REV IEW ART ICLE

Periodontitis among adult populations in the Arab World

Latfiya S. Al-Harthi, Mary P. Cullinan, Jonathan W. Leichter and W. Murray Thomson

Department of Oral Sciences, School of Dentistry, University of Otago, Dunedin, New Zealand.

Background: The Arab World consists of 22 countries from North and North-east Africa and the Middle East. Peri-odontal disease is an important global oral health burden, and is highly prevalent in developing countries. Objectives:The objective of this narrative review is to report on the recorded prevalence of periodontitis in the Arab World, andto examine the methods used in collecting the data. Data and sources: A search of the literature was performed usingthe PubMed database up to September 2011 to identify articles that reported on the prevalence of periodontal diseasein the 22 Arab countries. Reports kept in the World Health Organization (WHO) Global Health Data bank were alsoused in this review. Conclusion: There is a paucity of up-to-date data regarding the prevalence of periodontitis in theArab adult population. Most relevant data are at least 10 years old. From the literature available, it is clear that thereis a need for epidemiological data that are representative of the adult population from this region. Such data willenable proper development of guidelines, allocation of resources and the development of appropriate public healthprogrammes.

Key words: Periodontal diseases, periodontitis, oral health, Arab countries, Middle East

INTRODUCTION

The Arab World comprises 22 countries from Northand North-east Africa, and the Middle East. Thesecountries are Algeria, Bahrain, Comoros, Djibouti,Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauri-tania, Morocco, Oman, the Palestinian territories,Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia,the United Arab Emirates and Yemen. The provisionof dental care in most of these countries is through acombination of public and private services.Periodontal diseases are inflammatory conditions

affecting the tooth-supporting tissues. Gingivitis andperiodontitis are the two most common manifesta-tions. Periodontitis contributes extensively to the glo-bal burden of oral diseases1. It is also associated withsystemic conditions such as cardiovascular diseases2

and diabetes mellitus3. The mild-to-moderate form ofperiodontitis is the most common, with prevalenceestimates ranging from 13% to 57%, depending onthe sample characteristics and the case definitionused4–6. The extent and severity of periodontitisincreases with age7. The first published report on theprevalence of periodontitis from an Arab country wasan Egyptian study conducted in 19478; it reported the

prevalence of what was classified as ‘light’, ‘medium’and ‘severe’ periodontitis to be 27.6%, 25.2% and45%, respectively.In 1981, the F�ed�eration Dentaire Internationale

(FDI) and the World Health Organization (WHO)established the first global oral health goals9. Morerecently, goals for the year 2020 have been establishedjointly by the FDI, WHO and the International Asso-ciation of Dental Research (IADR)10. These goalsinvolve reducing the impact of oral diseases on healthand psychosocial development, and minimising theimpact of oral manifestations of systemic diseases10.However, knowledge and understanding of the occur-rence of oral diseases is a prerequisite for adequatemonitoring of progress towards oral health goals, andfor the proper allocation of resources.A recent review of the burden of oral diseases in

the Middle East found that little attention has beengiven to periodontitis in those countries11. It is there-fore appropriate to examine the published data onperiodontitis available from the Arab countries inorder to inform the development of oral care and dis-ease prevention strategies that are suitable for theneeds of the Arab population. This narrative literaturereview reports on the prevalence of periodontitis in

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International Dental Journal 2013; 63: 7–11

doi: 10.1111/idj.12002

the Arab World and examines the methodologicalimplications of the findings.

DATA SOURCES

A search of the literature was performed using thePubMed database up to September 2011 in order toidentify articles that reported on the prevalence ofperiodontal diseases in the Arab countries. Keywordsused in keyword/title/abstract searches included ‘peri-odontal disease’, ‘periodontitis’, ‘pocket depth’, ‘clini-cal attachment loss’, ‘CPITN’, ‘Arab’ and ‘MiddleEast’, together with the name of each of the Arabcountries. Data from the WHO Global Oral Healthperiodontal profile Data Bank (http://www.dent.niig-ata-u.ac.jp/prevent/perio/contents.html) were also usedin this review.

