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The Prevalence of Periodontitis in the US : Forget What You Were Told

P.N. Papapanou J DENT RES 2012 91: 907 originally published online 30 August 2012 DOI: 10.1177/0022034512458692 The online version of this article can be found at: http://jdr.sagepub.com/content/91/10/907

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PERSPECTIVE
P.N. Papapanou
Division of Periodontics, Section of Oral and Diagnostic Sciences, Columbia University College of Dental Medicine, 630 West 168th St., PH-7 E 110, New York, NY 10032, USA; pp192@columbia.edu J Dent Res 91(10): 907-908, 2012

The Prevalence of Periodontitis in the US: Forget What You Were Told

KEY WORDS: epidemiology, periodontal disease(s), examination, partial recording, full-mouth, methodology.

ew epidemiologic data on periodontal status derived from the 2009-2010 cycle of the National Health and Nutrition Examination Survey (NHANES) are published in this issue of the Journal of Dental Research (Eke et al., 2012a) and are worth commenting on for a number of reasons: first, because they represent the first national probability sample that used a full-mouth periodontal examination protocol [i.e., probing assessments of pocket depth and clinical attachment loss (AL) at 6 sites per tooth at all present teeth apart from third molars], instead of the random half-mouth, two-site per tooth examination methodology used in NHANES III and NHANES 1999-2000, or the random half-mouth, three-site per tooth protocol used in NHANES 2001-2004; second, because the prevalence of periodontitis in this publication is far higher than that reported in earlier epidemiologic studies from the US; third, because analysis of the data reaffirms the presence of substantial disparities in the distribution of periodontitis in the population, with certain race/ethnicity groups, and people of lower income and lower educational attainment showing poorer periodontal status than their more socioeconomically privileged counterparts; and last, because studies of prevalence are critically dependent on the case definitions used, and a universally accepted definition of periodontitis has yet to be established. Several methodological papers have suggested that the random half-mouth examination protocol based on either 2 (mesiobuccal and mid-buccal) or 3 (mesio-buccal, mid-buccal, disto-buccal) sites per tooth results in substantial underestimation of both the prevalence and the extent of periodontitis (Kingman and Albandar, 2002; Kingman et al., 2008; Eke et al., 2010). In their recent publication, Eke and co-workers demonstrated unequivocally the magnitude of the bias resulting from the use of these partial recording systems: The prevalence of total periodontitis [i.e., the sum of mild, moderate, and severe periodontitis according to the CDC/AAP definitions (Page and Eke, 2007; Eke et al., 2012c)] was 47.2% based on the fullmouth data, as compared with prevalence estimates of 19.5%
DOI: 10.1177/0022034512458692 Received July 27, 2012; Last revision July 30, 2012; Accepted July 30, 2012 International & American Associations for Dental Research

when the two-site or 27.1% when the three-site half-mouth protocol was used in the same sample. Likewise, the 8.5% prevalence of severe periodontitis according to the AAP/CDC definition based on the full-mouth data would have been underestimated by almost five-fold, if the NHANES III examination methodology were used. Interestingly, in an earlier publication, authors of the current article evaluated trends in oral health status in the US using the NHANES III and NHANES 1999-2004 data, and reported a substantial decline in the prevalence of periodontitis over a period of approximately 15 yrs (Dye et al., 2007). For example, the prevalence of AL 6 mm in individuals 20 to 64 yrs old was reported to decrease from 8.4% in NHANES III to 5.3% in NHANES 1999-2004. Given that the prevalence of AL 6 mm in dentate adults 30 yrs and older was as high as 25.5% in NHANES 2009-2010, the validity of the findings of the older publication must be questioned. While there is no longer any doubt that the earlier quoted prevalence estimates were biased, it is also uncertain whether the alleged trend for an improvement in periodontal status over time holds true. One could argue that since the same recording protocol was used in both studies, any observations regarding longitudinal changes in prevalence would reflect real trends. However, it is still unknown whether the partial NHANES methodology results in a consistent degree of bias across different levels of extent and severity of periodontitis or across different age groups. It must also be realized that, as long as periodontitis is defined by the presence of attachment loss of a certain magnitude, both a decline in edentulism and a higher retention of teeth in older age cohorts conceivably contribute to an increase in the prevalence of periodontitis, since attachment loss is frequent in older adults. Clearly, utilization of the full-mouth examination protocol in future cross-sectional, population-based studies will disclose definitive trends in periodontal status over time. The socio-demographic patterns in the distribution of periodontitis in the US population, according to the latest data, are largely consistent with those emerging in previous NHANES: The disease is most prevalent among males, current smokers, individuals below the federal poverty line, and those with the lowest education. Interestingly, Mexican Americans now appear to be somewhat more affected by periodontitis than NonHispanic Blacks, but both groups remain significantly more

