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 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.     

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.

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.     

Validity of Simple Self-Reported Periodontal Status Questions

ObjectiveThe aim of this research was to evaluate the validity of the questions developed by Thai periodontists on self-reported periodontal status and symptoms in identifying severe periodontitis amongst adults in Thailand.MethodsRegistered Electricity Generating Authority of Thailand (EGAT) employees completed medical examinations and full-mouth periodontal examinations. They also were interviewed using a self-reported questionnaire that was developed by Thai periodontists. The questions pertained to their periodontal status and symptoms comprising swollen gums, bad breath, loose teeth, bleeding on brushing, painful gums, and pus or abscesses. The participants were categorised as having nonsevere and severe periodontitis according to the Centers for Disease Control and Prevention in partnership with the American Academy of Periodontology (CDC/AAP) case definitions. Self-reported periodontal status and symptom results were compared with actual periodontal status. The area under the receiver operating characteristic curve (AUROCC), sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated.ResultsA total of 1393 EGAT employees participated in this study. The questions on self-reported periodontal status and all symptoms poorly identified patients with severe periodontitis, with an AUROCC of 0.52 to 0.60. The sensitivity was 5.0% to 40.2%; however, the specificity was good, at 73.2% to 99.1%. The validity of the self-reported questions was comparable amongst the sex, education, and income subgroups.ConclusionsThis study demonstrated that self-reported periodontal status and symptoms were inadequate in identifying patients with severe periodontal disease.     

Evaluation of the FDI Chairside Guide for Assessment of Periodontal Conditions: A Multicentre Observational Study

ObjectiveThere is a need to develop easy-to-use tools to screen for periodontal conditions in daily practice. This study aimed to evaluate the FDI World Dental Federation “Chairside Guide” (FDI-CG) developed by the Task Team of the FDI Global Periodontal Health Project (GPHP) as a potential tool for screening.MethodsDatabases from 3 centres in Germany, Hong Kong, and Spain (n = 519) were used to evaluate the association of the FDI-CG and its individual items with the periodontitis case definitions proposed by the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP) for population-based surveillance of periodontitis.ResultsStatistically significant differences were observed among the databases for the prevalence of periodontitis and the items included in the FDI-CG. The FDI-CG score and its individual components were significantly associated with the periodontal status in the individual databases and the total sample, with bleeding on probing showing the strongest association with severe periodontitis (odds ratio [OR] = 12.9, 95% CI [5.9; 28.0], P < .001, for those presenting bleeding on probing >50%), followed by age (OR = 4.8, 95% CI [1.7; 4.2], P = .004, for those older than 65 years of age). Those subjects with a FDI-CG score >10 had an OR of 54.0 (95% CI [23.5; 124.2], P < .001) and presented with severe periodontitis. A significant correlation was found between the different FDI-CG scoring categories (mild, moderate, and severe) and the categories for mild, moderate, and severe periodontitis using the Centers for Disease Control and Prevention and the American Academy of Periodontology criteria (r = 0.57, Spearman rank correlation test, P < .001).ConclusionThe FDI Chairside Guide may represent a suitable tool for screening the periodontal condition by general practitioners in daily dental practice.     

Periodontitis associated with chronic kidney disease among Mexican Americans

Objective: In comparison to non‐Hispanic whites, a number of health‐care disparities, including poor oral health, have been identified among Hispanics in general and Mexican Americans in particular. We hypothesized that Mexican Americans with chronic kidney disease (CKD) would have higher prevalence of chronic periodontitis compared with Mexican Americans with normal kidney function, and that the level of kidney function would be inversely related to the prevalence of periodontal disease. Methods: We examined this hypothesis using the National Health and Nutrition Examination Survey 1988‐1994 (NHANES III) data set. We followed the American Academy of Periodontology/Center for Disease Control and Prevention case definition for periodontitis. Glomerular filtration rate was estimated using the CKD‐Epidemiology equation for Hispanic populations. The classification to CKD stages was based on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Results: Periodontitis prevalence increased across the kidney function groups showing a statistically significant dose–response association (P < 0.001). Mexican Americans with reduced kidney function were twofold more likely to have periodontitis compared with Mexican Americans with normal kidney function after adjusting for potential confounders such as smoking, diabetes, and socioeconomic status. Multivariate adjusted odds ratio for periodontitis significantly increased with 1, 5, and 10 mL/minute estimated glomerular filtration rate reduction from the mean. Conclusion: This is the first report, to the best our knowledge, that showed an increase of periodontitis prevalence with decreased kidney function in this population.     

