29, 2002, 3169 Copyright C Blackwell Munksgaard 2002
Printed in Denmark. All rights reserved PERIODONTOLOGY 2000 ISSN 0906-6713 Periodontal diseases in North America Jnsir M. AIunNnnn More than 400 million people live in North America, according to the year 2000 census (58), including 281.4 million people in the United States of America, 30.8 million in Canada, and 100.4 million in Mexico. The three North American countries vary with regard to their ethnic make up, level of development, and gross domestic product (GDP). The U.S.A and Cana- da are similar in various aspects including their composition of a predominantly Caucasian popula- tion, and in that both have a high level of develop- ment and economic well-being, and well organized health systems. The year 2000 estimates of the total GDP for the U.S and Canada were 9896 and 689 bil- lion U.S. dollars, respectively, which translates into a per capita GDP of $35,829 and $22,370, respectively (17, 48). The year 2000 GDP gures for Mexico were 574 billion U.S. dollars, or a per capita GDP of $5893. The most recent census survey shows that the U.S. population is composed of 71.3% non-Hispanic whites, 12.2% non-Hispanic blacks, 11.9% of Hispan- ic origin, 3.8% Asians and 0.7% native Americans (55). In 1996 the population in Canada was com- prised of ethnic groups with the following origins: 66% Europeans, 26% of mixed background, 2% American Indians, and 6% of other ethnic origins. The population in Mexico is comprised of a mainly Hispanic population. The recent estimates show the following distribution of ethnic groups: 9% whites, 30% American Indians, 60% American Indian-Span- ish (Mestizo), and 1% of other ethnic groups. Health care services and manpower There are considerable differences between the three North American nations in the resources allocated to health care. The total expenditure on health (as a percentage of the GDP) was 13.7% in the USA, 8.6% 31 in Canada, and 5.6% in Mexico, and the percentages of these expenses that were sponsored through pub- lic expenditure were 44%, 72%, and 41%, respectively (58). There are also differences in the number of physicians in these countries, with the USA, Canada, and Mexico having 26, 21, and 15 physicians per 10 000 inhabitants in 1995 (48). The numbers of den- tists per 10000 inhabitants were: 6 in the USA, 5 in Canada, and 1 in Mexico. Dental care is, to a large extent, a pay per service/out of pocket payment ser- vice for civilian noninstitutionalized individuals. Third-party payments make up a proportion of these services. In the U.S.A., private dental insurance cov- ered about 49% of the total dental expenditures in 1999 (33). Epidemiology of periodontal diseases in North America This chapter is a comprehensive review of the epi- demiology of periodontal diseases in the North American populations and is based on a systematic review of relevant studies published in peer-review- ed English journals. A number of large surveys have been conducted during the last several years to as- sess the epidemiology of periodontal diseases in the U.S.A. In contrast, there have been only a limited number of studies from Canada and almost a com- plete lack of studies from Mexico. The representation of study samples and other methodologies used in these studies varied con- siderably. Generally, studies carried out before 1980 used disease classications of little relevance to our present understanding of periodontal disease patho- genesis and classication and/or used convenient study samples with inadequate representation of their target populations. Recent U.S. national sur- veys have been in a distinguished class with regard Albandar to their execution and fulllment of fundamental epidemiological principles of survey design, disease parameters assessed and representation of the target population. Early surveys Among the rst large epidemiological studies of periodontal diseases in North America is the study of Belting et al. (12) who examined 5014 men com- prising persons seeking dental treatment at the Vet- erans Administration regional outpatient dental clinic in Chicago between 1950 and 1952. The authors classied periodontitis into periodontitis simplex, periodontosis, and periodontitis complex, according to Orbans classication (47). Subjects without radiographic evidence of bone loss were classied as normal. Periodontitis simplex was dened as presence of moderate to severe marginal gingivitis, probing depth greater than 2mm, abundance of supragin- gival and subgingival calculus, radiographic horizon- tal bone loss, and pus discharge upon the appli- cation of pressure on the gingiva. Periodontitis com- plex included presence of moderate to severe marginal gingivitis, abundance of subgingival calcu- lus, radiographic vertical bone loss, probing depth greater than 2mm, and pus discharge from the gin- giva. Periodontosis was dened as absence of mar- ginal gingivitis or presence of only mild gingivitis, little supragingival and subgingival calculus, radio- graphic vertical bone loss, probing depth greater than 2mm, and no pus discharge when pressure was applied to the gingiva. It is worth noting that these classications were not very different from present classications of de- structive periodontal diseases. Periodontitis sim- plex seems consistent with the present classication of slight to moderate chronic periodontitis, and periodontitis complex is somewhat similar to the classication of advanced chronic periodontitis (8). Furthermore, the classication of periodontosis is somewhat inclusive of the criteria of juvenile peri- odontitis described by Baer (10). Findings The results of Belting et al. (12) showed that the prevalence of periodontitis was highest (42% of sub- jects) in the 4449years age cohort (Fig. 1), with an additional 11% of the subjects in this age group being completely edentulous. In the older age 32 groups, the prevalence of periodontitis decreased, and the percentage of edentulous subjects increased (Fig. 2), which suggests that periodontitis may burn out with aging due to tooth loss. The selection bias caused by the use of dental pa- tients could have resulted in an overrepresentation of disease-inictedsubjects inthe study sample. For this reason, the periodontal disease prevalence and the frequency of edentulous subjects that have been re- ported by Belting et al. (12) for the veteran population of Chicago is probably higher than the actual preva- lence for that population. On the other hand, it has been shown that radiographs underestimate the level of periodontal tissue loss (1), and the use of radio- graphic bone loss as a prerequisite criterion for the classication of periodontitis may have contributed to an underestimation of the prevalence of peri- odontitis in the group studied by Belting et al. (12). US National health surveys A systematic review of the dental literature identied several large epidemiologic surveys that have been conducted during the last few years in the United States. Some of these surveys were independent studies designed primarily to assess the dental health of the U.S. population, whereas others were conducted as part of larger health surveys designed to assess oral and systemic health. Generally, appro- priate design is a hallmark of these surveys, which included the use of pertinent methodology for de- ning disease parameters and adequate samples, representative of their target populations, as well as proper execution of studies. The National Health Survey Act was passed in 1956 to provide legislative authorization for a continuing survey to be conducted to collect statistical data on the amount, distribution, and effects of illness and disability in the United States. It was recognized that data collection for this purpose would involve at least three sources: direct interview of a sample of people; clinical tests, measurements, and physical examinations on the interviewed sample persons; and places where persons received medical care such as hospitals and clinics. As an implementation of this act, the National Center for Health Statistics (NCHS) conducted several large health surveys of the U.S. population. Three surveys were conducted between 1959 and 1970. The rst survey focused on selected chronic diseases in 1879-year-old persons, and the two other surveys focused on the growth and development of children. Periodontal diseases in North America Fig. 1. Percentage of subjects by severity of periodontitis in 5014 male VA dental patients in Chicago in 19501952. Periodontal disease was classied according to Orban (47) into periodontitis simplex, periodontosis, and periodontitis complex. As researchers began to discover links between dietary habits and disease, a new area of interest evolved: the study of nutrition and its relationship to health status. The National Health and Nutrition Examination Surveys (NHANES) are conducted by the NCHS to assess the health and nutritional status of the civilian noninstitutionalized population in the U.S. The NHANES surveys use a complex stratied multistage probability design, and consist of youth, Fig. 2. Percentage of persons who were completely edentu- lous and those with periodontitis among male Veterans Ad- ministration (VA) dental patients in Chicago in 19501952. 