Impact of post-traumatic stress disorder on oral health.

BACKGROUND: The stress experienced as an intense and traumatic event can increase the odds of orofacial pain, affect the biomechanics of masticatory system and compromise the periodontal health. This study was conducted to investigate the impact of post-traumatic stress disorder (PTSD) on oral health. METHODS: A case-control study with a convenience sample was designed. Probing pocket depth (PPD), clinical attachment level (CAL), bleeding on probing, and plaque were recorded at 6 sites per tooth. A visual analog scale (VAS) was used to evaluate the pain after probing. The Research Diagnostic Criteria for Temporomandibular Disorders Axis II (RDC/TMD Axis II) and Structured Clinical Interview (DSM-IV) were also applied. The final sample comprised 38 PTSD patients and 38 controls. RESULTS: Patients with PTSD had a higher degree of chronic pain, more depression and nonspecific physical symptoms (including and excluding pain) compared with the control group (Fisher exact test p < 0.001, and Chi-squared test, p < 0.001, < 0.001, < 0.001, respectively). Patients with PTSD also had more pain after periodontal probing compared with controls (Mann-Whitney, p = 0.037). The prevalence of sites with CAL or PPD ≥ 4, ≥ 5, ≥ 6 were not different between the groups. Age was associated with moderate periodontitis (multivariable logistic regression model, OR = 3.33, 95% CI = 1.03-10.75, p = 0.04). LIMITATION: The severity of PTSD precluded an ample sample size. CONCLUSIONS: Patients with PTSD presented a worse RDC/TMD Axis II profile, more pain after periodontal probing, and no difference related to periodontal clinical parameters. More studies are needed to confirm these findings.

Association of gingival crevicular fluid cortisol/dehydroepiandrosterone levels with periodontal status.

BACKGROUND: The aim of the present study is to examine whether anxiety and depression scale scores change with regard to clinical periodontal status and to investigate the association between the levels of stress-related hormones in gingival crevicular fluid (GCF) and extent/severity of periodontal disease. METHODS: One hundred twenty participants who fulfilled the study inclusion criteria were chosen. Patients with chronic periodontitis (CP) and those with healthy periodontal tissues/mild gingivitis were included. The clinical examinations were performed on the day after the psychologic evaluations which included anxiety and depression measurements. GCF sampling was undertaken the following day. Commercially available enzyme-linked immunosorbent assay kits were used to determine GCF cortisol and dehydroepiandrosterone (DHEA) levels. Study groups were assigned as follows: group 1, non-periodontitis; group 2, localized CP; and group 3, generalized CP. RESULTS: There were no significant differences with respect to age, sex, education, income level, occupation, or smoking history among the groups (P >0.05). There were no significant differences between the non-periodontitis and CP groups for any of the psychosocial scales (P >0.05). Group 3 had significantly higher mean DHEA scores compared with group 1 (P <0.05); however, the median cortisol scores showed no statistically significant differences among the three groups (P >0.05). CONCLUSIONS: Anxiety/depression scores and GCF cortisol levels did not show any difference with regard to clinical periodontal status. However, a significant association was found between elevated levels of GCF DHEA and the severity of periodontitis.

Clinical factors and self-perceived oral health.

Self-perceived oral health is affected not only by awareness of the clinical status but also by comparisons with people of a similar age. This study explored the relative contributions of clinical variables assessing caries, periodontal status, and prosthetic status to self-perceived oral health within two age groups. Data of 891 adults (35-44 yr of age) and 760 older people (65-74 yr of age) from the Fourth German Oral Health Study (DMS IV, 2005) were evaluated. Self-perceived oral health was obtained from questionnaires. Numbers of decayed, filled, and unreplaced teeth, mean attachment loss, bleeding on probing (BOP), the presence of a fixed denture, and the presence of a removable denture were assessed. Multinomial logistic regression models were developed for both age groups, separately, using stepwise methods. For adults, unreplaced teeth, filled teeth, decayed teeth, the presence of a removable denture, and mean attachment loss were added to the final model. For older people, the presence of a removable denture, unreplaced teeth, decayed teeth, mean attachment loss, filled teeth, and BOP were included in the final model. Awareness of the relative contributions of clinical variables to self-perceived oral health is important for obtaining a clearer understanding of patients' subjective and objective self-perceptions of oral health.

Psychosocial distress and periodontitis in adolescents.

