Hindawi

e Scientific World Journal

Volume 2020, Article ID 2146160, 8 pages
[Link]

Research Article
Global Prevalence of Periodontal Disease and Lack of
Its Surveillance

Muhammad Nazir , Asim Al-Ansari, Khalifa Al-Khalifa, Muhanad Alhareky,

Balgis Gaffar , and Khalid Almas
Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University,
Dammam, Saudi Arabia

Correspondence should be addressed to Muhammad Nazir; manazir@[Link]

Received 26 February 2020; Revised 23 April 2020; Accepted 28 April 2020; Published 28 May 2020

Academic Editor: Samir Nammour

Copyright © 2020 Muhammad Nazir et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. Periodontal disease is a public health problem and is strongly associated with systemic diseases; however, its
worldwide distribution is not fully understood. Objective. To evaluate global data of periodontal disease: (1) among adolescents,
adults, and older population and (2) in low-, middle-, and high-income countries. Methods. This ecological study included data of
periodontal disease from the World Health Organization’s data bank which are based on the Community Periodontal Index of
Treatment Needs (CPITN code: 0 = no disease; 1 = bleeding on probing; 2 = calculus; 3 = periodontal pocket (PD) 4-5 mm; 4 = PD
(6+ mm). Age- and income-related periodontal disease inequalities were evaluated across the globe. Results. Compared with 9.3%
of adults and 9.7% of older persons, 21.2% of adolescents had no periodontal disease (P � 0.005). Nearly 18.8% of adolescents
compared with 8.9% of adults and 5% of older persons had bleeding on probing (P ≤ 0.001). Similarly, 50.3% of adolescents, 44.6%
of adults, and 31.9% older persons demonstrated the occurrence of calculus (P � 0.01). On the other hand, older persons had the
highest prevalence of PD 4-5 mm and PD 6+ mm than adults and adolescents (P ≤ 0.001). The distribution of periodontitis
(CPITN code 3 + 4) in adults differed significantly in low- (28.7%), lower-middle- (10%), upper-middle- (42.5%), and high-
income countries (43.7%) (P � 0.04). However, no significant differences in periodontitis (CPITN code 3 + 4) were observed in
adolescents and older persons in low- to high-income countries. Conclusions. Within the limitations of data, this study found that
the distribution of periodontal disease increases with age. Periodontitis was the most common in older persons and in population
from high-income countries.

1. Introduction world [4]. It is one of the major causes of tooth loss which
can compromise mastication, esthetics, self-confidence,
Periodontal disease which comprises gingivitis and and quality of life [5, 6]. Globally, periodontal diseases
periodontitis is a common oral infection that affects the accounted for 3.5 million years lived with disability (YLD)
tissues that surround and support teeth [1]. The condition in 2016 [3]. During the period from 1990 to 2010, there
often presents as gingivitis which is characterized by was a 57.3% increase in the global burden of periodontal
bleeding, swollen gums, and pain, and if left untreated, it disease [7]. In 2010, worldwide loss of productivity due to
progresses to periodontitis which involves the loss of severe periodontitis was estimated to be US$54 billion per
periodontal attachment and supporting bone [2]. year [8]. The global prevalence of periodontal disease is
According to the Global Burden of Disease Study (2016), expected to increase in coming years due to growth in the
severe periodontal disease was the 11th most prevalent aging population and increased retention of natural teeth
condition in the world [3]. The prevalence of periodontal due to a significant reduction in tooth loss in the older
disease was reported to range from 20% to 50% around the population [9].
2 The Scientific World Journal

