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Prevalence and progression of untreated periodontal disease in a young Indonesianpopulation

Timmerman, M.F.

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GENERAL INTRODUCTION

CHAPTER 1

INTRODUCTION

A major objective of dental care is extending the life span of the dentition either

by prevention or by treatment of dental diseases. The mean number of teeth

present per person is therefore an important parameter in the assessment of the

longevity of the dentition (Sheiham et al. 1969). It is generally accepted that the

number of teeth decreases with age and that caries and periodontal disease are the

main causes of tooth loss, although the relative impact of these two disease

entities may vary in different population groups and geographic areas (Löe et al.

1978a). The data from the studies by Brekhus (1929) and Allen (1944) led many

to suppose that the greatest single reason for tooth loss after the age of 40 years

was periodontal disease. Later, this was confirmed in a survey in Winnipeg,

Manitoba, by Trott & Cross (1966). However, their results also showed, that the

percentage of teeth lost due to periodontitis was higher than the percentage of

patients, who lost teeth due to periodontitis. In other words, with regard to

periodontitis, relatively many teeth were lost in relatively few patients.

In a study of elderly people in Iowa, it was found that the distribution of tooth loss

over an 18-month period was highly skewed (Hunt et al. 1988). The same was

found in a study over a period of 28 years in Tecumseh (Burt et al. 1 990). In this

particular study, 14.4% of the population became edentulous. This group

accounted for 94% of all teeth lost during the study period. Among those who

remained dentate, 1 3.8% of the persons lost teeth. They accounted for 60 .2% of

all teeth that were lost in dentate persons in that period. These data invite to the

conclusion, that a minority of the population appears to be susceptible to extensive

tooth loss, just as a minority appears susceptible to severe manifestations of caries

(US Public Health Service 1 981 , Graves et al 1 986) and periodontal disease (Löe

et al. 1986, US Public Health Service 1987). However, tooth loss in itself is not

a disease. The question that arises, is the extent to which this skewed distribution

reflects social factors, as well as the underlying diseases. Studies seeking reasons

for tooth loss have not probed this issue (Ainamo et al. 1 984, Bouma et al. 1 985,

Cahen et al. 1985, Kay & Blinkhorn 1986, Bailit et al. 1987, Manji et al. 1988,

Hunt et al 1988, Chauncey et al. 1989, Niessen & Weyant 1989). A principal

finding in these studies is, that periodontal disease is not as important a reason for

tooth loss as once thought, but many questions on the relative impact of disease,

17

CHAPTER 1

pat ient a t t i tudes , and t rea tment ph i losophy on too th loss remain unanswered

(Wein t raub & Burt 1985) .

Epidemiologic surveys conduc ted t h roughou t the wor ld point to the a lmost

universal d is t r ibu t ion of caries and per iodontal diseases (Rüssel 1967 ) . Mos t

s tudies have found tha t per iodont i t is a f fec ts a s igni f icant percent of indiv iduals

before the age of 20 and af fect ing the major i ty of the adul t popu la t ion after the

age of 3 5 - 4 0 years. Studies report tha t the prevalence and average sever i ty of

per iodont i t i s , increased w i t h age for groups of indiv iduals unti l v i r tua l ly all middle-

aged people had the disease (for rev iew see Scherp 1 9 6 4 , B rown & Löe 1993 ) .

Whi le a large propor t ion of the populat ion is suscept ib le to per iodont i t i s , it appears

tha t there is a small segment of the populat ion tha t is suscept ib le to severe fo rms

of per iodont i t i s . This observat ion leads to the proposal tha t there are suscept ib i l i ty

or risk fac to rs tha t modu la te suscept ib i l i ty to des t ruc t ive per iodont i t i s . The

suscept ib i l i ty of indiv iduals appears to vary great ly depending upon w h i c h risk

fac to rs are operat ive (Genco 1996) .

