Periodontology 2000, Vol.
60, 2012, 147–155
Printed in Singapore. All rights reserved
Periodontal health through
public health – the case for oral
health promotion
R I C H A R D G. W A T T & P O U L E. P E T E R S E N
A significant proportion of the global population is
affected by periodontal diseases. Advanced progres-
sive periodontal diseases have a significant impact on
the oral health, and possibly general health, of an
estimated 10–15% of the adult population, a sizable
minority. Clinical treatment and traditional chairside
preventive approaches are ineffective, unaffordable
and inappropriate for the control of periodontal dis-
eases across most of the worldÕs population. A para-
digm shift away from this individualized treatment
approach to a population public health model is ur-
gently required to promote periodontal health and to
tackle social inequalities in this important chronic
condition.
This paper considers challenges to global health
that may impact on periodontal diseases and sum-
marizes the epidemiology of periodontal diseases.
The limitations of the dominant treatment model are
highlighted. Based on the recently published World
Health Organization (WHO) Commission on the So-
cial Determinants of Health (71), recommendations
for public health policies to prevent and control
periodontal diseases are then outlined. Finally, the
roles and responsibilities of the dental professions,
professional organizations and the research com-
munity in the promotion of population periodontal
health are discussed.
Threats to global health in the 21st
century
The dental profession has been criticised for adopting
a very narrow biomedical focus which has largely
ignored the broader determinants of oral health (63).
Failure to understand and appreciate the influence
on health, and indeed oral health, of societal, political
 2012 John Wiley & Sons A/S
PERIODONTOLOGY 2000
and environmental global changes has impeded the
development of future effective action to promote
oral health. A range of macro-level changes are cur-
rently taking place which will have a significant im-
pact on both general and oral health, including
periodontal outcomes.
Significant demographic changes are occurring
across the world. It is estimated that the worldÕs
population will increase from 6.9 billion in 2010 to
9.2 billion by 2050, with the greatest increases taking
place in low-income countries (61). Population age
profiles are also rapidly changing, with lower fertility
rates and an aging population occurring in high- and
middle-income countries in particular.
Economic and political instability has fueled rapid
urbanization in many low- and middle-income
countries, creating huge urban slums where living
conditions are exceptionally poor. The UN estimates
that over 36 million people are currently displaced
around the world due to conflict and political
oppression (62). Many of these displaced people are
ÔhousedÕ in refugee camps and various types of tem-
porary accommodation where even the most basic
necessities for living may not be available.
The significant public health impact of climate and
environmental change is now only beginning to be
fully realized (34). Global warming linked to green-
house gas emissions will have an adverse effect on
health in a variety of ways, including thermal stress,
extreme weather events, infectious diseases, and
threats to food and water supplies. The most imme-
diate and devastating impacts of these potentially
profound environmental changes will occur in low-
income countries among their most disadvantaged
populations.
The global banking crisis and subsequent eco-
nomic recession has resulted in job insecurity,
147
Watt & Petersen
unemployment and poverty for many millions across
the world, all factors known to adversely affect health
and worsen health inequalities (33). During a global
economic downturn, there will be a reduction in
public spending on social and health services and a
curtailment of the activities of non-governmental
organizations.
Finally, over the last 40 years, an epidemiological
transition has occurred in the burden of global dis-
eases (39). Chronic non-communicable diseases are
now the major cause of morbidity and mortality
across the globe. Conditions such as heart disease,
cancers, diabetes and arthritis are the major chronic
diseases affecting populations not only in the high-
and middle-income countries but also increasingly in
low-income countries.
In addition to the recognized impact of these
chronic conditions on population health, there is also
a growing realization of the global burden of physical
and mental disabilities. For example, in 2004 an
estimated 18.6 million people were severely disabled
and 79.7 million people had moderate long-term
disability (70). In all ages, both moderate and severe
levels of disability are higher in low- and middle-
income countries than in high-income countries.
All of these macro-level social, political and envi-
ronmental factors have a direct as well as an indirect
effect on the oral health of the population, including
periodontal status. This paper highlights the rele-
vance and importance of these factors and links them
to the recognized etiological basis of periodontal
health.
The periodontal disease challenge
What is the periodontal global health challenge in
terms of extent, severity, pattern and disease trends?
The answer to this question is limited by evolving
scientific concepts on the nature of periodontal dis-
ease and a lack of consensus in defining periodontitis
and severe periodontitis (5, 60). Other papers in this
volume of Periodontology 2000 and elsewhere have
reviewed the epidemiology of periodontal diseases in
greater detail (4, 42, 45). Therefore, this paper gives
only a brief summary informing, in particular, the
preventive policy agenda for periodontal health.
