Alcohol use and periodontal condition : results of population-based surveys

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DISSERTATIONS | RAJESWARI SANKARANARAYANAN | ALCOHOL USE AND PERIODONTAL CONDITION... | No 537

uef.fi

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND Dissertations in Health Sciences

ISBN 978-952-61-3217-4 ISSN 1798-5706

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

RAJESWARI SANKARANARAYANAN

ALCOHOL USE AND PERIODONTAL CONDITION

—RESULTS OF POPULATION-BASED SURVEYS

Alcohol Use and Periodontal Condition

This doctoral study examined the short and

long-term effects of alcohol use on periodontal condition in the Finnish adult population. The

findings showed no consistent association between the use of alcohol and the presence or

development of periodontal pockets. However, this study highlights that (i) individual factors

such as age, gender, and socioeconomic position could modify this association; and (ii) different alcohol use measures could have

different effects on periodontal condition.

RAJESWARI SANKARANARAYANAN

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ALCOHOL USE AND PERIODONTAL CONDITION—RESULTS OF POPULATION-

BASED SURVEYS

ALCOHOL USE AND PERIODONTAL CONDITION

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Rajeswari Sankaranarayanan

ALCOHOL USE AND PERIODONTAL CONDITION—RESULTS OF POPULATION-

BASED SURVEYS

ALCOHOL USE AND PERIODONTAL CONDITION

To be presented by permission of the

Faculty of Health Sciences, University of Eastern Finland for public examination in CA100 Auditorium, Kuopio

on 15 November, 2019, at 12 o’clock noon Publications of the University of Eastern Finland

Dissertations in Health Sciences No 537

Institute of Dentistry University of Eastern Finland

Kuopio 2019

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Associate professor (Tenure Track) Tarja Kvist, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Kai Kaarniranta, M.D., Ph.D.

Institute of Clinical Medicine, Ophthalmology Faculty of Health Sciences

Associate Professor (Tenure Track) Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O. Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto

Grano Oy, 2019 ISBN:978-952-61-3217-4(Print)

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Author’s address: Institute of Dentistry University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral Programme of Clinical Research Supervisors: Professor Anna Liisa Suominen, Ph.D.

Institute of Dentistry University of Eastern Finland KUOPIO

FINLAND

Professor Pekka Ylöstalo, Ph.D.

Department of Periodontology and Geriatric Dentistry University of Oulu

OULU FINLAND

Clinical lecturer Tuomas Saxlin, Ph.D.

Institute of Dentistry University of Eastern Finland KUOPIO

FINLAND

Reviewers: Docent Anna Maria Heikkinen, Ph.D.

Department of Oral health care City of Tampere

TAMPERE FINLAND

Postdoctoral researcher Tarja Tanner, Ph.D.

Department of Cariology, Endodontology & Pediatric Dentistry University of Oulu

OULU FINLAND

Opponent: Docent Kimmo Suomalainen, Ph.D.

Department of Oral and Maxillofacial Diseases, Tampere University Hospital,

TAMPERE FINLAND

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Sankaranarayanan, Rajeswari

Alcohol use and periodontal condition—results of population-based surveys Alcohol use and periodontal condition

Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 537. 2019, 74 p.

ISBN:978-952-61-3217-4(Print) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3218-1 (PDF) ISSN: 1798-5714 (PDF)

ABSTRACT

The effects of alcohol use on periodontal health are still unclear due to inconsistent findings from earlier epidemiological studies. Establishing whether alcohol use has a detrimental effect on periodontal health has been hampered by the limited number of longitudinal studies (especially incidence studies) and less evidence about the effects of different alcoholic beverages on the periodontium. The objective of this dissertation was to investigate whether alcohol use is associated with the presence and development of periodontal pockets.

In this dissertation, the cross-sectional studies (I–II) used data from the Health 2000 Survey, and the four-year longitudinal study (III) used data from the Health 2000 Survey and the Follow-up Survey on Finnish Adults’ Oral Health, whereas the 11-year longitudinal study (IV) used data from the Health 2000 Survey and the Health 2011 Survey. Participants’ periodontal condition was examined during the clinical oral examination, and information on alcohol use was obtained from the questionnaire and laboratory investigation (Gamma-glutamyltransferase, GGT).

Cross-sectional data were analyzed using the zero-inflated negative binomial regression model, while longitudinal data were analyzed using the negative binomial regression model and the Poisson regression model with robust variance estimator.

In the cross-sectional data, alcohol use (amount, frequency, use over the risk limit, type of beverage, and GGT) was inconsistently associated with deepened (≥4 mm) periodontal pockets. However, a positive association was observed between alcohol use (amount, frequency, and use over the risk limit) and deepened periodontal pockets among men, older participants, and among those with basic or intermediate education. Among highly educated non-smokers, frequent spirit intake was associated with a low likelihood of having deepened periodontal pockets, while among less educated non-smokers, frequent spirit intake was associated with a high likelihood of having deepened periodontal pockets. In the four-year follow-up data, alcohol use (amount, frequency, and use over the risk limit) at baseline was

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inconsistently associated with the development of deepened periodontal pockets.

Among smokers, the frequency of alcohol use was positively associated with the development of deepened periodontal pockets in at least two non-adjacent teeth, irrespective of gender, while among non-smokers, amount and use over the risk limit were weakly associated with the development of deepened periodontal pockets in at least two non-adjacent teeth only among women. In the 11-year follow-up data, alcohol use (amount, frequency, and type of beverage) was inconsistently associated with the development of deepened periodontal pockets in at least two non-adjacent teeth. In the total population, the frequency of alcohol use and the type of beverage were inversely associated with the number of teeth with deepened periodontal pockets. Among non-smokers, an inverse association was observed between the frequency of alcohol use and the number of teeth with deepened periodontal pockets.

