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The global burden of periodontaldisease: towards integration withchronic disease prevention andcontrol

PO U L E. PE T E R S E N & HI R O S H I OG A W A

Chronic diseases are the leading causes of death and

disability worldwide. Disease rates from these con-

ditions are accelerating globally, advancing across

every region and pervading all socioeconomic clas-

ses. According to the World Health Organization

(WHO) (85, 90, 91, 93), the major chronic diseases

currently account for about 40% of the global bur-

den of disease and by year 2020, their contribution

is expected to rise to 60% of the global burden of

disease. The most rapid increase in the burden of

chronic diseases is occurring in developing coun-

tries (33). Four of the most prominent chronic dis-

eases – cardiovascular diseases, cancer, chronic

obstructive pulmonary disease and type 2 diabetes –

are linked by common and preventable biological

risk factors, notably high blood pressure, high blood

cholesterol and being overweight, and by related

major behavioral risk factors. An unhealthy diet and

poor nutrition over a prolonged period of time,

physical inactivity, tobacco use, excessive use of

alcohol and psychosocial stress are the important

lifestyle components (18).

Diabetes mellitus is a heterogeneous group of dis-

orders with different causes, but all are characterized

by hyperglycemia. Type 1 (insulin-dependent diabe-

tes mellitus) is caused by destruction of the insulin-

producing cells. Type 2 (noninsulin-dependent

diabetes mellitus) is the result of insulin resistance

coupled with relative beta-cell failure (32). It has

recently been reported that Type 2 diabetes accounts

for ca. 90% of all cases of diabetes mellitus in the

populations of several countries (32, 85). Approxi-

mately 285 million people worldwide suffer from

diabetes mellitus and this number is predicted to

increase by about 50% by year 2030 (32). Figure 1

indicates that the incidence of diabetes will rise

considerably in the near future, and this may increase

the burden of periodontal disease and tooth loss.

Much of this increase will occur in developing

countries and will be caused by population growth,

ageing, unhealthy diets, obesity and sedentary life-

styles. The 40–59 years age-group currently has the

greatest number of people with diabetes (132 million

in 2010), more than 75% of whom live in developing

countries (32).

Available data suggest that the prevalence of diag-

nosed and undiagnosed diabetes mellitus in older

subjects approaches 20% (49). In the child popula-

tions of many countries, diabetes also adds to the

burden of disease, and Type 2 diabetes mellitus has

been described as a new epidemic (85). In 1992, the

incidence of Type 2 diabetes was rare in most child

populations, whereas during recent years it was

found to range from 8% to 45%, depending on geo-

graphic location (32, 37).

Tobacco use is a most important risk factor for

chronic disease. In the WHO European and Western

Pacific Regions, the prevalence rates of tobacco use

are high among adults, particularly men (Fig. 2A,B)

(95). During recent years, the global pattern of to-

bacco consumption has changed dramatically. Pre-

viously, the consumption of tobacco was prevalent

in high-income countries; however, a decline of to-

bacco use in these countries is now taking place. In

contrast, the consumption of tobacco in middle-

and low-income countries shows a dramatic

15

Periodontology 2000, Vol. 60, 2012, 15–39

Printed in Singapore. All rights reserved

� 2012 John Wiley & Sons A/S

PERIODONTOLOGY 2000

increase, which may have a significant bearing on

the burden of chronic disease, including periodontal

disease.

The entire population is at risk because of the

presence of many elevated risk factors in which

individual susceptibility is affected by culture,

socioeconomic factors and the environment. Action

to prevent the major chronic diseases should focus

on these upstream social determinants and on con-

trolling the behavioral risk factors in a well-integrated

manner. The population risks are amenable to

change through community-wide strategies. Com-

munity interventions use education or environmental

change to promote and facilitate lifestyle and

behavior changes needed to address a particular

problem.

Periodontal disease

Periodontal disease is one of the two most important

oral diseases contributing to the global burden of

chronic disease (12); the disease is highly prevalent

worldwide and therefore represents a major public

health problem to countries. There are different

clinical manifestations of periodontal disease, and it

may be acute or chronic (45). Gingivitis refers to the

inflammation of gingiva caused by bacteria accu-

mulating along the gingival margin. Periodontitis is a

more advanced inflammatory form of periodontal

disease, in which breakdown of the supporting tis-

sues of the teeth occurs. Clinical signs of the disease

include deepening of periodontal pockets and loss of

attachment, progressively leading to loosening of

teeth and ultimately to tooth loss. Periodontal

destruction may be caused by local factors, such as

dental biofilm, or it may reflect an inadequate im-

mune response. Gingivitis and periodontitis can also

be manifestations of certain systemic diseases, for

example, in people with general infection or among

people infected with HIV (45). In addition to the

chronic form of periodontal disease (i.e. gingivitis

and periodontitis), periodontal disease may manifest

in acute forms, such as necrotizing ulcerative gingi-

vitis with painful infection, which may destroy the

gingival tissue, or as necrotizing ulcerative peri-

odontitis in which the bone beneath the gingival

tissue becomes infected or exposed. Aggressive

forms of periodontitis may be found in young indi-

viduals, but the prevalence of this condition is low.

The aim of the present report was to highlight the

global burden of periodontal disease. The ultimate

burden of periodontal disease – tooth loss – and the

periodontal health status are described from WHO

epidemiological data. In addition, the importance of

key risk factors and oral health systems are empha-

sized, and essential national approaches for the

effective control and prevention of periodontal dis-

ease are considered from a public health perspec-

tive.

Fig. 1. Global projection for the number of people with diabetes. From International Diabetes Foundation, Diabetes Atlas

(32).

16

Petersen & Ogawa

The global burden of tooth loss

Periodontal disease, along with severe dental caries,

is a major cause of tooth loss, which directly affects

the quality of life of people in terms of reduced

functional capacity (e.g. chewing or biting), self-es-

teem and social relationships. Experience of severe

periodontal disease over the course of life ultimately

may manifest in the complete loss of natural teeth,

particularly at old age. The burden of complete tooth

loss was highlighted in the recent World Health

Survey (WHS) (60, 88). The WHS is a global survey

covering the adult population and it was designed to

collect national representative data on the state of

health and on the performance of health systems. In

all, 72 countries took part in the survey and data were

A

B

Fig. 2. Percentage of male (A) and female (B) tobacco users worldwide. From World Health Organization (95).

17

Global periodontal health

collected by standardized personal interviews. The

participating countries were finally categorized into

low-, middle- and high-income countries based on

their gross national income according to the World

Bank criteria (81). Figure 3 provides an overview of

the global burden of tooth loss among older people

(65–74 years of age) according to national income

level. A high prevalence rate (35%) of edentulism is

found in upper middle-income countries, whereas

the prevalence rate at the time of writing was low

(10%) for low-income countries. In high-income

countries somewhat lower figures for edentulism are

found when compared with upper middle-income

countries. In several high-income countries older

people often have had their teeth extracted early in

life because of pain or discomfort, leading to reduced

quality of life. Remarkably, in many of these coun-

tries there has been a positive trend of a significant

reduction in tooth loss among older adults during

recent years owing to changing lifestyles and the

effective use of preventive oral health services

(14, 60).

Self-reported oral health problemsand care

The WHS (88) also incorporated information on

perceived mouth problems and the capacity of –

including the responsiveness of – national health

systems. At the global level, the evidence of social

inequality was documented regarding the experi-

ence of problems with mouth ⁄ teeth among the

elderly (Fig. 3). In low-income countries, about

40% of 65- to 74-year-old subjects reported health

problems, whereas the corresponding value for

high-income countries was about 30%. Around the

world, social inequality in oral illness was also

manifest within countries, particularly when

education was used as an indicator of social

position.