FINDINGS

The literature search for articles on the prevalence ofperiodontitis in adults in the Arab world revealed fewstudies; these were either analytical studies on theassociation of periodontitis with different risk fac-tors12–21 or assessments of the effect of the use of themiswak22,23, or fluoride24. These (and a number ofother published studies from Kuwait, Saudi Arabia,Iraq, Jordan and Yemen) included reports on the peri-odontal status of adult samples25–34. Three of thestudies used pocket depth (PD) and/or clinical attach-ment loss (CAL) to determine periodontal sta-tus16,23,33. The remainder used the CommunityPeriodontal Index of Treatment Needs (CPITN)35 toreport on periodontal status.In 1992, periodontitis was reported as the percent-

age of people with one or more sextants with shallowor deep pockets [Community Periodontal Index (CPI)scores 3 and 4, respectively] in a Saudi Arabian studyof the adult population from the central province ofSaudi Arabia26. Just over one-quarter of those aged19 years and over had shallow pockets, and 9.0%had deep pockets26. A 2008 report from a study of anon-representative Saudi Arabian sample reported theprevalence of shallow pockets to be 37.4%, and nonehad deep pockets33. The latter finding was alsoreported in another Saudi Arabian study of a repre-sentative sample of young adults aged 20–24 years (inJeddah city), where none had deep pockets, whileshallow pockets were observed in 7.2%25. A Kuwaitistudy reported the periodontal status as the meannumber of sextants with PD greater than 3 mm; thiswas reported to be 1.5 for those aged 20 years andover30. An Iraqi study of a representative sample of1,418 individuals (aged 7–70 years) from three ran-domly selected rural villages in the province of Nine-vah Governorate was conducted in 199928. In this

study, shallow pockets were observed in 41.2% ofthose aged 25 years and over and 22.6% of the sameage group had deep pockets. In the Yemeni study,deep pockets were observed in 12.5% of the 35- to44-year age-group27. This was lower than estimatesfrom Iraq and higher than those from Saudi Arabia.The Moroccan study used a convenience sample oftwo areas with differing fluoride levels24. The preva-lence of shallow pockets was 32.4% and 54.6% inthose aged 21–30 years and 41–60 years, respectively,and the prevalence of deep pocketing was 8.5% and28.6%, respectively. The lowest reported occurrenceof periodontitis was in Jordan31, where the prevalenceof shallow pocketing was 4.7% and 18.6% in the 20–39 year age-group and 50–60 year age-group respec-tively; 4.1% and 11.1% of those age groups, respec-tively, had deep pockets. However, these comparisonsshould be treated with caution because, although allof the previous studies used the CPITN, the samplescomprised different age groups and some studiesexamined all teeth while others examined index teethonly.Few of the studies used PD and/or CAL to deter-

mine periodontal status12,14,16,21,23. The studies aredifficult to compare because they reported their datausing different case definitions and thresholds. More-over, some examined all teeth using six sites pertooth16,21 and others conducted partial examina-tions14,23. For example, a Sudanese study examinedindex teeth and defined periodontitis using differentthresholds of PD or CAL. They reported that approxi-mately one in 10 participants had at least one sitewith 4+ mm PD, 2% had at least one site with6+ mm PD, approximately half had at least one sitewith 4+ mm CAL and one in 12 had at least one sitewith 6+ mm CAL23. The Saudi Arabian study exam-ined all teeth using four sites per tooth, and theyreported the periodontal status as the mean probingdepth per person; this was reported to be 2.8 mm forthose aged 17 years and over14. The two Jordanianstudies examined all teeth (except third molars), usingsix sites per tooth, and defined periodontitis as thepresence of four or more teeth with one or more siteswith PD of 4+ mm and CAL of 3+ mm12,16. Thereported prevalence of periodontitis was 26.8% inone study16 and 30.9% in the other12.

