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Periodontology 2000, Vol.

29, 2002, 79103 Copyright C Blackwell Munksgaard 2002


Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Periodontal diseases in Africa
Viurxr BnrIur & FIrrriNc Scnru1z
The total population on the African continent com-
prises approximately 750 million people (1) repre-
senting an enormous ethnic variety. North Africa is
mainly inhabited by people of Arab descent whereas
sub-Saharan Africa is populated by a large number
of different indigenous African populations. Added
to this patchwork are a number of people of Euro-
pean and Indian descent. Africa can not be con-
sidered a coherent and uniform continent, as huge
differences may be observed between population
groups with regard to wealth, living conditions, ac-
cess to health care, educational possibilities, etc. A
wealthy and powerful, but numerically small elite
exists, which has access to health care facilities in
Europe and North America, and has received train-
ing and education in the best institutions abroad.
However, the vast majority of the indigenous African
populations live under very unfavorable conditions,
characterized by poverty, illiteracy, low life expect-
ancy, lack of educational possibilities, etc. Many
African countries are characterized by political insta-
bility and social unrest, and it is estimated that about
600,000 Africans died from the immediate conse-
quences of war or violence during the year 1998
(219).
The national economies of most countries on the
African continent are severely constrained and the
World Health Organization estimates that the 1992
overall per capita gross domestic product (GDP), ad-
justed for purchasing power for the African coun-
tries, was in the order of magnitude of US$1,200
(1985 US$) contrasting with the estimated US$17,900
for the US and US$10,100 for Europe (219). As
African economies are often based on the export of
only a few naturally occurring resources, they are ex-
tremely vulnerable to the effects of changes in the
international markets, a fact, which contributes to
constrain the economies. The climatic conditions
can be extreme, with severe droughts or oods,
which regularly cause famines or drive people away
people from their homes, thereby jeopardizing the
79
fundamental basis for existence of millions of people
(31). Basic commodities and facilities that are taken
for granted in more afuent societies, such as easy
access to safe water and sufcient food supplies, are
fundamental components in the daily struggle for
life among major sections of the African populations.
Low life expectancy among African
populations
The levels of child mortality are very high among
African populations and the levels of adult mortality
are also higher than in other parts of the world (219).
Consequently, the life expectancy is considerably
lower among African populations than elsewhere.
According to the World Health Organization (219),
the life expectancy at birth among African popula-
tions in the year 1998 was 49years for men and 51
years for women. The corresponding estimates for
the US population were 73 and 80years and for
European populations were 69 and 77years.
Causes of morbidity and mortality
It remains a sad fact for most African populations that
diseases which are considered trivial in more afuent
societies, such as measles, diarrheal disease and
respiratory infections, are major causes of morbidity
and mortality. Moreover, malaria accounts for one in
ve childhood deaths and indirectly contributes to ill-
ness and deaths fromrespiratory infections, diarrheal
disease and malnutrition(219). Finally, during the last
two decades an additional very serious burden has
been placed on the African continent: the HIV epi-
demic. It is thus estimated that about two thirds of the
global total of HIV infected persons, in 2000, 36.1 mil-
lion persons, live in sub-SaharanAfrica (41, 77). When
the children, spouses and elderly dependents of HIV
infected Africans are taken into account, the popula-
tionthat is directly affected by the HIVepidemic com-
prises more than one fourth of the total African popu-
Baelum & Scheutz
lation. The demographic impact of the HIV epidemic
is dramatic and a marked decline in life expectancy
has already been noted in many African countries,
with life expectancy by 1996 already being reduced to
the levels of the 1950s in many sub-Saharan countries
(41). This reduction reects the HIV infections that
occurred in the late 1980s. However, the prevalence of
HIV infection has continued to increase considerably
in many African countries, and it is therefore clear
that the HIV epidemic will continue, not only to seri-
ously alter the population demography and the social
infrastructure of many African populations, but also
to further challenge the existing weak health care sys-
tems.
General health care services
The general health care services are scarce, under-
staffed and undersupplied in most African countries.
The health budgets are generally very limited and
the World Health Organization has estimated that
the per capita health expenditure in African coun-
tries in 1995 amounted to an average of US$40, and
may amount to less than $10 US per capita (133).
These gures grossly contrast with the estimated per
capita health expenditure of US$2,500 for the USA,
and US$700 for the European region (219). For many
African countries, the ratio of physicians to popula-
tion is less than 10: 100,000, which contrasts with the
estimate for the US of 279: 100,000 (222). Similarly,
the ratio of nurses to population rarely exceeds 100:
100,000 whereas the corresponding estimate for the
US is 972: 100,000 (222).
Dental health care services
Scarcity, limited manpower and lack of supplies are
even more pronounced in the dental health care ser-
vices. The ratio of dentists to population is typically
in the range of 02 per 100,000 persons for the
African countries (15, 222). Most dentists are located
in capitals or major urban centers (15, 149) whereas
the majority of the population reside in rural areas.
The budgets available for dental health care services
are extremely limited. Using Tanzania as an example,
the annual budget available for dental health ser-
vices may amount to as little as 0.6% of the annual
per capita health budget (149), corresponding to
about 0.01% of GDP. In some countries, such as Tan-
zania, these constraints have resulted in implemen-
tation of plans for oral health care delivery that focus
on oral health education and prevention, provided
by persons already available within the local com-
80
munities, such as primary school teachers, maternal
and child health care aides and health assistants
(141, 149).
Perceived treatment needs,
demands and utilization of dental
health care services
The perceived need for dental treatment is quite
high among African populations. More than 50% of
adult Tanzanians (144) report that they have current
dental problems; between 30% of the English or
Africaans speaking South Africans and 66% of the
Xhosa speaking South Africans (76) report that
something is wrong with their teeth; and between
12% of the English speaking South Africans and 38%
of the Sotho speaking South Africans report that
something is wrong with their gums (76). While
these observations may seem to contrast with the
observation among Rhodesian student teachers that
74% of the interviewed persons considered that
nothing was wrong with their teeth (175), the dis-
crepancy is most likely explained by the young age of
the Rhodesian student population. Hence, a clinical
assessment of treatment requirements indicated a
substantial need for treatment, although mainly in
the form of llings, and to a lesser extent in the form
of extractions due to caries (175). This nding is con-
sistent with the observation that principle reason for
utilization of dental health care services is related to
pain experiences (74, 133, 175, 210).
The distribution of dental services within coun-
tries is uneven and dental professionals are mainly
located in urban centers (15, 157, 168) while the ma-
jority of the population resides in rural areas. Medi-
cal health services may therefore also be used to
solve dental problems (185) due to the greater ac-
cessibility of such services relative to the dental ser-
vices. Long distances, and costs of treatment and
transport are important barriers to seeking care in
dental service facilities (134, 156). However, ad-
ditional barriers may exist, and it has been suggested
that the burdens of life for African populations, e.g.
life threatening diseases and socioeconomic prob-
lems, far outweigh the perceived problems relating
to dental diseases (210), and that a much larger de-
mand for emergency dental care remains dormant.
This suggestion is consistent with the observation in
several studies among African populations that a
large number of teeth are indicated for extraction,
mainly due to caries (22, 116, 130, 206).
Periodontal diseases in Africa
Oral hygiene conditions and
practices
With very few exceptions (163), the oral hygiene con-
ditions among African populations have generally
been described as poor (8, 23, 24, 34, 40, 59, 61, 67,
85, 117, 135, 142, 152, 162, 174, 191, 192, 198, 206),
with accumulation of both plaque and calculus
being prevalent from early ages. Both plaque and
calculus deposits become more widespread and
heavy with increasing age (23, 24, 67, 117, 119, 135,
192, 206), although substantial portions of the popu-
lation do carry out oral hygiene procedures.
The methods used for tooth cleaning among
African populations include chewing sticks, chewing
sponges, plantainstems with charcoal powder, cotton
plant leaves with ash, use of cloth or ngers, or tooth-
brushes with or without toothpastes (2, 8, 34, 36, 40,
57, 75, 151-154, 163, 191), with chewing sticks being
the predominant tool used for oral hygiene pro-
cedures. Although the use of chewing sticks could be
advantageous, in that extracts of the plants used for
preparing these sticks have been shown to possess a
large range of antimicrobial properties (9, 89, 100, 201,
213, 214), these properties have not been docu-
mented to have signicant effects on oral hygiene
levels. The results of a fewstudies have suggested that
use of chewing sticks may be inferior to tooth brush-
ing with respect to plaque removal (70, 153) and that
use of chewing sticks is predictive of gingivitis (145),
but most studies conducted among African popula-
tions indicate that the means and methods used for
tooth cleaning do not seem to have any major impact
on oral hygiene levels (2, 40, 49, 154, 161, 184, 200,
209). However, a few studies have indicated that
chewing stick use may be more efcacious than tooth
brushing for oral hygiene (50), andinviewof the avail-
ability and low costs associated with the use of
chewing sticks, there seemto be no reason to attempt
to dissuade the use of the traditional methods for
tooth cleaning among African populations.
