Is Periodontal Disease a Public Health Problem?

Is periodontal disease IN BRIEF • Identifies the importance of the

definition of health and disease. OPINION a public health problem? • Argues for a wider approach to tackling the problem of periodontal disease. • Stresses the need to change the care P. Batchelor1 delivery system.

Clinically defined periodontal disease is highly prevalent, has considerable impacts on individuals and society and is costly to treat; the cost of dental care is the fourth highest costs of all diseases and consuming between 5 and 10% of all healthcare resources. Changes in the epidemiology of clinically defined periodontal diseases suggest that the prevalence of severe periodontal disease is low and rates of progression of periodontal destruction tend to be relatively slow. Current periodontal care modalities have a remarkably weak evidence base, with considerable resources allocated to fund interventions that include oral hygiene instruction, scale and polishes through to surgical interventions. The public health problem lies more in the failure in design of a contract between dental professionals and the state. Such a contract needs to recognise both the wider determinants of disease and the role that dental professionals could play: a contract that concentrated on rewarding outcomes, namely a diminution in treatment need, as opposed to one based simply on the number of interventions would be a major step forward.

INTRODUCTION health approach. Periodontal disease fulfils disease will remain a public health problem. Paedersen1 in a global review of oral dis- them: it is widespread; its consequences The challenge is to recognise the key issues: eases highlighted how oral diseases quali- in terms of social, psychological and eco- both politicians and dental professions, as fied as major public health problems due to nomic impacts on individuals, communities advocates for patients, need to act to address their high prevalence and incidence in all and health services are severe; the costs to them. Health is a political problem and only regions of the world. He went on to suggest society and to individuals are considerable; when the design of the delivery system that approaches to managing the problems and effective methods are available to pre- allows care workers to act as advocates for ranged from intensive one-to-one relation- vent, alleviate or cure the disease. Given the the public will the problems of periodontal ships between the patient and the care pro- above, why then does periodontal disease disease be tackled. vider through to a ‘public health approach’. remain such a problem? The balance between the two would be deter- This article will explore this question and DEFINING A PUBLIC mined by a number of factors including the suggest that the extremes of periodontal dis- HEALTH PROBLEM distribution of the condition and available ease are limited although for those that do Defining a public health problem forms resources. Defining how a condition is best suffer, it impacts severely on their qualities the central argument to the question as to managed is critical for a number of reasons. of life. The manifestations of periodonti- whether a health issue is a ‘public health’ as Most importantly, with the increasing finan- tis – bleeding, halitosis, gingival recession opposed to simply a ‘health’ problem. The cial pressure on healthcare systems, there is and tooth loss – can also have an impact distinction lies in what is understood by the a need to ensure that for a given outcome, beyond the individual sufferer. The costs of term public health. Winslow3 argued that expenditure is minimised; the cost effective- treating the disease are high because of the public health was: ‘the science and art of ness of differing interventions is key in deci- way in which dental care is organised: the preventing disease, prolonging life and pro- sion making. costs of treatment are expensive for indi- moting health through the organized efforts There are a number of criteria that are viduals and societies and remain so due to and informed choices of society, organiza- used to establish whether a condition is a the current inappropriate approaches used to tions, public and private, communities and public health problem2 and consequently manage the conditions. individuals.’ appropriate to be managed using a public The current state of knowledge of the Over 80 years later Rothstein4 reiterated diseases, and in particular associated risk the general sentiments in the definition 1Dental Public Health Unit, Department of Epidemiology factors, means that while there is sufficient arguing that there were three issues to dis- and Public Health, University College London, information to enable control of the com- tinguish between public health and health 119 Torrington Place, London, WC1E 6BT mon forms of the disease, existing interven- problems. These were where the health of Correspondence to: Dr Paul Batchelor Email: [email protected] tions are not effective. the population is threatened by something The key conclusion is that until shortcom- (including environmental factors not just Refereed Paper ings in currently adopted practices at all lev- diseases); where the government has pow- Accepted 8 August 2014 DOI: 10.1038/sj.bdj.2014.912 els, including those at societal and within ers or expertise to meet that threat; and ©British Dental Journal 2014; 217: 405-409 the care system are addressed, periodontal where the action of government will be more

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efficient or more likely to be beneficial than the public’s periodontal health appears to be FINDING AN the actions of individuals. improving. Internationally, the prevalence of APPROPRIATE SOLUTION This definition recognises that if a prob- severe periodontal disease is low and rates All societies aim to ensure the health of their lem exists, the solution is not simply derived of progression of periodontal destruction citizens. Governments try and achieve this through individual actions, for example tend to be relatively slow. A small propor- by developing healthcare systems that set attending for a dental appointment, but by tion of subjects exhibit severe and extensive out to address three main challenges: how those of society. However, this still fails to periodontitis with approximately 1 in 1,000 to improve the health status of both indi- address whether any given condition is a suffering from aggressive periodontitis. viduals and the population; how to develop problem. Sheiham5 suggested a number of Mild gingivitis is common in children and arrangements to protect citizens from threats criteria that are necessary to help establish