WHO Global Oral Health periodontal profile data

Table 1 summarises the WHO data for CPI scores 3and 4 from reports on periodontal status in the Arabcountries. The reported prevalence of shallow pocketsranged from 0% to 53%, and deep pockets rangedfrom 0% to 34%36. Despite being collected using theCPITN, epidemiological data in the Global OralHealth Data Bank are at least comparable because

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they use the same method of data collection and casedefinitions36. The contemporary relevance of the datais questionable because most estimates are at leasttwo decades old, and the most recent is 10 years old.Moreover, the most striking feature of this table iswhat is missing; that is, it does not have representa-tive data on periodontal diseases among the adultpopulation reported from more than half of the Arabcountries.

DISCUSSION

Most published surveys describing oral health status(including periodontal diseases) in the Arab worldhave been carried out in schoolchildren and adoles-cents37–43. The present review clearly demonstratesthe lack of data on periodontitis among the adultArab population. These are important data for oralhealth planning, as has been suggested by the WHOreport on oral health for the 21st century44. Anothergeneral finding from the studies reviewed is that peri-odontitis is more prevalent among older age groups.Furthermore, studies on the reasons for tooth extrac-tions in the Arab countries show that more than one-third of missing permanent teeth have been extractedbecause of periodontitis; in those older than 40 years,more teeth have been lost to periodontitis than forany other reason45–47. These facts emphasise the needfor new epidemiological studies of the periodontalhealth of the adult Arab population.The prevalence of periodontitis in the reported stud-

ies ranged from 0.0% to 54.6%. Data from the Glo-bal Oral Health Data Bank reported prevalence ofwhat they defined as ‘shallow pockets’ (CPI 3) rangedfrom 0% to 53%, and ‘deep pockets’ (CPI 4) ranged

from 0% to 34%.These wide ranges may result froma lack of standardisation of data collection andreporting. It is important that a standard and well-accepted approach is used in conducting epidemiologi-cal research on periodontal diseases. Studies shouldinclude the measurement of clinical characteristicssuch as periodontal destruction (including PD, CALand radiographically determined bone loss, where pos-sible), and the measurement of inflammation (such asbleeding on probing). While some of these factors(such as CAL and bone loss) reflect past disease, mea-sures of PD and such as bleeding on probing areneeded (and used together) to assess the presence orabsence of current disease48. Some epidemiologicalstudies have reported the prevalence of periodontitisbased on measuring no more than PD, but a limita-tion of this is that a greater PD may result from‘pseudo-pockets’, and not necessarily be associatedwith attachment loss. Thus, measurement of probingpocket depth does not provide an accurate measure ofaccumulated periodontal tissue destruction, and it isof limited value for the assessment of the extent andseverity of periodontitis49. It is important, therefore,to combine reports of CAL, PD and bleeding on prob-ing in epidemiological studies. Full-mouth clinicalassessment of periodontitis is considered to be thegold standard in epidemiological studies50 of the con-dition. Susin et al.51 studied the effect of underestima-tion of specific partial recording protocols and foundthat partial recordings that use full-mouth measure-ments produce less bias. They concluded that the biasin the assessment of CAL is influenced by the partialrecording design and the type and number of sitesassessed, and by the severity of disease in the popula-tion under investigation. The effect of using differentcombinations on estimates of the prevalence of peri-odontitis is presented in Table 2, which shows that, incomparison with the gold standard, the approachleading to the greatest bias is the use of only some ofthe teeth and some of the sites. Furthermore, thereporting of data should be standardised, both withinand among countries, in order to develop packages oforal care suitable for the needs of the Arab popula-tion. However, periodontal research does not yet haveuniformly established epidemiological criteria fordefining a case, with the result that different case

Table 1 Summary of the epidemiological data on theprevalence of periodontitis in adults from the GlobalOral Health Data Bank representing the Arab coun-tries*

Percentage of peoplewith highest score of:

Age range Year Country

CPI 4(PD6+ mm)

CPI 3(PD

4–5 mm)

13 45 35–44 1987 Algeria0 0 33–49 2000/2001 Comoros16 40 35–44 1990 Egypt11 37 35–44 199? Iraq8 14 35–44 1994 Lebanon34 53 35–44 1982/1983 Libya16 49 31–40 1987 Morocco0 8 35–44 1988 Saudi Arabia12 9 35–44 1998 Syria

*CPI, Community Periodontal Index: PD, pocket depth. Dataaccessed from the electronic site of WHO Global Oral Health peri-odontal profile Data Bank (http://www.dent.niigata-u.ac.jp/prevent/perio/contents.html) on 09/09/2011.

