Johnston

ORIGINALand
ARTICLE
Vieira

Caries Experience and Overall Health Status

Lindsay Johnstona/Alexandre R. Vieirab

Purpose: The aim of this work was to evaluate whether self-reported systemic diseases were associated with caries
experience.

Materials and Methods: Medical history data and caries experience (DMFT and DMFS; Decayed, Missing due to car-
ies, Filled Teeth/Surface) were obtained from the University of Pittsburgh School of Dental Medicine dental registry and
DNA repository. Information on 1,281 subjects was evaluated (839 with primary caries and 492 with secondary caries
experience). Regression analysis was used to test for association between caries experience and disease status.

Results: Associations were found between caries experience and specific conditions: stroke (R2 = 0.007, P = 0.001),
asthma (R2 = 0.003, P = 0.025), hepatitis (R2 = 0.009, P = 0.0001), liver disease (R2 = 0.009, P = 0.00001), high
blood pressure (R2 = 0.072, P = 0.00001) and diabetes (R2 = 0.03, P = 0.00001). We found primary caries to be as-
sociated with hepatitis (DMFT with R2 = 0.011, P = 0.002 and DMFS with R2 = 0.008, P = 0.006). We also found an
association between secondary caries and asthma (DMFS with R2 = 0.006, P = 0.04), high blood pressure (DMFT with
R2 = 0.014, P = 0.005 and DMFS with R2 = 0.043, P = 0.00001) and diabetes (DMFT with R2 = 0.013, P = 0.007 and
DMFS with R2 = 0.023, P = 0.00001).

Conclusion: Hepatitis, asthma, high blood pressure, stroke, liver disease and diabetes are associated with higher car-
ies experience.

Key words: AIDS, asthma, cardiovascular diseases, caries, diabetes, epilepsy, hepatitis, high blood pressure, HIV,
kidney disease, liver disease, stroke, tuberculosis

Oral Health Prev Dent 2014;2:163-170 Submitted for publication: 25.08.12; accepted for publication: 26.02.13
doi: 10.3290/j.ohpd.a31670

O ver the last decade, the possible role of oral

health as a risk factor for systemic disease has
been highlighted in multiple instances. Evidence
from paleopathology, medical explorers’ accounts,
population migration data, World Wars I and II and
epidemiology suggests caries and systemic chron-
ic non-communicable diseases are associated.
Dental and systemic disease associate based on
geography, genetics, history and cluster within indi-
viduals and within populations (Hujoel, 2009).
Family physicians commonly encounter patients
with caries (Nguyen and Martin, 2008). It is suggest-
a
System Analyst, Health Information Management, School of
Health and Rehabilitation Sciences, University of Pittsburgh,
Pittsburgh, PA, USA.
b
Associate Professor, Department of Oral Biology, University of
Pittsburgh, Pittsburgh, PA, USA.
Correspondence: Alexandre R. Vieira, 614 Salk Hall, Department of
Oral Biology, School of Dental Medicine, University of Pittsburgh,
3501 Terrace Street, Pittsburgh, PA, USA 15261. Tel: +1-412-383-
8972, Fax: +1-412-624-3080. Email: arv11@pitt.edu
ed that every individual should visit her/his dentist
at least once a year (Kay, 1999). However, poor and
minority individuals, who experience greater levels
of both dental and systemic disease, frequently face
cost and other system-level barriers to obtaining
care in the private practice dental delivery system
(Manski et al, 2001; Green et al, 2003; Riley et al,
2003). For these individuals, non-traditional sources
of dental care, such as physicians’ offices, other
medical settings and the hospital emergency room,
have been alternative options (Cohen and Manski,
2006). Unfortunately, according to a cross-section-
al, random-digit telephone survey sponsored by the
CDC and all US states and territories in 2003 (Lutfiy-
ya et al, 2008), although periodic medical examina-
tions of healthy individuals aiming to foster patients’
good health is proposed (American Medical Associa-
tion, 1983), only 2.6% of 97,001 healthy adults re-
ported have received primary prevention.
Even though the issues related to access to care
need to be addressed, dentistry has an important

