<Abstract> Korean Journal of Oral and Maxillofacial Pathology 2015;39(2):447-456 ISSN:1225-1577(Print); 2384-0900 (Online) Available online at http://journal.kaomp.org http;//dx.doi.org/10.17779/kaomp.2015.39.2.447 한국성인의전신건강상태와치주질환과의관련성분석 - 2012 년도제 5 기국민건강영양조사결과분석 - 이선미 1), 김기열 2), 김진 2) 동남보건대학교치위생과 1), 연세대학교치과대학구강병리학교실, 구강종양연구소 2) Analysis of the Relationship Between Systemic Health Status and Periodontal Disease in Korean Adults - Survey study of the Fifth Korea National Health and Nutrition Examination - Sun Mi Lee 1), Ki Yeol Kim 2), Jin Kim 2) Department of Dental Hygiene, Dongnam Health College 1), Department of Oral Pathology, Oral Cancer Research Institute, Yonsei University College of Dentistry 2) The purpose of this study was to synthetically examine the relationship between systemic diseases and periodontal diseases. The data obtained from the Fifth Korea National Health and Nutrition Examination Survey were used. SPSS 18.0 for Windows was applied for statistical analysis. The surveyed data were analyzed by using independent sample t-test for the difference between Body Mass Index and clinical test according to the existence of periodontal disease, and X2 test for the relationship between periodontal disease and systemic disease. Multiple logistic regression analysis was used in order to figure out the influence upon the periodontal disease prevalence among general characteristics and systemic diseases. As results, the values of high density lipoprotein (HDL) and HBA1C were statistically significant, depending on the presence of periodontal disease. As for the relationship between periodontal disease and systemic disease, hypertension (odds ratio 1.362, p<.05), cardiovascular disease (odds ratio 2.118, p<.05), arthritis (odds ratio 1.289, p<.05) and cirrhosis (odds ratio 6.124, p<.05) were statistically significant. According to Multiple logistic regression analysis, gender (odds ratio 1.24, p<.05), alcohol intake (odds ratio 1.25, p<.05), cardiovascular diseases (odds ratio 1.56, p<.05), and liver cirrhosis (odds ratio 1.17, p<.05) were related to the prevalence of periodontal diseases. In conclusion, the systemic diseases such as cardiovascular system, diabetes, and liver diseases revealed to have relationship with periodontal disease. To strengthen oral health education is needed to enhance systemic health as well as oral health. Moreover, basic biological research should be followed to support this surveyed study. Key words:periodontal disease, Systemic diseases Ⅰ. INTRODUCTION * Correspondence: Jin Kim Department of Oral Pathology, Oral Cancer Research Institute, Yonsei University College of Dentistry, 134 Shinchon-Dong, Seoul 120-752, Republic of Korea. Tel: +82-2-2228-3030, Fax: +82-2-392-2959 E-mail: jink@yuhs.ac Received: Feb 27, 2015; Revised: Mar 03, 2015; Accepted: Mar 28, 2015 치주질환은치아우식증과함께구강에서발생하는대표적만성질환으로치아표면에형성되는치면세균막과이에대한숙주의반응에의해치주조직이파괴되어결과적으로는치아상실을유발하는만성염증성질환이다 1). 만성치주질환은미흡한구강건강관리, 흡연, 고령화등으 이논문은교육부의재원으로한국연구재단의지원을받아수행된기초연구사업중중점연구소사업 ( 과제번호 : 2009-0094027) 으로이루어졌음.
로꾸준히그유병률이증가하고있다. 미국의경우 30세이상성인의 47.2% 가치주염을가지고있는것으로조사되었으며 2), 독일에서는 35세이상 95.0% 가임상적부착소실이 3mm 이상되는것으로조사되었다 3). 우리나라의경우는 19세이상성인의 26.8% 가치주염이있다고보고된바있으며 4), 2010년국민구강건강실태조사보고서에서도치주질환유병률이지속적으로증가하고있는것으로보고하고있고, 특히 35세이상의성인에게있어치아상실의주된원인으로알려져있다 5). 치주질환은초기에는동통이없고, 자각증상이없는관계로방치한상태가계속되기쉬우며환자가증상이있어내원했을때는질환이많이진행된경우가대부분이므로이런관점에서볼때질환의초기예방과조기발견, 조기치료가중요하다 6). 또한치주질환은일상생활에서도구강건강관련삶의질을저하시킬뿐만아니라, 의료비의증가와생산성의저하를일으키며, 여러가지전신질환의발생과도관련이있는대표적인질환으로알려져있다 7-9). 전신질환에는두가지기전으로영향을미치는것으로추정되는데, 첫째가치주질환유발세균과그독소가직접혈액을순환하면서전신면역염증을일으키는방식이고, 둘째는치주병소에서만들어진염증매개물질 (Interleukin-1(IL-1), Interleukin-6(IL-6), Tumor necrosis factor-alpha (TNF-a)) 및 C-Reactive Protein(CRP) 등이혈류를타고전신의각조직에전달되는방식이다 10). 전신질환이있는경우치주질환과의관련성을연구한결과를보면, Loesche 등 11) 은관상동맥환자에서상실치아수가많고치태지수가높다고보고하였고, Emingil 등 12) 은급성심근경색병력을가진사람에서탐침시출혈빈도와 4mm이상의치주낭비율이높다고보고하였다. 이처럼전신질환과치주질환사이에있어서원인과결과에대한인과관계를명확히구분하기는어렵지만최근치주질환과전신질환간의관련성에관한여러보고 13-31) 와함께치주질환자의전신상태에대한관심이많아지고있다. 그러나대부분연구들이단일질환과치주질환과의관계만을분석한연구들이고모든전신질환들을함께분석한연구는이루어지지않아본연구에서는전신질환과관련된변수들이치주질환에어떠한영향을미치는지종합적으로알아보고자한다. Ⅱ. MATERIALS AND METHODS 1. 연구대상본연구는국민건강영양조사제5기제3차년도 (2012) 자료를이용하였다 32). 본조사는 2012년 1월부터 12월까지전국 3,254가구, 만 1세이상가구원전체를조사대상으로실시되었고, 표본추출틀은 2009년인구자료와 2008년아파트시세조사자료를이용하였다. 표본조사구는시 도별 ( 서울, 6대광역시, 경기, 경상 강원, 충청, 전라 제주 ) 로 1차층화하고, 일반지역은성별, 연령대별인구비율기준 26개층, 아파트지역은단지별평당가격, 평균평수등을기준 24개층으로 2차층화한후추출하였다. 최종조사대상가구는추출된표본조사구내에서계통추출방법으로조사구당 20개가추출되었다. 수집된자료로부터한국성인의전신건강상태와치주질환관련성을파악하기위해 19세이상성인 6,293명을연구에포함하여분석하였다. 2. 연구도구제5기 3차년도 (2012) 국민건강영양조사 32) 는건강설문조사, 검진조사, 영양조사로이루어져있다. 본연구에사용된변수로는일반적특성 ( 성별, 연령 ) 건강행태 ( 흡연, 음주, 스트레스 ), 체질량지수 (Body Mass Index, BMI) 와임상검사로총콜레스테롤 (cholesterol, CHO), 고밀도지질단백질 (high density lipoprotein, HDL), 중성지방 (triglyceride, TG), 저밀도지질단백질 (low density lipoprotein, LDL) aspartate aminotransferase (AST), alanine aminotransferase (ALT), 백혈구 (white blood cells, WBC), 적혈구 (red blood cells, RBC), 헤모글로빈 (hemoglobin, HGB), 적혈구용적율 (hematocrit, HCT), 혈소판 (platelets, PLT), 공복혈당 (Fasting blood glucose, Glu), 당화혈색소 (HBA 1 C) 를이용하였다. 전신질환상태는건강설문조사중고혈압, 이상지혈증, 심혈관질환 ( 심근경색증또는협심증 ), 골관절염 ( 골관절염또는 448
