Prevalence of periodontal disease, its association with systemic diseases and prevention

Abstract

Periodontal diseases are prevalent both in developed and developing countries and affect about 20-50% of global population. High prevalence of periodontal disease in adolescents, adults, and older individuals makes it a public health concern. Several risk factors such as smoking, poor oral hygiene, diabetes, medication, age, hereditary, and stress are related to periodontal diseases. Robust evidence shows the association of periodontal diseases with systemic diseases such as cardiovascular disease, diabetes, and adverse pregnancy outcomes. Periodontal disease is likely to cause 19% increase in the risk of cardiovascular disease, and this increase in relative risk reaches to 44% among individuals aged 65 years and over. Type 2 diabetic individuals with severe form of periodontal disease have 3.2 times greater mortality risk compared with individuals with no or mild periodontitis. Periodontal therapy has been shown to improve glycemic control in type 2 diabetic subjects. Periodontitis is related to maternal infection, preterm birth, low birth weight, and preeclampsia. Oral disease prevention strategies should be incorporated in chronic systemic disease preventive initiatives to curtail the burden of disease in populations. The reduction in the incidence and prevalence of periodontal disease can reduce its associated systemic diseases and can also minimize their financial impact on the health-care systems. It is hoped that medical, dental practitioners, and other health-care professionals will get familiar with perio-systemic link and risk factors, and need to refer to the specialized dental or periodontal care.

Full text

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Prevalence of periodontal disease, its association with
systemic diseases and prevention
Introduction
Periodontal disease is a chronic inammatory disease of
periodontium and its advanced form is characterized by
periodontal ligament loss and destruction of surrounding
alveolar bone.1 It is the main cause of tooth loss and is
considered one of the two biggest threats to the oral health.1,2
There are approximately 800 species of bacteria identied in
the oral cavity3 and it is hypothesized that complex interaction
of bacterial infection and host response, modied by behavioral
factors such as smoking, can result in periodontal disease.4
The aim of the review is two-fold: (1) To evaluate the
prevalence of periodontal disease in different populations, risk
factors, and its association with systemic diseases and (2) to
discuss the strategies and measures to prevent and control
periodontal disease.
Prevalence of Periodontal Disease
Periodontal disease is the most common oral condition
of human population.5 The prevalence and incidence
statistics of periodontal diseases vary because of bias, case
misclassification, and the number of teeth and the sites
examined.6 According to the Canadian Health Measures Survey
2007-2009, the measurement of loss of periodontal ligament
attachment is considered the gold standard in reporting the
prevalence of periodontal disease.7 National Health and
Nutrition Examination Survey (NHANES) determined the
attachment loss (AL) and probing depth (PD) at six sites of all
teeth (excluding third molars) for the estimation of periodontal
disease in the U.S.8
The world Health Organization (WHO) has maintained global
oral health data bank using community periodontal index
(CPI).9 This global oral health data from large epidemiological
studies from different countries were gathered to show the
distribution of periodontal disease in adolescents, adults
and elderly populations (Figures 1-3).9 CPI index score
ranges from 0 to 4 and describes the periodontal condition
of individuals at population level. CPI score 0 represents
no periodontal disease; score 1 means gingival bleeding
on probing; score 2 shows the presence of calculus and
bleeding; score 3 indicates shallow periodontal pockets of
Periodontal diseases are prevalent both in developed and developing countries and
affect about 20-50% of global population. High prevalence of periodontal disease in
adolescents, adults, and older individuals makes it a public health concern. Several
risk factors such as smoking, poor oral hygiene, diabetes, medication, age, hereditary,
and stress are related to periodontal diseases. Robust evidence shows the association of
periodontal diseases with systemic diseases such as cardiovascular disease, diabetes,
and adverse pregnancy outcomes. Periodontal disease is likely to cause 19% increase
in the risk of cardiovascular disease, and this increase in relative risk reaches to 44%
among individuals aged 65 years and over. Type 2 diabetic individuals with severe form
of periodontal disease have 3.2 times greater mortality risk compared with individuals
with no or mild periodontitis. Periodontal therapy has been shown to improve glycemic
control in type 2 diabetic subjects. Periodontitis is related to maternal infection, preterm
birth, low birth weight, and preeclampsia. Oral disease prevention strategies should be
incorporated in chronic systemic disease preventive initiatives to curtail the burden of
disease in populations. The reduction in the incidence and prevalence of periodontal
disease can reduce its associated systemic diseases and can also minimize their nancial
impact on the health-care systems. It is hoped that medical, dental practitioners, and
other health-care professionals will get familiar with perio-systemic link and risk
factors, and need to refer to the specialized dental or periodontal care.
Keywords: Periodontal disease, epidemiology, risk factors, systemic disease,
preventive strategy
Muhammad Ashraf Nazir
Department of Preventive Dental Sciences,
University of Dammam College of Dentistry,
Dammam, Kingdom of Saudi Arabia
Address for correspondence:
Muhammad Ashraf Nazir,
Department of Preventive Dental Sciences,
University of Dammam College of Dentistry,
Dammam, Kingdom of Saudi Arabia.
E-mail: manazir@uod.edu.sa
Review Article
ABSTRACT
WEBSITE: ijhs.org.sa
ISSN: 1658-3639
PUBLISHER: Qassim University

