for research purposes prevalence of periodontal disease means

Epidemiology of Periodontal Diseases

• First Online: 20 October 2020

Cite this chapter

• Vibeke Baelum 4 &
• Rodrigo López 5  

Part of the book series: Textbooks in Contemporary Dentistry ((TECD))

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This chapter discusses key problems encountered by anyone who attempts to synthesize findings from epidemiological studies of periodontal diseases. These problems include the absence of a common understanding of disease, varying or unspecific disease definitions, different recordings used to assess disease, lack of consistency in the recording protocols, and the variable reporting of the results of studies. In addition, we address the biases introduced by differences in the levels of gingival inflammation and in the degree of tooth retention when attempting to compare measures of periodontitis across populations. We briefly review epidemiological findings regarding gingivitis and periodontitis according to key sociodemographic and behavioural factors, based on reviews published within the past two decades. As these reviews also show, caution should be exercised when attempting to synthesize the information provided in epidemiological studies of periodontal diseases.

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Baelum, V., López, R. (2021). Epidemiology of Periodontal Diseases. In: Peres, M.A., Antunes, J.L.F., Watt, R.G. (eds) Oral Epidemiology. Textbooks in Contemporary Dentistry. Springer, Cham. https://doi.org/10.1007/978-3-030-50123-5_4

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• Periodontal (Gum) Disease

Periodontal Disease in Adults (Age 30 or Older)

The prevalence of periodontal (gum) disease continues to be an important public health problem in the United States as 2 in 5 adults are affected by some form of this disease. Significant disparities continue to affect some population groups and smoking remains a major risk factor for periodontitis.

The table below presents information about the prevalence of severe and nonsevere (mild or moderate) periodontitis among dentate adults 30 years or older.

The table uses the Centers for Disease Control and Prevention (CDC)/American Academy of Periodontology (AAP) periodontitis case definitions for surveillance.

Per CDC/AAP, severe periodontitis is defined as having 2 or more interproximal sites with clinical attachment loss (CAL) 6 mm or greater (not on the same tooth) and 1 or more interproximal sites with periodontal probing depth (PPD) 5 mm or greater.

Nonsevere periodontitis is comprised of the two less severe categories of disease (moderate and mild periodontitis). Moderate periodontitis is defined as 2 or more interproximal sites with CAL 4 mm or greater (not on the same tooth) or 2 or more interproximal sites with PPD 5 mm or greater (also not on the same tooth); mild periodontitis is defined as 2 or more interproximal sites with CAL 3 mm or greater and 2 or more interproximal sites with PPD 4 mm or greater (not on the same tooth) or 1 or more sites with 5 mm or more.

Finally, total periodontitis is defined as the combination of mild, moderate, and severe periodontitis.

Prevalence of periodontitis classified by the CDC/AAP case definitions

• Overall, 42.2% (standard error, ± 1.4) of adults 30 years or older in the United States had total periodontitis, consisting of 7.8% with severe periodontitis and 34.4% with nonsevere periodontitis.
• The prevalence of nonsevere (mild or moderate) and of total—but not of severe—periodontitis increased with age.
• The prevalence increased with increasing number of teeth missing but not with increasing body mass index (BMI).
• Among dental health-related behavior subgroups, the prevalence of total periodontitis was highest among adults who did not use dental floss regularly (53.1%) and increased with increasing duration since last dental visit to 54.8% of those without a dental visit the past year.

Table: Prevalence of severe and nonsevere (mild or moderate) periodontitis among dentate adults 30 years or older

* Third molars were excluded. A Wald x 2 test was used for testing significance of proportion difference in each group. † P < .001. ‡ P < .05. §P < .01. ¶ Income values were missing in 895 respondents. # FPL: Federal poverty level. ** Body mass index values in kilograms per square meter were missing in 64 respondents. †† Based on data from National Health and Nutrition Examination Survey 2011-2014 only.

Data Source : The National Health and Nutrition Examination Survey (NHANES) has been an important source of information on oral health and dental care in the United States since the early 1970s. The table presents the latest NHANES data (collected between 2009 and 2014) regarding prevalence of severe and nonsevere (mild or moderate) periodontitis among dentate adults 30 years or older.

Reference : Eke PI, Thornton-Evans GO, Wei L, Borgnakke WS, Dye BA, Genco RJ. Periodontitis in US Adults: National Health and Nutrition Examination Survey 2009-2014. J Am Dent Assoc . 2018 Jul;149(7):576-588.e6. doi: 10.1016/j.adaj.2018.04.023. PMID: 29957185; PMCID: PMC8094373.

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• Periodontitis
• Roughly 42 percent of all dentate U.S. adults 30 years of age or older have periodontitis
• Attachment and bone loss associated with periodontal disease are results of the body’s immune response to plaque biofilm and its metabolic byproducts.
• While associations between periodontitis and various systemic conditions and diseases have been suggested by research, evidence of causality is mixed and the strength of the evidence differs for various conditions.
• In  2017 the World Workshop on the Classification for Periodontal and Peri-Implant Diseases and Conditions established a classification system for periodontitis that involves staging (i.e., the severity and extent of the disease) and grading (i.e., the potential for disease progression and treatment outcome).
• The goal of periodontal treatment is to eliminate dysbiotic plaque biofilm from the tooth surface and to establish an environment that allows the maintenance of health. This treatment of periodontal disease can be non-surgical or surgical with the optimal treatment being based on individual patient, site, and systemic factors.

NOTE : In 2017, the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) convened panels of experts to develop a classification system for periodontal and peri-Implant diseases and conditions. 1 In 2018, these panels published consensus reports that described periodontal diseases including: periodontal health, gingival diseases and conditions 2 ; periodontitis 3, 4 ; and other conditions affecting the periodontium 3, 4 ; as well as a system describing for peri-implant diseases (peri-implant health, peri-implant mucositis, and peri-implantitis). 5 This Oral Health Topic page will focus on classifications related to periodontitis.

Periodontal disease is a chronic infection that can result in the destruction of tooth-supporting structures (i.e., the gingiva, periodontal ligament, and/or alveolar bone) and eventual tooth loss. 6

According to analysis of data from the National Health and Nutrition Examination Survey (NHANES) collected from 2009 to 2014, roughly 42% of dentate adults 30 years of age or older in the United States have some form of periodontitis (mild, moderate or severe). 7 The prevalence of periodontitis increases with age; it is significantly more common in males than in females, and in non-Hispanic Blacks and Hispanics than non-Hispanic whites. 7

Periodontitis is an inflammatory disease of bacterial etiology resulting in loss of periodontal tissue attachment and alveolar bone. 8 The host response to the bacterial challenge leads to clinical signs such as deep pockets, bleeding on probing, gingival recession, and tooth mobility, which can ultimately cause tooth loss.

In 2018, the American Academy of Periodontology and the European Federation of Periodontology published the World Workshop Classification System for Periodontal and Peri-Implant Diseases and Conditions, which established a new approach to diagnosing periodontal disease to replace the system developed in 1999. The current classification system was endorsed by the American Dental Association in 2021.

Evidence of the association of periodontitis with systemic conditions is mixed (see the related Oral Health Topic page, Oral/Systemic Health ). Associations, though not causal relationships, with periodontitis have been suggested for several conditions:

• Cardiovascular diseases: Although a causal relationship has not been established, the presence of periodontal disease has been associated with various cardiovascular diseases including myocardial infarction, 9 hypertension, 10 and carotid atherosclerosis. 11 While research indicates a positive relationship between periodontal treatment and a short-term relationship on surrogate outcomes associated with cardiovascular disease, these studies have significant limitations and lack focus on true cardiovascular disease outcomes. 12
• Diabetes: Periodontal disease and diabetes are considered to have a bidirectional relationship: hyperglycemia has an effect on oral health and periodontitis has an effect on glycemic control. A 2018 systematic review by Graziani et al. concluded that periodontitis is associated with (1) higher HbA1c levels in individuals without diabetes and in individuals with type 2 diabetes, (2) worsened diabetes-related complications in individuals with type 2 diabetes, and (3) an increased prevalence of complications in individuals with type 1 diabetes. The effect of periodontal treatment on diabetes-related parameters such as glycemic control is still inconclusive. 13
• Respiratory diseases: Research suggests associations between periodontitis and respiratory diseases such as asthma, chronic obstructive pulmonary disease and pneumonia, possibly due to inflammatory processes and aspiration of microorganisms from the periodontal pocket. 14
• Pregnancy complications: An umbrella review of 23 systematic reviews found that periodontitis during pregnancy seems to contribute to increased risk of preterm birth, low birthweight infants and preeclampsia. 15 However, there was no effect of periodontal treatment found on pre-term birth prevention.
• Rheumatoid arthritis: A 2020 systematic review indicates that periodontitis may increase the risk of developing rheumatoid arthritis. 16
• Chronic kidney disease: Although there is no evidence on causal association, studies have shown a high periodontitis prevalence in chronic kidney disease populations also demonstrating racial and ethnic disparities. 17
• Cancers: Periodontal disease and periodontal pathogens have been associated with cancers. 18
• Dementias: Periodontitis and periodontal pathogens have been associated with dementias and Alzheimer’s Disease. 19

Notably, the 2017 system published by AAP/EFP eliminates use of the diagnostic categories “Chronic” and “Aggressive” periodontitis. These are now considered under the general category of “periodontitis,” owing to the determination that extent and severity does not distinguish these as separate disease. 3 Periodontitis is categorized by signs and symptoms of inflammation and attachment/radiographic bone loss.

Under the 2017 system, the current categories of periodontitis are 3

• Necrotizing periodontal diseases
• Periodontitis as a Manifestation of Systemic Diseases

Necrotizing periodontal diseases feature papilla necrosis, bleeding, and pain, and are associated with impaired immune response, 3 Periodontitis as a manifestation of systemic disease focuses on diseases and conditions other than diabetes (e.g., genetic disorders, neoplasms, and other metabolic and endocrine disorders). 4, 20

Disease that does not meet these criteria are considered as periodontitis.

Once the determination of periodontitis has been made, the disease is classified according to one of four Stages (I-IV) based upon the most severe area of disease presentation, which describe the disease severity and extent of disease, focusing on attachment and bone loss (Table 1A). The extent of disease is categorized by the extent of stage-defining destruction. After the Stage is determined, the case is assigned one of three Grades (A, B, C) that indicate the potential for disease progression and treatment outcome (Table 1B). Grading is based on supplemental considerations like direct evidence of disease progression, indirect evidence of disease progression (radiographic bone loss divided by age), smoking patterns, and diabetes and glycemic control. 3

The goal of periodontal treatment is to eliminate plaque, biofilm and calculus, from the tooth surface and establish an environment that can be maintained in health. 21 Treatment of periodontitis can be non-surgical or surgical. The optimal treatment is based on the patient, site and systemic factors.

Non-Surgical

The American Academy of Periodontology defines non-surgical treatment as the professional removal of supragingival and subgingival bacterial plaque or biofilm and calculus, which provides a biologically acceptable root surface, as well as patient adoption of a comprehensive daily plaque or biofilm control routine. 22

Non-surgical therapy includes 21 :

• Patient education and oral hygiene instruction
• Complete removal of supragingival calculus
• Restoration or temporization of carious lesions
• Treatment of areas where plaque and food debris can collect, including orthodontic treatment and removal of plaque retentive factors.