African populations the natural
history of periodontal diseases
The scarcity of health care services, including den-
tal health care services, and the poor oral hygiene
means that African populations provide a unique
opportunity to study the natural history of peri-
odontal diseases, as these diseases develop and
manifest themselves among children, adolescents
81
and adults. Established dental preventive programs
are almost nonexistent, antibiotics are very inac-
cessible and their usage is therefore extremely low.
As a result of the scarcity of dental health services,
the vast majority of the African populations have
never suffered the consequences of the theory of
focal infection (20, 35). In developed countries,
where dental services have been widespread and
easily accessible for many decades, the extensive
application by dental practitioners in the rst half
of this century of the focal infection theory to
caries and periodontal diseases resulted in tooth
extractions becoming accepted as an integral part
of normal dental treatment (35). This unfortunate
coupling of the focal infection theory, periodontal
diseases and tooth extractions has been a major
contributor to the continued and widespread belief
that periodontal diseases are the major causes of
tooth loss from the age of about 40years (20).
African populations thereby provide an opportunity
to study the natural course of periodontal diseases
when these diseases are not inuenced by needless
tooth extractions.
Apart from the generally poor oral hygiene con-
ditions and the scarcity of dental health care ser-
vices, additional factors must be considered before
periodontal epidemiological data on African popu-
lations can be interpreted as illustrations of the
natural history of periodontal diseases: As the life
expectancy in many African populations is con-
siderably lower than most other populations (219),
less information is available on the elderly among
the African populations. As an example, the WHO
Global Oral Data Bank contains no data pertaining
to the indicator age group 6574years for any
African population, and only a few reports exist on
this age group (146). The symptoms of destructive
periodontal disease accumulate with increasing age
(for review see: 20) and the scarcity of information
on elderly age groups makes it difcult to infer
what the consequences or end-points of the peri-
odontal diseases might have been had the African
populations had life-expectancies similar to those
characteristic for other populations.
Descriptive periodontal
epidemiological studies on
African populations
In parallel with the periodontal epidemiological data
for the rest of the world (20), the descriptive data
Baelum & Scheutz
available for African populations can be broadly cat-
egorized into three major groups according to the
methods used for recording periodontal diseases.
These methods include the Russell Periodontal
Index (179); the Community Periodontal Index of
Treatment Needs (CPITN) (7); and detailed measure-
ments of gingivitis, clinical attachment level, probing
pocket depth, gingival recession or radiographic as-
sessment of alveolar bone destruction. The 1977
WHO Basic Methods (216) which reect the tran-
sition from the Russell PI methodology recom-
mended by the WHO prior to 1978 (215) to the
CPITN methodology recommended thereafter (217)
have been used in a few studies of populations in
Swaziland, Mozambique and Rhodesia (85, 112, 175).
Ramfjords Periodontal Disease Index (170) has been
used to assess the periodontal conditions of a South
African Xhosa population (39), and the Gingival
Index (123) has been used to assess gingivitis among
Ugandan school children (104). In addition, a num-
ber of studies exist of populations in Nubia (124),
Zaire (54), Kenya (37, 202), Sierra Leone (32) and
Ghana (90) in which the methods used for recording
of periodontal diseases have not been described in
detail.
Most periodontal epidemiological studies using
the Russell PI among African populations were car-
ried out during the 1950s, 1960s and 1970s. The
populations for which Russell PI data exist comprise
study groups in West Africa (Ghana and Nigeria) (8),
East Africa (Tanzania, Kenya and Uganda) (8), Ethi-
opia (119, 162, 180, 181), Sudan (57, 171, 182), Niger-
ia (56, 58, 59, 61, 191193, 195), Cameroon (34),
Uganda (114, 198), Morocco (169), and Tanzania
(142).
The CPITN has been used extensively among
African populations since the early 1980s and data
are available for populations in most of the African
countries (2, 3, 35, 33, 40, 43, 50, 69, 78-80, 109, 116,
127, 139, 140, 143, 146, 155, 158, 163, 165, 167, 173,
205, 220, 221) (Table1).
Detailed and disaggregated data on gingivitis,
probing pocket depths, clinical attachment levels,
gingival recession or alveolar bone loss are available
for populations in Uganda (206); Kenya (24); Tanzan-
ia (19, 23, 70, 72, 117, 152, 183, 208); Guinea-Bissau
(135); South Africa (174); Nigeria (10, 126); Zaire
(108); Sudan (50); and Cameroon (34). Table2 details
the prevalence data available from studies in which
detailed recordings have been made among African
populations of gingival bleeding, radiographic bone
loss, probing pocket depth, clinical attachment loss
or gingival recession.
82
Methodological considerations
In a review which aims to synthesize the information
available on periodontal diseases among African
populations with a view to derive a few parsimoni-
ous and generalizable conclusions, some methodol-
ogical issues must be addressed: the multitude of
methods used for recording of periodontal diseases,
between examiner differences in the recordings and
the selection of the study groups from which the ob-
servations originate.
The methods used for recording
periodontal diseases
Use of the Russell PI involves the scoring of all teeth
present according to an ordinal scale of weights indi-
cating mild gingivitis, gingivitis, gingivitis with
pocket formation or advanced destruction with loss
of masticatory function (179). The tooth scores ob-
tained are combined into an arithmetic mouth mean
for the person and these individual PI scores are
further combined into a PI score for a group of per-
sons. The Russell PI was developed in a period char-
acterized by a very rm belief in the gingivitis-peri-
odontitis continuum (20), which is reected in the
amalgamation of signs of gingivitis and periodontitis
and in the recommendation to use the PI without
probing. The latter may have made the diagnosis of
pocketing very susceptible to the inuence of severe
gingivitis and poor oral hygiene. Moreover, the scor-
ing of signs of gingivitis and destructive periodontal
disease in the same weighted (ordinal) scale, and the
combination of these scores into mouth means and
further into group means assumes a generalized and
uniform distribution within the mouth and within
the group that effectively precludes an assessment of
the extent and distribution of destructive peri-
odontal disease in particular (20, 35). As a result of
these deciencies, the Russell PI have little bearing
on contemporary periodontal epidemiology and the
index is hardly ever used anymore.
