Periodontology 2000, Vol.
60, 2012, 15–39
Printed in Singapore. All rights reserved
The global burden of periodontal
disease: towards integration with
chronic disease prevention and
control
P O U L E. P E T E R S E N & H I R O S H I O G 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
 2012 John Wiley & Sons A/S
PERIODONTOLOGY 2000
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
Petersen & Ogawa
Fig. 1. Global projection for the number of people with diabetes. From International Diabetes Foundation, Diabetes Atlas
(32).
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
16
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. 2. Percentage of male (A) and female (B) tobacco users worldwide. From World Health Organization (95).
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
Global periodontal health
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
17
Petersen & Ogawa
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 problems
and 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-
50 Edentulous Problems with mouth/teeth
during the past year
40
Value (percentage)
30
20
10
0
Low Lower Upper High
middle middle
Income category of country
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
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.
80
Urban
Rural
Value (percentage)
60
40
20
Total 0
Low Lower Upper High Total
middle middle
Income category of country
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).
 Global periodontal health

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

The global burden of periodontal
disease
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
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-
100

control of periodontal disease. In addition, the CPI

population data may be helpful in oral health sur- 75
veillance at country and intercountry levels. While Score 4
this index has certain shortcomings as a stand-alone Score 3

Percentage
means of assessing the extent and severity of peri- 50 Score 2
odontal disease (53), it has been widely used for Score 1
descriptive periodontal epidemiological studies and Score 0
25
for needs assessment in both developed and devel-
oping countries. The major advantages of the CPI
are simplicity, speed, reproducibility and interna- 0
tional uniformity. In 1997, the WHO suggested AFRO AMRO EMRO EURO SEARO WPRO
WHO region
including information on loss of periodontal
Fig. 5. Maximal Community Periodontal Index (CPI)
attachment in oral health surveys (84). However,
scores of 15- to 19-year-old subjects, expressed as a per-
data on loss of attachment are scarce as, to date, centage and stratified according to World Heath Organi-
only a few countries have carried out such system- zation (WHO) region (89). AFRO, the African Region;
atic surveys. According to the WHO experience, the AMRO, the Americas Region; EMRO, the Eastern Medi-
recording of loss of attachment is often considered terranean Region; EURO, the European Region; SEARO,
the South-East Asia Region; WPRO, the Western Pacific
difficult to carry out in the field and time-consum-
Region.
ing.
Certain indicator age groups have been chosen by
the WHO for intercountry comparisons of oral health 100
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 75
countries have provided CPI data for warehousing in Score 4
Score 3
the WHO Global Oral Health Data Bank (89).
Percentage

Score 2
These are displayed through a component of the so- 50
Score 1
called WHO Country ⁄ Area Profile Programme (http:// Score 0
www.dent.niigata-u.ac.jp/prevent/perio/contents.
html). The standard parameters for presentation 25

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 0
AFRO AMRO EMRO EURO SEARO WPRO
scores: Score 0 = healthy periodontal conditions; WHO region
Score 1 = gingival bleeding; Score 2 = gingival Fig. 6. Maximal Community Periodontal Index (CPI)
bleeding and calculus; Score 3 = shallow periodontal scores of 35- to 44-year-old subjects, expressed as a per-
pockets (4–5 mm); Score 4 = deep periodontal pock- centage and stratified according to World Heath Organi-
ets (‡ 6 mm); Score 9 = excluded; and Score X = not zation (WHO) region (89). AFRO, the African Region;
AMRO, the Americas Region; EMRO, the Eastern Medi-
recorded or not visible. The extent of loss of attach-
terranean Region; EURO, the European Region; SEARO,
ment (LA) is recorded for sextants using the following the South-East Asia Region; WPRO, the Western Pacific
codes: Score 0 = LA 0–3 mm; Score 1 = LA 4–5 mm; Region.

