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. 2025 May 31;25:861. doi: 10.1186/s12903-025-06271-0

Burden of severe periodontitis: new insights based on a systematic analysis from the Global Burden of Disease Study 2021

Leng Wu 1,2, Chun-Ming Huang 1,2, Qiong Wang 3, Jian Wei 1,2, Long Xie 4,5,6,✉, Chuan-Yu Hu 1,2,✉
PMCID: PMC12125741  PMID: 40450275

Abstract

Background

Severe periodontitis is a significant public health concern. This study aimed to systematically analyze its burden by utilizing the Global Burden of Diseases (GBD) 2021 data and multiple analytical approaches, with the goal of providing evidence to reduce the disease burden and improve health inequalities.

Methods

The burden of severe periodontitis at different levels was analyzed using prevalence as the metric, combined with the Sociodemographic Index (SDI). Analyses incorporated including frontier analysis to estimate achievable outcomes and potential improvement spaces for disease burden, slope and concentration indexes to evaluate health inequalities, decomposition analysis to identify key drivers of changes in disease burden, and Joinpoint regression analysis and estimated annual percentage change to examine temporal trends over time.

Results

In 2021, the global age-standardized prevalence rate (ASPR) of severe periodontitis was 12,498.3 (95% UI: 10,526.8 to 14,493.4) per 100,000 population, with more than one billion people worldwide affected. Regardless of development level, most countries have significant potential to reduce severe periodontitis burden. High SDI countries bear a disproportionately large burden, with inequalities worsening over time. From 1990 to 2021, global cases of severe periodontitis increased by 91.54%, driven mainly by population growth (66.15%) and aging (30.84%). Among SDI regions, population was the primary contributor to the increase, with the largest impact (134.48%) in low SDI region. Aging contributed between 13.69% (low SDI region) and 37.21% (middle SDI region). Epidemiological change significantly affected only low SDI region (-48.17%). In 16 of 21 GBD regions, population growth was the primary driver of rising cases. Case numbers rose across all age groups, with a more pronounced increase among older adults, particularly in high SDI region. During the period, ASPRs in low and low-middle SDI regions consistently above the global average, which was higher than those in high and high-middle SDI regions but close to middle SDI region, with a clear decline observed in low SDI regions.

Conclusions

Severe periodontitis remains a major global health challenge, with substantial and growing burden, widening inequalities, and untapped opportunities for improvement. There is an urgent need for targeted policies and preventive strategies to address severe periodontitis effectively.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06271-0.

Keywords: Severe periodontitis, Prevalence, Global Burden of Disease 2021, Health inequalities, Frontier analysis

Introduction

Periodontitis is a host-mediated inflammation triggered by microorganisms leading to the loss of tissue support around the teeth, if uncontrolled, it can lead to aesthetic and functional complications, causing distress for patients and increasing the need for costly treatments [1, 2]. Periodontitis is not only the most common cause of tooth loss in adults, but also results in significant economic burden [3]. In 2018 alone, the financial impact in the US was approximately $154 billion and around €159 billion in Europe [4]. Additionally, periodontitis has been recognized as a non-communicable disease (NCD) sharing common risk factors with other NCDs, and a global consensus is emerging that periodontitis can negatively affect overall health by raising the risk of systemic diseases such as diabetes and cardiovascular diseases, and improving periodontal health can significantly benefit general health and well-being [2, 5].

Periodontitis is largely preventable and population-based data are essential for developing prevention programs [6]. However, consistently measuring and quantifying severe periodontitis in epidemiological studies remains challenging. These difficulties stem from variations in periodontal examination protocols, such as differences in the type of probes used or teeth and sites examined, as well as inconsistencies in how severe periodontitis is defined and diagnosed [7–9]. The Global Burden of Disease (GBD) study, an international effort to estimate disease burden worldwide providing valuable insights into global health challenges, is currently considered the leading data source for studying the burden of various diseases including severe periodontitis [10].

