Gina Thornton-Evans

Prevalence of Periodontitis in Adults in the United States: 2009 and 2010

This study estimated the prevalence, severity, and extent of periodontitis in the adult U.S. population, with data from the 2009 and 2010 National Health and Nutrition Examination Survey (NHANES) cycle. Estimates were derived from a sample of 3,742 adults aged 30 years and older, of the civilian non-institutionalized population, having 1 or more natural teeth. Attachment loss (AL) and probing depth (PD) were measured at 6 sites per tooth on all teeth (except the third molars). Over 47% of the sample, representing 64.7 million adults, had periodontitis, distributed as 8.7%, 30.0%, and 8.5% with mild, moderate, and severe periodontitis, respectively. For adults aged 65 years and older, 64% had either moderate or severe periodontitis. Eighty-six and 40.9% had 1 or more teeth with AL ≥ 3 mm and PD ≥ 4 mm, respectively. With respect to extent of disease, 56% and 18% of the adult population had 5% or more periodontal sites with ≥ 3 mm AL and ≥ 4 mm PD, respectively. Periodontitis was highest in men, Mexican Americans, adults with less than a high school education, adults below 100% Federal Poverty Levels (FPL), and current smokers. This survey has provided direct evidence for a high burden of periodontitis in the adult U.S. population.

Update on Prevalence of Periodontitis in Adults in the United States: NHANES 2009 to 2012

BACKGROUND This report describes prevalence, severity, and extent of periodontitis in the US adult population using combined data from the 2009 to 2010 and 2011 to 2012 cycles of the National Health and Nutrition Examination Survey (NHANES). METHODS Estimates were derived for dentate adults, aged ≥30 years, from the US civilian non-institutionalized population. Periodontitis was defined by combinations of clinical attachment loss (AL) and periodontal probing depth (PD) from six sites per tooth on all teeth, except third molars, using standard surveillance case definitions. For the first time in NHANES history, sufficient numbers of non-Hispanic Asians were sampled in 2011 to 2012 to provide reliable estimates of their periodontitis prevalence. RESULTS In 2009 to 2012, 46% of US adults, representing 64.7 million people, had periodontitis, with 8.9% having severe periodontitis. Overall, 3.8% of all periodontal sites (10.6% of all teeth) had PD ≥4 mm, and 19.3% of sites (37.4% teeth) had AL ≥3 mm. Periodontitis prevalence was positively associated with increasing age and was higher among males. Periodontitis prevalence was highest in Hispanics (63.5%) and non-Hispanic blacks (59.1%), followed by non-Hispanic Asian Americans (50.0%), and lowest in non-Hispanic whites (40.8%). Prevalence varied two-fold between the lowest and highest levels of socioeconomic status, whether defined by poverty or education. CONCLUSIONS This study confirms a high prevalence of periodontitis in US adults aged ≥30 years, with almost fifty-percent affected. The prevalence was greater in non-Hispanic Asians than non-Hispanic whites, although lower than other minorities. The distribution provides valuable information for population-based action to prevent or manage periodontitis in US adults.

Update of the Case Definitions for Population-Based Surveillance of Periodontitis

BACKGROUND This report adds a new definition for mild periodontitis that allows for better descriptions of the overall prevalence of periodontitis in populations. In 2007, the Centers for Disease Control and Prevention in partnership with the American Academy of Periodontology developed and reported standard case definitions for surveillance of moderate and severe periodontitis based on measurements of probing depth (PD) and clinical attachment loss (AL) at interproximal sites. However, combined cases of moderate and severe periodontitis are insufficient to determine the total prevalence of periodontitis in populations. METHODS The authors proposed a definition for mild periodontitis as ≥ 2 interproximal sites with AL ≥ 3 mm and ≥ 2 interproximal sites with PD ≥ 4 mm (not on the same tooth) or one site with PD ≥ 5 mm . The effect of the proposed definition on the total burden of periodontitis was assessed in a convenience sample of 456 adults ≥ 35 years old and compared with other previously reported definitions for similar categories of periodontitis. RESULTS Addition of mild periodontitis increases the total prevalence of periodontitis by ≈31% in this sample when compared with the prevalence of severe and moderate disease. CONCLUSION Total periodontitis using the case definitions in this study should be based on the sum of mild, moderate, and severe periodontitis.

