1. International Dental Journal 2013; 63: 7–11
REVIEW ARTICLE
doi: 10.1111/idj.12002
Periodontitis among adult populations in the Arab World
Latfiya S. Al-Harthi, Mary P. Cullinan, Jonathan W. Leichter and W. Murray Thomson
Department of Oral Sciences, School of Dentistry, University of Otago, Dunedin, New Zealand.
Background: The Arab World consists of 22 countries from North and North-east Africa and the Middle East. Peri-
odontal disease is an important global oral health burden, and is highly prevalent in developing countries. Objectives:
The objective of this narrative review is to report on the recorded prevalence of periodontitis in the Arab World, and
to examine the methods used in collecting the data. Data and sources: A search of the literature was performed using
the PubMed database up to September 2011 to identify articles that reported on the prevalence of periodontal disease
in the 22 Arab countries. Reports kept in the World Health Organization (WHO) Global Health Data bank were also
used in this review. Conclusion: There is a paucity of up-to-date data regarding the prevalence of periodontitis in the
Arab adult population. Most relevant data are at least 10 years old. From the literature available, it is clear that there
is a need for epidemiological data that are representative of the adult population from this region. Such data will
enable proper development of guidelines, allocation of resources and the development of appropriate public health
programmes.
Key words: Periodontal diseases, periodontitis, oral health, Arab countries, Middle East
prevalence of what was classified as ‘light’, ‘medium’
INTRODUCTION
and ‘severe’ periodontitis to be 27.6%, 25.2% and
The Arab World comprises 22 countries from North 45%, respectively.
and North-east Africa, and the Middle East. These In 1981, the Fdration Dentaire Internationale
e e
countries are Algeria, Bahrain, Comoros, Djibouti, (FDI) and the World Health Organization (WHO)
Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauri- established the first global oral health goals9. More
tania, Morocco, Oman, the Palestinian territories, recently, goals for the year 2020 have been established
Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, jointly by the FDI, WHO and the International Asso-
the United Arab Emirates and Yemen. The provision ciation of Dental Research (IADR)10. These goals
of dental care in most of these countries is through a involve reducing the impact of oral diseases on health
combination of public and private services. and psychosocial development, and minimising the
Periodontal diseases are inflammatory conditions impact of oral manifestations of systemic diseases10.
affecting the tooth-supporting tissues. Gingivitis and However, knowledge and understanding of the occur-
periodontitis are the two most common manifesta- rence of oral diseases is a prerequisite for adequate
tions. Periodontitis contributes extensively to the glo- monitoring of progress towards oral health goals, and
bal burden of oral diseases1. It is also associated with for the proper allocation of resources.
systemic conditions such as cardiovascular diseases2 A recent review of the burden of oral diseases in
and diabetes mellitus3. The mild-to-moderate form of the Middle East found that little attention has been
periodontitis is the most common, with prevalence given to periodontitis in those countries11. It is there-
estimates ranging from 13% to 57%, depending on fore appropriate to examine the published data on
the sample characteristics and the case definition periodontitis available from the Arab countries in
used4–6. The extent and severity of periodontitis order to inform the development of oral care and dis-
increases with age7. The first published report on the ease prevention strategies that are suitable for the
prevalence of periodontitis from an Arab country was needs of the Arab population. This narrative literature
an Egyptian study conducted in 19478; it reported the review reports on the prevalence of periodontitis in
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2. Al-Harthi et al.
the Arab World and examines the methodological study, shallow pockets were observed in 41.2% of
implications of the findings. those aged 25 years and over and 22.6% of the same
age group had deep pockets. In the Yemeni study,
deep pockets were observed in 12.5% of the 35- to
DATA SOURCES
44-year age-group27. This was lower than estimates
A search of the literature was performed using the from Iraq and higher than those from Saudi Arabia.