According to ADA clinical practice guidelines on non-surgical treatment, 23 derived from a 2015 systematic review, 23 scaling and root planing without adjuncts is the treatment of choice for patients who have periodontitis. The guidelines go on to endorse use of systemic sub-antimicrobial dose doxycycline along with scaling and root planing for patients with moderate-to-severe periodontitis. Specifically, the guidelines recommend oral doxycycline (20 mg twice a day) for 3 to 9 months following scaling and root planing for these patients.

Patients often require several treatment sessions for complete debridement of the tooth surfaces. 21 After scaling, root planing, and other adjunctive treatment approaches such as use of antibiotic therapy, the periodontal tissues require approximately 4 weeks to demonstrate optimal effects of nonsurgical therapy. 21

Many moderate to advanced cases require surgical access to the root surface for root planing and reducing pocket depth, which will allow the patient to achieve successful home care. 21

Surgical treatment entails 21 :

• Correction of anatomic conditions that predispose the patient to periodontitis, impair aesthetics, or impede placement of prosthetic appliances
• Extraction of teeth that cannot be successfully treated
• Placement of implants when teeth are lost

Surgical treatment options include 24 :

• Gum Graft Surgery: Gum graft surgery is intended to prevent further gingival (gum) recession and bone loss and to reduce sensitivity. During this procedure, tissue is taken from the palate or another donor source to cover exposed roots.
• Periodontal Pocket Reduction Procedures: In this approach, gingival tissue is folded back to allow for removal of disease-causing bacteria, after which the tissue is sutured back in place. This is intended to allow gingival tissue to reattach to the bone.
• Regenerative Procedures: These are procedures that are performed when there is bone destruction. Once again, the gingival tissue is folded back and the disease-causing bacteria are removed, after which membranes, bone grafts, or tissue-stimulating proteins are used to help promote regeneration of supporting periodontal tissues.

Maintenance

A patient with gingivitis can revert to a state of health with a reduced periodontium, but due to the host-related disease susceptibility, a periodontitis patient remains a periodontitis patient, even following successful therapy, and requires life‐long supportive care to prevent recurrence of disease. 2 Further, patients with more severe periodontitis Stage and Grade have been found to be more likely to experience disease recurrence and tooth loss without regular periodontal maintenance visits. 25

Much of the literature agrees that, after non-surgical and/or surgical periodontal treatment, patients could benefit from more frequent visits, possibly every 3-6 months. 26, 27 These appointments could include a review of home oral hygiene behaviors, ascertainment of exposure to risk factors such as tobacco use, professional plaque removal, and subgingival debridement, as needed. 26-28 Patients also could be assessed to determine if active therapy is needed to treat recurrent periodontal disease. 27

Researchers generally agree the maintenance phase is key to allow for close monitoring of the attachment level and pocket depth along with the other clinical variables, such as bleeding, exudation, tooth mobility. 21

• Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification. J Clin Periodontol 2018;45 Suppl 20:S1-S8.
• Chapple ILC, Mealey BL, Van Dyke TE, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018;89 Suppl 1:S74-S84.
• Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol 2018;45 Suppl 20:S162-S70.
• Jepsen S, Caton JG, Albandar JM, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol 2018;45 Suppl 20:S219-S29.
• Berglundh T, Armitage G, Araujo MG, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol 2018;45 Suppl 20:S286-S91.
• Periodontal Disease and Overall Health: A Clinician’s Guide. Yardley, PA: Professional Audience Communications, Inc.; 2010.
• Eke PI, Borgnakke WS, Genco RJ. Recent epidemiologic trends in periodontitis in the USA. Periodontol 2000 2020;82(1):257-67.
• Genco R, Williams R. Periodontal Disease and Overall Health: A Clinician’s Guide. Yardley, PA: Professional Audience Communications, Inc.; 2010.
• Xu S, Song M, Xiong Y, et al. The association between periodontal disease and the risk of myocardial infarction: a pooled analysis of observational studies. BMC Cardiovasc Disord 2017;17(1):50.
• Martin-Cabezas R, Seelam N, Petit C, et al. Association between periodontitis and arterial hypertension: A systematic review and meta-analysis. Am Heart J 2016;180:98-112.
• Zeng XT, Leng WD, Lam YY, et al. Periodontal disease and carotid atherosclerosis: A meta-analysis of 17,330 participants. Int J Cardiol 2016;203:1044-51.   Roca-Millan E, Gonzalez-Navarro B, Sabater-Recolons MM, et al. Periodontal treatment on patients with cardiovascular disease: Systematic review and meta-analysis. Med Oral Patol Oral
• Cir Bucal 2018;23(6):e681-e90.
• Cao R, Li Q, Wu Q, et al. Effect of non-surgical periodontal therapy on glycemic control of type 2 diabetes mellitus: a systematic review and Bayesian network meta-analysis. BMC Oral Health 2019;19(1):176.
• Gomes-Filho IS, Cruz SSD, Trindade SC, et al. Periodontitis and respiratory diseases: A systematic review with meta-analysis. Oral Dis 2020;26(2):439-46.
• Daalderop LA, Wieland BV, Tomsin K, et al. Periodontal Disease and Pregnancy Outcomes: Overview of Systematic Reviews. JDR Clin Trans Res 2018;3(1):10-27.
• Qiao Y, Wang Z, Li Y, et al. Rheumatoid arthritis risk in periodontitis patients: A systematic review and meta-analysis. Joint Bone Spine 2020;87(6):556-64.
• Ioannidou E, Hall Y, Swede H, Himmelfarb J. Periodontitis associated with chronic kidney disease among Mexican Americans. J Public Health Dent 2013;73(2):112-9.
• Nwizu N, Wactawski-Wende J, Genco RJ. Periodontal disease and cancer: Epidemiologic studies and possible mechanisms. Periodontol 2000 2020;83(1):213-33.
• Ma KS, Hasturk H, Carreras I, et al. Dementia and the Risk of Periodontitis: A Population-Based Cohort Study. J Dent Res 2022;101(3):270-77.
• Albandar JM, Susin C, Hughes FJ. Manifestations of systemic diseases and conditions that affect the periodontal attachment apparatus: Case definitions and diagnostic considerations. J Clin Periodontol 2018;45 Suppl 20:S171-S89.
• Newman MG, Takei HH. Newman and Carranza’s Clinical Periodontology. 13th ed. ed. Philadelphia: Elsevier; 2019.
• American Academy of Periodontology. Ad Hoc Committee on the Parameters of Care: Phase I therapy. J Periodontol 2000;71(Supplement):856.
• Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc 2015;146(7):525-35.
• American Academy of Periodontology Surgical Procedures. " https://www.perio.org/for-patients/periodontal-treatments-and-procedures/surgical-procedures/ ". Accessed March 7 2020.
• Ravida A, Galli M, Saleh MHA, et al. Maintenance visit regularity has a different impact on periodontitis-related tooth loss depending on patient staging and grading. J Clin Periodontol 2021;48(8):1008-18.
• Leow NM, Moreno F, Marletta D, et al. Recurrence and progression of periodontitis and methods of management in long-term care: A systematic review and meta-analysis. J Clin Periodontol 2021.
• Kwon T, Lamster IB, Levin L. Current Concepts in the Management of Periodontitis. Int Dent J 2021;71(6):462-76.
• Manresa C, Sanz-Miralles EC, Twigg J, Bravo M. Supportive periodontal therapy (SPT) for maintaining the dentition in adults treated for periodontitis. Cochrane Database Syst Rev 2018;1:CD009376.

Professional Resources

• Search JADA for articles related to periodontitis
• Clinical Practice Guideline for Nonsurgical Treatment of Chronic Periodontitis ADA Oral Health Topic Pages: o Diabetes o Oral-Systemic Health o Pregnancy
• ADA Library Services
• ADA Store o ADA Flip Guide to Periodontal Disease (W463) o Periodontal Disease: Keep Your Gums Healthy (W107) o Periodontal Disease: Don’t Wait Until it Hurts (W12120) o Periodontal Disease: Your Complete Guide (W120) o Healthy Mouth, Healthy Body: Making the Connection (W203)

Patient Resources

• For the Patient: Keeping an Eye on Your Gums
• MouthHealthy: Gum disease
• American Academy of Periodontology: Resources for Patients
• National Institute of Dental and Craniofacial Research: Periodontal (Gum) Disease
• Centers for Disease Control and Prevention: Periodontal Disease

Last Updated: June 9, 2022

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Research Services and Scientific Information, ADA Library & Archives.

Content on the Oral Health Topics section of ADA.org is for informational purposes only. Content is neither intended to nor does it establish a standard of care or the official policy or position of the ADA; and is not a substitute for professional judgment, advice, diagnosis, or treatment. ADA is not responsible for information on external websites linked to this website.

• Open access
• Published: 12 March 2022

Prevalence of periodontal disease among Indigenous and non-Indigenous populations: protocol for systematic review and meta-analysis

• Sonia Nath   ORCID: orcid.org/0000-0001-8714-7264 1 ,
• Brianna Poirier 1 ,
• Xiangqun Ju 1 ,
• Kostas Kapellas 1 ,
• Dandara Haag 1 &
• Lisa Jamieson 1  

Systematic Reviews volume  11 , Article number:  43 ( 2022 ) Cite this article

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Indigenous populations globally experience worse oral health than their non-Indigenous counterpart. Globally, the occurrence of periodontal diseases such as gingivitis and chronic periodontitis is high among Indigenous people. This systematic review aims to quantify, at a global level, the prevalence of periodontal disease among Indigenous populations compared to non-Indigenous populations.

This review will only consider studies that have reported the prevalence (%) of periodontal disease among Indigenous and compared against non-Indigenous populations. Studies that have no comparative population or data only on one particular population or lack of data on periodontal clinical assessment will be excluded. An electronic search will be conducted using keywords and appropriate MeSH terms across several databases capturing both published and unpublished articles. The search will be conducted from the time of database inception to February 2021. After the initial search, duplicates will be removed, and the remaining titles and abstracts will be assessed for eligibility. The full text of eligible studies will be assessed by two independent reviewers who will also complete the critical appraisals and data extraction. Outcomes measures would be the mean prevalence (%) and standard deviation of periodontal disease among Indigenous and non-Indigenous populations. From the selected studies, we will conduct a random-effects meta-analysis using standardized mean difference as the effect measure. Forest plots will be used for the visualization of differences in the prevalence of periodontitis. A subgroup analysis will be conducted based on the definition of periodontitis, age, publication type, and geographical location. Heterogeneity among studies will be assessed by I 2 and chi-square test. Egger’s test and funnel plots will be used to assess publication bias.

Our systematic review and meta-analysis will facilitate an increased understanding of the magnitude of periodontal disease inequalities that exist globally for Indigenous populations through pooled prevalence estimates. The findings will be helpful to design selective targeted preventive and interventional strategies for periodontal disease for reducing oral health inequalities at a global level.