The findings of this study showed that light-to-moderate alcohol use may not be considered a risk for the presence or development of deepened (≥4 mm) periodontal pockets. However, this study emphasized that age, gender, and socio-economic position could modify the association and that different alcohol use measures can result in different periodontal health outcomes.

National Library of Medicine Classification: QV 84, WM 273, WU 30, WU 113, WU 240-242

Medical Subject Headings: Oral Health; Periodontal Diseases; Periodontal Pocket;

Periodontium; Alcoholic Beverages; Alcohol Drinking; Gamma-glutamyltransferase;

Cross-Sectional Studies; Longitudinal Studies; Epidemiologic Studies; Follow-Up Studies; Dental Health Surveys;

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Sankaranarayanan, Rajeswari

Alkoholin käyttö ja hampaiden kiinnityskudosten kunto—väestötutkimuset Alkoholin käyttö ja hampaiden kiinnityskudosten

Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 537. 2019, 74 s.

ISBN: 978-952-61-3217-4 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3218-1 (PDF) ISSN: 1798-5714 (PDF)

TIIVISTELMÄ

Aikaisempien epidemiologisten tutkimusten havainnot alkoholin käytön vaikutuksista hampaiden kiinnityskudosten eli parodontiumin terveyteen ovat epäjohdonmukaisia. Alkoholin käytön vaikutuksen selvittämistä parodontiumin terveyteen on vaikeuttanut myös pitkäkestoisten tutkimusten rajallinen määrä (etenkin ilmaantuvuustutkimukset) sekä vähäinen tutkimusnäyttö siitä mikä merkitys eri alkoholijuomilla on. Tämän väitöskirjan tavoitteena oli selvittää liittyykö alkoholin käyttö syventyneiden ientaskujen esiintymiseen ja ilmaantuvuuteen.

Poikkileikkaustutkimuksissa (I–II) käytettiin Terveys 2000–tutkimuksen aineistoja. Nelivuotinen seurantatutkimus (III) hyödynsi Terveys 2000 –tutkimuksen sekäsuomalaisten aikuisten suun terveyden seurantatutkimuksen aineistoja ja 11- vuotinen seurantatutkimus (IV) Terveys 2000 ja Terveys 2011-tutkimuksien aineistoja. Osallistujien parodontiumin tila tutkittiin kliinisesti ja tiedot alkoholin käytöstä saatiin kyselylomakkeesta ja laboratoriotutkimuksista (Gamma- glutamyylitransferaasi, GGT). Poikkileikkaustietojen mallinnuksessa käytettiin zero- inflated negatiivista binomijakaumaa ja pitkittäisaineistojen mallinnuksessa negatiivista binomijakaumaamallia sekä robustia Poissonin regressiomallia.

Poikkileikkaustutkimusten tulosten mukaan alkoholin käyttö (määrä, tiheys, käyttö yli riskirajan, juoman tyyppi ja GGT) yhdistyivät epäjohdonmukaisesti syventyneiden (≥4 mm) ientaskujen esiintymiseen. Alkoholin käytön (määrä, tiheys ja käyttö yli riskirajan) ja syventyneiden ientaskujen välillä oli kuitenkin positiivinen yhteys miesten, iältään vanhempien ja perus- tai keskiasteen koulutuksen saaneiden keskuudessa. Korkeasti koulutettujen tupakoimattomien keskuudessa tiheä alkoholin käyttö yhdistyi pienemmällä todennäköisyydellä syventyneiden ientaskujen esiintymiseen, kun taas vähemmän koulutettujen tupakoimattomien keskuudessa tiheä alkoholinkäyttö yhdistyi todennäköisemmin syventyneiden ientaskujen esiintymiseen. Nelivuotisen seurantatutkimuksen mukaan alkoholin käyttö (määrä, tiheys ja käyttö yli riskirajan yläpuolella) oli epäjohdonmukaisesti

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yhteydessä syventyneiden ientaskujen ilmaantumiseen. Tupakoivien miesten ja naisten keskuudessa alkoholin käytön tiheys liittyi syventyneiden ientaskujen ilmaantumiseen vähintään kahteen ei-vierekkäiseen hampaaseen.

Tupakoimattomien naisten joukossa alkoholin määrä ja käyttö yli riski-rajan olivat sen sijaan vain heikosti yhteydessä ientaskujen ilmaantumiseen vähintään kahteen ei-vierekkäiseen hampaaseen. Yksitoistavuotisen seurantatutkimuksen mukaan alkoholin käyttö (määrä, tiheys ja alkoholijuoman tyyppi) liittyi epäjohdonmukaisesti syventyneiden ientaskujen ilmaantumiseen vähintään kahteen ei-vierekkäiseen hampaaseen. Koko tutkimusjoukossa alkoholin käytön tiheys ja alkoholijuoman tyyppi olivat käänteisesti yhteydessä hampaiden lukumäärään, joissa oli syventyneitä ientaskuja. Tupakoimattomien joukossa havaittiin alkoholin käytön tiheydellä olevan käänteinen yhteys ientaskullisten hampaiden ilmaantumiseen.

Tämän tutkimuksen tulokset osoittivat, että kevyttä tai kohtalaista alkoholin käyttöä ei voi pitää riskinä syventyneiden ientaskujen esiintymiselle tai ilmaantumiselle. Tämä tutkimus kuitenkin korosti sitä, että ikä, sukupuoli ja sosioekonominen asema voivat vaikuttaa yhteyteen ja erilaiset alkoholinkäyttötottumukset voivat johtaa erilaisiin terveysvaikutuksiin.

