On the back of the recent announcement of the results of the 2009 Adult Dental Health Survey, I wrote an editorial speculating on the impact that disease trends might have on our future work profiles and prospects.1 I opined that with the fall in caries and the consequent rise in caries-free (or relatively caries-free) generations there would be less for we dentists to do. I was, however, taken to task by M. Austin in the letters columns,2 and by others, who suggested that far from having less to do we would have very much more.

Their argument is that since more people are keeping more teeth for longer, then it stands to reason that there will be a proportionate increase in periodontal disease and that we will all be thoroughly engaged in treating that instead, as well as complex restorative work for the gradually reducing population dubbed the 'heavy metal' cohort. Really?

Lack of agreement

To help compound my doubts, I was recently invited to a round table discussion, which included amongst others some very eminent and respected periodontists, with the purpose of trying to distil some ways forward in estimating periodontal health and treatment. What struck me very early on was that there was hardly any agreement on what periodontal disease, or diseases, is or are, in terms of the definition of extent; is it gingivitis, periodontal pocketing, a particular level of attachment loss, tooth mobility? One of my very first 'View from the chair' humorous columns many years ago in this journal poked fun at a profession who seemed unable to define when a hole was a hole (as in caries diagnosis) and yet here there seemed if anything, even less agreement on its inflammatory rival.

However, not content with probing the definition of the condition, the assembled company proceeded to question, partly because of this lack of agreement on extent, the robustness of the epidemiology and whether gum health was improving, staying the same or getting worse in the UK. Some level of sanity did return when it was pointed out that about 10-15% of populations anywhere in the world experienced what was termed 'severe' periodontal disease which required a combination of both determined treatment and enthusiastic prevention in order to stabilise it. But that still leaves the overwhelming majority of us, or them, who have a level of periodontal disease that is, how shall we say?, 'acceptable' in that it is not life threatening, or even jeopardising function such as eating or socialising. No dentist around the table that evening demurred at all with the suggestion that each and every one of us present had some measure of gingival inflammation; even in professional circles it is taken for granted.

So, what do the public make of this situation? Do they perceive a problem? Do they care? With greater tooth retention into older age the role models have already started to emerge and yet whereas in the 'old days' it was accepted as part of the expected mythology of society and ageing that granny and granddad had lost their own teeth and wore dentures, now the expectation is quite different. This has come about not because of some politically correct diktat but because it is demonstrably true, the oldsters still have their own teeth which might be challenged by caries, restorations and gum disease, but that is to be 'expected' at their age.

Few at the meeting expressed any sense that there was a public clamour to eradicate periodontal disease, that anyone much understood it (hardly surprisingly if the experts are unable to agree) or that it was in any sense widely or impatiently perceived as a huge public, or more importantly, individual health problem. Inevitably, this understates the situation but what I think is instructive is that the obvious ravages of caries in years gone by did prompt a far greater sense of urgency to seek out and accept treatment. While patients may indeed turn up in our dental chairs concerned that their gums bleed when they brush their teeth, the degree to which advice is sought is very often tempered by aesthetic and fresh breath concerns as much as for distress over developing pocketing or bone loss. Education certainly has its place in this, and may indeed help to raise awareness but, with caries in relative retreat for so many years, should we not have sensed more of any impending public periodontal stampede by now?

If this is to be the case, that broadly, for the majority of the population, there will be an acceptance that mild, chronic, lifelong gum disease affects us all, like stiff joints, aching muscles and varying degrees of forgetfulness, then where will be the great pool of treatment need that might help us fill our days, our appointment books and our chairs? Then again, not that I want to cause panic and mayhem nor cry that the sky is falling, what if some clever oral product researcher comes up with a toothpaste ingredient that does for inflammation what fluoride does for demineralisation? Who cares? Probably we should start to, rather more than before and rather sooner than later.