Periodontology 2000, Vol.

29, 2002, 104121 Copyright C Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Periodontal diseases in Europe
Auunrv Snrinnr & GonInxnisnNnN S. Nr1uvrIi
No discipline advances smoothly and seamlessly,
and epidemiology is no exception to that rule. Dav-
ey Smith and Ibrahim (37) remind us that An issue
of increasing salience is the degree to which epi-
demiology contributes to understanding how the
world is (and contributes to ameliorating the nega-
tive features revealed) or is a bag of increasingly
complex tools for carrying out isolated studies of
particular diseases in particular populations.
Whether epidemiology will be progressive or a de-
caying scientic programme in the 21st century
will depend on how it deals with a series of key
challenges it faces. These statements are directly
relevant to dental epidemiology in general and
periodontal epidemiology in particular. The current
concern of periodontal epidemiology with
methods rather than health is worrying. Perhaps
we should heed the words of one of the leading
epidmiologists, Stallones (118), who considered
that there was a continuing concern for methods,
and especially the dissection of risk assessment,
that would do credit to a Talmudic scholar and
that threatens at times to bury what is good and
beautiful in epidemiology under an avalanche of
mathematical trivia and neologisms.
Epidemiology should lead to advances in under-
standing the determinants of disease in individuals
and populations and contribute to their alleviation
(37). In that context, the elegant concepts of Rose
(103) are of particular relevance. Rose pointed out
that the determinants of the distribution of chronic
disease within populations could be different to
the determinants of the variation in disease rates
between populations. Another important concept
which Rose promulgated, that applies to peri-
odontal disease as it does to other chronic dis-
eases, is that as the mean disease score for the
population decreases, there is a shift to the left in
the distribution of the disease and a reduction of
the proportion with high levels of disease. The rel-
evance of that concept to periodontal disease epi-
104
demiology is related to the considerable discussion
about the high risk group. If Rose is correct, then
that group should decrease as periodontal health
improves, as it has been in Europe (103).
This review will pay heed to the concerns of Davey
Smith and Ibrahim, Stallones and Rose. The main
focus will be on the distribution of different levels of
periodontal disease in Europe and on their public
health implications. The latter will rationally involve
a discussion on goals for periodontal health.
Accepted concepts by periodontal
epidemiologists
Periodontal epidemiologists in Europe have been
enlightened and informed by a number of import-
ant developments in scientic research in the way
that periodontal diseases progress, the extent of
periodontal diseases in European populations, the
determinants of periodontal disease and, to a lesser
extent, the assessment of periodontal needs. They
concur that progress of most periodontal disease is
very slow, if it progresses at all and that moderate
periodontal attachment loss is widespread but se-
vere forms of periodontal destruction are very un-
common (23, 70, 90, 92). Papapanou (94), in an
extensive review of the epidemiology of periodontal
disease for the 1996, World Workshop in Periodon-
tology (9), despite presenting evidence that there
is a signicant underestimation of the extent of
periodontal disease by certain indices, concluded
that ...it appears that severe forms of periodontal
disease affect a minority of subjects in developed
countries, probably not more than 10% of the
population. and ... the progression pattern of the
disease seems compatible with the retention of a
functional dentition throughout life (94) and there-
fore loss of teeth from destructive periodontal dis-
ease in old age is not inevitable... (31).
Periodontal diseases in Europe
Studies in the USA and Europe support Papapan-
ous conclusions. Burt et al. (31) analyzed data from
20,449 persons in the USA national NHANES I survey
and found that where good oral hygiene is main-
tained, age did not appear to be an important vari-
able in periodontal disease status. Similarly, Papa-
panou et al. (92) reported that although gingivitis
and probing depth increased with age, in the best
periodontal group, alveolar bone loss did not pro-
gress with age. Findings from a large population
based study of older Swedes, where periodontal con-
ditions were radiographically and clinically assessed
in the elderly, found that their condition were most-
ly good or fairly good (88). The studies showed that
advanced periodontal disease, even in European
people over 70years of age, does not affect many
teeth per person. Unsurprisingly, the conclusions
concur with those from North America (7, 78) and
Africa (19). Older groups have worse periodontal sta-
tus, but the preponderance of current evidence indi-
cates that the relationship between age and peri-
odontal disease is age associated rather than being
a consequence of aging (23).
There is general agreement that some loss of peri-
odontal attachment is acceptable, and tooth loss due
to periodontal disease is uncommon. Although shal-
low pockets may be relatively common, deep
pockets are uncommon. Most deep pockets are in
people over 65years and even if they live until 90
years, they are considered to have sufcient peri-
odontal support for the rest of their life (125, 114).
As severe rapidly progressing periodontal disease oc-
curs in a very small minority of people (125), the de-
tection of the high-risk group is a research problem
and screening is unjustied.
Papapanou (94), in a series of clinical and radio-
graphic longitudinal studies, showed that rates of al-
veolar bone loss were very slow in the majority of
adults, thereby conrming what was already known
from cross sectional studies. The corollary from low
prevalence in severe periodontal disease is that tooth
loss from the disease is not great. Indeed, the com-
mon statement that periodontal disease is the major
cause of tooth loss after the age of 35 has been refuted
(4, 22, 32, 34, 35, 59, 84, 102, 106). Because gingival in-
ammation and shallow pockets with little alveolar
bone loss are relatively common and account for over
80% of periodontal treatment, and gingival inam-
mation and shallow pockets are not considered to be
critical for the maintenance of periodontal health for
a lifetime, there has been considerable debate about
acceptable levels of periodontal health and goals. Pi-
lot (95) suggested that in order to dene objectives in
105
plaque control and realistic targets in periodontal
health care the following goals could be used: (a) a
level of plaque in quantity and quality that is compat-
ible with contained gingivitis, that is gingivitis that
does not progress into destructive periodontitis; (b) a
level of plaque which leads to a rate of progress of
periodontal disease which will not lead to unaccept-
able gingival recession; (c) a level of plaque which
leads to a rate of progress of periodontal destruction
which is compatible with keeping the natural func-
tioning dentition for the life time of the individual.
