Modifiable and Non-modifiable Risk Factors Affecting Oral and Periodontal Health and Quality of Life in South Asia



The study aimed to review the prevalence of periodontal disease and associated factors among developing South Asian countries. The review was also aimed at providing an insight into how such factors play a role in affecting the Quality of life of patients with compromised oral health.


It has been observed that Oral health directly correlates with the Quality of life of an individual, so it is imperative to understand this, particularly in the developing parts of the world.


A MeSH keyword search was carried out with the keywords: Periodontal diseases, Oral Health, Public Health, Asia, QoL, Quality of Life, Southeast Asia, Tobacco, and Risk Factors, and based on the findings, this detailed review was compiled.


The South Asian population forms 24.89% of the worldpopulation, while periodontal disease is an inflammatory condition that affects 11% of the globe. Several studies previously conducted across developing countries have shown that various factors like the socioeconomic status of an individual, smoking habit, consumption of alcohol, hypertension, history of diabetes, obesity, and stress are indirectly related to the onset of periodontal disease. Characteristics associated with specific populations like ethnicity, behavioral characteristics, and environmental factors may affect causing periodontitis.


Dental practitioners in this region should consider risk factors that can be altered significantly to uplift the periodontal health status of an individual, which is not being considered in many developing countries.

Keywords: Oral health, Public health, Tobacco, Risk factors, Smoking habit, Periodontal health.


Oral health disorders are considered to have a widespread presence, associated with a high rate of morbidity. While dental caries is prominent around the globe, nearly 15% of the adult population is greatly affected by severe periodontal disease [1]. The periodontium is a structure that holds and supports teeth and is formed by four components: the cementum, gingiva, periodontal ligaments, and the alveolar bone. Together, these four components act as a single unit to grasp the teeth and provide a supportive role [2]. Periodontal disease is an inflammatory condition that damages tissues that surround the teeth [3]. Histological alteration in gums occurs throughout the periodontal disease development and appears as sub-clinical inflammation. If the initial lesion is left untreated, the disorder progresses to form a chronic lesion. When a chronic lesion persists, bone tissue and ligaments of the periodontium are involved, and changes to the periodontal structure begin [4]. Ramseier and his colleagues in the year 2009 reported that the development of the disease is irregular, i.e., An exacerbation period followed by a remission period [5]. On the flip side, Mohamed and his colleagues in 2013 proposed that the action is persistent, with inconsistent episodes of exacerbation and remission [6].

Periodontal disease begins with gingivitis, an inflammatory process caused by bacteria in dental plaque, a microbial biofilm that forms on teeth and gingiva. Gingivitis is caused by plaque, which results in soft tissue inflammation, with no attachment loss and firm periodontium [7]. Chronic periodontitis occurs because of untreated gingivitis, resulting in deep periodontal pockets that may eventually cause tooth loss. Periodontal disease is associated with systemic conditions like atherosclerosis and diabetes mellitus [8]. Microorganisms found in dental plaque play a significant role that rapidly advances the development of periodontal disease in an individual.

Chronic periodontitis is classified into two conditions: generalized and localized. When the condition damages more than 10 teeth in a person's dentition, it is diagnosed as generalized chronic periodontitis, while localized chronic periodontitis affects less than 10 teeth. Gingivitis and chronic periodontitis progress occur by forming dental plaque, which is influenced by environmental factors, microbial biofilm, and genetic factors [8]. Periodontal diseases are commonly found in emerging nations like India. Lack of awareness of oral health, poor socioeconomic status, improper or lack of dental office visits, and poor literacy results in the widespread presence of periodontal disease [7].

If allowed to persist, periodontal disease results in obliteration of hard and soft tissues that eventually result in pocket formation and recession of gingiva [9]. It has been found that periodontal disease is a critical health problem as it has a direct relationship with systemic diseases like cardiovascular disease, diabetes mellitus, prematurely born infants with low birth weight, respiratory disease, and cerebral infarction [7]. Any negative change to the periodontal health of an individual can impact the quality of life of an individual, even though interventional treatment can help correct this in many cases. Since there is a lack of a specific oral health-related quality of life instrument, this review was prepared to provide an understanding of the situation in Southeast Asia with a special focus on periodontal health.


