Abstract
Background
Periodontal diseases among working-age individuals (15–69 years) represent a significant global health challenge, impacting oral health, quality of life, and economic productivity. Defined according to the 2021 Global Burden of Disease (GBD) framework, periodontal disease in this study encompasses symptoms such as halitosis, altered taste sensation, and occasional gingival bleeding that do not impair daily activities. Despite their prevalence, comprehensive analyses of the global burden of periodontal diseases specifically within this demographic remain limited.
Methods
We analyzed data from the GBD 2021 study, examining periodontal disease burden among individuals aged 15–69 years across 204 countries and territories from 1990 to 2021. Age-standardized rates of prevalence, incidence, and disability-adjusted life years (DALYs) were calculated. We employed joinpoint regression analysis to assess temporal trends, decomposition analysis to examine contributing factors, and frontier analysis to evaluate the relationship between disease burden and sociodemographic development.
Findings.
In 2021, global periodontal disease cases reached 951.3 million (95% UI: 729.0–1,183.3 million), with an age-standardized prevalence rate (ASPR: 17,011.6 per 100,000 persons) and 80.3 million new cases (ASIR: 1,464.7 per 100,000). The burden accounted for 6.2 million DALYs globally (age-standardized DALY rate: 110.8 per 100,000). Asia demonstrated the highest age-standardized rates across all metrics, while Low-middle SDI regions showed the highest ASPR (20,920.5 per 100,000) and ASIR (1,627.9 per 100,000). At the national level, Sierra Leone, Gambia, and Cabo Verde had the highest disease burden. Males consistently showed higher prevalence rates than females, with peak rates observed in the 50–59 age group. Joinpoint regression analysis revealed an overall increasing trend from 1990 to 2021 (AAPC: 0.04, 95% UI: 0.01–0.06), with notable variations across different time periods. While some countries like Qatar, UAE, and Jordan experienced over 500% increase in prevalence since 1990, Pacific island nations like Tonga and Tokelau achieved reductions exceeding 70%. Decomposition analysis identified population growth (74.56%) and aging (23.00%) as primary drivers of increased disease burden.
Interpretation.
Our analysis reveals significant global disparities in periodontal disease burden among the working-age population, with concerning increases in many regions from 1990 to 2021. The disproportionate burden in Low-middle SDI regions and South Asia, coupled with the substantial impact of population growth and aging, highlights the urgent need for targeted interventions. While some countries have achieved remarkable reductions in disease burden, the dramatic increases in others underscore the importance of strengthening preventive oral healthcare systems and addressing socioeconomic determinants. These findings emphasize the need for country-specific strategies, particularly in regions with rising burden, and can inform evidence-based policy making to reduce the impact of periodontal diseases on the global workforce.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-22566-x.
Keywords: Periodontal diseases, Global burden of disease, Working-age population, Prevalence, Disability-adjusted life years
Introduction
Periodontal diseases represent a significant global public health challenge, particularly among the working-age population (15–69 years). These conditions not only affect oral health but also have substantial implications for individuals'general health, quality of life, and socioeconomic productivity [1–3]. Like other health conditions affecting working-age individuals, periodontal diseases can impact employment prospects, work productivity, and lead to increased economic burden both at individual and societal levels [1, 3]. The World Health Organization has emphasized that oral diseases, including periodontal conditions, affect nearly 3.5 billion people worldwide, with periodontal disease being one of the most prevalent chronic inflammatory conditions [2]. Despite this significant burden, comprehensive global analyses focusing specifically on the working-age population have been limited [1, 2].
Previous Global Burden of Disease (GBD) studies have provided valuable insights into the overall burden of periodontal diseases across all age groups. However, understanding the specific patterns and trends among the working-age population is crucial, as this demographic represents the primary workforce and economic drivers of society. The impact of periodontal diseases in this age group can have far-reaching consequences, including decreased work productivity, increased healthcare costs, and reduced quality of life. Furthermore, the burden of periodontal diseases shows significant variations across different regions and socioeconomic groups, reflecting disparities in healthcare access, preventive services, and treatment availability [1]. Understanding these patterns is essential for developing targeted interventions and health policies [2].
This study aims to provide a comprehensive analysis of the global burden of periodontal diseases among the working-age population from 1990 to 2021, utilizing data from the GBD 2021. This analysis will help identify trends, patterns, and disparities in disease burden across different regions and socioeconomic contexts, potentially informing future healthcare policies and interventions.
Materials and methods
Study design and data collection
This analysis utilized comprehensive data from the GBD 2021 study, encompassing disease burden and risk factor assessments across 204 countries and territories over a 31-year period (1990–2021) [4]. Given that this study analyzed anonymous, aggregated, and publicly accessible data, the University of Washington's Medical Ethics Committee granted approval with an exemption from the informed consent requirement [4, 5]. The manuscript was prepared and structured following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies.
Periodontal diseases in this study were classified according to the 2021 GBD definitions. Periodontal disease was characterized by symptoms including halitosis, altered taste sensation, and occasional gingival bleeding that does not impair daily activities. The disease classification followed standardized diagnostic codes, specifically ICD- 10 (K05.0–K05.6) and ICD- 9 (523.0–523.9). A description of the methods for the estimation of the burden of periodontal diseases have been described previously [6]. Data on the global burden of periodontitis were extracted from the GHDx online query tool (https://ghdx.healthdata.org/gbd-results-tool). We collected comprehensive metrics including annual prevalence, incidence, and disability-adjusted life years (DALYs), both in absolute numbers and age-standardized rates (ASR), spanning from 1990 to 2021 across 25 regions and 204 countries/territories. Age-standardized prevalence rates (ASPR) are reported per 100,000 population, calculated using the GBD 2021 reference standard.
