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1 J Periodontol July 2005 Periodontal Disease and the Incidence of Tooth Loss in Postmenopausal Women Mine Tezal,* Jean Wactawski-Wende, Sara G. Grossi,* Jacek Dmochowski, and Robert J. Genco* Background: The role of periodontal disease as a predictor of incident tooth loss in postmenopausal women has not been determined. The aim of this cohort study was to determine the extent of the association between baseline periodontal status and incident tooth loss in a population of postmenopausal women. Methods: The study population included 106 dentate white postmenopausal women who participated in a cross-sectional study between 1989 and 1991 who were willing and eligible to have a repeat examination after 10 to 13 years. At baseline, full-mouth assessment of periodontal status was performed clinically and radiographically. Assessment of tooth loss during follow-up was assessed clinically by a periodontist. Odds ratio (OR) and its 95% confidence interval (CI) for each periodontal variable was obtained from separate multiple logistic regression analyses adjusting for the effect of age, household income, smoking, hormone therapy, snack consumption, and number of decayed teeth. Results: Sixty-one (57.5%) subjects lost at least one tooth during follow-up. Mean tooth loss per person was 1.81 ± After adjusting for confounders, each millimeter of alveolar bone loss at baseline increased the risk of tooth loss 3-fold (OR = 3.26; 95% CI: 1.60 to 6.64). The risk of tooth loss also increased 2.5 times for each millimeter of clinical attachment loss (OR = 2.50; 95% CI: 1.24 to 5.07). Probing depth (OR = 2.53; 95% CI: 0.98 to 6.53), gingival bleeding (OR = 1.99; 95% CI: 0.21 to 18.94), calculus (OR = 2.05; 95% CI: 0.91 to 4.61), and plaque (OR = 0.70; 95% CI: 0.13 to 3.34) were not significantly associated with incident tooth loss. Conclusion: Periodontal disease, especially measured by alveolar bone loss, is a strong and independent predictor for incident tooth loss in postmenopausal women. J Periodontol 2005;76: KEY WORDS Periodontal diseases; postmenopause; risk factors; tooth loss. * Department of Oral Biology, University at Buffalo, Buffalo, NY. Department of Social and Preventive Medicine, Epidemiology and Community Health, University at Buffalo. Department of Mathematics and Statistics, University of North Carolina Charlotte, Charlotte, NC. In the United States, about $1.5 billion is spent annually for replacement of missing teeth, which represents only a fraction of the actual amount that could be spent considering that not all missing teeth are replaced. 1,2 Tooth loss diminishes quality of life by causing loss of function and esthetics and, consequently, self-esteem. Distribution of tooth loss is highly skewed and only a small percentage of the population is responsible for the majority of tooth loss. 3 Summary data may mask differences between subpopulations that are exposed to different biological and social exposures. Postmenopausal women represent a subpopulation with unique factors. Estrogen deficiency after menopause 2,4 and consequent loss of bone mineral density 5,6 have been shown to be associated with increased rate of tooth loss. These relationships may be explained by increased severity of periodontal disease 7-12 and decreased bone mineral density 13,14 in estrogen deficiency. The role of baseline periodontal status on the incidence of tooth loss in postmenopausal women has not been assessed in previous studies. The aims of this study were to describe the distribution of incident tooth loss over 10.6 to 13.3 years of followup and determine to what extent the incidence of tooth loss is associated with the baseline periodontal variables in a population of postmenopausal women. MATERIALS AND METHODS Study Population The population of this cohort study was derived from individuals who participated 1123