The Community Periodontal Index of Treatment
Needs was developed as an extension of the Peri-
odontal Treatment Needs System (105) for the pur-
pose of identifying the prevalence and severity of
periodontal conditions with respect to treatment
needs in the community as well as in the individ-
ual (44). Use of the epidemiological part of the
CPITN, now called the CPI (218), involves the scor-
ing of 10 index teeth, representing sextants in the
mouth, on a nominal scale, according to the pres-
Periodontal diseases in Africa
Table1. An overview of the CPITN data for African populations
Reference Country 1519 years 3544 years
% persons who have as highest CPITN score
0 1 2 3 4 0 1 2 3 4
220, 221 Algeria 16 15 56 13 0 10 6 26 45 13
220 Benin 28 9 73 3 0
205 Burkina 8 10 82 0 0
Faso

0 3 97 0 0
3 13 84 0 0
221 Burkina Faso 0 0 1 25 75
220 Cap Verde 8 0 92 0 0
1 2 92 4 1
220 Djibouti 77 8 13 1 1
220, 221 Egypt 0 36 47 16 1 0 8 36 40 16
220 Ethiopia 0 36 54 9 0
40 Ghana 1 1 77 21 0
2 Ghana

24 1 73 2 0
6 1 89 4 0
3 1 91 4 0
220, 221 Ghana 9 16 72 2 1 4 9 49 32 5
25 Kenya 1 8 28 56 7 0 1 24 55 20
220, 221 Kenya 1 52 40 6 2 1 4 31 49 14
220, 221 Lesotho 15 30 49 6 0 8 3 55 28 6
220, 221 Libya 0 5 80 15 0 0 0 13 53 34
220, 221 Malawi 17 3 78 2 0 4 1 86 7 2
61 3 36 0 0
41 2 56 1 0
220, 221 Mauritius 1 20 41 33 5 0 1 19 48 32
78 Morocco

5 47 23 19 6 0 4 31 47 18
1 34 44 16 5 0 7 26 52 15
221 Morocco 4 4 46 28 14
3 5 31 40 16
220, 221 Namibia 0 1 90 9 0 0 0 83 15 2
2 15 20 35 25
79, 127 Namibia

6 47 47 0 0
58 36 6 0 0
42 41 17 0 0
220, 221 Niger 7 34 59 0 0 4 5 52 35 3
1 20 53 26 0
1 1 19 51 28
165 Niger 0 0 87 8 5
3 Nigeria 1 3 43 47 9 1 0 15 44 40
80 Nigeria

0 8 70 22 0
220, 221 Nigeria 1 3 46 42 8 1 0 15 45 39
8 12 60 20 0
4 11 85 1 0
220 Seychelles 1 4 93 0 0
83
Baelum & Scheutz
Table1. Continued
Reference Country 1519 years 3544 years
% persons who have highest CPITN score
0 1 2 3 4 0 1 2 3 4
155 Sierra Leone 0 3 44 44 9 0 1 5 42 53
221 Sierra Leone 19 21 46 14 0
220 Somalia 43 43 14 0 0
33 South Africa 2 1 11 96
173 South Africa 1 1 66 22 10
79, 127 South Africa 50 19 31 0 0
52 25 23 0 0
220, 221 South Africa 0 0 28 69 3 0 0 13 58 29
51 27 19 2 1
220, 221 Sudan 0 1 0 95 4 0 0 3 71 26
45 23 33 0 0
50 Sudan** 54 32 10 2
116, 220, 221 Tanzania 5 30 62 1 1 0 28 63 7
220, 221 Tanzania 19 62 1 0 6 3 81 9 1
0 1 18 57 23
6 3 81 9 1
146 Tanzania 3 5 85 8 0 5 1 83 11 0
220, 221 Zaire 1 96 2 0 1 1 93 4 1
0 0 39 45 16
69 Zimbabwe 23 21 47 8 0.4 9 9 60 19 4
220, 221 Zimbabwe 0 70 0 0 10 0 87 3 1

12 years;

1640 years;

11 years;

1219 years; *3554 years; **2065 years;



GOBD data quote 51%, which cannot be true
ence of pathologic pockets, calculus or gingival
bleeding. The scoring is done in a hierarchical
manner and a diagnosis is made of the worst nd-
ing in sextants and in subjects (7). The CPITN also
builds on a rm belief in the gingivitis-peri-
odontitis continuum but approaches the epidemi-
ology of periodontal diseases from the point of
view of the interventions that are considered
necessary, which has led to the inclusion of per-
ceived etiologic factors (calculus) in the scoring
system. The use of the CPITN for periodontal epi-
demiological purposes thus hinges on a view that
the signs and symptoms amenable to specic
forms of treatment can be used to indicate the
extent and severity of periodontal diseases. How-
ever, a comprehensive literature review indicates
that this view is not tenable (for review see: 20),
and the CPITN is of limited use for gaining insight
into the epidemiology of periodontal diseases.
Detailed recordings of gingival conditions, clinical
attachment level, probing pocket depth or radio-
graphic assessment of alveolar bone destruction may
be made on the full dentition or involve only partial
84
records of selected teeth. Clinical attachment levels
are either measured directly, or calculated on the
basis of measurement of probing pocket depth and
gingival recession. The use of detailed and disaggre-
gate recordings of gingivitis, probing pocket depth
and clinical attachment level reects a periodontal
disease paradigm in which periodontitis is not the
inevitable consequence of gingivitis; that the suscep-
tibility of teeth and individuals to periodontal dis-
eases may differ considerably; and that detailed data
focusing on the variation between populations, be-
tween subjects, between teeth and between sites are
needed in order to gain further insight into the pat-
terns of development and progression of gingivitis
and periodontitis (20, 35).
Comparability of the methods used to
record and report on periodontal
diseases
It is clear from the above that the methods used for
the recording of periodontal diseases in epidemio-
logical studies reect qualitatively different peri-
Periodontal diseases in Africa
odontal paradigms, and these differences make
comparability quite limited. Many studies have
shown that the prevalence and severity estimates, as
well as the distributional characteristics of the peri-
Table2. An overview of data on the prevalence of bone loss, clinical attachment loss (CAL), pocket depth and
recession among African populations
% persons with
Reference Country Age Bone Gingival CAL Pocket Recession
loss bleeding 4 mm 4 mm
206 Uganda 3544 44.3 36.4
55 83.7 57.9
10 Nigeria 15 62.1
19 57.5
20 60.4
21 59.9
126 Nigeria

1019 33.4
2029 58.0
3039 79.6
4049 85.8
5059 100
60 75.0
135 Guinea 12 91 9
Bissau 3039 93 83
5059 98 100
50 Sudan 2065 51.2
12 Tanzania 3034 79 45
3539 93 79
4049 95 89
50 98 84
183 Tanzania* 3444 5.2
117 Tanzania* 1545 93.8 5.2 27.2
70 Tanzania 7 32
8 32
9 37
10 28
11 23
12 23
12 27
13 28
152 Tanzania 715 100
24 Kenya 1524 18 75
2534 68 87
3544 91 83
4554 96 92
5565 99 95
108 Zaire 21 0
2130 2.2
3140 10.2
4150 33.3
5160 45.2
61 50.0

3mm; * 6mm
85
odontal conditions, differ considerably depending
on the method used for recording (5, 6, 14, 17, 24,
25, 27, 38, 45, 51, 73, 98, 99, 102, 111, 137, 138, 188,
189, 196, 197, 212). A large proportion of persons
Baelum & Scheutz
identied as healthy, or with gingivitis only, accord-
ing to their Russell PI scores will have periodontal
attachment loss (196). The proportion of persons di-
agnosed as having pockets is higher using the CPITN
than when the Russell PI is used (45). The CPITN is
ill-equipped to detect periodontitis susceptible
young persons as only 50% of the persons who have
clinical attachment loss of 2mm in at least 2 sites
may also present with deep pockets (17). In popula-
tions that are not a priori characterized as peri-
odontitis susceptible, the CPITN ndings indicate
worse periodontal conditions among young age
groups than do periodontal attachment loss nd-
ings, whereas the reverse is the case among older age
groups (27). The partial recordings in the CPITN lead
to underestimation of the prevalence of pocketing
(6, 25, 51, 73, 137) as scoring systems or recordings
based on partial selection of teeth are inherently bi-
ased towards an underestimation of the prevalence
of disease (4, 53, 66, 98, 99, 111, 172). Recording of
pocket depths may lead to gross underestimations of
the prevalence and severity of periodontal attach-
ment loss (27, 38, 138, 188, 189, 212). Taken together,
these differences make it impossible to draw valid
conclusions about the relative levels of periodontal
diseases in populations that have been examined
under different criteria.
The studies in which assessment of the peri-
odontal conditions are based on the use of the Rus-
sell PI or the CPITN indices are characterized by a
great deal of uniformity in the way the results are
presented. Typically, Russell PI data are presented in
the form of mean values for standardized age
groups, e.g. 59, 1014, 1519, 2024years, etc. The
CPITN data are presented as the worst recording
found in a person (prevalence data) or as the mean
number of sextants affected (severity data), for the
indicator age groups 1519, 3544 and 6574years.
Unfortunately, a similar uniformity does not exist
among the studies in which more detailed record-
ings of the periodontal conditions have been per-
formed. The results of these studies are presented in
the form of mean marginal bone loss index (34); %
persons with radiographically visible bone loss (108);
% persons, teeth or surfaces with recession (10, 208);
% persons or teeth with gingival inammation (10,
70); % persons or teeth with 3mm pockets (126);
mean gingival index, mean probing pocket depth
and mean clinical attachment loss (174); % persons
with pocket depth 4mm or clinical attachment
loss 4mm in CPITN index teeth (50); cumulative
frequency distributions of persons according to the
proportion of surfaces with pockets 4mm, 6mm
86
or 7mm (24, 135, 206), recession 1mm or 4
mm (135), or clinical attachment loss 4mm or 6
mm (206); cumulative frequency distributions of
persons according to the proportion of surfaces with
clinical attachment loss 4mm or 7mm (24); sur-
face prevalence of gingival bleeding (23, 135, 152);
cumulative frequency distributions of persons ac-
cording to the number of surfaces with pockets 4
mm or 7mm, or with clinical attachment loss 4
mm or 7mm (23); cumulative frequency distri-
butions of persons according to the number of sur-
faces with pockets 6mm (183); mean and median
number of teeth with pockets 3.55.5 and 5.5mm,
with recession 3.5mm or with gingivitis (117). As
the age groups studied also differ considerably be-
tween studies, it is exceedingly difcult to try to
undertake comparisons of the periodontal con-
ditions across populations that have been examined
using detailed and disaggregate recordings of gingi-
val inammation, recession, probing pocket depth,
clinical attachment loss or alveolar bone loss.
