KNHANES Survey

1. Jun-Beom Park, Kyungdo Han, Yong-Gyu Park
J Periodontol • November 2014
Dr Gauri Kapila
MDS II Year

2. INTRODUCTION
 Alcohol consumption is widespread, although the amount
and frequency may vary
 influences the immune system
 has a broad range of detrimental systemic effects
 higher risk of periodontal breakdown
 tooth loss
 affect the bone metabolism
 major role in extensive bone loss

3. INTRODUCTION
 Cross-sectional studies have suggested a positive
association between alcohol and periodontal disease
 assumed to be the result of self-neglect due to chronic
alcohol consumption
 52% of heavy drinkers stated that they frequently forgot to
brush their teeth
 Moreover, cigarette smoking and nicotine dependence
commonly co-occur with alcohol dependence

4. AIM AND PURPOSE
To assess the relationship between alcohol intake and
severity of periodontal disease in a large
probability sample of a Korean population using data from
the Korea National Health and Nutrition Examination
Survey (KNHANES)

5. MATERIALS AND METHODS
 Overview of the Survey
 Data from the KNHANES, conducted between 2008 and
2010 by the Division of Chronic Disease Surveillance under
the Korea Centers for Disease Control and Prevention and
the Korean Ministry of Health and Welfare, were used for this
study.
 20,229 individuals with complete data sets
 8,645 males [mean age: 43.8y]
 11,584 females [mean age: aged 45.9]

6. MATERIALS AND METHODS
 The survey was composed of three parts:
 a health interview survey
 a health examination survey
 a nutrition survey
 Trained interviewers conducted face-to-face interviews with a
structured questionnaire
 Physical examinations, blood sampling, and urine sampling
were performed at a mobile examination center

7. MATERIALS AND METHODS
 Demographic Variables – sex, age, alcohol intake, degree of
periodontal treatment needs, and smoking status
 The amount of pure alcohol consumed (in grams per day) -
average number of alcoholic beverages consumed and the
frequency of alcohol consumption

8. MATERIALS AND METHODS
 The participants were divided into three groups -
 non-drinker
 light-to-moderate drinker [1 to 30 g/day]
 heavy drinker [>30 g/day])
 The alcohol use disorders identification test (AUDIT) score
 (0 to 7, 8 to 14, 15 to 19, and ≥20) was used to divide the
participants into four levels
 High risk drinking >60 g pure alcohol per day for men and
>40 g per day for women

9. MATERIALS AND METHODS
 Individuals with household incomes in the lowest quartile
were designated as the low-income group
 Education level was classified as low if the respondent did
not study higher than ninth grade
 Smoking status was categorized into three groups:
 non-smokers
 ex-smokers
 current smokers

10. MATERIALS AND METHODS
 Regular exercise was defined as strenuous physical activity
performed for at least 20 minutes thrice/week
 Daily calcium intake was evaluated using a structured food
frequency questionnaire
 A face to-face interview was used to obtain data about
residential place and occupation

11. MATERIALS AND METHODS
 Anthropometric Measurements
 Body weight and height were measured to the nearest 0.1 kg
and 0.1 cm
 Waist circumference was measured at the narrowest point
between the lower border of the rib cage and the iliac crest

12. MATERIALS AND METHODS
 Body mass index (BMI) was calculated using the formula
weight/height2 (kg/m2)
 A standard mercury sphygmomanometer was used to
measure systolic blood pressure and diastolic blood
pressure

13. MATERIALS AND METHODS
 Periodontal Treatment Needs
 Assessed using WHO CPI probe
 Defined participants with periodontal treatment needs as CPI
code 3
 A CPI score of code 3 indicates that
≥1 site had a >3.5-mm pocket in the index teeth, which are
11,16/17, 26/27,31, 36/37, 46/47
 mouth was divided into sextants
 CPI probe with 0.5-mm ball tip
 approximately 20-g probing force was used

