Paul I. Eke

Purpose of Review This review provides an overview of the objectives, activities, and accomplishments of the CDC-AAP collaboration on public health aspects of periodontitis focusing mostly on surveillance. Dr. Robert Genco was co-chair of this effort. Recent Findings This initiative developed new standard periodontitis case definitions for surveillance and implemented for the first time a full-mouth periodontal examination protocol for NHANES 2009–2014. Measurements from this survey resulted in a significantly greater estimate of the national prevalence of periodontitis in US adults and improved our understanding of population risk factors associations with periodontitis. Notably, this initiative also developed, and validated by field-testing, a battery of eight questions for multivariable modeling of self-report measures for predicting periodontitis in populations. Summary This initiative resulted in significant improvements of surveillance of periodontitis and produced unique findings with important implications for advancing our understanding of population aspects of periodontitis in US adults at the national, state, and local levels. At long last, the world finally had a set of periodontitis case definitions that applied globally would enable valid comparisons between populations in different geographic settings and at different times.

The most important development in the epidemiology of periodontitis in the USA during the last decade is the result of improvements in survey methodologies and statistical modeling of periodontitis in adults. Most of these advancements have occurred as the direct outcome of work by the joint initiative known as the Periodontal Disease Surveillance Project by the Centers for Disease Control and Prevention and the American Academy of Periodontology that was established in 2006. This report summarizes some of the key findings of this important initiative and its impact on our knowledge of the epidemiology of periodontitis in US adults. This initiative first suggested new periodontitis case definitions for surveillance in 2007 and revised them slightly in 2012. This classification is now regarded as the global standard for periodontitis surveillance and is used worldwide. First, application of such a standard in reporting finally enables results from different researchers in different countries to be meaningfully compared. Second, this initiative tackled the concern that prior national surveys, which used partial‐mouth periodontal examination protocols, grossly underestimated the prevalence of periodontitis of potentially more than 50%. Consequently, because previous national surveys significantly underestimated the true prevalence of periodontitis, it is not possible to extrapolate any trend in periodontitis prevalence in the USA over time. Any difference calculated may not represent any actual change in periodontitis prevalence, but rather is a consequence of using different periodontal examination protocols. Finally, the initiative addressed the gap in the need for state and local data on periodontitis prevalence. Through the direct efforts of the Centers for Disease Control and Prevention and the American Academy of Periodontology initiative, full‐mouth periodontal probing at six sites around all nonthird molar teeth was included in the 6 years of National Health and Nutrition Examination Surveys from 2009‐2014, yielding complete data for 10 683 dentate community‐dwelling US adults aged 30 to 79 years. Applying the 2012 periodontitis case definitions to the 2009‐2014 National Health and Nutrition Examination Surveys data, the periodontitis prevalence turned out to be much greater than previously estimated, namely affecting 42.2% of the population with 7.8% of people experiencing severe periodontitis. It was also discovered that only the moderate type of periodontitis is driving the increase in periodontitis prevalence with age, not the mild or the severe types whose prevalence do not increase consistently with age, but remain ~ 10%‐15% in all age groups of 40 years and older. The greatest risk for having periodontitis of any type was seen in older people, in males, in minority race/ethnic groups, in poorer and less educated groups, and especially in cigarette smokers. The Centers for Disease Control and Prevention and the American Academy of Periodontology initiative reported, for the first time, the periodontitis prevalence estimated at both local and state levels, in addition to the national level. Also, this initiative developed and validated in field studies a set of eight items for self‐reported periodontitis for use in direct survey estimates of periodontitis prevalence in existing state‐based surveys. These items were also included in the 2009‐2014 National Health and Nutrition Examination Surveys for validation against clinically determined cases of periodontitis. Another novel result of this initiative is that, for the first time, the geographic distribution of practicing periodontists in relation to the geographic distribution of people with severe periodontitis is illustrated. In summary, the precise periodontitis prevalence and distribution among subgroups in the dentate US noninstitutionalized population aged 30‐79 years is better understood because of application of valid periodontitis case definitions to full‐mouth periodontal examination, in combination with reliable information on demographic and health‐related measures. We now can monitor the trend of periodontitis prevalence over time as well as guide public health preventive and intervention initiatives for the betterment of the health of the adult US population.

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

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

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

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

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