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4-5 mm; score 4 represents deep periodontal pockets of 6
mm or above.9
Compared with developed countries, developing nations have
higher prevalence of calculus and bleeding on probing among
adolescents (Figure 1). The proportion of adolescents with
calculus deposits ranged from 35% to 70% in developing countries
while it ranged from 4% to 34% in developed nations (Figure 1).
Similarly, 14-47% of adult populations in developed countries had
calculus deposits compared with 36-63% of adults in developing
nations. However, developed countries have higher percentage
of individuals with periodontal pockets of 4-5 mm (Figure 2).
Greater proportions of older individuals (65-74 years) exhibit
periodontal pockets of 6 mm or above compared with adult
populations in both developed and developing countries
(Figures 2 and 3).
Overall, periodontal disease affects about 20-50% of the
population around the globe.10
Risk Factors for Periodontal Disease
Several factors increase the risk of periodontal diseases. These
risk factors, modiable and non-modiable, contribute toward
the clinical signicance of periodontal diseases.
Figure 1: Proportions of adolescents (15-19 years) with and without periodontal conditions using community periodontal index in different
countries9 Pd: Pocket depth
Figure 2: Proportions of adults (35-44 years) with and without periodontal conditions using community periodontal index in different countries9
Pd: Pocket depth

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Modiable Risk Factors
Smoking
Smoking is one of the most important risk factors for
periodontitis, and the reduction in periodontal disease prevalence
is related to the drop in smoking rates.11 Negative effects of
smoking cigarette, cigar, cannabis, and pipe on periodontal
tissues are similar.12 The smokers are 3 times more likely to
have a severe form of periodontal disease than non-smokers.13
The smokers also present signicantly increased the loss of
alveolar bone and higher prevalence of tooth loss compared
with non-smokers, and they have poor outcomes of all forms of
periodontal treatments.10,12,14,15 Evidence suggests that smoking
changes oral microbial ora increases the level of certain
periodontal microorganisms or affects host response.11 The
nicotine has been shown to cause periodontal tissue breakdown,
directly or indirectly through interaction with other factors.16
Poor oral hygiene
Poor oral hygiene is linked with periodontal disease, and lack
of proper tooth brushing and other measures of oral hygiene can
encourage bacterial deposition and build-up of dental plaque on
teeth and gums which can set a stage for inammatory changes
in periodontal tissues.17 There is pronounced relationship
between poor oral hygiene and increased accumulation of
dental plaque, high prevalence and increased severity of
periodontal disease.18 Axelsson et al. conducted a prospective
study of 15 years duration and found no further deterioration
of periodontal structure among the subjects who maintained
proper oral hygiene and took routine professional dental care.19
Hormonal changes in females
Hormonal changes in women increase the likelihood of
periodontal disease.20 Females may experience gingival
inammation before menstruation and during ovulation due to
a high level of progesterone which blocks the repair of collagen
bers and causes the dilatation of blood vessels.21 Similarly,
pregnant women most frequently exhibit gingival changes,
gingivitis, and sometimes localized growth of gingival tissues.
Fortunately, these inammatory changes disappear within
few months after delivery without causing persistent damage
to periodontal tissues.22 Estrogen deciency reduces bone
density after menopause which can culminate in alveolar
bone loss and eventually falling of teeth. A longitudinal study
of 42,171 women at their postmenopausal stages showed that
the treatment of osteoporosis with estrogen hormonal therapy
resulted in reduced tooth loss.23
Diabetes mellitus
Literature consistently shows that diabetes mellitus is one
of the systemic risk factors for periodontal diseases which
can play a major role in initiation and progression of the
disease.24-26 Diabetes mellitus is associated with periodontal
ligament destruction which subsequently can lead to tooth
loss.27,28 Gingival crevicular uids and saliva have higher
concentrations of inammatory mediators including different
types of cytokines among diabetic patients with periodontitis
as compared to non-diabetic individuals with periodontal
disease.29 A report of a joint workshop of European Federation
of Periodontology and American Academy of Periodontology
identied dose-response relationship between the severity of
periodontal disease and adverse consequences of diabetes, and
periodontal treatment has been found as benecial as giving
an antidiabetic medication to the diabetic patients.29
Medications
Vulnerability to infections and periodontal diseases intensies
when there is diminished salivary flow due to certain
medications.20 The most common medications which can
Figure 3: Proportions of older adults (65-74 years) with and without periodontal conditions using community periodontal index in different
countries9 Pd: Pocket depth