The last target was the most important and was later
elaborated upon by Wennstrm et al. (125), who de-
veloped a systematic model based on their epidemio-
logical studies. Their concepts were given ofcial ap-
proval when all the chief dental ofcers of Northern
Europe adopted, as a goal for oral health, The reten-
tion throughout life of a functional, aesthetic, natural
dentition of not less than 20 teeth (shortened dental
arch) and not requiring recourse to a prosthesis
which is in line with broader concepts of health,
which do not make reference to absence of disease as
a criterion for health. We suggest that a reasonable
goal for periodontal disease control is to achieve a
level of plaque which is compatible with a rate of peri-
odontal destruction which will retain teeth essential
for a socially and personally acceptable dentition for
a lifetime and does not cause handicaps.
Advances in periodontal
epidemiology in Europe
Progression of periodontal disease
The work of the Boston group (116) on concepts of
progression of periodontal diseases has iconic status
in periodontal epidemiology. The burst theories have
been challenged but not refuted by Albandar (5) &
Sterne et al. (119, 120). The new concepts of peri-
odontal diseases require a radical change in ideas on
diagnosis and screening. The difculties in dening
periodontal health, the erratic nature of destructive
disease, and the poor sensitivity and specicity of
methods of predicting destructive disease suggest
that screening for periodontal disease is of question-
able value. This, and the fact that the Expert Com-
mittee of the WHO recognised that most gingival in-
ammation does not progress to periodontal disease
(127) and accepted the concept of contained gingi-
vitis in 1978. Indeed the use of the term gingivitis
for any inamed gingival is misleading and inaccur-
ate as anyone with one inamed papilla was con-
Sheiham & Netuveli
sidered a case in epidemiology and a patient in a
clinical setting. It is equivalent to calling a pimple,
pimpilitis and therefore skin disease. In 1996, the
Consensus Report on Periodontal Diseases: Epi-
demiology and Diagnosis of the World Workshop in
Periodontology (9) also concluded that in general,
the presence of gingival inammation, deep probing
depth, and alveolar bone loss have low positive pre-
dictive value for the progression of periodontitis.
The presence of bleeding on mechanical stimula-
tion is neither a good indicator of disease severity
nor a good predictor for the progression of peri-
odontitis (9).
One of the reasons for the low positive predictive
value of signs of gingival inammation for pro-
gression to periodontitis is because of the small num-
ber of gingival inammation sites that do convert to
periodontitis. In a 3-year longitudinal study, the inci-
dence of conversion of gingivitis to periodontitis was
so low that the number did not differ from that ex-
pected from measurement error (69, 70). The answer
to the question Does gingivitis always progress to
periodontitis is Clearly, not all gingivitis progresses
to periodontitis; ... (28): a concept supported as far
back as 1982 by Page & Schroeder (87). A perspective
on the levels of conversion of gingival inammation
to attachment loss is gained by the results of a 17-year
epidemiologic study. In the study, less than 1mm
attachment loss occurred in 66% of periodontal sites
present at both a baseline and a follow-up examina-
tion, although gingival inammation was widespread
in the dentitions. There was loss of attachment at
some sites, but the majority of sites were inamed
without measurable loss of attachment (57). Gingival
inammation is a necessary, but not exclusive, pre-
requisite for periodontitis. Even gingival bleeding on
probing, which is strongly associated with gingival in-
ammation, has a weak low positive predictive value
(30%) in predicting progression to periodontitis (63).
So, what we call periodontal disease is contentious.
Measurement of periodontal pockets (94), especially
those less than 5mm, is variable and if we add this to
the questionable naming of gingivitis as disease, this
should lead to further assessment of whether genuine
periodontal disease is as common as reported in Eur-
ope and North America, and whether periodontal dis-
ease is a public health problem at all. What is clear is
that advanced periodontal disease, where diagnosis
in unequivocal, occurs in a very small proportion of
adults. Therefore more attention should be addressed
to rates of progression of alveolar bone loss and
whether these rates are compatible with retaining
teeth for life.
106
Periodontologists in Europe have been at the fore-
front of epidemiological research on assessing the
rates of progression of alveolar bone loss and ques-
tioning the conversion of gingival inammation to
periodontitis (for reviewsee 115). They challengedthe
notion of averaging data, and as Papapanou (90)
stated ... prevalence data presented as average fre-
quencies of subjects affected by periodontal disease
were supplemented by an analysis revealing the ex-
tent, i.e. the number of affected units (teeth or tooth
sites), and the severity, i.e. the magnitude of lost peri-
odontal tissue support, within each examined indi-
vidual. A number of researchers have shown that al-
though older people are more likely to have less peri-
odontal support, advanced periodontal disease
affects a relatively small proportion of the population
(6, 13, 14, 49, 64, 90). In summarizing the studies on
progressioninEurope and elsewhere, Papapanou(90)
concluded that: (i) the progression of destructive
periodontitis is subject-related, (ii) comparatively few
individuals in the population show advanced peri-
odontal breakdown, and (iii) in the absence of treat-
ment, inammatory periodontal lesions will not
necessarily progress, i.e. showfurther loss of support-
ing periodontal tissue. Papapanous (90) main nd-
ings are typical for studies on the extent and pro-
gression of alveolar bone and periodontal attachment
loss (5, 24, 25, 30, 49, 72, 73). Albandar (5) showed that
90% of periodontal alveolar bone sites monitored
radiographically did not change over a 6-year period.
Although the level of alveolar bone decreases with
age, within each age group only a small proportion of
individuals and teeth are affected by alveolar bone
loss of 6mm or more. Whereas the majority of people
and tooth sites experience alveolar bone loss as they
age, the rate of loss is slow. The mean annual alveolar
bone loss in adults varied between 0.07 and 0.14mm/
year in persons aged 2565years; older subjects had
rates of 0.28mm/year (90) and advanced additional
bone loss affected only few subjects and tooth sites.
The rate of alveolar bone loss is so slowthat, consider-
ing the reliability of radiographic measurements,
Benn (25) calculated that it would take from 7 and 13
years to accurately detect 1mm of bone loss using
conventional radiography.
Assessment of the prevalence of
periodontal disease in Europe
Susceptibility to advanced periodontal disease is not
universal; there is a moderate prevalence of destruc-
Periodontal diseases in Europe
tive periodontal diseases (13, 28, 43, 47, 50, 51, 78,
113) and, most importantly, the worldwide preva-
lence of severe periodontal disease is very low (7,
15, 43, 97). What is more, as stated earlier, rates of
progression of periodontal destruction are very slow.
There is consensus that severe periodontal disease
occurs in a few teeth in a relatively small proportion
of people in any given age cohort, and the pro-
portion affected increases with age. Contrary to the
view that destructive periodontal was widespread in
Europe and that everyone was susceptible to ad-
vanced destructive periodontal disease, current epi-
demiological evidence indicates that mild gingival
inammation is common and many adults have
mild to moderate loss of periodontal attachment at
some sites of some teeth (28, 41, 43, 106, 113, 115).