2 Periodontal Disease and Tooth Loss in Postmenopausal Women Volume 76 Number 7 in the cross-sectional Erie County Study 15,16 on risk factors for periodontal disease between July 1989 and December Subjects were recruited using various methods including random selection from census tract data (N = 365), convenience patients who presented for treatment at the University at Buffalo, School of Dental Medicine (N = 325), and respondents to advertisements in local newspapers (N = 736). Subjects who had a history of invasive cancer or required antibiotic prophylaxis for subacute bacterial endocarditis were excluded at baseline. A total of 1,426 dentate men and women were enrolled in the Erie County Study. Follow-up data for the current study was obtained between May 2002 and June Inclusion criteria were female gender, permanent menopause at baseline, age at menopause 40 years, and presence of six natural teeth at baseline. Contacted subjects who developed cancer during follow-up were excluded. The cohort was restricted to white women due to an insufficient number of black women for statistical analyses. Information on menopausal status was not obtained at baseline. Therefore, only women aged 45 or older at baseline examination were targeted and information on menopausal status and age at menopause was obtained at follow-up retrospectively. A total of 303 subjects met the inclusion criteria for the follow-up study and were targeted for recruitment. Among the subjects targeted for recruitment, 34 (11.2%) had died, 23 (7.6%) moved out of town, 14 (4.6%) were unable to participate due to health reasons, 59 (19.5%) refused to participate, 32 (10.6%) did not respond after five or more telephone call attempts, and 35 (10.6%) could not be contacted due to disconnected or wrong telephone numbers. The final study population consisted of 106 subjects (35% of the target population). Definition of Variables Baseline clinical examination included assessments of clinical attachment loss (CAL), probing depth (PD), gingival bleeding (GB), supragingival plaque, and calculus and was performed on all existing teeth except the third molars by a team of nine trained and calibrated dentists according to the National Institutes of Health guidelines. 17 Supragingival plaque and gingival bleeding were assessed on three surfaces per tooth (buccal, mesio-buccal and lingual). The criteria for a positive plaque score was the visualization of plaque regardless of the amount. The presence of gingival bleeding was assessed in response to a periodontal probe (Michigan O probe) run along the gingival sulcus. For calculus, a single score was assigned for each tooth utilizing a no. 17 dental explorer according to the following scale: 0: calculus absent; 1: presence of supragingival calculus but no subgingival calculus; or 2: supragingival and subgingival calculus or subgingival calculus alone. CAL was measured on six surfaces per tooth (disto-buccal, buccal, mesio-buccal, distolingual, lingual, and mesio-lingual) and was defined as the distance between the cemento-enamel junction (CEJ) and base of the gingival sulcus. The distance from CEJ to gingival margin (GM) was measured with Michigan O probe, and PD at the same site was measured with a constant-force (20 g) electronic probe. 18 CAL was automatically calculated by a computer program according to the formula: CAL = PD (GM-CEJ). Alveolar bone loss (ABL) was determined from six anterior periapical and four posterior vertical bite-wing radiographs taken with a Rinn alignment system. E-speed films, size 0 for the anterior periapicals and size 2 for the posterior vertical bite-wings, were utilized. The radiographs were taken using an x-ray unit operating at 70 kvp and 15 ma setting. The patients wore a lead lined apron with a thyroid collar. An automatic processor was utilized for film processing. ABL was measured on mesial and distal surfaces of all teeth present, except the third molars and the canines, using a computer program working with digitized radiographic images. 