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RELATIONSHIP BETWEEN TOBACCO USE AND SELF-REPORTED ORAL HYGIENE HABITS
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ARTICLE 1
RELATIONSHIP BETWEEN TOBACCO USE
AND SELF-REPORTED ORAL HYGIENE HABITS JUDY A. ANDREWS, PH.D.; HERBERT H. SEVERSON, PH.D.; EDWARD LICHTENSTEIN, PH.D.; JUDITH S. GORDON, PH.D.
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A sample of 34,897 dental patients completed written surveys assessing their tobacco use, frequency of brushing and flossing and perception of oral health problems. Brushing two times per day was reported by 73.5 percent of the patients and flossing one time per day by 35.6 percent. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Compliance with daily flossing regimens was particularly low among smokeless tobacco users. Tobacco users also reported more oral health problems.
Recent investigations involving adults of all ages have identified
tobacco use as a major risk factor for poor oral health.1,2 Smokers have a greater mean probing depth3 and a greater loss of periodontal bone height as measured by the difference between the cementoenamel junction and the interdental septum4 than do nonsmokers. A patient’s use of smokeless tobacco (moist snuff and chewing tobacco) has been consistently related to high rates of leukoplakic lesions in the habitual site of tobacco placement.5 The results of a study of managed care dental patients showed that 73 percent of daily smokeless tobacco users had noncancerous and precancerous lesions and that the grade of lesion was related to frequency and years of tobacco use.6 As smokeless tobacco contains high levels of known carcinogens, there is strong evidence that regular smokeless tobacco use can cause cancer in the mouth, especially where the tobacco is routinely placed.7 Cigarette smoking has been associated with an impaired response to periodontal treatment8,9 and an increased incidence of dental implant failure.10 Recognizing the detrimental effects of tobacco use on oral health, organized dentistry has encouraged oral health professionals to assess and discourage patient tobacco use.11,12 The American Dental Association has recommended brushing at least two times per day13 and flossing at least one time per day.14 Adherence to this oral hygiene regimen is particularly important for tobacco users because of their high risk for poor oral health. Although several studies have reported on the dental health care of specific populations,15,16 few studies have examined compliance with oral hygiene regimens among cigarette smokers. The results of studies comparing smokers and nonsmokers are inconsistent. For example, while Bergstrom17 found no differences in compliance with an oral hygiene program between smoking and nonsmoking dental patients, Mendoza, Newcomb and Nixon18 reported that smokers were less compliant patients than nonusers. This inconsistency points to a need for further research examining the relationship between smoking and oral hygiene. To our knowledge, no studies have been conducted that examine the oral hygiene regimens of patients who use smokeless tobacco. As part of a larger project to evaluate the effectiveness of dental professionals providing advice to patients to quit smoking and
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
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RESEARCH TABLE 1
DEMOGRAPHIC VARIABLES OF SAMPLE, BY TOBACCO USE STATUS. NONUSERS
CIGARETTE SMOKERS
SMOKELESS TOBACCO USERS
30,136
4,029
632
100
Percentage Male
41.4
41.2
98.8
100.0
Mean Age (Years)
45.4
42.4
36.2
33.4
Percentage White
93.9
92.1
94.2
93.9
Percentage Single
28.8
35.5
30.7
38.8
Percentage With More Than a High-School Education
71.7
62.2
61.2
48.0
VARIABLE
n
using smokeless tobacco, we obtained information regarding self-reported tobacco use, oral hygiene and oral health problems from 34,897 dental patients. The primary purpose of this article is to describe the self-reported oral hygiene habits of both male and female cigarette smokers and male smokeless tobacco users and compare these habits with the self-reported habits of dental patients who reported being nonusers. We also examined the relationship between the tobacco use status and self-reported oral health problems of these patients. MATERIALS AND METHODS
Over an 18-month period, frontdesk personnel in 75 participating private dental practices in Oregon asked patients to complete a written survey before their hygiene visit. The survey included questions regarding patients’ brushing and flossing habits, current tobacco use and perceptions of their oral health problems. Patients reported on their brushing and flossing habits using four response categories 314
for each question. For brushing, the possible responses were three times per day or more, two times per day, one time per day and three times per week or less. For flossing, possible
Most patients (70 percent) had more than a high-school education, 94 percent were white, 57 percent were women and 30 percent were single. responses were two times per day or more, one time per day, three times per week and one time per week or less. All responding patients indicated if they had any of the following oral health problems: bleeding gums, receding gums, staining, mouth sores or bad breath. Patients also reported if they currently smoked cigarettes or used smokeless tobacco. Current smokers reported the average number of cigarettes smoked per day over the past seven days, and current smokeless tobacco users reported the
USERS OF BOTH CIGARETTES AND SMOKELESS TOBACCO
number of cans or pouches used per week. RESULTS
Based on information provided by 59 practices, 81 percent of eligible patients completed the survey, 6 percent refused to complete the survey, and 13 percent were mistakenly not given the survey by front-office personnel. The 34,897 patients who completed the survey ranged in age from 15 to 94 years with a mean age of 44.83 years (median = 43; standard deviation = 16.68). Most patients (70 percent) had more than a high-school education, approximately 94 percent were white, 57 percent were women and 30 percent were single (defined as not currently married or living with a partner). Prevalence of tobacco use. Among men in this sample, the prevalence of cigarette use, smokeless tobacco use and a combination of both cigarette and smokeless tobacco use was 11.16 percent, 4.25 percent and 0.67 percent, respectively. The prevalence of cigarette use among women was 11.80 percent. Only one woman used
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH TABLE 2
RELATIONSHIP BETWEEN DEMOGRAPHIC VARIABLES AND FREQUENCY OF SELF-REPORTED BRUSHING AND FLOSSING. VARIABLE (TOTAL SAMPLE)
TOTAL
BRUSHING
Three Times Per Day or More
4,477
n*
Two Times Per Day
21,053
FLOSSING
Three Times Per Week
One Time Per Day
Three Times Per Week or Less
Two Times Per Day or More
One Time Per Day
8,665
502
2,095
10,002
28.9
35.0
38.4
51.2†
One Time Per Week or Less
7,355 14,528
Percentage Male
42.6
26.8
38.3
59.2
77.1†
Mean Age (Years)
44.8
46.4
44.4
45.1
42.1†
55.2
48.8
43.3
40.9
Percentage White
93.7
93.6
93.6
94.0
91.1
91.9
93.6
93.8
94.2†
Percentage Single
29.6
29.7
30.0
28.0
39.1†
29.5
26.5
29.0
32.3†
Percentage With More Than a High-School Education
70.4
72.4
71.9
67.2
46.4†
63.9
73.0
75.5
68.2†
* The sample sizes do not total 34,897 each, because 200 patients did not indicate brushing frequency and 917 patients did not indicate flossing frequency. † P < .001.
