Original article

Periodontal disease in Norwegian old-age pensioners

Ola Norderyd, Birgitte Moesgaard Henriksen and Henrik Jansson
Department of Periodontology, Faculty of Odontology, Malmo University, Malmo , Sweden and Department of Periodontology, The Institute for Postgraduate Dental Education, Jo nko ping, Sweden

doi: 10.1111/j.1741-2358.2010.00380.x Periodontal disease in Norwegian old-age pensioners Purpose: To identify factors of importance for periodontal health and disease on an old-age Norwegian population. Materials and methods: From a random sample of 1152 urban and rural elderly Norwegians, aged 67 years or older, 582 individuals were agreed to participate in the study. After exclusion of edentulous individuals, 394 individuals were remained. A standardised clinical examination was performed by the same examiner. In conjunction with the clinical examination, a questionnaire was lled out regarding demographic and social status, educational level, tobacco habits and general condition. Results: In the examined population, 33% of the subjects had periodontal disease. Out of those, 12% had severe periodontitis, that is, 3 periodontal pockets 6 mm. All variables were tested separately in a logistic regression model with periodontal pockets 6 mm and above, as the outcome variable. After univariate testing the following variables were included in a multivariate logistic regression model: daily smoking, higher plaque score, rural living and lower education. Only daily smoking remained signicantly correlated to periodontal disease in the multivariate model. Conclusions: This study has shown a prevalence of periodontal disease in 33% of the study population. Out of those approximately 12% had more severe periodontitis. Daily tobacco use was the only factor signicantly correlated to presence of periodontal disease. Keywords: epidemiology, periodontal disease, elderly, risk factors. Accepted 16 January 2010

Introduction
The demography of the industrialised world has changed considerably in recent decades with a rapid increase in the proportion of elderly, especially those 80 years1. This change in demography will further change in the coming decades to even more elderly. Improved oral health in the adult population has resulted in a decreased number of edentulous individuals and, concomitantly, an increased number of individuals with more remaining teeth2. Today it is well established that infections in the oral tissues will result in increased levels of systemic inammation3. Several studies have shown that an increased level of systemic inammation is associated with, for example, insulin
4

resistance4,5 and cardiovascular disease (CVD)6. In an ageing population with more remaining teeth7 it is important to give the appropriate oral health care. More resources will be needed to take care of medically compromised individuals and there is also the risk of a possible association between oral infections and systemic inammation. Knowledge about the oral health status of the elderly is essential for planning and implementing oral health programmes and the optimisation of limited resources. Individual adequate oral health programmes will result in improved periodontal health, lower costs, time saving and less discomfort8,9. The aim of this study was to identify factors of importance for periodontal health and disease on an old-age Norwegian population.

2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 48

Periodontal disease in Norwegian

Materials and methods

Study subjects From a random sample of 1152 urban and rural elderly Norwegians, aged 67 years or older, 582 individuals were agreed to participate in the study. After exclusion of edentulous individuals, 394 individuals were remained. A detail description of the sample selection and sample procedures is described in Henriksen10. Oral examination A standardised clinical examination was performed by the same examiner, one of the authors (B.M.H), usually in dental clinics, but to some extent also in hospitals/institutions for the elderly or in the participants home. In conjunction with the clinical examination, a questionnaire was completed regarding demographic and social status, educational level, tobacco habits and general condition. The oral inspection was carried out with aid of a dental mirror and a periodontal probe (WHOprobe). Dentures were removed before the examination. The presence of periodontal disease was clinically registered for all teeth (6681) in the 394 dentate subjects. Periodontal pockets 4 mm or more were registered at the mesial surface on each tooth. The oral mucosal condition and oral hygiene were each registered with a mucosal score and a plaque score according to a four-graded scale11. Statistical analyses For descriptive analyses, mean values and SDs were calculated based on the subject as the unit. A logistic regression model with periodontal disease as the dependent variable was used for identifying factors associated with periodontal disease, the presence of periodontal pockets 6 mm. Two-sided p-values < 0.05 were considered statistically signicant. All analyses were made using the statistical software SAS (version 8.2 for WIN_PRO; SAS Institute Inc., Cary, NC, USA). Ethical requirements The Regional Medical Research Ethics Committee (RREC), appointed by the Ministry of Education, Research and Church Affairs upon recommendation from the Research Council of Norway, approved the study in accordance with the Helsinki

Declaration. All study participants, next of kin, or nursing personnel gave their signed, informed consent before inclusion in the project. Consent coming from other than the subject was given by the personal guardian or according to rules established by law at the institutions.

