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Discussion: Epidemiology ofgingivitis

Chester W. DouglassDepartment of Dental Care Administration,Harvard School of Dental Medicine, HarUniversity, Boston, Massachusetts, tJSA

I would like to make 4 comments ab outthe review that Professor Stamm hasjust presented. These comments relateto (1) the concern for the wide range ofgingivitis measures in the literature, (2)the concern for low scores in more re-cent surveys, (3) the possible trend inthe prevalence of periodontal disease,and (4) the implications that these issueshave for need of clinical trials research.The paper presents an excellent re-view of a very difficult literature. Dr.Stamm has identified the existing pub-lished data and drawn our attention to

the disconcerting wide range in gingi-vitis prevalence scores. The paper poin tsto a real problem by concluding thatour understanding of the epidemiologyof gingivitis is more often comprom isedthan is generally conceded. The con-be

The second issue that requires cotn-the first shows

In 1978,was convinced that this finding wasue to measurements error. It seemed5% of people with zero disease to 50%in 12 years.at the end of

the possibilityt the data m ight represent somethingto 2 further

First we examined that magnitude ofdif-no disease to% with no disease appears to be ae the distributions of all the scoresone finds substantialthe 2 distributions ofet al.the scores are faidy0.1 to 1.0.

It also appears thatis

possibly come from, the populationgroup with the lowest positive scores 12years earlier. Hence, I agree with Dr.Stamm: we cannot conclude that therehas been a substantial decline in gingi-vitis based on the existing national data .Instead, the increase in the number ofpersons with zero scores may reflectonly a minimal shift between the 0 and1 scores. Thus even if the scoring pro-cedures were precisely the same in1971-1974 as they had been in1960-1962, I still would agree with theconclusion not to overinterpret whatmight otherwise appear to be a largeimprovement in the proportion of thepopulation with no gingivitis or ad-vanced periodontal disease. Conversely,however, do not reject the possibilitythat there may be a real decline in gingi-vitis. Cleady, additional data areneeded.

The second set of logical consider-ations that was stimulated by Dr. So-

group looked at 7: oral hygiene stsmoking, fluorides, antibiotics, incoeducation and the utilization of decare. Each has been either hypothesor shown to be statistically associwith gingivitis. If the correlationtween gingivitis and each of the dient risk factors were found to be inposite directions, we would be left wdering what to believe. However,consistent pattern emerged, the dechypothesis may need to be given mserious consideration. This reviewconducted primarily by Marilie Gmon and was reported in the discussof our analysis of the 2 NCHS surveThe available evidence on smoking,come, education, dental care utilizatoral hygiene status, fluoride use and consumption of antibiotics all poina direction that is consistent withhypothesis that gingivitis could hdeclined between the 1960-62 a1971-74 surveys. I agree with D

literature for concurre nt events that questionab le of these data are the issmight suppo rt the hypothesis that gingi- of fluoride and antibiotic use. Howevvitis is declining. Dr. Stamm mentioned the data showing a marginal declineseveral of these factors. Our research gingivitis seem to be supported by

PERIODONTAL DISEASE

PERIODONTAFig. I. National t rends in the % dis tr ibut ion of adi;gender, and year of survey.Nalionale Tendenzen hinsiclulich der Verteilung Erwachsener im Alter von 18-79 Jahren aden Sehweregrad der Erkrankwig. auf das Ge.schlecht der Probanden und auf die Jahre. fiir die Ubersicht Geltung hat.Tendanees nationales dans la repartition (%) des adultes ages de 18 a 79 ans par .severite de

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Douglassconcurrent events operating cated statistical analyses should be of Dental Medicine where a collen our society. Thus, it seems to considered. I would underscore Dr. is hard at work using an electron mithat there was a decline in marginal Stamm 's suggestion that we should de- scope. Stibmerged in the study ofivitis occurring within the US popu- termine the amount of difference be- tracellular biochemistry, he exlaen the 2 national surveys, tween study groups that we would con- "Look at this slide. We defmitely etically, periodontitis as mea- sider to be clinically significant before fewer dentists!" The links between we start that study. Statisticians are con- tal research fmdings and national mmuch during this same time pe- stantly urging us to come to grips with power policy may not be so direct,The current NIDR national study whether the variations between 2 groups The truth is that basic research

well as the HANES III NCHS study has any clinical, health care delivery or probably be the source of the l give us additional data to make even biomedical significance. knowledge that may lead to neefirm conclusions regarding the Finally, as many of you know, the fewer dentists. It is in the biomein advance disease. major concern in my own analyses of laborato ries where these advancesFinally, regarding the implications these epidemiological data , is to con- most likely to be made. But ultimaclinical trials, I support Dr. Stamm 's sider how they translate into the need these laborato ry findings must be tions that clinical trials on gingi- for treatmen t, demand for dental care, under real conditions. Hence, I supis in children under 13 need to be and ultimately the supply of dentists. John Stam m's call for well-desiand if conducted must It is fashionable right now to translate clinical trials that can push us towude concurrent controls. If there many of our research finding s into im- that ultimate goal of identifyitiga secular decline in gingivitis, dis- plications for needing fewer dentists. cause and effect relationships thatdefinitions of diagnostic criteria. My anxiety dream is walking past a contrib ute to the control and eused, descriptions of research labora tory at Harvard School nation of periodontal disease.

Referenceome standard procedure in our Douglass, C. W., Gammon, M. D. & Orr, R. B. 1985. Oarch reports. Also, more sophis ti- prevalence of inflammatory periodontal diseases, youi

. HOROW ITZ: John Stamm may in teenagers. What we have is a group say up to 4 teeth aren 't importaive iiTiphed that there is a honnonal of, say, 8- and 9-year-oIds with very dir- have taken the view that if there's is. I think he made the statements lence than the children at 11, 12 years num erator to determine the rate , you adjust for plaque between of age who have somewhat better oral don 't believe that is overestimationand females, the difference may hygiene. If we re-examine the gingivitis an issue tha t relates to the discuar. The same should be done in in your children, I said that the blip is tha t Roy Page offered that gingivyounger children going to become smaller or eventually a real disease. We have to come to

and 12-year-olds, for will disappear, although I doubt that it with this more than we are at prewith 14- and 15-year-olds, be- will disappear entirely. The sex diffe- DR . FE LD MAN : We in the VAre you suggest a hormonal effect, rence that you talked about is one that tal longitudinal study have alsothere may be an overestimate of I said could be reduced by accounting interested in the association of smproblem by talking for the oral hygiene, but I did not say cigarette products, cigars and pipeeople that have gingivitis, where it would be eliminated. I just said that gingivitis over many years. We remay be confined to one or two specific the two would probably come closer to- published a series of papers that es only. gether and that the differences that we with the history of smoking in an ADR. STAMM: 1 quite agree with Dr. report may not be quite as sex-related ican adult popula tion and ginlass' notion that the oral hygiene as they appear to be at the outset. measurem ents. Distinct from thevel in teenagers changes, and that this Before we start talking about severity shown here, in our popula tion, l influence the level of gingivitis. But of gingivitis, we should know w hether was no difference in gingivitis bee note that the blip, if there is one, it is present or not. If someone believes cigarette smoke or pipe smoking,can be seen against what happens that if only a couple of teeth are in- pared with a group of non-sm okerchildren younger than 11 years of volved, then tha t's not really gingivitis, only differences observed wer

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