Table 2 Effect of different combinations of teeth andsites on prevalence estimates of periodontal disease

Some sites All sites Teeth

Least underestimation*

Most underestimation

Gold standard

Moderateunderestimation

All (except thirdmolars)

Some

*Depends on sites used (the best partial site combination is mesio-buccal, buccal and disto-lingual).

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Periodontitis in the Arab World

definitions have been used in different studies52, limit-ing the comparability of the disease estimates. It is alsoimportant that the surveys be conducted on represen-tative samples rather than convenience samples.Detailed descriptions of sampling procedures, the deri-vation and use of any sampling weights, and calibra-tion of examiners are important in allowing aninformed analysis and critique of the survey findings53.Moreover, according to current understanding of

the pathogenesis of periodontitis, other factors thatmay play a role in the progression of periodontitisshould be reported because they may be important inthe occurrence of the condition. Some of these factorsinclude tobacco use54–56 and diabetes57,58.

RECOMMENDATIONS FOR FUTURE WORK

• There is an urgent need for surveys on the preva-lence, extent and severity of periodontal diseases(gingivitis and periodontitis) in the adult populationsof the Arab countries. This is an important prerequi-site to aid practitioners and policy makers to developclear dental care strategies specific for this group

• Standardisation of data collection and reportingwill allow comparability of data from the differentcountries

• The combined use of CAL, PD and bleeding onprobing is critical in order to accurately report onperiodontal status.

REFERENCES

1. Petersen PE, Bourgeois D, Ogawa H et al. The global burden oforal diseases and risks to oral health. Bull World Health Organ2005 83: 661–669.

2. Beck J, Garcia R, Heiss G et al. Periodontal disease and cardio-vascular disease. J Periodontol 1996 67: 1123–1137.

3. Loe H. Periodontal disease. The sixth complication of diabetesmellitus. Diabetes Care 1993 16: 329–334.

4. Albandar JM, Brunelle JA, Kingman A. Destructive periodontaldisease in adults 30 years of age and older in the United States,1988–1994. J Periodontol 1999 70: 13–29.

5. Sheiham A, Netuveli GS. Periodontal diseases in Europe. Peri-odontol 2000 2002 29: 104–121.

6. Corbet EF, Zee KY, Lo EC. Periodontal diseases in Asia andOceania. Periodontol 2000 2002 29: 122–152.

7. Beck JD, Koch GG, Rozier RG et al. Prevalence and risk indica-tors for periodontal attachment loss in a population of oldercommunity-dwelling blacks and whites. J Periodontol 1990 61:521–528.

8. Dawson CE. Dental defects and periodontal disease in Egypt,1946–1947. J Dent Res 1948 27: 512–523.

9. Global goals for oral health in the year 2000. Federation Den-taire Internationale. Int Dent J 1982 32: 74–77.

10. Hobdell M, Petersen PE, Clarkson J et al. Global goals for oralhealth 2020. Int Dent J 2003 53: 285–288.

11. Morgano SM, Doumit M, Al-Shammari KF et al. Burden oforal disease in the Middle East: opportunities for dental publichealth. Int Dent J 2010 60: 197–199.

12. Khader YS, Bawadi HA, Haroun TF et al. The associationbetween periodontal disease and obesity among adults in Jor-dan. J Clin Periodontol 2009 36: 18–24.

13. Ashril NY, Al-Sulamani A. The effect of different types ofsmoking habits on periodontal attachment. J Int Acad Period-ontol 2003 5: 41–46.

14. Natto S, Baljoon M, Bergstrom J. Tobacco smoking and peri-odontal health in a Saudi Arabian population. J Periodontol2005 76: 1919–1926.

15. Al-Zahrani MS, Kayal RA. Alveolar bone loss and reportedmedical status among a sample of patients at a Saudi dentalschool. Oral Health Prev Dent 2006 4: 113–118.

16. Bawadi HA, Khader YS, Haroun TF et al. The associationbetween periodontal disease, physical activity and healthy dietamong adults in Jordan. J Periodontal Res 2010 46: 74–81.

17. Ababneh KT, Al Shaar MB, Taani DQ. Depressive symptomsin relation to periodontal health in a Jordanian sample. Int JDent Hyg 2010 8: 16–21.

18. El-Sayed A. Relationship between overall and abdominal obes-ity and periodontal disease among young adults. East MediterrHealth J 2010 16: 429–433.

19. Al-Shammari KF, Al-Ansari JM, Moussa NM et al. Associationof periodontal disease severity with diabetes duration and dia-betic complications in patients with type 1 diabetes mellitus.J Int Acad Periodontol 2006 8: 109–114.

20. Mokeem SA, Molla GN, Al-Jewair TS. The prevalence andrelationship between periodontal disease and pre-term low birthweight infants at King Khalid University Hospital in Riyadh,Saudi Arabia. J Contemp Dent Pract 2004 5: 40–56.

21. Khader YS, Rice JC, Lefante JJ. Factors associated with peri-odontal diseases in a dental teaching clinic population in north-ern Jordan. J Periodontol 2003 74: 1610–1617.

22. Al-Khateeb TL, O’Mullane DM, Whelton H et al. Periodontaltreatment needs among Saudi Arabian adults and their relation-ship to the use of the Miswak. Community Dent Health 19918: 323–328.

23. Darout IA, Albandar JM, Skaug N. Periodontal status of adultSudanese habitual users of miswak chewing sticks or tooth-brushes. Acta Odontol Scand 2000 58: 25–30.

24. Haikel Y, Turlot JC, Cahen PM et al. Periodontal treatmentneeds in populations of high- and low-fluoride areas of Mor-occo. J Clin Periodontol 1989 16: 596–600.

25. Farsi JM. Dental visit patterns and periodontal treatment needsamong Saudi students. East Mediterr Health J 2010 16: 801–806.

26. Guile EE. Periodontal status of adults in central Saudi Arabia.Community Dent Oral Epidemiol 1992 20: 159–160.

27. Mengel R, Eigenbrodt M, Schunemann T et al. Periodontal sta-tus of a subject sample of Yemen. J Clin Periodontol 1996 23:437–443.

28. Khamrco TY. Assessment of periodontal disease using theCPITN index in a rural population in Ninevah, Iraq. East Med-iterr Health J 1999 5: 549–555.

29. Behbehani JM, Shah NM. Oral health in Kuwait before theGulf War. Med Princ Pract 2002 11(Suppl 1): 36–43.

30. Behbehani JM, Scheutz F. Oral health in Kuwait. Int Dent J2004 54: 401–408.

31. El-Qaderi SS, Quteish Ta’ani D. Assessment of periodontalknowledge and periodontal status of an adult population in Jor-dan. Int J Dent Hyg 2004 2: 132–136.

32. Taani DS. Oral health in Jordan. Int Dent J 2004 54: 395–400.

33. Farsi N, Al Amoudi N, Farsi J et al. Periodontal health and itsrelationship with salivary factors among different age groups ina Saudi population. Oral Health Prev Dent 2008 6: 147–154.

34. Beiruti N, Van Palenstein Helderman WH. Oral health in Syria.Int Dent J 2004 54: 383–388.

10 © 2013 FDI World Dental Federation

Al-Harthi et al.

35. Ainamo J, Barmes D, Beagrie G et al. Development of theWorld Health Organization (WHO) community periodontalindex of treatment needs (CPITN). Int Dent J 1982 32: 281–291.

36. Periodontal country profile [database on the Internet]2010.Available from: http://www.who.int/oral_health/databases/niigata/en/index.html. Accessed 09 September 2011.

37. El-Angbawi MF, Younes SA. Periodontal disease prevalenceand dental needs among school children in Saudi Arabia. Com-munity Dent Oral Epidemiol 1982 10: 98–99.