smokeless tobacco, and no women used both cigarettes and smokeless tobacco. Tobacco use in our convenience sample of dental patients was approximately onehalf that of recent prevalence estimates of cigarette use (22 percent) from the Oregon Behavioral Risk Factor Study, or BRFS,19 and smokeless tobacco use (9 percent among men; 1 percent among women)20 among representative samples of adults in Oregon. However, dental patients in our sample were better educated than were the dental patients in the BRFS sample, as 35.0 percent were college graduates, compared with 25.6 percent in the BRFS sample (P < .001). Cigarette smokers smoked an average of 15 cigarettes a day. A can of chewing tobacco or snuff lasted
smokeless tobacco users an average of 4.5 days. Demographic characteristics associated with tobacco use. We used orthogonal χ2 analyses to compare demographics across the four tobacco status
Only one woman used smokeless tobacco, and no women used both cigarettes and smokeless tobacco. categories: nonusers, cigarette smokers, smokeless tobacco users and users of both cigarettes and smokeless tobacco. Specifically, we compared nonusers with tobacco users, cigarette smokers with a combination of smokeless tobacco users and users of both
cigarettes and smokeless tobacco, and smokeless tobacco users with users of both cigarettes and smokeless tobacco. As is shown in Table 1, the demographic characteristics of nonusers, cigarette smokers, smokeless tobacco users and users of both cigarettes and smokeless tobacco varied significantly (P < .001) with all variables except for race/ethnicity as a function of tobacco use status. While nonusers and cigarette smokers were more likely to be women, smokeless tobacco users and users of both types of tobacco were almost exclusively men. Tobacco users were more likely to be single than were nonusers. Cigarette smokers and smokeless tobacco users were less educated than were nonusers. Furthermore, male patients who used both cigarettes and smoke-
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
315
RESEARCH TABLE 3
ORAL HYGIENE HABITS OF TOBACCO USERS AND NONUSERS. TOBACCO USE STATUS CATEGORY
PERCENTAGE WHO BRUSH
PERCENTAGE WHO FLOSS
Three Times Per Day or More
Two Times Per Day
One Time Per Day
Three Times Per Week or Less
Two Times Per Day or More
One Time Per Day
Three Times Per Week
One Time Per Week or Less
Nonusers
8.6
56.0
33.1
2.3*
4.4
25.7
20.1
49.8*
Cigarette smokers
5.8
47.2
42.8
4.2
4.0
19.2
17.7
59.1†
Smokeless tobacco users
5.9
47.2
42.5
4.4
0.8
13.5
16.9
68.8
Users of both cigarettes and smokeless tobacco
4.0
44.4
46.5
5.1
2.0
15.2
14.1
68.7
Nonusers
16.7
65.4
17.4
0.5‡
7.6
33.7
23.3
35.4‡
Cigarette smokers
14.4
63.9
20.6
1.1
7.8
29.0
21.4
41.9
Males
Females
* Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. † Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. ‡ Significantly different from female cigarette smokers.
less tobacco were less educated than were male patients who used only one tobacco product. Demographic characteristics associated with self-reported brushing and flossing. Results of χ2 analyses suggested that sex, age, marital status and education varied significantly (P < .001) with the frequency of both self-reported brushing and flossing and that race/ethnicity varied (P < .001) with the frequency of flossing. When we examined the data in Table 2, we found that proportionately more men and younger, less-educated and single patients reported brushing and flossing less frequently than did women and older, more-educated and married patients. White patients reported flossing less frequently than did patients of other ethnic/racial groups. Oral hygiene and tobacco 316
use. We used analysis of covariance to assess the relationship between self-reported frequency of brushing and flossing and tobacco use status. We included the covariates of age and education, as they are positively related to oral hygiene15,17 and tobacco use.21 We performed separate analyses for each sex, as women tend to have better oral hygiene than do men,3 and, as previously noted, the prevalence of smokeless tobacco use among the women in our sample was very low. For men, we used orthogonal analyses to compare nonusers to tobacco users, cigarette smokers to smokeless tobacco users and smokeless users to users of both tobacco products. As Table 3 shows, overall, both male and female nonusers practiced significantly better self-reported oral hygiene, as measured by both frequency of
brushing and flossing, than did male and female tobacco users (P < .001 for all comparisons). There were no differences in brushing between male cigarette smokers and male smokeless tobacco users or between male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. However, male cigarette smokers reported that they flossed significantly more often than did male smokeless tobacco users (P < .001). The self-reported flossing habits of men who used only smokeless tobacco did not differ significantly from the flossing habits of men who used both types of tobacco. We found that most patients (73.5 percent) met the American Dental Association’s recommendation of brushing at least two times per day, while relatively fewer (35.6 percent) met the ADA’s recommendation of floss-
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH ing one time per day. Men who used cigarettes and/or smokeless tobacco were significantly (P < .001) less likely to conform to ADA recommendations for brushing (52.9 percent) and flossing (20.6 percent) than were nonusers (64.6 percent and 30.6 percent, respectively). Male smokeless tobacco users were significantly less likely to floss at least one time per day (14.7 percent) than were male cigarette smokers (23.2 percent), but they did not differ from male cigarette smokers in brushing two times per day. Female cigarette smokers were significantly less likely to both brush at least two times per day (78.3 percent) and floss at least one time per day (36.8 percent) than were female nonsmokers (82.1 percent and 41.3 percent, respectively) (P < .001). When we examined the relationship between the extent of tobacco use—as measured by the number of cigarettes smoked per day over the past seven days and the number of cans or pouches of smokeless tobacco used per week—and patients’ self-reported number of times of having brushed or flossed per day, we found a significant inverse linear relationship between the amount of cigarette use and the frequency of brushing for both women (P < .001) and men (P < .05) and between the amount of smokeless tobacco use and brushing for men (P < .001). The relationship between the extent of tobacco use and the frequency of flossing was not significant for either men or women. Oral health problems and tobacco use. For each tobacco use category, the percentage of respondents reporting that they had a specific oral health problem is given in Table 4. Both
TABLE 4
PERCENTAGE OF TOBACCO USERS AND NONUSERS REPORTING ORAL HEALTH PROBLEMS. TOBACCO USE STATUS CATEGORY
PERCENTAGE SELF-REPORTING EACH ORAL HEALTH PROBLEM
Bleeding Gingivae
Receding Gingivae
Staining
Mouth Sores
Bad Breath
Nonusers
11.6
14.9*
9.3*
2.6*
6.7*
Cigarette Smokers
10.6†
24.0
32.9†
2.0†
11.9
Smokeless tobacco users
17.7
26.4
21.2
4.0
9.3
Users of both cigarettes and smokeless tobacco
20.2
21.2
22.2
3.0
14.1
Nonusers
14.8
17.7‡
10.7‡
3.1
6.6‡
Cigarette smokers
14.0
27.3
34.5
2.4
13.9
Males
Females
* Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. † Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. ‡ Significantly different from female cigarette smokers.