Accuracy of NHANES Periodontal Examination Protocols

This study evaluates the accuracy of periodontitis prevalence determined by the National Health and Nutrition Examination Survey (NHANES) partial-mouth periodontal examination protocols. True periodontitis prevalence was determined in a new convenience sample of 454 adults ≥ 35 years old, by a full-mouth “gold standard” periodontal examination. This actual prevalence was compared with prevalence resulting from analysis of the data according to the protocols of NHANES III and NHANES 2001-2004, respectively. Both NHANES protocols substantially underestimated the prevalence of periodontitis by 50% or more, depending on the periodontitis case definition used, and thus performed below threshold levels for moderate-to-high levels of validity for surveillance. Adding measurements from lingual or interproximal sites to the NHANES 2001-2004 protocol did not improve the accuracy sufficiently to reach acceptable sensitivity thresholds. These findings suggest that NHANES protocols produce high levels of misclassification of periodontitis cases and thus have low validity for surveillance and research.

Trends in oral health by poverty status as measured by Healthy People 2010 objectives.

Objective. Poverty is a significant social determinant for oral health, yet Healthy People 2010 (HP 2010) does not monitor changes in oral health status by poverty. We assessed recent trends for six HP 2010 oral health objectives by poverty status. Methods. We used data from the 1988–1994 and 1999–2004 National Health and Nutrition Examination Surveys to analyze trends for HP 2010 age-specific objectives relating to caries experience, untreated tooth decay, dental sealants, periodontal disease, tooth retention, and complete tooth loss by poverty status. Results. Dental caries significantly increased from 19% to 24% for children aged 2–4 years, but when stratified by poverty, caries only increased significantly for non-poor 2- to 4-year-old children (10% to 15%) (Objective 21–1a). The largest percentage point increase in dental caries was for non-poor boys (9% to 18%). The use of dental sealants continues to grow in the U.S. The largest percentage point increase in sealant use (Objective 21–8) between the two survey periods was for all poor children aged 8 years (3% to 21%). Among adults aged 35–44 years, periodontal disease significantly declined in the U.S. from 22% to 16% (Objective 21–5b) and more adults retained all of their natural teeth (30% to 38%) (Objective 21–3). However, the increase in tooth retention was significant only for non-poor adults, particularly non-poor men (34% to 48%). Conclusions. Overall, the oral health status of Americans as measured by HP 2010 objectives mostly showed improvement or remained unchanged between 1998–1994 and 1999–2004. However, some changes in oral health status for some traditionally low-risk groups, such as non-poor children, may be reversing improvements in oral health that have consistently been observed in previous decades. These results suggest that poverty status is an important factor for planning and monitoring future national oral health goals.

Self-reported Measures for Surveillance of Periodontitis

The purpose of this study was to evaluate the performance of self-reported measures in predicting periodontitis in a representative US adult population, based on 2009-2010 National Health and Nutrition Examination Survey (NHANES) data. Self-reported gum health and treatment history, loose teeth, bone loss around teeth, tooth not looking right, and use of dental floss and mouthwash were obtained during in-home interviews and validated against full-mouth clinically assessed periodontitis in 3,743 US adults 30 years and older. All self-reported measures (> 95% item response rates) were associated with periodontitis, and bivariate correlations between responses to these questions were weak, indicating low redundancy. In multivariable logistic regression modeling, the combined effects of demographic measures and responses to 5 self-reported questions in predicting periodontitis of mild or greater severity were 85% sensitive and 58% specific and produced an ‘area under the receiver operator characteristic curve’ (AUROCC) of 0.81. Four questions were 95% sensitive and 30% specific, with an AUROCC of 0.82 in predicting prevalence of clinical attachment loss ≥ 3 mm at one or more sites. In conclusion, self-reported measures performed well in predicting periodontitis in US adults. Where preferred clinically based surveillance is unattainable, locally adapted variations of these self-reported measures may be a promising alternative for surveillance of periodontitis.

Advances in surveillance of periodontitis: the Centers for Disease Control and Prevention periodontal disease surveillance project.

