at any time during the 3 to 26 years
of follow-up and concluded that it may take decades for quitters to return to the tooth loss rate
of never-smokers (Krall et al., 1997). The use of other types of tobacco, such as cigar, pipe,
and smokeless tobacco, is also likely to be related to tooth loss risk, but few studies have
explored this hypothesis. A cross-sectional analysis of 705 subjects of the Baltimore
Longitudinal Study of Aging found that the number of missing teeth was higher among smokers
of pipes and cigars (Copeland et al., 2004). Both pipe and cigar smoking were independently
associated with increased tooth loss risk in a longitudinal study of 690 men (Krall et al.,
1999). In a representative survey of the US population (NHANES III), history of smokeless
tobacco use was associated with periodontal disease prevalence (Fisher et al., 2005). However,
whether or not the use of smokeless tobacco increases the risk of tooth loss has not been
investigated.
The purpose of the present study was to evaluate the associations between the various forms
of tobacco use (cigarette smoking, pipe or cigar smoking, chewing tobacco) and smoking
cessation and the incidence of tooth loss in a large, prospective study of U.S. health
professionals.

MATERIALS AND METHODS

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The Health Professionals' Follow-Up Study (HPFS) is an ongoing longitudinal cohort study
of 51,529 male health professionals, including dentists (58%), veterinarians (20%),
pharmacists (8%), optometrists (7%), osteopaths (4%), and podiatrists (3%). Participants were
40 to 75 years of age at the study baseline in 1986. Participants completed mailed questionnaires
every 2 years to provide information on medical history, and health behaviors. On average,
over 90% of the baseline population responded to each follow-up questionnaire. This study
was approved by the Human Subjects Committee at Harvard School of Public Health.
For the present analysis, we excluded men if at baseline they had: missing data for cigarette
smoking status, a cancer diagnosis by 1986, self-reported daily caloric intake outside the
plausible range of 800 to 4200, or 70 of the 131 dietary questions left blank. We also excluded
742 edentulous men (29% never, 57% former and 15% current cigarette smokers). The final
analytic sample included 43,112 men who contributed 569,366 person-years.
Exposure Assessment

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The baseline HPFS questionnaire asked detailed questions on the history of cigarette smoking.
Men who had smoked less than 20 packs of cigarettes in their lifetime were defined as never
smokers. Ever smokers of cigarettes reported the average number of cigarettes per day (0-4,
5-14, 15-24, 25-34, 35-44, 45+ cig/d) and, if former smokers, time since cessation (<1 year,
1-2 years, 3-5 years, 6-9 years, 10+ years). Information on cigarette and cigar or pipe smoking
(current, yes/no) was updated biennially. Ever-use of chewing tobacco was ascertained in the
1996 questionnaire (Have you ever chewed tobacco at least once a week for a year?).
Outcome Assessment
Participants reported baseline number of teeth in 1986 and incident tooth loss in two-years
intervals thereafter. Missing values on incident tooth loss were assumed to represent no tooth
loss during that follow-up period because only 10% of participants experienced tooth loss
biennially. Self-reported number of teeth and tooth loss have been found to be highly accurate
in various populations (Douglass et al., 1991; Gilbert et al., 2002; Pitiphat et al., 2002). Thus,
in this population of dentists and health professionals, self-reported number of teeth and tooth
loss are likely to have high validity.

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Assessment of potential confounders

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Diet was assessed at baseline and every four years thereafter with an expanded semiquantitative
food frequency questionnaire (Willett et al., 1985). Every two years, questionnaires also
assessed use of multivitamins and specific vitamin supplements. Validity of the dietary data
has been documented by comparisons with multiple weighed dietary records (Rimm et al.,
1992). Physical activity was assessed biennially and calculated as the sum of the activityspecific metabolic equivalent (MET) hours/week as a measure of total leisure-time physical
activity.
Data Analysis
Person-time for each participant was calculated from the date of return of the 1986
questionnaire to the date of first incident tooth loss, death, or January 31, 2002, whichever
occurred first.
Cox proportional-hazards models were used to obtain hazard ratios and 95% confidence
intervals for the association between tobacco use and risk of tooth loss. Former smokers were
categorized according to time since cessation (<1, 1-2, 3-5, 6-9 and 10+ years ago), and current
smokers were categorized according to intensity (<5, 5-14, 15-24, 25-34, 35-44, 45+ cigarettes/
day).