Periodontitis predicts elevated C-reactive protein levels in chronic kidney disease

Based on the existing evidence supporting a state of chronic inflammation in chronic kidney disease (CKD), we hypothesized that periodontal infection may affect the systemic inflammatory status of a nationally representative CKD population as measured by serum C-reactive protein (CRP). We examined this hypothesis using the National Health and Nutrition Examination Survey 1988-1994 (NHANES III) dataset including 2303 individuals. We followed the American Academy of Periodontology (AAP)/Centers for Disease Control and Prevention (CDC) case definition for periodontitis. We used a cutoff point of 30% sites with (PD) ≥ 5 mm and (CAL) ≥ 4 mm to define generalized periodontitis cases. We estimated glomerular filtration rate based on cystatin C levels using the relevant equation. Urinary albumin-to-creatinine ratio was calculated in milligrams per gram with a cutoff point of 30 mg/g. CKD was defined based on eGFR < 60 mL/min/1.73 m(2) and albuminuria ≥ 30 mg/g. Periodontitis was found in 427 (12.3%) individuals. Of individuals with periodontitis, 41.8% had serum CRP higher than 0.3 mg/dL compared with 27.1% of non-periodontitis and 53.1% of edentulous individuals (p = 0.001 for all comparisons). When the extent of periodontitis was used as one of the independent variables, the parsimonious model showed a strong independent association between extent of periodontitis and serum CRP levels (OR = 2.0, CI95% = 1.2-3.6).     

Periodontal disease,undiagnosed diabetes,and body mass index: Implications for diabetes screening by dentists

BackgroundPeriodontal disease and diabetes are widespread comorbid conditions that are detrimental to oral and overall health. Dentists' performing chairside screenings for undiagnosed diabetes mellitus (UDM) can be beneficial to both patients and providers. The authors determined UDM rates in a population-based study and whether UDM and periodontal disease were independently associated.MethodsData from 7,343 participants in the Atherosclerosis Risk in Communities study visit 4 were used to determine rates of UDM by periodontal status, edentulism, and body mass index. The authors used a χ² test or analysis of variance, along with a 2-stage logistic regression model, to determine relationships with UDM. UDM was defined as no self-reported diabetes and blood glucose levels (fasting glucose ≥ 126 milligrams/deciliter or nonfasting glucose > 200 mg/dL). Periodontal disease was defined using the Periodontal Profile Classes system adapted to stages and the Centers for Disease Control and Prevention and American Academy of Periodontology index.ResultsUDM rates overall were 5.6%. The highest rates occurred in patients who were obese and edentulous (12.6%) and obese and had severe periodontal disease (12.2%). Significant associations were found for UDM and severe periodontal disease (Periodontal Profile Classes system stage IV) (odds ratio, 1.78; 95% confidence interval, 1.10 to 2.88). Edentulism was significantly associated with UDM in the Periodontal Profile Classes system model (odds ratio, 1.87; 95% confidence interval, 1.27 to 2.75) and Centers for Disease Control and Prevention and American Academy of Periodontology index (odds ratio, 1.70; 95% confidence interval, 1.08 to 2.67). Hyperglycemia was found in participants of all body mass index categories.ConclusionsUDM is significantly associated with obesity, edentulism, and periodontitis. These characteristics could help dentists identify patients at higher risk of developing DM. Patients without these characteristics still have UDM, so dentists performing chairside diabetes screening for all patients would yield additional benefit.Practical ImplicationsDental offices are a major point of contact within the US health care system. Diabetes screening in this setting can provide important health information with direct relevance to patient care.     

Periodontal inflamed surface area and periodontal case definition classification

Objective: To assess whether a higher periodontal inflamed surface area (PISA) may reflect more severe periodontitis, and if so, to calculate which cut-off point should be used to classify a patient as suffering from periodontitis.

Material and methods: Eighty subjects were selected based on their periodontal status and were divided into 4 groups of 20 each; periodontally healthy, mild periodontitis, moderate periodontitis and severe periodontitis. In addition, demographic data, smoking status and socioeconomic status were also recorded.

Results: The highest mean PISA value was obtained for the severe periodontitis group (2309.42?±?587.69?mm²) and the least for the periodontally healthy (34.30?±?16.48?mm²). The PISA values corresponding to the three categories of periodontitis severity were significantly higher than the periodontally healthy group. When receiver operating characteristic (ROC) analysis was performed, a PISA value ≥130.33?mm² predicted the presence of periodontitis with a sensitivity of 98% and a specificity of 100%.