Burden description
To characterize the burden of periodontal diseases between 1990 and 2021, we analyzed the distribution of ASR per 100,000 population across 25 GBD regions and 204 countries/territories. Geographic variations in disease burden were visualized through global map plots, highlighting country/territory-specific ASR patterns. Additionally, we employed compound line graphs to illustrate the relationship between sociodemographic index (SDI) and ASR across GBD regions, revealing how periodontal disease burden correlates with socioeconomic development. The SDI, scaled from 0 to 100, serves as a composite indicator of socio-demographic development, incorporating three key metrics: lagged distributed income per capita, mean educational attainment, and total fertility rate [7].
Joinpoint regression analysis
We employed Joinpoint regression analysis to evaluate the temporal trends of periodontal diseases from 1990 to 2021 [8]. This sophisticated analytical approach utilizes segmented regression within a log-linear model framework to identify significant changes in disease burden trends through inflection points. The optimal inflection points were determined using the grid search method (GSM), which identifies points with the minimal mean squared error (MSE). Subsequently, we applied Monte Carlo permutation testing to determine the optimal number of join points, allowing for 0 to 5 points. We employed Joinpoint regression analysis to evaluate the temporal trends of periodontal diseases from 1990 to 2021. To quantify and interpret these temporal changes, we calculated several standardized metrics: 1) ASPR, which represents the number of prevalent cases per 100,000 population, adjusted for differences in age structure; 2) Annual percentage change (APC), which quantifies the year-to-year rate of change within specific time segments identified by the joinpoint model; and 3) Average annual percentage change (AAPC), which provides a summary measure of the trend over the entire study period, calculated as a weighted average of segment-specific APCs. These metrics enable rigorous comparison of disease burden trends across different time periods, regions, and populations, controlling for demographic variations.
Decomposition analysis
Through decomposition analyses, we examined the driving factors behind DALY changes across global, regional, and national levels during the study period [9]. This analytical approach provides detailed insights into the underlying causes influencing DALY trends. Specifically, we decomposed changes in periodontal disease-associated DALYs into three fundamental components: population growth, population aging, and epidemiological changes, enabling quantification of their respective contributions to overall DALY trends [9–11]. For calculating the population growth contribution, we estimated what the total DALYs would be in 2021 if only the total population had changed from 1990 levels while age structure and age-specific rates remained constant at their 1990 values. The difference between this counterfactual and the 1990 baseline, expressed as a percentage of the total change in DALYs, represents the contribution attributable to population growth alone. Analogous procedures were applied to determine the contributions of population aging and epidemiological changes (changes in age-specific rates). Population data for this analysis were derived from the UN Population Division's World Population Prospects 2022 revision, maintaining consistency with other GBD 2021 analyses [12]. This standardized decomposition methodology enables meaningful comparisons of demographic and epidemiological drivers across different regions and time periods.
Frontier analysis
To examine the relationship between periodontal disease burden and sociodemographic development, we conducted frontier analysis to construct an ASR-based frontier model using the SDI. Rather than employing traditional regression approaches, we utilized complex statistical methods to account for the non-linear relationship between SDI and disease burden, capturing the multidimensional factors influencing periodontal disease burden. The frontier analysis methodology determines the theoretical minimum ASR achievable for each country or territory based on its development level, establishing a benchmark for optimal performance. This approach quantifies the gap between current disease burden and potential minimum burden, identifying opportunities for improvement across different regions. We implemented locally weighted regression (LOESS) combined with local polynomial regression, utilizing various smoothing spans (0.3, 0.4, 0.5) to generate smooth frontier lines that capture the nonlinear SDI-ASR relationship [13]. To ensure analytical robustness, we performed 1000 bootstrap samples and calculated average ASR values for each SDI level. The improvement potential for each country or territory was assessed by measuring the absolute distance between their 2021 ASR and the frontier line (effective difference) [13].
BAPC model projection
This study employed the Bayesian Age-Period-Cohort (BAPC) model for predicting future periodontal disease burden, given its sophisticated capability to handle complex, high-dimensional, and sparse data characteristic of large-scale epidemiological studies like GBD 2021 [14]. The BAPC model extends the traditional generalized linear model (GLM) framework within a Bayesian context, enabling dynamic integration of age, period, and cohort effects. These effects are modeled to evolve continuously over time and are smoothed using a second-order random walk, yielding more precise posterior probability predictions. A key advantage of the BAPC model is its utilization of the Integrated Nested Laplace Approximation (INLA) method for approximating marginal posterior distributions. This approach effectively circumvents common challenges such as mixing and convergence issues typically associated with Markov Chain Monte Carlo techniques, while maintaining computational efficiency. The model's adaptability and robustness in handling time series data make it particularly appropriate for long-term disease burden projections. Given its comprehensive scope and ability to capture temporal trends, the BAPC model has been extensively validated and applied in epidemiological research, especially in studies involving age-structured population data and complex cohort effects. In this study, we utilized the"BAPC"R package to forecast the global burden of periodontal disease, leveraging GBD 2021 data and demographic projections from the IHME. This methodology enables sophisticated predictions of future disease burden while accounting for the complex interplay of age, period, and cohort effects.
Statistical analysis
We analyzed the global burden of periodontal diseases by examining incidence, prevalence, DALYs data obtained directly from the GBD 2021 dataset [15]. All rates are standardized and reported per 100,000 population. The 95% uncertainty intervals (UIs) were calculated within the GBD framework using the 2.5 th and 97.5 th percentiles from 1000 ordered estimates [15]. The UI calculation methodology involved generating 1000 draws from the posterior distribution, employing a bootstrapping method with replacement at each estimation step [15]. This approach enabled comprehensive quantification and propagation of uncertainty across all epidemiological variables within the GBD framework. The selection of 1000 bootstrap replications represents an optimal balance between accuracy and computational efficiency. While larger numbers of replications are possible, they yield minimal improvements in UI estimation while demanding substantially greater computational resources. This sampling size has been demonstrated to provide reliable uncertainty estimates while maintaining practical feasibility in large-scale epidemiological analyses. All procedures for analysis and graphic representation were performed utilizing the World Health Organization's Health Equity Assessment Toolkit and the statistical computing software, R (Version 3.5.2).
