Periodontology 2000, Vol. 67, 2015, 34–57 © 2014 John Wiley & Sons A/S.
ley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Periodontal disease in children
and adolescents of Latin America
J A V I E R E. B O T E R O , C A S S I A N O K U C H E N B E C K E R R OS
ADRIANA JARAMILLO & ADOLFO CONTRERAS
Periodontal diseases are a group of inflammatory
pathologies that mainly include gingivitis and
periodontitis. Gingivitis is a prevalent type of peri-
odontal disease in subjects of all ages, including
children and adolescents (2, 68, 71). Less prevalent
periodontal diseases include aggressive periodontitis,
acute necrotizing ulcerative gingivitis and diseases of
herpesvirus and fungal origin (6). Gingivitis and peri-
odontitis are considered to be a continuum of the
same inflammatory process, although it is important
to note that many gingivitis lesions do not progress to
periodontitis (46, 89). Immediately after tooth erup-
tion, bacterial biofilm begins to form at tooth surfaces
exposed to the oral cavity and in intimate contact
with the gingival margin. The severity of periodontal
disease depends on the level of biofilm accumulation,
the virulence of the biofilm bacteria and the humoral
and cellular immune responses to the biofilm micro-
biome.
Gingivitis in young individuals typically remains
chronic for a prolonged period of time without caus-
ing any damage to the periodontal ligament or bone.
However, an alteration of the balance between the
biofilm and the host can give rise to loss of periodon-
tal attachment. Chronic periodontitis and aggressive
periodontitis start as gingivitis but it has been difficult
to ascertain the biological processes involved in the
progression to periodontitis (7). Microbial dysbiosis,
overgrowth of pathogenic bacteria, herpesvirus reac-
tivation, immune-system disruption and acquired
and/or genetic susceptibility factors are probably
involved in disease progression from gingivitis to
periodontitis (23, 31, 70).
Epidemiology assesses the prevalence of diseases
and disease-associated factors in populations.
Epidemiologic data allow the identification of high-
risk populations and measures of potential value for
preventing disease. The topic of epidemiology of peri-
34
PERIODONTOLOGY 2000
€ ING, ANDRES DUQUE,
odontal diseases in children and adolescents of Latin
America, which is the focus of this review, is challeng-
ing as problems are encountered in terms of case def-
initions and the availability of adequate scientific
reports. Epidemiological data are scarce for some
parts of Latin America, especially with respect to
nationwide representative studies (38). The present
article addresses methodological issues pertaining to
the definition of periodontal disease in children and
adolescents, and then overviews the available epide-
miological findings on periodontal diseases of young
individuals in Latin America and potential risk factors
associated with the diseases. Information was
retrieved from country-wide studies and from studies
of selective populations.
Search methods
A systematic search was carried out using MEDLINE
(PubMed), LILACS, BIREME and SciELO to obtain
information on the periodontal condition of children
and adolescents in Latin America. The following
keywords in English, Spanish and Portuguese were
used in the search: ‘prevalence’, ‘frequency’, ‘gingivi-
tis’, ‘prepubertal periodontitis’, ‘juvenile periodonti-
tis’, ‘aggressive periodontitis’, ‘marginal bone loss’,
‘periodontal disease’, ‘children’, ‘adolescents’ and ‘ul-
ceronecrotizing gingivitis’. The previous terms used
for the disease currently known as ‘aggressive peri-
odontitis’ include ‘localized juvenile periodontitis’
(Fig. 1) and ‘generalized juvenile periodontitis’ (Figs 2
and 3), and these older diagnoses were also used in the
search of the available literature. The World Health
Organization (98) and the Panamerican Health Orga-
nization databases were also explored and a manual
search of local journals was performed. In addition,
the internet sites of the Ministry of Health from each
country were searched for data on oral health issues.
 Periodontal disease in Latin American children and adolescents
A C
B D
E G
F H
Literature reviews of periodontal disease in chil-
dren and adolescents have previously been published
in Periodontology 2000 (2, 43). Therefore, we decided
to focus on information that was not included in ear-
lier publications (i.e. mainly studies published in the
past 10 years). The studies included were preferably
of a size sufficient to provide a relatively precise
account of periodontal disease distribution in the
various countries of Latin America.
Methodological issues
Demmer & Papapanou (33) have provided a detailed
analysis of methodological issues in the study of
Fig. 1. Radiographic aspect of a
19-year-old patient with localized
aggressive periodontitis. Baseline
radiographs of maxillary (A, C) and
mandibular (E, G) molars show ini-
tial bone levels, and radiographs
taken 1 year later demonstrate rapid
bone-loss progression of the same
maxillary (B, D) and mandibular (F,
H) molars.
chronic and aggressive periodontitis. The present
article highlights some of the important issues in peri-
odontal epidemiology.
Case definition
Case definition is one of the most important issues
in epidemiology, and periodontal disease epidemiol-
ogy is no exception. The definition of gingivitis is rel-
atively simple, but the term ‘aggressive periodontitis’
is surrounded by controversy. One challenging issue
in the case definition of gingivitis (Fig. 4) is the
weight that should be given to gingivitis of little or
no clinical significance. If the presence of just one
site with bleeding on probing in a dentition is the
35
Botero et al.
A B C
cut-off point for the definition of gingivitis, the prev-
alence of gingivitis is practically 100% in all age
groups, including children and adolescents. If assess-
ing more clinically relevant gingivitis, the high preva-
lence figures for gingivitis decrease considerably. It is
also a matter of debate whether untreated severe
gingivitis is indeed a necessary prerequisite for
chronic or aggressive periodontitis (previously
known as juvenile periodontitis, prepubertal peri-
odontitis and early-onset periodontitis). A recent
review in Periodontology 2000 concludes that
although unique clinical features may exist for some
types of aggressive periodontitis, the clinical differ-
ence between aggressive periodontitis and chronic
periodontitis is not always discernable (7). Also, the
microbiology, the inflammatory response and the
outcome of treatment may not differ significantly
between patients with chronic periodontits and
those with aggressive periodontitis (7, 8, 32, 35, 89).
The diagnosis of ulcerative necrotizing periodontal
diseases, on the other hand, can be reliably made
based on distinct clinical signs.
The thresholds of clinical parameters used to
define the extent and severity of periodontal disease
are also fraught with uncertainty. Probing depths,
clinical attachment loss, radiographic bone level and
even tooth loss have been used to define degrees of
periodontal disease, but the use of any single clinical
parameter is associated with low diagnostic sensitiv-
ity. A combination of parameters, such as probing
36
Fig. 2. Clinical (A, B, C) and radio-
graphic (D) appearance of general-
ized aggressive periodontitis in
a 16-year-old woman.
depth and clinical attachment loss, increases the
probability of obtaining an accurate measure of the
periodontal disease status. However, a change in
cut-off points and in the number of affected sites
can result in a very different case definition and
prevalence rate of periodontal disease (29, 53, 75).
Case definition is an important topic in adult peri-
odontitis, but is not commonly considered in adoles-
cents (4) and is rarely considered in children.
Another problem of studying periodontal disease in
young subjects is the lack of periodontal clinical
recordings from dental visits at an early age. Difficult
child behavior in response to the inherent discom-
fort of a periodontal examination can complicate
data collection. In addition, assessment of periodon-
tal conditions in children can be difficult as a result
of the ongoing maturation of the dento–epithelial
junction, a high position of the gingival margin
(which may interfere with identification of the ce-
mento–enamel junction and its distance from the
alveolar bone), altered passive tooth eruption, the
presence of a mixed dentition and exfoliation of
deciduous teeth.
Periodontal indices
Periodontal indices have been developed to study the
epidemiology of periodontal diseases (Table 1). How-
ever, these indices can differ significantly in their esti-
mation of disease prevalence because of differences
 Periodontal disease in Latin American children and adolescents
B
A in case definition and the method of measuring peri-
B
Fig. 4. Mild gingivitis in a 6-year-old male patient (A) and in an
8-year-old female patient (B). Gingival inflammation and pla-
que accumulation are present in the mandibular anterior teeth.
Fig. 3. Clinical (A) and radiographic
(B) aspects of a 30-year-old man
with generalized aggressive peri-
odontitis. The patient was otherwise
healthy and presented with advanc-
ed periodontal attachment and bone
loss. Microbial analysis revealed a
subgingival microbiota composed of
Porphyromonas gingivalis (2.2 3 105
colony-forming units/ml), Fusobac-
terium spp. (1.5 3 105 colony-form-
ing units/ml), Prevotella intermedia
(2.9 3 106 colony-forming units/
ml), Tannerella forsythia (9 3 104
colony-forming units/ml), Campylo-
bacter spp. (1.6 3 105 colony-form-
ing units/ml) and Eikenella
corrodens (1.1 3 105 colony-forming
units/ml).
odontal disease. The use of partial mouth indices can
lead to overestimation or underestimation of disease
prevalence. A recent study of adolescents in Brazil
showed that partial-mouth examination protocols
may underestimate periodontal disease and sug-
gested that examination of at least two diagonal
quadrants may be necessary to quantify periodontal
disease in adolescents and young adults (77). The
Papillary, Marginal, Attached Index was originally
designed for the examination of children, and
although this index includes a score of periodontal
pockets, the severity and extent of more severe dis-
ease is not calculated, and the index is highly subjec-
tive. The Periodontal Disease Index was developed by
Ramfjord (81) to measure periodontal disease, but
this index can potentially over- or underestimate dis-
ease severity because only selected teeth are exam-
ined, and clinical attachment loss tends to be
underestimated because of recordings that fall inside
the set ranges of the index. Other periodontal indices
and their diagnostic proficiencies are presented in
Table 1.
The most serious deficiency of periodontal indices
is their focus on past periodontal destruction rather
than on current or future disease activity. Even
gingival bleeding on probing, which is a sign of more
37
Botero et al.

