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International Dental Journal (2001) 51.


Trends in caries and periodontal health epidemiology in Europe
Elmar Reich
WHO Collaborative Centre for the Standardisation in Dentistry, Biberach, Germany
The overall picture for caries and periodontal disease in Europe has improved over the last years. A very marked decline in caries prevalence was seen in children and adolescents. According to the DMF-figuresthe caries prevalence in adults and seniors has not declined as rapidly. Yet also in this age group there is in many countries a positive effect of a more preventivebased dentistry detectable. The number of edentulous adults in Europe has also been declining considerably. However, of concern is the increased risk for root surface caries in the remaining teeth. Advanced periodontaldisease is seen in around 20 per cent of the adults and more than 30 per cent in seniors. Changes in the prevalence of periodontitis are more difficult to assess because the treatment approach and the interest of patients retaining their teeth have also changed. Key wonls: Caries, periodontal disease, prevention, epidemiology

Correspondence to: Professor E. Reich, Matthias-Erzberger-Str. 3, D-88400 Biberach. Germany.
Q 2001 FDllWorld Dental Press 0020-6539/01/06392-07

Epidemiological data are used to describe the health status of populations. In many European countries epidemiological surveys are carried out on a regular basis’. Yet most often only children and adolescents are examined, so the available data for adults and seniors are sparse. Data from adults are also more difficult to collect and therefore the representative quorum is harder to achieve. Dental caries and periodontal diseases are the most prevalent diseases of the oral cavity. Caries prevalence is most often measured with the DMF-index’ which has been used worldwide for decades, thereby ensuring good comparability of data. The WHO and the WHO Regional Office in Europe have used DMF-figures to issue regional and global goals. The disadvantage of the DMF-index is the high diagnostic threshold of the caries diagnosis on the cavitation level. Also the problem of ‘hidden caries’ raises questions with regard to the real prevalence of dental caries in Europe. In industrialised countries the health care system has a big influence on the DMF-data3.In Europe, for example, a large percentage of the adult population has received restorative and prosthetic treatment. This treatment is influenced not only by the extent of oral diseases but also by the perceived treatment needs of the population as well as the health system and the regulations concerning reimburse-

0 and 3. The mean dft figures in that age group show a four-fold difference between countries like Sweden or Switzerland with dft values of 1. The reason for the slight increase in fluorosis prevalence is not only the wider application of fluoridated toothpastes but also the systemic use of fluoridated salt and also fluoridated mineral water. as was the goal set by the WHO. which is also used by many parents for the preparation of baby food. The prevalence of mild forms of fluorosis in Europe is usually below 10 per cent and severe forms. The increased use of fluorides has not increased fluorosis to any great extent9. There is a slight increase in those prevalence figures in Europe but it is not considered a health problem. First reports even show an increase of the caries prevalence in young children in some Scandinavian areas and in Switzerland. despite the wide use of fluoridated preventive products for caries prevention.O and countries like Poland with dft values of 4. This decrease happened despite the unchanged diet of the population and the many sucrose snacks eaten by children.The range of DMFT values is between 1. The decrease in caries prevalence began in the 1960s and 1970s in Scandinavian countries and Norway GI88W N8th8rl~1dS USA UK lrrland w8#) FI8nW E. Fluorosis of permanent teeth is.''.0. Mean caries prevalence of deciduous teeth of 5 to 7-year-old children Reich: Trends in caries and periodontal health epidemiology in Europe . Other indications for epidemiological examinations are the assessment of the relationship between different aetiological factors for caries and periodontitis as well as the evaluation of preventive and restorative treatments. although in some countries in Eastern Europe it is higher (FigureI).393 ment by third parties. Caries in children The caries prevalence of deciduous teeth differs widely in 5-7-yearold children in Europe (Figure I).0and over. detectable clinically. Ireland and Switzerland. not very prevalent with discrete and moderate forms of fluorosis amounting to around 10 per cent prevalence in 12-year-old children in Germany. Substantial caries reduction has been seen in most European countries in the last three decades. 1. are very sparse. The percentage of caries-free children has increased to more than 50 per cent of the 5 to 6-year-old children. The caries prevalence in adolescents in Europe is similar to that of children'. The main h l 8 n d (h#) Spain D8nmark Flnlrnd ltlly reason given is regular mechanical tooth cleaning4and the use of fluoridated oral hygiene products=. G8Iln8ny Chrchnya Hungary Slov8nla POIfU981 POl8nd 0 1 2 3 4 5 6 Flgurr. When those figures are compared to earlier figures in 1990 there is a decrease in caries prevalence but also a levelling off in the most advanced countries. The DMFT figures for 12-year-old children show a similar distribution between Scandinavian countries o r the Netherlands.