Comprehensive analysis based on GBD data can provide scientific evidence for public health strategies [11]. Recently, studies on analysis of GBD data increasingly incorporate methods like frontier analysis to estimate achievable outcomes and potential improvement spaces for the disease burden, the slope index and concentration index to quantify health inequalities and decomposition analysis determine the contributions of factors driving changes in disease burden [11–13]. Although several groups have assessed the burden of severe periodontitis using the GBD data, most focus on descriptive analysis and temporal trends, with only one incorporated decomposition analysis at the global level, and none have conducted frontier analysis or cross-country inequalities analysis [10, 14–18]. Recently, the GBD 2021 Oral Disorders Collaborators published estimates of prevalence and disability-adjusted life years for oral conditions like untreated caries, severe periodontitis, edentulism, and more at global, regional, and national levels from 1990 to 2021 [19]. Nascimento GG, et al. focused on the prevalence, incidence, and Years Lived with Disability of severe periodontitis and edentulism in 2021 and projected these rates for 2050 based on the data from GBD 2021, highlighting their continued public health importance and the expected rise in affected individuals in the coming decades [20]. In this study, we systematically estimated the burden of severe periodontitis at different levels based on updated GBD 2021 data employing methods like frontier analysis, slope and concentration indexes, and decomposition analysis incorporated, aiming to provide evidence for reducing the disease burden and improving health inequalities.

Methods

Data source

Data for this study were sourced from the GBD 2021, available through the GBD Results Tool [https://vizhub.healthdata.org/gbd-results/]. We extracted the estimated number of prevalence cases and age-standardized prevalence rates (ASPRs) of severe periodontitis, along with their corresponding 95% uncertainty intervals (UIs), across 5 SDI quintiles, 21 GBD regions, and 204 countries/territories from 1990 to 2021. We also gathered age-specific prevalence data for severe periodontitis in 5-year age groups, ranging from 15 to 19 years to 95 + years. The Sociodemographic Index (SDI) was used to reflect the level of social development, and the 204 countries and territories were classified into five development levels, from low to high, based on their SDI values, which range from 0 to 1, with higher SDI value indicating a higher socioeconomic status [21].

Case definition

GBD 2021 used a hierarchical preference for case definitions of severe periodontitis [21]. Briefly, when a study included multiple data types, preference was given to Community Periodontal Index of Treatment Needs (CPITN) = 4, then clinical attachment loss (CAL) > 6 mm, and finally pocket depth (PD) > 5 mm. All these were considered equivalently as reference definitions with no need for additional crosswalking. If sources lacked CPITN Class 4 data but included alternate definitions (CPITN Class 3, CAL > 5 mm, or CAL > 4 mm), the data were utilized after crosswalking in MR-BRT (Meta-regression—Bayesian, regularised, trimmed) to correct for systematic bias due to different case definitions. The GBD 2021 capstone publication offers a comprehensive overview of the case definitions, data input, modeling strategies (such as MR-BRT crosswalking approach and DisMod-MR 2.1 estimation) employed for severe periodontitis [19, 21].

Statistical analysis

We created global maps to visually highlight regional disparities in the prevalence of severe periodontitis for 2021, and examined the age-specific prevalence of severe periodontitis across 5 SDI quintiles over time. Pearson correlation analysis assessed the link between ASPR and the SDI across GBD regions.

Frontier analysis

We used frontier analysis to create an ASPR-based model using the SDI, and applied a combination of LOESS regression and local polynomial regression with different smoothing spans (0.3, 0.4, 0.5) to generate smoothed frontier lines, capturing the nonlinear relationship between SDI and ASPR of severe periodontitis [11]. To assess the improvement potential for each country/territory, we calculated the absolute distance (effective difference) between their ASPR in 2021 and the frontier line.

Cross-country inequality analysis

We analyzed inequalities in the prevalence of severe periodontitis using the slope index of inequality (SII) and concentration index [12]. The SII measures absolute inequality in a health metric between the most and least advantaged subgroups, calculated by regressing the prevalence rate against the SDI, based on the midpoint of the cumulative population distribution ordered by SDI. The concentration index assesses relative inequality by indicating how much a health measure is concentrated among either the disadvantaged or advantaged groups, determined through numerical integration of the area beneath the Lorenz curve.

Decomposition analysis

We employed decomposition analysis adopting the method proposed by Cheng et al., which dissects changes in case numbers into contributions from aging, population growth, and epidemiological changes allowing us to quantify each factor’s independent impact on overall case number changes [22].

Trend analysis

We analyzed time trends in ASPR using Joinpoint regression and the estimated annual percentage change (EAPC) [16, 23]. Joinpoint regression identifies shifts in trends by connecting different segments on a logarithmic scale at optimal points where significant changes occur. We calculated the annual percent change (APC) for each segment, and the average annual percent change (AAPC) was determined as the weighted average of these segments over the entire examined period.

Statistical analysis

All data analyses were executed using the R Software (version 4.3.3). APC, AAPC, EAPC, SII and concentration index were all reported along with corresponding 95% confidence intervals (CIs). p<0.05 deemed statistically significant.

Results

The prevalence of severe periodontitis in 2021

In 2021, around 1.07 (95% UI: 0.90 to 1.23) billion people worldwide had severe periodontitis, with an ASPR of 12,498.3 (95% UI: 10,526.8 to 14,493.4) per 100,000 population, and no significant gender differences observed. It was highly prevalent in those aged above 35 years, with the highest case number and prevalence rate observed in individuals aged 50–54 years and 55–59 years, respectively (Figure S1). Among 5 SDI regions, middle SDI region had the highest cases of ~ 0.35 billion (95% UI: 0.29 to 0.40) while low-middle SDI region reported the highest ASPR of 15,252.3 (95% UI: 12,777.2 to 17,553.5) per 100,000 population. Among 21 GBD regions, South Asia had the highest cases (0.31 billion, 95% UI: 0.26 to 0.36) and ASPR (17,566.1 per 100,000 population, 95% UI: 14,730.9–20,136.0) while Oceania reported the lowest. Across 204 countries/territories, India and China had the highest case numbers, each exceeding 200 million. ASPR was above 20,000 per 100,000 population in 12 countries, with Sierra Leone and Gambia reporting the highest rates, while Kiribati, Solomon Islands, and Vanuatu reported the lowest, all below 2,000 per 100,000 population. Further details are shown in Figure S2 and Table S1.

ASPR-based frontier analysis for severe periodontitis

The results of frontier analysis were shown in Fig. 1 and Table S2. In 2021, the ten countries/territories with the largest effective difference (EF) were Gambia, Sierra Leone, Cabo Verde, Ghana, Cameroon, Pakistan, Guinea, Denmark, Burkina Faso, and Liberia. Conversely, the ten countries/territories with the smallest EF were Somalia, Kiribati, Solomon Islands, Vanuatu, Micronesia (Federated States of), Papua New Guinea, Marshall Islands, Tuvalu, Spain, and Tonga. Additionally, frontier countries/territories with low SDI (<0.5) included Somalia, Niger, Papua New Guinea, Solomon Islands, and Vanuatu. High SDI (>0.85) countries with relatively larger EFs included Denmark, Germany, Norway, Belgium, and Canada.

Fig. 1.

Fig. 1

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Frontier analysis exploring the relationship between SDI and the ASPR for severe periodontitis across 204 countries/territories. The frontier is delineated with a solid black line, and countries and territories are presented as dots. (A) The color transition from light blue in 1990 to dark blue in 2021 illustrates changes over the years. (B) Frontier analysis based on SDI and ASPR for severe periodontitis in 2021, the leading 15 countries/territories with the largest EFs are highlighted in black. Countries with low SDI (below 0.5) and the smallest EFs are marked in blue, while those with high SDI (above 0.85) and the largest EFs marked in red. The change in ASPR from 1990 to 2021 is indicated by the color of the dots, red dots signifying decreases and blue dots indicating increases. ASPR, age-standardized prevalence rate; EF, effective difference; SDI, Sociodemographic Index

Cross-country inequality analysis

Results of cross-country inequality analysis (Fig. 2) indicated that significant inequalities in the prevalence of severe periodontitis related to SDI were observed globally, with high SDI countries bearing a disproportionately higher burden. From 1990 to 2021, the SII of severe periodontitis prevalence increased from 2129.86 (95% CI: 472.77 to 3786.94) to 7197.91 (95% CI: 5065.48 to 9330.34), indicating a worsening inequality, while the concentration index of severe periodontitis prevalence changed little. Inequalities across GBD regions were also observed (Table S3). In 2021, the highest positive SII and concentration index were observed in Caribbean and Oceania, respectively.

Fig. 2.