Even though oral and periodontal health concerns exist in many developed countries, they still have not been explored and understood in the South Asia region, including Nepal, India, Bangladesh, Cambodia, Myanmar, and Sri Lanka [10, 11]. Previous studies have also shown that migrants from South Asian countries pose a significant dental healthcare challenge as their attitude towards treatment is derived from their ethnic origin, culture, and experience [12, 13]. While several studies have been conducted across developed countries to analyze oral health attitudes, habits, and knowledge, there have been no reviews on the risk factors associated with these problems in developing countries. Therefore, this review was planned to synthesize evidence related to periodontal disease-causing risk factors across the South Asian region.

Since achieving good oral health is a worldwide goal, cultural, community, and individual aspects of various populations must be considered. The first step must be to identify and analyze regional risk factors that lead to lower oral and periodontal health standards in this region to set guidelines for new oral health programs in South Asia. Healthcare plans that encourage preventive care for periodontal disease should be given importance to bring about more awareness among the general public towards risk factors such as smoking, socioeconomic status, stress, and their direct impact on the general health of an individual [14].


In 2000, the Surgeon General of the United States of America emphasized that good oral health is crucial for general well-being [15]. In 2007 the World Health Organization board of executives recognized the relationship between general health, Quality of life, and oral health [16]. Current evidence shows the association between periodontitis and sporadic late-onset Alzheimer's disease, demonstrating epidemiologic, microbiologic, and inflammatory characteristics [17]. The link between periodontitis and the formation of peptic ulcers has been studied, and one of the etiological factors in such cases is the constant use of drugs like aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol consumption, and smoking [18]. Over time research has shown that periodontal problems lead to long-term issues such as erectile dysfunction, premature deliveries, osteoporosis, and preeclampsia [19-22].


4.1. Oral Health Status

While oral health problems affect more than half the world's population, chronic periodontitis affects more than 7% of the global population, making them a significant cause of concern [23]. South Asian countries such as India have reported a higher periodontal and oral problems incidence than their neighboring countries [24]. Previous research has shown that the prevalence of tooth decay and periodontal diseases was approximately 65% in rural areas in India [25]. Even after widespread periodontal and dental problems, the National non-communicable disease programs still do not include managing oral health problems.

4.2. Age

Many studies have stated that the prevalence of periodontal disease has been found to increase with advancing age [26]. Papapanou and his colleagues in the year 1989 found that the mean loss of bone in 70-year-old individuals was 0.28 mm, while it was only 0.07 mm among 25-year-old subjects [27]. Studies conducted in developed countries have described changes in periodontal disease progression patterns with a corresponding increase in age. Studies found that the destruction of periodontal structures and loss of bone is rarely found among subjects below 40 years of age. Whereas, in the elderly population, it was observed that advanced periodontal conditions led to a comparatively more rapid disintegration of periodontal structures [28]. The elderly population is physically vulnerable and often systemically and dentally compromised in the South Asian region [29].

4.3. Gender Predilection

Various studies have found increased destruction of periodontal structures in male population samples compared with females. This may be attributed to ignorance of oral hygiene measures in males compared to females, especially in low-income developing countries [30]. This association has not been established clearly, and any direct or direct effects related to gender predilection of periodontal diseases must be investigated further.

4.4. Socioeconomic Status (SES)

The link between socioeconomic status and periodontal disease has been demonstrated in several studies. Low socioeconomic status is associated with gingival and periodontal pathological conditions. Conversely, high educational qualifications and living standards have been shown to positively influence the periodontal health of an individual [31]. However, this factor varies widely and needs to be analyzed in detail across different targeted demographic groups across South Asia (Table 1) [32].

4.5. Culture and Literacy

Periodontal health is directly associated with an individual's education level. Previous studies have shown that individuals with a relatively high level of education have less predisposition toward periodontal disease [28]. Various studies conducted among populations of different races concluded that there is varied periodontal disease prevalence among different country races [28]. Although race and hereditary factors cannot be modified for a specific population, genetic linkage can risk periodontal disease among developing populations.

4.6. Alcohol

Several researchers have studied the association between behavior, improper oral hygiene, and severity of periodontal disease in alcohol-consuming individuals. Previous evidence shows that alcohol has a direct effect on the host's defense [33]. This is because of complement deficiency, improper neutrophil action (declined adherence, phagocytotic activity, and motility), and infection predisposition. Alcohol has a degenerating effect on hepatic activities such as prothrombin production, vitamin K activity, clotting, and hemorrhage [33]. Discoloration of gingiva, inflammation and bleeding are common among individuals who consume alcohol regularly [33]. A combination of vitamin B-complex and protein deficiency is common among alcohol-consuming individuals. It has also been observed that ethanol initiates bone resorption and inhibits bone formation. Based on results obtained from a previous study, the Alcohol per capita consumption in many South Asian countries exceeded the global average by an alarming margin [34]. Therefore, detailed National monitoring systems must be established in these countries to collect data on periodontal and oral health problems arising from alcohol consumption. This data can formulate policies and set up rehabilitation programs with government support.