male and female nonusers reported significantly less often that they had receding gingivae, staining and bad breath than did male and female tobacco users (P <.001, for all comparisons). Orthogonal χ2 analyses showed that male cigarette smokers reported that they had bleeding gingivae and mouth sores significantly less often and that they had staining significantly more often than did male patients who used smokeless tobacco, either alone or in combination with cigarettes (P < .01, for all comparisons). DISCUSSION
This study’s strengths include the assessment of a large sample of dental patients and the participation of 81 percent of all eligible patients. To our knowl-
edge, it is the first assessment of the self-reported oral hygiene habits of smokeless tobacco users. Despite these strengths, this study is limited in several ways. As comparisons with data from the BRFS19 show, patients in our sample are not representative of the general population in terms of either their tobacco use or their educational levels. The comparatively higher educational levels of our sample of patients may affect the representativeness of other data, including reported frequency of brushing and flossing. Further, responses were from patients in dental practices that had expressed interest in providing tobacco cessation activities to their patients within the context of the hygiene visit. Thus, respondents in
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
317
RESEARCH
Dr. Andrews is a re-
Dr. Severson is a re-
Dr. Lichtenstein is a
Dr. Gordon is a re-
search scientist,
search scientist,
research scientist,
search scientist,
Oregon Research
Oregon Research
Oregon Research
Oregon Research
Institute, 1715
Institute, Eugene,
Institute, Eugene,
Institute, Eugene,
Franklin Blvd.,
Ore.
Ore.
Ore.
Eugene, Ore. 974031983. Address
these practices also may not be representative of patients in dental practices in the state. Cost considerations prevented the direct assessment of plaque control and oral health problems through an oral health examination or examination of patients’ records. Thus, for this study, the assessment of oral hygiene and oral health is based on the less reliable self-report of the patient. If our survey had included questions about additional methods of interdental plaque control—in addition to brushing and flossing—and the frequency of dental health care visits, it would have been improved further. Although the majority of patients brushed at least two times per day, the frequency of flossing self-reported by this sample of patients was low, with less than one-third conforming to ADA recommendations of flossing at least one time per day. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Not only did tobacco users selfreport following less than the minimum oral hygiene recommendations, the amount of tobacco use was inversely related to the frequency of both brushing and flossing. Tobacco users also reported having more oral health problems.
reprint requests to Dr. Andrews.
318
The frequency of brushing and flossing among smokeless tobacco users was particularly low. The relevance of this finding increases, given the serious effects of smokeless tobacco has on oral health.6,7 We found that smokeless tobacco users perceived that they have more seri-
Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. ous oral health problems than do cigarette smokers or nonusers, but they do not compensate for these problems by increasing their compliance with oral hygiene regimens. While there is some controversy regarding the relative roles of oral bacteria and tobacco use as regulators of periodontal disease,3,22-24 evidence suggests that the use of oral hygiene regimens to control plaque can prevent or slow down the progress of periodontal disease,25-27 which is clearly associated with tobacco use.28-32 Therefore, cigarette smokers and smokeless tobacco users may be at greater risk of developing periodontal disease as a result of their poor oral hygiene habits and their tobacco use. Tobacco users’ low compli-
ance with oral hygiene regimens could be due to their general orientation toward health and health-related activities. Several researchers33,34 have shown a covariation in healthenhancing activities. Thus, those who engage in the unhealthy activity of using tobacco may be less likely to engage in health-enhancing behaviors such as the oral hygiene regimen recommended by their dentist or dental hygienist. It is likely that tobacco users who see their dental care providers are more likely to place a higher value on their health and are more likely to have better oral hygiene habits than are tobacco users who do not visit their dental care providers. Thus, if tobacco-using patients have poor oral hygiene habits, as our results suggest, the oral hygiene habits of the approximately 50 percent of the general population who use tobacco and do not see their dental care providers could be dismal. This study further substantiates the need for dental professionals to assess patients’ cigarette and smokeless tobacco use. Resolutions from the American Dental Association made in 1964 and reaffirmed several times since—most recently in 1992—encourage dentists to inform their patients about the oral health hazards of smoking and using smokeless tobacco.35,36 However, only 28.4 percent of our sample self-reported having received advice from their dentists to quit smoking, and 40.9 percent self-reported having received advice from their dentists to quit using smokeless tobacco. Several articles have reviewed dentists’ involvement in smoking cessation counseling
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH and advice regarding smokeless tobacco use37-39 and have described cessation programs that dental professionals can conduct, which include assessment of patients’ tobacco use as an essential component.40,41 Our findings provide additional rationale for this assessment. At a time when smokeless tobacco use is increasing, particularly among young people42 who are not knowledgeable about the health risks associated with its use,43,44 dental professionals can have an impact on decreasing initiation and promoting cessation among youth by providing brief advice and informational materials regarding health risks. As our findings suggest that tobacco use is a risk factor for low compliance with an oral hygiene regimen, we feel it would be appropriate to target tobacco users for additional education about the effects of good oral hygiene on periodontal disease. The principles used for increasing compliance and the message given to the patients could be tailored to different types of tobacco users. For example, messages about flossing could be tailored specifically to smokeless tobacco users, given their particularly low compliance with flossing. Wilson45 found that the less threatening the problem is, the lower the compliance with a regimen is. With this in mind, dental professionals could increase compliance with oral hygiene regimens by pointing out tobacco-related oral health problems and relating these problems to future health consequences, thus increasing their salience. This would be an ideal time to provide to tobacco users not only oral hygiene recom-
mendations but also advice on how to quit using tobacco and encouragement to set a quit date. Noting recommendations regarding tobacco use cessation and oral hygiene regimens in the patient’s chart is recommended, so the dental care provider can reinforce these recommendations on subsequent visits. As 50 percent of tobacco users see a dental provider each year, a brief intervention46 consistently delivered could have a major public health impact.
Tobacco use is a risk factor for low compliance with an oral hygiene regimen. CONCLUSION
As a result of this study, we have found that tobacco-using dental patients reported particularly poor oral hygiene and poor oral health. The results of this study further substantiate the need to identify all tobacco users, as well as to distinguish smokeless tobacco users from cigarette smokers as part of regular dental practice. These patients can then be targeted not only for oral hygiene compliance regimens but also for cessation advice. ■ The authors are indebted to Pam Unfried, Beth Over, Barbara Eisenhardt, Maureen Barckley and Christine Lorenz for their tireless work with the dental practices and the data analysis. The authors would also like to thank the dental practitioners and their office teams who made the study possible. This study was supported by grant number 1 RO1 HL48768 from the National Heart, Lung and Blood Institute. 1. Jette AM, Feldman HA, Tennstedt SL. Tobacco use: a modifiable risk factor for dental disease among the elderly. Am J Public Health 1993;83:1271-6. 2. Schenkein HA, Gunsolley JC, Koertge TE, Schenkein JG, Tew JG. Smoking and its effects on early-onset periodontitis. JADA 1995;126:1107-13.