류마티스성관절염 ), 폐결핵, 천식, 당뇨병, 갑상샘질환, B형간염, C형간염, 간경변증유병여부변수를이용하였고, 구강검사에서는치주질환유병여부변수를이용하였다. 3. 분석방법 Table 1. General characteristics Characteristics Division N (%) Gender Male Female 2,664(42.3) 3,629(57.7) 6,293(100.0) 모든통계적분석은통계분석용소프트웨어인 SPSS(SPSS 18.0 for Windows, SPSS Inc, USA) 를이용하였다. 조사된자료의특성에따라일반적특성과건강행태에대한내용은빈도와퍼센트로요약하여기술하였고, 치주질환유무에따른체질량지수와임상검사와의차이는독립집단간 t-검정, 치주질환유무와전신질환과의관계는 X 2 검정을이용하여분석하였다. Age Smoking 19-39 40-64 65 1,791(28.5) 2,836(45.1) 1,666(26.5) 6,293(100.0) 3,405(60.9) 2,186(39.1) 5,591(100.0) 일반적특성및전신질환관련요인중치주질환유병여부에미치는영향을알아보기위해서는다중로지스틱회귀분석을이용하였다. 통계적유의성판정을위한유의수준은 0.05 Alcohol intake 801(14.3) 4,792(85.7) 5,593(100.0) 로고려하였다. Stress 4,167(74.6) 1,420(25.4) 5,587(100.0) Ⅲ. RESULTS 1. 일반적사항연구대상자의일반적특성을살펴보면, 성별은남자 42.3%, 여자 51.7% 로여자가높았으며, 연령분포는 40-64세가 45.1% 로가장높았고, 19-39세 28.5%, 65세이상 26.5% 순으로나타났다. 흡연상태는 피우지않는경우 가 60.9%, 피우는경우 는 39.1% 의분포를보였으며, 음주경험은 없다 14.3%, 있다 85.7% 로나타났고, 스트레스인지에서는 스트레스를많이느낌 25.4%, 스트레스적게느낌 74.6% 로나타났다 (Table 1). 2. 치주질환유무에따른임상검사비교치주질환유무에따른체질량지수와임상검사수치를 t-test 로분석한결과는 Table 2와같다. 이상지질혈증검사항목중고밀도지질단백질에서치주질 환이있는경우 50.79 ml / dl보다치주질환이없는경우가 51.91 ml / dl로유의하게높게나타났고, 당뇨병검사항목중당화혈색소는치주질환이있는경우가 5.84% 로치주질환이없는경우 5.77% 보다유의하게높게나타났다. 다른항목에서는유의한차이가없는것으로나타났다. 3. 치주질환유무와전신질환과의관계치주질환유무와각전신질환과의관계를 X 2 검정으로분석한결과는 Table 3과같다. 대부분전신질환이있는경우치주질환이있는경우가높았으며, 특히질환중고혈압 (odds ratio 1.362, p<.05), 심혈관질환 (odds ratio 2.118, p<.05), 관절염 (odds ratio 1.289, p<.05), 간경변증 (odds ratio 6.124, p<.05) 을가지고있는경우치주질환이있는경우가통계적으로유의하게높게나타났다. 449
Table 2. The relationship between laboratory values and the presence of periodontal disease Characteristics N M±SD N M±SD t(p) BMI 3,442 23.67± 3.47 1,069 23.78± 3.43 -.912(.362) CHO 3,218 189.01± 36.22 990 189.88±35.66 -.662(.508) HDL 3,218 51.91± 12.65 990 50.79±12.48 2.433(.015 * ) TG 3,218 131.27±102.41 990 132.87±88.85 -.442(.659) LDL 3,218 119.87± 35.60 990 119.94±34.77 -.021(.938) AST 3,218 22.52± 18.79 990 22.65±11.82 -.198(.843) ALT 3,218 21.33± 24.94 990 21.65±18.92 -.369(.712) WBC 3,205 5.88± 1.63 987 5.95± 1.66-1.191(.234) RBC 3,205 4.52±.44 987 4.54±.44-1.271(.204) HGB 3,205 13.97± 1.61 987 14.02± 1.65 -.976(.329) HCT 3,205 41.60± 4.14 987 41.77± 4.23-1.129(.259) PLT 3,205 251.88± 58.14 987 253.30±58.94 -.669(.504) Glu 3,211 98.33± 