Results
Global and continental level
In 2021, the global burden of periodontal diseases reached 951,256,232.8 cases (95% UI: 729,035,190.8–1,183,321,459.9), with an ASPR of 17,011.6 per 100,000 persons (95% UI: 12,996.8–21,229.2) (Table 1, Fig. 1). This represents a 1.5% increase from 1990 levels. The global incidence comprised 80,274,873.1 new cases (95% UI: 51,314,623.7–110,800,790.2), corresponding to an age-standardized incidence rate (ASIR) of 1,464.7 per 100,000 persons (95% UI: 934.9–2,027.1) (Table S1,Fig. 1). In terms of disease burden, periodontal diseases accounted for 6,192,220.2 DALYs globally (95% UI: 2,414,774.6–12,836,557), with an age-standardized DALY rate of 110.8 per 100,000 persons (95% UI: 43.2–230.2) (Table S2,Fig. 1).
Table 1.
Prevalent cases for periodontal diseases in 2021 for both sexes and rate change of age-standardised rates by Global Burden of Disease (GBD)
| Location | 1990 | 2021 | ||
|---|---|---|---|---|
| Number | ASR | Number | ASR | |
| Global | 511,273,721.9 (348,066,669.6–681,372,362.6) | 16,763.3 (11,516.1–22,153) | 951,256,232.8 (729,035,190.8–1,183,321,459.9) | 17,011.6 (12,996.8–21,229.2) |
| Africa | 63,202,863.5 (44,475,552.5–82,086,981.8) | 22,464.1 (16,156.4–28,670.1) | 108,091,094.5 (79,950,144.5–140,726,831.4) | 15,962.4 (11,912.6–20,534.2) |
| America | 66,585,898 (44,694,130.9–89,621,499.2) | 15,832.4 (10,736.8–21,117.4) | 126,376,366.1 (96,027,992.4–159,144,116.7) | 16,405.6 (12,384.3–20,791.8) |
| Europe | 86,818,068.9 (61,009,471.1–114,247,019.4) | 14,393.3 (10,039.3–19,027.3) | 100,823,255.5 (68,802,122–137210478) | 13,908.9 (9298.7–19,372.6) |
| Asia | 293,588,023.8 (196,220,088.5–395,303,966.4) | 16,851.9 (11,422.1–22,413.8) | 614,676,733.5 (476,510,903.8–755,271,722.4) | 17,880.7 (13,810.7–22,044.5) |
| High SDI | 89,612,454.2 (62,181,808.6–119,083,548.8) | 13,743.5 (9510.1–18,296.3) | 126,843,491.6 (92,931,314.8–165,324,976) | 13,463.7 (9704.2–17,889.5) |
| High-middle SDI | 101,440,320 (66,684,297.8–138,073,576.2) | 14,440.2 (9497.8–19,583) | 165,170,486.4 (122,978,911.9–213,817,271.5) | 14,288.2 (10,493–18812.5) |
| Middle SDI | 150,035,720.7 (100,646,529.5–202,066,204.2) | 16,476.1 (11,244.5–21,861.4) | 313,921,462 (243,587,402.5–385,827,907.9) | 16,767 (12,950.9–20,693.9) |
| Low-middle SDI | 116,744,061.6 (80,440,610.8–154,287,969.6) | 20,564.1 (14,409.4–26,782.5) | 248,743,855.9 (189,664,285.7–307,571,989.3) | 20,920.5 (16,055–25711) |
| Low SDI | 52,976,349 (36,945,623.5–69,275,404.9) | 23,778.5 (16,918.9–30,561.1) | 95,923,866.8 (72,989,707.7–120,107,289.2) | 18,289 (14,088.5–22,600.1) |
| Andean Latin America | 3,023,916.5 (2,236,756–3,868,293.7) | 16,505.3 (12,415.8–20,810.4) | 7,225,713.6 (4,762,953.6–10,097,958.1) | 16,554.2 (10,976.5–23,001.8) |
| Australasia | 1,615,132.5 (987,961.6–2,320,562.6) | 11,252.8 (6875.2–16,167) | 3,339,317.1 (2,132,344.1–4,840,026.6) | 13,654 (8606.3–20,120.1) |
| Caribbean | 4,155,532.9 (2,866,049.1–5,522,078.2) | 21,146.1 (14,826.9–27,700.2) | 6,373,235.7 (4,377,728.4–8,601,141.2) | 18,857.7 (12,884.6–25,582.6) |
| Central Asia | 4,832,210 (3,111,346.5–6,684,239.2) | 13,540.9 (8764.1–18,557.5) | 8,432,943.4 (5,336,718.4–12,351,201.1) | 12,742.7 (8079.9–18,604.2) |
| Central Europe | 11,715,457.2 (7,694,823.8–16,084,220.8) | 12,353.6 (8041.4–17,062.8) | 13,915,095.8 (9,198,270.5–19,396,692.5) | 13,605.6 (8803.8–19,449.1) |
| Central Latin America | 15,591,451.9 (10,535,502.6–21,068,168.5) | 20,075.6 (13,949.6–26,497.8) | 34,866,268.5 (25,791,840.6–44,486,017.4) | 19,761.8 (14,613.7–25,224.7) |
| Central Sub-Saharan Africa | 5,625,458.2 (3,835,120.1–7,488,908.6) | 23,704.2 (16,604.1–30,764.8) | 7,553,853.9 (4,548,218–11,691,758.5) | 12,549.5 (7704–18933.2) |
| East Asia | 104,391,795.5 (68,125,733.5–142,846,066.4) | 14,655.5 (9678.7–19,818.5) | 195,893,145.5 (147,616,998.2–245,292,159) | 14,212.7 (10,553.5–18,061.5) |
| Eastern Europe | 28,014,948 (19,173,423.3–37,291,849.9) | 16,031.7 (10,840.1–21,493.5) | 27,392,361.4 (18,475,561.9–37,895,424.1) | 14,698.9 (9714.9–20,813) |