adults, and very few children demonstrate to their health and the costs of care should whether the issue under consideration is loss of bony support and loss of periodontal they require it; and how to ensure equitable indeed a public health problem. The crite- attachment. There is consensus that severe access.13 The contextual setting for the above ria include: the distribution and extent of periodontal disease occurs in a few teeth in challenges that all care systems face is that of the condition, namely how widespread is a relatively small proportion of people in limited resources. Even the wealthiest socie- it and whether the prevalence is increas- any given age group, and that the propor- ties face limitations in what care they can ing or decreasing; and the impact of the tion affected is greater in older age-groups. provide. All healthcare delivery systems have condition on individuals, for example the At an individual level there have also been implicit or explicit boundaries on the avail- extent to which the condition causes pain, considerable changes in our understanding ability of care related to whether a society discomfort and affects functions such as of the disease with the natural history of limits specific types of interventions for all eating, speaking, sleeping and social inter- periodontal disease progression being more citizens, limits the occasions when an individ- actions that cause embarrassment. Further complex than previously suggested. The old ual can receive it or simply who can receive it. impacts would include the financial cost of ‘continuous progression’ model of periodon- These issues raise the further question on treatment, absence from work and loss of tal disease considers that gingivitis progress the arrangements surrounding the decision- income that in turn may lead to impacts on to periodontitis. A slow loss of attachment making processes within a system. Is the the wider community. This would include follows and its bony support progressing design of the system aimed at ensuring those the effect it may have on people attend- continuously until the tooth is non-func- who seek care can have it or is there an ing school or work. There are the costs to tional. Such a model suggests that once a emphasis on targeting those with the greater the health services of treating the condi- person has periodontal disease only contin- needs? How is the balance between the more tion and finally, and most importantly, is uous treatment will prevent the inevitable immediate interventions that address a prob- the condition preventable and are effective progress of the destructive lesion to severe lem, for example dealing with acute myo- treatments available? periodontitis. There is little evidence to sup- cardial infarctions, balanced against longer Periodontal disease fulfils all the criteria. port this model. More recently, the model term issues such as preventing heart disease As Chapple has stated recently: ‘Periodontitis described has been challenged by one based in the first place? What is the process to is the most common chronic inflammatory on ‘bursts’. Key differences are recognising decide on allocating spending on say cancer disease seen in humans, affecting nearly that not all gingivitis progresses to irrevers- rather than dental care? Such questions have half of adults in the United Kingdom and ible periodontitis and that not all mild peri- led to the necessity to identify mechanisms 60% of those over 65 years. It is a major odontitis progresses to severe periodontitis. to prioritise, not only which interventions a public health problem, causing tooth loss, Individuals exhibit differences in exposure society is willing to provide for its citizens, disability, masticatory dysfunction, and and resistance and the most serious phases but also the arrangements through which poor nutritional status. Periodontitis also of periodontitis being not as common as the care will be delivered. That is far from compromises speech, reduces quality of formerly thought. Finally, there are growing simple. Musgrove14 highlighted nine crite- life, and is an escalating burden to the questions about the extent to which peri- ria grouped under three themes for helping healthcare economy.’ 6 odontal disease causes tooth loss.9 identify issues when considering the justi- In summary, periodontal disease using a These developments, however, do not fication for public spending on healthcare. disease definition is highly prevalent, has detract from periodontal disease being a These range from economic efficiency, considerable impacts on individuals and public health problem, but highlight that ethical reasons and political considerations. society and is costly to treat; the cost of it is essentially socio-political in character. Referring to a previous authored paper, dental care is the fourth highest costs of all As with other major non-communicable Musgrove15 added: ‘[Simply] being a public diseases and consuming between 5 and 10% diseases such as cardiovascular disease, good is not reason enough for the govern- of all healthcare resources.7–8 Periodontal obesity, diabetes and cancers, the social ment to finance a healthcare intervention, diseases are in the vast majority preventable determinants of dental diseases share com- because the result in improved health might and there are effective methods of manag- mon antecedents.10–12 Significant control of not be worth the cost - the same resources ing them. dental diseases can only be achieved in terms could be better used for another health ser- of social policy. The task of health workers is vice or for some non-health activity.’ THE NATURE OF to convince society to undertake the specific The issues raised by Musgrove get to the PERIODONTAL DISEASE social measures that are required to solve heart of the matter to help establish whether Our understanding of the disease process health problems, and to participate in the a health condition is worth addressing or itself has changed considerably over the implementation of these policies. Avoiding to consider if there are benefits that might years. Sheiham6 has summarised the changes the need for developing effective social poli- be accrued through other arrangements. as follows. At the population level the preva- cies for health in favour of concentration on Musgrove recognises that the funding of lence of destructive periodontal disease is problems of individual health behaviour is interventions outside of the healthcare considerably lower than previously esti- not only oversimplification but an evasion system may well provide improvements in mated and, in most industrialised countries, of professional responsibility. health conditions.