20.84 987 99.46±23.71-1.437(.151) HBA 1 C 3,205 5.77±.80 986 5.84±.92-2.085(.037 * ) *p<0.05 BMI: Body Mass Index, CHO: Total Cholesterol, HDL: High density Lipoprotein, TG: Triglyceride, LDL: Low density Lipoprotein, AST:aspartate aminotransferase, ALT:alanine aminotransferase, WBC: White blood cells, RBC: Red blood cells, HGB: Hemoglobin, HCT: Hematocrit, PLT: Platelets, Glu: Fasting blood glucose, HBA1C: Glycosylated homoglobin 4. 치주질환에영향을미치는전신질환요인 IV. DISCUSSION 일반적특성및전신질환관련요인중치주질환유병여부에미치는영향을알아보기위해다중로지스틱회귀분석을실시한결과는 Table 4와같다. 치주질환에영향을미치는변수로는일반적특성중에서는성별 (odds ratio 1.24, p<.05) 과음주여부 (odds ratio 1.25, p<.05) 가전신질환과관련해서는심혈관질환 (odds ratio 1.56, p<.05) 과간경변증 (odds ratio 1.17, p<.05) 이영향을미치는변수로나타났다. 인구고령화, 국민들의생활양식의변화, 환경악화등에따라우리나라의만성질환비중이크게증가하고있으며, 보건복지부 33) 에서는 HP 2020 목표인 건강수명연장과건강형평성제고 를달성하기위해서예방중심의상병관리, 건강생활실천확산, 인구집단별건강관리등의주요과제를제시하고있다. 이는과거에는사망의주된원인이급성질환이었다면, 최근에는만성질환과퇴행성질환이주요한사망원인으로대두되고있고, 서구화된식습관과생활패턴의변화, 신체활동의감소, 고령화등으로인해서만성질환의유병율이 450
Table 3. The relationship between periodontal disease and systemic disease Characteristics Total X 2 (p) odds ratio Underweight 162(76.8) 49(23.2) 211(100.0) BMI mal 2,198(76.6) 672(23.4) 2,870(100.0).513(.774) - Obesity 1,064(75.6) 343(24.4) 1,407(100.0) Hypertension 2,490(77.9) 752(72.2) 705(22.1) 290(27.8) 3,195(100.0) 1,042(100.0) 14.535(.000 * ) 1.362 Dyslipidemia 2,871(76.7) 371(74.9) 871(23.3) 124(25.1) 3,742(100.0) 495(100.0).766(.382) 1.102 Cardiovascular disease 3,163(77.0) 79(61.2) 945(23.0) 50(38.8) 4,108(100.0) 129(100.0) 17.279(.000 * ) 2.118 Arthritis 2,726(77.3) 516(72.6) 799(22.7) 195(27.4) 3,525(100.0) 711(100.0) 7.463(.006 * ) 1.289 Pulmonary tuberculosis 3,077(76.7) 165(74.0) 936(23.3) 58(26.0) 4,013(100.0) 223(100.0).848(.357) 1.156 Asthma 3,116(76.7) 126(73.7) 949(23.3) 45(26.3) 4,065(100.0) 171(100.0).806(.369) 1.173 Diabetes 2,974(76.9) 268(72.6) 893(23.1) 101(27.4) 3,867(100.0) 369(100.0) 3.433(.064) 1.255 Thyroid gland disease 3,122(76.6) 120(75.0) 954(23.4) 40(25.0) 4,076(100.0) 160(100.0).218(.641) 1.091 Hepatitis B 3,192(76.6) 50(71.4) 974(23.4) 20(28.6) 4,166(100.0) 70(100.0) 1.033(.309) 1.311 Hepatitis C 3,235(76.6) 7(53.8) 988(23.4) 6(46.2) 4,223(100.0) 13(100.0) 3.738(.053) 2.807 Cirrhosis 3,235(76.7) 7(35.0) 981(23.3) 13(65.0) 4,216(100.0) 13(100.0) 19.303(.000 * ) 6.124 *p<0.05 지속적으로증가되었기때문이다 34). 