| Eastern Sub-Saharan Africa | 19,659,000.2 (13,551,253.9–26,010,889.7) | 25,247.3 (17,980.3–32,504.4) | 31,837,615.9 (23,299,412.3–41,861,466.8) | 16,900.1 (12,558.1–21,831) |
| High-income Asia Pacific | 15,673,158.7 (9,866,399.9–21,919,046.5) | 11,505.3 (7219.9–16,152) | 19,889,733.8 (12,888,538.5–27,984,201.4) | 11,564.8 (7326.3–16,830.4) |
| High-income North America | 27,038,189.7 (17,836,680.4–36,772,309.7) | 13,523.7 (8915.9–18,365.7) | 39,336,828.5 (29,641,446–50,019,797) | 12,605 (9352.4–16,308.9) |
| North Africa and Middle East | 19,982,083.1 (12,734,808.7–28,271,233.4) | 12,972 (8409.9–18,040.7) | 64,902,272.1 (46,075,358.4–87,750,846.2) | 15,879.6 (11,376.7–21,253.1) |
| Oceania | 381,098.8 (236,524.1–542,110.2) | 13,292.4 (8427.9–18,567.7) | 207,199.3 (121,353.5–344,656.1) | 2847.3 (1680.5–4681.5) |
| South Asia | 125,010,989.5 (86,250,323.8–165,097,761.7) | 22,553.3 (15,844.6–29,320.8) | 291,345,610.3 (224,404,580.8–356,408,602.7) | 24,235.8 (18,781.4–29,490.3) |
| Southeast Asia | 34,372,108.5 (22,682,947.8–47,211,272.7) | 14,813.6 (9953.8–20,031) | 67,596,721.1 (50,640,660.2–84,924,395.2) | 13,222.9 (9897.2–16,629.3) |
| Southern Latin America | 5,207,902.9 (3,420,620.9–7,113,362.8) | 16,834.7 (11,069.3–22,948.7) | 8,953,183.8 (5,913,850.5–12,441,455) | 17,841.5 (11,719.8–24,949.2) |
| Southern Sub-Saharan Africa | 2,138,598.1 (1,267,048.3–3,204,387.9) | 9218.8 (5534.8–13,626.8) | 3,485,853 (2,383,363.4–4,964,504.5) | 7133.1 (4894.4–10,092.7) |
| Tropical Latin America | 12,306,220.8 (8,100,847.2–16,918,219.8) | 15,301.2 (10,248.6–20,730.4) | 30,467,127.4 (22,646,256.8–38,368,319.1) | 17,612.2 (13,053.3–22,254.7) |
| Western Europe | 43,786,887.2 (32,053,444.2–56,740,605.4) | 14,738 (10,728.1–19,176.9) | 47,048,390.5 (32,651,896.3–63,495,158.1) | 12,726.5 (8650.2–17,577.4) |
| Western Sub-Saharan Africa | 26,751,581.7 (19,687,269–33,700,561.5) | 30,342.3 (22,809.3–37,593.1) | 41,193,762.2 (32,216,310.6–50,918,502.9) | 18,231.9 (14,405.1–22,294.6) |
Fig. 1.
Trends in periodontal diseases incidence, prevalence and disability-adjusted life-years from 1990 to 2021
Continental analysis revealed distinct geographical patterns and temporal trends from 1990 to 2021. In 2021, Asia exhibited the highest age-standardized rates across all metrics—prevalence, incidence, and DALYs of periodontal diseases, reflecting a disproportionate burden in this region. The temporal changes in ASPR demonstrated clear divergent trends across continents: Asia and America showed progressive increases compared to their 1990 levels, potentially reflecting demographic transitions and changing risk factor profiles in these regions. In contrast, Africa and Europe experienced notable decreases over the same period, which may indicate successful implementation of oral health initiatives or changes in environmental risk factors.
This continental divergence was similarly reflected in ASIR patterns. Only Asia and America demonstrated positive trends in disease incidence: Asia's ASIR increased from 1,460 (95% UI: 779.4–2,161.2) in 1990 to 1,517.9 (95% UI: 995.6–2,065.7) in 2021, while America's rose from 1,475.3 (95% UI: 814.9–2,162) to 1,489.2 (95% UI: 937.1–2,083.6). In contrast, both Africa and Europe showed significant declining trends in ASIR compared to their 1990 levels, aligning with their prevalence patterns. Age-standardized DALY rates followed consistent patterns, with Asia and America showing increases while Africa and Europe experienced declines over the same period, suggesting that the overall disability burden closely tracked changes in disease occurrence.
Regional level
Regional analysis in 2021 revealed substantial disparities in periodontal disease burden across different sociodemographic and geographic regions. When categorized by socioeconomic development, Low-middle SDI regions had the highest ASPR of periodontal diseases at 20,920.5 per 100,000 persons (95% UI: 16,055–25,711) (Table 1 and Fig. 2), indicating a disproportionate burden in regions with intermediate development levels.
Fig. 2.
