Periodontology 2000, Vol.
29, 2002, 70–78 Copyright C Blackwell Munksgaard 2002
Printed in Denmark. All rights reserved
Periodontal diseases in Central
and South America
P G, C K. R, C S &
R O
Epidemiology is primarily concerned with the preva-
lence of diseases, and the determinants of health and
disease in populations. However, the prevalence of
periodontal diseases is very high in most populations
and pure descriptions of the prevalence, including
mild and reversible forms like gingivitis (prevalence
100%), would be of little or no value. Moreover, there
are indications that gingivitis should not be regarded
as belonging to the same entity of diseases as destruc-
tive forms of periodontitis (47, 53). Therefore, peri-
odontal epidemiology will, in addition to prevalence,
usually also be concerned with various entities of dis-
ease, as well as expressions of severity.
An inherent problem in periodontal epidemiology
is the lack of clear-cut criteria for disease and health,
which again is due to the difficulty in diagnosing
periodontitis as a disease. Current methods are, at
best, able to assess the disease status as a condition
caused by a distant or recent historic process (29).
The problem is dealt with by describing various
characteristics which either reflect the degree of in-
flammation (bleeding on probing), accumulated dis-
ease experience (clinical loss of attachment, radio-
graphic bone loss) or both (pocket depths). The pic-
ture is even more complicated if the extent of the
disease (number of quadrants, sextants, teeth or
sites involved) in each individual is also considered.
Furthermore, it is always difficult to assess how
much teeth that have already been lost have contrib-
uted to the condition at the time of a survey. Thus,
a finding of good periodontal condition in a popula-
tion may sometimes be the result of extensive tooth
loss. These and other methodological problems
faced in periodontal epidemiology have been re-
viewed by Papapanou (48) & Baelum (7).
Based on the above-mentioned options for de-
scribing the periodontal status of individuals, several
indices for measuring both extent and severity have
70
PERIODONTOLOGY 2000
ISSN 0906-6713
been used in epidemiological research in the field.
Also, different studies have used different examiners,
thus adding to the difficulties involved in comparing
or aggregating results from various studies to de-
scribe the disease status in larger regions. Further-
more, representative national studies are almost
nonexistent in Central and South America. An over-
view of CPITN data in The World Health Organiza-
tion (WHO) Global Oral Data Bank for adolescents of
15–19 years of age, comprising 39 countries, included
Jamaica only, from this region and may serve as an
illustration of this (49). Most other studies have been
performed on representative samples of defined
subpopulations or in various convenience samples
with unknown representativity.
Recordings of clinical attachment level and/or as-
sessment of bone level on roentgenograms are re-
garded as the most valid expressions of periodontal
status. However, very few representative epidemio-
logical studies in Latin America have employed these
criteria. The most common description used is the
Community Periodontal Index for Treatment Needs
(CPITN) (2), which is the method recommended by
WHO for population screening purposes (58). This
index has been criticized for not describing the peri-
odontal status accurately (6, 29, 33, 48), and for the
inherent hierarchy of the index not being valid for all
populations, particularly regarding the relationship
between gingivitis and calculus (24, 31). However,
disregarding studies based on CPITN would have
made it impossible to conduct a review. In addition,
we will argue that these indices will suffice for the
present review, with its limited interpretation of
data, and can contribute to rough estimates of
prevalence of affected individuals.
In addition to the difficulties in describing a dis-
ease like periodontitis, the rather complicated geo-
graphic and demographic situation in Central and

South America complicates the interpretation of
existing data, on a regional basis. Thus, throwing
some light on the geographic/demographical con-
ditions in this region, especially where they relate to
health indicators, seems appropriate. Various
sources on the Internet were searched for these pur-
poses.
The distribution of people and the economical
conditions differ between the countries in the re-
gion. For example, Argentina, Brazil, Chile and Mex-
ico cover 70% of Latin America (all countries south
of the USA, including Cuba and the Caribbean Is-
lands) in terms of territory. The demographical dis-
tribution parallels this, as more than 60% of the total
population of approximately 506,000,000 Latin
Americans live in these 4 countries. The economic
situation in Latin America is generally not good. Al-
though mean values may be similar to those of the
industrialized/developed countries, the distribution
of wealth is completely uneven, with a very small
proportion of the populations possessing a very
large portion of the wealth. Argentina, Brazil, Chile
and Mexico represent 78% of the Gross National
Product of Latin American countries, having re-
ceived the biggest amount of external help. However,
unemployment has been growing, especially in Ar-
gentina, Brazil, Chile, Colombia and Venezuela (from
7.5 to 20% in 2000).
