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Gingivitis and gingival recession in adults from high-fluoride and low-fluoride areas
Archs oral Bid. Voi. 17, pp. 12694277,
1972.
Peraamon Press. priatcd in Great
Britain.
GINGIVITIS AND GINGIVAL RECESSION IN ADULTS FROM HIGH-FLUORIDE AND LOWFLUORIDE AREAS J. J. MURRAY Department
of Children’s Dentistry, Institute of Dental Surgery, Eastman Dental Hospital, London WClX 8LD England
Summary-The prevalence of gingivitis and gingival recession in 1884 dentate adults, aged 15-65 yr, continuously resident in the natural fluoride area of Hartlepool (1.5 2.0 ppm F.) was compared with that in 2015 dentate adults from the low-fluoride town of York (0.15-0.28 ppm F.). The measurement of gingivitis was restricted to the anterior labial gingival sites, after the method described by JACKSON(1965). The prevalence of gingivitis did not vary with increasing age. Therefore, data for all age groups were combined. Eighty nine per cent in Hartlepool and 87 per cent in York had one or more gingival sites inflamed. In both communities, the slightly higher prevalence of gingivitis in males than in females disappeared when only those with good oral cleanliness were considered. In Hartlepool, the site prevalence of gingivitis was 37.2 per cent and in York 35.4 per cent. In those with good oral cleanliness, the site prevalence of gingivitis was 21.8 per cent in Hartlepool and 19.8 per cent in York. The maximum divergence between the two communities was 0.4 gingival units. No sex difference in the prevalence of gingival recession was observed in either community. Therefore, data for males and females were combined. In Hartlepool at 15-19 yr of age, 3 .O per cent were affected by gingival recession; at 60-65 yr, virtually 100 per cent were affected. The trend with age in York followed exactly the same pattern as that observed in Hartlepool. The percentage of teeth with gingival recession also increased steadily with age. In Hartlepool at 15-19 yr of age, 0.2 per cent of teeth had gingival recession. At 60-65 yr, 66.7 per cent of teeth were affected. The corresponding values in York were 0.2 per cent and 63.8 per cent. No significant differences were observed between Hartlepool and York data. It was concluded that fluoride in drinking water, at least up to the level of 2 ppm, has no effect of clinical signiticance on the prevalence of gingivitis or gingival recession in adults. INTRODUCTION THERE
is limited knowledge of the possible effect of fluoridated drinking water on the prevalence of periodontal disease. Commenting on this, the WORLD WORKSHOP IN PERIODONTICS (1966) states “The factual data on this point are small but fairly consistent and show that periodontal health improves as the fluoride intake increases.” Most of the studies on which this statement was based have been concerned with the prevalence of periodontal disease in children. There have been few surveys of the periodontal status of adults in fluoride and non-fluoride areas. RUSSELL (1957) used his Periodontal Index (RUSSELL, 1956) to assess periodontal disease in 379 adults continuously resident in Colorado Springs (fluoride concentration 2 *5 ppm in drinking water) and 144 adults resident in Boulder (fluoride-free). A significantly greater percentage of Colorado Springs residents were free from overt signs of disease. However, in those persons with periodontal disease, the severity of the disease was 1269
J. J.
1270
MURRAY
the same in both communities. ENGLANDER, KESEL and GUPTA (1963) examined 906 continuous residents of Aurora (1.2 ppm F.), aged 18-70 yr, and 948 residents in Rockford (0.1 ppm F.). The mean Periodontal Index (PI.) score for the Aurora community (O-69) was lower than that found in Rockford (0.84). The overall percentage of persons with no overt sign of periodontal disease was 15-l per cent in Aurora and 17.5 per cent in Rockford. These workers concluded that their findings did not provide a sufficient basis for the claim that lifelong consumption of fluoridated water has a direct deterrent effect upon periodontal disease. In both these surveys, periodontal disease was measured by the Periodontal Index, which is a weighted index giving minimal weight to gingivitis, and much greater weight to bone loss, The questions which need to be answered regarding the possible effect of fluoridated drinking water on periodontal disease are: firstly, does it have any long-term effect on the prevalence of gingivitis, and secondly, does it have any long-term effect on the prevalence of destructive forms of periodontal disease, involving irreversible loss of attachment of periodontal fibres. To answer these questions, it is necessary to measure the prevalence of gingivitis and loss of periodontal attachment separately. The purpose of this paper is to record the prevalence of gingivitis and gingival recession in adults living in high-fluoride and low-fluoride areas. MATERIALS
AND
METHODS
Clinical material A total of 1884 dentate adults, aged 1545 yr, continuously resident in Hartlepool, a natural fluoride area (1.5-2~0 ppm F.) was examined. A continuous resident was defined as a person who had been born in Hartlepool, had lived all his or her school Iife in the town, and had been away from the town during adult life for no more than 6 yr. A total of 2015 dentate adults from York, a lowfluoride area (0.15-0.2 ppm F), was examined for comparison. The number of males and females examined in each quinquennial age group in the two communities is recorded in Table 1. The sample was drawn from factories, offices and local authority establishments in the two towns and spanned the whole social scale; directors, professional people, whitecollar workers, skilled, semi-skilled and unskilled workers were examined. A detailed account of the method used to obtain the sample has been previously recorded (MURRAY, 1971). Overall, samples from the two communities were similar with respect to social class.
._ ,~__.._____
k3e
in years ~~_.
No. in group
Hartlepool .__...-..-..
___ Males
..Percentage with gingivitis
__._._I.__~~~
15-19 $jr;;
141 132
30-34
tzl
90.1 88.8 88.6
..-.
~_.~_ Females
No. in gr”Up
__~ %
York
_ Males
Percentage with gingivitis
_-.__-.._
No. in group
-._.
FelTl&S
-._..______
PWX#e gingivitis
No. in group
Percentage with gingivitis
-...___. ~__. __.
88.4 85.1 85.5
61 193 147
86.9 81 84.4.P
:::7
170
87.6
166
;;:y
89.0
:t
35-39
96
93.8
63
zz 50-54
z 2s
92.8 96.9 88.0
54 :;
$:I 90.9
182 184 ::
86.8 f%
55-59 60-65
32 12
93.8 83.3
20S
90.0 100.0
39
79.s
102 158 73
84.3 81-O
::
;;:;
:: ;:
92.7 93.0
;(;::
6
;;:;
PERIODONTAL
DISEASE IN ADULTS
FROM HIGH AND
LOW
FLUORIDE
AREAS
1271
The dental examinations were carried out in rooms set aside for the purpose in the various factories and establishments visited. Each person sat on a portable chair fitted with an adjustable head rest. An Anglepoise lamp was used to provide a consistent source of light. The gingival tissues were dried with a paper napkin before each examination. All examinations were carried out by the same examiner between September, 1968 and December, 1969. Standards of diagnosis and indices of measurement (i) Gingivitis. The examination was restricted to the labial surfaces of the gingiva associated with the incisor and canine teeth. The basic tissue units were those described by JACK.SON (1965), namely the ten papillae and twelve margins associated with the incisor and canine teeth. Gingivitis in a papilla or margin was only recorded if there was obvious redness or swelling at the site. This was a subjective assessment based on colour and degree of swelling. Mouth prevalence of gingivitis was defined as the proportion of people at each age group with one or more labial gingival sites present and inflamed. Site prevalence of gingivitis was detined as the number of labial sites affected by gingivitis, expressed as a proportion of the total number of sites present. (ii) Oral cleanliness. Three categories of oral cleanliness were recognized (JAMES et al., 1961). The assessment was confined to the labial surfaces of the incisor and canine teeth. Good-the teeth were clean. There was no sign of debris on the teeth when examined with a probe. Fair-there was some debris on the teeth but not sufficient to represent a poor standard of cleanliness. Poor-the teeth were dirty. There was considerable debris standing on the teeth. (iii) Gingival recession. Gingival recession was diagnosed if the amelo-cemental junction was visible on any aspect of a tooth. A periodontal probe was not used to aid diagnosis. Mouth prevalence of gingival recession was defined as the number of people with at least one tooth where the amelo-cemental junction was visible, expressed as a percentage of the total number of people in the age group. Tooth prevalence of gingival recession at any age group was determined as the number of teeth with gingival recession, expressed as a percentage of the total number of teeth present.