To ascertain whether national health systems

actually met the dental care needs of older people,

participants in the WHS were asked whether they

received care for their dental health problems. Some

48% of all age groups received medication for control

of infection; this was the case for 80% of people living

in low-income countries vs. 25% of people living in

high-income countries. In all, 40% of people had

instruction in oral hygiene and counseling on dental

care.

As illustrated in Fig. 4, the global social inequality

in health care was profound because fewer people

living in poor countries received care for their teeth

or mouth problems. In addition to the inequalities

across the world, the WHS data revealed huge dis-

parities within countries; in particular, the poor and

less educated older people were noticeably under-

served and without any natural teeth. Moreover, for

low- and middle-income countries the survey dem-

onstrated that people living in rural areas were less

likely to have oral health care. This is in contrast to

high-income countries where equal proportions of

older people living in urban and rural areas reported

having such care.

0

20

40

60

80

middleUpper middle

Low Lower High Total

UrbanRural

Income category of country

Valu

e (p

erce

ntag

e)

Fig. 4. Percentage of 65- to 74-year-old subjects in low-,

middle- and high-income countries who received health

care related to problems with mouth and teeth, stratified

by urbanization (60, 88).

0

10

20

30

40

50

middleUppermiddle

Low Lower High Total

Edentulous Problems with mouth/teeth during the past year

Income category of country

Valu

e (p

erce

ntag

e)

Fig. 3. Percentage of 65- to 74-year old subjects in low-,

middle- and high-income countries with no natural teeth

(edentulous) and percentage of people having experi-

enced problems with mouth ⁄ teeth during the past year

(60, 88).

18

Petersen & Ogawa

The global burden of periodontaldisease

The prevalence and severity of chronic periodontal

disease have been measured in population surveys

undertaken in countries with a wide range of

objectives, designs and measurement criteria (39).

The Community Periodontal Index (CPI) (64, 84) was

introduced by the WHO as a tool with which coun-

tries may produce profiles of their periodontal health

status and plan intervention programs for effective

control of periodontal disease. In addition, the CPI

population data may be helpful in oral health sur-

veillance at country and intercountry levels. While

this index has certain shortcomings as a stand-alone

means of assessing the extent and severity of peri-

odontal disease (53), it has been widely used for

descriptive periodontal epidemiological studies and

for needs assessment in both developed and devel-

oping countries. The major advantages of the CPI

are simplicity, speed, reproducibility and interna-

tional uniformity. In 1997, the WHO suggested

including information on loss of periodontal

attachment in oral health surveys (84). However,

data on loss of attachment are scarce as, to date,

only a few countries have carried out such system-

atic surveys. According to the WHO experience, the

recording of loss of attachment is often considered

difficult to carry out in the field and time-consum-

ing.

Certain indicator age groups have been chosen by

the WHO for intercountry comparisons of oral health

status and oral health surveillance. The essential

age-groups relevant to periodontal health are 15–19,

35–44 and 65–74 years. Over the past decades several

countries have provided CPI data for warehousing in

the WHO Global Oral Health Data Bank (89).

These are displayed through a component of the so-

called WHO Country ⁄ Area Profile Programme (http://

www.dent.niigata-u.ac.jp/prevent/perio/contents.

html). The standard parameters for presentation

of CPI data (84) are percentage of persons by

their maximal CPI score (prevalence rate) and the

mean number of sextants (severity) with certain CPI

scores: Score 0 = healthy periodontal conditions;

Score 1 = gingival bleeding; Score 2 = gingival

bleeding and calculus; Score 3 = shallow periodontal

pockets (4–5 mm); Score 4 = deep periodontal pock-

ets (‡ 6 mm); Score 9 = excluded; and Score X = not

recorded or not visible. The extent of loss of attach-

ment (LA) is recorded for sextants using the following

codes: Score 0 = LA 0–3 mm; Score 1 = LA 4–5 mm;

Score 2 = LA 6–8 mm; Score 3 = LA 9–11 mm; Score

4 = LA ‡ 12 mm; Score X = excluded; and Score

9 = not recorded.

The CPI databank is updated continuously and the

population data available in the WHO Global Oral

Health Data Bank are summarized in Figs 5–9,

according to WHO region, as follows: the African

Region (AFRO), the Americas Region (AMRO), the

Eastern Mediterranean Region (EMRO), the Euro-

0

25

50

75

100

AFRO AMRO EMROWHO region

EURO SEARO WPRO

Score 4

Score 3

Score 2

Score 1

Score 0

Perc

enta

ge

Fig. 5. Maximal Community Periodontal Index (CPI)

scores of 15- to 19-year-old subjects, expressed as a per-

centage and stratified according to World Heath Organi-

zation (WHO) region (89). AFRO, the African Region;

AMRO, the Americas Region; EMRO, the Eastern Medi-

terranean Region; EURO, the European Region; SEARO,

the South-East Asia Region; WPRO, the Western Pacific

Region.

0

25

50

75

100

AFRO AMRO EMROWHO region

EURO SEARO WPRO

Score 4

Score 3Score 2

Score 1

Score 0Perc

enta

ge

Fig. 6. Maximal Community Periodontal Index (CPI)

scores of 35- to 44-year-old subjects, expressed as a per-

centage and stratified according to World Heath Organi-

zation (WHO) region (89). AFRO, the African Region;

AMRO, the Americas Region; EMRO, the Eastern Medi-

terranean Region; EURO, the European Region; SEARO,

the South-East Asia Region; WPRO, the Western Pacific

Region.

19


pean Region (EURO), the South-East Asia Region

(SEARO) and the Western Pacific Region (WPRO).

The CPI data are expressed as the mean percentage of

subjects with certain CPI scores. In addition, country-

specific data are given in Table 1. The most severe

score or sign of periodontal disease (CPI Score = 4)

varies worldwide, from 10% to 15% in adult popu-

lations; however, the most prevalent score in all WHO

Regions is a CPI Score of 2 (gingival bleeding and

calculus), which primarily reflects poor oral hygiene.

For a few countries, sufficient data over time are

available for surveillance and this may allow assess-

ment of the impact of oral health programs. The

mean number of sextants with CPI scores is pre-

sented for the three age-groups of adults and by

WHO region. Poor periodontal health is particularly

reported at old age. For older people of both devel-

oping and developed countries the severe CPI scores

are profound; this pattern is also observed for coun-

0

1

2

3

4

5

6

AFRO

Mea

n nu

mbe

r of s

exta

nts

AMRO EMROWHO region

EURO SEARO WPRO

XScore 4

Score 3

Score 2Score 1Score 0

Fig. 7. Distribution of certain Community Periodontal

Index (CPI) scores, shown as mean numbers of sextants,

in 35- to 44-year-old subjects according to World Health

Organization (WHO) region (89). AFRO, the African Re-

gion; AMRO, the Americas Region; EMRO, the Eastern

Mediterranean Region; EURO, the European Region; SE-

ARO, the South-East Asia Region; WPRO, the Western

Pacific Region.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

CPI 0 CPI 1 CPI 2 CPI 3 CPI 4 CPI X CPI 9

CambodiaChina

DenmarkJapan

Lebanon

Madaga

scar

New Zealand

Republic of K

orea

Saudi A

rabia

USA

UR Tanzania

China-Hong k

ong

Mea

n nu

mbe

r of

sex

tant

s

Fig. 9. Distribution of Community

Periodontal Index (CPI) scores,

shown as mean numbers of sextants,

among 65- to 74-year-old subjects in

selected countries (89).