The global disease burden of periodontal diseases prevalence rate for both sexes in 204 countries and territories
Geographically, the burden showed marked variation, with South Asia demonstrating the highest regional burden with an ASPR of 24,235.8 per 100,000 persons (95% UI: 18,781.4–29,490.3), followed by Central Latin America at 19,761.8 per 100,000 persons (95% UI: 14,613.7–25,224.7). These high-burden regions contrast sharply with regions exhibiting markedly lower disease prevalence, including Oceania (2,847.3 per 100,000 persons; 95% UI: 1,680.5–4,681.5), Southern Sub-Saharan Africa (7,133.1 per 100,000 persons; 95% UI: 4,894.4–10,092.7), High-income Asia Pacific (11,564.8 per 100,000 persons; 95% UI: 7,326.3–16,830.4), and Central Sub-Saharan Africa (12,549.5 per 100,000 persons; 95% UI: 7,704–18,933.2). This regional variation suggests that factors beyond economic development influence disease patterns.
The incidence patterns paralleled prevalence distribution in 2021, with Low-middle SDI regions maintaining the highest ASIR among SDI regions at 1,627.9 per 100,000 persons (95% UI: 1,030–2,237.7), followed by Middle SDI regions at 1,454.4 per 100,000 persons (95% UI: 958.5–1,984.4) (Table S1 and Fig S1). High SDI regions reported the lowest ASIR at 1,245.1 per 100,000 persons (95% UI: 732.3–1,838.6). Geographically, South Asia, Central Latin America, and Tropical Latin America demonstrated the highest ASIR, while High-income Asia Pacific, Southern Sub-Saharan Africa, and Oceania exhibited the lowest incidence rates.
The disability burden, measured by age-standardized DALY rates, showed similar socioeconomic gradients but with notable temporal changes. In 2021, the highest burden was observed in Low-middle SDI regions at 136 per 100,000 persons (95% UI: 52.7–281.1), while High SDI regions reported the lowest rate at 87.6 per 100,000 persons (95% UI: 32.9–185.6) (Table S2, Fig S2).
Comparing 1990 and 2021 data revealed significant improvements in some regions. Low SDI regions demonstrated substantial progress, with age-standardized DALY rates declining from 154.5 per 100,000 persons (95% UI: 59.7–326) in 1990 to 118.8 per 100,000 persons (95% UI: 46.8–245.3) in 2021 (Table S2, Fig S2). Most remarkable was Oceania's transformation, which experienced the most dramatic decrease in age-standardized DALY rates, falling from 86.5 per 100,000 persons (95% UI: 32–192.6) to 18.4 per 100,000 persons (95% UI: 6.3–42.4), representing a 78.7% reduction. Despite these improvements in some regions, South Asia, Central Latin America, and the Caribbean continued to exhibit persistently high age-standardized DALY rates in 2021, each exceeding 120 per 100,000 persons.
National level
The ASPR of periodontal diseases ranges from approximately 2384.9 to 35,987 per 100,000 individuals. Notably, Sierra Leone (35,987 per 100,000 persons; 95% UI: 28,897.9–42,839.9), Gambia (35,015.4 per 100,000 persons; 95% UI: 27,521.6–42,300),
Cabo Verde (34,122.9 per 100,000 persons; 95% UI: 26,729.1–41,375.9), Ghana (33,237.6 per 100,000 persons; 95% UI: 25,647.1–40,508), Cameroon (32,285.7 per 100,000 persons; 95% UI: 24,555.7–39,699), Mali (31,608 per 100,000 persons; 95% UI: 23,344.2–39,210.8), and Burkina Faso (31,318.5 per 100,000 persons; 95% UI: 23,321.7–39,113.8) have the highest ASPR (Fig. 2A and Table 1). From 1990 to 2021, variations in the change of the ASPR were observed across countries. Notably, Turkey (18,156.9 per 100,000 persons; 95% UI: 12,311.9–24,890.7), Sierra Leone (35,987 per 100,000 persons; 95% UI: 28,897.9–42,839.9), and Lao People's Democratic Republic (7169.6 per 100,000 persons; 95% UI: 4227.6–11,257.3) experienced the most substantial relative increases in ASPR (Table 1). In a remarkable divergence from the data recorded in 1990, the prevalence cases in Qatar, the United Arab Emirates, and Jordan have skyrocketed by more than 500% (Fig. 2B). Conversely, the Pacific island nations of Tonga, Tokelau, Niue, and Nauru have demonstrated remarkable progress, with a dramatic reduction of over 70% in their prevalence cases relative to the figures from 1990 (Fig. 2B).
The ASIR for periodontal diseases ranged from 261.2 to 2235.9 per 100,000 population. In 2021, Sierra Leone (2235.9 per 100,000 persons; 95% UI: 1447.9–2870.1), Gambia (2170.2 per 100,000 persons; 95% UI: 1346.1–2854), Ghana (2120.2 per 100,000 persons; 95% UI: 1269.3–2843.9), Denmark (2103 per 100,000 persons; 95% UI: 1304.4–2802), and Cameroon (2091.2 per 100,000 persons; 95% UI: 1215.7–2840.4) had the highest ASIR (Fig.S1 and Supplementary Table S1). In a remarkable demographic transformation since 1990, Qatar, the United Arab Emirates, and Jordan have experienced an extraordinary surge in incidence cases, with rates climbing more than fourfold above their baseline figures. Meanwhile, painting a starkly different picture, the Pacific island nations of Tokelau, Niue, and Nauru have demonstrated exceptional progress in public health initiatives, successfully reducing their incidence cases by more than seventy percent from their 1990 levels (Fig S3). Similar to the ASIR, 8 nations with more than 200 age-standardized DALYs (Sierra Leone, Gambia, Cabo Verde, Ghana, Cameroon, Mali, Burkina Faso, Guinea). Sierra Leone had the highest age-standardized DALYs (235.9, 95% UI: 90.2–481.7, Supplementary Table S2) in 2021.