Although most people have gingivitis and calculus,
epidemiological surveys indicate that approximately
10–15% of the global adult population suffer from
progressive periodontitis (4, 42, 45). The extent and
severity of periodontitis increase with increasing age
and it is more common among men than women (3,
148
45). Oral hygiene levels and gingivitis scores are lower
among populations of high-income countries than
low- and middle-income countries (7). There are
stark socioeconomic differences within countries.
Lower income and less educated groups have signif-
icantly worse periodontal health than their more
affluent and educated contemporaries (17, 36).
Ethnic inequalities in periodontal outcomes have
also been highlighted. In the USA, African–Americans
have more periodontal disease than Whites of the
same age cohort (9, 10, 49).
As is the case with most other chronic diseases, a
consistent social gradient exists in the distribution of
periodontitis within a defined population (11, 29).
The social gradient indicates that socioeconomic
differences in periodontal outcomes do not occur
merely at the extremes of the social spectrum be-
tween the rich and poor, but across the entire social
hierarchy in a graded stepwise fashion. Indeed,
Sabbah et al. (48) have shown that the social gradient
in periodontal outcomes in a US population closely
mirrors the gradient in heart disease in the same
population, strongly indicating shared determinants
and pathways (Fig. 1).
In terms of trends over time, epidemiological data
suggest that in high- and middle-income countries
oral hygiene levels have improved in all age groups
and there has been a decline in the extent of gingivitis
(22, 36). These changes are most likely due to
changing social norms in relation to body hygiene
practices, together with an overall decline in smoking
rates in high-income countries. However, there is an
on-going debate about whether these positive trends
in periodontal health will be reversed with an
3
Education > 12 years
2.5
Education = 12 years
Education < 12 years
2
Odds ratio
1.5
1
0.5
0
Perceived oral Perceived Periodontitis Ischemic heart
health general health disease
Fig. 1. Education gradients in self-rated oral and general
health, periodontal disease and heart disease [Sabbah
et al. (48)].

increasingly aging population, many of whom will
retain increasing numbers of their own teeth for life.
Etiology of periodontal diseases –
understanding the broader picture
To be effective, population preventive measures need
to address the underlying causes of disease. With
periodontal diseases, the recognized main risk factors
are well established, namely, oral hygiene level, to-
bacco use, psychosocial factors and related systemic
diseases. The challenge is to recognize and then ad-
dress the distal underlying influences that determine
and pattern these risks to develop effective and sus-
tainable preventive interventions. There also needs to
be a recognition of the interlinking and common risks
and pathways shared by oral conditions such as
periodontal diseases and other chronic diseases (54).
Experimental studies first established the causal
relationship between dental plaque and gingivitis in
the 1960s (28) and this was later confirmed in epi-
demiological studies (2). The link between dental
plaque levels and gingival inflammation exists in all
ages, sexes and ethnic groups (2). In contrast, calcu-
lus accumulation has not been shown to cause peri-
odontal inflammation (65).
Effective self-care oral hygiene practices such as
toothbrushing, use of chewing sticks and interdental
cleaning are the key means of preventing and con-
trolling periodontal diseases (27). However, an array
of motivations and interconnected biological, devel-
opmental, psychological, social and cultural factors
influence oral hygiene practices. In addition, oral
hygiene and general hygiene practices are very
strongly related (15, 21). Different explanations for
the motivations for practicing hygiene behaviors
range from biological evolutionary concerns, to the
avoidance of infection and contagion (12) and
grooming and socialization processes initiating in
adolescence (21). Other fundamental influences on
hygiene practices include routines of daily activities
(1) and religious rituals and customs (16).
The use of tobacco remains the greatest threat to
global public health and is the single major cause of
health inequalities. Compelling epidemiological evi-
dence has also highlighted the important role of to-
bacco use on the extent and severity of periodontal
diseases. Studies have shown that smoking alone
accounts for more than 50% of the periodontitis
cases among the US adult population (58). Smoking
also adversely affects periodontal and other surgical
treatment outcomes through impaired wound heal-
Periodontal health through public health
ing. Smoking is a highly complex behavior and a
range of interrelated psychological, social and polit-
ical factors influence the initiation, continuation and
cessation of the habit. A social gradient exists for
smoking behavior, with poorer and uneducated
groups far more likely to smoke than their more
affluent and educated peers (24). Indeed, poorer
people are more likely to be heavy smokers and to be
more highly addicted to nicotine (23).
Psychosocial stress caused by discrimination,
poverty, unemployment and poor living conditions
adversely affect physical and mental health (33).
Psychosocial factors have also been associated with
poor periodontal health (53). For example, marital
stress and other stressful life events are associated
with periodontal disease progression (32).
A convincing body of evidence has also highlighted
that diabetics have an increased risk of periodontal
disease (20) as well as more severe and progressive
periodontal disease (58). The association between
periodontal disease and diabetes is the most consis-
tent and strongest link between oral health status and
chronic systemic diseases.
More limited evidence suggests that severe vitamin
C deficiency and malnutrition may result in poorer
periodontal status (37). Recent evidence has also
indicated a possible link between alcohol consump-
tion and increased risk of periodontal disease, al-
though more research is needed in this area (46).
Limitations of a clinical and
chairside preventive approach
The treatment, control and prevention of periodontal
disease epitomizes the dominance of the biomedical
model within the dental profession globally. The
philosophy underpinning the biomedical model fo-
cuses attention on the molecular, biological and, to a
lesser extent, behavioral basis of disease at the indi-
vidual level. Dental research priorities and teaching
curricula around the world are wedded to this ap-
proach. The biomedical model has heavily influenced
theoretical understanding of periodontal disease and
the need for surgical and clinical intervention to se-
cure and maintain periodontal health (6). Despite our
improved understanding of the etiology and natural
history of periodontal diseases, the biomedical ap-
proach dictates that the goal of periodontal therapy
be the complete removal of plaque and calculus, the
resolution of all gingivitis, and the eradication of all
deepened pockets to prevent tooth loss (7). To
achieve this goal, the considered view is that an
149
Watt & Petersen
intensive level of professional intervention is needed,
with clinical surgical procedures and on-going
maintenance therapy involving frequent and lengthy
visits for scaling. This creates a professional depen-
dency model in which the role of the clinician is
central to securing and maintaining good periodontal
health. This model is a high-risk approach where
individuals deemed at particular risk of disease pro-
gression are the central focus of therapy and care
(47). The preventive element in this biomedical ap-
proach focuses on supporting changes in hygiene,
and to some extent smoking behaviors, through
chairside advice and counseling.
What are the limitations of this approach in
tackling the global periodontal disease burden? The
traditional clinical approach to dental treatment is
expensive and a significant economic burden, even
in high-income countries. Overall, it is estimated
that the treatment of oral diseases is the fourth most
expensive condition to treat in industrialized coun-
tries (43). Based upon Community Periodontal Index
of Treatment Needs (CPITN) estimates of peri-
odontal treatment needs among children in Kenya,
the costs involved would exceed the total national
health care budget for the country (31). Even if the
finance was available to fund periodontal treatment
services, in most low- and middle-income countries
there are insufficient numbers of clinical personnel
to tackle the problem. The dental professionals that
do exist in low-, middle- and high-income countries
tend to be concentrated in urban middle-class
neighborhoods where the need for care is lower.
There is therefore limited access for populations
with high need such as the socially disadvantaged,
disabled, chronically sick and elderly in most set-
tings.
Perhaps the most striking limitation of the bio-
medical model is that it is ineffective at a population
level. Unless the underlying causes are addressed,
frequent and on-going periodontal therapy and
scaling will not prevent the reoccurrence of plaque
and calculus (26). Results have shown that the
chairside preventive approach is ineffective in
achieving sustained improvements in periodontal
outcomes (64). Individual advice and ÔlifestyleÕ
counseling may achieve immediate short-term posi-
tive changes in knowledge, plaque control and
bleeding scores, but these benefits are not sustained
unless there is adequate consideration of the under-
lying conditions and causes of poor periodontal
health (25, 56, 64). There is a clear need for a radically
different approach to promote periodontal health at a
population level.
150
Public health agenda on promotion
of population periodontal health
To prevent and control periodontal diseases at a
population level and to tackle periodontal disease
inequalities, a public health approach is required.
Developments in dental research and clinical den-
tistry have helped to improve clinical treatment
outcomes but a biomedical approach is not appro-
priate for dealing with a public health problem such
as periodontal disease. A radically different approach
is needed which is informed by public health re-
search and policy. Globally, public health policy led
by the WHO has advocated a range of population-
level actions to tackle chronic diseases and reduce
health inequalities (67). Population action to pro-
mote oral health needs to adopt a similar approach
and become embedded in the broader public health
agenda.
At the core of a public health approach is the need
to tackle the fundamental causes of poor health in
the population, the causes of the causes (47). Tradi-
tionally, the main factors have been the use of health
services and ÔlifestyleÕ factors influencing health.
However, scientific evidence has highlighted the
underlying influence of the psychosocial, economic,
environmental and political determinants of health
(13, 71). The social and material circumstances in
which people are born, grow, live, work and age have
a profound impact on health status and patterns of
inequality (33, 71). These ÔupstreamÕ or Ôstructural
driversÕ of social inequality create the conditions that
adversely affect health and well-being. These social
determinants not only pattern general health but
obviously also have a major influence on oral health
(40, 51, 63). With periodontal diseases, the broader
social conditions in society extensively affect the
ÔclassicÕ risk factors of hygiene, tobacco use, stress
and systemic diseases. Behavioral lifestyle factors
alone do not explain inequalities in periodontal
health (50, 52). For example, the quality of living
conditions and access to good sanitation and hygiene
facilities have a direct effect on hygiene practices.
Rather than focus on toothbrushing behaviors alone
in a very narrow and limited sense, action to promote
periodontal health needs to tackle the broader social
determinants of hygiene practices, tobacco use,
psychosocial stress and related systemic diseases. To
have a meaningful effect, one needs to address such
action at a population level rather than restrict it to
Ôhigh-riskÕ individuals, currently the dominant ap-
proach in clinical prevention. Due to limited scien-

tific understanding of periodontal disease process,
we are not able to predict accurately which individ-
uals will have rapidly progressive disease in the near
future and hence will require intensive therapeutic
intervention. Without an accurate predictive test, the
high-risk approach is severely limited (8, 47). In
contrast, in the population approach, broad public
health measures and policies are implemented to
reduce the overall risk in the whole population,
shifting the whole distribution of the disease to the
left (47). A perfect example of the value of this ap-
proach is the effect of policies on restricting smoking
in public spaces, which have had a significant impact
in reducing smoking rates in the countries where
these policies have been implemented. In addition,
these policies have positively influenced social
norms and attitudes towards smoking across the
population.
Recognition of the shared determinants of general
and oral health clearly highlights the importance of
multi-sectorial working and the need for comple-
mentary strategies. A broader public health agenda
must integrate action to tackle periodontal diseases.
In the past, oral health preventive programs have
often operated in isolation from other health ini-
tiatives. This has led to duplication of effort, lack of
consistency with health messages and wasted lim-
ited resources. With the common risk approach, in
which coordinated action is focused upon address-
ing the shared conditions and threats to health, oral
health promotion becomes embedded within public
health (54, 66). Clinical preventive measures and
health education activities alone are insufficient to
tackle the root causes of ill health. Instead, a range
of complementary health promotion strategies is
required. Back in 1986 the Ottawa Charter high-
SOCIOECONOMIC
& POLITICAL
CONTEXT
Governance
Material Circumstances
Social Position
Social Cohesion
Policy
Education Psychosocial Factors
Macroeconomic
Social Occupation Behaviors
Health Income Biological Factors
Gender
Cultural and
Societal norms and Ethnicity / Race
values Health Care System
SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES
Periodontal health through public health
lighted the importance of this approach in tackling
health inequalities (67) and it remains influential in
current WHO policy frameworks (71).
In 2008, following an extensive process of inter-
national consultation, WHO published a policy ac-
tion plan to tackle global health inequalities (71). A
detailed review of the extent and causes of health
inequalities and the social gradient is presented in
the WHO report. The conceptual framework
underpinning the detailed action plan adopts a
social determinants approach and highlights the
fundamental influence of social conditions in
determining health inequalities (Fig. 2). A compre-
hensive set of recommendations for action at a
local, national and international level are presented
(Table 1). Although oral health is not directly
identified as a priority, many of the actions and
recommendations outlined can be applied to oral
health improvement.
Public health strategies to promote
periodontal health
A range of public health strategies from international
policy agreements to the reorientation of local health
services presented below, illustrates how different
actions can be implemented to prevent periodontal
diseases. The WHO Framework Convention on To-
bacco Control (FCTC) is an outstanding example of
how international collaboration can be harnessed to
formulate powerful public health policy (69). The
FCTC adopted a radical approach which aimed to
tackle both the supply and demand for tobacco
through a range of complementary actions includ-
ing:
DISTRIBUTION
OF HEALTH
AND
WELL-BEING
Fig. 2. Commission on Social
Determinants of Health conceptual
framework. CSDH Final Report,
WHO 2008 (71), adapted from Solar
& Irwin, 2007 (55).
151
Watt & Petersen
Regulation of
• smoking in work and public places
• contents, packaging and labelling of tobacco
products
• prohibition of sales to and by minors
• illicit trade in tobacco products
Reduction in consumer demand by
• price and tax measures
• comprehensive ban on tobacco advertising, pro-
motion and sponsorship
• education, training, raising public awareness and
assistance with quitting
More than 167 countries have now adopted the FCTC,
which has helped to create a social environment in
many parts of the world where tobacco use is no
longer seen as a socially acceptable and desirable
behavior. The legislative framework has helped to
create smoke-free living and working conditions for
many millions of people. However, in some parts of
the developing world, tobacco use is increasing as a
direct consequence of aggressive marketing and
advertising by the tobacco industry. In these countries
tighter regulatory controls are needed to control the
supply and marketing of tobacco. This may require
international policy collaboration and fiscal support.
In what other ways could healthy public policies be
developed to improve the conditions of daily life di-
rectly related to periodontal diseases, in particular
the promotion of hygiene practices? Among disad-
vantaged populations a key determinant of self-care
hygiene practices is the ability to afford a toothbrush.
The production and sale of locally produced and
affordable toothbrushes would enable poorer popu-
lations to access and use these products. To achieve
this, partnerships between governments, multi-na-
tional companies, health professionals and local
communities are necessary. Fiscal action removing or
reducing taxation levels placed on oral hygiene
Table 1. Principles of action to achieve health equity
• Improve the conditions of daily life – the
circumstances in which people are born, grow,
live, work and age
• Tackle the inequitable distribution of power, money
and resources – the structural drivers of those
conditions of daily life – globally, nationally and locally
• Measure the problem, evaluate action, expand
the knowledge base, develop a workforce that is
trained in the social determinants of health, and
raise public awareness about the social determinants
of health
152
products would also have a major effect by making
these items more affordable and therefore accessible,
particularly in populations from low- and middle-
income countries (19).
Poor quality housing adversely affects general
health in a variety of ways, including mental health
problems, respiratory conditions and injuries (57).
Individuals and families who do not have access to
adequate hygiene and sanitation facilities may have
great difficulty performing regular oral hygiene
practices. Environmental action such as urban
regeneration and housing refurbishment programs
can improve health outcomes (57). Action to improve
the quality of housing conditions to ensure that
adequate hygiene and sanitation facilities are pro-
vided would have a potentially significant impact on
periodontal diseases, again particularly among the
most disadvantaged populations. Environmental ac-
tion to ensure that appropriate hygiene facilities are
also available in schools and colleges, workplaces,
hospitals and other public organizations would help
to create healthier settings for the local population.
The WHO health promoting schools network is a
good example of how policy can be used to develop
healthy settings in the community. The concept of
the health promoting school places emphasis on
developing a range of complementary polices and
actions that create a health promoting environment
for students, staff and the wider community (68).
Evaluation of this approach has shown that it has
beneficial effects on a variety of oral health outcomes
(30, 38, 44).
As general and oral hygiene behaviors share com-
mon motivations and influences, community pre-
ventive interventions should adopt an integrated
approach in developing appropriate self-care hygiene
practices. In schools, health literacy training should
focus upon grooming, socialization and self-confi-
dence building as a platform for the development of
hygiene practices. For example, the Philippines have
developed a community-based schools program, ÔFit
for SchoolÕ, where daily handwashing with soap, daily
toothbrushing with fluoride toothpastes, and bi-an-
nual deworming activities are delivered in elementary
schools across 22 provinces (35). This program has
been developed in an integrated fashion to tackle
major child health problems in an evidence-based
fashion. Handwashing with soap can reduce diarrhea
episodes by about 30% (18). It is also possible to
incorporate the promotion of self-care hygiene
practices into parenting and other life skills training
for young people. Such approaches recognize the
importance of empowerment and skills training in

the development of health literacy (41). In addition to
teaching hygiene and other practices to schoolchil-
dren, it is also important to train nursing and other
care professionals who are responsible for caring for
vulnerable groups in society. Older people living in
residential and nursing homes, disabled people and
individuals with complex clinical needs may all re-
quire special help from carers in maintaining good
oral hygiene.
Finally, there is the potential role of health services
in health promotion. A reorientation of health ser-
vices towards an evidence-based preventive ap-
proach is an important element of health promotion
(67). The delivery of appropriate preventive advice
and support should be a routine part of clinical care.
Dental professionals working in partnership with
other health professionals have an important role in
advising and supporting their patients (14). For
example, dentists and their teams have a role to play
in smoking cessation support, as well as providing
hygiene advice to their patients. Preventive advice
needs to be evidence-based and delivered using
appropriate communication and motivational skills
and techniques. Patients with systemic diseases such
as diabetes and AIDS require particular support to
ensure that their periodontal health is maintained.
Health professionals can also facilitate their patients
to access health promoting and affordable resources.
Selling and dispensing such resources as tooth-
brushes and nicotine replacement therapies at cost
price to their patients can promote the uptake and
use of these products, especially among socially dis-
advantaged groups.
Roles and responsibilities for
future action
To ensure that the agenda for action that has been
outlined is implemented it is important to consider
the respective roles and responsibilities of key play-
ers. At a clinical level, dental professionals need to
have an understanding of the social determinants
agenda to ensure that they appreciate the broader
policy picture and the limitations of what can be
achieved on a one-to-one basis with their patients.
Clinicians, however, do have a responsibility to pro-
vide evidence-based preventive care and support to
their patients and to refer them for more specialist
advice when appropriate.
In contrast, dental public health practitioners have
a significant role to play in promoting periodontal
Periodontal health through public health
health at a population level. They can act as policy
advocates lobbying for change in a range of areas at a
local, national and at times international level. Acting
as an oral health advocate ensuring that oral health
issues are included in other areas of public health
action is a very important role. Public health profes-
sionals can also be involved in program planning,
implementation and evaluation. The monitoring and
evaluation of interventions is often a neglected ele-
ment in planning but provides essential feedback on
the impact, process and outcomes of interventions.
National dental professional organizations and
international organizations such as the Fédération
Dentaire Internationale, the International Association
of Dental Research and WHO all have an important
role in oral health promotion policy development. In
addition, multi-national commercial companies
clearly have a significant part to play in population
efforts to improve periodontal health. However, it is
important that these professional and commercial
organizations recognize their responsibilities in tack-
ling oral health inequalities across the world.
Finally, major gaps exist in the understanding of
the pathways and determinants of inequalities in
periodontal disease. More rigorous research is also
needed on the evaluation of community interven-
tions to tackle oral health inequalities, and peri-
odontal disease in particular. The dental research
community therefore has an important role to play in
improving the evidence base for community action.
To achieve meaningful and sustainable results, all of
these different players need to work collaboratively
with colleagues outside of dentistry, and in many
cases beyond the health sector.
Summary
Periodontal diseases affect a significant proportion of
the worldÕs population, particularly the socially dis-
advantaged. Inequalities in periodontal health mirror
those patterns in other chronic diseases and share
common determinants. Clinical treatment and
chairside preventive advice alone will never tackle
this problem adequately. There is an urgent need for
population-based preventive efforts that address the
underlying causes of periodontal diseases. A com-
plementary range of public health policies need to be
implemented. Dental clinicians, public health prac-
titioners, professional and commercial organizations,
and researchers all have an important role to play in
promoting periodontal health.
153
Watt & Petersen
References
1. Abegg C, Croucher R, Marcenes WS, Sheiham A. How do
routines of daily activities and flexibility of daily activities
affect tooth cleaning behavior? J Public Health Dent 2000:
60: 154–158.
2. Albandar JM. Global risk factors and risk indicators for
periodontal diseases. Periodontol 2000 2002: 29: 177–206.
3. Albandar JM, Rams TE. Global epidemiology of periodontal
diseases: an overview. Periodontol 2000 2002: 29: 7–10.
4. Albander JM. Epidemiology and risk factors of periodontal
diseases. Dent Clin N Am 2005: 49: 517–532.
5. Baelum V, Lopez R. Defining and classifying periodontitis:
need for a paradigm shift? Eur J Oral Sci 2003: 111: 2–6.
6. Baelum V, Lopez R. Periodontal epidemiology: towards
social science or molecular biology? Community Dent Oral
Epidemiol 2004: 32: 239–249.
7. Baelum V, van Palenstein Helderman W, Hugoson A, Yee R,
Fejerskov O. A global perpsective on changes in the burden
of caries and periodontitis: implications for dentistry.
J Oral Rehabil 2007: 34: 872–906.
8. Batchelor P, Sheiham A. The limitations of a Ôhigh-riskÕ
approach for the prevention of dental caries. Community
Dent Oral Epidemiol 2002: 30: 302–312.
9. Beck JD, Koch GG, Rozier RG, Tudor GE. Prevalence and
risk indicators for periodontal attachment loss in a popu-
lation of older community-dwelling Blacks and Whites.
J Periodontol 1990: 61: 521–528.
10. Borrell LN, Burt BA, Gillespie BW, Lynch J, Neighors H.
Periodontitis in the United States: beyond Black and White.
J Public Health Dent 2002: 62: 92–101.
11. Borrell LN, Burt BA, Warren RC, Neighbors HW. The role of
individual and neighbourhood social factors on periodon-
titis: the third National Health and Nutrition Examination
Survey. J Periodontol 2006: 77: 444–453.
12. Curtis V. Dirt, disgust and disease: a natural history of
hygiene. J Epidemiol Community Health 2007: 61: 660–664.
13. Dahlgren G, Whitehead M. Policies and strategies to pro-
mote social equity in health. Stockholm: Institute for Future
Studies, 1991.
14. Department of Health. Delivering better oral health: an
evidence based toolkit. London: Department of Health,
2009.
15. Dorri M, Sheiham A, Watt RG. Relationship between gen-
eral hygiene behaviours and oral hygiene behaviours in
Iranian adolescents. Eur J Oral Sci 2009: 117: 407–412.
16. Douglas M. Purity and danger: an analysis of the concepts of
pollution and taboo. London: Routledge and Kegan Paul,
1966.
17. Dury TF, Garcia I, Adesanya M. Socioeconomic disparities
in adult oral health in the United States. Ann N Y Acad Sci
1999: 896: 322–324.
18. Ejemot RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand-
washing for preventing diarrhea. Cochrane Database Syst
Rev 2008: CD004265.
19. Goldman AS, Yee R, Holmgren CJ, Benzian H. Global
affordability of fluoride toothpaste. Glob Health 2008: 4:
7.
20. 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.
154
21. Hodge H, Holloway PJ, Bell CR. Factors associated with
toothbrushing behaviour in adolescents. Br Dent J 1982:
152: 49–51.
22. Hugoson A, Norderyd O, Slotte C, Thorstensson H. Distri-
bution of periodontal disease in a Swedish adult
population 1973, 1983 and 1993. J Clin Periodontol 1998:
25: 542–548.
23. Jarvis MJ. Why people smoke. Br Med J 2004: 328: 277–279.
24. Jarvis MJ, Wardle J. Social patterning of individual health
behaviours: the case of cigarette smoking. In: Marmot M,
Wilkinson R, editors. Social determinants of health. Oxford:
Oxford University Press, 2006: 224–337.
25. Kay L, Locker D. Is dental health education effective? A
systematic review of current evidence. Community Dent
Oral Epidemiol 1996: 24: 231–235.
26. Lembariti BS, Van der Weijden GA, van Palenstein Hel-
derman WH. The effect of a single scaling with or without
oral hygiene instruction on gingival bleeding and calculus
formation. J Clin Periodontol 1998: 25: 30–33.
27. Löe H. Oral hygiene in the prevention of caries and peri-
odontal disease. Int Dent J 2000: 50: 129–139.
28. Löe H, Theilade E, Jensen SB. Experimental gingivitis in
man. J Periodontol 1965: 36: 177–187.
29. Lopez R, Fernandez O, Baelum V. Social gradients in
periodontal diseases among adolescents. Community Dent
Oral Epidemiol 2006: 34: 184–196.
30. Malikaew P, Watt RG, Sheiham A. Association between
school environments and traumatic dental injuries. Oral
Health Prev Dent 2003: 4: 255–266.
31. Manji F, Sheiham A. CPITN findings and the manpower
implications of periodontal treatment needs for Kenyan
children. Community Dent Health 1986: 3: 143–151.
32. Marcenes W, Sheiham A. The relationship between work
stress and oral health status. Soc Sci Med 1992: 35: 1511–
1520.
33. Marmot M, Wilkinson R. Social determinants of health.
Oxford: Oxford University Press, 2006.
34. McMichael A, Woodruff R, Hales S. Climate change and
human health: present and future risks. Lancet 2006: 367:
859–869.
35. Monse B, Naliponguit E, Belizario V, Benzian H, van
Palenstein Helderman W. Essential health care package for
children: the Fit for School program in the Philippines. Int
Dent J 2010: 60: 85–93.
36. Morris AJ, Steele J, White DA. The oral cleanliness and
periodontal health of UK adults in 1998. In: Bradnock G,
Morris AJ, White DA, editors. A guide to the UK Adult
Dental Health Survey 1998. London: British Dental Asso-
ciation, 2001.
37. Moynihan P, Petersen PE. Diet and nutrition and the pre-
vention of dental diseases. Public Health Nutr 2004: 7: 201–
226.
38. Moysés ST, Moysés SJ, Watt RG, Sheiham A. Associations
between health promoting schoolsÕ policies and indicators
of oral health in Brazil. Health Promot Int 2003: 18: 209–218.
39. Murray CJ, Lopez AD. Global mortality, disability and the
contribution of risk factors: global burden of disease study.
Lancet 1997: 349: 1436–1442.
40. Newton JT, Bower EJ. The social determinants of health:
new approaches to conceptualizing and researching com-
plex casual networks. Community Dent Oral Epidemiol
2005: 33: 25–34.

41. Nutbeam D. The evolving concept of health literacy. Soc Sci
Med 2008: 67: 2072–2078.
42. Papapanou PN. Epidemiology of periodontal diseases: an
update. J Int Acad Periodontol 1999: 1: 110–116.
43. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S,
Ndiaye C. The global burden of oral disease and risks to
oral health. Bull World Org 2005: 83: 661–669.
44. Petersen PE, Kwan S. Oral health promotion: an essential
element of a health-promoting school. WHO information
series on school health. Geneva: World Health Organization,
2003.
45. Petersen PE, Ogawa H. Strengthening the prevention of
periodontal disease: the WHO approach. J Periodontol
2005: 76: 2187–2193.
46. Pitiphat W, Merchant AT, Rimm EB, Joshipura KJ. Alcohol
consumption increases periodontal risk. J Dent Res 2003:
82: 509–513.
47. Rose G. Sick individuals and sick populations. Int J Epi-
demiol 1985: 14: 32–38.
48. Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG.
Social gradients in oral and general health. J Dent Res 2007:
86: 992–996.
49. Sabbah W, Tsakos G, Sheiham A, Watt RG. The effects of
income and education on ethnic differences in oral health:
a study in US adults. J Epidemiol Community Health 2009:
63: 516–520.
50. Sabbah W, Tsakos G, Sheiham A, Watt RG. The role of
health-related behaviors in the socioeconomic disparities
in oral health. Soc Sci Med 2009: 68: 298–303.
51. Sanders SE. Social determinants of oral health: conditions
linked to socioeconomic inequalities in oral health in the
Australian population. Adelaide: Australian Institute of
Health and Welfare, 2007.
52. Sanders AE, Spencer AJ, Slade GD. Evaluating the role of
dental behaviour in oral health inequalities. Community
Dent Oral Epidemiol 2006: 34: 71–79.
53. Sheiham A, Nicolau B. Evaluation of social and psycho-
logical factors in periodontal disease. Periodontol 2000
2005: 39: 118–131.
54. Sheiham A, Watt RG. The common risk factor approach: a
rational basis for promoting oral health. Community Dent
Oral Epidemiol 2001: 28: 399–406.
55. Solar O, Irwin A. A conceptual framework for action on the
social determinants of health. Discussion paper for the
Commission on Social Determinants of Health. Geneva:
World Health Organization, 2007.
56. Sprod A, Anderson R, Treasure E. Effective oral health
promotion. Literature review. Cardiff: Health Promotion
Wales, 1996.
Periodontal health through public health
57. Taske N, Taylor L, Mulvihill C, Doyle N. Housing and public
health: a review of reviews of interventions for improving
health. London: National Institute for Health and Clinical
Excellence, 2005.
58. 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 (Sup-
pl.): 1085–1093.
59. Tomar SL, Asma S. Smoking-attributable periodontitis in
the United States: findings from NHANES III. J Periodontol
2000: 71: 743–751.
60. Tonneti MS, Claffey N. Advances in the progression of
periodontitis and proposal of definitions of a periodontitis
case and disease progression for use in risk factor research.
J Clin Periodontol 2005: 32 (Suppl. 6): 210–213.
61. United Nations. World population prospects: the 2008
revision. Geneva: Population Division of the Department of
Economic and Social Affairs, United Nations, 2010.
62. United Nations High Commissioner for Refugees. Statisti-
cal yearbook 2008. Trends in displacement, protection and
solutions. Geneva: UNHCR, 2008.
63. Watt RG. From victim blaming to upstream action: tackling
the social determinants of oral health inequalities.
Community Dent Oral Epidemiol 2007: 35: 1–11.
64. Watt RG, Marinho VC. Does oral health promotion improve
oral hygiene and gingival health? Periodontol 2000 2005:
37: 35–47.
65. White DJ. Dental calculus: recent insights into occurrence,
formation, prevention, removal and oral health effects of
supragingival and subgingival deposits. Eur J Oral Sci 1997:
105: 508–522.
66. World Health Organisation. Risk factors and comprehensive
control of chronic diseases. Geneva: WHO, 1980.
67. World Health Organization. The Ottawa charter for health
promotion. Health Promotion 1. i–v. Geneva: WHO, 1986.
68. World Health Organization. Health promoting schools: a
healthy setting for living, learning and working. Geneva:
WHO, 1998.
69. World Health Organization. WHO framework convention
on tobacco control. Geneva: WHO, 2003.
70. World Health Organization. The global burden of disease:
2004 update. Geneva: WHO, 2004.
71. World Health Organization. Closing the gap in a generation.
Health equity through action on the social determinants of
health. Final Report on the Commission on Social Deter-
minants of Health. Geneva: WHO, 2008.
155