j dent res 2012 papapanou 907 8

7/30/2019 j Dent Res 2012 Papapanou 907 8

1/3

http://jdr.sagepub.com/Journal of Dental Research

http://jdr.sagepub.com/content/91/10/907The online version of this article can be found at:

DOI: 10.1177/0022034512458692

2012 91: 907 originally published online 30 August 2012J DENT RES

P.N. PapapanouThe Prevalence of Periodontitis in the US : Forget What You Were Told

Published by:

http://www.sagepublications.com

On behalf of:

International and American Associations for Dental Research

can be found at:Journal of Dental ResearchAdditional services and information for

http://jdr.sagepub.com/cgi/alertsEmail Alerts:

http://jdr.sagepub.com/subscriptionsSubscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

What is This?

- Aug 30, 2012OnlineFirst Version of Record

- Sep 18, 2012Version of Record>>

by guest on March 21, 2013 For personal use only. No other uses without permission.jdr.sagepub.comDownloaded from

2012 International & American Associations for Dental Research
http://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/content/91/10/907http://jdr.sagepub.com/content/91/10/907http://www.sagepublications.com/http://www.sagepublications.com/http://www.dentalresearch.org/i4a/pages/index.cfm?pageid=3533http://jdr.sagepub.com/cgi/alertshttp://jdr.sagepub.com/cgi/alertshttp://jdr.sagepub.com/cgi/alertshttp://jdr.sagepub.com/subscriptionshttp://jdr.sagepub.com/subscriptionshttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsReprints.navhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsPermissions.navhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://jdr.sagepub.com/content/early/2012/08/29/0022034512458692.full.pdfhttp://jdr.sagepub.com/content/early/2012/08/29/0022034512458692.full.pdfhttp://jdr.sagepub.com/content/early/2012/08/29/0022034512458692.full.pdfhttp://jdr.sagepub.com/content/91/10/907.full.pdfhttp://jdr.sagepub.com/content/91/10/907.full.pdfhttp://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/http://online.sagepub.com/site/sphelp/vorhelp.xhtmlhttp://jdr.sagepub.com/content/early/2012/08/29/0022034512458692.full.pdfhttp://jdr.sagepub.com/content/91/10/907.full.pdfhttp://www.sagepub.com/journalsPermissions.navhttp://www.sagepub.com/journalsReprints.navhttp://jdr.sagepub.com/subscriptionshttp://jdr.sagepub.com/cgi/alertshttp://www.dentalresearch.org/i4a/pages/index.cfm?pageid=3533http://www.sagepublications.com/http://jdr.sagepub.com/content/91/10/907http://jdr.sagepub.com/


2/3

907

PERSPECTIVE

New epidemiologic data on periodontal status derived fromthe 2009-2010 cycle of the National Health and NutritionExamination Survey (NHANES) are published in this issue of

theJournal of Dental Research (Eke et al., 2012a) and are worth

commenting on for a number of reasons: first, because they rep-

resent the first national probability sample that used a full-mouthperiodontal 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 methodol-

ogy used in NHANES III and NHANES 1999-2000, or the ran-

dom half-mouth, three-sitepertooth protocol used in NHANES

2001-2004; second, because the prevalence of periodontitis in

this publication is far higher than that reported in earlier epide-

miologic 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 attain-

ment showing poorer periodontal status than their more socio-economically 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 ran-

dom half-mouth examination protocol based on either 2 (mesio-

buccal and mid-buccal) or 3 (mesio-buccal, mid-buccal,

disto-buccal) sitespertooth results in substantial underestima-

tion 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 demon-

strated unequivocally the magnitude of the bias resulting from

the use of these partial recording systems: The prevalence oftotalperiodontitis [i.e., the sum ofmild, moderate, and severe

periodontitis according to the CDC/AAP definitions (Page and

Eke, 2007; Eke et al., 2012c)] was 47.2% based on the full-

mouth data, as compared with prevalence estimates of 19.5%

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 ofsevere periodontitis according to the AAP/CDC

definition based on the full-mouth data would have been under-

estimated 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 improvementin 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 periodon-

titis 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 con-

tribute 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 peri-

odontal status over time.