Longitudinal studies in adults indicate that a rela-
tively small proportion of periodontal sites, or people,
experienced signicant loss of attachment over
periods ranging from6months to18years. Ismail et al.
(57) reported that 60% of periodontal sites had
changed by about 1mm, and 1.2%by more than 3mm
over 18years; 1.2% of Tecumseh, USA, subjects had
pocket depths that increased by more than3mmin18
years. Papapanou et al. (91) and Albandar (5) reported
that about 1.6% to 7% of subjects had lost more than
3mm of alveolar bone over 210-year periods. The
rates of site-specic attachment level change de-
pended on the threshold used for assessing change.
The information on prevalence and severity of peri-
odontal disease was summed up by Burt (32) and ap-
plies to Europe. Burt said that only a small proportion
of persons exhibit severe widespread periodontitis.
Mild gingivitis is common and most adults demon-
strate some loss of bony support and loss of probing
attachment and periodontitis is not the major cause
of tooth loss in adults. Those, and later conclusions
are based on studies such as those by Schaub (106) in
the Netherlands, Lembariti et al. (66) in Tanzania, and
Miller et al. (78), Brown et al. (29), Albandar et al. (7,
8) in the USA. Miller et al. (78), Brown et al. (29) and
Albandar et al. (7) reported relatively low prevalence
of severe destructive periodontitis among random
selections of a large sample of United States adults.
Brown et al. (29) found only 15% of the total adult
population had neither gingivitis nor periodontitis;
gingivitis without periodontitis occurred in 50%, peri-
odontitis (4mm or deeper) in 33% and advanced and
end-stage periodontal destruction in 8% and 4%, re-
spectively. Those gures suggest that periodontal dis-
eases are common. Yet, two thirds of the adult USA
population did not have any teeth with moderate
periodontitis of 46mm pockets, and approximately
107
25%had two or more teeth with pockets of that depth.
Similarly, in a later nationwide USA study, Albandar et
al. (7) reported that 65% of adults 3090years of age
had no periodontitis, although a high percentage had
gingival bleeding (8) or periodontal attachment loss,
much of which was below 4mm. In 90 percent of the
total teeth with attachment loss, the loss was below 4
mm. Attachment loss of 5mm or more occurred in
5.9%. Only 3.1% of persons had advanced peri-
odontitis, denedas two or more teethhaving 5mm
probing depth or four or more teeth having 4mm
probing depth or one or more posterior teeth with
grade II furcation involvement. The age group with
the highest percentage with advanced periodontitis
(6%) was the 7074years olds. On the other hand, Fox
et al. (40) found a high prevalence of severe attach-
ment loss in USA people aged 70 and over. They re-
ported a prevalence of gingival bleeding of 85% and
attachment loss 6mm to be 56%. Yet, in those with
severe attachment loss of 6mm, only 2.7 teeth per
person were affected. The number of teeth affected
did not increase in those aged 95years or elder.
In Europe, whilst loss of bony support and loss of
probing attachment is relatively common, low levels
of advanced periodontal disease are reported in most
of the representative populations studied (53, 82, 88,
111). Baerum et al. (21) reported that approximately
13% of Norwegians aged 4554years had one or more
pockets 6mm. Sheiham et al. (111) found that
whereas gingival bleeding occurred in the majority of
a sample of British adults, pocketing of 5mm or more
was uncommon and affected only a fewteeth per per-
son. In a national study of United Kingdom adults,
Morris et al. (82) reported that pockets greater than
5.5mmwere uncommon (5%) in the total adult popu-
lationstudiedwhichincludedolder adults. The preva-
lence in the 3544years olds was 5% and thereafter it
increased to 17%in 5564years olds and 15%in those
65 and over. In those aged 65 and over, only 4% had
pockets 8.5mm. The prevalence of teeth, as distinct
frommouths, withpocketing greater than3.5mmwas
low; only 12% of all teeth had pockets in the UK
sample. In Sweden, severe periodontal disease was
also uncommon (49, 53). Soder et al. (117) found that
82% of the Swedish 3140-year-old subjects had no
pockets with probing depth of 5mm. Only 6.7%had
25 teeth with probing depth of 5mm, and 5.6%, 6
or more teeth with deep pockets. In Denmark, Kierke-
gaard et al. (61) reported that 5% of a representative
adult sample aged 50 and over, had severe peri-
odontitis. Similarly in Switzerland, the prevalence of
deep pockets was low, 23%, while 25%of all ages had
moderate periodontal disease (107). These ndings
Sheiham & Netuveli
were repeated in France where Bourgeois et al. (26)
found low levels of periodontal disease in 3544years
olds. Gingivitis was common (80%) while deep
pockets (6mm) were rare (1.6%), affecting on aver-
age 0.1 sextants per subject, a level of disease that was
lower than levels reported by Miller et al. (78), who
found that 10% of adults had severe periodontal dis-
ease but also found that 58% had no loss of attach-
ment 3mm. Ahlberg et al. (3) reported that pockets
6mmwere foundinbetween5%and11%of Finnish
workers aged 3865years. Those results are similar to
levels reported in Italy where 10% had deep pockets
(122). Diamanti-Kipioti et al. (38), using radiographic
assessments to evaluate the pattern of destructive
periodontal disease in a rural and an urban sample of
2564years old Greek adults, reported that alveolar
bone loss was ubiquitous. Bone loss of 6mm
affected 18% the rural and 8% of the urban sample.
Twenty-ve percent of the subjects inthe rural sample
and 12% in the urban sample accounted for 75% of
the total number of tooth sites with bone loss of 6
mm. On clinical examination, deep pocketing of 6
mmwas detectedinbetween1.7%and8.0%of all sites
probed, and between 20% and 51% of the subjects in
each age cohort had at least one deep pocket. The
prevalence was lower in the urban sample; 0.64.7%
and 1549%, respectively (10). In elderly English
adults, Steele et al. (121) reported that moderate peri-
odontal disease was widespread. Higher prevalence
gures for pocketing of 6mm were reported in Ger-
many. Micheelis and Bauch (78) reported that 42% of
adults aged 3544years had a CPITN 3 (pockets 45
mm) and 16% a CPITN of 4 (pockets deeper than 6
mm). The percentage with CPITN 4 in adults aged
4554years was 22%.