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Johnston and Vieira
role in promoting overall health. While physicians
are missing opportunities to provide primary pre-
vention, the promotion of oral health has been sug-
gested as a way to promote overall health, since
there is a possible role of oral infections as a risk
factor for systemic disease. Caries remains the
most prevalent non-transmissible infectious dis-
ease in the USA and in the rest of the world (World
Health Organization, 2003). Research on the rela-
tionship between caries and systemic diseases has
provided evidence that caries may be associated
with cardiovascular diseases (Holm-Pedersen et al,
2005; Sugihara et al, 2010), esophageal cancer
(Dye et al, 2007), asthma (Stensson et al, 2008;
Anjomshoaa et al, 2009) and epilepsy (Anjomshoaa
et al, 2009). At least some of these associations
are proposed to be related to dietary habits. It has
been postulated that prevention of caries through
fermentable carbohydrate restriction helps reduce
the burden of diabetes, myocardial infarction and
other chronic non-communicable diseases (Yudkin,
1972a,b; Cleave, 1974; Hujoel, 2009).
In this study, a population from Pittsburgh, Penn-
sylvania was examined, since this population is at
particularly high risk for both oral and overall chron-
ic diseases (Anjomshoaa et al, 2009). Pittsburgh is
the largest city in the Appalachian region of the
United States and one of the poorest in the coun-
try. Despite the fact that Pittsburgh has had fluori-
dated water since 1953, nearly half of the children
in Pittsburgh between 6 and 8 years old have had
cavitated carious lesions according to a 2002
State Department of Health report (Pennsylvania
Department of Health, 2002). More than 70% of
15-year-olds in the city have had cavitated carious
lesions, the highest percentage in the state. Close
to 30% of the city’s children have untreated cavi-
tated carious lesions. That is more than double the
state average of 14%.
A better understanding of the possible relation-
ships between caries experience and systemic dis-
eases may provide new insight into the influences
of oral health on overall health. The purpose of this
study was to investigate whether caries experience
indicators are associated with concomitant sys-
temic disease in a high-risk population.
MATERIALS AND METHODS
All subjects were participants in the Dental Regis-
try and DNA Repository (DRDR) of the University of
Pittsburgh School of Dental Medicine. The primary
164
role of the School of Dental Medicine is to educate
dental health professionals, and students depend
on the patients’ commitment to complete neces-
sary educational requirements. For the most part,
patients treated are from the greater Pittsburgh
area; individuals with lower socioeconomic status
and hence higher risk for all oral and overall health
problems tend to be over-represented in the pa-
tient pool. However, the population treated at the
School of Dental Medicine and the individuals par-
ticipating in the registry well represent the distribu-
tion of individuals from Pittsburgh, which is com-
prised of approximately 65% Whites, 26% African
Americans with the remaining consisting of Hispan-
ics, Asians and other groups. Since September of
2006, all individuals seeking treatment at the Uni-
versity of Pittsburgh School of Dental Medicine
have been invited to be part of the registry. These
individuals give written informed consent authoris-
ing the extraction of information from their dental
records and collection of a saliva sample. Saliva
samples are stored for future genetic studies. This
project is approved by the University of Pittsburgh
Institutional Review Board. In January 2012, data
from 1,281 individuals with complete information
on medical history and caries experience were ex-
tracted from the registry for this project. Medical
history data are obtained from a standard form
used at the dental clinics. Patients are asked to fill
out the medical history form and information is
then revised by the dentist with the patient. The
severity of self-reported conditions is not described
in more detail unless it impacts potential dental
treatment; variables related to the severity of self-
reported medical conditions could not be included
in the present study.
To detect any confounders, ANOVA and Student’s
t-test were employed to determine sex and ethnicity
differences in caries experience. Further, simple
chi-square tests were used to determine sex and
ethnicity differences in each of the diseases re-
corded in the medical history. Caries experience
was defined by the DMFT (Decayed, Missing teeth
due to caries, Filled Teeth) and DMFS (Decayed,
Missing teeth due to caries, Filled Surfaces) scores.
These scores were generated from the information
from the last dental visit and were based on a mod-
ified World Health Organization protocol that also
included evaluations of radiographs and incipient
enamel (white spot) lesions. In other words, both
lesions in dentin (D3) and lesions in enamel (D1)
contributed to the DMFT and DMFS scores. Caries
experience data were recorded at the dental office
Oral Health & Preventive Dentistry

