Risk Indicators for Periodontitis in US Adults: NHANES 2009 to 2012

Background: Through the use of optimal surveillance measures and standard case definitions, it is now possible to more accurately determine population‐average risk profiles for severe (SP) and non‐severe periodontitis (NSP) in adults (aged 30 years and older) in the United States. Methods: Data from the 2009 to 2012 National Health and Nutrition Examination Survey were used, which, for the first time, used the “gold standard” full‐mouth periodontitis surveillance protocol to classify severity of periodontitis following suggested Centers for Disease Control/American Academy of Periodontology case definitions. Probabilities of periodontitis by: 1) sociodemographics, 2) behavioral factors, and 3) comorbid conditions were assessed using prevalence ratios (PRs) estimated by predicted marginal probability from multivariable generalized logistic regression models. Analyses were further stratified by sex for each classification of periodontitis. Results: Likelihood of total periodontitis (TP) increased with age for overall and NSP relative to non‐periodontitis. Compared with non‐Hispanic whites, TP was more likely in Hispanics (adjusted [a]PR = 1.38; 95% confidence interval 95% CI: 1.26 to 1.52) and non‐Hispanic blacks (aPR = 1.35; 95% CI: 1.22 to 1.50), whereas SP was most likely in non‐Hispanic blacks (aPR = 1.82; 95% CI: 1.44 to 2.31). There was at least a 50% greater likelihood of TP in current smokers compared with non‐smokers. In males, likelihood of TP in adults aged 65 years and older was greater (aPR = 2.07; 95% CI: 1.76 to 2.43) than adults aged 30 to 44 years. This probability was even greater in women (aPR = 3.15; 95% CI: 2.63 to 3.77). Likelihood of TP was higher in current smokers relative to non‐smokers regardless of sex and periodontitis classification. TP was more likely in men with uncontrolled diabetes mellitus (DM) compared with adults without DM. Conclusions: Assessment of risk profiles for periodontitis in adults in the United States based on gold standard periodontal measures show important differences by severity of disease and sex. Cigarette smoking, specifically current smoking, remains an important modifiable risk for all levels of periodontitis severity. Higher likelihood of TP in older adults and in males with uncontrolled DM is noteworthy. These findings could improve identification of target populations for effective public health interventions to improve periodontal health of adults in the United States.     

Environmental Tobacco Smoke and Periodontitis in United States Non‐Smokers, 2009 to 2012

Background: Epidemiologic studies using half‐mouth designs for assessment of periodontal disease prevalence have reported that environmental tobacco smoke (ETS) exposure of non‐smokers is associated with a two‐ to three‐fold increase in the odds of developing periodontitis. In response to the possibility of under‐reporting of periodontitis, the Centers for Disease Control updated periodontal examination procedures in 2009 for the National Health and Nutritional Examination Survey (NHANES), including full‐mouth, six‐site periodontal probing, and attachment loss assessment. Aims of this study are to estimate prevalence of periodontitis among United States non‐smoking adults exposed to ETS, report the values of the improved methods for estimating disease prevalence, and evaluate the predictive contribution of ETS exposure to periodontitis. Methods: A cross‐sectional study was conducted using NHANES data from the 2009 to 2012 examination cycle. To address these aims, oral examination data were used to determine prevalence of periodontitis among United States non‐smoking adults and to test the influence of ETS exposure on occurrence of periodontitis. Results: There was a 28% increase in the odds of periodontitis for those with any ETS exposure compared with those with no measurable exposure (Wald χ² test statistic [df] = 6.58 [1], P = 0.01; 95% confidence interval = 1.06 to 1.55). Conclusion: ETS exposure increases the risk of an individual developing periodontitis.     

Underestimation of periodontitis in NHANES surveys

The study design of national surveys of periodontal disease often uses partial-mouth examination protocols to rationalize the need for resources so that the collection of data from a large number of subjects can be achieved within the available means without significantly sacrificing precision and validity. Studies show that surveys that use partial examination protocols underestimate the prevalence of periodontitis, and the amount of underestimation varies depending on the number and type of sites examined, the case-definition of periodontal disease, tooth loss, and prevalence and severity of the disease. If a survey uses a partial-mouth examination it is recommended that the amount of underestimation be assessed in the same sample. This could be achieved by performing a full-mouth examination on a randomly selected subsample. Inflation factors should be calculated and used to adjust for the underestimation in disease prevalence because of the use of partial examination. Based on the NHANES III (1988 to 1994) data and adjusting for the bias caused by the examination protocol, it is estimated that approximately half of the United States population aged ≥30 years has periodontitis.     