14. MATERIALS AND METHODS
 Biochemical Measurements
 Blood samples were collected from the antecubital vein of each
participant after fasting for >8 hours to measure white blood cell
count and concentrations of serum FPG,TC, HDL-C, TG, insulin,
and serum 25- hydroxyvitamin D

15. MATERIALS AND METHODS
 Serum 25-hydroxyvitamin -D : 25-hydroxyvitamin -D 125I RIA kit
 Levels of FPG, TC, HDL-C, and TG : automatic analyzer by
enzymatic methods using commercially available kits
 Insulin levels : immunoradiometric assay using a kit
 WBC counts - laser flow cytometry

16. MATERIALS AND METHODS
 To be diagnosed with metabolic syndrome, 3 of the following
criteria were considered to be fulfilled:
 1) waist circumference ≥90 cm (M), ≥80 cm (F)
 2) fasting TG ≥150 mg/dL
 3) HDL-C <40 mg/dL (M) and <50 mg/dL (F)
 4) blood pressure ≥130/85 mm Hg
 5) FBG ≥100 mg/dL

17. MATERIALS AND NETHODS
 Diabetes was diagnosed when fasting blood sugar was >126
mg/dL or individual was using antidiabetic medications
 Hypertension was defined as systolic blood pressure
>160/90 mm Hg, or current use of systemic antihypertensive
drugs

18. MATERIALS AND METHODS
 Statistical Analyses
 Statistical analyses were performed using the survey procedure
of the statistical software package to account for the complex
sampling design
 P values <0.05 were considered statistically significant
 Odds ratios (ORs) and 95% confidence intervals (CIs) were
estimated after adjustment for potential confounders

19. RESULTS

21. Oral hygiene showed statistically significant relationships with periodontal
treatment needs

22. Adjusted OR (95% CI) of Periodontal Treatment
Needs (CPI ≥3) in Multivariate Logistic Regression
Model for Drinking
Association between drinking and periodontal treatment needs
remained after adjustment

23. Adjusted OR (95% CI) of Periodontal Treatment
Needs (CPI ≥3) in Multivariate Logistic Regression
Model for Drinking
In females, statistically significant correlations between drinking and
periodontal treatment needs could not be seen

24. DISCUSSION
 Previous cross-sectional studies have evaluated the effects
of alcohol consumption on the severity of periodontal
disease
 Alcohol consumption was reported to be associated with an
increased severity of clinical attachment loss (CAL) in a
dose-dependent fashion after controlling for age, gender,
education, income, smoking, diet, diabetes, number of
remaining teeth, and gingival bleeding
 Amaral CS, Luiz RR, Lea˜o AT. The relationship between alcohol dependence and
periodontal disease. J Periodontol 2008;79:993-998
 Tezal M, Grossi SG, Ho AW, Genco RJ. Alcohol consumption and periodontal disease.
The Third National Health and Nutrition Examination Survey. J Clin Periodontol
2004;31:484-488

25. DISCUSSION
 Other reports showed that the effect of drinking on periodontal
conditions is limited to individuals with deep periodontal pockets
associated with more than one-third of their teeth
 In another report, higher alcohol consumption, particularly the
intake of wine, was inversely associated with AL in men, but
such an association was not found in women
 Shimazaki Y, Saito T, Kiyohara Y, et al. Relationship between drinking and periodontitis: The
Hisayama Study. J Periodontol 2005;76:1534-1541
 Kongstad J, Hvidtfeldt UA, Grønbaek M, Jontell M, Stoltze K, Holmstrup P. Amount and type
of alcohol and periodontitis in the Copenhagen City Heart Study. J Clin Periodontol
2008;35:1032-1039

26. DISCUSSION
 As with any study, there is the possibility of residual
confounding by habits and lifestyle factors
 Smoking is associated with alcohol drinking, and to some
degree, the observed association may be due to residual
confounding by smoking
 Within the present study, men had a higher percentage of
current and ex-smokers compared with women

27. DISCUSSION
 Alcohol drinking may be associated with poor oral hygiene
practices, and the effect of alcohol on periodontal disease has
been explained by poor oral hygiene of chronic alcohol
consumers
 Similarly, periodontal diseases appeared to be caused primarily
by bad oral hygiene and poor dental care in heavy drinkers
 A negative association between the number of times of
toothbrushing and alcohol intake has been reported in Finland

