PRACTICE

adult dental health survey

The oral cleanliness and periodontal

health of UK adults in 1998
A.J. Morris,1 J. Steele,2 and D. A. White,3

useful and meaningful to the profession is as

Periodontal disease continues to be a major concern for dentists and great a challenge as collecting the data in the
patients. This paper reports the findings of the 1998 UK Adult first place.
Dental Health survey in relation to plaque, calculus, periodontal The variables recorded were visible
pocketing and loss of attachment. It is apparent from this study that plaque, calculus, pocketing and loss of
attachment. Calculus has been measured
moderate periodontal disease remains commonplace amongst UK consistently since the 1968 survey. Plaque
adults and that the associated risk factors of plaque and calculus are on the other hand has not been recorded in
in abundance, even amongst those who profess to be motivated its own right since the 1968 survey, though
about their oral health and attend the dentist regularly. The in 1978 debris, which included plaque, was
recorded. A measurement of the extent of
continued high prevalence of disease needs to be seen in the context
plaque was re-introduced in 1998 not only
of the far larger number of people who are now potentially at some because of its fundamental role in the peri-
risk, particularly in the older age groups, because of improvements odontal diseases, but also because it gives us
in tooth retention. However, the cumulative effect of disease means an indication of the effectiveness of tooth
that control of the periodontal diseases, even mild and slowly cleaning, potentially the most important
self-administered preventive dental inter-
progressing disease, will be a key issue if large numbers of teeth are
vention available for adults. Loss of attach-
to be retained into old age. If that level of control is to be achieved ment was also quantified for the first time in
we need a widespread improvement in our management of the this survey. This is a more robust measure of
disease, particularly in our ability to improve the oral cleanliness of historical disease experience than pocketing
the UK population. alone since it records movement of the
point of attachment of the periodontal tis-
sues from the normal position around the
s one of the two major oral conditions contemporary concepts and reflect the new neck of the tooth. This is probably a more
A affecting the adult population, it is
important to measure the prevalence of
patterns of disease resulting from increasing
retention of natural teeth late into life.
meaningful measure of the impact of dis-
ease in the growing population of dentate
periodontal diseases as part of a national A major consideration in adopting crite- older adults than pocketing alone. Pocket-
survey of oral health. Periodontal diseases ria was that they had to be as simple as possi- ing continued to be recorded separately,
have been recorded in some format in all of ble. A large number of examiners required since it is still an important prognostic indi-
the previous surveys of adult dental health training and calibration and, with the cator and may also indicate a treatment
in the UK, but continuity has been a prob- examination taking place in the home need. The 1998 study reported very deep
lem because of changing concepts of the dis- rather than a surgery, the lighting, seating pockets (greater than 8.5 mm) for the first
ease and how best to record and report it.1 position and limited range of instruments time so that more severe cases could be
The methodology adopted in the 1998 made accurate recording of periodontal identified. The equipment was restricted to
study2 was designed to provide a ‘best fit’ data a challenge. Even with very simple light, mirror and CPITN-C probe. A full
between conflicting requirements. On one indices, there are still difficulties for survey description of the methodology and criteria
hand to allow comparison with previous examiners.4,5 Plaque and calculus can be appears in the main report.2
studies,3 whilst on the other to reflect difficult to see against a similarly coloured All dentate respondents who agreed to an
tooth surface, while measuring both peri- oral examination were asked a series of
1Lecturer in Dental Public Health, School of odontal pockets and loss of attachment screening questions to identify any whose
Dentistry, The University of Birmingham; 2Senior simultaneously is a tiring and back straining health might theoretically be put at risk by
Lecturer in Restorative Dentistry, University of process for the examiner. The pattern of the the examination. Of the 3,817 respondents
Newcastle upon Tyne; 3Lecturer in Dental Public diseases is also complicated and makes examined, 300 (8%) were excluded on these
Health and Behavioural Science, School of Dentistry,
The University of Birmingham reporting the data difficult, there being no grounds. This is likely to be a higher propor-
*Correspondence to: A.J. Morris, Dental Public simple indicator of disease experience and tion than in the previous 1988 study, partic-
Health, School of Dentistry, St. Chads Queensway, activity. An additional complicating factor ularly for older respondents, because of
Birmingham, B4 6NN
is the very high prevalence of disease and its ethical committee advice to exclude addi-
REFEREED PAPER
Received 02.05.01; Accepted 07.06.01 dependence on tooth retention so that tional respondents with prosthetic joints as
© British Dental Journal 2001; 191: 186–192 describing these patterns in a way that is well as those with any suspicion of cardiac

186 BRITISH DENTAL JOURNAL VOLUME 191 NO. 4 AUGUST 25 2001

 PRACTICE
adult dental health survey

valve defects who would have been excluded

by the 1988 criteria. A further ten respon-
dents declined the periodontal examina- Table 1 Visible plaque and calculus in dentate adults
tion, having agreed to the rest of the
examination, presumably because it
involved probing soft tissue. Proportion of: adults teeth adults teeth
The prevalence of the various conditions with with with with
can be described at mouth (subject) as well visible visible calculus calculus
as tooth level. The latter is important where plaque plaque
the prevalence is high at the mouth level
since it is a more discriminating measure of All dentate adults 72 33 73 23
differences between groups of subjects. Loss
of attachment is reported in similar cate- Age
gories as pocketing, with 3.5 mm as the 16–24 72 34 61 15
threshold for diagnosis since it was mea- 25–34 70 30 71 21
sured using the bands on the CPITN-C 35–44 72 32 74 25
probe. 45–54 69 32 77 26
55–64 75 37 77 28
Results 65 and over 78 44 83 33
Plaque and calculus
Plaque was recorded only if it could be seen Gender
with the naked eye, without running an Men 76 38 76 26
instrument along the gingival margin. Con- Women 68 29 70 20
sequently, there had to be quite a large accu-
mulation of plaque on the tooth before it Social class
was coded as present. In normal circum- I,II,IIINM 70 30 71 21
stances, such a deposit would take a number IIIM 75 36 75 25
of days to accumulate. Calculus was IV, V 78 40 76 27
recorded both visually and with the help of a
CPITN probe. Reported dental attendance
The prevalence of recorded plaque was Regular check up 68 29 68 19
high; nearly three-quarters (72%) of sub- Occasional check up 72 32 75 21
jects examined had visible plaque on at least Only with symptoms 80 43 82 32
one tooth and there were only relatively
small differences between groups of respon- Reported frequency of tooth cleaning
dents (Table 1, Fig. 1). There were also only Never/less than once a day 87 55 78 38
relatively small differences between popula- Once a day 79 41 79 29
tion subgroups in the mean proportion of Twice a day 69 30 70 21
respondents’ teeth that had visible plaque More than twice a day 69 31 73 21
on the surface. Perhaps surprisingly, the
groups with the highest proportion of teeth
affected by plaque also tended to have fewer although this difference is statistically sig- cleaned once daily or less (79–87%), there
teeth to clean. Overall, the mean proportion nificant, it is not great in practical terms. were still over two-thirds of these self-
of teeth with plaque rose from 30% in the One of the more interesting findings was declared regular brushers who had visible
25–34 year age group to 44% in the 65 years that the participants who cleaned their teeth plaque deposits.
and over group. Those respondents who immediately before the examination (6%) Around three-quarters (73%) of subjects
reported that they attended the dentist for still had, on average, plaque on almost one- had calculus present on at least one tooth
regular check-ups were less likely to have third of their teeth; little different from those and there was an increase in the mouth
plaque (68%) than other respondents who chose not to. In this context, it is per- prevalence with age, from 61% amongst
(72–80%), and had a smaller proportion of haps no great surprise that, although partic- 16–24 year olds to 83% amongst those aged
teeth affected (29% compared to 43% in ipants who reported cleaning their teeth 65 years and over. The tooth prevalence of
people who attend only with pain). In other twice daily or more were less likely to have calculus showed a similar variation with age
words, they had cleaner mouths but visible plaque (69%) than people who though the range was greater. There was a

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adult dental health survey

the examination had calculus, this was com-

Fig. 1 Prevalence of plaque and calculus pared with 84% of respondents who reported
in dentate adults that their last dental visit had been between
one and five years previously. At the level of
the teeth, 19% of teeth in the former group
% teeth % teeth % adults % adults
had calculus present compared with 28% in
with with with with the latter. As expected, the distribution of
calculus plaque calculus plaque calculus at different sites in the mouth was
not even; only 11% had calculus present on
16-24 15 34 61 72 a maxillary canine or incisor (upper central
25-34 21 30 71 70 sextant) compared with 67% who had cal-
35-44 25 32 74 72 culus present on the corresponding
45-54 26 32 77 69 mandibular teeth (lower central sextant).
55-64 28 37 77 75 This reflects what dentists often report see-
65 and over 33 44 83 78 ing in their patients, calculus affecting lower
ALL 23 33 73 72 front teeth because of their close proximity
to the submandibular salivary ducts, whilst
upper front teeth are often the cleanest teeth
in the mouth because people often take
most care with them.

90 Pocketing
Pocketing was recorded in three categories
80 based on the familiar CPI scoring system.
70 Over half (54%) of subjects examined had
60 moderate pocketing or worse (greater than
50 3.5 mm) on at least one tooth (Table 2,
% affected

Fig. 2). There was a marked increase in the

40 mouth prevalence with age from 34%
30 amongst the 16–24 year age group to 67%
20 amongst those aged 65 years and over, even
though the latter age group had on average
10
far fewer teeth and may well have had peri-
0 odontally affected teeth extracted in the
16–24 past. The mouth prevalence of deeper
25–34 35–44 pocketing (greater than 5.5 mm) was 5% in
45–54
55–64 all subjects and also varied by age; less than
65 Age
and ALL 1% in the 16–24 year age group compared
over with 15% in the 65 years and over age
group. The mouth prevalence of very deep
% teeth with calculus % people with calculus pocketing (greater than 8.5 mm) was only
1% amongst all dentate respondents. Dif-
% teeth with plaque ferences in the prevalence of pocketing
% people with plaque
between groups of subjects other than by
age were relatively small.
The site-specific nature of the experience
two-fold increase in the proportion of teeth with 32% of teeth in those who reported of periodontal disease was reflected in the
with calculus with increasing age, from 15% that they only attended the dentist when relatively low tooth prevalence compared
in 16–24 year olds to 33% in those aged troubled by symptoms. The mouth and with the mouth prevalence; 12% of teeth
65 years and over, reflecting the findings for tooth prevalence of calculus also varied by examined had pocketing greater than
plaque. Amongst those who reported that reported time since last dental visit; 68% of 3.5 mm compared with 54% of mouths. The
they attended the dentist regularly for check participants who reported that their last tooth prevalence of pocketing greater than
ups, 19% of teeth had calculus compared dental visit had been less than a year before 3.5 mm varied greatly with age; there was

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nearly a five-fold difference between those

aged 16–24 year age group (5%) and the Table 2 Pocketing
65 years and over age group (23%). Differ-
ences between social classes and by reported
attendance pattern remained small, though
Proportion of dentate No Pocketing Pocketing Pocketing
those who reported visiting the dentist
adults with: pocketing greater greater greater
within the last year were almost half as likely
above than than than
to have moderate pockets as those who
3.5 mm 3.5 mm 5.5 mm 8.5 mm
reported not having visited the dentist in the
last five years (11% compared with 20%).
All dentate adults 46 54 5 1
An unexpected finding was the slight
increase in the mouth and tooth prevalence
Age:
of pocketing greater than 3.5 mm between
16–24 66 34 1 0
those who reported that they cleaned twice a
25–34 53 47 2 0
day and those who reported more frequent
35–44 41 59 5 0
cleaning. Though the numbers were small,
45–54 39 61 6 1
this may be because some of those who were
55–64 38 62 9 1
cleaning more than twice a day were doing
65 and over 33 67 15 4
so because they were aware of having estab-
lished disease and were making strenuous
Gender
efforts to remove plaque.
Men 43 57 6 1
Women 49 51 5 0
Loss of attachment
Loss of attachment was measured from the
Social class of head of household
level of the cemento-enamel junction to the
I, II, IIINM 48 52 6 1
base of the pocket. The millimetre categories
IIINM 44 56 5 1
used were the same as those for pocketing. In
IV, V 44 57 7 1
total, 43% of dentate respondents examined
had loss of attachment greater than 3.5 mm
Reported dental attendance
on at least one tooth and there was an
Regular check up 48 52 5 1
increase in the mouth prevalence with age
Occasional check up 45 56 4 1
from 14% amongst the 16–24 year age group
Only with symptoms 43 57 6 1
to 85% amongst the 65 years and over age
group (Table 3). The mouth prevalence of
Reported frequency of tooth cleaning
loss of attachment greater than 3.5 mm was
Never/less than once a day 38 62 7 0
lower than the mouth prevalence of pocket-
Once a day 42 58 6 1
ing greater than 3.5 mm in the younger age
Twice a day 49 51 5 1
groups and higher in the 55–64 year and
More than twice a day 44 56 6 0
65 years and over age groups. This reflects
higher levels of gingival recession in older
adults and ‘false pocketing’ resulting from
mild gingival enlargement without attach- 0.5% in the 16–24 year age group compared eting reported in younger age groups was
ment loss in younger people. Recession was with 31% in the 65 years and over age group. ‘false pocketing’ resulting from enlarged gin-
likely to be a very common feature in the As with pocketing, the tooth prevalence of givae rather than attachment loss. Differ-
older age groups and reflect a lifetime’s dis- loss of attachment was far lower than the ences between social classes and in reported
ease history. Because of this, loss of attach- mouth prevalence; 10% of teeth examined attendance pattern were small.
ment, which takes account of recession, had loss of attachment of greater than
indicates the real threat to the tooth from 3.5 mm compared with 43% of mouths. The Severe disease
loss of periodontal support more accurately tooth prevalence of loss of attachment of Moderate disease is widespread, but it is
than pocketing in older adults. The mouth greater than 3.5 mm varied greatly with age, those with severe disease who cause the
prevalence of loss of attachment greater than being 2% in the 16–24 year age group com- greatest of clinical problems and these are
5.5 mm was 8% in all dentate respondents pared with 30% in the 65 years and over age the individuals who are at greatest risk of
examined and also varied with age; less than group. This suggests that much of the pock- tooth loss. Although they occupy only a

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ferer of severe disease will have a very high

proportion of teeth affected by pockets at
Fig. 2 Prevalence of pocketing some level, but typically there will be rela-
tively few which are severely affected at any
one time and there will usually be a reason-
Proportion of No pocketing Pocketing Pocketing Pocketing able proportion of relatively unaffected
dentate adults above 4 mm– 6 mm– greater teeth (Fig. 3). Loss of attachment of over 5.5
with: 3.5 mm 5.5 mm 8.5 mm than 8.5 mm mm affects more people in the population
than pocketing of the same depth, particu-
16–24 66 33 1 0 larly amongst older adults, but the numbers
25–34 53 45 2 0 and proportions of teeth affected in those
35–44 41 54 5 0 with relatively advanced loss of attachment
45–54 39 55 5 1 is strikingly similar to that for deep pocket-
55–64 38 53 8 1 ing, and the distribution of affected teeth is
65 and over 33 52 11 4 similar (Fig. 4). Once again there are a few
teeth severely affected, but on a base of teeth
ALL 46 49 4 1
which are moderately affected.
The people who are more severely
affected are rather difficult to single out or
100% to profile. The social and gender influences
appear to be negligible, they do not neces-
sarily have the dirtiest mouths and they are
80% not much more likely to be dental non-
attenders. They are, however, likely to be
older. Although this may in part be that the
60% measures are of disease experience rather
% affected

than activity, the increase in the prevalence

of deep pockets and extensive loss of attach-
40% ment later in life is quite dramatic.

Discussion
20% The data derived from a large survey of this
sort are necessarily crude. Only a limited
number of variables are recorded and
0% maintaining the accuracy of measurements
is difficult. Examiners find it particularly
16-24 difficult to probe posterior teeth during a
25-34
35-44 45-54
55-64 home examination, so the prevalence of
Age 65
ALL deep pocketing and loss of attachment is
and probably under-recorded. Nevertheless,
over the population sample is large, highly rep-
resentative of the UK public and the data
Pocketing greater than 8.5 mm Pocketing 6 mm–8.5 mm quality issues described will not greatly
affect the differences between age groups
Pocketing 4 mm–5.5 mm No pocketing above 3.5 mm or associated with reported attendance
behaviour, nor the relative lack of differ-
ences between social and gender groups. As
it is possible that inter-examiner variability
small proportion of the dentate population teeth affected (mean 2.6) by such deep could give biased results by geographical
this group is important, but it is easy to lose pocketing, whilst they will have around ten region we have avoided any comparison
sight of them in a mass of population data. of their teeth affected by pocketing which is between areas, though there is no particu-
Amongst the 5% who have a pocket of over at least moderate (mean 11.4 teeth, 54% of lar reason to expect any major effect in this
5.5 mm, they have on average nearly three all teeth). In other words, the average suf- regard either.

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Table 3 Loss of attachment (LOA)

Proportion of dentate No LOA LOA LOA

adults with: LOA greater greater greater
above than than than
3.5 mm 3.5 mm 5.5 mm 8.5 mm

When looking at these results, it is worth All dentate adults 57 43 8 2

bearing in mind that only dentate adults
and standing teeth contribute to the data. Age
The population experience of disease 1–24 86 14 0 0
reported applies only to the 87% of the adult 25–34 74 26 2 0
population who have some natural teeth, we 35–44 58 42 3 0
know nothing about the former state of the 45–54 48 52 10 2
teeth of the edentulous, though technically 55–64 30 70 17 4
they are now unaffected. On the other hand, 65 and over 15 85 31 7
figures reported may well under-estimate
historical disease experience, since mouths Gender
rendered edentate by disease and extracted Men 54 46 9 2
teeth in partly dentate mouths (perhaps Women 61 40 7 1
extracted because of periodontal disease)
are both lost to the analysis. Social class of head of household
Despite all of these considerations, the I, II, IIINM 58 42 7 1
results of this study indicate that UK adults IIINM 56 44 9 2
have a high prevalence of plaque and calcu- IV, V 53 47 11 2
lus on their teeth, with surprisingly little dif-
ference between those who report higher Reported dental attendance
levels of dental motivation and those who Regular check up 57 43 7 2
do not. The regular brushers and reported Occasional check up 61 39 5 0
regular dental attenders did have less plaque Only with symptoms 56 44 10 2
than the smaller groups of infrequent
brushers and reported non-attenders, but Reported frequency of tooth cleaning
many of the former still had visible plaque Never/less than once a day 49 51 13 0
on a large proportion of their teeth. The Once a day 51 49 11 2
only reasonable conclusion to draw from Twice a day 61 39 6 2
this is that, despite their apparent efforts, More than twice a day 55 45 8 1
UK adults are not as efficient at plaque con-
trol as might be hoped. Oral hygiene is a
huge public and personal health issue and removal of calculus, at least on the removal increases quite sharply with age, underpin-
improved hygiene could be expected to of visible calculus. ning the need for continued monitoring.
result in benefits in terms of periodontal The prevalence of severe pocketing The results for loss of attachment indicate a
disease and dental caries. There is clearly (greater than 5.5 mm) is low overall, but high prevalence of significant loss of attach-
some room for improvement. over half the subjects examined had at least ment in older adults and this would merit
Differences in the prevalence of calculus one pocket over 3.5 mm present and 12% of closer study in future. Although it is
between groups are likely to reflect differ- teeth were similarly affected. This also reported in the same way as pocketing, the
ences not only in the frequency and effec-
tiveness of tooth cleaning but also the use of
dental services for the removal of calculus
Fig. 3 Proportion of teeth affected by different levels of
and the number of teeth present. The effect
of reduced numbers of teeth in the mouth pocketing in people with some pocketing in excess
on the prevalence of calculus will be limited of 5.5 mm
because the teeth most likely to be retained
in those with partially dentate mouths are
mandibular canines and incisors, teeth 12% 34% Pockets of 3.5 mm or less
which are more likely to have calculus. This
may partly account for the steeper trend in Pockets of 3.5–5.5 mm
tooth prevalence associated with age. Cal-
culus is however widespread in the UK
Pockets of greater than 5.5 mm
adult population and the data suggest that 54%
dental services do have an impact in the

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adult dental health survey

difficult to get a real feel for long-term

Fig. 4 Proportion of teeth affected by different levels of trends. The increased retention of natural
loss of attachment (LOA) in people with some teeth presents a particular problem in this
regard because as more teeth are retained
LOA in excessof 5.5 mm
there are more sites that may be affected by
disease, and more people with teeth to be
16% affected. Therefore, we may in part be vic-
30% tims of success on other fronts; even if our
LOA of 3.5 mm or less
management of the disease was improving,
LOA of 3.5–5.5 mm the retention of teeth might make it difficult
LOA of greater than 5.5 mm to demonstrate this until we make a consid-
erable impact on the disease. The continued
54% high prevalence needs to be seen in the con-
text of the far larger number of people who
are now potentially at some risk, particu-
interpretation is a little different; any loss of These include the frequency and effective- larly in the older age groups. The cumula-
attachment could be regarded as potentially ness of tooth cleaning, smoking and the use tive effect of disease means that control of
pathological for the purposes of analysis of dental services over a long period. The the periodontal diseases, even mild and
whereas pocketing is usually only regarded inclusion of tobacco use as a variable may be slowly progressing disease, will be a key
as potentially pathological above about a valuable addition in future studies, since issue if large numbers of teeth are to be
3.5 mm. Loss of attachment in older adults this is reported to be an important explana- retained into old age. If that level of control
is often a combination of extensive recession tory factor in the development of disease.7 is to be achieved we need a widespread
as well as some pocketing. The areas of Neither the reported frequency of oral improvement in our management of the
recession may be where there was a deep hygiene practices nor the reported use of disease, but particularly in our ability to
pocket in the past, though in some cases we dental services seemed to be strongly associ- improve the oral cleanliness of the majority
may be looking at creeping recession where ated with the prevalence of measurable dis- of the UK population.
deep pocketing was never present. The ease. This finding should be interpreted
important point is that attachment loss is with caution in view of the complex rela- We are grateful to the dental examiners, NHS
organizers and the Office for National Statistics for
generally irreversible and these results show tionship between health behaviour and dis- their assistance with this study.
the extent to which attachment is lost over a ease experience, for example people with
lifetime where teeth are retained. Moderate identified disease may be making a greater 1. Chapple I L C. Periodontal disease diagnosis:
current status and future developments. J Dent
and probably slowly progressing levels of effort to maintain their teeth. Despite these 1997; 25: 3-15.
disease, which will result in extensive words of caution, it is difficult to escape the 2. Kelly M, Steele J, Nuttall N, Bradnock G,
attachment loss and pose a real threat to suggestion that neither dental services nor Morris J, Nunn J, Pine C, Pitts N, Treasure E,
individual teeth over the course of a life- attempts at hygiene are having the impact White D. Adult Dental Health Survey: Oral
Health in the United Kingdom 1998. Walker A,
time, have affected a significant proportion on disease we might hope. Results from Cooper I, ed. London: The Stationary Office,
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retirement age. The fact that 85% of dentate dental-attenders benefit in real terms over a 3. Todd J E, Lader D. Adult dental health 1988:
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4. Mojon P, Chung J-P, Favre P, Budtz-Jörgensen
some teeth which have seen over 3.5 mm of by up to as much as five more retained teeth E. Examiner agreement on periodontal indices
loss attachment suggests that low grade but by the age of 65 years.2 The lack of any major during dental surveys of elders. J Clin Periodont
slowly destructive disease is the norm. difference in the prevalence of periodontal 1996; 23: 56-59.
5. Fleiss J L, Mann J, Paik M, Goultchin J, Chilton
Differences in the prevalence of pocketing disease according to reported attendance N W. A study of inter- and intra-examiner
and disease between various population pattern may suggest that, although it is reliability of pocket depth and attachment
subgroups were generally quite small. impossible to be certain of the mechanism, level. J Periodont Res 1991; 26: 122-128.
Assuming that inherent susceptibility does most of this benefit comes through restora- 6. Gray P G, Todd J E, Slack G L, Bulman J S.
Adult Dental Health in England and Wales in
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quences of a wide range of different factors. but, being a complex disease to measure, it is

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