19
Petersen & Ogawa

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

(SEARO) and the Western Pacific Region (WPRO).
5
Mean number of sextants The CPI data are expressed as the mean percentage of
4 X subjects with certain CPI scores. In addition, country-
Score 4 specific data are given in Table 1. The most severe
Score 3
3 score or sign of periodontal disease (CPI Score = 4)
Score 2
Score 1
varies worldwide, from 10% to 15% in adult popu-
2
Score 0 lations; however, the most prevalent score in all WHO
1
Regions is a CPI Score of 2 (gingival bleeding and
calculus), which primarily reflects poor oral hygiene.
0 For a few countries, sufficient data over time are
AFRO AMRO EMRO EURO SEARO WPRO
WHO region
available for surveillance and this may allow assess-
ment of the impact of oral health programs. The
Fig. 7. Distribution of certain Community Periodontal mean number of sextants with CPI scores is pre-
Index (CPI) scores, shown as mean numbers of sextants, sented for the three age-groups of adults and by
in 35- to 44-year-old subjects according to World Health
WHO region. Poor periodontal health is particularly
Organization (WHO) region (89). AFRO, the African Re-
gion; AMRO, the Americas Region; EMRO, the Eastern reported at old age. For older people of both devel-
Mediterranean Region; EURO, the European Region; SE- oping and developed countries the severe CPI scores
ARO, the South-East Asia Region; WPRO, the Western are profound; this pattern is also observed for coun-
Pacific Region.

100
90
80
Value (percentage)

70
60
50
40
30
20
10
0
lia dia ile ina ng ark bia dia an ao car ar nd rea bia nia SA
s tra bo Ch Ch g ko nm am In Jap L gas anm eala Ko Ara nza U Fig. 8. Maximal Community Peri-
Au Cam a y Z f i
on De G ad M ew lic o aud R T
a
odontal Index (CPI) scores, ex-
a -H M N u b S U
in p pressed as a percentage, of 65- to
Ch Re 74-year-old subjects in selected
CPI 0 CPI 1 CPI 2 CPI 3 CPI 4 CPI X CPI 9 countries (89).

6.0
Mean number of sextants

5.0

4.0

3.0

2.0

1.0

0.0
di
a
in
a
on
g
ar
k
pa
n n ar d
re
a ia ia A
bo Ch k m Ja ano asc a lan o rab z an US
m ng en Leb ag Ze o fK iA an Fig. 9. Distribution of Community
Ca Ho D ad w ic ud T
na
- M Ne ub
l Sa UR Periodontal Index (CPI) scores,
i p
Ch Re shown as mean numbers of sextants,
among 65- to 74-year-old subjects in
CPI 0 CPI 1 CPI 2 CPI 3 CPI 4 CPI X CPI 9 selected countries (89).

20
 Table 1. Community Periodontal Index (CPI) data, stratified by specific age-group(s) within countries, as reported to the World Health Organization (WHO) (89)

Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)

AFRO
Algeria 15–19 16 15 56 13 0

35–44 10 6 26 45 13
Benin 15 46 1 53 0 0

35–44 37 1 61 1 1
Burkina Faso 18 16 8 58 13 5

35–44 3 2 49 36 10
Cape Verde 15–19 1 2 92 4 1

Central African Republic 35–44 1 1 14 52 32

Comoros 15–19 8 1 90 0 0

33–49 2 0 84 0 0 14
Djibouti 15 77 8 13 1 1

Ethiopia 15 0 36 54 9 0
Gambia 15–19 7 8 56 20 9

35–44 1 0 25 28 46
Ghana 15 9 16 72 2 1

35–44 4 9 49 32 5
Kenya 15 1 52 40 6 2

35–44 1 4 31 49 14
Lesotho 15 15 30 49 6 0

35–44 8 3 55 28 6
Madagascar 18 19 6 66 3 0 6

35–44 8 5 67 17 3
65–74 1 0 17 5 2 75
Global periodontal health

21
22
Table 1. (Continued )

Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
Petersen & Ogawa

(Score 2) (Score 3) (Score 4)