The health care systems in these countries are not
very well organized, and have to cope with a lot of
changes due to changes in governments, economy,
etc. Databases for health problems are scarce. Long-
standing organized oral health programs are almost
nonexistent. In the year 2000, there were around 49
dentists per 100,000 inhabitants, the population/
dentist ratio ranging from 1:1200 in Argentina to
1:7000 in Grenada (60). These ratios must be con-
sidered in the context of the very uneven population
distribution within the countries and it should be
noted that only relatively small percentages of the
population in these countries have access to dental
care for economical and geographic reasons.
Methods
A systematic review of the published epidemio-
logical studies concerning periodontal conditions in
Central and South America was conducted. The fol-
lowing databases were scrutinized: MEDLINE, LI-
LACS (Latin America and Caribbean Literature in
Health Science) and BBO (Brazilian Library of Den-
Periodontal diseases in Central and South America
tistry). The search keywords, in English, Portuguese
and/or Spanish, were ‘epidemiology’, ‘periodontal
disease’, ‘periodontitis’, ‘gingivitis’ and ‘oral hygiene’.
Additionally, references from the lists of the articles
reviewed were included. The WHO Global Oral Data
Bank (59) was also exploited as a source of infor-
mation. Finally, relevant information on the total
sales of oral hygiene products (toothbrushes, denti-
frice, and dental floss) was collected from the Inter-
net1 in an attempt to throw some light on oral health
behavior.
We were not able to identify any national repre-
sentative studies of periodontal disease in the Latin
American region. Thus, for the purpose of the pres-
ent review paper, we have included only studies
where the samples are representative for identifiable
subgroups of a population, or relatively large, so that
representation in some way may be assumed. Sur-
veys filed in the WHO Global Oral Data Bank were
also used, although their degree of representa-
tiveness is largely unknown.
Studies published before the early 1980s were not
included, as changes in prevalence and severity of
periodontal diseases over time have been reported
from several European countries as well as from
North America (8, 11, 21, 33, 35). It is reasonable to
assume that such changes also happened in the re-
gion of interest. Furthermore, there has been a
change in the methodologies applied to epidemio-
logical studies of periodontal diseases that would
also affect the interpretation of data. This would
make it impossible to compare earlier data with
more recent data in a meaningful way.
Studies limited to certain subsamples of the popu-
lation that could not be extrapolated, due to age
group in the population or other general criteria,
were excluded, e.g. university students. Also, studies
concerning special subpopulations such as pregnant
women, patient groups, etc. were not considered.
Also, due to the scarcity of data from the region, it
seemed logical in this context to include subjects as
either displaying indicators of the disease at moder-
ate or severe levels or with gingivitis only and not to
describe the extent of periodontitis within the den-
tition.
Gingivitis is a reversible condition that is regarded
rather rarely to develop into periodontitis (6, 47), but
the condition may be regarded as a reflection of the
oral hygiene habits of these populations. As the
prevalence of the disease approaches 100% in all
1
Data kindly provided by Unilever – Brazil
71
Gjermo et al.
populations when mild forms are included (16, 17),
we have concentrated on more severe expressions of
the condition and have disregarded gingivitis occur-
ring concomitantly with periodontitis. By simplifying
the results and collapsing the data it is believed that
a better platform for comparisons on a population
level has been established.
The descriptive data for periodontal disease are
mainly presented as figures for periodontitis, as this
is what was most readily available from the studies.
Gingivitis and special forms of periodontitis, as early
onset periodontitis, are reviewed separately.
Within the general criteria for acceptance, i.e. rep-
resentation and size of samples, no studies of longi-
tudinal design could be found for Central and South
America. We also could not detect repeated descrip-
tive studies from the same region in the databases
searched. Thus, developmental trends for periodontal
diseases could not be described directly. However,
data on the sales of oral hygiene remedies have been
used to indicate an anticipated trend. Also, over time
the available manpower within oral care has in-
creased, although similar changes reported in other
parts of the world have not exerted an effect upon the
periodontal status of a population.
