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J Am Dent Assoc, Vol 137, No 2, 224-234.
© 2006 American Dental Association
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TRENDS

JADA Continuing Education

The relationship between cigarette smoking and perceived dental treatment needs in the United States, 1988–1994



Bruce A. Dye, DDS, MPH, Nathalie M. Morin, DDS, MPH and Valerie Robison, DDS, MPH, PhD


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Although factors affecting perceived dental treatment needs have been investigated, the effect of smoking status on perceptions of dental needs has not been examined.

Methods. The authors examined data on 13,227 dentate people aged 20 to 79 years from the Third National Health and Nutrition Examination Survey (NHANES III). Information was collected information on sociodemographic characteristics, cigarette smoking, perceived dental treatment needs and other factors during a home interview, and clinical oral health information was collected at a mobile examination center.

Results. In univariate analyses, current smokers were more likely than nonsmokers to perceive dental needs in all categories, except for the need for a dental cleaning. Multivariate regression results indicate that current smokers were more likely to report a need for periodontal treatment and dental extractions compared with nonsmokers (odds ratio [OR] = 1.40; 95 percent confidence interval [CI] = 1.05–1.87 and OR = 1.61; 95 percent CI = 1.22–2.14, respectively). The authors found an interaction between smoking and race/ethnicity in models describing the need for teeth to be filled/replaced and for orthodontic/cosmetic work.

Conclusions. Current smokers were more likely to have more perceived dental needs compared with nonsmokers.

Practice Implications. These results may be important for the advancement of efforts directed toward tobacco-use cessation programs and to understand factors that could affect dental care utilization.

Key Words: Perceived dental treatment needs; tobacco use; NHANES III

Although the prevalence of cigarette smoking in the United States has declined by nearly one-half since 1965,1 the public health burden of smoking remains extensive. Smoking causes serious illness among 8.6 million Americans and approximately 440,000 deaths each year.2 Moreover, nearly 5 percent of infant deaths in the United States may be attributable to maternal smoking.3

General health risk factors such as tobacco use can affect oral health. Smoking is a known risk factor for oral disease, such as oral cancer and periodontal disease.4–11 Maternal smoking may be associated with oral clefts,12 and Aligne and colleagues13 have suggested that passive smoking is associated with pediatric dental caries. Although tobacco use can significantly affect oral health status, little is known regarding the influence of smoking on the self-assessed need to seek dental care.

Among many factors that affect the use of dental services, perceived dental need is an important factor.14,15 Perceived dental treatment needs often differ from dentists’ treatment recommendations.16,17 In addition, perceived needs, when influenced by symptomatic experiences, have a greater effect on predicting dental care utilization.18–20 Gift and colleagues21 reported that perceived treatment needs were associated significantly with a lower self-rating of overall dental health, whereas perceived needs for preventive dental care were not. People with lower self-rated dental health status are less likely to seek any type of dental care,20 and episodic, problem-driven dental care users are more likely to use tobacco and to rate themselves at a lower health status.22

Although factors affecting a perceived need for dental care have been evaluated in a variety of populations, the relationship between smoking status and perceived dental treatment needs has not been analyzed sufficiently. For instance, it is known that smokers are more likely to report oral health problems such as bleeding or receding gingivae, staining and mouth sores,23 but it is not well-understood whether smokers are more likely to report other dentally related problems or needs compared with nonsmokers.

Our objective was to assess the role of smoking status along with sociodemographic, clinical and other behavioral factors in the prediction of perceived dental treatment needs in a cross-sectional study of adults in the United States.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We obtained data from 13,227 adults who participated in the Third National Health and Nutritional Examination Survey (NHANES III), 1988–1994.24 This survey was conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC), and it applied a complex, stratified, multistage probability design to produce a nationally representative sample for the noninstitutionalized civilian population of the United States. Mexican-Americans, non-Hispanic blacks and people who were younger than 6 years or older than 60 years were oversampled in NHANES III. Details of the sample design and informed consent methods have been described elsewhere.25,26

Our analyses used data obtained from the household interview questionnaire and a standardized oral health examination. Trained interviewers administered the interview questionnaire orally in the sampled participants’ homes, and trained dentists conducted the dental examinations in a mobile examination center (MEC). Detailed descriptions about NHANES III oral health component procedures, quality control and measurement issues are described elsewhere.25,27,28

We identified 20,050 adults who completed a home interview and excluded 3,057 people who were younger than 20 years or older than 79 years. From this group, we excluded 1,662 people who did not complete an MEC examination (which included physical examinations, dental examinations and other measures) and 402 people who did not complete the dental examination component of the MEC examination. We then excluded 1,426 people who were identified as edentulous and 276 people for whom complete perceived dental treatment needs information was not available. This yielded an analytical sample of 13,227 dentate adults aged 20 to 79 years.