Malawi 15–19 41 2 56 1 0

35–44 4 1 86 7 2
Mauritius 15 1 20 41 33 5

35–44 0 1 19 48 32
Namibia 15–19 0 1 90 9 0

35–44 0 0 83 15 2
Niger 18 0 0 99 0.3 0.3

35–44 0 0 87 8 5
Nigeria 15–19 1 3 46 42 8

35–44 1 0 15 45 39
Seychelles 17 1 4 93 0 0
Sierra Leone 15 0 3 44 44 9
35–44 0 1 5 42 53
South Africa 15–19 0 0 28 69 3
35–44 0 0 13 58 29
Tanzania 15–19 3 5 84 8 0
35–44 6 3 81 9 1

65–74 2 2 53 38 5
Togo 35–44 35 3 35 21 6

Zaire 35–44 0 0 39 45 16
Zimbabwe 15–19 23 21 47 8 1

35–44 9 9 59 19 4
 Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
AMRO
Argentina 34–45 3 14 43 26 14
Brazil 15–17 48 40 10 3 0
35–44 1 4 13 63 20

Canada 35–44 5 6 16 52 21
Chile 15–19 5 15 70 10 1

35–44 1 3 5 50 41
65–74 0 0 0 29 71

El Salvador 35–44 4 1 40 39 16
Jamaica 15 0 9 20 34 37

Mexico 15–19 49 36 14 1 0
Saint Vincent, the Grenadines 15–19 12 5 83 0 0
Uruguay 15–19 1 8 26 55 10
35–44 6 4 29 38 23
USA 15–19 17 13 33 32 5
35–44 4 10 27 38 20

65–74 5 8 24 31 32
West Indies 15–19 12 5 83 0 0

EMRO
Bahrain 15–19 18 8 71 2 0
Cyprus 15 35 34 30 0 0
35–44 9 9 61 19 1
Egypt 17 0 36 47 16 1
35–44 0 8 36 40 16
Global periodontal health

23
24
Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
Petersen & Ogawa

Iran 15–19 11 12 46 30 0

35–44 1 6 40 43 10
Iraq 35–44 1 11 41 37 11

Jordan 15 1 3 85 11 0
Lebanon 15 24 30 42 3 1

35–44 8 20 51 14 8
65–74 6 17 47 11 19
Libyan Arab J. 15 0 5 80 15 0
35–44 0 0 13 53 34
Morocco 16–20 3 40 34 17 5
35–44 3 5 31 40 16

Oman 15 26 3 69 2 0
Pakistan 15–19 26 20 52 2 0 5

35–44 9 8 53 24 6
Saudi Arabia 15–19 32 12 37 17 1

35–44 20 35 36 8 0
65+ 9 25 40 17 9

Slovenia 65+ 2 1 31 45 21
Somalia 15 43 43 14 0 0
Sudan 15–19 0 1 0 95 4
35–44 0 0 3 71 26
Syrian Arab Republic 15 14 26 53 6 0
35–44 6 6 67 9 12

Yemen 15–19 7 16 70 5 2
 Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
EURO
Armenia 15–19 11 7 74 8 0
Belarus 15 2 9 76 14 0
35–44 0 0 23 45 31

Belgium 35–44 1 5 30 34 30
Bulgaria 65–74 10 5 21 45 19
Croatia 15–19 16 20 52 12 0
35–44 6 6 41 32 15

65+ 0 0 17 48 35
Denmark 35–44 8 16 41 29 6

65–74 2 9 23 46 20
Estonia 15 2 16 78 4 0

35–44 0 0 34 53 13
65–74 0 1 4 26 69
Finland 15–19 34 40 26 0 0
35–44 2 7 56 29 6

65–74 2 2 37 32 27
France 15–19 45 3 51 1 0

35–44 9 6 63 13 10
65–74 17 12 39 29 3
Germany 15–19 7 11 11 62 9
35–44 1 12 14 52 21

65–74 1 4 7 48 40
Greece 15–19 30 30 33 7 0

35–44 6 29 39 20 6
Global periodontal health

25
 Table 1. (Continued )

26
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
Hungary 35–44 11 5 57 22 6
Petersen & Ogawa