Luokitus: QV 84, WM 273, WU 30, WU 113, WU 240-242

Yleinen suomalainen ontologia: hampaat; hampaan juuri; iensairaudet; ikenet; suun terveys; alkoholijuomat; alkoholinkäyttö; kyselytutkimus; pitkittäistutkimus;

poikittaistutkimus; terveystutkimus

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ACKNOWLEDGEMENTS

This doctoral research study was conducted at the Institute of Dentistry, University of Eastern Finland in collaboration with the National Institute for Health and Welfare, Finland. The present study was possible only with the support and contributions of several people.

I am indebted to my supervisors for all the learning opportunities. I am extremely grateful to my main supervisor, Professor Liisa Suominen, Head of the Institute of Dentistry. Her extensive guidance in statistical and research methods has enabled me to face complex problems during this study. I owe my gratitude to my second supervisor, Professor Pekka Ylöstalo, his knowledge of epidemiology along with his academic insights has kept me on track at times. Their collective guidance has been a major driving force for me to explore new themes in my study and has enabled me to decide appropriate statistical approaches at critical stages of this study.

I wish to thank my third supervisor, Clinical lecturer Tuomas Saxlin for his thought- provoking questions and guidance in scientific writing. His supervision and support in my doctoral research work have been indispensable.

It has been a great pleasure working with my co-author Professor Emeritus Matti Knuuttila, whose insightful comments and suggestions have been invaluable.

I would like to acknowledge the contributions of my other co-authors: Dr. Aino Keränen, Riitta Myllykangas and Dr. Sohaib Khan. I very much appreciate the help offered by Berita Korhonen in the administrative matters concerning the doctoral studies, specifically during the submission of this dissertation. Many thanks to Semantix Oy for refining the language of my articles and this dissertation work.

I would like to extend my gratitude to the National Institute for Health and Welfare and all the members of the Oral Health Committee for providing me with the opportunity to work with the Health 2000 and the Health 2011 survey data. I thank Researcher Tuija Jääskeläinen for her help in data acquisition, Research Professor Pia Mäkelä for her prompt response to queries regarding the data, and Research Manager Tommi Härkänen for his Statistical advice.

I would like to extend my sincere appreciation to Docent Anna Maria Heikkinen and Postdoctoral researcher Tarja Tanner, the official reviewers of this dissertation, for their constructive comments and valuable suggestions. I am honored that Docent Kimmo Suomalainen accepted to be my official opponent during the public defence.

I am fortunate to have the support and encouragement from my respected teachers, dear friends and fellow colleagues during these past years of my doctoral research work.

Special thanks go to my beloved parents, sister, and in-laws for all the love, support, and encouragement. I have eagerly awaited the finishing point of this research work, and I hope that you can take pride and acknowledgement in this achievement. To my dear supportive husband Muthuramanan Rameswaran, thank

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you for believing in my efforts and patiently waiting for me to finish my PhD.

I would also like to express my gratitude to The Faculty of Health Sciences, UEF, The Finnish Dental Society Apollonia, and The Finnish Foundation for Alcohol Studies for their financial support during this research work. I am particularly grateful to the Institute of Dentistry, University of Eastern Finland, Kuopio, Finland, where I have had the privilege of working as an early stage researcher.

"If I have seen further, it is by standing on the shoulders of giants before me."

− Sir Isaac Newton Kuopio, September 2019

Rajeswari Sankaranarayanan

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LIST OF ORIGINAL PUBLICATIONS

This dissertation is based on the following original publications:

I Sankaranarayanan R, Keränen AL, Saxlin T, Myllykangas R, Knuuttila M, Ylöstalo P, Suominen AL. Association between alcohol use and periodontal pockets in Finnish adult population. Acta Odontologica Scandinavica 77: 371−379, 2019.

II Sankaranarayanan R, Saxlin T, Knuuttila M, Ylöstalo P, Suominen AL. Intake of different alcoholic beverages and periodontal condition. Acta Odontologica Scandinavica, 77: 608–616, 2019.

III Sankaranarayanan R, Saxlin T, Ylöstalo P, Khan S, Knuuttila M, Suominen AL.

Alcohol use and periodontal pocket development: findings from a 4-yr longitudinal study. European Journal of Oral Sciences 127: 232−240, 2019.

IV Sankaranarayanan R, Saxlin T, Knuuttila M, Ylöstalo P, Suominen AL. Alcohol use and the development of periodontal pockets: an 11-year follow-up study.

Submitted.

The publications were adapted with the permission of the copyright owners.

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ABBREVIATIONS

IRR Incidence rate ratio NCD Non-communicable

diseases

NHANES National Health and Nutrition Examination Survey

NIAAA National Institute on Alcohol Abuse and Alcoholism NSAIDs Non-steroidal anti-

inflammatory drugs PPD Probing pocket depth RR Relative risk RSOD Risky single occasion

drinking

SD Standard deviation SEP Socioeconomic position THL National Institute for

Health and Welfare WHO World Health

Organisation ALDH Aldehyde dehydrogenase

AUDIT Alcohol Use Disorders Identification Test BAC Blood alcohol

concentration BMI Body mass index CAGE Cutting Down,

Annoyance by Criticism, Guilty Feeling, and Eye- Opener

CAL Clinical attachment loss CI Confidence intervals CPI Community Periodontal

Index

CRFA Common Risk Factor Approach

CRP C-Reactive protein GBD Global Burden Disease

GGT Gamma-

glutamyltransferase IARC International Agency for

Research on Cancer

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1 INTRODUCTION

Increased life expectancy, combined with other factors, has led to a situation in which there are a larger number of adults living with their natural teeth for a longer period of time than ever before. These changes have increased the number of people who suffer from oral diseases (Berkey, Meckstroth & Berg, 2001; Tonetti et al., 2017).