Conclusions: PISA is a periodontal parameter that may be used in conjunction with the Centers for Disease Control and Prevention – American Academy of Periodontology case definition classification in periodontal medicine research.     

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.     

Periodontal profile class is associated with prevalent diabetes,coronary heart disease,stroke, and systemic markers of C‐reactive protein and interleukin‐6

1 Background

This paper focuses on the Periodontal Profile Class (PPC) System that may be more informative and representative of periodontitis phenotypes than current case definitions of periodontitis. This study illustrates the unique aspects of the PPC compared with other periodontal indices for studying associations between periodontal disease and prevalent systemic conditions.

2 Methods

We computed odds ratios and 95% confidence intervals to compare associations between periodontal disease and prevalent systemic conditions using our new PPC and two traditional indices. We used the Bayesian Information Criterion (BIC) to determine the fit of the model and the magnitude of the contribution attributable to periodontal disease beyond traditional risk factors. The Atherosclerosis Risk in Communities (ARIC) Study (1996–1998) results were compared with results from the combined National Health and Nutrition Examination Survey 2009–2014 datasets.

3 Results

In the ARIC Study, high gingival inflammation, tooth loss, severe tooth loss, and severe disease PPC components were significantly associated with diabetes, coronary heart disease (CHD), high‐sensitivity C‐reactive protein, and interleukin (IL)‐6, while only severe disease was associated with stroke. Severe disease was associated with CHD using the Centers for Disease Control/American Academy of Periodontology index, and the European Periodontal index was associated with CHD and IL‐6.

4 Conclusions

The addition of the PPC to traditional variables associated with prevalent diabetes, stroke, CHD, and systemic measures of inflammation resulted in very strong improvement of the overall models, while the traditional indices were less likely to be associated and, if present, the associations were weaker. The PPC system provides specific insight into the individuals and periodontal characteristics of the phenotype that are associated with systemic conditions that may be useful in designing treatment interventions.     

Periodontal status of current methamphetamine users

Background

Methamphetamine (MA) use is associated with extensive dental caries. The purpose of this study was to determine the prevalence and severity of periodontal disease in a convenience sample of MA users.

Association of marijuana use with oral HPV infection and periodontitis among Hispanic adults: Implications for oral cancer prevention

1 Background

Despite limited data, research suggests that marijuana use is associated with oral HPV infection and periodontitis, two potential oropharyngeal cancer risk factors. We assessed these associations in a Hispanic adult population in Puerto Rico.

2 Methods

A cross‐sectional study of 735 adults assessed marijuana use, determined through an audio computer‐assisted self‐interview, and periodontitis and self‐collection of oral HPV samples following the National Health and Nutrition Examination Survey methodology. The Centers of Disease Control and Prevention/American Academy of Periodontology definition was used for periodontitis. HPV typing was performed using polymerase chain reaction with modified L1 consensus primers (MY09/MY11).

3 Results

26.5% of adults reported lifetime use of marijuana, 2.7% were frequent users (lifetime use ≥ 26 times, past year use ≥ 6 times, and past 30‐day use ≥2 times), 5.7% had oral HPV infection, and 20.1% had severe periodontitis. The multivariate logistic regression analysis showed that frequent marijuana users were more likely to have severe periodontitis (OR = (2.93, 95%: 1.08–7.96)) than never/once lifetime users after adjusting for age, sex, healthcare coverage, smoking, binge drinking, number of oral sex partners, and oral HPV infection. However, frequent marijuana use was not associated with oral HPV infection.

4 Conclusion

Marijuana use was associated with periodontitis, but not with oral HPV infection. Further evaluation of the role of marijuana use in oral HPV infection and periodontitis may inform novel preventive public health strategies, as marijuana users could be at increased risk of oral cancer.     

Accuracy of Self‐Reported Periodontal Disease in the Women's Health Initiative Observational Study