19,20 The program allows measurement of the distance from CEJ to bone crest in a line parallel to the long axis of the tooth. Information on covariates was obtained by questionnaires and included age (years), household income (<$10,000; $10,000 to 29,999; $30,000), smoking status (never, former, current), hormone therapy (never, former, current), number of snacks per day, and number of decayed teeth. For both smoking status and hormone therapy, current was defined as presence of the exposure at baseline regardless of the amount (dosage); former was defined as quitting the exposure before the baseline examination regardless of the time since quitting. At follow-up, missing teeth, caries, and restorations were assessed clinically by one periodontist, using the same criteria as the baseline examination. Subjects were also asked about the reasons for tooth loss and these were grouped as periodontal disease, caries, failed endodontic treatment, orthodontic reasons, fracture or accident, unerupted, and congenitally missing. Reliability of the Measurements During the study period, replicate measurements of ABL, CAL, and PD were obtained on randomly selected 20% of the subjects by nine calibrated examiners. Replicate measurements were performed on randomly selected quadrants and the examiner had no previous knowledge of the scheduled second measurements at the time of the first measurements. Overall, intraexaminer mean ± SD of differences between replicate measurements for PD was 0.57 ± 0.16 mm; for CAL, 0.76 ± 1124

3 J Periodontol July 2005 Tezal, Wactawski-Wende, Grossi, Dmochowski, Genco 33 mm; and for ABL, 0.30 ± 38 mm. Interexaminer mean ± SD of differences between replicate measurements for PD was 0.73 ± 0.12 mm; for CAL, 0.95 ± 0.18 mm; and for ABL, 0.34 ± 0.42 mm There was a perfect (100%) agreement on repeated assessment of tooth loss at follow-up. Statistical Analyses Descriptive statistics included means, standard deviations, frequencies, and proportions and were used to describe the study population and the distribution of tooth loss. Correlation coefficients, chi square tests, t tests, and crude odds ratios were used to select variables for the multivariate models. Variables that showed associations with incident tooth loss in unadjusted analyses (P <0.20) were entered into multivariate models. Over 50 baseline variables including demographic, lifestyle, health, professional, and self dental care characteristics were evaluated as potential confounders. Separate multiple logistic regression analyses were used to determine the independent effect of each periodontal variable on incident tooth loss after adjusting for the effects of confounders. Incident tooth loss was defined as 1 tooth loss between baseline and follow-up examinations. Odds ratios and their 95% CI were obtained. Possible interactions between independent variables were tested in multivariate models. Baseline characteristics of the study population and the population lost to follow-up were compared with chi square and t tests to assess the presence of systematic differences between the two populations as a source of possible bias. RESULTS Sixty-one (57.5%) subjects lost at least one tooth during follow-up. The mean number of teeth lost was 1.81 (range: 0 to 17). Among those who lost teeth, the average number of teeth lost was 3.15; the majority (35 [57.4%]) lost one or two teeth, 19 (31.1%) subjects lost three to five teeth, and the remaining seven (11.5%) subjects lost six to 17 teeth. None of the subjects became totally edentulous. During the follow-up period, a total of 192 teeth were lost. According to subject self-report, 119 (62%) teeth were lost due to periodontal disease and 73 (38%) teeth were lost due to caries or failed endodontic treatment. Eighteen (30%) subjects lost teeth due to periodontal disease (mean: 6.61 per person); 34 (55%) subjects lost teeth due to caries or failed endodontic treatment (mean: 2.15 teeth per person), and nine (15%) subjects lost teeth due to both periodontal disease and caries (mean: 8.11 teeth per person). The average follow-up time was 11.7 years and ranged between 10.6 and 13.3 years. The baseline age ranged from 45 to 73 years (mean: 58.03). All subjects had reached menopause at baseline, with an average age at menopause of 48.8 years. Slightly more than