Dental Care Visits among Dentate Adults with Diabetes and Periodontitis

Objectives: Two national surveys have shown that dentate adults with diabetes are less likely to visit a dentist than are those without diabetes; one survey showed this association only among women. We hypothesize that periodontal health among those with diabetes could explain this disparity. This report investigates the influence of periodontitis on the association between diabetes and dental care visits. It also tests whether disparities are limited to women. Methods: Data from the 1999‐2004 National Health and Nutrition Examination Survey were used. Covariates included age, sex, race/ethnicity, poverty status, education level, dental insurance, and periodontitis status. Weighted analyses were limited to dentate adults aged ≥25 years. Results: Overall, 56.8 percent of dentate adults with diabetes reported having a dental care visit in the preceding year compared with 64.7 percent for those without diabetes. In a multivariable model, diabetes status was significantly associated with having a dental care visit, independent of periodontitis status and covariates. Neither periodontitis status nor sex served as effect modifiers for the association between diabetes status and dental care visits. Conclusions: These data revealed that dental care visits for dentate adults with diabetes were unrelated to their periodontal health, suggesting that fear of periodontal therapy did not influence visit patterns. These data also showed that dental care visit disparities existed for all adults with diabetes, not just women. Future research should investigate whether factors that are indirectly related to diabetes status, such as competing costs, attitudes, and knowledge, are influencing dental care visit patterns among dentate adults with diabetes.     

Periodontitis Prevalence and Severity in Adults: A Cross‐Sectional Study in Norwegian Circumpolar Communities

Background: The aim of this study is to describe the prevalence, severity, and extent of periodontitis in the adult population of circumpolar communities in Norway using data from the Tromstannen–Oral Health in Northern Norway study. Methods: In this cross‐sectional survey, data were collected from a randomized population sample (aged 20 to 79 years) in Northern Norway. Periodontal conditions were assessed for 1,911 dentate adults with a full‐mouth periodontal examination. Probing depth (PD) and bleeding on probing were measured at six sites per tooth. Radiographic bone loss (BL) was examined using orthopantomograms. Results: According to the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions, 49.5% of participants had periodontitis, and 9.1% had severe periodontitis. Periodontitis prevalence and severity increased with age. Extent of BL and PD ≥4 mm also increased with age, but more rapidly and to a greater extent for BL. Prevalence of periodontitis was higher among men and varied between urban and rural areas. Periodontitis prevalence was positively associated with smoking, lower levels of education, and income. Conclusions: This study reveals a high burden of periodontitis among adults living in circumpolar communities in Norway. The results showed sociodemographic disparities regarding periodontitis and highlights the importance of further investigation of factors influencing periodontal health.     

Association Between High Serum Total Cholesterol and Periodontitis: National Health and Nutrition Examination Survey 2011 to 2012 Study of American Adults

Background: Clinical studies have suggested that lipids increase activity of white blood cells. The objective of this study is to examine whether high serum total cholesterol (STC) is associated with periodontitis. Methods: A total of 1,061 participants from the 2011 to 2012 National Health and Nutrition Examination Survey who underwent both periodontal examination and laboratory test for STC was included. To examine effects of high STC on periodontitis, odds ratios were calculated, adjusting for age, sex, education, income, smoking status, diabetes, body mass index, and calcium levels. Results: Statistically significant associations were observed between borderline as well as high STC and periodontitis. Study participants with STC between 200 and 239 mg/dL (borderline) were 1.67 times (95% confidence interval [CI]: 1.13 to 2.47) as likely to have periodontitis as those with normal levels (≤199 mg/dL), and those with STC ≥240 mg/dL (high) were 2.22 times (95% CI: 1.27 to 3.87) as likely to have periodontitis as those with normal levels. Conclusions: Positive significant association was observed between STC and periodontitis. Results of the present study provide insight into potential risk factors for periodontitis. High STC levels could be a potential risk factor for the disease; however, further studies need to be conducted to understand the actual relationship between STC levels and periodontitis and to establish causality and directional association.     