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All models contained cigarette, cigar/pipe and chewing tobacco variables, to mutually adjust
for type of tobacco use. The basic model included age (months) and race (Caucasian vs. other).
A multivariable model further adjusted for other variables that were significantly associated
with tooth loss (p<0.05) in bivariate analyses or that changed the effect estimates of the tobacco
use/tooth loss association by 5%. Cigarette smoking, pipe/cigar smoking, body mass index
(BMI), physical activity, diabetes, use of multivitamins/vitamin supplements and intakes of
nutrients/food groups were modeled as time-dependent variables.
Sensitivity analyses restricted the cohort to dentists, because reasons for tooth loss and accuracy
of self-reports may differ from non-dentists. Finally, because smoking increases the risk of
various cancers and cancer treatment (i.e., radiotherapy and chemotherapy) that may be
associated with increased tooth loss, a separate analysis censored person-time at the follow-up
preceding a first report of a cancer diagnosis.
All statistical tests were two-sided and calculated using SAS 9.1.2 (SAS Institute Inc., Cary,
NC).

RESULTS
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At baseline in 1986, 3,765 (8.7%) men were current cigarette smokers and 18,950 (44.0%)
were former cigarette smokers. Age, race, BMI, profession, multivitamin use and total caloric
intake were similar among never, former and current smokers (Table 1). Compared to never
smokers, current smokers, and particularly current heavy smokers, were more likely to be
diabetic and physically inactive, less likely to have had a routine physical exam, less likely to
take vitamin C supplements and more likely to consume alcohol. Furthermore, smokers had
lost more teeth prior to baseline.
Over the course of the follow-up between 1986 and 2002, 13,656 men lost at least one tooth
(average time until tooth loss: 8.4 years, range 0.1 13.4 years). There was a strong, dosedependent association between cigarette smoking and risk of tooth loss (Table 2). Among
current cigarette smokers, the risk of tooth loss increased steadily with increasing smoking
intensity. Compared to never smokers, current smokers who smoked 5-14 cigarettes per day
had twice the risk of tooth loss (HR: 1.94; 95% CI: 1.72, 2.18), and current smokers of 45 or
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more cigarettes per day had a three-fold higher risk of tooth loss (HR: 3.05; 95% CI: 2.38,
3.90). The association was independent of other tobacco use, age, race, BMI, physical activity,
diabetes, profession (dentist vs. non-dentist), routine medical exam, alcohol consumption,
caloric intake, multivitamin use, vitamin C supplement use.
Among former cigarette smokers, risk of tooth loss decreased steadily with increasing time
since cessation (Table 2). Compared to never smokers, men who quit smoking 10 or more years
ago had 20% (95% CI: 16%, 25%) greater risk of tooth loss. Multivariable adjustments and
restriction of the analysis to dentists yielded very similar hazard ratio estimates for cigarette
smoking.
Current pipe or cigar smoking was associated with a 20% (multivariate HR:1.20; 95% CI: 1.11,
1.30) increased risk of tooth loss compared to never or former smokers of pipes or cigars.
Results were similar when the analysis was restricted to dentists. Ever-use of chewing tobacco
was associated with incident tooth loss in the age- and race-adjusted analysis (HR:1.27; 95%
CI: 1.16, 1.39) as well as in the full multivariate model (HR:1.14; 95% CI: 1.04, 1.24), although
the association was attenuated when additional covariates were included. When restricted to
dentists, however, no statistically significant association between chewing tobacco and tooth
loss was observed (HR: 1.06; 95% CI: 0.90, 1.26).

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Censoring of person-time prior to a first diagnosis of cancer did not change the results (data
not shown).

DISCUSSION
In this large, prospective cohort study of male health professionals, we found a strong, dosedependent association between cigarette smoking and the risk of tooth loss, independent of
other risk factors and potential confounders. The risk of tooth loss declined after smoking
cessation as a function of time since cessation; however, compared to never smokers, the risk
of tooth loss remained elevated even 10 years after smoking cessation. Current smokers of pipe
or cigars also had increased risk of tooth loss. Ever-use of chewing tobacco seemed to increase
risk as well, though estimates were not as robust as for other types of tobacco.