33 adult, and family questionnaires followed by stan- dardized physical and health examinations under- taken in specially equipped modern mobile exami- nation centers. And, in order to provide sufcient data about certain subgroups, the NHANES design includes oversampling population groups that are believed to be at a high risk from nutritional and/or certain health problems. The oversampling of these groups was carried out at known rates, and the ad- justed sampling weights were then computed and used to adjust for the sampling design. Of the three NHANES surveys that were completed between 1971 and 1994, only NHANES I and NHAN- ES III included dental and periodontal examinations. Table1 shows a summary of the design of these two surveys. NHANES I The rst National Health and Nutrition Examination Survey (NHANES I) was conducted during 1971 1974 and included a probability sample of approxi- mately 28,000 subjects, which was approximately representative of the 194 million civilian noninstitu- tionalized U.S. population (1972U.S. population es- timates), except persons living on land reserved for American Indians and excluding Alaska and Hawaii states. Of this total sample, 20,749 persons had den- tal examination conducted by 7 dentists (37). Albandar The NHANES I study design included selecting primary sampling units (PSU) which were mostly in- dividual counties or adjacent counties. A total of 1900 PSUs were available; these were stratied and 65 units were selected with probability proportional to size. In the second stage, a random sample of seg- ments was selected consisting of approximately six households within each of the 65 PSUs. At the third stage, persons were selected randomly from a list of all eligible persons within each selected segment. One of the main emphasis of this survey was to pro- vide data about nutrition, and therefore the study specically oversampled population groups who were believed to be at high risk of malnutrition, in- cluding persons with low income, preschool children, women of childbearing age, and the elderly. The dental examination component of the NHAN- ES I survey included assessment of teeth status, den- tal caries, periodontal condition, occlusion (only persons 612years old), denture status, and the den- tal treatment needs. The oral hygiene status was as- sessed by the Simplied Oral Hygiene Index (31) on six teeth, and included a separate assessment of oral debris (Simplied Debris Index) and dental calculus (Simplied Calculus Index). The periodontal con- dition was assessed by the Periodontal Index (PI) (50) on all teeth present. The Periodontal Index clas- sies disease into mild gingivitis, gingivitis, gingi- vitis with pocket formation (increased probing depth together with loss of periodontal attachment), and advanced destruction with loss of masticatory function, drifting of teeth and increased tooth mo- bility. The index uses an ordinal scale to give differ- Table1. Summary of the design of the rst and third National Health and Nutrition Examination Surveys (NHAN- ES I and NHANES III) NHANES I NHANES III Survey period 19711974 19881994 Examined sample size 28000 30818 Age of target population 174years 2months and older Geographical area (Hawaii) Unites States (excluding Unites States Alaska and Hawaii) Total number of PSUs 1900 2812 Number of selected PSUs 65 89 Subgroups oversampled Low income, children 15years, Children 2months-5years, persons women 2044years, persons 60years and over, Mexican 65years and older Americans and blacks Average number of sample 1 23 persons per household 34 ent weights to these classications of disease (scores 1, 2, 6 and 8, respectively) and each tooth is given one score, and an average score for the individual is then calculated. It should be noted that the Russells periodontal index relies on visual inspection using a dental mirror to estimate the severity of disease and does not include probing or clinical attachment measurement of teeth. The NHANES I examiners used their clinical judg- ment and various pieces of information to recom- mend a treatment plan for each person. Some of the information used included oral hygiene status, the severity of periodontal disease, subjects age, the per- sons answers to questions about chewing and eat- ing, and the examiners evaluation of the probable benet of the recommended treatment. The evalu- ation of the treatment needs also included an esti- mation of the number of permanent teeth within each subject that needed extraction, and the identi- cation of the reasons for extractions. The Russellss PI has several validity limitations in its combined assessment of gingivitis and peri- odontitis, the subjective nature of measurement of disease, and the unwarranted weights assigned to different categories of disease. For these reasons, the Periodontal Index is currently viewed as inadequate for the assessment of periodontal status and has sel- dom been used since the 1980s. Undoubtedly, the use of this index in the 19711974 NHANES I survey is a major shortcoming, and there is very limited value in the ndings related to the prevalence and severity of periodontal disease in the U.S. popula- tion. Mexican-Americans and whites were included Periodontal diseases in North America in the same race-ethnic group, which is another limitation of this survey. Blacks were grouped in a second group, and other minorities were included in a third group. However, the NHANES I data may be adequate for deriving some inferences about the relative distri- butions of periodontal diseases and tooth loss by demographic variables, and the levels of oral hygiene among the various subgroups of the U.S. population. Findings The average PI scores increased steadily with age, and were higher in males than females (0.96 vs. 0.7) and in blacks than in whites (1.28 vs. 0.76). These differences between the four subgroups were con- sistent across all age groups (Fig. 3). However, given the nature of the PI scoring system, it is not feasible to determine whether the differences were due to a higher extent or severity of disease, or both. The Debris Index scores were higher in males than in females (0.75 vs. 0.57) and in blacks than in whites (0.94 vs. 0.62). In all four subgroups, the debris index scores decreased with age from 12-17years to 18-44 years, and then increased with increasing age, with black males showing the highest increase, and white females showing the lowest increase (Fig. 4). The Calculus Index scores increased steadily with age from 12-17years to 1844years, and were also higher in males than in females (0.41 vs. 0.30) and in blacks than in whites (0.62 vs. 0.32) (Fig. 5). The scores for the combined Oral Hygiene Index were 1.73 for black males, 1.16 for black females, 1.08 for white males, and 0.86 for white females. Fig. 3. Periodontal status (mean Periodontal Index scores, Russell (50)), by race, gender, and age. United States 19711974. 35 Dental Health Outcomes Survey The dental Health Outcomes Survey was conducted in 1981 sponsored by the Health Resources and Ser- vices Administrationof the U.S. Public Health Service. It was a household-based survey in which partici- pants 2years of age and older were selected using a multistage probability sampling design from all U.S. states, excluding Alaska and Hawaii, and also ex- cluded persons living in institutions or in other group quarters. Military personnel and their families living off military reservation were not excluded. The study sample included7078 persons in2428 households. Of these, periodontal data for 1792 persons 19years and older were available. These data were representative of approximately 147 million Americans, 19years of age and older, in the 1981 population (14). The assessment of periodontal disease used a modication of Russells Periodontal index. In con- trast to the original index (50), gingivitis was scored separately from periodontitis, and a periodontal probe was used to measure the probing depth of teeth. Obvious visual changes in color, form, and consistency were classied as gingivitis and were as- sessed on all permanent teeth. A tooth was scored with mild gingivitis (score 1) to indicate presence of overt gingivitis not circumscribing the tooth, or with gingivitis (score 2) if overt gingivitis was completely circumscribing the tooth. Periodontitis was dened as presence of probing depth 4mm or greater and was assessed on the mesial surface of fully erupted permanent teeth using a Hu Friedy .CP6 round probe with 0.48mm diameter and with a 46mm color band. A tooth was scored with 46mm pocket Albandar Fig. 4. Mean Debris Index scores (Greene & Vermillion (31)), by race, gender, and age. United States 19711974. (score 4), more than 6mm pocket (score 6), or with advanced destruction (score 8). Oral hygiene and dental calculus were assessed using a modication of the Oral Hygiene Index (49). The examinations were conducted by 42 dental examiners who were calibrated to a reference examiner on gingivitis and probing depth measurements. Findings Eighty two percent of adults, 19 years and older, had gingivitis in one or more teeth, and 60% had gingi- vitis in six or more teeth (16). There were only little changes in the prevalence and extent of gingivitis with increasing age (Fig. 6). Thirty six percent of the persons had periodontitis (probing depths of 4 mm), and only 15% of the persons had no peri- odontal disease. In the whole population, 28% per- Fig. 5. Mean Calculus Index (Greene & Vermillion (31)), by race, gender, and age. United States 1971 1974. 36 sons had moderate and 8% persons had advanced periodontitis (46mm and 7mm probing depth, respectively). The prevalence of periodontitis in- creased from 28.8% to 48% persons in the age groups 1944 years and 45 years, respectively, and was similar in the 4564 years and 65 years groups. The increase in the percentage of persons with peri- odontitis with age was inuenced by the severity of periodontitis (Fig. 7). Most persons with periodontitis had one or two teeth affected with moderate (46mm) probing depth, whereas a higher extent of involvement with disease was seen in persons with advanced peri- odontitis (7mm probing depth) (Fig. 8). Assess- ment of the distribution of periodontal diseases by tooth type showed that molars were the teeth most often affected with gingivitis and periodontitis. The higher percentage of molars with periodontitis was Periodontal diseases in North America Fig. 6. Percentage of persons, by number of teeth with gingivitis, and age. United States 1981. Fig. 7. Percentage of persons, by the deepest probing depth and age. United States 1981. Fig. 8. Percentage of persons, by the number of teeth with 46mm and 7mm probing depth and age. United States 1981. 