PURPOSE: To assess whether adolescents with periodontitis presented with higher scores for non-psychotic psychosocial disorders than control subjects without periodontitis. MATERIALS AND METHODS: A case control study (n = 160) nested in a well-defined adolescent population (n = 9,163) was performed using the 28-item Spanish version of the General Health Questionnaire. The inclusion criterion for being a case was a clinical attachment level of >= 3 mm in at least two teeth. Multiple logistic regression analyses were used to assess the association between periodontitis and psychosocial distress. RESULTS: The response rate was high and 94% of the participants answered all the items of the questionnaire. Similarly, the internal consistency of the instrument was high (Cronbach's = 0.91). The results of multiple logistic regression analyses, adjusted for age and gender, suggested an association between case status and higher total scoring for psychosocial distress (OR = 1.69). Among the four subdomains of the General Health Questionnaire, the dimensions 'somatic symptoms' and 'severe depression' appeared positively associated with periodontal case status, albeit not significantly. CONCLUSION: The findings of this study suggest that the association between periodontitis and dimensions of psychosocial distress can be documented early in life. This calls for awareness on the part of healthcare providers attending adolescents.

Use of the Arabic version of Oral Health Impact Profile-14 to evaluate the impact of periodontal disease on oral health-related quality of life among Jordanian adults.

We used the short-form of the Oral Health Impact Profile (OHIP-14) to assess the impact of periodontal diseases on the quality of life of Jordanian adults. A systematic random sample of 400 individuals was selected from patients referred to the periodontics clinic at the Dental Teaching Center in Irbid, Jordan. Those willing to participate were examined by specifically trained dentists and requested to complete the Arabic short-form version of the OHIP-14 questionnaire. Multivariate analysis of differences in OHIP-14 subscales among the periodontal disease groups was conducted using the general linear model multivariate procedure. This study included 400 adults (164 men and 236 women) aged between 18 and 60 years, with a mean (SD) of 36.7 (11.9) years. Of the 400 participants, 41.8% had chronic gingivitis, 19.8% had mild periodontitis, 23.3% had moderate periodontitis, and 15.3% had severe periodontitis. "Fairly often" or "very often" was reported for one or more items of the OHIP-14 by fewer than one-third of patients with gingivitis (32.9%) or mild periodontitis (31.6%), by about one-half of patients with moderate periodontitis (53.8%), and by about two-thirds of those with severe periodontitis (63.9%). There was a statistically significant association between the severity of periodontal disease and OHIP-14 scores (P < 0.05). Severe chronic periodontitis had a significantly greater impact on quality of life, specifically with regard to physical pain and physical disability (P < 0.05). Physical pain and physical disability were the dimensions most affected, and all OHIP-14 scores were significantly associated with severity of periodontal disease after adjusting for common confounders.

Clinical and socio-demographic factors influencing the oral health-related quality of life of Chinese elders.

OBJECTIVES: The objective of this study was to explore the clinical and socio-demographic factors influencing oral health-related quality of life (OHRQoL) of the Chinese elderly. METHODS: Two urban districts in Binzhou, Shandong Province, Eastern China were selected and 300 elders aged 60-80 years were recruited. The study subjects completed a structured questionnaire in an interview and underwent a clinical examination. The questionnaire included questions on socio-economic information and a Putonghua version of the General Oral Health Assessment Index (GOHAI) which had been validated for use in Chinese elders to evaluate their OHRQoL. Clinical examination was performed using the criteria recommended by the World Health Organization. Tooth status, periodontal health status, loss of attachment (LOA), and number of occluding tooth pairs were recorded. Duplicate examinations were conducted on 10% of the subjects. RESULTS: The mean GOHAI score of the subjects was 46.0 (SD 8.5). Result of an ANCOVA showed that subjects who were older, had no root caries, had no tooth with LOA > or = 6mm, or had more occluding pairs had higher GOHAI scores indicating better OHRQoL. CONCLUSION: The OHRQoL of the study elders was fair and was influenced by age and a number of clinical factors. With limited resources and dental manpower in China, higher priority should be given to the elders who are relatively younger, who have or are at high risk of developing root caries and advanced periodontal diseases, and who have few occluding tooth pairs.

Latin America: native populations affected by early onset periodontal disease.