Outcome variables. We used six variables describing perceived dental treatment needs. Each of these variables was derived from six possible responses to the question, "What type of dental care do you need now?" We used information regarding perceived treatment needs to create the following outcome variables:

– need for teeth to be filled or replaced (HAQ2A);
– need for extractions (HAQ2B);
– need for periodontal treatment (HAQ2C);
– need for relief from pain (HAQ2E);
– need for orthodontic or cosmetic work (HAQ2F);
– need for a dental cleaning (HAQ2K).

We derived the outcome variable "need for orthodontic or cosmetic work" from the response need "work to improve appearance"24 (BoxGo). Because the question about perceived dental needs was structured to capture possible multiple answers, participants were able to report several needs. We coded all responses of "don’t know" as missing information.


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  		BOX Perceived treatment needs question and valid answers in NHANES III,* 1988–1994.

 
Covariate selection. We included sociodemographic indicators that have been reported to be associated with oral health or perceived treatment needs.21

– We categorized race/ethnicity as non-Hispanic black, non-Hispanic white, Mexican-American and other. People who were identified as "other" were included only in the total population estimates.
– We grouped subjects into six age groups of 10-year intervals for the purpose of calculating prevalence estimates. For some of the analyses, we dichotomized age as 20 to 49 years or 50 to 79 years.
– We dichotomized poverty as at or below 100 percent of the federal poverty guideline (FPG) or above 100 percent of the FPG. We calculated the FPG by dividing total family income by the adjusted federal poverty income threshold.
– We included sex in the analyses.
– We described educational attainment as not having completed high school, having completed high school or having at least some college education.
– We categorized cigarette smoking status as being a current smoker, being a former smoker or never having smoked. People who reported that they had smoked at least 100 cigarettes (approximately five packs) in their lifetime but no longer smoked were classified as former smokers.
– We categorized dental history as having had no dental visit in the previous 12 months or having had a dental visit in the previous 12 months.
– Regarding dental insurance, another measure of potential dental care utilization, we categorized subjects as having any form of insurance that provides some dental benefits versus not having insurance.
– We based an assessment of poor oral health status on clinical examination data and defined it as the presence of periodontal disease or having at least two surfaces of untreated caries.
– Using previously reported criteria, we defined the presence of periodontal disease for this analysis as any periodontal site with attachment loss of 3 millimeters or more and pocket depth of 4 mm or more.29

Data analysis. We performed all statistical analyses using statistical software (SUDAAN version 7.5, Research Triangle Institute, Research Triangle Park, N.C.).30 We used sample weights to account for the unequal probability of selection and nonresponse of the study participants to produce prevalence estimates and related standard errors, as well as in the calculation of odds ratios (ORs) and 95 percent confidence intervals (CIs). In univariate analyses, we used paired t tests to assess potential differences for the outcome variable (that is, perceived dental treatment needs) within categories. We set statistical significance at P < .05.

Using logistic regression models, we calculated crude and adjusted ORs with 95 percent CIs. We used each of the six dependent variables in separate modeling processes. All independent variables were modeled as categorical variables, as previously described. We used multivariate nonautomated step-wise regression modeling to assess relationships between the covariates. We set an a priori standard for retaining variables to produce the most parsimonious model using a Satterthwaite-adjusted F statistic of P < .05. We assessed potential interactions throughout the modeling process and determined significance when the overall product term had a P < .05.


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Smoking status. Table 1Go shows selected sociodemographic and oral health–related characteristics according to cigarette smoking status. Fewer than one-half of the adults aged 20 to 79 years in the United States were nonsmokers (47.2 percent), 24.5 percent were former smokers and 28.3 percent were current smokers. More than 60 percent of current smokers were younger than 40 years, 53.3 percent were men, about 61 percent had had a dental visit in the previous 12 months and nearly 45 percent had poor oral health. Less than 60 percent of the nonsmokers were younger than 40 years, 39.3 percent were men, 72.1 percent had had a dental visit in the previous 12 months and 23.3 percent had poor oral health. Estimates for dental visits and oral health status for former smokers are similar in magnitude to those for nonsmokers. The percentage of Americans with dental insurance was similar across the three smoking status groups (ranging from approximately 46 to 49 percent).