Systematic review registration

PROSPERO CRD42020188531

Peer Review reports

Across global geographic and cultural differences, Indigenous peoples experience similar difficulties in defending their sovereignty and are among the most disadvantaged populations [ 1 , 2 ]. According to a United Nations (UN) report in 2009, there are approximately 350–500 million Indigenous peoples in 90 countries around the world [ 3 , 4 ]. The International Labour Organisation (1989) defines Indigenous people as “tribal peoples in independent countries whose social, cultural, and economic conditions distinguish them from other sections of the national community and whose status is regulated wholly or partly by their own customs or traditions or by special laws or regulations; and peoples in independent countries who are regarded as Indigenous because of their descent from the populations who inhabited the country, or a geographical region to which the country belongs, at the time of conquest or colonisation or the establishment of present state boundaries and who, irrespective of their legal status, retain some or all of their own social, economic, cultural, and political institutions [ 5 ].” Despite variance in the magnitude of health disparities, globally Indigenous peoples experience a higher burden of disease than their non-Indigenous counterparts [ 6 ]. The life expectancy of the Indigenous population is up to 20 years lower than the non-indigenous population and are more vulnerable to the impacts of climate change, natural hazards, and outbreaks such as COVID-19 [ 7 ]. The disadvantage, as a consequence of collective histories of oppression and marginalization, has resulted in increased rates of infections and chronic diseases [ 8 ]. Continuing impacts of colonialism, community displacement, and land appropriation combined with socioeconomic differences create complex barriers to accessing healthcare for Indigenous peoples [ 5 ].

Oral health is not exempt from health disparity trends among Indigenous populations and untreated dental caries, less restored teeth and periodontal disease have been reported to be higher [ 9 , 10 , 11 ]. Oral health is multidimensional, including emotional, physical, psychological, and social realms that are vital to general well-being [ 12 , 13 ]. Oral diseases have serious health and economic ramifications and are among the most widespread diseases globally [ 9 ]. Poor oral health among the Indigenous group not only impacts the oral cavity but can result in debilitating pain, limited social interactions, difficulties eating and speaking, embarrassment, and reduced quality of life [ 10 , 14 ].

According to Global Burden of Disease (GBD) estimates, severe periodontitis is the 11th most prevalent disease in the world [ 15 ]. The global prevalence rate for severe periodontal disease is gradually increasing despite efforts to prevent and control the progression of the disease [ 16 ]. Gingivitis and periodontitis are the most common oral infections with an overall global prevalence ranging from 20 to 50% [ 16 ]. The initial form of periodontal disease, gingivitis, presents as gingival bleeding, clinical inflammation, redness of the gingiva, and pain and if this condition is left untreated it progresses to clinical loss of connective tissue attachment, alveolar bone loss, and subsequently loss of tooth structure [ 17 ]. Periodontal disease results from interactions between bacteria and a variety of host risk factors, such as poorly managed diabetes, long-term tobacco smoking, stress, and genetic predisposition [ 18 ]. Several researchers have reported that the Indigenous population has a higher burden of periodontal disease than the non-Indigenous population [ 11 , 19 , 20 ] and often experience various barriers in accessing and utilizing dental services [ 20 ]. Therefore, it is crucial to identify the global estimates of periodontal disease that has been consistently present and increasing in the Indigenous community. The findings from this review would aim to facilitate researchers, clinicians, policymakers, and Indigenous communities in decision-making approaches to improve periodontal health.

A search of relevant databases showed no current or proposed systematic reviews regarding the prevalence of periodontal disease among Indigenous populations compared with non-Indigenous populations. To our knowledge, this will be the first evidence to highlight the disparities in the occurrence of periodontal disease among Indigenous populations and the first to report a comparative synthesis of results. A preliminary search of MEDLINE, Scopus, and EBSCOhost identified published data that fits within the inclusion criteria for this review. The research question of our review is “what is the magnitude of the disparity in the prevalence of periodontal disease among Indigenous populations compared to non-Indigenous/general populations globally among observational studies?”

The proposed systematic review will be conducted following the Joanna Briggs Institute (JBI) methodology for systematic reviews of prevalence [ 21 ]. The systematic review protocol has been registered in the International Prospective Register of Systematic Review (PROSPERO), registration number CRD42020188531. For reporting of this systematic review, the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) Protocols guidelines (Additional file 1 ) will be followed [ 22 ].

Inclusion criteria

Participants.

The review will include studies that have reported the prevalence of periodontal disease among Indigenous populations compared with non-Indigenous populations. This study will include Indigenous peoples from Australia (Aboriginal or Torres Strait Islanders), Canada (Inuit, Metes, First Nations), New Zealand (Maori), USA (American Indian and Alaskan Natives), Brazil (Amerindians, Xingu, Xavante Indians), and other countries, including but not limited to China, South Asia, Southeast Asia, South America, Africa, Central America, Arabia, former Soviet Union, Scandinavia, and the Pacific Islands [ 23 ]. Participants of all age groups, including children and adults, will be eligible for inclusion. The inclusion of studies will not be restricted by participant sex or geographical location.

The Indigenous status of participants will be defined by guidelines that are outlined in Article 33 of the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) [ 24 ]. As such, Indigeneity identified through self-identification, parent reporting for children, and utilization of country-specific identity registration systems would be eligible for inclusion.

This review will include all papers that have assessed the prevalence of periodontal disease, regardless of the definition of periodontal disease used. The definition of periodontal disease can be based on periodontal probing depth (PPD), clinical attachment level (CAL), or both [ 25 ]. Indices that assess periodontal disease would also be included such as community periodontal index (CPI) or periodontal index (PI) [ 26 ]. Measures of risk indicators for periodontal disease will be considered as secondary outcomes, such as the prevalence of bleeding on probing (BOP) from the gingiva, prevalence of calculus, and prevalence of plaque [ 25 ].

The primary outcomes of this review will be as follows:

The mean prevalence (%) of periodontitis among Indigenous people compared to non-Indigenous people according to different definitions of periodontitis.

The mean number of sites (%) associated with periodontitis.

The secondary outcomes of this review will be as follows:

The mean prevalence (%) of plaque index at a factor greater than 2.

The mean prevalence (%) of gingival index at a factor greater than 2.

The mean prevalence (%) of calculus.

The mean prevalence (%) of BOP.

Our review will consider studies that report the prevalence of periodontal disease in Indigenous populations from all countries without any geographic restriction. Participants can be recruited from a variety of sites, such as community settings, hospital/ clinical settings, or school settings.

Types of studies

This review will consider descriptive observational studies including descriptive cross-sectional studies that have comparative measures of periodontal disease between Indigenous versus non-Indigenous populations. Analytical observational studies will also be included. Data from national surveys, government reports, censuses, and government registries will additionally be considered. Baseline data from clinical trials which report on the prevalence of periodontal disease relevant to our inclusion criteria will be included. If a similar data set is used in more than one study for the same geographical area and periodontal outcome then the primary dataset will be used.

The exclusion criteria for this review will be as follows: (1) analytical or descriptive observational studies without a comparison group; (2) studies that do not measure periodontal disease through clinical assessment or have not reported the periodontal data separately for Indigenous and non-Indigenous populations; (3) studies that assess periodontal parameters through self-oral assessment; (4) studies with non-extractable data; (5) case reports, literature reviews, including systematic reviews and scoping reviews, letters, commentaries, opinion pieces, and editorials.

Search strategy

For our review, we will employ a three-stage search strategy. Firstly, a limited search of MEDLINE will be conducted to identify articles on this topic. The reviewers will analyze the text words contained in the title and abstract of the relevant articles and the index terms to describe the articles to develop an appropriate search string. The second step will involve using keywords and MeSH terms (Medical Subject Headings) to capture all relevant articles across MEDLINE, Scopus, and EBSCOhost (Dentistry and Oral Sciences Source), University of New Mexico Native Health Database, Bibliography of Native North Americans, and the Australian Indigenous HealthInfoNet. All electronic databases will be searched from review inception to February 2021. Finally, a reference list will be made of all selected articles and free-hand bibliography searching of relevant articles will be done to identify additional studies that might have been overlooked during the electronic search. Narrative reviews and standard textbooks related to the topic will be searched to identify relevant articles. The search strategy for MEDLINE has been described in Appendix 1 .

For unpublished data, a similar search will be conducted in Open Grey and ProQuest Dissertation. The authors will conduct an online search using a combination of keywords such as “Indigenous” or “Aboriginal” and “periodontitis” or “periodontal disease” or “gingivitis” or “gingival disease” to find relevant data from national oral health surveys, government reports, national censuses, and government registries. Websites and resources that have comparison data for periodontal disease among the Indigenous and non-Indigenous population will be considered for inclusion. All websites from the search result would be screened by two reviewers for eligibility for inclusion and a table will be made in a spreadsheet recording the title, URL, and date accessed ( Appendix 2 ). We will also contact experts in the field for additional unpublished data and advice on published work (e.g., E Kruger (Australia), R Arantes (Brazil), T Batliner (USA), J Broughton (New Zealand), and H Lawrence (Canada)).

Reviewer calibration

Calibration will be done before title and abstract screening and the study selection process. Both reviewers (SN & BR) will be calibrated for the screening process on a random sample of 5% of the total number of citations. Both reviewers will screen the selected articles independently and in duplicates. In case of any discrepancy, the outcome will be discussed among the reviewers until a consensus is reached and in case a consensus is not reached a third reviewer (LMJ) will be consulted. A kappa score will be calculated as a screening reliability score among the reviewers.

Study selection

Findings from the search strategy will be catalogued using EndNote X9 Version 3.3 (Clarivate Analytics, Philadelphia, PA, USA) and duplicate citations will be removed. The study selection process will be carried out in two steps: (1) title and abstract screening, (2) full-text screening.

The abstract and titles will be screened against the inclusion and exclusion criteria. For inclusion, studies must include a comparison of prevalence of any periodontal parameter between Indigenous and non-Indigenous population. The next step will be to retrieve the full text of all potentially relevant articles and import them into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The two independent reviewers (SN and BR) will assess the full text in detail for eligibility. Any reason for exclusion will be recorded in JBI SUMARI. The results of the search will be represented in a flow diagram according to the PRISMA guidelines [ 27 ].

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers (SN and BR) at the study selection stage using the standardized critical appraisal instrument in JBI SUMARI for prevalence studies [ 21 , 28 ]. Any appraisal disagreements will be resolved through mutual discussion or consultation of a third reviewer (LMJ) where necessary. The JBI SUMARI instrument [ 21 ] consists of a standardized checklist to ensure consideration of factors such as (1) sampling frame, technique, and size, (2) subject and setting detail, (3) data analysis, (4) methods for identification of the condition, (5) reliability of methods used for measuring the condition, and (6) adequacy of response rate. If any publications have missing information, the authors will be contacted via email. The results of the critical appraisals will be reported in narrative and table form. All studies, regardless of the results of their methodological quality, will undergo data extraction and analysis (where possible).

Data extraction

The investigators (SN and BR) will perform data extraction from included articles using a customized data extraction form generated in an excel spreadsheet. The extraction tool will be pilot-tested on a random sample (5%) of included studies and revised until a consensus is reached on the key variables and outcomes. Any disagreements that arise between the reviewers will be resolved through discussion, or by discussing with a third reviewer (LMJ). Authors of included papers will be contacted via email to request missing or additional data where required. The following fields will be included ( Appendix 3 ):

Study characteristics: study unique reference number, last name of the first author, year and place of publication, study setting, sampling design, sampling frame, and sample size calculations.

