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241]

Original Research

Periodontal Health Status and Treatment Needs of the

Community in Indonesia: A cross sectional Study
Agus  Susanto, Dyah N.  Carolina, Amaliya  Amaliya, Indra M.  Setia Pribadi, Aldilla  Miranda
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Bandung, Indonesia

Abstract
Aim: Periodontal disease is an oral disease with a quite high prevalence in the world, especially in the developing countries such as
Indonesia. The aim of this study was to evaluate the prevalence of periodontal disease, periodontal health status, and treatment needs of
the community in Indonesia. Materials and Methods: This is a descriptive study with cross-sectional approach. A total of 400 participants
were selected for the proposed research work from six Community Health Centre (Puskesmas) in Bandung City. The demographic and
sociodemographic data obtained from the questionnaire were recorded, including age, gender, address, occupation, and smoking habits.
The oral hygiene level was measured by using the Oral Hygiene Index simplified (OHI-S) and the Community Periodontal Index of
Treatment Needs (CPITN). Data were analyzed using chi-squared test and multiple linear regression analysis. Results: The oral hygiene
level was found good in 16.5%, fair in 68%, and poor in 15.5% of all the samples; the oral hygiene level in male tends to be worse than
women. The CPITN score of code 1 was found in 1%, code 2 in 54.25%, code 3 in 43.25%, and code 4 in 1.5% of all the samples. In total,
1% treatment needs required oral hygiene instruction, 97.5% oral hygiene instruction and oral scaling prophylaxis, and 1.5% complex
treatment. The frequency of brushing teeth and age were significantly associated with OHI-S score (P< 0.05), whereas age and sex (male
and female) were significantly associated with CPITN score (P < 0.05) in multivariate analysis. Conclusion: In the study population, the
number of patients who had gingivitis was 55.25% and who had periodontitis was 44.75%. The majority of them needs the primary and
secondary levels of preventive program to reduce the initiation or progression of periodontal diseases.

Keywords: Community Periodontal Index of Treatment Needs, Oral Hygiene Index Simplified, Oral Hygiene Status, Treatment Needs
Received: 24-06-2019, Revised: 07-10-2019, Accepted: 09-10-2019, Published: 28-03-2020

Introduction premature low-birth-weight babies, respiratory disease,

Periodontal disease is the most common oral disease in
the world, especially in the developing countries such as
Indonesia.[1] Periodontal diseases are chronic infectious
diseases that result in the inflammation of specialized
tissues that surround and support the teeth. It can lead
to a progressive loss of connective tissue attachment and
alveolar bone. This tissue destruction is characterized
by the formation of periodontal pockets.[2] The high
prevalence of periodontal disease is generally caused by
a lack of individual awareness, a rare visit for oral health
control, low socioeconomic status, and high levels of
illiteracy.[3] Periodontal disease are thought to be affecting
individual general health problem as the risk factor for
various systemic diseases such as cardiovascular disease,
and diabetes mellitus.[4]
Although microorganisms present in dental plaque
are the main etiologic factors responsible for initiation
and progression of periodontal diseases, several other
risk factors such as sociodemographic factors (age, sex,
education, income, occupation), medical conditions
(diabetes, cardiovascular disease (CVD), arthritis, kidney
disease, respiratory disease, stress), and habitual factors
Address for correspondence: Dr. Agus Susanto,
Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran,
Sekeloa Selatan I, Bandung 40132, Indonesia.
E-mail: agus.susanto@fkg.unpad.ac.id

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How to cite this article: Susanto A, Carolina DN, Amaliya A,

DOI: Setia Pribadi IM, Miranda A. Periodontal health status and treatment
10.4103/jioh.jioh_167_19 needs of the community in Indonesia: A cross sectional study. J Int Oral
Health 2020;12:114-9.

      
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Susanto, et al.: Periodontal health status and treatment needs
(smoking, tobacco use, alcohol, oral hygiene practices) are
also associated with periodontal disease.[5,6]
Preventive programs are needed to prevent periodontitis
at the community level. This plan is based on information
from the referral countries regarding determinant health
distribution regulation. A  national health survey on oral
health in Indonesia has not been existing yet. Local research
on the prevalence of periodontal diseases is also rare. CPITN
(Community Periodontal Index of Treatment Needs) is an
index to estimate the prevalence of periodontal disease and
the treatment needs, and most often used in a research survey
of periodontal disease in a community. Previous research
on the prevalence of periodontal disease in Bandung City
stated that the prevalence of 31% chronic periodontitis (CP)
and aggressive periodontitis was 3.13%.[7,8] Prevalence of
CP in general adult population was reported to be 30–35%,
with approximately 10–15% diagnosed with severe CP.[9]
In Malaysia, the prevalence of the CP and severe CP was
reported as 48.5 and 18.2%, respectively.[10] This study aimed
to determine the prevalence of periodontal disease, and
also periodontal health status and treatment needs in the
community population in Bandung City, Indonesia.
Materials and Methods
This is a descriptive study with cross-sectional approach.
The study was conducted from February to April 2016 in
Bandung, a capital city of West Java. There were total 30
community health centers in Bandung City. A multistage
stratified random sampling technique was used in selecting
the community health center. Six health centers were
chosen representing six development areas in the city of
Bandung. The inclusion criteria of the study included
the patients of aged 11–74  years, who had no history of
periodontal therapy in the last six month, patients who
were younger than 17 years gave consents by the parents
or their representative. The exclusion criteria of the study
included the patients with edentulous and acute oral
disease. A written informed consents were taken from
the participants before enrolling them into study. Sample
size was calculated using single population proportion
formula: n = p (1 – p) Z2 /d2 with an assumption of 95%
confidence level (Z2 = 1.96), d = degree of precision desired
(5%), and p = population proportion of oral hygiene status
or periodontal health status. In this study p (1–p) was taken
0.25 (or P  =  0.5). On the basis of the aforementioned
formula, we need 384 subjects to ensure adequate
sample size in light of anticipated responsive error. The
estimated sample size was increased of 400 patients. All
the examinations were carried out by trained dental
practitioners, who examined each person seated on dental
chair under adequate light. Intra-examiner reproducibility
tested using Kappa index was 0.74. The demographic and
sociodemographic data obtained from the questionnaire
were recorded, including age, gender, address, occupation,
medical records, oral hygiene habit, and smoking habit .
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Oral Hygiene Status
Oral hygiene status was assessed by Simplified Oral
Hygiene Index (OHI-S), which has two components:
the Debris Index-Simplified (DI-S) and the Calculus
Index-Simplified (CI-S), which are calculated separately
and are summed up to get OHI-S for an individual.[11,12]
The examination was carried out using mouth mirror
and explorer. The interpretation of index is as follows:
good—0 to 1.2, fair—1.3 to 3.0, and poor—3.1 to 6.0.[12,13]
Community Periodontal Index of Treatment Needs
Index
Periodontal index used was the CPITN by Ainamo
et al.[14] The teeth examined were 17, 16, 11, 26, 27, 37, 36,
31, 46, and 47. The examination was performed using the
WHO probes or CPITN probes and mouth mirror with
good lighting. Each tooth was checked for the pocket
depth, detection of calculus, and bleeding response.
Examination of each tooth was performed on the mesial,
midfacial, distofacial, mesiolingual/palatal, midlingual/
palatal, and distolingual/palatal parts. Before the study,
all operators were calibrated regarding the CPITN score
assessment.[14]
The scoring code criteria were as follows:
0 = healthy;
1 = bleeding on probing;
2 = supra or subgingival calculus;
3 = there is a pocket with a depth of 4–5 mm;
4 = there is a pocket with a depth of more than 6 mm.
The subjects were diagnosed with CP if they have the
scoring codes of 3 and 4. The categories of the treatment
needs were as follows:[14,15]
0 = no treatment (code 0);
I = improvement in personal oral hygiene (code 1);
II = oral hygiene + scaling (codes 2 and 3);
III = oral hygiene + scaling + complex treatment (code 4).
Statistical Analysis
Statistical analysis was performed using the Statistical
Package for the Social Sciences software version 20.0
(New York, USA), and the Shapiro–Wilk test was used
to test data normality. All collected data were processed
descriptively by presenting the size of the number and
analytically by making a cross-tabulation between one
variable and other variables. The significance value
was calculated by the chi-squared test. Multiple linear
regressions were used to estimate regression coefficients,
standard errors, and 95% confidence intervals (CIs).
A value of P < 0.05 was considered statistically significant.
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Susanto, et al.: Periodontal health status and treatment needs

Results higher in women than men. The frequency of brushing

teeth and age were significantly associated with OHI-S
A total of 400 subjects were selected to participate in the
score (P< 0.05), whereas age and sex (male, female) were
study: 110 men and 290 women. The subjects were divided
significantly associated with CPITN score (P< 0.05) in
into the following age groups: <14 years old, 15–24 years
multivariate analysis [Tables 4 and 5].
old, 25–34  years old, 35–44  years old, 45–54  years old,
55–64  years old, and 65–74  years old [Table 1]. The
highest number of subjects was found in the age group of Discussion
25–34 years old(128 people [32%]). Oral hygiene status as measured by the amount of
The oral hygiene level (OHI-S) included in the good supragingival plaque has been consistently shown by
category was found in 66 subjects (16.5%), fair in 272 cross-sectional studies to have a significant effect on
subjects (68%), and poor in 62 subjects (15.5%) [Table 2]. periodontal health.[16,17] In this study, majority of the
On the basis of the gender, the oral hygiene level of males subjects had a fair level of oral hygiene (66%). This result
was good in 10.9%, fair in 70.9%, and poor in 18.2%; was reflected by the good level of oral health knowledge;
however in females, the oral hygiene level was good in mostly brushed their teeth twice a day, although the
18.6%, fair in 66.9%, and poor in 14.5%. level of dental visits was still rare. On the basis of the
gender, the oral hygiene level of males was worse than
Table 3 shows the distribution of the subjects based on age females. This result may be reflected by the male’s lack
groups according to the CPITN index criteria. Among all of awareness regarding the importance of oral health
400 subjects, 4 subjects had bleeding on probing, 217 had as compared with female, and most male participants
calculus around their teeth, 173 had a shallow pocket, and (72.7%) also had smoking habits.
6 had a deep pocket. The percentage of the shallow and
deep pockets increases along with age, thus indicating that Periodontal disease is an inflammatory disease of
periodontal disease is associated with age. The percentage periodontal tissue caused by plaque bacteria. Several
of CPITN index for the presence of calculus in men risk factors and indicators have been associated with the
(60.9%) was found to be higher than women (51.7%). occurrence of destructive forms of periodontal diseases.
However, the shallow and deep pockets were found to be There is much evidence that cigarette smoking and diabetes
mellitus are important risk factors for clinical attachment
loss. Other risk factors, including age, gender, race,
socioeconomic status, and specific subgingival bacteria,
Table 1: Characteristics of study subjects (n = 400)
are also associated with periodontal disease.[18] Smoking
Characteristics N % habit is one of the risk factors with a large influence on the
Age (year) progression of periodontal disease.[19] Cigarette smoking,
 <14 4 1 nicotine, and its byproducts have a vasoconstrictive effect.
 15–24 115 28.8 They may be reducing the functionalactivity of leukocytes
 25–34 128 32
and macrophages in the saliva and crevicular fluid, as well
 35–44 81 20.3
as decreasing chemotaxis and phagocytosis of blood and
 45–54 47 11.8
tissue polymorphonuclear (PMN) leukocytes, thereby
 55–64 18 4.5
likely depressing phagocyte- mediated protective responses
 65–74 7 1.8
to periodontal pathogens, reducing the oxidation-
X (SD): 32.8 (12.3)
reduction potentials (Eh) and increasing the proportion
Range: 11–74
of anaerobic bacteria in dental plaque.[20]
Gender
 Female 290 72.5 The results of this study showed that the prevalence and
 Male 110 27.5 severity of periodontal disease increases with age. This is
Occupation in line with previous studies which stated that the severity
 Housewife 179 44.8 of periodontal disease increases because of the untreated
  Government officer 17 4.3 cumulative effect of disease process over a period of time
 Self-employed 45 11.3 instead of aging process.[21,22] The extent and severity of
  Private employees 92 23.0 periodontal disease were shown to be different in different
 Jobless/student 67 16.8 age groups and the general trend observed in the majority
Smoking habit status on male subject of the studies had increasing severity with age.[23] The
 Smoking 80 72.7 prevalence and severity of periodontitis increases with age,
  Not smoking 30 27.3 generally affecting both sexes equally. Periodontitis as an
Tooth-brushing frequency age-related disease, not age related. It is not the age of the
 Once 29 7.3 individual that causes an increase in disease prevalence,
 Twice 269 67.3 but rather the length of time periodontal tissue that is
  More than thrice 102 25.5 challenged by chronic plaque accumulation.[24,25]