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  		TABLE 1 Demographic characteristics of dentate adults aged 20 to 79 years, according to smoking status, United States, 1988–1994.*

 
Perceived dental needs. Table 2Go presents the weighted distributions for the six areas of perceived dental needs. Thirty-two percent of subjects reported that they perceived a need to have teeth filled or replaced, 10.1 percent perceived a need for dental extractions, 6.1 percent perceived a need for periodontal treatment or orthodontic/cosmetic work, 22.5 percent perceived a need for a dental cleaning and 1.7 percent reported a need for pain relief. Current smokers were more than twice as likely as former smokers or nonsmokers to perceive a need for dental extractions (17.3 percent versus 7.0 percent and 7.3 percent, respectively). Current and former cigarette smokers were no more likely than non-smokers to perceive a need for a dental cleaning.


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  		TABLE 2 Dentate adults aged 20 to 79 years who reported perceived dental treatment needs, by selected characteristics, United States, 1988–1994.*

 
People with poor oral health status were more likely to perceive a need for all of the types of dental treatments examined (except for a dental cleaning) compared with those without poor oral health. Almost one-fourth of all Americans with poor oral health perceived a need for dental extractions (23.2 percent). Compared with people who had had a dental visit in the previous 12 months, those without a dental visit were more likely to perceive a need for dental care across most of the categories of perceived treatment needs. The study results showed that differences between men and women regarding perceived dental treatment needs were minimal.

Table 3Go (page 230) shows logistic regression results for each perceived dental need. Being a current cigarette smoker was independently associated with the perceived need for dental extractions (OR = 1.61; 95 percent CI = 1.22 to 2.14) and periodontal treatment (OR = 1.40; 95 percent CI = 1.05 to 1.87), but it was not associated with the perceived need for a dental cleaning or relief from dental pain. However, smoking status did produce a significant interaction with race/ethnicity for the perceived needs of having teeth filled or replaced and orthodontic/cosmetic work.


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  		TABLE 3 Perceived dental treatment needs models for adults aged 20 to 79 years, United States, 1988–1994.*{dagger}

 
In addition to being a current smoker, having poor oral health, being a non-Hispanic black, living below the FPG, not having had a dental visit in the previous 12 months, and not having dental insurance were independently associated with subjects’ perceived need for dental extractions. Factors other than smoking that significantly predicted the perceived need for periodontal treatment included age 20 to 49 years (OR = 1.33; 95 percent CI = 1.04 to 1.70), Mexican-American ethnicity (OR = 1.45; 95 percent CI = 1.09 to 1.93) and having poor oral health status (OR = 2.00; 95 percent CI = 1.59 to 2.51). Having poor oral health status, being aged 20 to 49 years and not having had a dental visit in the previous 12 months were associated with the perceived need for having teeth filled or replaced regardless of racial/ethnic status.

Because we found significant interactions, additional analyses were required to better understand how the interactions affected some of the perceived treatment needs. Table 4Go (page 231) shows the results of these perceived treatment needs outcomes stratified by race/ethnicity. Being a current smoker was predictive in some models that described the perceived need for teeth to be filled or replaced and for orthodontic/cosmetic work. Non-Hispanic white current smokers were more likely to perceive a need to have teeth filled or replaced (OR = 1.49, 95 percent CI = 1.22 to 1.81) and for orthodontic/cosmetic work (OR = 1.86, 95 percent CI = 1.37 to 2.52) compared with non-Hispanic white nonsmokers. Furthermore, Mexican-American smokers were more likely to report a perceived need for orthodontic/cosmetic work compared with Mexican-American nonsmokers (OR = 1.43; 95 percent CI = 1.09 to 1.87).


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  		TABLE 4 Perceived dental treatment needs stratified by racial/ethnic status for selected covariates.*{dagger}

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
The results of this study suggest that current cigarette smokers are more likely to have greater perceived dental needs compared with non-smokers, and that these perceived needs tend to cluster around treatments related to a history of dental disease, such as needing teeth filled or replaced, extractions and periodontal work. These findings also are important because they highlight some differences in perceptions of oral health according to race/ethnicity and smoking status in the United States, particularly in the perceived need for orthodontic/cosmetic work and having teeth filled or replaced.

