Periodontology 2000, Vol.
16, 1998, 16-33
Priiited in Denniark All rights reserved
Epidemiology of periodontal
disease among older adults:
a review
DAVIDLOCKER,GARYD. SLADE& HEATHER
MURRAY
Over the past 30 years, clinical and epidemiological
research have transformed our understanding of the
natural history and distribution of periodontal dis-
ease (25, 26). A model widely accepted during the
1960s suggested that periodontitis was a slowly and
continually progressive condition. Beginning as gin-
givitis, it inevitably developed to affect periodontal
ligament, leading to loss of bone and the ultimate
loss of teeth. It was also accepted that periodontal
disease was widespread, affected the majority of the
adult population and that, ultimately, virtually every-
one was susceptible to severe disease. These con-
clusions were based on studies that used invalid
measures of periodontal disease and the erroneous
interpretation of data from cross-sectional epide-
miological studies (26). In comparison, contempor-
ary approaches emphasize the episodic nature of the
disease, in which short periods of tissue destruction
are followed by long periods of remission and heal-
ing, and that rates of progression of the disease are
low and severe disease is far from universal.
In spite of these considerable advances, much re-
mains unknown or unclear regarding the nature of
periodontal disease and its extent and severity
within contemporary populations (60). Knowledge
concerning risk factors for periodontal destruction
is also accumulating, but uncertainties remain (20).
These stem from the nature of the disease itself,
problems in measuring its presence and severity and
the difficulties involved in undertaking studies that
conform to strict epidemiological criteria.
This chapter critically reviews the current epide-
miological literature on periodontal disease. It high-
lights the essential requirements of studies designed
to estimate prevalence, incidence and risk and some
of the methodological problems involved in con-
ducting epidemiological research that have a bearing
on the quality of the evidence available to date.
16
C o p y r i g h t 0 Muiiksgaard 1998
PERIODONTOLOGY 2000
ISSN 0906-6713
Identifying and selecting
the literature
Relevant articles for this review were identified by
a search of computerized databases using the key
words “periodontal diseases”, “epidemiology” and
“adults”. A manual search was conducted of
journals in which articles on the epidemiology of
periodontal disease appear: Journal of Periodonto-
logy; Journal of Periodontal Research; Journal of
Clinical Periodontology; Periodontology 2000;
Journal of Public Health Dentistry; Community
Dentistry and Oral Epidemiology; Gerodontics; Ger-
odontology; Journal of Dental Research; Interna-
tional Dental Journal; Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology & Endodontics;
Journal of the American Dental Association; British
Dental Journafi Journal of the Canadian Dental As-
sociation; Australian Dental Journal; New Zealand
Dental Journal; and Scandinavian Dental Journal.
The time period for the search was 1980 to 1996.
Only studies with the following characteristics were
included:
epidemiological studies of community-dwelling
older adults or studies including older adults.
Here older adults were defined as individuals aged
45 years and over. This definition was used in or-
der to capture current and future elderly people
and because some studies used the age range 45
to 55 years when reporting prevalence and inci-
dence data;
studies that were population-based, where appro-
priate, with subjects selected using random sam-
pling methods; and
studies using clinical attachment level, attach-
ment loss or bone loss as indicators of periodontal
disease and disease progression.

Consequently, articles were selected only if they ad-
equately represented the population of interest, met
basic epidemiological criteria and measured peri-
odontal disease appropriately.
Measuring periodontal disease
With current technology, the best epidemiological
measures of periodontal disease assess loss of
attachment. Clinical attachment level represents the
vertical distance in millimeters from the cemento-
enamel junction to the point of clinical periodontal
attachment. In order to fully capture the degree of
destruction of periodontal support, Carlos et al. (27)
proposed the Extent and Severity Index. Extent rep-
resents the proportion of examined sites per subject
that have clinical attachment level of a given thresh-
old (usually 2 mm or more), and severity represents
the mean clinical attachment level per subject for
sites with that threshold. For samples or subgroups,
the scores are summarized to yield a mean of the
percentage (extent) and a mean of the mean (se-
verity).
Attachment loss represents the difference between
measures of clinical attachment level at two points
in time and indicates the degree of additional loss
over the time period in question. Bone loss repre-
sents the vertical amount of bone lost at the mesial
or distal (or both) surface of the tooth and is ex-
pressed in millimeters or as a percentage of total
root length. As with clinical attachment level, attach-
ment loss and bone loss can be expressed in terms
of extent and severity (62).
Accordingly, studies using Russell’s Periodontal
Index (65), the Community Periodontal Index of
Treatment Needs (1) or pocket probing depth meas-
urement were excluded from this review because of
limitations in their ability to accurately and fully
characterize periodontal disease (8, 10, 16, 27). For
example, measures that rely solely on pocket depths
substantially underestimate the prevalence of peri-
odontal disease and are also insensitive to disease
progression (16).
Definition of epidemiology
Epidemiology can be defined as “the study of the
distribution and determinants of disease in human
populations” (36). Distribution refers to the fre-
quency and severity of disease within a population
or its subgroups. Frequency is measured in terms of
Epidemiology of periodontal disease among older adults
prevalence and incidence and severity or extent by
indexes or scales that quantify levels of disease. The
determinants of disease refer to factors that increase
the risk of disease onset or that identify population
subgroups most likely to have the disease under
consideration.
All diseases and disorders, including those affect-
ing the oral cavity and related structures, are amen-
able to study by epidemiological approaches (25).
The power of epidemiology as a discipline stems
from the fact that the application of epidemiological
principles can lead to the control of epidemics or a
marked reduction in the frequency of a disease in
a population even when the biological mechanisms
responsible for the disease are unknown or not well
understood (25).
Characteristics of epidemiological
studies
Epidemiological studies of periodontal disease must
follow the general principles of epidemiology. In this
regard they are distinct from clinical studies. Import-
ant differences between the two concern the selec-
tion of subjects, definitions of periodontal disease
and the units of analysis.
Selection of study subjects
Prevalence refers to the total number of cases of a
disease in a population at a given point in time or
over a given period of time. Incidence refers to the
number of new cases of a disease appearing in a
population at risk over a defined period of time. In
this context, the population at risk refers to individ-
uals with a probability of acquiring the disease of
interest. Prevalence can be estimated using a cross-
sectional survey, whereas incidence requires a longi-
tudinal study in which the same individuals are
examined at two points in time.
One of the fundamental requirements of epide-
miological studies designed to estimate prevalence
and incidence is that they be population-based. That
is, they study random samples drawn from general
populations, population subgroups defined by age,
sex or race or populations at risk. In these studies,
samples must be random so that results can be gen-
eralized to the population from which the subjects
were drawn, and sample sizes must be sufficiently
large to give estimates of the required level of pre-
cision.
17
Locker et al.
These requirements mean that epidemiological
studies are difficult and usually costly to conduct.
This is particularly the case with studies of adults
and older adults. The main problem here is that the
selection of a random sample requires a sampling
frame or list of each individual in the population of
interest. In many jurisdictions, such lists are unavail-
able, incomplete or inaccessible. Where population
lists are unavailable, alternative approaches, such as
a preliminary household enumeration (14) or the use
of telephone interview surveys based on random di-
git dialing (54, 29), are effective methods of subject
recruitment but increase the effort and costs of a
study. If random sampling methods are not used or if
participants are selected from restricted population
subgroups, such as dental attenders, study subjects
constitute a convenience sample and inferences
about wider populations cannot be drawn.