37 Albandar particularly evident in persons 45 years of age and older. Advanced periodontitis was more uniformly distributed between the tooth types. The maxillary central incisors were the least periodontally involved tooth type. Brown et al. (16) assessed the intraoral distribution pattern of advanced periodontitis and found a high bilateral symmetry of disease, and the symmetry was most signicant in the younger age group. They sug- gested that the lesser symmetry in the older age group may be attributed to tooth loss. The Oral Hygiene Index score increased with age (46), and the mean OHI score for all persons was 0.86. National Survey of Employed Adults and Seniors (19851986) The National Survey of Oral Health in U.S. Employed Adults and Seniors was conducted by the NIDR in 19851986 to assess the oral health status of adults in the United States. The target population of the survey was adults 1864 years old in U.S. business establishments, and seniors 65 years and older visit- ing senior centers. The sampling frame included a multistage sampling design. For employed persons, the sampling design included selecting counties or groups of contiguous counties (rst stage), ZIP area codes within counties (second stage), clusters of es- tablishments (third stage), business establishments within clusters (fourth stage), and employees (fth stage). For seniors, the sampling design consisted of Table2. Epidemiology of periodontal diseases in employed persons 1864years, and seniors 65 years of age. The National Survey of Oral Health in U.S. Employed Adults and Seniors, 19851986. The survey used partial examinations of two randomly selected quadrants and two sites per tooth, the mesiobuccal and buccal sites Employed persons Seniors Variable males females total males females total Gingival bleeding 47.0 39.2 43.6 53.0 43.8 46.9 Probing depth 4mm 17.1 10.7 14.3 29.8 18.4 22.2 Probing depth 5mm 5.2 3.1 4.3 12.1 5.3 7.6 Attachment loss 3mm 49.4 38.7 44.6 91.3 83.8 86.3 Attachment loss 4mm 28.0 19.2 24.1 77.5 63.5 68.2 Attachment loss 5mm 16.7 9.8 13.6 64.0 45.6 51.7 Gingival recession 1mm 55.37 45.73 51.1 92.6 86.1 88.3 Dental calculus (total) 87.1 80.0 83.9 92.3 87.2 88.9 Dental calculus 58.5 47.2 53.5 73.6 61.5 65.6 (subgingival) 38 selecting counties or groups of counties (rst stage), clusters of senior centers within the primary sam- pling units (second stage), and seniors 65 years and older who attended the senior center on the day the exam teams were at the center (third stage). For more details about the sampling design of this sur- vey, see Kingman & Albandar (39). For the purpose of this survey, senior centers were dened as a community facility where older persons, as individuals or in groups, come together for ser- vices and activities such as educational programs, creative arts, health services or work. The business establishments were selected from public lists, and the senior centers were compiled from lists con- rmed by state and local area agencies on aging. The samples were stratied into 7 geographic regions of the contiguous 48U.S. states. For employed persons, the sample was also stratied by urban/rural, in- come, percent minorities in the sampled counties, and by size of business establishments. The survey sample included 15,132 persons 1864 years of age representing about 100 million em- ployed persons in the corresponding age group. These were sampled from 786 business establish- ments, 280 clusters, and 70 primary sampling units. The sample consisted of an additional 5,686 persons aged 6585 years representing about 4 million seniors visiting senior centers, and these were re- cruited from 208 centers in the same 70 primary sampling units as the employed persons. The re- sponse rate was 91% for employed persons and 86% for seniors (44). Periodontal diseases in North America This was the rst U.S. national survey to assess gingival status, dental calculus, gingival recession, probing depth, and attachment loss. Similar meas- urement methods of disease were used in this survey and in the NHANES III survey (see description of methods below). A partial recording system was used consisting of a half-mouth design, randomly se- lecting one maxillary and one mandibular quadrant, and examining two sites per tooth; the midbuccal and the mesiobuccal surfaces. In addition to the above parameters, the survey assessed coronal and root caries for 28 permanent teeth, and also gathered information about the participants demographics, dental health history and coverage by dental in- surance. The dental examinations were conducted by nine examination teams each including a dentist, a data recorder and a local coordinator. The examinations were performed in mobile examination centers using portable equipments, within the business es- tablishment or senior centers. The dental examiners were trained and calibrated to a reference examiner. Certain demographic characteristics were noted for the employed persons and seniors surveyed in this study. Sixty seven percent of the employed per- sons had household incomes of $20,000 or more, which is slightly above average income for the same age group in the general U.S. adult population (64% had an income of $20,000 or more in 1985). In ad- dition, the employed persons were educated for longer (number of school years) than the general population of similar ages as reported in the 1981 census. On the other hand, the surveyed seniors had a somewhat lower household income than the U.S. Fig. 9. Percentage of employed per- sons and seniors with gingival bleeding, by age. United States 1985 1986. 39 population 65 years of age and older, and much lower income than the employed persons. Forty three percent of dentate seniors and 58% of edentu- lous seniors had household income below $7,500, whereas only 38% of U.S. households in the same age group had income below $7,000 of 1985 dollars. Findings from the 19851986 national survey A summary of ndings from this survey are shown in Table2. Gingival status: Gingival bleeding on gentle prob- ing occurred in one or more teeth in 43.6% of the U.S. employed adults 1864 years olds and in 46.9% of seniors. The percentage of employed persons with gingival bleeding declined slightly with age from 48% in the 1819 years old to 40% in the 6064years old, but remained steady in seniors (Fig. 9). Males had signicantly higher prevalence of gingival bleeding than had females for both employed persons and seniors (Table2), and this pattern was consistent for all age groups (Fig. 10). Probing depth: 14.3% of employed adults and 22.2% of seniors had one or more teeth with 4mm probing depth. The prevalence of 4mm probing depth increased with age from 4% subjects in the 1819 years group to 22% subjects in the 6064 years group. In seniors, however, it decreased slightly with age from 24% to 22% subjects in the 65years to 80 85 years groups (Fig. 11). The prevalences of 4 mm and 5mm probing depths were signicantly higher in males than in females, both in the em- ployed as well as in seniors (Fig. 12, Table2), and the difference between the two gender groups was Albandar Fig. 10. Percentage of employed persons and seniors with gingival bleeding, by age and gender. evident in all age groups (Fig. 13). Also, males had a higher extent of increased probing depth than fe- males. Attachment loss: The prevalence of attachment loss of 3mm, 4mm, and 5mm, respectively, were 44.6%, 24.1%, and 13.6% in employed adults, and 86.3%, 68.2%, and 51.7% in seniors. The percen- tage of persons with 2mm attachment loss in- creased with age from 52% in the 1819 years group to 93% in the 6064 years group, and remained high in seniors (Fig. 14). Male employed adults and seniors had a higher prevalence of attachment loss than females, irrespective of age (Fig. 15). In seniors, the difference between the two gender groups in- creased with the increase in the severity of attach- ment loss, whereas in employed adults the difference Fig. 11. Percentage of employed per- sons and seniors with 4mm prob- ing depth, by age. United States 19851986. 40 between males and females was consistent (Fig. 16). The extent of attachment loss was also higher in males than in females. Gingival recession: 51.1% of adults and 88.3% of seniors had one or more teeth with 1mm re- cession. The prevalence of gingival recession in adults increased from 11% persons in the 1819 years to 86% persons in the 6064 years groups, and remained consistent in seniors (Fig. 17). Gingival re- cession was more prevalent in males than in fe- males, particularly in persons 35 years of age and older (Fig. 18). Dental calculus: Supragingival and subgingival dental calculus was found in one or more teeth in 83.9% of adults and 88.9% of seniors, and subgingi- val dental calculus alone was found in 53.5% and Periodontal diseases in North America Fig. 12. Percentage of employed per- sons and seniors, by probing depth and gender. 65.6%, respectively. The prevalence of calculus in- creased slightly with age in adults and seniors, al- though the increase was larger for subgingival calcu- lus (Fig. 19). In all age groups males had dental cal- culus more often than females, and the difference between males and females was larger for subgingi- val calculus (Fig. 20). Dental insurance coverage: Employed persons had a fairly extensive dental insurance coverage, with 58% of the participants being covered by public or private plans for some portion of their dental ex- penses, 41% of persons reported not having cover- age, while the coverage status of the remaining 1% of persons was unknown. Seniors reported less fre- quency of dental insurance coverage than the em- ployed persons, with 32% of dentate and 35% of Fig. 13. Percentage of employed persons and seniors with 4mm probing depth, by age and gender. 41 edentulous persons having dental insurance. The percentage of employed persons with dental cover- age increased with increasing age from 52% to 66% in the age groups 1839years, but declined steadily thereafter back to 52% in the 6064years group (Fig. 21). In seniors, the percentage of persons with cover- age was consistent, with only a slight decrease in the older age groups. The relationship between dental insurance cover- age and gender among employed persons varied by age. Thus, a higher percentage of employed males than females in the age groups 1834years, and a lower percentage of males than females in the age groups 3564years were without coverage (Fig. 22). Similarly, more female seniors than males were with- out coverage, but the difference decreased signi- Albandar Fig. 14. Percentage of employed persons and seniors with 2mm attachment loss, by age. United States 19851986. (A cutoff threshold of 2mm for attachment loss was reported by Miller et al. (44)). cantly with age and the percentage was comparable in the 80years and older age group. Also, race inu- enced the rate of coverage. In adults, blacks in the youngest and the oldest age groups were less often covered than whites. On the other hand, whites in the age group 3049years were less likely to have coverage than blacks (Fig. 23). Utilization of dental services: 59% of adults, 55% of the dentate seniors and 13% of edentulous seniors reported having visited a dentist within the last 12 months. The majority of persons had visited a den- tist within the last 2years, and only 20% of 1864 years-old adults and 24% of dentate seniors reported Fig. 15. Percentage of employed persons and seniors with 2mm attachment loss, by age and gender. 