Table 1. Indices used to measure periodontal disease in epidemiological studies

Index Description Extension Considerations

Authors (year)
(reference)
Papillary Marginal P0: normal; no inflammation Partial mouth Extensive, only selected
Attached Gingiva Index teeth are assessed
P1: mild papillary engorgement; slight increase
Schour & Massler Mainly visible
in size
(1950) (57) examination

Schour & Massler P2: obvious increase in size of gingival papilla;

(1947) (100) bleeding on pressure
P3: excessive increase in size of gingival papilla with
spontaneous bleeding
P4: necrotic papilla
P5: atrophy and loss of papilla (through
inflammation)
M0: normal; no inflammation visible
M1: engorgement; slight increase in size;
no bleeding
M2: obvious engorgement; bleeding
on pressure
M3: swollen collar; spontaneous bleeding;
beginning of infiltration into attached gingiva
M4: necrotic gingivitis
M5: recession of the free marginal gingiva below
the cemento–enamel junction as a result of
inflammatory changes
A0: normal, pale rose; stippled
A1: slight engorgement with loss of stippling;
change in color may or may not be present
A2: obvious engorgement of attached gingiva with
marked increase in redness; pocket formation
present
A3: advanced periodontitis; deep pockets evident
Periodontal Index 0: negative. Neither overt inflammation nor loss of Full mouth Composite index, which
Russell (1956) (86) function caused by the destruction of supporting takes into
tissue is noted consideration changes
caused by gingivitis
1: mild gingivitis. Overt inflammation in the free
and periodontitis. The
gingiva is present but does not circumscribe
major disadvantage is
the tooth
that it does not
2: gingivitis. Inflammation surrounds the tooth, consider the degree
but there is no apparent break in the epithelial of periodontal
attachment. destruction (clinical
4: used only when radiographs are available. Early attachment loss)
bone loss is noticeable
6: gingivitis with pocket formation. The epithelial
attachment of gingiva to tooth is broken. There is
no interference with normal function. The tooth
is not loose or drifting
8: advanced destruction with loss of function.
The tooth may be loose or drifting. It may sound
dull on percussion and may be depressible in
the socket

38
 Periodontal disease in Latin American children and adolescents

Table 1. (Continued)

Index Description Extension Considerations

Authors (year)
(reference)
Periodontal Disease Index 0: normal gingiva; absence of clinical inflammation Partial mouth Although it measures
Ramfjord (1959) (81) and bleeding clinical attachment
loss, the values
1: slight to moderate gingivitis in some areas around
between the ranges
the tooth
are underestimated.
2: slight to moderate gingivitis around the tooth When index teeth are
3: intense gingivitis; ulceration; bleeding severely affected this
could lead to
4: clinical attachment loss <3 mm overestimation
5: clinical attachment loss 3–6 mm
6: clinical attachment loss >6 mm
Gingival Index 0: normal gingiva; absence of clinical inflammation Full mouth/ Highly subjective.
̈
Loe & Silness (1963) (48) and bleeding partial mouth Does not include
when modified periodontal
1: slight inflammation; absence of bleeding
destruction. Only
2: moderate inflammation; swelling; redness; considers changes
bleeding on probing in the marginal
3: intense inflammation; swelling; morphologic periodontium
changes; spontaneous bleeding
Community Periodontal 0: normal gingival, absence of clinical inflammation Partial mouth It does not consider
Index of Treatment and bleeding periodontal
Needs destruction.
1: bleeding on probing
Ainamo et al. Underestimation and
(1982) (1) 2: bleeding on probing, supra- and subgingival overestimation could
calculus; iatrogenic restorations occur. Not designed
3: shallow periodontal pockets 4–5 mm for children and young
adults (<20 years
4: deep periodontal pockets >6 mm of age)
Extent and Severity Index A tooth site is considered diseased only when loss Partial mouth Frequent
Carlos et al. (1986) (16) of attachment exceeds 1 mm. The result (Extension (28 surfaces) overestimation.
Severity) is expressed as two numbers, in which Descriptive nature
the first is the extension (number of sites) and
the second is the mean clinical attachment loss
(in mm)
Extent and Severity Index Identify the 10 proximal tooth sites that provide Partial mouth
based on partial Extent and Severity estimates of clinical (10 sites)
assessment attachment loss, which are maximally coherent
Papapanou et al. to the full-mouth scores
(1993) (76)

Mean probing depth Six sites per tooth, excluding third molars Full mouth Time consuming.
It provides a more
Mean probing depth = sum of all measurements/
precise assessment
number of teeth 9 6
of the periodontal
condition
Mean clinical Six sites per tooth excluding third molars Full mouth Time consuming.
attachment loss It provides a more
Mean clinical attachment loss = sum of all
precise assessment
measurements/number of teeth 9 6
of the periodontal
condition

serious disease, has not always been included in peri- probing depths, clinical attachment levels and bleed-
odontal indices. The best available periodontal indi- ing-on-probing sites. Radiographic analysis would be
ces employ full-mouth examination with recording of helpful, but may be impractical, or even unethical, in