Accordingly, the conduct and reporting of preva-
lence studies requires the following: 1) definition of
the target population; 2) identification of the sam-
pling frame or approach and method of ensuring
random selection; 3) calculation of the response rate;
4) checking that the subjects from whom data are
collected are representative of the target population;
and 5) weighting of data if the sampling design
means that subjects have different probabilities of
selection or if subjects who participate are not repre-
sentative according to sex, age or any other import-
ant characteristic. In the absence of such infor-
mation, it is not possible to determine whether and
to whom study results may be generalized. In ad-
dition, incidence studies require examination of the
rates of loss to follow-up and checking to ensure that
subjects at follow-up remain representative of the
target population (64). In both types of study, assess-
ment of the effect of nonresponse bias may be
necessary if response rates are low or loss to follow-
up is high (53).
Identification of risk indicators and risk markers
for oral diseases can be based on information col-
lected in cross-sectional surveys. However, the
identification of risk factors usually requires analytic
approaches such as case-control (retrospective) or
cohort (prospective) studies that allow temporal re-
lationships to be established and causal inferences
to be drawn. Both types of study may be, but are not
necessarily, population-based (36). Rather, subjects
are often selected to maximize internal validity. In a
case-control study, internal validity is facilitated by
choosing subjects on whom complete information
on exposure to a risk factor can be obtained; in a
cohort study it is facilitated by using subjects who
18
can easily be followed over time to ensure high fol-
low-up rates.
While representativeness is not necessary to
identify a valid association between exposure to a
risk factor and a disease, it should be regarded as
desirable for two reasons. First, the association be-
tween exposure and disease is more likely to be bi-
ased if subjects are not representative. Second, they
produce “sample-based’’estimates rather than true
“population-based’’ estimates of risk. Consequently,
there is always some uncertainty with regard to gen-
eralizing to the population at large the findings of
analytic studies using unrepresentative samples.
Case definition
The fundamental principle on which epidemiology
is based is the division of a population into groups;
those with the disease (cases) and those without the
disease (non-cases or controls). A clear and unequi-
vocal definition of a case, preferably based on bio-
logical considerations, is required (15). However, in
most studies of periodontal disease, case definitions
are arbitrary (30) and inconsistent (63).
A case may be defined based on three types of
measures of periodontal disease. The first consists of
measures of cumulative disease experience. Clinical
attachment level, attachment loss and bone loss
measured in millimeters constitute such measures.
The second consists of measures of treatment need
such as the Community Periodontal Index of Treat-
ment Needs and usually involve the measurement
of periodontal pockets, which are important in the
clinical management of the disease (16). The third
consists of measures of current disease activity.
These use biological indicators to identify individ-
uals experiencing periodontal breakdown at one or
more sites. Clearly, these types of measures may or
may not coincide; an individual with significant
attachment loss at numerous sites may show little in
the way of pocketing or currently active sites.
From an epidemiological point of view, one import-
ant difference between these types of measures con-
cerns the extent to which missing teeth may influence
case identification. The quite substantial tooth loss
usually observed in older populations, much of which
involves periodontally involved teeth, means that dis-
ease experience is based on observation of teeth that
are “healthy survivors”. Consequently, lifetime dis-
ease experience is likely to be underestimated (63)
and subjects misclassified in terms of case status.
However, tooth loss has no effect on measures of
treatment need or current disease activity.

Currently, the case definitions used in epidemio-
logical studies involving clinical attachment level,
attachment loss or bone loss appear to be either dis-
tributional or clinical in origin. A widely used case
definition is the presence of one or more sites with
clinical attachment level of 2 mm or more (59).How-
ever, in studies of older adults a higher threshold is
used because such a finding is virtually universal
and insensitive to subgroup differences. The ration-
ale underlying the choice of these thresholds is rarely
described. More clinically oriented case definitions
usually involve both attachment loss and pocket
depth. For example, Beck at a1 (14) defined a serious
case of periodontal disease in older adults as follows:
four or more sites with clinical attachment level of 5
mm or more with at least one of those sites having
a pocket depth of 4 mm or more. Others have used
distribution based definitions and consider those in
the upper 20th percentile of the distribution of mean
clinical attachment level to be a severe case (55).
Case definitions in studies of the incidence of
periodontal disease are even more problematic,
largely because change is assessed by subtracting
baseline measurements of clinical attachment level
from follow-up measurements. Here, it becomes cru-
cial to distinguish between genuine clinical change
and measurement error arising out of differences in
probe angulation and probing force, inconsistent
probe positioning or reading errors. In order to ac-
count for such error, some studies have adopted a
threshold of 3 mm or more (or three times the stan-
dard deviation of differences in replicate examin-
ations) of change and report incidence in terms of
the proportions of subjects with this level of change
at one or more sites (23). As these investigators rec-
ognize, this excludes individuals with less than 3 mm
of ‘real’change so that rates are based on only a sub-
set of incident cases. As with prevalence studies
based on clinical attachment level, longitudinal
studies using attachment loss corrected for error
may also misclassify study subjects in terms of case
status. Conversely, some studies make no allowance
for measurement error and may misclassify subjects
in the opposite direction.
Units of analysis
A consistently reported methodological issue that
arises in periodontal disease epidemiology is the
unit of analysis. While the unit of analysis in epi-
demiology is the individual, epidemiological studies
of periodontal disease use the site as the unit of ob-
servation. Consequently, measurement of the pres-
Epidemiology of periodontal disease among older adults
ence and severity of periodontal disease requires the
summary of observations from multiple sites (16).
Examples of summary measures that convert site-
level observations to individual-level data are to be
found in the Extent and Severity Index of Carlos et
al. (27) described above. Where sites are used as the
unit of analysis, statistical methods that take account
of the fact that sites within an individual are not in-
dependent are needed (16). Some studies fail to dis-
tinguish between these two levels of analysis. For ex-
ample, the extent of disease is sometimes reported
as the overall proportion of sites examined with loss
exceeding a given threshold (site-level analysis),
rather than the mean of the proportions observed in
each subject (individual-level analysis). In the for-
mer, failure to correct for the non-independence of
sites within each subject leads to bias whose magni-
tude and direction is unknown (48).
These methodological and analytical consider-
ations need to be borne in mind when appraising
the epidemiological literature on periodontal dis-
ease.
Studies of the prevalence of
periodontal disease in older adults
Clinical attachment level
Thirteen reports were located that described studies
using randomly selected samples from general popu-
lations of adults or older adults that measured disease
experience using clinical attachment level. Four (5-7,
72) were excluded since prevalence rates were not
given or could not be calculated from the data. The
design characteristics and results of the remaining
nine are summarized in Tables 1 and 2 (14,24,29,31,
38,40,54,58,68).Seven other articles reported the re-
sults of studies using subjects who were not randomly
selected or were selected from restricted groups such
as individuals attending senior centers or regular den-
tal attenders so that generalization of the findings to
wider populations was somewhat problematic. These
studies are also summarized in Tables 1 and 2 (4, 11,
32,34,41, 56, 59).
In general, the results of these prevalence studies
are difficult to compare due to differences in the age
of the subjects included and differences in the num-
ber of teeth and sites that were probed. Some studies
used partial- as opposed to whole-mouth examin-
ations and the number of sites probed varied from
two to six. Partial-mouth recordings and limiting
probing to buccal and mesial sites can seriously
underestimate the prevalence of advanced attach-
19
Locker et al.

Table 1. Design characteristics of population-based studies of prevalence of periodontal disease

Location or Number of older Sites or
Authors source of subjects subjects by age teeth probed Definition of prevalent cases
~ ~ . ~ ~ . . _ _ _ _ _ . . --~ .,.

