Periodontal health and global public health.

Chronic diseases are a growing burden to people, to health-care systems and to societies across the world. The rapid increase in the burden of chronic diseases is particularly prevalent in the developing countries. Periodontal disease is one of the two most important oral diseases contributing to the global burden of chronic disease. In addition to social determinants, periodontal health status is related to several proximal factors. Modifiable risk factors, such as tobacco use, excessive alcohol consumption, poor diet and nutrition, obesity, psychological stress and insufficient personal/oral hygiene, are important and these principal risk factors for periodontal disease are shared by other chronic diseases. The present monograph is devoted to the existing evidence on the practice of public health related to periodontal health. Public health is defined as the process of mobilizing and engaging local, national and international resources to assure that people can be healthy. Social determinants of health, environmental hazards and unhealthy lifestyles are prioritized in modern public health-care. Disease prevention and health promotion are cornerstones in actions for public health. This volume of Periodontology 2000 is entitled 'Periodontal health and global public health'; the 12 articles of this volume discuss different aspects of this statement. It covers a range of subjects from public health issues to patient care. This monograph intends to stimulate community action research in the field of periodontology in order to help the development of appropriate public health intervention and relevant surveillance programs. It also expects to stimulate health authorities and professional organizations to initiate and support actions to promote periodontal health in their respective countries.

The global burden of periodontal disease: towards integration with chronic disease prevention and control.

Chronic diseases are accelerating globally, advancing across all regions and pervading all socioeconomic classes. Unhealthy diet and poor nutrition, physical inactivity, tobacco use, excessive use of alcohol and psychosocial stress are the most important risk factors. Periodontal disease is a component of the global burden of chronic disease, and chronic disease and periodontal disease have the same essential risk factors. In addition, severe periodontal disease is related to poor oral hygiene and to poor general health (e.g. the presence of diabetes mellitus and other systemic diseases). The present report highlights the global burden of periodontal disease: the ultimate burden of periodontal disease (tooth loss), as well as signs of periodontal disease, are described from World Health Organization (WHO) epidemiological data. High prevalence rates of complete tooth loss are found in upper middle-income countries, whereas the tooth-loss rates, at the time of writing, are modest for low-income countries. In high-income countries somewhat lower rates for edentulism are found when compared with upper middle-income countries. Around the world, social inequality in tooth loss is profound within countries. The Community Periodontal Index was introduced by the WHO in 1987 for countries to produce periodontal health profiles and to assist countries in the planning and evaluation of intervention programs. Globally, gingival bleeding is the most prevalent sign of disease, whereas the presence of deep periodontal pockets (≥6 mm) varies from 10% to 15% in adult populations. Intercountry and intracountry variations are found in the prevalence of periodontal disease, and these variations relate to socio-environmental conditions, behavioral risk factors, general health status of people (e.g. diabetes and HIV status) and oral health systems. National public health initiatives for the control and prevention of periodontal disease should include oral health promotion and integrated disease-prevention strategies based on common risk-factor approaches. Capacity building of oral health systems must consider the establishment of a financially fair service in periodontal care. Health systems research is needed for the evaluation of population-oriented oral health programs.

Recording and surveillance systems for periodontal diseases.

This paper describes tools used to measure periodontal diseases and the integration of these tools into surveillance systems. Tools to measure periodontal diseases at the surveillance level have focussed on current manifestations of disease (e.g. gingival inflammation) or disease sequelae (e.g. periodontal pocket depth or loss of attachment). All tools reviewed in this paper were developed based on the state of the science of the pathophysiology of periodontal disease at the time of their design and the need to provide valid and reliable measurements of the presence and severity of periodontal diseases. Therefore, some of these tools are no longer valid. Others, such as loss of periodontal attachment, are the current de-facto tools but demand many resources to undertake periodical assessment of the periodontal health of populations. Less complex tools such as the Community Periodontal Index, have been used extensively to report periodontal status. Laboratory tests for detecting putative microorganisms or inflammatory agents present in periodontal diseases have been used at the clinical level, and at least one has been tested at the population level. Other approaches, such as self-report measures, are currently under validation. In this paper, we do not review indices designed to measure plaque or residual accumulation around the tooth, indices focussed only on gingival inflammation or radiographic approaches with limited applicability in surveillance systems. Finally, we review current case-definitions proposed for surveillance of periodontal disease severity.

Oral health care systems in developing and developed countries.