39
Botero et al.
large epidemiological studies. Contemporary studies
only request a radiographic examination if indicated
by the clinical information and therefore radiographic
epidemiological data are scarce.
The Community Periodontal Index of Treatment
Needs and the later variant, named the Community
Periodontal Index, are perhaps the periodontal indi-
ces most commonly utilized in epidemiological
studies (1). These two indices were designed for
population-based studies and are easy to use, but
have several disadvantages. For instance, only six
teeth are examined in children and youngsters
under 20 years of age. This was proposed to avoid
mislabeling a deep sulcus, resulting from an erupt-
ing tooth, as periodontal disease. Only gingival
bleeding and calculus are recorded in young indi-
viduals, which may lead to underestimation of the
destructive types of disease. This was illustrated in
the study of Benigeri et al. (10), who found that a
tooth with a pocket depth of ≥6 mm was detected
in 8.5% of adults if only two sites were examined
per tooth. However, the percentage of teeth with a
pocket depth of ≥6 mm increased to 21.4% if prob-
ing was performed in all surfaces of every tooth.
The partial recording system resulted in underesti-
mation of the prevalence of subjects having at least
one tooth with Community Periodontal Index of
Treatment Needs periodontitis scores of 3 and 4.
Despite the criticism of the Community Periodontal
Index of Treatment Needs index, especially with
40
regard to treatment needs, the index has been used
in numerous epidemiological studies. The World
Health Organization no longer supports the treat-
ment-need part of the index and now also measures
attachment loss instead of periodontal pocket
depth. The lack of uniformity between the two
World Health Organization indices can complicate
the process of data analysis.
Language, availability and local
relevance of scientific papers
Language, availability and local relevance of scientific
papers are issues in Latin America, where a large pro-
portion of articles are written in Spanish or Portu-
guese and are published in local journals or websites
(i.e. that of the Ministry of Health). Articles not writ-
ten in English may provide important information
but are not readily accessible to researchers outside
the region and hence are not frequently cited. Local
studies may also show methodological deficiencies,
which must be considered when interpreting the
published results.
Periodontal disease in Brazil
Brazil is the largest country (8,514,877 km2) in Latin
America, with a population of more than 190 million
and with almost 240,000 dentists (Fig. 5). Brazil is also
Fig. 5. Map showing demographic
information and number of dentists
in Latin American Countries. Dispar-
ity in the number of dentists avail-
able for the population is evident
among the countries (99).
 Periodontal disease in Latin American children and adolescents
the Latin American country with the greatest number
of studies of periodontal disease occurrence
(Table 2). However, large heterogeneity in periodon-
tal case definition and great disparity among popula-
tions from various regions of the country make it
virtually impossible to merge data from different
studies.
The 2004 nationwide representative survey of 15-
to 19-year-old individuals found, using Community
Periodontal Index estimates, that 46.2% exhibited
gingival health, 18.8% exhibited gingival bleeding
and 33.4% exhibited supragingival calculus; regard-
less, periodontal pockets of ≥4 mm were present in
fewer than 2% of the study individuals (59). Nicolau
et al. (66), Antunes et al. (5), Biazevic et al. (11) and
Freire et al. (36) found gingival bleeding and dental
calculus in approximately 20% of children and ado-
lescents, but virtually no pockets of ≥4 mm. How-
ever, Maltz & Barbachan e Silva (54), Maltz et al.
(55), Feldens et al. (34) and Rebelo et al. (82), who
also used the Community Periodontal Index esti-
mates, demonstrated gingivitis in more than 90% of
Brazilian children and adolescents, and 15–35%
exhibited bleeding gingiva. Nogueira dos Santos
et al. (67) found calculus in approximately 50% of
young subjects.
A higher prevalence of periodontal breakdown has
been reported in large studies with full-mouth
periodontal examination. Cortelli et al. (26), demon-
strated, in the south-east region of Brazil, a prev-
alence of 3.7% for generalized aggressive
periodontitis and a prevalence of 1.7% for localized
aggressive periodontitis. Susin & Albandar (92)
found a prevalence of 2.1% for aggressive periodon-
titis and a prevalence of 18% for chronic periodonti-
tis in 14- to 19-year-old subjects. Susin et al. (91)
demonstrated gingival recession in almost 30% of
14- to 19-year-old subjects. A radiographic-based
study, performed by Guimaraes et al. (41) in 2- to
11-year-old children, found definite bone loss in
fewer than 1% and questionable bone loss in
approximately 10% of subjects. A retrospective lon-
gitudinal study based on bitewing radiograph exam-
ination of 3- to 10-year-old subjects with no obvious
signs of periodontitis initially found that periodontal
bone loss increased with age, and the presence of
tooth surfaces with either caries or restorations
increased the probability of bone loss (97). Two
smaller studies of riverside isolated communities
found clinical attachment loss of ≥3 mm in 100% of
the individuals (24) and aggressive periodontitis in
approximately 10% (25). One, 52-month longitudinal
study of untreated children and adolescents
observed an increasing number of periodontal sites
of ≥4 mm and a 34% increase in alveolar bone loss
(28).
Some peculiarities have been published on peri-
odontal diseases in children and adolescents from
Brazil. A nationwide epidemiological study of 16,126
adolescents, 15–19 years of age, found that 35.6%
had experienced dental and gingival pain in the past
6 months (14). Significant associations were
observed between dental and gingival pain and
female gender, low income, nonstudents and stu-
dents enrolled in public schools with grades that
were low for the age group (14). Also, a higher prev-
alence of oral pain was associated with higher pre-
valences of dental caries and calculus (14). A study
of HIV-infected children, 0–14 years of age, revealed
that only 12.5% of subjects were plaque-free and
that 58.9% showed gingivitis, with an average of 4.4
bleeding sites (84). A study in southern Brazil found
a high level of gingivitis in children with cerebral
palsy, which was probably related to poor oral-
hygiene habits (40).
A microbiological study of aggressive and chronic
periodontitis found that the occurrence of periodon-
topathic bacteria was similar to that reported in other
countries (27). Interestingly, the level of periodontitis
in adolescents was positively related to the presence
of leukotoxic Aggregatibacter actinomycetemcomitans
strains (27). A genetic study identified a positive asso-
ciation between aggressive periodontitis and two
markers – rs1935881 and rs1342913 – in the FAM5C
gene (19).
In sum, the studies from Brazil point to increasingly
severe periodontal disease in subjects with heavy
accumulations of plaque and calculus and of low
socio-economic status.
Periodontal disease in Argentina
Argentina is the second-largest country in South
America and has a population of over 40 million
(Fig. 5). An epidemiological study of 2,279 children,
7–8 and 12–13 years of age, was carried out in eight
different regions of Argentina (30) (Table 3). In the 7–
8 years’ age group, the prevalence of marked gingivi-
tis was 2.7%, compared with the 12–13 years’
age group, in which the prevalence was 27.2%. The
author also compared the prevalence of gingivitis
between two populations of different ethnic origins
and found that native Americans were more affected
compared with Caucasians (24.7% versus 15.4%,
respectively) (30).
41
Botero et al.

