Reasons of tooth mortality by continents in the last 20 years

Introduction: The reasons for tooth loss have been well defined for several centuries. However, systematic analysis of the causes of tooth loss in the first years of the present century would shed light on the current manifestation of this phenomenon. Objective: Determine the main causes of tooth mortality in the last 20 years. Methods: A systematic review was conducted using the Boolean search engines in PubMed, Web of Science, Scopus and SciELO bibliographic search platforms. The search was based on the following MeSH terms: cause, motive, mortality, extraction, dental extraction, loss, and combinations thereof. The articles included were in English or Spanish. Calibration was performed by the authors to evaluate the articles to be selected. Results: A total 593 articles were retrieved: 16 from Web of Science, 39 from Scopus, 531 from Pubmed and 1 from SciELO, of which 26 were included in the study. A predominance was found of articles published in English (80.8 percent). The main causes of tooth mortality dealt with were dental caries (92.30 percent) and periodontal disease (50.0 percent). Conclusions: The evidence obtained in the last 20 years is insufficient to determine the main reasons for dental extraction by continent. There is little availability of articles about areas from the most densely populated and developed countries in each continent. The articles included showed a predominance of dental caries and periodontal disease as the main reasons for dental extraction(AU)

Introducción: Las razones de la pérdida dentaria han sido bien definidas desde hace varios siglos. Sin embargo, sistematizar sobre las causas en los primeros años del presente siglo aportaría una visión de cómo se manifiestan en la actualidad. Objetivo: Determinar las principales causas de mortalidad dental en los últimos 20 años. Métodos: Se realizó una revisión sistemática utilizando los motores de búsqueda booleanos en la plataforma de búsqueda bibliográfica de PubMed, Web of Science, Scopus y SciELO. Las palabras clave utilizadas para la búsqueda fueron MesH: causa, motivo, mortalidad, extracción, extracción dental, pérdida y una combinación entre ellas. Se incluyeron artículos en español e inglés. Se realizó una calibración entre los autores para la evaluación de los artículos a seleccionar. Resultados: Como resultado de la búsqueda se obtuvieron 593 artículos, de los cuales 16 fueron de Web of Science, 39 de Scopus, 531 de Pubmed y 1 de SciELO. Los artículos incluidos en el estudio fueron 26. Predominaron las investigaciones publicadas en inglés (80,8 por ciento), que destacó entre los motivos de mortalidad dental estudiados, se encontró un predominio de caries dental (92,30 por ciento) y enfermedad periodontal (50,0 por ciento). Conclusiones: La evidencia obtenida en los últimos 20 años para determinar las principales razones de extracción dentaria por continentes es insuficiente y se observa la poca presencia de artículos en poblaciones de países con mayor desarrollado y número de habitantes de cada continente. Los artículos incluidos mostraron un predominio de la caries dental y la enfermedad periodontal como los principales motivos de extracción dentaria(AU)

Periodontal status at diagnosis predicts non-disease-specific survival in a geographically defined cohort of patients with oropharynx squamous cell carcinoma.

BACKGROUND: The aim of this study was to examine periodontal status with a time-efficient screening method from a cohort of newly diagnosed oropharynx squamous cell carcinoma (OPSCC) patients and to study to what extent dental disease level predicted survival. Aims/objective: Can measuring level of dental pathology based on a blind investigation of a routine orthopantogram (OPG) obtained during diagnostic workup reveal prognostic information? MATERIALS AND METHODS: We included 97 patients diagnosed between 2003 and 2010. Radiographic alveolar bone loss was measured. At least 4 mm bone loss from cement-enamel junction on at least two teeth was registered as periodontal pathology. The number of missing and filled teeth (MFT), residual roots and apical radiolucencies were noted. Clinical data were determined through hospital patient records. RESULTS: The horizontal bone loss discriminated between hr-HPV(+) versus hr-HPV(-) status, but secondary to age and smoking history at diagnosis. Vertical and horizontal bone loss predicted survival directly, and adjusted by gender, patient, smoking history, TN stage and hr-HPV tumor infection at diagnosis. CONCLUSIONS: Degree of periodontal OPG pathology at the time of OPSCC diagnosis to some extent predicted hr-HPV infection, but predicted non-disease-specific long-term survival. SIGNIFICANCE: Degree of periodontal OPG pathology at diagnosis predicts prognosis.