42 that they had not visited a dentist for 3 or more years. With increasing age, more employed adults had visited a dentist within 1year, and less frequently be- tween 1 and 2years (Fig. 24). In seniors, the fre- quency of visiting a dentist was dependent on eden- tulous status. Thus, the percentage of dentate seniors who visited a dentist within one year was fairly stable with increasing age, whereas the edentu- lous seniors visited a dentist less frequently with ag- ing (Fig. 25). Among adults 2064years of age, a higher percen- tage of females visited a dentist within the last 1year, Periodontal diseases in North America Fig. 16. Percentage of employed per- sons and seniors, by severity of attachment loss and gender. and a higher percentage of males did not visit a den- tist for 3 or more years (Fig. 26). A similar pattern was seen for dentate seniors (Fig. 27). The disparity in utilization of dental services was more signicant between the race groups, with 61% of whites and 43% of blacks visiting a dentist within the last year, and 18% and 30%, respectively, visiting a dentist 3 or more years ago. This pattern of higher utilization of dental services in whites than blacks increased with age, so that a higher percentage of whites than Fig. 17. Percentage of employed persons and seniors with 1mm gingival recession, by age. United States 19851986. 43 blacks visited a dentist within 1year in the older than in the younger age groups (Fig. 28). In 40.8% of employed persons, regular checkups were given as the main reason for their last dental care visit. The percentage of whites reporting regular checkups was 43.64%, whereas blacks reported only 18.8%. In contrast, 28.1% of dentate seniors and only 10.5 of edentulous seniors had regular checkups as the reason for their last dental care visit. A higher percentage of females than males among employed Albandar Fig. 18. Percentage of employed persons and seniors with gingival recession, by age and gender. whites and dentate seniors had regular checkups (Fig. 29). There was no difference between the sexes for employed blacks. NHANES III (19881994) It is reasonable to contend that, considering its com- prehensiveness and scale, the third National Health and Nutrition Examination Survey (NHANES III) is Fig. 19. Percentage of employed persons and seniors with dental calculus, by age. United States 19851986. 44 the most signicant epidemiological survey of peri- odontal and systemic health that has been con- ducted to date in the world. The NHANES III was conducted during the period 19881994 and in- cluded 30,818 survey sample persons representing the approximately 247 million (1990U.S. population estimates) civilian noninstitutionalized U.S. popula- tion, 2months and older (57). For the purpose of this survey, the U.S. was strati- ed into 2,812 CPUs, and 89 units of these were se- Periodontal diseases in North America Fig. 20. Percentage of employed persons and seniors with dental calculus, by age and gender. lected with probability proportional to size (25). The second stage of the design consisted of selecting area segments within each CPU. The segments were either blocks, combinations of blocks, or sets of ad- dresses selected from building permits. The third stage included selecting, within each area segment, households or certain types of group quarters such as dormitories. All eligible household members were Fig. 21. Percentage of employed persons and seniors who reported having dental insurance coverage, and those without coverage, by age. United States 19851986. 45 listed and a subsample of persons was selected based on sex, age, and race-ethnicity. The study de- sign included oversampling population groups of children 2months to 5years, persons 60years and over, and Mexican-Americans and blacks. Sampling weights were assigned to each person sampled in this survey. Details of the derivation of the sampling weights are described elsewhere (25, 39). Albandar Fig. 22. Percentage of employed persons and seniors who did not have dental insurance coverage, by age and gender. United States 19851986. The health status assessment component of the NHANES III included a detailed interview consisting of demographic, socioeconomic, dietary, and health- related questions. Upon completion of the interview, the participants went through extensive physical and dental examinations and biochemical tests. Some of the parameters assessed included cardiovascular dis- eases, respiratory diseases, kidney disease, diabetes mellitus, diabetic retinopathy and vision, thyroid function, reproductive health, gall bladder disease, arthritis and related musculoskeletal conditions, os- teoporosis, allergy, immunization, infectious dis- Fig. 23. Percentage of employed per- sons without dental insurance cover- age, by age and race. 46 eases, hearing, exposure to toxic substances, mental health, health behaviors, and anonymous analyses of HIV status and drug use. The oral health component of NHANES III in- cluded, but was not limited to, the assessment of oral soft tissue lesions, tooth condition, dental caries, removable prosthesis, occlusion and occlusal characteristics, evidence and history of trauma to permanent incisors, and periodontal status. The periodontal examination was performed on subjects 13years and older. Persons with medical conditions requiring premedication with antibiotic Periodontal diseases in North America Fig. 24. Percentage of employed persons, by time period since last dental visit, and age. United States 19851986. or having certain other conditions were excluded from the periodontal examination. These included persons with bacterial endocarditis, rheumatic fever, congenital heart disease, heart valve problems; or pacemakers or other articial materials in heart, vein, or arteries; hip, bone, or joint replacement; kid- ney disease requiring renal dialysis, or persons with hemophilia. About 6% of persons 13 years and older, and 8.7% of persons 30 years and older were ex- cluded for medical reasons (3). Fig. 25. Percentage of dentate seniors and all seniors (dentate and edentulous), by time period since last dental visit, and age. United States 19851986. 47 The periodontal examination consisted of meas- urement of periodontal supporting tissues including attachment loss, probing pocket depth and furcation involvement (3); and the assessment of gingival bleeding, dental calculus, and gingival recession (4). In addition, blood samples were collected for various assays. The periodontal examination was carried out in two randomly selected quadrants, one maxillary and one mandibular. All fully erupted teeth in these two quadrants were assessed, excluding third mo- Albandar Fig. 26. Percentage of employed persons who reported had visited a dentist within past 12months or infrequently (3 or more years), by age and gender. lars. A maximum of 14 teeth per individual were examined for periodontal parameters. The assessment of the periodontal supporting tissues status was made by clinical measurement of the distance from the cemento-enamel junction (CEJ) to the free gingival margin (FGM) and the dis- tance from the FGM to the bottom of pocket/sulcus at 2 sites per tooth, the mesiobuccal and mid-buccal surfaces. The National Institute of Dental and Fig. 27. Percentage of dentate seniors who reported had visited a dentist within past 12months or infrequently (3 or more years), by age and gender. 48 Craniofacial Research (NIDCR) periodontal probe was used. From these two measurements, the prob- ing pocket depth (FGM to bottom of pocket/sulcus), periodontal attachment loss (CEJ to bottom of pocket/sulcus), and gingival recession (CEJ to FGM) were calculated. Assessment of furcation involvement was made on ve posterior teeth using explorer .17 (maxillary molars and premolars) and explorer .3 (mandibular Periodontal diseases in North America Fig. 28. Percentage of employed persons who reported had visited a dentist within past 12months or infrequently (3 or more years), by age and race. molars). Partial furcation involvement (grade I) was scored in sites where the explorer was denitely catching into but did not pass though the furcation. Total furcation involvement (grade II) was used when the explorer could be passed between the roots and through the entire furcation. It is import- ant to note that the NHANES III was the rst na- tional survey to assess the periodontal involvement of the furcation area of teeth. Gingival bleeding was assessed by inserting the NIDCR periodontal probe not more than 2mm into Fig. 29. Percentage of employed persons and dentate seniors reporting that the main reason for last dental visit was for regular checkup, by gender and race. 49 the gingival sulcus distal to the midpoint of the buccal surface and moving into the mesial interproximal area, and bleeding sites were scored after a single quadrant was probed (4). Dental calculus was scored as follows: supragingival calculus only present (score 1); subgingival calculus only present, or supra- gingival and subgingival calculus both present (score 2). It is important to note that as score 2 was used to indicate presence of subgingival calculus only or pres- ence of both supragingival and subgingival calculus, the measurement method does not allowaccurate as- sessment of the prevalence and extent of supragin- gival calculus. Various other dental parameters were assessed, including the assessment of tooth condition and tooth retention (24, 42). The periodontal examination was made by trained dentists, and the data were entered directly by a health technician using an automated computer data entry program. Approximately 5% of the exam- ined survey sample was recalled for repeated second examination at each of the 89 NHANES III survey locations. The intraexaminer measurement error as- sessment was made for each examiner by comparing measurements of the examiners initial and repeated examinations of the same sample person. Inter- examiner bias and reliability were evaluated in- directly by making separate comparisons of each survey examiner with a reference examiner. The three examiners who conducted most survey exami- nations in the NHANES III had acceptable intraob- Albandar server reliability and were scoring consistently with the reference examiner (3, 38, 39). Periodontitis Index Albandar et al. (3) described a periodontitis index to measure the prevalence and severity of periodontitis in the U.S. population. The periodontitis index classied each person as having either mild, moder- ate or advanced periodontitis, or with no peri- odontitis, based on the number (or