The reason for this decline in West Germany was explained by the installation of prophylactic programmes in schools as well as the increase in the use of fluoridated toothpastes. Mean caries prevalenceof permanent teeth of 12-year-old children Switzerland followed by the UK. higher caries prevalence in West Germany compared to East Germany. children from low social economic families and also immigrants showed less reduction". toothpastes. there is still a proportion of around 20 per cent in this age group with high caries prevalence ijgures all over Europe'~". Especially. At this time fluoridated salt also became available and was used especially by many families in Germany with children. A slight decline in caries prevalence was seen in East International Dental Journal (2001) Vol. salt and by special school programmes. In other European countries like Germany and France caries reduction began later (Figure 3).394 Ireland (East) Spaln Denmark Rnland Itsly A mDMFT 1 I Norway Netherlands USA UK Iraland (W est) W. Caries in adults Caries decline in children was measurable soon after the preventive . and that water fluoridation was discontinued in the Netherlands (in the 1970s) the decrease of the caries prevalence continued there and in other countries.6 Germany from the first investigation in the 1970s to the year 1990. Germany Hungary Slovenia Portugal Llthuank Romanla Poland 0 1 2 3 4 5 6 Figurn 2. The caries increment in Bavarian school children was reduced by half between 1989 and 1995 (Figure4. Ireland and the Netherlands. The first examinations in the 1970s showed a two-fold. The additional decrease" in West Germany in the 1990s was caused by individual preventive measures in practices for children age 6 to 12 years.Germany E. but not all children had the same benefit of this caries reduction. Despite the increase of cavityfree children'' in 6-year-old Bavarian children ( F i g u r e4). Despite that fact. which are not representative for the whole populations. In those countries fluoride became available to the population in general some forty years ago by fluoridated drinking water. This fluoridated salt had been available some years earlier in France and dentists applied preventive measures (UFSBD). 5VNo. In this time the caries prevalence in West Germany dropped considerably and a further caries decrease was seen at the beginning of the 1990s. The application of fissure sealants was made available by the social security system in Germany together with other preventive measures that resulted in another steep decline in caries. The first data were drawn from regional studies.

The prevalence of persons with root surface caries varies from 7-20 per cent. Caries prevalence in seniors does not differ widely in Europe. Only a few figures regarding root surface caries are available. What is obvious from these data is the reduction of edentulous seniors over the last 20 years.4 0.4 1.6 1. Seniors from 65-74 years of age have DMFfigures from 22 to 27 in Europe15.2 b k +girls 1 0.East Germany A .8 E n 0. Caries prevalence in 12-year-old children in France and Germany 1. Adults from 35-44 years of age3 have DMFvalues ranging from 14 to 20 (Figure 6).2 0 1989 1992 1995 1998 Figurrr 4.395 8 7 DMFT +-West Germany 4.6 0. Not surprisingly the root surface Reich: Trends in caries and periodontal health epidemiology in Europe . Change in caries prevalence of 9-year-old Bavarianchildren measures were applied.France 6 5 - 4 3 2 1 I I I I I I I I Figurn 3. As a general problem some reported data are not based on a representative sample of the population and the DMF-index overestimates the figures in a population with a high amount of restorative treatment. changes caused by preventive measures cannot be detected as soon as in children. Because of the DMF-index. as well as other factors affecting the disease14 in adults. Caries prevalence figures of adults are based either on 28 or 32 teeth.

Canes prevalence in adults (35 -44 years of age) caries prevalence is much higher than in younger adults. The polarisation of the caries distribution was not reduced and still around 20 per cent of the population in adolescence account for 80 per cent of the cavitated lesions.1 0 1989 1992 Figure 5. The prevalence figures for adults are decreasingin some countries. Canes incrementof Bavarian school children - 1992 1995 - ~~ USA UK S lov en la BDMFT>45 BDMFTi JI Norway Ireland Greece E-Germany W -Germany France Finland Be'orus I ~ ~~~ r n 0 5 10 15 20 25 Figure 6.2 0. Periodontitis Early onset periodontitis is much . International Dental Journal (2001) Vol. The prevalence of root surface caries of persons varies from 15 per cent to 90 per cent and the RCI from 12 per cent to 28 per cent ( F k m 7). But the treatment of caries in adults in Europe and the number of teeth with root surface caries might be increasing.396 % 0. 511N0. But the methodology of diagnosing root surface caries is not as well standardised as for coronal caries.6 The prevalence of cavitated caries in Europe has decreased considerablyin children and adolescence. while the number of teeth extracted because of caries has also been reduced.3 0.

