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Prevalence of periodontitis in the Indian population: A literature review

Article  in  Journal of Indian Society of Periodontology · March 2011

DOI: 10.4103/0972-124X.82261 · Source: PubMed

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Review Article

Prevalence of periodontitis in the

Indian population: A literature review
Shaju Jacob P., Zade R. M., Manas Das

Department of Abstract:
Periodontics, Background: Periodontitis is one of the major reasons for tooth loss in adults. India, with a population of over
Chhattisgarh Dental 1 billion, is bound to become a developed nation soon. This transition will require a population that is healthy,
College and Research including in terms of periodontal health. Early studies done in India gave an indication that the population is highly
Institute, Rajnandgaon, susceptible to periodontitis. Aim: This paper reviews the prevalence of periodontitis in the Indian population.
Settings and Design: Review of periodontitis prevalence studies on the Indian population. Materials and
Chhattisgarh, India
Methods: After identifying articles from PubMed and hand searching, the epidemiology of periodontitis is reviewed
together with the case definition, study settings, type of population, age and other factors as all these are bound
to affect the prevalence rates determined in various studies. Statistical Analysis: None. Results: This review
identifies very limited number of studies that provide prevalence data and faces difficulty in comparing various
studies due to nonstandardization of case definition and use of nonrepresentative samples. There is a high
prevalence of periodontitis among the adults and the economically weak population. Conclusions: There is a
very urgent need for standardized population-based studies with a robust design to identify the true prevalence
of periodontitis, which in turn will help in planning oral health policies and creating the necessary infrastructure.
Key words:
Access this article online
Cross-sectional studies, epidemiology, India, periodontitis, prevalence
Website:
www.jisponline.com
INTRODUCTION from early epidemiological studies using an
DOI: index system that gave weight to gingivitis and

I
10.4103/0972-124X.82261
ndia is one of the major emerging market
Quick Response Code: economies with a population of over 1 billion
and – is very diverse in geography, culture,
tradition, habits and even race. This diversity also
extends to literacy rates, health indicator rates
infant mortality rate (IMR) and hygiene practices.
This variation is reflected in the periodontitis
prevalence as is revealed by the two major
surveys conducted.[1,2]
There has been a general perception that oral
health in India is considered to be the least
important. In India,[1] the dental-care scenario
is unique. At present, there are more than 267
dental colleges, producing approximately 19,000
dental graduates per year and almost 3,000
Address for specialists. The dental colleges offer excellent
correspondence: tertiary care, in a cost-effective manner. India
Dr. Shaju Jacob P. is becoming a favored tourist destination for
Department of Periodontics orodental treatment of international standards.
and Oral Implantology, On the other hand, even the most basic oral
Chhattisgarh Dental
College and Research
health education and simple interventions like
Institute, Post Box 25, pain relief and emergency care for acute infection
Village Sundara, and trauma are not available to the vast majority
Rajnandgaon, of population, especially in the rural areas.
Chhattisgarh - 491 441, One of the reasons is lack of epidemiological
India. data to identify areas needing oral health care.
E-mail: shajujacob@yahoo.
There also prevails a view that people in Asia
com
are particularly susceptible to periodontitis.
Submission: 31-10-2009 This view of a particularly high prevalence of
Accepted: 09-08-2010 periodontal diseases appears to have originated
moderate periodontitis resulting from poor oral
hygiene and calculus deposition.[3] Albandar[4]
in an overview concluded that subjects of Asian
ethnicity had the third highest prevalence of
periodontitis.
The aim of this review is to determine the
prevalence of periodontitis in India.
MATERIALS AND METHODS
Using keywords “Periodontitis” and “India”,
“Periodontal” and “India”, PubMed was
searched for articles. Out of the 163 articles
found, all articles that included prevalence
studies were selected. As very few prevalence
studies have been done in the representative
Indian population, all available studies in which
prevalence data was available were considered
regardless of any other inclusion criteria. Some
articles from Indian journals that had prevalence
data on periodontitis but were not indexed
by PubMed were also selected. Totally 14
publications, which included 2 national surveys,
were included [Table 1].
To begin with, this review will consider 2
important surveys — one by Dental Council
of India and the other by Government of India
in collaboration with WHO. Early “classic”
periodontal epidemiological studies in India

Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011 29

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Jacob P., et al.: Periodontitis prevalence in India
are also reviewed to understand why India was considered
to be a region of periodontitis endemicity. In this review,
moderate periodontitis is considered to be present if a person
has at least one site with a probing depth of ≥4 mm; and
severe periodontitis, at least one site with a probing depth
of ≥6 mm.
National Oral Health Survey and Fluoride Mapping (2002-
2003), Dental Council of India, New Delhi, 2004
This is the first ever national-level epidemiological survey
done in India. The aim of the survey was to collect information
covering various dimensions of oral health, including
prevalence of oral health problems. Each state was divided
into a few homogeneous regions comprising of a number
of districts, on the basis of agro-climatic factors used by the
Planning Commission. A three-stage sampling design was
adopted to select 210 rural and 110 urban subjects in each of
the age groups, viz., 5, 12, 15, 35-44, 65-74 years, from each
homogeneous region. WHO probe was used for periodontal
measures, and CPI index was used for disease assessment.
The prevalence of periodontal disease increased with age.
The prevalence was 57%, 67.7%, 89.6% and 79.9% in the age
groups 12, 15, 35-44 and 65-74 years, respectively (periodontal
disease is not evaluated in 5 year olds). The lower prevalence in
older age could be due to loss of teeth in the elderly. Moderate
periodontitis was seen in 17.5% of the 35-44 years group;
and 21.4%, in the 65-74 years group; whereas severe disease,
defined as at least one tooth with ≥6 mm probing depth, was
seen in 7.8% in the 35-44 years group and 18.1% in the 65-74
years group. No marked gender differentials were observed,
and marginally higher prevalence was seen in rural subjects.
“Cleaning teeth regularly” group showed significantly reduced
prevalence of periodontal disease, while use of toothbrush
was found to be significantly better than finger cleaning. The
survey was basically a prevalence survey with less emphasis
on risk factors. This survey gave a reliable baseline data at the
national and state levels.
Oral health in India
A report of the multicentric study, carried out under the
Directorate General of Health Services, Ministry of Health
and Family Welfare, Government of India; and World Health
Organization collaborative program.
Under the Government of India and World Health Organization
collaborative program on oral health, a multicentric oral health
survey was envisaged in the year 2004, in order to have a
baseline data of the burden of oral diseases and associated risk
profile of the population for four index age groups, viz., 12, 15,
35-44 and 65-74 years. This survey was conducted in 7 different
geographical locations in India, viz., Arunachal Pradesh, Delhi,
Maharashtra, Puducherry, Rajasthan, Orissa and Uttar Pradesh,
covering 3,200 samples from each site, thus surveying a total of
22,400 persons in rural and urban areas of the selected districts.
In the 35-44 years and 65-74 years age groups, high prevalence
(100%) of periodontal disease was reported from few of the
states (Orissa, Rajasthan) in this study. The prevalence of loss
of attachment (3 mm or more) was 78% in the 35-44 years
group and 96% in 65-74 years group in Maharashtra in the
present study. The prevalence of attachment loss of >3 mm
in the 35-44 years group was highest in Maharashtra (78%),
followed by Orissa (68%) and Delhi (46%). The rest of the
30 Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011
centers had prevalence ranging between 15% and 33%. The
prevalence of loss of attachment was significantly higher in
the 65-74 years group as compared to the 35-44 years group.
The highest prevalence in 65-74 years group was recorded in
Maharashtra (96%), followed by Orissa (90%), Delhi (85.5%),
Rajasthan (75%), Uttar Pradesh (68%) and Puducherry (55%).
Arunachal Pradesh recorded the lowest prevalence, viz., 20%.
The general trend observed for loss of attachment was that it
was higher in the rural than in the urban population and was
higher in males as compared to females. But in the geriatric
age group, the prevalence of loss of attachment was higher
among females.
Shah [5] in her report for the National Commission on
Macroeconomics observed that more advanced periodontal
disease with pocket formation and bone loss, which could
ultimately lead to tooth loss if not treated properly, may affect
40% to 45% of the population of India. She also pointed out
that only some 7 studies were documented and highlighted
totally incoherent data. Moreover, most of the studies have been
conducted on the pediatric population, in whom periodontal
diseases are not widely prevalent.
Sood[6] in a field survey in Ludhiana did a systematic sampling
on 500 urban and 500 rural subjects. In the total population,
68.9% had bleeding gums, 97.0% had calculus, 29.1% had
shallow pockets (moderate periodontitis) and 12.5% had
deep pockets (≥6 mm, severe periodontitis) as assessed by
WHO-recommended methods. He found periodontal disease
significantly associated with coronary artery disease (CAD);
however, the sample size was small in the CAD group (34
subjects).
Singh et al.[7] did a prevalence study in the rural and urban
subjects of Ludhiana. He found that the urban subjects had
higher prevalence of moderate and severe periodontitis as
compared to rural subjects.
Jagadeesan et al.[8] did a systematic random sampling of
rural women in Puducherry. The prevalence of moderate
periodontitis increased with age; the risk of being affected by
periodontitis was 2.3 times for persons above 35 years of age
than below.
Doifode et al.[9] in a field survey of two randomly selected
nagars of Nagpur found prevalence of periodontal disease
being 34.8%. The disease definition was not given; hence
the level of periodontitis could not be ascertained. Age, low
socioeconomic status, betel nut/leaf chewing, tobacco chewing,
ghutka chewing and smoking were significantly associated with
periodontal disease.
Vandana et al.[10] found 27% prevalence of periodontitis in
fluorosis-affected patients attending Periodontics OPD.
Prevalence increased with age and was significantly more
among females. The prevalence should be considered keeping
in mind that the population was a hospital-based one. The
increased prevalence found among females could be attributed
to their increased treatment-seeking behavior.
“Classic” periodontal epidemiological studies in India
The study by Greene [11] is one of the earliest studies. It
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Jacob P., et al.: Periodontitis prevalence in India