Hoover & Tynan (38) Saskatoon, Canada 79 aged 45 years 4 sites, 6 teeth Subjects with 2 3 mm of clinical
and over attachment
...
level at 21 site
.. ~

Beck et al. (14) Five counties in 690 aged 65 years Zsites, all teeth Subjects with 21 sites with:
North Carolina, and over a) clinical attachment level of 2 4 mm
USA b) clinical attachment level of 2 7 mm
Hunt et al. (40) Two counties, 262 aged 70 years 2 sites, all teeth Subjects with 21 sites with:
Iowa, USA and over a) clinical attachment level of 2 4 mm
b) clinical attachment level of 2 7 mm
.
. ~

Locker & Leake (54) Four communities 378 aged 50-64 2 sites, all teeth Subjects with 2 1 teeth with:
in Ontario, years, 293 aged 65 except third a) clinical attachment level of 2 4 mm
Canada years and over molars b) clinical attachment level of 2 7 mm
~
~- . . .... .-
Fox et al. (31) Six New England 554 aged 70 years 3 sites plus Subjects with 2 1 teeth with
states, USA and over “worst” site, a) clinical attachment level of 2 4 mm
all teeth b) clinical attachment
. .~
level of 2 6 mm
~~~

Slade & Spencer (68) Two cities, South 801 aged 60 years 3 sites, all teeth Subjects with 2 1 sites with:
Australia and over a) clinical attachment level of 4 mm
b) clinical attachment level of 7 mm
~ ~. ... ~ ...
Miyazaki et al. (58) Kitakyushu, Japan 423 aged 65 years 10 index teeth, Subjects with 21 sites with:
and over number of sites per a) clinical attachment level of 2 4 mm
tooth not stated b) clinical attachment level of 2 6 mm
.._ .
.. ..
Dolan et al. (29) Four counties in 761 aged 45 years All teeth; 6 sites Subjects with 2 1 sites with:
northern Florida, and over measured, a) clinical attachment level of 2 4 mm
USA greatest b) clinical attachment level of 2 7 mm
attachment loss
recorded - .... ..... _.
(ZU-....
~~ ~~

Brown et al. United States not stated 2 sites, teeth in Subjects with one site with:
population two randomly a) 2 3 mm of clinical attachment level
selected b) 2 5 mm of clinical attachment level
quadrants, third
-. . -
molars excluded
National Institute Attenders at 5689 aged 265 2 sites in Subjects with:
of Dentaf Research senior citizens’ 2 randomly a) 2 1 sites 24 mm of clinical
(59) centers, USA selected quadrants attachment level
b) 25 mm of clinical attachment level
~. ..
Ismail et al. (41) Residents of two 129 aged 47-74 2 sites, Ramfjord Subjects with:
communities in years teeth a) 21 sites 4-6 mm of clinical
New Mexico, USA attachment level
___- __._-
b) 2 7 mm of loss (check above)
McFall et al. (56) Attenders at 36 538 aged 55 years 2 sites, Ramfjord Subjects with:
dental practices and over teeth a) 21 sites 2 4 mm of clinical
in two North attachment level
Carolina counties, b) 2 6 mm of clinical attachment level
USA
~~ .
. ...___.___
.
Gilbert & Heft (32) 14 senior activity 671 aged 65 years 2 sites, all Subjects with:
centers in 6 and over remaining teeth a) 2 1 sites 2 4 mm of clinical
Florida counties, except third attachment level
____ USA molars b) 2 7 mm of clinical attachment level
Bagramian et al. Amish and non- 68 Amish and 98 6 sites, all teeth 21 sites with clinical attachment
(11, 12) Amish farming non-Amish aged except third level of 2 6 mm
families, 45 years and over molars
~~ ~-
Michigan, USA
Grossi et al. (34) Residents of Erie 538 aged 55-74 All teeth, sites not Overall mean attachment loss of
County, New York, years stated 2 4 mm
USA
~~.~ .
~

Anagnou- Farmworkers and 57 aged 55-64 4 sites, all teeth 2 1 sites with clinical attachment level
Vareltzides (4) hospital years except third of 2 6 mrn
employees, Greece molars
~ ~ ~~~~~~~~~~
__

ment loss (31, 63). Even where whole-mouth record- of periodontal disease experience. In the studies
ing was used, variation in the type and number of using the whole-mouth approach, the number of
teeth remaining can lead to differences in estimates teeth present and examined ranged from a mean of

20
 Epidemiology of periodontal disease among older adults

Table 2. Prevalence, extent and severity of periodontal disease in population-based studies

Authors Definition of prevalent case" Prevalence rate Extent" Severity"
~~ ~~~~~

Hoover & TGan Clinical attachment level 2 3 mm 72% - -

(38)
_ _ _ _ _ _ _ ~ -
Beck et al. (14) Clinical attachment level 2 4 mm Blacks: 95% All: 69% All: 3 33 mm
Clinical attachment level 2 7 mm Whites: 85% Blacks: 78% Blacks: 3.98 mm
Blacks: 58% Whites: 65% Whites: 3.06 mm
Whites: 32%
_ _ _ _ _ _ _ _ ~
Hunt et al. (40) Clinical attachment level 2 4 mm Buccal sites: 65% 59% 1.74 mm
Clinical attachment level 2 7 m m Mesial sites: 56%
Buccal sites: 14%
Mesial sites: 11%
Locker & Leake Clinical attachment level 2 4 mm 88% 77% 2.44 mm
(54) Clinical attachment level 2 7 mm 25%
Fox et al. (31) Clinical attachment level 2 4 mm 95% - -
Clinical attachment level 2 6 mm 56%
Slade & Spencer Clinical attachment level 2 4 mm 79% 78% 3.09 mm
(68) Clinical attachment level 2 7 mm 28%
______
Miyazaki et al. Clinical attachment level 2 4 mm 65-74 years: 56% - -
(58) Clinical attachment level 2 6 mm 75-84 years: 69%
2 8 5 years: 50%
65-74 years: 16%
75-84 years: 22%
-
285 years: 14%
Dolan et al. (29) Clinical attachment level 2 4 mm 92% - -
Clinical attachment level 2 7 mm 35%
Brown et al. (24) Clinical attachment level 2 3 mm 55-64 years: 74% 55-64 years: 48% 55-64 years: 2.9 m m
Clinical attachment level 2 5 mm 3 6 5 years: 81% 265 years: 55% 265 years: 3.0 mm
55-64 years: 35%
2 6 5 years: 41%
National Clinical attachment level - Mean clinical
Institute of 2 4 mm 68% attachment level:
Dental Research 2 6 mm 34% Males 3.54 mm
(59) Females 2.99 mm
Ismail et al. (41) Clinical attachment level 4-6 m m 72% 7% of sites had -
Clinical attachment level 2 7 mm 34% 27.0 mm of clinical
attachment level
McFall et al. (56) Clinical attachment level 2 4 mm 60% - Mean clinical
2 6 mm 22% attachment level:
2.10 mm
Gilbert & Heft Clinical attachment level 2 4 mm 86% 88% 3.7 m m
(32) 24%
Bagramian et al. Clinical attachment level 2 4 mm Amish 87% 42% of sites in Mean clinical
(11, 12) Non-Amish 65% Amish had 2 4 mm attachment level:
clinical attachment Amish:
level; 15% 2 6 mm 45-54 1.78 mm
255 2.18 mm
Non-Amish:
45-54 0.89 mm
255 1.69 mm
Grossi et al. (34) Mean clinical attachment level 2 4 mm 25% - -
__ .- ._-
Anagnov- Clinical attachment level 2 6 mm Farmworkers % sites 2 6 mm Mean clinical
Vareltzides 68% clinical attachment attachment level:
et al. (4) Hospital level: Farmworkers 4.8 mm
employees 32% Farmworkers 26% Hospital employees
Hospital employees 4.5 mm
21%
"Subject with 2 1 sites having a clinical attachment level of the stated threshold
"As defined by Carlos et al. (271, unless otherwise stated.