Distribution of periodontal disease in
European populations
As shown above, the prevalence of advanced peri-
odontal disease in European adults is low. As numer-
ous studies have been carried using CPITN and the
WHO Oral Health Database can be readily analyzed
and may give an idea of variations of periodontal con-
ditions inEurope, a re-analysis of the WHOdata using
the WHO database was carried out to assess the
prevalence of gingival bleeding, shallow and deep
pockets in Europe. The CPITN classication system
for assessing periodontal needs was developed by
WHO and then widely recommended in the WHO
Oral Health Basic Surveys Methods manual. The
CPITN was not designed as a measure of disease and
it is not surprising that it does not measure the extent
108
of periodontal disease accurately. Its use has been
criticized (94). Using the WHO database, Miyazaki et
al. (80) reported that pocketing of 6mmwas very in-
frequent in adolescents. In Europe, only 2 of the 35
studies reporting scores of 4 CPITN. What is more,
when any pockets were present, they only affected a
small minority andinless thantwo sextants. Inadults,
in 38 surveys, the percentage of subjects with pockets
6mm ranged from 2 to 40% (81).
There are a number of problems in adding up
prevalence data from different studies in the WHO
database and nding an average by dividing the total
thus obtained by the number of studies. Different
studies have different base numbers, and the differ-
ences between studies conducted in different coun-
tries, and in the same country at different times, and
by different people will be considerable. A routine
method for resolving these problems does not exist.
A new approach was therefore used to circumvent
the problems. The analysis used the proportion of
subjects classied as positive for a CPITN code, and
their base numbers. With this information it was
possible to calculate the standard error of the pro-
portion as Sqrt (p(1-p)/n), where p was the pro-
portion and n was the number of subjects. However,
when p was small (0.3), this formula did not yield
the correct standard error and so the procedure
given by Agresti and Coull (2) was used. The 95%
condence levels for the proportion were calculated
in the usual manner. Pooling of the proportions
weighted by their variation was achieved by trans-
forming the proportion and the lower and upper
condence levels to ratio scales as p/(1-p). These ra-
tios and condence levels (obtained by transform-
ation) were pooled using the statistical package,
STATA. Pooled proportions and their condence
levels were obtained from results of the meta-analy-
sis by back transformation. Considerable heteroge-
neity existed between studies within and between
countries, and therefore, caution should be exercised
when interpreting these results.
Using this approach, the proportion of European
3544years olds with shallow periodontal pockets
(3.55.5mm) ranged from 13% to 54%. The mean for
East Europe was 45% and for West Europe was 36%.
These percentages were similar for Non-European
rich economies but higher than the 10 poorest coun-
tries in the data base (Table1). The proportion of
adults with deep periodontal pockets (5.5mm) was
below 10% in many West European countries but
some East European countries had between 30 and
40% affected (Table2). The number of sextants per
person affected with deep pockets was very low; 0.1
Periodontal diseases in Europe
0.8. In most West European countries, deep pockets
were foundinbetween0.1 and0.2 sextants per person
(Table3), a nding supporting the more detailed epi-
demiological studies discussed earlier.
Trends in periodontal diseases in Europe
There has been an improvement in periodontal
health in a number of European countries. Sheiham
Table1. The proportion of 3544year-old subjects with shallow periodontal pockets CPITN score 3
Country No of studies Period Mean LCL UCL
Finland 1 1982/83 29 24 35
France 5 1985/89 23 13 38
Germany 10 1985/92 45 35 54
Greece 2 1985/88 25 22 29
Ireland 1 1989/90 13 10 17
Italy 2 1983/85 41 31 52
Malta 1 1986 17 13 22
Netherlands 3 1981/86 53 44 62
Norway 1 1983 57 53 60
Portugal 1 1984 38 34 42
San Marino 1 1987 26 18 37
Spain 1 1985 21 8 43
Turkey 1 1987 29 25 33
United Kingdom 2 1985/88 54 38 70
Belarus 1 1986 45 40 50
Estonia 1 1987 53 48 58
Hungary 2 1985/91 21 13 32
Kyrgystan 1 1987 46 41 51
Poland 3 1986/90 32 18 51
Russian Federation 1 1991 54 43 64
Slovenia 2 1987 16 2 63
Tajikistan 1 1987 50 45 55
Turkmenistan 1 1987 39 34 44
Yugoslavia 2 1986/87 47 44 49
East Europe 45 41 49
West Europe 36 32 40
Europe 37 31 42
Non-European Rich economies 37 33 42
Table 10 poorest countries in the data 28 18 40
base
LCL, UCL: Lower and upper condence limits
NonEuropean rich economies were USA, Japan, Australia, New Zealand and Hong Kong
The 10 poorest countries were: Tanzania, Sierra Leone, Malawi, Bangladesh, Niger, Kenya, Nigeria, Burkina Faso, India
and Laos
109
et al. (111) reported a marked improvement in peri-
odontal health of English factory workers examined
twice by the same examiner 14years apart using the
same index and allowing for extracted teeth. Hans-
en et al. (47) showed that there was a marked re-
duction in the need for periodontal treatment in
Norwegians aged 35years and older between 1973
and 1984. Hugoson et al. (1, 2) assessed changes in
periodontal health in a broad cross section of Swed-
Sheiham & Netuveli
ish cohorts for 20years by means of 3 cross-sec-
tional investigations performed in 1973, 1983, and
1993. A clear reduction in the plaque score was
seen between 1973 and 1983 in all age groups. Gin-
givitis values corresponded well with the values of
dental plaque, by exhibiting the same pattern, with
a clear reduction in gingivitis scores. Both the pro-
portions and the cumulative proportions are
Table2. The proportion of 3544years-old subjects with deep periodontal pockets CPITN score 4
Country No Period Mean LCL UCL
of studies
Finland 1 1982/83 7 4 9
France 4 1985/89 16 10 24
Germany 9 1985/92 13 8 19
Greece 2 1985/88 12 6 20
Ireland 1 1989/90 2 1 4
Italy 2 1983/85 14 10 18
Malta 1 1986 3 1 5
Netherlands 3 1981/86 11 7 2
Norway 1 1983 8 6 10
Portugal 1 1984 8 6 10
San Marino 1 1987 9 3 15
Spain 1 1985 18 16 21
Turkey 1 1987 6 4 8
United Kingdom 2 1985/88 13 11 16
Belarus 1 1986 31 26 36
Estonia 1 1987 13 10 17
Hungary 2 1985/91 4 1 15
Kyrgystan 1 1987 31 27 35
Poland 3 1986/90 16 7 34
Russian Federation 1 1991 30 20 39
