Consensus Report

Advances in the behaviouraland public health aspects ofperiodontitis.Group D Consensus report of the fifth Europeanworkshop in periodontology

Davies I, Karring T, Norderyd O. Advances in the behavioural and public healthaspects of periodontitis. Consensus report of the fifth european workshop inperiodontology. J Clin Peridontol 2005; 32 (Suppl. 6): 326–327.r Blackwell Munksgaard 2005.

Key words: periodontitis; behavioral sciences;public health; health economics

Accepted for publication 1 April 2005

The focus of this group was to reviewand analyse information relating to pub-lic health and health behaviour regard-ing periodontal diseases. This includedthe examination of relevant epidemiolo-gical, clinical, behavioural and econom-ic issues to establish the state of currentknowledge, identify areas of study,recommend action and suggest appro-priate research endeavour.

Three papers were reviewed. The firstconsisted of a broad overview of theimpact of preventive programmes uponthe epidemiology of periodontal dis-eases (Gjermo 2005). The second wasan extensive review of both oral healthand health management literature, pre-senting cost–benefit, cost-effectivenessand cost–utility analyses and their rele-vance in the evaluation of the outcomesof periodontal prevention and therapy(Bragger 2005). The final paper was aclassically structured systematic reviewof socio-economic factors in the mani-festation and treatment of periodontaldiseases (Klinge & Norlund 2005).After discussion and amendment, thepapers were accepted.

Important matters quickly emerged.

� The substantial difficulties in mak-ing meaningful comparisons acrossdifferent epidemiological studies ofperiodontal diseases.

� The value of including sound eco-nomic data, in addition to clinicaldata, in the assessment of preventiveand therapeutic programmes.

� The observation that revealing thenature of the inter-relationshipbetween disease and socio-econom-ic issues was confounded, in part bystudy designs and more significantlyby the overwhelming effects ofsmoking on periodontal health.

Such was the coincidence of the materi-al analysed; the group debated thepapers in parallel. From the conclusionsthat were drawn, the following questionswere raised, and the actions recom-mended by the group are therefore pre-sented in an integrated fashion.

Questions Addressed andRecommended Action

What kind of epidemiological data onperiodontal diseases are needed?

In noting the lack of coherence in epide-miological approaches that made it diffi-cult to draw conclusions across studies,it is recommended that epidemiologicalstudies conducted to assess prevalence andincidence should include and report on:

� population samples representativefor the defined aims;

� measurable parameters that are uni-versally recognizable in order todefine the disease in a consistent andreproducible way;

� well-defined socio-economic data,including issues such as education,health attitudes and behaviouralhabits, using scales appropriate forthe (sub)population studied whenapplicable; and

� cumulative frequency analysis aswell as patient-centred outcomes.

What is the nature of the studies needed

to conclude that new preventive,diagnostic and intervention measures are

truly beneficial for a society?

Future clinical trials should includeeconomic parameters as well as patient-centred outcomes.

Do periodontal preventive programmes orcampaigns have an effect on a population

level?

There is evidence showing that anappropriate oral hygiene level is effec-tive in reducing the prevalence andseverity of periodontal diseases on apopulation level. Data show that popu-lations in countries with an existingemphasis on prevention have a better

Ian Davies1, Thorkild Karring2 andOla Norderyd3 on behalf of theEuropean Workshop inPeriodontology group En

1Department of Periodontology, University of

Hong Kong, Hong Kong; 2Department of

Periodontology, University of Aahrus,

Aahrus, Denmark; 3Department of

Periodontology, The Institute for

Postgraduate Dental Education,

Jonkoping, Sweden

326

nGroup participants: Pierre Baehni Urs Bragger,

Hugo de Bruyn, Per Gjermo, Ioanna Kamma,

Bjorn Klinge, Daniel van Steenberghe, Mary

Cullinan, Henry Tennenbaum, Jan Wennstrom

J Clin Periodontol 2005; 32 (Suppl. 6): 326–327 Copyright r Blackwell Munksgaard 2005

periodontal condition. However, changesin periodontal disease levels as assessedin epidemiological studies cannot beattributed to single programmes orcampaigns. These activities usually trig-ger a cascade of events that, together,combine to lead to the improvementobserved in the periodontal health inthe society.