Age and sex patterns
Regarding prevalence patterns, ASPR peaked globally and across all five SDI regions among individuals aged 50–59 years. Males consistently demonstrated higher ASPR compared to females. Among the five SDI regions, only the Low SDI category showed a notable decline in ASPR compared to 1990 levels, while the remaining SDI regions maintained relatively stable rates over this period (Fig. 3). The DALYs patterns showed similar trends to those observed in prevalence (Fig S4). In terms of incidence patterns, the peak age group was 40–49 years across most regions, with low SDI regions being the exception, where the highest ASIR occurred in the 65–69 age group. In High SDI regions, males exhibited higher ASIR than females, while other SDI regions showed similar ASIR between males and females (Fig S5).
Fig. 3.
Age-standardized prevalence rates of periodontal diseases by sex, age group, and socio-demographic index, 1990 and 2021
Joinpoint regression analysis
Temporal trend analysis of periodontal disease burden revealed distinct patterns with several inflection points between 1990 and 2021 (Fig. 4). Overall, the global ASPR showed a modest but statistically significant increase during the entire 31-year period, with an AAPC of 0.04 (95% UI: 0.01 to 0.06).
Fig. 4.
Joinpoint regression analysis of ASPR of periodontal diseases from 1990 to 2021
This overall trend can be divided into four distinct phases, each with its own APC indicating the rate of change during that specific period. Initially, from 1990 to 1994, there was a significant decline with an APC of − 0.61 (95% UI: − 1.04 to − 0.37), which may correspond to early implementation of preventive oral health measures in many regions. The period from 1994 to 2006 showed relative stability. Subsequently, from 2006 to 2010, there was a more pronounced decline with an APC of − 1.57 (95% UI: − 1.72 to − 1.36), potentially reflecting improvements in oral healthcare access and preventive strategies during this period. This declining trend reversed during 2010–2015, when the ASPR increased substantially with an APC of 2.23 (95% UI: 2.1 to 2.36), which may reflect changing population demographics, improved disease detection, or shifts in risk factor prevalence. Finally, from 2015 to 2021, the rate resumed a declining trend, albeit at a slower pace, with an APC of − 0.16% (95% UI: − 0.28 to − 0.05).
The 2010–2015 period marked a significant deviation from the previous declining trends, showing a substantial increase with an APC of 2.23 (95% UI: 2.1 to 2.36). This notable reversal coincided with several important developments in periodontal epidemiology and healthcare systems. First, this period followed the 2009–2010 global economic recession, which likely reduced access to preventive dental care in many regions. Second, this timeframe saw the implementation of the 2012 CDC-AAP case definitions for population-based surveillance of periodontitis, which improved detection rates and standardized diagnosis. Third, data collection methods for the GBD study underwent refinement during this period, potentially capturing previously under-reported cases. Additionally, this period coincided with aging populations in many middle-SDI regions and increasing prevalence of risk factors such as diabetes and smoking in developing economies. The regional analysis revealed that this increase was most pronounced in Low-middle SDI regions, suggesting these factors had differential impacts across socioeconomic strata. Finally, from 2015 to 2021, the rate resumed a declining trend, albeit at a slower pace, with an APC of − 0.16 (95% UI: − 0.28 to − 0.05), possibly reflecting renewed prevention efforts and improved oral healthcare policies following the concerning increase in the previous period.
When analyzed by sociodemographic development level, contrasting patterns emerged. Low-middle SDI and middle SDI regions both exhibited overall increasing trends from 1990 to 2021, with AAPCs of 0.05 (95% UI: 0.04 to 0.06) and 0.05 (95% UI: 0.02 to 0.08), respectively. These increases may reflect population growth, urbanization processes, and changes in lifestyle factors in these regions. In contrast, other SDI regions showed decreasing trends: high-middle SDI regions demonstrated a slight decline with an AAPC of − 0.05 (95% UI: − 0.1 to 0), while low SDI regions exhibited the most substantial decrease with an AAPC of − 0.84 (95% UI: − 0.86 to − 0.81). The more pronounced decline in low SDI regions despite resource limitations suggests potential benefits from targeted oral health interventions or changes in environmental risk factors in these areas.
Decomposition analysis
The decomposition analyses revealed distinct patterns in the contributions of population-level determinants (aging, population growth, and epidemiologic change) to changes in disease burden metrics at global, SDI strata, and GBD super-regional levels (Fig.S6 and Supplementary Table S3). Globally, population growth emerged as the predominant driver, accounting for 74.56% of changes in DALYs, while aging and epidemiological change contributed 23.00% and 2.43%, respectively. Similar patterns were observed for incidence changes, with population growth contributing 86.37%, followed by aging (13.30%) and epidemiological change (0.33%). For prevalence changes, population growth remained the leading contributor at 74.20%, with aging accounting for 23.18% and epidemiological change contributing 2.62%. In the African region, population growth emerged as the predominant driver, accounting for 166.80% of the increase in DALYs, whereas epidemiological factors contributed negatively (− 73.51%), and aging effects were minimal (6.71%). The Americas demonstrated more moderate patterns, with population growth contributing 70.63% to DALYs changes, complemented by aging (24.29%) and epidemiological factors (5.08%). A distinct pattern was observed in Europe, where aging predominated (85.19%), with additional contributions from population growth (42.27%) and negative epidemiological effects (− 27.46%). The Asian region showed intermediate patterns, with population growth contributing 64.39%, aging 27.07%, and epidemiological changes 8.54%.
High-SDI regions showed substantial contributions from both population growth (64.42%) and aging (42.54%), with negative epidemiological effects (− 6.96%). In high-middle-SDI regions, population growth and aging contributed nearly equally (53.36% and 49.58%, respectively). Middle-SDI regions demonstrated predominant population growth effects (62.36%), moderate aging impacts (35.16%), and minimal epidemiological changes (2.48%). Low-middle-SDI regions showed marked population growth effects (85.69%) with lesser contributions from aging (11.78%). Most notably, low-SDI regions exhibited the highest population growth contribution (152.50%), accompanied by negative aging (− 1.61%) and epidemiological (− 50.89%) effects.