9.5 (40) to a mean of 22.3 (29). The data may then Relatively few reports included an explicit case
not reflect true differences among populations in definition on which prevalence rates were based.
disease experience but differences in methods andl Where a definition was given it was usually couched
or tooth loss. in terms of the percentage of subjects with at least

21
Locker et al.
one site with attachment loss over a certain thresh-
old level. Although attachment loss of 2 mm or more
is generally taken to indicate a diseased or previously
diseased site, the use of this as a threshold results in
prevalence rates of 95 to 100%. Consequently,
thresholds of 3 mm or more, 4 mm or more or 617
mm or more of loss have been used. The reporting
of data in graphs showing cumulative frequencies
and/or bar charts meant that prevalence rates often
had to be estimated and in some cases data had to
be “decoded” (63) in order to obtain rates. In many
studies, the extent and severity of disease as defined
by Carlos et al. (27) were given, and these have also
been included in the tables. Where possible, stat-
istics for older adults overall are given unless only
data specific to sites or subgroups were reported.
In six of the population-based studies summar-
ized in Tables 1 and 2, prevalence rates based on a
clinical attachment level of 3 mm or 4 mm at one or
more sites ranged from 72% to 95%. Two studies (40,
58) reported rates of 50% to 65% although both
probed the fewest number of teeth. Using the more
stringent threshold of 6 or 7 mm of clinical attach-
ment level, rates were lower and varied from 14% to
58%. The extent (the mean proportion of sites with
loss of 2 mm or more) of periodontal disease varied
from 48% to 78% and the severity (mean loss in sites
with loss of 2 mm or more) varied from 2.44 to 3.98
mm. Hunt et al. (40) calculated severity as mean
attachment loss beyond 1 mm in sites having more
than 1 mm of loss. In their population of elderly
Iowans, severity was 1.74 mm.
Broadly comparable results were obtained by the
six studies in which selected groups of older adults
were assessed. For example, Gilbert & Heft (32) re-
ported prevalence rates of 86% and 24% when
thresholds of 4 mm or more and 6 mm or more of
loss were used and extent and severity scores of 88%
and 3.7 mm respectively. Higher rates and a higher
mean loss were reported by Anagnou-Vareltzides et
al. (4) among older Greek subjects. However, their
estimates were based on relatively small numbers of
individuals not selected at random.
These data indicate that the majority of subjects
have some experience of periodontal disease and a
substantial minority have some advanced loss. How-
ever, where advanced loss occurs, it affected rela-
tively few sites. For example, Ismail et al. (41) report
that only 7% of the sites they examined had loss of
7 mm or more. Similarly, in a South Australian study
(681, only 5% of subjects aged 60 to 64 years and 10%
of subjects aged 80 years and over had 20% or more
of sites with 7 mm or more of loss. Using a definition
22
of serious periodontal disease as 4 or more sites with
loss of attachment of 5 mm or more with one of
those sites having a pocket of 4 mm or more, Beck
et al. (14) reported that 16% of white subjects and
46% of black subjects in their study had this level of
disease.
Bone loss
Relatively few studies involving non-patient popula-
tions or groups have assessed bone loss and they
varied considerably in terms of measurement.
In a study of unreferred patients to Glasgow Den-
tal Hospital, which included 74 subjects aged 50 to
73 years (44), 54% had advanced bone loss (defined
as bone loss exceeding 50% of optimum bone
height) and 5% had generalized advanced bone loss
(defined as advanced bone loss in 50% or more or
remaining teeth). Three-quarters of the teeth with
advanced bone loss were located in 28% of subjects.
In a study of a random sample of Swedish adults
that included 258 aged 50 years and over, Salonen et
al. (66) found that bone height as a proportion of
total root length varied from 76% in those aged 50
to 59 years to 65% in those aged 80 years and over.
A similar study by Hugoson et al. (39) reported that
12% of 50-year-olds, 38% of 60-year-olds and 60% of
70-year-olds had bone loss around the majority of
remaining teeth that exceeded one third of normal
bone height.
Diamanti-Kipioti et al. (28) studied farmworkers
recruited through a local agricultural union and em-
ployees of a major hospital in an urban area. A mean
advanced bone loss of 6 or more mm was observed
in 40% of the former and 10% of the latter. General-
ized advanced bone loss was concentrated in a mi-
nority. In the farmworker sample, 30% of subjects
accounted for 75% of the sites with advanced bone
loss of 6 mm or more.
Studies of the incidence of
periodontal disease
Attachment loss
Ten reports were located that addressed periodontal
attachment loss over time in non-patient adult
populations including older adults. The design
characteristics and results are summarized in Tables
3 and 4.
Of the reports identified, four (9, 42, 67, 71) were
problematic in terms of interpretation in that it was
 Epidemiology of periodontal disease among older adults

Table 3. Design characteristics of population-based studies of incidence

Number of
Location or older subjects Sites or Definition of
Authors source of subjects Duration according to age teeth probed incident case
.- ~~ ~

Lindhe et al. (51) City of Ushiku, 12 months Not stated 6 sites per tooth, No definition. Mean
Japan 24 months all teeth attachment level change
used as indicator of
progression
Lindhe et al. (52) City of Ushiku, 12 months Not stated 6 sites per tooth, 2 3 mm of attachment loss at
Japan 24 months all teeth 2 1 sites, that is, > 2 mm in
either examination period
Levy et al. (50) Rural Iowans, USA 2 years 197 aged 270 at Buccal and 2 2 mm of attachment loss at
baseline mesial sites 2 1 or 2 2 sites
Haffajee et al. City of Ushiku, 12 months 40 aged 50-59; 6 sites per tooth, Attachment loss of 2 3 mm at
(35) Japan 51 aged 260 all teeth 21 sites
-~ ~

Brown et al. (23) Five counties in 18 months 492 aged 265 at 2 sites for each 2 3 mm of attachment loss at
North Carolina, base1ine remaining tooth 2 1 , 2 2 or 2 3 sites
USA
Beck & Koch (19) Five counties in 36 months 492 aged 265 at 2 sites for each 2 3 mm of attachment loss at
North Carolina, baseline remaining tooth 2 1 sites
USA
~ _ _ _ _

Ismail et al. (42) City of Tecumseh, 28 years 22 subjects; 35-59 4 sites, Progression measured as
Michigan, USA at baseline Ramfjord teeth difference in mean loss from
1959 to 1987 -~
Baelum et al. (9) Langing County, 6 years 37 subjects aged 4 sites, all teeth a. Attachment loss 2 3 mm
USA 55-69 years; 15 in at one site
“best” and “worst” b. Attachment loss 2 4 mm
periodontal at one site
category at
baseline
Wennstrom et al. Patients attending 12 years 46 subjects aged 3 sites, all teeth -
(71) 12 clinics, 54-65 except third
Varmland, Sweden molars
Regular dental
visitors
Ship & Beck (67) Volunteer 10 years 17 subjects aged 2 sites, 2 2 mm of attachment loss
participants in 50-59, 40 aged Ramfjord teeth
Baltimore 60-79
Longitudinal
Stu& of Aging,
USA

unclear whether or not subjects were randomly
sampled at baseline, the study included very few
older adults or data were not reported specifically
for subjects who were 50 years and over at baseline.
Of the remainder three reported data from a random
sample of Japanese adults aged 20 to 79 years at 12-
and 24-month follow-ups (35, 51, 52) and three were
longitudinal studies of random samples of United
States adults aged 65 years and over at baseline (19,
23, 50).