Fig. 2

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Absolute and relative cross-country inequality in prevalence of severe periodontitis. (A) Health inequality regression curves and for prevalence of severe periodontitis. (B) concentration curves for prevalence of severe periodontitis. SDI, Sociodemographic Index; SII, slope index of inequality; GBD, Global Burden of Disease; CI, concentration index

Changes in prevalence cases of severe periodontitis

From 1990 to 2021, global cases of severe periodontitis rose by 91.54%, with India and China contributing 48.22% of this rise. All 5 SDI regions had increased, with middle SDI region reporting the largest increase. All GBD regions, except Oceania, experienced increases, with South Asia and East Asia leading the growth, contributing 35.61% and 21.98%, respectively. More details are provided in Table S1.

From 1990 to 2021, there were significant increases in prevalence cases across all age groups, especially among older adults (Figure S1). Among 5 SDI regions, cases increased more obviously among younger people in lower SDI regions, while in higher SDI regions, cases rose significantly among the elderly (Fig. 3A). In low SDI region, the proportion of cases across age groups remained stable, with a much higher proportion in age groups under 35 years than high SDI region, in which the proportion of cases increased in age groups over 55 years but decrease in those under 45 years (Fig. 3B).

Fig. 3.

Fig. 3

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The time trends of severe periodontitis prevalence from 1990 to 2021 by 17 age groups across SDI regions. (A) The time trend of the number of severe periodontitis-related prevalence cases by age groups in 5 SDI regions. (B) The age structure proportions of severe periodontitis-related prevalence cases across SDI regions over time. SDI, Sociodemographic Index

Decomposition analysis of increased severe periodontitis cases

Figure 4 and Table S4 presented the decomposition analysis results of the increase in severe periodontitis cases over the study period. Globally, population and aging contributed 66.15% and 30.84% to the increase, respectively. Across SDI regions, population was the primary contributor, with the most significant impact in low SDI region (134.48%). The contribution of aging varied slightly across SDI regions, ranging from 13.69% in low SDI region to 37.21% in middle SDI region. Epidemiological change significantly affected only the low SDI region (-48.17%). At the GBD regional level, Central Asia saw the largest contributions from epidemiological changes and population at -934.26% and 1460.58%, respectively, followed by Eastern Europe at 376.39% and 414.65%. Aging had the greatest impact in Eastern Europe (-691.04%), with Central Asia following at -426.32%.

Fig. 4.

Fig. 4

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Contribution of population growth, aging, and epidemiological change to the increase in the global and regional case number of severe periodontitis from 1990 to 2021. The black dots represent the total value of change attributed to all three components. For each individual component, a positive value means an increase in the severe periodontitis-related prevalence cases linked to that component, while a negative value means a decrease. SDI, Sociodemographic Index; GBD, Global Burden of Disease

Trends in ASPR of severe periodontitis over the time

Over the study period, ASPRs in low and low-middle SDI regions consistently surpassed the global average, which was higher than those in high and high-middle SDI regions, but close to that in middle SDI region (Fig. 5A). At the GBD regional level, a negative correlation between ASPR and SDI was observed (R=-0.51, P < 0.001), with ASPR decreasing as SDI increased (Fig. 5B).

Fig. 5.

Fig. 5

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Trends in ASPR of severe periodontitis globally and across different regions from 1990 to 2021. (A) Temporal trends in ASPR for severe periodontitis globally and in 5 SDI regions. (B) The trend in ASPR of severe periodontitis globally and in various GBD regions by SDI. *p < 0.05; ASPR, age-standardized rate of prevalence; SDI, Sociodemographic Index; APC, annual percentage change; AAPC, average annual percentage change

From 1990 to 2021, the global ASPR slightly increase overall, while ASPR in low SDI region showed a clear decline (AAPC = -1.12, 95% CI: -1.28 to -0.95), notably from 1996 to 2009 (Fig. 5A and Table S5). Similar ASPR trends with significant decline were noted in Oceania, Central, Western, and Eastern Sub-Saharan Africa, with Oceania experiencing the largest drop (Figure S3 and Table S1). At the national level, Turkey had the highest positive EAPC at 2.55 (95% CI: 1.96 to 3.13), while Kiribati had the largest drop (EAPC=-7.06, 95% CI: -8.04 to -6.07) (Figure S4 and Table S1).