3. Stoltenberg JL, Osborn JB, Pihlstrom BL, et al. Association between cigarette smoking, bacterial pathogens, and periodontal status. J Periodontol 1993;64:1225-30. 4. Bergstrom J, Eliasson S, Preber H. Cigarette smoking and periodontal bone loss. J Periodontol 1991;62:242-6. 5. Mattson ME, Winn DM. Smokeless tobacco: association with increased cancer risk. Natl Cancer Inst Monogr 1989;8:13-6. 6. Little SJ, Stevens VJ, Severson HH, Lichtenstein E. An effective smokeless tobacco intervention for dental hygiene patients. J Dent Hyg 1992;66(4):185-90. 7. U.S. Department of Health and Human Services. The health consequences of using smokeless tobacco: A report of the advisory committee to the Surgeon General. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service 1986:2874. 8. Preber H, Bergstrom J. Effect of cigarette smoking on periodontal healing following surgical therapy. J Clin Periodontol 1990;17:324-8. 9. Grossi SG, Zambon J, Machtei EE, et al. Effects of smoking and smoking cessation on healing after mechanical periodontal therapy. JADA 1997;128:599-607. 10. Bain CA, Moy PK. The association between the failure of dental implants and cigarette smoking. Int J Oral and Maxillofac Implants 1993;8:609-15. 11. Secker-Walker RH, Solomon LJ, Haugh LD, et al. Smoking cessation advice delivered by the dental hygienist: a pilot study. Dent Hyg 1988;62:186-92. 12. Van Dyk W. Helping patients quit. JADA 1989;118:136 13. American Dental Association. Basic brushing. Chicago: American Dental Association, Division of Communications; 1996. 14. American Dental Association. Basic flossing. Chicago: American Dental Association, Division of Communications; 1984. 15. Ronis DL, Lang WP, Farghaly MM, Ekdahl SM. Preventive oral health behaviors among Detroit-area residents. J Dent Hyg 1994;68:123-30. 16. Lang WP, Farghaly MM, Ronis DL. The relation of preventative dental behavior to periodontal health status. J Clin Periodontol 1994;21:194-8. 17. Bergstrom J. Oral hygiene compliance and gingivitis expression in cigarette smokers. Scand J Dent Res 1990;98:497-503. 18. Mendoza AR, Newcomb GM, Nixon KC. Compliance with supportive periodontal therapy. J Periodontol 1991;62:731-6. 19. Tobacco, Oregonians, and health. Oregon Health Trends 1995;40:1-7. 20. Tobacco and Oregonians. Oregon Health Trends 1992;28:2-9. 21. Cigarette smoking among adults: United States 1995. MMWR 1997;46:1217-20. 22. Zambon JJ, Grossi SG, Machtei EE, et al. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J Periodontol 1996;67:1050-4. 23. Preber H, Bergstrom J, Linder LE. Occurrence of periopathogens in smoker and non-smoker patients. J Clin Periodontol 1992;19:667-71. 24. Preber H, Linder L, Bergstrom J. Periodontal healing and periopathogenic microflora in smokers and non-smokers. J Clin Periodontol 1995;22:946-52. 25. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol 1981;8:239-48.
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RESEARCH 26. Corbet EF, Davis WIR. The role of supragingival plaque in the control of progressive periodontal disease. J Clin Periodontol 1993;20:307-13. 27. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol 1985;11:504-14. 28. Ismail AI, Burt BA, Eklund SA. Epidemiologic patterns of smoking and periodontal disease in the United States. JADA 1983;106:617-21. 29. Grossi SG, Genco RJ, Machtei EE, et al. Assessment of risk for periodontal disease. Part 2: risk indicators for alveolar bone loss. J Periodontol 1995;66:23-9. 30. Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. Part 1: risk indicators for attachment loss. J Periodontol 1994;65:260-67. 31. Bergstrom J, Floderus-Myrhed B. Cotwin control study of the relationship between smoking and some periodontal disease factors. Community Dent Oral Epidemiol 1983;11:113-6. 32. Locker D. Smoking and oral health in older adults. Can J Public Health 1992;83:429-32. 33. Aaro LE, Laberg JC, Wold B. Health behaviours among adolescents: towards a hy-
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pothesis of two dimensions. Health Educ Res (Special Issue: Measurement in health education research) 1995;10:83-93. 34. Donovan JE, Jessor R, Costa FM. Structure of health-enhancing behavior in adolescence: a latent-variable approach. J Health Soc Behav 1993;34:346-62. 35. American Dental Association. Resolution 22H-1964. In: ADA Transactions 1964. Chicago: American Dental Association; 1965:276. 36. American Dental Association. Resolution 1H-1992. In: ADA Transactions 1992. Chicago: American Dental Association; 1993:598. 37. Geboy MJ. Dentists’ involvement in smoking cessation counseling: a review and analysis. JADA 1989;118:79-83. 38. Secker-Walker RH, Chir MB, Solomon LJ, Flynn BS, Dana GS. Comparisons of the smoking cessation counseling activities of six types of health professionals. Prev Med 1994;23:800-8. 39. Mecklenburg RE. Managing hard-core smokers: oral health team challenges and opportunities. Health Values 1994;18:6-16. 40. Cohen SJ, Stookey GK, Katz BP, Drook CA, Christen AG. Helping smokers quit: a randomized controlled trial with private practice dentists. JADA 1989;118:41-5.
41. Wood GJ, Cecchini JJ, Nathason N, Hiroshige K. Office-based training in tobacco cessation for dental professionals. JADA 1997;128:216-24. 42. Severson HH. Smokeless tobacco: A deadly addiction. Waco, Texas: Health EDCO; 1997. 43. Lynch BS, Bonnie RJ, eds. Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, D.C.: Committee on Preventing Nicotine Addiction in Children and Youths, Institute of Medicine, 1994:155. 44. U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, Ga.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994:101. 45. Wilson TG. A review of the literature with possible applications to periodontics. J Periodontol 1986;58:706-14. 46. Stevens VJ, Severson HH, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: a smokeless tobacco cessation intervention in the dental office. Am J Public Health 1995;85:231-5.