RESULTS (i) Prevalence of gingivitis by mouths
The prevalence of gingivitis in males and females in Hartlepool and York is recorded in Table 1. No trend with age was observed in either community so the age groups have been combined. In Hartlepool, the mean mouth prevalence of gingivitis in anterior labial gingival sites for males was 90.7 per cent and for females 87.8 per cent; this difference was statistically significant (p < 0 *05, x2 = 4.05) but clinically the difference was extremely small. No difference was observed between the mouth prevalence of gingivitis in York males (86.7 per cent) and York females (86.3 per cent). In subsequent analyses, the results for males and females have been combined. The mouth prevalence of gingivitis (sexes combined) is recorded in Table 2. In Hartlepool, mouth prevalence of gingivitis varied from 86.5 to 93 - 1 per cent; in York the range was from 82.6 to 90.4 per cent. The mean value in Hartlepool was 89 - 1 per cent and in York was 86 ~6 per cent. The difference was statistically signihcant (p < O-05, x2 = 5.47) but clinically the difference was extremely small. The prevalence of gingivitis in those with good oral cleanliness in the two communities is also recorded in Table 2. In both communities, the 15-19 yr group showed the lowest prevalence of gingivitis (78 -9 per cent in Hartlepool and 64.7 per cent in York) and the 50-54 yr age group showed the highest prevalence of gingivitis (87.0 per cent in Hartlepool and 8 1.0 per cent in York), but the numbers in the older age
J, J. MURRAY
1272 t-ABLE 2.
MOUTH PREVALENCE. OF GINGIVITIS BY AGE AND ORAL CLEANLINESS(SBXESCOHBINED)
No. in Broup
15-19 w24 25-29 30-34 35-39 2 55-59 60-65
:9” 181 174 159 112 123 47 52 17 Total 1884
York
Hartlc~ool
_-______ All people
Perc$nz3ge gingivitis 88.8 86.5 87.3
- .- .--._ Those with good oral cleanliness ..--_-___.-. No. in Perci;Z%e group gingivitis 237 “Z
ZE
ii;
90.2 91.9 89.4 92.3 88.2 y$y
57 i?i 21 8 ‘%i
78.9 75.0 78.9 81.9 86.6
All people .--.._ -_________. No. in P”‘c$eBe group gingivitis 163 305 266 221 Z%
g:;
264 136 105 45
YE
Total 2015
86.0 82.0 87-O
85.3 82.6 84.2 88.7 88.5 87.9 g:: 85.7 80.0 y;y
Those with good oral cleanliness No. in SoUP
t:: 121 129 1:: ‘i;: :i
Tgo?*
Pemage gingivitis 64-l 67.2 71.1 76.6 77.5 74.3 g:; 76.5 71.4 MeaIl 14.3
groups were too small to determine whether any definite trend occurred in either community. Therefore, the age groups have been combined. In Hartlepool, the mean value was 79.9 per cent, and in York 74.3 per cent. The difference was statistically significant @ < O*Ol, x2 = 7.69) but clinically the difference was extremely small. (ii) Prevalence o~gi~giuitis by sites The site prevalence of gingivitis in males and females in Hartlepool and York is recorded in Table 3. No trend with age was observed in either community so the age groups have been combined. In Hartlepool, the mean number of sites affected in males was 39.6 per cent and in females 35.6 per cent. The difference was statistically significant (p < 0.001, x2 = 65 *9) but in clinical terms was extremely small. The mean value for York males (37.0 per cent) was higher than that for York females (32-4 per cent). This difference was statistically significant (p < 0.001, x2 = 85.2) although clinically the difference was extremely small. This very small sex difference disappeared when only those people with good oral cleanliness were compared (Table 4). Therefore, data for males and females with good oral cleanliness have been combined. No trend with age was observed in Hartlepool, so the results for all ages were combined. The mean number of sites affected was 21.8 per cent. In York, the site prevalence of gingivitis rose from 15 45 per cent at 15-19 yr to 20.9 per cent at 30-34 yr and then stayed at this level to age 55-59 yr; combining all age groups, the site prevalence of gingivitis was 19.8 per cent. The difference between the communities was statistically significant (p < O*OOl,x2 = 23.3) but clinically the difference was only 0.4 gingival units. (iii) Prevalence ofgingival recession The prevalence of gingival recession in males and females in both Hartlepool and York is recorded in Table 5. There was no observable sex difference in either community and so data for males and females have been combined. In Hartlepool at 15-l 9 yr, 3 *Oper cent of people had one or more teeth affected. There was a steady
1273
PERIODONTAL DISEASE IN ADULTS PROM HIGH AND LOW FLUORIDE AREAS TABLE3. SIIZ PREVALENCE OF 01~0lvms Hartlepool
Age in
15-19 20-24 25-29
Malu
Females
Pert+Sites present ~$.a.;
Sites Pew+present ~g$s&~
3043 2818 ::z’:
%. g:
Kf ‘z: 619 205
g 31 .o 40.5 43.0
Total 16142
Mean 39.6
Total 23240
:z zz SO-54 ‘E?
BY AOEAND SEX York
-. Combined
Males
38.8 34.2 31.0
1308 1521
::‘:
3623 3282
:.‘:’
1104 951 433 348 95
31:s 32.6 32.8 29.5 39.1
2227 2495
::: 31.9 41.6 37.0 Meall 37.2
Total 25772
‘% 3809
% 300 Total 39382
40.1 34.9 35.8
1315 3104 4058
Age in years 15-19 :!% :z+ zz SO-54 55-59 60-65
Females
2192 ::;;
28.9 :;:;
3507 %Z
32.0 31.9 34.8
3517 3300
39.7 37.1
1055 1486
34.1
4512
36.6
3471 3310 1633 1430 634
:;:; 38.5 27.1 34.2
1528 1682
E’! 37:s 47.1 25.2 45.1
z: 4838 2342 1776 737
37.0 37.5 41.1 26.9 36.3
Mean 32.4
Total 39769
MeaIl 37.0
103 :z Total 13997
149 ::.;: 23.5 $1:
4315
23.1
3682 ‘% 925
20.5 22.7 25.4 19.5
Mean 35.4
York Combined
Males
Females
__ Sites Percqnt- Sites Percent- Sites PercentSites Percent- Sites Percentpresent y& present ;g.E; present ;g&te; present aawEeiEe present gait;
1121 867 1011
Percent.aaevtitt
37.2 36.1 35.2
Hartlepool Males
Combined ~_
Sites PeryntSites Percqnt- Sites Percqnt- Sites present a~geelte; present ;gege,“d” present zag::; present
zz! 1550
y;y
Females
Combined Sites Perceptpresent ;Ee;;ey
22.4
239
16.7
871
15.2
1110
15.5
z 1738 t;;:
19.6 22.1 24.5 21.6
1807 959 f%
15.2 16.9 19.0 22.4
1697 790 602 808
18.0 19.5 :::1:
2656 2697 2004 2160
17.0 17.7 20.9
3.2
1428 1563
:z .
;;7’
23.5
::;:
;;:;
%
21’o 21.1 15.4
zz
‘%
TO:::
‘I”,‘.“;
7158
%: 29.0 24.0 Mean 20.5
g:‘: 22.7 16.7 Mean 19.8
411 ;1:
30.4 17.0
z
20.1 19.7
1175
247 217 84 Total 6034
25.5 29.0 16.7 Mean 21.6
228 188 62 Total 12449
23.7 27.7 21.0 Meall 21.9
‘::: 405 146 Total 18483
24:6 28.4 18.5 Mean 21.8
422 Total 10568
497 Total 17726
rate of increase up to 40 yr of age, when approximately 75 per cent of mouths were affected, after which the rate of increase continuously reduced, until at the age of 60-65 years virtually 100 per cent of the population were affected by gingival recession. In York at 15-19 years of age, 1.8 per cent of mouths were affected. The trend with age in York followed exactly the same pattern as that found in Hartlepool, the York values being slightly lower than those obtained in Hartlepool until approximately 45 yr, after which age the values were effectivelythesame as those in Hartlepool. The percentage number of teeth affected by gingival recession in males and females of both communities is recorded in Table 6. Up to the age of 50-54 yr, there was no observable sex difference in either community. In the last two age groups, values for females were lower than for males in both communities, but the numbers of males and females were very small and these observed differences were likely to have been caused by the sample size. Therefore, values for the sexes have been combined. In Hartlepool at 15-19 years of age, O-2 per cent of teeth were affected. There was a steady
Hartlepool Males
Age in years
~No. in Percentgroup age with gingival recession
York
FUlXIl.% No. in group
Combined
Percentage with gingival recession
No. in group
Males
Percentage with gingival recession
15-19
141
0.7
449
3-8
590
3.1
20-24 25-29 30-34 35-39 4044 45-49 50-54 55-59 60-65
132 107 100
22.4 15.9 47.0
297 :4
z; !z
:8”:: 87.5 ‘%I
35.1 14.5 48.6 63.5 77.8 87.5 77.3 90.0 80.0
429 I81 174 159 123 112 fi
27.6 14.9 47.7 70.4 78.0 87.5 89.4 94.2 94.1
32 12
.
100.0
63 54 2
20 4
17
No. in Percentgroup age with gingival recession
1% 193 t70 166 184 182
II__.-__-._
Females
Combined
No. in Percentgroup age with gingival recession
I.6
102
21.8 6.8 45.3 60.8 77.7 86.3 94.6 95.3 97.4
158 73 51
2.0 17.8 6.3 27.5 40.5 68.6 82.9 88.4 90.0 100-O
:z 2: 20 6
No. in Percentgroup aaewith gingival recession
I63
1.8
266 305 221
2;:: 41.2 54.6 74.8 85 2 92.6
% 264 136 105 4s
::1:
rate of increase with age until, at 60-65 yr, 66 07 per cent of teeth were affected by gingival recession. In York at 15-19 yr of age, 0.2 per cent of teeth were affected; the rate of increase was exactly the same as that in Hartlepool until, at 60-65 yr, 63.8 per cent of teeth were affected by gingival recession.
Hartlepool
M&S Age in years
Teeth present
Percentage with gingival receuion
15-19 20-24 25-29
3763 3470 f:z
0.0 :‘:
;;I;; zz
231.5 1582
23.9 1119 43.7 29.6
55-59 50-54 60-65
*::I: 635 206
t::9” 75.7
Teeth present
York
.- -
Females
Combined
Percentagcwith gingival recession
Teeth present
Males
Percent~gewitb gingival recession
Teeth prosent
Females
Percentagewith gin&al recession
Teeth present
Combined
Percentage&b gingival recession
Teeth present
-
Petcentagewith gin&al recession
12039 E;:
0.3 2.0 7.5
15802 11197 4637
0.2 ::;
1589 3652 &ui
0.1 0.8 ;:;
2606 3930 1:::
0.2 0.7 3.5
4195 7582 6390
0.2 0.7 4.1
1773 1021
1%
ii:: 28.1 28.4
4291 3861 2400 2837
20.4 11.3 29.1 37.0
% 3644
la.6 27.1 37.1
1556 1705 1546
11.2 4.9 :::y
% 4938 5349
I:.:: 25 35.6
361 426 94
40.7 41.8 46.8
a79 %
42.4 2:::
% 1403 614
55.7 50.0 65.5
342 718 98
43.3 38.7 53.1
2296 1750 712
z: 63.8
.
I
DISCUSSION
The relationship of three variables, age, sex, standard of oral cleanliness, with the prevalence of gingivitis in anterior labial sites in Hartlepool and York, were measured. The prevalence of gingivitis was very high and was independent of age. The absence of debris, measured by a good oral cleanliness rating, was associated with less gingivitis. In those with good oral cleanliness, mouth prevalence was 80 per cent in Hartlepool and 74 per cent in York, a finding similar to that reported by SUTCLIEFE (1968) in a survey of ll-yr-old West Riding children. In his study, 85 per cent of children had gingivitis; when only those with good oral cleanliness was considered, the mouth prevalence of gingivitis fell to 74.9 per cent. The mouth prevalence of gingivitis in
PERIODONTAL
DISEASE
IN ADULTS
FROM
HIGH
AND
LOW
FLUORIDE
AREAS
1275
the present study was also very similar to that reported in 15 yr old children from Hartlepool and York (MURRAY,1969). JACKSON(1965), in a survey of adult females in Leeds, reported that mouth prevalence of gingivitis was approximately 60 per cent up to the age of 25 yr. After this age, mouth prevalence of gingivitis increased to approximately 90 per cent and maintained this value at least up to the age of 44 yr. Data from Hartlepool and York followed exactly the same trend, but Hartlepool values were statistically higher than York values, although in clinical terms the differences were insignificant. The index of measurement used, mouth prevalence of gingivitis, is really too insensitive to explain very small differences between groups; a more sensitive unit of measurement is the prevalence of gingivitis in individual sites. There was no discernable relationship between age after 15 yr and the site prevalence of gingivitis in either community. Data for all ages could therefore be combined. In Hartlepool, the site prevalence of gingivitis for all ages was 37 *2 per cent and in York it was 35 *4 per cent. The small sex differences observed in both communities disappeared when only those males and females with good oral cleanliness were compared. Therefore, the apparent sex differences were almost certainly due to a slightly higher standard of oral cleanliness in females than males. The absence of debris was associated with a lower site-prevalence of gingivitis. In those with good oral cleanliness, the site prevalence of gingivitis was approximately 20 per cent in both communities. The site prevalence of gingivitis in Hartlepool was effectively the same as in York, for all people and for those with good oral cleanliness. The maximum divergence between the two sets of results was 0.4 gingival units, which was clinically insignificant. It was therefore concluded that fluoride drinking water at least up to the level of 2 ppm has no effect of clinical significance on the prevalence of gingivitis. This confirmed the previous finding in 15-yr-old children in Hartlepool and York (MURRAY, 1969). No differences were observed, between Hartlepool and York data, in the prevalence of gingival recession, which was independent of sex but strongly associated with age. This confirms the findings of KITCHIN (1941), SANDLERand STAHL (1954), STAHL and MORRIS(1955), SCHEI et al. (1959) and GORMAN(1967). In particular, the results of the present study were very similar to those recorded by SANDLERand STAHL. (1954). In their study, at 61-70 yr of age, 64.9 per cent of teeth had gingival recession ; in the present study, at 60-65 yr of age 64.6 per cent of teeth were affected. The observed association between age and gingival recession does not necessarily prove a cause and effect relationship. However, there does seem to be a need for further investigation into factors affecting gingival recession in different communities. Acknowledgements-This study was facilitated by a research grant from the Joseph Rowntree Memorial Trust. I am indebted to Professor D. JACKSON,University of Leeds Dental School, for his encouragement and direction. I would also like to thank Dr. H. MILLIGAN, Medical Officer of Health, Hartlepool. Dr. R. W. M. MOORE, Medical Officer of Health, York, and the management and staff of all establishments visited for their kind help and co-operation.
