Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Research
  • Published:

Association between tooth loss and mortality in patients with rheumatoid arthritis

British Dental Journal volume 239, pages 266–273 (2025)Cite this article

Abstract

Aim This study aimed to examine the association between all-cause and cardiovascular mortality in patients with rheumatoid arthritis (RA) who have missing teeth.

Methods Data were obtained from RA patients aged 18 and older from the National Health and Nutrition Examination Surveys conducted between 1999-2004 and 2011-2014. Participants underwent detailed oral examinations. The relationship between the number of missing teeth and mortality risk was analysed using Cox regression models and restricted cubic splines.

Results A cohort of 1,720 patients was followed for up to 187 months, during which 627 deaths occurred, including 191 attributable to cardiovascular causes. In RA patients, each additional missing tooth was associated with a 2% increase in all-cause mortality risk. Patients with 15-28 missing teeth demonstrated hazard ratios (HRs) of 4.05 (95% confidence interval [CI]: 2.94-5.57) for all-cause mortality and 2.47 (95% CI: 1.19-5.14) for cardiovascular mortality, compared to those with no missing teeth. Notably, when the number of missing teeth reached ten or more, the risk of cardiovascular mortality decreased by 14% per additional missing tooth (HR: 0.86 [95% CI: 0.81-0.91]).

Conclusions In patients with RA, when the number of missing teeth is <10, cardiovascular mortality risk increased with additional tooth loss, whereas when the number is ≥10, cardiovascular mortality risk decreased with further tooth loss.

Key points

  • In patients with rheumatoid arthritis, the number of missing teeth shows no nonlinear association with all-cause mortality but associated with cardiovascular mortality in a non-linear pattern.

  • When the number of missing teeth is <10, the cardiovascular mortality risk in patients with rheumatoid arthritis increases with additional tooth loss; when the number is ≥10, the cardiovascular mortality risk decreases as tooth loss increases.

  • The association between tooth loss and mortality independent of periodontitis.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The datasets generated and/or analysed during the current study are available in the NHANES website: https://wwwn.cdc.gov/nchs/nhanes/default.aspx.

References

  1. Di Matteo A, Bathon J M, Emery P. Rheumatoid arthritis. Lancet 2023; 402: 2019-2033.

  2. Smolen J S, Aletaha D, McInnes I B. Rheumatoid arthritis. Lancet 2016; 388: 2023-2038.

  3. Jang S, Kwon E-J, Lee J J. Rheumatoid arthritis: pathogenic roles of diverse immune cells. Int J Mol Sci 2022; 23: 905.

  4. Finckh A, Gilbert B, Hodkinson B et al. Global epidemiology of rheumatoid arthritis. Nat Rev Rheumatol 2022; 18: 591-602.

  5. Lee Y-K, Bae S-C. Mortality in Korean patients with rheumatoid arthritis. J Rheum Dis 2021; 28: 113-118.

  6. Aviña-Zubieta J A, Choi H K, Sadatsafavi M, Etminan M, Esdaile J M, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum 2008; 59: 1690-1697.

  7. Myllykangas-Luosujärvi R A, Aho K, Isomäki H A. Mortality in rheumatoid arthritis. Semin Arthritis Rheum 1995; 25: 193-202.

  8. Myasoedova E, Davis J M 3rd, Crowson C S, Gabriel S E. Epidemiology of rheumatoid arthritis: rheumatoid arthritis and mortality. Curr Rheumatol Rep 2010; 12: 379-385.

  9. England B R, Thiele G M, Anderson D R, Mikuls T R. Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications. BMJ 2018; DOI: 10.1136/bmj.k1036.

  10. Widdifield J, Paterson J M, Huang A, Bernatsky S. Causes of death in rheumatoid arthritis: how do they compare to the general population? Arthritis Care Res 2018; 70: 1748-1755.

  11. Avina-Zubieta J A, Thomas J, Sadatsafavi M, Lehman A J, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis 2012; 71: 1524-1529.