Discussion

This study provided the most comprehensive analysis to date on the prevalence of severe periodontitis worldwide. Consistent with previous studies, our findings showed that: there was a notable increase in the global burden of severe periodontitis from 1990 to 2021, primarily driven by population growth, followed by aging; [10, 16, 17]. Prevalence rose with age, peaking around 60 years, and then remained high; [10, 16, 20] At the GBD regional level, ASPR generally declined as SDI increased [10, 16, 17]. Our study also offered new insights. First, regardless of development level, most countries/territories showed great potential to reduce the burden of severe periodontitis. Second, high SDI countries bear a disproportionately high burden, with SDI-related inequalities worsening over time. Third, in all the 5 SDI regions and 16 of the 21 GBD regions, population was the primary driver of rising cases, while epidemiological change was the second contributor to the increase in low SDI region, aging was the leading factor in four GBD regions. Fourth, the number of prevalent cases rose significantly across all age groups, with a more pronounced increase among older adults, particularly in high SDI region. Lastly, contrary to GBD2019 findings, this study observed significant decreases in ASPRs in low SDI region and several GBD regions from 1990 to 2021.

Consistent with previous GBD findings, the prevalence of severe periodontitis rose with age, peaking at 50–59 years [10, 16, 20]. This trend is attributed to the cumulative progression of the disease over time, rather than greater susceptibility in older individuals [24]. The life-course approach, which emphasizes starting oral disease prevention early in childhood and continuing throughout life [25], holds promise for reducing the burden of severe periodontitis in the future. In addition to the high prevalence among older adults, we observed a more significant rise in cases within this group, particularly in high SDI region, underscoring the need to prioritize periodontal health in the elderly. Older adults often face challenges such as weaker immune responses, systemic conditions like diabetes and cardiovascular diseases requiring complex medications, reduced cognitive and self-care abilities, and financial barriers, all of which can hinder effective periodontal care [26]. Periodontitis shares risk factors with other NCDs like tobacco use, obesity, hyperglycemia, and dyslipidemia. These factors accumulate with age, accelerating the progression of periodontitis and contributing to related systemic diseases [2, 10]. The 2011 and 2019 UN high-level meetings stressed that integrating dental services into healthcare via the Common Risk Factor Approach provides a cost-effective strategy to enhance oral and overall health [10, 27]. Considering the current use of periodontal health services and the shared risk factors between periodontal and chronic systemic diseases, there is an urgent need to promote interprofessional education and practice [28].

For the first time, we conducted a frontier analysis on the burden of severe periodontitis. The frontier line marks the threshold of efficient performance, offering insights into a country’s management of disease burden [11]. Countries below the frontier face inefficiencies, often due to resource underutilization or systemic barriers like inequitable access to dental care, poor integration of oral health into public health systems, or lack of education and targeted interventions for high-risk groups. These countries can improve by addressing these barriers and adopting practices from more efficient performers. Countries on the frontier are considered efficient, managing disease burden effectively and can serving as benchmarks, while can pursue further innovations to sustain performance. Those above the frontier outperform expectations, demonstrating exceptional efficiency and can act as global leaders in sharing knowledge and strategies for effective disease management. According to the results, most countries, regardless of their development level, have significant potential to reduce it. Among the ten countries/territories with the smallest EF, Spain had the highest SDI of 0.77, with strong oral healthcare system and high public awareness. In recent years, Spain has made significant strides in improving periodontal health by boosting oral health education in schools and communities, focusing on oral health campaigns to reduce high-risk factors such as smoking cessation and enhanced diabetes management, and encouraging regular preventive check-ups for early detection of periodontal issues [29, 30]. The public sector has expanded its services, particularly targeting young populations by offering free routine oral check-ups for children aged 6 to 15 [30]. Notably, low SDI countries like Somalia, Niger, Papua New Guinea, Solomon Islands, and Vanuatu were found to be above or on the frontier. This suggests that despite their limited resources, these countries have effectively managed severe periodontitis. Their experiences may offer valuable insights for other similar low- and middle-income countries. However, it’s important to note that limited epidemiological data on periodontal diseases in low SDI countries may not accurately reflect the true burden [19]. In Somalia, a low-income country where most people live in poverty, access to healthcare and dental services is scarce, with fewer than 100 dentists concentrated in urban areas. Oral health issues like tooth decay and periodontal disease are widespread in low- and middle-income countries, along with limited awareness of modern dental practices. As severe periodontitis generally increases with age, Somalia’s predominantly young population—over 70% under age 30—might contribute to its lower prevalence of the disease [31]. In contrast, high developed countries such as Denmark, Germany, Norway, Belgium, and Canada have not met expectations in controlling severe periodontitis, indicating that other factors may offset the benefits of development. For example, in Germany, severe periodontitis remains widespread, affecting 17.5% of those aged 35–44 years and 41.9% of those aged 65–74 years, with goals to reduce these rates to 10% and 20% by 2030 [32, 33]. Further research is needed to uncover the success factors of high-performing countries and the barriers faced by underperforming countries in managing severe periodontitis.

