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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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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. with certain race/ethnicity groups. population-based studies will disclose definitive trends in periodontal status over time. 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. authors of the current article evaluated trends in oral health status in the US using the NHANES III and NHANES 1999-2004 data. Given that the prevalence of AL ≥ 6 mm in dentate adults 30 yrs and older was as high as 25. as compared with prevalence estimates of 19. and reported a substantial decline in the prevalence of periodontitis over a period of approximately 15 yrs (Dye et al. PH-7 E 110. 2012c)] was 47. the validity of the findings of the older publication must be questioned. mid-buccal.4% in NHANES III to 5. moderate. Last revision July 30. probing assessments of pocket depth and clinical attachment loss (AL) at 6 sites per tooth at all present teeth apart from third molars]. 2010). and a universally accepted definition of periodontitis has yet to be established.2% based on the fullmouth data. 630 West 168th St. 2008. and those with the lowest education. second. partial recording. 2012. if the NHANES III examination methodology were used. in an earlier publication. but both groups remain significantly more
Downloaded from jdr. One could argue that since the same recording protocol was used in both studies.. Eke et al. because analysis of the data reaffirms the presence of substantial disparities in the distribution of periodontitis in the population. disto-buccal) sites per tooth results in substantial underestimation of both the prevalence and the extent of periodontitis (Kingman and Albandar. because the prevalence of periodontitis in this publication is far higher than that reported in earlier epidemiologic studies from the US.e. Several methodological papers have suggested that the random half-mouth examination protocol based on either 2 (mesiobuccal and mid-buccal) or 3 (mesio-buccal. the 8. For example. because studies of prevalence are critically dependent on the “case” definitions used.. 2007.com by guest on March 21. it is also uncertain whether the alleged trend for an improvement in periodontal status over time holds true.sagepub. the prevalence of AL ≥ 6 mm in individuals 20 to 64 yrs old was reported to decrease from 8. utilization of the full-mouth examination protocol in future cross-sectional. 2012 © International & American Associations for Dental Research
when the two-site or 27.e. and people of lower income and lower educational attainment showing poorer periodontal status than their more socioeconomically privileged counterparts.. examination. © 2012 International & American Associations for Dental Research
. Kingman et al. because they represent the first national probability sample that used a full-mouth periodontal examination protocol [i. No other uses without permission. and last. Accepted July 30. Interestingly. 2007).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.5%
DOI: 10. methodology. 2012
The Prevalence of Periodontitis in the US: Forget What You Were Told
KEY WORDS: epidemiology.. third.. periodontal disease(s). NY 10032. as long as periodontitis is defined by the presence of attachment loss of a certain magnitude. Eke et al.N. current smokers.. 2012a) and are worth commenting on for a number of reasons: first.1% when the three-site half-mouth protocol was used in the same sample. any observations regarding longitudinal changes in prevalence would reflect real trends. full-mouth. Papapanou
Division of Periodontics.3% in NHANES 1999-2004. the sum of mild. since attachment loss is frequent in older adults. Section of Oral and Diagnostic Sciences. Mexican Americans now appear to be somewhat more affected by periodontitis than NonHispanic Blacks. It must also be realized that.1177/0022034512458692 Received July 27. individuals below the federal poverty line. 2012. are largely consistent with those emerging in previous NHANES: The disease is most prevalent among males. instead of the random half-mouth. Likewise..5% in NHANES 2009-2010. However. 2002. Clearly. The socio-demographic patterns in the distribution of periodontitis in the US population. and severe periodontitis according to the CDC/AAP definitions (Page and Eke. 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. three-site per tooth protocol used in NHANES 2001-2004.PERSPECTIVE
P. according to the latest data.. two-site per tooth examination methodology used in NHANES III and NHANES 1999-2000. Columbia University College of Dental Medicine. 2013 For personal use only. or the random half-mouth. In their recent publication.edu J Dent Res 91(10): 907-908. While there is no longer any doubt that the earlier quoted prevalence estimates were biased. pp192@columbia. Interestingly. USA. New York. 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.
Thornton-Evans G. editors. Ford ES. and quality of life.