Again, problems in data abstraction, different
definitions of an incident case and differences in
time periods meant that the incidence rates reported
by these studies are not strictly comparable. Never-
theless, they all suggest that substantial proportions
of older adults experienced additional attachment
loss over a defined threshold of 2 mm or 3 mm in
one or more sites over relatively short periods of
time. For example, Levy et al. (50) reported that 35%
of Iowans aged 70 years and over had at least one
site with 2 mm or more of attachment loss over a 2-
year period. Brown et al. (23), using the more strin-
gent criterion of 3 mm or more of loss at one or more
sites, reported 18-month incidence rates of 58% and
46% for black and white residents of North Carolina
aged 65 years and over. Three-year incidence rates
were 74% for blacks and 54% for whites (19). In all
studies, incidence rates were substantially lower
when more demanding case definitions were used.
Broadly comparable rates were reported in the three
articles describing the results of the longitudinal
study conducted in Japan.
Although incidence rates were high, the extent
and severity of attachment loss was low. Brown et
al. (23) found that only a small percentage of sites
examined (6%for blacks and 3% for whites) showed

23
 Table 4. Incidence, extent and severity in population-based studies
Authors Incidence rate Extent” Severity”
~- _________ ~ ~
~ ~~ ~~~

Lindhe et al. (51) - - a. 0.0 mm per year in subjects

Lindhe et a1 (52)
-~~~
Levy et al. (50)
__ - -
~-
a 53% of those 50-59 years
had 2 1 sites \nth loss
>2 mm; 62% of those
60-79 years
b. 22% of those 50-59 and
40% of those 60-79
>2 mm loss at 2 2 sites
a. 35% had 2 1 sites with
2 2 . 0 m m loss
b. 17% had 2 2 sites with
22.0 mm loss
aged 50-59 vears
b. 0115 mm pgr year in
subjects
__
aged 60-79 years”
- -
_ _ _ _ _ ~
- a. 20% mean attachment loss
of 0.2 mm
b. 7% attachment loss of
greater than 0.4 mm
~~ ~

Haffajee et al. (35) a. 32% of those 50-59 years

b 43% of those >GO years
.- ~ _ _ _ ~ ~ -~
Brown et a1 (23) a. 58% blacks, 46% whites 21 a. 6% of sites for blacks a. 3.54 mm for blacks
sites with 2 3 mm of loss b. 3% of sites for whites b. 3.37 mm for whites
b. 36% blacks, 27% whites (loss of 2 3 mm at 2 1 sites)
2.2sites
c. 24% blacks, 16% whites
2 3 sites
Beck et al. (19) a. 74% of blacks 21 sites with a. 11% of sites for blacks a. 4.6 mm for blacks
2 3 mm of loss b. 6% of sites for whites b. 4.3 mm for whites
b. 53% of whites . .-
(loss of 2 3 mm at 21 sites) ~~~

Ismail et al. (42) a. Increase of 1.34 mm in

overall mean loss
b. 23% with mean loss of
2 2 mm
__ - - . - .
~ ~~

Baelum et al. (9) a. 100% of “best” and “worst” 15% of sites in “best” and a. Mean attachment loss of
had loss of 2 3 mm at 24% of sites in “worst” 1.21 mm in “best” group,
2 1 sites groups loss 2 3 mm 1.36 mm in “worst” group
h 73% and 86% had loss of b. Range of mean change per
person,
2 4 mm at 2 1 sites
___+0.03 to -3.19 mm
Wennstrom et al. 39% of sites with loss of Increase in mean loss from 2.3
(71) 2 3 mm at baseline, mm to 2.6 mm
49% at follow-up
Ship PC Beck (67) % of sites losing 2 2 mm: Mean attachment loss in sites
50-59 years 28% with 2 2 mm of loss:
60-69 years 17% 50-59 years 2.40 mm
70-79 years 26% 60-69 years 2.70 mm
70-79 years 2.73 mm
--_______. -
’ PerLentdge ot sites examined with stated threshold of lo?$
” Menn loss in sites with loss or overall mean loss

evidence of attachment loss of 3 mm or more, and
overall mean loss beyond 3 mm over the 18-month
observation period was approximately 0.5 mm or
less. At 3 years, the proportion of sites with loss in-
creased to 11% for blacks and 6% for whites (19).
Similarly, Lindhe et al. (51) found little overall
change in attachment loss in their sample of Ja-
panese.
In a more detailed analysis of the data from the
North Carolina study, Beck & Koch (17) evaluated
subjects with at least one site with 3 mm or more of
loss over 18 months to determine whether their dis-
ease progression manifested as increased probing
depth, with no change in the position of the free gin-
gival margin, or as more gingival recession with
probing depths remaining stable. Overall, 46% of
subjects with loss had more than half their loss
manifesting as increased probing depth, and the re-
mainder had more than half their loss manifesting
as recession.
In two further articles, data on attachment loss
trends over three years were reported. For both
blacks and whites, those who lost attachment during
the first 18-month period of observation were more
likely to experience loss during the second 18-month
period (18). However, sites that lost attachment dur-
ing the first period were no more likely to experience
loss over the second than sites that remained stable
 Epidemiology of periodontal disease among older adults

over the first period. These findings were consistent
with an episodic model of periodontal disease in
which people with loss are at risk of further loss but
sites with loss are not. The 3-year data also indicated
that 41% of subjects had no loss of attachment, 28%
had loss only at sites with no loss at baseline (new
lesions), 11%had loss only at sites with loss at base-
line (progressing lesions) and 20% experienced both
kinds of loss (19). More subjects had new lesions
than had progressing lesions because at baseline
there were many more sites with no disease than
with disease. Consequently, most disease occurs in
previously healthy sites.
The remaining studies summarized in Tables 3
and 4 differed considerably in approach. Ismail et
al. (42) examined 165 subjects first assessed 28 years
earlier, of whom 22 were aged 35 to 59 years at base-
line. This group showed an overall increase in mean
attachment loss of 1.34 mm over this period and 23%
had a mean loss of 2 mm or more. Data were not
reported separately for those aged 50 to 59 at base-
line, although it is likely that few survived to follow-
up. This study illustrates the high attrition rates
(70%)that characterize studies conducted over long
time periods.
Baelum et al. (9) selected 30 individuals from a
random sample of 587 people aged 20 to 80 years
old in China who took part in a 1984 epidemiological
survey. They were divided into two groups of 15
(worst and best) according to attachment loss and
probing depths at baseline. Periodontal examin-
ations in 1984 and 1990 revealed some of the highest
incidence rates reported: 100% of both the worst and
best groups had one or more sites with 3 mm or
more of attachment loss over 10 years and 73% and
86% respectively had loss of 4 mm or more in at least
one site. However, small numbers make these esti-
mates unreliable, and the highly selected nature of
the two groups precludes generalization to a wider
population.
Similar problems affect the interpretation of the
results of the study by Wennstrom et al. (71).A total
of 225 subjects, including 46 aged 54 to 65 years,
were randomly selected from a baseline population
recruited from among the patients attending 12
community dental clinics in one county in Sweden.
In order to be selected at baseline, subjects needed
to have at least 10 teeth and be a regular dental at-
tender. Given these criteria and the fact that the pro-
cess by which subjects were initially selected is not
described, the results cannot be generalized with any
certainty.
Ship & Beck (67) reported on a 10-year longitudi-
nal study of 95 subjects of whom 17 were aged 50 to
59 years, 30 were aged 60 to 69 years and 10 were
aged 70 to 79 years at baseline. All were volunteer
participants in the Baltimore Longitudinal Study of
Aging and as such were community-dwelling, non-
smoking, ambulatory white people of middle socio-
economic status who visited a dentist at least once
per year. Although based on a limited sample, both
in terms of numbers and selection processes, this
study confirms that relatively little change in peri-
odontal status occurs over even lengthy periods of
time.