  12. Zulfiqar A A, Niazi R, Pennaforte J L, Andres E. Rheumatoid arthritis and cardiovascular risk factor: literature review. Rev Med Liege 2018; 73: 634-639.

  13. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388: 1459-1544.

  14. DeStefano F, Anda R F, Kahn H S, Williamson D F, Russell C M. Dental disease and risk of coronary heart disease and mortality. BMJ 1993; 306: 688-691.

  15. Garcia R I, Krall E A, Vokonas P S. Periodontal disease and mortality from all causes in the VA Dental Longitudinal Study. Ann Periodontol 1998; 3: 339-349.

  16. Bond J C, McDonough R, Alshihayb T S, Kaye E K, Garcia R I, Heaton B. Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years. J Clin Periodontol 2023; 50: 71-79.

  17. Inchingolo F, Inchingolo A M, Avantario P et al. The effects of periodontal treatment on rheumatoid arthritis and of anti-rheumatic drugs on periodontitis: a systematic review. Int J Mol Sci 2023; 24: 17228.

  18. Wen S, Beltrán V, Chaparro A, Espinoza F, Riedemann J P. Association between chronic periodontitis and rheumatoid arthritis. A systematic review. Rev Med Chil 2019; 147: 762-775.

  19. Joseph R, Rajappan S, Nath S G, Paul B J. Association between chronic periodontitis and rheumatoid arthritis: a hospital-based case-control study. Rheumatol Int 2013; 33: 103-109.

  20. Rak D, Kulloli A M, Shetty S K et al. Correlation between rheumatoid arthritis and chronic periodontitis: a systematic review and meta-analysis. Minerva Dent Oral Sci 2024; 73: 294-302.

  21. Vogtmann E, Etemadi A, Kamangar F et al. Oral health and mortality in the Golestan Cohort Study. Int J Epidemiol 2017; 46: 2028-2035.

  22. Lee H J, Choi E K, Park J B, Han K D, Oh S. Tooth loss predicts myocardial infarction, heart failure, stroke, and death. J Dent Res 2019; 98: 164-170.

  23. Schwahn C, Polzer I, Haring R et al. Missing, unreplaced teeth and risk of all-cause and cardiovascular mortality. Int J Cardiol 2013; 167: 1430-1437.

  24. De Pablo P, Dietrich T, McAlindon T E. Association of periodontal disease and tooth loss with rheumatoid arthritis in the US population. J Rheumatol 2008; 35: 70-76.

  25. US Centers for Disease Control and Prevention. National health and nutrition examination survey: oral health - dentition. 2006. Available at https://wwwn.cdc.gov/Nchs/Data/Nhanes/Public/1999/DataFiles/OHXDENT.htm (accessed July 2025).

  26. US Centers for Disease Control and Prevention. National health and nutrition examination survey: oral health - periodontal. 2004. Available at https://wwwn.cdc.gov/Nchs/Data/Nhanes/Public/1999/DataFiles/OHXPERIO.htm (accessed July 2025).

  27. Eke P I, Page R C, Wei L, Thornton-Evans G, Genco R J. Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 2012; 83: 1449-1454.

  28. US Centers for Disease Control and Prevention. National health and nutrition examination survey: medical conditions. 2006. Available at https://wwwn.cdc.gov/Nchs/Data/Nhanes/Public/1999/DataFiles/MCQ.htm (accessed July 2025).

  29. Sun L, Ye Z, Ling Y et al. Relationship between polycyclic aromatic hydrocarbons and rheumatoid arthritis in US general population, NHANES 2003-2012. Sci Total Environ 2020; 704: 135294.

  30. Krebs-Smith S M, Pannucci T E, Subar A F et al. Update of the Healthy Eating Index: HEI-2015. J Acad Nutr Diet 2018; 118: 1591-1602.

  31. National Cancer Institute. The Healthy Eating Index - population ratio method. 2021. Available at https://epi.grants.cancer.gov/hei/population-ratio-method.html (accessed July 2025).