Patton and colleagues31 recently reported the results of a study of racial/ethnic variance in perceived dental treatment needs among patients with HIV/AIDS. Their study examined the perceived need for dental restorations and extractions, but not for periodontal treatment. Our findings suggest that smoking status does influence the perceived need for dental restorations, but only among non-Hispanic whites. However, non-Hispanic blacks were more likely than non-Hispanic whites to report a perceived need for dental extractions, regardless of smoking status. Our findings also indicate that being Mexican-American was independently associated with the perceived need for periodontal treatment, but the strength of the association was weak, indicating that being non-Hispanic black was independently associated with the perceived need for receiving periodontal treatment.

Interactions involving race/ethnicity. The presence of interactions involving race/ethnicity in the regression models describing three perceived dental needs (teeth filled/replaced, dental cleaning and orthodontic/cosmetic work) is an important finding. When we exclude the need for a dental cleaning, the influence of smoking on the remaining two perceived dental needs varied across racial/ethnic groups but only among current cigarette smokers. For instance, among non-Hispanic whites, current smokers were more likely than those who never smoked to perceive a need to have teeth filled or replaced or for orthodontic/cosmetic work. However, this smoking relationship existed among Mexican-Americans only with regard to the perceived need for orthodontic/cosmetic work, and it did not exist among non-Hispanic blacks with regard to the perceived need to have teeth filled or replaced or for orthodontic/cosmetic work.

These findings suggest that smoking and cultural influences may significantly affect the decision-making processes involved in rationalizing the need for care, thus affecting dental care utilization. Variations in cigarette smoking within racial/ethnic populations in the United States may be influenced by varying levels of acculturation and exposure to media messages.32 Our findings may be the result of a complex commingling of many factors such as affordability of cigarettes and susceptibility to advertising, as well as lifestyle and community values.

Since the landmark surgeon general’s report on smoking and health in 196433 and the more recent surgeon general’s report on the health consequences of smoking,6 an abundance of additional information has emerged that demonstrates a relationship between smoking and poor oral health status. However, information regarding the effects of smoking on self-assessed oral health status and dental needs is scarce.

Our findings suggest that cigarette smoking is associated with some perceptions of dental needs that are independent of poor oral health status, particularly the need for periodontal treatment and extractions, as well as the need to have teeth filled or replaced. Poor dental and general health behaviors are predisposing factors for poor oral health and overall health.34 Because a strong correlation exists between the perceived need for dental care and perceptions of general health status21 and because people do perceive that oral health affects their overall quality of life,35 addressing unmet perceived dental needs could affect patients’ quality of life.

Improving periodontal health. Improving periodontal health could have a significant impact on improving the quality of life for many Americans. For instance, the most recent surgeon general’s report on smoking states that sufficient evidence exists to infer a causal relationship between smoking and periodontitis.6 Furthermore, current cigarette smokers are about four times as likely to have periodontitis compared with nonsmokers, and approximately 42 percent of cases of periodontitis in the United States most likely are attributed to current smoking.10

Our findings suggest that smokers were only slightly more likely to perceive a need for periodontal treatment (OR = 1.40, 95 percent CI = 1.05 to 1.87) compared with nonsmokers, independent of clinical oral health status. In addition, the findings show no relationship between smoking and a perceived need for a dental cleaning. This suggests that a renewed public health effort directed toward periodontal disease awareness and tobacco use is needed.

Tobacco use, alcohol use or both remain the major risk factors for oral cancer, particularly among people 45 years and older who have been diagnosed with oral squamous cell carcinoma.36,37 Not only is cancer of the oral cavity one of the 10 leading cancers in men, a significant disparity in five-year survival rates exists between racial/ethnic groups (60 percent for non-Hispanic whites and 36 percent for blacks).38 In addition, smokers are less likely than nonsmokers to visit a dentist, and this may decrease their opportunities for being diagnosed at an earlier disease stage.39,40

In a study that used a portion of NHANES III data, Gift and colleagues21 reported that a strong relationship existed between the frequency of dental visits and perceived dental treatment needs. However, our findings indicate that this relationship is not consistent across the varying types of perceived dental treatment needs examined. For instance, not having had a dental visit in the previous 12 months was associated with the perceived need for a dental cleaning only among non-Hispanic whites. People acting on the perception of a need for a cleaning may be more likely to receive an oral cancer screening as part of a dental checkup or preventive appointment than those seeking treatment for a more specific issue such as pain relief or the need for a dental filling or an extraction. This may help us better understand why racial/ethnic disparities in the prevalence of oral cancer exist and the importance of developing effective public health interventions that lead to increased utilization of dental care and, possibly, earlier detection of cancerous lesions.