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minimize the ow of saliva and produce dryness of mouth
include tricyclic antidepressants, atropine, antihistamine, and
beta blockers.30 Some drugs (phenytoin, cyclosporine, and
nifedipine) can induce the abnormal growth of gingival tissues
which frequently complicates the appropriate removal of dental
plaque underneath the enlarged gingival mass, and thus, can
further aggravate the existing periodontal disease.20
Stress
It is clear from evidence that stress reduces the flow of
salivary secretions which in turn can enhance dental plaque
formation.15 Rai et al. observed a positive association between
stress scores and salivary stress markers (cortisol, salivary
CgA, b-endorphin, and a-amylase), tooth loss, clinical AL
(5-8 mm), and PD of 5-8 mm.31 A meta-analysis of about
300 empirical articles has indicated that stress is related to
immune system and different immunological changes occur
in response to different stressful events.32 The depressed
individuals have been shown to possess a higher concentration
of cortisol in gingival crevicular uid, and they respond poorly
to periodontal treatment. Academic stress also results in poor
oral hygiene and inammation of gingiva with increased
concentration of interleukin-1β.15
Non-modiable Risk Factors
Age
The risk of periodontal disease increases with the advancing
age that is why the high prevalence of periodontal disease
is seen among elderly population.23 Research identied that
age is associated with periodontal disease, and clinical AL
was signicantly higher among individuals aged 60-69 years
compared with group of adults 40-50 years.33
Hereditary
Hereditary is one of the factors associated with periodontitis
which makes some people more susceptible to the disease than
the others.24 The complex interplay of genetic factors with
environmental and demographic factors has been hypothesized
to demonstrate wide variations among different racial and
ethnic populations.34
Association of Periodontal Disease with
other Medical Conditions
Cardiovascular disease
Consistent body of evidence explains the relationship between
cardiovascular diseases and periodontal diseases. A systematic
review identied that periodontitis is a risk factor for coronary
heart disease, and the association is independent of other risk
factors such as diabetes, smoking, and socioeconomic status.35
In a meta-analysis of eight prospective and one retrospective
studies, it has been found that periodontal disease is likely to
cause a 19% increase in the risk of cardiovascular disease and
this increase in relative risk reaches to 44% among individuals
aged 65 years and over.36 Another systematic review and meta-
analysis of 11 studies (ve cohort and six cross-sectional studies)
found that periodontal disease with increased levels of systemic
bacterial markers was associated with coronary heart disease.37
Similarly, a meta-analysis of 29 studies (22 case–control and
cross-sectional studies, and seven cohort studies) reported
pooled odds ratio of 2.35 and pooled relative risk of 1.34 which
suggest that individuals with periodontal disease had greater
risk and higher odds of developing heart disease than those
without periodontal disease.38 Periodontal disease association
with stroke and peripheral artery disease is even stronger than
coronary heart disease (Figure 4).10
Metabolic disease
There are bi-directional relationship and synergism between
diabetes and periodontal disease.39 A prospective cohort study
of 628 subjects (35 years and older) with a follow-up of
11 years identied that type 2 diabetic individuals with severe
periodontal disease had 3.2 times the risk of mortality due to
ischemic heart disease compared to the individuals with no
or mild periodontal disease (Figure 4).40 Likewise, a meta-
analysis concluded that periodontal therapy improves glycemic
control for at least 3 months in type 2 diabetic subjects.41 A
systematic review provided the evidence to support the role
of periodontal disease in the development of type 2 diabetes
and its complications.42
Scientific literature consistently supports a relationship
between periodontitis and insulin resistance. It has been
argued that periodontal disease exacerbates insulin resistance,
a chronic condition implicated in the pathogenesis of metabolic
disease and type 2 diabetes mellitus.43 Lim et al. evaluated
data of 16,720 subjects from a national survey and identied
an association between insulin resistance and periodontitis in
postmenopausal Korean women.44 It has also been suggested
that periodontal intervention can reduce insulin resistance in
diabetic patients.45
Several systematic reviews have proposed an association between
obesity and periodontal disease and it has been identied as a risk
factor for the development of periodontitis.46-48 Recently, obesity
has been shown to increase oxidative stress in periodontal tissues
and cause their destruction.49,50 The prevalence of obesity is
increasing dramatically around the globe51 and its association
with periodontitis calls for the attention of health-care providers
to prevent these public health issues.
Adverse pregnancy outcomes
Periodontitis is related to adverse pregnancy outcomes which
include maternal infection, preterm birth, low birth weight,
preeclampsia, and microbiological and immunological
factors are implicated in the underlying mechanisms.52-55
Low socioeconomic status, smoking, and urinary tract