Table 2. Studies of periodontal disease in children and adolescents in Brazil

Authors Number of Male/Female Age Clinical findings Remarks

(year) subjects ratio (years)
(reference)
Maltz & 1,000 students 447/553 12 Full-mouth Gingival Bleeding Representative sample.
Barbachan e from public Index. Prevalence of gingival Gingival Bleeding Index
Silva (2001) and private bleeding in public and private was higher in students
(54) schools schools: 98.1% and 95.7%, from public schools
respectively. Extension of
Gingival Bleeding Index (mean
Gingival Bleeding Index) in
public and private schools: 21.7%
and 14.7%, respectively
Maltz et al. 233 students Not available 8–10 Full-mouth Gingival Bleeding Two school-based
(2001) (55) examined in Index. Mean Gingival Bleeding cross-sectional surveys
1975 and 185 Index in 1975: 24.5%. Mean performed in the
students Gingival Bleeding Index in same school, with
examined in 1996: 35.5% different children,
1996 in 1975 and 1996.
A significant increase
(P = 0.001) was
observed in average
Gingival Bleeding
Index
Cortelli et al. 600 individuals 244/356 15–25 Full-mouth periodontal The presence of
(2002) (26) from the examination and radiographic periodontal destruction
region of Vale examination. Prevalence of was higher in female
do Paraıba localized aggressive periodontitis: students than in male
1.66%. Prevalence of generalized students (P < 0.05)
aggressive periodontitis: 3.66%.
Prevalence of incipient
periodontitis: 14.3%
Nicolau et al. 652 adolescents Not available 13 Full-mouth gingival bleeding 311 families were
(2003) (66) (Community Periodontal Index interviewed and early
score 1). Worst score in each life-course experiences
tooth considered. Prevalence of (such as being born in
gingival bleeding: 99%. Severity a family with a low
of gingival bleeding – individuals socio-economic status,
with <62% of bleeding sites: presently living in an
48.6% overcrowded house,
mother with <8 years
of education, those
with schooling delay,
without nuclear
families and who
experienced severe
paternal punishment)
presented the worst
gingival status
Susin et al. 266 individuals 133/130 14–19 Full-mouth periodontal A high level of gingival
(2004) (91) from a examination. Prevalence of recession was observed
representative gingival recession ≥1 mm: 29.5%. in this population,
sample of the Prevalence of gingival recession mainly related to
metropolitan ≥2 mm: 12.2%. Prevalence of periodontal disease.
area of Porto gingival recession ≥3 mm: 5.9% Analytical model
Alegre demonstrated significant
association with the
presence of calculus
and smoking

42
 Periodontal disease in Latin American children and adolescents

Table 2. (Continued)

Authors Number of Male/Female Age Clinical findings Remarks

(year) subjects ratio (years)
(reference)
rio da 7,772
Ministe Not available 15–19 Periodontal examination: Representative sample
 de (2003) individuals
Sau Community Periodontal of the whole country.
(59) from all Index. Prevalence of The worst periodontal
regions in the healthy periodontium: conditions were found in
country 46.18%. Prevalence of less-developed regions
gingival bleeding: 18.77%.
Prevalence of calculus: 33.4%.
Prevalence of 4–5 mm pockets:
1.19%. Prevalence of ≥6 mm
pockets: 0.15%
Susin & 612 individuals 291/321 14–29 Full-mouth periodontal Analytical model
Albandar from a examination. Prevalence of demonstrated significant
(2005) (92) representative aggressive periodontitis in association with
sample of the 14- to 19-year-old-subjects: 2.1% socio-economic status,
metropolitan smoking and the
area of Porto presence of calculus
Alegre
Feldens et al. 490 children 260/230 3–5 Full-mouth visible plaque and Visible plaque and gingival
(2006) (34) from nursery Gingival Bleeding Index. bleeding were positively
schools Prevalence of visible plaque: 99%. associated. Gingival
Prevalence of gingival bleeding: Bleeding Index was more
77% severe in posterior than
in anterior teeth.
Associations were
observed between
gingival bleeding and
gender (boys presented
higher occurrence), low
socio-economic status
and anterior maxillary
teeth without spacing
Nogueira dos 971 individuals 458/513 10–18 Periodontal examination: The study was performed
Santos et al. from public Community Periodontal Index. in two cities, using two
(2007) (67) (municipal Prevalence of healthy sextants different methodologies.
and state) and in municipal, state and private Data from Recife (n = 40)
private schools schools: 31.4%, 244.0% and were not considered.
54.2%, respectively. Prevalence A significant association
of gingival bleeding in municipal, was observed between
state and private schools: 20.4%, the type of school and the
21.6% and 27.0%, respectively. prevalence of periodontal
Prevalence of calculus in conditions, with students
municipal, state and private from private schools
schools: 58.1%, 54.5% and 18.8%, presenting healthier
respectively periodontal states
Costa et al. 44 students 21/23 Mean age Longitudinal study with Despite the reduced
(2007) (28) from a public at 52 months of follow-up. number of individuals, a
school baseline: Periodontal examination: longitudinal approach
12.4 years clinical attachment level and allowed us to understand
bone loss. 34% increase in the progression of
bone loss over time. Prevalence periodontal breakdown
of sites with bone loss in adolescents
increased from 2.1% to 7.5%
(P < 0.001). Increased number
of sites with clinical attachment
loss ≥4 mm

43
Botero et al.

Table 2. (Continued)

Authors Number of Male/Female Age Clinical findings Remarks

(year) subjects ratio (years)
(reference)
Biazevic et al. 247 individuals 130/117 15–17 Periodontal examination: Association between the
(2008) (11) from a Community Periodontal Index. presence of periodontal
cross-sectional Prevalence of healthy sextants: disease approached
population 47.8%. Prevalence of gingival significance with Oral
study bleeding: 39.8%. Prevalence of Health Impact Profile
calculus: 9.7%. Prevalence of (P = 0.053)
pockets 4–5 mm: 2.8%
Corraini et al. 39 individuals 21/18 12–19 Full-mouth periodontal Clinical attachment loss
(2008) (24) from an examination. Prevalence of is highly prevalent.
isolated clinical attachment loss ≥3 mm: Associations were
riverside 100%. Prevalence of clinical observed with smoking
population, attachment loss ≥4 mm: 7.7%. and the presence of
with no access Prevalence of clinical attachment dental calculus
to dental care loss ≥7 mm: 5.1%. Prevalence of
probing depth ≥3 mm: 100%.
Prevalence of probing depth
≥5 mm: 5.1%. Prevalence of
probing depth ≥7 mm: 5.1%
Antunes et al. 1,799 735/1,064 15–19 Periodontal examination: Representative sample.
(2008) (5) adolescents Community Periodontal Index. Gingival bleeding and
from 35 cities Prevalence of healthy sextants: calculus were associated
in the state of 65.7%. Prevalence of gingival with gender (higher values
Sa~o Paulo bleeding: 21.6%. Prevalence were found in male
of calculus: 19.4% subjects), different from
white ethnicity, school
delay and household
crowding. Access to dental
services showed a positive
association with better
periodontal conditions
Rebelo et al. 889 students 399/490 15–19 Full-mouth Lo € e & Silness Gingival Representative
(2009) (82) from public Index. Prevalence of gingival cross-sectional survey
and private bleeding: 53.3%. Reported
schools severity of gingivitis – mild:
78.5%; moderate: 16.1%;
severe: 0.11%.
Corraini et al. 39 individuals 21/18 12–19 Full-mouth periodontal Individuals with aggressive
(2009) (25) from an examination. Prevalence of periodontitis presented
isolated aggressive periodontitis in male high amounts of
riverside subjects: 9.5%. Prevalence of plaque-retaining factors
population, aggressive periodontitis in female
with no access subjects: 11.1%
to dental care
Freire et al. 1,947 students 941/1,006 12 Periodontal examination: Representative sample.
(2010) (36) from public Community Periodontal Index. Students from public
and private Prevalence of healthy schools presented the
schools in periodontium in public and worst periodontal
Goiania private schools: 71.4% and 93.6%, conditions (P < 0.001)
respectively. Prevalence of
gingival bleeding in public and
private schools: 19.1% and 1.3%,
respectively. Prevalence of
calculus in public and private
schools: 9.5% and 5.1%,
respectively