0102030405060708090

100

Valu

e (p

erce

ntag

e)

CPI 0 CPI 1 CPI 2 CPI 3 CPI 4 CPI X CPI 9

Australia

CambodiaChile

China

Denmark

GambiaIndia

JapanLa

o

Madaga

scar

Mya

nmar

New Zealand

Republic of K

orea

Saudi A

rabia

USA

UR Tanzania

China-Hong k

ongFig. 8. Maximal Community Peri-

odontal Index (CPI) scores, ex-

pressed as a percentage, of 65- to

74-year-old subjects in selected

countries (89).

20

Petersen & Ogawa

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29


tries with advanced oral health systems, reflecting the

fact that systems may have only a modest impact on

periodontal disease control at the population level.

Public health: recording of periodontaldisease

The CPI measure was included in the 1987 WHO

manual on oral health surveys (83) and since then it

has been widely used in oral health surveys under-

taken for planning programs and determining the

need for specific intervention. The system has been a

valuable tool, although it has shown certain limita-

tions. The scoring system is based on the assumption

of conditions following an ordinal scale; this may

be questioned from the current understanding of

mechanisms involved with gingivitis, development of

periodontal pocketing and loss of attachment. An-

other difficulty relates to the recording of CPI in tooth

loss, particularly regarding the specification of teeth

for replacement if indicator teeth are not present.

While the original CPI may have relevance for

planning health programs, the system has been

shown to be weak in the evaluation of periodontal

disease action programs. For the 5th edition of the

WHO manual for oral health surveys (94), the WHO

designed a new, modified CPI system, taking weak-

nesses of the original CPI into consideration while

ensuring simplicity and reproducibility. The new

system reflects an effort of giving higher public health

priority to periodontal disease as a significant com-

ponent of the burden of oral disease. As is the case for

dental caries, the periodontal status of all teeth pres-

ent is recorded. Scores relevant to specific disease

conditions are applied to the individual tooth, namely

the presence ⁄ absence of gingival bleeding and the

presence ⁄ absence of periodontal pockets of 4–5 or

‡ 6 mm. Calculus is not recorded because this is not a

disease condition. Recording of all teeth present will

allow identification of indicator teeth as used in the

previous CPI system. The new modified system has

been field tested in several oral health surveys carried

out in countries of different size and of different

economies, ranging from Bahrain to China.

Socio-environmental conditions

Reviews of the oral health literature (14, 43) indicate

significant intercountry and intracountry variability

in the prevalence of periodontal disease, and great

variations are shown in socio-environmental condi-

tions, oral health systems, behavioral risk factors and

in the general health status of people.Ta

ble

1.

(Co

nti

nu

ed)

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un

try

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e-g

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(ye

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ed

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(Sc

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+

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(Sc

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AF

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fric

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ric

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Re

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dit

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eg

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the

Eu

rop

ea

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EA

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ou

th-E

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;W

PR

O,

the

We

ste

rnP

ac

ific

Re

gio

n.

30

Petersen & Ogawa

Several epidemiological studies have established a

significant relationship between socioeconomic sta-

tus and periodontal disease in various age groups, in

other words poor periodontal disease status is linked

to low income or to low education (2, 11, 14, 19, 53).

For instance, in a study carried out by Drury et al.

(19), there was a 10–20% difference in periodontal

disease prevalence and severity between people of

higher and of lower socioeconomic status in the

United States (US) population. The WHO Interna-

tional Comparative Surveys (ICSII, 1997) (14) docu-

mented that this pattern was also found in Germany,

Japan, Latvia, New Zealand, Poland and the USA. In

France, however, studies of adult people showed only

minor differences in periodontal status when stratified

by income and education (30). In Denmark, the new

modified CPI system was used recently in a nation-

wide survey of subjects in 35–44 and 65–74 years age-

groups, and significant social inequalities in indicators

of periodontal disease were found for both age-groups

(i.e. teeth affected by gingival bleeding, pockets 4–

5 mm and pockets of ‡6 mm) (41).

The vast majority of epidemiological studies on

periodontal health have been conducted in high-in-

come countries (14, 64). However, in some low- and

middle-income countries, surveys on social factors in

periodontal health have been carried out during re-

cent years, encompassing children, adolescents and

adult population groups. These studies demonstrated

that poor periodontal status was most prevalent

among people living in poverty. For example, in

Africa, comparative studies based on use of the CPI

index have been undertaken in Madagascar (62),

Tanzania (61) and Burkina Faso (79), and in Asia

comprehensive information is available from China

(31). In Lao PDR, the new modified WHO CPI

recording system was used in a recent survey of

gingival health in children (35) and it was found that

the percentage of teeth with gingival bleeding was

relatively high among children living under poor

socioeconomic conditions. Socio-environmental fac-

tors are highly responsible for distinct profiles of

periodontal disease observed in populations living in

certain geographical regions or locations; for

example, there are considerable differences in the

occurrence of periodontal disease in urban vs. rural

populations (14).

In addition to intercountry variation, the distri-

bution of periodontal disease within countries also

differs according to race or ethnic group, regarding

both prevalence and severity (10, 11, 54). Beck et al.

(7) showed that groups of Black people in the USA

had a risk of periodontal destruction three times

higher than that of White people of the same age

cohort, and studies by Borrell et al. (10) found that

African-Americans were twice as likely to have

periodontal disease as were Caucasian-Americans.

The effect of ethnic group on periodontal health

status was also documented in adults of certain

developing countries in Africa and Asia (31, 40, 59,

62, 79).

Behavioral factors in periodontaldisease

In addition to poor oral hygiene, the important risk

factors for severe periodontal disease relate to the use

of tobacco, to malnutrition, excessive alcohol con-

sumption, stress, diabetes mellitus and certain other

systemic disease conditions (27, 52, 65, 67, 74).

Tobacco

Smokers have a high risk of periodontal disease and

lesions of the oral mucosa (26, 66). In addition, there

is strong evidence that smokeless tobacco, or tobacco

chewing, has a significantly adverse effect on peri-

odontal health (1, 46). A dose-response effect of to-

bacco consumption on periodontal disease has been

documented (13, 38, 75), in which the prevalence

rates and severity of periodontal disease increased in

relation to the number of cigarettes consumed and

years of smoking. Stopping smoking means a lower

risk of periodontal disease. Tobacco consumption

may also diminish the immune response, aggravate

periodontal disease and thereby lead to the loss of

natural teeth (38). Studies have shown that smoking

may account for more than half of the cases of

periodontitis among American adults (75). Tradi-

tionally, the use of tobacco was frequent in many

high-income countries and this may help to explain

the current levels of poor periodontal health status in

middle-aged and older people.

Diet

Most chronic diseases, such as cardiovascular dis-

ease, diabetes, cancers, obesity and dental disease,

are strongly related to diet (50, 52, 86), and a series of

studies has concluded that this is caused particularly

by diets rich in saturated fatty acids and nonmilk

extrinsic sugars, and by diets low in polyunsaturated

fats, fibre and vitamins A, C and E. Severe vitamin C

deficiency and malnutrition may result in aggravated

periodontal disease (52); however, relatively few re-

31


ports are available on the role of diet and nutrition in

the etiology of periodontal disease (86). Hence, it is

necessary to investigate further the evidence of an

association between dietary factors and periodontal

disease. As a result of reduced oral functioning, tooth

loss often has a negative impact on dietary habits and

therefore also has an adverse effect on nutrition sta-

tus. This has been reported particularly in older

people (36, 63).