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infection are already known to be associated with premature
birth; however, more recently it was found that periodontal
disease is also strongly linked with premature birth incidents
(Figure 4).56
Rheumatoid arthritis (RA)
Periodontal disease is prevalent among RA patients, and
the disease is thought to initiate autoimmune response in
RA (Figure 4).57 It is suggested that both periodontal disease
and RA have similar underlying pathogenic mechanisms.57
The individuals with RA have high prevalence of alveolar
bone destruction and tooth loss which are also sequelae of
periodontal disease.58
Respiratory diseases
The importance of maintaining optimum oral care among
patients with chronic obstructive pulmonary disease
(COPD) has been emphasized due to its association with
periodontitis. Chung et al. used data of 5,878 adults from
a Korean national survey and found signicantly higher
prevalence of periodontitis among COPD patients compared
with healthy individuals.59 In a large cohort study, about
22,332 patients with COPD were compared with individuals
without COPD and it was suggested that subjects with COPD
were at increased risk of developing periodontal disease.60
Similarly, a meta-analysis of 14 epidemiological studies
revealed a signicant association between periodontal disease
and COPD and periodontal disease was recognized as an
independent risk factor for COPD (Figure 4).61 It has also
been suggested that oral and periodontal microorganisms are
implicated in bacterial pneumonia.62
Chronic kidney disease (CKD)
There is a bidirectional relationship between periodontal
disease and CKD. Fisher and Taylor identied periodontitis
as a risk factor for CKD in an epidemiological study of
11,955 adults in the U.S.63 A systematic review of four
observational and three interventional studies found that
patients with periodontitis are at increased risk of CKD and
periodontal treatment results in positive outcomes in persons
with CKD.64 Ioannidou and Swede observed a dose-response
relationship between periodontal disease and different stages
of CKD, and they found that individuals with CKD were
30-60% more likely to develop moderate periodontitis.65
Later, in another study by Ioannidou et al., it was shown
that Mexican Americans with low kidney functions were
twice more likely to have periodontal disease compared with
subjects with normal kidney functions.66 Similarly, Iwasaki
et al. demonstrated a link between periodontitis and reduced
kidney functions in Japanese older individuals.67 In a recent
prospective cohort study with 14 years of follow-up, Ricardo
et al. found that CKD individuals with periodontitis had 35%
greater risk of mortality compared with CKD patients without
periodontal disease (Figure 4).68
Cancers
Increased cancer risk because of periodontal disease has
been demonstrated by Michaud and colleagues.69 The risk
of tongue cancer increases 5.23 times with each millimeter
loss of alveolar bone.70 Fitzpatrick and Katz observed that the
relationship between periodontitis and oral, esophageal, gastric,
and pancreatic cancers have been reported more consistently
in literature than with lung and prostate cancers (Figure 4).71
Impairment of cognitive function
Older adults face decline in their cognitive abilities, which affect
their behaviors including oral hygiene habits.72 There is modest
evidence about an association between periodontal disease
and poor cognitive functions as periodontal inammation
has been shown to affect cognition in elderly populations.73,74
The analysis of data from Third NHANES-III identied high
levels of serum maker of periodontitis (P. gingivalis IgG) in
individuals with impaired cognitive performance.75 Further, a
recent study by Kamer and associates found that clinical AL
can promote amyloid β accumulation in the brain which can
cause cognitive dysfunction.76
Prevention of Periodontal Disease
WHO recommends employing integrated public health
preventive strategies which should be based on common risk
factor approach. Risk factors such as smoking, stress, and low
socioeconomic status are associated with periodontal disease as
well as other systemic chronic diseases; therefore, inclusion of
oral disease prevention strategies in chronic systemic disease
preventive initiatives can curtail the burden of disease at the
level of population.77
Oral hygiene practices
Proper mouth cleaning, regular tooth brushing, and dental
ossing are most effective in preventing oral disease and
periodontitis. Despite utmost signicance of tooth brushing,
about half of the population brush twice a day.78 There are
various sizes, shapes, and types of toothbrushes; however, two
more common types include powered toothbrushes and manual
toothbrushes. Powered toothbrushes offer more advantage over
the manual toothbrushes in reducing dental plaque.79
Diet
Although the role of diet in the prevention of dental caries is
more signicant compared with preventing periodontal disease;
nonetheless, poor diet can negatively affect periodontal tissues
causing rapid progression of disease.80 The vitamin C deciency
as a risk factor for periodontal disease has been discussed in
the literature. Nishida et al. used a sample of 12,419 adults and
showed that there was increased risk of periodontal disease due
to the poor dietary intake of vitamin C, and also observed a
dose-response relationship between vitamin C and the severity