Bone loss
Four reports were located that presented the results
of three studies of bone loss over time. These are
summarized in Tables 5 and 6. In all, the nature of
the sample and its selection are unclear, although
Lavstedt et al. (49) suggest that their unselected
sample of residents of a county in Sweden were rep-
resentative of the population from which they were
drawn. All were studies of adults and included rela-

Table 5. Design characteristics of longitudinal population-based studies of bone loss

Number and age of older
Authors Subjects Duration subjects at baseline Radiographs Measure of bone loss
__ __ ____
__-
Albandar et al. Swedish factory 2 years 29 aged 51-60 years; 6 periapical, a. % of sites with
(2) workers, regular dental 13 aged 61-68 years 3 in each jaw 2 2 mm of bone loss
visitors, volunteers b. mean bone loss
(mm)
Albandar ( 3 ) As above 6 years 52 aged 46-57; As above As above
34 aged 2 5 8
Lavstedt et al. Unselected sample of 10 years 54 aged 51 to 60 years; Intraoral full ABD index: alveolar
(49) residents of Stockholm 17 aged 61-65 years mouth survey bone loss as a % of
County mean root length
Papapanou Not stated 10 years 43 aged 50-55 years; 6 periapical, Mean bone loss (mm)
et al. (61) 42 aged 260 years 4 bitewings
__ -

25
Locker et al.
Table 6. Incidence, extent and severity of bone loss
Authors Incidence rate Extent”
Albandar et al. (2) - % of sites with 2 2 mrn of bone loss:
51-55 years 8%
56-60 years 7%
61-68 years 8%
Albandar (3) - % of sites with 2 2 mm of bone loss:
46-57 years 5%
258 years 4%
Lavstedt et al. (49) - Mean ABD index/rnean bone loss:
Papapanou et al. (61) - -
‘I Percentage of sites with stated threshold of loss.
tively few subjects aged 50 years and over at baseline
and even fewer aged 60 years and over.
Across the four reports, age-specific estimates of
mean annual bone loss range from 0.051 mm to 0.28
mm with the majority around 0.15 mm. The percen-
tage of sites that had lost 2 mm or more of bone was
generally low. In a study of Swedish factory workers
(2) it ranged from 7% to 8% according to age over
2 years. Because of the small numbers of subjects
involved, all these estimates should be treated with
caution.
Other findings from these studies confirm those
obtained from studies of attachment loss. They indi-
cate that: 1) although the majority of individuals
Table 7.Terms used in analytic epidemiological
studies
Risk factor
Causal correlate of disease frequency, as evidenced by:
1) exposure precedes disease (longitudinal study
design required);
2) strength of association (statistically significant and
clinically important elevated risk ratio observed
after controlling for other potential confounding
risk factors); and
3) consonance with existing biological knowledge
(in vitro experimental studies) and population
epidemioIogy
Risk indicator
Suspected causal correlate of disease frequency
Satisfies criterion 1 for risk factor, but insufficient for
criteria 2 and 3
Risk marker
Non-causal correlate of disease frequency
No known biological causal mechanism accounts for
disease correlation
Severity
Mean bone loss:
51-55 years 0.32 mm
56-60 years 0.29 mm
61-68 years 0.34 mm
Mean annual bone loss:
46-57 years 0.066 mm
2 5 8 years 0.051 rnm
51-55 years 7%/1.1 mm
56-60 years 10%/1.6 rnrn
61-75 years 7%/1.1 rnm
Mean bone loss:
50 years 1.5 mm
55 years 1.3 mm
60 years 1.0 mm
65 years 0.9 mm
70 years 2.8 mm
show loss, the majority of sites do not; 2) advanced
loss was concentrated in a few individuals; 3) where
loss occurred, intra- and inter-individual differences
were observed; 4) where two observational periods
were used a very small proportion of sites (1.2%)
showed loss in each period; 5) findings on the as-
sociation between baseline loss and further loss were
inconsistent; and 6) the data tend to support a ran-
dom, episodic model of disease. However, since the
analyses on which these conclusions were based
were conducted using all subjects, it is not known
whether they apply specifically to the older adults
included in the studies.
Analytic epidemiology:
identification of risk factors for
periodontal disease
Analytic epidemiology is concerned with identifymg
correlates of disease in human populations. Three
distinct types of correlates have been described
(Table 7): risk factors, which are causal (that is, bio-
logical or psychosocial causes of disease); risk indi-
cators, which are thought to be causal but have not
been demonstrated to be so in studies using appro-
priate methods; and risk markers, which are not in-
volved in causation but identify individuals or
groups who experience relatively high rates of dis-
ease (13). Risk factors are often regarded as the most
useful types of disease correlates because of the po-
tential to reduce the incidence of disease by reduc-
ing exposure to those factors.

No single study can definitively identify a risk fac-
tor. Instead it is necessary to compile evidence from
several sources that collectively meet criteria for cau-
sation, such as those proposed by Hill (37). For epi-
demiological studies, three of the most important
criteria are: time sequence (exposure precedes dis-
ease); strength of association (magnitude of elevated
risk and dose-response gradient) and consonance
with existing knowledge (57). The latter rests on a
combination of biological experimental evidence
(demonstrating cellular or subcellular mechanisms
that relate exposure to a pathological process in-
volved in the disease) and population epidemiology
(demonstrating that the distribution of disease
within populations is found to follow the distri-
bution of the proposed causal factors) (47).
For many correlates that are statistically associ-
ated with disease occurrence, there have been insuf-
ficient studies to meet all of the criteria above and
their status as risk factors remains uncertain. For ex-
ample, based on data from cross-sectional studies,
systemic osteoporosis is thought to be a potential
risk factor for periodontal disease (43). Where there
are reasonable theoretical grounds and cross-sec-
tional epidemiological data to believe that such fac-
tors may be involved in causing disease, they should
be referred to as risk indicators. Further studies are
then justified in order to establish their status as
causes of disease.
The third type of correlate is a risk marker, which
is associated with disease occurrence but is not in-
volved in causing disease. For example, low socio-
economic status can be confirmed as a risk marker
for periodontal disease based on numerous cross-
sectional and longitudinal epidemiological studies.
However, there is no specific biological mechanism
by which, for example, low educational attainment
causes periodontal attachment loss. In part, the re-
lationship may exist because people with low educa-
tional attainment may have increases in other risk
factors (for example, periodontal pathogens, smok-
ing or less use of dental services). Even though
educational attainment cannot be regarded as a risk
factor, there clearly is value in identifying it as a risk
marker, because it provides a rationale for public
health interventions and for pursuing other research
that identifies the behavior or exposures that ac-
count for this correlation. Since some studies have
found a significant correlation between socioecon-
omic status and periodontal destruction, even after
controlling for these other factors (34), it may be that
these variables are documenting a general suscepti-
bility to disease.
Epidemiology of periodontal disease among older adults
A final use for all categories of disease correlates
(risk factors, risk indicators and risk markers) is their
combination in risk prediction models. These aim to
identify individuals most likely to experience peri-
odontal disease so that they can be targeted for more
intensive clinical care. Although risk prediction is an
appealing clinical concept, it is only one step in a
process of improving efficiency in delivering oral
health care (69). If an effective intervention is not
available or cannot be delivered to high-risk individ-
uals, risk prediction has little value other than pro-
viding practitioners with an improved ability to ad-
vise patients about prognosis. In addition, the set of
explanatory variables that are identified in risk pre-
diction studies usually cannot be used to make inter-
pretations about causal variables (13). This is be-
cause some of the best risk predictors are strongly
linked to past disease activity (for example, prior
attachment loss or tooth mobility) and, in multivari-
ate models, their strong correlation with future dis-
ease activity tends to displace other causal variables
from the model.