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
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ARTICLE 1
RELATIONSHIP BETWEEN TOBACCO USE
AND SELF-REPORTED ORAL HYGIENE HABITS JUDY A. ANDREWS, PH.D.; HERBERT H. SEVERSON, PH.D.; EDWARD LICHTENSTEIN, PH.D.; JUDITH S. GORDON, PH.D.
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A sample of 34,897 dental patients completed written surveys assessing their tobacco use, frequency of brushing and flossing and perception of oral health problems. Brushing two times per day was reported by 73.5 percent of the patients and flossing one time per day by 35.6 percent. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Compliance with daily flossing regimens was particularly low among smokeless tobacco users. Tobacco users also reported more oral health problems.
Recent investigations involving adults of all ages have identified
tobacco use as a major risk factor for poor oral health.1,2 Smokers have a greater mean probing depth3 and a greater loss of periodontal bone height as measured by the difference between the cementoenamel junction and the interdental septum4 than do nonsmokers. A patient’s use of smokeless tobacco (moist snuff and chewing tobacco) has been consistently related to high rates of leukoplakic lesions in the habitual site of tobacco placement.5 The results of a study of managed care dental patients showed that 73 percent of daily smokeless tobacco users had noncancerous and precancerous lesions and that the grade of lesion was related to frequency and years of tobacco use.6 As smokeless tobacco contains high levels of known carcinogens, there is strong evidence that regular smokeless tobacco use can cause cancer in the mouth, especially where the tobacco is routinely placed.7 Cigarette smoking has been associated with an impaired response to periodontal treatment8,9 and an increased incidence of dental implant failure.10 Recognizing the detrimental effects of tobacco use on oral health, organized dentistry has encouraged oral health professionals to assess and discourage patient tobacco use.11,12 The American Dental Association has recommended brushing at least two times per day13 and flossing at least one time per day.14 Adherence to this oral hygiene regimen is particularly important for tobacco users because of their high risk for poor oral health. Although several studies have reported on the dental health care of specific populations,15,16 few studies have examined compliance with oral hygiene regimens among cigarette smokers. The results of studies comparing smokers and nonsmokers are inconsistent. For example, while Bergstrom17 found no differences in compliance with an oral hygiene program between smoking and nonsmoking dental patients, Mendoza, Newcomb and Nixon18 reported that smokers were less compliant patients than nonusers. This inconsistency points to a need for further research examining the relationship between smoking and oral hygiene. To our knowledge, no studies have been conducted that examine the oral hygiene regimens of patients who use smokeless tobacco. As part of a larger project to evaluate the effectiveness of dental professionals providing advice to patients to quit smoking and
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C
RESEARCH TABLE 1
DEMOGRAPHIC VARIABLES OF SAMPLE, BY TOBACCO USE STATUS. NONUSERS
CIGARETTE SMOKERS
SMOKELESS TOBACCO USERS
30,136
4,029
632
100
Percentage Male
41.4
41.2
98.8
100.0
Mean Age (Years)
45.4
42.4
36.2
33.4
Percentage White
93.9
92.1
94.2
93.9
Percentage Single
28.8
35.5
30.7
38.8
Percentage With More Than a High-School Education
71.7
62.2
61.2
48.0
VARIABLE
n
using smokeless tobacco, we obtained information regarding self-reported tobacco use, oral hygiene and oral health problems from 34,897 dental patients. The primary purpose of this article is to describe the self-reported oral hygiene habits of both male and female cigarette smokers and male smokeless tobacco users and compare these habits with the self-reported habits of dental patients who reported being nonusers. We also examined the relationship between the tobacco use status and self-reported oral health problems of these patients. MATERIALS AND METHODS
Over an 18-month period, frontdesk personnel in 75 participating private dental practices in Oregon asked patients to complete a written survey before their hygiene visit. The survey included questions regarding patients’ brushing and flossing habits, current tobacco use and perceptions of their oral health problems. Patients reported on their brushing and flossing habits using four response categories 314
for each question. For brushing, the possible responses were three times per day or more, two times per day, one time per day and three times per week or less. For flossing, possible
Most patients (70 percent) had more than a high-school education, 94 percent were white, 57 percent were women and 30 percent were single. responses were two times per day or more, one time per day, three times per week and one time per week or less. All responding patients indicated if they had any of the following oral health problems: bleeding gums, receding gums, staining, mouth sores or bad breath. Patients also reported if they currently smoked cigarettes or used smokeless tobacco. Current smokers reported the average number of cigarettes smoked per day over the past seven days, and current smokeless tobacco users reported the
USERS OF BOTH CIGARETTES AND SMOKELESS TOBACCO
number of cans or pouches used per week. RESULTS
Based on information provided by 59 practices, 81 percent of eligible patients completed the survey, 6 percent refused to complete the survey, and 13 percent were mistakenly not given the survey by front-office personnel. The 34,897 patients who completed the survey ranged in age from 15 to 94 years with a mean age of 44.83 years (median = 43; standard deviation = 16.68). Most patients (70 percent) had more than a high-school education, approximately 94 percent were white, 57 percent were women and 30 percent were single (defined as not currently married or living with a partner). Prevalence of tobacco use. Among men in this sample, the prevalence of cigarette use, smokeless tobacco use and a combination of both cigarette and smokeless tobacco use was 11.16 percent, 4.25 percent and 0.67 percent, respectively. The prevalence of cigarette use among women was 11.80 percent. Only one woman used
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH TABLE 2
RELATIONSHIP BETWEEN DEMOGRAPHIC VARIABLES AND FREQUENCY OF SELF-REPORTED BRUSHING AND FLOSSING. VARIABLE (TOTAL SAMPLE)
TOTAL
BRUSHING
Three Times Per Day or More
4,477
n*
Two Times Per Day
21,053
FLOSSING
Three Times Per Week
One Time Per Day
Three Times Per Week or Less
Two Times Per Day or More
One Time Per Day
8,665
502
2,095
10,002
28.9
35.0
38.4
51.2†
One Time Per Week or Less
7,355 14,528
Percentage Male
42.6
26.8
38.3
59.2
77.1†
Mean Age (Years)
44.8
46.4
44.4
45.1
42.1†
55.2
48.8
43.3
40.9
Percentage White
93.7
93.6
93.6
94.0
91.1
91.9
93.6
93.8
94.2†
Percentage Single
29.6
29.7
30.0
28.0
39.1†
29.5
26.5
29.0
32.3†
Percentage With More Than a High-School Education
70.4
72.4
71.9
67.2
46.4†
63.9
73.0
75.5
68.2†
* The sample sizes do not total 34,897 each, because 200 patients did not indicate brushing frequency and 917 patients did not indicate flossing frequency. † P < .001.