Health care systems are essential for promoting, improving and maintaining health of the population. Through an efficient health service, patients can be advised of disease that may be present and so facilitate treatment; risks factors whose modification could reduce the incidence of disease and illness in the future can be identified, and further, how controlling such factors can contribute to maintain a good quality of life. In developed countries, clinics or hospitals may be supported by health professionals from various specialties that allow their cooperation to benefit the patient; these institutions or clinics may be equipped with the latest technical facilities. In developing countries, health services are mostly directed to provide emergency care only or interventions towards certain age group population. The most common diseases are dental caries and periodontal disease and frequently intervention procedures aim, at treating existing problems and restore teeth and related structure to normal function. It is unfortunate that the low priority given to oral health hinders acquisition of data and establishment of effective periodontal care programmes in developing countries but also in some developed countries where the periodontal profile is also less than satisfactory. Despite the fact that in several developed countries there are advanced programmes oriented to periodontal disease treatments, the concern is related to the lack of preventive oriented treatments. According to data available on periodontal status of populations from developed countries, despite the number of dentists and trained specialists, dental health professionals do not presently meet adequately the need for prevention, focusing mainly on curative care. The need for strengthening disease prevention and health promotion programmes in order to improve oral health conditions and particularly periodontal status in the majority of countries around the world is evident. Unfortunately, in many countries, the human, financial and material resources are still insufficient to meet the need for oral health care services and to provide universal access, especially in disadvantaged communities, in both developing and developed countries. Moreover, even though the most widespread illnesses are avoidable, not all population groups are well informed about or able to take advantage of the proper measures for oral health promotion. In addition, in many countries, oral health care needs to be fully integrated into national or community health programmes. Improving oral health is a very challenging objective in developing countries, but also in developed countries, especially with the accelerated aging of the population now underway and intensifying over the coming years.

Periodontal health through public health--the case for oral health promotion.

Periodontal diseases are highly prevalent, particularly amongst socially disadvantaged populations, impact on quality of life and are costly to treat. Clinical treatments and chairside preventive approaches alone will never adequately address this problem. Indeed in many parts of the developing world clinical care and chairside prevention are both unaffordable and inappropriate for the control of periodontal diseases. A paradigm shift away from the individualized treatment approach to a population public health model is needed to promote periodontal health and, in particular to address social inequalities in periodontal status. Public health measures need to focus on the underlying determinants of periodontal diseases. Poor hygiene, tobacco use, psychosocial factors and related systemic diseases are the main risk factors for periodontal diseases. Public health interventions need to tackle these factors but also must recognize and act upon the distal underlying influences that determine and pattern these identified risks. Recognition also needs to be placed on the interlinking and common risk factors shared by periodontal diseases and other chronic conditions. A complementary range of public health policies acting at local, regional, national and international levels need to be implemented to achieve sustainable improvements in oral health. To be effective these policies need to link across the broader public health agenda and require public engagement and support. Clinicians, public health practitioners, commercial organizations and professional groups all have an important role to play in promoting periodontal health.

Translating science into action: periodontal health through public health approaches.

Clinical and public health research data have shown that a number of individual, professional and community health measures may be valuable in preventing the major oral diseases. The fundamental gap in knowledge, however, is not confined to 'what to do' but rather 'how' to translate the scientific findings into effective and sustainable programs for groups and populations. The advances in oral health science have not yet benefitted the poor and disadvantaged population groups around the world to the fullest extent possible and this has led to inequalities in periodontal health as well as in other chronic diseases. Research on the causative role of tobacco use in periodontal disease is strong because of the fact that tobacco-induced disease ultimately may lead to the loss of teeth. Studies also indicate that wound healing may be negatively affected by the use of tobacco. Likewise, research has shown that extreme use of alcohol, poor diet and nutrition, and psychological stress all have negative effects on periodontal health. Research on sociobehavioral risk factors has great implication to prevent periodontal disease. The case for tobacco is illustrated in this report. The global exposure to tobacco use in adults and adolescents is outlined. Because of the global Framework Convention for Tobacco Control (2003), the solid research on the harmful effect of tobacco is now being widely used for public health. The importance of tobacco prevention within the context of health-promoting schools is emphasized. Research on other population-directed strategies and their implications on public health would be instrumental to integrated prevention of chronic disease and periodontal disease. Community interventions and delivery of preventive oral care by oral health services may have positive outcomes for periodontal health but periodontal research needs to be further strengthened by the provision of sound evidence. It is somewhat remarkable that research on true population-directed actions in prevention of periodontal disease is most unusual. The high need for reorientation of periodontal research toward public health is discussed in this report as well as the responsibilities of oral health organizations, research institutions and health authorities.

Consumption of dental services among adults in Denmark 1994-2003.

The purpose of the present study was to measure the consumption of dental services among adults in Denmark and to analyze at what level socio-demographic/socio-economic factors influence dental attendance and oral examinations. A sample of 10% of the total population of 18 yr or older was randomly drawn from a population register, based on a cross-sectional design. Information on the use of dental services was retrieved from public registers along with data on gender, age-group, regions, ethnicity, education, marital status, and income. In addition, a cohort of persons was drawn from the sample in 1999 including only persons who were registered as residents in Denmark from 1999 to 2003. Over time, an increase in the number of dental visits and oral examinations was found among persons older than 45 yr, whereas a decrease was observed in the younger age-groups. Logistic regression analysis was applied to determine the effect of various variables on the experience of dental visits and oral examinations, and relatively high odds for dental attendance and oral examinations was found for the following: younger adults; women; married persons; high income; high education; and persons of Danish origin. The present dental healthcare system does not yet seem to have established mechanisms to address social inequalities in the consumption of dental services.