Comparability between examiners
The extent to which between-examiner differences
may inuence the comparisons of periodontal dis-
ease levels between populations examined by differ-
ent examiners using the same criteria remains a con-
troversial issue. When A.L. Russell designed the PI to
alleviate the paucity of reliable epidemiologic data
(179) he was very aware that the primary requisite of
an epidemiologic method is comparability of results,
mentioning wide variations in the skill and judg-
ment of individual examiners as one of the major
sources of variation that might preclude such com-
parisons. Unfortunately, very little data exist on the
between examiner agreement when periodontal
conditions are assessed using the PI or the CPITN
index systems, probably owing to the fact that these
indices from their very birth were launched as index
systems designed precisely to allow for quantitative
comparisons between or within human populations
(179) or to ensure simplicity, speed and interna-
tional uniformity (44, 167). However, the data pre-
sented by Russell (179) indicate that differences be-
tween examiners in the PI recordings may amount
to as much as 30% of the maximum PI score as-
signed. These results were obtained in children with
rather low PI scores by examiners who had in fact
been trained and calibrated prior to the assessments
and the extent of differences between noncalibrated
examiners in populations with higher PI scores re-
mains unknown.
Periodontal diseases in Africa
Even though one of the main purposes of the Rus-
sell PI was to provide a tool which through rigid
suppression of examiner judgment could be used to
dene the relative prevalence (or risk) by contrast
in two populations (179) the Russell PI literature is
characterized by rather ambiguous views regarding
the impact of between examiner differences. While
some have stated that Due to lack of intercali-
brations of the various surveyors prior to the studies,
no reliable gures can be quoted regarding the abso-
lute differences in severity from one area of the
world to another (171), and A comparison of the
severity of periodontal disease in Uganda with that
found in other countries is of limited value, since
the scoring of the individual investigators may vary
considerably (198) such comparisons nevertheless
remain the hallmark of the Russell PI era, and the
Russell PI literature is replete with between popula-
tion comparisons.
There is little doubt, however, that between
examiner differences in the detailed assessment of
clinical attachment levels, probing pocket depth
and alveolar bone loss may be considerable (1, 18,
24, 122) and may seriously jeopardize the validity
of conclusions drawn based on comparisons of the
results of examinations that have been carried out
by different (noncalibrated) examiners. While be-
tween-examiner differences may to some extent be
accounted for through the inclusion of dummy
variables in analytical studies employing multiple
examiners (122), there is no way of correcting for
the possible between examiner bias in descriptive
studies. Apart from jeopardizing the external valid-
ity of the results of a given study, between exam-
iner differences may also compromise the internal
validity. As an example, the between examiner dif-
ferences in the recordings of clinical attachment
levels are likely to be more and larger at the lower
end of the scale of measurements than at the more
severe end (unpublished data). As clinical attach-
ment level loss tends to increase with increasing
age examiner discrepancies may therefore also
serve to distort comparisons between different age
groups examined by the same examiner.
Representativity of study groups
It is a widely held belief that the generalizability of
ndings from a particular study depends on the
study group being representative of the general
population. One of the dictums arising from this
concept is that valid comparisons of disease levels
between two (or more) populations (e.g. countries)
87
can be made only if the study groups are representa-
tive of the underlying, general populations. Hence,
in reviews on the epidemiology of periodontal dis-
ease one may nd statements such as In selecting
publications for inclusion in this chapter... consider-
ation has been given to ... whether the sample could
be considered to be representative of the general
population (103). However, for reasons that will be
detailed in the following, this request for repre-
sentativity of study groups for reasons of generaliz-
ability is a theoretical objective more than a practi-
cally achievable goal.
Representativity means that the study subjects are
represented in the study group (the actual group of
persons examined) with a frequency corresponding
to their occurrence in the population at large (the
target population) with respect to all the character-
istics that are important (causally related) to the
phenomenon under study (e.g. periodontal dis-
eases). However, for any given disease entity a multi-
tude of variables may be important for representativ-
ity and these may be grouped in one of three main
categories (128): time variables (e.g. decade, calen-
dar year); place variables (e.g. country, region); and
person variables (e.g. age, gender, ethnicity, socio-
economic status, educational level, etc.). For peri-
odontal diseases, it is known that there may be
major effects on disease levels of a large number of
time variables (30, 52, 91-95, 97); of place variables
(16, 21, 46, 120, 121); and of person characteristic
variables (for review see: 20). In addition to the
known factors, a potentially large number of un-
known determinants may be operating. Ensuring
representativity of a study group therefore means
ensuring representativity with respect to a very large
number of known and unknown factors.
The issue of representativity of study groups be-
comes particularly pertinent when between popula-
tion contrasts are considered using broad denitions
of the target population, for example when dening
the target population at the national level. However,
it is precisely these broader between population
contrasts that could be important, as it is likely that
the distributions of disease, as well as of the determi-
nants of disease, are much more heterogeneous
across populations than within populations (177). In
the words of Rose (177): To nd the determinants
of prevalence and incidence rates, we need to study
characteristics of populations, not characteristics of
individuals.
In the presence of known, as well as unknown de-
terminants, the only way to try to achieve a repre-
sentative study group is to generate a random
Baelum & Scheutz
sample of the target population. The idea is that
simple random sampling will, with the caveat of the
statistical concept of in the long run, ensure a ran-
dom, and thereby unbiased, distribution in the
sample of all the determinants for the disease in
question. However, the generation of random
samples from a given population depends on the
existence of detailed demographic information, and
such is rarely available for African populations. It is
therefore not surprising that most of the data de-
scribing the periodontal conditions among African
populations are based on studies of convenience
samples. When random sampling has been per-
formed in the epidemiological studies among
African populations, it has almost always been in the
form of stratied random cluster sampling (24, 33,
67, 69, 71, 78, 116, 143, 145, 146, 163, 192, 205) of
persons in well dened, but nationally restricted
geographic locations, e.g. selected villages, towns,
counties, provinces, or regions of a country. The
clusters used have typically been households, 10-
cells, teaching institutions or school classes.
However, even if a random sample has been gen-
erated, there may still be a considerable difference
between the sample generated and the population
that can actually be studied. Only rarely is it possible
to motivate everybody in a sample to participate in
the examinations. If the proportion of nonpartici-
pants is large and selective, a severe distortion of the
study group relative to the study sample may be the
result. In case of dental surveys in an African setting
it is, for example, quite likely that persons who have
some form of dental complaints are more willing to
participate in an epidemiological study than are per-
sons without such complaints, particularly as dental
health services are scarce. This has led some to ex-
clude those persons who appear at the examination
site asking for dental treatment (198), which on the
other hand may bias the results towards under-
estimation of disease levels. In other settings the
scenario could well be the reverse, i.e. persons who
have ample access to dental health care may decide
not to participate in a study precisely because they
consider all is well. Unfortunately, very few reports
on periodontal epidemiological studies conducted
among African populations contain information on
the number and distribution of nonparticipants (24,
130). It is therefore exceedingly difcult to evaluate
the magnitude of selection bias in these periodontal
epidemiological studies.
This discussion of the practical difculties in-
volved in obtaining representativity of study groups
leads to the conclusion that the generalizability of
88
ndings from epidemiological studies is more a mat-
ter of scientic conjecture than of the statistical
mechanics of establishing the study groups (178).
Synthesis of the knowledge derived from the many
observations made over many decades by different
observers using different methods of recordings in a
large number of diverse study groups is a process
that goes beyond the sampling procedures and the
statistical considerations. The hallmark of scientic
reasoning is to evaluate a particular set of obser-
vations in the light of what is known about factors
that could have inuenced the ndings. In the pres-
ent context, the crucial issue is to judge to what ex-
tent differences between sets of observations could
represent artifacts, i.e. have arisen due to methodol-
ogical factors, such as different recording methods,
between examiner differences, ill-dened (or differ-
ent) survey sampling methods, and low study par-
ticipation rates, or whether they can be attributed to
real differences reecting different exposures. De-
tailed knowledge regarding most of these possibly
very inuential methodological factors is insufcient
for essentially all the African population groups
examined for periodontal diseases. It is therefore ex-
ceedingly difcult to draw valid conclusions regard-
ing the levels of periodontal diseases based on be-
tween population contrasts, particularly national
contrasts. Although conceivably smaller, similar
problems may also exist for within population com-
parisons.
Periodontal diseases among
African populations
In view of the many methodological factors that
could inuence the results of comparisons of studies
made in different populations at different time
periods, using different recording methods, different
examiners, different sampling schemes, etc., we nd
it most appropriate to discuss the data on the epi-
demiology of periodontal diseases among African
populations broadly based on the conclusions actu-
ally drawn by the different investigators themselves.
The Russell PI data
As previously mentioned, between population com-
parisons were the hallmark of the Russell PI era (171,
180, 181) and the Russell PI studies carried out
among African populations led to a general consen-
sus that the prevalence and severity periodontal dis-
Periodontal diseases in Africa
ease was very high among African populations.
Ramfjord et al. (171) thus concluded that there is An
almost 100% prevalence of periodontal disease in
developing countries. However, the requirements for
judging a person free from periodontal disease were
very strict. As an example, Skougaard et al. (198)
concluded that their data showed a high prevalence
of periodontal disease in Uganda as none of the
1394 persons examined had a PI score of 0. Thereby,
the requirement for being diagnosed free from peri-
odontal disease was complete absence of signs of
gingivitis or worse periodontal conditions.
The Russell PI ndings in African populations
were also seen to support the view that periodontal
diseases are more prevalent and severe among
African populations than among populations in de-
veloped countries (193, 211). The higher severity of
periodontal diseases among African populations was
almost singularly attributed to the very poor oral hy-
giene levels observed among these populations. Rus-
sell thus concluded (181) None of these differences
(between population differences [authors insert]), as
far as it is independent of age and mouth cleanli-
ness, can exert very much effect on disease scores;
90% or more of the variance in the PI is accounted
for by the combined effect of age and oral hygiene,
no matter which combination of populations is
studied and Ramfjord et al. (171) went on to say ...
the effect of other conditions related to the severity
of periodontal disease, such as age, sex, race, geogra-
phy, urban and rural living, income, education, and
nutrition, all can be explained almost entirely on the
basis of the differences in the oral hygiene status.
However, more recent analyzes of the Russell PI
data have demonstrated that these views are not ten-
able. Hence, a comparison of the data on peri-
odontal disease presented by Sheiham (192, 194) on
populations in Nigeria and Great Britain revealed a
relationship between age, oral hygiene (OHI scores)
and Russell PI scores which is inconsistent, not only
with the view that a xed and universally valid re-
lationship exists between these parameters, but also
with the view that African populations are more se-
verely affected than populations in developed coun-
tries (20, 26). Thus, the British population exhibited
much higher PI scores than the two Nigerian popula-
tions studied, but had better or similar oral hygiene
conditions (Figs13).
The data on the rural Nigerian populations exam-
ined by Sheiham (192) (Figs. 2 and 3) are the only
data sets on African populations that originate in ob-
servations made by the same examiner within a
short time period using the same criteria and com-
89
parable sampling methods. In the Yoruba villages,
the whole population was examined, whereas in the
Ibo villages, random cluster sampling was employed.
The data clearly indicate higher PI scores among the
Yoruba than among the Ibo populations, but the oral
Fig. 1. Russell PI and OHI scores according to age for a
British population(180).
Fig. 2. Russell PI and OHI scores according to age for a
rural Nigerian (Yoruba) population (180).
Fig. 3. Russell PI and OHI scores according to age for a
rural Nigerian (Ibo) population (180).
Baelum & Scheutz
hygiene scores were also higher for the Yoruba popu-
lation than for the Ibo population. An attempt was
made to compare the two populations taking into
account the oral hygiene scores, and this resulted in
a slight tendency for Ibos within each range of Oral
Hygiene to have less severe periodontal disease than
Yorubas with a similar Oral Hygiene Index (192).
However, because of the small numbers in each
group and the distributions of the Periodontal
Indexes, statistical testing was inappropriate (192).
The Russell PI data on African populations show
that mean PI scores increase with increasing age,
such that the PI scores observed among the oldest
age groups in many populations are consistent with
the diagnosis of advanced or even terminal peri-
odontal disease (179). It is therefore somewhat sur-
prising that in the Russell PI era very little emphasis
was placed on describing the results of these severe
periodontal conditions in terms of tooth loss. The
Russell PI literature on African populations is thus
essentially devoid of data on tooth loss, although
some inference may be made on the basis of those
studies in which DMFT (decayed, missing or lled
teeth) data are also presented for the populations
studied. Mean DMFT values were lower than 5
among the 4549years-old East and West Africans
studied by Akpabio (8), among the 4554years-old
Ethiopians studied by Olsson (160, 162), and among
the 50 year-old Nigerians studied by Sheiham
(191, 192), lower than 3 among 50 year-old Ethiop-
ians studied by Littleton (119), and lower than 2
among the 3039-year old Sudanese examined by
Emslie (57). This indicates comparatively low levels
of tooth mortality even among middle-aged and
elderly African populations. Answering the question
why the mean number of missing teeth in the older
age groups was so low relative to the high percentage
of persons who were in the terminal stages of peri-
odontal disease, Sheiham (2) ascribed this nding to
the fact that with approximately 50 dentists for 55
million people, teeth are relatively seldom extracted
by professional persons. Nigerians may therefore re-
tain their teeth until they become so mobile as to
allow easy extraction without the use of dental in-
struments. By deduction, such mobile and easily ex-
tracted teeth do not seem to have been a very fre-
quent outcome of terminal periodontal disease
among the Nigerian populations studied. In this
context, it is noteworthy that having described the
universality and severity of periodontal disease
among the East and West African populations exam-
ined, Akpabio (8) concluded his report with the fol-
lowing statement: Although periodontal disease ap-
90
pears to be almost universal amongst the African
population I examined, it seems that extensive use
of Dental Hygienists could alleviate the condition
considerably, and serve as an effective preventive
measure, in most cases.
The CPITN data
The most prominent ndings when African popula-
tions have been examined using the CPITN is the
very high prevalence of calculus in 1519-year-old-
as well as in the 3544-year-old-age groups (Table1).
Persons with a healthy periodontium (CPITN score
0) are rarely observed, and gingival bleeding is the
worst condition in only a minor proportion of the
persons examined. While shallow pocket depths of
3.55.5mm are relatively frequent, deep pockets
(5.5mm) are rather infrequent (Table1). When the
number of sextants with the various CPITN scores is
considered, these contrasts become even more pro-
nounced, and the mean number of sextants with
deep pockets is typically less than 0.5 among 3544
years-old age groups (69, 78, 140, 143, 221), although
values in the order of magnitude of 1 sextant per
person have been reported (31, 55, 221).
As previously mentioned, the CPITN approaches
the epidemiology of periodontal diseases from the
point of view of identifying levels of periodontal
conditions in populations for which specic inter-
ventions might be considered (166). However, the
few attempts that have indeed been made to trans-
late the periodontal conditions observed among
African populations into treatment needs estimates,
as recommended (7), have resulted in treatment
needs estimates that are completely out of pro-
portion to the African reality. Based on data from the
national survey in Nigeria, Eigbe (55) estimated that
a total of 32,031 working years would be required to
perform oral hygiene education, 19,093 working
years would be required to complete scaling, and 803
working years would be needed to complete com-
plex periodontal treatment according to the CPITN
for the Nigerian population. Similarly, Mumghamba
et al. (146) estimated that 26,000 working years
would be required to treat the Tanzanian population
according to the recommendations inherent in the
CPITN, and Manji & Sheiham (132) estimated that
the treatment needs (excluding follow-up care) ac-
cording to the CPITN for the total Kenyan child
population aged 515years would amount to be-
tween 1,432 and 4,297 working years. These nding
led to the conclusion that the practical conse-
quences of using the CPITN for planning purposes
Periodontal diseases in Africa
are that the amount of resources apparently required
to provide care is excessive by any standards and
that the estimates are quite out of proportion to the
public health importance of the periodontal diseases
in the population (132). Leaving aside that the effect
on a population of actually providing the treatments
recommended remains undocumented, these esti-
mates clearly show the inappropriateness of the
CPITN as a tool for planning dental health services.
Although attempts have recently been made to de-
emphasize the treatment needs aspect of the CPITN
by renaming it to the Community Periodontal Index
(CPI) (218) and by recommending recording of loss
of attachment in the CPI index teeth, it remains a
fact that the index does still not describe the full
extent of loss of attachment in an individual (218).