This section considers two main questions that
have been addressed in analytic epidemiological
studies of periodontal disease among current and
future elderly people. The studies reviewed in this
section are limited to longitudinal studies, because
they provide the best evidence about risk factors.
However, numerous cross-sectional and case-con-
trol studies have identified risk indicators and risk
markers, and these have been reviewed elsewhere
(15, 21, 63). These include sociodemographic and
socioeconomic factors, behavioral factors, psy-
chosocial factors, dental visiting patterns, general
health status and medical conditions, prior peri-
odontal disease experience and other oral diseases.
Factors associated with periodontal disease experi-
ence in cross-sectional studies do not always sur-
vive multivariate analysis (151, nor do they necess-
arily enter models predicting the incidence of dis-
ease.
Aging as a risk factor for
periodontal disease
There is debate about the extent to which physio-
logical and pathological changes that accompany
aging are due to the aging process itself or caused
by concomitant pathoses, medication usage or social
and environmental change (46). Nevertheless, since
numerous age-associated changes can be observed
27
Locker et al.

in the biochemical, immunological and physiologi-
cal processes of periodontal tissues, there are
reasonable grounds to suspect that increasing age
could potentially be a risk factor for periodontal dis-
ease. A recent review of the epidemiological litera-
ture (26) concluded that age is associated with some
moderate loss of periodontal attachment and al-
veolar bone loss, but that the amount is rarely of
therapeutic significance. The review noted that
cross-sectional studies measuring disease experi-
ence necessarily show more attachment loss and
bone loss among older age groups, since clinical
attachment level and bone loss are (effectively) irre-
versible measures of prior disease experience.
Consequently, it is unclear whether the higher level
of disease experience in older adults is a function of
time or aging. Hence, longitudinal studies are
needed to address whether aging is a risk factor for
periodontal disease.
Table 8 summarizes information from eight longi-
tudinal studies reported during the last decade that
have examined potential relationships between age
and attachment loss or bone loss. Four studies found
significant bivariate relationships, although for one
of them ( 3 ) ,the relationship was not linear with in-
creasing age. The age effect persisted in multivariate
analysis for two of those studies. No age associations
were observed in three studies in Table 8, although
the studies of Brown et al. (23) and Beck et al. (19)
were confined to people aged 265 years, whereas the

Table 8. Relationship between age and periodontal disease incidence

Authors Location Population Methods Findings
Papapanou Sweden 25-70 years; 201 people; Bivariate analysis: mean annual bone
et al. (61) source of subjects bone loss all teeth; loss=0.28 mm aged 270, 0.14 mm aged
not stated 10 years of follow-up 40-55, 0.07 mm aged 25-39 ( R 0 . 0 5 ) .
Multivariate analysis: age was implicated
(P=0.08) as risk factor after controlling for
baseline bone loss, tooth type and site
USA Random sample 165 people; Bivariate analysis: mean clinical
of community- clinical attachment level attachment level increase= 1.34 aged
dwelling people; all teeth/4 sites; 36-50, 1.23 mm aged 26-35, 1.21 mm aged
5-60 years over 28 years of follow-up 16-25, 0.8 mm aged 5-15. Multivariate
analysis: age was significant (P<0.05) risk
factor after controlling for smoking, tooth
mobility and plaque
Haffajee et al. Japan Random sample 271 people; Bivariate analysis: % of people with 2 2
(35) of community- clinical attachment level m m increase in clinical attachment level=
dwelling people; all teeth/6 sites; 43% aged r 6 0 years, 32% aged 50-59 years,
20-79 years 1 year of follow-up 31% aged 40-49 years; <20% for younger
ages (RO.01).
Multivariate analysis: age was significant
risk factor after controlling for baseline
tooth loss, pocket depth and recession
Albandar (3) Norway Employed people at 142 people; bone loss Bivariate analysis: % of people with >O
industrial plant; from 6 periapical mm increase in bone loss=4.3 aged 18-33
18-67 years radiographs / person; years, 7% aged 34-45 years, 13% aged
6 years of follow-up 46-57 years; 10% aged 57-67 years
(R0.05)
Grbic et al. USA Periodontal 75 people with =) 18 teeth Multivariate analysis: age associated with
(33) patients; '30 years and periodontal disease; 2 1 sites having 22.5 mm clinical
clinical attachment level attachment level increase, after controlling
excluding third molars; for number of teeth and baseline clinical
6 months of follow-up attachment level
Brown et al. USA Random sample 492 people; Bivariate analysis: no differences among
(23) of community- clinical attachment level 4 age groups in extent and severity of
dwelling people: all teeth/2 sites; clinical attachment level increase.
'65 years 18 months of follow-uD Multivariate analysis: no effect of age
-.
Beck & Koch USA As above 338 people Multivariate analysis: no effects of age
(19) clinical attachment level
all teeth/2 sites
3 years of follow-ur,
Ship & Beck USA Healthy men, 95 men Bivariate analysis: no differences among
(67) volunteers in aging clinical attachment level 5 age groups in % of sites losing 2 2 mm of
study; 29-76 years 6 index teeth/2 sites; clinical attachment level
8-12 vears of follow-ur,

28
 Epidemiology of periodontal disease among older adults

study of Ship & Beck (67) relied on partial-mouth
recordings and was confined to a selected sample of
healthy men.
The studies in Table 8 should be considered in
light of other earlier studies that have shown equivo-
cal relationships between age and the risk of inci-
dent periodontal disease. For example, in an earlier
study of the cohort described in Table 8, Albandar et
al. (2) found a curvilinear relationship between 2-
year incidence of attachment loss and age, such that
the incidence rate peaked in the age range 33-56
years. This finding is noteworthy in light of other
epidemiological studies that suggest that the inci-
dence of tooth loss is highest during middle dge (61,
71). Although periodontal disease is not thought to
be the major cause of tooth loss among adults, the
loss of teeth in epidemiological studies usually pro-
duces an underestimate of periodontal disease inci-
dence, since attachment loss tends to be greater in
teeth that are extracted (whether or not the extrac-
tion is due to periodontal disease), and such teeth
cannot be measured in follow-up studies.
In summary, the consistent findings from the
studies reviewed above indicate statistically sig-
nificant relationships between age and incidence
of periodontal disease. However, this age-associ-
ated increase in risk may not be linear, since some
studies show no significant differences within age
groups above the age of 65 years. A more import-
ant issue is the magnitude of any increase in risk:
the studies that demonstrate statistically significant
associations do not necessarily indicate that this
will lead to a serious clinical outcome for older
adults. For example, the 28 year follow-up study of
Ismail et al. (42) reported an odds ratio of 10.4 for
people aged 36-50 compared with people aged 5-
15 years. While this is comparable in magnitude
with other clinically important risk factors (for ex-
ample, the smoking odds ratio in the same study
was 14), it corresponds to a mean increase in clin-
ical attachment level of only 1.34 mm over 28
years. As Burt (26) concluded, this level of in-
creased risk probably is not sufficient, alone, to
cause tooth loss, which he cites as the most clin-
ically iinportant endpoint of periodontal disease.
The most important clinical conclusion to draw
from these studies concerning the effects of aging
is that increased age poses some increased risk for
periodontal destruction, but the amount of destruc-
tion due to age alone is probably consistent with
“successful aging” rather than accelerated patholog-
ical processes. Indeed, it is probably appropriate to

Table 9. Risk factors, risk indicators and risk markers for periodontal disease among older adults“
Authors Location Risk factors Risk indicators and markers ..
-..