Periodontal diseases are one of the most common oral diseases worldwide. In Finland, the prevalence of periodontitis is high and has remained quite high over the last 40 years (Suominen-Taipale et al., 2008; Suominen et al., 2018). The risk factors for periodontal disease are quite well known; the most important of these are the presence of pathogenic bacteria, tobacco smoking, and poorly controlled diabetes.

Alcohol use is considered to be an aetiological factor for more than 200 diseases (World Health Organisation, 2014), yet there is an ongoing debate about the risks and benefits of alcohol use for human health. Harmful use of alcohol causes many diseases and has several social and economic consequences to societies at large. As a result, the World Health Organisation’s (WHO) global strategy aims to reduce the harmful use of alcohol by 2025 (World Health Organisation, 2010). In this context, it seems obvious that alcohol use should be studied as a potential risk factor for periodontal disease.

While there have been numerous studies on the association between alcohol use and periodontal health, the results of these studies are, to a large extent, conflicting (Sakki et al., 1995; Tezal et al., 2001; Tezal et al., 2004; Nishida et al., 2004; Lages et al., 2012; Park et al., 2014). To date, there have been only a few longitudinal studies, and of those, most have predominantly focussed on the progression of periodontal disease (Ogawa et al., 2002; Jansson, 2008; Nishida et al., 2010; Hach et al., 2015;

Wagner et al., 2017) and the findings have been contradictory. Presently, only limited evidence exists about the role of alcohol use in the development of periodontal disease (Pitiphat et al., 2003; Okamoto et al., 2006).

Earlier studies that have explored the alcohol-periodontitis association have mostly assessed alcohol use in terms of amount and frequency of use (Sakki et al., 1995; Torrungruang et al., 2005; Bouchard et al., 2006; Nishida et al., 2010; Lages et al., 2012) but very few have explored the effect of the types of alcoholic beverages consumed (Pitiphat et al., 2003; Tezal et al., 2001; Tezal et al., 2004; Kongstad et al., 2008). Epidemiological data suggests that the association between alcohol use and periodontal disease varies according to age (Sakki et al., 1995; Torrungruang et al., 2005; Akpata et al., 2016), gender (Kongstad et al., 2008; Park et al., 2014; Wagner et al., 2017), and socio-economic position (Shizukuishi et al., 1998; Pitiphat et al., 2003;

Nishida et al., 2010).

A recent meta-analysis (Wang et al., 2016) reported a dose-response association between alcohol use and periodontitis. However, the analysis underlined the need to investigate the effect of the types of alcoholic beverages and the need for more longitudinal studies on the topic. While the meta-analysis suggested a detrimental

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effect of alcohol on periodontal health, the effect was found only in some adult populations (Wang et al., 2016). This stresses the importance of studying the topic further and in more detail. For example, it would be beneficial to conduct studies in different populations in order to account for the genetic differences among populations which may affect alcohol intake and alcohol tolerance (Joslyn et al., 2010).

Considering the knowledge gaps about the effects of alcohol use on periodontal health in general, and the effect of alcohol use on the development of periodontal disease, the aim of this dissertation was to investigate whether alcohol use is associated with periodontal condition and periodontal disease development.

Additionally, this dissertation provides evidence about the role of age, gender, and socioeconomic position (SEP) on the association of alcohol use with periodontal condition..

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2 REVIEW OF THE LITERATURE

2.1 ALCOHOL USE

Several definitions of alcoholic beverage have been put forward by different organisations and countries. In Finland, the National Institute for Health and Welfare (THL) has defined an alcoholic beverage as “a beverage intended for consumption containing 2.8−80 percent by volume of ethyl alcohol” (Jääskeläinen, Virtanen &

Räikkönen, 2017). The total volume and patterns of alcohol use together depict the alcohol use trends at population and individual levels.

2.1.1 Volume of alcohol use

The volume of alcohol consumption takes into account the total alcohol consumption per capita (documented and undocumented) in liters of pure alcohol per person per year and the total alcohol consumption in grams of pure alcohol per person per day. A recent report by the WHO estimated that the prevalence of current drinkers was highest in the European region in 2016 (i.e. 59.9%). According to this report, in Finland, the prevalence of heavy episodic drinking among current drinkers in 2016 (≥ 15 years old) was estimated to be 39% and the total alcohol consumption per capita in drinkers (≥15 years old) was 14.8 l of pure alcohol per year (World Health Organisation, 2018).

The average daily intake of alcohol in Finland in 2016 was 31.9g of pure alcohol.

This was quite close to the global estimates (i.e. 32.8g of pure alcohol) (World Health Organisation, 2018). In 2010, the WHOs’ global strategy to reduce the harmful use of alcohol defined harmful use of alcohol as “the drinking that causes detrimental health and social consequences for the drinker, the people around the drinker and society at large, as well as patterns of drinking that are associated with increased risk of adverse health consequences”(World Health Organisation, 2010). Despite the global strategy and local implementation of it, the THL stated in its recent report that the total alcohol consumption (documented and undocumented) remained around the same level from 1990 to 2017 and was 10.3 l of pure alcohol in the Finnish population in 2017 (THL, päihdetilastollinen vuosikirja 2018) (Figure 1).

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Source: Based on Statistics Finland and the THL, Finland 2018

Figure 1. Consumption of alcoholic beverages per capita in total population (aged ≥15 years) in Finland

2.1.2 Patterns of alcohol use

Globally, the alcohol use patterns differ based on two factors: most used alcoholic beverages and prevailing drinking patterns. It has been estimated that spirits (44.8%) are the most commonly used beverage worldwide, followed by beer (34.3%), wine (11.7%), and other miscellaneous alcoholic beverages (9.3%). These proportions vary across countries, as well as over a period of time within the same country (World Health Organisation, 2018).