  32. Yuan S, Song C, Zhang R, He J, Dou K. Dietary Inflammation Index and its association with long-term all-cause and cardiovascular mortality in the general us population by baseline glycemic status. Nutrients 2022; 14: 2556.

  33. Rehkopf D H, Needham B L, Lin J et al. Leukocyte telomere length in relation to 17 biomarkers of cardiovascular disease risk: a cross-sectional study of US adults. PLos Med 2016; DOI: 10.1371/journal.pmed.1002188.

  34. Ando A, Tanno K, Ohsawa M et al. Associations of number of teeth with risks for all-cause mortality and cause-specific mortality in middle-aged and elderly men in the northern part of Japan: the Iwate-KENCO study. Community Dent Oral Epidemiol 2014; 42: 358-365.

  35. Janket S J, Baird A E, Jones J A et al. Number of teeth, C-reactive protein, fibrinogen and cardiovascular mortality: a 15-year follow-up study in a Finnish cohort. J Clin Periodontol 2014; 41: 131-140.

  36. Shen R, Chen S, Shen J, Lv L, Wei T. Association between missing teeth number and all-cause and cardiovascular mortality: NHANES 1999-2004 and 2009-2014. J Periodontol 2024; 95: 571-581.

  37. Tu Y-K, Galobardes B, Smith G D, McCarron P, Jeffreys M, Gilthorpe M S. Associations between tooth loss and mortality patterns in the Glasgow Alumni Cohort. Heart 2007; 93: 1098-1103.

  38. Kang J, Smith S, Pavitt S, Wu J. Association between central obesity and tooth loss in the non-obese people: results from the continuous National Health and Nutrition Examination Survey (NHANES) 1999-2012. J Clin Periodontol 2019; 46: 430-437.

  39. Romagna C, Dufour L, Troisgros O et al. Periodontal disease: a new factor associated with the presence of multiple complex coronary lesions. J Clin Periodontol 2012; 39: 38-44.

  40. Tada A, Miura H. Association of mastication and factors affecting masticatory function with obesity in adults: a systematic review. BMC Oral Health 2018; 18: 76.

  41. Nowjack-Raymer R E, Sheiham A. Association of edentulism and diet and nutrition in US adults. J Dent Res 2003; 82: 123-126.

  42. Albrecht K, de Pablo P, Eidner T et al. Association between rheumatoid arthritis disease activity and periodontitis defined by tooth loss: longitudinal and cross-sectional data from two observational studies. Arthritis Care Res 2025; 77: 169-177.

  43. Kinane D F, Stathopoulou P G, Papapanou P N. Periodontal diseases. Nat Rev Dis Primers 2017; 3: 17038.

  44. Hujoel P P, Drangsholt M, Spiekerman C, Derouen T A. Examining the link between coronary heart disease and the elimination of chronic dental infections. J Am Dent Assoc 2001; 132: 883-889.

  45. Aoyama N, Suzuki J-I, Kobayashi N et al. Associations among tooth loss, systemic inflammation and antibody titers to periodontal pathogens in Japanese patients with cardiovascular disease. J Periodontal Res 2018; 53: 117-122.

  46. Nguyen T C, Witter D J, Bronkhorst E M, Pham L H, Creugers N H. Dental functional status in a southern vietnamese adult population-a combined quantitative and qualitative classification system analysis. Int J Prosthodont 2011; 24: 30-37.

  47. Solomon D H, Giles J T, Liao K P et al. Reducing cardiovascular risk with immunomodulators: a randomised active comparator trial among patients with rheumatoid arthritis. Ann Rheum Dis 2023; 82: 324-330.

  48. Heathfield S K, Parker B, Zeef L A, Bruce I N, Alexander M Y. Certolizumab pegol attenuates the pro-inflammatory state in endothelial cells in a manner that is atheroprotective. Clin Exp Rheumatol 2013; 31: 225-233.

  49. Hussein M, Farag Y M K, Sonis S. Differential associations of rheumatoid arthritis and periodontitis or tooth loss: a cross-sectional study. J Clin Periodontol 2023; 50: 307-315.

