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Periodontal Disease is Prevalent Among Adults in France
DIAGNOSIS
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Epidemiology of periodontal status in dentate adults in France, 2002-2003 Bourgeois D, Bouchard P, Mattout C. J Periodontal Res 2007;42(3):219-27
LEVEL OF EVIDENCE 4
PURPOSE/QUESTION To assess the prevalence and extent of periodontal disease among adults in France, and to describe the disease distribution by age groups, gender, and type of teeth affected.
SOURCE OF FUNDING French government and industry.
TYPE OF STUDY/DESIGN Survey
Periodontal Disease is Prevalent Among Adults in France SUMMARY Subjects A total of 29 health examination centers of the French National Health Insurance system were selected nonrandomly, covering 22 administrative regions in France. In these centers, 2144 consenting subjects (age 35 to 64 years, 51% women) participated in this study.
Exposure Age, gender, and tooth type were recorded. Other exposures were mentioned but not reported in the results.
Main Outcome Measure Occurrence of periodontal disease was measured in terms of prevalence (percentage of subjects) and extent (percentage of sites) of various severities of clinical attachment loss and pocket depth. A full-mouth clinical examination was performed on 4 sites per tooth using a disposable PDT Sensor probe.
Main Results There were 28.8% of subjects who had one or more sites with $5 mm probing depth (average: 1.7 sites/subject), and 46.7% of subjects who had $5 mm attachment loss (average: 3.3 sites/subject). Attachment loss increased with age, whereas probing depth was weakly correlated with age. Men had significantly more disease than women.
Conclusions (of authors) Approximately 50% of adults in France have severe attachment loss. Periodontal pockets are uncommon in France.
COMMENTARY AND ANALYSIS
J Evid Base Dent Pract 2008;8:89-90 1532-3382/$34.00 Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2008.03.008
Surveys provide valuable information about the health of populations, which other study designs cannot provide. As in other types of studies, the evidence attained in a survey can be misleading if the survey methodology is inadequate. Adequate surveys use a sample that is representative of the target population and use valid measurement methods to produce reasonably accurate measurements of the traits under investigation.1 There are only a few periodontal surveys that fulfill these criteria. This study used a reasonably large sample with adequate coverage of different administrative regions in France; however, it is unclear whether the sample is representative of adults in France. Out of 116 national health examination centers, 29 centers were selected nonrandomly for inclusion in the survey. Using a convenience method to select the primary sampling units (PSU) would simplify the logistics of the survey. On the other hand, it may lead to biased selection of PSUs. Also, the text mentions that sampling involved stratification by age, gender, and ‘‘socioprofessional’’ category. It is unclear how this stratification was performed. Another
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
determinant for sample representation is whether all adults in France are uniformly eligible and willing to use the services of these health centers. Consequently, the conclusions of this study may be applicable to those who attended the health centers for whatever reason. Measurement reproducibility was assessed first for 5 ‘‘regional’’ examiners who achieved a weighted kappa coefficient of 0.75 (there is no mention of who they were calibrated against). Subsequently, the ‘‘regional’’ examiners calibrated other dental examiners in 24 examination centers who also achieved a weighted kappa coefficient of 0.75. Some issues were not adequately clarified. For instance, how many ‘‘gold examiners’’ did the survey have, and what is the total number of dental examiners (a conservative estimate is 29)? The magnitude of measurement errors increases by increasing the number of examiners. Also, since the measurement method uses a ‘‘6-grade index’’ (2.3.4.5.7.9) (whatever this means), it is not explained how the kappa coefficient was weighted. The high number of examiners, and the multiple standards (‘‘gold’’ examiners) add more potential sources of measurement error. Epidemiological studies assess the prevalence and severity of diseases/conditions, and as such provide valuable data about the health status of the population. This study found that approximately half of adults in France have severe ($5 mm) attachment loss, more than one fourth of adults have moderate or deep ($5 mm) periodontal pockets, and 10% have deep ($6 mm) pockets. This is consistent with similar findings in another survey showing that approximately half of US adults have chronic periodontitis.2 Given the high prevalence rates in this survey, the stated conclusion that periodontal pockets are uncommon in France is unjustified. Also unjustified is the statement in the discussion section that the study findings support ‘‘the hypothesis put forward elsewhere that severe forms of periodontal damage affect only a minority of the population.’’ Indeed findings in this survey, as well as those of other surveys3,4 clearly suggest that periodontitis and loss of periodontal support are common in this and many other populations. This survey shows that, among adults in France, deep periodontal pockets are less prevalent than severe periodontal attachment loss. This is a predicted finding that has also been reported previously in other Western populations3,4 and is attributed mainly to the apical migration of the gingival margin, presumably as a result of local in-
90
flammation. Based on the finding that 10% of the study sample had deep ($6 mm) periodontal pockets, the authors concluded that the treatment need is not high, and periodontitis is not a major public health issue in this population. This conclusion is unwarranted. Loss of periodontal attachment, which is the primary measure of the outcome of periodontitis, is highly prevalent in this and other populations worldwide. There is evidence that both systemic and periodontal infections may contribute to a higher risk for certain systemic diseases.5-7 The high prevalence of attachment loss is an indication that periodontitis is common, and as such may be regarded as a public health issue. Given the high prevalence of attachment loss among adults in France, it is rational to recommend implementing public measures of periodontal disease prevention in order to improve oral and systemic health. This important goal was not addressed in this survey.