Masticatory difficulties resulting from periodontal dis- obtain comparable data to evaluate global distribution and
ease can interfere with the intake of food, thus negatively trends of periodontal disease [24].
affecting nutrition and the general health of patients [5]. In The WHO collaborates with many organizations and
addition, periodontal disease is associated with other individuals worldwide to collect information about oral
common systemic conditions such as diabetes, cardiovas- conditions and oral health services and maintains under the
cular disease, adverse pregnancy outcomes, rheumatoid WHO oral health country/area profile programme (CAPP).
arthritis, and chronic obstructive pulmonary disease For this study, data were retrieved from the WHO oral
[10–14]. The metastatic spread of microorganisms and their health data bank about periodontal health profile of
products from dental plaque and inflammatory mediators countries that were maintained and updated by the Niigata
from periodontal tissues to other organs of the body is University Graduate School of Medical and Dental Sciences
believed to account for this periodontal and systemic disease in Japan [25]. The WHO periodontal disease data are based
connection [14–16]. on scores of CPI for adolescents (15–19 years), adults (35–44
Different segments of the population are dispropor- years), and older persons (65–74 years). CPI score ranges
tionally affected with periodontal disease [17]. Evidence has from 0 to 4 and a score 0 � healthy periodontal conditions or
suggested an inverse relationship between income and no periodontal disease; score 1 � gingival bleeding; score
periodontal disease [18]. It was reported that low-income 2 � calculus and bleeding; score 3 � shallow periodontal
individuals had 1.8 times increased odds of severe peri- pockets (4–5 millimeters); and a score 4 � deep periodontal
odontal disease than high-income individuals [17]. Peri- pockets (6 millimeters or more) [26].
odontal disease inequalities exist among different age Periodontal Country Profile data from 2000 to 2016 were
groups, and the severity of the disease increases with ad- used for our analysis. Data between 1981 and 1999 were
vancing age. In an epidemiological study, it was found that excluded from the study to provide more recent estimates of
the highest prevalence of chronic periodontist was found in periodontal disease. Periodontal disease data were compared
the elderly population (82%), followed by adults (73%) and among adolescents, adults, and older persons in selected
adolescents (59%) [19]. It is known that periodontal disease countries [25]. The World Bank (2017) categorizes countries
can be prevented; however, patients with periodontal disease into low-income, lower-middle-income, upper-middle-in-
usually seek oral care when the disease reaches an advanced come, and high-income. Low-income countries had gross
stage because its early stages are usually asymptomatic [20]. national income (GNI) per capita ≤ $995; lower-middle-
Therefore, early diagnosis and treatment are crucial for the income countries had GNI per capita $996 and $3,895;
maintenance of periodontal health. upper-middle-income countries had GNI per capita between
The analysis of global data about the prevalence of $3,896 and $12,055; and high-income countries had GNI per
periodontal disease is useful for policy development and the capita ≥ $12,056 [27].
allocation of financial and human resources for preventive Statistical Package for Social Science (SPSS Statistics for
measures and the provision of treatment. However, the Windows, Version 22.0, Armonk, NY: IBM Corp) was used
prevalence of periodontal disease in different age groups and for statistical analysis. CPITN (codes 3 and 4) was combined
in low-income, middle-income, and high-income countries as indicators of periodontitis to present disease distribution
is not fully understood. Therefore, this study aimed to among adolescents, adults, and older population. The
compare global data of periodontal disease among pop- Kruskal–Wallis test was performed to compare periodontal
ulation of adolescents, adults, and older persons. The study disease data among adolescents, adults, and older population
also evaluated the prevalence of periodontal disease in low in selected countries. Similar comparisons were made
through high-income countries. among low-income, lower-middle-income, upper-middle-
income, and high-income countries. A P value of ≤0.05 was
2. Methods considered statistically significant.

