Cancer is seen more often in individuals with chronic in-flammatory conditions, which has led to the exploration oflinks between cancer and periodontitis. Tooth loss andpoor oral health also show relationships with several can-cers, although these are not clearly surrogates for periodon-titis. Current research has found no real way to control forconfounding factors such as smoking and socioeconomicstatus. Only one study met the threshold criteria for peri-odontitis, but it has been identified as a risk factor for oro-digestive and pancreatic cancer and possibly other cancers.

Discussion.—Few studies met the threshold set forperiodontitis and supported an association with any ofthe conditions investigated.

Clinical Significance.—A few basics need tobe addressed to clarify what might link peri-odontitis and systemic diseases. It is important

to reach a consensus on what constitutes peri-odontitis for future studies. The stringent defi-nition used in this review eliminated manystudies that might have contributed to supportassociations. In addition, longitudinal studiesthat focus specifically on riskwould be valuable.Because of the important effects of the studiedconditions on public health, efforts should bemade to clarify whether improved periodontalhealth can have systemic influences.

Linden GJ, Lyons A, Scannapieco FA: Periodontal systemic associa-tions: review of the evidence. J Clin Periodontol 40:S8-S19, 2013

Reprints available from G Linden, Periodontal Dept, School ofDentistry, Queen’s Univ, Grosvenor Rd, Belfast BT12 6BP, UK;e-mail: g.linden@qub.ac.uk

Periodontal DiseasesNational adult prevalence data

Background.—Periodontal disease is included as partof the Healthy People 2020 concerns, underscoring itsimportance as a public health problem in the UnitedStates. The National Health and Nutrition Examination Sur-vey (NHANES) has assessed the periodontal status of theUS population since 1960. Although the early surveysused visual evaluations to detect disease, later studieshave used probe measurements to assess pocket depth(PD) and gingival recession around teeth using variouspartial mouth periodontal examination (PMPE) protocols.As PMEP protocols have evolved, subsequent NHANEShave sampled up to three sites (mid-buccal, mesiobuccal,and distal sites). However, periodontitis is not evenlydistributed throughout the mouth, so prevalence esti-mates based on PMPE protocols tend to underestimate dis-ease in the population, which can be of significance.Efforts to improve the surveillance of periodontitis in USadults and the perceived need to establish accurate base-line data on periodontitis prevalence in the Unite Stateshas led to the inclusion of the full-mouth periodontal ex-amination (FMPE) protocol in the NHANES 2009-2010 cy-cle Probe measurements are collected from six sites pertooth for all teeth except third molars using this protocol.The data on periodontal status among US adults collectedduring the NHANES 2009-2010 were compared to thosecollected during earlier NHANES cycles.

Earlier NHANES Data.—Earlier versions of theNHANES used the PMPE protocols, testing from tworandomly selected quadrants of the mouth for PD and attwo sites per tooth (mid-buccal and mesiobuccal) forattachment loss (AL). The estimates for moderate or severeperiodontitis were 26% in NHANES III and 17% in NHANES1999-2004. AL of 3 mm or greater and PD of 4 mm of greaterin adults age 30 years or older was 53.1% and 23.1%, respec-tively, in the NHANES III. Combining the NHANES III andNHANES 1999-2004 data yielded total prevalences of19.5% and 27.1%, respectively, for AL R 3 mm and PD R4 mm.

NHANES 2009-2010 Data.—Adults age 30 years orolder had a total prevalence of periodontitis of 47.2%, rep-resenting about 65 million US adults. Prevalences of mild,moderate, and severe disease were 8.7%, 30.0%, and8.5%, respectively, for this age group. Total periodontitiswas 24.4% for adults age 30 to 34 years but rose to 70.1%for adults age 65 years or older. Men, Mexican Americans,persons with low educational status, those living at thegreatest poverty levels, and current smokers all had higherprevalences of periodontitis.