Alcohol

High alcohol consumption aggravates the risk of a

wide variety of conditions, such as increased blood

pressure, liver cirrhosis, cardiovascular disease, dia-

betes and cancers of the mouth (86). Recent research

also indicates that excessive alcohol consumption is

associated with increased severity of periodontal

disease (65, 74). People who use tobacco are more

likely to drink alcohol and eat a diet high in fats and

sugars but low in fibre and polyunsaturated fatty

acids, and those with a heavy consumption of to-

bacco and alcohol are thus more likely to be at higher

risk of severe periodontal disease.

Stress

It is well known that cardiovascular disease, diabetes

and other chronic diseases are related to psychoso-

cial factors (42, 47), but there is also evidence that

stress is linked to periodontal disease (27). Moreover,

significant life events are associated with periodontal

disease, possibly through physiological responses,

which increase susceptibility (17).

Oral hygiene

Oral hygiene habits fluctuate by culture across the

world. In general, people of high-income countries

have adopted healthy lifestyles, including regular tooth

brushing and use of fluoridated toothpaste (3, 76). Oral

hygiene aids, in terms of dental floss and toothpicks,

are widely used. However, oral hygiene habits show

substantial variation within countries in relation to

personal income, level of education and place of resi-

dence (14). In particular, education is a strong deter-

minant of oral hygiene practices as reported by the

WHO International Collaborative Studies II (14) and

other studies carried out in different countries (55).

Meanwhile, regular oral hygiene practices are less

frequent in middle- and low-income countries but

are linked to social status indicators (5, 44). In certain

cultures, the tradition of oral hygiene is weak or

mouth cleaning is ritual, for example, the use of

Miswaki, and oral cleaning by the use of fingers and

charcoal or salt is common in some settings (4, 34). It

is worth noting that modern oral hygiene measures,

such as the use of manufactured toothbrushes, are

now being adopted in middle- and low-income

countries; however, the use of affordable fluoridated

toothpaste is still an important challenge.

Knowledge and attitudes in relation to periodontal

disease have been studied in populations of several

countries (55). Most people are aware of the impor-

tance of bacteria and the importance of preventing

periodontal disease by oral hygiene. However, the

relevance of tobacco and diet is seldom emphasized.

In certain settings people may have a rather diffuse

understanding of the prevention of periodontal dis-

ease; for example, the importance of using fluoride is

reported along with relevant answers. In general,

knowledge about the causal factors and the preven-

tion of periodontal disease is lower than for dental

caries (55).

Periodontal health and diabetesmellitus

Of the associations observed between oral health

status and chronic systemic diseases, the link

between severe periodontal disease and diabetes

mellitus is the most consistent (28, 48, 69, 70). It is

widely documented that people with diabetes have a

higher risk of periodontal disease, and periodontal

disease has been considered as the sixth complica-

tion of diabetes (29, 70, 72). Extensive studies have

reported significant associations between diabetes

and the severity of periodontal disease (28, 69, 71).

Taylor (71, 73) concluded, from his literature review

of severe periodontal disease and diabetes mellitus,

that not only was there a greater prevalence of peri-

odontal symptoms in patients with diabetes mellitus

but the progression of periodontal disease was also

more aggressive or rapid.

One epidemiological study has been conducted

among the Pima Indians (51). Significantly poorer

periodontal health was reported in patients with Type

2 diabetes, and the relative risk of periodontal disease

in subjects with diabetes was 2.6 after controlling for

confounding factors such as age and sex. In studies of

subjects with Type 2 diabetes, the odds of destructive

loss of attachment were about three times higher

than among nondiabetic subjects (8, 20).

32

Petersen & Ogawa

HIV ⁄ AIDS and periodontal health

The HIV ⁄ AIDS pandemic has become a human, so-

cial and economic disaster, with far-reaching impli-

cations for individuals, communities and countries

(Fig. 10). No other disease has so dramatically high-

lighted the current disparities and inequities in

healthcare access, economic opportunity and the

protection of basic human rights. Sub-Saharan Africa

has been most severely affected, with an estimated

22.5 million people living with HIV (78). In South-

East Asia there are more than 4 million people in-

fected, and further spread could lead to millions

more becoming infected in the coming decade. The

epidemic in Latin America is well established with

nearly 2 million people infected, and rapid growth

has been observed in recent years in Eastern Europe

and central Asia. Globally, the major mode of HIV

transmission is through sexual intercourse, injecting

drug use, mother-to-child transmission and through

contaminated blood in healthcare settings. The rela-

tive importance of the different modes of transmis-

sion varies between and within regions of the world.

A number of studies have demonstrated the nega-

tive impact on oral health of HIV infection (16).

Because of the compromised immune system and a

poor oral hygiene status, infected people are vulner-

able to periodontal disease. In addition to severe

chronic gingivitis, poor periodontal health may

manifest as acute necrotizing gingivitis, which is of-

ten seen in children and adolescents, and as necro-

tizing periodontitis, which is mostly seen among

adults (16). In particular, such disease conditions are

observed in Sub-Saharan Africa and in remote areas

of South-East Asia where people have little access to

oral health care, including periodontal care.

Noma (debilitating oro-facial gangrene) is an

important disease burden in certain developing

countries, particularly among young children in

Africa and Asia (21–25). Severe acute periodontal

disease manifests at the onset of noma. Noma pri-

marily starts as a localized gingival ulceration and

spreads rapidly through the oro-facial tissues,

establishing itself with a blackened necrotic centre.

About 70–90% of cases are fatal in the absence of

care. Fresh noma is seen predominantly in the 1–

4 years age-group, although late stages of the dis-

ease occur in adolescents and adults. Poverty is the

key risk condition for development of noma; the

environment inducing noma is characterized by

severe malnutition and growth retardation, unsafe

drinking water, deplorable sanitary practices, resi-

dential proximity to unkempt animals and a high

prevalence of infectious diseases, such as measles,

malaria, diarrhea, pneumonia, tuberculosis and

HIV ⁄ AIDS.

Periodontal problems amongpeople with disabilities

The oral health of people who are physically or

mentally disabled is often impaired (6, 68). They may

have limited capacity to detect and recognize early

symptoms of disease. They may have limited ability

to cope with everyday tasks related to personal hy-

giene, including oral hygiene, which are critical to

the maintenance of an independent existence. Oral

Western &Central Europe820 000

[720 000 910 000]

Eastern Europe& Central Asia1.4 million

[1 3 million – 1 6 million][720 000 – 910 000] [1.3 million 1.6 million]North America1.5 million

[1.2 million – 2.0 million] East Asia770 000

[560 000 – 1.0 million]Middle East & North Africa

460 000[400 000 – 530 000]

South & South-East Asia4.1 million

[3 7 million – 4 6 million]

Caribbean240 000

[220 000 – 270 000]

Sub-Saharan Africa22.5 million

[20.9 million – 24.2 million]

[3.7 million 4.6 million]

Oceania57 000

[50 000 – 64 000]

Central &South America1.4 million

[1.2 million – 1.6 million][50 000 – 64 000]

Total: 33.3 million [31.4 million – 35.3 million]

Fig. 10. Global estimates of adults

and children living with HIV/AIDS,

2009 (78), UNAIDS, 2010.