Globally, there are discrepancies in the prevalence of peri- 3. Results

odontal disease in epidemiological studies due to the dif-
ferences in sample size, sampling technique, disease The study analyzed data of adolescents (15–19 years), adults
measurement method/diagnostic technique, definitions of (35–44 years), and older persons (65–74 years) from 27 low
periodontal disease, socioeconomic conditions of study to high income countries. Belarus had the highest prevalence
population, and timing of study [21, 22]. However, the use of of periodontal disease among adolescents because there was
a universally accepted diagnostic method remains one of the no adolescent without periodontal disease (0 percent of
challenges in epidemiological investigations of periodontal adolescents with no disease CPITN Code = 0). This was
disease [22]. Although periodontal disease is frequently followed by Norway (1% with no periodontal disease) and
diagnosed by probing or loss of attachment, patient dis- Germany with 2% of adolescents with no periodontal dis-
comfort due to pain on probing, long time for examination, ease. Periodontitis (CPITN code 3 + 4) in adolescents was
and the possibility of the spread of infection are concerns in most common in Norway (66%), followed by Iran (30%) and
population studies [23]. The World Health Organization Belarus (15%). Germany and Taiwan had 14% of their ad-
(WHO) proposed the use of community periodontal index olescents with periodontitis (CPITN code 3 + 4) (Figure 1).
(CPI), a needs assessment tool for the planning of resources Two most populated countries in the world, China and
in 1977. The extensive use of CPI around the world helped India, had no adult without periodontal disease (0 percent of
The Scientific World Journal 3

Figure 1: Prevalence of periodontitis (CPITN code 3 + 4) among adolescents (15–19 years).

adults with no disease CPITN code � 0). In addition, Belarus 6 + mm were highly distributed in older persons than adults
had no adults without periodontal disease, while Germany and adolescents and differences were significant (P ≤ 0.001).
and Taiwan had 1% of adults with no disease. Adults in Significant differences were observed regarding bleeding
Belarus (76%), Germany (73%), and Nepal (64%) demon- on probing (P � 0.018) when data were compared among
strated the highest prevalence of periodontitis (CPITN code low-income (3.12%), lower-middle-income (9.77%), upper-
3 + 4). More than half of adult population in Poland (62%), middle-income (10.05%), and high-income countries
Malaysia (60%), Libya (56%), Iran (53%), and Taiwan (53%) (13.96%). Calculus was the most commonly distributed
had periodontitis (CPITN code 3 + 4) (Figure 2). among lower-middle-income countries (58.66%), and dif-
Hundred percent of older persons in China, India, and ferences were significant (P � 0.028).
Croatia have periodontal disease (0 percent of older persons Lower-middle-income countries had the lowest distri-
with no disease CPITN Code � 0). The highest prevalence of bution (0.5%) of periodontitis (CPITN code 3 + 4) and high-
periodontitis (CPITN code 3 + 4) in older persons was found income countries had the highest distribution of disease
in Germany (88%), Croatia (83%), Nepal (73%), and Taiwan (13.9%), and differences were not significant (P � 0.26).
(73%) (Figure 3). However, there were significant differences in the distri-
Figure 4 shows the overall prevalence of periodontal bution of periodontitis (CPITN code 3 + 4) in adults in low-
disease in adolescents, adults, and older persons. The (28.7%), lower-middle- (10%), upper-middle- (42.5%), and
presence of calculus is the most common in adolescents, high-income countries (43.7%) (P � 0.04). The distribution
adults, and older persons, and this is followed by the oc- of periodontitis (CPITN code 3 + 4) in older persons did not
currence of PD 4-5 mm. There were statistically significant differ significantly in low-income to high-income countries
differences in the prevalence of no disease, bleeding on (P � 0.58) (Figure 5).
probing, calculus, PD 4-5 mm, and PD 6 + mm among
adolescents, adults, and older population. The adolescents
had the highest prevalence of no periodontal disease (21.2%)
4. Discussion
compared with adults (9.3%) and older population (9.7%) The present study demonstrated that the global prevalence of
(P � 0.005). On the other hand, 18.8% of adolescents periodontal disease increases with age from adolescents to
compared with 8.9% of adults and 5% of older persons had adults and older population. It was also found that CPI 3 (PD
bleeding on probing (P ≤ 0.005). Similarly, half the ado- 4-5 mm) and CPI 4 (PD 6 + mm) were highly concentrated
lescents (50.3%), adults (44.6%), and older persons (31.9%) among older people. A previous WHO questionnaire-based
demonstrated calculus (P � 0.01). PD 4-5 mm and PD study from 46 countries found that periodontal disease,
4 The Scientific World Journal

Figure 2: Prevalence of periodontitis (CPITN code 3 + 4) among adults (35–44 years).

Figure 3: Prevalence of periodontitis (CPITN code 3 + 4) among older persons (65–74 years).
The Scientific World Journal 5

57.6
CPITN 4 = PD 6+ mm 0.4 8.9 18.1 High income countries 43.7
13.9
41.6
CPITN 3 = PD 4-5 mm 9.1 27.7 30.6 Upper middle income countries 42.5
9.5
42.7
CPITN 2 = Calculus 50.3 44.6 31.9 Lower middle income coutries 10.0
0.5
40
CPITN 1 = Bleeding on probing 18.8 8.9 5 Low income coutries 28.7
2.7

CPITN 0 = No disease 21.2 9.3 9.6 Older persons (P = 0.58)

Adults (P = 0.04)
Adolescents (P = 0.26)
Adolescents
Adults Figure 5: Distribution of periodontitis (CPITN code 3 + 4) in low-
Older persons income, lower-middle-income, upper-middle-income, and high-
Figure 4: Global distribution of periodontal disease in adolescents, income countries.
adults, and older persons.
and Asian) [39]. Twenty-five percent of European pop-
reflected by CPI 3 and CPI 4, was the most frequent in older ulation was over the age of 60 years or over in comparison
population [28]. Similarly, poor periodontal health in older with 5% of African population in 2017 [39]. Older pop-
people has been previously illustrated in Indonesia, and it ulation makes a considerable segment of the society in high
was reported that there was a significant correlation (co- income countries that may account for the increased oc-
efficient correlation � 0.251, P ≤ 0.001) between the age of currence of periodontal pockets in these countries [28].
older persons and periodontal disease [19]. Data from Empirical research has shown an inverse relationship
National Health and Nutrition Examination Surveys in the between the severity of periodontal disease and individual
U.S. showed that 40.7% of 65 years and older population income [18]. Borrell et al. indicated that low-income subjects
experienced attachment loss of ≥6 mm, and 22.7% dem- had significantly higher odds of (odds ratio � 1.8) having
onstrated periodontal pockets ≥5 mm [29]. A review of 75 severe periodontal disease than high-income subjects [17].
studies reported that the prevalence of severe periodontitis Similarly, the report of the third National Health and Nu-
increases with age and peaks at the age of 40 years and then trition Examination Survey (NHANES III) in the U.S.
remains stable in older age, hence exhibiting a high burden showed that individuals living in the low socioeconomic
of disease in the elderly population [30]. An epidemiological neighborhood were 1.81 times more likely to have peri-
study in Sweden found that the proportion of subjects with odontitis than those living in the high socioeconomic
pocket depths of more than 4 mm increased with age [31]. neighborhood [40]. The Korean National Health and Nu-
The severity of periodontal disease increases with advancing trition Examination Survey IV (2007-209) also found similar
age, and similar patterns of occurrence of disease were re- trends of increased periodontal disease among low-income
ported in several studies [32–36]. individuals [41]. The literature has consistently shown in-
High prevalence of periodontal disease in older pop- equalities about periodontitis among individuals of varying
ulation can be attributed to poor oral hygiene, lack of income backgrounds [42, 43].
government financing for oral health services, and lack of Low income is one of the barriers to access to oral health
oral health promotion programs and policies aimed at the care. The utilization of dental services is related to the
older population in various countries around the world [28]. availability of dental insurance. It is documented that in-
In addition, the high concentration of periodontal de- dividuals with dental insurance perform more routine dental
struction in older people could be because of the cumulated visits than those without dental insurance [44]. Similarly,
effect of untreated periodontal disease over a period of time low-income individuals may have low perception about the
rather than the effect of age on periodontal disease [37]. importance of oral health or may not be fully aware of the
Aging is known to impair the immune and inflammatory need for dental care and may also have low expectation of
responses which contribute to periodontal tissue destruction good health [45]. Therefore, individuals from high-income
in older subjects [38]. segments of the society compared with low income people
In the present study, disparities in the severity of peri- are more likely to have dental insurance and receive both
odontal disease demonstrated by CPI 3 and CPI 4 existed in preventive and curative dental care. These factors contribute
low-, middle-, and high-income countries. It was found that to the retention of natural teeth among high-income indi-
high-income countries had the highest prevalence of CPI 3 viduals [9].
(PD 4-5 mm) and CPI 4 (PD 6 + mm). Globally, the number High distribution of periodontal disease particularly CPI
of older persons increased from 382 million in 1980 to 962 3 and CPI 4 in high-income countries in the present study
million in 2017, and it is projected to increase to 1.4 billion can be explained by the exponential growth in the aging
by 2030 [39]. Similarly, the older population has increased population and increased retention of natural teeth among
dramatically during the last four decades particularly in individuals in these countries. Policy-makers, public health
high-income countries (European and North American professionals, and stakeholders should consider the effect of
countries) compared with low-income countries (African increased life expectancy and retention of natural teeth when
6 The Scientific World Journal

developing policies and programs to improve periodontal than high-income countries. The prevalence of periodontal
health, particularly in high-income countries. They should pockets was the most frequent in high-income countries.
integrate oral health programs into national health programs
as emphasized by the World Health Organization [28]. 6. Recommendations
Periodontal disease is a global public health problem.
There is a dramatic increase in the burden of periodontal (i) The WHO through collaborations should establish
disease during the last decades, and a large body of evidence surveillance of periodontal disease to systemically
shows its strong significant association with systemic dis- collect epidemiological information in a similar way
eases; however, limited periodontal data are available in the as it is obtained for many systemic diseases from
WHO oral health data bank. Oral health programs aimed at most countries
preventing periodontal disease require robust epidemio- (ii) Funding should be provided to conduct national
logical data, and the allocation of health resources to provide surveys in low-income countries
treatment for periodontal disease cannot be achieved in the (iii) High prevalence of periodontal disease in rapidly
absence of updated and reliable data. Of 193 countries of the progressing older population warrants the inte-
United Nations, periodontal disease data of only 20 coun- gration of periodontal disease prevention programs
tries for adolescents, 27 countries for adults, and 18 and policies into general health preventive
countries for older persons were maintained by the WHO. initiatives
Even data of a few countries were collected during the last
(iv) The development of integrated oral and systemic
five years. Moreover, there was no continuous and sys-
health policies should commence at local, national,
tematic collection of epidemiological data from different
and international levels
countries. This lack of periodontal disease surveillance at the
global stage calls for integrated actions from public health
professionals, researchers, periodontologists, and local,
Data Availability
national, and global health organizations. The SPSS data file of this study is available from the cor-
Empirical research does provide important information; responding author upon request.
however, an ecological comparison among countries shows
meaningful trends and patterns of periodontal disease. The Conflicts of Interest
study included data of periodontal disease based on the
CPITN which provided reliable and valid comparisons and The authors declare that there are no conflicts of interest
valuable information for stakeholders. The CPITN instru- regarding the publication of this paper.
ment is commonly used in epidemiological studies due to its
wider acceptance among researchers. However, the CPITN Acknowledgments
uses probing depth as the main clinical parameter to
measure periodontitis which is known to overestimate the The World Health Organization maintains data about
prevalence of periodontitis. Hence, the instrument may not periodontal health profile of countries.
show actual severity and extent of periodontal disease in a
screened population [46]. The inclusion of data from 2000 Supplementary Materials
till 2016 provided as recent information as possible. How-
ever, the exclusion of periodontal disease information be- Table 1: prevalence of periodontal disease among adoles-
tween 1981 and 1999 limits the generalizability of study cents (15–19 years); Table 2: prevalence of periodontal
disease among adults (35–44 years); Table 3: prevalence of
findings. In addition, data were collected from various
periodontal disease among older persons (65–74 years).
countries at different points in time. Therefore, the study
(Supplementary Materials)
findings call for establishing a surveillance system for
periodontal disease by continually collecting national rep-
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