with the use of proper illumination and with the gen-
tle use of the explorer. Missing teeth due to perio-
dontal disease, trauma or orthodontic treatment
were not counted in the DMFT/DMFS scores to
avoid inflating these indexes. Also, dental prosthe-
ses involving sound teeth as bases for pontics were
not counted as filled teeth to avoid inflating the
DMFT/DMFS scores. These data were revised by a
calibrated dentist from a team of 12 professionals.
Calibration is performed annually before the start
of every school year but no inter- or intra-examiner
agreement rate data are generated. Individuals
were also defined as having primary disease experi-
ence (individuals with no evidence of failed restora-
tive treatment) or secondary disease experience
(individuals with evidence of recurrent carious le-
sions and previous restorations that failed). Logis-
tic regression was used to analyse main-effect
models to predict caries status based on self-re-
ported past and current disease status collected
from the medical history included in the registry.
The confounding variables included age, sex, eth-
nicity, tobacco use, alcohol use and medication in-
take. All analyses were adjusted for these variables.
RESULTS
Table 1 provides frequencies of self-reported sys-
temic conditions by sex and ethnicity. A total of
1,281 subjects were studied, with ages ranging
from 6 to 94 years and a mean age of 47.71 years
(median 48 years, standard deviation 17.68 years).
The univariate logistic regression analysis of all
data provided statistical evidence of an associa-
tion between caries and stroke (DMFT with
R2 = 0.006, P = 0.004 and DMFS with R2 = 0.007,
P = 0.001), asthma (DMFT with R2 = 0.003,
P = 0.03 and DMFS with R2 = 0.003, P = 0.025),
hepatitis (DMFT with R2 = 0.008, P = 0.001 and
DMFS with R2 = 0.009, P = 0.0001), liver disease
(DMFT with R2 = 0.009, P = 0.00001 and DMFS
with R2 = 0.008, P = 0.001), high blood pressure
(DMFT with R2 = 0.038, P = 0.00001 and DMFS
with R2 = 0.072, P = 0.00001) and diabetes (DMFT
with R2 = 0.019, P = 0.00001 and DMFS with
R2 = 0.03, P = 0.00001).
839 participants out of 1,281 in the DRDR had
primary carious lesions, a 65.5% prevalence rate.
Subjects’ ages ranged from 6 to 94 years, with a
mean age of 46.10 years (median 45.13 years,
standard deviation 17.77 years). The mean DMFT
score was 17.08, while the mean DMFS was 56.58.
Vol 12, No 2, 2014
Johnston and Vieira
DMFT scores ranged from 0 to 28, while DMFS
scores ranged from 0 to 140.
Table 3 shows the results from the univariate lo-
gistic regression for individuals with primary caries.
Primary caries was found to be associated with
hepatitis (DMFT with R2 = 0.011, P = 0.002 and
DMFS with R2 = 0.008, P = 0.006). No other dis-
ease showed a statistically significant association
with primary caries.
Of the 1,281 participants listed in the DRDR,
492 had secondary carious lesions, a 38.4% preva-
lence rate. The subjects’ ages ranged from 11 to
89 years, with a mean age of 50.48 years (median
52 years, standard deviation 17.18 years). The
mean DMFT score was 18.35, while the mean