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of periodontal disease.81 A diet high in fruits, vegetables and
low in fat and sugars is required for the healthy periodontal
tissues. Vitamins C and E have antioxidant properties which
help to reduce the production of reactive oxygen radicals formed
during the inammatory process.80 Low-calorie intake has been
shown to reduce inammatory changes and diminish the tissue
damage in periodontal disease.82
Use of uoride
Stannous uoride has antiplaque and antigingivitis effects
and it reduces the proportion of bacteria and spirochetes
in subgingival areas, thus can help to promote gingival
health.83,84 He et al. conducted a randomized double-
blinded trial to investigate the antimicrobial role of stannous
fluoride dentifrice in periodontal disease and found a
signicant reduction in gingival bleeding over a period of
2-month.85
Use of antimicrobial agents
Chlorhexidine, triclosan, essential oils and zinc in
toothpastes, mouthwashes and gels are used to control
specific periodontal bacteria as well as plaque.86,87
Chlorhexidine reduces dental plaque (55% reduction in
dental plaque) and gingival inammation (30-45% decrease
in gingivitis) by lowering inflammatory mediators.88
Gunsolley compared the effectiveness of antiplaque and
antigingivitis mouthrinses with oral hygiene instructions
and adult prophylaxis and found great improvement in oral
hygiene due to antiplaque and antigingivitis mouth rinses.89
Moreover, research data from several clinical trials support
that antimicrobial mouth rinses have equal or greater efcacy
in controlling gingival disease than the use of interproximal
dental oss.90-92
Smoking cessation
Since smoking is a major risk factor for periodontal disease,
therefore smoking cessation can prevent a considerable
proportion of periodontitis cases.93 Smoking cessation not only
inhibits further progression of periodontal disease but can also
reduce the periodontal tissue destruction.94
Community and high risk approaches
Breast cancer and cervical cancer screening are considered
successful examples of screening for the prevention of
diseases, but the decision of oral screening should be based
on careful evaluation of nancial burden, ethical aspects, and
efcacy and adverse effects of the intervention.95 In addition,
implementation of oral health promotion policies at local,
national and international levels can help bring sustainable
reduction in periodontal disease burden and improve the
quality of life of people. Scaling is considered the most
common professional preventive measure for periodontal
disease. Because of the association between periodontal
disease and cardiovascular disease, scaling has recently been
shown to reduce the incidence of acute myocardial infarction
and stroke.96
Conclusion and Recommendations
• Although periodontal disease is the most prevalent
infectious oral condition but is treatable and preventable.
• The reduction in the incidence and prevalence of
Figure 4: Association between periodontal disease and various systemic conditions

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periodontal disease can result in lowering its associated
systemic diseases and complications.
• Decreased periodontal disease burden can minimize
treatment needs and can reduce nancial impact on health-
care systems.
• High prevalence of periodontal disease also necessitates
the establishment of surveillance system for oral diseases
in the community.
• Preventive programs for periodontal disease should utilize
common risk approaches to reduce the magnitude of other
chronic diseases.
• Cost-effective strategies would also enhance
interdisciplinary collaborations among health-care
providers.
• Health-care providers should be familiar with perio-
systemic link and should be able to diagnose and refer
the patients to specialized dental or periodontal care to
improve the quality of life of their patients.
Further research is needed to explore the underlying
mechanisms and risk factors of periodontal disease and develop
innovative preventive strategies.
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