65–74 7 10 46 26 11
Ireland 15 43 21 35 1 0
35–44 6 8 71 13 2
Israel 15–19 40 48 12 0 0
35–44 1 3 24 50 22
Italy 15–19 39 10 48 3 0
35–44 3 4 45 36 12
Kyrgyzstan 15 1 5 92 2 0
35–44 0 0 23 46 31

65–74 0 0 1 8 91
Lithuania 15 6 18 75 2 0

Malta 35–44 0 1 78 17 2
the Netherlands 15–19 6 47 29 16 1

35–44 4 6 34 48 7
65–74 1 10 32 42 15

Norway 35 1 19 13 58 8
Poland 35–44 9 8 58 19 6

65–74 10 15 52 19 4
Portugal 15 21 16 63 0 0

35–44 3 0 47 38 8
Russian Fed. 15 1 10 80 9 1

35–44 0 1 15 54 29 4
San Marino 15–19 45 25 28 2 0

35–44 8 23 37 25 7
 Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
Slovakia 18–19 23 24 51 2 0
34–49 8 5 44 29 15

64–76 63 4 18 11 4
Slovenia 15 8 66 23 3 1

35–44 1 4 68 5 22
65–74 0 0 12 45 43
Spain 35–44 4 7 75 13 1
65–74 3 8 65 20 4
Tajikistan 15 0 0 70 30 0
35–44 0 0 20 50 30
Turkey 15–19 26 51 21 2 0
35–44 3 24 38 29 6
Turkmenistan 15 2 4 86 7 0
35–44 0 0 21 39 40

65–74 0 0 3 13 84
UK 15–19 12 36 49 3 0

35–44 4 1 20 62 13
65–74 3 1 19 60 17
The former 15–19 6 29 51 13 1
Yugoslavia
35–44 1 1 34 48 16

SEARO
Bangladesh 18 5 5 66 22 1

35–44 3 1 36 40 21
Bhutan 15–19 6 14 75 6 0
Global periodontal health

27
28
Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
Petersen & Ogawa

India 15–19 6 11 79 5 0

35–44 2 2 37 40 19
65–74 0 3 25 38 16
Indonesia 15 0 3 54 41 2
35–44 1 0 56 36 6 18

Maldives 15–19 37 20 42 0 0
Myanmar 35–44 0 0 63 35 2

65–74 0 0 34 45 14
Nepal 15–16 26 8 61 5 0

35–44 0 0 28 38 34 7
Sri Lanka 35–44 5 1 55 27 10
Thailand 18 3 3 87 7 0
35–44 1 0 53 35 11

WPRO
Australia 18 0 2 58 38 2

35–44 6 10 47 24 13
65+ 7 13 36 31 14
Cambodia 15–19 41 0 59 0 0
35–44 3 1 92 4 0

65–74 0 0 54 41 5
China 35–44 0 0 64 32 4

65–74 0 1 55 37 7
Cook Islands 15–19 0 4 80 15 0

35–44 0 0 34 57 9
 Table 1. (Continued )
Country Age-group No symptoms Gingival bleeding Gingival bleeding + Shallow periodontal Deep periodontal Others
(years) (Score 0) (Score 1) calculus pockets: 4–5 mm pockets: ‡6 mm (Score X or 9)
(Score 2) (Score 3) (Score 4)
Fiji 15–19 28 14 58 1 0
35–44 6 6 74 13 1
French Polynesia 15–19 82 3 13 2 0
35–44 17 1 45 31 6
Hong Kong 15–19 2 2 70 26 1
35–44 0 0 26 57 17

65–74 0 0 34 51 15
Japan 15–19 34 25 36 5 0

35–44 18 10 45 23 4
65–74 9 7 27 43 15
Korean Republic 15–19 35 17 39 8 1
35–44 30 4 48 15 3

65–74 20 2 28 34 17
Lao P.D. Republic 15–19 9 8 83 0 0

35–44 0 0 94 4 2
65–74 0 0 70 17 13
Malaysia 15–19 17 10 69 4 0
35–44 5 3 61 23 9
New Zealand 15–19 58 21 16 5 0
35–44 11 3 38 44 4

65–74 10 2 45 36 7
Niue 35–44 1 1 94 1 1
Papua New Guinea 15–19 4 25 55 14 2
35–44 1 2 39 33 25
Global periodontal health

29
Petersen & Ogawa

tries with advanced oral health systems, reflecting the

fact that systems may have only a modest impact on

(Score X or 9)
periodontal disease control at the population level.

