Gingival Bleeding Indices

Whereas the clinical assessment of gingival color, form, and texture is

subjective in nature,
gingival bleeding is an objective diagnostic sign of inflammation. Research
suggests that bleeding
on gentle probing of the gingival sulcus may occur before changes in color,
form, or texture are
apparent.35,38,54 Since 1974, numerous indices that measure bleeding only,
such as the gingival
bleeding index and the Eastman interdental bleeding index, have been
published and reviewed
elsewhere.22,23,56 Periodontal probes are used with most indices; however,
toothpicks and dental
floss are used to elicit bleeding with some indices.56 Among the indices that
require the use of
periodontal probes, the type of probe and the angulation, depth, and force of
probing vary. Even
though gingival bleeding is a sign of inflammation, the bleeding from the
gingival sulcus may be
associated with other forms of periodontal disease, not just gingivitis. For
indices that require
insertion of the periodontal probe to the bottom of the gingival sulcus,
bleeding may be a sign of
periodontitis rather than gingivitis. Gingival bleeding indices are used in
clinical practice, surveys
of population groups, and clinical trials of antiplaque and antigingivitis
agents.

Nidcr Protocol for Assessment of Gingival Bleeding

In several of its national surveys, such as the NIDR National Survey of Oral
Health in U.S.
Employed Adults and Seniors (19851986) and the Third National Health and
Nutrition
Examination Survey (19881994), the National Institute of Dental and
Craniofacial Research
(NIDCR) has used the presence or absence of gingival bleeding as an
indication of gingival
health. The gingival assessment is just one of several components of the
NIDCR protocol for the
assessment of periodontal disease. For this approach, the facial and
mesiofacial sites of teeth in
two randomly selected quadrants, one maxillary and one mandibular, are
assessed for bleeding.
A special probe known as the NIDR probe is used in these
assessments. The NIDR probe is

color-coded and is graduated at 2, 4, 6, 8, 10, and 12 mm. To begin the

assessment, the examiner
dries a quadrant of teeth with air. Then, starting with the most posterior
tooth in the quadrant
(excluding the third molar), the examiner places a periodontal probe 2 mm
into the gingival
sulcus at the facial site and carefully sweeps the probe from the mesiofacial
to the mesial
interproximal area. After probing the sites in the quadrant, the examiner
assesses the presence or
absence of bleeding at each probed site. The same procedure is repeated for
the remaining
quadrant. For an individual, the number or percentage of teeth or sites with
bleeding can be
calculated. For population groups, the prevalence of gingival bleeding,
usually defined as
bleeding at one or more sites, can be determined.

How Much Gingivitis Is Present?

Data on the dental health of the U.S. population come from the third National
Health and Nutrition
Examination Survey (NHANES III), conducted from 1988 to 1994. The survey
was the seventh in a
series of national surveys designed to provide estimates of the health status
of the U.S. population.
This survey used the NIDCR protocol for gingival bleeding, as just described.
According to data
from NHANES III, 54% of the noninstitutionalized civilian U.S. population age
13 years and older
had gingival bleeding in at least one gingival site.79 Gingival bleeding was
most prevalent in the 13to 17-year-old group (63%) and declined gradually through the 35- to 44year-old group (Figure 81). The prevalence increased again at the 45- to 54-year-old group but
remained fairly constant in
older groups. On average per person, 10% of all sites had gingival bleeding;
however, among
persons with gingival bleeding, an average of 18% of sites had gingival
bleeding. The extent of
gingival bleeding among persons with gingival bleeding was higher in the
younger and older groups
than in the middle age groups (Figure 8-2).