REFERENCES 1. Kingman K, Albandar JM. Methodological aspects of epidemiological studies of periodontal diseases. Periodontol 2000 2002;29:11-30. 2. Albandar JM. Epidemiology and risk factors of periodontal diseases. Dent Clin North Am 2005;49:517-32. 3. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in the United States, 19881994. J Periodontol 1999;70:13-29. 4. Morris AJ, Steele J, White DA. The oral cleanliness and periodontal health of UK adults in 1998. Br Dent J 2001;191:186-92. 5. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc 2006;137(Suppl): 14S-20S. 6. Moutsopoulos NM, Madianos PN. Low-grade inflammation in chronic infectious diseases: paradigm of periodontal infections. Ann N Y Acad Sci 2006;1088:251-64. 7. Tonetti MS, D’Aiuto F, Nibali L, Donald A, Storry C, Parkar M, et al. Treatment of periodontitis and endothelial function. N Engl J Med 2007;356:911-20.
REVIEWER Jasim M. Albandar, DMD, PhD Professor Department of Periodontology and Oral Implantology 3223 North Broad Street Temple University School of Dentistry Philadelphia, PA 19140 [email protected]
June 2008
ARTICLE ANALYSIS & EVALUATION ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION Epidemiology of periodontal status in dentate adults in France, 2002-2003 Bourgeois D, Bouchard P, Mattout C. J Periodontal Res 2007;42(3):219-27
LEVEL OF EVIDENCE 4
PURPOSE/QUESTION To assess the prevalence and extent of periodontal disease among adults in France, and to describe the disease distribution by age groups, gender, and type of teeth affected.
SOURCE OF FUNDING French government and industry.
TYPE OF STUDY/DESIGN Survey
Periodontal Disease is Prevalent Among Adults in France SUMMARY Subjects A total of 29 health examination centers of the French National Health Insurance system were selected nonrandomly, covering 22 administrative regions in France. In these centers, 2144 consenting subjects (age 35 to 64 years, 51% women) participated in this study.
Exposure Age, gender, and tooth type were recorded. Other exposures were mentioned but not reported in the results.
Main Outcome Measure Occurrence of periodontal disease was measured in terms of prevalence (percentage of subjects) and extent (percentage of sites) of various severities of clinical attachment loss and pocket depth. A full-mouth clinical examination was performed on 4 sites per tooth using a disposable PDT Sensor probe.
Main Results There were 28.8% of subjects who had one or more sites with $5 mm probing depth (average: 1.7 sites/subject), and 46.7% of subjects who had $5 mm attachment loss (average: 3.3 sites/subject). Attachment loss increased with age, whereas probing depth was weakly correlated with age. Men had significantly more disease than women.
Conclusions (of authors) Approximately 50% of adults in France have severe attachment loss. Periodontal pockets are uncommon in France.
COMMENTARY AND ANALYSIS
J Evid Base Dent Pract 2008;8:89-90 1532-3382/$34.00 Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jebdp.2008.03.008
Surveys provide valuable information about the health of populations, which other study designs cannot provide. As in other types of studies, the evidence attained in a survey can be misleading if the survey methodology is inadequate. Adequate surveys use a sample that is representative of the target population and use valid measurement methods to produce reasonably accurate measurements of the traits under investigation.1 There are only a few periodontal surveys that fulfill these criteria. This study used a reasonably large sample with adequate coverage of different administrative regions in France; however, it is unclear whether the sample is representative of adults in France. Out of 116 national health examination centers, 29 centers were selected nonrandomly for inclusion in the survey. Using a convenience method to select the primary sampling units (PSU) would simplify the logistics of the survey. On the other hand, it may lead to biased selection of PSUs. Also, the text mentions that sampling involved stratification by age, gender, and ‘‘socioprofessional’’ category. It is unclear how this stratification was performed. Another
JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
determinant for sample representation is whether all adults in France are uniformly eligible and willing to use the services of these health centers. Consequently, the conclusions of this study may be applicable to those who attended the health centers for whatever reason. Measurement reproducibility was assessed first for 5 ‘‘regional’’ examiners who achieved a weighted kappa coefficient of 0.75 (there is no mention of who they were calibrated against). Subsequently, the ‘‘regional’’ examiners calibrated other dental examiners in 24 examination centers who also achieved a weighted kappa coefficient of 0.75. Some issues were not adequately clarified. For instance, how many ‘‘gold examiners’’ did the survey have, and what is the total number of dental examiners (a conservative estimate is 29)? The magnitude of measurement errors increases by increasing the number of examiners. Also, since the measurement method uses a ‘‘6-grade index’’ (2.3.4.5.7.9) (whatever this means), it is not explained how the kappa coefficient was weighted. The high number of examiners, and the multiple standards (‘‘gold’’ examiners) add more potential sources of measurement error. Epidemiological studies assess the prevalence and severity of diseases/conditions, and as such provide valuable data about the health status of the population. This study found that approximately half of adults in France have severe ($5 mm) attachment loss, more than one fourth of adults have moderate or deep ($5 mm) periodontal pockets, and 10% have deep ($6 mm) pockets. This is consistent with similar findings in another survey showing that approximately half of US adults have chronic periodontitis.2 Given the high prevalence rates in this survey, the stated conclusion that periodontal pockets are uncommon in France is unjustified. Also unjustified is the statement in the discussion section that the study findings support ‘‘the hypothesis put forward elsewhere that severe forms of periodontal damage affect only a minority of the population.’’ Indeed findings in this survey, as well as those of other surveys3,4 clearly suggest that periodontitis and loss of periodontal support are common in this and many other populations. This survey shows that, among adults in France, deep periodontal pockets are less prevalent than severe periodontal attachment loss. This is a predicted finding that has also been reported previously in other Western populations3,4 and is attributed mainly to the apical migration of the gingival margin, presumably as a result of local in-
90
flammation. Based on the finding that 10% of the study sample had deep ($6 mm) periodontal pockets, the authors concluded that the treatment need is not high, and periodontitis is not a major public health issue in this population. This conclusion is unwarranted. Loss of periodontal attachment, which is the primary measure of the outcome of periodontitis, is highly prevalent in this and other populations worldwide. There is evidence that both systemic and periodontal infections may contribute to a higher risk for certain systemic diseases.5-7 The high prevalence of attachment loss is an indication that periodontitis is common, and as such may be regarded as a public health issue. Given the high prevalence of attachment loss among adults in France, it is rational to recommend implementing public measures of periodontal disease prevention in order to improve oral and systemic health. This important goal was not addressed in this survey.
REFERENCES 1. Kingman K, Albandar JM. Methodological aspects of epidemiological studies of periodontal diseases. Periodontol 2000 2002;29:11-30. 2. Albandar JM. Epidemiology and risk factors of periodontal diseases. Dent Clin North Am 2005;49:517-32. 3. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal disease in adults 30 years of age and older in the United States, 19881994. J Periodontol 1999;70:13-29. 4. Morris AJ, Steele J, White DA. The oral cleanliness and periodontal health of UK adults in 1998. Br Dent J 2001;191:186-92. 5. Demmer RT, Desvarieux M. Periodontal infections and cardiovascular disease: the heart of the matter. J Am Dent Assoc 2006;137(Suppl): 14S-20S. 6. Moutsopoulos NM, Madianos PN. Low-grade inflammation in chronic infectious diseases: paradigm of periodontal infections. Ann N Y Acad Sci 2006;1088:251-64. 7. Tonetti MS, D’Aiuto F, Nibali L, Donald A, Storry C, Parkar M, et al. Treatment of periodontitis and endothelial function. N Engl J Med 2007;356:911-20.
REVIEWER Jasim M. Albandar, DMD, PhD Professor Department of Periodontology and Oral Implantology 3223 North Broad Street Temple University School of Dentistry Philadelphia, PA 19140 [email protected]
June 2008