907
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908

Papapanou

J Dent Res 91(10) 2012

affected than non-Hispanic Whites. These disparities in oral and periodontal health status follow a pattern similar to that observed for other chronic diseases, such as metabolic syndrome and diabetes mellitus (Ford et al., 2010; Huffman et al., 2012). Finally, some thoughts on case definitions of periodontitis: The lack of a universally acceptable definition partly reflects the fact that a sharp distinction between periodontal health and disease is unfeasible and inevitably arbitrary, since the distribution of the signs and symptoms of periodontitis is continuous with respect to both extent, i.e., percent of affected teeth or tooth surfaces, and severity, i.e., pocket depth or amount of tissue loss (Baelum and Lopez, 2004). To gain some historical perspective, it is worth remembering that 50 years ago, Scherp pointedly stated that the varieties of periodontal diseases are almost limitless, depending on ones taste for subclassification (Scherp, 1964). In a 1996 essay in the Lancet, J.G. Scadding discussed the logic of diagnosis in disease terminology and pointed out that a meaningful disease definition should refer to the sum of the abnormal events shown by a group of living organisms in association with a specified characteristic or set of characteristics by which they differ from the norm for their species in such a way as to place them at a biological disadvantage (Scadding, 1996). In their current work, Eke and co-workers used the CDC/ AAP case definitions for population-based surveillance of periodontitis (Page and Eke, 2007; Eke et al., 2012b,c) that are based on combinations of specific levels of AL and PD, but also presented the percentage of US adults exhibiting attachment loss of various levels of severity, as well as prevalence estimates based on definitions suggested by the European Federation of Periodontology (Tonetti and Claffey, 2005). Notably, the authors do not report on the prevalence of the two currently recognized main forms of the disease, chronic and aggressive periodontitis. This is likely because of the recognized difficulties in distinguishing between the two forms on the basis of a single examination (Demmer and Papapanou, 2010), but also due to the fact that no young adults under 30 yrs (the age at which aggressive periodontitis typically manifests itself) were included. A closer look at the recent NHANES data reveals that 70% of the US adults aged 65 yrs or older had some form of periodontitis according to the CDC/AAP definition, and that 86% and 45% showed attachment loss of 4 mm and 6 mm, respectively. Considering these high prevalence figures, and reflecting on Scaddings writings above, one certainly wonders what should be considered the periodontal status norm in this age cohort. It would also be valuable to precisely define the biological disadvantage from which these adults suffer because of their periodontal condition, in terms of function, oral or general health, and quality of life. Given that the same level of severity of periodontitis has different prognostic implications with respect to risk for disease progression and tooth loss at different ages (Papapanou and Lindhe, 2008), would it not be logical to introduce some age-specific epidemiologic definitions of periodontitis that both reflect a clear deviation from the norm and

are associated with a concrete biological disadvantage? In other words, now that we have re-established that periodontitis is virtually ubiquitous, is it not time to define levels of disease that may make more sense to focus on from both a biological and a public health perspective? Analysis of the data presented by Eke et al. challenges us to re-think some of these issues and to conduct the appropriate research that will produce evidencebased answers.

Acknowledgment
The author declares no potential conflict of interest with respect to the authorship and/or publication of this perspective.

References
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