Periodontal conditions among employed adults in Spain

J Clin Periodontol 2016; 43: 548–556 doi: 10.1111/jcpe.12558 Periodontal conditions among employed adults in Spain Carasol M, Llodra JC, Fern
andez-Meseguer A, Bravo M, Garc
ıa-Margallo MT, Calvo-Bonacho E, Sanz M, Herrera D. Periodontal conditions among employed adults in Spain. J Clin Periodontol 2016; 43: 548–556. doi:10.1111/jcpe.12558. Abstract Aim: To assess the prevalence and severity of periodontal conditions among a representative sample of employed adults in Spain. Material and Methods: A national cross-sectional study was conducted during 2008–2011. Periodontal status of 5130 workers, stratified by gender, age and occupation, was assessed based on Community Periodontal Index (CPI) and Clinical Attachment Level (CAL), following the WHO criteria. Results: The percentage of subjects with periodontal pockets (CPI codes 3–4) was 38.4%, [95% Confidence Interval (CI): 36.4–40.5] increasing significantly in subjects ≥45 years; 13.7% (95% CI: 12.8–14.7) of workers showed CAL 4–5 mm, while 7.7% (95% CI: 7.0–8.5) showed CAL ≥6 mm, again increasing significantly in the population ≥45 years. Prevalence of worse periodontal conditions was significantly higher in male workers, in subjects with primary school education and lower income, and in smokers and former smokers. The periodontal condition in young adults (35–44 years) was worse in comparison with those previously reported in Spanish national surveys. Conclusion: Prevalence of destructive periodontal diseases was age-, gender-, education-, income- and tobacco smoking-related. Young adults showed worse periodontal conditions than has been previously reported in national surveys in Spain. It is suggested to include oral evaluation and preventive strategies in workrelated medical check-ups. Conflict of interest and source of funding statement The authors declare that they have no conflict of interests. This study was supported by Cualtis, previously named Sociedad de Pre
n de Ibermutuamur, a comvencio pany that focuses specifically on preventing diseases and accidents, by monitoring and promoting workers’ health. The authors were fully independent in preparing the protocol, conducting the research, interpreting the results and preparing the manuscript. 548 Periodontal diseases are an important public health problem worldwide. The Global Burden of Disease Study (2010) reported that in the period between 1990 and 2010, severe periodontitis was the sixth most prevalent condition in the world with a global age-standardized prevalence of 11.2% (Kassebaum et al. 2014). Previous worldwide reviews have also reported that milder forms of periodontitis affect even a higher percentage of adults (Dye 2012, Petersen & Ogawa 2012). In Europe, several national epidemiological surveys have been Miguel Carasol1, Juan Carlos Llodra2,
ndez-Meseguer3, Ana Ferna Manuel Bravo2, Mar
ıa Teresa Garc
ıaMargallo4, Eva Calvo-Bonacho3, Mariano Sanz1 and David Herrera1,5 1 ETEP (Etiology and Therapy of Periodontal Diseases) Research Group, University Complutense, Madrid, Spain; 2Faculty of Odontology, University of Granada, Granada, Spain; 3Ibermutuamur, Madrid, Spain; 4 Cualtis, Madrid, Spain; 5Spanish Society of Periodontology (SEPA), Spain Key words: cross-sectional study; periodontal condition; prevalence; Spain; working population Accepted for publication 26 March 2016 conducted in countries with different socioeconomic conditions and different organizations of dental health services [for review, see (Sheiham & Netuveli 2002, K€ onig et al. 2010)]. Since these disease trends change over time, epidemiological surveys are periodically needed to study their prevalence, extension and severity, as well as the possible systemic and professional health repercussions (Genco & Genco 2014). In Spain, excluding the first national study on the prevalence of periodontal diseases and tooth decay (Gimeno de Sande et al. 1971), © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Periodontal status in working population national studies have been conducted since 1993 with homogeneous design criteria, thus, allowing to compare those conducted in 2000, 2005 and 2010 (Llodra et al. 2002, Bravo et al. 2006, Llodra 2012). All of them followed the World Health Organization (WHO) criteria for oral health surveys (WHO 1997). Those studies on general population included age strata of 5–6, 12, 15, 35–44 and 65– 74 years. Employed adults in Spain, although not representative of the whole population, can provide data on a broad sub-population of it, as it comprised more than 20 million people from 16 years to 65–70 years of age at the period of study. It was the aim of this study to assess the prevalence and severity of periodontal diseases, as well as the associated systemic health and socio-demographic factors, in a representative sample of the Spanish employed population. This study was part of a wide survey that aimed to study the oral health status and oral health care needs of the Spanish adult employed population using the WHO criteria. Material and Methods Workers’ Oral Health (WORALTH) Study was an oral epidemiological survey conducted on a representative sample of the Spanish employed population, from April 2008 to June 2011, following the WHO criteria for Oral Health Surveys (WHO 1997). The protocol was reviewed and approved by Ibermutuamur Ethics Committee. The paper was prepared following the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (von Elm et al. 2008). Signed informed consents were obtained from all participants before enrolment in the study, in accordance with principles of good clinical practice (ICH/ISO 14155) and the Helsinki Declaration (2008). Sampling A proportionate stratified random sampling method was applied. Strata were defined according to the geographical area, age, and gender of workers. Sample size of each stratum was defined in proportion with the Spanish Labour Force Survey, 2nd quarter (Instituto Nacional de Estad
ıstica 2008). Four geographical areas were defined as in previous Oral Health Surveys conducted in Spain: Centre, Northeast and East Coast, Northwest and South of Spain. Those four geographical areas comprised the whole country and they were used in order to define strata sample size. We aimed to mirror the percentage of subjects in the Spanish Labour Force Survey (Instituto Nacional de Estad
ıstica 2008) by age and gender, at each geographical area. Workers were approached on occasion of their work-related annual check-up. The inclusion process followed this procedure: (i) when workers underwent their routine medical check-up, the computer program at the admission desk detected if the combination of variables (age, gender and occupation) met any of the strata criteria in that geographical area (the order of selection was determined by arrival to admission desk and data input); (ii) workers were given detailed information with the consent forms and, then, were led to an oral examination room, filling a questionnaire on oral health before the clinical examinations were carried out by a trained examiner, with an assistant. The number of teeth present was not used as an inclusion criterion. This procedure was followed until the complete sample strata were recruited. A net sample size of 5154 subjects was included after 47 subjects refused to attend the oral examination. In Spain, workers attend annually, work-related medical check-up during their working hours. We may also add that dental care in Spain is almost privately financed. This may clarify the fact that only 47 workers declined participation, as the majority of workers were gladly surprised to have the opportunity of having a free oral examination, along with the medical check-up, in such convenient circumstances. Demographic characteristics of decliners were not different from those of participants. Of this sample of 5154 subjects, 24 were edentulous, and therefore were excluded for periodontal assessment [Community Periodontal Index (CPI) and Clinical Attachment Level (CAL)], resulting in 5130 subjects. The flow chart of the Study is © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 549 presented in the Supporting Information, Figure S1. Socio-demographic variables and smoking status Socio-demographic and behavioural variables were obtained from the medical check-up and a questionnaire (gender, occupation, country of origin, smoking status, education and income level). Five age strata were defined: under 25, 25–34, 35–44, 45–54 and 55 years or older. Employed adults were classified into two major categories according to the Spanish National Classification of Occupations (Instituto Nacional de Estad
ıstica 1994): white-collar (non-manual occupations), and blue-collar (manual occupations). Smoking habit was categorized as: never smoker, former smoker (who quit at least 12 months ago), current smoker of ≤10 cigarettes/day, and current smoker of >10 cigarettes/day. The country of origin was categorized into two groups: Spain and other countries. Education level was categorized into three levels: low (primary school), medium (secondary school) or high (university). Income level was categorized into three levels based on the net income of the family unit: ≤1200, 1200–3600 and >3600 euro/month respectively. Oral examination and assessment of periodontal status Clinical examinations were carried out in a portable dental chair with a headrest, with a standardized light lamp and examination position of the subjects, plane mouth mirrors and periodontal WHO probes. A recording clerk assisted each examining dentist. Following the WHO criteria (WHO 1997), periodontal conditions were assessed by the CPI and CAL. The ten index teeth were assessed at three buccal sites (mesiobuccal, midbuccal, distobuccal) and three lingual sites (mesiolingual, midlingual, distolingual) and the highest value was recorded at each sextant. Training and calibration of examiners Following the WHO criteria (WHO 1993), training and calibration sessions were conducted by an experienced WHO epidemiologist, who acted as the benchmarked examiner 550 Carasol et al. (“Gold Standard”) for the nine examining dentists. On the first day, examiners were instructed on the criteria and examination method. On the second day, the calibration exercises were carried out. A total of 72 patients (eight for each of the nine examiners) with some extent of periodontal disease, were selected from 100 subjects previously explored. Crossed-examinations with gold standard were carried out to analyse inter-examiner agreement. Kappa index values ranged between 0.67 and 0.79 for the nine examiners, which are considered “substantial agreement” according to Landis & Koch’s (1977) scale. We did not find significant differences between the CPI-subject scores and the CAL-subject scores. Intra-examiner variability was measured throughout the data recruitment. Statistical analysis Descriptive statistics were calculated for all variables. Percentages and 95% confidence intervals (95% CI) were used for categorical data, and means and standard deviations (SD) in the case of quantitative variables. A chi-squared test was performed to test the association between each explanatory variable and three categories of CAL: 0–3 mm; 4–5 mm; ≥6 mm. The Pearson chi-squared statistic was corrected for the survey (or complex) design with the secondorder correction of Rao and Scott, and was converted into an F statistic. Finally, backward logistic regression was conducted with the purpose of identifying significant associations of all variables considered with CAL ≥6 mm. Backward logistic regression was selected in order to reduce the number of covariables. A variable was removed from the model if its associated p-value was <0.10. Crude and adjusted odds ratios, and 95% CIs were calculated. All analyses were carried out using IBM SPSS Statistics 22.0.0.0, and STATA v.13. Data were treated taking into account the stratified sampling method, using commands for data analysis of complex samples and weighting calculations on the basis of distributions of the stratification variables in the Spanish working population (Spanish Labour Force Survey), and in our sample. Results A complete description of sociodemographic and behavioural variables of net sample size (n = 5154) is shown in the Supporting Information, Table S1. The proportion of edentulous subjects was very low, as stated before, and almost perceptible in subjects ≥45 years. The number of teeth present was high, and varied from 27.4 in the <25 years age group to 21.7 in subjects ≥55 years (Table S1). Prevalence and severity of periodontal condition The periodontal condition of final sample size (n = 5130) measured by CPI is shown in Table 1. The percentage of subjects with periodontal pockets (CPI codes 3–4) was 38.4% (43.2% for males, 31.6% for females) and this percentage significantly increased with age, reaching 65.1% in subjects aged 55 years or older. Worse periodontal condition was significantly more prevalent in males, subjects with blue-collar occupations, primary school studies, net income bellow 1200 euro/month, former smokers and smokers of more than 10 cigarettes/day. Results for prevalence data measured by CAL are presented in Table 2. Overall, 78.6% of subjects did not show loss of attachment, while 7.7% of subjects showed CAL ≥6 mm. The prevalence of subjects in the categories CAL (4–5 mm) and CAL (≥6 mm) was significantly higher in subjects ≥45 years, males, subjects with primary school education, former smokers and smokers of ≥10 cigarettes/day. Severe periodontitis was more prevalent in males and subjects with net income bellow 1201 euro/month, while former smokers and smokers of ≥10 cigarettes/day showed a similar percentage of subjects with severe CAL (≥6 mm), 11.8% and 11.5% respectively. The severity of the periodontal condition was measured by mean number of sextants in each CPI or CAL code by age strata (Tables 1 and 2). In all groups of age, the mean number of sextants with deep pockets or CAL ≥6 mm was low. No significant differences were found between the analysed variables in regards to severity of periodontal disease related to the presence of periodontal pockets or CAL ≥4 mm. Socio-demographic factors associated with the periodontal condition Table 3 shows the multiple logistic regression results for subjects with CPI codes ≥3. Age was the most significant factor associated with an increased odds ratio (OR) for worse periodontal condition, with men showing an increased probability of CPI codes ≥3 [OR = 1.43 (1.23–1.66)], similar to blue-collar occupation and the two lower income categories. Taking as reference the subjects who had never smoked, former smokers, smokers of ≤10 and of >10 cigarettes/ day significantly predicted poorer periodontal conditions. Table 4 shows the multiple logistic regression results for subjects with high CAL (≥6 mm). Gender was a significant factor associated with worse periodontal condition, men showing an increased probability of high CAL [OR = 2.15 (1.59– 2.90)]. Taking as reference the <25 year group, subjects 35–44 years [OR = 3.67 (1.43–9.38)], subjects ≥45 years [OR = 14.84 (5.91–37.29)] and subjects 55 years or older [OR = 24.85 (1.56–3.02)] had an increased probability of a poorer periodontal condition than subjects under 25 years of age. The association of primary school education and worse periodontal condition was statistically significant, compared with those in the university group. Taking as reference the subjects who had never smoked, we found again that former smokers, smokers of ≤10 and of >10 cigarettes/day had significantly predicted poorer periodontal conditions than never smokers. Periodontal condition in the 35- to 44-year stratum The periodontal condition, measured by CPI and CAL, in the 35- to 44year-old stratum is presented in Table 5, together with data from previous oral health surveys performed in Spain. The prevalence of CPI 3 was 29.2% and it reached 8.4% for CPI 4. The prevalence of CAL 4–5 mm was 14.4%, and 4.5% for CAL ≥6 mm. Regarding the © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Periodontal status in working population 551 Table 1. Percentage distribution of subjects classified according to the Community Periodontal Index (CPI), stratified by age, gender, occupation, country of origin, education, net income (monthly), and smoking status. Severity of periodontal disease by age strata: mean number of sextants by CPI Percentage of subjects who have as highest code (95% Confidence Interval [CI]) n Code 0 (%) All subjects Age group (years) <25 Mean sextants (95% CI) 25–34 Mean sextants (95% CI) 35–44 Mean sextants (95% CI) 45–54 Mean sextants (95% CI) ≥55 Mean sextants (95% CI) Gender Male Female Occupation White-collar Blue-collar Country of origin Spain Others Education Primary school Secondary school University Net income (monthly) <1200€ 1201 to 3600€ >3601€ Smoking status Never Former smoker Smoker ≤10 cigarettes/day Smoker >10 cigarettes/day 5130 459 1498 1455 1118 599 5.4 (4.8–6.1) 6.3 1.81 6.5 1.82 6.0 1.64 3.9 1.19 3.7 0.97 (4.4–8.9) (1.63–1.98) (5.4–7.9) (1.73–1.92) (4.9–7.3) (1.55–1.74) (2.9–5.2) (1.09–1.29) (2.5–5.5) (0.84–1.11) 2979 2151 4.1 (3.4–4.9) 7.3 (6.3–8.5) 2647 2483 7.0 (6.1–8) 3.8 (3.1–4.6) 4434 517 Code 1 (%) 7.6 (6.9–8.4) 12.6 1.73 10.1 1.54 7.4 1.16 4.6 0.93 3.2 0.74 (9.9–15.9) (1.60–1.87) (8.7–11.7) (1.47–1.61) (6.2–8.9) (1.10–1.23) (3.5–6) (0.85–1.01) (2.1–4.9) (0.64–0.84) Code 3 (%) 48.7 (47.3–50.1) 28.3 (27.1–29.5) 10.1 (9.3–11) 65.6 2.00 60.8 1.92 48.8 1.78 36.1 1.58 28.1 1.35 14.4 0.42 20.0 0.59 29.3 1.08 36.8 1.49 41.2 1.63 1.0 0.02 2.6 0.05 8.4 0.16 18.6 0.38 23.9 0.48 (61.1–69.8) (1.85–2.16) (58.3–63.2) (1.84–2.01) (46.2–51.4) (1.70–1.86) (33.3–39) (1.48–1.67) (24.6–31.8) (1.22–1.48) (11.5–17.9) (0.32–0.52) (18.1–22.1) (0.53–0.66) (27–31.7) (1.00–1.16) (34–39.7) (1.38–1.59) (37.3–45.2) (1.49–1.78) Code 4 (%) (0.4–2.4) (0.00–0.05) (1.9–3.5) (0.03–0.07) (7.1–9.9) (0.13–0.19) (16.4–21) (0.33–0.44) (20.7–27.5) (0.39–0.57) <0.001 47.3 (45.5–49.1) 50.5 (48.4–52.6) 30.4 (28.8–32.1) 25.3 (23.5–27.2) 12.8 (11.6–14.0) 6.3 (5.3–7.4) <0.001 9.2 (8.2–10.4) 5.8 (4.9–6.8) 51.8 (49.9–53.7) 45.3 (43.4–47.3) 23.7 (22.1–25.4) 33.2 (31.4–35.1) 8.3 (7.3–9.4) 11.9 (10.7–13.2) <0.001 5.4 (4.8–6.1) 6.3 (4.5–8.7) 7.2 (6.5–8) 11.1 (8.7–14.1) 49.3 (47.8–50.8) 41.9 (37.7–46.2) 28 (26.7–29.3) 29.6 (25.8–33.7) 10.0 (9.2–10.9) 11.1 (8.7–14.1) 0.003 1296 2070 1580 2.8 (2–3.8) 4.8 (4.0–5.8) 8.6 (7.3–10.1) 3.9 (3.0–5.1) 7.9 (6.8–9.1) 10.4 (9.0–12.0) 39.9 (37.3–42.6) 50 (47.8–52.2) 53.6 (51.1–56.0) 35.8 (33.2–38.4) 29.2 (27.3–31.2) 20.5 (18.6–22.6) 17.6 (15.6–19.8) 8.1 (7.0–9.4) 7 (5.8–8.4) <0.001 1466 2576 519 4 (3.1–5.1) 6.6 (5.7–7.6) 4.9 (3.4–7.1) 6.8 (5.6–8.2) 7.9 (6.9–9.0) 8.9 (6.7–11.7) 43.9 (41.4–46.5) 51.2 (49.3–53.1) 57.5 (53.2–61.7) 32.1 (29.8–34.5) 26.3 (24.6–28.0) 19.6 (16.4–23.2) 13.1 (11.5–14.9) 8.1 (7.1–9.2) 9.2 (7.0–12.0) <0.001 2463 652 707 722 7.3 4.1 3.0 1.7 9.9 5.6 6.3 2.8 51.7 40.8 51.7 41.8 23.2 34.6 30.3 39.5 7.9 14.9 8.7 14.2 <0.001 (6.3–8.4) (2.8–5.9) (2.0–4.5) (1.0–2.9) 5.4 (4.6–6.3) 10.6 (9.4–12) Code 2 (%) p-value (8.8–11.1) (4.1–7.6) (4.7–8.3) (1.8–4.3) (49.7–53.7) (37.1–44.6) (48.0–55.4) (38.3–45.4) (21.6–24.9) (31.0–38.3) (27.0–33.8) (36.0–43.1) (6.9–9.0) (12.4–17.8) (6.8–11.0) (11.8–16.9) Code 0, Gingival health; Code 1, presence of gingival bleeding; Code 2, supra or subgingival calculus; Code 3, moderate periodontal pocket (4–5 mm); Code 4, deep periodontal pocket (≥6 mm). severity of periodontal disease, the mean number of sextants with CPI 3 was 1.08, while the mean number of sextants with LA 4–5 mm was 0.37. Discussion This study on a representative sample of the Spanish occupied population, showed that the prevalence of a poorer periodontal condition was age-related and gender-related, as has been reported recently (Eke et al. 2015). Higher CAL codes were significantly more prevalent over 45 years and these increased with age. These results are in contrast with those referred to severe periodontitis, where the prevalence of this condition reached its peak at age 40 years and remained stable at older ages (Kassebaum et al. 2014). Males showed higher prevalence of poor periodontal condition than females, in accordance with other studies (Hermann et al. 2009, Holtfreter et al. 2009). Moreover, the results showed that gender and age were the most significant factors associated with worse periodontal condition, and that primary school education was also significantly associated with CAL ≥6 mm, while income was not, according to other studies that found an association with the educational level (Borrell et al. 2006). Tobacco smoking was significantly predictive for periodontal disease, in agreement with previous studies [for review, see (Genco & Borgnakke 2013)]. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd We acknowledge the current standards for reporting epidemiological studies published by Holtfreter et al. (2015), and the limitations of the WHO methodology for oral health surveys (WHO 1997), but it was chosen because of the cost-benefit of this methodology, the practicability to perform it in the context of a work-related medical check-up and the opportunity to compare results with data from previous WHO oral health surveys performed in Spain (Llodra et al. 2002, Bravo et al. 2006, Llodra 2012). Results of the periodontal condition in the 35- to 44-year-old stratum, the so-called young adults’ cohort by WHO methodology (WHO 1997), showed a lower prevalence of CPI 0 in young adults 552 Carasol et al. Table 2. Percentage distribution of subjects classified according to Clinical Attachment Level (CAL), stratified by age, gender, occupation, country of origin, education, net income (monthly), and smoking status. Severity of periodontal disease by age strata: mean number of sextants by CAL n All subjects Age group (years) <25 Mean sextants (95% CI) 25–34 Mean sextants (95% CI) 35–44 Mean sextants (95% CI) 45–54 Mean sextants (95% CI) ≥55 Mean sextants (95% CI) Gender Male Female Occupation White-collar Blue-collar Country of origin Spain Others Education Primary school Secondary school University Net income (monthly) <1200€ 1201 to 3600€ >3601€ Smoking status Never Former smoker Smoker ≤10 cigarettes/day Smoker >10 cigarettes/day 5130 459 1498 1455 1118 599 Percentage of subjects with CAL (95% Confidence Interval [CI]) 0–3 mm (%) 4–5 mm (%) 78.6 (77.5–79.7) 13.7 (12.8–14.7) 96.5 5.91 93.3 5.79 81.1 5.40 63.5 4.63 50.0 3.96 2.5 0.06 5.4 0.12 14.4 0.37 21.5 0.67 26.7 0.83 (94.4–97.8) (5.87–5.96) (91.9–94.5) (5.76–5.83) (79.0–83.0) (5.34–5.47) (60.6–66.3) (4.52–4.74) (46.0–54.0) (3.78–4.14) p-value ≥6 mm (%) 7.7 (7.0–8.5) (1.4–4.4) (0.02–0.09) (4.4–6.7) (0.09–0.15) (12.7–16.3) (0.32–0.41) (19.2–24.0) (0.60–0.74) (23.3–30.4) (0.72–0.94) 1.0 0.01 1.3 0.01 4.5 0.03 14.9 0.10 23.3 0.16 (0.4–2.4) (0.00–0.02) (0.8–2.0) (0.00–0.01) (3.5–5.7) (0.02–0.03) (12.9–17.1) (0.08–0.12) (20.1–26.8) (0.12–0.19) <0.001 2979 2151 74.5 (72.9–76.0) 84.2 (82.6–85.7) 15.3 (14.1–16.6) 11.6 (10.3–13.0) 10.2 (9.2–11.3) 4.3 (3.5–5.2) <0.001 2647 2483 81.4 (79.9–82.8) 75.6 (73.9–77.2) 12.4 (11.2–13.7) 15.1 (13.7–16.6) 6.3 (5.4–7.3) 9.3 (8.2–10.5) <0.001 4434 517 78.7 (77.5–79.9) 76.5 (72.7–80.0) 13.3 (12.3–14.3) 17.4 (14.4–20.9) 8.0 (7.2–8.8) 6.2 (4.4–8.6) 0.022 1296 2070 1580 68.0 (65.4–70.5) 80.8 (79.0–82.4) 84.1 (82.2–85.8) 18.0 (16.0–20.2) 13.1 (11.7–14.6) 11.1 (9.6–12.7) 13.9 (12.1–15.9) 6.2 (5.2–7.3) 4.8 (3.9–6.0) <0.001 1466 2576 519 75.3 (73.0–77.4) 80.3 (78.7–81.8) 80.7 (77.1–83.9) 14.9 (13.2–16.8) 13.2 (11.9–14.6) 11.3 (8.9–14.3) 9.8 (8.4–11.4) 6.4 (5.5–7.4) 8.0 (6.0–10.7) <0.001 2463 652 707 722 82.9 69.7 82.3 69.5 11.8 17.8 10.9 18.6 (6.0%) when compared with data reported in the 2000, 2005 and 2010 Spanish Oral Health Surveys (19.3%, 14.8% and 16.0% respectively) (Llodra et al. 2002, Bravo et al. 2006, Llodra 2012). Conversely, it was similar to those reported by other European surveys (Petersen & Ogawa 2012). For the prevalence of moderate periodontal pockets (CPI 3), it was higher (29.2%) than in the Spanish surveys 2000 and 2005 (21.4% and 21.5% respectively), and much higher than the prevalence reported in the 2010 survey (11%). In Europe, Sheiham & Netuveli (2002) calculated, in their review, a mean prevalence of 36% for CPI 3 in western countries. Regarding CPI 4, a prevalence of 8.4% was reported, this percentage being clearly higher than the figures from the previous Spanish surveys, (81.4–84.3) (66.1–73.1) (79.3–84.9) (66.0–72.7) (10.6–13.1) (15.1–20.9) (8.8–13.4) (15.9–21.6) but similar to other epidemiological studies (Miyazaki et al. 1991, Petersen & Ogawa 2012, Kassebaum et al. 2014), and lower if compared with some reports from Eastern European countries (Holtfreter et al. 2010). The explanation for the higher prevalence of CPI codes 3–4 in this study, as compared with other Spanish oral health surveys, could be related to the sample distribution by gender. In this study, males represented 59.1% of the 35- to 44-yearold stratum, whereas in the Spanish oral health surveys 2000, 2005 and 2010, males represented 45.9%, 49.6% and 46.3%, respectively (Llodra et al. 2002, Bravo et al. 2006, Llodra 2012), similar to other European surveys (G€ atke et al. 2012). The higher percentage of males in this study resulted from mirroring 5.3 12.5 6.8 11.9 (4.5–6.3) (10.2–15.3) (5.2–8.9) (9.7–14.5) <0.001 the composition of the employed population in Spain (Instituto Nacional de Estad
ıstica 2008). Another reason to explain this significant increase may be due to the changes in the rates of the edentulous population in Spain. Although low, the rate of edentulous subjects of the 35–44 years stratum has diminished from 0.6% in the 2000 oral health survey to 0.0% in our study (data not shown). Hence, the increase in the number of teeth present may contribute to the higher prevalence of periodontal diseases or, at least, the need for treating more teeth in order to maintain acceptable rates of periodontal condition (Sch€ utzhold et al. 2015). In regard to CAL, the prevalence of CAL ≥4 mm was 18.9%, lower than the data reported in 2000, 2005 and 2010 Spanish surveys (20.7%, © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Periodontal status in working population 553 Table 3. Multiple logistic regression of the effect of various factors on the odds of a high Community Periodontal Index (CPI) code (≥3), expressed as crude odds ratio (OR) with 95% confidence interval (CI) Effect on the odds of a high (≥3) CPI code Female Male Age group (years) <25 25–34 35–44 45–54 ≥55 Occupation White-collar Blue-collar Net income (monthly) >3601€ 1201 to 3600€ <1200€ Smoking status Never Former smoker Smoker ≤10 cigarettes/day Smoker >10 cigarettes/day Region Centre Northeast and East Northwest South Crude OR 95% CI p-value Adjusted OR 95% CI p-value 1 1.64 1.48–1.83 <0.001 1 1.43 1.23–1.66 <0.001 1 1.59 3.31 6.78 10.17 1.22–2.08 2.54–4.30 5.19–8.88 7.56–13.67 0.001 <0.001 <0.001 <0.001 1 1.77 3.85 7.78 11.96 1.28–2.44 2.80–5.28 5.59–10.84 8.28–17.28 <0.001 <0.001 <0.001 <0.001 1 1.75 1.56–1.96 <0.001 1 1.36 1.16–1.60 <0.001 1 1.29 2.03 1.05–1.59 1.64–2.53 0.016 <0.001 1 1.35 1.97 1.05–1.73 1.49–2.59 0.018 <0.001 1 2.17 1.42 2.57 1.82–2.60 1.19–1.68 2.17–3.04 <0.001 <0.001 <0.001 1 1.63 1.70 2.34 1.31–2.02 1.38–2.10 1.92–2.86 <0.001 <0.001 <0.001 1 1.24 0.17 1.05 1.07–1.43 0.12–0.22 0.90–1.23 0.003 <0.001 0.498 1 1.06 0.12 0.93 0.88–1.29 0.08–0.17 0.76–1.13 0.515 <0.001 0.468 Table 4. Multiple logistic regression of the effect of various factors on the odds of a high Clinical Attachment Level (CAL) code (≥6 mm), expressed as crude odds ratio (OR) with 95% confidence interval (CI) Effect on the odds of a high CAL (≥6 mm) Female Male Age group (years) <25 25–34 35–44 45–54 ≥55 Education University Secondary school Primary school Smoking status Never Former smoker Smoker ≤10 cigarettes/day Smoker >10 cigarettes/day Region Centre Northeast and East Northwest South Crude OR 95% CI p-value Adjusted OR 95% CI p-value 1 2.55 1.99–3.26 <0.001 1 2.15 1.59–2.90 <0.001 1 1.30 4.48 16.77 28.99 0.49–3.46 1.80–11.14 6.85–41.02 11.75–71.53 0.601 0.001 <0.001 <0.001 1 1.12 3.67 14.84 24.87 0.36–2.78 1.43–9.38 5.91–37.29 9.71–63.67 0.822 0.007 <0.001 <0.001 1 1.29 3.19 0.96–1.75 2.59–4.25 0.094 <0.001 1 1.22 1.87 0.86–1.73 1.31–2.68 0.260 0.001 1 2.56 1.30 2.42 1.89–3.46 0.92–1.84 1.81–3.25 <0.001 0.140 <0.001 1 1.49 1.61 2.15 1.07–2.08 1.11–2.33 1.55–2.99 0.020 0.013 <0.001 1 0.57 0.33 0.57 0.48–0.73 0.21–0.51 0.44–0.75 <0.001 <0.001 <0.001 1 0.44 0.27 0.36 0.32–0.60 0.16–0.46 0.26–0.52 <0.001 <0.001 <0.001 33.2% and 25.7%, respectively). CAL data derived from using CPI methodology varies widely in European surveys, ranging from 20.0% in Denmark (Krustrup & Erik Petersen 2006) to 83.9% in Germany (Schiffner et al. 2009). Although it has been stated that loss © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd of attachment increases steadily with age, while probing pocket depth tends to stabilize in older groups of people (Holtfreter et al. 2009), this 554 Carasol et al. Table 5. Prevalence (%) and severity (mean number of sextants) of periodontal condition by CPI codes (0–3–4) and CAL in adults 35– 44 years. Comparative between 2000, 2005, 2010 and WORALTH 2011 surveys in Spain CPI Survey 2000 2005 2010 WORALTH 2011 CAL Survey 2000 2005 2010 WORALTH 2011 Cohort 35–44 years (n) 535 540 512 1455 Percentage of subjects who have CPI code Code 0 % (95% CI) 19.3 14.8 16.0 6.0 Cohort 35–44 years (n) 535 540 512 1455 (13.8–24.8) (7.1–22.5) (12.7–19.3) (4.9–7.3) Code 3 % (95% CI) 21.4 21.5 11.0 29.3 (15.1–27.7) (12.1–30.9 (8.2–13.8) (27.1–31.7) Mean number of sextants with CPI codes Code 4 % (95% CI) Code 0 mean (95% CI) Code 3 mean (95% CI) Code 4 mean (95% CI) 4.2 3.9 5.0 8.4 2.88 2.52 2.69 1.64 0.68 0.57 0.52 1.08 0.07 0.06 0.11 0.16 (1.9–6.6) (2.6–5.3) (3.0–6.9) (7.1–9.9) Percentage of subjects with CAL 0–3 mm% (95% CI) 79.3 66.8 74.3 81.1 4–5 mm % (95% CI) (73.0–85.6) (62.8–70.7) (70.3–77.8) (79.0–83.0) 14.9 25.9 19.7 14.4 (10.6–19.2) (22.4–29.8) (16.5–23.4) (12.7–16.3) (2.37–3.39) (2.15–2.89) (2.45–2.93) (1.55–1.74) (0.43–0.93) (0.33–0.81) (0.40–0.64) (1.00–1.16) (0.01–0.13) (0.04–0.08) (0.06–0.17) (0.13–0.19) Mean number of sextants with CAL ≥6 mm % (95% CI) 0–3 mm mean (95% CI) 4–5 mm mean (95% CI) ≥6 mm mean (95% CI) 5.8 7.3 6.0 4.5 5.38 5.01 5.20 5.40 0.33 0.67 0.50 0.37 0.08 0.16 0.13 0.03 (1.0–8.2) (5.3–9.7) (4.3–8.5) (3.5–5.47) (5.18–5.58) (4.74–5.28) (5.10–5.20) (5.34–5.47) (0.23–0.43) (0.42–0.92) (0.40–0.60) (0.32–0.42) (NA) (NA (NA) (0.02–0.03) CPI, Community Periodontal Index; CAL, Clinical Attachment Level; n, number; CI, confidence interval; WORALTH: Workers’ Oral Health; Code 0, periodontal health; Code 3, moderate periodontal pocket (4–5 mm); Code 4, deep periodontal pocket (≥6 mm); NA, not available. did not seem to be the case for this study, since both CPI and CAL increased with age, as it has been described in other studies from Denmark (Krustrup & Erik Petersen 2006) and the United Kingdom (Morris et al. 2001). In regard to the degree of severity, the present results showed a higher mean number of sextants, both for CPI codes 3 and 4, than what has been described in other European countries (Sheiham & Netuveli 2002) as well as in the previous Spanish surveys, thus, depicting a worsening of the periodontal condition in this population over time. However, no differences were found when comparing the mean number of sextants with CAL ≥4 mm, conversely to the mean number of sextants with CAL ≥6 mm, lower in our study than in previous Spanish surveys. There are few epidemiological studies in Europe assessing changes over time in the periodontal conditions in the employed population; two of them (Sheiham et al. 1986, Ahlberg et al. 1996) reported an improvement in the periodontal condition, comparing CPI after 14 and 15 years respectively. In Spain, if the results of the four national studies performed since 2000 are compared, the prevalence of periodontal pockets ≥4 mm among young adults (aged 35–44 years) increased from 25.6% to 37.6% between 2000 and this study. Regarding CAL, the prevalence of CAL ≥4 mm among young adults decreased from 20.7% to 18.9% between 2000 and this survey. One limitation of this study could emanate from the partial recording protocol used. Since periodontitis has not a uniform distribution in the mouth, partial recording protocols can underestimate prevalence values (Beck et al. 2006). Although standards for reporting chronic periodontitis prevalence and severity in epidemiologic studies have been recently proposed (Holtfreter et al. 2015), the methodology of this study was chosen in order to be consistent with previous WHO oral health surveys in Spain, where this partial recording protocol was also used. Obviously, CPI is not the gold standard in periodontal epidemiology and has several limitations, but this method has provided high sensitivities for prevalence estimates of 4 mm and 6 mm probing pocket levels (≥90 %) and underestimated the prevalence of PD ≥4 mm by less than 5% (Kingman & Albandar 2002). The magnitude of the bias associated with the partial-mouth protocol used in this survey could not be evaluated as previously suggested (Susin et al. 2005), because a 10% random subsample of the total study sample using a full-mouth approach (n = 513) was omitted due to financial reasons. Although the employed population is not representative of the whole Spanish population, as it has been remarked previously, it comprises 20 million people from a total of 46 million residents in Spain during the period of the survey. In addition, the opportunity of personal oral (periodontal) advice is guaranteed at least once a year during medical check-up, goal not easy to achieve in general population. Among the strong points of this study, one is the large sample size, since 5154 subjects were evaluated, as well as its representativeness, since it included subjects from different regions and occupations, who were examined on the same day of the yearly check-ups. This sample represented more than 20 million workers (data not shown) of the active population in Spain, for whom oral care is almost completely privately financed, as it is for the general population. Another strong point of the study is the adequacy of the data collection, as clinical examinations were carried out under ideal conditions, which may have contributed to detect more pathology than the previous Spanish national surveys. In addition, this study provides the starting point for further analysis of epidemiologic data in association with comprehensive data from the medical records and other oral variables. The results of this study, assessing a representative sample of the Spanish working population, showed that poorer periodontal condition is © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Periodontal status in working population age-related (worse over 45 years) and gender-related (worse in males), and also tobacco smoking-related. The periodontal condition in young adults was worse than was previously reported in national surveys. These results suggest that additional efforts should be made to improve oral health awareness, and one strategy could be (as done in this study) to include oral evaluation and preventive strategies in work-related medical check-ups, since they may give the advantage of examining individuals who may not have attended a dental office otherwise. 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ıa Universidad Complutense de Madrid Plaza Ram
on y Cajal; 28040 Madrid Spain E-mail: mcarasol@gmail.com 556 Carasol et al. Clinical Relevance Scientific rationale for the study: No previous evaluations of the prevalence of the periodontal condition in the working population have been performed in Spain. Principal findings: Periodontal condition of workers in Spain is worse in adults over 45 years, and also in males, smokers, and workers with primary school education. Young adults presented a worse periodontal status than it has been previously reported in three national surveys, using the same WHO methodology. Practical implications: Work-related medical check-ups should include oral evaluation and preventive strategies in order to examine subjects who may not have attended a dental office, otherwise. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd