Periodontitis is considered a silent epidemic in Malaysia, as it meets the criteria of being both an epidemic and a silent disease. Nearly half the adult population in Malaysia has periodontitis, placing a huge economic burden on the country. Periodontitis patients with diabetes face double jeopardy, as the two diseases exacerbate each other. However, most people are unaware of the relationship between oral and systemic health, and periodontitis often goes undetected until it significantly impacts quality of life. There is an urgent need for education about periodontitis to address this silent epidemic.

1. PERIODONTITIS PATIENTS WITH DIABETES:
A DOUBLE JEOPARDY
Is Periodontitis A Silent Epidemic In Malaysia?
22NDMDASCIENTIFICCONVENTION&TRADEEXHIBITION2015
24TH JANUARY2015
SUNWAYPYRAMIDCONVENTIONCENTRE
TUTI NINGSEH MOHD DOM
BDS, MPH, PhD
Periodontology Research Team, UKM and partners
www.sihatgusi.info

2. • “Periodontitis patients with diabetes: a
double jeopardy?”
• Is it really a double jeopardy?
• Or is there to too much ado over
nothing?
Double jeopardy:
• Punishment of a person twice for the
same offence?
• Considerable danger or trouble from
two sources?
• Twice danger of harm, loss or failure

3. Is periodontitis a silent epidemic?
First of all what does it mean when we say
that a disease is a silent epidemic?
As we can see there are two elements to
this question:
• First, is periodontitis an epidemic?
• And second, is it a silent disease?

4. 1. Is periodontitis an epidemic?
• A disease is said to be of epidemic proportions when its
occurrence is more than would be expected in a
community or region during a given time period.

5. Global epidemiology of periodontal disease
• Most countries > 90% have periodontal disease (Morris et al 2001, Borrell et al 2002)
• 5 – 20% adults affected with severe periodontitis (Petersen & Ogawa 2005)
• Trends:
• Europe: shallow pockets (37%), deep pockets (14%)
(Borrell et al 2002)
• Asia: shallow pockets (8 – 57%), deep pockets (5 –
28%)
(Corbet et al 2002)

6. • Global Burden of Disease Study of 291 diseases and injuries:
• Severe periodontitis is sixth most prevalent (11%)!
(1) Marcenes, W et al 2013. Global Burden of Oral Conditions in 1990-2010: A systematic analysis. J Dent
Res, 92, (7) 592 (2) Kassebaum, E. et al 2014. Global Burden of Severe Periodontitis in 1990-2010: A
systematic review and Meta-regression. JDR 93 (11): 1045
Global Burden of Disease Study, 2014

7. In 2010, about 94.0% of Malaysian adults have periodontal
disease
4.1% have bleeding
41.4% have calculus
30.3% have shallow pockets
18.2% have deep pockets
• This is translated into a total of 48.5% of the adult
population with periodontitis, or an estimated quantum of
11.5 million adults!
Source : National Oral Health Survey of Adults, Malaysia 2010

8. Is periodontitis an epidemic in Malaysia?
• The increase in prevalence and severity of periodontal disease among adults is multiple!
• The increase in prevalence of periodontitis among youngest adults is alarming!
YEAR NOHSA, 2000 NOHSA, 2010
Age group Adult 15-19yrs Adult 15-19yrs
Periodontal disease
(including gum disease and
presence of calculus)
87.2% 74.2% 94.0% 90.4%
Periodontitis
(CPI 3 and 4)
25.2% 3.0% 48.5% 19.8%
Severe periodontitis
(CPI 4 only)
5.5% 0.3% 18.2% 3.0%
Source : National Oral Health Survey Malaysia,2000 and 2010

9. • A silent disease or disorder is one that produces no clinically
obvious signs or symptoms
• Periodontal disease has long been viewed as a silent
disease because of its symptomless nature in the early
stages and during most of its course
• As it is largely painless, most people with periodontal
disease are unaware that they have it
2. Is periodontitis a silent disease?
Does periodontal disease have any impact on people’s quality
of life?

10. Impact of periodontal disease on quality of life:
Evidence from the literature
Clinical Studies
• Reisine et al 1985
• Needleman et al 2004
• Brennan et al 2007
• Cunha-Cruz et al 2007
• Aslund et al 2008
• Patel et al 2008
• Jowett et al 2009
• Araujo et al 2010
• O’Dowd et al 2010
• Tsakos et al 2010
• Tuti NMD 2013
Population Studies
• Ng et al 2006
• Brennan et al 2007
• Lopez & Baelum 2007
• Lawrence et al 2008
• Marino et al 2008
• Bernabe & Marcenes 2010
• Jansson et al 2014

11. Reasons for seeking dental care among patients with
periodontitis
0
5
10
15
20
25
30
35
40%
Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In
Malaysia. PhD thesis 2013.