The usefulness of the CPI/CPITN data for under-
standing the epidemiology of periodontal diseases is
therefore limited (20, 28).
Data on probing pocket depth, clinical
attachment loss and gingival recession
Irrespective of whether the periodontal condition
under consideration is gingivitis, probing pocket
depth, gingival recession, clinical attachment loss or
alveolar bone level, the detailed periodontal record-
ings have four dimensions: i) the severity in each
site, (ii) the number and types of sites affected in
each tooth, (iii) the number and types of teeth
affected in each person, and (iv) the number of per-
sons affected in the study population. Unfortunately,
the traditional ways of dealing with these many di-
mensions in data sets that are based on detailed and
disaggregate recordings of the periodontal con-
ditions have either been to calculate mean values
(34, 117, 174) or to focus on only one of the dimen-
sions (10, 108, 126, 152, 208). However, detailed data
do exist on African populations which may be used
to glean information on the distribution of persons
according to the severity of the periodontal con-
ditions (23, 24, 50, 135, 206).
Figs. 48 are based on data from a detailed study
of the periodontal conditions among 1131 adult Ken-
yans aged 1565years (24) and represent the typical
ndings from these studies. The cumulative fre-
quency distributions demonstrate that clinical
attachment loss 1mm is very prevalent as 70% of
the 1519years old Kenyans have at least one site
affected, and attachment loss 1mm may be found
in virtually all persons over the age of 25years exam-
ined (Fig. 4). Moreover, there is a marked increase
with increasing age in the number of sites with clin-
91
Fig. 4. The cumulative frequency distribution of adult
Kenyans according to the number of sites per person with
clinical attachment loss 1mm (19).
Fig. 5. The cumulative frequency distribution of adult
Kenyans according to the number of sites per person with
clinical attachment loss 4mm (19).
Fig. 6. The cumulative frequency distribution of adult
Kenyans according to the number of sites per person with
clinical attachment loss 7mm (19).
Baelum & Scheutz
ical attachment loss 1mm as seen from the shift
upward towards the right of the cumulative fre-
quency distribution curves. Clinical attachment loss
4mm is also frequently observed, affecting be-
tween 18% and 99% of the persons examined, de-
pending on age (Fig. 5). However, for all age groups
a marked right skewedness is observed of the cumu-
lative frequency distributions such that a relatively
minor, but increasing with age, fraction of the study
population has a high number of sites affected. This
right skewedness of the cumulative frequency distri-
butions is even more pronounced when clinical
attachment loss 7mm is considered (Fig. 6). Prob-
ing pocket depths 4mm are frequently observed,
affecting between 75% and 95% of the subjects
examined, depending on age (Fig. 7), although a pro-
nounced right skewedness is also observed for this
parameter. Deep periodontal pockets (7mm) are
Fig. 7. The cumulative frequency distribution of adult
Kenyans according to the number of sites per person with
probing pocket depth 4mm (19).
Fig. 8. The cumulative frequency distribution of adult
Kenyans according to the number of sites per person with
probing pocket depth 7mm (19).
92
less frequent, affecting 3%-38% of the persons, de-
pending on age (Fig. 8), and right skewedness is very
pronounced, indicating that the major burden of
pocketing is observed in a small fraction of the study
population. Moreover, a substantial number of sites
may have clinical attachment loss in the absence of
a deepened pocket, indicating that the essential
characteristic of breakdown is that of a gradual re-
cession of the highly inamed gingival margin ac-
companying the loss of attachment (24). Taken to-
gether, these observations may be interpreted to
show that severe destructive periodontal disease
among African populations is conned to a minority
of persons (20, 24). Furthermore, as very poor oral
hygiene conditions prevail and gingivitis is wide-
spread and severe in these African populations (23,
24, 135, 174, 206), the ndings have been interpreted
to contest the poor oral hygiene-gingivitis-peri-
odontitis-tooth loss continuum. Based on obser-
vations among adult Kenyans the following was con-
cluded: From a holistic viewpoint, it seems that in
humans it is possible to have a massive microbial
accumulation along the marginal periodontium for
a period of some 20years (from 6 to 25years of age)
without there being any signicant sign of irrevers-
ible breakdown except at a few sites in a minority of
individuals. This appears to be the case, despite the
marginal gingival being markedly inamed through-
out this period of time. Even at late age, a substantial
number of individuals remain almost unaffected by
clinical attachment loss despite the presence of se-
vere gingivitis (24).
This interpretation has been met with a great deal
of off-the-record skepticism, primarily from the
proponents of the gingivitis-periodontitis-tooth loss
continuum. The main counter arguments have been
that the African populations available for study rep-
resent survivors whose host resistance factors are
better than among other more average population
groups or that the periodontally diseased teeth have
been lost already. While the possible impact of the
survivorship argument cannot be evaluated, it re-
mains a fact, however, that not only do African
populations retain a large number of teeth, they also
retain more teeth than is typically seen for similar
age groups in European and North American popu-
lations (23, 34, 117, 130, 135, 192, 206) (Table3).
Moreover, studies which have attempted to assess
the reasons for tooth loss among African popula-
tions, either in the form of actual extractions or in
the form of teeth indicated for extraction for various
reasons, have typically concluded that dental caries
is the main reason for tooth loss among African
Periodontal diseases in Africa
populations and far exceeds periodontal disease as
a cause of tooth loss (22, 67, 107, 130, 206). When
assessing the reasons for tooth loss among African
Table3. Mean number of teeth retained among adult African populations
Reference Country Age group Mean no. of Remarks
teeth present
34 Cameron 4673 24.6 max. 28 teeth
135 Guinea-Bissau 3039 29.6 max. 32 teeth
5059 24.4
131 Kenya 1524 30.0 max. 32 teeth
2534 30.1
3544 28.6
4554 26.9
55 24.1
125 Nigeria 2029 27.3 max. 28 teeth
(dental clinic 3039 26.6
population) 4049 25.0
5059 22.7
60 21.5
192 Nigeria 2024 27.9 max. 28 teeth
(urban 2529 27.8
population) 3034 27.6
3539 27.0
4044 26.5
4549 24.9
50 23.9
193 Nigeria 2024 28.0 max. 28 teeth
(rural 2529 27.8
population) 3034 27.4
3539 26.4
4044 26.8
4549 27.2
50 23.8
67 Tanzania 2534 30.5 max. 32 teeth
3544 30.1
4554 29.1
22 Tanzania 3034 29.5 max. 32 teeth
3539 28.5
4049 26.5
50 23.9
208 Tanzania 2034 27.2 max. 28 teeth
3544 26.3
4564 21.9
117 Tanzania 1519 27.0 max. 28 teeth
2024 27.3
2529 26.8
3044 26.7
45 25.0
206 Uganda 3544 30.5 max. 32 teeth
55 28.8
68 Zimbabwe 1519 28.1 max. 32 teeth
3544 24.7
93
populations, one must take into account that teeth
may be extracted or mutilated for ritual reasons.
Such customs are practiced with varying intensity in
Baelum & Scheutz
different tribal groups and typically affect upper or
lower incisors and canines (8, 37, 57, 114, 130, 154,
155, 202, 206). These customs could compromise the
assessment of the causes of tooth loss if due account
is not made of the possibility of tribal extractions.
A few attempts have been made to compare the
ndings on attachment loss, periodontal pocketing
and tooth loss among African populations with the
ndings in other populations in different parts of the
world (21). The result of these comparisons was a
striking similarity between population groups orig-
inating in very different socio-economic, ethnic and
cultural environments with respect to their destruc-
tive periodontal disease proles, although the South
Pacic Island population groups studied by Cutress
et al. (46) appeared to be more severely affected by
periodontal attachment loss. However, in view of the
fact that the effect of between examiner differences,
different sampling methods, and different partici-
pation rates remain unaccounted for, it is still un-
clear whether the apparent similarity between
attachment loss levels in different populations does
indeed mask true between population differences in
the levels of destructive periodontal disease. As the
exposure to the determinants of the periodontal dis-
eases is likely to be vastly different between the dif-
ferent population groups studied, with Sri Lankan
tea plantation workers (121), rural Chinese and rural
Kenyans (21) at the one end of the spectrum, and
Japanese (223) and US citizens (136) at the other end
of the spectrum, such comparisons may, however, be
of vital importance for the further elucidation of the
causes of the incidence of periodontal diseases
(177).
Analytical periodontal
epidemiological studies microbial
risk factors
The literature on the epidemiology of periodontal
diseases among African populations is essentially
devoid of longitudinal studies, and risk factor
studies, apart from the many in which oral hygiene
scores have been bivariately related to periodontal
index scores, are very few. Higher Russell PI scores
have been associated with higher age, higher oral hy-
giene scores and lower socio-economic status
among Nigerian populations (61). The risk factors for
gingivitis among adult Tanzanians were male gender,
presence of plaque or calculus and use of chewing
stick for oral hygiene procedures (145). The risk fac-
94
tors for periodontal pockets were age of 35years or
more, presence of plaque and rural residence, and
the risk factors for gingival recession were age of 35
years or more, male gender, lower educational sta-
tus, and presence of plaque and gingival inam-
mation (145).
Microbiological studies indicate that the strains of
Actinobacillus actinomycetemcomitans, Porphyro-
monas gingivalis and Prevotilla intermedia isolated
among adult Kenyans are similar to both type strains
and strains isolated from Swedish adults (47). How-
ever, A. actinomycetemcomitans, P. gingivalis and P.
intermedia can be isolated more frequently among
adult Kenyans than among European and North
American populations. Among the seven putative
periodontopathogens assessed, P. gingivalis was the
only microorganism that could distinguish between
diseased sites (attachment loss 5mm and pocket
depth 4mm) and nondiseased sites (attachment
loss 1mm and pocket depth 3mm) as well as be-
tween the diseased and nondiseased rural Kenyan
individuals (48). Sudanese and Norwegian peri-
odontitis patients harbored P. intermedia, P. gingi-
valis, A. actinomycetemcomitans, Fusobacterium nu-
cleatum and Capnocytophaga species in similar
levels, the only difference being high levels of enteric
rods among the Sudanese patients (12). Tanzanian
cases (dened as persons having 3 teeth with
pockets 5mm) had higher spirochete counts in
sites with shallow pockets than did controls (dened
as persons with no pockets 3mm), indicating a
host effect on the subgingival microora (118). A
study from Cameroon demonstrated that peri-
odontitis patients (dened as persons with at least 4
pockets 6mm) tested positive for P. gingivalis,
Bacteroides forsythus, A. actinomycetemcomitans, F.
nucleatum, Treponemas denticola, Campylobacter
rectus, Peptostreptococcus micros, Selenomonas nox-
ia, Streptococcus intermedius, Eikenella corrodens,
and Veillonella parvula more frequently than did
healthy subjects (no pockets 3mm), whereas Strep-
tococcus mitis, Streptococcus sanguis, and Actinomyc-
es naeslundii were more frequently detected in the
healthy than in the diseased persons (13). This study
concluded that the prevalences of the investigated
putative periodontal pathogens and benecial spe-
cies in the healthy and diseased Cameroonians were
similar to those reported for adults in the West and
in some developing countries (13) and this con-
clusion seems to cover most of the observations
made among African population groups. Notwith-
standing this, some evidence has been provided that
a microbial diversity may exist which could distin-
Periodontal diseases in Africa
guish some African populations from other popula-
tions. Hence, Haubek et al. (81, 83, 84) demonstrated
the existence of a highly toxic clone of A. actinomyce-
temcomitans which seems conned to juvenile peri-
odontitis patients of African origin. This clone has
moreover, been associated with the occurrence of
early onset periodontitis patients among Moroccan
adolescents (82).
Special forms of periodontal
diseases among African
populations
Relatively little information is available on the preva-
lence and distribution of special forms of peri-
odontal diseases, such as early onset periodontitis,
necrotizing ulcerative gingivitis, and noma (cancrum
oris), among African populations. The fact that the
nomenclature regarding periodontitis in teenagers
and young adults has undergone many changes over
the years has further contributed to the shortage of
information about early onset periodontitis. Until a
few decades ago, the term periodontosis was used
to describe a form of periodontal destruction occur-
ring in teenagers and young adults in whom the ex-
tent and severity of destruction was considered in-
commensurate with the amount of debris and calcu-
lus observed. Later, early onset periodontitis was
considered to encompass a group of diseases diag-
nosed in persons under the age of 35years, the main
groups being prepubertal, juvenile, and rapidly pro-
gressive periodontitis. The most recent development
in the classication of periodontal diseases among
children and adolescents is the recommendation to
discard the term early onset periodontitis in favor of
aggressive periodontitis (110). As these changes have
bearings for the criteria used to diagnose the con-
ditions, it is necessary to review the literature ac-
cording to the classication adhered to by the inves-
tigators.
Early onset periodontitis/periodontosis
Emslie (56) reported 5 cases of periodontosis, all of
whom were teenagers, except for one 21year-old,
among Nigerian children and young adults. How-
ever, the total number of subjects examined was
not stated, and it is therefore not possible to derive
a prevalence estimate based on the information
provided. Akpabio (8) reported on occasional cases
of degenerative periodontitis complex among
95
Ghanaian and Nigerian persons under the age of 25
years. Littleton (119) found no cases of peri-
odontosis among 1085 Ethiopians aged 584years.
Emslie (57) found 3 cases of periodontosis among
645 persons aged 1519years in Sudan, yielding a
prevalence estimate of 0.5%. The most systematic
attempts to estimate the prevalence of early onset
periodontitis are those of Harley & Floyd (80) and
Albandar et al. (11). Based on a screening examina-
tion of more than 1000 schoolchildren, Harley &
Floyd (80) estimated the prevalence of juvenile
periodontitis among 1219years old Nigerians to be
0.8%. In huge contrast with these ndings, Alband-
ar et al. (11) reported that 28.8% of Ugandan school
attendees aged 1225years had early onset peri-
odontitis. The difference between the results of
these two studies is even more pronounced when
the criteria for detecting early onset periodontitis
are considered. Hence, while Harley & Floyd (80)
used radiographic evidence of a distance between
the alveolar bone and the CEJ 2mm as the indi-
cator of early onset periodontitis, Albandar et al.
(11) used much more strict criteria, presence of
clinical attachment loss 4mm in interproximal
sites, for a positive diagnosis of early onset peri-
odontitis. In the latter study, the attachment levels
were calculated based on recordings of gingival re-
cession and pocket depth, and this may have given
rise to an exaggeration of the attachment loss. Con-
versely, projection geometry may easily lead to a
masking of incipient bone loss, and the results of
Harley & Floyd (80) could therefore underestimate
the prevalence. If, on the other hand, both assess-
ments are valid, the results indicate that huge con-
trasts may exist, and that Ugandan populations
may have an exceptionally high prevalence of early
onset periodontitis. Although the information is
limited, the data available do not uniformly indi-
cate the prevalence of periodontitis to be substan-
tially higher among African children and adoles-
cents than among similar age groups in other
populations (for review see: 103).
Necrotizing gingivitis and noma
(cancrum oris)
Most reports on African populations point to the fact
that necrotizing gingivitis and its serious sequela,
noma (cancrum oris), is conned to children (8, 56,
58, 101, 129, 159, 164, 191). However, the prevalence
estimates vary considerably depending on country
and region. Sheiham (190, 191) estimated the preva-
lence of necrotizing gingivitis among Nigerian
Baelum & Scheutz
children aged 26years to range between 1.7% and
26.9%, depending on location. Enwonwu (58) esti-
mated the prevalence of necrotizing ulcerative gingi-
vitis to be 15.3% among rural Nigerian children aged
010years, with most cases seen from 2 to 6years.
Taiwo (203, 204) observed necrotizing ulcerative gin-
givitis in 27.4% of the children under the age of 12
years attending a dental clinic in Nigeria, with esti-
mates ranging from 2.4% of the children with good
oral hygiene to 66.7% of the children with poor oral
hygiene. A large epidemiological study conducted
among children in Senegal showed an overall preva-
lence of necrotizing ulcerative gingivitis among 0
14-year-old-children of 2.1%, with the majority of
cases being observed among the 19years olds (150).
Olsson (162) did not observe a single case of acute
necrotizing gingivitis among 1,700 Ethiopians aged
654years, whereas Littleton (119) found two young
persons with ulceromembranous gingivitis among
1085 Ethiopians aged 584years. Emslie (57) found a
single case of acute ulcerative gingivitis among 54
children under the age of 10years in Sudan. Kaimen-
yi (106) found 82 cases of acute necrotizing gingivitis
among 53572 patients attending a hospital dental
clinic in Kenya. Thirty of these cases were seen in
children aged 26years, 16 cases were seen among
710-year-old children, and 22 cases were observed
among 2130-year-old-persons. Although the preva-
lence among 010-year-old children was low
(0.15%), the observation of a substantial number
of cases of necrotizing gingivitis among the 2130-
year olds was remarkable, and possibly attributable
to the upsurge of AIDS (106).