DMFS score was 61.74. DMFT scores ranged from
1 to 28, while DMFS scores ranged from 1 to 128.
Table 4 shows the results on secondary caries
from the univariate logistic regression. An associa-
tion was found between secondary caries and asth-
ma (DMFS with R2 = 0.006, P = 0.04), high blood
pressure (DMFT with R2 = 0.014, P = 0.005 and
DMFS with R2 = 0.043, P = 0.00001) and diabetes
(DMFT with R2 = 0.013, P = 0.007 and DMFS with
R2 = 0.023, P = 0.00001).
DISCUSSION
This cross-sectional analysis of a population from
Pittsburgh, PA, USA at high risk for caries experi-
ence and systemic diseases provides evidence
that supports an association between caries expe-
rience and specific systemic conditions, namely
hepatitis, asthma, high blood pressure, stroke, liv-
er disease and diabetes.
Asthma is one of the most common chronic ail-
ments in children and its frequency has steadily in-
creased in the last two decades (Mannino et al,
1998; Steinbacher and Glick, 2001). A number of
studies have investigated oral health in individuals
with asthma, but the results are conflicting. Meta-
analysis suggests that being affected by asthma
doubles the risk of caries in both primary and per-
manent dentition (Alavaikko et al, 2011). The pre-
sent results confirm a previous analysis of a dataset
from Pittsburgh (Anjomshoaa et al, 2009) and the
meta-analysis by Alavaikko et al (2011) which sug-
gested an association between higher caries experi-
ence and asthma in adults. Individuals with asthma
appear to accumulate higher amounts of dental bio-
film, as well as present with higher salivary levels of
mutans streptococci (Botelho et al, 2011). `2 ago-
165
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Table 1 Total* individuals affected by selected systemic conditions by sex and ethnicity and mean DMFT and DMFS
by sex and ethnicity
Primary Secondary Disease status by Primary Secondary
Disease status by sex (N) caries caries ethnicity (N) caries caries
Females 79 44 White 82 48
Asthma Males 38 18 Black 26 11
Other 9 3
Females 35 29 White 42 34
Diabetes Males 39 24 Black 27 13
Other 5 6
Females 18 9 White 25 14
Epilepsy Males 18 12 Black 7 5
Other 4 2
Females 13 6 White 24 15
Hepatitis Males 17 11 Black 5 2
Other 1 0
Females 97 72 White 129 105
High blood
Males 95 68 Black 52 28
pressure
Other 11 7
Females 0 0 White 6 3
HIV/AIDS Males 8 4 Black 2 1
Other 0 0
Females 9 6 White 9 6
Kidney disease Males 5 4 Black 4 3
Other 1 1
Females 4 3 White 12 9
Liver disease Males 12 8 Black 4 2
Other 0 0
Females 8 9 White 14 11
Stroke Males 12 8 Black 5 5
Other 1 1
Females 6 4 White 8 5
Tuberculosis Males 6 3 Black 2 1
Other 2 1
Primary Secondary Caries experience Primary Secondary
Caries experience by sex caries caries by ethnicity caries caries
Females 17.08 18.12 White 17.93 18.69
DMFT Mean Males 17.07 18.62 Black 15.88 17.7
Other 13.65 39.16
Females 56.58 60.93 White 60.15 62.78
DMFS Mean Males 56.67 62.63 Black 52.94 60.88
Other 39.16 53.05
* Some individuals reported more than one disease, hence totals from this table are larger than the number of subjects studied.

