{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T07:32:28Z","timestamp":1789889548687,"version":"4.0.1"},"reference-count":52,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["aap.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Periodontology"],"published-print":{"date-parts":[[2026,6]]},"abstract":"Abstract<\/jats:title>\n \n Objectives<\/jats:title>\n To assess associations between the poverty\u2010income ratio (PIR) and periodontitis severity using Application of the 2018 Periodontal Status Classification to Epidemiological Survey Data (ACES) framework.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n Three NHANES cycles (2009\u20132014) with adults aged \u226530 years with complete periodontal examinations (\n n<\/jats:italic>\n \u00a0=\u00a010,598) were included. Staging (I\u2013IV), grading (A\u2013C), and extent (localized\/generalized) were derived. The primary exposure was the poverty\u2010income ratio. The covariates included smoking (current\/former\/never), HbA1c, and BMI. The analytic sample for the PIR main effects was\n n<\/jats:italic>\n \u00a0=\u00a09708. Stage\/grade used multinomial logistic regression; extent used binary logistic regression. Full models included the main effects and interactions; non\u2010significant interactions were removed. Significance was set at\n p\u00a0<\/jats:italic>\n <\u00a00.05. Analyses were performed in R.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n A higher PIR was protective across outcomes: stage IV versus I RRR\u00a0=\u00a00.58, stage III 0.73; and stage II 0.87 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); grade C versus A 0.74, grade B 0.83 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); generalized extent OR\u00a0=\u00a00.93 (\n p\u00a0<\/jats:italic>\n <\u00a00.001). Smoking showed a graded risk: current versus never \u2013 stage III RRR\u00a0=\u00a02.19, stage IV 3.82 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); grade B 1.57, grade C 2.18 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); generalized OR\u00a0=\u00a01.46 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); former versus never generalized OR not significant (\n p\u00a0<\/jats:italic>\n =\u00a00.24). The HbA1c increases were associated with a higher severity: stages II\u2013IV versus I RRRs\u00a0=\u00a01.56\/1.97\/2.14 (all\n p\u00a0<\/jats:italic>\n <\u00a00.001); grades B\/C versus A 1.58\/1.82 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); extent OR\u00a0=\u00a01.00 (\n p\u00a0<\/jats:italic>\n =\u00a00.81). With BMI models, the BMI showed slight associations for stage\/grade (RRR\u22480.93\u20130.98), while the PIR remained strongly associated: stage II\/III\/IV RRRs\u00a0=\u00a00.69\/0.48\/0.30 (all\n p\u00a0<\/jats:italic>\n <\u00a00.001); grade B\/C 0.54\/0.43 (\n p\u00a0<\/jats:italic>\n <\u00a00.001); extent OR for PIR\u00a0=\u00a00.93 (\n p\u00a0<\/jats:italic>\n <\u00a00.001), BMI OR\u00a0=\u00a01.00 (\n p\u00a0<\/jats:italic>\n =\u00a00.184).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Within the limitations of this cross\u2010sectional analysis, a higher PIR was associated with a lower periodontitis severity, smoking, and higher HbA1c with higher severity, and the BMI effects were minimal.<\/jats:p>\n <\/jats:sec>\n \n Plain language summary<\/jats:title>\n \n Gum disease is common and tied to overall health. People with less income and consequently fewer resources for preventative care may face a higher risk for disease. We analyzed three cycles of the US National Health and Nutrition Examination Survey (2009\u20132014). Adults aged \u226530 years with complete dental examinations (\n n<\/jats:italic>\n \u00a0=\u00a010,598) were classified using the 2018 staging\/grading system that defines disease severity (stage) and the risk for progression (grade). Socioeconomic status was measured by the poverty\u2010income ratio (PIR). We examined links between PIR and disease stage, grade, and whether the disease was localized or generalized, and considered smoking, blood sugar (HbA1c), and body mass index (BMI). Our results demonstrated that a higher PIR (more resources) was consistently linked to less severe and less widespread disease. Current smoking showed strong, stepwise increases in severity and spread; former smoking was not linked to spread. A higher HbA1c was tied to more severe stages and grades, but not to spread. The BMI showed only small, inconsistent effects. Overall, lower income, smoking, and poor blood\u2010sugar control tracked with worse periodontal status.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/jper.70064","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T17:46:53Z","timestamp":1768844813000},"page":"1327-1339","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Periodontitis severity and its social and clinical determinants: An ACES framework\u2010based NHANES analysis"],"prefix":"10.1002","volume":"97","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9676-4598","authenticated-orcid":false,"given":"Meng Xuan","family":"Chen","sequence":"first","affiliation":[{"name":"Department of Periodontics and Oral Medicine University of Michigan School of Dentistry Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-8109-3623","authenticated-orcid":false,"given":"Yue","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Mechanical & Industrial Engineering University of Toronto Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0747-8114","authenticated-orcid":false,"given":"Chen Xuan","family":"Wei","sequence":"additional","affiliation":[{"name":"Department of Biologic and Materials Sciences and Prosthodontics University of Michigan School of Dentistry Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6581-2104","authenticated-orcid":false,"given":"Hamoun","family":"Sabri","sequence":"additional","affiliation":[{"name":"Department of Periodontics and Oral Medicine University of Michigan School of Dentistry Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5067-7317","authenticated-orcid":false,"given":"Muhammad H. A.","family":"Saleh","sequence":"additional","affiliation":[{"name":"Department of Periodontics and Oral Medicine University of Michigan School of Dentistry Ann Arbor Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(24)02811-3"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.adaj.2018.04.023"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/odi.12428"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1902\/jop.2016.160013"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1002\/JPER.17-0721"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1002\/JPER.19-0390"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.13965"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.14132"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.13506"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0528.2007.00406.x"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1177\/154405910708601014"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-0757.2011.00416.x"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.5888\/pcd16.180553"},{"key":"e_1_2_10_15_1","first-page":"1547","article-title":"The effect of neighborhood disadvantage on diabetes prevalence","volume":"2017","author":"Sheets L","year":"2018","journal-title":"AMIA Annu Symp Proc"},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1007\/s13679-020-00398-7"},{"key":"e_1_2_10_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)61602-X"},{"key":"e_1_2_10_18_1","doi-asserted-by":"publisher","DOI":"10.1902\/jop.2000.71.5.743"},{"key":"e_1_2_10_19_1","doi-asserted-by":"publisher","DOI":"10.1002\/cap.10117"},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.2334\/josnusd.51.587"},{"key":"e_1_2_10_21_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-051X.2008.01249.x"},{"key":"e_1_2_10_22_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.13679"},{"key":"e_1_2_10_23_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00414-016-1434-0"},{"key":"e_1_2_10_24_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600-051X.1991.tb00419.x"},{"key":"e_1_2_10_25_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-023-27474-x"},{"key":"e_1_2_10_26_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-024-63058-z"},{"key":"e_1_2_10_27_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.13507"},{"key":"e_1_2_10_28_1","doi-asserted-by":"publisher","DOI":"10.1002\/JPER.21-0296"},{"key":"e_1_2_10_29_1","doi-asserted-by":"publisher","DOI":"10.1002\/JPER.24-0561"},{"key":"e_1_2_10_30_1","doi-asserted-by":"publisher","DOI":"10.3389\/froh.2025.1609961"},{"key":"e_1_2_10_31_1","doi-asserted-by":"publisher","DOI":"10.1111\/prd.12568"},{"key":"e_1_2_10_32_1","doi-asserted-by":"publisher","DOI":"10.1177\/00220345251323183"},{"key":"e_1_2_10_33_1","first-page":"1","volume-title":"Center for Health Care Strategies, Inc","author":"Canonico M","year":"2019"},{"key":"e_1_2_10_34_1","doi-asserted-by":"publisher","DOI":"10.1111\/prd.12447"},{"key":"e_1_2_10_35_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pec.2004.02.011"},{"key":"e_1_2_10_36_1","doi-asserted-by":"publisher","DOI":"10.1111\/prd.12569"},{"key":"e_1_2_10_37_1","doi-asserted-by":"publisher","DOI":"10.3389\/froh.2021.725460"},{"key":"e_1_2_10_38_1","volume-title":"Global oral health status report: towards universal health coverage for oral health by 2030","author":"Organization WH","year":"2022"},{"key":"e_1_2_10_39_1","doi-asserted-by":"publisher","DOI":"10.1111\/cdoe.12830"},{"key":"e_1_2_10_40_1","doi-asserted-by":"publisher","DOI":"10.1177\/1090198114568304"},{"key":"e_1_2_10_41_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0013371"},{"key":"e_1_2_10_42_1","first-page":"2024","article-title":"Impact of smoking on cost\u2010effectiveness of 10\u201348 years of periodontal care","author":"Ravid\u00e0 A","year":"2000","journal-title":"Periodontology"},{"key":"e_1_2_10_43_1","doi-asserted-by":"publisher","DOI":"10.1002\/JPER.25-0055"},{"key":"e_1_2_10_44_1","doi-asserted-by":"publisher","DOI":"10.3390\/jpm13050814"},{"key":"e_1_2_10_45_1","doi-asserted-by":"publisher","DOI":"10.1111\/prd.12063"},{"key":"e_1_2_10_46_1","doi-asserted-by":"publisher","DOI":"10.1034\/j.1600-0528.2002.300304.x"},{"key":"e_1_2_10_47_1","doi-asserted-by":"publisher","DOI":"10.4103\/jpbs.jpbs_515_22"},{"key":"e_1_2_10_48_1","doi-asserted-by":"publisher","DOI":"10.2337\/dc11-2453"},{"key":"e_1_2_10_49_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12903-023-03743-z"},{"key":"e_1_2_10_50_1","doi-asserted-by":"publisher","DOI":"10.1111\/jcpe.12417"},{"key":"e_1_2_10_51_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-789X.2010.00808.x"},{"key":"e_1_2_10_52_1","first-page":"1","article-title":"Association between obesity and periodontitis in US adults: NHANES 2011\u20132014","author":"Liu L","year":"2023","journal-title":"Obesity Facts"},{"key":"e_1_2_10_53_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00784-021-04172-4"}],"container-title":["Journal of Periodontology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/aap.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jper.70064","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/aap.onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/jper.70064","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/aap.onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/jper.70064","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,10]],"date-time":"2026-07-10T03:00:00Z","timestamp":1783652400000},"score":1,"resource":{"primary":{"URL":"https:\/\/aap.onlinelibrary.wiley.com\/doi\/10.1002\/jper.70064"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,19]]},"references-count":52,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2026,6]]}},"alternative-id":["10.1002\/jper.70064"],"URL":"https:\/\/doi.org\/10.1002\/jper.70064","archive":["Portico"],"relation":{},"ISSN":["0022-3492","1943-3670"],"issn-type":[{"value":"0022-3492","type":"print"},{"value":"1943-3670","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,19]]},"assertion":[{"value":"2025-09-04","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-11-19","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-01-19","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}