Frontier analysis
To understand the achievable improvements in periodontal disease DALY rates relative to sociodemographic development, we conducted a frontier analysis utilizing age-standardized DALY rates and SDI data from 1990 to 2021 (Fig. 5A). The frontier line represents the lowest observed DALY rates among countries and territories at each SDI level, defining optimal performance benchmarks. We quantified the effective difference—the gap between observed and potentially achievable DALYs—which represents the theoretical improvement possible given a location's sociodemographic resources. Analysis of 2021 data revealed that the highest effective differences from the frontier (range, 155.28–214.16) were observed in the Gambia, Sierra Leone, Cabo Verde, Ghana, Pakistan, Guinea, Burkina Faso, Liberia, Bhutan, and Bangladesh, indicating substantially higher periodontal disease burden than expected for their sociodemographic development (Fig. 5B, Supplementary Table S4). Conversely, the lowest effective differences (range, 0.34–6.09) were found in Fiji, Tokelau, Spain, Tonga, Samoa, Marshall Islands, Papua New Guinea, Micronesia, Vanuatu, and Solomon Islands, suggesting optimal performance relative to their development status (Fig. 5B, Supplementary Table S4).
Fig. 5.
Frontier analysis exploring the relationship between SDI and age-standardized DALY rates for periodontal diseases
BAPC model projection
Based on the analysis of ASR of periodontal diseases over the past 32 years, we projected ASR changes for the next 25 years, accounting for temporal and age-related variations. Our prevalence projections indicate a consistent upward trend across most age groups. Specifically, by 2046, the ASPR are projected to reach 40,463.516 per 100,000 persons in the 50–54 age group and 39,496.47 per 100,000 persons in the 55–59 age group (Figure S7, TableS5). Similarly, the ASIR in the 45–49 age group is expected to reach 2,303.598 per 100,000 persons (Figure S8,TableS5). The burden of disease, measured in DALYs, is projected to remain highest in the 50–54 age group, reaching 259.198 per 100,000 persons by 2046 (Figure S9,TableS5).
Discussion
This study presents the first comprehensive analysis of global periodontal disease burden specifically focusing on the working-age population from 1990 to 2021. Our findings reveal substantial variations in disease burden across regions and countries, with concerning trends that demand immediate attention from public health professionals and policymakers. The case definition of periodontal disease in this study follows the methodology of previous GBD studies to ensure comparability of estimates across time periods. While this definition encompasses symptoms that overlap with gingivitis, this approach was maintained to ensure consistency with established GBD methodology and to capture the complete burden of periodontal conditions [16, 17].
The substantial global burden of periodontal diseases, affecting 951.3 million individuals in 2021, represents a significant public health challenge that cannot be ignored. The observed ASPR of 17,011.6 per 100,000 persons indicates that periodontal diseases remain highly prevalent among the working-age population, aligning with previous studies highlighting the pervasive nature of these conditions globally [18]. This burden's magnitude is particularly concerning given its potential impact on workforce productivity and quality of life [19].
The analysis of temporal trends reveals a modest but steady increase in disease burden from 1990 to 2021, with an AAPC of 0.04. This persistent upward trend suggests that despite advances in dental care and prevention strategies, the global community has not successfully reduced the burden of periodontal diseases [19]. Tonetti et al. [19] previously highlighted similar concerns regarding the challenging nature of controlling periodontal disease progression at a population level. The increasing trend might be attributed to improved detection and diagnosis, aging populations, and changes in risk factors such as smoking and diabetes prevalence, as suggested by recent epidemiological studies [20]. Our findings demonstrate substantial regional variations in disease burden, with Asia showing the highest ASR across all metrics. The disproportionate burden in Low-middle SDI regions, with an ASPR of 20,920.5 per 100,000 persons, reflects significant healthcare disparities that mirror broader socioeconomic inequalitie. Peres et al. [21] have previously emphasized how such disparities in oral health often reflect systemic inequalities in healthcare access and resource distribution. The remarkable success of some Pacific island nations in reducing their disease burden by over 70% since 1990 provides valuable insights for policy development. These achievements demonstrate that significant improvements are possible with appropriate interventions, though the specific factors contributing to these successes warrant further investigation. Conversely, the substantial increases in prevalence (> 500%) observed in countries like Qatar, UAE, and Jordan raise significant concerns. These trends might be attributed to rapid urbanization, lifestyle changes, improved disease detection, and population demographic shifts, as documented in recent studies of oral health transitions in developing economies [22, 23].
Our decomposition analysis reveals that population growth (74.56%) and aging (23.00%) are the primary drivers of increased disease burden. This finding has profound implications for healthcare planning and aligns with previous research [24]. The relationship between sociodemographic development and disease burden, as revealed by our frontier analysis, suggests a complex interaction that requires careful consideration in policy development.
The higher burden in Low-middle SDI regions indicates that economic development alone may not guarantee improved oral health outcomes without targeted interventions and policy measure [25]. This observation supports previous findings regarding the need for comprehensive approaches to oral health improvement that address both healthcare access and social determinants of health [26].
Several limitations of this study should be acknowledged. First, like other studies using the GBD database, our analysis was constrained by the limitations inherent to the GBD study methodology. The GBD estimates rely heavily on modeling in regions with limited or no primary data, which may affect the accuracy of estimates in these areas. Second, the cross-sectional nature of many included studies limits our ability to establish causal relationships between observed trends and their potential drivers. Finally, our study did not account for potential variations in disease severity within the category of severe periodontitis, which could mask important clinical and epidemiological patterns. Future research incorporating more detailed severity classifications could provide better insights for clinical practice and public health planning.
