To our knowledge, this is the first large-scale population-based cohort study investigating the association between periodontal disease and osteoporosis by gender. In this study, a significant association was observed between periodontitis and osteoporosis specifically in women. Different definitions of periodontal diseases might be attributed to the inconsistencies of results obtained in the previous studies.33,34 Three categories of periodontal treatments have been prescribed by the Bureau of National Health Insurance, Taiwan (Table 1). The first is subgingival curettage (root planning) that is performed based on the codes 91006C (full mouth), 91007C (1/2 arch), and 91008C (localized 3 teeth and less). The second is periodontal flap operation: codes 91009B (localized, <3 teeth with PD >5 mm) and 91010B (1/3 arch, 4–6 teeth with PD ≥5 mm). The third is gingivectomy or gingivoplasty—91011C (localized, <3 teeth affected) and 91012C (1/3 arch). However, gingivectomy with restorative or aesthetic indications was excluded. Individuals receiving the first or third treatments ought to have at least 1 of 6 probing sites of 1 tooth with PD >5 mm. The Taiwanese NHI system allows beneficiaries to receive tooth scaling twice a year. The ICD codes recorded in Taiwan's NHI program may not truly indicate the presence of severe periodontitis and because of that, periodontal treatment codes (3 categories used in Taiwan) were considered more reliable than the ICD-9 code.35 The periodontal status among individuals registered in NHIRD might be different from those diagnosed through general clinical examination.
PD is one of the major clinical indices of periodontitis as defined by the NHI Professional Peer Review Committee (Table 1). Dentists are required to assess PD at 6 sites per tooth (distobuccal, distolingual, mesiobuccal, mesiolingual, midbuccal, and midlingual), with at least 1 site having a PD of ≥5 mm for all the periodontal treatments listed in Table 1. Radiographs were taken to assist in diagnosis and treatment. The British Society of Periodontology suggests periodontal disease where a basic periodontal examination score of ≥5.5 mm is found.29 This is similar to that defined by the NHI program as mentioned earlier and which has been used in this study. Some studies defined periodontitis as having >2 interproximal sites and with PD ≥5 mm, radiographic bone loss, and clinical attachment loss (CAL) >6 mm.6 Several studies have used PD as one of the variables to evaluate the severity of periodontal disease and have also reported positive association between PD and osteoporosis.10,21,24 Recently, a report by the OSTEODENT (Diagnostic validity of dental radiography techniques for identifying osteoporotic patients) multicenter research project found greater CAL in osteoporotic than normal women. However, there was no difference in PD between these 2 groups.21 PDs of 2.15 to 2.43 mm have been used to define periodontitis in Hellenic women. The pockets used in this study were of ≥5 mm as shown in all the periodontal treatments (Table 1).
A hospital-based cross-sectional study that enrolled 34 postmenopausal Taiwanese women aged 50 to 59 years reported a significant relationship between PD and osteoporosis at interproximal instead of the faciolingual sites.16 A significant association also existed between the mandibles, but not the maxilla at both the interproximal and faciolingual sites. The statistical power might have reduced when the PD values recorded at the 6 sites of each tooth were considered.28,29,36 PD might be one of the valuable parameters to assess the relationship between periodontal disease and osteoporosis. Selection of sites might be another vital issue that requires further investigation. This study has shown an association between periodontal disease and osteoporosis although the prevalence of osteoporosis had been underestimated in NHIRD.37 However, the OR of osteoporosis in periodontal and nonperiodontal individuals may have been influenced by nondifferential misclassifications, hence, producing a bias toward the null. Unlike other studies, this study made use of large sample size. The mean PD of osteoporotic individuals (2.43 mm) have been reported to be higher than that of normal bone mineral density (2.15 mm) in Hellenic women.21 The trend of PD was similar to that of CAL, but the results were insignificant as a result of small sample size. Similar results were obtained by a well-defined age cohort in Linköping community in Sweden, but such results ought to be interpreted with caution.28
The most important limitation of this study is that the information retrieved from the database did not contain health-related behaviors or status such as smoking, tooth brushing, alcohol consumption, dietary calcium, and number of teeth or tooth loss as well as social and ecologic parameters. Nevertheless, possible effects due to confounding bias from above factors were probably minimized by adjusting for age, gender, insurance cost, and geographical region.
The association between periodontitis and osteoporosis was significant in Taiwanese women.
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