44
 Periodontal disease in Latin American children and adolescents

Table 2. (Continued)

Authors Number of Male/Female Age Clinical findings Remarks

(year) subjects ratio (years)
(reference)
Guimaraes 450 healthy 234/216 2–11 Bone loss was measured in Convenience sample from
et al. (2010) children bitewing and periapical dental clinics. Limited
(41) treated in radiographs. Prevalence of external validity.
pediatric definite bone loss of ≥3 mm, No association with
dentistry measured from cemento-enamel age was observed
clinics junction to alveolar bone
crest: 0.85% in male subjects
and 0.46% in female subjects.
Prevalence of questionable
bone loss of >2 mm
but <3 mm, measured
from cemento-enamel
junction to alveolar bone
crest: 9.82% for male subjects
and 6.48% for
female subjects
Bonanato 551 individuals 277/274 5 Gingival bleeding, visible plaque Representative sample.
et al. (2010) from a random and calculus were measured and Analytical approach
(13) sample in Belo a prevalence of 18.5% of indicated an association
Horizonte gingivitis, 45.4% of visible plaque between social and
and 8.9% of calculus was cultural factors and the
observed prevalence of oral
diseases
Susin et al. 619 individuals 291/321 14–19 Full-mouth periodontal Analytical model
(2011) (93) from a examination. Prevalence of demonstrated significant
representative chronic periodontitis in 14- to association with older
sample of the 19-year-old subjects: 18.2% age, socio-economic
metropolitan status and the presence
area of Porto of calculus
Alegre

Chiappe et al. (21) examined the periodontal status
of 19-year-old individuals enrolled in the School of
Dentistry at the University of Buenos Aires. At the
start of the study, 34.7% of periodontal sites exhibited
bleeding on probing and 91% of the students showed
at least one site with bleeding on probing; and 7.9%
of periodontal sites presented ≥1 mm of clinical
attachment loss and 49.6% of the students had at
least one site with ≥1 mm of attachment loss. In bite-
wing radiographs, 2.95% of sites presented alveolar
bone loss of >2 mm (21). There were no significant
differences between the initial examination and a 2-
year follow-up examination in bleeding on probing,
clinical attachment loss and alveolar bone loss (21).
Moreno & Esper (63) studied incisors and first molars
in subjects 14–18 years of age and found prevalences
of 1 and 2 mm of clinical attachment loss to be 39.8%
and 7.4%, respectively (63). Barletta et al. (9) exam-
ined 14- to 15-year-old subjects from two schools in
La Plata, Argentina. They detected no signs of peri-
odontitis, but Gingival Index scores of, respectively, 1
and 2 were found in 67.7% and 13.4% of the subjects
(9).
Periodontal disease in Mexico
Mexico is the third-largest country in Latin America
and has the second-largest size of population
(Fig. 5). Five periodontal studies with considerable
population samples (i.e. of more than 300 subjects)
have been performed in Mexico (Table 4). The first
study, which included 1,263 children of 13–17 years
of age, found a prevalence of gingivitis of 44%
using the Russel Index (PI) (73). The next three
studies examined a sample of 300–500 children of
4–16 years of age and found a prevalence of gingi-
vitis of 13–70% (45, 64, 74). The most representa-
tive study included 25,764 young individuals (88).
This study demonstrated that the 6- to 9-year’ age

45
Botero et al.

Table 3. Studies of periodontal disease in children and adolescents in Argentina

Authors Number of Male/Female Age Clinical findings Remarks

(year) subjects (% or number) (years)
(reference)
de Mun~ iz 2,279 Not available 7–8 75% presented with plaque Oral Health survey.
(1985) (30) 12–13 deposits. Prevalence of Calculus and gingivitis
calculus was 0.4% in increased with age.
7-year-old subjects and A lack of adequate dental
16.1% in 13-year-old care was found in all
subjects. Prevalence of regions evaluated
gingivitis was 2.7% in
7-year-old subjects and
27.2% in 13-year-old subjects
Chiappe et al. 475 dental 31.7%/68.3% 19 Prevalence of gingivitis was After studying dentistry
(1997) (21) students. Two 91%, measured as bleeding for 2 years the
years later 240 on probing positive in at prevalence of gingivitis
dental students least one site. Prevalence was similar but the
were of alveolar bone loss >2 mm severity was lower.
re-examined was 3.0% and in no subjects Periodontal condition
did measurements exceed was not substantially
3 mm modified
Moreno & 394 227/167 14–18 Clinical attachment loss Minimal clinical
Esper (2003) of 1 mm= 38.9% and of attachment loss was
(63) 2 mm=7.4% observed and in no
case exceeded 2 mm
Barletta et al. 149 57.6%/42.4% 14–15 67.7% with Gingival Index Gingival Index was used.
(2006) (9) score = 1 No signs of periodontitis
13.4% with Gingival Index were observed. None of
score = 2 the subjects presented a
Gingival Index score of 3.
However, 32.8% of
subjects had gingival
bleeding

group was almost free of gingival inflammation
(Community Periodontal Index score 0 = 91.7%);
the 10- to 14-year’ age group still presented high
figures of health (Community Periodontal Index
score 0 = 83.3%), despite the fact that 10.3% pre-
sented with gingivitis and 6.4% with calculus; and
the 15- to 19-year’ age group revealed periodontal
health in only half of the subjects, with 18.7% pre-
senting with gingivitis, 15.9% with calculus, and,
although 1.2% had pockets of 4–5 mm, only 0.2%
showed pockets of >6 mm (88). Two studies
assessed gingival inflammation in a sample of <80
subjects with ages between 4–5 and 10–19 years
and found prevalences of gingivitis of 39% and
71.6%, respectively (18, 94). Another study exam-
ined bitewing radiographs of 4-year-old children
and found a frequency of marginal bone loss of
7.8% (17). A common finding in the studies from
Mexico was that poor plaque control and low
socio-economic status increased the frequency of
gingivitis, and gingivitis also increased with increas-
ing age. Unfortunately, no studies have attempted
to quantify the level of aggressive periodontitis in
Mexico.
Periodontal disease in Colombia
and Venezuela
Colombia is the fifth country in size in Latin America
with a population of over 40 million (Fig. 5). In 1998,
Colombia conducted the third National Study of Oral
Health in rural and urban regions (83) (Table 5). Gin-
gival bleeding on probing was observed in 72.1% of 7-
year-old subjects and in 84.1% of 12-year-old subjects
(83). Calculus and defective dental fillings were found
in 60.9% of the 7- to 12-year-old subjects (83). In the
group of 15- to 19-year-old subjects, 89.2% presented
with gingival bleeding and 60.9% presented with cal-
culus and defective dental fillings (83). All gingivitis
patients required periodontal treatment according to
the Community Periodontal Index of Treatment

46
 Periodontal disease in Latin American children and adolescents

xico
Table 4. Studies of periodontal disease in children and adolescents in Me

Authors Number Male/Female Age Clinical findings Remarks

(year) of (% or (years)
(reference) subjects number)