Figure 81
Percentage of persons in the United States with one or more sites of gingival
bleeding. (Data

from US Department of Health and Human Services, National Center for

Health Statistics: Third
National Health and Nutrition Examination Survey, 1988-1994, NHANES III
Examination Data
File (CD-ROM), Public Use Data File Documentation Number 76200,
Hyattsville, Md, 1996,
Centers for Disease Control and Prevention.)
A study of U.S. schoolchildren age 14 to 17 years reported that the
prevalence of gingival bleeding
was 61.5%, essentially identical to the prevalence reported among those age
13 to 17 years in the
NHANES III study.14 Both surveys used the NIDCR gingival sweep method for
eliciting gingival
bleeding. The prevalence decreased with age from a high of 65% in 14-year
87olds to a low of 57%
in 17-year-olds. On average per child, 6% of sites measured had gingival
bleeding with probing.
In NHANES III, gingival bleeding was assessed at periodontal sites without
regard to the
periodontal status of the tooth. According to a definition cited earlier,
gingivitis is inflammation of
the gingiva in which the junctional epithelium remains attached to the tooth
at its original level.32 If
the prevalence of gingival bleeding from NHANES III data is recalculated
using only periodontal
sites without attachment loss (<1 mm), the prevalence of one or more sites
per person with gingival
bleeding decreases slightly from 54% to 47%. This indicates that about 7% of
the people had
bleeding only in sites with attachment loss. The remainder of individuals
either did not have any
bleeding in sites with attachment loss or had bleeding in sites with and
without attachment loss.

Figure 82
Mean percentage of sites per person with gingival bleeding among persons
in the United States
with gingival bleeding. (Data from US Department of Health and Human
Services, National
Center for Health Statistics: Third National Health and Nutrition Examination
Survey, 19881994, NHANES III Examination Data File (CD-ROM), Public Use Data File
Documentation
Number 76200, Hyattsville, Md, 1996, Centers for Disease Control and
Prevention.)

Is More or Less Gingivitis Present Now than

Previously?
Although it is generally believed that the prevalence of gingivitis is declining
in the United States,
the epidemiologic data needed to make that claim do not exist.8 Since 1960,
several national health
surveys have assessed periodontal health: the Health Examination Survey
(HES) (19601962),
NHANES I (19711974), the Health Resources and Services Administration
(HRSA) survey of
households (1981), the National Institute of Dental Research (NIDR) study of
employed adults
(1985-1986), and NHANES III (19881994). However, because of differences
in populations,
sampling methods, and periodontal measurement methods, comparisons of
results between these
surveys are difficult, if not impossible, to make. Table 8-2 summarizes
periodontal findings from
studies based on data from these surveys. Even if results from these studies
could be compared, they
do not support the view that the prevalence of gingivitis is declining.

Does My Patient with Gingivitis Fit the Typical

Profile?
Gingivitis is so common that any patient presenting with gingivitis could be
considered typical;
however, gingivitis is more prevalent among certain groups. Adolescents
have a higher prevalence
of gingivitis than prepubertal children or adults. The rise of sex hormones
during adolescence is
suspected to be the cause of the increased prevalence. Studies suggest that
the increase in sex
hormones during puberty affects the composition of the subgingival
microflora.36,53,55 One study
found that increased serum levels of testosterone in boys and estradiol
HES, Health Examination Survey; HANES I, First Health and Nutrition
Examination
Survey; HRSA, Health Resources and Services Administration; NIDR, National
Institute of
Dental Research; NHANES III, Third National Health and Nutrition Survey.
* References refer to published studies that analyzed data from these
surveys. Periodontal
findings in any given column are from the study referenced in the top cell.

