Periodontology 2000, Vol.

29, 2002, 710 Copyright C Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Global epidemiology of
periodontal diseases:
an overview
Jnsir M. AIunNnnn & Tnorns E. Rnrs
This volume aims to provide a comprehensive
evaluation of the distribution of various types of
periodontal diseases from each of the worlds ve
major geographic regions. Epidemiology is the
study of the health and disease in populations, as
compared to individuals (20). Study of the distri-
bution of human periodontal diseases and their
risk factors on a global scale offers a unique inves-
tigational model that can provide power and gener-
alization to observations on the periodontium
made initially among more limited populations. In
assessing causation between periodontal diseases
and their suspected etiologic risk factors, it is use-
ful to demonstrate consistency of the relationships
in multiple, representative population samples.
When diverse study approaches in various popula-
tions by different investigators produce similar con-
clusions on the distribution of periodontal diseases
and/or their associations with putative risk factors,
then one can be more condent that real phenom-
enon and/or causal relationships exist (29). Indeed,
population-based studies provide external validity
to observations obtained from more discrete sub-
ject groups, and enable generalization of the con-
clusions (14). Alternatively, differences in peri-
odontal disease patterns among various population
groups can be exploited to uncover previously un-
identied risk factors that may not be expressed in
all populations.
Available population-based periodontal disease
data originate from studies encompassing a wide
range of objectives, designs and measurement cri-
teria (18). The lack of standardized study design,
denition of periodontal disease status, methods for
disease detection and measurement, and criteria for
subject selection markedly limit interpretation and
7
analysis of available population-based periodontal
disease data from around the world. However, sev-
eral broad trends on the nature of human peri-
odontal diseases are apparent across the wide range
of population-based data.
Population studies conrm the close relationship
between dental plaque and gingivitis that was ini-
tially described by Le et al. (21) in nonpopulation-
based studies. Throughout the globe, dental plaque
growth and inammation of gingival tissue are
ubiquitous and strongly linked, irrespective of age,
gender or racial/ethnic identication. More than
82% of U.S. adolescents have overt gingivitis and
signs of gingival bleeding (2), with similar or higher
prevalences of gingivitis being reported for children
and adolescents in other parts of the world (4, 12,
13, 15, 25). A high prevalence of gingivitis is also
found in adults, with more than half of the U.S. adult
population estimated to exhibit gingival bleeding (1,
6, 24), and other populations showing even higher
levels of gingival inammation (25).
While gingivitis parallels the level of oral hygiene
in a population, it is by itself a poor predictor of sub-
sequent periodontitis disease activity (5, 16, 19).
However, young subjects with overt gingival in-
ammation more frequently exhibit periodontal
attachment loss than adolescents without gingival
inammation (2). Furthermore, gingivitis always ap-
pears to precede the development of periodontitis,
as no data from around the world indicate that the
onset of periodontitis occurs without gingival in-
ammation.
It is clear from global epidemiology data that a less
pronounced relationship appears to exist between
dental plaque and severe periodontitis. Severe forms
of human periodontitis frequently affect only a sub-
Albandar & Rams
set of population groups globally, even though
plaque-induced gingivitis and slight to moderate
forms of periodontitis are widespread within the
same population groups. A relatively small subset of
populations in the United States (6), Central and
South America (15), Europe (27), Africa (7), and Asia/
Oceania (10) exhibit severe forms of periodontal
attachment loss with deep periodontal pocket for-
mation. The relatively lower occurrence of severe
periodontitis in many of the studied populations
may in part be attributed to the lack of standardized
study design and disease measurement criteria used,
and the effects of marked tooth loss in persons with
severe periodontitis, which would serve to reduce
the prevalence of severe periodontitis as edentulous
conditions occur. However, it is likely that ad-
ditional, unidentied risk factors beyond dental
plaque and gingivitis alone are important in the
onset and pathogenesis of severe forms of peri-
odontitis.
In this regard, the relative contribution of various
proposed risk factors in severe periodontitis remain
to be fully delineated. Most studies fail to assess
aspects of study subjects (i.e. genetic, biochemical,
microbiologic and/or immunologic markers) be-
yond basic demographic characteristics. There is a
relative paucity of analytic studies which account
for a wide range of potential independent risk fac-
tors for severe periodontitis. For example, several
gene polymorphisms have been investigated rela-
tive to their associations with periodontitis, and
some of these have been shown to be related to
increased risk for aggressive disease (5). The most
signicant gene aberrations studied so far are those
thought to be associated with altered host immune
response to infection, including interleukin-1 (IL-
1) gene, vitamin D receptor gene, and fMLP recep-
tor gene.
However, the effects of various genetic risk factors
are not exclusive, and these effects explain only a
part of the variance in the occurrence of aggressive
periodontitis, and to a lesser degree, chronic peri-
odontitis. Studies show that there is a signicant in-
teraction between genetic factors and other environ-
mental and demographic factors, including a poss-
ible modifying effect of smoking, and a variability in
the occurrence of certain genotypes in different
race-ethnicity groups (5). Hence, more analytic
studies encompassing a wider range of potential risk
variables are needed to better understand the role of
these and other factors in the increased susceptibil-
ity to destructive periodontal diseases.
Another problem with many population-based
8
periodontal studies has been the reliance upon
measurement of probing depth as an indicator of
disease status. At a population level, probing pocket
depth measurements are of limited value for the ap-
praisal of the extent and severity of periodontal dis-
eases for the following reasons:
O An increase in the probing depth at a given tooth
site may or may not be associated with attach-
ment loss at that site.
O The probing pocket depth at a given site is a
changeable measure. A reduction of the probing
depth with aging due to gingival recession is fre-
quently observed (22), and does not necessarily
indicate improved periodontal status.
O Probing depth does not provide an accurate
measure of periodontal tissue destruction ac-
cumulated over a persons lifetime as reliably as
assessments of periodontal attachment level.
Signicant disparities appear to exist in the level of
periodontitis among young, adult and senior popu-
lations in the world. Subjects of African ethnicity
seem to have the highest prevalence of peri-
odontitis, followed by Hispanics and Asians. Dis-
parities in periodontal status appear to occur large-
ly between the poor and the rich. Populations with
a lower socioeconomic level cannot afford dental
treatment. These populations often lack healthy at-
titudes and behaviors for oral health, as well as for
systemic health. In addition, periodontal disease
susceptibility is further aggravated by the apparent
occurrence in these populations of certain biologi-
cal and microbiological risk factors that further in-
crease their predisposition to periodontal diseases
(3, 5).
Epidemiologic data can form the basis for selec-
tion and implementation of strategies to prevent and
treat periodontal diseases. Three broad strategies
have been advanced (26, 28):
O Population strategy: uses a community-wide ap-
proach in which health education and other
favorable life practices are introduced in the com-
munity, and unfavorable behaviors are attempted
to be changed.
O Secondary prevention strategy: includes detecting
and treating individuals with destructive peri-
odontal diseases. Basically, health education is an
integral part of this strategy, although it is more
customized to the needs of the individual patient.
Dental health education approaches to improve
the oral hygiene of the individual patient, al-
Global epidemiology of periodontal diseases
though successful in the short-term, have been
shown to be relatively ineffective in making sus-
tained changes in oral hygiene behaviors (27).
This may be partly due to the failure to incorpor-
ate social contextual factors and other factors,
such as loss of function and esthetics, and the
general health impact of periodontal diseases, in
these programs.
O Identication of high risk groups for periodontitis:
the early detection of active disease and identi-
cation of subjects and groups who are more likely
to develop destructive periodontal diseases in the
future are important elements of dental care sys-
tems planning.
The selection of the most appropriate of the above
strategies for a given population group is dependent
upon the disease distribution and nature of risk fac-
tors pertinent to periodontal diseases in that par-
ticular population.
In the future, adoption of better oral hygiene
should have a notable impact on the occurrence of
periodontal disease. Awareness of the occurrence of
disease, the infectious nature of these diseases, and
the available means of risk assessment and disease
prevention (11, 23), may be achieved through a
better interaction between oral health providers and
community decision makers, and changes in the
educational programs in the population to promote
healthy attitudes. The advent of uoride and its ef-
fect in markedly reducing the incidence of dental
caries has resulted in a notable increase in tooth re-
tention worldwide (9), and a higher number of re-
tained teeth may be accompanied by increases in the
prevalence and severity of periodontal attachment
loss in the population (17). Finally, as more people
are living longer, with retention of their teeth, a
greater prevalence of destructive periodontal disease
may be expected to occur (8).
Although behavioral changes, including better oral
hygiene habits, smoking cessation programs, and
other behavioral and promotional programs may po-
tentially improve periodontal health, the overall
benets may be offset and even surpassed by the
increases in the prevalence and severity of peri-
odontal attachment loss which will accompany the
anticipated increase in tooth retention and longer
life expectancy. In the coming years on a global
basis, it may be foreseen that a decrease in preva-
lence and severity of periodontal attachment loss in
populations younger than 50years is likely together
with an increase in periodontal disease in older age
groups.
9
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