Slovenia 2 1987 21 18 24
Tajikistan 1 1987 30 25 35
Turkmenistan 1 1987 40 35 45
Yugoslavia 2 1986/87 15 13 17
East Europe 23 17 30
West Europe 9 7 12
Europe 14 11 17
Non-European rich economies 12 9 16
10 poorest countries in the data base 20 10 36
LCL, UCL: Lower and upper condence limits
NonEuropean rich economies were USA, Japan, Australia, New Zealand and Hong Kong
The 10 poorest countries were Tanzania, Sierra Leone, Malawi, Bangladesh, Niger, Kenya, Nigeria, Burkina Faso, India,
and Laos
110
needed to interpret Hugosons data. The pro-
portions show that in 1993 more subjects over the
age of 50years had alveolar bone loss (Fig. 1). In the
cumulative proportion curves this is shown as con-
vergence of the 1993 curve with 1983. However, the
overall burden of periodontal disease was less in
1993 than 1983. The increase in periodontal disease
in the elderly could be ascribed, rightly as Hugoson
Periodontal diseases in Europe
Table3. Mean number of sextants per person with shallow and deep pockets (CPITN 3 and 4); 3544-year-old
subjects
Country Year Number Shallow pockets Deep pockets
Finland 1982/83 299 0.7 0.1
France 1989 88 0.4 0.1
Germany 1992 364 1.9 0.5
Greece 1988 106 0.5 0.1
Ireland 1989/90 395 0.2 0.0
Italy 1985 21352 1.1 0.2
Netherlands 1983 180 1.5 0.2
Portugal 1984 616 0.8 0.1
Spain 1989 477 0.3 0.0
Turkey 1987 494 0.8 0.1
United Kingdom 1988 603 2.1 0.2
Belarus 1986 327 1.8 0.7
Estonia 1987 434 1.2 0.2
Hungary 1991 824 0.3 0.0
Kyrgyzstan 1987 449 1.6 0.5
Poland 1990 664 0.4 0.1
Russian Fed. 1991 85 2.4 0.6
Slovenia 1987 406 1.1 0.3
Tajikistan 1987 356 1.7 0.6
Turkmenistan 1987 377 1.2 0.8
et al. (49) noted, to greater retention of teeth and
the tendency to treat teeth with alveolar bone loss
more conservatively than in the past. Hugoson et al.
(49) considered that the higher fees for reparative
care could lead dentists to de-emphasize preventive
services and to treat severely affected teeth which
would have been extracted in the past. Dentists re-
Fig. 1. Trends in periodontal disease
in Jonkoping between 1983 and 1993
(53).
111
dened the diagnostic thresholds and thereby
allowed retention of more periodontally compro-
mised teeth in older people.
Further evidence of an improvement in peri-
odontal health in Europeans comes from a compre-
hensive series of successive cross-sectional oral
health surveys of Finnish recruits, carried out in
Sheiham & Netuveli
1976, 1981, 1986, and 1991. The study clearly showed
that there has been a signicant decrease in treat-
ment needs, self-reported gingival bleeding, and
teeth with 4mm periodontal pockets among young
men since 1976 (3). On the other hand, a study in
elderly Swedish showed that although the Bleeding
Index was the same in the two cohorts, the fre-
quency of surfaces with attachment level 3mm
had increased signicantly from 1981 to 1990 in the
older cohort (4). That may be due to the marked re-
duction in edentulousness, by 10% in males and 18%
in females, and the retention of more teeth in more
people (4).
The causes of periodontal disease
Periodontal disease is a social disease; it is a dirt
disease determined by social factors. Periodontal
diseases are more prevalent among the less econ-
omically and educationally privileged groups in the
social hierarchy (5). It is universally found that sex,
socio-economic and educational status, age and
marital quality (6) determine periodontal status. The
relationship between plaque and periodontal dis-
ease has stood the test of time (127). The etiology
of chronic inammatory periodontal diseases can be
considered in terms of the microorganisms involved,
the local environmental factors other than bacteria,
and the role played by the host defence systems.
There is extensive evidence to suggest that the direct
cause of gingivitis and periodontitis is the accumu-
lation of microbial plaque on the cervical region of
the teeth and its extension apically along the root
surface (7).
The association between calculus and periodontal
disease has led to the erroneous conclusion that cal-
culus is a direct cause of the disease. The conclusion
was supported by observations that there was a clin-
ical improvement after calculus removal. There is no
scientic evidence that calculus directly causes the
initiation of gingivitis or periodontitis, ... (8). Calcu-
lus is inert (70) and acts as a retentive factor for
plaque. Other local factors, such as defective dental
restorations and prosthetic appliances and diet are
the main factors affecting the accumulation of
plaque. Tobacco smoking is one of the main risk fac-
tors for periodontal disease (9, 10, 94).
Because of the importance of plaque in the etiol-
ogy of periodontal disease, considerable attention
has focussed on toothbrushing habits. Epidemio-
logical studies suggest that, contrary to unsubstan-
tiated statements that oral hygiene habits are not
good, levels of oral cleanliness and plaque control
112
achieved by the majority of populations in industri-
alized countries are adequate and levels of plaque
are lower than the threshold for severe destructive
periodontal disease that would be of personal and
public health concern.
An important factor that affects toothcleaning be-
havior is the control people have over their working
lives. People who have a less routinized and more
exible day, have higher tooth cleaning frequencies
than those who have a less exible and more routin-
ized lives. People who have a more exible day
cleaned their teeth more effectively than those who
have a less exible day and had less bleeding on
periodontal probing (12).
Public health approaches to promoting
periodontal health
Approaches to preventing and controlling peri-
odontal disease have changed markedly. Systematic
reviews of the effectiveness and efciency of indi-
vidualized dental health education to changing oral
hygiene behavior have been relatively ineffective in
making sustained changes in toothbrushing habits.
The reason for the unacceptably high failure rates in
changing behavior is the failure to recognize the so-
cial contextual factors that are related to health be-
havior in general.
There are other reasons for the lack of success in
promoting periodontal health:
O models of the life history of periodontal disease
that have been outlined since the 1970s suggest
that most periodontal inammation does not pro-
gress to severe destructive periodontal disease.
Therefore concepts of risk and susceptibility need
revising.