166 Oral Health & Preventive Dentistry

 Johnston and Vieira

Table 2 Summary results of the analysis with caries

Medication Tobacco Alcohol
  Statistic Age Sex Ethnicity use use use DMFT DMFS
2
Adjusted R -0.001 -0.001 -0.001 0.01 0.002 0.012 0.00 0.00
Epilepsy
P-value 0.666 0.566 0.937 0.0001 0.056 0.0001 0.407 0.392
2
Adjusted R 0.008 0.00 0.001 0.013 0.001 -0.001 0.006 0.007
Stroke
P-value 0.0001 0.526 0.168 0.0001 0.117 0.649 0.004 0.001

Adjusted R2 -0.001 0.019 0.00 0.016 -0.012 -0.001 0.003 0.003

Asthma
P-value 0.725 0.00001 0.272 0.00001 0.317 0.958 0.03 0.025

Adjusted R2 0.00 -0.001 0.00 0.00 0.001 0.001 0.001 0.001

Tuber-
culosis
P-value 0.461 0.892 0.399 0.297 0.157 0.087 0.118 0.168

Adjusted R2 0.001 0.001 -0.001 0.001 0.016 0.017 0.008 0.009

Hepatitis
P-value 0.097 0.137 0.71 0.104 0.00001 0.0001 0.001 0.0001
2
Adjusted R 0.005 0.004 0.00 0.003 0.00 0.025 0.009 0.008
Liver
disease
P-value 0.007 0.008 0.217 0.018 0.468 0.00001 0.00001 0.001
2
High Adjusted R 0.194 -0.001 0.009 0.17 0.004 -0.001 0.038 0.072
blood
pressure P-value 0.00001 0.938 0.0001 0.00001 0.01 0.99 0.00001 0.00001
2
Adjusted R 0.051 -0.001 0.006 0.042 0.004 0.00 0.019 0.03
Diabetes
P-value 0.00001 0.869 0.003 0.00001 0.016 0.44 0.00001 0.00001
2
Adjusted R -0.001 0.009 0.00 0.002 0.003 0.005 0.00 -0.001
HIV/AIDS
P-value 0.737 0.00001 0.315 0.016 0.037 0.007 0.423 0.673

nists in asthma medication decrease the salivary
secretion rate, and patients using these products
have increased levels of lactobacilli and mutans
streptococci (Ryberg et al, 1987, 1991). Although it
is possible that medication use increases suscepti-
bility for caries, the present data does not suggest
that medications are associated with higher caries
experience in asthmatics. Genes in the immune
signaling pathway are differentially expressed in
asthmatic individuals (Schmidt-Weber, 2006) and
could underlie the association between asthma and
high caries experience. One of these genes is CD-
14, which is described as a classical example of a
gene-environment interactive factor in asthma
(Simpson et al, 2006). Variation in CD-14 has been
also associated with resistance to abscess or fistu-
la formation in children with four or more caries le-
sions (De Soet et al, 2008). Immune response regu-
lators may be the common factors that underlie the
association between asthma and caries.
Asthma is unlikely to be a single disease but
rather a series of complex, overlapping individual
diseases or phenotypes, each defined by its unique
interaction of genetic and environmental factors.
These conditions include syndromes characterised
by allergen-exacerbated, non-allergic and aspirin-
exacerbated factors along with syndromes best
distinguished by their pathological findings (eosino-
philic, neutrophilic, pauci-granulocytic), response
to therapy (corticosteroid resistant) and natural his-
tory (remodeling prone) (Borish and Culp, 2008).
The data available for this study were taken from
self-reported medical histories and none of the de-
tailed descriptions listed above were available. Al-
lergic sensitisation can be detected by a positive
skin-test result to at least one common allergen in
93.5% of cases with severe asthma (Expert Panel
Report 3, 2007). Non-allergic asthma has a more
likely onset during adulthood, and shows female
predominance and a higher degree of severity

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Table 3 Summary results of the analysis with primary caries

Medication Tobacco Alcohol

  Statistic Age Sex Ethnicity use use use DMFT DMFS
2
Adjusted R -0.001 -0.001 -0.001 0.013 0.009 0.001 0.00 0.00
Epilepsy
P-value 0.473 0.994 0.787 0.001 0.004 0.186 0.265 0.311
2
Adjusted R 0.012 0.00 0.00 0.012 0.00 0.003 0.002 0.007
Stroke
P-value 0.001 0.363 0.439 0.001 0.405 0.059 0.128 0.008