In Finland, for example, people nowadays predominantly consume beer (48.8%) followed by spirits (21.5%), wine (20.6%), and other alcoholic beverages (9.1%) (World Health Organisation, 2018). However, there has been a change in the

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Source: Alcoholic Beverage Consumption. THL; Valvira. Adapted from: Yearbook of Alcohol and Drug Statistics 2018, THL, Finland (THL, päihdetilastollinen vuosikirja 2018).

Figure 2. Change in intake of different alcoholic beverages consumed by the Finnish population (1950 to 2017)

With regard to patterns of drinking, several definitions have been used to define moderate and excessive drinking. For example, the term moderate drinking was defined as “up to one drink per day for women and up to two drinks per day for men” by the Dietary Guidelines for Americans (US Department of Health and Human Services, 2017). Excessive drinking comprises binge drinking and heavy drinking.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defined binge drinking as “a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL typically after four drinks for women and five drinks for men—in about two hours” (National Institute on Alcohol Abuse and Alcoholism, 2004). The Dietary guidelines for Americans 2015−2020 deﬁned binge drinking as “four drinks or more for women and five drinks or more for men within about two hours” (US Department of Health and Human Services, 2017). According to the Finnish Drinking Habits Study conducted in 1992, frequent binge drinking was defined as “consuming seven or more units of alcohol twice or more times a week” (Holmila, 1995). The Dietary guidelines for Americans 2015−2020 deﬁned heavy drinking as “the consumption of eight drinks or more a week for women or 15 drinks or more a week for men” (US Department of Health and Human Services, 2017).

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Researchers have also used terms such as “heavy episodic drinking” or “risky single occasion drinking (RSOD)” alternatively to describe “a pattern of heavy drinking over a defined period” (Courtney & Polich, 2009). The often-used cut-off limit for RSOD is “intake of 60‒70 g of ethanol for men and 40‒60 g of ethanol for women per drinking occasion” (Gmel, Kuntsche & Rehm, 2011). Another term used in alcohol research is “risky drinking”, which is defined as “consumption of large amounts (more than four standard drinks) of alcohol on a single occasion, as well as drinking in situations likely to result in harm for young people” (Gilligan, Kypri &

Lubman, 2012).

Finnish drinking culture mainly includes frequent heavy drinking occasions (Mäkelä, Tigerstedt & Mustonen, 2012) and heavy episodic drinking (Mäkelä et al., 2001). The drinkers in the younger age group (15–19 years) are more prone to heavy episodic drinking, which is defined as “consumption of at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days” (World Health Organisation, 2018). An important change that has occurred over the past is the shrinking of the gender gap in the alcohol consumption of Finns (Mäkelä, Tigerstedt

& Mustonen, 2012; Bloomfield et al., 2001). These changes in alcohol consumption—

along with the change in the preference for alcoholic beverages from spirits to beer over time—have resulted in increased alcohol-related harm (Mäkelä, 2011).

Additionally, recent data from the Statistics Finland also shows an increase in

alcohol-related mortality from 1969 to 2017.

(https://findikaattori.fi/en/65#_ga=2.23475898.1094491125.1551543268-672133193.

1551442071).

There is a large variation in the terminology that has been used in research. Earlier epidemiological studies have used various alcohol use measures such as amount/volume (Tezal et al., 2001; Gay, Tran & Paquette, 2018), frequency (Lages et al., 2012), type of beverage (Pitiphat et al., 2003), biological markers such as Gamma- glutamyltransferase (GGT) levels (Khocht et al., 2003), and others such as AUDIT and CAGE score (Lages et al., 2012; Park et al., 2014; Kim et al., 2014).

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2.2 ALCOHOL USE AND HEALTH

Alcohol use influences the development, course, and outcomes of diseases, and it has been estimated that in 2016, around 3 million deaths globally were attributed to the harmful use of alcohol (World Health Organisation, 2018). The adverse health effects of alcohol use are mainly dependent on the volume and pattern of drinking (Rehm et al., 2003), but also on the type of alcoholic beverage consumed (Mäkelä, Mustonen & Österberg, 2007).

2.2.1 Harmful effects of alcohol use

There is a considerable amount of evidence demonstrating that alcohol use causes many communicable and non-communicable diseases, as well as injuries (intentional and unintentional) (Rehm et al., 2010b; Rehm et al., 2017a). Reports confirm a causal association of alcohol use with many diseases, suggesting that higher levels of alcohol use can lead to an exponential increase in the risk of diseases. Studies have pointed out a detrimental causal association of alcohol use with some communicable diseases, such as tuberculosis (Rehm et al., 2009), human immunodeficiency virus infection (Rehm et al., 2017c), and pneumonia (Samokhvalov, Irving & Rehm, 2010).

Previous research has concluded that the use of alcohol is causally associated with many gastrointestinal diseases, such as liver cirrhosis (Rehm et al., 2010a) and pancreatitis (Samokhvalov, Rehm & Roerecke, 2015), as well as injuries (Cherpitel, 2009). Likewise, alcohol use has been causally linked with many neuropsychiatric conditions, for example, epilepsy (Leach, Mohanraj & Borland, 2012) and Alzheimer or other dementia conditions (Daulatzai, 2015). Because alcohol use is a risk for many cancers—for example, the cancer of the pharynx, larynx, mouth, esophagus, and liver, to name just a few—the International Agency for Research on Cancer (IARC) has recognized it as a carcinogen (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2012). Some other non-communicable diseases, such as cardiovascular diseases including hypertension (Briasoulis, Agarwal & Messerli, 2012), ischemic heart disease (Roerecke, Rehm, 2014), and cardiomyopathy (Rehm et al., 2017b), are also associated with chronic alcohol use.