smokeless tobacco, and no women used both cigarettes and smokeless tobacco. Tobacco use in our convenience sample of dental patients was approximately onehalf that of recent prevalence estimates of cigarette use (22 percent) from the Oregon Behavioral Risk Factor Study, or BRFS,19 and smokeless tobacco use (9 percent among men; 1 percent among women)20 among representative samples of adults in Oregon. However, dental patients in our sample were better educated than were the dental patients in the BRFS sample, as 35.0 percent were college graduates, compared with 25.6 percent in the BRFS sample (P < .001). Cigarette smokers smoked an average of 15 cigarettes a day. A can of chewing tobacco or snuff lasted
smokeless tobacco users an average of 4.5 days. Demographic characteristics associated with tobacco use. We used orthogonal χ2 analyses to compare demographics across the four tobacco status
Only one woman used smokeless tobacco, and no women used both cigarettes and smokeless tobacco. categories: nonusers, cigarette smokers, smokeless tobacco users and users of both cigarettes and smokeless tobacco. Specifically, we compared nonusers with tobacco users, cigarette smokers with a combination of smokeless tobacco users and users of both
cigarettes and smokeless tobacco, and smokeless tobacco users with users of both cigarettes and smokeless tobacco. As is shown in Table 1, the demographic characteristics of nonusers, cigarette smokers, smokeless tobacco users and users of both cigarettes and smokeless tobacco varied significantly (P < .001) with all variables except for race/ethnicity as a function of tobacco use status. While nonusers and cigarette smokers were more likely to be women, smokeless tobacco users and users of both types of tobacco were almost exclusively men. Tobacco users were more likely to be single than were nonusers. Cigarette smokers and smokeless tobacco users were less educated than were nonusers. Furthermore, male patients who used both cigarettes and smoke-
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
315
RESEARCH TABLE 3
ORAL HYGIENE HABITS OF TOBACCO USERS AND NONUSERS. TOBACCO USE STATUS CATEGORY
PERCENTAGE WHO BRUSH
PERCENTAGE WHO FLOSS
Three Times Per Day or More
Two Times Per Day
One Time Per Day
Three Times Per Week or Less
Two Times Per Day or More
One Time Per Day
Three Times Per Week
One Time Per Week or Less
Nonusers
8.6
56.0
33.1
2.3*
4.4
25.7
20.1
49.8*
Cigarette smokers
5.8
47.2
42.8
4.2
4.0
19.2
17.7
59.1†
Smokeless tobacco users
5.9
47.2
42.5
4.4
0.8
13.5
16.9
68.8
Users of both cigarettes and smokeless tobacco
4.0
44.4
46.5
5.1
2.0
15.2
14.1
68.7
Nonusers
16.7
65.4
17.4
0.5‡
7.6
33.7
23.3
35.4‡
Cigarette smokers
14.4
63.9
20.6
1.1
7.8
29.0
21.4
41.9
Males
Females
* Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. † Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. ‡ Significantly different from female cigarette smokers.
less tobacco were less educated than were male patients who used only one tobacco product. Demographic characteristics associated with self-reported brushing and flossing. Results of χ2 analyses suggested that sex, age, marital status and education varied significantly (P < .001) with the frequency of both self-reported brushing and flossing and that race/ethnicity varied (P < .001) with the frequency of flossing. When we examined the data in Table 2, we found that proportionately more men and younger, less-educated and single patients reported brushing and flossing less frequently than did women and older, more-educated and married patients. White patients reported flossing less frequently than did patients of other ethnic/racial groups. Oral hygiene and tobacco 316
use. We used analysis of covariance to assess the relationship between self-reported frequency of brushing and flossing and tobacco use status. We included the covariates of age and education, as they are positively related to oral hygiene15,17 and tobacco use.21 We performed separate analyses for each sex, as women tend to have better oral hygiene than do men,3 and, as previously noted, the prevalence of smokeless tobacco use among the women in our sample was very low. For men, we used orthogonal analyses to compare nonusers to tobacco users, cigarette smokers to smokeless tobacco users and smokeless users to users of both tobacco products. As Table 3 shows, overall, both male and female nonusers practiced significantly better self-reported oral hygiene, as measured by both frequency of
brushing and flossing, than did male and female tobacco users (P < .001 for all comparisons). There were no differences in brushing between male cigarette smokers and male smokeless tobacco users or between male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. However, male cigarette smokers reported that they flossed significantly more often than did male smokeless tobacco users (P < .001). The self-reported flossing habits of men who used only smokeless tobacco did not differ significantly from the flossing habits of men who used both types of tobacco. We found that most patients (73.5 percent) met the American Dental Association’s recommendation of brushing at least two times per day, while relatively fewer (35.6 percent) met the ADA’s recommendation of floss-
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH ing one time per day. Men who used cigarettes and/or smokeless tobacco were significantly (P < .001) less likely to conform to ADA recommendations for brushing (52.9 percent) and flossing (20.6 percent) than were nonusers (64.6 percent and 30.6 percent, respectively). Male smokeless tobacco users were significantly less likely to floss at least one time per day (14.7 percent) than were male cigarette smokers (23.2 percent), but they did not differ from male cigarette smokers in brushing two times per day. Female cigarette smokers were significantly less likely to both brush at least two times per day (78.3 percent) and floss at least one time per day (36.8 percent) than were female nonsmokers (82.1 percent and 41.3 percent, respectively) (P < .001). When we examined the relationship between the extent of tobacco use—as measured by the number of cigarettes smoked per day over the past seven days and the number of cans or pouches of smokeless tobacco used per week—and patients’ self-reported number of times of having brushed or flossed per day, we found a significant inverse linear relationship between the amount of cigarette use and the frequency of brushing for both women (P < .001) and men (P < .05) and between the amount of smokeless tobacco use and brushing for men (P < .001). The relationship between the extent of tobacco use and the frequency of flossing was not significant for either men or women. Oral health problems and tobacco use. For each tobacco use category, the percentage of respondents reporting that they had a specific oral health problem is given in Table 4. Both
TABLE 4
PERCENTAGE OF TOBACCO USERS AND NONUSERS REPORTING ORAL HEALTH PROBLEMS. TOBACCO USE STATUS CATEGORY
PERCENTAGE SELF-REPORTING EACH ORAL HEALTH PROBLEM
Bleeding Gingivae
Receding Gingivae
Staining
Mouth Sores
Bad Breath
Nonusers
11.6
14.9*
9.3*
2.6*
6.7*
Cigarette Smokers
10.6†
24.0
32.9†
2.0†
11.9
Smokeless tobacco users
17.7
26.4
21.2
4.0
9.3
Users of both cigarettes and smokeless tobacco
20.2
21.2
22.2
3.0
14.1
Nonusers
14.8
17.7‡
10.7‡
3.1
6.6‡
Cigarette smokers
14.0
27.3
34.5
2.4
13.9
Males
Females
* Significantly different from male cigarette smokers, male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. † Significantly different from male smokeless tobacco users and male users of both cigarettes and smokeless tobacco. ‡ Significantly different from female cigarette smokers.