28. DISCUSSION
 Socioeconomic status seems to be related to periodontal
treatment needs
 Percentages of males with periodontal treatment needs were
(max) 39.5% -middle school graduates and 25.4% (min) -
high school graduate
 Percentages of females with periodontal treatment needs
were (max) 26.0% -middle school graduates and 10.4%
(min) - university or higher groups
 Percentages of males and females with periodontal
treatment needs were least - 26.0% and 14.7% for the fourth
quartile of income

29. DISCUSSION
 There are several possible explanations for the detrimental
effects of alcohol on periodontal disease
 Alcohol impairs neutrophil function and increases monocyte
production of inflammatory cytokines, such as TNF-α and
IL-1 and -6, in the gingival crevice

30. DISCUSSION
 Elevated monocyte prostaglandin E2 is seen in acute
ethanol-stimulated human monocytes, and prostaglandin E2
is considered a potent stimulator of bone resorption a/w loss
of periodontal attachment tissue
 Alcohol may stimulate bone resorption and inhibit bone
formation by a direct effect of ethanol or by a rise in cortisol
 Systemic conditions may modify the host response against
periodontal pathogens, and these factors can increase the
host’s susceptibility for periodontal disease activity

31. DISCUSSION
 A bidirectional relationship between diabetes and periodontal
disease is suggested, and there is evidence that hyperglycemia
in diabetes is associated with adverse periodontal outcomes
 Significant associations were noted with hypertension and
periodontal disease, and periodontal disease was associated
with metabolic syndrome
 Previous studies reported that calcium intake affected bone
mineral density, peak bone mass, and calcium balance and was
important in the maintenance of bone health

32. DISCUSSION
 Vitamin D is involved in the proper mineralization of bone, and
the intake of vitamin D is necessary for the maintenance of
healthy bones
 The above discoveries may explain the association of higher
alcohol intake with periodontal treatment needs
 Further studies are needed to confirm this relationship and to test
for possible underlying mechanisms

33. CONCLUSION
 Men with a higher alcohol intake were more likely to have
periodontal treatment needs regardless of their age,
socioeconomic factors, systemic conditions (including diabetes,
hypertension, and metabolic syndrome), and the number of times
of toothbrushing per day in multivariable adjusted models
 By contrast, in women, alcohol intake was not independently
associated with periodontal treatment needs

34. Strengths of the study
 Present study uses nationally representative sample of
Koreans with sufficient power for the investigation of these
relationships
 An additional strength is the availability of relevant
confounding factors
 Considers the relation of medium level alcoholics with the
periodontal needs

35. Limitations of the study
 Design of this study is cross-sectional where exposure and
outcome are measured at the same time, while their
interrelated sequences are unknown
 Use of partial-mouth recording protocols of CPI may
underestimate the prevalence of periodontal disease
 Confounding effects of presence of microbial pathogens was
not controlled
 It was not made sure if the subjects included had periodontal
problems after acquiring the habit of drinking alcohol

36. CONCLUSION
 Within the limits of this study, alcohol drinking is not a true
risk factor but a POTENTIAL RISK INDICATOR for
periodontal treatment needs in men
 Further prospective studies are needed to confirm this
relationship and to test for possible underlying mechanisms

37. RELATED STUDIES
 Effect of alcohol consumption on periodontal disease
Mine Tezal et al
J. Periodontol February 2001
 The relationship between alcohol and periodontal
disease Christine de silva et al
J. Periodontol June 2008
 Alcohol Consumption and Periodontitis: Quantification
of Periodontal Pathogens and Cytokines Eugenio J. P. et
al
Journal of Periodontology 2015
 The effect of alcohol consumption on periodontal bone
support in experimental periodontitis in rats Daniela
martins de souza et al
 Journal of Applied Oral Sciences 2006

38. THANK YOU
HAVE A GOOD DAY