Millions of individuals are affected by early onset periodontal disease in Latin America, a continent that includes more than 20 countries. The decision-makers claim that the disease is not commonly encountered. In 2009, 280,919 authorized immigrants were registered in the United States versus 5,460,000 unauthorized (2,600,000 in California). The objective of the present article is to raise awareness about the high prevalence of the disease among Latin Americans and the good prognosis of preventive measures associated with minimal financial cost.

The relationship between social network, social support and periodontal disease among older Americans.

AIM: The objectives of this study were to examine the relationship between social network, social support and periodontal disease among older American adults and to test whether social network and support mediates socioeconomic inequality in periodontal disease. MATERIALS AND METHODS: Data pertaining to participants aged 60 years and over from the National Health and Nutrition Examination Survey 2001-2004 were used. Periodontal disease variables were extent loss of periodontal attachment ≥3 mm and moderate periodontitis. Social support and networks were indicated by the need for emotional support, number of close friends and marital status. RESULTS: Widowed and those with lowest number of friends had higher rates of the extent of loss of periodontal attachment (1.27, 95% CI: 1.03, 1.58) and (1.22, 95% CI: 1.03, 1.45), respectively. Marital status and number of friends were not significantly associated with moderate periodontitis after adjusting for behavioural factors. The need for more emotional support was not related to periodontal disease in this analysis. Social networks and support had no impact on socioeconomic inequality in periodontal disease. CONCLUSION: Certain aspects of social network, namely being widowed and having fewer friends, were linked to the extent of loss of periodontal attachment but not to the definition of moderate periodontitis, in older adults.

Effect of initial periodontal therapy on oral health-related quality of life in patients with periodontitis in Japan.

BACKGROUND: It is becoming increasingly important for periodontists and dental hygienists to take a biopsychosocial approach to care when considering periodontal interventions. However, information on how patients perceive periodontitis and its treatment is limited. The purpose of the present study is to gain insight into the patient perception of oral health and the impact that periodontitis and treatment have on self-assessed quality of life (QoL). METHODS: This was a prospective, two-center, clinical study in Japan. Patients with periodontitis were assessed for their perceptions of oral health by using an instrument for oral health-related QoL (OHRQL) before and after initial periodontal therapy. RESULTS: A total of 58 patients (mean age: 53.6 years; 23 male and 35 female) participated in the study and completed initial periodontal therapy. At baseline, 97% of the patients perceived that their oral health status impacted on their QoL in one or more ways. Pain, eating and chewing, and psychologic function were identified as compromised OHRQL domains. More than one-half of the patients rated their overall oral health as poor. Initial periodontal therapy, consisting mainly of oral hygiene instructions and scaling and root planing, significantly improved OHRQL scores (P = 0.0027). The effect size was calculated to be 0.51, indicating a moderate improvement. Compared with baseline, a significantly higher proportion of patients reported rarely or never having a problem regarding OHRQL domains such as pain (P = 0.0049) and eating and chewing (P = 0.0145) after treatment. No significant difference in the OHRQL improvement was found with respect to disease severity. CONCLUSIONS: Periodontitis negatively affected QoL in this population of Japanese patients with periodontitis. Conventional non-surgical periodontal therapy has a potential to ameliorate patient perceptions of oral health.

The role of cognitive ability in socio-economic inequalities in oral health.

Studies have postulated a role for cognitive ability in socio-economic inequalities in general health. This role has not been examined for oral health inequalities. We examined whether cognitive ability was associated with oral health, and whether it influenced the relationship between oral health and socio-economic position. Data were from the Third National Health and Nutrition Examination Survey (1988-1994), for participants aged 20-59 years. Oral health was indicated by extent of gingival bleeding, extent of loss of periodontal attachment, and tooth loss. Simple reaction time test, symbol digit substitution test, and serial digit learning test indicated cognitive ability. Education and poverty-income ratio were used as markers of socio-economic position. Participants with poorer cognitive ability had poorer oral health for all indicators. The association between oral health and socio-economic position attenuated after adjustment for cognitive ability. Cognitive ability explained part, but not all, of the socio-economic inequalities in oral health.

Oral health and cognitive function in the Third National Health and Nutrition Examination Survey (NHANES III).