1276
J. J. MURRAY R&urn&La prevalence des gingivites et du dechaussement gingival chez 1884 sujets adultes, ages de 15-65 am, habitant depuis toujours la region naturellement fluoruree de Hartlepool (1,5-2,0 ppm de F) est comparee a celle de 2015 sujets ad&es habitant la ville peu fluoruree de York (0,15-0,28 ppm de F). Le degre de gingivite n’a et& determine que dans les regions gingivales vestibulaires anterieures, d’apres la methode d&rite par JACKSON (1965). La prevalence de la gingivite ne varie pas avec l’augmentation de Page. Par suite, les resultats de tous les groupes d’age ont CtCmelanges. Quatre vingt neuf pour cent, a Hartlepool, et 87 pour cent a York presentent une inflammation au niveau d’une ou plusieurs unites gingivales. Dans les deux villes, la prevalence de gingivites, legerement plus Clevee chez les hommes, disparait lorsqu’on ne retient que les sujets avec une bonne hygiene. A Hartlepool la prevalence de localisation des gingivites est de 37,2 pour cent et a York elle est de 35,4 pour cent. Chez les sujets, a bonne hygiene buccale, cette prevalence est de 21,8 pour cent a Hartlepool et de 19,8 pour cent a York. La difference maximale entre les deux villes est 0,4 unite gingivale. Aucune difference selon le sexe n’est observee dans les deux villes concernant le dechaussement. Les resultats des hommes et des femmes ont par suite et6 melanges A Hartlepool, a Page de 15-19 ans, 3,0 pour cent des sujets presentent du dechaussement: a 60-65 ans, 100 pour cent des sujets sont pratiquement atteints. Cette variation en fonction de Page est identique a York. Le pourcentage de dents dkhausses augmente progressivement avec l’age. A Hartlepool, a 15-19 ans, 0,2 pour cent des dents sont dechaussees. A 6&66 ans, 66,7 pour cent des dents sont atteintes. Les valeurs correspondantes a York sont respectivement de 0.2 et 63,8 pour cent. Aucune difference significative n’est observee entre les deux villes. 11en ressort que le fluor dans l’eau potable, au moins a des concentrations de 2 ppm, n’a pas d’effet clinique sur la prevalence de la gingivite ou le dechaussement chez l’adulte.
Zusammenfassung-Es wurde die Hlufigkeit von Gingivitis und Gingivaretraktionen bei 1884 bezahnten Erwachsenen zwischen 15 und 65 Jahren, die standig in der Gegend von Hartlepool (mit 1,5-2,0 ppm natiirlichem Fluorid) wohnten, mit der Gingivitishlufigkeit von 2015 bezahnten Erwachsenen aus der Stadt York mit dem niedrigen Fluoridgehalt von 0,15-0,28 ppm F verglichen. Die Bestimmung der Gingivitis wurde auf die anterioren labialen Gingivaabschnitte nach der von JACKSON (1965) beschriebenen Methode beschrankt. Die Hlufigkeit der Gingivitis veranderte sich mit ansteigendem Alter nicht. Deshalb wurden die Ergebnisse fiir alle Altersgruppen kombiniert. In Hartlepool hatten 98 Prozent und in York 87 Prozent einen oder mehr entziindete Gingivaabschnitte. In beiden Gemeinden verschwand die leicht hijhere Gingivitishlufigkeit bei Mannem gegentiber der bei Frauen, wenn lediglich die Personen mit guter Mundhygiene berticksichtigt wurden. In Hartlepool betrug die Lokalisationspravalenz der Gingivitis 37,2 Prozent, in York 35,4 Prozent. Bei jenen Personen mit guter Mundhygiene betrug die entsprechende Gingivitispravalenz 21.8 Prozent fur Hartlepool und 19,8 Prozent fur York. Die maximale Divergenz zwischen beiden Gemeinden betrug 0,4 Gingivaeinheiten. In keiner der Gemeinden 1ieB sich ein Geschlechtsunterschied beziiglich der Pravalenz von Gingivaretraktionen feststellen. Deshalb wurden die Ergebnisseftir Manner und Frauen kombiniert. In Hartlepool waren 3 Prozent der 15-19 Jahre alten Personen mit Gingivaretraktion behaftet; in der Altersgruppe 6@-65 Jahre waren dies 100 Prozent. Genau die gleichen Alterszusammenhange waren in York zu erkermen. Auch der Prozentsatz van Zlhnen mit gingivalen Retraktionen wuchs mit dem Alter standig an. Bei den 15-19 Jahre alten Personen aus Hartlepool hatten 0,2 Prozent der ZBhne gingivale Retraktionen. Bei den 60-65 Jahre alten Menschen waren 66,7 Prozent aller Zahne behaftet. Die entsprechenden Werte fur York betrugen 0,2 Prozent bzw. 63,8 Prozent. Zwischen den Ergebnissen aus Hartlepool und York waren keine signifikanten Unterschiede zu beobachten. Daraus wird der Schlug gezogen, dal3 Fluorid im Trinkwasser bis zur Konzentration von 2 ppm keine Auswirkungen auf die klinische Erscheinung und Hlutigkeit von Gingivitis und Gingivaretraktionen der Erwachsenen entfaltet.
PERIOIXINTAL DISEASEIN ADULTSFROM HIGH AND
LOW
FLUORIDE
AREAS
1277
REFERENCES
ENGLANDER,H. R., KESEL, R. G. and GUPTA, O.P. 1963. Effect of natural fluoride on periodontal health of adults. Am. J. publ. Hlth 53, 1233-1241. GORMAN,W. J., 1967. Prevalence and etiology of gingival recession. J. Periodont. 38, 316-322. JACKSON.D. 1956. The measurement of gingivitis. Br. dent. J. 118, 521-527. - JAMES,P: M. C., JACKSON,D., SLACK, G. L. and LAWTON,F. E.‘l961. Gingival health and dental cleanliness in English school children. Archs oral Biol. 3, 57-66. KITCHIN, P. C. 1941. The prevalence of tooth root exposure and the relation of the extent of such exposure to the degree of abrasion in different age classes. J. dent. Res. 20, 565-581. MURRAY,J. J. 1969. Gingivitis in 15 year old children from high fluoride and low fluoride areas. Archs oral Biol. 14, 951-957. MURRAY, J. J. 1971. Adult dental health in fluoride and non-fluoride areas. Part l-Mean DMF values by age. Br. dent. J. 131, 391-395. RUSSELL,A. L. 1956. A system of classifying and scoring for prevalence surveys of periodontal disease. J. dent. Res. 35, 350-359. RUSSELL,A. L. 1957. Fluoride domestic water and periodontal disease. Am. J. publ. HIth 47, 688694. RUSSELL,A. L. 1960. Indices for recording periodontal disease. World Health Organization. Expert committee on dental health (periodontal disease). W.H.O. Geneva. SANDLER,H. C. and STAHL,S. S. 1954. The influence of generalized diseases on clinical manifestations of periodontal disease. J. Am. dent. Ass. 49, 656-667. SCHEI, O., WAERHAUG,J., L~VDAL, A. and ARNo, A. 1959. Oral conditions among army personnel at the army engineer centre. J. Periodont. 26, 180-185. SUTCLIFFE,P. 1968. Chronic anterior gingivitis: an epidemiological study in school children. Br. dent. J. K&47-55. WORLD WORKSHOPIN PERIODONTICS 1966. University of Michigan, U.S.A. p. 168.