Mortality rate and oral health - a cohort study over 44 years in the county of Stockholm.

OBJECTIVE: To study the association between oral health and all-cause mortality rate over 44 years. In addition, the specific relations between oral health and death caused by cardiovascular disease (CVD), cancer or other reasons were investigated. MATERIALS AND METHODS: An epidemiological investigation studying the oral health of the population consisting of 1393 randomly selected subjects was performed in the County of Stockholm. The individuals were invited to a clinical examination, an interview and a radiographic examination. The incidence of mortality during the years 1970-2014 as well as the causes of death according to the death certificate were registered in 2015. Cox regression survival analysis was used for investigating the effect of several variables upon the time to the outcome of death. RESULTS: Forty-six percent of the subjects were still alive at the end of the year 2014. Cancers caused 27% of the deaths, while 22% died due to CVD. The mortality risk was positively and significantly correlated to oral health when compensated for age, sex, smoking and social status. In addition, the mortality risk caused by CVD, cancer or other reasons was significantly increased for those with poor oral health. CONCLUSIONS: Oral health was found to be a risk indicator of death caused by CVD and cancer as well as for all-cause mortality. Thus, the associations are unspecific. Harmful lifestyle factors impact dental health behavior as well as mortality risk. This might contribute to the association between oral health and mortality risk.

Periodontal disease and pneumonia mortality in haemodialysis patients: A 7-year cohort study.

AIM: To evaluate the association between periodontal disease and pneumonia mortality in haemodialysis patients. MATERIALS AND METHODS: This prospective cohort study included 211 patients (mean age, 64.4 years) undergoing haemodialysis at a single medical centre. The patients underwent a baseline clinical dental examination in 2008 and were then followed up until July 2015. Periodontal disease was defined as the presence of clinical attachment loss of ≥4 mm in ≥30% of the probed sites. The primary endpoint, that is death from pneumonia, was determined by reviewing death certificates and was analysed using the competing-risks regression model. RESULTS: At baseline, 92 patients (43.6%) had periodontal disease. The median follow-up period was 84 months (interquartile range, 36-86 months). Of the 68 deaths that occurred, 21 were from pneumonia. The multivariable competing-risks regression model showed that periodontal disease was significantly associated with death from pneumonia (adjusted subhazard ratio, 3.49; 95% confidence interval, 1.14-10.64), after adjusting for other baseline health characteristics. CONCLUSIONS: The results of this study suggest that periodontal disease is independently associated with pneumonia mortality in haemodialysis patients. Future studies evaluating the potential effect of oral interventions for periodontal health improvement on pneumonia in haemodialysis patients would be of great interest.

Association between periodontal disease and mortality in people with CKD: a meta-analysis of cohort studies.

BACKGROUND: Periodontal disease occurs relatively prevalently in people with chronic kidney disease (CKD), but it remains indeterminate whether periodontal disease is an independent risk factor for premature death in this population. Interventions to reduce mortality in CKD population consistently yield to unsatisfactory results and new targets are necessitated. So this meta-analysis aimed to evaluate the association between periodontal disease and mortality in the CKD population. METHODS: Pubmed, Embase, Web of Science, Scopus and abstracts from recent relevant meeting were searched by two authors independently. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for overall and subgroup meta-analyses. Statistical heterogeneity was explored by chi-square test and quantified by the I2 statistic. RESULTS: Eight cohort studies comprising 5477 individuals with CKD were incorporated. The overall pooled data demonstrated that periodontal disease was associated with all-cause death in CKD population (RR, 1.254; 95% CI 1.046-1.503; P = 0.005), with a moderate heterogeneity, I2 = 52.2%. However, no evident association was observed between periodontal disease and cardiovascular mortality (RR, 1.30, 95% CI, 0.82-2.06; P = 0.259). Besides, statistical heterogeneity was substantial (I2 = 72.5%; P = 0.012). Associations for mortality were similar between subgroups, such as the different stages of CKD, adjustment for confounding factors. Specific to all-cause death, sensitivity and cumulative analyses both suggested that our results were robust. As for cardiovascular mortality, the association with periodontal disease needs to be further strengthened. CONCLUSIONS: We demonstrated that periodontal disease was associated with an increased risk of all-cause death in CKD people. Yet no adequate evidence suggested periodontal disease was also at elevated risk for cardiovascular death.