Participant characteristics: total number of cases, the total number of controls, definition of cases and controls, mean age, method of data collection, parameters of periodontal disease, and periodontitis definition used.

Outcome measures: the mean (%) prevalence of periodontitis and mean (%) number of sites involved with periodontitis, mean (%) prevalence of bleeding sites, mean (%) prevalence of sites with calculus, mean (%) prevalence of sites with dental plaque, and mean (%) prevalence of sites with gingival inflammation.

Overall findings: the outcome of the study with the main results.

Data analysis and synthesis

Where appropriate, extracted data will be collated for meta-analysis using the JBI SUMARI software [ 28 ]. Where statistical pooling is not possible, findings will be presented in narrative form using tables to aid in data presentation. For this systematic review, Indigenous populations will be considered as the experimental group and non-Indigenous populations as the control group. The mean (%) prevalence and standard deviation (SD) of periodontitis would be the effect estimate from each study. Random effects models will be used for analysis and will be reported as the standardized mean difference with a 95% confidence interval for the differences between the Indigenous and non-Indigenous populations. The random-effects model allows for the differences in the outcome effect from study to study occurring due to differences in the population characteristics (such as age and geographic location) and study characteristics (study sample and sampling design) and other factors [ 29 ]. For individual studies, the weight will be calculated on the inverse of the variance. To assess heterogeneity standard chi-squared, Tau squared, and I 2 tests will be used. The I 2 index will be interpreted as low, moderate, or high inconsistency if the values are equal to 25%, 50%, and 75% respectively [ 30 ]. To address heterogeneity we will conduct a subgroup meta-analysis and omit studies that have been identified as outliers by visualizing the forest plots. A subgroup analysis of different periodontal disease definitions, age, publication type, and geographical location will be done. Sensitivity analyses will be conducted to test decisions made during the process of conducting the review. Publication bias will be assessed using Egger’s test and visualizing the funnel plot asymmetry [ 31 ].

This protocol describes a planned systematic review and meta-analysis to estimate the pooled prevalence of periodontitis among Indigenous and non-Indigenous populations. Previous systematic reviews [ 11 , 32 , 33 ] have shown the prevalence of periodontal disease only among Indigenous populations without any comparison to general populations and has been restricted to specific countries without any global comparison. A comparative analysis is crucial in understanding the magnitude of the diseased condition affecting Indigenous peoples. The prevalence of periodontal disease affecting Indigenous adults is documented as being substantially higher among Indigenous than non-Indigenous groups [ 11 , 34 , 35 , 36 ], reaching as high as 97.8% [ 36 ].

Exploration of the burden of periodontal disease experienced by Indigenous peoples is important due to the continuous nature of the disease and the possible result of bone loss. Identifying variances in the experience of periodontal disease is critical due to the common experience of inflammatory response similar to other systemic conditions [ 37 , 38 ]. There are established links between periodontal disease and heart and lung disease, diabetes, strokes, and low birth weight of babies of mothers with periodontal disease [ 39 , 40 , 41 , 42 ]. Periodontal disease is irreversible and successful treatment only restores periodontal health with reduced and compromised periodontium. The anatomical damage from the previous periodontal disease continues to persist, and the inverse architecture of the soft tissues may impair further plaque control. This makes maintenance of periodontally compromised teeth very difficult and eventually leads to loss of tooth structure [ 43 ]. If Indigenous populations have a higher burden of periodontal disease, such early tooth loss would impact the overall quality of life and general health and thus increase the economic burden of the country [ 44 ]. Findings of this systematic review will be relevant to policymakers and public health officials who inform oral health practices and interventions for Indigenous communities.

Availability of data and materials

The dataset that would be generated and analyzed for the current systematic review will be available from the corresponding author on reasonable request.

Abbreviations

Bleeding on probing

Clinical attachment level

Community periodontal index

Joanna Briggs Institute System for the Unified Management, Assessment, and Review of Information

Periodontal index

Periodontal probing depth

Preferred Reporting of Items for Systematic Review

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SN and LMJ conceived the idea of the project; SN, BP, designed the protocol. XJ and SN developed the search strategy for the protocol. SN would overview subgroup and sensitivity analysis. KK and DH oversaw all the stages of the manuscript. All the authors read and approved the final manuscript.

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Additional file 1..

PRISMA-P 2015 Checklist.

Search string for OVID MEDLINE conducted on February 2021:

exp Periodontitis.mh

noexp Periodontal Diseases.mh

noexp Gingival disease*.mh

Gingival recession*.mh

Gingivitis.mh

Gingival pocket*.mh

Periodont*.mp

Oral hygiene.mp

First nation or First nations.mp

Pacific islander or Pacific islanders.mp

Torres strait islander or Torres strait islanders.mp

Aboringin*.mp

Alaska*.mp.

Amerind*.mp

Chukotka.mp

Circumpolar.mp

Greenland*.mp

indigen*.mp

Navajo or Navajo

Siberia*.mp

African continental ancestry.mp

Asian continental ancestry.mp

Arctic regions

Oceanic ancestry.mp

Indigenous health services.mp

Ethnic group*.mp

Limit 55 to humans

Mh = MeSH heading

mp = multipurpose-searches in title, original title, abstract, subject heading, name of substance and registry word fields

*wildcard symbol = broadens the search strategy by capturing the denoted word stem and all other derivatives beginning with the same letters

Exp = exploded indexing terms (MeSH heading)

Noexp = non exploded indexing terms (MeSH headings)

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Nath, S., Poirier, B., Ju, X. et al. Prevalence of periodontal disease among Indigenous and non-Indigenous populations: protocol for systematic review and meta-analysis. Syst Rev 11 , 43 (2022). https://doi.org/10.1186/s13643-022-01913-8

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Prevalence of periodontal disease among adults in India: A systematic review and meta-analysis

Chandrashekar janakiram.

a Amrita Vishwa Vidyapeetham, Amrita School of Dentistry, Department of Public Health Dentistry, Kochi, 682041, India

Abhishek Mehta

b Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India

Ramanarayanan Venkitachalam

We designed this systematic review of the available literature to measure the pooled prevalence of periodontal disease among Indian adults.

An electronic search was conducted for studies assessing the prevalence of periodontal disease (gingivitis and periodontitis) in India. The search yielded forty studies, of which thirty eligible cross-sectional studies assessing the prevalence among those 18 years and above were included. The methodological quality of the included studies was assessed. Meta-analyses were conducted for periodontitis outcomes, stratified for different covariates like age groups, gender, geographic region, population group, type of index and study quality. Pooled prevalence was used to estimate overall effect, with 95% confidence intervals (CI).

A total of 92,219 adults participated in 30 studies included for qualitative analysis. Studies utilizing convenience sampling were excluded from quantitative analysis. Pooled prevalence estimates of periodontitis and gingivitis were assessed on from 24 to 21 studies respectively. We found that overall prevalence of periodontal disease was 51% (CI: 41.9-60.1) and gingivitis was 46.6% (CI: 37.8-55.5). Prevalence of mild to moderate periodontitis was 26.2% (CI: 21.1-31.6), while for severe periodontitis it was 19% (CI: 14.3-24.2). Participants 65 years or above had highest proportion of severe periodontitis (32.7%, CI: 23.7-42.5). Urban population showed the highest prevalence of mild to moderate periodontitis 22.7% (CI: 17.3-28.5). Females had lower prevalence (34.4%) of the periodontitis than males (42.2%). The methodological heterogeneity of included studies was low.

Half of Indian adults suffer from some form of periodontal disease. There is need to adopt uniform and accurate measurement tools for recording periodontal condition.

1. Introduction

Chronic diseases globally have exhibited a steady rise, sparing no region or socioeconomic class. Periodontal disease, a component of this rising global burden essentially shares similar risk factors with other chronic diseases. 1 However, unlike these, periodontal health seldom garners any attention. Quantifying periodontal disease in a meaningful manner, hence, is critical to its prioritization.

The National Oral Health Survey of India (2002), provides a comprehensive national data on periodontal disease prevalence. 2 However, India has not seen an annual or five-yearly conduct of oral health survey for active monitoring of the disease burden. Additionally, unlike dental caries, periodontal epidemiological methods have been inconsistent. 3 This inconsistency stems from changing case definitions and variations in measurement tools, probing locations, extent of oral cavity examined, and type of probes used by oral epidemiologists. 4 So also, the surveillance of periodontal disease on regular intervals is not feasible due to chronic nature of disease and high cost of survey. The aggregate of these factors is responsible for the lack of adequate data and thereby lack of priority for oral health action. 5

Several prevalence studies 6 , 7 , 8 , 9 , 10 , 11 undertaken in India have estimated region wise specific burden of periodontal disease, however, none of them individually account for nationally representative sample. Previously published systematic reviews 3 , 12 , 13 have failed to report the pooled estimates of the periodontal diseases prevalence. Hence, this systematic review was designed to generate nationally representative data on the burden of periodontal disease among the adult population in India from previously published point prevalence studies.

2. Materials and methods

This systematic review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 14 statement. Search method to identify relevant studies using focus question is as follows:

Population: Adults > 18 years.

Intervention ​= ​Not applicable.

Determinant : Prevalence.

Outcomes : Periodontal disease.

2.1. Focused question

What is prevalence of periodontal diseases (gingivitis and periodontitis) among the adult population of India?

2.2. Eligibility criteria

This systematic review was limited to cross-sectional studies. Included studies assessed the prevalence and severity of periodontal disease among participants aged over 18 years using the Community Periodontal Index of Treatment Needs (CPITN) or Community Periodontal Index (CPI).

2.3. Definition of disease

In this systematic review, the term “periodontal diseases” includes both gingivitis (gingival inflammation) as well as periodontitis (loss of periodontal attachment). For assessing prevalence of gingivitis we considered CPI/CPITN code of 1 and 2 and for periodontitis it was code 3 and 4. Periodontitis were further classified into mild to moderate (CPI code 3) and severe category (CPI code 4 or presence of loss of attachment). This classification of severe periodontal disease was used previously by Kassebaum et al. 1

2.4. Information sources and search

An electronic search was performed with the databases PubMed/MedLine, PubMed Central, Scopus, Complimentary index, Ebscohost, SciELO, Open DOAR, TRIP, Science Citation Index,and Web of Science. We employed a platform-specific search strategy consisting of combinations of controlled terms (MeSH) and text words. The following search strategy was used; MeSH terms: “periodont∗"[All Fields] AND “prevalence"[All Fields] AND “India"[All Fields] and key words such as Community Periodontal Index of Treatment Needs (CPITN) or Community Periodontal Index (CPI) with no language restrictions. Additionally, the bibliographies of retrieved articles were reviewed. The studies published from January 1, 1982 to December 2018 among adult populations were selected. We limited our search from 1982 onwards because that year WHO adopted CPITN index with minor modifications. This final index was then used for recording periodontitis in human populations worldwide. Two authors (AM and CJ) independently eliminated any duplicate from the gathered results and examined the remaining articles by title and abstract. Any disagreement was adjudicated with a third reviewer (RV). Subsequently, the full texts were obtained and analysed for further inclusion/exclusion. Studies that did not meet the inclusion criteria were excluded. Full-text of articles identified from title and abstract screenings were reviewed thereafter.