1972.
Peraamon Press. priatcd in Great
Britain.
GINGIVITIS AND GINGIVAL RECESSION IN ADULTS FROM HIGH-FLUORIDE AND LOWFLUORIDE AREAS J. J. MURRAY Department
of Children’s Dentistry, Institute of Dental Surgery, Eastman Dental Hospital, London WClX 8LD England
Summary-The prevalence of gingivitis and gingival recession in 1884 dentate adults, aged 15-65 yr, continuously resident in the natural fluoride area of Hartlepool (1.5 2.0 ppm F.) was compared with that in 2015 dentate adults from the low-fluoride town of York (0.15-0.28 ppm F.). The measurement of gingivitis was restricted to the anterior labial gingival sites, after the method described by JACKSON(1965). The prevalence of gingivitis did not vary with increasing age. Therefore, data for all age groups were combined. Eighty nine per cent in Hartlepool and 87 per cent in York had one or more gingival sites inflamed. In both communities, the slightly higher prevalence of gingivitis in males than in females disappeared when only those with good oral cleanliness were considered. In Hartlepool, the site prevalence of gingivitis was 37.2 per cent and in York 35.4 per cent. In those with good oral cleanliness, the site prevalence of gingivitis was 21.8 per cent in Hartlepool and 19.8 per cent in York. The maximum divergence between the two communities was 0.4 gingival units. No sex difference in the prevalence of gingival recession was observed in either community. Therefore, data for males and females were combined. In Hartlepool at 15-19 yr of age, 3 .O per cent were affected by gingival recession; at 60-65 yr, virtually 100 per cent were affected. The trend with age in York followed exactly the same pattern as that observed in Hartlepool. The percentage of teeth with gingival recession also increased steadily with age. In Hartlepool at 15-19 yr of age, 0.2 per cent of teeth had gingival recession. At 60-65 yr, 66.7 per cent of teeth were affected. The corresponding values in York were 0.2 per cent and 63.8 per cent. No significant differences were observed between Hartlepool and York data. It was concluded that fluoride in drinking water, at least up to the level of 2 ppm, has no effect of clinical signiticance on the prevalence of gingivitis or gingival recession in adults. INTRODUCTION THERE
is limited knowledge of the possible effect of fluoridated drinking water on the prevalence of periodontal disease. Commenting on this, the WORLD WORKSHOP IN PERIODONTICS (1966) states “The factual data on this point are small but fairly consistent and show that periodontal health improves as the fluoride intake increases.” Most of the studies on which this statement was based have been concerned with the prevalence of periodontal disease in children. There have been few surveys of the periodontal status of adults in fluoride and non-fluoride areas. RUSSELL (1957) used his Periodontal Index (RUSSELL, 1956) to assess periodontal disease in 379 adults continuously resident in Colorado Springs (fluoride concentration 2 *5 ppm in drinking water) and 144 adults resident in Boulder (fluoride-free). A significantly greater percentage of Colorado Springs residents were free from overt signs of disease. However, in those persons with periodontal disease, the severity of the disease was 1269
J. J.
1270
MURRAY
the same in both communities. ENGLANDER, KESEL and GUPTA (1963) examined 906 continuous residents of Aurora (1.2 ppm F.), aged 18-70 yr, and 948 residents in Rockford (0.1 ppm F.). The mean Periodontal Index (PI.) score for the Aurora community (O-69) was lower than that found in Rockford (0.84). The overall percentage of persons with no overt sign of periodontal disease was 15-l per cent in Aurora and 17.5 per cent in Rockford. These workers concluded that their findings did not provide a sufficient basis for the claim that lifelong consumption of fluoridated water has a direct deterrent effect upon periodontal disease. In both these surveys, periodontal disease was measured by the Periodontal Index, which is a weighted index giving minimal weight to gingivitis, and much greater weight to bone loss, The questions which need to be answered regarding the possible effect of fluoridated drinking water on periodontal disease are: firstly, does it have any long-term effect on the prevalence of gingivitis, and secondly, does it have any long-term effect on the prevalence of destructive forms of periodontal disease, involving irreversible loss of attachment of periodontal fibres. To answer these questions, it is necessary to measure the prevalence of gingivitis and loss of periodontal attachment separately. The purpose of this paper is to record the prevalence of gingivitis and gingival recession in adults living in high-fluoride and low-fluoride areas. MATERIALS
AND
METHODS
Clinical material A total of 1884 dentate adults, aged 1545 yr, continuously resident in Hartlepool, a natural fluoride area (1.5-2~0 ppm F.) was examined. A continuous resident was defined as a person who had been born in Hartlepool, had lived all his or her school Iife in the town, and had been away from the town during adult life for no more than 6 yr. A total of 2015 dentate adults from York, a lowfluoride area (0.15-0.2 ppm F), was examined for comparison. The number of males and females examined in each quinquennial age group in the two communities is recorded in Table 1. The sample was drawn from factories, offices and local authority establishments in the two towns and spanned the whole social scale; directors, professional people, whitecollar workers, skilled, semi-skilled and unskilled workers were examined. A detailed account of the method used to obtain the sample has been previously recorded (MURRAY, 1971). Overall, samples from the two communities were similar with respect to social class.
._ ,~__.._____
k3e
in years ~~_.
No. in group
Hartlepool .__...-..-..
___ Males
..Percentage with gingivitis
__._._I.__~~~
15-19 $jr;;
141 132
30-34
tzl
90.1 88.8 88.6
..-.
~_.~_ Females
No. in gr”Up
__~ %
York
_ Males
Percentage with gingivitis
_-.__-.._
No. in group
-._.
FelTl&S
-._..______
PWX#e gingivitis
No. in group
Percentage with gingivitis
-...___. ~__. __.
88.4 85.1 85.5
61 193 147
86.9 81 84.4.P
:::7
170
87.6
166
;;:y
89.0
:t
35-39
96
93.8
63
zz 50-54
z 2s
92.8 96.9 88.0
54 :;
$:I 90.9
182 184 ::
86.8 f%
55-59 60-65
32 12
93.8 83.3
20S
90.0 100.0
39
79.s
102 158 73
84.3 81-O
::
;;:;
:: ;:
92.7 93.0
;(;::
6
;;:;
PERIODONTAL
DISEASE IN ADULTS
FROM HIGH AND
LOW
FLUORIDE
AREAS
1271
The dental examinations were carried out in rooms set aside for the purpose in the various factories and establishments visited. Each person sat on a portable chair fitted with an adjustable head rest. An Anglepoise lamp was used to provide a consistent source of light. The gingival tissues were dried with a paper napkin before each examination. All examinations were carried out by the same examiner between September, 1968 and December, 1969. Standards of diagnosis and indices of measurement (i) Gingivitis. The examination was restricted to the labial surfaces of the gingiva associated with the incisor and canine teeth. The basic tissue units were those described by JACK.SON (1965), namely the ten papillae and twelve margins associated with the incisor and canine teeth. Gingivitis in a papilla or margin was only recorded if there was obvious redness or swelling at the site. This was a subjective assessment based on colour and degree of swelling. Mouth prevalence of gingivitis was defined as the proportion of people at each age group with one or more labial gingival sites present and inflamed. Site prevalence of gingivitis was detined as the number of labial sites affected by gingivitis, expressed as a proportion of the total number of sites present. (ii) Oral cleanliness. Three categories of oral cleanliness were recognized (JAMES et al., 1961). The assessment was confined to the labial surfaces of the incisor and canine teeth. Good-the teeth were clean. There was no sign of debris on the teeth when examined with a probe. Fair-there was some debris on the teeth but not sufficient to represent a poor standard of cleanliness. Poor-the teeth were dirty. There was considerable debris standing on the teeth. (iii) Gingival recession. Gingival recession was diagnosed if the amelo-cemental junction was visible on any aspect of a tooth. A periodontal probe was not used to aid diagnosis. Mouth prevalence of gingival recession was defined as the number of people with at least one tooth where the amelo-cemental junction was visible, expressed as a percentage of the total number of people in the age group. Tooth prevalence of gingival recession at any age group was determined as the number of teeth with gingival recession, expressed as a percentage of the total number of teeth present.
RESULTS (i) Prevalence of gingivitis by mouths
The prevalence of gingivitis in males and females in Hartlepool and York is recorded in Table 1. No trend with age was observed in either community so the age groups have been combined. In Hartlepool, the mean mouth prevalence of gingivitis in anterior labial gingival sites for males was 90.7 per cent and for females 87.8 per cent; this difference was statistically significant (p < 0 *05, x2 = 4.05) but clinically the difference was extremely small. No difference was observed between the mouth prevalence of gingivitis in York males (86.7 per cent) and York females (86.3 per cent). In subsequent analyses, the results for males and females have been combined. The mouth prevalence of gingivitis (sexes combined) is recorded in Table 2. In Hartlepool, mouth prevalence of gingivitis varied from 86.5 to 93 - 1 per cent; in York the range was from 82.6 to 90.4 per cent. The mean value in Hartlepool was 89 - 1 per cent and in York was 86 ~6 per cent. The difference was statistically signihcant (p < O-05, x2 = 5.47) but clinically the difference was extremely small. The prevalence of gingivitis in those with good oral cleanliness in the two communities is also recorded in Table 2. In both communities, the 15-19 yr group showed the lowest prevalence of gingivitis (78 -9 per cent in Hartlepool and 64.7 per cent in York) and the 50-54 yr age group showed the highest prevalence of gingivitis (87.0 per cent in Hartlepool and 8 1.0 per cent in York), but the numbers in the older age
J, J. MURRAY
1272 t-ABLE 2.
MOUTH PREVALENCE. OF GINGIVITIS BY AGE AND ORAL CLEANLINESS(SBXESCOHBINED)
No. in Broup
15-19 w24 25-29 30-34 35-39 2 55-59 60-65
:9” 181 174 159 112 123 47 52 17 Total 1884
York
Hartlc~ool
_-______ All people
Perc$nz3ge gingivitis 88.8 86.5 87.3
- .- .--._ Those with good oral cleanliness ..--_-___.-. No. in Perci;Z%e group gingivitis 237 “Z
ZE
ii;
90.2 91.9 89.4 92.3 88.2 y$y
57 i?i 21 8 ‘%i
78.9 75.0 78.9 81.9 86.6
All people .--.._ -_________. No. in P”‘c$eBe group gingivitis 163 305 266 221 Z%
g:;
264 136 105 45
YE
Total 2015
86.0 82.0 87-O
85.3 82.6 84.2 88.7 88.5 87.9 g:: 85.7 80.0 y;y
Those with good oral cleanliness No. in SoUP
t:: 121 129 1:: ‘i;: :i
Tgo?*
Pemage gingivitis 64-l 67.2 71.1 76.6 77.5 74.3 g:; 76.5 71.4 MeaIl 14.3
groups were too small to determine whether any definite trend occurred in either community. Therefore, the age groups have been combined. In Hartlepool, the mean value was 79.9 per cent, and in York 74.3 per cent. The difference was statistically significant @ < O*Ol, x2 = 7.69) but clinically the difference was extremely small. (ii) Prevalence o~gi~giuitis by sites The site prevalence of gingivitis in males and females in Hartlepool and York is recorded in Table 3. No trend with age was observed in either community so the age groups have been combined. In Hartlepool, the mean number of sites affected in males was 39.6 per cent and in females 35.6 per cent. The difference was statistically significant (p < 0.001, x2 = 65 *9) but in clinical terms was extremely small. The mean value for York males (37.0 per cent) was higher than that for York females (32-4 per cent). This difference was statistically significant (p < 0.001, x2 = 85.2) although clinically the difference was extremely small. This very small sex difference disappeared when only those people with good oral cleanliness were compared (Table 4). Therefore, data for males and females with good oral cleanliness have been combined. No trend with age was observed in Hartlepool, so the results for all ages were combined. The mean number of sites affected was 21.8 per cent. In York, the site prevalence of gingivitis rose from 15 45 per cent at 15-19 yr to 20.9 per cent at 30-34 yr and then stayed at this level to age 55-59 yr; combining all age groups, the site prevalence of gingivitis was 19.8 per cent. The difference between the communities was statistically significant (p < O*OOl,x2 = 23.3) but clinically the difference was only 0.4 gingival units. (iii) Prevalence ofgingival recession The prevalence of gingival recession in males and females in both Hartlepool and York is recorded in Table 5. There was no observable sex difference in either community and so data for males and females have been combined. In Hartlepool at 15-l 9 yr, 3 *Oper cent of people had one or more teeth affected. There was a steady
1273
PERIODONTAL DISEASE IN ADULTS PROM HIGH AND LOW FLUORIDE AREAS TABLE3. SIIZ PREVALENCE OF 01~0lvms Hartlepool
Age in
15-19 20-24 25-29
Malu
Females
Pert+Sites present ~$.a.;
Sites Pew+present ~g$s&~
3043 2818 ::z’:
%. g:
Kf ‘z: 619 205
g 31 .o 40.5 43.0
Total 16142
Mean 39.6
Total 23240
:z zz SO-54 ‘E?
BY AOEAND SEX York
-. Combined
Males
38.8 34.2 31.0
1308 1521
::‘:
3623 3282
:.‘:’
1104 951 433 348 95
31:s 32.6 32.8 29.5 39.1
2227 2495
::: 31.9 41.6 37.0 Meall 37.2
Total 25772
‘% 3809
% 300 Total 39382
40.1 34.9 35.8
1315 3104 4058
Age in years 15-19 :!% :z+ zz SO-54 55-59 60-65
Females
2192 ::;;
28.9 :;:;
3507 %Z
32.0 31.9 34.8
3517 3300
39.7 37.1
1055 1486
34.1
4512
36.6
3471 3310 1633 1430 634
:;:; 38.5 27.1 34.2
1528 1682
E’! 37:s 47.1 25.2 45.1
z: 4838 2342 1776 737
37.0 37.5 41.1 26.9 36.3
Mean 32.4
Total 39769
MeaIl 37.0
103 :z Total 13997
149 ::.;: 23.5 $1:
4315
23.1
3682 ‘% 925
20.5 22.7 25.4 19.5
Mean 35.4
York Combined
Males
Females
__ Sites Percqnt- Sites Percent- Sites PercentSites Percent- Sites Percentpresent y& present ;g.E; present ;g&te; present aawEeiEe present gait;
1121 867 1011
Percent.aaevtitt
37.2 36.1 35.2
Hartlepool Males
Combined ~_
Sites PeryntSites Percqnt- Sites Percqnt- Sites present a~geelte; present ;gege,“d” present zag::; present
zz! 1550
y;y
Females
Combined Sites Perceptpresent ;Ee;;ey
22.4
239
16.7
871
15.2
1110
15.5
z 1738 t;;:
19.6 22.1 24.5 21.6
1807 959 f%
15.2 16.9 19.0 22.4
1697 790 602 808
18.0 19.5 :::1:
2656 2697 2004 2160
17.0 17.7 20.9
3.2
1428 1563
:z .
