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

Tuti Ningseh Mohd Dom, PhD

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?

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

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

I. Must place large burden on societyGlobal 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

Global burden of periodontal disease

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

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

9.84.5

57.5

20

5.2 33.2 4.1

41.4

30.3

18.2

2.7

Perc

ent

CPI Score

2000

2010

Periodontal ConditionCP 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

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%

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Periodontal disease can affect quality of life

Source: Economic Burden and Cost-effectiveness Analysis of Periodontitis

Management In Malaysia. PhD thesis 2013.

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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

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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 637Open flap debridement 674

Regeneration with enamel matrix derivatives (EMD) 3025

Root coverage 734

Crown lengthening 617Root resection 1312

Guided bone regeneration 1036

Periodontal disease is expensive to treat

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Disease severityCost (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

Periodontal disease is expensive to treat

Tuti et al 2014. Cost analysis of Periodontitis management inpublic sector specialist dental clinics BMC Oral Health 14:56

Clinical burden of periodontitis based on national epidemiological survey findings and census report on

Malaysian population

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  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

National economic burden of periodontitis: societal perspective

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 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.

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)

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III. Availability of upstream preventive strategies

Upstream-downstream interventions

‘Upstream’Healthy public policy

MidstreamPreventive

DownstreamCurative

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

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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.

Petersen PE & Baehni PC. 2012. Periodontal health andGlobal public health. Periodontology 2000 60:7-14

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

Social determinants of healthSocial 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

Are we tackling it right?

How do we gain control of these factors

Recognised main risk factorsOral hygiene

levelTobacco

usePsychosocial

factors

Related systemic disease

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?

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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

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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 teethBad taste in mouth.Inefficient chewing.

In reality, many people do not know that these are symptoms of periodontal disease

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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

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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.

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

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

Can small changes make huge difference?

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(1) WHO 2000: Common Risk-Factor Approach

(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

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

(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

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

Are we at the tipping point?

Are we ready to make changes?