  50. Jin S, Zhao J, Li M, Zeng X. New insights into the pathogenesis and management of rheumatoid arthritis. Chronic Dis Transl Med 2022; 8: 256-263.

  51. Chen L, Wu B, Mo L et al. Associations between biological ageing and the risk of, genetic susceptibility to, and life expectancy associated with rheumatoid arthritis: a secondary analysis of two observational studies. Lancet Healthy Longev 2024; DOI: 10.1016/S2666-7568(23)00220-9.

  52. Cai B, Zhou M, Xiao Q, Zou H, Zhu X. L-shaped association between serum 25-hydroxyvitamin D and all-cause mortality of individuals with rheumatoid arthritis. Rheumatology 2023; 62: 575-582.

  53. Che Q-C, Jia Q, Zhang X-Y, Sun S-N, Zhang X-J, Shu Q. A prospective study of the association between serum klotho and mortality among adults with rheumatoid arthritis in the USA. Arthritis Res Ther 2023; 25: 149.

  54. Polzer I, Schwahn C, Völzke H, Mundt T, Biffar R. The association of tooth loss with all-cause and circulatory mortality. Is there a benefit of replaced teeth? A systematic review and meta-analysis. Clin Oral Investig 2012; 16: 333-351.

  55. Muñoz Aguilera E, Leira Y, Miró Catalina Q et al. Is systemic inflammation a missing link between periodontitis and hypertension? Results from two large population-based surveys. J Intern Med 2021; 289: 532-546.

  56. Cochran S D, Björkenstam C, Mays V M. Sexual orientation and all-cause mortality among US adults aged 18 to 59 years, 2001-2011. Am J Public Health 2016; 106: 918-920.

Download references

Acknowledgements

We thank the participants and staff of the National Health and Nutrition Examination Survey 1999-2004 and 2011-2014 for their valuable contributions.

Author information

Authors and Affiliations

  1. Department of Immunology and Rheumatology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical University, China

    Andi Xu, Chunhong Zhang & Honghua Lv

  2. Department of Nephrology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, Zhejiang, China

    Qiankun Zhang & Limei He

Authors
  1. Andi Xu
    View author publications

    Search author on:PubMed Google Scholar

  2. Chunhong Zhang
    View author publications

    Search author on:PubMed Google Scholar

  3. Honghua Lv
    View author publications

    Search author on:PubMed Google Scholar

  4. Qiankun Zhang
    View author publications

    Search author on:PubMed Google Scholar

  5. Limei He
    View author publications

    Search author on:PubMed Google Scholar

Contributions

LH had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: AZ and LH; statistical analysis: AX, CZ; acquisition, or interpretation of data: AAX, CZ, and HL; drafting of the manuscript: AX and CZ; critical review of the manuscript for important intellectual content: HL, QZ, and LH; obtained funding: AX.

Corresponding author

Correspondence to Limei He.

Ethics declarations

The authors declare no conflicts to declare. This work was supported by Lishui Science and Technology Bureau (2024SJZC082). This study adheres to guidelines in the Declaration of Helsinki. The National Center for Health Statistics (NCHS) Ethics Review Board approved NHANES project, and all participants provided written informed consents. The approvals for the NHANES protocols for the periods 1999-2004 and 2011-2014 were obtained separately and can be accessed on the NHANES website (https://www.cdc.gov/nchs/nhanes/about/erb.html?CDC_AAref_Val=https://www.cdc.gov/nchs/nhanes/irba98.htm). Since NHANES data are de-identified and anonymised during analysis, conducting secondary analyses on the data did not require additional ethical approval or informed consent.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xu, A., Zhang, C., Lv, H. et al. Association between tooth loss and mortality in patients with rheumatoid arthritis. Br Dent J 239, 266–273 (2025). https://doi.org/10.1038/s41415-025-8665-8

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41415-025-8665-8

Search

Advanced search

Quick links