percentages) of teeth showing certain thresholds of probing depth and attachment loss. The probing depth was calcu- lated to show the depth of the periodontal pocket that is apical to the cementoenamel junction around teeth. Thus, the attachment loss measurement at a given tooth surface was equal to, or greater than, the calculated probing depth measurement. The reason for using both the number and percentages of teeth with a given criterion in this classication system is because the NHANES III examined only two ran- Table3. Epidemiology of periodontal diseases in U.S. adults 30years of age and older examined in the third National Health and Nutrition Examination Survey (NHANES III) in 19881994. The survey used partial examina- tions of two randomly selected quadrants and two sites per tooth, the mesiobuccal and buccal sites. Albandar et al. (3), Albandar & Kingman (4) Gender Race-Ethnicity Variable Males Females Whites Blacks Mexican- total Americans Prevalence (% persons) Gingival bleeding 54.4 46.3 48.6 55.7 63.6 50.3 Attachment loss 3mm 58.7 47.8 51.2 64.7 56.3 53.1 Attachment loss 4mm 38.8 27.0 30.7 44.8 37.5 32.7 Attachment loss 5mm 24.4 15.7 18.1 31.4 23.2 19.9 Probing depth 3mm 68.3 59.8 61.5 76.5 75.0 63.9 Probing depth 4mm 27.6 18.9 20.2 39.8 32.6 23.1 Probing depth 5mm 11.4 6.6 7.2 19.5 12.9 8.9 Gingival recession 1mm 61.3 54.9 57.9 59.5 54.2 58.0 Gingival recession 3mm 27.4 17.8 21.6 27.8 23.5 22.5 Dental calculus (total) 92.5 91.1 90.9 95.8 96.4 91.8 Dental calculus (subgingival) 60.6 49.9 51.1 75.6 73.4 55.1 Extent (% teeth per person) Gingival bleeding 15.0 12.1 12.7 16.6 19.4 13.5 Attachment loss 3mm 23.6 15.9 18.3 28.2 21.5 19.6 Attachment loss 4mm 13.4 8.1 9.7 17.0 12.0 10.6 Attachment loss 5mm 7.9 4.1 5.2 10.7 6.9 5.9 Probing depth 3mm 22.9 16.5 17.6 31.5 26.1 19.6 Probing depth 4mm 6.5 4.0 4.3 10.6 7.1 5.2 Probing depth 5mm 2.2 1.1 1.3 4.3 2.4 1.6 Gingival recession 1mm 25.3 19.5 22.0 24.9 21.0 22.3 Gingival recession 3mm 8.2 4.9 6.1 9.1 6.9 6.5 Dental calculus (total) 55.2 45.8 46.8 69.8 63.1 50.3 Dental calculus (subgingival) 32.0 23.1 23.5 49.3 41.6 27.4 50 domly selected quadrants (half-mouth), and the use of percentages has the potential to reduce the under- estimation due to this partial recording. The index also assessed the extent of furcation involvement of teeth and included that in the assessment of the periodontal status of the person. This is the only periodontitis index that includes a component for the assessment of the furcation involvement of teeth in the appraisal of the severity of periodontitis. Persons with 6 or more teeth present, not includ- ing third molars, were assessed. The classication of advanced periodontitis included persons with two or more teeth (or 30% of the examined teeth) with 5mm probing depth, or four or more teeth (or 60% of the teeth) with 4mm probing depth, or one or more posterior teeth with total furcation involve- ment (grade II). The classication of moderate peri- odontitis included persons without advanced peri- odontitis, and having one or more teeth with 5mm probing depth, or two or more teeth (or 30% of the teeth) with 4mm probing depth, or one or more Periodontal diseases in North America posterior teeth with partial furcation involvement (grade I) together with 3mm probing depth. Mild periodontitis included persons without moderate or advanced periodontitis, and with one or more teeth with 3mm probing depth, or one or more pos- terior teeth with partial furcation involvement. Per- sons who had 6 or more teeth present and who were without the above criteria of periodontitis were classied with no periodontitis. Periodontal ndings in NHANES III A summary of the NHANES III survey ndings are shown in Table3. Periodontitis: in the U.S. dentate adults, aged 30 years and older and with 6 teeth present, 3.1% had advanced periodontitis, 9.5% had moderate peri- odontitis, 21.8% had mild periodontitis, and 65.5% had no periodontitis (3). The prevalence of peri- odontitis (all severities) increased steadily with in- creasing age (Fig. 30). However, moderate and ad- vanced periodontitis increased in prevalence be- tween 30 and 70 years of age, and then leveled off and slightly declined thereafter. Among adult Americans, males had higher preva- lence of periodontitis than females, regardless of age (Fig. 31). However, in the older age groups, the distri- bution of periodontitis between the two sexes varied somewhat by the severity of the disease. Thus, males had only slightly higher prevalence of moderate and advanced periodontitis than had females in the 80 years group, whereas the prevalence of periodontitis (cumulative for various severities) was higher in fe- males than in males in persons 8590years old. This Fig. 30. Percentage of persons, by severity of periodontitis (Extent and Severity of Periodontitis Index, Albandar et al. (3)) and age. United States 19881994. 51 pattern of difference between the two genders, and the decline in prevalence of moderate and advanced periodontitis in males after 80 years of age (Fig. 31), may be attributed to a higher loss of teeth in males than in females, particularly in the older age groups. Non-Hispanic blacks had the highest prevalence of periodontitis, followed by Mexican-Americans, whereas non-Hispanic whites had signicantly less periodontitis than either of the other two race groups (Fig. 32). When only moderate-advanced periodontitis was assessed, the difference in preva- lence between blacks and Mexican-Americans was less pronounced. All three race-ethnic groups showed a decline in the prevalence of moderate-ad- vanced periodontitis in the older age groups. Periodontal attachment loss: Attachment loss was highly prevalent in the U.S. adult population, with more than half (53.1%) of subjects 30 years and older showing one or more teeth with 3mm attachment loss, and 32.7% with 4mm attachment loss (3). The prevalence and extent of attachment loss increased steadily with increasing age (Fig. 33), and both par- ameters were signicantly higher in males than in females (Fig. 34), and in blacks and Mexican-Ameri- cans than in whites (Fig. 35). The mean percentages of persons 30 years and older with attachment loss of 4mm were: 38.8% in males, 27% in females, 44.8% in blacks, 37.5% in Mexican-Americans and 30.7% in whites (Table3). Attachment loss affected most frequently the mandibular incisors and the maxillary molars (Fig. 36). Probing pocket depth: 64% of adults had one or more teeth with probing depth of 3mm and ap- proximately 23% had a probing depth of 4mm. The Albandar Fig. 31. Percentage of persons, by severity of periodontitis, age and gender. percentages of persons (prevalence) and the percen- tages of teeth per person (extent) with probing depth of 4mm were steady in the 3039 years and 4049 years age groups, and increased slightly with age thereafter (Fig. 37). However, both the prevalence and the extent of probing depth of 4mm decreased in persons 80 years of age and older. The prevalence and extent of probing depth of 4mm were signicantly higher inmales thanin females (Fig. 38), and in blacks and Mexican-Americans compared to whites (Fig. 39, Table3). Blacks had the highest probing depth meas- urements among the three race-ethnicity groups. Mo- lars were the tooth types most often affected with 3 mm probing depth (Fig. 40). Furcation involvement: approximately 5% of 30 Fig. 32. Percentage of persons, by severity of periodontitis, age and race-ethnicity. 52 39 years old persons had one or more posterior teeth with furcation involvement, and this percentage in- creased steadily with age and reached 40% in the 80 90 years age group (Fig. 41). Also the number of teeth affected increased with age from 2% to 22% in the corresponding age groups, respectively. Gingival status: half of the adult population (50.3%) had gingival bleeding in at least one tooth, and there was a modest increase in prevalence and extent with the increase in age (Fig. 42). Further- more, the increase in prevalence of gingival bleeding with age occurred mostly in subjects who had exten- sive involvement of teeth (more than 50% of teeth affected) with gingival bleeding (Fig. 43), while in persons with limited extent of gingival bleeding Periodontal diseases in North America Fig. 33. Prevalence (percentage of persons) and extent (percentage of teeth per person) of 4mm attachment loss, by age. United States 19881994. (only 2550% of the teeth affected) the prevalence was constant in the various age groups. Gingival bleeding was more prevalent and involved more teeth (higher extent) in males than in females (Fig. 44), and in Mexican-Americans, followed by blacks, and whites, respectively (Fig. 45). Dental calculus: a very high percentage (92%) of adult Americans had one or more teeth with dental calculus in all age groups (Fig. 46). By the age of 3039 years, 45% of the teeth had calculus, and this in- creased to 67% teeth in the 8090 years old group. More than half of the persons (55.1%) had subgingival calculus, andthe prevalence andextent of subgingival Fig. 34. Prevalence and extent of attachment loss of 4mm, by age and gender. 53 calculus showed a positive correlation with age (Fig. 46). The percentage of persons with supragingival or subgingival calculus was very high in males and fe- males (Fig. 47) and in the three race-ethnicity groups (Fig. 48), though slightly fewer whites than Mexican- Americans or blacks had calculus. On the other hand, subgingival calculus alone occurred signicantly more often in males than in females (Fig. 47), and in Mexican-Americans and blacks than in whites (Fig. 48). Furthermore, the numbers of teeth with calculus were signicantly higher in males than in females (Fig. 49), and in Mexican-Americans and blacks than in whites (Fig. 50). The extent of involvement of teeth with dental calculus in Mexican-Americans was be- tween that of blacks and whites. Gingival recession: 22.5%of the subjects had gingi- val recession 3mm. The prevalence and extent of gingival recession increased steadily with increasing age (Fig. 51), with 10% of 3039 years old and 60% of 8090 years old persons had one or more teeth with 3mm gingival recession. Males had signicantly higher prevalence and extent of gingival recession than females (Fig. 52). The prevalence and extent of gingival recession were comparable in the three race- ethnic groups with a somewhat higher level of calcu- lus in blacks than in Mexican-Americans and whites, particularly in the older age groups (Fig. 53, Table3). Surveys of periodontal diseases in U.S. seniors An epidemiological study conducted during 1985 1986 examined 1,042 persons aged 65 years and Albandar Fig. 35. Prevalence and extent of attachment loss of 4mm, by age and race-ethnicity. older comprising seniors attending 14 senior activity centers in Florida, selected from 166 centers in 6 Floridian counties (30). The sample included 671 dentate persons who were examined clinically using diagnostic criteria and methodology similar to those used in the 19851986U.S. National Survey of em- ployed adults and seniors. These criteria included selecting two random quadrants and a partial exami- nation of two sites per tooth (as described above). The results showed a high prevalence of moderate and severe attachment loss, a high prevalence of moderate probing depth, and a low prevalence of deep probing depth (Table4). There was a weak re- Fig. 36. Percentage of persons with attachment loss of 3mm, by tooth type and age group. United States 19881994. 