The socio-demographic patterns in the distribution of peri-

odontitis 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 Non-

Hispanic Blacks, but both groups remain significantly more

DOI: 10.1177/0022034512458692

Received July 27, 2012; Last revision July 30, 2012; Accepted July 30, 2012

International & American Associations for Dental Research

P.N. Papapanou

Division of Periodontics, Section of Oral and Diagnostic Sciences, Colum-

bia University College of Dental Medicine, 630 West 168th St., PH-7 E 110,

New York, NY 10032, USA; [email protected]

J Dent Res 91(10): 907-908, 2012

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

The Prevaene ofPeriodontitis in the US:Foret What You Were Tod


http://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/


3/3

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 dis-

ease is unfeasible and inevitably arbitrary, since the distributionof 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 limit-

less, 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 characteris-

tics by which they differ from the norm for their species in sucha 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 peri-

odontitis (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 distin-

guishing between the two forms on the basis of a single exami-

nation (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 peri-

odontitis 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 evidence-

based answers.

AcKNOWlEDgmENT

The author declares no potential conflict of interest with respect

to the authorship and/or publication of this perspective.

REFERENcESBaelum V, Lopez R (2004). Periodontal epidemiology: towards social sci-

ence or molecular biology? Community Dent Oral Epidemiol32:239-

249.

Demmer RT, Papapanou PN (2010). Epidemiologic patterns of chronic and

aggressive periodontitis.Periodontol2000 53:28-44.

Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, et al.

(2007). Trends in oral health status: United States, 1988-1994 and

1999-2004. Vital Health Stat11:1-92.

Eke PI, Thornton-Evans GO, Wei L, Borgnakke WS, Dye BA (2010).

Accuracy of NHANES periodontal examination protocols. J Dent Res

89:1208-1213.

Eke PI, Thornton-Evans G, Dye B, Genco R (2012a). Advances in surveil-

lance of periodontitis: the Centers for Disease Control and Prevention

Periodontal Disease Surveillance Project.J PeriodontolFeb 11. [Epub

ahead of print Feb 11, 2012] (in press).

Eke PI, Page RC, Wei L, Thornton-Evans G, Genco RJ (2012b). Update of

the case definitions for population-based surveillance of periodontitis.

J Periodontol[Epub ahead of print Mar 16, 2012] (in press).

Eke PI, Dye BA, Wei L, Thornton-Evans G, Genco R (2012c). Prevalence

of periodontitis in adults in the United States: 2009 and 2010. J Dent

Res 91:914-920.

Ford ES, Li C, Zhao G (2010). Prevalence and correlates of metabolic syn-drome based on a harmonious definition among adults in the US.

J Diabetes 2:180-193.

Huffman MD, Capewell S, Ning H, Shay CM, Ford ES, Lloyd-Jones DM

(2012). Cardiovascular health behavior and health factor changes

(1988-2008) and projections to 2020: results from the National Health

and Nutrition Examination Surveys. Circulation 125:2595-2602.

Kingman A, Albandar JM (2002). Methodological aspects of epidemiologi-

cal studies of periodontal diseases.Periodontol2000 29:11-30.

Kingman A, Susin C, Albandar JM (2008). Effect of partial recording proto-

cols on severity estimates of periodontal disease. J Clin Periodontol

35:659-667.

Page RC, Eke PI (2007). Case definitions for use in population-based sur-

veillance of periodontitis.J Periodontol78(7 Suppl):1387S-1399S.

Papapanou PN, Lindhe J (2008). Epidemiology of periodontal diseases. In:

Clinical periodontology and implant dentistry. Lindhe J, Karring T,

Lang NP, editors. London, UK: Blackwell Publishers, pp. 129-179.Scadding JG (1996). Essentialism and nominalism in medicine: logic of

diagnosis in disease terminology.Lancet348:594-596.

Scherp HW (1964). Current concepts in periodontal disease research: epide-

miological contributions.J Am Dent Assoc 68:667-675.

Tonetti MS, Claffey N (2005). Advances in the progression of periodontitis

and proposal of definitions of a periodontitis case and disease progres-

sion for use in risk factor research.J Clin Periodontol32(Suppl 6):210-

213.


http://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/http://jdr.sagepub.com/

j dent res 2012 papapanou 907 8

Documents