      
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Susanto, et al.: Periodontal health status and treatment needs

Table 2: OHI-S score based on age group

Age group OHI-S amount (%) Subject amount (%)
Good (0) (n = 66) Fair (1) (n = 272) Poor (2) (n = 62)
11–14 0 (0) 1 (25) 3 (75) 4 (1)
15–24 20 (17.4) 85 (73.9) 10 (8.7) 115 (28.75)
25–34 18 (14.1) 84 (65.6) 26 (20.3) 128 (32)
35–44 12 (14.8) 53 (65.4) 16 (19.8) 81 (20.25)
45–54 12 (25.5) 31 (66) 4 (8.5) 47 (11.75)
55–64 2 (11.1) 13 (72.2) 3 (16.7) 18 (4.5)
65–74 2 (28.6) 5 (71.4) 0 (0) 7 (1.75)
P = 0.017

Table 3: CPITN score based on age group

Age group Subject CPITN amount (%)
Amount (%) Healthy (0) Bleeding (1) Calculus (2) Shallow pockets (3) Deep pockets (4)
11–14 1 (0.25) 0 1 (25.0) 3 (75.0) 0 0
15–24 115 (28.75) 0 1 (0.9) 81 (70.4) 33 (28.7) 0
25–34 128 (32) 0 0 68 (53.1) 58 (45.3) 2 (1.6)
35–44 81 (20.25) 0 2 (2.5) 36 (44.4) 42 (51.9) 1 (1.2)
45–54 47 (11.75) 0 0 23 (48.9) 23 (48.9) 1 (2.1)
55–64 18 (4.5) 0 0 6 (33.3) 11 (61.1) 1 (5.6)
65–74 7 (1.75) 0 0 0 6 (85.7) 1 (14.3)
Total 400 0 4 (1) 217 (54.25) 173 (43.25) 6 (1.5)
Rs = 0.256 
P < 0.001

Table 4: Multiple regression OHI-S with several independent variable

Variable OHI-S
Regression coefficient SE 95% CI P
Age –0.003 0.004 –0.010 to 0.004 0.391
Sex (M,F) –0.181 0.101 –0.380 to 0.018 0.038*
Tooth brushing frequency –0.197 0.084 –0.362 to (–0.033) 0.019*
Constanta 3.016
P 0.008*
R2 2.7%
SE = standard error, CI = confidence interval, R2 = coefficient of determination
*Statistically significant at P < 0.05

The results showed that the oral health status was based influenced by hormones during puberty and decreased
on the CPITN criteria. The number of patients who organ function and disease in elderly.
had gingivitis (codes 1 and 2) was 55.25%, and who had
The prevalence of periodontitis in this study was 44.75%.
periodontitis (codes 3 and 4)  was 44.75%. The CPITN
This result was higher than the study reported by Han
index is a clinical parameter commonly used to assess the
et  al.,[28] who stated that the prevalence of periodontitis
prevalence and status of oral health in epidemiological
in Asia was only around 32.3%. However, the prevalence
studies of periodontal disease. This index can be used on a
of periodontitis in this study was almost the same as the
survey in groups that are large, simple, and relatively easy
research conducted by Jagedeesan et al.[29] suggested that
to do, and having international uniformity for screening
in Pondicherry the overall prevalence was 45%. Different
the population.[26] According to the data taken from the
results with previous studies were possible because of
third National Health and Nutrition Examination Survey
differences in the periodontitis parameters, subject
(NHANES III), gingival bleeding was most prevalent in
population, rural and city location, and social status. All
the 13–17-year-old group (63%) and declined gradually
of which will affect the periodontal health status.
through the 35–44-year-old group.[27] The extent of gingival
bleeding was found higher in the younger and older group On the basis of the CPITN criteria, the highest
than in the middle age groups.[27] This condition may be percentage of study subjects who received the score of

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Susanto, et al.: Periodontal health status and treatment needs
Table 5: Multiple regression CPITN with several independent variable
Variable
Regression coefficient
Age 0.012
Sex (M,F) 0.102
Tooth brushing frequency –0.007
Constanta 1.897
P 0.001*
R2 8.1%
SE = standard error, CI = confidence interval, R2 = coefficient of determination
*Statistically significant at P < 0.05
2 (presence of calculus) in the 15–24-year-old age group
was 70.4%. The shallow pocket was found in 85.7% of the
65–74-year-old age group, and deep pocket was found in
14.3% of the 65–74-year-old age group. The presence of
calculus in male was found to be higher in percentage as
compared with female, but the presence of deep pockets
tends to be found more on the female subjects. The
male subjects obtained a score of 2 (calculus) because
of the male’s lack of awareness on maintaining the oral
hygiene and their smoking habits. About 80% of male
subjects in this study were smokers. Smoking may alter
the neutrophil chemotaxis, phagocytosis, and oxidative
burst. It can also increase the secretion of the tumor
necrosis factor alpha, prostaglandin E2, neutrophil
collagenase, and elastase in the gingival crevicular
fluid.[6]
The relationship between the level of oral hygiene (OHI-S)
and the CPITN index had shown a positive relationship.
It is possible that the oral hygiene level is associated with
the severity of periodontal disease. In this study, most of
the subjects had fair oral hygiene level and CPITN index
of code 2. Oral hygiene was significantly associated with
periodontal status using the CPITN index. Subjects with
poor oral hygiene also had poor periodontal status. Poor
oral hygiene leads to poor periodontal status through
direct mechanisms such as high bacterial challenge to
periodontal tissue, exotoxin, endotoxin, proteolytic, and
hydrolytic enzymes release, and also toxic metabolic
products; indirect mechanisms occurred through
hypersensitivity reactions, activation of antigen and
antibody reactions, and activation of complements.[30]
Individuals with poorer oral hygiene or higher plaque
score were more likely to have more severe periodontal
disease.
In this study, only 1.5% of all subjects needed complex care.
Periodontal treatment needs in this study population were
mostly oral hygiene instruction and oral prophylaxis, which
were found in 97.5% of the subjects. This result indicated
that majority of the research subject population required
primary and secondary levels of preventive program
to educate, motivate, and instruct people regarding the
oral hygiene maintenance, and provide the treatment
118 118  Journal of International Oral Health ¦ Volume 12 ¦ Issue 2 ¦ March-April 2020
CPITN
SE 95% CI P
0.002 0.008–2.192 0.001*
0.060 –0.016 to 0.219 0.045*
0.049 –0.104 to 0.090 0.890
in its early stage to reduce the chances of initiation or
progression of periodontal disease. Limitations of this
study were heterogen subjects, and great variation in age
groups. In addition, this cross-sectional study is limited to
only six community health centers in Bandung. Therefore,
the results of this study cannot be generalized to entire
Bandung area. With regard to the indices used, CPITN
does not evaluate the clinical attachment loss; hence, it
cannot determine the criterion of the disease. To the best
of author knowledge, this is first publication of CPITN
study in Bandung City. A  study by Savira et  al.[31] only
examined study population in patients with diabetes
mellitus.
Conclusion
Within the limitation of this study, it can be concluded
that the number of patients who had gingivitis was
55.25% and who had periodontitis was 44.75% in the
study population. The majority of them needs primary
and secondary level of preventive program to reduce the
initiation or progression of periodontal diseases. Age
and sex (male, female) were significantly associated with
CPITN score.
Acknowledgement
We thank all the respondents and staff of the
Periodontology Department, the Faculty of Dentistry for
the support of this study.
Ethical policy and institutional review board statement
The ethical approval of the research was obtained from
Health Research Ethics Committee, Faculty of Medicine,
Universitas Padjadjaran (Protocol no.  089/UN6.C1.3.2/
KEPK/PN/2016).
Financial support and sponsorship
This research was funded by research grant from
Universitas Padjadjaran.
Conflicts of interest
There are no conflicts of interest.
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Susanto, et al.: Periodontal health status and treatment needs
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