What is the relationship between socio-economic factors and the prevalence of

periodontal diseases?

Based on an analysis of relevant studies,with designs that have included smokingin their analysis, the socio-economicvariables hitherto associated with perio-dontal diseases in fact appear to be ofless importance than smoking per se.Data in non-smokers have shown thateducational level can have an impact onperiodontal diseases.

How can the economical aspects of

providing oral health care be evaluated inperiodontal research?

In order to conclude that preventive,diagnostic or therapeutic measures aretruly beneficial for the society, there hasto be clarity in the use of the relevantterminology.

Efficacy is defined as the probabilityof an intervention being beneficial topatients provided under ideal conditions.

Effectiveness concerns the care pro-vided to the general population underconditions found in practice.

A cost–benefit analysis weighs allcosts against all consequences of anintervention in monetary units.

A cost-effectiveness analysis balancescost in monetary units against the out-come presented in non-monetary units,i.e. clinical parameters or survival.

A cost–utility analysis weighs monetarycosts against consequences represented ina respective utility (e.g. survival of a tooth

with/without recession, mobility, sensitiv-ity, aesthetic impairment).

The allocation of available resourcesto achieve the best possible outcomesinvolves the utilization of instrumentssuch as cost–benefit, cost-effectivenessand cost–utility analysis in clinicaltrials. Clinical endpoints with differentquality outcomes can thereby be relatedto the monetary costs involved to reachthat respective condition. Cost–utilityanalysis will allow the prioritization ofthe allocation of resources so as toemphasize preventive measures.

Has it been shown to be cost effective to

have a preventive programme forperiodontal diseases on a population

level?

Thus far, an economic benefit from exten-sive periodontal programmes aimedat prevention of periodontal diseasesin a general population has not beenreported. An indirect benefit of the pro-grams, however, could be seen for somesubgroups related to caries reduction.

On a population level, is there aneconomic advantage from the use of

genetic and/or microbiological testing for

managing periodontal diseases?

There is currently no data supporting thecost–benefit advantage of using thesetests for population screening.

Currently what are the core messages to

oral health professionals and policymakers regarding the prevention and

treatment of periodontal diseases?

Three matters are highlighted:

� An appropriate oral hygiene level iseffective in reducing the prevalenceand severity of periodontal diseaseson a population level. Data implythat smoking cessation will alsohave a favourable impact on perio-

dontal diseases, including costsavings.

� Accumulating evidence, derived fromepidemiological and interventionstudies, indicate emerging relation-ships between chronic inflamma-tory/infectious diseases and suchconditions as heart and lung diseasesand stroke and perinatal outcomes.Periodontal diseases are the mostprevalent chronic inflammatory dis-eases in humans and therefore maybecome another priority in a globalhealth approach.

� With the limited resources availableto governments and communities,cost–utility analyses indicate thatoral health care programmes shouldinclude an emphasis on identifiedrisk groups such as smokers, dia-betics and other medically compro-mised groups.

References

Bragger, U. (2005) Cost–benefit, cost-effective-

ness and cost–utility analyses of periodontitis

prevention. Journal of Clinical Perio-

dontology 32, (Suppl. 6) 301–313.

Klinge, B. & Norlund, A. (2005) A socio-

economic perspective on periodontal di-

seases – a systematic review. Journal

of Clinical Periodontology 32, (Suppl. 6)

314–325.

Gjermo, P. E. (2005) Impact of periodontal

preventive programmes on the data from

epidemiologic studies. Journal of Clinical

Periodontology 32, (Suppl. 6) 294–300.

Address:

O. Norderyd

Department of Periodontology

The Institute for Postgraduate

Dental Education

P.O. Box 1030

SE-551 11

Jonkoping

Sweden

E-mail: ola.norderyd@ltjkpg.se

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