As studies employ various ways of describing the
disease indicators, we have chosen to regard subjects
with indications of moderate loss of support in one
or more sites of the mouth (pocket depths 3–5 mm,
clinical loss of attachment or radiographic loss of
bone 1–3 mm) as having moderate periodontal dis-
ease. Those with one or more sites displaying worse
figures were regarded as having severe periodontitis.
This dichotomization of persons with periodontitis
has been used because it may separate those indi-
viduals who run the risk of loosing a substantial
number of teeth due to the disease from those who
probably will not (12, 50).
Since the indicators chosen reflect the accumu-
lated disease experience in a population, there is al-
ways a strong association between periodontitis and
age in epidemiological studies. However, the various
studies have employed different ways of grouping for
age. Therefore, we have collapsed the data for age
and separated only between young individuals
(under the age of 30–35 years), middle aged (from 30-
35 to 50-55 years) and older individuals (above 50–55
years of age). The exact results of the studies have
been slightly adapted to fit the above description.
Both the dichotomization (12, 50) and the age
grouping have recently been used to successfully aid
interpretation in a review of epidemiology of peri-
odontal disease in Europe (28).
72
Descriptive studies
Gingivitis
Two studies comprising 7–14 years olds have been
conducted in Brazil by the same examiner. One
study described gingivitis in 320 high-medium social
class children (16) while the other dealt with 491 in-
dividuals from a low socio-economical area (17). The
prevalence of gingivitis was 98.4% and 100%, respec-
tively, indicating the universality of this condition.
Pure prevalence data would therefore be meaning-
less. Thus, we have tried to focus on the prevalence
of severe forms. In the above mentioned studies, the
severity of gingivitis was expressed by a mean Gingi-
val Index (GI) of 1.24 irrespective of socio-economi-
cal group. Both studies revealed a slightly higher
mean value for GI among boys than among girls,
which was considered not to be of clinical relevance
by the authors. A somewhat smaller study from a pri-
vate school in São Paulo supports these conclusions
(4).
A large study (2279 individuals) has been per-
formed in 8–9 and 12–13 years olds from urban and
rural areas of Argentina (18). By means of the WHO
recommended methodology (58) a prevalence of
15.7% of ‘intense gingivitis’ was observed in this
population. The criteria described are: percent of
children with each one of the parameters (soft de-
posits, calculus and intense gingivitis), as well as the
mean number of involved segments per child for the
same clinical parameters. The prevalence and sever-
ity of gingivitis increased with age. Only 2.7% of the
7-year-old had intense gingivitis, whereas 27.2% of
the 14-year-old had this condition. The mean num-
ber of involved segments also increased from 0.0 to
0.6, respectively, for these 2 ages. The in-between
groups (8–12 years), displayed intense values, which
supports the statement.
Gingivitis was also studied in a random sample
of 700 Mexican schoolchildren aged 11–17 years
(30). The results showed a mean value of the GI
(39) of 1.26, indicating similar prevalence to the
previously described Brazilian studies (16, 17). A
statistically significant difference between boys (1,
30) and girls (1, 20) was reported. This gender
difference is in accordance with results from simi-
lar studies from around the world, but its clinical
significance is questionable.
Maltz et al. (44) assessed oral conditions in stu-
dents (8–10 years old) in Porto Alegre, Brazil, over
time. Although a 70% decline in caries prevalence
over 21 years was reported, virtually no improve-

ment of gingival conditions occurred over the same
period.
The present review confirms the belief that gingi-
vitis is wide spread, with a slight tendency towards
higher prevalence in low socio-economic groups and
slightly more severe in males than in females. This
finding is in accordance with reports from other geo-
graphic regions. There are also indications that the
recorded improvement in caries prevalence in some
parts of Central and South America is not ac-
companied by a similar improvement in the gingival
conditions (44). This may indicate that caries reduc-
tion is not a result of improved oral hygiene.
Adult periodontitis
Descriptive data for periodontitis are compiled in
Table I. Several countries in the area are not repre-
sented in the table as no epidemiological studies
fulfilling the requirements of this review could be
found. From the studies that allowed calculation of
a ‘total prevalence’ of severe disease, a range from 4
to 19% of persons affected was observed. Although
there is reason to believe that the variation may in
part be due to methodological variation among the
studies, real geographic differences may exist. The
study by Pinto et al. (51) comprising a large number
of individuals representative of Brazilian urban areas
display figures comparable to other parts of the
world (9, 29, 36).