Others
Public health: recording of periodontal
disease

AFRO, the African Region; AMRO, the Americas Region; EMRO, the Eastern Mediterranean Region; EURO, the European Region; SEARO, the South-East Asia Region; WPRO, the Western Pacific Region.
The CPI measure was included in the 1987 WHO
Deep periodontal
pockets: ‡6 mm

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

has been widely used in oral health surveys under-
(Score 4)

taken for planning programs and determining the

need for specific intervention. The system has been a

12

25
0

1
0

0
0

3
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
Shallow periodontal
pockets: 4–5 mm

be questioned from the current understanding of

mechanisms involved with gingivitis, development of
periodontal pocketing and loss of attachment. An-
(Score 3)

other difficulty relates to the recording of CPI in tooth

loss, particularly regarding the specification of teeth
4

0
6
35

29
58

61

for replacement if indicator teeth are not present.

While the original CPI may have relevance for
Gingival bleeding +

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
(Score 2)
calculus

designed a new, modified CPI system, taking weak-

nesses of the original CPI into consideration while
76

60
59

40
87

58
38

13

ensuring simplicity and reproducibility. The new

system reflects an effort of giving higher public health
Gingival bleeding

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-
(Score 1)

ent is recorded. Scores relevant to specific disease

conditions are applied to the individual tooth, namely
14
7

7
3

0
1

the presence ⁄ absence of gingival bleeding and the

presence ⁄ absence of periodontal pockets of 4–5 or
No symptoms

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

(Score 0)

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
2

1
0

0
13

26

52

Data are given as percentage of maximal CPI score.

been field tested in several oral health surveys carried

out in countries of different size and of different
Age-group

economies, ranging from Bahrain to China.

(years)

15–19

35–44
15–18

15–19
15–19

35–44
15–19

35–44

Socio-environmental conditions
Table 1. (Continued )

The Philippines

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

significant intercountry and intracountry variability
Singapore

in the prevalence of periodontal disease, and great

Vanuatu

Vietnam
Tonga
Country

variations are shown in socio-environmental condi-

tions, oral health systems, behavioral risk factors and
in the general health status of people.

30

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
Global periodontal health
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 periodontal
disease
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
Petersen & Ogawa
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
32
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 diabetes
mellitus
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).
 Global periodontal health

