Discussion: Epidemiology of gingivitis

Chester W. Douglass
Department of Dental Care Administration,

Harvard School of Dental Medicine, Harvard

University, Boston, Massachusetts, tJSA

I would like to make 4 comments about possibly come from, the population group looked at 7: oral hygiene status, the review that Professor Stamm has group with the lowest positive scores 12 smoking, fluorides, antibiotics, income, just presented. These comments relate years earlier. Hence, I agree with Dr. education and the utilization of dental to (1) the concern for the wide range of Stamm: we cannot conclude that there care. Each has been either hypothesized gingivitis measures in the literature, (2) has been a substantial decline in gingi- or shown to be statistically associated the concern for low scores in more re- vitis based on the existing national data. with gingivitis. If the correlation becent surveys, (3) the possible trend in Instead, the increase in the number of tween gingivitis and each of the differthe prevalence of periodontal disease, persons with zero scores may reflect ent risk factors were found to be in opand (4) the implications that these issues only a minimal shift between the 0 and posite directions, we would be left wonhave for need of clinical trials research. 1 scores. Thus even if the scoring pro- dering what to believe. However, if a The paper presents an excellent re- cedures were precisely the same in consistent pattern emerged, the decline view of a very difficult literature. Dr. 1971-1974 as they had been in hypothesis may need to be given more Stamm has identified the existing pub- 1960-1962, I still would agree with the serious consideration. This review was lished data and drawn our attention to conclusion not to overinterpret what conducted primarily by Marilie Gamthe disconcerting wide range in gingi- might otherwise appear to be a large mon and was reported in the discussion vitis prevalence scores. The paper points improvement in the proportion of the of our analysis of the 2 NCHS surveys. to a real problem by concluding that population with no gingivitis or ad- The available evidence on smoking, inour understanding of the epidemiology vanced periodontal disease. Conversely, come, education, dental care utilization, of gingivitis is more often compromised however, do not reject the possibility oral hygiene status, fluoride use and the than is generally conceded. The con- that there may be a real decline in gingi- consumption of antibiotics all point in clusion that the measurements must be vitis. Cleady, additional data are a direction that is consistent with the fundamentally different across different needed. hypothesis that gingivitis could have studies must surely be correct. The second set of logical consider- declined between the 1960-62 and The second issue that requires cotn- ations that was stimulated by Dr. So- 1971-74 surveys. I agree with Dr. ment is the fmding that a second national survey 12 years after the first shows literature for concurrent events that questionable of these data are the issues much lower levels of gingivitis. In 1978, might support the hypothesis that gingi- of fluoride and antibiotic use. However, I was convinced that this finding was vitis is declining. Dr. Stamm mentioned the data showing a marginal decline in due to measurements error. It seemed several of these factors. Our research gingivitis seem to be supported by the inconceivable that scores could go from 25% of people with zero disease to 50% of people with zero disease in 12 years. PERIODONTAL DISEASE It was Dr. Socransky who, at the end of a noon-time research seminar suggested that we should consider the possibility that the data might represent something that is actually happening and see where that takes us. This idea led to 2 further analyses. First we examined that magnitude of change in the individual scores. The difference from 25% with no disease to 50% with no disease appears to be a large change. However, when you examine the distributions of all the scores in both surveys, one finds substantial stability between the 2 distributions of gingivitis scores. Fig. 1 (Douglass et al. PERIODONTA 1985) shows that the scores are faidy Fig. I. National trends in the % distribution of adi; stable except those from 0.1 to 1.0. gender, and year of survey. These are the low PI scores which repre- Nalionale Tendenzen hinsiclulich der Verteilung Erwachsener im Alter von 18-79 Jahren auf sent gingivitis more than they represent den Sehweregrad der Erkrankwig. auf das Ge.schlecht der Probanden und auf die Jahre. fiir die advanced disease. It also appears that die Ubersicht Geltung hat. the 1971-1974 increase in zero scores is Tendanees nationales dans la repartition (%) des adultes ages de 18 a 79 ans par .severite de la coming from the closest place it could maladie, par sexe et par dale de I'etude.

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Douglass

other concurrent events operating cated statistical analyses should be of Dental Medicine where a colleague within our society. Thus, it seems to considered. I would underscore Dr. is hard at work using an electron microme that there was a decline in marginal Stamm's suggestion that we should de- scope. Stibmerged in the study of ingingivitis occurring within the US popu- termine the amount of difference be- tracellular biochemistry, he exlaims, lation between the 2 national surveys, tween study groups that we would con- "Look at this slide. We defmitely need Parenthetically, periodontitis as mea- sider to be clinically significant before fewer dentists!" The links between densured in the 2 NCHS surveys did not we start that study. Statisticians are con- tal research fmdings and national manchange much during this same time pe- stantly urging us to come to grips with power policy may not be so direct, riod. The current NIDR national study whether the variations between 2 groups The truth is that basic research will as well as the HANES III NCHS study has any clinical, health care delivery or probably be the source of the new will give us additional data to make even biomedical significance. knowledge that may lead to needing more firm conclusions regarding the Finally, as many of you know, the fewer dentists. It is in the biomedical trend in advance disease. major concern in my own analyses of laboratories where these advances are Finally, regarding the implications these epidemiological data, is to con- most likely to be made. But ultimately, for clinical trials, I support Dr. Stamm's sider how they translate into the need these laboratory findings must be tested suggestions that clinical trials on gingi- for treatment, demand for dental care, under real conditions. Hence, I support vitis in children under 13 need to be and ultimately the supply of dentists. John Stamm's call for well-designed questioned, and if conducted must It is fashionable right now to translate clinical trials that can push us towards include concurrent controls. If there many of our research findings into im- that ultimate goal of identifyitig the is a secular decline in gingivitis, dis- plications for needing fewer dentists. cause and effect relationships that will creet definitions of diagnostic criteria. My anxiety dream is walking past a contribute to the control and ehmimeasurements used, descriptions of research laboratory at Harvard School nation of periodontal disease. examiner training, the reliability of the measures, and a discussion on the limits of the data, should all be clearly stated Reference and become standard procedure in our Douglass, C. W., Gammon, M. D. & Orr, R. B. 1985. O research reports. Also, more sophistiprevalence of inflammatory periodontal diseases, youi

General discussion
DR. HOROWITZ: John Stamm may hcive iiTiphed that there is a honnonal givitis. I think he made the statements that if you adjust for plaque between males and females, the difference may disappear. The same should be done in terms of age among younger children in comparing 11- and 12-year-olds, for example, with 14- and 15-year-olds, before you suggest a hormonal effect, Also, there may be an overestimate of the extent of the problem by talking about people that have gingivitis, where it may be confined to one or two specific sites only. DR. STAMM: 1 quite agree with Dr. Douglass' notion that the oral hygiene level in teenagers changes, and that this will influence the level of gingivitis. But please note that the blip, if there is one, also can be seen against what happens in children younger than 11 years of age. Please notice that most studies will reveal that among those children, plaque scores are higher than they are in teenagers. What we have is a group of, say, 8- and 9-year-oIds with very dirlence than the children at 11, 12 years of age who have somewhat better oral hygiene. If we re-examine the gingivitis in your children, I said that the blip is going to become smaller or eventually will disappear, although I doubt that it will disappear entirely. The sex difference that you talked about is one that I said could be reduced by accounting for the oral hygiene, but I did not say it would be eliminated. I just said that the two would probably come closer together and that the differences that we report may not be quite as sex-related as they appear to be at the outset. Before we start talking about severity of gingivitis, we should know whether it is present or not. If someone believes that if only a couple of teeth are involved, then that's not really gingivitis, then we're going to have a real measurement problem. Where you say 2 teeth aren't important, somebody else may say up to 4 teeth aren't important. I have taken the view that if there's some numerator to determine the rate, and I don't believe that is overestimation. It's an issue that relates to the discussion that Roy Page offered that gingivitis is a real disease. We have to come to grips with this more than we are at present, DR. FELDMAN: We in the VA dental longitudinal study have also been interested in the association of smoking cigarette products, cigars and pipe with gingivitis over many years. We recently published a series of papers that dealt with the history of smoking in an American adult population and gingivitis measurements. Distinct from the data shown here, in our population, there was no difference in gingivitis between cigarette smoke or pipe smoking, compared with a group of non-smokers. The only differences observed were decreases in plaque accumulation in smokers, most likely attributable to some noxious effect of the smoke. In addition.