Carranza 115 Not 4 7.8% presented marginal bone loss Bitewing radiographs were
et al. (1998) available used to assess marginal
(17) bone loss. Incipient
marginal bone loss was
observed at an early age
Carrillo et al. 74 44.6%/ 10–19 Gingivitis 71.6% Ramfjord Periodontal Disease
(2000) (18) 55.4% Index was used to assess
periodontal tissues.
Gingival inflammation
showed a tendency to
increase with age,
Ramfjord Index scores
of 2 and 3 were obtained
Orozco et al. 1,263 45.1%/ 13–17 Gingivitis 44% Ramfjord’s Periodontal
(2002) (73) 54.9% Disease Index was used to
assess periodontal tissues.
Economic status influenced
the prevalence of the disease:
low-income populations
had a higher prevalence
of gingivitis
Murrieta 389 Not 8–12 Gingivitis 20.6% Gingival Index was used to
et al. (2004) available assess inflammation.
(64) Gingival inflammation
lower than expected. Poor
oral hygiene was the main
indicator for gingivitis
rez-Lo
Jua  pez 382 48%/52% 4–6 Gingivitis 70% (PI) Gingival inflammation was
et al. (2005) highly prevalent and
(45) increased with age

Ortega et al. 590 45.3%/ 13–16 Gingivitis 13.7% No periodontal probe was
(2007) (74) 54.7% <13 years old: 12.3% gingivitis used; a visual
>14 years old: 60.5% gingivitis examination was performed.
The prevalence of gingivitis
increased with age
SIVEPAB 25,764 Not 6–9 Community Periodontal Index score 0 = 91.7% Large scale National Oral
(2010) (88) available health survey with a
Community Periodontal Index score 1 = 7.1%
representative sample.
Community Periodontal Index score 2 = 1.2% Periodontal pockets of
10–14 Community Periodontal Index score 0 = 83.3% 4–5 mm appeared in the
15- to 19-year-old
Community Periodontal Index score 1 = 10.3% subjects and the presence
Community Periodontal Index score 2 = 6.4% of pockets
of >6 mm was very low
15–19 Community Periodontal Index score 0 = 64.1%
Community Periodontal Index score 1 = 18.7%
Community Periodontal Index score 2 = 15.9%
Community Periodontal Index score 3 = 1.1%
Community Periodontal Index score 4 = 0.2%

47
Botero et al.
Table 4. (Continued)
Authors Number Male/Female Age Clinical findings
(year) of (% or (years)
(reference) subjects number)
Taboada & 77 51.9%/ 4–5 Gingival inflammation 39%
Talavera 48.1%
(2011) (94)
PDI, periodontal disease index.
Needs (83). Deep periodontal pockets, as defined by
the Community Periodontal Index of Treatment
Needs, were observed in 1% of the 7- to 12-year-old
individuals (83). Of the 15- to 19-year-old subjects,
31.4% exhibited localized attachment loss and 1.4%
generalized attachment loss (83). Clinical attachment
loss in 15- to 19-year-old subjects was slight (1–
2.9 mm) in 31%, moderate (3–4 mm) in 1.7% and
severe (>5 mm) in 0.1%, according to the Extent and
Severity Index (76). No attachment loss was seen in
67.3% of the study subjects.
Go mez-Restrepo et al. (39), in a large random sam-
ple of 14- to 17-year-old individuals, found clinical
attachment loss of ≥1 mm in 40.6% of subjects, of
≥2 mm in 29.9% and of ≥3 mm in 16.0%, and attach-
ment loss was greater in male subjects than in female
subjects (P < 0.05). Interproximal attachment loss of
≥1 mm, ≥2 mm and ≥3 mm was, respectively, 34.2%,
21.4% and 11.7% (39). Orozco et al. (72) found that in
7- to 14-year-old subjects from a native island com-
munity, 45.4% had a Community Periodontal Index
of Treatment Needs score of 1, 40.9% had a score of 2
and 13.7% had a score of 3. In the 15- to 19-year old
subjects, a Community Periodontal Index of Treat-
ment Needs score of ≥2 was observed in 77.8% of
subjects and a Community Periodontal Index of
Treatment Needs score of 4 was found in 11.1% (72).
These results point to increased severity of periodon-
tal disease in communities with low access to
professional dental care. However, in another native
community from the southeast of Colombia, Triana
et al. (95) found a lower need for treatment (Commu-
nity Periodontal Index of Treatment Needs score
0 = 59.7%, score 1 = 30.5% and score 2 = 9.7%) in
children 7–12 years of age.
Between 1965 and 2000, Jime nez et al. (44)
described children and adolescents with acute necro-
tizing ulcerative gingivitis (n = 29), necrotizing ulcer-
ative periodontitis (n = 7) and noma/cancrum oris
(n = 9). The individuals were not infected with HIV,
but virtually all presented with predisposing condi-
48
Remarks
Papillary Marginal
Attached Gingival Index
was used. Gingivitis starts
at an early age and was
associated with poor
plaque control. O’Leary
plaque index was 75.4%
tions such as acute herpetic gingivostomatitis, mea-
sles and leukemia. Low socio-economic status,
malnutrition and poor oral hygiene habits were
identified as contributory factors. Microbiological
examination of noma lesions identified gram-nega-
tive bacteria, Neisseria species, fusiform bacilli, Lepto-
trichia buccalis and fungi.
Periodontal data from Venezuela are scarce. Navaz
et al. (65) found a prevalence of gingivitis of 40–60%
in children 6–9 years of age, and this high prevalence
was associated with unfavorable attitudes and low
educational level of the parents. Another study (12)
found that necrotizing ulcerative gingivitis was more
prevalent (32,44%) in the 15–20 age group than adults
and it was associated with previous history of gingivi-
tis and poor oral hygiene.
Periodontal disease in Chile
Large population studies have been conducted in
Chile (Table 6). In 1991, Lo pez et al. (50) reported a
prevalence of aggressive periodontitis of 0.32% in
2500 adolescents, 15–19 years of age. Another large
study of 9,163 individuals, of 12–21 years of age,
found that clinical attachment loss of ≥1 mm
occurred in 69.2% of the study subjects, of ≥2 mm in
16.0% and of ≥3 mm occurred in 4.5% (51). Interprox-
imal clinical attachment loss of ≥1 mm was observed
in 56.4% of the study subjects, of ≥2 mm in 13.1% and
of ≥3 mm in 3.7% (51). The mean number of peri-
odontal sites with clinical attachment loss of ≥1 mm
ranged from 4.3 to 6.6, with clinical attachment loss
of ≥2 mm in 2.6–4.3 sites and of ≥3 mm in 1.5–4.0
sites (51). Clinical attachment loss was positively
associated with infrequent tooth brushing, dental vis-
its <1 year ago and attending a government-sup-
ported school. A national study of oral health in 2007
found that the frequency of gingivitis increased with
age, as follows: 2-year-old subjects, 2.6%; 4-year-old
subjects, 6.2%; 6-year-old subjects, 55%; and 12-year-
 Periodontal disease in Latin American children and adolescents

Table 5. Studies of periodontal disease in children and adolescents in Colombia and Venezuela

Country Authors Number of Male/ Age Clinical findings Remarks

(year) subjects Female (years)
(reference) (% or
number)

