Periodontitis in India and Bangladesh . Need for a population based approach in epidemiological surveys . A Literature review

Background: Early surveys showed people of India and its neighbors to be highly susceptible to periodontitis. This was based on the early surveys which estimated a higher prevalence. Aim: This paper reviews the prevalence of periodontitis in India and Bangladesh and attempts to find out why the populations of the Indian subcontinent were considered more susceptible to periodontitis. Settings and design: Review of periodontitis prevalence studies on the Indian and Bangladeshi population. Methods and material: After identifying articles from Pub Med, DAOJ and hand searching, the epidemiology of periodontitis is reviewed. Results and conclusion: This review identifies that very few studies have been done on representative population. Yet it can be certainly concluded that there is a high prevalence of periodontitis in the adults and the economically weak population which can be reduced by adopting preventive public health strategies. Conclusions: Standardized population based studies in a representative population with a robust design to identify the true prevalence of periodontitis is needed.


Introduction
India and Bangladesh share more in common than being two of the most populous nations in terms of population density.Culture, trade, security are some of the areas where the two countries meet.The two countries are also considered to be affected by periodontitis, the major reason for tooth loss in adults, which is higher than the western nations.Oral health has been neglected for long in India.With the formulation of the Oral health policy India has started recognizing the benefits of having a healthy population including in oral health.In India, dental care scenario is unique 1 .At present there are more than 267 dental schools, producing approximately 19,000 dental graduates/year and almost 3000 specialists.Bangladesh has 14 dental schools (Bangladesh Medical and Dental Council).The dental schools are major players for inexpensive oral care and also offer excellent tertiary care.On the other hand, even the most basic oral health education, simple interventions like pain relief, emergency care for acute infection and trauma are not available to the vast majority of population, especially in rural area.There is variation in the periodontitis prevalence as reflected in the two major surveys conducted 1,2 .Lack of epidemiological data on representative rural population compounds the problem further.Albandar 3 in an overview concluded that subjects of Asian ethnicity had the third highest prevalence of periodontitis.The aim of this review is to find the prevalence of periodontitis in India and Bangladesh.

Method
Using keywords "Periodontitis" and "India", "Periodontal" and "India" and "Periodontitis" and "Bangladesh", "Periodontal" and "Bangladesh" various index were searched including PubMed and medIND.Search for India gave 163 articles while Bangladesh had 12 articles.Studies which gave prevalence data on periodontitis were selected and thus 13 articles were selected for the review.
In this review moderate periodontitis is considered if a person has at least one site 4mm and severe periodontitis at least one site 6mm of probing depth.Helderman 13 in a review observed the prevalence of subjects with deep periodontal pockets in Bangladesh was 26 per cent and it can tentatively be concluded that Bangladesh belongs to the 20 per cent of countries in the world where periodontal conditions of the population are among the worst.
Akhter 14 found that of the 582 patients attending Dhaka Dental College Hospital who underwent extractions of their teeth, 18.5% was due to periodontal reasons.
Arvidson-Bufano 15 found shallow pockets in 34% of the urban slum group and in 42% of the rural group, in a survey of 826 individuals residing in Central and Western Bangladesh.

Discussion
School and hospital population are easy to access and study.But they are convenient samples which cannot be generalized to the target population.There is an increase of about 10% between the prevalence in general population and hospital based population.The early studies 4,5 were done on school population.The school population will be a young population and only persons affordable to attend the schools will be represented.And the school population is least representative of the periodontitis susceptible population.But if young persons show levels of periodontitis as seen in Ramfjord 5 surveys, it is a cause for alarm as it reflects a poor hygiene status and dental service utilization by the population.
Another limitation observed was the use of CPITN as a case definition for periodontitis.CPITN is a treatment need index to find the prevalence of persons requiring treatment.It does not give true prevalence in terms of severity and extent.Further the prevalence data should correlate with tooth loss to find if the increased prevalence of periodontitis is reflected in increased tooth mortality.This will also help us to find at what level of severity of periodontitis is tooth loss a consequence.Abnormal Probing depth is a cause for concern if it leads to increased risk for tooth loss and its threshold should be identified based on its consequence.Yet very little data are available on tooth loss. 7e WHO Global Oral Health Programme 16 formulated the policies and the necessary actions for the improvement of oral health.The strategy is that oral disease prevention and the promotion of oral health needs to be integrated with chronic disease prevention and general health promotion as the risks to health are linked (like tobacco consumption and the standard of hygiene).Yet for effective integration of oral disease management with other chronic diseases, prevalence data along with risk due to various factors should be available.Oral disease including periodontal disease and tooth loss is a serious public-health problem.Its impact on individuals and communities in terms of pain and suffering, impairment of function and reduced quality of life, is considerable.With the growing consumption of tobacco in many low and middle income countries, the risk of periodontal disease, tooth loss and oral-cavity cancer is likely to increase.Naseem Shah 7 in her report for the National Commission on Macroeconomics and Health (NCMH) observed that for periodontal diseases the projection is alarming with prevalence at present being 45% for 15+ years, and the actual prevalence in lakhs will be 2957.6(year 2000), 3190.2(year2005), 3413.8(year2010) and 3624.8(year2015).Due to the rampant use of paan masala and gutka by persons of all age groups and both the sexes' periodontal disease prevalence will increase than projected.If minor periodontal diseases are included, the proportion of population above the age of 15 years with this disease could be 80%-90%.Concerned 11 with the urgent need for action in promoting sound oral health, prevention of dental caries and periodontal diseases and to give impetus to activities to promote oral health, WHO had dedicated World Health Day 1994 to oral health.

Conclusion
There is a lack of prevalence data of the Indian and Bangladesh population.Case definitions have to be formed with the local population in mind.As Bangladesh and India share more in common, a common approach can be developed to study periodontal diseases with the subcontinent's uniqueness in mind.This will help us utilizing the scarce resources available to combat and prevent periodontitis and its related tooth loss.______________

National Oral Health Survey and Flouride Mapping, 2002-2003, Dental
Moderate periodontitis was seen in 17.5% of 35-44yr old, and 21.4% in 65-74 yr old, whereas severe disease defined as at least one tooth with >6mm probing depth was 7.8% in 35-44yr old, and 18.1% in 65-74 yr old.No marked gender differentials were observed and marginally higher prevalence seen in rural subjects.This survey gave a reliable baseline data at a national and state level.Under the Government of India and World Health Organization collaborative program on oral health, a Multicentric oral health survey was envisaged in the year 2004, in order to have a baseline data of the oral diseases burden and associated risk profile of the population for four index age group i.e 12, 15, 35-44 and 65-74 years.This survey was conducted in seven different geographical locations in India i.e.

Table 1 :
Prevalence data of periodontitis