Elsevier

Atherosclerosis

Volume 203, Issue 2, April 2009, Pages 550-556
Atherosclerosis

Tooth loss, hypertension and risk for stroke in a Korean population

https://doi.org/10.1016/j.atherosclerosis.2008.07.017Get rights and content

Abstract

Tooth loss has been suggested as a potential risk factor for stroke. We conducted a prospective cohort study of stroke in Korea on hypertension, diabetes, smoking, and tooth loss to characterize their independent effects and interactions.

The overall risk of stroke and the risk of different subtypes of stroke were evaluated in relation to tooth loss using Cox proportional hazards models among 867,256 Korean men and women, aged 30–95 years, who received health insurance from the National Health Insurance Corporation and were medically evaluated between 1992 and 1995, with tooth loss measured.

The overall prevalence of having at least one tooth removed among the people in the study was 29.8% (31.9% for men and 22.3% for women). During a 14-year follow-up, 28,258 strokes with 5105 fatal strokes occurred. For men and women, tooth loss was associated with total stroke and stroke subtypes. In a multivariable model adjusting for selected covariates, a graded association between higher tooth loss and higher risk of total stroke was observed in men [≥7 lost teeth versus 0 (hazard ratio (HR) = 1.3; 95% confidence interval (CI), 1.2–1.4)] and in women (HR = 1.2; 95% CI, 1.0–1.3). The HRs for ischemic and hemorrhagic stroke were also similar in men and women. There was evidence of interaction of hemorrhagic stroke risk with hypertension and tooth loss.

Tooth loss is independently associated with increased risk of stroke and hypertension does interact antagonistically, particularly for hemorrhagic stroke.

Introduction

Stroke is one of the most common causes of death worldwide, particularly in Asia where established risk factors, including older age, hypertension, diabetes, obesity, cigarette smoking, and heavy alcohol consumption [1], [2], are common. Recent reviews have suggested that infections may be risk factors for stroke [3], [4]. Two case–control studies [5], [6] and four longitudinal studies [7], [8], [9], [10] have evaluated the association between oral conditions and stroke, and four of the six have found significant associations.

Although many epidemiological studies have addressed these and other stroke risk factors, there has been limited exploration of the combined effects of these exposures, reflecting the limitations posed by the study sizes and exposure data available in the studies carried out to date. Synergism among such common factors as tooth loss, hypertension, diabetes, and cigarette smoking would have substantial public health and clinical relevance because it would place some individuals at extremely high risk.

The authors are conducting a prospective cohort study of the causes of cancer and atherosclerotic cardiovascular diseases in a cohort of 1.3 million Koreans, also known as the Korean Cancer Prevention Study (KCPS). The participants were initially identified by their participation in a routine clinical examination carried out by the National Health Insurance Corporation [11]. Of the 1.3 million patients, over 860,000 participants had a record of tooth loss between 1992 and 1995. In this paper, we address the relationship between the number of teeth lost and risk for stroke in this subgroup of the KCPS.

Section snippets

Study population

The KCPS is a cohort study designed to assess risk factors for mortality and morbidity from all causes, atherosclerotic and cardiovascular diseases (ASCVD), and cancer as well as medical morbidity. This analysis is based on a subset of KCPS participants with recorded tooth loss. The development of this cohort from participants in the Korea Medical Insurance Corporation has been described elsewhere [11], [12]. In brief, the cohort was selected from government employees, teachers, and dependents

Results

The cohort included 867,256 participants aged 30 and over at study entry who were followed up for a total of 11,078,892 person-years with a median follow-up of 13.9 years. The population was mostly middle-aged, with approximately four times as many men as women. The mean age at baseline was 43.1 years for men and 42.6 years for women (Table 1). Males were much more likely to be current smokers (59.6%) than women (2.2%) and were also more likely to drink alcohol (78.5% compared to 15.0%).

Tooth

Discussion

In this large prospective cohort study of Korean men and women, we documented that hypertension, diabetes, cigarette smoking, and tooth loss are independent risk factors for stroke in men and women. There was evidence for interaction among tooth loss and hypertension, particularly for hemorrhagic stroke.

Recent studies have suggested that several systemic conditions, such as obesity, hypertension, hyperlipidemia, and diabetes, are related to periodontitis [1], [2]. The present results are

Acknowledgments

We thank the staff of the Korean National Health Insurance Corporation, who provided the data for this study.

Sources of funding: This study was funded by the Seoul City R&BD program (10526).

References (23)

  • H.I. Morrison et al.

    Periodontal disease and risk of fatal coronary heart and celebrovascular disease

    J Cardiovasc Risk

    (1999)
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