It is worth noting that most of these above-mentioned effects are attributed to the effects of volume of alcohol consumed, except for injuries and ischemic heart diseases, for which both the volume of alcohol consumed and drinking patterns are important (Rehm et al., 2010b). Beyond the detrimental health effects of alcohol use, the often-debated beneficial effects of alcohol use needs to be mentioned. A low-risk drinking pattern has been reported to have some beneficial effects, notably in the case of diabetes (Baliunas et al., 2009), ischemic heart disease, ischemic stroke, and Alzheimer or other dementia conditions (Collins et al., 2009). A meta-analysis reported that light-to-moderate wine intake has cardio-protective effects (Di Castelnuovo et al., 2002), suggesting that the type of beverage could explain the cardio-protective effect of alcohol. Another report also suggested that moderate wine intake has a beneficial effect on diabetes, osteoporosis, and neurological diseases

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(Artero et al., 2015). However, a question about the risks and benefits of different alcoholic beverages on health remains unanswered.

2.2.2 Conceptual models for alcohol effects on health

The effects of the total volume and pattern of drinking imply that both these factors contribute to the burden of chronic diseases. Considering this, Rehm and colleagues included these factors in their conceptual model (Rehm et al., 2010b). In addition to these factors, the role of societal and individual (sociodemographic and socioeconomic) factors in the harmful effects of alcohol use on health has been emphasized (Blas & Kurup, 2010). Societal factors include drinking culture, alcohol policy, drinking environment, and the healthcare system. Individual factors include age, gender, genetics, and socioeconomic position (Blas & Kurup, 2010). In addition to the total volume and pattern of drinking, another pathway proposed by Mäkelä et al. includes the effects of the type of beverage consumed on the health outcomes (Mäkelä, Mustonen & Österberg, 2007). The type of beverage may have a marginal effect compared with other measures of alcohol use (Figure 3; modified from Mäkelä, Mustonen & Österberg, 2007; Rehm et al., 2010b; Blas & Kurup, 2010). The harmful effects caused by alcohol use are explained by multiple mechanisms including, (a) detrimental effects on organs and tissues; (b) injuries or poisoning due to acute intoxication; and (c) self-harm due to dependence (Rehm et al., 2003).

SOCIETAL FACTORS

Drinking culture Alcohol policy

INDIVIDUAL FACTORS

Age Gender Genetics

ALCOHOL USE Needs and

preferences

Volume Pattern Beverage type

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2.2.3 Alcohol effects on health by age, gender, genetics, and socioeconomic position (SEP)

As noted earlier, individual characteristics may influence alcohol-related health outcomes. Studies have reported that alcohol effects differ by age, gender, and SEP.

It has been reported that both young and older individuals are more prone to the adverse effects of alcohol than other age groups (Mustonen, 2000), but the underlying reasons may be different for these groups (young and older). One of the reasons for this could be a difference in drinking behaviors, as it is known that heavy episodic drinking occasions are common among young individuals, for example (General, 2007), while, in older individuals, frequent drinking (Wilsnack et al., 2009) and the inability to handle the same volume/pattern of alcohol use with increasing age can increase their susceptibility to the consequences of alcohol intake.

Likewise, alcohol-related harm has been reported in both men and women. The increased alcohol-related harm among men has been suggested to be related to their high-risk and frequent drinking behavior (Wilsnack et al., 2009), whereas it can be assumed that this harm is more pronounced among women due to the biological differences between genders (Wilsnack, Wilsnack & Kantor, 2013). Current evidence suggests that alcohol affects men and women disproportionately. It has been reported by Rehm et al. that women suffer more from alcohol-related cardiovascular diseases and cancers than men (Rehm et al., 2010b), whereas, on the other hand, it is estimated that alcohol-related mortality is higher among men than women (World Health Organisation, 2014). Additionally, ethnic differences with regard to alcohol intake and alcohol tolerance may also distinguish the experience of adverse effects among different populations (Joslyn et al., 2010).

Socioeconomic position can also affect the consequences of alcohol intake. For example, earlier research suggests that people belonging to a lower SEP are more prone to the harmful effects of alcohol use (Grittner et al., 2012). This susceptibility among individuals with a lower SEP can most likely be attributed to their risky drinking behavior and limited or lack of access to healthcare services (Schmidt et al., 2010). The disproportionate effect of alcohol that causes greater harm in vulnerable populations who consume an equal amount of alcohol compared to well-off populations is termed the ´alcohol harm paradox´ (Jones et al., 2015). The exact mechanism for this phenomenon is unclear, but several explanations have been proposed. Some of these include the clustering of risk factors or unhealthy behaviors, such as, smoking and alcohol; the difference in drinking patterns (Huckle, You &

Casswell, 2010); the choice of beverage (Mortensen et al., 2001); differences in drinking behavior with regard to SEP (Bloomfield et al., 2006); and lastly differences in access to healthcare.

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2.3 ALCOHOL USE AND DENTAL CARIES, EROSION, AND TOOTH LOSS

In the past decades, researchers have focused on the association between alcohol use and oral health. For example, a longitudinal study conducted in Stockholm showed that heavy alcohol intake was associated with a higher number of decayed tooth surfaces and apical lesions (Jansson, 2008). Another study conducted among 55-yr-old Finnish adults also reported an association of higher use of alcohol with increased prevalence of dental caries (Sakki et al., 1994). Besides the risk of caries, alcohol use was also reported to be associated with a high risk for dental erosion (Manarte et al., 2009).

A pilot study examined the oral health of alcoholic patients, and the researchers reported a high prevalence of plaque accumulation and gingival inflammation in these individuals (Araujo et al., 2004). Tooth loss, which in most cases is related to caries or periodontitis, was associated with alcohol intake in both the US population (Copeland et al., 2004) and the midwestern population (Klein, Klein & Knudtson, 2004). Studies also suggest that alcohol-dependent individuals have poor oral health outcomes. This is related to their poor oral hygiene habits, a lack of proper dental care, as well as limited access to healthcare (Movin, 1981; Novacek et al., 1995;

Khocht et al., 2009). In addition, an IARC report suggested a causal association between alcohol use and cancers of the oral cavity (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2012).