OBJECTIVES: To investigate the association between oral health and cognitive function in early-, mid-, and late-adult life. METHODS: A secondary analysis was carried out of a large, well-characterized community sample (NHANES III). Analyzed variables included three measures of oral health (gingival bleeding, loss of periodontal attachment, loss of teeth) and three measures of cognitive function: the Symbol Digit Substitution Test (SDST), the Serial Digit Learning Test (SDLT) (both in 5138 participants aged 20-59 years), and a Story Recall test (in 1555 participants aged >or=70 years). Other covariates in linear regression models included age, gender, ethnicity, education and poverty, and cardiovascular risk factors. RESULTS: Worse scores on all three measures of oral health status were significantly associated with poorer performance on all three measures of cognitive function after adjustment for age. Education was an important confounding factor. However, after full adjustment for all other covariates, gingival bleeding (%) and loss of periodontal attachment (%) remained associated with relative impairment on SDST score (B coefficients both = 0.003), and gingival bleeding was associated with relative impairment on SDLT (B = 0.017). No effect modification by age was observed. CONCLUSIONS: Poor oral health is associated with worse cognitive function throughout adult life. This may, in part, be accounted for by early life education and social status. However, the possibility of direct causal pathways requires further investigation.

Oral health impact of periodontal diseases in adolescents.

The need for treatment of destructive periodontal diseases is based on observations made by oral health professionals, who, prompted by clinical findings, recommend treatment. We hypothesized that clinical signs of periodontal destruction have an impact on the oral-health-related quality of life of adolescents. We conducted a cross-sectional study among 9203 Chilean high school students sampled by a multistage random cluster procedure. We recorded clinical attachment levels and the presence of necrotizing ulcerative gingivitis. The students answered the Spanish version of the Oral Health Impact Profile and provided information on several socio-economic indicators. The results of multivariable logistic regression analyses (adjusted for age, gender, and tooth loss) showed that both attachment loss [OR = 2.0] and necrotizing ulcerative gingivitis [OR = 1.6] were significantly associated with higher impact on the Oral Health Related Quality of Life of adolescents. Individuals in lower socioeconomic positions systematically reported a higher impact on their oral-health-related quality of life.

A community study on the relationship between stress, coping, affective dispositions and periodontal attachment loss.

BACKGROUND: Psychological factors may increase the risk for periodontal diseases. Contemporary conceptualization of the stress process supports the evaluation of stress at three levels: stressors, moderating and mediating factors, and stress reactions. OBJECTIVE: This study was undertaken to investigate the relationship of periodontal disease in terms of clinical attachment level (CAL) to psychosocial stress, making reference to the major components of stress process. METHODS: A cross-sectional study of 1000 subjects aged 25-64 years in Hong Kong was conducted. Subjects were asked to complete a set of questionnaires measuring stressors including changes, significant life event and daily strains, stress reactions including physiological and affective responses, and coping and affective dispositions. CAL was assessed. RESULTS: Individuals with high mean CAL values had higher scores on the job and financial strain scales than periodontally healthy individuals (P < 0.05), after adjusting for age, gender, cigarette smoking and systemic disease. Depression, anxiety trait, depression trait, problem-focused coping, and emotion-focused coping were also related to CAL. Logistic regression analysis indicated that all these factors were significant risk indicators for periodontal attachment loss, except problem-focused coping, which reduced the odds of CAL. Individuals who were high emotion-focused copers, low problem-focused copers, trait anxious, or trait depressive had a higher odds of more severe CAL. CONCLUSION: Chronic job and financial strains, depression, inadequate coping, and maladaptive trait dispositions are significant risk indicators for periodontal attachment loss. Adequate coping and adaptive trait dispositions, evidenced as high problem-focused coping and low anxiety/depression trait, may reduce the stress-associated odds.

Oral health-related quality of life and periodontal status.

BACKGROUND: As patient-centered approaches become more popular, increasing attention is being given to assess the effects of various human health situations on an individual's overall quality of life (QoL). Measures have been used in dentistry to study the effects of orthodontic treatment and oral surgery, but so far little has been reported about the effects of periodontal disease. OBJECTIVE: This study assessed the impact of periodontal health status on QoL. METHODS: A subsample of 767 subjects were selected from a community study (n=1000) which investigated the association between psychological factors and clinical periodontal attachment level (CAL). The sample included subjects with full-mouth mean CAL3 mm (high/severe periodontal attachment loss group). The subjects were requested to complete the Chinese short-form version of Oral Health Impact Profile (OHIP-14S) and a checklist of self-reported periodontal symptoms during the previous 12 months. RESULTS: A total of 727 subjects (95%) completed the questionnaire. The OHIP-14S and subscale scores were significantly associated with six of seven of the self-reported periodontal symptoms. A comparison of the mean OHIP-14S scores of the healthy/low and the high/severe periodontal attachment loss groups revealed significant differences in respect of the subscales of functional limitation, physical pain, psychological discomfort, physical and psychological disabilities. CONCLUSION: This study demonstrates a significant association between oral health-related QoL and periodontal disease.

Association between psychosocial factors and periodontitis: a case-control study.

OBJECTIVE: This case-control study investigated the association between life events, anxiety, and depression with periodontitis. METHODOLOGY: The study counted with 165 individuals, both sexes, 35-60 years of age. Case group included 96 individuals suffering from periodontal disease; and in control group 69 subjects with no history of periodontitis. Clinical examinations were performed by a single examiner. Psychological assessment included four inventories: Life Events Scale, Beck Anxiety Inventory, State-Trait Anxiety Inventory and Beck Depression Inventory. Bivariate and multivariate logistic regression analyses were performed to compare cases and controls. RESULTS: Mean probing depth and clinical attachment level were 3.44+/-0.80 and 4.01+/-1.61 in the case group and 1.96+/-0.19 and 0.95+/-0.50 in the control group, respectively (p<0.05). Positive association of periodontitis with age (odds ratio (OR)=1.15 95% confidence interval (CI): 1.06-1.24), male gender (OR=2.71, CI: 1.13-6.49), smoking (OR=6.05, CI: 1.67-21.94) and educational level (OR=6.49, CI: 1.14-36.95) was confirmed. Bivariate analysis did not demonstrate significant mean differences in life events, anxiety symptoms, trait or state of anxiety, or depression symptoms between cases and controls. Multivariate logistic regression, controlling for confounding factors, demonstrated no significant association between psychosocial factors and periodontal disease. CONCLUSIONS: Within the limits of this study it is possible to conclude that there was no significant association between periodontitis and the psychosocial factors analysed.

The influence of stress and anxiety on the response of non-surgical periodontal treatment.

AIM: The aim of this study was to evaluate the influence of stress and anxiety on the response to non-surgical periodontal treatment (NPT) in patients with chronic periodontitis. METHOD: Sixty-six patients (mean age 46.1 +/- 8 years) were assigned to three groups: control group, probing pocket depth (PPD) or=4 and 6 mm, n=20. Stress, state anxiety (SA) and trait anxiety (TA) and plaque index (PI), gingival index, PPD and clinical attachment level (CAL) were recorded at baseline and 3 months after NPT. RESULTS: TA scores were different among groups at baseline and after NPT. TA was related to periodontitis at baseline and after NPT. PI was associated with the SA at baseline. The reduction of frequency of CAL >6 mm was correlated with TA after adjusting for confounders. Stressed subjects did not show reduction of frequency of PPD >6 mm (T1), CAL 4-6 mm and CAL >6 mm (T2). CONCLUSIONS: The data suggest an influence of trait of anxiety and stress on the response to NPT.

Forty-eight-month periodontal attachment loss incidence in a population-based cohort study: role of baseline status, incident tooth loss, and specific behavioral factors.

BACKGROUND: The objectives of this study were to: 1) test hypotheses that behavioral factors, baseline clinical status, and incident tooth loss are significantly associated with attachment loss incidence (ALI) and 2) quantify the effect of incident tooth loss on conclusions made about ALI. METHODS: The Florida Dental Care Study was a prospective study of persons > or =45 years old. In-person interviews and examinations were conducted at baseline and 48 months, with telephone interviews in between. RESULTS: Of 560 persons with baseline and 48-month examinations, 22% of persons and 1.8% of teeth had ALI. This was highest among persons with no dental visit during follow-up (person-level incidence of 46%; 5.0% tooth-level incidence). Statistically significant covariates in a multivariable regression of ALI were: losing a tooth due to periodontal reasons after baseline, but before the 48-month examination; not receiving a dental cleaning; and baseline factors (worst attachment level of > or =7 mm, not flossing, a molar tooth, current smoker). CONCLUSIONS: A substantial percentage of persons experienced ALI. Baseline attachment level and behavioral factors were significantly associated with ALI. Persons with incident tooth loss were also at increased risk for ALI, and teeth lost during follow-up had worse baseline attachment level. Had these teeth not been lost before the final examination, the ALI estimate could only have been higher. These findings demonstrate that those at greatest risk for ALI are least likely to enter the dental care system, and among those who do, one health outcome (tooth loss) can affect conclusions made about the incidence of another (ALI).

