periodontal health through public health approaches
TRANSCRIPT
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?