half of the study population (54.8%) had high school or higher education and the majority of the study population (59.4%) had a household income between $10,000 and $29,999. More than a quarter of the study population (26.4%) had a history of hormone therapy (HT) and 22.6% were still on HT at baseline. Only two (1.9%) women reported having osteoporosis at baseline. The percentages of current and former smokers at baseline were 17.9% and 34%, respectively. About half of the study population (47.2%) consumed two or more snacks a day. The study population had an average of remaining teeth and 1.26 decayed teeth at baseline (Table 1). The subjects had mean ABL of 2.68 mm, mean CAL of 2.24 mm, mean PD of 2.17 mm, mean gingival bleeding of 0.34, mean calculus of 1.02 and mean plaque of 0.64 (Table 2). Those who lost teeth had significantly higher mean baseline ABL (2.99 versus 2.25, P = 0.001) compared to those who did not lose teeth. They also had higher mean CAL (2.37 versus 2.07, P = 0.058), PD Table 1. Description of the Study Population at Baseline (N = 106) Follow-up time (years) ± 0.66 ( )* Age (years) ± 7.58 ( ) Age at menopause (years) ± 4.43 ( ) Education (years) (45.2) >12 57 (54.8) Household income <$10, (14.2) $10,000-29, (59.4) $30, (26.4) Hormone therapy Never 78 (73.6) Former 4 (3.8) Current 24 (22.6) Osteoporosis No 104 (98.1) Yes 2 (1.9) Smoking status Never 51 (48.1) Former 36 (34.0) Current 19 (17.9) N snacks <2/day 56 (52.8) 2/day 50 (47.2) N remaining teeth ± 4.92 ( ) N decayed teeth 1.26 ± 2.07 ( ) * Mean ± SD (range). N (%). 1125

4 Periodontal Disease and Tooth Loss in Postmenopausal Women Volume 76 Number 7 Table 2. Description of the Study Population by Baseline Periodontal Variables Table 3. Description of Incident Tooth Loss by Baseline Periodontal Variables Variable Mean ± SD (range) Tooth Loss ABL (mm) 2.68 ± 1.02 ( ) CAL (mm) 2.24 ± 0.79 ( ) PD (mm) 2.17 ± 0.52 ( ) Gingival bleeding (0-1) 0.34 ± 0.19 ( ) Calculus (0-2) 1.02 ± 0.61 ( ) Plaque (0-1) 0.64 ± 0.29 ( ) Table 4. Crude Odds Ratios of Baseline Periodontal Variables for Incident Tooth Loss (N = 106) Variable OR 95% CI P ABL (per mm) CAL (per mm) PD (per mm) Gingival bleeding (0-1) Calculus (0-2) Plaque (0-1) (2.21 versus 2.11, P = 0.38), gingival bleeding (0.35 versus 0.33, P = 0.57), calculus (1.09 versus 0.92, P = 0.14), and plaque (0.64 versus 0.63, P = 0.87), but these differences were not statistically significant (Table 3). The risk of tooth loss significantly increased by 2.5- fold for each millimeter of alveolar bone loss at baseline (OR = 2.56; 95% CI: 1.49 to 4.40). Tooth loss also increased with increasing levels of baseline CAL (OR = 1.72; 95% CI: 0.97 to 3.05), PD (OR = 1.48; 95% CI: 0.69 to 3.18), gingival bleeding (OR = 1.77; 95% CI: 0.24 to 12.83), and calculus (OR = 1.64; 95% CI: 0.85 to 3.15), but these associations did not reach statistical significance. There was no relationship between baseline plaque levels and incident tooth loss (OR = 1.11; 95% CI: 0.30 to 4.14) (Table 4). After adjusting for age, household income, smoking, hormone therapy, number of snacks per day, and number of decayed teeth, the risk of tooth loss significantly increased by 3-fold for each millimeter of ABL at baseline (OR = 3.26; 95% CI: 1.60 to 6.64) and by 2.5 times for each millimeter of CAL at baseline (OR = 2.50; 95% CI: 1.24 to 5.07). The risk of tooth loss also increased Variable 0 1 P* ABL (mm) 2.25 ± ± CAL (per mm) 2.07 ± ± PD (per mm) 2.11 ± ± Gingival bleeding (0-1) 0.33 ± ± Calculus (0-2) 0.92 ± ± Plaque (0-1) 0.63 ± ± * t tests. Mean ± SD. Table 5. Adjusted* Odd Ratios of Baseline Periodontal Variables for Incident Tooth Loss N OR 95% CI P ABL (per mm) CAL (per mm) PD (per mm) Gingival bleeding (0-1) Calculus (0-2) Plaque (0-1) * Age, income, smoking, hormone therapy, number of snacks per day, and number of decayed teeth. with increasing levels of baseline PD (OR = 2.53; 95% CI: 0.98 to 6.53), gingival bleeding (OR = 1.99; 95% CI: 0.21 to 18.94), and calculus (OR = 2.05; 95% CI: 0.91 to 4.61), but these associations were not statistically significant. There was no relationship between baseline plaque levels and the risk of incident tooth loss (OR = 0.70; 95% CI: 0.13 to 3.34) (Table 5). DISCUSSION In this study, roughly 5% of the study population per year lost at least one tooth during follow-up, with a mean number of 1.81 teeth per person (0.16 teeth per year). Two previous cohort studies have reported incidence of tooth loss in postmenopausal women. 4,6 In a retrospective cohort study of 7 years with 189 healthy postmenopausal women with a mean age of 60 years, 24% of the subjects (3.4% per year) lost at least one tooth