SCIENCE TRANSFER

There is a widespread tendency to misinterpret epidemiologic data on

periodontal disease by
assuming that a statistically significant relationship between two variables
proves cause and effect.
Even if the increase in one variable precedes in time the increases in
another, this type of data can
only suggest, not prove, a causal relationship. Another confounding process
is that both variables
may change because of the effect of a third variable or groups of variables,
further complicating
the true connection between them (see Chapter 2). These relationships have
importance, however,
since they can be the basis for planning inductive research to establish cause
and effect.
Different techniques for measuring gingival bleeding on probing are used in
epidemiologic
estimations of gingivitis and are described as specific procedures for
different indices. Clinically,
the bleeding seen with routine probing of pockets on individual patients
during periodontal
charting is comparable to Bleeding on Probing (BOP) used in epidemiologic
research. The deeper
penetration of the probe with charting will most likely increase the chance of
bleeding compared
with the epidemiologic indices of gingivitis that use superficial probing with
sweeping techniques.
All bleeding on probing is caused by gingival inflammation coupled with
ulceration of the
epithelial lining of the gingival sulcus. This can occur as early as 2 days after
gingivitis begins in
healthy gingiva and frequently persists throughout the development of
gingivitis and periodontitis.
In many cases, if plaque and calculus are removed, the epithelial ulceration
will heal, and gingival
bleeding on probing is eliminated. This healing of the ulceration can take 7 to
10 days. If plaque
then reaccumulates in the region (e.g., because of inadequate oral hygiene),
ulceration and
bleeding can return in 2 days. Thus, for individual patients, bleeding on
probing is a good
indicator of current inflammatory disease activity at all stages of periodontal
disease.
Factors such as smoking appear to be related to the incidence of periodontal
disease, but these
confirmed etiologic relationships do not necessarily have the same degree of
effect on the patients

response to treatment. Response to treatment is a separate issue that

clinicians need to focus on in
order to give a basis for scientifically based treatment planning. Surgical
procedures in which
blood supply is of paramount importance (e.g., mucogingival surgery for root
coverage) may be
more affected by smoking than regenerative bone-grafting procedures in
which osteoprogenitor
cell activation is pivotal.
and progesterone in girls were associated with increased levels of the
periodontal pathogens
Prevotella intermedia and Prevotella nigrescens.55 Hormonal effects also may
be responsible for the
increased prevalence during pregnancy and among women.30
As shown in Figure 8-1, males in all age groups are more likely to have
gingivitis than females. The
prevalence of gingivitis is especially high for males age 13 to 17 years. Also,
males with gingivitis
have more involved sites than females (see Figure 8-2), especially in the
younger groups. Although
the reason for the existence of these gender differences is not known, poorer
plaque control among
males could likely explain much of their higher prevalence and extent of
disease.

Why Do Patients Have Gingivitis, and What Puts

Them at Risk?
It is clear from experimental and epidemiologic studies that microbial plaque
is the direct cause of
gingivitis.45,51,59,65 The cause-and-effect relationship between plaque and
gingival inflammation was
demonstrated in a classic study by Le et al.51 in which 12 individuals (9
dental students, 1
instructor, and 2 laboratory technicians) were asked to abstain from all
measures of oral hygiene.
Dental plaque began to form quickly, and the amount of plaque increased
with time. All subjects
developed gingivitis within 10 to 21 days. The mean GI score increased from
0.27 at baseline to
1.05 at the end of the no-brushing period. Gingival inflammation resolved
in all subjects within 1
week of resuming hygiene measures. The authors concluded that bacterial
plaque was essential in
the production of gingival inflammation.
Because bacterial plaque is the cause of the most common form of gingivitis,
factors that influence

the oral hygiene status of individuals would likely influence the prevalence of
gingivitis. The
generally poorer oral hygiene status of males may explain the higher
prevalence and extent among
males.3 Poorer oral hygiene also may explain the higher prevalence of
gingivitis among adolescents.
Even though the increased levels of circulating sex hormones have been
implicated in the higher
prevalence, the influence of plaque control on gingivitis may be more
important than the rising
levels of hormones.77 The conversion of bleeding gingival sites to
nonbleeding sites with oral
hygiene interventions alone provide strong evidence for the role of poor oral
hygiene in the etiology
of gingivitis.7,15,24
Few population-based studies of the association between oral hygiene status
and gingivitis have
been published. In NHANES I, information on toothbrushing frequency and
oral hygiene status was
collected. A study that investigated the associations between these factors,
and the periodontal index
(PI) reported that increased toothbrushing frequency and better oral hygiene
scores were associated
with lower PI scores.76 These associations remained statistically significant
after controlling for age,
race, socioeconomic status, alcohol consumption, smoking habits, and dental
visits. Although this
study was based on the PI, an index of periodontal disease, gingivitis is a
component of all but the
most severe category. In NHANES III, information on the presence or absence
of calculus was
collected. However, this study has not reported any association between
calculus and gingival
health.
Although smoking is one of the most important risk factors for adult
periodontitis, its role in
gingivitis is unclear. Several studies have indicated that gingival bleeding is
reduced among
smokers.13,66 Plaque levels in the smokers were either similar to or greater
than plaque levels in
nonsmokers. This reduction in gingival bleeding among smokers may be the
result of the
vasoconstrictive effects of nicotine in cigarette smoke. In clinical practice the
smoking status of
patients should be considered when gingival bleeding is assessed.