Background: This study examines the accuracy of self‐reported periodontal disease in a cohort of older females. Methods: The study comprised 972 postmenopausal females aged 53 to 83 years who completed baseline (1997 to 2001) and follow‐up (2002 to 2006) whole‐mouth oral examinations. Examinations included: 1) probing depth, 2) clinical attachment level, and 3) oral radiographs for alveolar crestal height in a study ancillary to the Women's Health Initiative Observational Study (WHI‐OS) conducted in Buffalo, New York, called the OsteoPerio study. Participants also self‐reported any history of diagnosis of periodontal/gum disease on a WHI‐OS study‐wide questionnaire administered during the time interval between the two OsteoPerio examinations. Results: Participants reporting diagnosis of periodontal/gum disease on the WHI‐OS questionnaire (n = 259; 26.6%) had worse oral hygiene habits, periodontal disease risk factors, and clinical periodontal measures compared with those not reporting periodontal/gum disease. Frequency of reported periodontal/gum disease was 13.5%, 24.7%, and 56.2% across OsteoPerio baseline examination categories of none/mild, moderate, and severe periodontal disease, respectively (trend: P <0.001), defined by criteria of the Centers for Disease Control and Prevention/American Academy of Periodontology (CDC/AAP). Sensitivity, specificity, and positive and negative predictive values for reported periodontal disease status were 56.2%, 78.8%, 32.8%, and 90.7%, respectively, when CDC/AAP‐defined severe periodontal disease at baseline was the criterion measure (prevalence of 15%) and were 76.0%, 77.4%, 22.0%, and 97.4%, respectively, when tooth loss to periodontitis (prevalence of 7%) was the criterion. Conclusion: A simple question for self‐reported periodontal disease characterizes periodontal disease prevalence with moderate accuracy in postmenopausal females who regularly visit their dentist, particularly in those with more severe disease.     

Disparities in periodontitis prevalence among chronic kidney disease patients

Because of adverse effects of uremia in the innate and adaptive immune systems, we hypothesized that chronic kidney disease (CKD) patients would have higher prevalence of moderate periodontitis compared with individuals without CKD. We examined this hypothesis using the NHANES III dataset, including 12,081 adults stratified by Race-Ethnicity. We followed the American Academy of Periodontology/Centers for Disease Control and Prevention definition for moderate periodontitis. Estimated glomerular filtration rate (GFR) was calculated based on calibrated serum creatinine levels according to the Modification of Diet in Renal Disease Study formula. Analyses incorporated NHANES sampling weights. Overall, 14.6% of individuals with CKD were classified as having moderate periodontitis, compared with 8.7% in the non-CKD group (p = 0.001). A significant dose-response association (p = 0.001) was observed between prevalence of moderate periodontitis and CKD stages among non-Hispanic Blacks and Mexican-Americans, but not so for non-Hispanic Whites. Prevalence of periodontitis among participants with CKD was substantially higher among non-Hispanic Blacks (38.9%) and Mexican-Americans (37.3%) compared with non-Hispanic Whites (12.9%). Multivariate logistic regression models showed that Mexican-Americans and non-Hispanic Blacks with CKD were approximately 30% to 60% more likely to have moderate periodontitis compared with those without CKD, after adjustment for diabetes status and other potential confounders.     

Prevalence of periodontitis according to Hispanic or Latino background among study participants of the Hispanic Community Health Study/Study of Latinos

BackgroundHispanics and Latinos are an ethnically heterogeneous population with distinct oral health risk profiles. Few study investigators have examined potential variation in the burden of periodontitis according to Hispanic or Latino background.MethodsThe authors used a multicenter longitudinal population-based cohort study to examine the periodontal health status at screening (2008–2011) of 14,006 Hispanic and Latino adults, aged 18 to 74 years, from four U.S. communities who self-identified as Cuban, Dominican, Mexican, Puerto Rican, Central American or South American. The authors present weighted, age-standardized prevalence estimates and corrected standard errors of probing depth (PD), attachment loss (AL) and periodontitis classified according to the case definition established by the Centers for Disease Control and Prevention and the American Academy of Periodontology (CDC-AAP). The authors used a Wald χ² test to compare prevalence estimates across Hispanic or Latino background, age and sex.ResultsFifty-one percent of all participants had exhibited total periodontitis (mild, moderate or severe) per the CDC-AAP classification. Cubans and Central Americans exhibited the highest prevalence of moderate periodontitis (39.9 percent and 37.2 percent, respectively). Across all ages, Mexicans had the highest prevalence of PD across severity thresholds. Among those aged 18 through 44 years, Dominicans consistently had the lowest prevalence of AL at all severity thresholds.ConclusionsMeasures of periodontitis varied significantly by age, sex and Hispanic or Latino background among the four sampled Hispanic Community Health Study/Study of Latinos communities. Further analyses are needed to account for lifestyle, behavioral, demo- graphic and social factors, including those related to acculturation.Practical ImplicationsAggregating Hispanics and Latinos or using estimates from Mexicans may lead to substantial underestimation or overestimation of the burden of disease, thus leading to errors in the estimation of needed clinical and public health resources. This information will be useful in informing decisions from public health planning to patient-centered risk assessment.     

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.