Tobacco-use cessation activities. The CDC has highlighted tobacco control activities as a critical element in the effort to reduce oral and pharyngeal cancers.41 The American Dental Association has promoted smoking prevention activities in the dental office,42 and dental professionals have been encouraged to promote tobacco-use cessation and to treat tobacco dependence.43,44 Moreover, many dental patients have expressed their belief in surveys that dentists should actively encourage smoking cessation.45

Nevertheless, many dental providers continue to perceive barriers to implementing smoking-cessation activities, such as a lack of time and reimbursement mechanisms, low confidence in the chance of achieving success, as well as expected patient resistance.46 Overcoming these barriers and identifying best practices are important for increasing the numbers of smokers who quit. Given that an effective smoking-cessation program in dental practices could realize a quit rate of at least 2 percent,47 it is conceivable that tens of thousands of people in the United States could stop smoking each year if all dentists were to actively encourage smoking cessation.

Targeting messages to smokers. Understanding the relationship between perceived dental needs and smoking could improve opportunities to design and deliver tobacco-use cessation messages that are more meaningful to targeted people. Most smoking-cessation activities are offered during the dental hygiene appointment, which is used less by problem-oriented dental care users. Because problem-driven dental care users are more likely to smoke22 and smokers are more likely to have a perceived need for dental extractions, developing a smoking-cessation message that can be integrated into the dental visit in which an extraction is performed may resonate better with smokers.

If the goal of any smoking intervention program is to reach more smokers, tobacco-use cessation activities should be part of other treatment-oriented appointments as well. Our findings also suggest that some smokers are more likely to perceive a need for orthodontic/cosmetic dental work compared with nonsmokers. Tobacco-use cessation messages targeted toward non-Hispanic white and Mexican-American smokers and delivered by orthodontists or dental providers specializing in cosmetic dentistry may offer another key opportunity to deliver a targeted smoking-cessation message in dental practice.

Study limitations and strengths. This study investigated smoking status as a predictor of various perceived dental needs. One limitation of our study was its inability to assess the direct impact that smoking cessation may have on perceived dental needs independent of other covariates measured (such as receiving routine dental care). Moreover, a cross-sectional study design does not permit a definitive evaluation of causality or temporal relationships. One strength of our study was the use of a nationally representative sample not selected by potentially confounding factors. Another was not aggregating a variety of perceived needs into one general category, such as clinical needs (for example, a composite variable consisting of the need to have teeth filled/replaced or extracted, as well as the need for periodontal treatment).


   CONCLUSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
This, to our knowledge, is the first study to evaluate the relationship between smoking status and perceived dental treatment needs after controlling for oral health status. Our findings show that current cigarette smokers in the United States are more likely to have more perceived dental needs compared with nonsmokers; moreover, race/ethnicity may act as an effect modifier (that is, a factor that modifies the effect of a reputed causal determinant) in this relationship for the specific perceived needs of having teeth filled/replaced and orthodontic/cosmetic work.

These findings are important for dental health professionals, researchers and public health policy-makers. Recognizing influential predictors of perceived dental needs may improve our understanding of factors that motivate people to seek dental care and can assist in planning tobacco-use cessation programs for communities and individual patients. These findings add to our expanding knowledge linking smoking with lower oral health awareness and perceived dental problems. By helping patients understand the association between smoking and perceived dental needs, dentists and hygienists can provide additional encouragement to refrain from using tobacco products.


   FOOTNOTES
 

Dr. Dye is dental epidemiology officer, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Md., and a member of the dean’s faculty, University of Maryland School of Dentistry, Baltimore. Address reprint requests to Dr. Dye, CDC/NCHS/NHANES Program, 3311 Toledo Road, Room 4416, Hyattsville, Md. 20782, e-mail "bfd1{at}cdc.gov".


At the time this study was conducted, Dr. Morin was a resident in dental public health, National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, Md. She now is director of dental policy and programs, Canadian Forces Dental Services, Ottawa, Ontario.


At the time this study was conducted, Dr. Robison was epidemiologist, Division of Oral Health, Centers for Disease Control and Prevention, Atlanta. She currently is epidemiologist and chief, Surveillance Team for the Surveillance Epidemiology and Outbreak Investigations Branch, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention.


The authors thank Elvine Y. Jin, DDS, Toronto, Bruce A. Anderson, DDS, MAGD, Sault Ste. Marie, Mich., Felix Marcial, DDS, MSD, Seattle, and Timothy L. Ricks, DMD, MPH, Nixon, Nev., for reviewing the manuscript and providing comments.


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 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
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Tobacco still is oral health enemy number one
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