A risk fac tor for per iodonta l disease is an env i ronmenta l , behaviora l , or b io logic

fac tor con f i rmed by tempora l sequence, usual ly longi tudinal s tud ies, w h i c h if

present , d i rect ly increases the probabi l i ty of a disease occur r ing , and if absent ,

reduces th is probabi l i ty . Risk fac tors are part of the causal cha in , or expose the

host to the causal cha in . Once disease occurs , removal of a risk fac tor may no t

result in a cure (Last 1 9 8 8 , Amer ican Academy of Per iodonto logy 1996 ) . Some

risk fac to rs are modi f iab le , whi le others cannot be modi f ied or cannot easily be

mod i f i ed . Those fac tors tha t cannot be modi f ied are of ten called ' de te rm inan ts ' or

background fac to rs . 'Risk fac tor ' o f ten implies a modi f iab le cond i t ion . The t e rm risk

indicator is used to descr ibe plausible correlates of disease ident i f ied in cross-

sect ional s tudies or case-contro l s tudies, wh i le risk fac tors are best appl ied to

those corre lates conf i rmed in longi tudinal s tudies. Risk indicators are no t a lways

con f i rmed as risk fac to rs in longi tudinal studies (Beck 1994) . The te rm 'r isk marker '

is used more in the predict ive sense and usually refers to a risk fac tor , w h i c h is

associated w i t h an increased probabi l i ty of disease in the fu tu re .

Changes in our know ledge of the et io logy of per iodonta l d iseases, and the

recogni t ion of the potent ia l impor tance of suscept ib i l i ty fac tors as they a f fec t

in i t iat ion and progression of per iodont i t is , have led to intense s tudy of speci f ic risk

fac tors for des t ruc t ive per iodontal disease.

18

INTRODUCTION

Epidemiologic studies show more periodontal disease in older age groups than in

younger groups (Marshall-Day et al. 1955, Schei et al. 1959, Abdellatif & Burt

1987, Miller et al. 1987, Grossi et al. 1994, Grossi et al. 1995). This may be

caused by cumulative tissue destruction over a lifetime rather than an age-related,

intrinsic deficiency or abnormality which affects periodontal susceptibility. More

recent studies suggest that at least in the moderately elderly the rate of periodontal

destruction is the same throughout adulthood ((Holm-Pedersen et al. 1975,

Machtei et al. 1994). When considering the oral hygiene status, age is not of

substantial influence on periodontal disease (Abdellatif & Burt 1 987). Only at older

age (between 75 and 96) more severe increase of periodontal disease has been

reported (Douglass et al. 1 993, Fox et al. 1 994). At ages up to 75 years, age by

it self does not seem to be an intrinsic risk factor.

A consistent finding in all national surveys in the United States is that periodontal

disease is more prevalent in males than in females (U.S. Public Health Service

1965, U.S. Public Health Service 1979, Miller et al. 1987). Risk analyses of

periodontitis in other populations are not unanimous about gender as a risk factor

(Umeda et al. 1 998, Gamonal et al. 1 998, Norderyd et al. 1 999). But, like in the

United States, if a significant association is reported, males most often show a

higher risk than females. Reasons for this have not been explored in detail, but are

thought to be more a matter of differences in behaviourthan in genetic background

(Position Paper AAP 1996).

Socio-economic status was historically found to relate to gingivitis and poor oral

hygiene (U.S. Public Health Service 1965, U.S. Public Health Service 1979). This

does not account for periodontitis (Miller et al. 1 987). Both in developing countries

(Russell 1962, Waerhaug 1967, Wertheimer et al. 1967) and in industrialized

countries (Grossi et al. 1994, Grossi et al. 1995) it was found that lower socio­

economic status was not associated with severity of periodontitis. It is not clear

how other factors like true genetic racial/ethnic influence and cultural factors

confound in this multifaceted variable.

Whereas oral hygiene measures correlate well with gingivitis, many cross-sectional

studies show a poor correlation between levels of plaque and supragingival calculus

and periodontitis (Löe et al. 1 986, Cutress et al. 1 982, Baelum et al. 1 986, Baelum

et al. 1 988a, 1 988b, Ismail et al. 1 987, Ismail et al. 1 986, Lembariti et al. 1 988,

Löe et al. 1992, Okamoto et al. 1988). Subgingival calculus as a separate entity

19

CHAPTER 1

has not been studied epidemiologically.

Plaque and calculus were discovered for their role in periodontal disease in the

cross-sectional studies of the late fifties and early sixties (Lövdal et al. 1958,

Ladavalya & Harris 1959, Schei et al. 1959, Mobley & Smith 1963). Controlled

studies in Western populations show, that the amount of plaque has a low

correlation with the amount of attachment loss measured (Lindhe et al. 1989,

Badersten et al. 1 990, Machtei et al 1 993, Grossi et al. 1 994, Grossi et al. 1 995).