O changes in concepts of what is potentially import-
ant periodontal pathology have led to a re-evalu-
ation of the importance of periodontal disease as
a dental public health problem.
O lay views of the relative unimportance of peri-
odontal disease have been substantiated. Gingival
inammation seldom causes discomfort, social
embarrassment or loss of function. Instead of ex-
pecting people to know that they have periodontal
disease, dentists need to review their ideas and
place more emphasis on the social aspects of peri-
odontal inammation such as oral malodour, gin-
gival recession and bleeding and redness.
The two main changes in knowledge about peri-
odontal disease, are:
Periodontal diseases in Europe
O a small proportion of persons exhibit severe wide-
spread periodontitis. Mild gingivitis is common
and most adults demonstrate some loss of bony
support and loss of probing attachment.
O there is consensus that severe periodontal disease
occurs in a few teeth in a relatively small pro-
portion of people in any given age cohort, and the
proportion affected increases with age.
O periodontitis is not the major cause of tooth loss
in adults.
O the severity and rate of loss of periodontal support
does not lead to signicant psychological and so-
cial impact related to gingival recession and mo-
bility or to signicant tooth loss.
Assessment of those at risk of severe
periodontal disease
An important part of planning dental care systems
is diagnosing those with active disease and detecting
cases that are likely to develop disease in the future.
The prime objective of screening is to detect disease
at an earlier stage than would normally occur when
people present with the illness, on the assumption
that earlier treatment would alter the natural history
of the disease in a signicant proportion of cases
(13). Despite encouraging developments in the
bacteriology and immunological aspects of peri-
odontal diseases, there are still major gaps in knowl-
edge that need to be addressed before screening can
be recommended (14). There is not sufcient evi-
dence on prognostic indicators of severe periodontal
disease in the very small minority of people who de-
velop rapidly progressing periodontal disease, nor is
there for predicting future destructive periodontal
disease. Research is progressing to develop indi-
cators. At present, biotechnology cannot be used in
the practice setting for prognostic indicators. There-
fore, population screening for potential periodontal
destruction is not justied (13).
The public health approaches
Health Education
Dental health education is considered to be the most
important method of controlling periodontal dis-
eases. The control of dental plaque is essential for
the control and prevention of periodontal diseases.
Health education to improve the effectiveness of oral
cleaning is the main approach as regular removal of
plaque by the individual is the only rational long-
113
term measure to control dental plaque. Yet, there are
very few effective public dental health education
programs. We should be concentrating on providing
people with the skills for informed decision-making
and oral hygiene practice. To do so requires a sound
knowledge of health education, communication
techniques and the theories of health behavior.
Planned health education has a number of goals.
One is to reinforce and maintain existing positive
health behaviors or to improve the behavior so that
individual or group health will be promoted and im-
proved. Another is to facilitate informed decision-
making and to remove those barriers that inhibit free
choice, rather than achieving health-related changes.
Health education is concerned with the acquisition
of knowledge and understanding, changes in beliefs
and attitudes and the acquisition of skills. Some
shortcomings of dental health education programs
are that they:
O fail to develop adequate educational and social di-
agnoses before developing the programme.
O are not integrated with a broad health promotion
strategy involving health, as well as educational
departments and agencies and individuals in the
community.
O use fear arousal victim blaming techniques.
O use the same educational approach for all people.
Teaching all people, irrespective of their age, gen-
der, culture, socio-economic background and
concerns, in the same way is comparable to giving
all cardiac patients the same drugs, diet and exer-
cise routine.
The models used in dental health education have
serious limitations and are usually ineffective in
changing oral hygiene behaviors for a signicant
length of time or to a degree which would have a
real effect on periodontal health. Programs that have
been successful in changing dental health behavior
of schoolchildren have been based on one or more
of the following models: persuasive communication,
behavior modication, belief-consistency tech-
nique, social learning theory or group dynamics.
They include active participation, a high level of
teacher cooperation and parent involvement.
The objective of all informal and formal education
for dental health is to achieve a level of oral cleanli-
ness and rate of periodontal disease which is com-
patible with maintaining a functional, aesthetically
acceptable natural dentition throughout life. The
aim is to elicit, to facilitate and maintain effective
oral hygiene practices and an understanding and
Sheiham & Netuveli
availability of current care to facilitate informed
choices.
Dental health education in perspective
Dental health education is part of health education
and it is therefore relevant to review developments
in health education as a whole. Health education re-
quires an analysis of the publics behaviors and be-
liefs about periodontal disease, a move away from
reliance on professional expertise towards valuing
lay competence and a move away from authoritarian
health education to more supportive approaches.
Such changes require a change in control in pro-
viderconsumer relationships; reducing the distance
between provider and consumer with a concomitant
shift from collegiate control, when the provider de-
nes the needs of patients and the manner in which
those needs are catered for, to patients dening their
own needs and the manner in which they are met.
Health education is predicated on the assumption
that various behaviors which affect disease are sus-
ceptible to change by planned programs carried out
by professionals. Planned health education inter-
ventions are largely unsuccessful. The most common
method of health education used in dentistry is the
KAP method. Many health educators see providing
information, as a means to change attitudes and mo-
tivate people into adopting desirable dental health
behaviors as their goals. This simplistic linear se-
quence, knowledge attitude change temporary
behavior/activity habit, may create temporary
changes in behavior, but these changes are seldom
permanent. The approach is based on the KAP for-
mula which argues that knowledge (K) leads to atti-
tude (A) change which is a prerequisite for a change
in practice (P). A change in behavior does not in-
variably follow changes in knowledge and attitudes,
and therefore the KAP approach is discouraged (for
review see (15)). Information and knowledge in
themselves are unlikely to lead to recommended ac-
tions if they conict with existing motives, attitudes,
beliefs and values, and are not consonant with social
group norms. Health information is a necessary but
insufcient condition for making health choices.
The public may have good reasons for complying
or not with dentally prescribed behaviors. Individ-
uals cannot easily change their lifestyle in response
to recommendations. Constraints to carrying out the
recommended methods include the limits of time
and interference in their own and other peoples rou-
tines.
Whenever prevention of periodontal disease is as-
114
sessed, the nger points at the failure of the public
to carry out preventive measures and to adhere to
dental regimens. Consequently, professionals incor-
rectly recommend more frequent reinforcement and
the use of chemotherapeutic measures. The wide-
spread tendency to underestimate and misunder-
stand the substantial efforts that the public is mak-
ing in matters related to dental health has led to an
overemphasis of profession-based therapeutic meas-
ures, preventive techniques and behaviormodi-
cation methods. One reason for the apparent lack of
success in communication between dentists and the
public is the dental professionals xed image of the
public, which was inaccurate. Reliance on these x-
ed generalizations prevents understanding or empa-
thy with people. If one has a distorted image of the
public and tries to communicate in terms of that im-
age, the behavior may be inappropriate. A distorted
image may create a we-they situation, with the pa-
tient being dened as the inferior they. The dis-
torted image is a formidable barrier to communi-
cation with the public
In most European countries, 8090% of people
clean their teeth once to twice a day. The situation
is one of activity, not of apathy. Dentists consider
people apathetic if they are not doing what dentists
want them to do. But people may be actively doing
what they want. Patients should be seen as active
people rather than passive recipients of advice. This,
in turn, could enhance mutual understanding, re-
spect and learning.
What are the patients motives for brushing their
teeth? Toothbrushing can be either health-directed
or health-related. Health-related behaviors are those
that affect health but are not carried out for health
reasons. Toothbrushing is part of body hygiene, a
washing, cleaning and grooming habit that is copied
from parents and friends and signicant others.
Many social, psychological and educational variables
inuence oral cleaning behavior. As tooth cleaning
is associated with grooming and personal hygiene,
the majority of people do clean their teeth regularly.
Mouth feel, freshness, mouth smell and appearance
are common reasons for brushing. Health directed
brushing to prevent or reduce gum disease is com-
mon. People brush for a mixture of health-directed
and health-related reasons (12). Morning brushing
can be health-related and evening brushing, health-
directed. To design more effective methods of dental
health education, more information is needed on
factors inuencing tooth cleaning.
Failure of the conventional health education ap-
proach is due to a failure to take account of determi-
Periodontal diseases in Europe
nants of health related behaviors that are outside the
control of individuals, a lack of relevance to health
concerns and information needs of the target audi-
ence, and a prescriptive style of communication.
Stereotypical exhortations to change which require
unrealistic disruptions to routines are unlikely to be
effective (12). Health educators must accept that
change is a process, and people are at different states
of readiness to act, and are taxed to varying degrees
by environmental factors. As long as dentists fail to
recognize and use information about health behav-
ior, barriers to change and education, they deprive
themselves of the ability to develop more effective
health promoting approaches.
Most dental education is not education but in-
struction. It relies heavily on exhortation, infor-
mation on disease, unrealistic, unnecessarily com-
plicated regimens and fear arousal. Oral cleanliness
education should enhance skills, involvement, sup-
port and reinforcement of tooth cleaning, as well as
information. The efciency of personal mechanical
oral hygiene practices will be enhanced through an
understanding of factors determining performance
rather than by attempts to improve aids and tech-
niques. As most people do clean their teeth regularly,
the emphasis should be on performance (12). Modi-
fying the brushing method slightly by suggesting a
nger or pen holding grip instead of a st grip to
hold the brush changes the scrub into an effective
toothbrushing method.
Public health strategies
The changes in concepts and treatment mentioned
have considerable implications for the future prac-
tice of dentistry in general and for public health ap-
proaches to periodontal diseases in particular. The
most important implication is the reassessment of
periodontal diseases as a public health problem in
general and a dental public health problem in par-
ticular. For a disease to be considered a public health
problem that requires action, it should full the fol-
lowing conditions:
O the disease must be widespread (or if it is uncom-
mon it must be serious).
O consequences (impact) to the community and to
individuals must be severe.
O effective methods must be available to prevent, al-
leviate, or cure the disease.
O costs to the community and to individuals must
be great.
115
Although severe periodontal disease is not wide-
spread, the costs of treating the disease are high be-
cause of the organization of dental care, and this
qualies it as a dental public problem. In addition,
the symptoms of periodontal diseases such as
bleeding, halitosis, gingival recession and tooth loss
have an impact on many people. Also, we have suf-
cient information to control common forms of the
disease.
Goals for periodontal disease
control
The goal of a plaque free mouth is both unrealistic
and unnecessary.
A reasonable goal for periodontal disease control
is to achieve a level of plaque which is compatible
with a rate of periodontal destruction which will re-
tain teeth essential for an socially and personally ac-
ceptable dentition for a lifetime; one that does not
cause handicaps.
Reduction in the quantity of dental plaque will re-
duce the severity of gingival inammation and the
probability of destructive periodontal diseases.
Strategies for controlling
periodontal diseases
The plan for controlling periodontal disease has
three components:
O a population strategy for altering life practices,
and in particular, oral cleaning effectiveness to re-
duce the dental plaque level in the community.
O a secondary prevention strategy to detect and
treat people with destructive periodontal disease.
O a high-risk strategy for bringing preventive and
therapeutic care to individuals at special risk.
Population strategy (102, 103, 112)
A reduction in plaque in the general population can
be achievedusing the informationonfactors affecting
tooth cleaning behavior. As tooth cleaning is associ-
ated with grooming, personal hygiene and religious
beliefs, most people do cleantheir teeth regularly. The
objective of health education is to improve the effec-
tiveness of tooth cleaning behavior. As tooth cleaning
is part of general hygiene behavior, programs directed
Sheiham & Netuveli
at improving tooth cleanliness should be incorpor-
atedintohealtheducationdirectedat improving body
cleanliness and grooming. These programs should
emphasize lay competence, be supportive and non-
mystifying, and should not blame the victim.
The health education programme should incorpor-
ate methods and concepts which will encourage the
maintenance of an adequate level of oral cleanliness
without professional reinforcement. The programme
should therefore stress the following factors:
O Tooth cleaning behavior is part of general cleanli-
ness.
O Relevance of behaviors.
O Social acceptability of tooth cleaning methods.
O Easily incorporated into daily activities.
O The simplicity of tooth cleaning.
O Feedback methods to assess whether cleaning is
being carried out effectively.
Programs should contain the following components:
O a community-wide approach incorporating the
principles of integration with general health edu-
cation, diversity of educational approaches and
community participation in planning and im-
plementation.
O community leader education to improve health
behavior through better understanding and in-
volvement of leaders of public opinion. They act
as role models and their management and organ-
izational skills help to implement preventive strat-
egies.
O public education to increase awareness and
knowledge of good hygiene behavior by educating
all age groups in a continuing and consistent pro-
gramme.