PubMed database up to September 2011 in order to The Moroccan study used a convenience sample of
identify articles that reported on the prevalence of two areas with differing fluoride levels24. The preva-
periodontal diseases in the Arab countries. Keywords lence of shallow pockets was 32.4% and 54.6% in
used in keyword/title/abstract searches included ‘peri- those aged 21–30 years and 41–60 years, respectively,
odontal disease’, ‘periodontitis’, ‘pocket depth’, ‘clini- and the prevalence of deep pocketing was 8.5% and
cal attachment loss’, ‘CPITN’, ‘Arab’ and ‘Middle 28.6%, respectively. The lowest reported occurrence
East’, together with the name of each of the Arab of periodontitis was in Jordan31, where the prevalence
countries. Data from the WHO Global Oral Health of shallow pocketing was 4.7% and 18.6% in the 20–
periodontal profile Data Bank (http://www.dent.niig- 39 year age-group and 50–60 year age-group respec-
ata-u.ac.jp/prevent/perio/contents.html) were also used tively; 4.1% and 11.1% of those age groups, respec-
in this review. tively, had deep pockets. However, these comparisons
should be treated with caution because, although all
of the previous studies used the CPITN, the samples
FINDINGS
comprised different age groups and some studies
The literature search for articles on the prevalence of examined all teeth while others examined index teeth
periodontitis in adults in the Arab world revealed few only.
studies; these were either analytical studies on the Few of the studies used PD and/or CAL to deter-
association of periodontitis with different risk fac- mine periodontal status12,14,16,21,23. The studies are
tors12–21 or assessments of the effect of the use of the difficult to compare because they reported their data
miswak22,23, or fluoride24. These (and a number of using different case definitions and thresholds. More-
other published studies from Kuwait, Saudi Arabia, over, some examined all teeth using six sites per
Iraq, Jordan and Yemen) included reports on the peri- tooth16,21 and others conducted partial examina-
odontal status of adult samples25–34. Three of the tions14,23. For example, a Sudanese study examined
studies used pocket depth (PD) and/or clinical attach- index teeth and defined periodontitis using different
ment loss (CAL) to determine periodontal sta- thresholds of PD or CAL. They reported that approxi-
tus16,23,33. The remainder used the Community mately one in 10 participants had at least one site
Periodontal Index of Treatment Needs (CPITN)35 to with 4+ mm PD, 2% had at least one site with
report on periodontal status. 6+ mm PD, approximately half had at least one site
In 1992, periodontitis was reported as the percent- with 4+ mm CAL and one in 12 had at least one site
age of people with one or more sextants with shallow with 6+ mm CAL23. The Saudi Arabian study exam-
or deep pockets [Community Periodontal Index (CPI) ined all teeth using four sites per tooth, and they
scores 3 and 4, respectively] in a Saudi Arabian study reported the periodontal status as the mean probing
of the adult population from the central province of depth per person; this was reported to be 2.8 mm for
Saudi Arabia26. Just over one-quarter of those aged those aged 17 years and over14. The two Jordanian
19 years and over had shallow pockets, and 9.0% studies examined all teeth (except third molars), using
had deep pockets26. A 2008 report from a study of a six sites per tooth, and defined periodontitis as the
non-representative Saudi Arabian sample reported the presence of four or more teeth with one or more sites
prevalence of shallow pockets to be 37.4%, and none with PD of 4+ mm and CAL of 3+ mm12,16. The
had deep pockets33. The latter finding was also reported prevalence of periodontitis was 26.8% in
reported in another Saudi Arabian study of a repre- one study16 and 30.9% in the other12.
sentative sample of young adults aged 20–24 years (in
Jeddah city), where none had deep pockets, while
WHO Global Oral Health periodontal profile data
shallow pockets were observed in 7.2%25. A Kuwaiti
study reported the periodontal status as the mean Table 1 summarises the WHO data for CPI scores 3
number of sextants with PD greater than 3 mm; this and 4 from reports on periodontal status in the Arab
was reported to be 1.5 for those aged 20 years and countries. The reported prevalence of shallow pockets
over30. An Iraqi study of a representative sample of ranged from 0% to 53%, and deep pockets ranged
1,418 individuals (aged 7–70 years) from three ran- from 0% to 34%36. Despite being collected using the
domly selected rural villages in the province of Nine- CPITN, epidemiological data in the Global Oral
vah Governorate was conducted in 199928. In this Health Data Bank are at least comparable because
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3. Periodontitis in the Arab World
Table 1 Summary of the epidemiological data on the from 0% to 34%.These wide ranges may result from
prevalence of periodontitis in adults from the Global a lack of standardisation of data collection and
Oral Health Data Bank representing the Arab coun- reporting. It is important that a standard and well-
tries* accepted approach is used in conducting epidemiologi-
cal research on periodontal diseases. Studies should
Percentage of people Age range Year Country
with highest score of: include the measurement of clinical characteristics
such as periodontal destruction (including PD, CAL
CPI 4 CPI 3
(PD (PD
and radiographically determined bone loss, where pos-
6+ mm) 4–5 mm) sible), and the measurement of inflammation (such as
bleeding on probing). While some of these factors
13 45 35–44 1987 Algeria
0 0 33–49 2000/2001 Comoros (such as CAL and bone loss) reflect past disease, mea-
16 40 35–44 1990 Egypt sures of PD and such as bleeding on probing are
11 37 35–44 199? Iraq needed (and used together) to assess the presence or
8 14 35–44 1994 Lebanon
34 53 35–44 1982/1983 Libya absence of current disease48. Some epidemiological
16 49 31–40 1987 Morocco studies have reported the prevalence of periodontitis
0 8 35–44 1988 Saudi Arabia based on measuring no more than PD, but a limita-
12 9 35–44 1998 Syria
tion of this is that a greater PD may result from
*CPI, Community Periodontal Index: PD, pocket depth. Data ‘pseudo-pockets’, and not necessarily be associated
accessed from the electronic site of WHO Global Oral Health peri-
with attachment loss. Thus, measurement of probing
odontal profile Data Bank (http://www.dent.niigata-u.ac.jp/prevent/
perio/contents.html) on 09/09/2011. pocket depth does not provide an accurate measure of
accumulated periodontal tissue destruction, and it is
they use the same method of data collection and case of limited value for the assessment of the extent and
definitions36. The contemporary relevance of the data severity of periodontitis49. It is important, therefore,
is questionable because most estimates are at least to combine reports of CAL, PD and bleeding on prob-
two decades old, and the most recent is 10 years old. ing in epidemiological studies. Full-mouth clinical
Moreover, the most striking feature of this table is assessment of periodontitis is considered to be the
what is missing; that is, it does not have representa- gold standard in epidemiological studies50 of the con-
tive data on periodontal diseases among the adult dition. Susin et al.51 studied the effect of underestima-
population reported from more than half of the Arab tion of specific partial recording protocols and found
countries. that partial recordings that use full-mouth measure-
ments produce less bias. They concluded that the bias
in the assessment of CAL is influenced by the partial
DISCUSSION
recording design and the type and number of sites
Most published surveys describing oral health status assessed, and by the severity of disease in the popula-
(including periodontal diseases) in the Arab world tion under investigation. The effect of using different
have been carried out in schoolchildren and adoles- combinations on estimates of the prevalence of peri-
cents37–43. The present review clearly demonstrates odontitis is presented in Table 2, which shows that, in
the lack of data on periodontitis among the adult comparison with the gold standard, the approach
Arab population. These are important data for oral leading to the greatest bias is the use of only some of
health planning, as has been suggested by the WHO the teeth and some of the sites. Furthermore, the
report on oral health for the 21st century44. Another reporting of data should be standardised, both within
general finding from the studies reviewed is that peri- and among countries, in order to develop packages of
odontitis is more prevalent among older age groups. oral care suitable for the needs of the Arab popula-
Furthermore, studies on the reasons for tooth extrac- tion. However, periodontal research does not yet have
tions in the Arab countries show that more than one- uniformly established epidemiological criteria for
third of missing permanent teeth have been extracted defining a case, with the result that different case
because of periodontitis; in those older than 40 years,
more teeth have been lost to periodontitis than for Table 2 Effect of different combinations of teeth and
any other reason45–47. These facts emphasise the need sites on prevalence estimates of periodontal disease
for new epidemiological studies of the periodontal Some sites All sites Teeth
health of the adult Arab population.
Least underestimation* Gold standard All (except third
The prevalence of periodontitis in the reported stud- molars)
ies ranged from 0.0% to 54.6%. Data from the Glo- Most underestimation Moderate
bal Oral Health Data Bank reported prevalence of underestimation Some
what they defined as ‘shallow pockets’ (CPI 3) ranged *Depends on sites used (the best partial site combination is mesio-
from 0% to 53%, and ‘deep pockets’ (CPI 4) ranged buccal, buccal and disto-lingual).
© 2013 FDI World Dental Federation 9

4. Al-Harthi et al.
definitions have been used in different studies52, limit- 12. Khader YS, Bawadi HA, Haroun TF et al. The association
between periodontal disease and obesity among adults in Jor-
ing the comparability of the disease estimates. It is also dan. J Clin Periodontol 2009 36: 18–24.
important that the surveys be conducted on represen-
13. Ashril NY, Al-Sulamani A. The effect of different types of
tative samples rather than convenience samples. smoking habits on periodontal attachment. J Int Acad Period-
Detailed descriptions of sampling procedures, the deri- ontol 2003 5: 41–46.
vation and use of any sampling weights, and calibra- 14. Natto S, Baljoon M, Bergstrom J. Tobacco smoking and peri-
tion of examiners are important in allowing an odontal health in a Saudi Arabian population. J Periodontol
2005 76: 1919–1926.
informed analysis and critique of the survey findings53.
15. Al-Zahrani MS, Kayal RA. Alveolar bone loss and reported
Moreover, according to current understanding of medical status among a sample of patients at a Saudi dental
the pathogenesis of periodontitis, other factors that school. Oral Health Prev Dent 2006 4: 113–118.
may play a role in the progression of periodontitis 16. Bawadi HA, Khader YS, Haroun TF et al. The association
should be reported because they may be important in between periodontal disease, physical activity and healthy diet
among adults in Jordan. J Periodontal Res 2010 46: 74–81.
the occurrence of the condition. Some of these factors
17. Ababneh KT, Al Shaar MB, Taani DQ. Depressive symptoms
include tobacco use54–56 and diabetes57,58. in relation to periodontal health in a Jordanian sample. Int J
Dent Hyg 2010 8: 16–21.
18. El-Sayed A. Relationship between overall and abdominal obes-
RECOMMENDATIONS FOR FUTURE WORK ity and periodontal disease among young adults. East Mediterr
• There is an urgent need for surveys on the preva- Health J 2010 16: 429–433.
19. Al-Shammari KF, Al-Ansari JM, Moussa NM et al. Association
lence, extent and severity of periodontal diseases
of periodontal disease severity with diabetes duration and dia-
(gingivitis and periodontitis) in the adult populations betic complications in patients with type 1 diabetes mellitus.
of the Arab countries. This is an important prerequi- J Int Acad Periodontol 2006 8: 109–114.
site to aid practitioners and policy makers to develop 20. Mokeem SA, Molla GN, Al-Jewair TS. The prevalence and
clear dental care strategies specific for this group relationship between periodontal disease and pre-term low birth
weight infants at King Khalid University Hospital in Riyadh,
• Standardisation of data collection and reporting Saudi Arabia. J Contemp Dent Pract 2004 5: 40–56.
will allow comparability of data from the different 21. Khader YS, Rice JC, Lefante JJ. Factors associated with peri-
countries odontal diseases in a dental teaching clinic population in north-
• The combined use of CAL, PD and bleeding on ern Jordan. J Periodontol 2003 74: 1610–1617.
probing is critical in order to accurately report on 22. Al-Khateeb TL, O’Mullane DM, Whelton H et al. Periodontal
treatment needs among Saudi Arabian adults and their relation-
periodontal status. ship to the use of the Miswak. Community Dent Health 1991
8: 323–328.
23. Darout IA, Albandar JM, Skaug N. Periodontal status of adult
REFERENCES Sudanese habitual users of miswak chewing sticks or tooth-
brushes. Acta Odontol Scand 2000 58: 25–30.
1. Petersen PE, Bourgeois D, Ogawa H et al. The global burden of
oral diseases and risks to oral health. Bull World Health Organ 24. Haikel Y, Turlot JC, Cahen PM et al. Periodontal treatment
2005 83: 661–669. needs in populations of high- and low-fluoride areas of Mor-
occo. J Clin Periodontol 1989 16: 596–600.
2. Beck J, Garcia R, Heiss G et al. Periodontal disease and cardio-
vascular disease. J Periodontol 1996 67: 1123–1137. 25. Farsi JM. Dental visit patterns and periodontal treatment needs
among Saudi students. East Mediterr Health J 2010 16: 801–806.
3. Loe H. Periodontal disease. The sixth complication of diabetes
mellitus. Diabetes Care 1993 16: 329–334. 26. Guile EE. Periodontal status of adults in central Saudi Arabia.
Community Dent Oral Epidemiol 1992 20: 159–160.
4. Albandar JM, Brunelle JA, Kingman A. Destructive periodontal
disease in adults 30 years of age and older in the United States, 27. Mengel R, Eigenbrodt M, Schunemann T et al. Periodontal sta-
1988–1994. J Periodontol 1999 70: 13–29. tus of a subject sample of Yemen. J Clin Periodontol 1996 23:
437–443.
5. Sheiham A, Netuveli GS. Periodontal diseases in Europe. Peri-
odontol 2000 2002 29: 104–121. 28. Khamrco TY. Assessment of periodontal disease using the
CPITN index in a rural population in Ninevah, Iraq. East Med-
6. Corbet EF, Zee KY, Lo EC. Periodontal diseases in Asia and
iterr Health J 1999 5: 549–555.
Oceania. Periodontol 2000 2002 29: 122–152.
29. Behbehani JM, Shah NM. Oral health in Kuwait before the
7. Beck JD, Koch GG, Rozier RG et al. Prevalence and risk indica-
Gulf War. Med Princ Pract 2002 11(Suppl 1): 36–43.
tors for periodontal attachment loss in a population of older
community-dwelling blacks and whites. J Periodontol 1990 61: 30. Behbehani JM, Scheutz F. Oral health in Kuwait. Int Dent J
521–528. 2004 54: 401–408.
8. Dawson CE. Dental defects and periodontal disease in Egypt, 31. El-Qaderi SS, Quteish Ta’ani D. Assessment of periodontal
1946–1947. J Dent Res 1948 27: 512–523. knowledge and periodontal status of an adult population in Jor-
dan. Int J Dent Hyg 2004 2: 132–136.
9. Global goals for oral health in the year 2000. Federation Den-
taire Internationale. Int Dent J 1982 32: 74–77. 32. Taani DS. Oral health in Jordan. Int Dent J 2004 54: 395–400.
10. Hobdell M, Petersen PE, Clarkson J et al. Global goals for oral 33. Farsi N, Al Amoudi N, Farsi J et al. Periodontal health and its
health 2020. Int Dent J 2003 53: 285–288. relationship with salivary factors among different age groups in
a Saudi population. Oral Health Prev Dent 2008 6: 147–154.
11. Morgano SM, Doumit M, Al-Shammari KF et al. Burden of
oral disease in the Middle East: opportunities for dental public 34. Beiruti N, Van Palenstein Helderman WH. Oral health in Syria.
health. Int Dent J 2010 60: 197–199. Int Dent J 2004 54: 383–388.
10 © 2013 FDI World Dental Federation

5. Periodontitis in the Arab World
35. Ainamo J, Barmes D, Beagrie G et al. Development of the 49. Albandar JM, Rams TE. Global epidemiology of periodontal
World Health Organization (WHO) community periodontal diseases: an overview. Periodontol 2000 2002 29: 7–10.
index of treatment needs (CPITN). Int Dent J 1982 32: 281– 50. Papapanou PN. Periodontal diseases: epidemiology. Ann Peri-
291. odontol 1996 1: 1–36.
36. Periodontal country profile [database on the Internet]2010. 51. Susin C, Kingman A, Albandar JM. Effect of partial recording
Available from: http://www.who.int/oral_health/databases/ protocols on estimates of prevalence of periodontal disease.
niigata/en/index.html. Accessed 09 September 2011. J Periodontol 2005 76: 262–267.
37. El-Angbawi MF, Younes SA. Periodontal disease prevalence 52. Preshaw PM. Definitions of periodontal disease in research.
and dental needs among school children in Saudi Arabia. Com- J Clin Periodontol 2009 36: 1–2.
munity Dent Oral Epidemiol 1982 10: 98–99.
53. Kingman A, Albandar JM. Methodological aspects of epidemio-
38. Hussein S, doumit M, Doughan B et al. Oral health in Leba- logical studies of periodontal diseases. Periodontol 2000 2002
non: a pilot pathfinder survey. East Mediterr Health J 1996 2: 29: 11–30.
299–303.
54. Haber J. Smoking is a major risk factor for periodontitis. Curr
39. Al-Ismaily M, Al-Khussaiby A, Chestnutt IG et al. The oral Opin Periodontol 1994: 12–18.
health status of Omani 12-year-olds – a national survey. Com-
munity Dent Oral Epidemiol 1996 24: 362–363. 55. Grossi SG, Zambon JJ, Ho AW et al. Assessment of risk
for periodontal disease I. Risk indicators for attachment loss.
40. Abid A. Oral health in Tunisia. Int Dent J 2004 54: 389–394. J Periodontol 1994 65: 260–267.
41. El-Nadeef MA, Al Hussani E, Hassab H et al. National survey 56. Schatzle M, Faddy MJ, Cullinan MP et al. The clinical course
of the oral health of 12- and 15-year-old school children in the of chronic periodontitis: V Predictive factors in periodontal dis-
United Arab Emirates. East Mediterr Health J 2009 15: 993– ease. J Clin Periodontol 2009 36: 365–371.
1004.
57. Cianciola LJ, Park BH, Bruck E et al. Prevalence of periodontal
42. Elamin AM, Skaug N, Ali RW et al. Ethnic disparities in the disease in insulin-dependent diabetes mellitus (juvenile diabe-
prevalence of periodontitis among high school students in tes). J Am Dent Assoc 1982 104: 653–660.
Sudan. J Periodontol 2010 81: 891–896.
58. Grossi SG, Skrepcinski FB, DeCaro T et al. Response to peri-
43. Fanas SH, Omer SM, Jaber M et al. The periodontal treatment odontal therapy in diabetics and smokers. J Periodontol 1996
needs of Libyan school children in Kufra and Tobruk. J Int 67: 1094–1102.
Acad Periodontol 2008 10: 45–49.
44. Organization WH. Oral health for the 21st century. Geneva:
WHO/ORH/Oral C21.94; 1994. Correspondence to:
45. Haddad I, Haddadin K, Jebrin S et al. Reasons for extraction W. Murray Thomson,
of permanent teeth in Jordan. Int Dent J 1999 49: 343–346. Professor of Dental Epidemiology and Public Health,
46. Hassan AK. Reasons for tooth extraction among patients in Editor, New Zealand Dental Journal,
Sebha, Libyan Arab Jamahiriya: a pilot study. East Mediterr Head, WHO Collaborating Centre for Dental
Health J 2000 6: 176–178.
Epidemiology Public Health,
47. Al-Shammari KF, Al-Ansari JM, Al-Melh MA et al. Reasons
for tooth extraction in Kuwait. Med Princ Pract 2006 15: 417–
Department of Oral Sciences,
422. Sir John Walsh Research Institute,
48. Tonetti MS, Claffey N. Advances in the progression of peri- School of Dentistry, the University of Otago,
odontitis and proposal of definitions of a periodontitis case and PO Box 647, Dunedin, New Zealand.
disease progression for use in risk factor research Group C con- Email: murray.thomson@otago.ac.nz
sensus report of the 5th European Workshop in Periodontology.
J Clin Periodontol 2005 32(Suppl 6): 210–213.
© 2013 FDI World Dental Federation 11