Conclusions
The global burden of periodontitis has increased substantially from 1990 to 2021, with the age-standardized prevalence rate rising by 8.44% worldwide. Population growth has been the primary driver, accounting for 67.9% of the increase in prevalent cases. Less developed regions show disproportionately higher disease burdens, indicating significant healthcare disparities. These findings emphasize the urgent need for comprehensive policy reforms, including implementing workplace oral health programs, expanding dental insurance coverage, and strengthening preventive care services. Integration of periodontal care into primary health services should follow successful models demonstrated in countries like Sweden and Denmark, where dental hygienists work alongside primary care physicians and routine periodontal screenings are incorporated into regular health check-ups. In New Zealand and Australia, the implementation of oral health assessments in primary care settings and coordination between dental and medical professionals has shown promising results in early detection and management of periodontal diseases. Future public health initiatives should prioritize specific preventive strategies, including: (1) school-based oral health education programs focusing on proper brushing techniques and interdental cleaning; (2) community water fluoridation where feasible; (3) regular professional dental cleaning subsidies for high-risk populations; and (4) targeted smoking cessation programs to address this major risk factor. Management approaches should emphasize early detection through routine screenings, standardized treatment protocols, and long-term maintenance programs, while considering region-specific challenges and resource availability.
Supplementary Information
Supplementary Material 1: TableS1 Incidenece for periodontal diseases in 2021 for both sexes and rate change of age-standardised rates by Global Burden of Disease (GBD).
Supplementary Material 2: TableS2 DALYs for periodontal diseases in 2021 for both sexes and rate change of age-standardised rates by Global Burden of Disease (GBD).
Supplementary Material 3: TableS3:Decomposition analysis.
Supplementary Material 4: TableS4: Frontier analysis.
Supplementary Material 5: TableS5: BAPC model projection.
Supplementary Material 6: Fig.S1: The global disease burden of periodontal diseases incidence rate for both sexes in 204 countries and territories.
Supplementary Material 7: Fig.S2: The global disease burden of periodontal diseases DALYs rate for both sexes in 204 countries and territories.
Supplementary Material 8: Fig.S3: Change incidence cases of periodontal diseases.
Supplementary Material 9: Fig.S4: Age-standardized DALYs rates of periodontal diseases by sex, age group, and socio-demographic index, 1990 and 2021.
Supplementary Material 10: Fig.S5: Age-standardized incidence rates of periodontal diseases by sex, age group, and socio-demographic index, 1990 and 2021.
Supplementary Material 11: Fig.S6:Population-level determinant changes in aging, population growth, and epidemiological changes for periodontal diseases.
Supplementary Material 12: Fig.S7: Future forecasts of global prevalence burden of periodontal diseases across age groups.
Supplementary Material 13: Fig.S8: Future forecasts of global incidence burden of periodontal diseases across age groups.
Supplementary Material 14: Fig.S9: Future forecasts of global DALYs burden of periodontal diseases across age groups.
Acknowledgements
Not applicable.
Abbreviations
- AAPC
Average Annual Percentage Change
- ASIR
Age-Standardized Incidence Rate
- ASPR
Age-Standardized Prevalence Rate
- BAPC
Bayesian Age-Period-Cohort
- DALY
Disability-Adjusted Life Year
- GBD
Global Burden of Disease
- GHDx
Global Health Data Exchange
- ICD
International Classification of Diseases
- INLA
Integrated Nested Laplace Approximation
- LOESS
Locally Weighted Regression
- SDI
Socio-Demographic Index
- UI
Uncertainty Interval
Authors’ contributions
All authors (Haojie Fu, Xinyu Li, Ruhong Zhang, Jiaxue Zhu, Xudong Wang) made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.
Funding
There is no funding support in this study.
Data availability
GBD study 2021 data resources were available online from the Global Health Data Exchange (GHDx) query tool (http://ghdx.healthdata.org/gbd-results-tool).
Declarations
Ethics approval and consent to participate
An ethics approval and the consent to participate was not necessary.
Consent for publication
All participants in this study consented to publication.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Haojie Fu and Xinyu Li co-first author.
Contributor Information
Ruhong Zhang, Email: zhangruhong@163.com.
Jiaxue Zhu, Email: zhuxile521@163.com.
Xudong Wang, Email: xudongwang70@hotmail.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Material 1: TableS1 Incidenece for periodontal diseases in 2021 for both sexes and rate change of age-standardised rates by Global Burden of Disease (GBD).
Supplementary Material 2: TableS2 DALYs for periodontal diseases in 2021 for both sexes and rate change of age-standardised rates by Global Burden of Disease (GBD).
Supplementary Material 3: TableS3:Decomposition analysis.
Supplementary Material 4: TableS4: Frontier analysis.
Supplementary Material 5: TableS5: BAPC model projection.
Supplementary Material 6: Fig.S1: The global disease burden of periodontal diseases incidence rate for both sexes in 204 countries and territories.
Supplementary Material 7: Fig.S2: The global disease burden of periodontal diseases DALYs rate for both sexes in 204 countries and territories.
Supplementary Material 8: Fig.S3: Change incidence cases of periodontal diseases.
Supplementary Material 9: Fig.S4: Age-standardized DALYs rates of periodontal diseases by sex, age group, and socio-demographic index, 1990 and 2021.
Supplementary Material 10: Fig.S5: Age-standardized incidence rates of periodontal diseases by sex, age group, and socio-demographic index, 1990 and 2021.
Supplementary Material 11: Fig.S6:Population-level determinant changes in aging, population growth, and epidemiological changes for periodontal diseases.
Supplementary Material 12: Fig.S7: Future forecasts of global prevalence burden of periodontal diseases across age groups.
Supplementary Material 13: Fig.S8: Future forecasts of global incidence burden of periodontal diseases across age groups.
Supplementary Material 14: Fig.S9: Future forecasts of global DALYs burden of periodontal diseases across age groups.
Data Availability Statement
GBD study 2021 data resources were available online from the Global Health Data Exchange (GHDx) query tool (http://ghdx.healthdata.org/gbd-results-tool).