;;7’
23.5
::;:
;;:;
%
21’o 21.1 15.4
zz
‘%
TO:::
‘I”,‘.“;
7158
%: 29.0 24.0 Mean 20.5
g:‘: 22.7 16.7 Mean 19.8
411 ;1:
30.4 17.0
z
20.1 19.7
1175
247 217 84 Total 6034
25.5 29.0 16.7 Mean 21.6
228 188 62 Total 12449
23.7 27.7 21.0 Meall 21.9
‘::: 405 146 Total 18483
24:6 28.4 18.5 Mean 21.8
422 Total 10568
497 Total 17726
rate of increase up to 40 yr of age, when approximately 75 per cent of mouths were affected, after which the rate of increase continuously reduced, until at the age of 60-65 years virtually 100 per cent of the population were affected by gingival recession. In York at 15-19 years of age, 1.8 per cent of mouths were affected. The trend with age in York followed exactly the same pattern as that found in Hartlepool, the York values being slightly lower than those obtained in Hartlepool until approximately 45 yr, after which age the values were effectivelythesame as those in Hartlepool. The percentage number of teeth affected by gingival recession in males and females of both communities is recorded in Table 6. Up to the age of 50-54 yr, there was no observable sex difference in either community. In the last two age groups, values for females were lower than for males in both communities, but the numbers of males and females were very small and these observed differences were likely to have been caused by the sample size. Therefore, values for the sexes have been combined. In Hartlepool at 15-19 years of age, O-2 per cent of teeth were affected. There was a steady
Hartlepool Males
Age in years
~No. in Percentgroup age with gingival recession
York
FUlXIl.% No. in group
Combined
Percentage with gingival recession
No. in group
Males
Percentage with gingival recession
15-19
141
0.7
449
3-8
590
3.1
20-24 25-29 30-34 35-39 4044 45-49 50-54 55-59 60-65
132 107 100
22.4 15.9 47.0
297 :4
z; !z
:8”:: 87.5 ‘%I
35.1 14.5 48.6 63.5 77.8 87.5 77.3 90.0 80.0
429 I81 174 159 123 112 fi
27.6 14.9 47.7 70.4 78.0 87.5 89.4 94.2 94.1
32 12
.
100.0
63 54 2
20 4
17
No. in Percentgroup age with gingival recession
1% 193 t70 166 184 182
II__.-__-._
Females
Combined
No. in Percentgroup age with gingival recession
I.6
102
21.8 6.8 45.3 60.8 77.7 86.3 94.6 95.3 97.4
158 73 51
2.0 17.8 6.3 27.5 40.5 68.6 82.9 88.4 90.0 100-O
:z 2: 20 6
No. in Percentgroup aaewith gingival recession
I63
1.8
266 305 221
2;:: 41.2 54.6 74.8 85 2 92.6
% 264 136 105 4s
::1:
rate of increase with age until, at 60-65 yr, 66 07 per cent of teeth were affected by gingival recession. In York at 15-19 yr of age, 0.2 per cent of teeth were affected; the rate of increase was exactly the same as that in Hartlepool until, at 60-65 yr, 63.8 per cent of teeth were affected by gingival recession.
Hartlepool
M&S Age in years
Teeth present
Percentage with gingival receuion
15-19 20-24 25-29
3763 3470 f:z
0.0 :‘:
;;I;; zz
231.5 1582
23.9 1119 43.7 29.6
55-59 50-54 60-65
*::I: 635 206
t::9” 75.7
Teeth present
York
.- -
Females
Combined
Percentagcwith gingival recession
Teeth present
Males
Percent~gewitb gingival recession
Teeth prosent
Females
Percentagewith gin&al recession
Teeth present
Combined
Percentage&b gingival recession
Teeth present
-
Petcentagewith gin&al recession
12039 E;:
0.3 2.0 7.5
15802 11197 4637
0.2 ::;
1589 3652 &ui
0.1 0.8 ;:;
2606 3930 1:::
0.2 0.7 3.5
4195 7582 6390
0.2 0.7 4.1
1773 1021
1%
ii:: 28.1 28.4
4291 3861 2400 2837
20.4 11.3 29.1 37.0
% 3644
la.6 27.1 37.1
1556 1705 1546
11.2 4.9 :::y
% 4938 5349
I:.:: 25 35.6
361 426 94
40.7 41.8 46.8
a79 %
42.4 2:::
% 1403 614
55.7 50.0 65.5
342 718 98
43.3 38.7 53.1
2296 1750 712
z: 63.8
.
I
DISCUSSION
The relationship of three variables, age, sex, standard of oral cleanliness, with the prevalence of gingivitis in anterior labial sites in Hartlepool and York, were measured. The prevalence of gingivitis was very high and was independent of age. The absence of debris, measured by a good oral cleanliness rating, was associated with less gingivitis. In those with good oral cleanliness, mouth prevalence was 80 per cent in Hartlepool and 74 per cent in York, a finding similar to that reported by SUTCLIEFE (1968) in a survey of ll-yr-old West Riding children. In his study, 85 per cent of children had gingivitis; when only those with good oral cleanliness was considered, the mouth prevalence of gingivitis fell to 74.9 per cent. The mouth prevalence of gingivitis in
PERIODONTAL
DISEASE
IN ADULTS
FROM
HIGH
AND
LOW
FLUORIDE
AREAS
1275
the present study was also very similar to that reported in 15 yr old children from Hartlepool and York (MURRAY,1969). JACKSON(1965), in a survey of adult females in Leeds, reported that mouth prevalence of gingivitis was approximately 60 per cent up to the age of 25 yr. After this age, mouth prevalence of gingivitis increased to approximately 90 per cent and maintained this value at least up to the age of 44 yr. Data from Hartlepool and York followed exactly the same trend, but Hartlepool values were statistically higher than York values, although in clinical terms the differences were insignificant. The index of measurement used, mouth prevalence of gingivitis, is really too insensitive to explain very small differences between groups; a more sensitive unit of measurement is the prevalence of gingivitis in individual sites. There was no discernable relationship between age after 15 yr and the site prevalence of gingivitis in either community. Data for all ages could therefore be combined. In Hartlepool, the site prevalence of gingivitis for all ages was 37 *2 per cent and in York it was 35 *4 per cent. The small sex differences observed in both communities disappeared when only those males and females with good oral cleanliness were compared. Therefore, the apparent sex differences were almost certainly due to a slightly higher standard of oral cleanliness in females than males. The absence of debris was associated with a lower site-prevalence of gingivitis. In those with good oral cleanliness, the site prevalence of gingivitis was approximately 20 per cent in both communities. The site prevalence of gingivitis in Hartlepool was effectively the same as in York, for all people and for those with good oral cleanliness. The maximum divergence between the two sets of results was 0.4 gingival units, which was clinically insignificant. It was therefore concluded that fluoride drinking water at least up to the level of 2 ppm has no effect of clinical significance on the prevalence of gingivitis. This confirmed the previous finding in 15-yr-old children in Hartlepool and York (MURRAY, 1969). No differences were observed, between Hartlepool and York data, in the prevalence of gingival recession, which was independent of sex but strongly associated with age. This confirms the findings of KITCHIN (1941), SANDLERand STAHL (1954), STAHL and MORRIS(1955), SCHEI et al. (1959) and GORMAN(1967). In particular, the results of the present study were very similar to those recorded by SANDLERand STAHL. (1954). In their study, at 61-70 yr of age, 64.9 per cent of teeth had gingival recession ; in the present study, at 60-65 yr of age 64.6 per cent of teeth were affected. The observed association between age and gingival recession does not necessarily prove a cause and effect relationship. However, there does seem to be a need for further investigation into factors affecting gingival recession in different communities. Acknowledgements-This study was facilitated by a research grant from the Joseph Rowntree Memorial Trust. I am indebted to Professor D. JACKSON,University of Leeds Dental School, for his encouragement and direction. I would also like to thank Dr. H. MILLIGAN, Medical Officer of Health, Hartlepool. Dr. R. W. M. MOORE, Medical Officer of Health, York, and the management and staff of all establishments visited for their kind help and co-operation.