Table 1.
The socioeconomic and health expenditure profile of Southeast Asian countries [32].
Country Population Life
Health Expenditure
(% of GDP)
GDP Per Capita
Brunei Darussalam 430,000 77 2.5 73,200
Cambodia 15,709,000 64 7.5 3,300
Indonesia 255,994,000 72 3.1 10,600
Lao PDR 6,912,000 64 2 5000
Malaysia 30,514,000 75 4 24,700
Myanmar 56,320,000 66 1.8 4,700
Philippines 100,998,000 69 4.4 7000
Singapore 5,674,000 85 4.6 82,800
Thailand 67,946,000 74 4.6 14,400
Vietnam 94,349,000 73 6 5,600
Table 2.
An overview of the gender-wise tobacco consumption in Southeast Asia [44].
Country Smoking
Male % Female%
Brunei Darussalam 36.3 3.7
Cambodia 32.9 2.4
Indonesia 66 6.7
Lao PDR 50.8 7.1
Malaysia 43 1.4
Myanmar 43.8 8.4
Philippines 41.9 5.8
Singapore 21.1 3.4
Thailand 37.7 1.7
Vietnam 45.3 1.1

4.7. Tobacco Smoking

There is enough evidence to prove that individuals who smoke have a higher predisposition to periodontal destruction [35]. Consumption of tobacco-based products on a long-term basis has led to periodontal disease progression [36]. Risk factors like smoking alter the host immune response, inhibiting bacteria's activity and forming dental plaque [37]. Smoking individuals with periodontal disease do not present with inflammatory signs and bleeding of the gingiva because nicotine consumption is responsible for local vasoconstriction and declined blood flow [28, 38]. According to a previous study, the Southeast Asian region houses 400 million tobacco users, of which the males form the majority of the smokers, while their female counterparts indulge in smokeless tobacco use [39]. In South Asian countries such as Bangladesh, three out of five adults were exposed to second-hand smoke [40]. An area of grave concern is the mortality caused by tobacco consumption, which was found to be approximately 135000 each year according to previously obtained data [41]. In countries such as India, Sri Lanka, and Myanmar, there is high consumption of smokeless tobacco, which is highly addictive [42]. Tobacco consumption claims more than 1.6 million lives in the Southeast Asian region annually, which also ranks among the largest producers of such products [43]. The Southeast Asian region accounts for 81% of the world's smokeless tobacco users and more than 22% of the adult smokers globally, which makes it a worrying problem [43] (Table 2) [44].


Periodontal disease is a dormant disease that does not show many clinical characteristics unless severe progression occurs. Geriatric research has shown that older adults lack nutrition due to loss of teeth and deteriorated periodontal health [45]. Conditions such as loss of teeth, loss of bone, and gingival recession directly impact aesthetics and indirectly influence an individual's quality of life [46]. The periodontal health status of an individual is essential to maintain the teeth firmly in their place. When periodontal health is ignored, halitosis becomes a barrier to an individual's social well-being [47]. Improper alignment of teeth again leads to bad aesthetics, which might hinder the social capabilities of a person and affect different aspects of one's life, such as employment, speaking arrangements, and public image [8]. Several studies have been conducted to help associate an individual's periodontal health with cardiovascular disease, stress, and obesity. Periodontal health and pregnancy have a similar relationship with metabolic syndrome and inflammatory response [8].


To summarize, periodontal health literacy levels are low among the South Asian population, and many practices are influenced by age, literacy, and culture. The factors mentioned above must be considered if preventive and interventional programs are planned in this region to improve periodontal health. There needs to be an in-depth analysis of cultural factors across this region to understand and implement periodontal health improvement programs.

Though the periodontal disease has a direct and indirect association with various systemic conditions, its importance is only being realized in developing regions such as South Asia in the past few years. Factors like tobacco usage and alcohol consumption significantly affect periodontal health. The risk factors that can be altered must be included in public health awareness campaigns to understand better individuals who indulge in a few or many of these habits. This review details the factors that influence periodontal health both directly and indirectly and helps get a better understanding of how to improve the Quality of life.


WHO = World Health Organization
NSAIDs = Nonsteroidal Anti-Inflammatory Drugs
SES = Socioeconomic Status


Not applicable.




The authors declare no conflict of interest, financial or otherwise.


Declared none.


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