Coping with stress: its influence on periodontal therapy.

BACKGROUND: Individual stress coping strategies appear to influence periodontal disease: individuals with inadequate stress behavior may be at greater risk of developing disease. The purpose of this 24-month prospective study was to examine the influence of different coping behaviors on a non-surgical periodontal therapy and on the course of periodontal disease. METHODS: In 80 patients with chronic periodontitis, a non-surgical periodontal treatment was conducted after their individual stress coping strategies had been recorded. After 2 years of regular maintenance, their periodontal condition was evaluated. The stress coping questionnaire was used to obtain psychodiagnostic data. Clinical attachment loss (CAL) served as the clinical parameter. RESULTS: Patients with a defensive coping style had statistically significant poorer attachment values (P= 0.000) after 2 years compared to patients with other coping behaviors. The percentage of sites with slight to moderate CAL (<5 mm) was significantly less in patients with a defensive coping style than in patients with other coping strategies (P = 0.000). The number of sites with severe advanced CAL (>5 mm) was significantly correlated with a suppressive coping style (P= 0.0001). None of the individual stress coping styles revealed significant overall changes over time. The subtest of drug use (alcohol, nicotine, tranquilizers) as well as changes in this subtest over time were significantly correlated with the CAL (P = 0.003); an increase in the t value of the subtest of drug use was accompanied by a significant increase in CAL. CONCLUSIONS: The results of this study show that passive coping strategies were more pronounced in advanced disease as well as in cases of poor response to a non-surgical periodontal treatment, whereas patients with active coping modes had milder disease and a more favorable course of treatment. Thus, maladaptive behavior, especially in association with behavior-related risk factors such as smoking, are of great importance in the medical history, treatment, and maintenance of patients with periodontal disease.

Relationship between stress factors and periodontal disease.

AIMS: In addition to bacterial infections, adverse effects of immunological changes, in particular, stress factors may represent precipitating parameters of inflammatory periodontal diseases. The purpose of the present clinical study was to identify a possible relationship between an increase in life stress and the development of the loss of periodontal attachment. METHODS: A total number of 120 patients with chronic periodontitis (PA group) were examined and compared with a control group of 122 patients (exclusion criterion: pathological periodontal changes) matched for age and gender. The individual life situation and possible stress factors were evaluated by the use of a questionnaire, which comprised questions on various aspects of everyday life. RESULTS: The comparison of the results obtained for the two groups yielded statistically significant differences on all except one question. The control group achieved substantially lower scores on a scale from 0 (positive attitude) to 10 (negative attitude) in the evaluation of the degree to which a life event was perceived as stressful than the group with periodontal disease. For example, the average intensity score on the subjective assessment of emotional equilibrium ranged at 5.8 +/- 2.2 in the group of patients with periodontal disease (PA group) compared to 3.6 +/- 2.0 in the control group. The question regarding significant familial changes was answered positively by 37.5% of patients in the PA group, and by 22.9% of the controls. From among the questions designed to provide information on specific dental problems, those regarding clenching or grinding of the teeth were answered positively by 45.0% of the PA group and by 22.3% of the patients from the control group. CONCLUSION: The results of the present study suggest that life event stress may exert an unfavourable effect on the course of chronic periodontitis.

Behavioral risk indicators of attachment loss in adult Floridians.

This study investigated behavioral and sociodemographic risk indicators of attachment loss (AL) at baseline in subjects of the Florida Dental Care Study: 873 subjects with at least 1 tooth, and who were 45+ years or older, participated for an in-person interview and dental examination; 761 subjects were probed for AL. Calibrated examiners used a modified NIDR protocol from the 1985-86 Survey of US Employed Adults and Seniors. Results were weighted to reflect actual population proportions. 92% of subjects had at least 1 site of 4+ mm AL, and 35% had at least 1 severe site (7+ mm AL). In a single multivariate regression, not having a recent dental check-up, not using dental floss, being a current smoker, and being diabetic were significantly associated with a higher probability of having 1 or more severe sites. Blacks were less likely than whites to be regular users of dental care, use dental floss, and be non-smokers. Similar findings were found for low income adults and rural residents. Risk groups (low income, blacks, rural residents) were more likely to present with modifiable risk indicators for AL, suggesting the need for targeted interventions.