Table 1: Prevalence data of periodontitis from various studies done on the Indian population
Year Author Sample Population Age range Prevalence (%) Periodontitis Characteristics Significant factors
size definition/
threshold
1956 Sanjana et al.[13] 1445 Urban 16-50 N.A. N.A. Age
1957 Ramfjord et al.[12] 1677 Urban + 11-17, 10 at age 17 PDI Low Oral hygiene status
Rural 19-30 years socioeconomic
status
1960 Greene[11] 802 Urban 11-17 <2 Periodontal Low Rural scores for debris,
males Index socioeconomic calculus, and the
(Russell) status oral hygiene index —
significant
1960 Greene[11] 748 Rural 11-17 <2 Periodontal Low Rural, scores for debris,
males Index socioeconomic calculus, and the
(Russell) status oral hygiene index —
significant
1960 Greene[11] 63 Rural 18-30 30.2 Periodontal Low Rural, scores for debris,
males Index socioeconomic calculus, and the
(Russell) status oral hygiene index —
significant
2000 Doifode et al.[9] 5061 Urban, 0-60+ 34.8 N.A. Betel nut/leaf chewing,
Repre- tobacco chewing, ghutka
sentative chewing, smoking, age,
population low socioeconomic status
2000 Jagadeesan 912 Field >15 years 20.63-moderate N.A. Age, illiteracy, marital
et al.[8] survey, and 25.6- severe status, agricultural
rural periodontitis laborers, chewing habits
women and type of brushing
2004 Bali et al.[2] 310per Urban and 5, 12, 35- 17.5-moderate CPITN Cleaning teeth regularly,
region rural 44, 65-74 and 7.8- severe toothbrush
groups periodontitis
(35-44 years)
21.4-moderate
and 18.1-severe
periodontitis (65-
74 years)
2004 Ranganathan 1000 Urban. HIV 31-40 36.3 N.A. Smoking, age
et al.[15] Males
2004 Ranganathan 1000 Urban. HIV 21-30 22.6 N.A. Age
et al.[15] Females
2005 Sood[6] 1000 Field N.A. 29.1-moderate CPITN Coronary artery disease
survey and 12.5-severe
periodontitis
2005 Singh et al.[7] 1000 Field >15 years 39.4-moderate CPITN Urban
survey and 16.9-severe
periodontitis
2005 Singh et al.[7] 500 Field >15 years 43.2-moderate CPITN
urban survey and 22.9-severe
periodontitis
2005 Singh et al.[7] 500 Field >15 years 31.7-moderate CPITN
rural survey and 11.0-severe
periodontitis
2007 Ranganathan 136 Urban 29.2±4.9 86 CPITN Low HIV status
et al.[14] dental socioeconomic
patients status
2007 Vandana et al.[10] 1029 Periodon- 15-74 years 27 (24.2-M, CPITN Fluorosis Sex, age, poor hygiene
tics OPD 32.8-F) status
2007 WHO[1] 3200 Field 12, 15, 35- 15-moderate WHO
Arunachal survey 44, 65-74 and 2.6-severe
Pradesh age group periodontitis
(35-44 years);
18-moderate
and 0.6-severe
periodontitis (65-
74 years)