치주질환은유병률이매우높으면서도치료를소홀히하기쉬운인체의대표적인만성염증질환으로만성치주질환이전신적건강에영향을끼치고있음은많은연구와논문으로밝혀지고있다. 일반적특성중치주질환유병여부에영향을미치는변수는다중로지스틱회귀분석결과성별 (odds ratio 1.24, p<.05) 과음주여부 (odds ratio 1.25, p<.05) 로나타났는데, 이는장 13) 의연구에서치주질환의연관성에대해서는대부분의수치가흡연군및음주군에서높은수치를나타낸결과와정등 14) 의치주질환유병과관련이있는일반건강행위는현 재흡연을하는경우, 일주일에음주횟수가많을수록치주질환`의비율이높게나타난결과와비슷하였다. 그러나성별도영향을미치는변수로나타난점을고려해볼때음주나흡연등의습관등에기인한것만으로는보이지않고, 오히려성별에따른호르몬의차이등근본적인남녀의차이가더큰요인이라고생각된다. 치주질환이있는경우전신질환과의관계는임상검사수치를비교한결과를보면이상지질혈증검사항목중고밀도지질단백질에서치주질환이있는경우 50.79ml / dl보다치주질환이없는경우가 51.91 ml / dl로유의하게높게나타났고, 다른항목에서는유의한차이를확인할수는없었지만치주 451
Table 4. Multiple logistic regression analysis of the relationship between periodontal disease and systemic disease Gender(male=0) female Age(19-39=0) 40-64 65 Smoking(=0) Alcohol intake(=0) Stress(=0) BMI(underweight=0) mal Obesity Hypertension(=0) Dyslipidemia(=0) Cardiovascular disease(=0) Arthritis(=0) Pulmonary tuberculosis(=0) Asthma(=0) Diabetes(=0) Thyroid gland disease(=0) Hepatitis B(=0) Hepatitis C(=0) Cirrhosis(=0) Constant B S.E Wald p Exp(B).218.107 4.142.042 * 1.244 -.119.121.969.325.888 -.120.098 1.508.219.887.201.108 3.463.063 1.222.222.109 4.177.041 * 1.249.023.086.072.788.977.072.187.147.702 1.074.040.081.246.620.961.154.098 2.463.117.857.069.121.328.567 1.072.571.195 8.569.003 * 1.565.096.105.824.364.909.122.161.567.452.886.020.184.012.914.980.032.133.058.809.968.085.191.195.659.919.074.282.069.793.929 1.024.561 3.325.068.359 1.735.480 13.041.000 * 1.176 2.445.830 8.674.003 11.534 *p<0.05 452
질환이있는경우약간높았다. 이는치주질환과총콜레스테롤, 중성지방과의관계를확인한연구인 Katz 등 15) 과 Madjid 등 16) 은모두관계가있다고보고하였으며, 국내연구인이 17) 의연구에서는치주질환의심도가증가할수록총콜레스테롤, 중성지방이증가하였으며, 고밀도지질단백질은치주염이심해짐에따라감소하였다는결과와유사하였다. 전신질환이있는경우치주질환과의관계를살펴보면당뇨병의경우여러역학연구를통해치주질환의위험인자로알려져있으며, Khader 등 18) 은 1970-2003 년사이의문헌고찰을통해 23개논문, 약 2만명대상의메타분석결과당뇨병환자는정상군에비해치주조직의소실이유의하게증가하였고, 혈당조절이되지않을수록심한치주질환이증가하였다고보고하였다. 본연구에서당뇨병과치주질환과의관계판단기준은공복혈당과당화혈색소로확인하였다. 치주질환이있는경우공복혈당과당화혈색소가높게나타났으며특히당화혈색소에서는통계적으로유의한차이를보였다. 이는기존의연구 17) 와도유사하였다. 