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Indicator Details — Emerging Topics: Incidence-rate Ratio of CKD by Status of Periodontal Diseasea,b,c
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  • D-ARIC and JHS

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  • Model, Periodontal Disease
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Published literature or one-time analysis, ongoing surveillance not available Published literature or one-time analysis, ongoing surveillance not available

Footnotes:
a Unadjusted model: Severe level of periodontal disease compared to no periodontal disease has a p-value of 0.03.

b Adjusted model: Severe level of periodontal disease compared to no periodontal disease has a p-value of 0.02.

c The adjusted model includes adjustment for age, sex, diabetes, hypertension, smoking, and income.




Periodontal disease has been implicated as a novel risk factor for CKD. Within a population of African American participants enrolled in the Dental-Atherosclerosis Risk in Communities study (D-ARIC) (1996 to 1998), and subsequently enrolled in the Jackson Heart Study (JHS) (2000 to 2004), the rate of incident CKD was significantly higher among those with severe periodontal disease than among those without periodontal disease.
Chart Explanation: The incident-rate ratio for CKD was significantly higher among those with severe periodontal disease than among those without periodontal disease. In the unadjusted model, the incidence-rate ratio of CKD among those with severe periodontal disease compared with those with no periodontal disease was 2.63 (CI of 1.10-6.31), p=0.03. In the adjusted model, the incidence-rate ratio between those with severe periodontal disease compared with those without disease increased to 2.96 (CI of 1.14-7.67), p=0.02. For both the unadjusted and adjusted models, the rate of incident CKD among patients with mild/moderate periodontal disease was not statistically significant. Future studies are needed to examine further the causal relationship between periodontal disease and CKD.
A cohort of African American participants enrolled in the Dental-Atherosclerosis Risk in Communities study (D-ARIC), were subsequently enrolled in the Jackson Heart Study (JHS). The D-ARIC study, which was conducted between 1996 and 1998, involved a subgroup of the ARIC study cohort visit 4.The ARIC study was a longitudinal study of 15,792 individuals aged 45-64 years recruited from 4 U.S. suburban communities with a primary purpose of investigating the etiology and natural history of atherosclerosis, including the determination of risk factors. Participants underwent an oral examination by dental hygienists. The clinical measures examined were bleeding on probing, probing depth, and gingival recession. The JHS is a community-based cohort study with the primary focus of examining risk factors for cardiovascular disease among African Americans. The study was conducted between 2000 and 2004. All participants were living in the tri-county area of Jackson, Mississippi. The final cohort of individuals enrolled in both the D-ARIC and JHS studies was comprised of 669 individuals. There were 240 males, 459 females, and the average age was 65.

The main outcome measure was incident CKD at follow-up (i.e., the first JHS visit), which was defined as estimated glomerular filtration rate (eGFR) <60 ml/minute/1.73m2 with >5% annualized kidney function loss. The eGFR was calculated using calibrated serum creatinine. The Chronic Kidney Disease Epidemiology Collaboration equation was used. The primary predictor was periodontal disease, which was determined using the Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP) 2003 consensus definition. According to this, severe periodontal disease was defined as the presence of ≥2 interproximal sites with clinical attachment loss (CAL) ≥6 mm (not on the same tooth) and ≥1 interproximal sites with probing depth (PD) ≥5 mm. Moderate periodontal disease was defined as ≥2 interproximal sites with CAL ≥4 mm (not on the same tooth) or ≥2 interproximal sites with PD ≥5 mm, also not on the same tooth. Mild periodontal disease was defined as ≥2 interproximal sites with CAL ≥3 mm and ≥2 interproximal sites with PD ≥4 mm (not on the same tooth) or 1 site with PD ≥5 mm. As a secondary predictor, the authors also measured the presence of a periodontal inflamed surface area. The ultimate goal of the authors was to examine the association of periodontal disease with worsening kidney function.

This indicator is based on analysis in published literature: Grubbs V, Vittinghoff E, Beck JD, et al. Association between periodontal disease and kidney function decline in African Americans: The Jackson Heart Study. J Periodontol. 2015;86(10):1126-1132
http://www.ncbi.nlm.nih.gov/pubmed/26110451
FieldData
Description of MeasureIndicidence-Rate Ratio of CKD Associated with Periodontal Disease
Data SourceDental-Atherosclerosis Risk in Communities Study and the Jackson Heart Study
Type of Data SourceThe D-ARIC study was a longitudinal study; JHS was a prospective community-based cohort study
Data SetThe Jackson Heart Study summarized data from published literature; the D-ARIC study was a longitudinal clinical study involving an oral examination
Health Care Data SystemNo
Regional or NationalRegional
Demographic GroupJackson Heart Study: 5,301 noninstitutionalized African Americans, aged 21 years or older from Jackson, Mississippi, Metropolitan Statistical Area counties (Hinds, Madison, Rankin); D-ARIC: 15,792 individuals aged 45-64 years recruited from 4 U.S. suburban communities 
NumeratorIncident CKD at follow-up (Jackson Heart Study visit) accompanied by rapid eGFR decline (>5% annual loss)
DenominatorBaseline participants who did not have missing data for the necessary covariates 
Definition of CKD
eGFR < 60 mL/min/1.73 m2 
Glomerular Filtration RateEstimated, MDRD Study equation: GFR = 186.0 x (serum creatinine)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)
Primary Data Source IndicatorPeriodontal Disease
Primary Indicator Method of MeasurementSevere periodontal disease was defined as the presence of ≥2 interproximal sites with attachment loss (AL) ≥6 mm (not on the same tooth) and ≥1 interproximal sites with PD ≥5 mm. Moderate periodontal disease was defined as ≥2 interproximal sites with clinical AL ≥4 mm (not on the same tooth) or ≥2 interproximal sites with PD ≥5 mm, also not on the same tooth. Mild periodontal disease was defined as ≥2 interproximal sites with AL ≥3 mm and ≥2 interproximal sites with PD ≥4 mm (not on the same tooth) or 1 site with PD ≥5 mm
Secondary Data Source IndicatorPresence of periodontal inflamed surface area (PISA)
Secondary Indicator Method of MeasurementCalculated for each participant using clinical attachment loss (CAL), recession, and bleeding upon probing (BOP)
Frequency of Measurement (Primary)Once (cross-sectional)
Period Currently Available2004
Pending DataNone
U.S. Region Covered by Primary VariableCommunities in Mississippi
Additional Data Items of InterestStratification variables of interest (age, sex, smoking status, and annual income)
Limitations of IndicatorDemographically limited study; obesity not included as a confounder in analyses; there may be additional, unidentified confounders acting in the association of periodontal disease with kidney function decline
Analytical ConsiderationsThe data were adjusted for demographics (age and sex); comorbidities and health-related behaviors (hypertension, diabetes, and smoking); and socioeconomic status (income) as potential confounders. Covariates were added to the model sequentially to examine incremental effects of each confounder category on the likelihood on incident CKD
References and Sources:
  • Grubbs V, Vittinghoff E, Beck JD, et al. Association between periodontal disease and kidney function decline in African Americans: The Jackson Heart Study. J Periodontol. 2015;86(10):1126-1132.
    http://www.ncbi.nlm.nih.gov/pubmed/26110451

Suggested Citation:
Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance System—United States.
website. http://www.cdc.gov/ckd