Public Health Implications of Chronic Periodontal Infections in Adults

Summary Remarks: The CDC Perspective
William R. Maas, DDS, MPH, Director, Division of Oral Health, Centers for Disease Control and Prevention

Because this meeting was neither organized nor conducted to achieve consensus among participants, each departs with a unique take-home message. The depth of expertise and breadth of backgrounds of the speakers as well as the mix of attendees enriched both formal discussions and the informal ones that occurred during breaks. Presenters were particularly responsive in sharing their thoughts about the public health implications of associations considered. The discussion periods addressed the two contexts of periodontitis, i.e., both as an undesirable threat to oral health, in its own right, and as a potential risk factor for systemic disease.

Throughout this conference, such public health implications were conditional, predicated on future demonstration of causal relationships and effective interventions. Based on the current state of the evidence for these associations and interventions, recommendations for periodontal treatment on the basis of potential systemic disease outcomes remain premature. Thus, it seems inappropriate to initiate new public health programs to prevent these outcomes. It is clearly important, however, to prevent and treat periodontal infections to maintain and improve oral health.

Clearly, much more research is needed. Where randomized clinical trials are feasible, they can provide evidence of the effect of periodontal treatment on systemic outcomes. Another approach would add assessment of periodontal status to ongoing trials addressing the disease outcomes of interest. During discussion periods, attendees raised questions about the costs of and justification for randomized trials, given limited and inconclusive current evidence from observational studies published in the peer-reviewed literature. Additional observational studies of representative populations might permit estimation of potential benefits from preventing and controlling periodontal infections and guide further research.

In spite of the preliminary, inconclusive nature of accumulated evidence, the reported association between severe periodontitis among pregnant women and their birth outcomes represents one of the more compelling arguments for public health intervention considered at this meeting. Although meeting participants focused on treatment of periodontitis during pregnancy, their discussions only briefly considered the potential benefits of primary prevention. As a public health goal, it may be possible to create a situation in which women have healthy gums before they become pregnant. Then, it is not a large leap to broaden the commitment and ask what public health aspirations should be for young adults, both men and women. How can the 15% likely to experience severe destruction of their periodontium be predicted? How early can persons with the hyperinflammatory phenotype be identified? Using public health approaches, could the situation that exists today—many young adults reaching middle age without ever having early periodontal infection identified and treated—be rectified?

A second compelling finding, one that should prompt serious thinking about health care in the United States, comes from data showing that persons with diabetes report lower use of dental care than do those without diabetes. This lower use is particularly evident among Hispanics and non-Hispanic blacks, who are overrepresented among those with diabetes. So, if dental public health professionals believe that diabetes and its complications are serious, how should they respond to the fact that many of those who don’t seek or receive regular dental care are black, Hispanic, or poor? If the only way to detect those at risk for periodontal destruction is through clinical assessment, what approaches might increase the number of young adults with diabetes who receive such an assessment? What interventions might reach dental and other health professionals, as well as persons with diabetes and the general public with this important message?

Smoking represents yet a third major issue from this meeting. Because it is an independent, very strong risk factor both for periodontal infection and for cardiovascular disease, future research must address whether their association represents co-morbidity resulting from smoking. Public health action need not wait for these research findings, however. Good evidence documents that tobacco cessation counseling provided by dentists and other dental personnel can be just as effective as that by other health care providers. For some persons, the dental setting may even be more effective, because ill effects of the tobacco habit are readily apparent in the smoker’s mouth. Public policies are making it more difficult for people to smoke; places to smoke have been reduced, while the cost of cigarettes has increased. Still, people with nicotine addiction typically must make many serious attempts to quit smoking before achieving success. Dental personnel have to accept that such multiple attempts are the nature of this particular intervention—and thus, they must persist in asking about the patient’s readiness to quit, as well as in offering encouragement for any cessation efforts. Given smoking’s role in periodontal infection, dental clinicians should spend as much time on tobacco prevention and cessation as on oral hygiene behaviors. Periodontists and their staffs probably ought to be among the most successful tobacco cessation counselors in all of health care and could provide leadership for the rest of the dental profession and the community at large.

Based on what is now known, it seems clear that there are several public health approaches to explore for preventing and controlling periodontal infections. The capacity of oral health programs within state and local health agencies can be built, so they become active partners in broader ongoing efforts to: a) reduce tobacco use, particularly smoking, at the individual and community levels; b) educate persons with diabetes and their health care professionals about the periodontal implications of diabetes and the benefits of regular care; and c) consider targeted health communication efforts to make key groups aware of effective preventive interventions.

While applying what is known, research investments also must occur to expand the knowledge base. Some of that research will focus on basic science questions or test interventions with clinical trials, but substantial needs for epidemiologic, health services, and applied, community-based research also exist. For example, could susceptible groups best be reached by adding an oral health component to an existing intervention trial or ongoing program? This meeting has revealed how far we have come with the science—yet how far we must still go to achieve the goal of periodontal health for all.

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Historical Document
Page last reviewed: February 2, 2005
Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion