Reprinted with permission from The Journal of Public Health Dentistry,
the official journal of American Association of Public Health Dentists,
Vol. 43, No.2-Spring, 1983, pp 106-117.
Periodontal Disease America:
a Personal and National Tragedy

A position paper prepared for the American Association of Public Health Dentists
by the AAPHD Subcommittee on Preventive Periodontics, October 24, 1981

Chairman:
Jefferson F. Hardin, DDS, MS
Associate Professor Departments of Periodontics and Community Dentistry
School of Dentistry, Medical College of Georgia Augusta, GA 30912

Members:
Richard K. Ames, DDS, MPH
Elizabeth Bernhard, DMD, MPH
Stephanie Dort, BS, RDH, MPH
Robert Bagramian, DDS, DrPH
John Nasi, DDS, MS
James Cecil, DMD, MPH
John Stamm, DDS, DDPH, MScD

Ralph Frew, DDS, MPH
Don Boggs, DDS, MPH
Bruce Butler, DDS, MPH
Hedy Quam, BS, RDH
J. Earl Williams, DDS, MPH, DrPH
Diane Troyer, BS, RDH, MEd
John M. Allen, DDS, MPH
Jerry Garnick, DDS, MS

Introduction

Countless papers, surveys, and statistics attest to the magnitude of the American
periodontal disease problem. In a -review of the economic and social impact of the
disease, Ingle(1) stresses the insidious and painless nature of the process, which
only in its later stages becomes "a personal and national tragedy." He estimated in
1969 that the total cost of prevention and treatment of periodontal disease, including
costs for extractions and full denture replacement was $2.33 billion.	

Periodontal disease is the leading cause of tooth loss. The 1960-62 National Health
Survey considered the 75 percent rate of periodontal disease among adults 18-79 to be
underestimated because 20 million persons in the survey population were excluded be-
cause they were com­pletely edentulous. Chilton and Miller(2) summarized the
well-known discouraging scope of the national periodon­tal disease problem:

Background

In responding to its charge from the Executive Council, the AAPHD Subcommittee on Com-
munity Preventive Periodontics has attempted to bring into focus a number of disparities
between what is known concerning periodon­tal disease and the lack of any widespread, co-
ordinated effort to control it.

The 16 member Subcommittee is made up of epidemiologists, dental public health admini-
strators, periodontists, dental hygienists, and public health practi­tioners. This group
has shared a profound sense of con­cern that sharp imbalances exist between programs for
controlling dental caries and periodontal disease. These imbalances can be better under-
stood in the context of fluoridation:

For over 35 years, increasingly widespread and suc­cessful efforts at community fluori-
dation have provided a classical, efficient, and cost-effective basis for controlling a
major dental disease.

Fluoridation, with its well-documented predictability, has provided a sound concept
upon which those concerned with public health could "hang their hats." Understand­ably,
then, caries became the target for a concentrated, universal effort, rather than perio-
dontal disease. Although equally ubiquitous, periodontal disease simply does not respond
to the same classic single-agent community preventive approaches. Moreover, it is in-
sidious and painless until the advanced stages, and not well understood by a public which
has been educated to perceive dental disease as caries exclusively.

And last, there are increasing indications that fluorida­tion's dramatic effect in re-
ducing caries is affecting the nature of dental practice.(3,4) Scholle,(5) in commenting
on the combined protective effect of fluoridation, topical fluorides, and sealants, sug-
gests an alternative to the frustration of increased concern over decreased 'busyness':

So forthrightly, in fact, have caries control and fluorida­tion moved from the research
arena into widespread im­plementation that caries might be regarded increasingly as an
administrative [political also-ed.] rather than as a scientific problem. Clearly, mili-
tant efforts to expand fluoridation benefits must continue, and this Subcommit­tee does
not advocate either an abandonment or diminu­tion of effort in this regard. Recently,
Faine(6) and our sister AAPHD Committee on Fluoridation have described strategies to
combat a formidable new generation of sociopolitical obstacles to fluoridation which
will certain­ly demand such intensified and innovative responses.

Nevertheless, the hard evidence of fluoridation success should allow appropriate, con-
cerned agencies to reassess the nature of the national oral disease threat. Indeed, the
American Association of Public Health Dentists itself is an organization which should be
affected critically by such a timely examination. We advocate this position while recog-
nizing that ours is an organization whose very birth and development has paralleled that
of fluoridation itself. Within our membership and archives are enshrined the distinguished
pioneers of fluoridation-dedicated and vi­sionary dental scientists who have left a splen-
did legacy to the children of the world.(8)

An unforeseen and unfortunate by-product of this dramatic success story has been a tunnel-
vision approach to public health dentistry. A simple survey of 19 years of the Journal
of Public Health Dentistry reveals only 35 papers devoted primarily to periodontal disease,
out of some 350 published. This finding suggests that, historical­ly, public health dentistry
may have become primarily caries-oriented rather than concerned with oral health on a
broader, more comprehensive scale. Timely reappraisal, however, of the AAPHD organizational
objectives relative to periodontal diseases can have a major positive impact on the oral
health of the nation, as well as on the con­tinued relevance and vitality of the Association
itself.

Subcommittee Approach to Periodontal Literature and Base of Knowledge

The Subcommittee has reviewed and shared a con­siderable number of individual papers related
to all aspects of preventive periodontics. The immensity of the task of a thorough review,
however, has necessitated a concentration on several international workshops and symposia
dealing with the subject.9 -16 Each of these documents comprises a series of important
position papers, includi ng extensive literature reviews, critical analyses, summaries, and
recommendations. The Sub­committee has been impressed with the quality of these resources.
They form a significant body of scientific knowledge which can be brought to bear on national
strategy to control periodontal disease. Furthermore, directions are clearly available in
their various recommen­dations for research, education, dental practice, and public health
program development.

Jackson(17) studied the recent scientifically conducted longitudinal evaluations of the pre-
ventive and therapeutic procedures in periodontics. His comprehensive review provides an
accurate and valuable state-of-the-art sum­mary of what is known:

1. Gingivitis can almost be eliminated by either daily oral hygiene [measures]
alone or a combina­tion of daily oral hygiene [measures] and prophy­laxis.

2. Periodontal and gingival health seem to im­prove and the loss of periodontal
attachment seems to diminish as the number of prophylaxes and oral hygiene ap-
pointments increases up to four per year, but age, dental disease activity,
economics, and practicality may influence the clinician to choose less-frequent
recalls with lit­tle compromise in periodontal health.

3. Any type of treatment is beneficial, but the maximum benefit is obtained by
combining sub­gingival deposit removal by the therapist with in­tensive, enthu-
siastic oral hygiene instructions.

4. The value of periodontal treatment, including scaling, root planing, and
surgical procedures in preventing or slowing down the rate of epithelial migra-
tion is proven both in patients with initial periodontal disease and in patients
with advanced periodontal disease.

5. The foregoing is valid only if the patient can maintain a plaque-free or
relatively plaque-free dentition.

6. Patients unable to accomplish good oral hygiene [status] should not be subject
to periodontal surgical procedures, because such procedures will, in all likelihood,
increase the rate of destruction.

7. Regeneration of bone in intraosseous defects can occur with a high degree of
predictability in the presence of low plaque levels.


Listgarten(18) and many other investigators also acknowledge that enough knowledge is
available to pre­vent most forms of periodontal disease, and the difficulty of applyin
this information to the implementation of ef­fective preventive programs.

Heifetz and Suomi(19) and others(20) have appraised the value of plaque-control methods in
public health programs and are plainly skeptical. They think that successful pro­grams fro
caries and periodontal disease control must operate "independent of the patients' perfor-
mance and cooperation." Obviously, fluoridation rather than plaque control provides the
direction in the case of caries. These papers suggest the pressing need to develop an
effec­tive chemother-peutic agent to prevent periodontal disease, especially since behaviora
modification technology to effect compliance in personal plaque-control procedure is not
well developed.

Sheiham(21) cautions that the American public interest in oral cleanliness is indicated by 
over one billion dollars in sales of oral hygiene devices: and should not be under­estimated.
Unfortunately, even most adult consumers think that they are controlling caries and their
plaque ­control efforts generally are not good enough to prevent periodontal disease.
Nevertheless, oral cleanliness, for whatever motivation, seems to be a reasonably integral
part of the culture. It remains to be sufficiently exploited to produce a universal signifi-
cant effect on controlling periodontal disease.(22)

The North Carolina Studies(16, 23, 24, 25)

More than any studies in recent years, the documents associated with the North Carolina
Dental Studies have served to focus attention on a population's increasing periodontal
disease problem while caries prevalence is being reduced dramatically and steadily. The
studies are significant for several reasons:

The impressive collaborative project represents the combined efforts of the North Carolina
Dental Society, the dental section of the State Health Department, the North Carolina State
Board of Dental Examiners, the Universi­ty of North Carolina (Schools of Dentistry and Public
Health and Health Services Research Center), the Research Triangle Institute, the Kellogg
Foundation, and the Dental Foundation of North Carolina.

Extensive surveys of dental health status in North Carolina were conducted in 1963 and 1977,
allowing data comparison and analyses of the 14-year trends.

The North Carolina findings should provide directions for other states and agencies concerned
with national oral health problems. They have further implications for den­tal education,
community programs, and research. The major findings of the studies are:

North Carolina authorities regard periodontal disease as rampant, having significantly worsened
in 14 years. Thus, periodontal disease is firmly established as North Carolina's major dental
public health problem.

National Priorities in Oral Health

Fluoridation and dental health were identified among 15 priority areas for health improvement
in the 1979 Surgeon General's Report on Health Promotion and Disease Prevention.26 In 1980,
specific objectives necessary to at­tain those health improvement goals within this decade

were described in a subsequent federal document, Pro­moting Health/Preventing Disease: 
Objectives for the Nation.27 Although the report was weighted toward fluoridation and considered
periodontal disease the se­cond most prevalent disease, the specific objectives for periodontal
health improvement "by 1990 or earlier" included:

a. Decreasing prevalence of gingivitis in children 6 to 17 years to 18 percent, from 23 percent
in 1971-74.

b. Decreasing prevalence of gingivitis and destructive periodontal disease in adults to about
20 percent, down from 24 percent recorded for adults aged 18 to 74 years in 1971-74.

c. At least 75 percent of adults should be aware of the necessity for both thorough personal
oral hygiene and regular professional care in the prevention and control of periodontal disease.
In 1972 only 52 percent were aware of the impor­tance of oral hygiene, and only 28 percent were
concerned about regular professional care.

The 1980 report further stated a basic assumption that organized dentistry as well as a broad
range of state and local health agencies will "increase their concern for and expand their
activities to support fluoridation, school­based prevention-oriented dental programs, and perio-
don­tal health promotion."

The Subcommittee thinks that any major new thrust in periodontal disease prevention should be
based on official identification of periodontal disease by government agen­cies and dental pro-
fessional organizations as the rank­ing national oral disease priority. Its prevalence, the
relative absence of effective public health preventive measures, and the socioeconomic impact
of the disease justify this priority. Such recognition will have an impor­tant bearing on federal
dental research efforts, on undergraduate and continuing dental education, on prac­tice, on
strategies for community-based preventive ap­proaches, and, of course, on the health of citizens.

The General Dentist and Periodontal Practice

Because it is universally acknowledged that periodontal diseases do not yet respond to mass
medication with specific vaccines or chemotherapeutic agents, profes­sional personnel resources
must be assigned an especial­ly critical role in preventive efforts. These roles include person-
nel for health education and for all levels of preven­tion, diagnosis, and treatment.

The general dental practitioners should be regarded as the pivotal elements in the broad scheme
of preventive and therapeutic periodontal programming. Whether in the private sector, public
health, military, or institutional set­ting, virtually all patients seeking dental services must
flow through them. In terms of efficient and effective patient management, they may refer
patients with noncomplex, early disease to their hygienists for primary care. The large propor-
tion of patients with intermediate stages of disease are appropriately their own responsibility
for therapy. They may exercise another option for patients with advanced disease: referral to
or consultation with a specialist-level periodontist.

It is at this critical point, however, where the literature reveals that the dental generalist
has become, by default, part of the problem rather than part of the solution to periodontal
disease. Bellini(28) observed that periodontal therapy represents less than 3 percent of the total
dental service rendered to the U.S. population. A 1980 survey by the U.S. Department of Health
and Human Services revealed that regardless of 20 variables analyzed, the amount of time the
general dentist devoted to periodon­tal treatment remained constant at 5 percent, with restorative
procedures (44 percent) and prosthodontics (22 percent) accounting for the majority.(29) The
statistics are consistent with Douglass and Day's anaylsis(22) of dental costs in the United States.
Their data reveal that patient expenditures for general practitioners' services amounted to only
7.67 percent for preventive services (94 percent prophylaxes) and only 0.78 percent for perio-
dontal treat­ment. Crown-and-bridge services have become the na­tion's largest single expenditure
for dental care-about 35 percent of all dental care expenses. The investigators add that "the
increased cost-effectiveness (in terms of disease control and teeth saved) of these services
over the basic corrective types of care is not known."

Perhaps the most disconcerting finding in the previously mentioned North Carolina studies was
that the state's general practitioners report that they spend less than two percent of their
time treating periodontal disease. In com­menting on this observation Bawden(23) wrote:

It seems to me that our graduates have adequate backgrounds and clinical
experiences in periodon­tics, and that failure to become involved very much
in the treatment of periodontal disease is a matter of attitude on their
part and the part of their pa­tients. . . . It is time for the students to
be oriented to the fact that periodontal disease is the most serious dental
health problem in the state and that much more of their efforts should be
directed to the management of the problem.

In North Carolina, however, "Project 80" is underway, as a joint response by the state dental
society and the UNC Department of Periodontics to the manpower study findings.(25) Project 80
is a multiphasic community de­monstration project aimed at intensifying education in periodontal
disease awarness, prevention, and treatment for citizens and general dentists alike. Like the
original studies, this follow-on effort may provide a model for similar projects on a national
scale.

There are many possible explanations for periodontal noninvolvement by general dentists.
Generally, they lack confidence in periodontal diagnosis, treatment planning, and therapeutic
procedures. Many do not understand or fully appreciate modern concepts of periodontal disease
control and cure. Virtually all practitioners are more com­fortable, more intrigued, and more
challenged by tradi­tional reparative styles of practice, including the associated economic
aspects. Unless they become periodontally oriented, however, these traditionalists-the majority-
may not be able to survive from an economic standpoint as the effect of fluoridation on caries-
related dental practice increases. Research exploration of den­tists' attitudes toward periodontal
disease, their knowledge and technical deficiencies, their periodontal practice­management skills,
and mechanisms to retain and remotivate them should carry a high priority. The entire approach to
periodontal diagnosis and treatment must be simplified for both student and practitioner so they
will not be awed by the process.

The responsibilities of practice aside, the non manage­ment of periodontal disease for those in
society who seek care is a national disaster. Eventually, the legal pressures and consumer mili-
tancy may force an improvement sooner than internal professional monitoring can correct the
situation.

Consumer advocacy for improved dental service was heightened with publication of a dentist
directory, in­cluding guidelines for selection of a dentist, by a Washington-based organization,
the Public Citizen's Health Research Group.30 The comprehensive directory provided recommen-
dations and patient-consumer expec­tations for health assessments, plaque-control programs,
radiation safety, and descriptions of a periodontal ex­amination which might have appeared in a
dental text:

PERIODONTAL EXAMINATION (gum examination)
The dentist should make note of any area of bleeding gums, tooth mobility or unusual
colorings or the presence of bad breath. He should also use a tapered thin instrument 
(periodontal probe) to ex­amine the depth of the space between the gum and the tooth as 
an indication of the health of your gums and supporting structures. The measure­ment of 
the periodontal pocket depth (normal is 0-3 mm, or 1/8 inch) plus a standardized oral 
hygiene index should be included in your dental record. Ask your dentist what your 
pocket depth is and your plaque index (oral hygiene index). (Remember, 67.9% of those 
between 12-17 years had some form of gum disease.) - Bleeding gums are not healthy and 
(are) an indication of disease!

It is apparent that building a "constituency" in support of periodontal disease prevention
can have a potent negative impetus as well as the better-known positive, pro­fessionally
sponsored variety. Organized dentistry's perception of consumer power must be considered
unclear at this time.

Cohen has been one of the most eloquent and persis­tent critics of the generalists' minimal
dedication to the periodontal needs of the population. At the 1981 National Conference on
Dental Education,31 he suggested that the phenomenon is a reflection of the traditional
emphasis of most dental curricula, where restorative, prosthodontic, and oral surgery
departments are dominant.

Focusing on the growing consumer alarm over profes­sionally neglected periodontal disease,
Cohen states:

It is tragic to learn of the large numbers of patients who have been receiving care
on a regular basis, only to find out that they are suffering from ad­vanced periodontal 
disease. It may surprise a reader of the litigation section of the Journal of the American
Dental Association to learn that there are more than 300 malpractice suits pending in the
State of California alone, initiated by patients with chronic periodontal destruction
against den­tal hygienists and dentists who were responsible for their maintenance care.

Wade(32) found that plaque scores and plaque control of dentists (themselves) were worse than
those of patients. When such depressing information is coupled with the aforementioned indi-
cators of negative dentist attitudes toward periodontal disease, it becomes obvious that the
dentist is something less than a dependable resource in the preventive periodontics campaign.

Dental Hygienist or Preventive Periodontal Therapist?

The Subcommittee has indicated previously that in the global scheme of preventive periodontics,
the general dentist-for better or worse-is the pivotal element. Sear­ching analysis of both
literature and practice, however, will reveal that it is the dental hygienist-of all those in
the dental professional hierarchy-who is the critical ele­ment in that same scheme.

Because of a complex of social, political, legal, and economic factors, however, the full
potential of the hygienist resource has not been brought to bear optimal­ly on the nation's
primary oral health problem. Current evaluations of the hygienist's role are frequently over-
­shadowed by the issue of independent practice-a natural, predictable outgrowth of improved
education, ex­panded responsibility, and enhanced professionalism.

O'Leary, Koerber, and Catherman(33) compared specially trained dental hygiene students with
senior dental students in a variety of "periodontally expanded func­tions." The hygienist-
trainees were significantly better than the future dentists in periodontal examination,
prob­ing accuracy, tooth mobility and plaque assessments, and root planing. Root planing,
in particular, is the basis for all phases of periodontics: prevention, treatment, and
maintenance. Cohen31 considers root preparation to be the most difficult technique to master
in the entire dental repertoire.

With these skills, then, coupled with the dentists' well ­documented abdication from
periodontal responsibilities, it is logical to regard the dental hygienist as the primary
preventive therapist in periodontics.(34) Indeed, there may be as much merit in increasing
the hygienists' training and influence in periodontics as there may be in exhortations to 
general dentists to increase their periodontal activity-a minicapitulation to their strong
reparative heritage. Cor­ollary to this proposition is a realization that efforts to ex­pand
the hygienist's role in restorative rather than periodontal disciplines are misdirected.

Schallhorn(35) describes in considerable detail the impor­tance of maintenance therapy as
"the most critical aspect of dental treatment." He provides a comprehensive review
of both hygienist and dentist responsibilities in all phases of preventive periodontics,
including a minute-by-minute procedure analysis of a typical preventive recall appoint­ment.
Few papers in the recent literature have highlighted the transcendant role of the hygienist
as effectively. The number of practicing dental hygienists has increased ten­fold during the
past 30 years from 3,190 in 1950 to 32,200 in 1977. Unfortunately, however, there may be as
many hygienists not practicing as there are those in practice. This great pool of trained
therapists could possibly be reactivated by new strategies in periodontal disease con­trol
and by facilitation of reentry into practice for working parents. The number of trained
hygienists will likely con­tinue to increase throughout this decade.36 They should be given
[seek-ed.] an increased role in the control of periodontal disease in both the public as
well as the private sector, free from unnecessarily restrictive provi­sions in dental practice
acts. The dental profession must acknowledge eventually that dental hygienists are even more
appropriately trained to provide preventive periodon­tal therapy than dentists.(33) This is
especially true in view of the fact that the economics of preventive periodontal therapy as
provided by the hygienist are favorable not only to the patient and to the hygienist but to
the dentist and the public health administrator as well.

Strategies for a National Program

The growing realization of the primacy of the American periodontal disease problem evokes
a natural interest in developing a broad strategy for preventing the disease, or controlling
it sufficiently to lessen its impact on socie­ty. Unfortunately, in addition to the recognized
lack of a specific preventive agent, the absence of a universal, powerful constituency for
periodontal disease eradication presents a formidable barrier to progress.

Many targeted, federally supported health programs have been initiated because of the lack
of an adequate knowledge base to identify potential preventive interven­tions in the disease
process. Kidney disease, diabetes, and sickle-cell anemia have benefited from such infor-
ma­tional deficiencies, but the common factor in the initiation of these programs seems to
have been the political in­fluence of a large and vocal group of people who are af­fected by
the disease or condition, either directly or indirectly.

In the instance of periodontal disease, the constituen­cy vacuum is complicated. The public
does not seem aware that a serious oral health problem exists. Moreover, only a fraction of
the half of the American population who may seek other than just episodic dental care have
had their periodontal needs diagnosed and treated. In the absence of a massive simultaneous
effort to motivate den­tists toward periodontal involvement, intensive campaigns to encourage
people "to see their dentists" seem almost thoughtless.

Neither the professional public health community, the federal government, nor the dental
research and educa­tional sectors have realistically contributed to the type of constituency
necessary for society-wide periodontal disease control. To get things going, this Sub-
committee has developed an interest in exploring the concept of a "National Periodontal
Disease Program." Rather obvious­ly, a model exists in the National Caries Program, which
serves to coordinate and amplify a wide range of anti caries initiatives in addition to
fluoridation. Without a constituen­cy, however, such an approach is probably inopportune.

Short of the "task force" approach, however, the Sub­committee feels that progress can be made
through realignment-toward the periodontal disease problem-of overall emphasis, staffing, and
budgets within the federal and state dental agencies. Furthermore, through improved coordination-
internally, and externally with other organ­izations-some progress may be anticipated through
such initiatives by the AAPHD. For example, the American Association of Public Health Dentists
should stimulate development of a permanent Committee on Public Health within the American
Academy of Periodontology, while it strengthens its own programs in periodontics. Such organi-
zational cross-fertilization is vital in building an in­formation exchange system.

The Subcommittee is emphatic that the major thrust of preventive periodontics programs in public
health be directed toward children and youth. Recognizing the ear­ly insidious onset of periodon-
tal disease in the teens and early adulthood, effort should be directed toward improv­ing the 
periodontal health of the young. Some dental public health programs shun supervised brushing and
flossing in school programs because of their lack of evidence in reducing caries incidence
significantly. Never­theless, it is the only means of plaque removal which can be done on a daily
basis. Clinical studies should be con­ducted to ascertain the impact of plaque control, as used
in the supervised classroom setting, upon the incidence and severity of periodontal disease in
school-age groups.

Cons(37), describing the dental health program for the State of New York Department of Health, 
comments on the statistics of the National Health Surveys relating to periodontal disease in
children. While the statistics reveal that 68 percent of youth ages 12-17 have periodontal
disease, only 5.8 percent have destructive periodontal disease characterized by pockets, and
the remainder have only relatively mild gingivitis associated with a few teeth.  This same
report indicates that 39 percent of children 6-11 have periodontal disease and one out of
125 has evidence of chronic, destructive periodontal disease characterized by pockets. Forty
percent of this age group had some degree of gingivitis, mild in severity and limited to only
a few teeth. Unfortunately, the report comments that periodontal disease to most youths is not
perceived as an imminent threat.

While concentrating on the preventive approach for the young, care must be taken not to neglect
the adults who are presently experiencing the results of the lack of prevention and care in
their early years. Whatever public thrust is designed to bring home the message otpreven­tion
of periodontal disease must include some direction for the current sufferer. As a profession,
we should be prepared to shoulder the task of alleviating or, at least, slowing down the
onslaught of periodontal destruction in the adult population.

New Strategies in Periodontal Disease Control

Many old beliefs about dental disease control must at last be put to the scientific test
if much improvement is to be achieved in the periodontal health of the population. Den­tal
health education in the form of plaque-control instruc­tion has frequently been found inef-
fective in public health clinical trials. The problem here may not be the objective but the
unacceptability of the plaque-control methods that were offered as a means of reaching the
objective and the age group at which they were directed. It is possible to interpret the
literature to show that ideal brushing and flossing may be unreasonably difficult skills
for all but a few compulsive individuals to master. Other methods of oral hygiene must be
evaluated. Among these are an­tibacterial rinses and subgingival cleaning devices such as
toothpicks and flexible points.

Recent advances in preventive periodontal theory which may provide needed new therapeutic
strategies center on the work of Loe, Loesche, Keyes, and Listgarten.(38 41)  These
investigators and others have focused clinical at­tention on specific target organisms in
the oral microflora and evaluated chemo-mechanical treatment regimens designed to suppress
or eliminate them. The continuing search for an acceptable antibacterial agent has recently
begun to focus on low concentration stannous fluoride compounds which offer previously
established anticario­genic benefits along with strong antimicrobial effects.42 It is necessary
to develop such an agent which could be used daily in combination with simple mechanical
clean­sing technics to control both crown and root caries as well as disease of the periodontium.
This combination is par­ticularly needed if we are to realize an effective preven­tive perio-
dontics program suitable for implementation as a public health measure.

It is now evident that caries is being brought under con­trol not by toothbrushing but by
fluoride compounds in drinking water, dentifrices, gels: and rinses. By contrast, it seems
that the control and prevention of .periodontal disease will not be accomplished so much by
means of the toothbrush and dental floss as by antibacterial agents, microscopic bacterial
monitoring, and simple-to-use sub­gingival and interproximal cleansing devices. These lat­ter
methods could be utilized by dentists and hygienists in either the public health or the private
practice sectors. It is possible to foresee public dental clinics and private practices
exclusively devoted to the diagnosis, prevention, and control of dental diseases. In the past
such practices would not have been technically or economically feasible, yet today they may
become a reality as competition in the dental marketplace intensifies and as innovative forms
for the provision of dental care emerge.

Thus, an understanding of the historical neglect of periodon!al disease by general dentists
and dental public health specialists alike can provide, at least, a logical basis for productive,
timely new partnerships. For example, massive public health promotional efforts, coupled with
public health-managed clinics for periodontal disease screening and detection, can be coordinated
with extraor­dinary referral initiatives involving the private sector.

Whereas these partnerships obviously challenge and serve dental professionals, they probably
provide the best hope for widespread periodontal control for the nation until the scientific
research gap is closed.

Conclusions

1. Caries is responding so dramatically to preventive and treatment measures in society,
especially community fluoridation, that periodontal disease should now be recognized and
established as the principal oral disease threat in the nation.

2. Private general practitioners and dental public health programs at all levels have
neglected periodontal disease. 3. There is an impressive body of knowledge that can be 
brought to bear on the diagnosis, prevention, and treat­ment of periodontal disease, which
is widespread in soci­ety without an effective preventive system.

4. Research in periodontal disease may not be directed or targeted efficiently.

5. There is enough knowledge available to prevent most forms of periodontal disease.
There is, however, a critical need for coordination of research, administrative, and health
care efforts to control/prevent periodontal disease at the organizational, state, and
national levels.

6. There is a need for a powerful, efficient, and sustained public health educational and
promotional program to enhance awareness of periodontal disease in the public at large as
well as in practitioners of dentistry.

7. The most critical research needs identified are:

a. the development of effective and acceptable chemotherapeutic agents to prevent
periodontal disease,

b. determination of the role of professional and patient behavior in the maintenance
of periodon­tal health,

c. investigation of the role of inadequate nutrition in enhancing susceptibility to
periodontal disease, d. design and evaluation of the effectiveness of improved dental
health care systems on the periodontal health of communities, and

e. studies on how effectively to educate and motivate the general dental practitioner
to recognize and treat periodontal disease in its early stages.

Recommendations


1. The American Association of Public Health Dentists should adopt the position
that periodontal disease is the greatest oral threat to health of the American people.
AAPHD should recommend to the ADA and APHA that they adopt a similar official posture.

2. The American Dental Profession needs to undertake an aggressive effort to bring the
problem of periodontal disease in the United States under more effective con­trol.
Prevention of the disease should have the highest priority.

3. The American Association of Public Health Dentists should examine its internal
organizational structure to determine if its present resources and philosophical
orien­tation are directed sufficiently toward the prevention of periodontal disease.

4. The American Association of Public Health Dentists should assume leadership in
establishing an interorgan­izational committee to coordinate and act as a clear­ing-
house for national preventive periodontics matters: research, demonstration projects,
public information, and continuing education. Participation should include the American
Dental Association, The American Academy of Periodontology, The American Dental
Hygienists' Associa­tion, The Academy of General Dentistry, and elements of appropriate
federal health agencies.

5. The American Association of Public Health Dentists should initiate planning for a
major, multimedia health education program to inform the public of the threat that
periodontal disease poses to the oral health of every citizen.

6. The American Association of Public Health Dentists should assign a high priority
to establishment of oral health programs in elementary, junior, and senior high schools.
Such programs would include oral health education and promotion as well as preventive
caries and periodontal disease pliOQrams. Plaque-control programs should be ex­plained,
conducted, and targeted, as much as possible, to the prevention of periodontal disease.

7. The American Association of Public Health Dentists should establish a major workshop
to explore ways to build a broad-based national constituency dedicated to preven­tion of
periodontal disease. Participants should include representatives from consumer-advocate
groups; federal health agencies; federal and state legislatures; national education and
parent-teacher associations; third-party payment industry; national communications media;
marketing, advertising, and public opinion survey organ­izations; labor unions; and the
dental profession.

8. The American Association of Public Health Dentists should establish lines of communi-
cation with elements of the North Carolina Dental Manpower Project, including a special
liaison team. This initiative should assess the im­pact of the North Carolina studies on
other state popula­tions and explore the development of state and national demonstration
projects dedicated to periodontal disease awareness and prevention.

9. The American Association of Public Health Dentists should assign a special task force
to study the feasibility of establishing a national periodontal disease program.

REFERENCES:

1. Ingle, J.I. The health, economic, and cultural impact of periodontal disease on an
aging population. Presented at N.I.H. Conference on Aging, Louisville, Ky. 1975.

2. Chilton, N.W. and Miller, M.F. Epidemiology: a position paper and review of the
literature. International Conference on Research in the Biology of Oral Disease,
Chicago, 1977, p. 135.

3. Mandel, I. A Look Ahead: Caries Research, J.A.D.A. 102:626, May 1981. 4. Mann,
W.V. A Look Ahead: Dental Education, J.A.D.A. 102:626, May 1981.

5. Scholle, R.H. Ednorial: Caries Prevention, Second Thoughts, J.A.D.A. 102:602,
April 1981.

6. Faine, R.C., et al. The 1980 fluoridation campaign: a discussion of results,
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7. AAPHD Subcommittee on Fluoridation, Position Paper on Fluoridation, 24 October
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8. McClure, F.J. Water Fluoridation: the Search and the Victory, U.S. Dept.
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9. Ramfjord, S.P., Kerr, D.A., and Ash, M.M. World Workshop in Periodon­tics
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basic review document until 1966.

10. The International Conterence on Research in the Biology of Periodontal
Disease (1977) 495 pages. This is one of the most comprehensive assess­ment
available on every aspect of periodontal disease: epidemiology, micro­biology
pathogenesis, prevention, evaluation of therapy, and socio­economic impact.

11. Oral Health, Dentistry, and the American Public: The Need for an Improved
Oral Health Care Delivery System (1974) 372 pages. A searching analysis of the
delivery system, with implications for specific oral diseases, fund­ing, quality 
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12. Prevention of Major Dental Disorders. Proceedings of an international
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Periodontology, Vol. 6, No.7, Dec. 1979.

13. Efficacy of Treatment procedures in Periodontics. Proceedings ot a work­
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14. Epidemiology, Etiology, and Prevention of Periodontal Diseases. Report
of a WHO Scientific Group. Technical Report Series 621 (1978), 60 pages. A
succinct discussion of the topic, with valid and useful recommenda­tions for
research, program development, and assessment of periodontal status and 
treatment needs.

15. Surgical Therapy for Periodontitis: Background Paper and Initial Review
Panel Recommendations. Workshop sponsored by National Institute of Dental
Research, Bethesda, Md. (1981) A state-of-the-art conference of periodontal
surgery, but with important sections on etiology, path<x,jenesis, prevention,
and research. Relatively few of the recommendations for tuture research relate
to periodontal surgery and reflect the fact that the workshop was far more
comprehensive than its title suggests.

16. Bawden, JW. and DeFriese, Planning for Dental Care on a Statewide Basis:
The North Carolina Dental Manpower Project, Dental Foundation of North Carolina,
Chapel Hill, 1981, 227 pages. A unique landmark project with ser­ious implication
for the problems of neglected periodontal disease in all states.

17. Jackson, D.B. Longitudinal Studies: What has been learned about the
pre­vention and treatment of periodontal disease. Clin. Prevo Dent. 1 :18-22,
May.June, 1979.

18. Listgarten, M. Prevention of periodontal disease in the future, in Preven-­
tion of Major Dental Disorders (ref. 12), J. Clin. Perio. 6:61-65.

19. Heifetz, S.B. and Suomi, J.D. The Control of dental caries and periodontal
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21. Sheiham, A. Prevention and Control of Periodontal Disease, in Int. Conf.
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Dent. Ed. 43:332-333, 1979.

23. Bawden, J.W. Information and implications for change: Guest editorial.
J. Dent. Ed. 45:557-8, Sept. 1981.

24. Bawden, J.W. et al: Problems and potentials in Dental Manpower Planning:
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1981.

25. Hutchens, L.H. Summary Report of Project 80, N.C. Dent. Gazette,
Jul-Aug. 1981, p. 6-9.
	
26. Healthy People: The Surgeon General's Report on Health Promotion
and Disease Prevention, U.S. Dept. of Health and Human Services,
U.S. Public Health Service, 1979.	.

27. Promoting HealthlPreventing Disease: Objectives for the Nation, U.S.
Dept. of Health and Human Services, U.S. Public Health Service,
pp. 51-55, Fall, 1980.
	
28. Bellini, H.T. and Gjermo, P. Applicatoin of the Periodontal Treatment
Need System (PTNS) in a group of Norwegian industrial employees.
Comm. Dent. Oral Epidemiol. 1:22-29, 1973.

29. An Exploration of Dental Practice, U.S. Dept. of Health and Human
Services, Aug. 1980.
	
30. Nash, G. and Wolfe, S. Taking the Pain out of Finding a Good Dentist,
with a Washington D.C. Dentist Directory, Health Research Group,
Washington D.C. 1975, pp. 1-56.
	
31. Cohen, D.W. Dental Education of the Future. J. Dent. Ed. 45:713-723,
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32. Wade, A.B. Report on Periodontal Awareness, Perio. Abstr. 20:4-10, 1972.

33. O'Leary, T., Koerber, L.G., and Catherman, J.L. Preparing Dental Hy­giene
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34. Reeves, R. et al. What is the future role of auxiliaries in periodontics,
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35. Schall horn, R. and Snider, L.S. Periodontal Maintenance therapy.
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36. Report of Allied Health Personnel, U.S. Dept. of Health, Education,
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37. Cons. N.C. Using effective str!.tegies to implement a program's 
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38. Loe, H. 8i Schiott, C.R. (1970a) The Effect of Suppression of the 
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39. Loesche, W.J. (1976) Chemotherapy ot Dental Plaque Infections.
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40. Keyes, P.H., Morrison, R., Rams, T.E., and Sarlatti, D.E. Diagnosis
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1. Listgarten, M.A., Linhe, J. and Hellden, L. (1978a) The Effect of 
Tetracycline and/or scaling on Human Periodontal Disease: Clinical,
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42. Leverett, D.H., McHugh, W.D., and Jensen, a.E. The Effect of Daily
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