Oral health and public health: the effects and costs of Periodontitis

Periodontitis, a gum condition related to plaque, is one of the world’s most prevalent health conditions – although lower income groups suffer the most. It affects the whole body, and also carries significant social and economic costs for both individuals and society. Preventable and treatable through community-level interventions, periodontitis is a public health challenge and a health inequalities issue. Representatives from the Egas Moniz Higher Education Cooperative and associated institutions explain the condition and its health impacts.

by José João Mendes, João Botelho, Vanessa Machado, Björn Klinge, Antonio Pedro Alves de Matos and Gil Alcoforado 

Estimated reading time: 6 minutes

Periodontitis and its effects

Periodontitis is a gum condition characterised by a chronic inflammatory reaction, driven by dental plaque¹. This oral disease has harmful systemic effects, as it is linked to the circulation of inflammatory and toxic products ². Clinically, patients suffering from periodontitis suffer from symptoms gum bleeding, tooth movement and, ultimately, tooth loss ^3,4. Periodontitis is one of the most prevalent conditions worldwide –  The WHO estimates that 40% of adults aged 65- 74 suffer from it. It has severe economic and social consequences ^5–7 ;In 2018, periodontitis cost an estimated €158B in economic loss in Europe ⁸.

Periodontitis and Public Health

The problem is more prevalent and severer in low-income and middle-income countries⁹, but even in rich and developed countries the prevalence is worrisome ⁶. Tackling Periodontitis is therefore a public health concern and worldwide health priority.

If untreated, periodontitis can be responsible for enduring impaired quality of life, impaired systemic health, and work productivity loss. It is not surprising that developing countries, with greater financial restrictions, show continuing deterioration of their periodontal conditions as well as other health-related issues.

The management of periodontitis is cost-effective, and community level measures can reduce the burden of disease. We must prioritise prevention, diagnosis, and management, and particularly focus on raising awareness. We need a better integration of dental healthcare within the assorted relevant health systems. Efficient societal public-health campaigns should be reinforced by messages directed at individual patients. Lastly, people need more affordable dental and periodontal care, especially those in low-income countries.

Ultimately, the unstopped progression of periodontitis, as well as increases in life expectancy, will lead to a higher number of patients without teeth. While the majority cannot afford implant treatments, the ones who can often maintain bad oral health habits. This will increase the risk of infection around implants – peri-implantitis – very similar to what happens in periodontitis. Placing implants in patients who have lost their teeth due to periodontitis risks creating a second wave of a disease which is still poorly understood, and where therapeutic approaches are not yet fully developed.

The effects of periodontitis on the body 

Peri-implantitis and periodontitis are localised in the mouth. However, many studies identify relationships with systemic illnesses. Some of these relationships are bidirectional – that means that periodontitis impacts the clinical markers of a particular condition as well as vice-versa. Periodontitis has been implicated in diabetes mellitus ^10,11, obesity and metabolic syndrome ¹², cardiovascular diseases ^13,14, cancer ¹⁵, rheumatoid arthritis ¹⁶, adverse pregnancy outcomes ¹⁷, polycystic ovary syndrome ¹⁸, and bacterial vaginosis ^19.  More recently, it has been linked to an increased risk of complications from COVID-19 ²⁰. Bearing in mind these close links between periodontitis and systemic diseases, the situation is likely to get worse in low-income populations.

Prevention, health literacy, and ways forward

Despite increasing scientific robustness of Periodontal Medicine, periodontitis is not a disease with a drug-based treatment. It is dependent on preventive behaviour including the actions of the patient, and the physical interventions by the dentist. This fact may help to explain its difficult management in terms of public health and high prevalence. Also, we should be concerned about the neglect of oral health and dental illiteracy; the strategy to combat periodontal diseases should integrate these issues.

Lack of support from public health services to dental medicine has prompted initiatives from civil society, for example the NGO ‘mundo a sorrir’ (Smiling world). Institutions are helping too, for example Egas Moniz has a large, long standing dental clinic which provides reduced cost dental care under public and private health systems. It has built up  a large patient database over the years. Further, it’s regional study on periodontal health formed the basis for a successful, free of charge, still ongoing, treatment and follow up programme of the patients identified by the study.

Very recently, the World Health Organization outlined a global strategy on tackling oral diseases, including periodontitis ²¹. Along with this important programme, research must focus more on the underlying mechanisms through which periodontitis impacts systemic conditions. This would give us a knowledge base which could facilitate the development of new approaches to the disease. We need forward-looking, long-term and multi-centric studies to establish the prospective impact of patients’ suffering and the final outcomes of the treatment of this condition. Also, we need more studies regarding genomics, epigenetics, and microbiomics, among others, to better understand this disease and how to control it. The mission of Egas Moniz at the core of a wider European effort in alignment of the new EuroHealthNet 5-year plan to reduce health inequalities, includes working towards the solution of these challenges.