Three maps were constructed for three age groups,
based on the available data on the epidemiology of
periodontitis from Central and South American
Countries (Figs 1–3). The white areas represent the
regions where data were not available. For countries
where more than one study was available, the data
were compiled and the percentage of subjects with
severe periodontitis in each age group was esti-
mated. Studies with results that were considered
outliers (West Indies (1), Chile (2) and Jamaica, and/
or used a relatively small sample (Mexico (1) and
Chile (1)) (Table 1) were not included in the maps.
Early onset periodontitis
Gjermo et al. (27) tried to establish the prevalence of
bone loss in a group of Brazilian teenagers. For that
purpose, 304 adolescents from a low socio-economic
area were radiographically examined. The results
showed that 28% of subjects had one or more sites
with bone loss. Among those subjects, 8 displayed a
type and pattern of bone loss consistent with local-
ized juvenile periodontitis.
Periodontal diseases in Central and South America
However, Tinoco et al. (55) described large vari-
ations in the prevalence of localized juvenile peri-
odontitis in various Brazilian cities. Using different
methodology, they performed a two-staged screen-
ing procedure in 7843 Brazilian teenagers from 3 dif-
ferent cities (Belo Horizonte, Rio de Janeiro and Vo-
torantin). The initial screening was performed using
a toothpick to detect possible pockets of 5 mm and
more. One hundred and nineteen persons with such
findings went through a thorough clinical and radio-
graphic examination, resulting in the diagnosis of lo-
calized juvenile periodontitis in 25 subjects, and in-
dicating an overall prevalence of 0.3%. However, the
range of prevalence among cities was 0.1–1.1%. The
screening method was validated in a separate study
and indicated that probably only 1 person from the
initial population of approximately 8,000 had been
misclassified as not having localized juvenile peri-
odontitis (43).
Lopez et al. (42) studied the prevalence of local-
ized juvenile periodontitis in Chile. A random
sample of individuals, 15–19 years old (n Ω 2,500),
was screened for pockets ⬎5 mm which were then
radiographically examined. After examination, a
prevalence of 0.32% was determined.
The true prevalence of an uncommon disease
such as localized juvenile periodontitis is difficult to
ascertain and large Standard Errors of the estimates
have to be taken into account when comparisons be-
tween studies and populations are made.
We found only one study concerning the preva-
lence of acute necrotizing periodontal disease in the
region. In a random sample from Santiago, Chile,
9203 students aged 13–21 years were examined. A
prevalence of ulcerations and/or necrotic areas of
6.7% was reported (40). The criteria used were, how-
ever, not commensurate with the usually accepted
criteria for the diagnoses of acute necrotizing ulcer-
ative gingivitis. This may explain the relatively high
prevalence reported. The findings of this study were
positively correlated with regularity of visits to the
dentist and with diabetes.
Analytical studies
An association between age and destructive peri-
odontal disease, similar to that reported for other
parts of the world, has been shown in Latin America.
Due to the cumulative nature of loss of periodontal
support, this association may reflect the length of
exposure to the etiologic factors. However, there are
73
Gjermo et al.

indications that the rate of periodontal disease pro-
gression may change by age (5), or that natural re-
pair processes in the periodontium are impaired by
increasing age (22). Other biologic explanations of
increased susceptibility by age have also been offer-
ed (10, 14, 34, 45).
Analytical studies performed in Central and South
America predominantly focussed on differences
among social strata of the population. These data are
of great interest as socio-economical disparities in
this region are significant. Although it has been
claimed that periodontal diseases are mainly a result
of an imbalance between the microbial challenge
and the susceptibility of the host, the socio-econ-
omic background does appear to impact upon the
prevalence and severity of periodontitis in a popula-
tion (9, 32, 46).
The largest study included in this review was from
a random sample of more than 10,000 people in Bra-
zil (51). There was a tendency towards higher preva-
lence of severely affected subjects among the socio-
economically less favored for all age groups. In the
middle-aged group (35–44 years old) the prevalence
of subjects with severe disease in the lowest socio-
economic stratum was 5.5% while the corresponding
figure for the highest stratum was 4.5%.