2.4 ALCOHOL USE AND PERIODONTAL DISEASE

2.4.1 Periodontal disease

Periodontal disease is an infectious disease that results in the inflammation of the soft tissues and bone that surround and support the teeth. Periodontal disease manifests in the early stages as gingival bleeding (gingivitis), followed by periodontal pocketing, clinical attachment loss, and eventually tooth loss

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with a low SEP (which in their study was defined as those less educated and those living below the poverty line), and current smokers (Eke et al., 2012). The Global Burden Disease (GBD) study in 2010 reported severe periodontitis as the sixth most prevalent condition worldwide with a prevalence of 11% (Marcenes et al., 2013). In 2015, the GBD study assessed the progress of the “Global Goals for Oral Health 2020”

in 195 countries. The study reported that the oral health situation had not improved over a span of 25 years from 1990 to 2015, and the prevalence of severe periodontitis had remained quite stable over these years (Kassebaum et al., 2017).

The prevalence of periodontitis (indicated by the presence of deepened periodontal pockets) in Finland decreased from 77% to 64% over a period of two decades from 1980 to 2000. However, this improvement was relatively minor compared with other oral health outcomes (Suominen-Taipale, 2004). There was a major decline in the prevalence among the middle-aged group, while the decline among the older age groups was miniscule. The Health 2000 Survey in Finland revealed that 64% of the population had periodontal pockets of ≥4 mm, and 21% of the population had periodontal pockets of ≥6 mm. The corresponding figures for men and women for periodontal pockets of ≥4 mm was 72% and 57%, and for deep periodontal pockets of ≥6 mm they were 26% and 16%, respectively (Suominen- Taipale et al., 2008). During the next decade from 2000 to 2011, periodontal health improved only slightly. According to the Health 2011 Survey, periodontitis prevalence measured by deepened periodontal pockets of ≥4 mm was 70% in males and 58% in females, whereas the prevalence of ≥6 mm pockets was 21% among men and 14% among women (Suominen et al., 2018).

2.4.2 Link between periodontal disease and other diseases

Numerous earlier studies have reported that periodontal disease can cause pathological effects outside the oral cavity. It has been proposed that bacterial dissemination from the oral biofilm, shared risk factors (smoking, stress, aging, race or ethnicity, and male gender), and inflammatory mediators from the inflamed periodontium result in a systemic disease burden (Page, 1998). A substantial amount of evidence supports the association of periodontal disease with chronic diseases, particularly diabetes (Borgnakke et al., 2013; Graziani et al., 2018), cardiovascular diseases (Dietrich et al., 2013); pre-term low birth weight babies; and respiratory diseases (Li et al., 2000). Additionally, the loss of masticatory function because of severe periodontitis may have a negative impact on nutrition and quality of life. The link between oral health and general health may possibly contribute to the chronic non-communicable disease (NCD) burden (Tonetti & Kornman, 2013).

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2.4.3 Risk factors for periodontal disease

The multi-factorial nature of periodontal disease makes it important to identify the risk factors for the disease. These risk factors can be categorized as modifiable, non-modifiable, and risk characteristics of individuals (Figure 4).

Some of these risk factors are common to both periodontal disease and major chronic NCDs such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer. Based on this, researchers have advocated the common risk factor approach (CRFA) as a more effective way of tackling these chronic NCDs, as well as oral diseases like periodontal disease (Sheiham & Watt, 2000).

Source: Based on previous literature (Genco, Borgnakke, 2013; Reynolds, 2014; Borgnakke, 2016;

AlJehani, 2014)

Time Modifiable Risk Factors

Plaque accumulation Tobacco smoking Diabetes mellitus Cardiovascular disease Drug-induced disorders Stress

Obesity

Lack of physical activity C-reactive protein- Oral hygiene practices Access to health services Nutrition

Alcohol use (?)

Non-modifiable Risk Factors Osteoporosis Hematological Disorders Host response Female hormonal alterations Pregnancy Alzheimer’s disease and dementia

Individual Risk Characteristics Age

Gender

Genetic predisposition SEP

Race

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Both cross-sectional studies (Sakki et al., 1995; Kongstad et al., 2008; Park et al., 2014; Kim et al., 2014; Merchant et al., 2017) and longitudinal studies have reported conflicting results. To date, only a very limited number of studies have examined the effects of alcohol use on periodontal disease development in periodontally healthy individuals (incidence) (Pitiphat et al., 2003; Okamoto et al., 2006), while others have focused on the progression of the disease (Ogawa et al., 2002; Jansson, 2008; Nishida et al., 2010; Hach et al., 2015; Wagner et al., 2017). Recent meta-analysis based on observational studies reported a dose-dependent effect, although the authors emphasized the need for more longitudinal studies and further studies investigating the effects of different alcoholic beverages on periodontal health (Wang et al., 2016).

Animal studies have explored the association between alcohol and periodontal disease, of which some studies reported a positive association between alcohol use and periodontal disease (Irie et al., 2008; Maia Dantas et al., 2012; Surkin et al., 2014;

de Souza et al., 2017), while another study showed no such association (Liberman et al., 2011).

Previous studies have shown that the effects of alcohol use on the periodontium differ by age, gender, or even SEP. With regard to age, studies conducted among older adults have reported alcohol use to be associated with poor periodontal condition (Sakki et al., 1995), while others reported no association (Torrungruang et al., 2005), except in cases of alcohol intoxication (Akpata et al., 2016). Regarding gender, some reports suggest that harmful effects can be observed only in men (Pitiphat et al., 2003; Park et al., 2014; Wagner et al., 2017), whereas others reported no harmful effects in men (Okamoto et al., 2006), while some studies found harmful effects in women (Wu et al., 2013; Susin et al., 2015). Currently, there is not enough data to compare the effects between different age groups or between men and women.