In addition, the SII and concentration index were applied to analyze health inequalities in severe periodontitis prevalence across countries. While high-SDI countries are typically thought to have lower disease burdens due to better access to medical resources, our findings reveal that these countries actually bear a disproportionately high burden of severe periodontitis, with worsening health inequalities over time, a similar pattern is seen in rheumatoid arthritis and osteoarthritis, where high-SDI countries show unequal disease distribution and worsening outcomes [34–36]. This highlights the need for increased resources to focus on prevention, management, and treatment of severe periodontitis as sociodemographic factors evolve. This inequality in severe periodontitis burden may be attributed to three primary factors. First, high SDI countries always experience significant population aging, which raises the prevalence and severity of periodontitis. In fact, the prevalence of severe periodontitis increases significantly with age (as discussed above). Second, even in developed countries, periodontal treatment outcomes can be suboptimal. Despite aging populations increasing demand for periodontal care, referrals to periodontists are declining, with general dentists addressing the need instead, as seen in the United States [37]. Lastly, diagnostic bias due to disparities in healthcare access and data quality between countries with different SDI levels—the lack of empirical data in low and middle SDI countries along with better coverage and data quality in developed countries—could play a role [19, 21]. Addressing inequalities in severe periodontitis requires targeted strategies to tackle social, economic, and structural barriers driving unequal disease burdens through global collaboration. Key focus areas may include improving access to care, enhancing preventive measures, addressing social determinants, targeting shared NCD risk factors, and investing in data collection and surveillance for severe periodontitis.

From 1990 to 2021, global cases of severe periodontitis increased sharply, with East and South Asia—particularly India and China—being the largest contributors. Previous reports have also highlighted the serious burden of severe periodontitis in these countries [23, 38]. Additionally, Tropical and Andean Latin America experienced the largest percentage increases in case numbers. These findings emphasize the urgent need to raise awareness about periodontal health and implement more effective intervention strategies in these areas. Population growth was the primary driver of increased severe periodontitis cases globally, across all SDI and most GBD regions, aligning with previous findings and predictions [10, 39]. However, in regions like Eastern Europe, Central Europe, East Asia, and high-income Asia-Pacific, aging was the main factor contributing to the rise, underscoring the critical need to prioritize periodontal care for the elderly in these areas. Furthermore, our findings indicate that these demographic drivers affect the burden in low-SDI regions differently compared to other SDI regions, underscoring the need for region-specific approaches. Addressing changes in population size and aging through policy alone is challenging, thus, it is crucial to understand the reasons behind the rising incidence and to implement effective prevention measures.

Over the past 30 years, the ASPR of severe periodontitis has increased slightly by 0.28%, highlighting the inadequacy of current periodontal health measures in reducing the disease burden. This is likely due to factors such as population aging, the bidirectional relationship between chronic diseases and periodontitis, limited access to periodontal care, low public awareness of periodontal health, a focus on cavities rather than periodontal prevention, healthcare inequalities, and weak policies enforcement. To reduce the ASPR in the future, steps should include expanding health education and prevention efforts, developing tailored policies for different populations (especially adults and the elderly), integrating periodontitis care into chronic disease management, and improving the equity and accessibility of dental services in public health systems.