5 J Periodontol July 2005 Tezal, Wactawski-Wende, Grossi, Dmochowski, Genco In that study, tooth loss was assessed by questionnaires. In the second study with 42,171 postmenopausal registered nurses, aged 56 to 71 years, from 11 states across the United States, 23% (11.5% per year) of the population reported having lost at least one tooth in the last 2 years by mailed questionnaires. 4 Therefore, incidence of tooth loss in our population was within the range of previous studies that examined a postmenopausal women population. This study was the first one that assessed the role of baseline periodontal disease on the incidence of tooth loss in postmenopausal women. The three previous cohort studies 4-6 of tooth loss examining postmenopausal women populations did not adjust for or assess the effect of baseline periodontal disease levels. In our study, among periodontal variables, ABL was the strongest predictor of incident tooth loss. After adjusting for confounders, each millimeter of ABL at baseline increased the risk of future tooth loss by more than three times. CAL and PD were also associated with incident tooth loss; however, the point estimates for these associations were somewhat more modest than for ABL. The reason for their weaker associations is partly due to lower precisions of these measurements compared to ABL measurements. In addition, some systemic factors in postmenopausal women such as reduced bone mineral density after menopause may have a more direct relationship with ABL compared to PD and CAL. After the addition of ABL, neither CAL nor PD contributed significantly to the model. Therefore, of the three periodontal measures, ABL was the best predictor of the incidence of tooth loss. Four previous cohort studies assessed the effect of baseline ABL on the risk of incident tooth loss in other populations In a retrospective cohort study of 0.33 to years with 100 consecutive adult maintenance patients (no age, gender, or race information was reported) from a clinician s appointment book who had initially moderate to severe periodontitis, 1% alveolar bone loss at baseline was associated with a 3% increase in the risk of tooth loss (relative risk = 1.03, P = ) after adjusting for probing depth, furcation involvement, mobility, parafunctional habit without a bite-guard, and smoking. 22 Another retrospective cohort study 23 of 23 years follow-up in 690 predominantly white veteran men (97%) aged 21 to 75 years at baseline, showed that mean ABL at baseline (r = 0.12, P <0.001) and percent sites with ABL progression (r = 0.11, P <0.001) were significantly associated with the number of teeth lost during follow-up after adjusting for age, smoking, education, probing depth, and number of remaining teeth at baseline. ABL was measured at two sites per tooth from periapical radiographs with Schei ruler with 20% increments. 23 In a retrospective cohort study of 1.6 to 5.2 years with 415 predominantly white (95.6%) men and women with mild or no periodontal disease and aged 25 to 75 years at baseline, subjects who lost at least one tooth during follow-up had significantly higher baseline ABL compared to subjects who did not lose teeth (2.43 mm versus 1.95 mm, P = ). 24 Finally, in a prospective cohort study of 20 years with 515 white men and women from Stockholm, aged 18 to 65 years at baseline, mean ABL at baseline was significantly related to the number of teeth lost during follow-up both in unadjusted analyses (r = 0.49, P <0.001) and after adjusting for plaque, number of missing teeth at baseline, age, and education (β =0.25, P <0.001). 