The influence of prevalent cohort bias in the association between periodontal disease progression and incident coronary heart disease

Research output: Contribution to journalArticlepeer-review


  • Brenda Heaton
  • Katie M. Applebaum
  • Kenneth J. Rothman
  • Daniel R. Brooks
  • Timothy Heeren
  • Raul I. Garcia

Colleges, School and Institutes


In longitudinal studies, the onset of the index condition (e.g. exposure) does not always coincide with the start of a study's observation period, leading to the possibility of bias in estimation that derives from studying prevalent exposure rather than new exposure. We investigate the possible role of this bias in the relationship between periodontitis progression and coronary heart disease (CHD) among a cohort of men participating in the Veterans Administration Dental Longitudinal Study.

At baseline, there were 298 men with existing (i.e., prevalent) periodontitis. During follow-up, routine dental inspection identified 163 new (i.e., incident) cases of periodontitis. Change in mean alveolar bone loss score (MBLS) served as the measure of disease progression. Tabular analyses were performed to obtain crude, stratified, and adjusted measures of the association for periodontitis cases overall and separately for prevalent and incident cases. Potential bias was evaluated by comparing estimates across these subcohorts.

Among all periodontitis cases, increasing MBLS was associated with increasing risk of CHD event. Subdividing periodontal cases into new and prevalent cases revealed that the relationship was most pronounced among incident periodontitis cases (incident rate ratio for MBLS change >0.5 = 5.4), compared with prevalent cases (incident rate ratio for MBLS change >0.5 = 2.5).

Studying prevalent cases of periodontitis underestimates the association between incidence periodontitis and CHD.


Original languageEnglish
Pages (from-to)741-746
Number of pages6
JournalAnnals of Epidemiology
Issue number10
Early online date30 Jul 2014
Publication statusPublished - 1 Oct 2014