The review protocol was registered in PROSPERO data with reference number CRD42018098531.

2.5. Data collection process and data items

A Microsoft Excel spreadsheet was used to classify included studies based on year of publication, language, demographic characteristics of participants, authors, place of the study, sample size and sampling technique used, sample size in terms of gender, age range of the studied population, overall age and gender wise prevalence and severity of periodontitis by two reviewers (AM and CJ). The weighted proportion difference was calculated for the outcomes (measured by different scales/indices) of each study. Based on the level of heterogeneity, fixed or random-effects model were used to calculate a pooled estimate of periodontitis and its 95% confidence intervals (CIs).

2.6. Quality assessment

All included studies were assessed independently and in duplicate by two review authors (AM and CJ) for study design characteristics and features of internal validity. A quality assessment instrument was developed to assess the quality of the eligible studies. Each study was assessed in the following domains; study settings, sampling strategy, measurement tools, analysis method and generalizability of findings. The sum of the points awarded to each question was divided by the highest possible score (8) to generate a fraction (between 0 and 1). The overall quality of each study was then assessed by ranking the studies. A score of 0–0.3, 0.4–0.6, and 0.7–1.0 was considered as low, moderate, and high quality respectively ( Table 1 ). Review authors were not blinded to author information and source institution. Any disagreement was resolved by discussion or by third party adjudication.

Table 1

Characteristics of Included studies.

2.7. Synthesis of findings

The decision to pool studies was based on the absence of significant methodological heterogeneity in terms of patient demographic characteristics, measures used to assess periodontal disease and the quality of the studies.We performed an evaluation of the heterogeneity of the data using the Q statistic, a chi-square test, at a threshold p -value of less than 0.10. 39 The consistency was assessed visually using by the I 2 statistic. 40 An I 2 value above 75% was indicative of high heterogeneity. The I 2 statistic describes the proportion of variation in point estimates attributable to heterogeneity rather than sampling error. Subgroup analyses were performed for age, gender, place of the study and quality of the studies variables.

Meta-analysis was performed using Meta XL software developed for use with Microsoft Excel. Meta-analysis was undertaken using a random-effects model. Pooled prevalence was calculated with 95% Confidence Interval (CI) based on the total sample size and number affected. Subgroup analysis was done with respect to gender (males and females), age group (<35 years, 35–65 years, > 65 years), population sub-group (tribal, rural, urban and general), study quality (moderate and high), region (North, East, West, South and Central India) and the index used (CPI and CPITN). The chi-square test (using OpenEpi software) was applied to assess the relationship between gender and prevalence of periodontal disease.

3.1. Study selection

Electronic searches from all sources retrieved 4052 citations ( Fig. 1 ). After removal of duplicates, 3550 records were left for screening. Title and abstracts were screened to yield 40 studies (3510 citations were excluded). Of these 40 studies, 10 did not meet the inclusion criteria [missing values of outcome (CPI scores) (2), variation in index used periodontal assessment viz. did not use either CPI or CPITN (8)].

Search strategy.

3.2. Study description

Selected characteristics of the included studies are summarized in Table 1 . Thirty studies were included for the systematic review, of which 24 studies comprising 68,140 adults were included for the meta-analysis. Six studies 8 , 21 , 22 , 25 , 28 , 31 were excluded from meta-analysis for having used convenience sampling for selection of study participants. The pooled estimate of gingivitis, and periodontal disease was estimated from 21 studies (66,368 participants), and 24 studies (68,140 participants) respectively ( Table 2 ). Ten studies assessed periodontal disease using CPI index, while 20 studies by CPITN. Only three studies were conducted before the year 2000. The target population was unspecified in 14 studies which may be tribal, urban or rural areas of the settings, while 10 studies assessed the prevalence from rural population. Nearly 74% (n ​= ​22) of studies scored high for methodological parameters based on quality assessment.

Table 2

Pooled Prevalence of periodontal diseases.

3.3. Synthesis of results

Overall, the prevalence of periodontal disease was 51.0% (CI: 41.9–60.1, 24 studies, 68,140 participants). The pooled prevalence of gingivitis was 46.6% (CI: 37.8–55.5, 21 studies, 66,368 participants) and periodontitis was 51% ( Table 2 ). Males had a higher proportion (42.2%) of periodontitis than females (34.4%). Compared to other age groups, participants aged 65 years and above had higher prevalence (63.6%, CI: 51.3–75.1, 15 studies) of periodontitis, while participants age below 35 years had higher proportion of gingivitis (52.9%, CI: 36.4–69.1, 13 studies). Urban population had higher burden of the gingivitis (63.9%, CI: 57.4–70.2), while periodontal disease was more common among rural participants (48.9%, CI: 32.9–65.1, 19 studies).

3.4. Subgroup analysis

The subgroup analysis of the pooled estimate of prevalence of periodontitis according to its severity is described in Table 3 . Nearly 25% of the sample size had prevalence of mild to moderate periodontitis (26.2%, CI: 21.1–31.6, 24 studies), while severe type was only 19.0% (CI: 14.3–24.2, 24 studies). When severity of periodontitis was stratified by age, sex and type of population, males had higher proportion of (19.3%, CI: 11.3–28.8, 9 studies) severe periodontitis than females (14.4%). Persons aged between 35 and 65 years had high proportion (30.0%, CI: 24.7–35.5, 19 studies) of mild to moderate type of periodontitis compared to other age groups, while 65 and above years showed high prevalence of 32.7% (CI: 23.7–42.5, 15 studies) in the severe periodontitis category. Urban population showed higher prevalence estimates for severe periodontitis compared to rural population ( Table 2 ).

Table 3

Subgroup analysis - Pooled prevalence of periodontal diseases.

Among the studies assessing periodontitis by CPI and CPITN, the prevalence of the mild to moderate periodontitis was very close to overall pooled estimate ( Table 3 ). However, studies that used CPI only, overestimated pooled proportion by 5.2% compared to overall estimate of severe periodontitis. In contrast, the studies that used CPITN, underestimated the prevalence by 3.3% from overall estimate.

Table 4 describes the prevalence of the periodontitis according the region of the studies in India. Except for studies conducted in Eastern India, other regions of India do not show substantial variation in the severe or mild to moderate type of periodontitis.

Table 4

Pooled estimates of periodontal disease according to various geographic divisions of India.

4. Discussion

Periodontal disease is one of the two most important oral diseases contributing to the global burden of chronic disease, thereby qualifying as a major global public health problem. Estimation of the burden of periodontal disease in India has been challenging due to lack of technical expertise, low priority for oral health care, and high economic cost. 5 The assumption that periodontal disease is an age-related condition compounded by a poor understanding of its natural history and wide variations in its measurement especially in community settings explains the limited number of studies undertaken to estimate prevalence of periodontal diseases. The National Oral Health Survey 2002, remains India’s solitary National Survey using the WHO methodology, 2 estimating the burden of periodontal disease. For reasons unknown, there has been no further nationally representative data on periodontal disease in India. Nevertheless, coinciding with growth of large number of dental teaching institutions in 1990s, an increasing number of point prevalence studies estimating the periodontal disease in India have been reported in literature. A systematic review of these studies is essential in estimating the burden of periodontal disease in India. Previous reviews have had methodological issues like being narrative 12 or performing qualitative analysis only, 13 and none attempted to provide the estimate of the prevalence of periodontal disease in India. This systematic review provides pooled estimate of periodontal diseases (gingivitis, types of periodontitis) by metanalysis technique.

The overall prevalence of the periodontal disease in India from the included 24 studies involving 68,140 adults was 51.0% (95% CI:41.9–60.1). These figures translate into the estimate that nearly one in two Indian adults or 320 million people have some form of periodontal disease. This estimate is similar to the prevalence of periodontal disease (47.2%) in American adults. 41 However, methodological quality is rather different among prevalence estimates of American and Indian studies. The methodological assessment of periodontal disease estimates is superior among American studies that have used regular NHANES data as opposed to Indian estimates from heterogenous studies.

The changes in measurement methodologies has enhanced the understanding of the relationship between plaque, gingivitis and periodontitis. The CPITN index was developed to facilitate performance of population-based surveys under a variety of conditions. The CPITN index was endorsed by WHO 42 and has been adopted in many epidemiological studies. We used the CPI score of 3 as mild to moderate periodontitis which corresponds to 4–5 ​mm clinical loss of attachment. CPI score of 4, CPITN score of 2 and 3,4 of loss attachment index were grouped to be classified as severe type of periodontitis which signifies loss of attachment of more than 5 ​mm. This variation in indices may have overestimated the severe type of periodontitis in this review which could be considered as a potential limitation of this review.

The included studies in this review used either CPI or CPITN indices, so estimates of periodontal disease by either of the indices were different from when the indices were pooled together thereby suggesting variations in interval estimates. Even though the included studies scored high for quality assessment, but due to random effect variations, the present estimate may not be precise. When compared with this review findings, studies in other countries 43 showed wide variation in estimates while employing CPI scores of 3 or 4. The proportion of CPI score of 3 ranged from 57% (Hong Kong) to 8% (Saudi Arabia). For a CPI score of 4, the percentages ranged from 28% (Nepal) to more than 5% (Sri Lanka, Syria and New Zealand). Similar results were obtained in Africa, a CPI score of 3 was frequent and a CPI score of 4 was more infrequent. 44 The prevalence of a CPI score of 3 was reported to be more than 50% in studies originating from Kenya, Morocco, South Africa and Tanzania, and <5% in studies from Zimbabwe and Zaire. The prevalence of a CPI score of 4 was reported to be >30% in studies from Libya, Mauritius, Nigeria, Sierra Leone and South Africa. 44

Nearly 25% participants had prevalence of periodontitis of mild to moderate type (26.2%, CI: 21.1-31.6), while severe type was only 19% (CI: 14.3-24.2). The current estimate of severe type of periodontitis is higher than recent Global Burden of Disease Study (GBD, 1990–2010) 1 of severe periodontitis with prevalence of 11.2% and around 743 million people affected worldwide. The global prevalence of generalized, severe periodontitis among adults, ranged from 5 to 15% regardless of geographical and measuring tool considerations.

The overall prevalence of periodontitis was highest in older age group adults. Such burden of periodontitis will continue to increase with the growing ageing population of India, associated with increased tooth retention and possible lack of importance afforded to geriatric dental care; a common phenomenon globally. 1 , 45 , 46 Gingival bleeding is an early sign of periodontitis and a leading risk marker for existing periodontal inflammation that accounts for the onset and progression of periodontitis. This review reports the prevalence of gingivitis to be around 47%. This figure is indicative of the population being at risk for periodontal disease and its burden may be more than 51% of the Indian population. The prevalence of periodontal disease derived in this review can be regarded as valid representation of the Indian population. However, due to lack of prevalence studies prior to 2000 in literature, a trend analysis could not be performed. Future prevalence studies in India should be based on full mouth measurement of pocket depth and attachment loss rather than being index based.