The overall picture of oral health in Central Europe is good. World Health Organisation. Periodontal disease does not seem to be the major cause of tooth-loss in Europe anymore. Fluorose bei den Jugendlichen. Deutscher Arzteverlag. 8. Karies / Fiillungen bei Envachsenen. Evidence-based recommendations for disease prevention. lnt Dent J 1994 44: 257-261. O’Mullane D M. Pravalenzen zu ausgewahlten klinischen Variablen bei den Kindern/Jugendliche (12Jahre). WHO. The data for periodontal disease are recorded with a variety of indices and measurements. Reich: Trends in caries and periodontalhealth epidemiology in Europe . 7.6mm. ORCA Symposium 1995 Curies Res 1996 30: 23 7-2 5 5. The changes are not as uniform in Central and Eastern Europe. J Can Dent Assoc 1998 6 4 295-306. Editors Lang K. Moderate forms with small pockets range from 31-62 per cent. lnt DentJ 1991 41: 171-174. The severity varies from 1. Introduction and rationale for the use o f fluoride for caries prevention. Moderate disease with pocket probing depth of up to 5mm is seen in 20-30 per cent of this population. Geneva 1994. Cologne 1999.74mm attachment loss to 4. especially regarding the behaviour of children. 4. Active agents in dentifrice Anticaries efficacy. Bgaard B. Chapter 9. Geneva. Root caries prevalence in seniors (65 . Schiffner U.74 years of age) less a problem in Europe than in the United States. Lindhe J . Quintessence. Clinical effect and mechanism o f cariostatic action o f fluoride-containing toothpastes: a review. Karring T. In: Chemotherupeutic ugents. 10. The caries decline in Western Europe is astonishing. R0lla G. Berlin. E. Brothwell D J. Vribic V. According to the ‘extent and severity index’ the extent vanes for seniors from 59-88 per cent”. There is not a uniform standard as with caries. 2. The prevalence of advanced periodontal disease increases with age. 9. References 1 .DMS I l l . These prevalence figures increase to values of 20 per cent to 30 per cent in advanced periodontitis in seniors (65 to 74 years of age)” and to 30 per cent to 60 per cent of moderate disease as maximum values. Chapter 8. Reich. This trend does not seem to be as uniform as with caries and more research is needed to give a clear picture. Jutai D G K. Marthaler T M. 1997. 5. 6. In adults’‘ from 35-44 years of age perhaps 10 per cent show an advanced form of periodontal attachment loss in one or more teeth.3 in Deutsche Mundgesundheitsstudie . O’Mullane D M. An update o f mechanical oral hygiene practices. Deutscher Arzteverlag: Cologne 1999. Reich E. WHO Technical Report Series # 846. Hawkins R J . As the prevalence of periodontal disease increases with age. According to the CPI index the prevalence of advanced periodontal disease with probing pocket depth above 5mm varies between 7 per cent and 18 per cent for adults from 35 to 44 years of age. The prevalence o f dental caries in Europe 1990-1995. bearing in mind that only very few representative studies have used this index. Busic Methoh 4th ed. a higher proportion of older people are affected. Reich E.397 % I I I I I I I h C w 0 94 0 94 0 94 L a h 94 t 00 00 Figure 7. Schiffner U. 3.1 in Deutsche Mundgesundheitsstudie DMS 111. Orul Heulth Sumty. Schiffner U. Here the political transition and the dental services available have undergone great changes in recent years. Reich E. For adults and seniors the question of adequate treatment for caries and periodontal disease has to be addressed and answered regionally according to the dental services available. Fluorides and Orul Health. Some data suggest that in some countries there has also been a decline in periodontal disease over the last 20 years. 1995.

2 in Deutsche Mundgcsundheitsstudie - DMS III. Chapter 10. fionenkaries / Wurzelkaries/ Fullungen bei den Senioren. Cologne 1999. Cologne 1999. Deutscher Arzteverlag. Bjertness E. N B. Pitts. Reich E. LAGZ Bayern Deutscher Arzteverlag. International Dental Journal (2001) Vol. Schiffner U. 511No. Chapter 10.2 in Deutsche Mundgesundheitsstudie .1 in Derrtsche Mundgesundheitsstudie - D M S Ill. 16.6 . Vehkalati M.D M S Ill. Varsio S. 12.398 Chapter 8 in Deutsche Mundgesundheits&die . Inequalities in children’s caries experience: the nature and size of the UK problem. Cologne 1999. Reich E. B F.D M S III. Community Dent Health 1998 15: 296-300. Parodontalerkrankungen bei den Erwachsenen. Reich E. Eriksen H M. et al. 1976 . Hansen. Tarkokonen L.1993. 14. A follow-up study of Oslo citizens from the age of 35 to 50 years. Chapter 9. 1 1. Cologne 1999. Deutscher Arzteverlag. Zahngesundheit Bayerischer Schulkinder. 15. Factors of importance for changes in dental caries among adults. Reich E. Parodontalerkrankungen bei den Senioren. Caries Res 1997 31: 161-165. Deutscher Arzteverlag. 17. 13. Deutscher Arzteverlag. Cologne 1999. Acta Odontol Stand 1992 50: 193-200. Decrease in and Polarization of Dental Caries Occurrence among Child and Youth Populations.