Periodontal health through public health approaches: Are we at the tipping point?

1. Periodontal health through public health
approaches: Are we at the tipping point?
Tuti Ningseh Mohd Dom, PhD

2. Lecture Highlights
• Is periodontal disease a public health
problem?
• What are the determinants of periodontal
disease?
• Are we tackling it right?
• Can small changes make huge difference?
• Are we at the tipping point?

3. Is periodontal disease a
public health problem?
• It is one of the two most important oral diseases
contributing to the global burden of chronic
diseases.
• Gingivitis: inflammation of gingiva caused by
bacteria accumulating along the gingival margin.
• Periodontitis: more advanced inflammatory
form in which the breakdown of the supporting
tissues of teeth occurs

4. Criteria of a public health problem
1. It must place a large burden on society, a burden that is
getting larger despite existing control efforts;
2. The burden must be distributed unfairly (i.e., certain
segments of the population are unequally affected);
3. Must be evidence that upstream preventive
strategies could substantially reduce the burden of the
condition; and
4. Such preventive strategies are not yet in place

5. I. Must place large burden on society
Global Burden of Oral Conditions
• Oral diseases affect 3.9 billion people worldwide
• 291 diseases and injuries: untreated caries in
permanent teeth is the most prevalent condition
(35% of world population)
• Severe periodontitis is number six (11%) and
severe tooth loss (<9 teeth) is number 36 (2.3%)
Marcenes, W et al 2013. Global Burden of Oral Conditions in 1990-2010:
A systematic analysis. J Dent Res vol. 92, (7) 592-597

6. Global burden of periodontal disease
Petersen PE & Ogawa H. 2012. The global burden of periodontal disease:
Towards integration with chronic disease prevention and control

7. Highest Periodontal Score in Dentate Adults
in 2000 & 2010
0
10
20
30
40
50
60
CPI 0 CPI 1 CPI 2 CPI 3 CPI 4 Excl.
sextant
9.8
4.5
57.5
20
5.2 33.2 4.1
41.4
30.3
18.2
2.7
Percent
CPIScore
2000
2010
Periodontal
Condition
CP I = 0 (Healthy)
CPI = 1 (Bleeding)
CPI = 2 (Calculus)
CPI = 3
(Shallow Pockets)
CPI = 4
(Deep Pockets)
• About 3 times increase in prevalence of deep pockets
• Decrease in prevalence of CPI 2
• ‘Excluded sextants’ refers to subjects with excluded sextants

8. International Comparisons for 35-44 yr olds
Country Year Prevalence of
Periodontal
Disease
Malaysia 2010 97.3%
Thailand 2006/2007 93.4%
Japan 2005 82%
Sri Lanka 2002/2003 98.6%
Spain 2005 97.5%
Norway 2003 99.0%
Greece 2005 10.0%

9. 8/25/2015 9
Periodontal disease can affect quality of life
Source: Economic Burden and Cost-
effectiveness Analysis of Periodontitis
Management In Malaysia. PhD thesis 2013.

10. 8/25/2015 10
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

11. Total cost per procedure = dental equipment cost + dental consumables cost+
staff salary + administrative cost (building, traveling, staff training, utilities,
professional services, printing, hospitality, cleaning and sterilisation services)
Unit cost per periodontal procedures (selected items only)
Procedures Unit cost (RM)
Comprehensive dental and periodontal examination
(including radiographs)
120
Full-mouth supra-gingival debridement (scaling) 215
Full-mouth subgingival debridement 637
Open flap debridement 674
Regeneration with enamel matrix derivatives (EMD) 3025
Root coverage 734
Crown lengthening 617
Root resection 1312
Guided bone regeneration 1036
8/25/2015 11
Periodontal disease is expensive to treat

12. Disease severity
Cost (RM)
Mean S.D
Mild 1,757 978
Moderate 2,545 1,499
Severe 3,174 1,277
Average cost of periodontitis managementi
Malaysian specialist periodontal clinics
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Periodontal disease is expensive to treat
Tuti et al 2014. Cost analysis of Periodontitis management in
public sector specialist dental clinics BMC Oral Health 14:56

13. Clinical burden of periodontitis based on national
epidemiological survey findings and census report on
Malaysian population
8/25/2015 13
Moderate
periodontitis
Severe
periodontitis
All cases
% of population with
periodontitis (Oral
Health Division, MOH,
2012)
30.30% 18.20% 48.5%
Number of adults at
risk of periodontitis
(aged 15 and above)
(National census
report, 2011)
- -
23,757,994
Number of adults
estimated as having
periodontitis
7,198,672 4,323,955 11,522,627

14. National economic burden of periodontitis:
societal perspective
8/25/2015 14
Item 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
Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis Management In Malaysia.
PhD thesis 2013.