Results
In this population of Norwegian old-age pensioners (6799 years), 32% were completely edentulous. Among the 394 dentate subjects, the mean number of remaining teeth was 17 (Table 1). Of those individuals, 24% had 19 teeth, 27% had 1019 teeth and half of the examined individuals had 20

Table 1 Characteristics of the examined 394 dentate individuals. n Age 6774 7584 85 Gender Male Female Demographic status Urban Rural Education (years in school) 79 1012 1317 >18 Systemic disease No systemic disease 12 systemic diseases 3 systemic diseases Medication No medicines 12 medicines 3 medicines Cardiovascular diseases Diabetes Smoking Daily Partial dentures Teeth (mean number SD) Dental plaque No easily visible plaque Small amounts of visible plaque Moderate amounts of visible plaque Abundant amounts of plaque Presence of periodontal pockets 6 mm 198 166 27 192 199 256 135 245 68 63 12 105 232 54 120 170 101 184 17 % 51 42 7 49 51 65 35 63 18 16 3 27 59 14 31 43 26 47 4

66 17 162 41 17.2 8.0 96 135 107 44 130 25 35 28 12 33

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O. Norderyd et al.
100

80

Cum. % of subjects

60

40

20

0 0 1 2 3 4 5 6 No. of periodontal pockets 7 8 9

Figure 1 Cumulative percentage of individuals in relation to number of periodontal pockets 6 mm.

teeth or more. Individuals with 20 teeth were more common in the urban area (Oslo), comprising 65% of the population, compared with 35% in rural areas. Forty-one percent of the 394 subjects had partial dentures. Of the examined persons, 27% were systemically healthy and 31% took no prescribed medication. Forty-seven percent of the individuals had selfreported cardiovascular disease and 4% had diabetes. In this population, 17% of the subjects were daily smokers. According to the plaque score classication system, 60% of the individuals had acceptable oral hygiene. In the examined population, 33% of the subjects had periodontal disease and out of those, 12% had severe periodontitis, that is, 3 periodontal pockets 6 mm (Fig. 1). Correlation with the presence of periodontal disease could be seen for the following variables after univariate testing: daily tobacco use, higher plaque score and lower education level (Table 2). After testing these factors in a multivariate model together with demographic status, with periodontal pockets 6 mm as the outcome variable, only daily tobacco use remained statistically signicant correlated to periodontal disease (Table 3). Neither any other correlation with demographic status, older age, educational level, systemic diseases, medication, level of dental plaque control nor presence of dentures was found controlling all different variables in these models.

Discussion
In this study, no differences in periodontal status were seen in this population of old-age pensioners, whether they were city or rural living. This nding is similar to that found in a Swedish study comparing two adult populations living in the city of Jo nko ping and in the surrounding county12. Sixty-three percent of the investigated population had only completed elementary school. Similar gures have been reported by Paulander et al.13. In their investigation, for subjects with an age of 65 years, 68% (75% female and 62% male) had completed elementary school, and for 75 year-olds the corresponding numbers were 73% (77% female and 69% male). However, our ndings did not reveal any statistical signicant difference between educational level and periodontal disease as reported by Paulander et al.13 In this study, a prevalence of diabetes was observed in 4% of the population, which is in accordance with Andersson et al.14 and Berger et al.15, who found the same prevalence in a Swedish population living in a similar area to the present study. There were no statistical signicant differences between subjects with or without diabetes. However, from a statistical point of view, the sample size in this study was too small in relation to the prevalence of diabetes to provide enough power to detect a possible relationship between diabetes and periodontal disease.

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Periodontal disease in Norwegian

Table 2 Univariate analysis of variables characterising all dentate individuals. Odds ratio (OR) 1.0 1.3 1.6 1.0 0.9 1.0 1.1 1.2 1.1 1.1 1.0 1.1 1.1 1.0 0.9 1.1 0.8 2.2 0.6 1.2 1.5 1.8

Factors included Age 6774 7584 85 Gender Male Female Demographic status Living in city Rural living Education (years in school) 79 1012 1317 >18 Systemic diseases 12 3 Medication 12 3 Cardiovascular diseases Diabetes Smoking Daily Partial dentures Presence of Dental plaque Small amounts of visible plaque Moderate amounts of visible plaque Abundant amounts of plaque

95% condence interval (CI) 1.0, 1.0 0.9, 1.8 0.8, 3.1 1.0, 1.0 0.6, 1.4 1.0, 1.0 0.7, 1.6 0.6, 0.7, 0.8, 1.0, 2.5 1.8 1.4 1.0

0.8, 1.5 0.6, 2.2 0.7, 0.5, 0.7, 0.3, 1.3 1.6 1.6 2.4

1.3, 3.8 0.4, 0.9 1.0, 1.5 1.0, 2.3 1.0, 3.6

Table 3 Multivariate logistic regression analyses with no periodontal pockets 6 mm and presence of periodontal pockets 6 mm as dependent (outcome) variables. Odds ratio (OR) 2.2 1.2 1.0 1.0

Factors included Daily tobacco use Higher plaque score Living in rural area Lower educational level

95% condence interval (CI) 1.3, 0.9, 0.6, 0.7, 3.8 1.5 1.6 1.3

A recently published meta-analysis of longitudinal and cross-sectional studies demonstrated that subjects with periodontal disease are at signicantly

elevated relative risk of developing CVD16. However, when asking the examined subjects about CVD, nearly half of the examined population (47%) answered that they had CVD problems. The question asked, however, did not give a clear picture of the severity level of CVD. The result of this study for edentulous individuals is not in accordance with Hugoson et al.2, as only 1% (70-year-olds) and 4% (80-year-olds) of the investigated subjects were edentulous. This is signicantly lower compared with this study. In this study, the absence/presence of periodontal pockets was used as an outcome variable for periodontal health/disease. Using the number of lost teeth as a measure of periodontal health/disease is more difcult as the main reasons (caries or periodontitis) for tooth loss are often unknown. There are also differences in how dentists judge what level of periodontal disease is possible to treat. In a Norwegian study there was a poor correlation between the histological level of periodontal attachment loss on extracted teeth and the level (forceps level) reported by different dentists as a reason for extracting the teeth17. Today, there is good evidence that smoking in general has a negative inuence on health. In this study, 17% of the subjects were dened as being smokers. Smoking was the only factor signicantly correlated to the presence of periodontal disease. This is in agreement with results from other crosssectional studies1820, where a relationship has been established between tobacco smoking and periodontal disease. Traditionally, clinical probing pocket depth (PPD) with a millimetre graded probe has been used within dentistry to register periodontal health and disease. When periodontally healthy, there is seldom a PPD of more than 3 mm. Increased PPD can either be caused by the gingival inammation itself or in combination with an inammatory breakdown of the periodontal attachment. A PDD of 6 mm has been correlated to periodontal disease, that is, breakdown of the periodontal attachment21. In this study, radiographic examinations were not performed, so no data on periodontal/alveolar bone level were available. No signicant correlation with periodontal disease and oral hygiene level could be seen in this study. Even if the presence of bacterial plaque is necessary to initiate periodontal disease, plaque as a diagnostic variable is not very useful due to the generalised presence of bacterial plaque at proximal tooth sites in populations irrespective if the individuals are periodontally healthy or diseased2.

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In conclusion, this study has shown a prevalence of periodontal disease in 33% in the study population. Out of those, approximately 12% had more severe periodontitis. Daily tobacco use was the only factor signicantly correlated to presence of periodontal disease.

10.

11.

Acknowledgements
The authors would like to thank Mats Nilsson, PhD, for helping with the statistical analyses.
12.

Conicts of interest
The authors declare that they have no conict of interest. No external funding, apart from the support of the authors institution, was available for this study.

13.

14.

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Correspondence to: Ola Norderyd, Department of Periodontology, The Institute for Postgraduate Dental Education, P.O. Box 1030, SE-551 11 Jo nko ping, Sweden Tel.: +46 36 324611 E-mail: ola.norderyd@lj.se

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