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Important strengths of this study are its prospective design, large sample size, long follow-up,
and detailed, biennially updated data on smoking, allowing for fine exposure categories and
precise estimates. Considering that tooth loss is the outcome of a complex process that may
involve numerous factors that are also related to tobacco use (e.g., diet, health behaviors),
another strength of this study is our ability to adequately control for such confounders.
Furthermore, the cohort's relative homogeneity minimizes potential confounding by factors
such as socio-economic status and access to care.
The path by which cigarette smoking affects tooth loss is presumed to involve periodontitis.
In addition to periodontitis, dental caries may also contribute to the increased risk of tooth loss
among smokers (Ylostalo et al., 2004). Associations have been reported between cigarette
smoking and root caries (Fure, 2004; Hahn et al., 1999; Phelan et al., 2004), coronal caries
(Axelsson et al., 1998; Drake et al., 1997), endodontic treatment (Krall et al., 2006a) and
periapical periodontitis (Kirkevang and Wenzel, 2003), although not consistently (Bergstrom
et al., 2004).
We found that risk of tooth loss declines as early as one year after smoking cessation. However,
it may take more than 10 years of abstinence for the risk to decline to that of never smokers.
This is in agreement with results from the VA Dental Longitudinal Study, where after 12 years
of cessation the risk of tooth loss approached that of never smokers (Krall et al., 1997; Krall
et al., 2006b).
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These results suggest that following smoking cessation, the effect of smoking on tooth loss
declines less rapidly than the effect of smoking on periodontitis (Bergstrom et al., 2000; Bolin
et al., 1993; Tomar and Asma, 2000). Using NHANES III data, we estimated the half-life of
the effect of smoking on periodontal disease at 1.5 years (Dietrich and Hoffmann, 2004),
suggesting that the risk for periodontal disease for former smokers should approach that of
never smokers approximately 6 years after quitting. This apparent difference in the half-life of
the effects of smoking on periodontal disease vs. tooth loss may be explained by factors other
than periodontitis, such as caries, that also mediate the effect of smoking on tooth loss risk.
Our finding that cigar or pipe smoking is associated with risk of tooth loss confirms earlier
work. In a cross-sectional study, men who smoked pipes or cigars had a higher prevalence of
moderate or severe periodontitis and fewer teeth remaining than non-smokers (Albandar et
al., 2000). In a longitudinal study, we earlier found that cigar smoking is associated with
significantly higher rates of tooth loss (Krall et al., 1999). However, it is uncertain by exactly
how much the risk increases as we only had a dichotomous measure of current cigar or pipe
smoking, i.e., the comparison group included both never and former smokers.

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We found a significant positive association between ever-use of chewing tobacco and risk of
tooth loss only among the non-dentist health professionals. Previous studies of smokeless
tobacco and tooth loss are lacking, and our results should be interpreted with caution.
Multivariable adjustment resulted in a marked attenuation of the hazard ratio, and no
association was evident when the analysis was restricted to dentists. Although residual or
unknown confounding may explain the small association found, it is likely that our measure
of chewing tobacco use was insufficient to accurately estimate an association with tooth loss.
We did not have specific information on dose, duration, or timing (i.e., ages) of chewing
tobacco use, and it may be that a large proportion of everusers were men who used chewing
tobacco in the distant past.
Our results provide evidence for a strong time- and dose-dependent association between
tobacco smoking and risk of tooth loss among men. However, these results may not be directly
generalizable to women. A somewhat stronger association between smoking and tooth loss
was reported among women in a cross-sectional study of 8,409 young Finnish adults (Ylostalo
et al., 2004). Lastly, as the majority of HPFS participants were Caucasian, generalizability of
our findings to other racial/ethnic groups is uncertain.
In conclusion, there is a strong association between cigarette, pipe, or cigar smoking and
subsequent tooth loss in men. Current heavy cigarette smokers have a three-fold greater risk
of incident tooth loss, compared to never smokers. The risk declines soon after cessation of
cigarette smoking, but remains elevated for more than ten years compared to never smokers.

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ACKNOWLEDGEMENTS
This investigation was supported by NIDCR Grants R03 DE016357 and K24 DE00419, and the U.S. Dept. of Veterans
Affairs.

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n=20,397
53 10
94%
25.3 3.2
20.2 25.5
2.5%
58%
53%
2.7%
6.4%
8 12
1993 619
42%
37%
86%
9.4%
1.6%
0.9%

Never

n=13,400
57 9
94%
25.5 3.2
20.4 24.8
3.1%
58%
54%
5.2%
7.5%
13 16
1976 612
44%
37%
82%
12%
2.3%
1.8%

10+ years

Former

n=5,550
53 9
94%
26.0 3.2
17.8 22.2
3.6%
55%
52%
7.8%
6.5%
14 17
1985 625
42%
33%
76%
14%
3.6%
3.0%

<10 years
n=1,135
55 9
92%
25.2 3.0
17.6 22.1
2.7%
63%
51%
4.3%
13%
15 17
1983 630
45%
35%
78%
13%
3.0%
2.7%

15 cig/d

Cigarette Smoking (HPFS baseline 1986)

n=1,369
55 9
92%
25.3 3.1
13.8 17.9
2.9%
56%
45%
4.1%
7.5%
16 19
1973 611
40%
31%
72%
16%
4.4%
4.1%

Current
15-24 cig/d

n=1,261
55 9
95%
25.6 3.4
10.9 16.1
4.0%
52%
43%
3.9%
4.9%
20 23
2111 655
41%
30%
68%
18%
4.2%
4.8%

25+ cig/d

Chewing tobacco was ascertained in 1996.

Except for age, all variables have been adjusted by direct standardization to the age distribution of the entire study population. SD=standard deviation. BMI=body mass index. MET=metabolic equivalents.

Age [years]
Caucasian [%]
BMI [kg/m2]
Physical activity [MET]
Diabetes [%]
Dentist [%]
Medical Exam [%]
Chewing tobacco use [%]b
Pipe/cigar use [%]
Alcohol [g/d]
Calories (kcal/d)
Multivitamin use [%]
Vitamin C Supplement use [%]
Number of teeth 25-32
17-24
11-16
1-10

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Table 1

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Baseline characteristics of participants in the Health Professionals Follow-up Study (mean SD for continuous variables and proportions
for categorical variables) a, b
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1.0
1.2
1.5
1.6
1.9
2.6
1.4
1.8
2.2
2.7
2.9
3.2
1.0
1.2
1.0
1.3

5040
719
498
356
88
126
289
500
262
188
65
12990
666
10297
533

HR

5525

events
n

Reference
1.2, 1.4

Reference
1.1, 1.3

1.1, 1.6
1.6, 2.1
2.0, 2.4
2.4, 3.0
2.5, 3.4
2.5, 4.0

1.1, 1.3
1.4, 1.6
1.5, 1.8
1.7, 2.1
2.1, 3.2

Reference

1.0
1.1

1.0
1.2

1.4
1.9
2.3
2.7
2.9
3.0

1.2
1.5
1.6
1.9
2.6

1.0

Entire cohort (n = 43,112)

Model 1 b
95% CI
HR

Reference
1.0, 1.2

Reference
1.1, 1.3

1.2, 1.7
1.7, 2.2
2.1, 2.5
2.4, 3.1
2.5, 3.3
2.4, 3.9

1.2, 1.3
1.4, 1.6
1.5, 1.8
1.7, 2.1
2.1, 3.2

Reference

Model 2 c
95% CI

5110
392

6475
348

86
158
254
125
85
27

2605
344
246
189
40

2674

events
n

1.0
1.1

1.0
1.2

1.8
1.9
2.4
2.8
3.2
3.2

1.3
1.5
1.7
2.0
2.8

1.0

HR

Reference
0.9, 1.3

Reference
1.1, 1.4

1.5, 2.2
1.6, 2.3
2.1, 2.8
2.3, 3.3
2.5, 3.9
2.2, 4.6

1.2, 1.4
1.4, 1.7
1.5, 1.9
1.8, 2.4
2.0, 3.8

Reference

1.0
1.1

1.0
1.2

1.8
2.0
2.5
2.8
3.1
3.0

1.3
1.5
1.7
2.0
2.8

1.0

Dentists only (n = 26,284)

Model 1 b
95% CI
HR

Reference
0.9, 1.3

Reference
1.1, 1.3

1.5, 2.2
1.7, 2.3
2.2, 2.8
2.3, 3.4
2.5, 3.8
2.1, 4.5

1.2, 1.4
1.4, 1.7
1.5, 2.0
1.8, 2.4
2.0, 3.9

Reference

Model 2 c
95% CI

c
Model 2 is adjusted for age, race, BMI, physical activity, diabetes, profession (dentist vs. non-dentist), routine medical exam, alcohol consumption, caloric intake, multivitamin use, and vitamin C
supplement use

Model 1 is adjusted for age and race

All models are mutually adjusted for all tobacco (cigarette, pipe/cigar, and chewing tobacco) variables.

Cigarette smoking
Never
Former
10+ years
6-9 years
3-5 years
1-2 years
< 1 years
Current
1- 4 cig/d
5-14 cig/d
15-24 cig/d
25-34 cig/d
35-44 cig/d
45+ cig/d
Pipe/Cigar smoking
Never/Former
Current
Chewing tobacco
Never
Ever

NIH-PA Author Manuscript

Table 2

NIH-PA Author Manuscript

Hazard-Ratios (HR) and 95% confidence intervals (CI) for incidence of tooth loss by smoking status in the Health Professionals Followup Study a
Dietrich et al.
Page 9

J Dent Res. Author manuscript; available in PMC 2008 November 11.