male and female nonusers reported significantly less often that they had receding gingivae, staining and bad breath than did male and female tobacco users (P <.001, for all comparisons). Orthogonal χ2 analyses showed that male cigarette smokers reported that they had bleeding gingivae and mouth sores significantly less often and that they had staining significantly more often than did male patients who used smokeless tobacco, either alone or in combination with cigarettes (P < .01, for all comparisons). DISCUSSION
This study’s strengths include the assessment of a large sample of dental patients and the participation of 81 percent of all eligible patients. To our knowl-
edge, it is the first assessment of the self-reported oral hygiene habits of smokeless tobacco users. Despite these strengths, this study is limited in several ways. As comparisons with data from the BRFS19 show, patients in our sample are not representative of the general population in terms of either their tobacco use or their educational levels. The comparatively higher educational levels of our sample of patients may affect the representativeness of other data, including reported frequency of brushing and flossing. Further, responses were from patients in dental practices that had expressed interest in providing tobacco cessation activities to their patients within the context of the hygiene visit. Thus, respondents in
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317
RESEARCH
Dr. Andrews is a re-
Dr. Severson is a re-
Dr. Lichtenstein is a
Dr. Gordon is a re-
search scientist,
search scientist,
research scientist,
search scientist,
Oregon Research
Oregon Research
Oregon Research
Oregon Research
Institute, 1715
Institute, Eugene,
Institute, Eugene,
Institute, Eugene,
Franklin Blvd.,
Ore.
Ore.
Ore.
Eugene, Ore. 974031983. Address
these practices also may not be representative of patients in dental practices in the state. Cost considerations prevented the direct assessment of plaque control and oral health problems through an oral health examination or examination of patients’ records. Thus, for this study, the assessment of oral hygiene and oral health is based on the less reliable self-report of the patient. If our survey had included questions about additional methods of interdental plaque control—in addition to brushing and flossing—and the frequency of dental health care visits, it would have been improved further. Although the majority of patients brushed at least two times per day, the frequency of flossing self-reported by this sample of patients was low, with less than one-third conforming to ADA recommendations of flossing at least one time per day. Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. Not only did tobacco users selfreport following less than the minimum oral hygiene recommendations, the amount of tobacco use was inversely related to the frequency of both brushing and flossing. Tobacco users also reported having more oral health problems.
reprint requests to Dr. Andrews.
318
The frequency of brushing and flossing among smokeless tobacco users was particularly low. The relevance of this finding increases, given the serious effects of smokeless tobacco has on oral health.6,7 We found that smokeless tobacco users perceived that they have more seri-
Tobacco users brushed and, particularly, flossed much less frequently than did nonusers. ous oral health problems than do cigarette smokers or nonusers, but they do not compensate for these problems by increasing their compliance with oral hygiene regimens. While there is some controversy regarding the relative roles of oral bacteria and tobacco use as regulators of periodontal disease,3,22-24 evidence suggests that the use of oral hygiene regimens to control plaque can prevent or slow down the progress of periodontal disease,25-27 which is clearly associated with tobacco use.28-32 Therefore, cigarette smokers and smokeless tobacco users may be at greater risk of developing periodontal disease as a result of their poor oral hygiene habits and their tobacco use. Tobacco users’ low compli-
ance with oral hygiene regimens could be due to their general orientation toward health and health-related activities. Several researchers33,34 have shown a covariation in healthenhancing activities. Thus, those who engage in the unhealthy activity of using tobacco may be less likely to engage in health-enhancing behaviors such as the oral hygiene regimen recommended by their dentist or dental hygienist. It is likely that tobacco users who see their dental care providers are more likely to place a higher value on their health and are more likely to have better oral hygiene habits than are tobacco users who do not visit their dental care providers. Thus, if tobacco-using patients have poor oral hygiene habits, as our results suggest, the oral hygiene habits of the approximately 50 percent of the general population who use tobacco and do not see their dental care providers could be dismal. This study further substantiates the need for dental professionals to assess patients’ cigarette and smokeless tobacco use. Resolutions from the American Dental Association made in 1964 and reaffirmed several times since—most recently in 1992—encourage dentists to inform their patients about the oral health hazards of smoking and using smokeless tobacco.35,36 However, only 28.4 percent of our sample self-reported having received advice from their dentists to quit smoking, and 40.9 percent self-reported having received advice from their dentists to quit using smokeless tobacco. Several articles have reviewed dentists’ involvement in smoking cessation counseling
JADA, Vol. 129, March 1998 Copyright ©1998-2001 American Dental Association. All rights reserved.
RESEARCH and advice regarding smokeless tobacco use37-39 and have described cessation programs that dental professionals can conduct, which include assessment of patients’ tobacco use as an essential component.40,41 Our findings provide additional rationale for this assessment. At a time when smokeless tobacco use is increasing, particularly among young people42 who are not knowledgeable about the health risks associated with its use,43,44 dental professionals can have an impact on decreasing initiation and promoting cessation among youth by providing brief advice and informational materials regarding health risks. As our findings suggest that tobacco use is a risk factor for low compliance with an oral hygiene regimen, we feel it would be appropriate to target tobacco users for additional education about the effects of good oral hygiene on periodontal disease. The principles used for increasing compliance and the message given to the patients could be tailored to different types of tobacco users. For example, messages about flossing could be tailored specifically to smokeless tobacco users, given their particularly low compliance with flossing. Wilson45 found that the less threatening the problem is, the lower the compliance with a regimen is. With this in mind, dental professionals could increase compliance with oral hygiene regimens by pointing out tobacco-related oral health problems and relating these problems to future health consequences, thus increasing their salience. This would be an ideal time to provide to tobacco users not only oral hygiene recom-
mendations but also advice on how to quit using tobacco and encouragement to set a quit date. Noting recommendations regarding tobacco use cessation and oral hygiene regimens in the patient’s chart is recommended, so the dental care provider can reinforce these recommendations on subsequent visits. As 50 percent of tobacco users see a dental provider each year, a brief intervention46 consistently delivered could have a major public health impact.