A limited number of earlier studies have explored whether the effects of alcohol use on periodontal health differs by SEP. However, these studies have been conducted among specific occupational groups. A study among male healthcare professionals (Pitiphat et al., 2003) and other studies among Japanese factory workers (Shizukuishi et al., 1998; Nishida et al., 2004; Nishida et al., 2010) reported an association between alcohol use and periodontal disease. There are no studies so far where the association is studied in different socio-economic groups in the same study population.

2.4.5 Plausible mechanisms linking alcohol use with periodontal disease outcomes

Although periodontal disease is a multi-factorial disease, pathogenic bacteria in dental plaque is the main etiological factor. One study suggested higher levels of pathogenic species in the sub-gingival microbiota among alcoholics compared to non-alcoholics (Amaral et al., 2011). Findings among alcohol-dependent individuals have also suggested an increased sub-gingival bacterial load, which eventually alters

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the microbiological and immunological periodontal parameters (Lages et al., 2015).

It has been suggested that heavy alcohol use could reduce the host immune responses by altering the innate and adaptive immune responses. These altered responses could lead to an increased level of inflammatory cytokines; impaired functioning of neutrophils, macrophages, and T cells; and increased susceptibility to infections (Szabo & Mandrekar, 2009; Szabo, 1999).

Some of these mechanisms were proposed in previous epidemiological studies to explain the detrimental effect of alcohol on periodontal health (Tezal et al., 2001;

Pitiphat et al., 2003). These explanations are further supported by findings where it was reported that alcohol dependence could impair neutrophil function (Khocht 2013). Experimental research suggests that alcohol use can also affect bone metabolism by inhibiting osteoblastic activity and thus reducing bone formation, eventually contributing to periodontal tissue damage (Dyer, Buckendahl & Sampson, 1998; Turner et al., 2001). Studies have also reported that ethanol intake could increase alveolar bone loss (Souza et al., 2009). Conversely, other studies suggest that poor oral hygiene and poor dental care, rather than alcohol intake, contribute to a high risk of periodontal disease (Movin, 1981; Novacek et al., 1995).

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able 1. Existing literature on alcohol use and periodontal disease association. Author (Year)Gender Age (years) Sample size

Alcohol use (Exposure) Periodontal parameter (Outcome)Confounders Main findings RR (95% CI) in the highest category Longitudinal studies: Incidence Pitiphat et al. (2003)Male 40–75 n=39,461 Questionnaire: alcohol use (g/day), type of beverage

Self-reported: one question about periodontal diseaseAge, smoking, BMI, physical activity, diabetes, total calories ≥30 g/day: 1.27(1.08−1.49) No effect of beverages Okamoto et al. (2006)Male 43.5 n=1,332

Questionnaire: alcohol use (g/day) 0; <20; >20

CPI scores: based on PPDAge, smoking No association ≥20 g/day: 1.05(0.73−1.51) Longitudinal studies: Progression Ogawa et al. (2002)Male and female 70 n= 436

Alcohol drinking habits: daily vs not dailyCAL < 6 mm; CAL > 6mmGender, smoking, missing teeth, visit dentist regularly, need for treatment, recent visit to dentist in a year, use of floss, use of interdental brush, brushing frequency, blood pressure levels, liver agents, immunoglobulins, lip factors, nutritional factors

No significant correlation Jansson (2008)Male and female 18–65 n=477

Questionnaire: alcohol use (cl/day): ≤5; >5 Longitudinal bone Loss; Bleeding index; Plaque index; Calculus index Age, gender, smoking, decayed teeth, dental visits, education level, diabetes, coronary heart disease

No association Nishida et al. (2010)Male and female 18−63 n=224

Questionnaire: alcohol use (g/day): <33; ≥33. Percentage of teeth with a PPD ≥ 3.5 mm: above or below the upper 20th percentile of the percentage, as periodontitis or non- periodontitis Age, gender, BMI, smoking habit, and frequency of toothbrushing ≥ 33 g/day: 3.43(1.57– 7.48) ≥ 33 g/day and ALDH2*1/*2 genotype: 4.28(1.20–15.3) Table 1. Continues

Alcohol use and periodontal condition : results of population-based surveys

uef.fi

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

RAJESWARI SANKARANARAYANAN

ALCOHOL USE AND PERIODONTAL CONDITION

—RESULTS OF POPULATION-BASED SURVEYS

This doctoral study examined the short and

long-term effects of alcohol use on periodontal condition in the Finnish adult population. The

findings showed no consistent association between the use of alcohol and the presence or

development of periodontal pockets. However, this study highlights that (i) individual factors

such as age, gender, and socioeconomic position could modify this association; and (ii) different alcohol use measures could have

different effects on periodontal condition.

RAJESWARI SANKARANARAYANAN

ALCOHOL USE AND PERIODONTAL CONDITION—RESULTS OF POPULATION-

BASED SURVEYS

Rajeswari Sankaranarayanan

ALCOHOL USE AND PERIODONTAL CONDITION—RESULTS OF POPULATION-

BASED SURVEYS

ABSTRACT

TIIVISTELMÄ

ACKNOWLEDGEMENTS

LIST OF ORIGINAL PUBLICATIONS

CONTENTS

ABBREVIATIONS

1 INTRODUCTION

2 REVIEW OF THE LITERATURE

2.1 ALCOHOL USE

2.2 ALCOHOL USE AND HEALTH

SOCIETAL FACTORS

2.3 ALCOHOL USE AND DENTAL CARIES, EROSION, AND TOOTH LOSS

2.4 ALCOHOL USE AND PERIODONTAL DISEASE