Relationship Between Frequent Recreational Cannabis (Marijuana and Hashish) Use and Periodontitis in Adults in the United States: National Health and Nutrition Examination Survey 2011 to 2012

Background: Recreational use of cannabis, following its legalization in some countries, poses emergent oral and periodontal health concerns. The objective of this study is to examine the relationship between frequent recreational cannabis (FRC) (marijuana and hashish) use and periodontitis prevalence among adults in the United States. Methods: Data from the National Health and Nutrition Examination Survey (NHANES) 2011 to 2012 were analyzed. Primary outcome (periodontitis) was defined using the Centers for Disease Control and Prevention/American Academy of Periodontology classification as well as continuous measurements of probing depth (PD) and clinical attachment loss (AL). Exposure of interest was self‐reported cannabis use, defined as “FRC use” versus “non‐FRC use.” Bivariate and multivariable regression models were performed using the entire analytical sample (model 1) as well as those who had never used tobacco (never‐users) (model 2). Results: Of 1,938 participants with available cannabis use data and essential covariates, 26.8% were FRC users. Mean number of sites per participant with PD ≥4, ≥6, and ≥8 mm and AL ≥3, ≥5, and ≥8 mm was significantly higher among FRC users than among non‐FRC users (mean difference in number of PD sites: 6.9, 5.6, and 5.6; P <0.05; mean difference in number of AL sites: 12.7, 7.6, and 5.6; P <0.05). Average AL was higher among FRC users than among non‐FRC users (1.8 versus 1.6 mm; P = 0.004). Bivariate analysis revealed positive (harmful) association between FRC use and severe periodontitis in the entire sample (odds ratio [OR]: 1.7, 95% confidence interval [CI]: 1.3 to 2.4; P = 0.002) as well as in never‐smokers (OR: 2.0, 95% CI: 1.2 to 3.5; P = 0.01). This association was retained in multivariable models adjusted for demographics (age, sex, race/ethnicity, and income level), alcohol and tobacco use, diabetes mellitus, and past periodontal treatment (model 1: adjusted OR [aOR]: 1.4, 95% CI: 1.1 to 1.9; P = 0.07; model 2: aOR: 1.9, 95% CI: 1.1 to 3.2; P = 0.03). Conclusion: FRC use is associated with deeper PDs, more clinical AL, and higher odds of having severe periodontitis.     

Periodontitis in the United States: beyond black and white

OBJECTIVES: This paper examines whether historical disparities in periodontal status between African Americans and whites in the United States have increased, decreased, or remained the same over the 15-year period between the First National Health and Nutrition Examination Survey (NHANES I, 1971-74) and the Third National Health and Nutrition Examination Survey (NHANES III, 1988-94). METHODS: This study compared the magnitude of the relative and absolute differences in the periodontal status of African-American and white adults in NHANES I and again in NHANES III. RESULTS: The prevalence of periodontitis in the US adult population in NHANES I was 31.6 percent, with African Americans exhibiting higher prevalence than whites. In NHANES III, using a different case-definition for periodontitis, the overall prevalence was 11.9 percent, with African Americans again exhibiting higher prevalence than whites. The magnitude of the intrasurvey relative and absolute differences between African Americans and whites increased between NHANES I and NHANES III. This finding remained after adjustment in the logistic regression analyses. After adjustment for all covariates in the model, African Americans were more likely to exhibit periodontitis than whites in both NHANES I (odds ratio [OR] = 1.31; 95% confidence intervals [CI] = .78, 2.19) and NHANES III (OR = 2.09; 95% CI = 1.68, 2.60). However, the CI included 1.00 in NHANES I. CONCLUSIONS: Disparities in periodontitis between African Americans and whites are pervasive and have increased over time. This increase appears to be driven by social, cultural, and behavioral factors.     

Prevalence of periodontitis: misclassification,under-recognition or over-diagnosis using partial and full-mouth periodontal examination protocols

Objective: The aim of this cross-sectional study was to assess the bias in estimating the prevalence of periodontitis due to partial-mouth periodontal examination protocols (PMPE) and to relate the severity and extent of periodontal damage to periodontitis misclassification when applying case definitions by Centres of Disease Control and Prevention and American Academy of Periodontology (CDC/AAP).

Materials and methods: A full-mouth periodontal examination (FMPE) was performed in 721 adults living in North Italy to identify moderate and severe periodontitis. These results were compared with those obtained with two PMPE protocols analyzing two interproximal sites on all teeth (fMB-DL) or four interproximal sites in two random diagonal quadrants (pMDB-MDL).