54 lationship between the prevalence of periodontal tissue loss and age in this age cohort (Fig. 54). Over a third (35.6%) of the subjects were edentulous, and dentate persons had a mean of 17 remaining teeth. A survey of community-dwelling Medicare ben- eciaries in New England states examined a repre- sentative random sample aged 70 years and older, and used methodology and periodontal disease par- ameters similar to those used in recent U.S. national surveys (23, 27). The study employed in-home, full- mouth examinations on 3 sites per tooth, the mesio- buccal, buccal, and distolingual sites (Table4). The results revealed a rather high prevalence of destruc- Periodontal diseases in North America Fig. 37. Prevalence and extent of probing depth of 4mm, by age. United States 19881994. tive periodontitis in this population. Attachment loss of 4mm and 7mm was noted in 95% and 56% of the persons, and 21% and 87% of the persons had probing depths of 4mm and 7mm, respectively. Gingival bleeding was noted in one or more teeth of 85% of the subjects. The percentage of edentulous persons was 37.6%, and the mean number of teeth in dentate persons ranged from 17.9 to 21.5 in the different age and gender cohorts. The study also found a signicantly higher prevalence of attach- ment loss and pocketing in males than in females (Table4) and a higher prevalence of moderate prob- ing depth in the low-income compared to the high income groups. Hunt et al. (34) examined a group of 262 dentate Fig. 38. Prevalence and extent of probing depth of 4mm, by age and gender. 55 elders 70 years old from two rural Iowa counties using full-mouth examinations and periodontal par- ameters similar to those used by the NIDCR in re- cent U.S. national surveys. The results showed that moderate periodontal breakdown was highly preva- lent, and about 15% of the persons had one or more teeth with attachment loss of 7mm or more. A survey of community-dwelling elderly blacks and whites in North Carolina used a stratied, clus- tered sampling design with oversampling of blacks, and selected 690 persons who had in-home full- mouth examinations of 2 sites per tooth (mesio- buccal and buccal) using NIDCR periodontal probe (11). The estimated prevalence of probing depth of gingival bleeding in one or more teeth 4mm was 80% in whites and 92% in blacks, and the prevalence of attachment loss of 6mm was 45% in whites and 70% in blacks. The periodontal health of Native Americans, 65 74 years old was assessed in a random sample of Sioux and Navajo Indians surveyed in 1990 using the CPITN probe and measurements on all surfaces of 10 CPITN teeth (52). It was estimated that 22% of the persons had pockets deeper than 5.5mm (CPITN score 4), and about 60% had pockets 3.5mm (CPITN scores 3 & 4). Epidemiological studies in Canada A recently published study reported the epidemi- ology of periodontal diseases among Canadian adults aged 3544 years in Quebec (15). The survey Albandar Fig. 39. Prevalence and extent of probing depth of 4mm, by age and race-ethnicity. Fig. 40. Percentage of persons with probing depth of 3mm, by tooth type and age group. United States 19881994. Fig. 41. Prevalence and extent of fur- cation involvement, by age. United States 19881994. 56 Periodontal diseases in North America included 2,110 randomly selected persons using a stratied sample of randomly selected census areas and households in Quebec. The sample was Fig. 42. Prevalence and extent of gin- gival bleeding, by age. United States 19881994. Fig. 43. Percentage of persons, by the extent of gingival bleeding and age. United States 19881994. Limited: 2550% of teeth; extensive: 50100% of teeth have gingival bleeding. Fig. 44. Prevalence and extent of gingival bleeding, by age and gender. 57 weighted by area of residence, age, sex and edu- cation to represent Quebecs adult population aged 3544 years. The clinical examinations were under- Albandar Fig. 45. Prevalence and extent of gingival bleeding, by age and race-ethnicity. taken in 19941995 and were performed by 10 den- tists. Measurements were made on each tooth, exclud- ing third molars, and included the assessment of gingival bleeding, dental calculus and probing depth. Periodontal probing depth was measured from the free gingival margin and scored the deepest site around the tooth. In addition, measurements on two sites only per tooth, the mesiobuccal and ves- tibular, on all teeth and on two random quadrants were also performed and reported in another study (13) to assess the amount of underestimation due to partial recording. The study employed the WHO community peri- odontal index probe, and used a questionnaire to as- sess the individuals perception of his/her general Fig. 46. Prevalence and extent of dental calculus, by age. United States 19881994. 58 and dental health, preventive habits, utilization of dental services, socio-demographic data, and medi- cal history. The authors noted that the study sample included more females than males, and a higher per- centage of subjects with a high education (university degree) than those who had not. The results of this survey suggested a high level of periodontal diseases, with 81.1% of the persons having one or more teeth with gingival bleeding, 75% persons having dental calculus, 73.6% persons with probing depth of 4mm, and 21.4% persons with probing depth of 6mm (15). The prevalence of probing depth of 6mm was signicantly higher in persons of English or other spoken languages (27.4% persons) than in French-speaking persons (20.1% persons), and in persons with low income, of less Periodontal diseases in North America than Canadian $30,000 (29% persons), as compared to persons with a medium income between $30,000 and $60,000 (18.5% persons), and those with an in- come of $60,000 (16.9% persons). The prevalence of severe disease was signicantly higher in males than in females (Table4). However, after adjusting for other confounders, only gender and income were signicantly associ- ated with a higher prevalence of probing depth of 6mm, with an estimated odds ratio of 1.9 and 2.0, respectively. Locker et al. (41) studied the oral health status of adolescents in Ontario, Canada and examined 721 Fig. 47. Percentage of persons with dental calculus, by age and gender. Fig. 48. Percentage of persons with dental calculus, by age and race-ethnicity. 59 8th grade schoolchildren aged 1314 years from 15 randomly selected schools and comprising a high percentage of immigrants. They assessed gingivitis, dental calculus and debris on six indicator teeth, and also evaluated the need for periodontal scaling and prophylaxis in these children. Their results showed a higher prevalence of gingival inammation and cal- culus and poorer oral hygiene in immigrants than in Canadian-born children. They also found signi- cantly higher periodontal treatment needs including subgingival scaling and prophylaxis in immigrants than in Canadian-born children (Table5). Galan et al. (28) examined a sample of persons 60 Albandar Fig. 49. Extent of dental calculus, by age and gender. years of age and older that comprised most of in- habitants in 3 Eskimo communities in this age group in the Keewatin region of Canadian North-west Territories. The subjects were examined clinically using the WHO CPITN methodology. The assess- ments showed that 86% and 49% of the persons had probing depth of 4mm and 6mm, respectively. Thirty ve percent of the subjects were completely edentulous (21% of males, and 79% of females), and the mean number of teeth present was 8.2 teeth. Fig. 50. Extent of dental calculus, by age and race-ethnicity. 60 Conclusions Periodontal diseases in the U.S.A. Prevalence and severity of disease Results from recent U.S. national surveys show that periodontal diseases are prevalent in the U.S. adult population. Among dentate persons aged 30 years and older and with 6 remaining teeth, about 35% had chronic periodontitis (dened as one or more Periodontal diseases in North America Fig. 51. Prevalence and extent of gingival recession of 3 mm, by age. United States 19881994. teeth with attachment loss and probing depth of 3 mm), including 3.1% with advanced periodontitis, 9.5% with moderate periodontitis, and 21.8% with mild periodontitis (3). The prevalence of attachment loss of 4mm ranged from 24% among employed persons 1864 years of age, 32.7% in adults 3090 years old, and 68% in seniors aged 65 years and older (Tables2 and 3). The corresponding gures for the prevalence rates of probing depth of 4mm were 14%, 33%, and 22% persons, respectively. About half of the adult popula- tion had gingival bleeding in one or more teeth, more than 90% of persons had dental calculus, and 23% of persons had gingival recession of 3mm. Fig. 52. Prevalence and extent of gingival recession of 3mm, by age and gender. 61 A rst glance at the values in Tables2 and 3 gives the impression of higher prevalence rates and severity of periodontal diseases, and poorer oral hygiene status (assessed as level of calculus) in the NHANES III (19881994) than the adults (19851986) surveys. Al- though a temporal change in periodontal status be- tween the employed adults and NHANES III surveys cannot be completely discounted, the difference is more probably explained by methodological factors, particularly the conceptual denition of the target populations (39). The target populations in the 1985 1986 survey were employed adults, and seniors at- tending senior centers. These two populations may potentially have a better periodontal status than the rest of the population in their corresponding demo- graphic strata. In addition, there were other study de- sign differences between the two surveys, such as the type of age cohorts used, examiners variability, and the survey sampling design including the oversam- pling scheme used in the NHANES III survey. Another issue which needs to be noted when ap- praising the periodontal status of the U.S. popula- tion is the partial recording system used in most re- cent surveys. Recent national surveys have examined two randomly selected quadrants, and only two sites per tooth, the buccal and the mesiobuccal sites. Hunt & Fann (35) compared half-mouth measure- ments of various periodontal parameters with full- mouth measurements in older dentate adult popula- tions. They concluded that the means (severity) of these measurements were similar and highly corre- lated, whereas the prevalence rates of selected levels Albandar of moderate or severe periodontal disease wereund- erestimated by about 13% in the half-mouth meas- urements. Two other studies reported much higher levels of underestimation as a result of partial examinations. Diamanti-Kipioti et al. (21) reported a prevalence rate of 24% persons with severe periodontal disease (dened as6mm probing depth) using an exami- nation protocol consisting of 2 quadrants and 2 sites per tooth, as compared to a prevalence of 47% per- sons when using a full-mouth examination and 4 sites per tooth. This suggests underestimation of ap- proximately 50% in the prevalence of severe disease when a partial examination is performed. Benigeri et al. (13) found a comparable level of underestimation due to partial recordings. They esti- mated a 25% underestimation in the prevalence of 6mm pockets which they attributed to examining 2 quadrants, compared to examination of all teeth; and approximately 60% underestimation when using 2 sites per tooth, compared to measurements made on all surfaces of the tooth. Kingman & Albandar (39) assessed the under- estimation attributed to various partial recording protocols using a data set of young adults with or without periodontitis and reached conclusions simi- lar to those described above. They estimated that a half-mouth protocol using two random quadrants and two sites per tooth (buccal and mesiobuccal) has a sensitivity ranging between 0.41 and 0.64 for prevalences of attachment loss of 4mm, and a sen- sitivity ranging between 0.61 and 0.73 for preva- lences of probing depth of 4mm. Kingman & Albandar (39) also showed that the Fig. 53. Prevalence and extent of gingival recession of 3mm, by age and race-ethnicity. 62 sensitivity of a partial recording protocol can be used to estimate the full mouth prevalence value using an ination factor. Accordingly, the results of the U.S. national surveys may be adjusted to compensate for an underestimation due to the partial examinations used in most surveys. Results of the studies cited above (13, 21, 39) suggest that the prevalence rate estimates of parameters of moderate and severe periodontitis from the national surveys described above should be inated by about 4050%. In other words, one may deduce that about 56% and 1520% of adults have advanced and moderate periodontitis, respectively. And, with about 2530% of the subjects having mild periodontitis, it is reasonable to con- clude that about half of the U.S. adult population 30 years and older have periodontitis. Age relationship Figs 55 and 56 are based on the NHANES III data and show the relationship of prevalence and extent of periodontitis with age. With increasing age there is a corresponding increase in the percentage of per- sons having attachment loss of 3mm and an in- volvement of more teeth. However, this relationship seems to be inuenced by the severity of disease, in that the percentage of persons with severe peri- odontitis declined in the oldest age groups (Fig. 56). This decline may be due to loss of teeth with the most severe disease in the older age groups. Surveys in seniors A wide prevalence range for various parameters of destructive disease has been shown for U.S. seniors. Periodontal diseases in North America The highest level of disease for this age cohort was reported by Douglass et al. (23) and Fox et al. (27) among New England seniors using full-mouth clin- ical examination on 3 sites per tooth (Table4). A rela- tively high level of disease was also reported for North Carolina seniors by Beck et al. (11) using full- mouth examinations of 2 sites per tooth, and in Table4. Studies of the epidemiology of periodontal diseases in United States seniors Reference, Methods Findings region and age group Gilbert & Heft (30) 1,042 persons attending 14 senior Attachment loss4 mm: 86.8% Florida, 6 counties activity centers selected among 166 centers Attachment loss7 mm: 24.2% 65 years 671 dentate persons were examined Probing depth4mm: 54.1% clinically using diagnostic criteria Probing depth7mm: 3.4% and methodology similar to those Edentulism: 35.6% used in the 19851986 US. National Mean number remaining teeth in survey of employed adults and dentate persons: 17.0 seniors. Partial examination in two random quadrants and two sites per tooth (mesiobuccal and buccal) Douglass et al. Random sample selected using a 2- Attachment loss4mm: 95% (male: (23), Fox et al. (27) stage, stratied, cluster sampling design 95%, female: 94%) New England representative of Medicare beneciaries. Attachment loss7mm: 56% (male: 70 years 554 dentulous persons examined by 62%, female: 51%) in-home, full-mouth clinical Probing depth4mm: 87% (male: examination, on 3 sites per tooth 90%, female: 85%) (mesiobuccal, buccal, and Probing depth7mm: 21% (male: distolingual). 29%, female: 16%) Used methodology and denitions Gingival bleeding: 85% of periodontal disease parameters Dental calculus: 93% (males: 93%, fe- similar to that of U.S. national males: 86%) surveys Edentulism: 37.6% Mean number remaining teeth in dentate persons: range 21.517.9 Hunt et al. (34) 262 dentate persons examined by Probing depth4 mm: 32% Iowa, 2 rural full-mouth examinations and Attachment loss7 mm: 15% counties periodontal parameters similar to Edentulism: 40% 70 years those used by the NIDCR in recent U.S. national surveys. Beck et al. (11) A random sample representative of Probing depth4 mm: 80% in whites, North Carolina, community-dwelling elderly blacks and 92% in blacks. 5 counties and whites selected by a stratied, Attachment loss6 mm: 45% in 65 years clustered sampling design with whites, and 70% in blacks. oversampling of blacks. 690 persons examined in-home using full-mouth examinations of 2 sites per tooth (mesionbuccal and buccal) using NIDCR periodontal probe. Skrepcinski & A random sample of Sioux and Probing depth 3.5mm (CPITN Niendorff (52) Navajo Indians, CPITN methodology, scores 3 & 4): 59.4% Native Americans measurements on all surfaces of Probing depth 5.5mm (CPITN 6574 years 10 CPITN teeth score 4): 22.1% 63 Floridian elders by Gilbert & Heft (30) who used 2 quadrants and 2 sites per tooth. All three studies showed a higher prevalence of periodontitis than was reported in the NIDR national survey of em- ployed adults and seniors and the NHANES III. As pointed out above, it is likely that an important pro- portion of the difference in the level of disease be- Albandar Fig. 54. Prevalence of attachment loss and periodontal pockets, by age. Periodontal status of Floridian seniors age 65years and older (Gil- bert & Heft (30)). Table5. Studies of the epidemiology of periodontal diseases in Canada Reference, region Methods Findings and age group Locker et al. (41) 721 schoolchildren from 15 Dental calculus: 44.6% in Canadian-born, Ontario schools randomly selected among 72.9% in immigrants 1314 years 104 schools in the city of North Need dental prophylaxis: 13.6% of York. Canadian-born, 37.3% of immigrants In-school clinical examinations, Need subgingival scaling: 25.8% of six index teeth, and 4 sites per Canadian-born, 53.1% of immigrants tooth Brodeur et al. (15), 2110 persons selected using a Full-mouth examinations: Benigeri et al. (13) stratied sample of randomly Gingival bleeding: 81.1% Quebec selected census areas and Dental calculus;: 75% 3544 years households in Quebec and Probing depth4 mm: 73.6% weighted by area of residence, age, Probing depth6mm: 21.4% sex and education. (males:25.8%, females 17.1%) Full-mouth clinical examination of Half-mouth examinations: all teeth, excluding third molars, Probing depth4 mm: 45.6% and scored the deepest site around Probing depth6 mm: 8.5% the tooth using WHOS CPITN periodontal probe. Separate half-mouth assessments were also made in two randomly selected quadrants, and two sites per tooth, the mesiobuccal and buccal. Galan et al. (28) 54 persons (35 dentate) comprised Probing depth 4mm: 86% Keewatin region most inhabitants in this age group Probing depth 6mm: 49% in North-west in 3 Inuit (Eskimo) communities. Mean number of remaining teeth: 8.2 Territories Clinical examination using the (2.6 in maxilla, 5.5 in mandible) 60 years WHO CPITN methodology. Edentulism: 35% (21% males, 79% females) 64 Periodontal diseases in North America Fig. 55. Percentage of persons and percentage of teeth per persons with 3mm attachment loss, by age. United States 19881994. tween these studies is due to differences in study de- sign (39). Oral health behaviors The almost universal occurrence of dental calculus in the U.S. adult population suggests inadequate oral hygiene practices and other unhealthy behaviors. The NHANES I data showed poorer oral hygiene among males than females, and in blacks than whites. The mean oral hygiene index scores was 1.73 Fig. 56. Percentage of persons, by se- verity of periodontitis and age. United States 19881994. 