The Centers for Disease Control and Prevention (CDC) has as one of its strategic goals to support and improve surveillance of periodontal disease. In 2003, the CDC initiated the CDC Periodontal Disease Surveillance Project in collaboration with the American Academy of Periodontology to address population-based surveillance of periodontal disease at the local, state, and national levels. This initiative has made significant advancements toward the goal of improved surveillance, including developing valid self-reported measures that can be obtained from interview-based surveys to predict prevalence of periodontitis in populations. This will allow surveillance of periodontitis at the state and local levels and in countries where clinical resources for surveillance are scarce. This work has produced standard case definitions for surveillance of periodontitis that are now widely recognized and applied in population studies and research. At the national level, this initiative has evaluated the validity of previous clinical examination protocols and tested new protocols on the National Health and Nutrition Examination Survey (NHANES), recommending and supporting funding for the gold-standard full-mouth periodontal examination in NHANES 2009 to 2012. These examinations will generate accurate estimates of the prevalence of periodontitis in the US adult population and provide a superior dataset for surveillance and research. Also, this data will be used to generate the necessary coefficients for our self-report questions for use in subsets of the total US population. The impact of these findings on population-based surveillance of periodontitis and future directions of the project are discussed along with plans for dissemination and translation efforts for broader public health use.

A Brief History of National Surveillance Efforts for Periodontal Disease in the United States

National efforts directed toward improving our understanding of the epidemiology of periodontal disease began nearly a half century ago following the development of Russells periodontal index (PI). United States Public Health Service agencies began national surveillance activities for periodontal disease with the first National Health Examination Survey in 1960 to 1962, and this continued periodically through 2004 in the National Health and Nutrition Examination Survey (NHANES). Periodontal disease status was assessed by using the PI in the earlier national health surveys, but beginning in the 1980s, direct measures for clinical attachment loss were made in national health surveys and continued through 2004 in NHANES. This article provides a general history of the development and implementation of national surveillance efforts for periodontal disease from the mid-1950s to 2005. It also provides brief background information on the factors that have influenced these national surveillance efforts.

Recording and surveillance systems for periodontal diseases.

This paper describes tools used to measure periodontal diseases and the integration of these tools into surveillance systems. Tools to measure periodontal diseases at the surveillance level have focussed on current manifestations of disease (e.g. gingival inflammation) or disease sequelae (e.g. periodontal pocket depth or loss of attachment). All tools reviewed in this paper were developed based on the state of the science of the pathophysiology of periodontal disease at the time of their design and the need to provide valid and reliable measurements of the presence and severity of periodontal diseases. Therefore, some of these tools are no longer valid. Others, such as loss of periodontal attachment, are the current de-facto tools but demand many resources to undertake periodical assessment of the periodontal health of populations. Less complex tools such as the Community Periodontal Index, have been used extensively to report periodontal status. Laboratory tests for detecting putative microorganisms or inflammatory agents present in periodontal diseases have been used at the clinical level, and at least one has been tested at the population level. Other approaches, such as self-report measures, are currently under validation. In this paper, we do not review indices designed to measure plaque or residual accumulation around the tooth, indices focussed only on gingival inflammation or radiographic approaches with limited applicability in surveillance systems. Finally, we review current case-definitions proposed for surveillance of periodontal disease severity.

Predicting Periodontitis at State and Local Levels in the United States

The objective of the study was to estimate the prevalence of periodontitis at state and local levels across the United States by using a novel, small area estimation (SAE) method. Extended multilevel regression and poststratification analyses were used to estimate the prevalence of periodontitis among adults aged 30 to 79 y at state, county, congressional district, and census tract levels by using periodontal data from the National Health and Nutrition Examination Survey (NHANES) 2009–2012, population counts from the 2010 US census, and smoking status estimates from the Behavioral Risk Factor Surveillance System in 2012. The SAE method used age, race, gender, smoking, and poverty variables to estimate the prevalence of periodontitis as defined by the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions at the census block levels and aggregated to larger administrative and geographic areas of interest. Model-based SAEs were validated against national estimates directly from NHANES 2009–2012. Estimated prevalence of periodontitis ranged from 37.7% in Utah to 52.8% in New Mexico among the states (mean, 45.1%; median, 44.9%) and from 33.7% to 68% among counties (mean, 46.6%; median, 45.9%). Severe periodontitis ranged from 7.27% in New Hampshire to 10.26% in Louisiana among the states (mean, 8.9%; median, 8.8%) and from 5.2% to 17.9% among counties (mean, 9.2%; median, 8.8%). Overall, the predicted prevalence of periodontitis was highest for southeastern and southwestern states and for geographic areas in the Southeast along the Mississippi Delta, as well as along the US and Mexico border. Aggregated model-based SAEs were consistent with national prevalence estimates from NHANES 2009–2012. This study is the first-ever estimation of periodontitis prevalence at state and local levels in the United States, and this modeling approach complements public health surveillance efforts to identify areas with a high burden of periodontitis.