Colombia Ministerio de 2,682 Not 7–19 Extent and Severity Large-scale oral health
Salud (1999) available Index 21%: 1.1 mm. survey. Gingivitis was
(83) Gingivitis 72.1% in highly prevalent.
7-year-old subjects; Community Periodontal
gingivitis 84.1% in Index of Treatment Needs
12-year-old subjects. and Extent and Severity
Periodontal pockets Index. Periodontal pockets
of >5 mm in 15- to were only
19-year-old observed with increasing
subjects: 1% age
Colombia Orozco et al. 40 Not 7–19 65% of subjects with More than half of the
(2004) (72) available Community sample required some
Periodontal Index type of periodontal
of Treatment Needs treatment
score of > 1, and
complex periodontal
treatment needs in
11.1% of those
subjects
Colombia Triana et al. 82 Not 7–12 30.5% with Community Better oral health
(2005) (95) available Periodontal Index of conditions in this
Treatment Needs population compared
score of 1 and 9.7% with Oral Health National
with Community Survey data
Periodontal Index
of Treatment Needs
score of 2
Colombia Jimenez et al. 45 Not 2–26 Necrotizing ulcerative Not a population-based
(2005) (44) available gingivitis: 29 subjects study. Reflects socio-
(64.4%). Necrotizing economic and hygiene
ulcerative periodontitis: conditions associated
7 (15.6%). Noma: 9 (20%) with necrotizing
periodontal diseases such
as necrotizing ulcerative
gingivitis and necrotizing
ulcerative periodontitis.
Patients with no HIV
infection, in contrast with
other reports
Colombia Go mez- 629 49.8%/ 14–17 The prevalence of clinical Students randomly
Restrepo 50.2% attachment loss selected from public
et al. (2008) ≥1 mm was 40.6%; schools of low and
(39) of ≥2 mm was 29.9%; medium socio-economic
and of ≥3 mm levels. Male gender was
was 16% associated with a higher
probability of having
clinical attachment loss,
using a logistic regression
model
Venezuela Navaz et al. 132 Not 6–9 40–60% presented Gingivitis was frequently
(2002) (65) available with a gingival index associated with the
of 1 unfavorable attitudes
and low educational level
of the parents

49
Botero et al.

Table 6. Studies of periodontal disease in children and adolescents in Chile

Authors (year) Number of Male/Female Age Clinical findings Remarks

(reference) subjects (% or (years)
number)

 pez (1991) (50)

Lo 2,500 52.7%/47.3% 15–19 Aggressive periodontitis After initial screening,
0.32% 27 subjects were
suspected as having
aggressive periodontitis.
Only in eight was
this confirmed by
clinical and radiographic
examinations
 pez et al.
Lo 9,163 4,652/4,510 12–21 Overall clinical attachment Overall, clinical attachment
(2001) (51) loss of ≥1 mm was loss was highly frequent in
observed in 69.2% of the adolescents. Nonetheless,
students, clinical attachment more extensive clinical
loss of ≥2 mm was observed attachment loss of ≥4 mm
in 16% and clinical was less frequent (<2% of
attachment loss of ≥3 mm subjects). Variables such as
was observed in 4.5%. infrequent toothbrushing,
Interproximal clinical dental visits more than
attachment loss of ≥1 mm 1 year ago and attending a
was observed in 56.4% of school that receives
the students, interproximal government support showed
clinical attachment loss of a positive association with
≥2 mm was observed in clinical attachment loss
13.1% and interproximal
clinical attachment loss of
≥3 mm was observed in
3.7%.
Mean number of sites with
clinical attachment loss of
≥1 mm = 4.3–6.6; with
clinical attachment loss of
≥2 mm = 2.6–4.3; and with
clinical attachment loss of
≥3 mm = 1.5–4.0
 pez et al.
Lo 9,163 4,653/4,510 12–21 Necrotizing ulcerative Diabetes and lack of dental
(2002) (52) gingivitis 6.7% check-ups were associated
with necrotizing ulcerative
gingivitis
MINSAL 500 Not available 2 Gingivitis 2.6% National Health survey.
(2007) (62) Gingival inflammation
increases with age and is
more prevalent in the
low-income population
506 Not available 4 Gingivitis 6.2% National Health survey.
Gingival inflammation
increases with age and is
more prevalent in the
low-income population
6 Gingivitis 55% Number of subjects not
reported, which makes
analysis difficult
Soto et al. 2,232 1,093/1,139 12 Healthy 33%; gingivitis 67% The prevalence of gingivitis
(2007) (90) was higher in rural areas.
Calculus prevalence was
28.1%

50

Table 6. (Continued)
Authors (year) Number of Male/Female Age
(reference) subjects (% or (years)
number)
Varas et al. 1,637 Not available 6–8
(2008) (96)
old subjects, 66% (20, 62, 90). Varas et al. (96) found
 pez
gingivitis in 29.6% of 6- to 8-year-old children. Lo
et al. (52) studied 9,163 subjects, 12–21 years of age,
and detected acute necrotizing ulcerative gingivitis in
6.7% (52). They identified an association between
acute necrotizing ulcerative gingivitis and diabetes
and lack of periodic dental visits (52). Rivera et al.
(85), in a study of rural children of 4–5 years of age,
found gingivitis (9.2%) and caries (49.2%) to be asso-
ciated with poor oral hygiene (85), but the prevalence
of gingivitis was lower than previously reported
(20, 62).
Periodontal disease in Nicaragua,
Panama, Cuba and the Dominican
Republic
The most northern region of Latin America encom-
passes several small countries and some Caribbean
nations (Fig. 5). National surveys on periodontal dis-
ease in Central America are scarce (Table 7). Medina
et al. (58) studied 1,080 children, 5, 12 and 15 years of
age, from urban and rural locations in Nicaragua.
They found gingivitis in 77% of the 12-year-old sub-
jects and in 68.5% of the 15-year-old subjects (58), and
gingivitis was more prevalent (> 90% in same age
groups) in the rural population (58). Periodontal pock-
ets of >5 mm were not found in children, but were a
common finding in adults over 30 years of age.
The national study of oral health in Panama (37)
̈
included 3,763 children of 6–19 years of age. The Loe
and Silness Gingival Index revealed that slight gingival
inflammation (Gingival Index = 0.63–0.73) was pres-
ent in 55.0% of the young population. Three studies
from Cuba (78–80), of 2- to 12-year-old children,
found a prevalence of gingivitis of 20–52% and a rela-
tionship between gingivitis and poor nutritional con-
dition. In the Dominican Republic, Collins et al. (22)
examined the periodontal status of 12- to 21-year-old
subjects. Gingivitis was detected in 39% of the sub-
jects (22). Clinical attachment loss of ≥1 mm was
present in 49.5%, of ≥2 mm in 15.0% and of ≥3 mm in
Periodontal disease in Latin American children and adolescents
Clinical findings Remarks
Gingivitis 29.57%; 2.08% Community Periodontal Index
presented calculus of Treatment Needs index
was used. Gingival bleeding
increased with age
4.0% of the subjects (22). Interproximal attachment
loss of ≥1 mm occurred in 33.6%, of ≥2 mm in 10.9%
and of ≥3 mm in 3.5% of the subjects (22).
Periodontal disease in Bolivia,
Ecuador, Paraguay and Uruguay
In 1995, The Panamerican Health Organization and
the World Health Organization examined the oral
health situation in Bolivia (69). In children 6–15 years
of age, 39% revealed slight gingival inflammation
and 34% moderate gingival inflammation. Only 27%
were essentially free of gingival inflammation (69)
(Table 8). The National Study in Oral Health in Ecua-
dor (60) reported a prevalence range of 30–44% for
gingivitis in children 6–12 years of age. Gingivitis was
more prevalent (44%) in the 10–11 years’ age group
and lower in the 12 years’ age group (30%), which
may indicate a tendency for reduced periodontal dis-
ease with increasing age in early puberty (60)
(Table 8). The National Survey of Oral Health in Para-
guay found that 54.5% of 12- to 15-year-old subjects
were periodontally healthy, 38.8% showed slight
gingivitis and 6.7% revealed both gingivitis and calcu-
lus (61) (Table 8). A study from Uruguay (15) found
one patient (1%) with localized aggressive periodonti-
tis in a small sample of 11- to 18-year-old subjects.
Another study (3) in Uruguay in 76 HIV infected
children found a prevalence of 75% for gingivitis and
0.7% for necrotizing ulcerative gingivitis.
Concluding remarks and future
perspectives
This review shows that inflammatory periodontal dis-
eases are prevalent in children and adolescents in
Latin America. Gingivitis affects 34.7% of young Latin
American individuals (Fig. 6), with the highest preva-
lences found in Colombia (77%) and Bolivia (73%)
and the lowest prevalence in Mexico (23%). The
prevalence of gingivitis ranged from 31 to 56% in the
51
Botero et al.