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J. J. MURRAY R&urn&La prevalence des gingivites et du dechaussement gingival chez 1884 sujets adultes, ages de 15-65 am, habitant depuis toujours la region naturellement fluoruree de Hartlepool (1,5-2,0 ppm de F) est comparee a celle de 2015 sujets ad&es habitant la ville peu fluoruree de York (0,15-0,28 ppm de F). Le degre de gingivite n’a et& determine que dans les regions gingivales vestibulaires anterieures, d’apres la methode d&rite par JACKSON (1965). La prevalence de la gingivite ne varie pas avec l’augmentation de Page. Par suite, les resultats de tous les groupes d’age ont CtCmelanges. Quatre vingt neuf pour cent, a Hartlepool, et 87 pour cent a York presentent une inflammation au niveau d’une ou plusieurs unites gingivales. Dans les deux villes, la prevalence de gingivites, legerement plus Clevee chez les hommes, disparait lorsqu’on ne retient que les sujets avec une bonne hygiene. A Hartlepool la prevalence de localisation des gingivites est de 37,2 pour cent et a York elle est de 35,4 pour cent. Chez les sujets, a bonne hygiene buccale, cette prevalence est de 21,8 pour cent a Hartlepool et de 19,8 pour cent a York. La difference maximale entre les deux villes est 0,4 unite gingivale. Aucune difference selon le sexe n’est observee dans les deux villes concernant le dechaussement. Les resultats des hommes et des femmes ont par suite et6 melanges A Hartlepool, a Page de 15-19 ans, 3,0 pour cent des sujets presentent du dechaussement: a 60-65 ans, 100 pour cent des sujets sont pratiquement atteints. Cette variation en fonction de Page est identique a York. Le pourcentage de dents dkhausses augmente progressivement avec l’age. A Hartlepool, a 15-19 ans, 0,2 pour cent des dents sont dechaussees. A 6&66 ans, 66,7 pour cent des dents sont atteintes. Les valeurs correspondantes a York sont respectivement de 0.2 et 63,8 pour cent. Aucune difference significative n’est observee entre les deux villes. 11en ressort que le fluor dans l’eau potable, au moins a des concentrations de 2 ppm, n’a pas d’effet clinique sur la prevalence de la gingivite ou le dechaussement chez l’adulte.
Zusammenfassung-Es wurde die Hlufigkeit von Gingivitis und Gingivaretraktionen bei 1884 bezahnten Erwachsenen zwischen 15 und 65 Jahren, die standig in der Gegend von Hartlepool (mit 1,5-2,0 ppm natiirlichem Fluorid) wohnten, mit der Gingivitishlufigkeit von 2015 bezahnten Erwachsenen aus der Stadt York mit dem niedrigen Fluoridgehalt von 0,15-0,28 ppm F verglichen. Die Bestimmung der Gingivitis wurde auf die anterioren labialen Gingivaabschnitte nach der von JACKSON (1965) beschriebenen Methode beschrankt. Die Hlufigkeit der Gingivitis veranderte sich mit ansteigendem Alter nicht. Deshalb wurden die Ergebnisse fiir alle Altersgruppen kombiniert. In Hartlepool hatten 98 Prozent und in York 87 Prozent einen oder mehr entziindete Gingivaabschnitte. In beiden Gemeinden verschwand die leicht hijhere Gingivitishlufigkeit bei Mannem gegentiber der bei Frauen, wenn lediglich die Personen mit guter Mundhygiene berticksichtigt wurden. In Hartlepool betrug die Lokalisationspravalenz der Gingivitis 37,2 Prozent, in York 35,4 Prozent. Bei jenen Personen mit guter Mundhygiene betrug die entsprechende Gingivitispravalenz 21.8 Prozent fur Hartlepool und 19,8 Prozent fur York. Die maximale Divergenz zwischen beiden Gemeinden betrug 0,4 Gingivaeinheiten. In keiner der Gemeinden 1ieB sich ein Geschlechtsunterschied beziiglich der Pravalenz von Gingivaretraktionen feststellen. Deshalb wurden die Ergebnisseftir Manner und Frauen kombiniert. In Hartlepool waren 3 Prozent der 15-19 Jahre alten Personen mit Gingivaretraktion behaftet; in der Altersgruppe 6@-65 Jahre waren dies 100 Prozent. Genau die gleichen Alterszusammenhange waren in York zu erkermen. Auch der Prozentsatz van Zlhnen mit gingivalen Retraktionen wuchs mit dem Alter standig an. Bei den 15-19 Jahre alten Personen aus Hartlepool hatten 0,2 Prozent der ZBhne gingivale Retraktionen. Bei den 60-65 Jahre alten Menschen waren 66,7 Prozent aller Zahne behaftet. Die entsprechenden Werte fur York betrugen 0,2 Prozent bzw. 63,8 Prozent. Zwischen den Ergebnissen aus Hartlepool und York waren keine signifikanten Unterschiede zu beobachten. Daraus wird der Schlug gezogen, dal3 Fluorid im Trinkwasser bis zur Konzentration von 2 ppm keine Auswirkungen auf die klinische Erscheinung und Hlutigkeit von Gingivitis und Gingivaretraktionen der Erwachsenen entfaltet.
PERIOIXINTAL DISEASEIN ADULTSFROM HIGH AND
LOW
FLUORIDE
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REFERENCES
ENGLANDER,H. R., KESEL, R. G. and GUPTA, O.P. 1963. Effect of natural fluoride on periodontal health of adults. Am. J. publ. Hlth 53, 1233-1241. GORMAN,W. J., 1967. Prevalence and etiology of gingival recession. J. Periodont. 38, 316-322. JACKSON.D. 1956. The measurement of gingivitis. Br. dent. J. 118, 521-527. - JAMES,P: M. C., JACKSON,D., SLACK, G. L. and LAWTON,F. E.‘l961. Gingival health and dental cleanliness in English school children. Archs oral Biol. 3, 57-66. KITCHIN, P. C. 1941. The prevalence of tooth root exposure and the relation of the extent of such exposure to the degree of abrasion in different age classes. J. dent. Res. 20, 565-581. MURRAY,J. J. 1969. Gingivitis in 15 year old children from high fluoride and low fluoride areas. Archs oral Biol. 14, 951-957. MURRAY, J. J. 1971. Adult dental health in fluoride and non-fluoride areas. Part l-Mean DMF values by age. Br. dent. J. 131, 391-395. RUSSELL,A. L. 1956. A system of classifying and scoring for prevalence surveys of periodontal disease. J. dent. Res. 35, 350-359. RUSSELL,A. L. 1957. Fluoride domestic water and periodontal disease. Am. J. publ. HIth 47, 688694. RUSSELL,A. L. 1960. Indices for recording periodontal disease. World Health Organization. Expert committee on dental health (periodontal disease). W.H.O. Geneva. SANDLER,H. C. and STAHL,S. S. 1954. The influence of generalized diseases on clinical manifestations of periodontal disease. J. Am. dent. Ass. 49, 656-667. SCHEI, O., WAERHAUG,J., L~VDAL, A. and ARNo, A. 1959. Oral conditions among army personnel at the army engineer centre. J. Periodont. 26, 180-185. SUTCLIFFE,P. 1968. Chronic anterior gingivitis: an epidemiological study in school children. Br. dent. J. K&47-55. WORLD WORKSHOPIN PERIODONTICS 1966. University of Michigan, U.S.A. p. 168.