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The nature of health problems facing care Lopez state, the distinction between what is instruction (OHI). In fact, repeated OHI might systems has seen the balance between acute termed periodontal health and disease is not have a similar effect as PMPR. Some forms and chronic diseases change. Currently, it fixed. The definitions change according to of PMPR might achieve greater patient sat- is the management of chronic disease that professional agendas. This is a view that is isfaction. There is little difference in benefi- set the challenges: obesity, diabetes, respira- in agreement with Borrell and Papapanou19 cial or adverse effects of different methods tory and coronary conditions. Societies are who highlighted the lack of uniformity in of PMPR.’ attempting to adapt their care systems to definitions and highlights a key failing of Bierne et al.21 also reinforced this view. confront the challenges, not least by adopt- current care delivery systems. The systems They concluded:‘(the evidence) is of insuf- ing a growing role for what is termed a concentrate on a ‘disease’ model and pay ficient quality to reach any conclusions ‘public health’ approach. Such an approach no heed to the wider definitions of health. regarding the beneficial and adverse effects introduces the idea of identifying the ‘cause Because a person may have a number of of routine scaling and polishing for peri- of the cause’ and even the ‘cause of the cause teeth with a loss of attachment of 4 or 5 mm odontal health and regarding the effects of the cause’.16 It makes the important dis- is in itself not a problem. The real issue is of providing this intervention at different tinction between disease and the determi- how the periodontal state impacts on the time intervals.’ nants of disease. qualities of life of individuals. Perhaps the most critical observation was The outstanding issue of what we actu- What such a broader approach creates is that made by Sheiham and Netuveli22 who ally mean by health remains. No longer is a problem when assessing the magnitude of stated: ‘In an era of evidence-based health- a definition based simply the absence of future health problems. Individuals are now care, the current uncritical position where clinical disease adequate. The term has a retaining more teeth and for longer. This has any inflammation of the gingivae or shallow wider meaning and needs to include vari- a direct impact on the size of the periodontal pocketing is considered in need of treatment ous social dimensions, for example function problem. For example, an individual who is untenable. Advanced periodontal disease and well-being. has lost all their teeth does not have a perio- does affect a relatively small percentage of dontal problem. However if they retain more adults and is more common in older people. THE CRITICAL ISSUE OF DEFINING teeth that are functional and in which the The progression pattern of the disease seems PERIODONTAL DISEASE AND aesthetics are acceptable, the volume of the compatible with retention of a functional ITS NATURAL HISTORY problem will still increase if a disease-based dentition throughout life for the majority of As discussed earlier our understanding of model is used to quantify the magnitude of people in Europe.’ the nature and epidemiology of conditions the problem. Unless the assessment is made All the authors of reviews come to remark- affecting the periodontal tissues has changed in terms of impacts on qualities of life, the ably similar conclusions. The evidence base considerably over the last 50 years.17 They additional number of pockets can only create to underpin care modalities is very poor. identify four main features of what they a higher level of clinically assessed disease. There is not only a lack of consensus in what termed the periodontal diseases. These are The above issues highlight the importance is termed periodontal disease but the care that: clinical attachment loss of 1 mm or of defining what periodontal disease is. It is modalities themselves lack justification for greater is highly prevalent even in very not the level of disease per se, but its defi- their adoption. This indicates that if a prob- young subjects; within a given popula- nition that is critical when answering the lem in managing periodontal health does tion, the prevalence of attachment loss, the question as to whether periodontal disease exist it may be far more deep-rooted than extent of attachment loss and the severity is a public health problem. the disease itself. of attachment loss increase with age; within a given age group, the distribution of the HOW EFFECTIVE ARE SO WHAT EXACTLY extent and severity of destruction tends to be CURRENT CARE MODALITIES? IS THE PROBLEM? right-skewed to such a degree that a minor Notwithstanding the lack of definitions there Hugoson and Norderyd23 provided a review fraction of the subjects carries the major bur- still remains a need to assess the impact of of global trends in the prevalence of peri- den of destruction in the group; and, within care modalities. Considerable resources are odontitis. Using the existing clinical indi- a given population, the intra-oral pattern allocated to fund interventions that include ces they concluded that there was a strong of distribution of periodontal destruction is oral hygiene