CHRONIC PERIODONTITIS
Periodontitis is inflammation of the periodontium that extends beyond the
gingiva and produces
destruction of the connective tissue attachment of the teeth.68 No longer
considered a single disease,
periodontitis is now considered to exist in three primary forms: chronic,
aggressive, and as a
manifestation of systemic diseases (see Box 7-3). Chronic periodontitis is the
most common form.
Chronic periodontitis progresses slowly and generally becomes clinically
significant in adults but may
be observed in children. For epidemiologic purposes, a case of chronic
periodontitis is a person with
the disease. As with gingivitis, methods to measure periodontitis and the
amount of disease necessary
to consider a person a case vary widely across studies.

How Is Periodontitis Measured?

Periodontal Index
In the early 1950s, gingivitis indices were gaining in popularity; however, no
index was available
to measure more advanced stages of periodontal disease. Motivated by the
lack of valid indices for
measuring the prevalence of periodontal disease in population groups,
Russell69 developed the
periodontal index (Box 8-3). Use of the PI requires a minimum of equipment:
a light source, a
mouth mirror, and an explorer. The supporting tissues for each tooth in the
mouth are scored
according to a progressive scale that gives little weight to gingival
inflammation and relatively
great weight to advanced periodontal disease.69 Box 8-3 identifies the
scoring criteria for the PI.
An individuals score is the sum of the tooth scores divided by the number of
teeth examined. The
population score is the sum of the individual scores divided by the number of
persons examined.
Periodontal probing was not recommended because, according to Russell, it
added little and
proved to be a troublesome focus of examiner disagreement.69

BOX 83
Scores and Criteria* for Periodontal Index (PI)
0 = Negative. There is neither overt inflammation in the investing tissues nor
loss of function
caused by destruction of supporting tissues.

1 = Mild gingivitis. There is an overt area of inflammation in the free gingiva,

but this area does
not circumscribe the tooth.
2 = Gingivitis. Inflammation completely circumscribes the tooth, but there is
no apparent break
in the epithelial attachment.
6 = Gingivitis with pocket formation. The epithelial attachment has been
broken, and there is a
pocket (not merely a deepened gingival crevice caused by swelling in the
free gingiva). There is
no interference with normal masticatory function; the tooth is firm in its
socket and has not
drifted.
8 = Advanced destruction with loss of masticatory function. The tooth may
be loose, may have
drifted, may sound dull on percussion with a metallic instrument, and may be
depressible in its
socket.
The PI is fast and easy to use. However, one important criticism of the index
is that it
underestimates the prevalence of disease.67

Periodontal Disease Index

As a consultant to the World Health Organization for a 1957 study of
periodontal disease in India,
Ramfjord67 was faced with the inadequacies of the available indices for
measuring periodontal
disease. Taking the most valuable features of existing indices and adding
new features to
compensate for their shortcomings, Ramfjord developed his own system for
measuring
periodontal disease.67 This system became known as the periodontal disease
index (PDI). One
unique aspect of the PDI was the examination of six preselected teeth in the
mouth: the maxillary
right first molar, maxillary left central incisor, maxillary left first premolar,
mandibular left first
molar, mandibular right central incisor, and mandibular right first premolar.
This selection of teeth
became known as the Ramfjord teeth. Another unique aspect of the PDI was
the use of the
cementoenamel junction (CEJ) as a fixed landmark for measuring periodontal
attachment loss.
To begin an assessment using the PDI, the examiner dries the areas around
the six teeth. Next, the