Periodontal Disease Associated with Aortic Arch Atheroma in Patients with Stroke or Transient Ischemic Attack.

BACKGROUND: Periodontal disease (PD) is associated with recurrent vascular event in stroke or transient ischemic attack (TIA). In this study, we investigated whether PD is independently associated with aortic arch atheroma (AA). We also explored the relationship PD has with AA plaque thickness and other characteristics associated with atheroembolic risk among patients with stroke or TIA. Finally, we confirmed the association between AA and recurrent vascular event in patients with stroke or TIA. METHODS: In this prospective longitudinal hospital-based cohort study, PD was assessed in patients with stroke and TIA. Patients with confirmed stroke and TIA (n = 106) were assessed by calibrated dental examiners to determine periodontal status and were followed over a median of 24 months for recurrent vascular events (stroke, myocardial infarction, and death). The extent of AA and other plaque characteristics was assessed by transesophageal echocardiography. RESULTS: Within our patient cohort, 27 of the 106 participants had recurrent vascular events (including 16 with stroke or TIA) over the median of 24-month follow-up. Severe PD was associated with increased AA plaque thickness and calcification. The results suggest that PD may be a risk factor for AA. In this cohort, we confirm the association of severe AA with recurrent vascular events. CONCLUSIONS: In patients with stroke or TIA, severe PD is associated with increased AA plaque thickness, a risk factor for recurrent events. Further studies are needed to confirm this finding and to determine whether treatment of PD can reduce the rate of AA plaque progression and recurrent vascular events.

Periodontal disease, edentulism, and pancreatic cancer: a meta-analysis.

Background: Periodontal disease (PD), now our commonest infectious disorder leads to tooth loss, and has been linked to various systemic diseases, including various types of cancer. The aim of this study is to provide a systematic review and a meta-analysis of the relationship between PD, edentulism, and pancreatic cancer (PC). Patients and methods: From an initial review of 327 references we selected eight studies concerning periodontitis or edentulism with sufficient quantitative information to allow us to examine the risk of PC. We used relative risks (RRs), hazard ratios, or odds ratios to measure the association between periodontitis, edentulism, and PC. We employed random effects models to obtain summary risks, and we also provide measures of study differences and possible biases. Results: The summary RR for periodontitis and PC was 1.74 [95% confidence interval (CI) 1.41-2.15] and 1.54 for edentulism (95% CI 1.16-2.05). There was no evidence of heterogeneity for either variable, and no evidence of publication bias. The studies included reports from three continents, suggesting that the association is generalizable. Most of the studies were adjusted for variables thought to be associated with PC, such as gender, smoking, BMI, diabetes, and alcohol. Conclusions: Using meta-analysis, both periodontitis and edentulism appear to be associated with PC, even after adjusting for common risk factors. As yet, the mechanisms linking oral disease and PC are uncertain, but could be related to changes in the oral microbiome-an area of current research.

Association of Periodontal Destruction and Diabetes with Mortality.

Current evidence indicates the effects of periodontitis on diabetes as well as mortality, for which diabetes itself represents a risk factor. However, the possible interaction of these 2 chronic conditions regarding mortality has not yet been investigated. Therefore, the purpose of this study was to evaluate whether periodontal destruction interacts with diabetes on all-cause and cardiovascular disease (CVD) mortality or if diabetes serves as a mediator in this association. The study sample comprised 3,327 participants aged 20 to 81 y from the Study of Health in Pomerania. Periodontal destruction was assessed via clinical attachment level (CAL) and the number of missing teeth. Information on mortality (date and ICD-10 code) was ascertained from death certificates. Directed acyclic graphs were used to identify potential confounders, and Cox proportional hazard models were applied. In 36,701 person-years of follow-up, 263 study participants deceased, 89 due to CVD. Fully adjusted main effect models resulted in hazard ratios of 1.01 (95% confidence interval [95% CI]: 1.002 to 1.01) for extent of CAL ≥3 mm, 1.10 (95% CI: 1.03 to 1.18) for mean CAL, and 1.03 (95% CI: 1.01 to 1.04) for the number of missing teeth regarding all-cause mortality. Analogous results were obtained for CVD mortality, with hazard ratios of 1.01 (95% CI: 0.99 to 1.02), 1.10 (95% CI: 0.98 to 1.23), and 1.02 (95% CI: 0.99 to 1.05) for extent of CAL, mean CAL, and the number of missing teeth, respectively. Findings did not indicate additive interaction of periodontal destruction and diabetes regarding all-cause and CVD mortality. Similarly, no substantial evidence was found to demonstrate the presence of multiplicative interaction or mediation. Besides adjustment for baseline covariates, time-varying covariates were also considered and led to comparable results. In summary, despite their reciprocal relationship, periodontal destruction and diabetes may be independent risk factors for all-cause and CVD mortality.