instruction, scale and polishes possibility of a trend of a lower prevalence rather distinct and corroborates the molar- through to surgical interventions. These have especially within Europe and the USA with incisor pattern originally considered charac- a remarkably weak evidence base. Perhaps more specific data from Sweden showing teristic for juvenile periodontitis. the most damning of statements regarding that periodontal health can be significantly What Baelum and Lopez18 highlight is how progress in identifying appropriate care improved at the population level. The ques- the definitions of periodontal disease have modalities for periodontal disease was that tion that arises is how is this being achieved? altered to meet the requirements of a par- provided by Herrera et al.19 They felt that: A theoretical framework for improv- ticular set of scientific beliefs. The definitions ‘it would be inappropriate to make defini- ing periodontal health that recognises the have changed from a time when a microbio- tive and specific recommendations regarding wider determinants has been proposed by logical solution was sought: ‘plaque-induced’ clinical practice based on the limited meta- Watt and Petersen.30 In their review they and ‘not plaque-induced’ periodontal disease, analysis and the review of these 25 studies’. concluded that periodontal diseases affect a through a period when ‘active’ and ‘inactive’ Needleman et al.20 in a systematic review significant proportion of the world’s popula- sites might provide an insight into address- of professional mechanical plaque removal tion, particularly the socially disadvantaged. ing the professionally defined problem, to the for prevention of periodontal diseases also They added that inequalities in periodontal current vogue of ‘periodontal medicine’, in drew similar conclusions regarding the health mirror those patterns in other chronic which an individual’s general health is linked lack of evidence to underpin clinical prac- diseases and share common determinants to their periodontal status. tice. They stated: ‘There appears to be little and concluded that clinical treatment and These issues of definition of what is peri- value in providing professional mechanical chairside preventive advice alone will never odontal disease are critical. As Baelum and plaque removal (PMPR) without oral hygiene tackle the problem.

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A mechanism to overcome the shortfalls into account. Instruments that measure this To achieve the goal the care system needs was proposed by Thomson et al.25 They pro- and how they change need to be adopted. to manage periodontal conditions in terms vided a coherent approach to addressing the There is a lack of an evidence base to that move away from one based on a clinical problems that periodontal disease creates underpin current individual interventions. disease model. A focus on aspects such as based on three strategies: (i) a population Even for perhaps the most common inter- outcomes of care, ‘upstream’ health improve- strategy for altering life practices, particu- vention adopted, dental health education, ments, population orientation and care con- larly those determining smoking behaviour Watt and Marinho’s30 conclusions can be tinuum management that is patient-centred and oral self-care (plaque removal) in the summarised by the question ‘If dental health provides an appropriate starting point.32 community; (ii) a secondary prevention education works why then is there a need to Only then can solutions to the problems aris- strategy to detect and treat people with reinforce it every year?’ ing from the spectrum of periodontal condi- destructive periodontal disease; and (iii) Despite these issues, delivery systems tions that affect citizens be managed in an a high-risk strategy for treating existing have continued to support such approaches. efficient and effective manner. disease and preventing further disease in They have at the same time failed to adopt Such a solution does not distract from those at special risk. They argued that the arrangements that incentivise healthcare the role that the dental professions can play Common Risk Factor Approach and the professions to use arrangements that have in tackling periodontal problems. However, health promotion approach are key aspects been shown to be effective. Such arrange- the delivery system needs to adapt to allow of these strategies. ments recognise the wider public health care providers to fulfil their potential roles Indeed, Lopez and Baelum26 reinforced the approaches needed to address the prob- in supporting patients and the public at need to step outside of the traditional care lem. Jurgensen et al.31 summarised matters large. It is a political as well as a clinical system arguing some of the interventions succinctly. They argued that public health role: the professions need to act as advo- that might be relevant for the prevention research could facilitate integrated disease cates for patients. The design of a contract and control of periodontitis at the popula- prevention, enable the development of between dental professionals and the State tion level do not fall within the territories appropriate oral health systems and build that recognised both the wider determinants of traditional dentistry. With the strong evi- capacity