25,26 It is not possible to directly compare our results to previous studies that employed other populations due to different measurement methods, statistical analyses, and follow-up periods. However, the predictive ability of ABL for incident tooth loss seems to be stronger in postmenopausal women compared to other populations. This may be explained by the high rate of systemic bone loss in postmenopausal women. A limitation of our study is that no information was available on systemic bone loss (i.e., bone density) and only two women reported having osteoporosis at baseline; therefore, we could not evaluate this parameter. Since systemic bone loss has been shown to be a significant factor for tooth loss, 5,6 future studies of postmenopausal women with larger samples sizes are needed for an estimate of ABL effect size adjusted by systemic bone loss. Another limitation of this study was the exclusion of third molars from clinical examination and the exclusion of canines from ABL measurements at baseline. Exclusion of third molars is a potential source of bias because loss of these teeth is not counted in the incidence rates. However, the effect of bias on the estimated rate of tooth loss is likely to be low. In a study of extractions with a random sample of dental practices, only 1.9% of adults lost third molars and half of these subjects lost other teeth as well. 27 In our study, this bias is expected to be even lower due to the older age of the subjects. The bias from excluding the canines from ABL measurements is also negligible since the mean ABL was used as the independent variable. Loss to follow-up in our study was high (65%) due to a long follow-up period and the older age of subjects. The study population was compared to the population lost to follow-up by baseline variables to evaluate whether the observed results were biased. The population lost to follow-up had a significantly lower baseline number of missing teeth (21.44 versus 22.78, P = 0.03) and years of education (12.86 versus 13.49, P = 0.05) compared to the study population. Therefore, the effects of these two variables on incident tooth loss may be underestimated in our study. However, there were no significant differences in periodontal variables between the two populations. Therefore, effects of periodontal variables on incident tooth loss were not biased. In previous literature, loss to follow-up for 9- to 15-year 1127

6 Periodontal Disease and Tooth Loss in Postmenopausal Women Volume 76 Number 7 cohort studies ranged between 42% and 86% Therefore, the follow-up rate of our study was within the range of previous studies with similar follow-up periods. The long follow-up period, reliable and highly sensitive methodology to measure periodontal status by trained and calibrated examiners, and a well-defined baseline population are advantages of this study and allowed us to test the study hypotheses reliably. We can conclude that periodontal status at baseline, especially measured by alveolar bone loss, is a strong independent predictor for incident tooth loss in postmenopausal women. Control of periodontal disease can significantly reduce tooth loss in postmenopausal women. ACKNOWLEDGMENTS This study was supported by USPHS grant DE04898, DSA grant DE00158, NIDCR grants 1R01-DE13505 and T32-DE07034, and Army grant DAMD REFERENCES 1. Miller Y, Locker D. Correlates of tooth loss in a Canadian adult population. J Can Dent Assoc 1994;60: Paganini-Hill A. The benefits of estrogen replacement therapy on oral health. The Leisure World cohort. Arch Internal Med 1995;155: Marcus SE, Drury TF, Brown LJ, Zion GR. Tooth retention and tooth loss in the permanent dentition of adults: United States, J Dent Res 1996;75: Grodstein F, Colditz GA, Stampfer MJ. Tooth loss and hormone use in postmenopausal women. Compend Contin Educ Dent 1998;(Suppl. 