References

1. Hajishengallis, G. Periodontitis: from microbial immune subversion to systemic inflammation. Nat. Rev. Immunol. 15, 30–44 (2015).
2. Hajishengallis, G. & Chavakis, T. Local and systemic mechanisms linking periodontal disease and inflammatory comorbidities. Nat. Rev. Immunol. (2021) doi:10.1038/s41577-020-00488-6.
3. Carvalho, R. et al. Predictors of tooth loss during long-term periodontal maintenance: An updated systematic review. J. Clin. Periodontol. (2021) doi:10.1111/jcpe.13488.
4. Graziani, F., Karapetsa, D., Alonso, B. & Herrera, D. Nonsurgical and surgical treatment of periodontitis: how many options for one disease? Periodontol. 2000 75, 152–188 (2017).
5. Kassebaum, N. J. et al. Global Burden of Severe Periodontitis in 1990-2010: A Systematic Review and Meta-regression. J. Dent. Res. 93, 1045–1053 (2014).
6. Kassebaum, N. J. et al. Global Burden of Severe Tooth Loss: A Systematic Review and Meta-analysis. J. Dent. Res. 93, 20S-28S (2014).
7. Tonetti, M. S., Jepsen, S., Jin, L. & Otomo-Corgel, J. Impact of the global burden of periodontal diseases on health, nutrition and wellbeing of mankind: A call for global action. J. Clin. Periodontol. 44, 456–462 (2017).
8. Botelho, J. et al. Economic burden of periodontitis in the United States and Europe – an updated estimation. J. Periodontol. (2021) doi:10.1002/JPER.21-0111.
9. Peres, M. A. et al. Oral diseases: a global public health challenge. The Lancet 394, 249–260 (2019).
10. Simpson, T. C. et al. Treatment of periodontal disease for glycaemic control in people with diabetes mellitus. Cochrane Database Syst. Rev. (2015) doi:10.1002/14651858.CD004714.pub3.
11. Preshaw, P. M. et al. Periodontitis and diabetes: a two-way relationship. Diabetologia 55, 21–31 (2012).
12. Genco, R. J. & Borgnakke, W. S. Risk factors for periodontal disease. Periodontol. 2000 62, 59–94 (2013).
13. Muñoz Aguilera, E. et al. Periodontitis is associated with hypertension: a systematic review and meta-analysis. Cardiovasc. Res. 116, 28–39 (2020).
14. Rydén, L. et al. Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study. Circulation 133, 576–583 (2016).
15. Corbella, S. et al. Is periodontitis a risk indicator for cancer? A meta-analysis. PLOS ONE 13, e0195683 (2018).
16. Hussain, S. B. et al. Is there a bidirectional association between rheumatoid arthritis and periodontitis? A systematic review and meta-analysis. Semin. Arthritis Rheum. 50, 414–422 (2020).
17. Sanz, M. & Kornman, K. Periodontitis and adverse pregnancy outcomes: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J. Periodontol. 84, S164–S169 (2013).
18. Machado, V., Escalda, C., Proença, L., Mendes, J. J. & Botelho, J. Is There a Bidirectional Association between Polycystic Ovarian Syndrome and Periodontitis? A Systematic Review and Meta-analysis. J. Clin. Med. 9, 1961 (2020).
19. Escalda, C., Botelho, J., Mendes, J. J. & Machado, V. Association of bacterial vaginosis with periodontitis in a cross-sectional American nationwide survey. Sci. Rep. 11, 1–9 (2021).
20. Marouf, N. et al. Association between periodontitis and severity of COVID‐19 infection: A case–control study. J. Clin. Periodontol. 00, 1–9 (2021).
21. WHO includes three dental preparations in list of essential medicines for first time. https://www.ada.org/publications/ada-news/2021/october/who-includes-three-dental-preparations-in-list-of-essential-medicines-for-first-time.

José João Mendes

President of Egas Moniz at Egas Moniz

• President of Egas Moniz - Cooperativa de Ensino Superior, CRL
• President of Egas Moniz Research Center and Egas Moniz Dental Clinic Head
• Associate Professor at Egas Moniz University Institute. Global Burden of Disease Collaborator
• Member of the Board of the Portuguese Association for Private Higher Education
• Representative of Egas Moniz at the Academic Network of Health Sciences of Lusophony

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João Botelho

Researcher at Egas Moniz

• Researcher at Egas Moniz Research Center and Global Burden of Disease Collaborator
• PhD Student of Biomedical Sciences at Porto University and Higher Education Teaching Certificate by Harvard's Derek Bok Center for Teaching and Learning
• Alumni of Egas Moniz - Cooperativa de Ensino Superior, CRL

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Vanessa Machado

Researcher at Egas Moniz

• Researcher at Egas Moniz Research Center and Global Burden of Disease Collaborator
• Holds a PhD in Biomedical Sciences from Oporto University and a certificate in Higher Education from Harvard's Derek Bok Center for Teaching and Learning
• Alumni of Egas Moniz - Cooperativa de Ensino Superior, CRL

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Bjorn Klinge

Professor at Instituto Universitario, Egas Moniz

• Special Guest Professor Instituto Universitario, Egas Moniz, Lisbon, Portugal
• Professor, Malmo University, Professor em. Karolinska Institutet, Sweden
• Specialist in Periodontology (gum diseases)

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António Pedro Alves de Matos

Biologist (PhD) at Egas Moniz

• Biologist (Ph. D.) and expert in electron microscopy technologies
• Twice President of the Portuguese Society for Microscopy and President-elect/President of the Society for Ultrastructural Pathology
• Executive Director of CiiEM (Egas Moniz Interdisciplinary research Centre) and Head of its Electron Microscopy Unit (Cmicros)
• Specialist in ultrastructural pathology

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Gil Alcoforado

Director at IUEM

• Director of IUEM, President of the European Section of the International College of Dentists
• Treasurer of the European Association of Osseointegration
• Past-President of the European Federation of Periodontology
• Specialist in Periodontology

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