It is widely held that noma (cancrum oris) de-
velops from a precursor lesion in the form of necrot-
izing ulcerative gingivitis, but little is known about
the frequency of this transition. Noma has been ob-
served in Sierra Leone (37), South Africa (115), Gam-
bia (129), Nigeria (60, 101, 159, 164, 190) and Senegal
(150) and prevalence estimates in the order of mag-
nitude of 0.1% among 06-year-old children have
been quoted (62). These estimates corroborate the
ndings of Sheiham (190) who observed 2 cases of
noma and 6 cases with evidence of past cancrum
oris among 3,507 Nigerian children examined. How-
ever, in a large epidemiological survey conducted
among more than 50,000 children aged 014years in
Senegal, 12 cases of noma were found, yielding a
somewhat lower prevalence estimate of 0.02% (150).
Moreover, in view of the fact that 2.1% of these Sen-
egalese children had necrotizing gingivitis (150), it
would seem that the progression from necrotizing
gingivitis to noma is a relatively infrequent event, an
96
interpretation that corroborates previous obser-
vations (58). Several studies indicate the risk factors
for necrotizing gingivitis and noma among African
children to be poverty, malnutrition, poor oral hy-
giene, antecedent infectious diseases, such as
measles, close proximity to livestock and poor sani-
tary conditions (42, 58, 60, 62-64, 101, 115, 164, 186,
203, 204).
Trends for change in the
occurrence of periodontal diseases
in Africa
In the industrialized part of the world, two major
factors have been identied as possibly inuential
in altering the epidemiological characteristics of
periodontal diseases over time: improved oral hy-
giene levels and a change within the dental health
profession towards more conservative approaches
to the treatment of periodontal diseases, in particu-
lar destructive periodontal disease (for review see:
20). The improved oral hygiene conditions manifest
themselves in reduced levels of gingivitis (52, 94),
but the possible effect of this improvement on the
levels of destructive periodontal disease may be
overshadowed by the effects of improved tooth re-
tention. Hence, studies indicate that increased
tooth retention may be accompanied by increases
in the prevalence and severity of destructive peri-
odontal disease (95, 96), possibly as a result of a
change over time in the attitudes of patients and
dental professionals towards the preservation of the
periodontally diseased teeth.
For African populations, none of these factors
seem relevant. No data exist which document im-
proved oral hygiene conditions over time among
African populations, and given the scarcity of den-
tal health care services and dental preventive pro-
grams it is also difcult understand what might
bring about such changes. Moreover, as detailed
above, tooth retention is already considerable
among African populations, greater than among
many populations in the industrialized part of the
world, making it very difcult to conceive of
changes in the occurrence of destructive peri-
odontal disease among African populations as a re-
sult of increased tooth retention.
However, given the extent of the HIV-epidemic
among African populations (41), it is relevant to con-
sider the possible impact of this infection on the epi-
demiology of periodontal diseases in Africa. HIV-in-
Periodontal diseases in Africa
fection causes a gradual deterioration of the cell-me-
diated immune response, which in turn increases
susceptibility to the development of a multitude of
viral, fungal and sometimes bacterial infections, just
as malignancies are frequently observed. As the
compromised host defence also affects the dento-
gingival region, it is a biologically plausible hypoth-
esis that HIV-infection and periodontal diseases may
be associated.
Not surprisingly, the literature is replete with
studies that associate HIV infection/AIDS with peri-
odontal diseases (for reviews see: 87, 88, 113, 147,
148). The early literature focused on HIV infection
being associated with unusual types of lesions, such
as necrotizing gingivitis and necrotizing peri-
odontitis, whereas more recent studies have primar-
ily been concerned with HIV infection as a risk factor
for the development and progression of the normal
forms of periodontal disease known from nonin-
fected subjects. However, the results of the studies
are somewhat contradictory. While a number of
studies, all conducted among European or North
American populations, indicate that HIV-infection is
a risk factor for destructive periodontal disease (29,
176, 199) there is no evidence for a similar associ-
ation among African populations. A few studies have
been conducted among African populations, and the
results of these studies do not support HIV infection
as a risk factor for destructive periodontal disease in
a Tanzanian population (133, 187). One explanation
for the different observations could be that as medi-
cal care is essentially absent for the HIV-infected
African populations, their survival times are too
short to allow for the development of signicant
periodontal disease (187). Moreover, some obser-
vations indicate that the medical treatment given to
HIV-infected persons in European and North Ameri-
can populations may per se add to the development
or progression of periodontal diseases. Hence, Tom-
ar et al. (207) found that even when age and im-
munological status was controlled for, a higher risk
of severe periodontal destruction was observed
among young HIV infected subjects receiving Azido-
thymidine (AZT) than among HIV infected persons
who do not take this drug.
Based on these considerations it therefore seems
unlikely that the HIV-epidemic among African popu-
lations may result in a time trend for increasing
levels of periodontal diseases among these popula-
tions. The burden of the HIV-epidemic to the African
health care systems is already huge. It is therefore
difcult to foresee a change in the health care pro-
vided to the HIV-infected populations that could
97
bring about an increase in the survival times of suf-
cient magnitude to allow for a marked effect on
periodontal disease levels.
Concluding remarks
Periodontal epidemiology is the study of variations
in the occurrence of periodontal diseases, and the
reasons behind these variations. Periodontal epi-
demiology involves three aspects that form a hier-
archy: (i) a description of the distribution of peri-
odontal diseases, (ii) identication of causes of the
problems, and (iii) application of the information
from descriptive and analytical studies to control of
the problems. Is there a periodontal disease prob-
lem among African populations? is thus a key ques-
tion that must be addressed before goals for im-
provement are possibly set and appropriate policies
for control are adopted.
The periodontal epidemiological literature review-
ed in the preceding sections conveys the answers
that have been provided by oral health professionals.
The Russell PI data have been taken to indicate that
periodontal disease (gingivitis) is widespread and se-
vere among African populations. The CPITN data in-
dicate very poor oral hygiene conditions with calcu-
lus deposits being common; a fairly high occurrence
of shallow pockets, whereas deep pockets are in-
frequent. The detailed and disaggregated data on
periodontal diseases in African populations indicate
that tooth retention is generally high; that the oral
hygiene conditions are poor; and gingivitis common
and pronounced. These data also point out that al-
though clinical attachment loss is frequent, the
major attachment loss burdens are carried by minor
fractions of the African populations.
With the CPITN data as the most prominent ex-
ample, it is an implicit assumption underpinning
many of the periodontal epidemiological reports,
that the data indicate a need for major improvement
in the periodontal conditions among African popu-
lations. However, not only are the interventions pro-
moted by dental health professionals in response to
these needs of questionable effectiveness; they are
also out of proportion to the public health signi-
cance of periodontal diseases relative to the many
more serious health burdens carried by the African
populations; just as they are out of proportion to the
resources available for health care. It is important
to bear in mind that the treatment needs described
remain the needs as judged by dental professionals.
Baelum & Scheutz
Up to now, the dental profession has dened oral
health in terms of oral disease, dental caries and
periodontal diseases in particular, and has ...re-
mained the exclusive judge of disease presence, ab-
sence or severity, as well as the nal adjudicator on
what interventions are needed (86). However, this
professionally authored normative need assessment
has continued to out-rank more meaningful socio-
dental indicators of oral health impact in communi-
ties (86), and it is a fact that very little is known
about the socio-dental impact for the African popu-
lations of periodontal diseases. This lack of knowl-
edge is a major concern, as any oral disease inter-
vention should reect the needs and demands of the
populations rather than serving the particular inter-
ests and views of dental health professionals. The
little information available on the socio-dental im-
pact of periodontal diseases among African popula-
tions indicates that the use of dental services are
mainly related to pain experiences, and, with the ex-
ception of necrotizing gingivitis and noma, pain is
not a cardinal feature of periodontal diseases. Eden-
tulism is very rare among African populations, the
levels of tooth loss are low, and it would seem that
the goals formulated by the FDI and WHO for tooth
retention (65) are indeed met in many African popu-
lations. Dental caries is the main cause of tooth loss
and there is little room for further improvement in
tooth retention among African populations by
means of interventions focused to periodontal dis-
eases. Periodontal diseases would therefore seem to
constitute a health issue of low priority among
African populations for whom the sequelae of war,
poverty, political instability, social crisis and weak
health systems are much more prominent and se-
vere.
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