Albandar 2002 Epidemiology North America

Periodontology 2000, Vol.
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
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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).
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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
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
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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
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
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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
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).
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
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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
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
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-
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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,
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-
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.
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-
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
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
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)
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
Dental calculus (subgingival) 60.6 49.9 51.1 75.6 73.4 55.1
Extent (% teeth per person)
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
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
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
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-
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
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
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
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.
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
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.
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
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). Hence, there is an
urgent need to investigate the epidemiology of peri-
Albandar
odontal diseases in Mexico in order to plan resource-
ful programs for the prevention and control of peri-
odontal disease in the Mexican population.
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