12. Quality of life impacts among patients with
periodontitis using Oral Health Impact Profile
Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In
Malaysia. PhD thesis 2013.
9 in 10 patients experience functional limitation, physical pain and
psychological discomfort

13. Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In
Malaysia. PhD thesis 2013.
0 10 20 30 40 50 60 70
Mobility
Self-care
Usual activities
Pain/discomfort
Anxiety/depression
EQ-5D descriptive scores for periodontal patients –
percentage with scores 2 (some/ moderate
problems) and/or 3 (extreme problems)
Aggressive periodontitis Chronic periodontitis
Quality of life impacts among patients with
periodontitis using general EuroQoL Index
Pain/discomfort and anxiety/ depression are experienced by up to 65% of periodontitis patients.
These impacts are experienced by more aggressive periodontitis patients.

14. • Periodontal disease may be a silent disease because its
early signs may not be clear to the patient.
• However in due time its subsequent manifestations may
impact the patients’ quality of life in various ways.
• Implication: There is a need to increase people’s
awareness of the early signs of periodontal disease

15. Economic Burden of Periodontitis
• When many people are affected with a particular
disease, huge amount of resources are needed
to treat it.

16. Average cost in RM
Provider cost Patient cost Total cost
Per patient/
year
2,524 296 2,820
Per outpatient
visit
337 39 376
Periodontal disease is expensive to treat
Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics
BMC Oral Health 14:56a
What the government pays! What society pays!

17. Disease severity
Average Cost
(RM)
Mild 1,757
Moderate 2,545
Severe 3,174
The more severe, the more costly!
Tuti et al 2014. Cost analysis of Periodontitis management in public sector specialist dental clinics
BMC Oral Health 14:56

18. Items Measurement
Number of adults estimated as having
periodontitis nationwide
11,522,627
Cost of managing a periodontitis patient RM 2, 820
Projected economic burden RM 32.5 billion
Economic burden as a percentage of
Malaysia’s *GDP
3.83%
*Malaysia's GDP (Gross Domestic Product), 2011 = RM 847.3 billion
Economic burden on the country is high!
Source: Economic Burden and Cost-effectiveness Analysis of
Periodontitis Management In Malaysia. PhD thesis 2013.
Managing severe periodontitis patients alone would cost the
government about RM 10.9 billion, which was 64.7% of the Ministry
of Health budget (MoH budget, 2011 = RM 16.9 billion)

19. 8/7/2015 19
The double jeopardy?!
Systemic diseases Patients with periodontitis
(n, %)
None 176 (54.0)
Diabetes 88 (27.8)
Cardiovascular diseases 19 (5.8)
Hypertension 92 (28.2)
Others (congenital heart disease,
asthma, gout)
34 (10.4)
Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In
Malaysia. PhD thesis 2013.

20. Most prominent chronic diseases
Chronic diseases are the leading causes of death and disability
worldwide.
Major chronic diseases currently account for about 40% of the
global burden of disease and expected to rise to 60% in 2020
Linked by:
• Common and preventable biological risk factors: notably
high blood pressure, high blood cholesterol and being
overweight
• Related major behavioral risk factors: unhealthy diet and
poor nutrition over a prolonged period of time, physical
inactivity, tobacco use, excessive use of alcohol and
psychosocial stress
Cardiovascular
disease
Cancer
Chronic
obstructive
pulmonary
disease
Type-2
diabetes

21. Periodontal disease - the 6th complication of
diabetes
• In 1997, the American Diabetes Association stated PD as the sixth
complication of DM after retinopathy, nephropathy, neuropathy,
macroangiopathy and delayed wound healing (Furukawa et al. 2007)
• Individuals with type 2 diabetes have approximately threefold
increased odds of having periodontitis compared with those without
diabetes (Shlossman et al 1990, Emrich et al 1991)
• There is a fourfold increased risk of progressive alveolar bone loss in
adults with type 2 diabetes compared with that in adults who did not
have diabetes (Taylor et al 1998)
• Adults with poorly controlled diabetes had an almost threefold
increased risk of having periodontitis compared with that in adult
subjects without diabetes, while subjects with diabetes and good
glycemic control had no significant increase in risk (Tsai et al 2002)

22. Periodontal disease and childhood diabetes
• “Interestingly, in this study
we found that periodontitis
can start in childhood in
diabetes, as early loss of
tooth-supporting structures
was significantly increased
even in our 6 to 11-year-
old subgroup.”
• Lalla E, Cheng B, Lal S, et al.
Periodontal changes in children
and adolescents with diabetes:
A case-control study. Diabetes
Care. 2006;29:295-299.

23. Jeffcoat, M., et. al., Periodontal Therapy Improves Outcomes in
Systemic Conditions, 2014
A considerable amount of medical resources is being used for
managing DM, PD and their several complications that can occur.
A healthy mouth could mean thousands in healthcare savings!

24. Needs and concerns of patients with diabetes
No previous knowledge between
oral health and diabetes
Lack of awareness of relationship
Between oral health and diabetes
Difficulties with reading materials
Do not understand language and
medical terms used
Valerio et al 2010
Care needed overwhelming

25. • Patients with diabetes do not know that periodontal disease is a
highly likely complication of diabetes, and that it may have an impact
on glycemic control
• Patients with periodontitis do not know they have a risk of getting
diabetes
Focus group discussion held in UKM Faculty of Dentistry, November 2014

27. 8/7/2015 27
In reality, many people do not know the signs
and symptoms of periodontal disease
The need to educate people and
health care workers about
periodontal disease is
PRESSING!

28. • Detect silent diseases before they strike