Contd...

Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011 31

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Jacob P., et al.: Periodontitis prevalence in India

Table 1: (Contd./-
Year Author Sample Population Age range Prevalence (%) Periodontitis Characteristics Significant factors
size definition/
threshold
2007 WHO[1] Delhi 3200 Field 12, 15, 35- 34-moderate WHO
survey 44, 65-74 and 1.0-severe
age group periodontitis
(35-44 years);
1.7-moderate
and 1.7-severe
periodontitis (65-
74 Years)
2007 WHO[1] 3200 Field 12, 15, 35- 48-moderate WHO
Maharashtra survey 44, 65-74 and 2.9-severe
age group periodontitis
(35-44 years);
55.2-moderate
and 4.5-severe
periodontitis (65-
74 years)
2007 WHO[1] Orissa 3200 Field 12, 15, 35- 35.7-moderate WHO
survey 44, 65-74 and 9.7-severe
age group periodontitis
(35-44 years),
42-moderate
and 15.6-severe
periodontitis (65-
74 years)
2007 WHO[1] 3200 Field 12, 15, 35- 26.3-moderate WHO
Puducherry survey 44, 65-74 and 4.7-severe
age group periodontitis (35-
44 years)
2007 WHO[1] 3200 Field 12, 15, 35- 48-moderate WHO
Rajasthan survey 44, 65-74 and 2-severe
age group periodontitis (35-
44 years)
2007 WHO[1] 3200 Field 12, 15, 35- 23.5-moderate WHO
Uttar Pradesh survey 44, 65-74 periodontitis
age group (35-44 years);
34.5-moderate
and 14-severe
periodontitis (65-
74 years).
2008 Parmar et al.[16] 168 Dental 32.7±0.7 54.76 N.A. Quid chewing
OPD,
chewers
2008 Parmar et al.[16] 197 Dental 30.4±0.8 31 N.A. Quid chewing
OPD, non-
chewers
2008 Rooban et al.[17] 100 Dental 18-48 76.7 N.A. Drug abuse — less
OPD periodontitis
2008 Rooban et al.[17] 100 Drug 18-48 23.3 N.A. Drug abuse — less
abusers (32.78) periodontitis