for public health intervention for of disease and the role that dental profes- dence base linking diabetes and periodontal periodontal health. sionals could play would be a start. Indeed health27 along with the aforementioned link a contract that concentrated on rewarding with smoking28 strengthen their argument SUMMARY outcomes, namely a diminution in treatment for a wider approach to address problems. In attempting to answer the question as need, as opposed to one based simply on the The above again reinforces the idea that to whether periodontal disease is a public number of interventions, would be a major it is not periodontal disease that is the pub- health problem, a series of complex issues step forward. Until then periodontal disease lic health problem. The problem is in the are raised, answers to which are more intri- will remain a public health problem but it is mindset of those designing solutions to cate than might initially appear. Perhaps the a consequential not causative link: the cur- problems based on definitions of disease and most critical issue centres on how a society rent design of the care management system the adopted care approaches to date. These defines and hence what it infers by the term does not help but hinders improvements in need to change. ‘periodontal disease’. The current emphasis disease levels. is based on a definition that adopts clinical WHERE DOES THAT LEAVE US: 1. Paedersen P E. The World Oral Health Report 2003: disease as its measure. This has consider- continuous improvement of oral health in the 21st THE QUESTIONS THAT NEED able implications not least of which is that century - the approach of the WHO Global Oral ADDRESSING it seeks the solution on a model of care that Health Programme. Community Dent Oral Epidemiol 2003; 31 (Suppl 1): 3–24. It is remarkable that despite the considerable is flawed. It cannot and will not ever provide 2. Daly B, Batchelor P A, Treasure E T, Watt R G. resources allocated within healthcare systems a solution to ‘periodontal disease’. This is the Essential dental public health. 2nd ed. Oxford: Oxford University Press, 2013. to address what is termed periodontal disease public health problem. It is dealing with a 3. Winslow C A. The untilled fields of public health. there remains no clear understanding of it or challenge that lies in recognising that the Science 1920; 51: 23–33. its management. As Prato et al.29 comment: periodontal tissues allow a functional den- 4. Rothstein M A. Rethinking the meaning of public health. J Law Med Ethics 2002; 30: 144–149. ‘even today, in periodontology, clinical sig- tition that in turn provide individuals with 5. Sheiham, A, Watt R. Oral health prevention and nificance is judged only on the basis of statis- the means to enjoy various qualities of life policy. 1996. In Murray J J, Nunn J H, Steel J G (eds). tical values (for example, the p value).’ including eating and smiling. pp 241-258. Prevention of oral diseases. 4th ed. Oxford University Press, 2003. This ignores the very purpose of sound The more appropriate question lies not 6. Chapple I L C. Time to take periodontitis seriously. periodontal tissues, namely to allow a func- in asking whether periodontal disease is BMJ 2014; 348: 2645. tional and aesthetic dentition that meets the a public health problem but whether the 7. Petersen P E, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and needs of citizens. approach adopted in the delivery system is. risks to oral health. Bull World Health Organ 2005; It is not periodontal disease that is the pub- The challenge is to move away from a ‘dis- 83: 661–669. lic health problem but the current approach ease centric’ model of care to one in which 8. World Health Organisation. Dental diseases and oral health. 2003. Online information available at adopted in attempting to address citizens’ the focus is on the wider qualities associ- http://www.who.int/oral_health/publications/en/ needs. The approach is flawed. There is a ated with health. Such an approach requires orh_fact_sheet.pdf (accessed 20 July 2014). 9. Chauncey H H, Glass R L, Alman J E. Dental caries. narrowness in the thinking behind the defi- health professionals to work with policy Principal cause of tooth extraction in a sample of US nition and assessment of an individual’s makers, the education and training system male adults. Caries Res 1989; 23: 200–205. needs derived from periodontal measurement. and politicians to achieve the reorientation 10. Sheiham A. Public health aspects of periodontal diseases in Europe. J Clin Periodontol 1991; 18: 362–369. Current models concentrate on the clinical of health systems. Periodontal disease may 11. Sheiham A, Watt R G. The Common Risk Factor disease and the assessment is defined in ways well be associated with a public health prob- Approach: a rational basis for promoting oral health. that are continually changing. The impacts of lem but the cause lies with the care system Community Dent Oral Epidemiol 2000; 28: 399–406. 12. Watt R G, Sheiham A. Integrating the common the range of conditions known as periodontal itself. The problem with periodontal disease risk factor approach into a social determinants diseases on individuals are not being taken is one of association not causation. framework. Community Dent Oral Epidemiol 2012;

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