Adjusted R2 -0.001 0.019 0.00 0.015 0.002 -0.001 -0.001 0.002

Asthma
P-value 0.502 0.00001 0.414 0.00001 0.113 0.805 0.880 0.099

Adjusted R2 0.000 -0.001 -0.001 -0.001 0.002 -0.001 0.00 0.001

Tuber-
culosis P-value 0.442 0.997 0.490 0.473 0.100 0.594 0.295 0.191

Adjusted R2 0.001 -0.001 -0.001 0.004 0.020 0.004 0.011 0.008

Hepatitis
P-value 0.163 0.454 0.789 0.034 0.00001 0.034 0.002 0.006

Adjusted R2 0.006 0.004 0.00 0.003 0.022 -0.001 -0.001 0.010

Liver
disease P-value 0.017 0.043 0.288 0.059 0.00001 0.885 0.541 0.002

Adjusted R2 0.196 -0.001 0.100 0.135 -0.001 0.015 0.002 0.053

High blood
pressure P-value 0.00001 0.884 0.002 0.00001 0.996 0.00001 0.087 0.00001

Adjusted R2 0.053 -0.001 0.011 0.039 -0.001 0.001 0.001 0.021

Diabetes
P-value 0.00001 0.619 0.002 0.00001 0.903 0.233 0.226 0.00001

Adjusted R2 -0.001 0.008 -0.001 0.001 0.005 0.005 0.003 -0.001

HIV/AIDS
P-value 0.545 0.004 0.455 0.184 0.018 0.021 0.048 0.572

(Bell, 2004). This is noteworthy, since the results
of this study show more women affected by asth-
ma (Table 1).
Our initial work also suggested epileptic individu-
als have a higher caries experience (Anjomshoaa et
al, 2009), but these findings were not confirmed in
the current analysis. With respect to high blood
pressure and stroke, association with higher caries
experience may be influenced by medication intake
and older age. Chronic use of medication to control
blood pressure may decrease salivary flow, which
can then increase caries activity (Tuominen et al,
2003). A link between active root caries and cardi-
ac arrhythmias may exist in individuals older than
80 years (Holm-Pedersen et al, 2005) but our study
population was not enriched with individuals from
that age group. Similarly, diabetes is associated
with older age and medication intake in the present
data; these factors may lead to the loss of caries-
protective effect of saliva (Collin et al, 1998). Car-
ies is also associated with intervals of more than
one year since the last dental visit in patients with
liver disease (Guggenheimer et al, 2007). These
patients have high rates of edentulism when older,
which may inflate DMFT and DMFS scores despite
the fact that the current sample is not enriched
with the very elderly, who are particularly less likely
to have had a recent dental evaluation (mean of 88
months since the last dental appointment).
This study has several weaknesses that deserve
consideration. Caries data were extracted from clini-
cal patient records which presumably have a good
level of standardisation in the description of the
presence of caries lesions, fillings and extracted
teeth due to the fact that the records belong to the
same educational institution and thus follow a single
philosophy; nevertheless, the data could be influ-
enced by variation in the way caries is described. The
definitions used here for systemic diseases – de-
spite being comprehensive – are based on self-re-
ported information, and may lack precision in some
instances. Regarding the DMFT and DMFS scores,

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Table 4 Summary of the results of the analysis with secondary caries

Medication Tobacco Alcohol

  Statistic Age Sex Ethnicity use use use DMFT DMFS
2
Adjusted R -0.002 0.00 -0.001 0.005 0.004 0.016 -0.002 -0.002
Epilepsy
P-value 0.813 0.350 0.589 0.058 0.090 0.003 0.960 0.998
2
Adjusted R 0.002 -0.002 0.001 0.012 -0.001 -0.002 0.001 0.002
Stroke
P-value 0.179 0.994 0.197 0.009 0.505 0.818 0.248 0.183