33


disease – including periodontal problems – is often

given low priority, especially among disadvantaged

people and people with disabilities in developing

countries. Several studies reported that such popu-

lation groups have higher levels of periodontal

problems and that they are more likely to experience

oral pain and discomfort (9, 15, 40, 77).

Oral health systems

The availability of oral health manpower varies

greatly across countries, which has a bearing on the

delivery of oral health care. For example, in several

developing countries of Africa, the dentist to popu-

lation ratio is 1:150,000 or more, in contrast to 1:2,000

in industrialized countries. In low- and middle-in-

come countries, the shortage of dentists is critical

and service is primarily confined to tackling pain or

discomfort through radical care, such as tooth

extraction. Periodontal care is highly neglected in

these countries. Meanwhile, most high-income

countries have private systems for oral health care;

third-party payment systems involving private health

insurance or public reimbursement schemes are of-

ten implicated, whereas in some countries oral health

services are based on high public or government

participation. The Second WHO International Col-

laborative Study (14) was undertaken to measure the

health outcome of oral health systems. In order to

include different oral health systems, the study

comprised selected countries: France, Germany, Ja-

pan, Latvia, New Zealand, Poland and the USA.

Periodontal health data were collected in standard

population groups by use of the original CPI index.

The international comparative data demonstrated in

general that the periodontal health status of people

was not related to the use of oral health systems

available. Meanwhile, it is worth noting that the lack

of such an association could be related to limitations

of the recording system used.

The need for public healthintervention: global perspectives

Periodontal disease and its ultimate consequence –

tooth loss – are important public health problems in

countries around the globe. The intention of the

present report was to outline the global pattern of

periodontal disease based on WHO epidemiological

data and to highlight key risk factors. The health

impact of periodontal disease on individuals and

communities is considerable as a result of pain and

suffering, impairment of function and reduced quality

of life. The greatest burden of periodontal disease is on

the disadvantaged and poor populations, and the so-

cial inequality exists not only within countries but

between countries around the world. The current

pattern of periodontal disease reflects distinct risk

profiles related to living conditions, environmental

and behavioral factors and oral health systems, and the

implementation of preventive oral-health schemes.

Social determinants

Causal factors involved in chronic diseases are

specified in Fig. 11 (85); the underlying socioeco-

nomic, cultural, political and environmental deter-

minants are important. To reduce the burden of

periodontal disease and the pronounced inequities in

periodontal health, action is needed to address the

underlying social determinants of health. It is vital to

tackle root causes rather than symptoms, focusing on

structural upstream factors that cause poor health

and create inequalities. Thus, policies and legislation

for periodontal health must focus on social circum-

stances such as income, educational attainment,

employment and housing. Conversely, measures that

focus on downstream factors only, such as lifestyle

and behavioral influences, have limited success in

reducing the health gap between rich and poor

populations (43, 80).

Causes of chronic diseases

UnderlyingSocioeconomic,Cultural, Politicaland EnvironmentalDeterminants

Common ModifiableRisk Factors

Globalization

Unhealthy dietPhysical inactivity

Raised blood pressureRaised blood glucose

Heart diseaseStroke

Diabetes

CancerChronic respiratory diseases

Abnormal blood lipidsOverweight/obesity

Tobacco use

AgeHeredity

UrbanizationPopulation ageing

NonmodifiableRisk Factors

Intermediate RiskFactors

Main ChronicDiseases

Fig. 11. The chain of causal factors

and mechanisms in chronic disease

(85).

34

Petersen & Ogawa

Lifestyles

Several chronic and oral diseases and conditions

have common risk factors related to tobacco use,

excessive consumption of alcohol, unhealthy diet and

personal hygiene (Fig. 12) (54). The fact that these

factors are modifiable provides several unique

opportunities in population-oriented periodontal

disease prevention. National public health programs

focusing on risk factor modification must incorporate

concerns for oral health, including periodontal

health. Periodontal disease is highly prevalent in

most countries of the world. The trend of reduction in

tobacco use in several high-income countries may

help to prevent periodontal disease and tooth loss. In

contrast, unless effective tobacco-prevention pro-

grams are established in middle- and low-income

countries, severe periodontal disease and tooth loss

may increase dramatically and this development may

subsequently lead to loss of quality of life. Thus, the

implementation of the WHO Framework Convention

for Tobacco Control (87) may contribute greatly to

the achievement of periodontal health.

An important strategy for preventing periodontal

disease is the establishment of tobacco-intervention

programs, which incorporates concerns for oral

health. Wherever oral health professionals are avail-

able, it is the responsibility of the profession to

initiate or maintain efficient tobacco-prevention

programs. In addition, periodontal health concerns

are essential to integrate when diet and alcohol

interventions are organized. Consumption of a bal-

anced diet is essential to ensure a good nutritional

status and development and maintenance of an

optimal immune system; at present the challenges in

diet are particularly high in community settings of

low-income countries. On the other hand, reducing

the consumption of alcohol as a risk factor of chronic

disease is a particular challenge in high-income

countries; control of excessive consumption of alco-

hol may have a positive contribution to periodontal

health.

General health – periodontal health

The rapidly growing incidence of people who are

overweight, obese and with diabetes in several

countries may have a harmful impact on the peri-

odontal health of the population. This is particularly

the case in the regions of Africa and Asia where

growth rates of diabetes are very high. National

public health programs for the prevention of diabetes

must incorporate concerns to periodontal health; in

particular, the need is high for such an intervention

in low- and middle-income countries where people

have limited access to oral health services.

People with HIV ⁄ AIDS suffer from specific oral

lesions; neglect of proper oral hygiene coupled with

HIV infection has a negative effect on periodontal

health. In addition, pain and restriction in oral

functioning may lead to poor dietary habits and poor

nutritional status. Prevention of periodontal disease

is essential in the prevention of HIV ⁄ AIDS. Activities

may also include screening, early detection of oral

lesions and referral for special care. This may require

the systematic training of oral health personnel or

primary health workers if oral health staff are not

available.

The key risk factors in noma are severe poverty,

malnutrition, unsafe drinking water, deplorable san-

itary practices and infectious diseases (e.g. measles,

malaria and HIV ⁄ AIDS). Fighting poverty, improving

education and economic growth, and working to-

wards providing a healthy environment are impor-

tant elements for preventing noma; not only the

prevention of periodontal manifestations but also

other symptoms of noma will benefit from commu-

nity development in the countries affected, particu-

larly in Africa and Asia.

Self-care: oral hygiene

National public health authorities have a significant

role to play in improving the personal hygiene of

people, including oral hygiene. The authorities must

ensure that people are aware of the importance of

good oral health and that oral health-related knowl-

edge and attitudes are supportive of health behavior.

Communication on the benefits of oral health and on

proper oral hygiene techniques may need to be de-

livered by several types of media and channels in

TobaccoCancer, including oro-pharyngeal

Respiratory diseases

Cardiovascular disease

Obesity

Diabetes

Oral disease

Diet

Stress

Hygiene

Alcohol

Fig. 12. Common risk factors for chronic disease,

including oral disease (54, 85).

35


order to reach the whole population because the

effectiveness of different types of communication

media vary depending on the socio-cultural condi-

tions within countries. In high-income countries,

written communication or e-learning will be useful,

whereas television and radio are considered powerful

in middle- and low-income countries. In many low-

income countries, significant proportions of people

are illiterate and this may complicate their under-

standing of the messages delivered. Therefore, health

messages for oral hygiene will also show country-

specific variation. Manufactured toothbrushes for

oral cleaning are readily available in high-income

countries; in some middle-income countries manu-

factured toothbrushes might be produced locally but

they are often of low quality; whereas in low-income

countries toothbrushes are less available or accessi-

ble to people living in poverty. In low- and middle-

income countries proper sanitary facilities and clean

water are also important issues, and the public health

authorities play a vital role in ensuring the appro-

priate infrastructure for oral hygiene.