Tobacco use is a risk factor for low compliance with an oral hygiene regimen. CONCLUSION
As a result of this study, we have found that tobacco-using dental patients reported particularly poor oral hygiene and poor oral health. The results of this study further substantiate the need to identify all tobacco users, as well as to distinguish smokeless tobacco users from cigarette smokers as part of regular dental practice. These patients can then be targeted not only for oral hygiene compliance regimens but also for cessation advice. ■ The authors are indebted to Pam Unfried, Beth Over, Barbara Eisenhardt, Maureen Barckley and Christine Lorenz for their tireless work with the dental practices and the data analysis. The authors would also like to thank the dental practitioners and their office teams who made the study possible. This study was supported by grant number 1 RO1 HL48768 from the National Heart, Lung and Blood Institute. 1. Jette AM, Feldman HA, Tennstedt SL. Tobacco use: a modifiable risk factor for dental disease among the elderly. Am J Public Health 1993;83:1271-6. 2. Schenkein HA, Gunsolley JC, Koertge TE, Schenkein JG, Tew JG. Smoking and its effects on early-onset periodontitis. JADA 1995;126:1107-13.
3. Stoltenberg JL, Osborn JB, Pihlstrom BL, et al. Association between cigarette smoking, bacterial pathogens, and periodontal status. J Periodontol 1993;64:1225-30. 4. Bergstrom J, Eliasson S, Preber H. Cigarette smoking and periodontal bone loss. J Periodontol 1991;62:242-6. 5. Mattson ME, Winn DM. Smokeless tobacco: association with increased cancer risk. Natl Cancer Inst Monogr 1989;8:13-6. 6. Little SJ, Stevens VJ, Severson HH, Lichtenstein E. An effective smokeless tobacco intervention for dental hygiene patients. J Dent Hyg 1992;66(4):185-90. 7. U.S. Department of Health and Human Services. The health consequences of using smokeless tobacco: A report of the advisory committee to the Surgeon General. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service 1986:2874. 8. Preber H, Bergstrom J. Effect of cigarette smoking on periodontal healing following surgical therapy. J Clin Periodontol 1990;17:324-8. 9. Grossi SG, Zambon J, Machtei EE, et al. Effects of smoking and smoking cessation on healing after mechanical periodontal therapy. JADA 1997;128:599-607. 10. Bain CA, Moy PK. The association between the failure of dental implants and cigarette smoking. Int J Oral and Maxillofac Implants 1993;8:609-15. 11. Secker-Walker RH, Solomon LJ, Haugh LD, et al. Smoking cessation advice delivered by the dental hygienist: a pilot study. Dent Hyg 1988;62:186-92. 12. Van Dyk W. Helping patients quit. JADA 1989;118:136 13. American Dental Association. Basic brushing. Chicago: American Dental Association, Division of Communications; 1996. 14. American Dental Association. Basic flossing. Chicago: American Dental Association, Division of Communications; 1984. 15. Ronis DL, Lang WP, Farghaly MM, Ekdahl SM. Preventive oral health behaviors among Detroit-area residents. J Dent Hyg 1994;68:123-30. 16. Lang WP, Farghaly MM, Ronis DL. The relation of preventative dental behavior to periodontal health status. J Clin Periodontol 1994;21:194-8. 17. Bergstrom J. Oral hygiene compliance and gingivitis expression in cigarette smokers. Scand J Dent Res 1990;98:497-503. 18. Mendoza AR, Newcomb GM, Nixon KC. Compliance with supportive periodontal therapy. J Periodontol 1991;62:731-6. 19. Tobacco, Oregonians, and health. Oregon Health Trends 1995;40:1-7. 20. Tobacco and Oregonians. Oregon Health Trends 1992;28:2-9. 21. Cigarette smoking among adults: United States 1995. MMWR 1997;46:1217-20. 22. Zambon JJ, Grossi SG, Machtei EE, et al. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J Periodontol 1996;67:1050-4. 23. Preber H, Bergstrom J, Linder LE. Occurrence of periopathogens in smoker and non-smoker patients. J Clin Periodontol 1992;19:667-71. 24. Preber H, Linder L, Bergstrom J. Periodontal healing and periopathogenic microflora in smokers and non-smokers. J Clin Periodontol 1995;22:946-52. 25. Axelsson P, Lindhe J. Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. J Clin Periodontol 1981;8:239-48.
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RESEARCH 26. Corbet EF, Davis WIR. The role of supragingival plaque in the control of progressive periodontal disease. J Clin Periodontol 1993;20:307-13. 27. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol 1985;11:504-14. 28. Ismail AI, Burt BA, Eklund SA. Epidemiologic patterns of smoking and periodontal disease in the United States. JADA 1983;106:617-21. 29. Grossi SG, Genco RJ, Machtei EE, et al. Assessment of risk for periodontal disease. Part 2: risk indicators for alveolar bone loss. J Periodontol 1995;66:23-9. 30. Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. Part 1: risk indicators for attachment loss. J Periodontol 1994;65:260-67. 31. Bergstrom J, Floderus-Myrhed B. Cotwin control study of the relationship between smoking and some periodontal disease factors. Community Dent Oral Epidemiol 1983;11:113-6. 32. Locker D. Smoking and oral health in older adults. Can J Public Health 1992;83:429-32. 33. Aaro LE, Laberg JC, Wold B. Health behaviours among adolescents: towards a hy-
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pothesis of two dimensions. Health Educ Res (Special Issue: Measurement in health education research) 1995;10:83-93. 34. Donovan JE, Jessor R, Costa FM. Structure of health-enhancing behavior in adolescence: a latent-variable approach. J Health Soc Behav 1993;34:346-62. 35. American Dental Association. Resolution 22H-1964. In: ADA Transactions 1964. Chicago: American Dental Association; 1965:276. 36. American Dental Association. Resolution 1H-1992. In: ADA Transactions 1992. Chicago: American Dental Association; 1993:598. 37. Geboy MJ. Dentists’ involvement in smoking cessation counseling: a review and analysis. JADA 1989;118:79-83. 38. Secker-Walker RH, Chir MB, Solomon LJ, Flynn BS, Dana GS. Comparisons of the smoking cessation counseling activities of six types of health professionals. Prev Med 1994;23:800-8. 39. Mecklenburg RE. Managing hard-core smokers: oral health team challenges and opportunities. Health Values 1994;18:6-16. 40. Cohen SJ, Stookey GK, Katz BP, Drook CA, Christen AG. Helping smokers quit: a randomized controlled trial with private practice dentists. JADA 1989;118:41-5.
41. Wood GJ, Cecchini JJ, Nathason N, Hiroshige K. Office-based training in tobacco cessation for dental professionals. JADA 1997;128:216-24. 42. Severson HH. Smokeless tobacco: A deadly addiction. Waco, Texas: Health EDCO; 1997. 43. Lynch BS, Bonnie RJ, eds. Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, D.C.: Committee on Preventing Nicotine Addiction in Children and Youths, Institute of Medicine, 1994:155. 44. U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, Ga.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994:101. 45. Wilson TG. A review of the literature with possible applications to periodontics. J Periodontol 1986;58:706-14. 46. Stevens VJ, Severson HH, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: a smokeless tobacco cessation intervention in the dental office. Am J Public Health 1995;85:231-5.
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