Among all adults, 86% had one or more sites with AL of 3mmor greater; the highest prevalence (96.7%) was found in

Volume 59 � Issue 1 � 2014 49

adults age 65 years or older. AL of 7 mm or greater in one ormore sites was seen at a greater prevalence among adultswith less than a high school education, whose rate was28.7% compared to the overall prevalence of 15%. MexicanAmerican adults had the highest prevalence of PD of 4 mmor greater in one or more teeth at 67.3% versus 41.0%among all adults. Considering all adults, 56.4% had an ALof 3 mm or greater in at least 5% of probed sites, and19.4% had this degree of AL in at least 30% of their probedsites. PD of 4 mm or greater was found in at least 5% of alltested sites in 18.7% of adults, and 4.1% had at least 30% ofthe tested sites affected. PD of 4mmor greater was noted inat least 5% of tested teeth in 32.0% of adults, and 13.6% hadthis degree of PD in 30% of the teeth.

AL severity generally increased with increasing age butPD severity tended to remain steady at 15% across agegroups. Both total and moderate periodontitis increasedwith increasing age in all groups of adults, but the preva-lence of mild and severe periodontitis was less than 15%for all age groups.

Discussion.—The FMPE approach yieldedmuch higherrates of periodontal disease and greater measures ofseverity among US adults than were obtained with thePMPE evaluations. In addition, the periodontitis burdenwas confirmed to affect various sociodemographic seg-ments of the adult US population disproportionately.Mexican Americans and Non-Hispanic blacks had the high-est prevalence of periodontitis. Increasing poverty levelsand lower education were associated with a higher preva-lence of periodontitis. The highest periodontitis prevalencerates were noted in Mexican Americans, adults with low

50 Dental Abstracts

education levels, adults at less than 100% of the federalpoverty level (FPL), and current smokers.

Clinical Significance.—FMPE data allow a bet-ter representation of persons, teeth, and sitesassessed and should yield a more accurate esti-mation of the prevalence of periodontitisamong US adults. The use of conservative casedefinitions for periodontitis is also a plus. Theestimates reported should rightly be consideredinterim national estimates, with at least 4 to 6years of data needed to affirm themwith respectto all the subgroups of adults in the UnitedStates. The NHANES confirms a high burden ofperiodontitis in US adults and disparities inprevalence relative to sociodemographic seg-ments. It is clear that there could be a substantialeconomic benefit to instituting prevention andtreatment interventions for this disease, partic-ularly among elderly persons. With the agingof populations, the problem will increase ifappropriate measures are not taken.

Eke PI, Dye BA, Wei L, et al: Prevalence of periodontitis in adults inthe United States: 2009 and 2010. J Dent Res 91:914-920, 2012

Reprints available from PI Eke, Div of Population Health, Natl Ctr forChronic Disease and Health Promotion, Ctrs for Disease Controland Prevention (CDC), Atlanta, GA 30341; e-mail: peke@cdc.gov

Adjunctive antimicrobial therapy

Background.—Left untreated, periodontal disease canlead to destruction of the tooth-supporting apparatusand eventually the tooth itself. A specific group of 10 and15 pathogenic bacterial species that adhere to toothsurfaces in biofilms shows significant associations withperiodontitis, but the approaches to treatment remainhighly nonspecific, consisting mainly of mechanicaldebridement (scaling and root planing [SRP]) of the rootsurface. This intervention has demonstrated long-termsuccess for many patients, although some do not respondadequately. SRP is limited by the inability to access somedeep, tortuous pockets and furcations, a lack of efficacyagainst some pathogens and oral niches, and the commondevelopment of secondary side effects such as gingivalrecession, loss of tooth substance, and dentin

hypersensitivity. To overcome some of these limitations,antimicrobial agents have been used adjunctively withSRP. The evidence supporting the adjunctive use of antimi-crobials, whether systemic or local, for the treatment ofperiodontitis were updated.

Systemic Antimicrobial Therapy.—Currently, systemicantimicrobial agents used adjunctively with SRP offerbenefits over SRP alone in terms of clinical attachment level(CAL) gains and reductions in probing pocket depths (PPD)in deep pockets. The changes range from 0.2 to 0.6 mm forCAL and 0.2 to 0.8 mm for PPD. Certain patients—thosewith deep pockets, progressive or highly active disease, orspecific microbiologic profiles—may see clinically relevantresults from the adjunctive use of antimicrobial agents.