65 in black males and 0.86 in white females, or twice as high. Lang et al. (40) found that only about 20% of 319 adults in the Detroit, Michigan area reported regular use of dental oss. Approximately 47% of the U.S. population were covered by private dental insurance in the mid 1980s (Health Insurance Association of America 1984 1985), and 58% of employed persons were covered by public or private plans for some portion of their dental expenses. Insurance coverage appeared to be inuenced by age, gender and race. Fifty nine percent of employed adults, 55% of den- tate seniors, and 13% of edentulous seniors reported visiting a dentist during the last one year. A study conducted in 1995 (53) found that 66% of about 4 000 adults in California reported visiting a dentist in the preceding year. Furthermore, a greater likelihood of dental visits was found among persons aged 35 years or older, and among persons with dental in- surance than those without. Most of the employed adults aged 1864 years said they had visited a dentist within the last 2 'years. Only 20% of adults and 24% of dentate seniors had not visited a dentist for 3 or more years. About 41% of adults said that regular checkups were the main reason for their last dental care visit, and this per- centage was higher in females than in males, and in whites than in blacks. However, there may be a signicant variation within the U.S. population. A study in Michigan (40) found a much higher percen- tage of regular visits, with 75% of the subjects re- ported having a dental checkup at least once a year. Albandar Disparities Results of recent national surveys show signicant disparities in the periodontal health status among Americans. Compared to whites and Mexican- Americans, blacks have the highest prevalence and severity of periodontitis, the highest prevalence, ex- tent and severity of attachment loss and probing depth, and show higher levels of dental calculus and gingival recession. Mexican-Americans have some- what better periodontal status than blacks, though signicantly worse than whites. Also, studies have consistently shown that males have poorer peri- odontal health than females. A similar trend seems to occur among senior age groups (Table4). In a recent comprehensive review, Albandar et al. (7) concluded that race-ethnicity is an important risk factor for destructive periodontal diseases. It has been suggested that both biological and environ- mental factors may be implicated in the observed differences in disease occurrence between race-eth- nic groups. Genetic factors are important risk modi- ers in the pathogenesis of periodontitis (7), and there are also data suggesting that there are signi- cant differences between races in the prevalence of certain periodontitis-associated genotypes (9). In ad- dition, comparison of the neutrophil chemotaxis re- sponse to fMLP antigens has disclosed signicantly higher responses in whites than in blacks (51). Dif- ferences in environmental and behavioral factors also exist. Dolan et al. (22) found that blacks were less likely than whites to be regular users of dental care, which is consistent with the ndings of the 19851986 national survey. In addition, blacks were less likely to use dental oss and were more likely to be smokers. Moreover, results from the NIDR adults and seniors survey showed a signicant disparity be- tween the race groups and by gender in the utiliza- tion of dental services. Visiting a dentist regularly was signicantly more common among whites than blacks, and this difference increased with age. Only 18.8% of blacks reported having regular checkups, whereas 43.6% of whites said they did so. Also, reg- ular checkups among employed whites and dentate seniors appear to be more common in females than in males, whereas it was similar in black males and females. It has been pointed out that failure to address den- tal needs of underserved communities throughout the U.S. has reached a crisis level (20). This study concurs with this conclusion and conrms that a wide gap still exists in the level of periodontal health 66 between subgroups of the U.S. population. The in- equities are particularly high among blacks and Mex- ican-Americans, and the elderly. Other groups with low income and with no dental insurance may also be regarded as subpopulations with unmet dental needs. A recent report (52) used data collected by the In- dian Health Service (IHS) to describe the periodontal status of American Indians and Alaska Natives. Pri- marily, two sets of data were of interest, a random sample of Sioux and Navajo Indians surveyed in 1990 (ICS survey), and the 1991 IHS survey in dental pa- tients (IHS survey). The study used the CPITN meth- odology and assessed the probing depth on 10 index teeth. They reported that the prevalence of CPITN score 4 (probing depth 5.5mm) was 2021% in 35 44 years old persons, and 22% (IHS survey) and 32% (ICS survey) in 6574 years old persons. These preva- lence rates are much higher than results reported in recent national surveys for comparable age groups. However, due to the differences in methodologies for assessing disease, and the use of study samples based on dental patients, it is difcult to ascertain how much of these differences are due to study de- sign. Smoking Tobacco smoking is an important risk factor for the development of destructive periodontal diseases and also makes diseases management more difcult (5, 7, 29, 54). It is estimated that approximately 24% of U.S. adults were current smokers in 1998 (18). Na- tional data show a change during recent years in smoking behaviors and suggest a pattern that is dif- ferent between races and gender groups. Whereas there has been a decline in the prevalence of ciga- rette smoking among adults (18), the prevalence of adolescents who smoke has increased. It has been estimated that daily smoking among high school seniors in the U.S. has increased from 17% to 22% in the period between 1992 and 1996 (36), and high school students who reported smoking in the pre- ceding month increased from 27.5% to 36% in the period between 1991 and 1997 (19, 56). Analysis of national data on the smoking behavior of adults by race for persons aged 2564 years and controlling for socioeconomic status and demo- graphic factors showed that smoking frequency is generally not higher among blacks than whites, and that heavy smoking in blacks is far less common than in whites (45). However, the results also showed that the likelihood that black smokers may quit Periodontal diseases in North America smoking is signicantly smaller than for white smokers, regardless of their socioeconomic status or demographic factors. This may have implications for smoking cessation and prevention programs. Findings from the 19821984 Hispanic Health and Nutrition Examination Survey (HHANES) showed that U. S. Hispanics, particularly males, had a high prevalence of health risk behaviors including higher level of cigarette smoking and alcohol use, poor die- tary practices, and less likelihood of having routine dental and medical examinations (43). Half of 2034 years old Cuban-Americans smoked cigarettes (32). In addition, among American adults, blacks and His- panics have signicantly higher prevalence of dia- betes mellitus than whites. The prevalence of dia- betes was found to be two to three times greater for Mexican-Americans and Puerto Ricans than for non- Hispanic whites (26). These differences may also ex- plain some of the disparities in the periodontal health status among Americans described above. Periodontal diseases in Canada A review of the literature found only a few large epi- demiological studies and a lack of national surveys of good representation of the population in Canada. Although there is no compelling evidence to suggest that the prevalence and severity of periodontal dis- eases are different among the populations of Canada and the U.S.A., at least one study showed a higher prevalence of periodontal diseases in a subpopula- tion in Canada. Using clinical examinations and a partial recording protocol (two randomly selected quadrants, and two sites per tooth) of a cohort of 3544 years old subjects in Quebec, the prevalence rates of probing depth of 4mm and 6mm were 45.6% and 8.5%, respectively (13). A full-mouth ex- amination of the same group of persons, and prob- ing the deepest site of the tooth found even higher levels of disease (73.6% and 21.4%, respectively), and showed that 81% persons had gingival bleeding and 75% persons had calculus (15). Comparing the above gures with those of similar age cohorts reported in the NHANES III survey (which used a similar examination protocol) for the U.S. population revealed signicant differences. In the age groups 3039 and 4049years, respectively, 22.2% and 21.4% persons had probing depth of 4 mm; 2.7% and 3.6% persons had probing depth of 6mm; 47.8% and 48% persons had gingival bleeding; and 45.3% and 49.1% persons had calculus 67 (3, 4). It is difcult to ascertain why the prevalence rates of various periodontal parameters were sig- nicantly higher in the Canadian study than the U.S. national survey, although the contribution of differ- ences in study design and examination methodolo- gies cannot be ruled out. For instance, the examina- tion of the Canadian cohort used the WHOs CPITN periodontal probe and a signicantly longer exami- nation time per person than in the NHANES III sur- vey. In addition, the examiners conducted a partial recording (2 quadrants and 2 sites per tooth) and a complete examination (the worst site around the tooth, on all teeth) on the same persons in the Can- adian study, so it is possible that a more comprehen- sive examination including all teeth and the deepest site around the tooth may have inuenced the exam- iners judgment when conducting the assessments using a partial-examination. The ndings of Locker et al. (41) suggest that also in Canada there may be signicant inequities in the prevalence and severity of periodontal diseases among certain subpopulations, such as recent immi- grants. Other ndings suggest a higher level of dis- ease in persons with low socioeconomic level (15), and it also likely that other groups may have a simi- lar disparity, such as minorities of certain ethnic groups with unfavorable oral health behaviors and other risk factors. Periodontal diseases in Mexico This review revealed a lack of data on the epidemi- ology of periodontal diseases in Mexico. As de- scribed above in this chapter, Mexico has a signi- cantly lower level of development and poorer econ- omy than the other two North American nations, and a less developed health system and a lower den- tist to population ratio. Taking into consideration the less developed Mexican health system and the nd- ings in U.S. studies that Americans of Mexican or other Hispanic ethnicity have signicantly higher prevalence and severity of periodontal diseases than the white U.S. population, it is reasonable to antici- pate a signicantly higher level of periodontal dis- eases in Mexico than in the U.S. or Canadian popu- lations. This is consistent with the ndings of Alban- dar et al. (2) in the 19861987 national survey of U.S. children which showed a signicantly higher preva- lence of early onset aggressive periodontitis in His- panic children than in whites (6). 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