김등 19) 은공복혈당의높은수치가치주염을비롯한구강건강에악영향을끼치는위험인자로작용함을보여주었고, 권등 20) 과서 21) 의연구에서도당뇨병과치주질환이관련성이있는것으로보고하였다. 그러나장 13) 의연구에서는당뇨와관련된모든수치가정상인에비해높게나타났으나유의성은인정되지않았다. 치주질환과당뇨병은서로영향을미쳐서, 당뇨병은치주질환을악화시키고, 치주질환은혈당조절을더욱어렵게하는악순환을거듭하는것으로알려져있다 18). 따라서적절한치주치료는당뇨병환자의혈당조절의개선에도움을주기때문에치주병과당뇨병이서로영향을미치는양방향관련성을가진다고볼수있다 22). 비만과의관계에있어서는본연구에서는거의차이가없는것으로나타났는데, 최 23) 의연구에서도치주질환과비만도지표인체질량지수간에는유의한상관관계를보이지않은것과같은결과를보였으나, 장 13) 의연구결과비만과치주상태와의연관성에있어비만군에서상실치아등급과치은지수가높게나타났다고보고하였고, Saito 등 24) 은 Waist-Hip Ratio(WHR), 체질량지수, 체지방이치주염과연관이있다고보고하였으며, 공과한 25) 은 20세이상성인 439명을대상으로연구한결과에서비만으로판정받은경우치주질환을함 께가지고있을위험이높아진다고보고하였다. 본연구에서연관성이없는것으로나타난것은비만은섭취하는열량과소비하는열량의불균형으로나타나는것이고, 치주질환은평소개인이구강관리를어떻게했는지에따라달라질수있으므로그정도에따른차이로생각된다. 고혈압과의관계에있어서는본연구결과위험도가 1.362 배로나타나, 서 26) 의연구에서고혈압유병여부가치주질환과통계적으로유의하게나타난결과와유사하였다. 심혈관질환과관련해서 Beck 등 27) 의연구에서치주질환의심도가급성심근경색의발병과유의하게관련이될수있다는것을보여주었고, Paul 28) 은치주질환환자에게서심혈관질환의빈도가 19% 정도증가한다고보고하였다. 본연구에서는 X 2 검정결과 2.11 배, 회귀분석결과 1.56 배의위험성을보였다. 류마티스관절염도위험인자를공유하고공통적인병리경로를가지며기능장애와손실이라는결과를가지고있는많은유사성을보이는질병으로 De Pablo 등 29) 은류마티스관절염과치주질환은연관성의강도나시간성의관계는불확실하지만여러가지생물학적으로의관련이있다고보고하였고, 류마티스관절염환자에서일반인에비해치주질환의위험성이 1.82배로나타났고, 신등 30) 의연구에서도 1.91배의위험성을보여비슷한수준을보였으며본연구에서는 1.28 배의위험성을보였다. 간은뇌기능을포함신체적기능을지지하는혈당수치의유지라는중요한역할과지질과당대사와연관된매우중요한기관이다. 간과관련된연구에서는치주염이지질대사에영향을끼치며 15) 치은조직에서염증성사이토카인의방출이순환을통해서간의지질대사를증가시킨다고하였고, Saito 등 24) 의일본여성을대상으로연구한결과에서도지방간이치주염과관련이있다고보고하였다. 최 23) 의연구에서도치주질환은간기능표지자와상관성이있고간기능과관련이있는것을보고하였으며, 김 31) 의연구에서도간질환과치주질환의독립적인관련성을보여주었다. 본연구에서는간기능임상검사수치와는차이가없었으나 X 2 검정 (6.12 배 ) 과회귀분석 (1.17 배 ) 결과에서는간경변증이관련이있는변수로나타났다. 결과적으로대부분의전신질환들이치주질환과관련성이 453
있는것을확인할수있었으며, 여러선행연구들에서제시된바와같이전신질환중치주질환과관련이높은심혈관계, 당뇨, 간질환등은국민들의건강악화및의료비부담이증가하게되므로보건경제학적측면에서도관심을가지고관리해야하며, 구강보건교육을통해구강건강관리에대한중요성인식과더불어치주건강을잘유지 관리할수있도록치과계에서함께노력해야될것으로판단된다. 이논문의제한점으로는전신질환의유무에대한사항이전문의의진단결과가아닌대상자의자기기입식으로이루어져정확한병의유무를판단하기에는무리가있고, 각질환에따라대상자의수가적어결과를일반화하기에는무리가있다. 또한단면조사의제한점으로인하여인과관계를설명하기에는무리가있을수있으며, 발전적인연구를위해서는계속적인추적조사를통한코호트연구의필요성이있음을시사한다. 그러나우리나라국민건강정보를대표할수있는대규모국민건강영양조사의자료를이용하여위험정도를분석한자료라는것에의미를둘수있으며, 건강설문조사에서이루어진전신질환대부분의변수들이분석에사용되어해석한결과로향후전신질환과치주질환관련성을밝히기위한다양한연구의기초자료로활용될수있을것이다. V. REFERENCES 1. Burt B, Position P: Epidemiology of periodontal diseases. J Periodontol 2005;76:1406-1419. 