4.1. Strengths and limitations

There has been a reduction in the use of CPITN ⁄ CPI in epidemiological studies 47 in other parts world, a gradual increase in use of standard measurements of pocket depth and attachment loss have been employed. This has necessitated changes in instrumentation, i.e. the type of probe used and accompanying measurement procedures. These modifications have also promoted changes in the definition of periodontitis for population-based studies. The measurement of pocket depth and attachment loss is now considered as appropriate scoring system rather than index based. 4 The magnitude of under-estimation of prevalence may depend on variation in partial mouth scoring system and the type of measure being assessed, which is affected by the true population prevalence. Predominantly the studies in India have either used CPI or CPITN, so estimates may not be true population prevalence as compared to measurement of pocket depth and attachment loss scoring system. In its recent modifications in Oral Health Survey Basic methods (2013), WHO also recommends full mouth CPI and Loss of Attachment index rather index tooth or partial mouth recording system. Also, further variations of periodontal diseases like aggressive periodontitis were not considered for this review due to lack of epidemiological studies assessing the same.

Our estimates are reasonable to assume representativeness for two reasons, one the included studies were from 13 (geographical) out of 30 Indian states and one nationally representative data and second, the number of participants included in this review is large which reflects the precise estimate of prevalence of periodontal disease. From the available literature, this review estimate is the only available data for prevalence of the periodontal disease in India.

5. Conclusion

Periodontal diseases encompass both reversible (gingivitis) as well as irreversible (periodontitis) changes in soft tissues surrounding and supporting the tooth. These diseases are pandemic and are considered a major public health problem. As India lacks continuous surveillance of oral diseases, pooling data from various prevalence studiesis the only option to assess the burden of oral diseases in our population. Evidence from the current pooled analysis of prevalence studies shows a very high burden of periodontal diseases among Indian adults. Oral health policy makers and public health personnel can utilize data from this review to draft measures required for reducing the burden of periodontal disease in Indian population.

Ethics statement

The current study was determined exempt from review by the Faculty of Dentistry, Jamia Millia Islamia Institutional Review Board. The authors do not have any financial or other competing interests to declare.

Author contribution

A Mehta contributed to the design of the review, data acquisition, data interpretation and analysis and drafted the manuscript. C Janakiram contributed to the design of the review, data interpretation and analysis and drafted the manuscript; R Venkitachalam contributed to the statistical analysis anddrafted the manuscript. All authors gave final approval and agree to be accountable to all aspects of the work.

Acknowledgements

The authors wish to thank Dr. Vinita Sanjeevan (Department of Public Health Dentistry, Government Dental College, Goa) for her valuable inputs in preparation of this article.

Prevalence of periodontitis in dentate people between 2011 and 2020: A systematic review and meta-analysis of epidemiological studies

Affiliations.

• 1 Clinical Research Unit (CRU), Egas Moniz Center for Interdisciplinary Research, Egas Moniz School of Health & Science, Almada, Portugal.
• 2 Evidence-Based Hub, Egas Moniz Center for Interdisciplinary Research, Egas Moniz School of Health & Science, Almada, Portugal.
• 3 Unit of Basic Oral Investigation (UIBO), Universidad El Bosque, Bogotá, Colombia.
• 4 Department of Periodontics, School of Dental Medicine, The University of Pennsylvania, Philadelphia, Pennsylvania, USA.
• PMID: 36631982
• DOI: 10.1111/jcpe.13769

Aim: The aim of the study was to evaluate the prevalence of periodontitis in dentate people between 2011 and 2020.

Materials and methods: PUBMED, Web of Science, and LILACS were searched up to and including December 2021. Epidemiological studies reporting the prevalence of periodontitis conducted between 2011 and 2020 were eligible for inclusion in this review. Studies were grouped according to the case definition of confidence as confident (Centers for Disease Control [CDC] AAP 2012; CDC/AAP 2007; and Armitage 1999) and non-confident (community periodontal index of 3 or 4, periodontal pocket depth >4 mm, and clinical attachment level ≥1 mm). Random effects meta-analyses with double arcsine transformation were conducted. Sensitivity subgroup and meta-regression analyses explored the effect of confounding variables on the overall estimates.

Results: A total 55 studies were included. The results showed a significant difference, with confident case definitions (61.6%) reporting nearly twice the prevalence as non-confident classifications (38.5%). Estimates using confident periodontal case definitions showed a pooled prevalence of periodontitis of 61.6%, comprising 17 different countries. Estimates reporting using the CDC/AAP 2012 case definition presented the highest estimate (68.1%) and the CDC/AAP 2007 presented the lowest (48.8%). Age was a relevant confounding variable, as older participants (≥65 years) had the highest pooled estimate (79.3%).

Conclusion: Between 2011 and 2020, periodontitis in dentate adults was estimated to be around 62% and severe periodontitis 23.6%. These results show an unusually high prevalence of periodontitis compared to the previous estimates from 1990 to 2010.

Keywords: periodontal disease; periodontitis; prevalence; systematic review.

© 2023 The Authors. Journal of Clinical Periodontology published by John Wiley & Sons Ltd.

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May 24, 2024

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Research finds connection between risk factors for periodontitis and general health

by Kari Øverby, University of Oslo

Periodontitis is a disease that affects the supporting tissues of the teeth and is associated with other types of diseases. A study conducted at the faculty of dentistry shows that patients with severe periodontitis also have a higher prevalence of cardiovascular disease, diabetes, and COPD.

The study is published in the journal BMC Oral Health with related previous research published in Journal of Clinical Periodontology .

Ida Haukåen Stødle is a specialist in periodontology and has just completed her doctorate at the faculty.

She shares the following:

The overall purpose of my thesis was to investigate the prevalence of periodontitis and to examine whether we could identify conditions that may be associated with periodontitis. Since periodontitis affects many people, these associations may also be relevant for many, and therefore we have a responsibility to address these potential associations with our patients, says Ida.

Oral health is important for overall health. Maybe we should not consider oral health as something separate but consider health in general. To highlight oral health on its own entails an artificial focus. Interaction between different diseases indicates that we must consider general health as part of periodontal treatment. We should inform patients and encourage them to speak to their general practitioner if they have severe periodontitis and other health challenges, Ida continues.

Periodontitis is an inflammatory condition that can lead to tooth loss and is caused by bacteria that naturally occur in the oral flora. The disease can develop if there is an overgrowth of these bacteria, but not for everyone. The susceptibility varies among individuals.

A new classification of periodontitis

Part of the task was to look at the prevalence of periodontitis in the surveyed population. In 2018, a new globally accepted classification of periodontal diseases was published, which forms the basis for the initial investigations, says Stødle.

We reported the overall prevalence and further prevalence of different severity levels of periodontitis. Once we had identified the participants with periodontitis, we further examined them for any other concurrent diseases, such as cardiovascular disease and diabetes.

We know that several conditions are associated with periodontitis. We selected some to see how they were expressed using the new classification. The findings largely corresponded to previous observations. We also found that those with severe periodontitis, those with significant periodontal bone loss, also have a higher prevalence of other diseases compared to those with little or no periodontitis.

We also included rheumatic conditions in this research but found no association with periodontitis for individuals with rheumatism. This was somewhat surprising because we already know about this association, and since rheumatoid arthritis is also an inflammatory condition, one would expect these diseases to occur together, Ida explains.

There may be several reasons why we did not observe any association. How we included rheumatic conditions in the material, whether we have thoroughly differentiated between healthy and sick individuals, and whether the dataset is large enough, for example. We did not attempt to distinguish between the various forms of rheumatoid arthritis. These factors contribute to the findings in our studies.

Uncertain findings for celiac disease and associations with periodontitis

We also looked at celiac disease. It was a separate study; it was exciting because there is little research on these two diseases. We had no expectations that there would be any difference in periodontal bone loss in individuals with and without celiac disease.

Nevertheless, we found that those with celiac disease have less frequent bone loss as if celiac disease protected against periodontitis. We do not know what lies behind this observation or how the relationship can be explained, and due to this uncertainty, it is hard to draw any conclusions. It would be exciting if further research could be done on this, says Ida.

Extensive and comprehensive material

The studies are based on a vast material, in which almost 5,000 adults from Nord-Trøndelag have participated. The transferability is good for small towns and rural areas. The population from larger cities, where the demography may differ, is not included. Therefore, the findings cannot necessarily represent all population groups in Norway. Population studies (the HUNT studies) have been conducted in this population in Nord-Trøndelag several times, precisely because it is particularly suitable due to stability.

The public dental service (DOT) in Trøndelag, in collaboration with the Oral Health Competence Center, TkMidt carried out the clinical oral and dental health examinations used in the doctoral work. The dentists and dental hygienists who collected this large amount of data did extensive work.

There were periodontal examinations, but also caries examinations and examinations of mucous membranes, in addition to X-rays of all the nearly 5000 participants. The X-rays consisted of a panoramic X-ray image and four smaller images from each participant.

X-rays and further work were analyzed in collaboration with my supervisors, Odd Carsten Koldsland and Anders Verket. The results of the X-ray analysis were compared with data from the clinical examinations. Statistical calculations also made up a significant part of the analyses. Several employees from TkMidt contributed to this. The work has resulted in three articles, Ida explains.

Self-reported disease

The method is partly based on self-reported illness and not exclusively on medical examinations. Self-reported data is weaker than if we had confirmed medical diagnoses and it must be considered when interpreting findings. Blood samples have been obtained from all participants, including blood sugar measurements.

This strengthens the material, and studies have shown that when the disease is well-defined, such as diabetes, there is a good correlation between self-reported illness and an actual diagnosis. Self-reporting is a limitation in our data, but not to such an extensive extent that we do not believe the results.

Medical personnel also obtained many other variables, such as weight, height, and blood pressure. We had a vast amount of data on inflammatory mediators or cells. We did not use it because some choices had to be made. But the data from HUNT are extensive and good and are well-suited for a hypothesis-generating study like this, says Ida.

Preventing periodontitis and diseases associated with periodontitis

We know that the treatment of periodontitis reduces inflammation and can improve blood sugar control in some cases for diabetics. These are connections we need to keep a high focus on. We need to communicate information so patients and health care professionals can benefit from this knowledge—for treatment and to prevent disease.

Risk factors are often the same for several diseases and conditions, including periodontitis, such as smoking. By reducing smoking, the risk for multiple conditions is also reduced. We can discuss this with patients and refer them further if needed.

We should specifically pay attention to the part of the population that goes to the dentist but may not easily seek other health care services. Collaboration across health care professions and having good information flow should be central in preventing periodontitis and diseases associated with periodontitis, concludes Ida.

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• Open access
• Published: 30 May 2024

Association of specific nutritional intake with periodontitis

• Alfonso Varela-López 1 ,
• Beatriz Bullon 2 ,
• Isabel Gallardo 2 ,
• Jose Luis Quiles 1 &
• Pedro Bullon 2  

BMC Oral Health volume  24 , Article number:  640 ( 2024 ) Cite this article

82 Accesses

Metrics details

The present study aimed to evaluate nutritional intake among a group of male patients in the dental clinic with and without periodontal disease to search for associations between nutritional profile and periodontal health.