O mass-media methods to increase community
awareness of body hygiene and tooth cleanliness,
the availability of oral hygiene aids and plaque
disclosing agents could be used for feedback.
O environmental changesencouragement of
health-promoting behavior may be achieved by
modifying the environment, e.g. improvements in
hygiene at schools and in the workplace, provision
of washing facilities and the introduction of mar-
keting practices which encourage the sale of good
oral hygiene aids at low cost.
O professional education to improve tooth-cleaning
instruction by professional personnel. Teachers,
nursery school attendants, health visitors, nurses,
doctors, dentists and other dental personnel and
health educators should be provided with specic
116
oral hygiene education so that they can provide
accurate information and set good examples.
O the benets of smoking cessation should be inte-
grated into general health education and health
promotion.
The objective of all informal and formal dental
health education is to foster negotiation and collab-
oration so that patients might be helped to make in-
formed choices. It involves acquisition of knowledge
and understanding and the development of skills for
self-care. The aim is to elicit, facilitate and support
the maintenance of effective oral cleaning practices.
To achieve the aims and objective, a planned con-
sistent, integrated series of strategies should be
adopted.
The plan should be based on the following con-
cepts:
O integration and use of common risk factor ap-
proach. Dental health education should be inte-
grated with general health education.
O oral cleanliness education should be integrated
with general health education about body cleanli-
ness, grooming and self-esteem. Smoking cess-
ation is pivotal in improving oral hygiene.
O an oral cleanliness education program must in-
corporate a number of diverse educational ap-
proaches.
O early intervention. The earlier the intervention in
the health career, the more effective the result.
The inuence of primary and secondary socializa-
tion is paramount in establishing good tooth-
brushing habits.
O participation. Community, public and staff par-
ticipation in the planning process should increase
the probability of success.
O evaluation is needed to assess whether the pro-
gramme is achieving the aims, whether it is doing
so effectively and efciently and whether their
planning methods are sound.
Secondary prevention strategy
Assessment of periodontal treatment
needs and periodontal status
Information on the treatment needs of populations
is required to quantify the resources required to pre-
vent and treat periodontal diseases. Such data also
Periodontal diseases in Europe
provide a rational basis for setting goals and moni-
toring the effectiveness of current strategies.
Treatment
Oral hygiene education is the most important aspect
of periodontal treatment for those with signs of peri-
odontal disease. In most people, toothbrushing
alone will be adequate in controlling dental plaque
and reversing early periodontal disease. In some
people at certain sites in the mouth, dental oss with
or without other mechanical aids would be necess-
ary. Health education programs, including oral
cleanliness, should stress the following toothbrush-
ing guidelines:
O emphasize effectiveness rather than frequency
brushing more than twice daily does not improve
periodontal health unless it is done effectively.
O the scrub method should be encouraged.
O hold the brush with a nger (pen grip), not a st
grip.
O the brush ends should be directed at the gum
margins.
O ensure all teeth surfaces are cleaned.
O use a short-headed nylon toothbrush.
Removal of gross calculus and factors favoring
plaque retention will facilitate oral cleanliness.
When the person has learnt adequate oral hygiene
skills, recall intervals for reassessment can be stead-
ily increased from to 12 and 18 months.
High Risk Strategy (102, 103, 112)
There are a small number of people who will have
severe progressive destructive periodontal disease
despite effective tooth-cleaning practices. In these
cases, appropriate antimicrobial therapy could be
used to change the bacterial ora in the pockets.
People with AIDS present special periodontal
problems. The manifestation of periodontal lesions
is often severe. The other groups of people requir-
ing a high-risk strategy are those with medical or
sociopsychological conditions which would be
affected by periodontal disease. Both the peri-
odontal and the medical high-risk groups should
be assessed by socio-psychological, as well as clin-
ical and bacteriological methods, because there is
growing evidence that psychological states can af-
fect the immune response and alter the bacterial
ora of the mouth.
It is apparent that a combination of a population
117
strategy, a secondary prevention strategy and a
high-risk strategy is essential in achieving the ob-
jectives of maintaining a functional, aesthetically
and socially acceptable natural dentition for the
lifespan of most people. The balance of effort
should be heavily weighted towards the population
strategy. If that strategy is adopted, the need for
treatment would be reduced and treatment would
be more successful.
The adoption of a population strategy would be
socially and economically more acceptable for a
number of reasons. Firstly, periodontal disease is
not considered an important public health prob-
lem. Epidemiological evidence supports this con-
sideration. Second, altering exposure distributions
to the whole population may be the most effective
way of reducing the prevalence of severe peri-
odontal disease, both in the population as a whole
and also specically among those who are at
highest risk.
Manpower implications
The most important aspect of a public health ap-
proach in preventing and controlling periodontal
diseases is health promotion strategies that improve
general body cleanliness and oral cleanliness. This
could be communicated through an integrated ap-
proach with general hygiene programs carried out by
primary health workers and teachers. A well-trained
dental health educator could fulll this role. They
could teach teachers, nursery school attendants,
health visitors, nurses, doctors, dentists and other
dental personnel and health educators.
Dental health educators are the most valuable an-
cillary in periodontal health programs. They should
integrate their activities with those of the health edu-
cation/promotion department.
The treatment and care of the vast majority of
people with periodontal diseases can be carried out
by dental ancillaries. Dentists are not required for
treating routine cases. Their role is to diagnose and
produce a treatment plan. Evaluation and monitor-
ing of prevention, treatment and trends in peri-
odontal health should be routinely carried out by an
epidemiologist.
Conclusions
This review of the extent of periodontal disease in
Europe and scientic ndings on the life history of
Sheiham & Netuveli
the disease indicates that there is an urgent need to
reassess the status of periodontal disease as a dental
public health problem and the guidelines and indi-
cations for its treatment. In an era of evidence-based
health care, the current uncritical position where any
inammation of the gingivae or shallow pocketing is
considered in need of treatment is untenable.
Advanced periodontal disease does affect a rela-
tively small percentage of adults and is more common
in older people. The progression pattern of the dis-
ease seems compatible with retention of a functional
dentition throughout life for the majority of people in
Europe. Periodontal disease seldom causes dis-
comfort, social embarrassment or perceived loss of
function and does not affect oral health related qual-
ity of life in most people (62).
Periodontal health appears to be improving in
Europe. Periodontal disease in Europe, as elsewhere,
is determined by social factors that affect oral health
related behaviors. More attention should be focused
on facilitating effective mouth cleaning practices
and smoking cessation.
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