Papapanou et al. Sweden Mean bone level change over 10 years Greater baseline bone loss: distal sites;
(61) maxillary sites; molars and incisors
Ismail et al. (42) USA Mean clinical attachment level Current smoker; tooth mobility
increase of 2 2 mm over 28 years
. . ~~

Haffajee et al. (35) Japan 2 1 sites with 2 3 mm clinical Greater % of s i t e F k h pocket probing depth-
attachment level increase over 1 year >3 mm; greater number of missing teeth;
greater % of sites with recession > l mm
Bolin et al. (22) Sweden Mean bone level change over 10 years Smokers >quit smokers >never smokers;
plaqueh
___.. .- __-. ~.~
Brown et al. (23) USA 2 2 sites with 2 3 mm clinical Blacks: Preuotellu intermediu >2%;
attachment level increase over 18 Porphyromonas gingivulis >2%; not flossing
months regularly; memory getting worse; dental
visit 2 3 years ago
Whites: J? gingivulis >2%: medical care in
last 6 months; felt depressed;
smoke cigarettes regularly
Beck & Koch (19) USA People with clinical attachment level No history of calcium useb; no history of
increase, mainly due to greater cervical abrasion; greater salivary flow;
pocket probing depth reported bleeding p m s : use of tobacco?
use of mouthwash
Beck et al. (18) USA 1) New clinical attachment level 1) Low income; medication use; smokeless
( 2 3 m m increase at sites with tobacco use: history of oral pain
<3 mm at baseline); 2) Low income; medication use; cigarette
2) Progressing clinical attachment level smoking: BANA positive; E! gingivalis
( 2 3 m m increase at sites positive; reported financial problems
with 2 3 mm at baseline)
a This table is confined to risk factors and risk indicators and markers, other than age, as identified in multivariate models from longitudinal studies that
included older adults (age 250 years).
Involved in interactions with other variables in the model

29
view the aging-periodontitis association as a ration-
ale for redefining appropriate endpoints of peri-
odontal therapy, such that the objective of treatment
is to maintain a functioning dentition rather than a
perfect level of periodontal attachment. For ex-
ample, Wennstrom et al. (70) have proposed age-re-
lated thresholds that could be used to decide on ap-
propriate levels of therapy.
Other risk factors, indicators and
markers for periodontal disease
Five of the longitudinal studies in Table 8 together
with two other longitudinal studies provide ad-
ditional information about risk factors for peri-
odontal disease among older adults, and the results
are summarized in Table 9.
Several of the studies found that baseline indi-
cators of disease (greater probing pocket depth, re-
cession or clinical attachment level, mobility or
missing teeth) were significant predictors. As noted
already, these variables can best be regarded as risk
markers, since they capture prior disease experience,
rather than causal risk factors. They may be regarded
as proxies for combinations of risk factors. Moreover,
the analyses that use such variables in multivariate
models may overlook specific microbiological or be-
havioral risk factors.
The risk factors identified in Table 9 include ciga-
rette smoking and periodontal pathogens, which
have also been identified as risk indicators in nu-
merous cross-sectional studies, both among older
adults (45, 55) and other age groups (21). For ex-
ample, a recent meta-analysis of cross-sectional and
case-control studies found an overall odds ratio of
2.8 for periodontal disease (using various case defi-
nitions) comparing smokers with nonsmokers (63).
The fact that smoking has emerged as a factor in
many studies with different designs and approaches
adds weight to the conclusion that it plays an im-
portant causal role. Other behavioral factors in-
cluded in Table 9 relate to plaque accumulation and
receipt of dental care although the totality of the evi-
dence with respect to these variables means that
their role remains uncertain.
For other predictors in Table 9, the biological
pathway to link exposure with periodontal destruc-
tion is less clear, and hence their status as risk fac-
tors is uncertain. For example, worsening memory,
feelings of depression and low income could influ-
ence oral hygiene behavior or may increase stress,
30
either of which would be involved in causing peri-
odontal disease. On the other hand, these may serve
as markers of other causal mechanisms, such as re-
ceipt of preventive dental care or reference other, as
yet unknown, risk factors. ClearIy, additional studies
are warranted to confirm the risk factor status of
these variables and to identify others not yet in-
cluded in the research conducted to date.
Summary
Although many epidemiological studies have been
conducted concerning periodontal disease, the ma-
jority were not included in this review because of
deficiencies in the measures used. Although it is in-
creasingly common for studies in this field to
measure periodontal disease using clinical attach-
ment level, attachment loss or bone loss, the evi-
dence pertaining to prevalence, incidence and risk
in older adult populations is limited. Although it is
the best indicator to date, characterizing periodontal
disease by means of attachment loss has some limi-
tations. Prevalence and incidence rates may vary ac-
cording to the number of teeth and sites probed and
bias and case misclassification may occur because
of the healthy survivor effect. Moreover, prevalence
data that document lifetime disease experience are
of little use in planning for periodontal treatment
needs. Problems with sampling or subject selection
and idiosyncratic ways of reporting data also limit
the quality of the evidence currently available. In or-
der to standardize the collection of data on loss of
attachment and to measure it as accurately as poss-
ible, Papapanou (63) recommends that studies use
full-mouth periodontal examinations and the assess-
ment of clinical attachment level at four sites on
each remaining tooth.
Given the inconsistencies in and problems with
the methods used in the studies reviewed above,
only broad conclusions can be drawn concerning
periodontal disease in older adults. These confirm
the conclusions reached in other reviews of the
literature.
. While moderate levels of attachment loss are to
be found in a high percentage of middle-aged and
elderly subjects, severe loss is confined to a mi-
nority, albeit a substantial one. Severe loss is evi-
dent in only a few sites and, in general, affects
only a small proportion of sites examined. Never-
theless, approximately one-fifth of older individ-
uals have experienced more generalized severe

loss; the rate is much higher in the oldest subjects
and subjects from minority groups. Although not
universal, severe disease is common in some older
populations and some population subgroups.
Studies using common approaches are needed to
fully elucidate the extent to which disease experi-
ence varies across different populations.
Similar conclusions can be drawn from preva-
lence studies measuring bone loss. These show
that a minority of subjects accounted for most
sites with advanced loss.
Studies of incidence suggest that 50-75% of older
adults experience additional loss of attachment of
2 or 3 mm or more at a minimum of one site over
relatively short periods of time. Rates fall dramati-
cally when more stringent case definitions are
used. Moreover, relatively few sites examined
show evidence of additional loss so that, although
rates are high, extent and severity are low.
More detailed analyses of incidence data, al-
though few, indicate that new lesions are more
common than progressing lesions, and the pat-
tern of loss tends to support an episodic model
of periodontal disease progression. These findings
need to be replicated.
Studies of incidence based on bone loss report a
similar pattern to those based on attachment loss.
Although most individuals show loss, the majority
of sites do not, and more generalized loss is con-
centrated in a minority of subjects.
Although periodontal disease is time-associated,
and aging itself appears to be responsible for
some attachment loss, it is of a magnitude that is
unlikely to be of clinical significance.
Numerous factors have been found to be associ-
ated with periodontal disease prevalence and in-
cidence. The majority of these are likely to prove
to be risk markers rather than risk factors. Cur-
rently, the evidence concerning the causal role
of smoking and particular periodontal patho-
gens is stronger than for most other putative
risk factors.
Because of limitations in the data, this review has
addressed only a few questions concerning the epi-
demiology of periodontal disease in adults. Page (60)
has identified three important issues that need to be
addressed. These concern changes in the prevalence
of periodontal disease, the better characterization of
high-risk groups and subpopulations and the re-
lationship between oral hygiene and the onset and
course of periodontal disease. These are also import-
ant questions that need to be answered with respect
Epidemiology of periodontal disease among older adults
to the disease experience of current and future
elderly people. Further, more methodologically
oriented research is required to assess the effects of
tooth loss and measurement protocols on estimates
of prevalence, incidence and risk.
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