To this purpose, nutritional intake of macronutrients, fiber, vitamins, and minerals were compared evaluating both clinical parameters and periodontal status. Non periodontitis patients were compared with stage III and IV periodontitis and its extension according to the 2017 classification.

After multivariate analysis, statistically significant associations were found between the dietary intake of energy, total fat, cholesterol, calcium, saturated fat, monounsaturated fat and folic acid and iodine and periodontitis status. This study reports an inverse association between cholesterol and iodine and periodontitis and a direct association with saturated fat, monounsaturated fat, and folic acid.

Conclusions

Maintaining an adequate intake of fat, iodine, calcium, and cholesterol and avoiding an excessive intake of energy, saturated fat, monounsaturated fat, and folic acid could be important to controlling periodontitis.

Peer Review reports

Various factors have been associated with the etiology of periodontal disease. Undoubtedly, oral microorganisms are indispensable for the pathogenesis of periodontal disease. Therefore, the primary cause is poor oral hygiene, leading to the formation of dental plaque containing microorganisms [ 1 ]. In addition to these local elements, several systemic factors appear to influence periodontal health, many of them shared with systemic conditions such as cardiovascular disease [ 2 ], and obesity [ 3 ]. In this sense, there is a set of well-established risk factors for periodontitis that include alcohol and drug abuse, stress, smoking, genetics, and hormonal alterations [ 4 ]. Similarly, the nutritional status of the host has been widely recognized as a possible promoting factor in many inflammatory conditions such as periodontal diseases [ 5 ]. In fact, nutritional factors are of vital importance for the equilibrium between oral microorganisms and the host response, which depends on the onset and progression of periodontal disease [ 6 ]. The relationship of nutrition and oral health is well known and in recent years a large number of reviews have been published that highlight the link between nutrition and periodontal disease in recent years [ 5 , 7 ]. However, the results of the epidemiological studies still present differences.

Currently, standardized periodontal therapy is based on manual supragingival and subgingival debridement, with additional supportive antibiotic therapy in strictly defined clinical situations. However, once periodontitis is diagnosed, a common claim is to consider additional benefits of controlling the nutritional status of patients in combination with periodontal therapy [ 8 ]. The aim of the study was to evaluate nutritional intake among a group of male patients with and without periodontitis in different states to look for associations between nutritional profile and periodontal health.

Male subjects over 35 years of age attending the Dental School of the University of Sevilla, who have not experienced a prior cardiac event, and who had no significant coronary disease attending the Dental School of the University of Sevilla (Control) without clinical records of cardiac events, diabetes or periodontal disease diagnosis and treatment were asked to participate in the study. Informed consent was obtained from each subject, the study protocol was in accordance with the ethical guidelines of the Declaration of Helsinki of 1975 and was approved by the Local Research Committee (1588-N-20, 12-21-2016).

Clinical examination

General and lifestyle data.

Demographic characteristics (age, height, and weight), medical record (heart rate (HR), diastolic blood pressure (DPB), systolic blood pressure (DPB), waist circumference (WC)), and body mass index (BMI) were recorded. BMI was calculated from standardized measurements of weight and height (weight in kg divided by height in square meters). The Minnesota Leisure Time Physical activity [ 9 ] was used to evaluate the level of physical activity. The average weekly exercise hours were obtained asking for the hours spent walking. Smoking status was obtained asking if they are a current smoker (someone who smoke at least one cigarette per day) a former smoker (someone who do not smoke now but smoked in the past) or a never-smoker (someone who has never smoked). Non-smoker were considered any of both, never-smoker and former smoker.

Oral examination

The number of remaining teeth was recorded. The following periodontal parameters were recorded: clinical probing depth (PD) as the distance between the gingival margin and the bottom of the pocket, clinical attachment level (CAL) as the distance between the cemento–enamel junction and the bottom of the pocket at six sites per tooth; bleeding on probing (BOP) was also recorded after 10 s at four sites [ 10 ]. All periodontal measures were evaluated by the same examiner, whose evaluations of the first ten subjects were calibrated for reproducibility prior to the study; an intra-subject correlation coefficient of 92% was found for PD.

The patients were classified as periodontitis patients and non-periodontitis patients (NoP) and periodontitis patient, respectively, if they were or not within the stage III and IV definition established in the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions periodontitis [ 11 ]. In turn, periodontitis patients were subdivided into localized periodontitis (LP) generalized periodontitis patients (GP) according to the extent and distribution criteria, LP was defined when < 30% of teeth were involved, whereas GP was defined when ≥ 30% of teeth were involved [ 11 ]. Furthermore, mean PD, mean CAL and the proportion of sites with PD ≥ 4 mm and CAL ≥ 5 mm were calculated.

Assessment of dietary intake

Dietary intake was estimated using a 91-item semiquantitative food frequency questionnaire (FFQ). This FFQ that includes foods from 13 different groups (meats, fish, eggs, legumes, cereals, dairy products, fats, vegetables, fruits, sweets and cakes, drinks, nuts, sauces, and others) was based on previously developed and validated questionnaires for the Spanish population [ 12 ]. An additional section provides information on the use of nutritional or dietary supplements. The FFQ items represent mainly a single food, but sometimes comprised of sets of commonly associated foods. Participants were asked to indicate the number of portions of these foods they consumed per day, week, month, or year during the past year. The portion sizes quantified by household measures (i.e., one cup) were explained item by item in the FFQ. Standard serving sizes and food models [ 13 , 14 , 15 , 16 ] were provided as a reference to aid participants in estimating portion size. A trained person helped the participants complete the FFQ when necessary. All values were then converted to dairy consumption frequencies, and this was multiplied by the size of the portion to calculate the grams of food consumed per day. Nutritional and energy intakes were calculated by multiplying the frequency of consumption of each food item (in grams consumed per day) by the mean content of energy and each nutrient (calculated for the food item concerned) per 100 g of product according to the Food Composition Database by Mataix et al. [ 17 ] The daily intake of nutrients for individual FFQ items was then summed to obtain the daily intake of each nutrient or energy. All nutrient and food intakes were then adjusted for energy using the residual method.

Statistical analysis

All statistical analyses were performed using IBM SPSS 25.0 Statistics software. Data were presented as mean ± standard deviation (SD) or percentage or as median ± interquartile rank (IQR) if the variable does not have a normal distribution. The Kolmogorov-Smirnov test has been used to verify the normal distribution of the quantitative data. ANOVA test for parametric distributions and Mann-Whitney U and Kruskal-Wallis test for non-parametric distribution have been used. The post hoc test utilized for the parametric distribution was Student’s t test with the previous Levine test on the homogeneity of variances, and for the nonparametric distribution, the Mann–Whitney U test was used. Categorical variables were analyzed with a chi-square test to determine the groups that make a difference. Statistical significances with p-values of 0.05 or less were considered. Binary logistic regression analysis was used to analyze the probability of LP and GP according to the intake of caloric intake and the different evaluated nutrient normalized and non-normalized by total energy intake. Similar models adjusted for confounders were also performed. Confounders were selected by performing logistic regression analysis models to calculate the probability of localized and generalized periodontitis using the Backward LR method that considers all target variables, which were all those factors whose values were statistically significant different between groups of patients. Finally, only smoking status was considered for the subsequent adjusted models. Moreover, unadjusted and adjusted ordinal logistic regression models with diagnosis of periodontitis with three ordered categories (non-periodontitis and localized and generalized periodontitis) were also performed.

General data

Table  1 shows the mean and SD or median and IQR values of the general data, anthropometrical measures, and physical activity of the sample population. A total of 112 subjects were enrolled in the study, 59 attendants received a diagnosis of NoP, 13 were LP and 40 were GP. GP patients were younger than those with NoP and LP. GP also had lower values of BMI and walking hours values than NoP, while the HR and DBP values were higher. Table  2 shows smoking status with more current smoker in GP than in NoP.

Oral health

The mean values of different clinical periodontal health parameters, including the number of remaining teeth, percentages of teeth with BOP, mean PD, percentages of sites with PD ≥ 4 mm, mean CAL and percentages of sites with CAL ≥ 5 mm are presented in Table  3 . BOP was high in GP compared to NoP. The number of remaining teeth was only lower in LP compared to NoP and GP. The values of PD and CAL show the highest values in GP than LP and the lowest in NoP.

Dietary intake and periodontal health

Table  4 shows the values of oral health parameters according to dietary intake of nutrients only for nutrients that show statistically some significant difference among dietary intake tertiles in the value of some the parameters. No differences were obtained except for two nutrients in one parameter each one. Mean PD value was lower in the lowest tercile of intake of saturated fat normalized by energy intake respect than the second tercile. Regarding the percentage of sites with BOP, the individuals in the lowest tercile of iron intake had a lower value than those in the highest, but this was not observed if the intakes were adjusted by energy consumption.

Table  5 shows the results of the regression analysis for dietary intakes of nutrients showing any statistically significant association. The unadjusted logistic model, increased odds of having GP were associated with the lowest tercile 1 of non-normalized intakes of carbohydrates, fiber, potassium, vitamin A, B1 B2, B6, B9 and C and normalized intakes of fiber, potassium, and vitamin C, compared to the highest consumption tercile. Similar associations were found for the second tercile of non-normalized intakes of vitamin A, C, B1 B2, B6 and potassium and normalized fiber intake. Although the odds of having GP calculated for the lowest tercile 1 of intake of phosphorus, calcium, and energy respect than the highest terciles were not statistically significant, an increased odds was found for the second terciles. Terciles 1 and 2 of fiber, potassium and, vitamin C consumption normalized by energy intake and tercile 1 of energy-intake-normalized consumption of fiber and potassium were associated with localized to generalized periodontitis prevalence with increased odds compared to the highest terciles. In the model adjusted by smoking status, only associations between GP prevalence and non-normalized intake of carbohydrates, vitamin A, B2, B6, C and iron remained statistically significant. Both the lowest and second tercile of phosphorus consumption non-normalized by caloric intake were also associated. In case of potassium and fiber intake, only the association with the lowest tercile 1 remained significant. Among those normalized by energy intake, only the lowest terciles of fiber, vitamin C, and potassium consumption were associated with generalized periodontitis prevalence.

Ordered logistic modeling also resulted in similar findings produced by standard logistic regression for the lowest terciles of fiber, potassium, and vitamin B6 intake, compared to the highest terciles, as well as the second tercile of caloric intake. In an unadjusted model, the lowest terciles of fiber and potassium consumption non-normalized and normalized by energy intake were associated with increased odds of having more generalized periodontal disease compared with the highest fiber and potassium consumption tercile, respectively. This association was also statistically significant for non-adjusted intake of vitamin C normalized by energy intake and vitamin B6 consumption non-normalized by energy intake. Likewise, the second tercile of energy intake was associated with increased odds of having more GP. In a model controlling for smoking status, only the lowest terciles of fiber and potassium intake normalized by caloric consumption were associated with increasing extension of periodontitis despite this association also was found for vitamin B6 and potassium non-normalized consumption.