Downloaded from jdr. Huffman et al. Barker LK. 2012). Eke PI. 1964). Shay CM. © 2012 International & American Associations for Dental Research
. depending on one’s taste for subclassification” (Scherp. Capewell S. 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. 2012] (in press). J Periodontol Feb 11. In a 1996 essay in the Lancet. Current concepts in periodontal disease research: epidemiological contributions. Ning H. Genco R (2012c). Eke PI (2007). Essentialism and nominalism in medicine: logic of diagnosis in disease terminology. Considering these high prevalence figures. Susin C. Page RC. Thornton-Evans G. UK: Blackwell Publishers. Vital Health Stat 11:1-92. Papapanou PN (2010). In: Clinical periodontology and implant dentistry. It would also be valuable to precisely define the “biological disadvantage” from which these adults suffer because of their periodontal condition. Eke PI. Effect of partial recording protocols on severity estimates of periodontal disease. Thornton-Evans G. 2008). Smith V. Dye BA. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US. as well as prevalence estimates based on definitions suggested by the European Federation of Periodontology (Tonetti and Claffey. Dye B.. J. in terms of function.e.sagepub. In their current work. Borgnakke WS. Methodological aspects of epidemiological studies of periodontal diseases. 2010. Lopez R (2004). i. i.. J Periodontol 78(7 Suppl):1387S-1399S. Lang NP. the authors do not report on the prevalence of the two currently recognized main forms of the disease. 2007. and reflecting on Scadding’s writings above. J Am Dent Assoc 68:667-675. Accuracy of NHANES periodontal examination protocols. Demmer RT. Genco R (2012a). Epidemiology of periodontal diseases. J Dent Res 89:1208-1213. Tan S. Eke PI. et al. Wei L. Finally. Notably. respectively. J Clin Periodontol 35:659-667. (2007). Lewis BG. J Periodontol [Epub ahead of print Mar 16. Kingman A. oral or general health. To gain some historical perspective. pp. 2013 For personal use only. but also due to the fact that no young adults under 30 yrs (the age at which aggressive periodontitis typically manifests itself) were included. Thornton-Evans GO. Albandar JM (2002).com by guest on March 21. J Diabetes 2:180-193. 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. challenges us to re-think some of these issues and to conduct the appropriate research that will produce evidencebased answers. No other uses without permission. Eke and co-workers used the CDC/ AAP case definitions for population-based surveillance of periodontitis (Page and Eke. 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. This is likely because of the recognized difficulties in distinguishing between the two forms on the basis of a single examination (Demmer and Papapanou. 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. 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. Page RC. since the distribution of the signs and symptoms of periodontitis is continuous with respect to both extent. and severity. [Epub ahead of print Feb 11. Li C. Circulation 125:2595-2602. Advances in the progression of periodontitis and proposal of definitions of a periodontitis case and disease progression for use in risk factor research. Karring T.
The author declares no potential conflict of interest with respect to the authorship and/or publication of this perspective. Kingman A. Lancet 348:594-596.. Papapanou PN. These disparities in oral and periodontal health status follow a pattern similar to that observed for other chronic diseases. Dye BA.
Baelum V. Wei L.908
J Dent Res 91(10) 2012
affected than non-Hispanic Whites.G. Tonetti MS. pocket depth or amount of tissue loss (Baelum and Lopez. 1988-1994 and 1999-2004. Lindhe J. Scadding JG (1996). but also presented the percentage of US adults exhibiting attachment loss of various levels of severity. Albandar JM (2008). Periodontol 2000 53:28-44. Epidemiologic patterns of chronic and aggressive periodontitis. 1996). London. 2005). Huffman MD. Update of the case definitions for population-based surveillance of periodontitis. Case definitions for use in population-based surveillance of periodontitis. such as metabolic syndrome and diabetes mellitus (Ford et al. Periodontol 2000 29:11-30. percent of affected teeth or tooth surfaces. Thornton-Evans G. it is worth remembering that 50 years ago. Wei L. Eke et al. Lloyd-Jones DM (2012). Scherp pointedly stated that ‘the varieties of periodontal diseases are almost limitless. Ford ES. Prevalence of periodontitis in adults in the United States: 2009 and 2010.c) that are based on combinations of specific levels of AL and PD. Cardiovascular health behavior and health factor changes (1988-2008) and projections to 2020: results from the National Health and Nutrition Examination Surveys. Dye BA (2010). now that we have re-established that periodontitis is virtually ubiquitous. 2010). Zhao G (2010). Genco RJ (2012b). 2012b. Claffey N (2005). Trends in oral health status: United States. 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. and that 86% and 45% showed attachment loss of ≥ 4 mm and ≥ 6 mm. 2004). Eke PI. Advances in surveillance of periodontitis: the Centers for Disease Control and Prevention Periodontal Disease Surveillance Project.. one certainly wonders what should be considered the periodontal status “norm” in this age cohort.. Lindhe J (2008). 129-179. chronic and aggressive periodontitis. 2012] (in press).e. Scherp HW (1964). J Clin Periodontol 32(Suppl 6):210213. J Dent Res 91:914-920. Periodontal epidemiology: towards social science or molecular biology? Community Dent Oral Epidemiol 32:239249.