2. Thornton-Evans G, Eke P, Wei L, et al: Centers for disease control and prevention(cdc). periodontitis among adults aged 30 years-united States, 2009-2010. MMWR Surveill Summ 2013;62:129-135. 3. Holtfreter B, Kocher T, Desvarieux M, Micheelis W: Prevalence of periodontal disease and treatment demands based on a German dental survey(dms Ⅳ). J Clin Periodontol 2010;37:211-219. 4. Han DH, LEE HJ, Lim S: Smoking induced heavy metals and periodontitis: findings from the Korea National Health and Nutrition Examination Surveys 2008-2010. J Clin Periodontol 2013;40:850-858. 5. Ministry of Health & Welfare. 2010 Korean National Oral Health Survey: III Summary Report. Seoul: Ministry of Health & Welfare; 2010:475. 6. Morrison EC, Ramfjord SP, Burgett FG, Nissle RR, Shick RA: The significance of gingivitis during the maintenance phase of periodontal treatment. J Periodontol 1982;53: 31-34. 7. Field AE, Coakley EH, Must A: Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med 2001;161: 1581-1586. 8. Kim JW, Kwon HJ, Lee SG, Choi YH: The relationship between periodontal disease and the prevalence of cardiovascular diseases. J Korean Acad Oral Health 2007;31:387-395. 9. Baek HJ, Choi YH, Song KB, Kwon HJ: The association of metabolic syndrome and periodontitis in Korean adult population. J Korean Acad Oral Health 2010;34: 338-345. 10. Nagasawa T, da M, Katagiri S, et al: Relationship between Periodontitis and Diabetes - Importance of a Clinical Study to Prove the Vicious Cycle. Intern Med 2010;49:881-885. 11. Loesch W, Schook A, Chen Y, Dominguez L, Grossman N: Assessing the relationship between dental disease and coronary heart disease in elderly US veterans. J Am Dent Assoc 1998;129:301-311. 12. Emingil G, Buduneli E, Akilli A, Atilla G: Association between periodontal disease and acute myocardial infarction. J Periodontol 2000;71:1882-1886. 13. Jang HB: The relationship between systemic condition and periodontal disease. [Master s thesis]. Seoul: Univ. of Korea, 2007. 14. Jung JO, Lee KH, Youn HJ: The correlation between 454
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