Also the predictive value of the amount of plaque for future progression of

periodontitis is low (Claffey et al. 1 990, Haffajee et al. 1 991 ). On the other hand,

in their 28-year longitudinal study on risk factors for tooth loss, Burt et al. (1 990)

found that edentulous persons had higher baseline scores for plaque, calculus and

gingivitis, then the age-matched dentate persons. Among dentate persons the

baseline gingivitis score and the baseline number of teeth were risk factors for

partial tooth loss. In this study periodontal attachment loss > 4 mm and

educational attainment were significant risk factors in the regression analysis.

When considering the best predictor for future attachment loss, the amount of

existing disease in relation to age seems to be the best choice (Haffajee et al.

1 991 , Grbic et al. 1 991 , Grbic & Lamster 1 992). However this is still an inexact

procedure (Position Paper AAP 1996).

A few members of the periodontal microflora have been considered as putative

pathogens for initiation and progression of periodontal disease. Slots et al. (1 986)

reported, in a retrospective study, a relationship between the presence of

Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis and Prevotella

intermedia and progression of periodontal disease. Hence, the value of the

presence of these 3 micro-organisms as a predictor for periodontal breakdown was

investigated in adult cases with refractory periodontitis during a 12 months

evaluation period. Progression of disease (attachment loss > 2 mm) was not

observed at sites without detectable levels of A. actinomycetemcomitans, P.

gingivalis and P. intermedia (Wennström et al. 1 987). Also microbial epidemiologic

studies have shed light on the role of specific periodontal micro-organisms in

periodontal disease. Carlos et al. (1988) found the presence of Prevotella

intermedia, along with gingival bleeding and calculus was correlated with

attachment loss in a group of Navajo adolescents aged 1 4 to 19. An epidemiologic

study of oral bacteria as risk indicators for periodontitis in older adults reported,

20

INTRODUCTION

that the difference in the prevalence of periodontal disease between blacks and

whites was explained, in part, by different prevalences of P. gingivalis and P.

intermedia (Beck et al. 1992). Grossi et al. (1994, 1995) tested a panel of micro­

organisms including A. actinomycetemcomitans, B. fosythus, Campylobacter

rectus, Capnocytophaga species, Eubacterium sabureum, F. nucleatum, P.

gingivalis, and P. intermedia. Of these micro-organisms, only P. gingivalis and B.

forsythus were associated with an increased risk for attachment loss after

adjustment for age, plaque, smoking and diabetes. The same two micro-organisms

were also identified as risk indicators for periodontal alveolar bone loss.

As is apparent from all these studies, variables that may be accounted for as risk

factors for periodontal disease are not unanimously found to be so. The complex,

multifaceted structure of these variables and their confounding influence on the

multifactorial disease process of periodontitis, may be the reason for the difficulty

to assess the quality and quantity of the effects of these factors. A problem of

performing studies in Western populations is that there is always some form of

treatment effect involved. Ethical considerations do not allow for abstention of

therapeutic measures in such a population. The effect of treatment influences the

results of these studies to an extent that cannot be controlled for.

Therefore, a longitudinal study was initiated in 1987 in a young population, which

had not received regular dental care, in order to establish the role of possible

clinical and microbiological risk factors for initiation and progression of

periodontitis. In 1 987, all subjects in the age range of 1 5-25 years, living in a small

village on a tea estate on western Java, Indonesia, entered the study. The material

presented in this thesis describes data on changes in the clinical periodontal

condition of the study population over a 7 years period between 1987 and 1994

and the relationship with clinical parameters and with presence of various

periodontal bacteria in the oral cavity both at the start and at the end of the

investigation.

21

CHAPTER 1

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2 3

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2 5

CHAPTER 1

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2 6

INTRODUCTION

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CHAPTER 1

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Wennst röm, J.L., Dahlén, G., Svensson, J . & Nyman, S. (1987) Actinobacillus

actinomycetemcomitans, Bacteroides gingivalis and Bacteroides intermedius: predictors of

at tachment loss? Oral Microbiology and Immunology 2, 158-62.

Wertheimer, F.W., Brewster, R.H. & White, C.L. (1967) Periodontal disease and nutrit ion in

Trinidad. Journal of Periodontology 38 , 100-104.

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