Results: Both PMPE systems estimated the prevalence of moderate periodontitis with limited bias (?2.79% for pMDB-MDL and ?3.49% for fMB-DL), whereas produced larger relative biases for severe periodontitis (?28.74% versus???14.55%). The percentage of under-recognition of existing periodontal disease was 8.9% under fMB-DL and 15.5% under pMDB-MDL. The diagnosis of moderate and severe periodontal disease was correctly assigned to individuals with on average 8% and 30% of pathological sites, respectively.

Conclusion: These findings suggest that PMPE systems provide high level of bias when using CDC/AAP case definitions.     

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.     

Periodontitis in US Adults: National Health and Nutrition Examination Survey 2009-2014

Background

This report presents weighted average estimates of the prevalence of periodontitis in the adult US population during the 6 years 2009-2014 and highlights key findings of a national periodontitis surveillance project.

Accuracy of Partial‐Mouth Examination Protocols for Extent and Severity Estimates of Periodontitis: A Study in a Chinese Population With Chronic Periodontitis

Background: Partial‐mouth periodontal examination (PMPE) has been widely used in periodontal epidemiologic studies. In this study, the authors evaluate the accuracy of extent and severity estimates from PMPE protocols in a Chinese population. Methods: The study enrolled 200 individuals with periodontitis, ages 22 to 64 years. Full‐mouth examination was performed to determine probing depth (PD), attachment loss (AL), and bleeding on probing (BOP) at mesio‐buccal (MB), mid‐buccal (B), disto‐buccal (DB), mesio‐lingual (ML), mid‐lingual (L), and disto‐lingual (DL) sites per tooth. Extent and severity estimates from 15 PMPE protocols were derived from and compared to full‐mouth data. Relative bias (RB) and intraclass correlation coefficients (ICCs) were calculated. Bland‐Altman plots were used to evaluate the agreement patterns across disease levels. Results: Of the 15 PMPE protocols, the random half‐mouth six‐sites per tooth (r6sites) protocol performed best in both extent (AL ≥2, ≥4, or ≥6 mm; PD ≥4 or ≥6 mm; and BOP) and severity (AL and PD) estimates, with RB within 5.0% and ICCs ≥0.950 in most cases. MB‐B‐DB and MB‐B‐DL protocols generally resulted in RB within 20.0% for extent and within 5.0% for severity. Protocols involving only interproximal sites (MB‐DB, MB‐DL, and MB‐DB‐ML‐DL) showed good accuracy in AL (RB within 20.0% for extent and within 3.0% for severity), but overestimated PD (RB 12.5% to 54.2% for extent and >10.0% for severity). The community periodontal index teeth protocol caused severe overestimation of up to 110.4% for extent and 14.6% for severity. Conclusion: The r6sites protocol is best for assessing extent and severity for AL, PD, and BOP under the study conditions.     

Influence of Periodontitis in the Development of Nosocomial Pneumonia: A Case Control Study

Background: Although a number of studies on the role of periodontitis in the development of nosocomial pneumonia (NP) have been published, the debate surrounding the existence and nature of this association continues. The present study investigates the influence of periodontitis in NP. Methods: This case‐control study involved 315 individuals: 85 cases (with NP) and 230 controls (without NP), at a general hospital in Feira de Santana, Bahia, Brazil. Sociodemographic characteristics, health conditions, and lifestyle habits were recorded. A full‐mouth periodontal examination was performed and periodontal condition assessed. The diagnosis of NP was made in accordance with established medical criteria, after physical, microbiologic, and/or radiographic examination. Logistic regression was used to calculate the strength of the association between periodontitis and NP. Results: Individuals with periodontitis were three times as likely to present with NP (unadjusted odds ratio [OR_unadjusted] = 3.06, 95% confidence interval [95% CI]: 1.82 to 5.15) as those without periodontal disease. After adjusting for age, time between hospitalization and data collection, last visit to dentist, smoking habit, and present occupation, the association measurement had a slight decrease (OR_adjusted = 2.88, 95% CI: 1.59 to 5.19), but the results continued to be statistically significant. Conclusion: These findings suggest that periodontal infection may influence the development of NP, highlighting that periodontitis is a factor positively associated with this respiratory tract infection.