examiner assesses the severity of gingival inflammation around the six

teeth. Gingival scores for a
tooth range from G0 for absence of inflammation to G3 for severe
gingivitis. At the mesial,
facial, distal, and lingual side of each of the six teeth, the distance from the
free gingival margin to
the CEJ and the distance from the free gingival margin to the bottom of the
gingival sulcus are
measured in millimeters with a periodontal probe. If the free gingival margin
is on the cementum,
its distance from the CEJ is recorded as a negative number. The distance
from the CEJ to the
bottom of the gingival sulcus is the difference between these two
measurements. The distance
from the CEJ to the bottom of the gingival sulcus is a measurement of
periodontal attachment loss.
Ramfjords method for measuring this distance is often referred to as the
indirect method for
measuring periodontal attachment loss. The PDI score for each tooth is
based on the assessment
of gingival inflammation and the depth of the gingival sulcus in relation to
the CEJ (Box 8-4). If
the gingival sulcus does not extend apically to the CEJ in any of the
measured areas, the PDI score
for the tooth is the gingival score. If the gingival sulcus extends below the
CEJ in any of the
measured areas by 3 mm or less, the PDI score is 4. Teeth with sulcus
measurements of 3 to 6 mm
and greater than 6 mm are given scores of 5 and 6, respectively. The PDI for
the individual is the
sum of the tooth scores divided by the number of teeth examined. If any of
the six preselected
teeth are missing, another tooth is not substituted in its place. In addition to
the PDI score for
periodontal disease, the PDI provides a method for calculating tooth scores
for calculus, occlusal
attrition, mobility, and proximal contacts.

BOX 84
Scores and Criteria for Periodontal Index (PDI)
Perform Gingival Assessment
G0 = Absence of inflammation.
G1 = Mild to moderate inflammatory gingival changes not extending all
around the tooth.
G2 = Mild to moderate severe gingivitis extending all around the tooth.

G3 = Severe gingivitis characterized by marked redness, tendency to bleed,

and ulceration.
Record Pockets
The distance from the free gingival margin to the cementoenamel junction
(CEJ) and the
distance from the free gingival margin to the bottom of the gingival crevice
or pocket should be
recorded for the mesial, the facial, the distal, and the lingual aspects of each
tooth examined. The
interproximal recording should be secured at the buccal aspect of the
interproximal contact areas
with the probe pointing in the direction of the long axis of the tooth.
If the gingival margin is on enamel:
1. Measure from gum margin to the CEJ, and record the measurement on the
crown of the
schematic tooth. If the epithelial attachment is on the crown and the CEJ
cannot be felt by the
probe, record the depth of the gingival crevice on the crown.
2. Measure from the gingival margin to the bottom of the pocket when the
crevice extends
apically to the CEJ, and record the measurement on the root of the schematic
tooth. (The
distance from the CEJ to the bottom of the pocket can then be found by
subtracting
measurement number 1 from measurement number 2.)
If the gingival margin is on cementum:
1. Measure from the CEJ to the gingival margin. Record as a minus value on
the root of the
schematic tooth.
2. Measure from the CEJ to the bottom of the gingival crevice. Record value
on the root.
Modified from Ramfjord SP: J Periodontol 30:51, 1959.
Although the PDI is rarely used today, two aspects of the index are often
used: selection of the six
Ramfjord teeth and the method for measuring pocket depth and loss of
periodontal attachment.
Ramfjords technique for measuring pocket depth and periodontal
attachment loss has been used
in national surveys (e.g., NHANES).

Extent and Severity Index

The PI and the PDI yield scores that represent the severity of periodontal
disease in individuals or
populations, but these scores do not provide information on the extent of
disease. The extent and

severity index (ESI) of periodontal disease was developed to provide

separate estimates of the
extent and severity of periodontal disease in individuals and populations.21
Unlike the PI and PDI,
the ESI does not assess gingival inflammation. Instead, it estimates the loss
of periodontal
attachment using the periodontal probing method developed by Ramfjord for
the PDI.67 A
threshold of disease must be established to calculate the extent score for an
individual. In their
initial study of the ESI, Carlos et al.21 considered a site to be diseased when
attachment loss
exceeded 1 mm. (Because the measurements in epidemiology studies are
rounded down to the
next lowest millimeter, greater than 1 mm means 2 mm or greater, or 2
mm.) For an individual,
the extent score is the percentage of sites examined that have attachment
loss greater than 1 mm.
The severity score for an individual is the average loss of attachment per site
among the disease
sites. The ESI is expressed as a bivariate statistic: ESI = (Extent, Severity).
For example, an
individuals ESI of (20, 3.0) would be interpreted as 20% of sites examined
had disease, and of the
diseased sites, the average loss of attachment was 3.0 mm. The ESI for a
population would be the
average extent and severity scores for the individuals examined.
When ESI scores from two sites per tooth in the whole mouth were compared
with an assessment
of one upper and one lower quadrant, the developers of the ESI found that
little information was
lost from the half-mouth assessment.21 However, the ESI has been used for
full-mouth
examinations on as many as six sites per tooth.

NIDCR Protocol for Periodontal Disease

Assessment
The NIDCR periodontal disease assessment, as used in NHANES III, contains
three parts: a
periodontal destruction assessment, gingival assessment, and calculus
assessment.79 The gingival
assessment is described in the previous section on gingivitis. The
periodontal destruction
examination involves an assessment of loss of periodontal attachment and
furcation involvement.

Loss of periodontal attachment is the distance (in millimeters) from the CEJ
to the bottom of the
gingival sulcus. This distance is measured at the facial and mesiofacial sites
of teeth in two
randomly selected quadrants, one maxillary and one mandibular, using the
indirect measurement
method developed by Ramfjord.67 Probing is carried out with the use of the
NIDCR probe, which
is color-coded and has markings at 2, 4, 6, 8, 10, and 12 mm. In NHANES III,
loss of attachment
was reported in millimeters for each site measured. Periodontal pocket
depth, or the distance from
the free gingival margin to the bottom of the sulcus, also was reported in
millimeters for each site.
Furcation involvement is assessed on eight teeth: the maxillary first and
second molars, the
maxillary first premolars, and the mandibular first and second molars. The
assessment requires the
use of a #17 dental explorer for the maxillary teeth and a #3 cowhorn
explorer for the mandibular
teeth. The extent of furcation involvement is assessed at the mesial, facial,
and distal surfaces of
the maxillary molars; the mesial and distal sides of the premolars; and the
facial and lingual
surfaces of the mandibular molars. If furcation involvement does not exist,
the site is scored as 0.
If partial involvement exists but the probe cannot pass through the furcation,
the site is scored as 1.
If the explorer can pass between the roots (through involvement), the site is
scored as 2.
At each site assessed for loss of attachment, the presence or absence of
supragingival and
subgingival calculus is assessed. Subgingival calculus is detected using the
NIDCR probe. A score
of 0 is recorded for the site if no calculus is present; a score of 1 is recorded
if only supragingival
calculus is present; and a score of 2 is recorded if supragingival and
subgingival calculus are
present.
Beginning in 1999, NHANES became a continuous, annual survey (e.g.,
NHANES 1999, 2000,
2001) rather than a periodic survey. All other aspects of the examination
were the same as for
NHANES III. The survey data are released every 2 years. Thus the datarelease cycle for the

ongoing (and continuous) NHANES is described as NHANES 19992000,

NHANES 20012002,
NHANES 20032004, and so on. To produce estimates with greater statistical
reliability,
combining two or more 2-year cycles of the continuous NHANES is
encouraged and strongly
recommended. The NIDCR periodontal protocol was slightly modified for the
NHANES 1999
2000 studies by adding a mesiofacial site to the examination, resulting in
three sites examined per
tooth.

Radiographic Assessment of Bone Loss

The radiographic assessment of bone loss is an important part of the clinical
diagnosis of
periodontal disease. However, for the purposes of estimating the prevalence
or incidence of
periodontitis in population groups, radio-graphs are rarely used because of
ethical and practical
considerations. In studies in which radiographic bone loss is used as a
measure of periodontitis,
bone loss is usually measured from bite-wing radiographs as the distance
from the CEJ to the
alveolar crest. Bone loss can be expressed as this distance in millimeters or
as a percentage of the
root length. Various studies have used bone loss thresholds ranging from
greater than 1 mm to
greater than 3 mm.9 Bone loss measurements from radiographs are highly
correlated with
measurements of attachment loss taken with periodontal probes.9 The three
main sources of error
in the assessment of bone loss are (1) variations in projection geometry, (2)
variations in film
contrast and density, and (3) obstruction of the view by other anatomic
structures.9 Computerized
programs can detect bone changes as small as 0.5 mm when measuring
bone loss from sequential
radiographs.41 Also, advanced image-processing techniques, such as digital
subtraction
radiography and computer-assisted densitometric image analysis, can
enhance the ability to detect
bone loss over time.41

Figure 83
Percentage of persons in the United States with periodontal attachment loss
according to

different thresholds of attachment loss. (Data from Albandar JM, Brunelle JA,
Kingman A:
Destructive periodontal disease in adults 30 years of age and older in the
United States, 1988
1994, J Periodontol 70:13, 1999.)

How Much Chronic Periodontitis Is Present?

The most recent data for the prevalence of periodontal disease in the United
States come from
NHANES III (1988-1994). Because the assessment of periodontitis in a crosssectional survey such
as NHANES III is a cumulative measure of periodontal destruction, separating
chronic periodontitis
in adults from other forms is not possible. However, an analysis of NHANES III
data for adults age
30 years and older was reported.4 The prevalence of periodontal attachment
loss depends greatly on
the threshold chosen, ranging from a high of 99% for a threshold of greater
than 1 mm to a low of
7% for a threshold of greater than 7 mm (Figure 8-3). At a threshold of
greaterthan 3 mm, the
prevalence of attachment loss in at least one site in the mouth was 53.1%.
The prevalence of
attachment loss increased steadily with age, from a low of 35.7% for the 30to 39-year-old group to
a high of 89.2% for the 80- to 90-year-old group (Figure 8-4). On average per
person, 19.6% of the
teeth had attachment loss greater than 3 mm. Among people with at least
one site of attachment loss
greater than 3 mm, an average of 36.6% of the teeth per person was
affected. The mean percentage
of teeth affected also increased with age (Figure 8-5). Maxillary molars and
mandibular incisors
were more likely than other teeth to have attachment loss greater than 3
mm, whereas maxillary
central incisors were the least likely.

Figure 84
Percentage of persons in the United States with periodontal attachment loss
of greater than 3
mm. (Data from Albandar JM, Brunelle JA, Kingman A: J Periodontol 70:13,
1999.)

Figure 85
Mean percentage of teeth per person in the United States with attachment
loss of greater than 3
mm. (Data from Albandar JM, Brunelle JA, Kingman A: J Periodontol 70:13,
1999.)

As with attachment loss, the prevalence of periodontal pockets depends

greatly on the threshold
chosen (Figure 8-6). Generally, pockets greater than 3 mm are considered to
reflect disease. The
prevalence of periodontal pockets greater than 4 mm was 23.1%. The
increase in the prevalence of
attachment loss with increasing age is not seen with pocket depth (Figure 87). The average extent
of pockets greater than 4 mm was 5.2% of teeth per person, and the extent
varied little with age
(Figure 8-8).
The answer to the question, How much adult periodontitis is out there?
must be, It depends on
the case definition used.

Figure 86
Percentage of persons in the United States with periodontal pockets
according to different
thresholds of pocket depth. (Data from Albandar JM, Brunelle JA, Kingman A: J
Periodontol
70:13, 1999.)

Figure 87
Percentage of persons in the United States with periodontal pockets of
greater than 4 mm. (Data
from Albandar JM, Brunelle JA, Kingman A: J Periodontol 70:13, 1999.)