Periodontal disease and chronic kidney disease among Aboriginal adults; an RCT.

BACKGROUND: This study will assess measures of vascular health and inflammation in Aboriginal Australian adults with chronic kidney disease (CKD), and determine if intensive periodontal intervention improves cardiovascular health, progression of renal disease and periodontal health over a 24-month follow-up. METHODS: The study will be a randomised controlled trial. All participants will receive the periodontal intervention benefits, with the delayed intervention group receiving periodontal treatment 24 months following baseline. Inclusion criteria include being an Aboriginal Australian, having CKD (a. on dialysis; b. eGFR levels of < 60 mls/min/1.73 m(2) (CKD Stages 3 to 5); c. ACR ≥ 30 mg/mmol irrespective of eGFR (CKD Stages 1 and 2); d. diabetes plus albuminuria (ACR ≥ 3 mg/mmol) irrespective of eGFR), having moderate or severe periodontal disease, having at least 12 teeth, and living in Central Australia for the 2-year study duration. The intervention involves intensive removal of dental plaque biofilms by scaling, root-planing and removal of teeth that cannot be saved. The intervention will occur in three visits; baseline, 3-month and 6-month follow-up. The primary outcome will be changes in carotid intima-media thickness (cIMT). Secondary outcomes will include progression of CKD or death as a consequence of CKD/cardiovascular disease. Progression of CKD will be defined by time to the development of the first of: (1) new development of macroalbuminuria; (2) 30 % loss of baseline eGFR; (3) progression to end stage kidney disease defined by eGFR < 15 mLs/min/1.73 m(2); (4) progression to end stage kidney disease defined by commencement of renal replacement therapy. A sample size of 472 is necessary to detect a difference in cIMT of 0.026 mm (SD 0.09) at the significance criterion of 0.05 and a power of 0.80. Allowing for 20 % attrition, 592 participants are necessary at baseline, rounded to 600 for convenience. DISCUSSION: This will be the first RCT evaluating the effect of periodontal therapy on progression of CKD and cardiovascular disease among Aboriginal patients with CKD. Demonstration of a significant attenuation of CKD progression and cardiovascular disease has the potential to inform clinicians of an important, new and widely available strategy for reducing CKD progression and cardiovascular disease for Australia's most disadvantaged population. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trial Registry ANZCTR12614001183673.

Changes in vitamin D supplement use and baseline plasma 25-hydroxyvitamin D concentration predict 5-y change in concentration in postmenopausal women.

Few studies have prospectively examined predictors of change in plasma concentrations of 25-hydroxyvitamin D [25(OH)D]. We sought to determine the predictors of 5-y change in 25(OH)D. Plasma 25(OH)D concentrations were assessed at baseline (1997-2000) and 5 y later (2002-2005) in 668 postmenopausal women enrolled in the Osteoporosis and Periodontal Disease Study. Baseline and changes in demographic, dietary, lifestyle, and health-related factors were tested as predictors of change in 25(OH)D concentrations by using multivariable linear regression. The mean 5-y change in 25(OH)D (mean ± SD) was 7.7 ± 0.7 nmol/L (P < 0.001). In our predictive model (n = 643), predictors explained 31% of the variance in change in 25(OH)D concentrations and included baseline 25(OH)D, baseline and change in vitamin D supplementation and physical activity, change in season of blood draw, BMI, whole-body T score, and baseline hormone therapy use. Baseline 25(OH)D and change in vitamin D supplementation explained the most variation (25%) in 25(OH)D. Exploratory analyses showed a borderline significant interaction between tertiles of baseline 25(OH)D and change in vitamin D supplementation over time (P = 0.06). The greatest mean increase in 25(OH)D (22.9 ± 16.8 nmol/L), with adjustment for other statistically significant predictors, occurred in women whose baseline 25(OH)D concentration was ≤51.0 nmol/L (tertile 1) and who increased supplementation use over time. These results confirm the importance of supplementation in increasing 25(OH)D concentrations in aging women, even after other statistically significant predictors are controlled for. These data also suggest that this is especially true among aging women with inadequate 25(OH)D (e.g., <50 nmol/L).