Oral health systems

In high-income countries, the burden of oral disease

has been tackled through the establishment of ad-

vanced oral health systems, which primarily offer

curative services to patients. Most systems are based

on care provided by private dental practitioners,

while organized public oral health systems are in

place in a few high-income countries. Some countries

have third-party payment systems, which share pa-

tient costs in dental care. In general, such reim-

bursement schemes focus on restorative dental care

and in some cases on removable dentures, while

periodontal care has low priority. Traditional clinical

treatment of periodontal disease by private dental

practitioners is extremely costly to patients and there

is an urgent need for adjustment of reimbursement

schemes in favor of periodontal care. The cost burden

is particularly high among underprivileged patients

and older people. It is worth noting that private sys-

tems do not encompass the whole population be-

cause accessibility to services is relatively low among

disadvantaged groups. In the case of periodontal

care, poor people are mostly underserved; thus, it is

emphasized that financially fair healthcare interven-

tion must be introduced in order to tackle the pro-

found social inequality in periodontal care.

In contrast to high-income countries, low- and

middle-income countries have a critical shortage of

dentists and other oral health personnel. Investment

in oral health – including periodontal health – is low,

or even neglected by public health authorities. The

situation often reflects a lack of national policy for

oral health, and the limited resources available are

primarily allocated to emergency oral care and pain

relief. Thus, in low-resource communities, advanced

clinical periodontal care is not realistic in the context

of public health and therefore low-cost intervention

and integrated disease prevention must be strength-

ened. Capacity building of oral health systems,

including the formulation of oral health policies,

legislation, relevant action plans, organization of

financially fair primary oral health services and pro-

vision of oral health personnel or primary health

workers appropriately trained in periodontal care and

health promotion, are important challenges for low-

and middle-income countries.

The Ottawa Health Promotion Charter (1986) (82)

emphasized the high need for orientation of health

services towards health promotion and disease pre-

vention, and it is still recommended for public health

authorities to implement such an appropriate or-

ientation of oral health services. The WHO World

Health Report 2008 (92) has underlined the signifi-

cance of outreach primary health care. Across the

world, building capacity for primary oral health care

must include mechanisms for outreach care to the

poor and disadvantaged population groups and facil-

itate the delivery of preventive periodontal care and

community-oriented health promotion. In all coun-

tries, systematic training in periodontal care is

important and should be a priority element in under-

graduate and continuing education programs for oral

health personnel. In areas �where there is no dentist�,specially trained primary health workers can play a

vital role to cover the underserved population groups.

Surveillance, evaluation and research

Surveillance underpins public health action by linking

data with health policies and programs (58). Surveil-

lance provides ongoing (continuous or periodic) col-

lection, analysis and interpretation of population

health data, and the timely dissemination of such data

to users. Properly conducted surveillance ensures that

countries have the information they need to control

disease now or to plan strategies to prevent disease

and adverse health events in the future. The goal is to

assist governments, health authorities and health

professionals to formulate policies and programs to

prevent disease and to measure the progress, impact

and efficacy of efforts to control diseases that are al-

ready affecting their populations.

36

Petersen & Ogawa

It is unfortunate that only a few countries have

conducted time-series studies on periodontal health;

this is primarily because large-scale oral epidemio-

logical surveys are expensive and time-consuming.

Nevertheless, such epidemiological data may help to

plan action programs for the control of periodontal

disease and for the sharing of information, on the

evidence of community programs, for periodontal

disease prevention and for health promotion. The

original CPI index has some limitations for use in

program evaluation and health systems research but

it is a hope that the new modified CPI system may be

helpful in this task. The WHO has developed

surveillance procedures for risk factors to chronic

disease. The system incorporates self-reported

information on risk factors for periodontal disease,

including measurements of socioeconomic status,

oral hygiene, dental attendance, use of tobacco,

consumption of alcohol, dietary habits and nutri-

tional status, diabetes and dentate status.

Role of the WHO in promotion oforal health globally

Progress towards a healthier world requires strong

political action, broad participation and sustained

advocacy. The WHO Global Oral Health Programme

has worked hard over the years to put oral health high

on the health agenda of policy and decision makers

worldwide. Promotion of periodontal health globally

is given a high priority. In 2007, the World Health

Assembly agreed on a Resolution (WHA.60.17), which

reads: �Oral health: action plan for promotion and

integrated disease prevention� (56, 57). This statement

is a wide-ranging policy that provides direction

towards achieving better oral health of people in the

193 Member States. The WHO statement is an impetus

for countries to develop or adjust national oral health

programs, including periodontal health and the

related risk factors. The action plan for oral health

promotion and integrated disease prevention includes

recommendations on public health, implementation

of community-based programs for integrated pre-

vention of disease, health promotion and evaluation

of such programs through health systems research.

The WHO contributes to raising the awareness of

the global challenges to periodontal health, and the

specific and unique needs of low-income and mid-

dle-income countries and of poor and disadvantaged

population groups; in addition, the WHO provides

advice and technical support to countries for the

development and implementation of periodontal

health programs within integrated approaches to

surveillance, monitoring and the prevention and

management of chronic noncommunicable diseases.

References

1. Akhter R, Hassan NM, Aida J, Takinami S, Morita M.

Relationship between betel quid additives and established

periodontitis among Bangladeshi subjects. J Clin Period-

ontol 2008: 35: 9–15.

2. Albandar JM, Tinoco EMB. Global epidemiology of peri-

odontal diseases in children and young persons. Period-

ontol 2000 2002: 29: 153–176.

3. Albertsson KW, van Dijken JW. Awareness of toothbrushing

and dentifrice habits in regularly dental care receiving

adults. Swed Dent J 2010: 34: 71–78.

4. Al-Khateeb TL, Farsi JM, O�Mullane DM. Relationship be-

tween attitudes, behaviour and levels of dental caries

among 15-year-old Saudi Arabian and Irish children. J Ir

Dent Assoc 1990: 36: 56–59.

5. Amin TT, Al-Abad BM. Oral hygiene practices, dental

knowledge, dietary habits and their relation to caries

among male primary school children in Al Hassa, Saudi

Arabia. Int J Dent Hyg 2008: 6: 361–370.

6. Angelillo IF, Nobile CG, Pavia M, De Fazio P, Puca M,

Amati A. Dental health and treatment needs in institu-

tionalized psychiatric patients in Italy. Community Dent

Oral Epidemiol 1995: 23: 360–364.

7. Beck JD, Koch GG, Rozier RG, Tudor GE. Prevalence

and risk indicators for periodontal attachment loss in a

population of older community-dwelling blacks and

whites. J Periodontol 1990: 61: 521–528.

8. Borges-Yanez SA, Irigoyen-camacho ME, Maupome G. Risk

factors and prevalence of periodontitis in community-

dwelling elders in Mexico. J Clin Periodontol 2006: 33: 184–

194.

9. Borrell LN, Beck JD, Heiss G. Socioeconomic disadvantage

and periodontal disease: the Dental Atherosclerosis Risk in

Communities study. Am J Public Health 2006: 96: 332–339.

10. Borrell LN, Burt BA, Gillespie BW, Lynch J, Neighbors H.

Periodontitis in the United States: beyond black and white.