In Chile, a correlation between both socio-econ-
omic status and level of education, and the prevalence
of periodontal disease has been reported (25). In the
middle-aged group of a random sample of the popu-
lation of Santiago, the prevalence of moderate to se-
vere periodontal breakdown (codes 3 and 4 of CPITN)
did not differ significantly in subjects with a low and
middle socio-economic background (99.5% and

Table 1. Percent distribution of dentate subjects with one or more teeth with signs of moderate (m) and severe
(s) periodontal disease according to age and country – data obtained with CPITN
Country Sample Young Young Middle Middle Old Old Total Total Source
size (m) (s) aged (m) aged (s) (m) (s) (m) (s)
Argentina 532 25 6 35 37 34 39 28 19 Gasparini & Buri,
1998 (26)
Brazil 10398 7 1 22 6 N/A 7 N/A 4 Pinto et al., 1986 (51)
Brazil 1854 50 5 56 27 41 51 52 15 Flores de Jacoby et al.,
1991 (23)
Brazil 528 23 3 50 9 49 18 32 6 Dini and
Guimarães, 1994 (20)
Brazil 1633 5 1 Campos Jr et al., 1994
(13)
Brazil 1956 1 0 Dini et al., 1997 (19)
Chile (1) 77 3 0 WHO, 1994 (59)
Chile (2) 120 34 37 WHO, 1994 (59)
Chile 2400 10 1 Lopez, Rios &
Fernandez, 1996 (41)
Chile 1025 50 41 29 71 Gamonal et al., 1998
(25)
El Salvador 728 39 16 WHO, 1994 (59)
Jamaica 393 34 37 WHO, 1994 (59)
Mexico (1) 63 41 2 WHO, 1994 (59)
Mexico (2) 144 1 0 WHO, 1994 (59)
Nicaragua 178 62 11 35 37 Smith & Lang, 1993 (54)
Uruguay 313 55 10 38 23 WHO, 1994 (59)
W Indies (1) 132 51 34 WHO, 1994 (59)
W Indies (2) 456 14 3 WHO, 1994 (59)
W Indies (3) 122 0 0 WHO, 1994 (59)
W Indies 702 3 1 Vignarajah, 1994 (56)

74

Fig. 1. Map of Central and South America indicating preva-
lence and severity of periodontal diseases among young
individuals according to country.
Fig. 2. Map of Central and South America indicating preva-
lence and severity of periodontal diseases among middle-
aged individuals according to country.
Periodontal diseases in Central and South America
98.0%, respectively). However, the prevalence of these
conditions in the high socio-economic group was
56.0%. Also, periodontally healthy individuals were
found in the latter group only. Similar findings have
been reported from a random sample of young people
(41), where students from a better socio-economic
situation presented with a higher mean number of
healthy sextants compared to those with a less favor-
able socio-economic background. An earlier study
from Chile reported that 6 out of a total of 8 cases with
localized juvenile periodontitis originated from the
lower socio-economic stratum (42). This would indi-
cate a higher prevalence among the poorer parts of
the population, but interpretation must be made with
caution due to the low number of cases.
In two Brazilian studies comprising individuals
with different socio-economic background, em-
ploying the same methodology, the gingival con-
dition was not associated with the socio-economic
level of the participants (16, 17). This may reflect a
reduced sensitivity of the GI when used as a mean,
and may indicate that frequency distribution of a
specific finding, for instance bleeding on provo-
cation, would be a better analytical tool. Thus, Abbeg
(1) has shown a positive correlation between socio-
economic factors and levels of plaque and gingivitis
Fig. 3. Map of Central and South America indicating preva-
lence and severity of periodontal diseases among old indi-
viduals according to country.
75
Gjermo et al.

in adults, using percentage of bleeding sites as the giene habits, data describing the sale of oral hygiene
end point for gingivitis. products per capita may be used as an indicator of
Differences in gender have also been studied in oral hygiene on a population level. Changes in sale
these populations but no clear-cut tendency was figures over time may thus reflect changes in oral
found. Some studies have shown differences (16, 17, health behavior and possibly predict future disease
25, 30) but these were small and inconclusive. development in the population. Information on such
sales for 1995 through 1999 in Brazil is shown in Fig.