Adjusted R2 -0.002 0.017 -0.001 0.017 -0.001 -0.001 0.003 0.006

Asthma
P-value 0.632 0.002 0.466 0.002 0.527 0.424 0.111 0.046

Adjusted R2 -0.002 -0.002 -0.002 -0.001 0.00 -0.001 -0.001 -0.001

Tuber-
culosis P-value 0.832 0.819 0.628 0.427 0.339 0.477 0.388 0.452

Adjusted R2 0.00 0.002 -0.002 -0.002 0.024 0.015 0.007 0.006

Hepatitis
P-value 0.346 0.141 0.792 0.868 0.00001 0.009 0.340 0.051

Adjusted R2 0.001 0.004 -0.001 0.002 -0.002 0.026 0.006 0.003

Liver
disease P-value 0.204 0.086 0.510 0.165 0.692 0.00001 0.045 0.101

Adjusted R2 0.184 -0.002 0.005 0.142 0.006 -0.002 0.014 0.043

High blood
pressure P-value 0.00001 0.692 0.068 0.00001 0.046 0.926 0.005 0.00001

Kidney Adjusted R2 0.003 -0.002 -0.001 0.006 -0.001 0.000 0.001 0.001
disease or
dialysis P-value 0.132 0.648 0.454 0.048 0.452 0.370 0.204 0.211

Adjusted R2 0.044 -0.002 -0.001 0.044 0.009 0.00 0.013 0.023

Diabetes
P-value 0.00001 0.773 0.474 0.00001 0.020 0.295 0.007 0.00001

Adjusted R2 -0.002 0.007 -0.001 0.001 -0.001 0.002 -0.001 -0.002

HIV/AIDS
P-value 0.817 0.034 0.497 0.215 0.527 0.173 0.446 0.876

one can argue that they may be inflated in adults by
the inherent deficiencies of restorative materials and
techniques. In addition, failed fillings are relatively
common and replaced with larger ones encroaching
on more surfaces. Common periodontal and pros-
thetic reasons for tooth extraction as well as simple
economic choices can also inflate caries scores. Al-
though these factors were considered when extract-
ing the caries data, they may still have influenced the
data. Additional modeling was performed using only
the number of decayed teeth and the results did not
change to any relevant extent (data not shown), which
may partially suggest that the caries experience data
used here is not heavily influenced by the variables
described above. Caries incidence rates and years of
systemic disease experience would have been more
desirable measures, but it was not possible to ex-
trapolate this information from the majority of indi-
viduals studied. DMFT and DMFS scores from adults
provide very little insight on how the disease pro-
gressed (active acute and chronic vs inactive peri-
ods) and no longitudinal data were available to allow
evaluation of disease progression.
CONCLUSION
Although our study is based on self-reported medi-
cal history and therefore cannot provide more detail
on the specific types of conditions the subject re-
ported, we had the advantage of studying a group at
higher risk for systemic diseases and with very high
caries experience. This factor likely decreased het-
erogeneity and improved the ability to find associa-
tions. This study provides statistically significant evi-
dence that caries is associated with asthma,

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Johnston and Vieira
diabetes, hepatitis, liver disease, high blood pres-
sure and stroke. These results are potentially impor-
tant because they suggest that individuals suffering
from these conditions should receive more individu-
alised attention regarding caries prevention.
ACKNOWLEDGEMENTS
The authors are indebted to the individuals who participated in this
study. Jacqueline Noel provided administrative support. Sarah Vin-
ski revised the text for grammar and style. Data for this study was
provided by the Dental Registry and DNA Repository of the School
of Dental Medicine, University of Pittsburgh. Financial support was
provided by the School of Dental Medicine, University of Pittsburgh,
and by the NIH Grant 5TL1RR024155.
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