of South-East Asia where people have little access to

HIV ⁄ AIDS and periodontal health oral health care, including periodontal care.
Noma (debilitating oro-facial gangrene) is an
The HIV ⁄ AIDS pandemic has become a human, so- important disease burden in certain developing
cial and economic disaster, with far-reaching impli- countries, particularly among young children in
cations for individuals, communities and countries Africa and Asia (21–25). Severe acute periodontal
(Fig. 10). No other disease has so dramatically high- disease manifests at the onset of noma. Noma pri-
lighted the current disparities and inequities in marily starts as a localized gingival ulceration and
healthcare access, economic opportunity and the spreads rapidly through the oro-facial tissues,
protection of basic human rights. Sub-Saharan Africa establishing itself with a blackened necrotic centre.
has been most severely affected, with an estimated About 70–90% of cases are fatal in the absence of
22.5 million people living with HIV (78). In South- care. Fresh noma is seen predominantly in the 1–
East Asia there are more than 4 million people in- 4 years age-group, although late stages of the dis-
fected, and further spread could lead to millions ease occur in adolescents and adults. Poverty is the
more becoming infected in the coming decade. The key risk condition for development of noma; the
epidemic in Latin America is well established with environment inducing noma is characterized by
nearly 2 million people infected, and rapid growth severe malnutition and growth retardation, unsafe
has been observed in recent years in Eastern Europe drinking water, deplorable sanitary practices, resi-
and central Asia. Globally, the major mode of HIV dential proximity to unkempt animals and a high
transmission is through sexual intercourse, injecting prevalence of infectious diseases, such as measles,
drug use, mother-to-child transmission and through malaria, diarrhea, pneumonia, tuberculosis and
contaminated blood in healthcare settings. The rela- HIV ⁄ AIDS.
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). Periodontal problems among
Because of the compromised immune system and a people with disabilities
poor oral hygiene status, infected people are vulner-
able to periodontal disease. In addition to severe The oral health of people who are physically or
chronic gingivitis, poor periodontal health may mentally disabled is often impaired (6, 68). They may
manifest as acute necrotizing gingivitis, which is of- have limited capacity to detect and recognize early
ten seen in children and adolescents, and as necro- symptoms of disease. They may have limited ability
tizing periodontitis, which is mostly seen among to cope with everyday tasks related to personal hy-
adults (16). In particular, such disease conditions are giene, including oral hygiene, which are critical to
observed in Sub-Saharan Africa and in remote areas the maintenance of an independent existence. Oral

Western & Eastern Europe

Central Europe & Central Asia
820 000 1.4 million
[720 000 – 910 000] [1 3 million – 11.66 million]
[1.3
North America
1.5 million
[1.2 million – 2.0 million] East Asia
770 000
[560 000 – 1.0 million]
Middle East & North Africa
Caribbean
460 000
[400 000 – 530 000]
240 000
[220 000 – 270 000] South & South-East Asia
4.1 million
[3
[3.77 million – 44.66 million]
Sub-Saharan Africa
Central & 22.5 million
South America [20.9 million – 24.2 million]
1.4 million Oceania
[1.2 million – 1.6 million] 57 000
[50 000 – 64 000]

Fig. 10. Global estimates of adults

and children living with HIV/AIDS,
Total: 33.3 million [31.4 million – 35.3 million] 2009 (78), UNAIDS, 2010.

33
Petersen & Ogawa
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.
Causes of chronic diseases
Underlying Common Modifiable Intermediate Risk
Socioeconomic, Risk Factors Factors
Cultural, Political Unhealthy diet Raised blood pressure
and Environmental
Determinants Physical inactivity Raised blood glucose
Tobacco use Abnormal blood lipids
Globalization
Urbanization Nonmodifiable Overweight/obesity
Risk Factors
Population ageing
Age
Heredity
34
The need for public health
intervention: 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).
Main Chronic
Diseases
Heart disease
Stroke
Cancer
Chronic respiratory
diseases
Diabetes Fig. 11. The chain of causal factors
and mechanisms in chronic disease
(85).

Tobacco
Cancer, including oro-
pharyngeal
Alcohol Respiratory diseases
Cardiovascular disease
Diet Obesity
Diabetes
Stress Oral disease
Hygiene
Fig. 12. Common risk factors for chronic
including oral disease (54, 85).
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
Global periodontal health
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
disease, 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
35
Petersen & Ogawa
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
36
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 Ôwhere there is no dentistÕ,
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.

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 of
oral 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: ÔOral health: action plan for promotion and
integrated disease preventionÕ (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
Global periodontal health
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, OÕMullane 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, Stjernswärd 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, Ramón JM, Echeverrı́a 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
Petersen & Ogawa
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 période 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. Jürgensen 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.
38
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. Kruger E, Jacobs A, Tennant M. Sustaining oral health services
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. Lin HC, Schwarz E. Oral health and dental care in modern-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.

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.
Global periodontal health
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 adultsÕ 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
Health Organization, 2002.
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.
Geneva: World Health Organization, 2008.
92. World Health Organization. The world health report 2008.
Primary health care (Now More Than Ever). Geneva: World
Health Organization, 2008.
93. World Health Organization. World health statistics 2009.
Geneva: World Health Organization, 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).
39