J Public Health Dent 2002: 62: 92–101.

11. Borrell LN, Burt BA, Neighbors HW, Taylor GW. Social

factors and periodontitis in an older population. Am J

Public Health 2004: 94: 748–754.

12. Bratthall D, Petersen PE, Stjernsward JR, Brown J. Oral and

craniofacial diseases and disorders (chapter 38). In: Jami-

son DT, Breman JG, Measham AR, Alleyne G, Claeson M,

Evans DB, Jha P, Mills A, Musgrove P, editors. Disease

control priorities in developing countries. New York: World

Bank Health and Oxford University Press, 2006: 723–736.

13. Calsina G, Ramon JM, Echeverrıa JJ. Effects of smoking on

periodontal tissues. J Clin Periodontol 2002: 29: 771–776.

14. Chen M, Anderson RM, Barmes DE, Leclercq M-H, Lyttle

CS. Comparing oral health care systems a second interna-

tional collaborative study. Geneva: World Health Organi-

zation, 1997.

15. Clarke M, Locker D, Murray H, Payne B. The oral health of

disadvantaged adolescents in North York, Ontario. Can J

Public Health 1996: 87: 261–263.

37


16. Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in

infection with human immunodeficiency virus. Bull World

Health Organ 2005: 83: 700–706.

17. Croucher R, Marcenes W, Torress M, Hughes F, Sheiham A.

The relationship between life events and periodontitis. A

case control study. J Clin Periodontol 1997: 24: 39–43.

18. Detels R, McEwen J, Beaglehole R, Tanaka H. Oxford text-

book of public health, 4th edn. Oxford: Oxford University

Press, 2004.

19. Drury TF, Garcia I, Adesanya M. Socioeconomic disparities

in adult oral health in the United States. Ann NY Acad Sci

1999: 896: 322–324.

20. Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in

non-insulin dependent diabetes mellitus. J Periodontol

1991: 62: 123–130.

21. Enwonwu CO. Epidemiological and biochemical studies of

necrotizing ulcerative gingivitis and noma (cancrum oris)

in Nigerian children. Arch Oral Biol 1972: 17: 1357–1371.

22. Enwonwu CO. Noma: a neglected scourge of children in

sub Saharan Africa. Bull World Health Org 1995: 73: 541.

23. Enwonwu CO, Edozien JC. Epidemiology of periodontal

disease in Western Nigerians in relation to socioeconomic

status. Arch Oral Biol 1970: 15: 1231–1244.

24. Enwonwu CO, Falkler WA, Idigbe EO, Afolabi MB, Ibrahim

M, Onwujekwe D, Savage KO, Meeks V. Pathogenesis of

oro-facial gangrene (noma): confounding interations of

malnutrition and infection. Am J Trop Med Hyg 1999: 60:

223–232.

25. Enwonwu CO, Phillips RS, Ibrahim CD, Danfillo IS. Nutri-

tion and oral health in Africa. Int Dent J 2004: 54: 344–351.

26. Gelskey S. Cigarette smoking and periodontitis: methodol-

ogy to assess the strength of evidence in support of causa-

tion. Community Dent Oral Epidemiol 1999: 27: 16–24.

27. Genco RJ, Ho AW, Grossi SG, Dunford RG, Tedesco LA.

Relationship of stress, distress, and inadequate coping

behaviours to periodontal disease. J Periodontol 1999: 70:

711–723.

28. Grossi SG, Genco RJ. Periodontal disease and diabetes mell-

itus: a two-way relationship. Ann Periodontol 1998: 3: 51–61.

29. Grossi SG, Skrepcinski FB, DeCaro T, Zambon JJ, Cummins

D, Genco RJ. Response to periodontal therapy in diabetics

and smokers. J Periodontol 1996: 67(Suppl): 1094–1102.

30. Hescot P, Bourgeois D, Berger P. La situation en France

pour la periode 1993–1995. Londres: FDI World Dental

Press, 1996.

31. Hong-Ying W, Petersen PE, Jin-You B, Bo-Xue Z. The sec-

ond national survey of oral health status of children and

adults in China. Int Dent J 2002: 52: 283–290.

32. IDF. Diabetes atlas, 4th edn. Brussels: International Dia-

betes Federation, 2009.

33. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson

M, Evans DB, Jha P, Mills A, Musgrove P, editors. Disease

control priorities in developing countries. New York: World

Bank Health and Oxford University Press, 2006.

34. Jordan RA, Lucaciu A, Fotouhi K, Markovic L, Gaengler P,

Zimmer S. Pilot pathfinder survey of oral hygiene and

periodontal conditions in the rural population of The

Gambia (West Africa). Int J Dent Hyg 2011: 9: 53–59.

35. Jurgensen N, Petersen PE. Oral health and the impact of

socio-behavioural factors in a cross sectional survey of 12-

year old school children in Laos. BMC Oral Health 2009: 29:

1–11.

36. Kandelman D, Petersen PE, Ueda H. Oral health, general

health, and quality of life in older people. Spec Care Dentist

2008: 28: 224–236.

37. Kaufman FR. Type 2 diabetes mellitus in children and

youth: a new epidemic. J Pediatr Endocrinol Metab 2002:

15: 737–744.

38. Kibayashi M, Tanaka M, Nishida N, Kuboniwa M, Kataoka

K, Nagata H, Nakayama K, Morimoto K, Shizukuishi S.

Longitudinal study of the association between smoking as

a periodontitis risk and salivary biomarkers related to

periodontitis. J Periodontol 2007: 78: 859–867.

39. Kingman K, Albandar JM. Methodological aspects of epi-

demiological studies of periodontal diseases. Periodontol

2000 2002: 29: 11–30.

40. KrugerE,JacobsA,TennantM.Sustainingoralhealthservices

in remote and indigenous communities: a review of 10 years

experience in Western Australia. Int Dent J 2010: 60: 129–134.

41. Krustrup U, Petersen PE. Periodontal conditions in 35–44

and 65–74-year-old adults in Denmark. Acta Odontol Scand

2006: 64: 65–73.

42. Kune S. Stressful life events and cancer. Epidemiology 1993:

4: 395–396.

43. Kwan S, Petersen PE. Oral health: equity and social deter-

minants. In: Blas E, Sivasankara Kurup A, editors. Equity,

social determinants and public health programmes.

Geneva: WHO, 2010: 159–176.

44. LinHC,SchwarzE.Oralhealthanddentalcareinmodern-day

China. Community Dent Oral Epidemiol 2001: 29: 319–328.

45. Lindhe J, Lang NP, Karring T. Clinical periodontology and

implant dentistry, 5th edn. Oxford: Wiley-Blackwell, 2008.

46. Ling LJ, Hung SL, Tseng SC, Chen YT, Chi LY, Wu KM, Lai

YL. Association between betel quid chewing, periodontal

status and periodontal pathogens. Oral Microbiol Immunol

2001: 16: 364–369.

47. Marmot M, Wilkinson R. Social determinants of health.

Oxford: Oxford University Press, 1999.

48. Mealey BL, Oates TW; American Academy of Periodontol-

ogy. Diabetes mellitus and periodontal diseases. J Period-

ontol 2006: 77: 1289–1303.

49. Meneilly GS, Tessier D. Diabetes in the elderly adults.

J Gerontol A Biol Sci Med Sci 2001: 56: 5–13.

50. Moynihan P, Petersen PE. Diet, nutrition and the preven-

tion of dental diseases. Public Health Nutr 2004: 7: 201–226.

51. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad

MF, Genco RJ, Knowler WC. Periodontal disease and non-

insulin-dependent diabetes mellitus in Pima Indians.

Diabetes Care 1990: 13: 836–840.

52. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M,

Genco RJ. Dietary vitamin C and the risk for periodontal

disease. J Periodontol 2000: 71: 1215–1223.

53. Papapanou PN. Epidemiology of periodontal diseases: an

update. J Int Acad Periodontol 1999: 4: 110–116.

54. Petersen PE. The World Oral Health Report 2003: contin-

uous improvement of oral health in the 21st century – the

approach of the WHO Global Oral Health Programme.

Community Dent Oral Epidemiol 2003: 31(Suppl. 1): 3–23.

55. Petersen PE. Inequalities in oral health: the social context

for oral health. In: Pine C, Harris R, editors. Community

dent health. London: Quintessence, 2007: 31–58.

56. Petersen PE. World Health Organization global policy for

improvement of oral health – World Health Assembly 2007.

Int Dent J 2008: 58: 115–121.

38

Petersen & Ogawa

57. Petersen PE. Global policy for improvement of oral health

in the 21st century – implications to oral health research of

World Health Assembly 2007, World Health Organization.

Community Dent Oral Epidemiol 2009: 37: 1–8.

58. Petersen PE, Bourgeois D, Bratthall D, Ogawa H. Oral

health information systems – towards measuring progress

in oral health promotion and disease prevention. Bull

World Health Organ 2005: 83: 686–693.

59. Petersen PE, Kaka M. Oral health status of children and

adults in the Republic of Niger, Africa. Int Dent J 1999: 49:

159–164.

60. Petersen PE, Kandelman D, Arpin S, Ogawa H. Global oral

health of older people – call for public health action.

Community Dent Health 2010: 27(Suppl. 2): 257–268.

61. Petersen PE, Nyandindi U, Kikiwilu EN, Mabelya L, Lem-

bariti BS, Poulsen VJ. Oral health status and oral health

behaviour of school children, teachers and adults in Tan-

zania (Technical report). Geneva: World Health Organiza-

tion, 2002.

62. Petersen PE, Razanamihaja N. Oral health status of chil-

dren and adults in Madagascar. Int Dent J 1996: 46: 41–47.

63. Petersen PE, Ueda H. Oral health in ageing societies: inte-

gration of oral health and general health. Report of a

meeting convened at the WHO Centre for Health Devel-

opment in Kobe, Japan, 1–3 June 2005. Geneva: World

Health Organization, 2006.

64. Pilot T. The periodontal disease problem. A comparison

between industrialised and developing countries. Int Dent J

1998: 48(Suppl. 1): 221–232.

65. Pitiphat W, Merchant AT, Rimm EB, Joshipura KJ. Alcohol

consumption increases periodontal risk. J Dent Res 2003:

82: 509–513.

66. Salvi G, Lawrence H, Offenbacher S, Beck J. Influence of

risk factors on the pathogenesis of periodontitis. Period-

ontol 2000 1997: 14: 173–201.

67. Sandberg GE, Sundberg HE, Wikblad KF. A controlled study

of oral self-care and self-perceived oral health in type two

diabetic patients. Acta Odontol Scand 2001: 59: 28–33.

68. Simon EN, Matee MI, Scheutz F. Oral health status of

handicapped primary school pupils in Dar es Salaam,

Tanzania. East Afr Med J 2008: 85: 113–117.

69. Soskolne WA, Klinger A. The relationship between peri-

odontal diseases and diabetes: an overview. Ann Period-

ontol 2001: 6: 91–98.

70. Taylor GW. Bidirectional interrelationships between dia-

betes and periodontal diseases: an epidemiological per-

spective. Ann Periodontol 2001: 6: 99–112.

71. Taylor GW, Borgnakke WS. Periodontal disease: associa-

tions with diabetes, glycemic control and complications.

Oral Dis 2008: 14: 191–203.

72. Taylor GW, Burt BA, Becker MP, Genco RJ, Shiossman M.

Glycemic control and alveolar bone loss progression in

type 2 diabetics. Ann Periodontol 1998: 3: 30–39.

73. Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M,

Knowler WC, Pettitt DJ. Severe periodontitis and risk for

poor glycemic control in subjects with non-insulin-

dependent diabetes mellitus. J Periodontol 1996: 67(Suppl):

1085–1093.

74. Tezal M, Grossi SG, Ho AW, Genco RJ. The effect of alcohol

consumption on periodontal disease. J Periodontol 2001:

72: 183–189.

75. Tomar SL, Asma S. Smoking-attributable periodontitis in

the United States: findings from NHANES III. National

health and nutrition examination survey. J Periodontol

2000: 71: 743–751.

76. Tseveenjav B, Suominen AL, Hausen H, Vehkalahti

MM. The role of sugar, xylitol, toothbrushing fre-

quency, and use of fluoride toothpaste in maintenance

of adults� dental health: findings from the Finnish

National Health 2000 Survey. Eur J Oral Sci 2011: 119:

40–47.

77. Uetani M, Jimba M, Kaku T, Ota K, Wakai S. Oral health status

of vulnerable groups in a village of the Central Highlands,

southern Vietnam. Int J Dent Hyg 2006: 4: 72–76.

78. United Nations Programme on HIV ⁄ AIDS (UNAIDS).

Global report: UNAIDS report on the global AIDS epidemic

2010. Geneva: UNAIDS, 2010.

79. Varenne B, Petersen PE, Ouattara S. Oral health status of

children and adults in urban and rural areas of Burkina

Faso, Africa. Int Dent J 2004: 54: 83–89.

80. Watt RG. From victim blaming to upstream action: tackling

the social determinants of oral health inequalities. Com-

munity Dent Oral Epidemiol 2007: 35: 1–11.

81. World Bank. List of economics. New York: World Bank, 2010.

82. World Health Organization. Ottawa charter for health

promotion: first international conference on health pro-

motion. Geneva: World Health Organization, 1986.

83. World Health Organization. Oral health surveys basic

methods, 3rd edn. Geneva: World Health Organization, 1987.

84. World Health Organization. Oral health surveys basic meth-

ods, 4th edn. Geneva: World Health Organization, 1997.

85. World Health Organization. The world health report 2002.

Reducing risks, promoting healthy life. Geneva: World


86. World Health Organization. Diet, nutrition and the pre-

vention of chronic diseases. Geneva: WHO. WHO Technical

Report Series No. 916, 2003.

87. World Health Organization. Framework convention on to-

bacco control. Geneva: World Health Organization, 2003.

World Health Assembly, May 2003 (Resolution WHA56.1).

88. World Health Organization. World health survey (WHS).

Geneva: World Health Organization, 2006. Available at:

(http://www.who.int/healthinfo/survey/en/index.html).

89. World Health Organization. The WHO global oral health

data bank. Geneva: World Health Organization, 2007.

Available at: (http://www.who.int/oral_health).

90. World Health Organization. World health statistics 2007.

Geneva: World Health Organization, 2007.

91. World Health Organization. The WHO global health atlas.


92. World Health Organization. The world health report 2008.

Primary health care (Now More Than Ever). Geneva: World


93. World Health Organization. World health statistics 2009.


94. World Health Organization. Oral health surveys-basic

methods, 5th edn. Geneva: World Health Organization,

2011 (in press).

95. World Health Organization. World health statitics 2011.

Geneva: World Health Organization, 2011. (in press).

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