4, and indicates a constant increase in the number of
toothbrushes and amount of dentifrice sold. How-
Oral hygiene habits ever, the sale of dental floss is slightly increased in
1999 only. Data from Argentina and Chile on the per
Oral hygiene patterns have rarely been studied in capita sale of toothbrushes and dentifrice in 1999 are
Latin American populations, but a few studies are presented, together with the Brazilian data from 1999,
available that may elucidate this phenomenon. Ab- in Fig. 5. Assuming that changes in the prevalence and
beg (1) studied oral hygiene habits among workers severity of periodontitis due to improved oral hygiene
in Brazil and concluded that most individuals had routines on a population basis are observed first in
reasonable oral hygiene routines, i.e. the median and young individuals, these data tend to support the dis-
mode values for self reported toothbrushing fre- tribution and severity of periodontitis in the 3 coun-
quency was 3 times a day. Less than 1% reported tries depicted in Figs 1, 2 and 3.
to brush their teeth less than once daily. Those who
reported never to use dental floss or toothpicks
amounted to 32.5% and 45.4%, respectively. Only
interdental cleaning habits showed variations among Concluding remarks
socio-economic groups, flossing being more com-
mon in the higher socio-economic groups whilst The most striking feature of the present review is the
toothpicking was more prevalent in the low socio- lack of representative population surveys on peri-
economic group. It is suspected that these activities, odontal diseases in Central and South America. In
particularly the toothpicking, were more related to fact, we were unable to find published reports from
removal of food particles after a meal than to con-
scious dental plaque removal. Over-reporting of so-
cially acceptable habits would be expected and
should be taken into account when interpreting such
data. In particular, an inaccurate correlation be-
tween social strata may be due to increased aware-
ness of what are regarded to be ‘good habits’ among
the higher social strata of the population.
Recently, a representative sample from a Brazilian
city was interviewed about their oral hygiene habits
(15). All participants owned a toothbrush and tooth-
brushing habits did not differ between the socio-
economical strata. However, flossing was more preva-
Fig. 4. Oral hygiene products sales for the years 1995
lent in the medium and high socio-economic groups.
through 1999 in Brazil.
The association between oral hygiene and gingi-
vitis is firmly established world wide, whereas the
relationship between oral hygiene and destructive
forms of periodontitis remains obscure. However,
there is a universal agreement that prevention of gin-
givitis through improved oral hygiene will prevent
periodontitis on a population basis (3). Thus, im-
provement of oral hygiene in a population would, in
theory, result in reduced prevalence of periodontitis,
and data exists to support this belief (38).
In the absence of data on oral hygiene or oral hy- Fig. 5. Oral hygiene products sales in 1999.

76

the majority of the countries in the region, as dis-
played in Figs 1, 2 and 3. This may reflect the extent
to which periodontal diseases are regarded as a
problem by the health authorities in these countries.
In several of the few existing surveys, data concern-
ing periodontal conditions were collected as a com-
plement to epidemiology of dental caries. Also, since
tooth loss is the ultimate result of poor oral health,
it is reasonable to assume that this outcome may
have a strong impact on the conditions surveyed.
However, the CPITN that was used in most surveys
does not readily lend itself to valid estimates of tooth
loss. Thus, this aspect was not thoroughly assessed
in this review.
In a convenience sample from the Brazilian Army,
Lemos et al. (37) found the main reason for extrac-
tion to be dental caries. Also, a study from Antigua
showed that caries was responsible for 61.6% of all
tooth extractions, whereas periodontal disease was
responsible for only 29.9% of the extractions (57).
However, this study revealed that periodontitis was
the main cause of extractions in people over 50 years
of age (71.6%, 68.7% and 52.9% for those aged 51–
60, 61–70 and 71 years and older, respectively).
Pizzarro et al. (52) examined to what extent peri-
odontal diseases were responsible for tooth loss in a
representative sample from the city of Santiago
(Chile). For both age groups (35–44 and 65–74 years
old), caries was the main cause of tooth loss, while
periodontal diseases caused 15.75% and 42.09% of
lost teeth, respectively.
When reviewing data on the epidemiology of peri-
odontal diseases in a region with few data one may
be tempted to include data of poorer quality, in
terms of representation of the background popula-
tion and the disease assessment methods used. This
should be taken into account when interpreting this
review.
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