22):S9-S Krall EA, Dawson-Hughes B, Papas A, Garcia R. Tooth loss and skeletal bone density in healthy postmenopausal women. Osteoporos Int 1994;4: Krall EA, Garcia RI, Dawson-Hughes B. Increased risk of tooth loss is related to bone loss at the whole body, hip and spine. Calcif Tissue Int 1996;59: Reinhardt RA, Payne JB, Maze CA, Patil KD, Gallagher SJ, Mattson JS. Influence of estrogen and osteopenia/osteoporosis on clinical periodontitis in postmenopausal women. J Periodontol 1999;70: Mealey BL, Moritz AJ. Hormonal influences: Effects of diabetes mellitus and endogenous female sex steroid hormones on the periodontium. Periodontology ;32: Sooriyamoorthy M, Gower DB. Hormonal influences on gingival tissue: Relationship to periodontal disease. J Clin Periodontol 1989;16: Grossi SG. Effect of estrogen supplementation on periodontal disease. Compend Contin Educ Dent 1998;(Suppl. 22):S30-S Genco RJ, Grossi SG. Is estrogen deficiency a risk factor for periodontal disease? Compend Contin Educ Dent 1998;(Suppl. 22):S23-S Tezal M, Wactawski-Wende J, Grossi SG, Ho AW, Dunford R, Genco RJ. The relationship between bone mineral density and periodontitis in postmenopausal women. J Periodontol 2000;71: Kribbs PJ. Comparison of mandibular bone in normal and osteoporotic women. J Prosthet Dent 1990;63: Payne JB, Zachs NR, Reinhardt RA, Nummikoski PV, Patil K. The association between estrogen status and alveolar bone density changes in postmenopausal women with a history of periodontitis. J Periodontol 1997;68: Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994;65: Grossi SG, Genco RJ, Machtei EE, et al. Assessment of risk for periodontal disease. II. Risk indicators for alveolar bone loss. J Periodontol 1995:66; Diagnostic criteria for dental examinations. In: Oral Health of United States Adults. Epidemiology and Oral Disease Prevention Program. Bethesda, MD: National Institute of Dental Research; 1987: NIH publication no Gibbs CH, Hirschfelt JW, Lee JG, et al. Description and clinical evaluation of a new computerized probe the Florida probe. J Clin Periodontol 1988;15: Hausmann E, Allen K, Dunford R, Christersson L. A reliable computerized method to determine the level of the radiographic alveolar crest. J Periodontal Res 1989;24: Hausmann E, Allen K, Carpio L, Christersson LA, Clerehugh V. Computerized methodology for detection of alveolar crestal bone loss from serial intraoral radiographs. J Periodontol 1992;63: Machtei EE, Christersson LA, Grossi SG, Dunford R, Zambon JJ, Genco RJ. Clinical criteria for the definition of established periodontitis. J Periodontol 1992;63: McGuire M, Nunn M. Prognosis versus actual outcome. III. The effectiveness of clinical parameters in accurately predicting tooth survival. J Periodontol 1996;67: Krall E, Garvey A, Garcia R. Alveolar bone loss and tooth loss in male cigar and pipe smokers. J Am Dent Assoc 1999;130: Machtei EE, Hausmann E, Dunford R, et al. Longitudinal study of predictive factors for periodontal disease and tooth loss. J Clin Periodontol 1999;26: Jansson L, Lavstedt S, Zimmerman M. Prediction of marginal bone loss and tooth loss a prospective study over 20 years. J Clin Periodontol 2002;29: Jansson L, Lavstedt S. Influence of smoking on marginal bone loss and tooth loss a prospective study over 20 years. J Clin Periodontol 2002;29: Locker D, Ford J, Leake JL. Incidence of and risk factors for tooth loss in a population of older Canadians. J Dent Res 1996;75: Nordstrom G, Bergman B, Borg K, Nilsson H, Tillberg A, Wenslov J. A 9-year longitudinal study of reported oral problems and dental and periodontal status in 70- and 79-year-old city cohorts in northern Sweden. Acta Odontol Scand 1998;56: Eklund SA, Burt BA. Risk factors for tooth loss in the United States. Longitudinal analysis of national data. J Public Health Dent 1994;54: Holm G. Smoking as an additional risk for tooth loss. J Periodontol 1994;65: Warren JJ, Watkins CA, Cowen HJ, Hand JS, Levy SM, Kuthy RA. Tooth loss in the very old: year incidence among elderly Iowans. Community Dent Oral Epidemiol 2002;30: Correspondence: Dr. Mine Tezal, 4433 Chestnut Ridge Rd., Amherst, NY mtezal@buffalo.edu. Accepted for publication November 23,

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