38. Hussein S, doumit M, Doughan B et al. Oral health in Leba-non: a pilot pathfinder survey. East Mediterr Health J 1996 2:299–303.

39. Al-Ismaily M, Al-Khussaiby A, Chestnutt IG et al. The oralhealth status of Omani 12-year-olds – a national survey. Com-munity Dent Oral Epidemiol 1996 24: 362–363.

40. Abid A. Oral health in Tunisia. Int Dent J 2004 54: 389–394.

41. El-Nadeef MA, Al Hussani E, Hassab H et al. National surveyof the oral health of 12- and 15-year-old school children in theUnited Arab Emirates. East Mediterr Health J 2009 15: 993–1004.

42. Elamin AM, Skaug N, Ali RW et al. Ethnic disparities in theprevalence of periodontitis among high school students inSudan. J Periodontol 2010 81: 891–896.

43. Fanas SH, Omer SM, Jaber M et al. The periodontal treatmentneeds of Libyan school children in Kufra and Tobruk. J IntAcad Periodontol 2008 10: 45–49.

44. Organization WH. Oral health for the 21st century. Geneva:WHO/ORH/Oral C21.94; 1994.

45. Haddad I, Haddadin K, Jebrin S et al. Reasons for extractionof permanent teeth in Jordan. Int Dent J 1999 49: 343–346.

46. Hassan AK. Reasons for tooth extraction among patients inSebha, Libyan Arab Jamahiriya: a pilot study. East MediterrHealth J 2000 6: 176–178.

47. Al-Shammari KF, Al-Ansari JM, Al-Melh MA et al. Reasonsfor tooth extraction in Kuwait. Med Princ Pract 2006 15: 417–422.

48. Tonetti MS, Claffey N. Advances in the progression of peri-odontitis and proposal of definitions of a periodontitis case anddisease progression for use in risk factor research Group C con-sensus report of the 5th European Workshop in Periodontology.J Clin Periodontol 2005 32(Suppl 6): 210–213.

49. Albandar JM, Rams TE. Global epidemiology of periodontaldiseases: an overview. Periodontol 2000 2002 29: 7–10.

50. Papapanou PN. Periodontal diseases: epidemiology. Ann Peri-odontol 1996 1: 1–36.

51. Susin C, Kingman A, Albandar JM. Effect of partial recordingprotocols on estimates of prevalence of periodontal disease.J Periodontol 2005 76: 262–267.

52. Preshaw PM. Definitions of periodontal disease in research.J Clin Periodontol 2009 36: 1–2.

53. Kingman A, Albandar JM. Methodological aspects of epidemio-logical studies of periodontal diseases. Periodontol 2000 200229: 11–30.

54. Haber J. Smoking is a major risk factor for periodontitis. CurrOpin Periodontol 1994: 12–18.

55. Grossi SG, Zambon JJ, Ho AW et al. Assessment of riskfor periodontal disease I. Risk indicators for attachment loss.J Periodontol 1994 65: 260–267.

56. Schatzle M, Faddy MJ, Cullinan MP et al. The clinical courseof chronic periodontitis: V Predictive factors in periodontal dis-ease. J Clin Periodontol 2009 36: 365–371.

57. Cianciola LJ, Park BH, Bruck E et al. Prevalence of periodontaldisease in insulin-dependent diabetes mellitus (juvenile diabe-tes). J Am Dent Assoc 1982 104: 653–660.

58. Grossi SG, Skrepcinski FB, DeCaro T et al. Response to peri-odontal therapy in diabetics and smokers. J Periodontol 199667: 1094–1102.

Correspondence to:W. Murray Thomson,

Professor of Dental Epidemiology and Public Health,Editor, New Zealand Dental Journal,

Head, WHO Collaborating Centre for DentalEpidemiology & Public Health,Department of Oral Sciences,

Sir John Walsh Research Institute,School of Dentistry, the University of Otago,

PO Box 647, Dunedin, New Zealand.Email: murray.thomson@otago.ac.nz

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Periodontitis in the Arab World