15. II. Burden is distributed unfairly
• Extent and severity of periodontitis
increase with age ( Albandar & Rams 2002, Petersen &
Ogawa 2005)
• More common among men than women
(Albandar & Rams 2002, Petersen & Ogawa 2005)
• Significantly worse periodontal health
among lower income and lower educated
groups (Dury et al 1999, Morris et al 2001)

16. III. Availability of upstream preventive
strategies
8/25/2015 16

17. Upstream-downstream interventions
‘Upstream’
Healthy public policy
Midstream
Preventive
Downstream
Curative
National & local policy initiatives
Legislation & regulation
Training other professional groups
Treatment
Rehabilitation
Patient
education
Healthy settings
Community development
Media campaigns
School dental health education
IV. Upstream preventive
strategies not in place

18. Some examples of upstream health
promotion strategies
• Dissemination of information, education and communication
to individuals, to change health- related behavior, knowledge,
attitudes and beliefs.
• Using advocacy, mass communication and social marketing
to shift cultural norms.
• Legislation and regulation, to reduce population exposure to
health risks and encourage healthy lifestyles.
• Empowering and supporting communities to take action for
health and disease control.
• Orienting health systems toward primary healthcare, in other
words, universal coverage in healthcare, early detection of
disease, prevention and early intervention, optimal patient
education and placing people at the center of service delivery.
8/25/2015 18
Petersen PE & Baehni PC. 2012. Periodontal health and
Global public health. Periodontology 2000 60:7-14

19. What are determinants of health?
GENETIC • Factors which determine an individual’s
predisposition to disease
BIOLOGICAL • Factors in which disease is caused by bacteria
or viruses
LIFESTYLE
• Factors in which behaviours contribute to
disease: smoking, diet, alcohol
ENVIRONMENTAL
• Factors such as geographical, geological,
climatic: housing, pollution, noise
SOCIAL
• Factors connected with membership of particular
social groups, which may influence other factors:
age, gender, class

20. Social determinants of health
Social determinants of health are economic and social conditions that influence
the health of people and communities
Social gradient (class)
Stress
Early life
Social exclusion
Work
Unemployment
Social support
Addiction
Food

22. Are we tackling it right?
How do we gain control of these
factors
Recognised main risk factors
Oral hygiene
level
Tobacco
use
Psychosocial
factors
Related
systemic
disease

23. General socio-
economic, cultural &
environmental
conditions.
Living & working
conditions
Social &
community
networks
Individual
lifestyle
factors
Age, gender,
genetics
How much control do we have over
these determinants of health?

24. How we deal with periodontal disease
• Goal of periodontal therapy: complete removal of plaque
and calculus, resolution of all gingivitis, eradication of
pockets.
• We treat patients at chairside --- this is expensive, poses
a significant economic burden and ineffective at
population level as it promotes professional dependency
• We promote oral health through school dental health
education and public campaigns --- there is not much
emphasis on periodontal health and no programme
evaluation
• Population-directed intervention for periodontal health is
a highly neglected area
8/25/2015 24

25. 8/25/2015 25
Gums bleed during brushing.
Gums bleed spontaneously.
Red, swollen gums.
Loose teeth.
Teeth look longer than usual.
Food stuck in between teeth.
Teeth that drift/move.
Extra space between teeth.
Pus discharge.
Smelly breath.
Sensitive teeth
Bad taste in mouth.
Inefficient chewing.
In reality, many people do not know that
these are symptoms of periodontal disease

26. The bigger picture
• Controlling oral hygiene: motivation,
developmental, psychological, social and
cultural factors
• Tobacco cessation: psychological, social and
political factors in initiation, continuation and
cessation
• Psychosocial factors: discrimination, poverty,
unemployment, poor living conditions
• Related systemic disease: e.g. diabetes
8/25/2015 26

27. 8/25/2015 27
Patients with periodontal disease & systemic disease
Co-morbidities Chronic 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.

28. Burden of chronic diseases
• Chronic diseases are the leading causes
of death and disability worldwide.
• Rates accelerate globally, advance across
every region and all socioeconomic
classes.
• Major chronic diseases currently account
for about 40% of the global burden of
disease and expected to rise to 60% in
2020

29. Most prominent chronic diseases
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

30. Can small changes make huge difference?

31. 8/25/2015 31
(1) WHO 2000: Common Risk-Factor Approach

32. (2) Partners in oral health
• Food retailers
• Food producers
• Advertising
industry
• Water industry
• Dental
Associations
• Diabetes
Association
• Etc
• Medical doctor
• Nurses
• Pharmacists
• Teachers
• Parents/ carers
• Universities
• Dental products
suppliers
Education
Health
professionals
Commerce &
industry
Voluntary
organizations

33. Jeffcoat, M., et. al., Periodontal Therapy Improves Outcomes in Systemic Conditions,
Abstract, American Association of Dental Research, March 21, 2014
A healthy mouth could mean thousands in
healthcare savings

34. (3) Reorienting health services
• Recognise early signs of periodontal
disease, and teach the public to do the
same
• Provide early intervention
• Primary care to make appropriate referrals
for management

35. Can small changes make huge
differences?
• To improve quality of care in management
of periodontal disease through
– Early disease detection,
– Appropriate referrals,
– Joint management with medical doctors

36. Are we at the tipping point?
Are we ready to make changes?