used Russell index for periodontitis. The periodontal index
(Russell, 1956) includes both gingival inflammation and
periodontal destruction, with weight given to marked gingival
inflammation, which makes reversible marked inflammation
equivalent to irreversible periodontal destruction in the
calculation of the index. The study surveyed young persons
aged 11 to 17 years comparing urban and rural persons and
also a seperatesmall sample of 69 persons aged 18 to 30 years.
The population was selected from schools of low socioeconomic
status. Ninety-seven per cent of the 11- to 17-year-old persons
examined had overt evidence of periodontal disease, while
fewer than 2% of the total had obvious periodontal pockets.
All the 63 persons over 17 years of age had overt gingival
inflammation, and 19 (30.2%) had obvious periodontal pockets.
Persons with obvious periodontal pockets (periodontitis)
constituted 0.2%, 0.4%, 1% and 6% in the 11, 13 15 and 17 age
groups, respectively.
Ramfjord et al.[12] in their paper discuss a WHO survey done
in India along with 4 other countries. They observed that
there was 100% prevalence of periodontal disease (including
gingivitis) in India. Periodontitis was found to start after age
15; and at 17 years, 10% of Indian boys had periodontitis. This
periodontitis was due to accumulation of calculus, plaque and
debris rather than due to age, sex, geography, economic status
or nutrition.

32 Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011

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Jacob P., et al.: Periodontitis prevalence in India
Sanjana et al.[13] did a study on Bombay residents in 1956 and
found 83.2% had signs of periodontal disease. As prevalence
of pockets was not specified separately, the true prevalence
of periodontitis could not be ascertained. The population
seemed to belong to low socioeconomic strata, with age being
a risk factor.
Other studies
Ranganathan et al.[14] compared the prevalence of periodontitis
in HIV seropositive and seronegative patients in Chennai. The
controls were dental patients attending the OPD of a dental
college. The prevalence was high at 86% when assessed by
Community Periodontal Index for Treatment Needs (CPITN).
The lower threshold of at least one site with probing depth
≥3 mm and the population being patients seeking dental care
could be the reasons for the high prevalence. Periodontitis
was seen in 92.7% of HIV patients, which if compared with
prevalence in the general population is extraordinarily high.
Ranganathan et al.[15] report the prevalence of periodontitis in
1,000 HIV-positive patients; 22.6% females and 36.3% males
had periodontitis, with an odds ratio of 1.96. None of females
examined were smokers, while 50% of males examined were
smokers. Smoking and increased age were important reasons
for increased prevalence of periodontitis among males.
Parmar et al.[16] compared chewers of areca nut with or without
tobacco with non-chewers in a hospital-based population and
found 22.6% of chewers were smokers and the chewers had a
prevalence of periodontitis of 54.76%, while the controls had
a prevalence of 31%. The quid chewers were at higher risk for
periodontitis and gingival recession, irrespective of sex, age
and smoking status.
Rooban et al.[17] compared drug abusers with controls from a
dental hospital. They found there was a higher prevalence of
periodontitis among controls despite the number of smokers
being significantly high among drug abusers. This may be
probably as a result of selection bias; dental disease would
obviously be more prevalent among dental hospital patients.
DISCUSSION
The populations mostly studied have been hospital-based
populations because of the convenience (convenient sample).
The prevalence assessed among these types of samples will
be higher than that assessed among the general population as
persons with dental problems attend hospitals, and they are not
representative of the general population. The prevalence in the
hospital-based population is about 10% higher as compared to
that in the general population. The early studies[11,12] were done
on school population, another popular and convenient sample.
The school population represents a young population, and only
those who can afford to attend schools will be represented;
and the school population is the least representative of the
periodontitis-susceptible population. However, if young
persons show levels of periodontitis as seen in the Ramfjord
et al,[12] surveys, it is a cause for alarm as it reflects a poor
hygiene status and dental service utilization by the population.
Another limitation observed was the use of CPITN as a case
definition for periodontitis. CPITN is a treatment need–based
Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011 33
index, meant to find out the prevalence of persons requiring
treatment. It does not give true prevalence rates in terms of
severity and extent. A person with a site of >10 mm will be
in the same scale as a person with a single site of 6 mm (Code
4). The partial recording will give an underestimation of
prevalence.
Further, the prevalence data should correlate with tooth loss
to find if the increased prevalence of periodontitis is reflected
in increased tooth mortality. This will also help us find at what
level of severity of periodontitis is tooth loss a consequence.
Abnormal probing depth is a cause for concern if it leads
to increased risk for tooth loss, and its threshold should be
identified based on its consequence. Yet very little data are
available on tooth loss.[5]
In the World Oral Health Report (2003),[18] the WHO Global
Oral Health Program formulated the policies and the necessary
actions for the improvement of oral health. The strategy is that
oral disease prevention and the promotion of oral health need
to be integrated with chronic disease prevention and general
health promotion as the risks to health are linked (like tobacco
consumption and the standard of hygiene). As for the major
chronic diseases, socio-environmental factors are indirect
causes of oral disease; moreover, a core group of modifiable
risk factors is common to many chronic diseases and injuries,
as well as most oral diseases. These common risk factors are,
however, preventable as they relate to life style — such as
dietary habits, use of tobacco and excessive consumption
of alcohol — and the standard of hygiene. Yet for effective
integration of oral disease management with management of
other chronic diseases, prevalence data along with risk due to
various factors should be available. Oral disease, including
periodontal disease and tooth loss, is a serious public health
problem. Its impact on individuals and communities in terms
of pain and suffering, impairment of function and reduced
quality of life is considerable. With the growing consumption
of tobacco in many low- and middle-income countries, the
risk of periodontal disease, tooth loss and oral-cavity cancer
is likely to increase. Moreover, periodontal disease and tooth
loss are linked to chronic diseases such as diabetes mellitus;
the growing incidence of diabetes in several countries may
therefore have a negative impact on oral health. Yet to
formulate policies, the true prevalence of periodontitis, which
affects economy and the quality of life, needs to be assessed.
Theoretically and in most studies, abnormal loss of attachment
has been regarded as periodontitis; this definition is not useful
as most persons above 35 years of age have at least one site ≥3
mm. The definition of at least one site ≥6 mm can be regarded
as useful for population-based assessment of prevalence. Let
us also remember that this threshold of 6 mm is not based on
studies on Indian population. We also should strive to find the
definition of destructive periodontitis suitable for the diverse
Indian population.
Shah [5] in her report for the National Commission on
Macroeconomics and Health (NCMH) observed that for
periodontal diseases, the projection is alarming, with
prevalence at present being 45% for 15+ years group, and
the actual prevalence in lakhs will be 2957.6 (year 2000),
3190.2 (year 2005), 3413.8 (year 2010) and 3624.8 (year 2015).
Due to the rampant use of paan masala and ghutka by persons
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Jacob P., et al.: Periodontitis prevalence in India