In the present study, periodontal health has been positively related to the dietary intake of fiber, vitamin C, and potassium. In general, inverse associations have been previously reported between intake of dietary fiber [ 18 , 19 ], potassium [ 20 ], and vitamin C [ 19 , 20 , 21 , 22 ] and any form of periodontal disease. Similarly, the inverse association between fiber intake and vitamin C and the risk of periodontal disease has been confirmed by a, meta-analysis that includes nine publications in community-dwelling older adults [ 23 ] but this was also found for fatty acids, vitamin C and E, and calcium intake. In turn, the risk of periodontal disease was higher in individuals with the highest sugar intake in a meta-analysis evaluating the possible role of the role of dietary patterns in periodontal health, including nine studies [ 24 ]. Similarly, dietary intake of vitamin E [ 20 ], but also carbohydrates [ 25 ], phosphorus [ 21 , 25 ], iron and vitamins B6 and B12 [ 20 ] were also inversely associated with any form of periodontal disease by at least one of the cited studies. Interestingly, the association with vitamin B9 intake was the most common relationship reported in such studies [ 19 , 20 , 21 ]. Additional studies also reported inverse associations with total fat dietary intakes [ 26 , 27 ], polyunsaturated fat [ 28 ] and calcium [ 29 ], but also vitamin A [ 30 ], B1 [ 31 ] vitamin B2 [ 30 , 31 ], vitamin B3 [ 31 , 32 ] and confirmed results for vitamin B9 [ 33 ], and iron [ 20 , 32 ]. However, the association found for the incidence of periodontitis with vitamin B1, and E has been reported to be nonlinear in one of the studies [ 30 ]. Therefore, many of the previously reported associations with periodontitis have not been observed in the population of the present study. Regarding vitamin C intake, observational studies are less clear., Some cross-sectional studies found a significant association present only in certain strata [ 32 , 34 , 35 ]. In fact, it has been suggested that age and smoking may be related to the efficacy of vitamin C for the prevention of periodontal disease, but this can depend on the characteristics of the population [ 5 ]. However, Jeong et al. [ 24 ] reported a higher risk of periodontal disease in the lowest vitamin C intake group after performing a meta-analysis to evaluate the possible role of diet patterns in periodontal health that included nine studies. Interestingly, a more recent study found a nonlinear association between vitamin C intake and periodontitis prevalence. According to this, excessive vitamin C intake would increase the risk of periodontitis [ 30 ].

Among the studies mentioned, some of them concomitantly evaluated associations between periodontal health and multiple dietary intakes [ 20 , 21 , 26 , 27 , 30 ]. As in the present study, none of the mentioned studies found statistically significant associations between periodontal health and dietary intake of proteins, cholesterol, calcium, magnesium, selenium, zinc, and vitamins B1, B12 and K, although this also occurred with fiber and potassium. Other studies evaluating association with the intake of one or two nutrients also reported statistically significant results. This occurred with sugars [ 36 , 37 , 38 ] and vitamin C [ 35 ] and D [ 39 , 40 ], but also calcium [ 29 , 41 , 42 ] and magnesium [ 43 ]. Moreover, two cross-sectional studies focused on dietary fiber intake [ 18 , 44 ] in a sample of 5,052 individuals from NHANES 2009–2010 and 2011–2012, supporting the results of the present study. In contrast, a study in non-smokers subjects [ 41 ] reported no correlation between calcium intake and the CPI score, although it was inversely associated with the percentage of sites with BOP. Similarly, no association has been previously found between folate intake and CPI, although it suggested that it influences BOP [ 33 ].

It is possible that associations between nutritional intake and periodontal disease only appeared when individual with or without nutritional deficiencies and are compared. In these cases, such associations could only be detected in subjects with very low dietary intakes. Some studies evaluated the possible associations of inadequate intake according to the proper nutritional recommendations. In this sense, it has been suggested that the risk of periodontitis was reduced with sufficient intake of vitamin A, B1, B2, and E [ 30 ]. Inappropriate vitamin B3 intake also showed higher odds of periodontitis in other study and this association was stronger in women and participants aged 40–59 years. However, this was not found for calcium, vitamin A, B1, B2, and C, and iron intake below the recommendations [ 31 ]. Similarly, in the cross-sectional study by Park et al. [ 32 ] in young adults, inadequate vitamin B3 intake was significantly associated with periodontitis, which also occurred in the subgroups of women and current non-smokers. Furthermore, calcium nutritional deficiencies have been reported to increase susceptibility to periodontal disease. Calcium intake within age-specific recommendations was associated with a lower likelihood of severe periodontitis in adult participants of the Danish Health Examination Survey (DANHES) 2007–2008 [ 42 ].

In the present study, periodontitis was diagnosed according to the stage III and IV definition of the 2017 World Workshop on the Classification of Periodontal and periimplant Diseases and Conditions [ 11 ]. According to this diagnose our data show that the values of PD and CAL show the highest values in GP compared to LP and the lowest in NoP. Many cross-sectional studies categorized their samples into patients with moderate to severe periodontitis and those without periodontitis or a less severe form of this disease [ 18 , 30 ]. Furthermore, the possible association with the severity of the disease that classifies individuals into different degrees of periodontitis has also been evaluated [ 21 ]. Sometimes, both strategies have been combined [ 18 ]. Among studies conducting alterative comparisons, the associations reached statistical significance when patients with more severe disease were compared with the rest of the population, including health attendants and patients with a mild or slight form of the disease. In particular, this occurred in the study by Nielsen et al. [ 18 ] who reported suggesting an association between the risk of severe periodontitis, but also the severity of periodontitis and the fiber intake. As here, the high prevalence of periodontitis and the extension of periodontitis in the analyzed population could condition the absence of significant associations with mild to severe periodontitis. In fact, mild or no periodontitis were grouped into the referent category to mitigate the risk of bias due to a potentially excessive prevalence of mild periodontitis in the population [ 45 ].

The associations between clinical parameters and dietary intake also evidenced the relationship between nutritional intake and the severity of periodontal disease. However, more ancient studies using additional clinical variables usually did not find many differences between nutritional intake categories or correlations with nutritional intake. No correlation was found between RPI (which scored the presence and severity of gingival bleeding and pocket depth) and the dietary intakes of phosphorus and potassium, but also iron, calcium vitamin A, B1, B2, B3, in patients from a dental clinic [ 46 ]. Another study in non-smokers subjects [ 41 ] reported no correlation between calcium intake and CPI score, although it was inversely associated with percentage of sites with BOP. Similarly, no association has been previously found between folate intake and CPI despite of it being suggested that it has an effect on BOP [ 33 ]. Here, differences in the proportion of site with a PD of 4 mm or more supported the role of fiber and potassium, but without other parameters. Therefore, choosing the appropriate oral health-related parameter to compare nutritional intake groups is a critical point.

However, if total energy intake is associated with the outcome, the adjustment for it is important in epidemiological analyses because it can operate as a confounding variable since intakes of most nutrients are associated with energy intake, often strongly. Even, it has been suggested that, if not associated with the outcome, differences in total energy intake can result in extraneous variation in nutrient intake due to individual differences in physical activity, body size, and metabolic efficiency. In this situation, failure to adjust for total energy intake can lead to misclassification of biologically important variation in nutrient intake and result in attenuation of associations [ 47 , 48 ]. In the present study, the residual model that indirectly adjusts for total energy by using a residual was used to adjust for energy intake [ 47 ]. This estimates the average relative causal effect of total energy intake but provides biased estimates even in the absence of confounding. In the study that reported associations for potassium, but also iron and vitamins B6 and B12, single nutrient intakes were expressed as mean intakes per 1000 kcal of total energy [ 20 ]. A similar adjustment was made by Hamasaki et al. [ 26 ]. However, in most of the studies mentioned, no energy adjustment method was described [ 18 , 21 , 30 , 32 ]. Moreover, the difficulties in interpreting the “nutrient density model” have been previously pointed out [ 47 ]. Differences in the models used or the absence of an adjustment for energy intake may also explain some of the apparent heterogeneity between existing nutritional studies. In fact, the intake of nutrients previously associated with higher odds of having any periodontal disease, at least in severe form, was also associated with severe periodontitis or periodontitis severity here after adjustment by smoking, such as vitamin B1, B2, B6 and iron.

However, the current study presents some limitations. First, the cross-sectional design does not allow for a longitudinal evaluation of the cause-and-effect relationship between exposure and outcome and therefore can only be used to build a hypothesis. Indeed, this design also does not allow us to properly investigate reverse causality (i.e., effect of periodontitis on nutritional capacity and dietary changes). Furthermore, no molecular parameters supporting the biological plausibility of such an association were registered. Second, FFQ estimated the nutrient and energy dietary intake to be not as accurate as other quantitative dietary assessment methods, and the usual portion size questions are prone to measurement error since they are based on generic memory [ 49 ]. This error can be at least partially mitigated by using a less biased dietary assessment method as a reference instrument. Importantly, FFQs would be less affected by reactivity, and if they are shorter FFQs, as in this case, they will have higher response rates and lower respondent burdens [ 50 ]. Unfortunately, such information only represents the current diet, which along with possible memory errors and bias may not represent the real nutritional status of the sample. Furthermore, FFQ collected dietary data using a context-specific food list to estimate the usual diet, and additional measurement errors can be introduced when food lists are not specific to the studied population and when they use inconsistent or imprecise portion sizes [ 51 ] or when food lists are not granular enough to make an accurate match to a food composition table to derive the nutrient content of the diet. However, FFQs were adapted and validated instruments for the context of this study were used. Furthermore, since the study population was selected among patients attending the Dental School of the University of Sevilla, the risk of selection bias could not be ruled out, which can reduce the generalizability of the study.

This study found a significant association between dietary intake of energy, fiber, potassium, and vitamin C intake and generalized periodontitis, as well as the extension of periodontitis. To our knowledge, this was the first study to report an inverse association between potassium intake and periodontitis. Adjusting nutrient intake could help prevent and treat periodontal disease in dental patients. Maintaining an adequate intake of fiber, potassium, and vitamin C could be important to controlling periodontitis. However, due to the cross-sectional design of the present study, at least new additional cohort studies should be conducted on groups of patients with similar characteristics before establishing any diet guidelines for populations.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.In Methods is described that the study has been approved by the Local Research Committee Hospital Virgen Macarena Sevilla Spain with the identification number: 1588-N-20, 12-21-2016.

Abbreviations

body mass index

probing pocket depth

clinical attachment level

nonperiodontitis patients

localized periodontitis

generalized periodontitis

semiquantitative food frequency questionnaire

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This research was funded by the grant PID2019-106778RB-I00, funded by MCIN/AEI/ https://doi.org/10.13039/501100011033 FEDER “Una manera de hacer Europa”.

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AV-L conceptualized the study, interpreted and analyzed the data, and drafted the manuscript; BB contributed to the collection of the data and interpretation of the data; IG contributed to the collection of the data and interpretation of the data; JLQ contributed to the study conception and design; PB conceptualized the study, interpreted and analyzed the data, and drafted the manuscript. All authors read and approved the final manuscript.

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Varela-López, A., Bullon, B., Gallardo, I. et al. Association of specific nutritional intake with periodontitis. BMC Oral Health 24 , 640 (2024). https://doi.org/10.1186/s12903-024-04384-6

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