Prospective association of periodontal disease with cardiovascular and all-cause mortality: NHANES III follow-up study.

BACKGROUND: It has been suggested that periodontal disease (PD) was associated with an increased risk for cardiovascular diseases (CVD), although evidence is inconclusive. PURPOSE: We first sought to prospectively evaluate the relationship of PD to CVD and all-cause mortality using a national representative sample in the United States. METHODS: The study population consisted of 10,849 participants who were 30 years or older and received a periodontal examination from NHANES III mortality follow-up sample (1988-2006). CVD and all-cause deaths were ascertained from the National Death Index records. The causes of death were defined using the International Classification of Disease coding (ICD-10). The severity of PD was categorized as non-PD, modest and severe PD based on clinical attachment loss and pocket depth. RESULTS: Of the study sample, 3105 and 561 participants were identified as modest and severe PD cases, respectively. After up to 18 years of follow-up, there were total 2894 deaths, of which 1225 were from CVD. The levels of inflammation markers (high sensitivity C-reactive protein, white cell count and fibrinogen) were significantly higher in men with severe PD compared to men without PD (p<0.05). The prospective associations were evaluated using multivariable Cox proportional-hazards models. After adjusting for age, gender, race, household income and traditional risk factors of CVD, severe PD was associated with an increase risk of CVD mortality and all-cause mortality in men aged 30-64 years (HR=2.13 with 95% confidence interval of 1.37-3.31 for CVD mortality; HR=1.64 with 95% confidence interval of 1.25-2.15 for all-cause mortality). In addition, significant linear trends were found in CVD and all-cause mortality across the severity of PD (p<0.001). However, no significant associations were found in men aged ≥65 and in women. CONCLUSIONS: There appears to be prospective associations between PD and CVD and all-cause mortality in men aged 30-64 years. Inflammation may be one possible pathway to link PD with CVD.

Maternal periodontal disease and perinatal mortality.

BACKGROUND: Periodontal disease has been associated with increased perinatal mortality. AIMS: To examine the association between maternal periodontal disease and perinatal mortality. METHODS: We performed a retrospective and prospective matched case-control study of women with unexplained perinatal mortality at more than 20 weeks gestational age. Women were matched for socioeconomic status, smoking status and time since delivery. All women underwent a detailed periodontal examination and completed a questionnaire describing oral health symptoms. No intervention took place. RESULTS: Fifty-three women who had experienced a perinatal death and 111 controls completed the study. Thirty-two women were recruited retrospectively and 21 women were recruited prospectively. Twenty-three (43.4%) women who had experienced a perinatal death and 27 (24.3%) controls had periodontal disease. There were no differences in oral health behaviours or symptoms between cases and controls. Perinatal death was associated with periodontal disease (odds ratio (OR) 2.34, 95% confidence interval (CI) 1.05, 5.47). Periodontal disease was more strongly associated with perinatal mortality due to extreme prematurity (OR 3.60, 95% CI 1.20, 12.04). Multivariate analysis showed this relationship to be consistent after inclusion of higher parity, country of birth, advanced maternal age and maternal obesity in the model (OR 4.56, 95% CI 1.25, 21.27). CONCLUSIONS: Maternal periodontal disease may contribute to perinatal mortality, especially that caused by extreme prematurity.

Periodontal treatment: potential to reduce cardiovascular morbidity and/or mortality.

Cardiovascular diseases (CVDs) are one of the major reasons of morbidity and mortality globally. They are some multifactorial diseases and most of which may be primarily associated with atherosclerotic lesions. Periodontal disease is an infection of tooth-supporting tissues, which is highly prevalent in populations. Continuing studies have revealed that periodontal disease is another important risk factor for cardiovascular diseases. The host-mediated inflammatory response to periodontal pathogens and their components, release of matrix metalloproteinases, alteration in lipoprotein metabolism and poor dietary habits may contribute to the atheroma pathogenesis in patients with periodontal disease. Based on these data, we hypothesized that periodontal treatment, along with the primary and secondary prevention of traditional risk factors of cardiovascular diseases (smoking, hypertension, dyslipidaemia, diabetes, obesity and lack of exercise), might reduce morbidity and/or mortality of cardiovascular diseases. Evidences from recent studies have supported our hypotheses partly. Further well-designed, double blinded, randomized and controlled clinical trials with larger sample size in this area are still needed.