of all age groups and both the sexes, periodontal disease
prevalence will be higher than projected. If minor periodontal
diseases are included, the proportion of population above
the age of 15 years with this disease could be 80% to 90%.
Concerned[9] with the urgent need for action, it is vital to
promote sound oral health, prevention of dental caries and
periodontal diseases and give impetus to activities that
promote oral health, WHO had dedicated World Health
Day 1994 to oral health. The objectives were to mobilize the
dental health resources for promotive action and increase
in basic research.
CONCLUSION
There is a lack of data regarding prevalence of periodontitis
among the Indian population. As Doifode[9] observed, “(For)
planning of national or regional oral health promotion
programs, to prevent and treat oral health problems, baseline
data about magnitude of problems and various epidemiological
factors is required. Basic oral health surveys provide such type
of data. India has vast geographic area divided into states,
which differ with regard to their socioeconomic, educational,
cultural and behavioral tradition. These factors may affect oral
health status. Hence to obtain nationwide representative data,
nationwide multicentric study is required. More practicable
alternative is to develop regional database; review of such
observations from various regions may give understanding of
national scenario.” There should be a general representative
survey of at least all the districts in India to understand the
true prevalence of periodontitis. This task is not huge if the
responsibility is taken by the 250 odd dental colleges to study
their immediate geographical areas. The identification of the
disease burden will help to judiciously utilize the limited
resources available for periodontal health.
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How to cite this article: Shaju JP, Zade RM, Das M. Prevalence of
periodontitis in the Indian population: A literature review. J Indian Soc
Periodontol 2011;15:29-34.
Source of Support: Nil. Conflict of Interest: None declared.

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34 Journal of Indian Society of Periodontology - Vol 15, Issue 1, Jan-Mar 2011

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