This study has several limitations. Changes in disease burden estimates across GBD cycles can result from the addition of new data, improvements in estimation methods, and dataset instability. A key challenge lies in the heterogeneity of data sources, which contributes to the instability in GBD analyses. In each GBD release, some existing data may not be identified or included. Low SDI countries often face challenges with insufficient data collection and monitoring. In some countries, particularly those in the African region, the South-East Asia region, and the region of the Americas, data on oral conditions were scarce or not aligned with the GBD case definition or measurement method [19]. For countries with limited or no original data, estimates are made using the DisMod-MR tool, which cannot fully reflect reality. The lack of empirical data in low and middle SDI countries and variations in data collection methods may lead to underestimations of disease burden. Disparities in healthcare access and data quality between countries with different SDI levels may introduce diagnostic bias in global and regional burden analyses, affecting assessments of temporal trends and health inequality. Sub-Saharan Africa, home to 32 of the world’s least developed countries and characterized by inadequate healthcare infrastructure, faces a significant and growing burden of periodontal diseases [40]. Unlike findings from GBD 2019, we observed a marked overall decline in ASPR in low SDI region, as well as in Oceania and Central, Western, and Eastern Sub-Saharan Africa, and a much lower ASPR level in Southern Sub-Saharan Africa [10, 16–18]. These differences between GBD 2019 and 2021 likely stem from GBD study limitations.

Moreover, the GBD study employs a diverse case definition for severe periodontitis, primarily based on the CPITN assessment, which is consider unreliable (non-confident definition). This raises concerns about the accuracy of the prevalence data, potentially leading to underestimation. GBD estimates are often lower than those reported in other studies. For instance, a recent meta-analysis of studies published between 2011 and 2020 reported a pooled prevalence of periodontitis among dentate adults at about 62%, with severe periodontitis at 23.6%, much higher than GBD estimates [8]. However, the results showed significant variability due to varying case definitions, with confident case definitions (Centers for Disease Control [CDC]/American Academy of Periodontology [AAP] 2012; CDC/AAP 2007; and Armitage 1999) reporting prevalence rates nearly double those from non-confident classifications (community periodontal index of 3 or 4, PD > 4 mm, and CAL ≥ 1 mm) [8].

Conclusions

In summary, severe periodontitis remains a significant public health concern, particularly prevalent among older adults. Its burden has grown over time, primarily driven by population growth. Most countries/territories, regardless of development level, have substantial potential to reduce this burden. High SDI countries bear a disproportionately large burden, with inequalities worsening over time. These results underscore the challenges in managing severe periodontitis and provide valuable insights for shaping public health policy and optimizing resource allocation. To reduce the burden of periodontal diseases and improve health inequality, there is a pressing need to: adopt a life-course approach to periodontal care, promote interprofessional education and practice, integrate oral health care into primary health care, and strengthen global cooperation. Furthermore, the disparity in severe periodontitis burden observed between GBD 2019 and 2021 emphasizes the importance of improving data collection and analysis systems, addressing disparities in epidemiological primary data, and enhancing data quality, particularly in low SDI countries.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (1.2MB, pdf)

Acknowledgements

The authors appreciate the collaborators of the Global Burden of Disease study for their work.

Abbreviations

GBD

Global Burden of Diseases

SDI

Sociodemographic index

ASPR

Age-standardized prevalence rate

UI

Uncertainty interval

NCD

Non-communicable disease

CPITN

Community Periodontal Index of Treatment Needs

CAL

Clinical attachment loss

PD

Pocket depth

MR-BRT

Meta-regression—Bayesian, regularised, trimmed

SII

Slope index of inequality

EAPC

Estimated annual percentage change

APC

Annual percent change

AAPC

Average annual percent change

CI

Confidence interval

EF

Effective difference

CDC

Centers for Disease Control

AAP

American Academy of Periodontology

Author contributions

Chuan-Yu Hu contributed to conception and design, data interpretation, critically revised the manuscript. Leng Wu and Long Xie contributed to data collection, analysis, and interpretation, drafted and critically revised the manuscript. Chun-Ming Huang contributed to data interpretation, drafted and critically revised the manuscript. Qiong Wang and Jian Wei contributed to data interpretation and critically revised the manuscript. All authors gave their final approval and agree to be accountable for all aspects of the work.

Funding

This study was supported by the National Natural Science Foundation of China (82472966) and the Foundation of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (2023B29).

Data availability

Data used in this study were sourced from the GBD 2021, available through the GBD Results Tool (https://vizhub.healthdata.org/gbd-results/).

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

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.

Contributor Information

Long Xie, Email: xielong@whu.edu.cn.

Chuan-Yu Hu, Email: chuanyuhu@hust.edu.cn.

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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 (1.2MB, pdf)

Data Availability Statement

Data used in this study were sourced from the GBD 2021, available through the GBD Results Tool (https://vizhub.healthdata.org/gbd-results/).

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