Periodontal disease adversely affects the survival of patients with end-stage renal disease.

Periodontal disease is associated with cardiovascular disease and is thought to accelerate systemic atherosclerosis. Here we examined the relationship between periodontitis and cardiovascular disease mortality in outpatients on hemodialysis using a retrospective analysis of 168 adult patients in New York City and North Carolina. During 18 months of follow-up, cardiovascular disease and all-cause mortality were determined from a centralized dialysis registry. One hundred patients had mild or no periodontal disease but the remaining 68 had moderate-to-severe disease defined as 2 or more teeth with at least 6 mm of inter-proximal attachment loss. At baseline, the proportion of males was significantly lower in the moderate-to-severe group. Compared with mild or no periodontal disease, moderate-to-severe disease was significantly associated with death from cardiovascular causes. Adjustment for age, gender, center and dialysis vintage, smoking status, and history of diabetes mellitus or hypertension did not diminish the strength of this association. Our findings suggest a need for larger studies to confirm this connection, along with intervention trials to determine if treating periodontitis reduces cardiovascular disease mortality in dialysis patients.

[The influence of surgical and restorative dental treatment prior to cardiac valve surgery on the long-term demand of dental treatment: a prospective clinical study]. / Eine klinisch prospektive Untersuchung zum Einfluss der Fokussanierung vor Herzklappenoperation auf den langfristigen zahnärztlichen Behandlungsbedarf.

The study objective was to evaluate the long-term influence of non-radical surgical and restorative dental treatment modalities prior to elective cardiac valve replacement on the subsequent dental treatment demand. A total of 305 patients preceding cardiac valve surgery were screened and the appropriate dental treatment was initiated. After 36 months 80 patients were re-evaluated clinically, of which 60 required dental restorations of 155 teeth, mostly due to periodontal pathology. Independent of the sub-group there was a statistically substantial increase of the treatment demand compared to the time of initial examination. In addition, at the time of final re-evaluation the definite treatment need significantly increased far beyond anticipation, potentially due to inadequate dental procedures during the follow-up interval. Irrespective of any dental treatment or antibiotic application, endocarditis did not occur in any patient. Non-radical dental restoration prior to cardiac valve replacement can only be successful, if a standardized dental follow-up with common monitoring forms is provided. The risk of prosthetic valve infective endocarditis based on a dental focus is probably overestimated.

Periodontal disease and mortality in type 2 diabetes.

OBJECTIVE: Periodontal disease may contribute to the increased mortality associated with diabetes. RESEARCH DESIGN AND METHODS: In a prospective longitudinal study of 628 subjects aged > or =35 years, we examined the effect of periodontal disease on overall and cardiovascular disease mortality in Pima Indians with type 2 diabetes. Periodontal abnormality was classified as no or mild, moderate, and severe, based on panoramic radiographs and clinical dental examinations. RESULTS: During a median follow-up of 11 years (range 0.3-16), 204 subjects died. The age- and sex-adjusted death rates for all natural causes expressed as the number of deaths per 1,000 person-years of follow-up were 3.7 (95% CI 0.7-6.6) for no or mild periodontal disease, 19.6 (10.7-28.5) for moderate periodontal disease, and 28.4 (22.3-34.6) for severe periodontal disease. Periodontal disease predicted deaths from ischemic heart disease (IHD) (P trend = 0.04) and diabetic nephropathy (P trend < 0.01). Death rates from other causes were not associated with periodontal disease. After adjustment for age, sex, duration of diabetes, HbA1c, macroalbuminuria, BMI, serum cholesterol concentration, hypertension, electrocardiographic abnormalities, and current smoking in a proportional hazards model, subjects with severe periodontal disease had 3.2 times the risk (95% CI 1.1-9.3) of cardiorenal mortality (IHD and diabetic nephropathy combined) compared with the reference group (no or mild periodontal disease and moderate periodontal disease combined). CONCLUSIONS: Periodontal disease is a strong predictor of mortality from IHD and diabetic nephropathy in Pima Indians with type 2 diabetes. The effect of periodontal disease is in addition to the effects of traditional risk factors for these diseases.