Table 7. Studies of periodontal disease in children and adolescents in Nicaragua, Panama, Cuba and the Dominican
Republic

Country Authors Number of Male/Female Age Clinical Remarks

(year) subjects (% or number (years) findings
(reference)

Nicaragua Medina et al. 1,080 50%/50% 5–15 Urban The Community

(2007) (58) Periodontal Index of
12 years of age: 77%
Treatment Needs
gingivitis
index was used.
15 years of age: 68.5% Rural areas
gingivitis presented more
>5 mm pockets 0% periodontal disease
and were associated
Rural with household
12 years of age: 96.5% income. The
gingivitis presence of
gingivitis and depth
15 years of age: 97.5% of periodontal
gingivitis pockets increased
>5 mm pockets 0% with age


Panama Galvez et al. Total number of Not available 6–11 Gingivitis 55.9%. National oral health
(2008) (37) subjects = 10,063: 12 Gingival Index: 0.66 survey with a
Lo pez et al. 3,763 were children 13–18 in 6- to 11-year-old representative
(2010) (49) and adolescents 19 subjects; 0.72 in sample. Gingival
12-year-old subjects; Index was used.
0.71 in 13- to 18-year- Slight gingival
old subjects; and 0.73 inflammation was
in 19-year-old subjects prevalent and
increased with age
Cuba Quin~ onez 230 Not available 2–5 Gingivitis 20% Gingivitis was
et al. (2004) associated with
(78) poor nutritional
condition
Cuba Quin~ onez 52 Not available 5–12 Gingivitis 52% Gingivitis was
et al. (2006) associated with poor
(79) nutritional condition
Cuba Quin~ onez 400 Not available 2–5 Gingivitis 52% Gingivitis was
et al. (2008) associated with poor
(80) nutritional condition
Dominican Collins et al. 1,963 952/1,021 12–21 Overall, 49.5% of the Oral health survey.
Republic (2005) (22) students examined had Logistic regression
at least one site with model revealed that
clinical attachment loss only age significantly
of ≥1 mm; clinical increased the
attachment loss was probability of having
≥2 mm in 15% and clinical attachment
≥3 mm in 4.0% of the loss
students. 33.6% of
students had
interproximal clinical
attachment loss of
≥1 mm; 10.9% had
interproximal clinical
attachment loss of
≥2 mm and 3.5% had
interproximal clinical
attachment loss of
≥3 mm

52
 Periodontal disease in Latin American children and adolescents

Table 8. Studies of periodontal disease in children and adolescents in Bolivia, Ecuador, Paraguay and Uruguay

Country Authors (year) Number of Male/Female Age Clinical findings Remarks

(reference) subjects (% or (years)
number)

Bolivia Ocampo & Baez 2,410 Not available 6–15 Community Representative sample. The
(1997) (69) Periodontal Index Community Periodontal
score 0 = 27% Index was used and
increased with age in all
Community
locations. Gingivitis and,
Periodontal Index
in general, poor oral health
score 1 = 39%
was associated with lack of
Community preventive programs
Periodontal Index
score 2 = 34%
Ecuador Ministerio de 2,757 Not available 6–7 Gingivitis 39% Information regarding
Salud Publica pockets was not considered
8–9 Gingivitis 42%
(1988) (60) because the periodontal
10–11 Gingivitis 44% examination process was
12 Gingivitis 30% not explained in the article

Paraguay Ministerio de 1,442 Not available 12–15 Community National Oral health survey.
Salud (2008) Periodontal Index Gingivitis was highly
(61) score 0 = 54.5% prevalent
Community
Periodontal Index
score 1 = 38.8%
Community
Periodontal Index
score 2 = 6.7
Uruguay Campi et al. 100 Not available 11–18 Aggressive After initial screening, just one
(1996) (15) periodontitis 1% case was compatible with
the characteristics of juvenile
periodontitis

remaining countries. Gingivitis needs to be identified

Fig. 6. Adjusted prevalence estimate of gingivitis in Latin
America. The adjusted prevalence was calculated by
including the total number of subjects and the number of
subjects with gingivitis from at least one representative
study in each country. The dotted vertical line indicates
the adjusted prevalence of gingivitis in Latin American
countries (34.7%; 95% CI, 34.4–35.1). The box given for
each country represents the mean prevalence and is rela-
tive in size according to the number of subjects included.
Horizontal bars and ticks represent the minimum and
maximum prevalence reported in the studies included.
Boxes without horizontal bars are the results from only
one national health study from a specific country.
and treated in young individuals as it poses a risk for
development of periodontitis when such individuals
become adults (47, 87). The average rate of periodon-
titis in the young population in Latin America was
<10%. However, the number of studies on periodontitis
in children and adolescents is very limited and addi-
tional studies are warranted. The most common risk
factors for periodontal disease in Latin America
are poor oral hygiene and low socio-economic
status.
Nonetheless, despite the need for more studies, the
information currently available is very useful for
establishing national policies on the promotion, pre-
vention and treatment of periodontal disease.
Destructive periodontal disease can be expected to be
reduced or avoided if prevention and treatment of
severe gingivitis is initiated early in life. The possibil-
ity that untreated periodontal disease can negatively
affect the general health puts extra pressure on
improving the periodontal health of young people in

53
Botero et al.
Latin America. Effective allocation of health-care
resources depends on the identification of high-risk
populations and the institution of efficient and low-
cost therapies. Figure 5 shows a great disparity in the
dentist/population ratio among Latin American
countries (56). Limited access to dental care, espe-
cially in rural and low socio-economic status commu-
nities, may explain, in part, the relatively high
prevalence of periodontal disease among young peo-
ple in Latin America.
The use of oral home-care products (toothpaste
and toothbrushes) has increased, but seems to have
had little effect on the prevalence of gingivitis. Data
from Brazil indicated a per-capita increase, between
1992 and 2002, of 38% in toothpaste, 138% in tooth-
brushes and 177% in dental floss, and the use of oral
health-care products has further increased from 2002
to 2006 (42). Those data show that there is a general
concern for good oral health, but effective strategies
for delivering efficient, safe and low-cost preventive
care have still to be identified and implemented in
Latin America.
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