7. Epidemiology of Periodontal Disease Flashcards
• When doing epidemiology, you need to think of both ____ and ____
prevalence
severity
• There are different forms of periodontal disease:
◦ Gingivi:s
‣ There are different levels of gingivi:s.
◦ Periodonitis
‣ ____
• Localized
• Generalized
‣ ____
• Mild
• Moderate
• Severe
chronic
aggressive
Periodontal Diseases are Among Leading Causes of YLD
This was a study that assessed burden of major diseases worldwide
◦ It was published in Lancet a few years back
This graph ranks the ____ of diseases – from the most burdensome for a popula:on to the least burdensome
The most burdensome condi:ons are ____ and ____ disorder.
At the top across all geographic areas Alzheimers is very common in Western Europe but not so common in Africa.
◦ Why? ____. People must live long enough to develop Alzheimers
The opposite is true with Malaria. It’s not seen so much in Western World, but seen in ____ What’s interes:ng for us is that we have lot of systemic diseases here as well.
◦ #31 = periodontal disease. Usually in top ____ across many countries. Mostly in western world, not so much in Africa
◦ Caries and edentulism make the cut as well, but Periodontal Disease is at the top of oral diseases
global burden back pain major depressive life expectancy africa 25
Importance of Studying Epidemiology of Periodontal Diseases
- ____ and risk factors
- ____ of disease: initiation and peak
- Prevalence of severe forms: allocation of ____ and ____ strategies
etiology
course
resources
public health
Importance of Studying Epidemiology of Periodontal Diseases
• E:ology and risk factors
◦ Risk factors = Diabetes, smoking, the effect of gene:cs. By looking at ____, you can beDer understand the
e:ology of disease
‣ Can try to establish ____ if you have something that preceded the disease
• Compare US (lec picture – NYC) and Rio de Janiero (right picture)(where Dr. Teles is from)
◦ Both countries have about the same number of people with severe Periodontal Disease – 18-20 million people
◦ But, because the USA is a more affluent country than Brazil, even though they have the same number of people,
the popula:on in the USA will be beDer ____ and beDer able to ____ their disease than in Brazil
◦ So, ____ of a country will have an impact in some of the findings that you see epidemiologically
• These studies are important for you to generate ____
◦ When you collect a lot of epidemiological data, you iden:fy people who have severe disease and also people who
are resistant to disease.
◦ S:mulates us to think “Why is this? Why are some people more suscep:ble or resistant?”
• One challenge to all these epidemiological studies is the ____. (Methodological challenges)
◦ In her masters she had to examine almost 400 people – that was a challenge.
◦ NHANES (Na:onal Health and Nutri:on Examina:on Survey) usually does millions of people
◦ Need a lot of resources and a lot of ____ because you need mul:ple examiners – all need to be calibrated to
all probe the same way, all probe the same sequence, all collect the data the same way, etc.
◦ ____ can impact the outcome you get from these studies
risk factors
causality
trated
resolve
affluence hypotheses methodology calibration methodological studies
• Early 1900s – :me of ____
◦ Thought that many of the ailments of the human bodies came from ____ that were infected – ulcers,
depression, infec:on, cancer, etc.
◦ This was way before ____. These were ____ observa:ons
• People proposed ____ - the thought was, “if we extract teeth – we won’t have the problems.” Seemed very smart at the :me
focal infection teeth scientific method anecdotal therapeutic edentulism
• The 1955 Gingivitis Study was one of first studies acer ____
◦ Came from Marshall-Day in 1955
◦ First ____ study
• Back at that :me, they didn’t have capability to do this extent of comprehensive examina:on
◦ Basically would see if there was ____
◦ If there was any bone loss, you would classify as ____
◦ If any teeth were lost, you would deem it as ____
- At that time, the conclusion was that disease would continue from ____
- Regardless, all of this (info on chart) reinforced the idea that disease is ____; once it starts with gingivitis it just keeps going all the way to periodontitis
scientific method epidemiological gingivitis/bleeding/bone loss perio tooth mortality gingivitis > periodontitis > tooth loss inevitable
1956-1982
Era of indices
PD caused by ↓ OH ↑ Age Progression is linear and continuous
• Later on, we come to a :me when people start using ____
• Up un:l then, people were compounding age, tooth loss, bone loss, probing
• Later on, people started to use indices to make composites to sum up all these parameters into one ____
◦ Ex: ____: a composite of plaque, bleeding, bone loss
• What can you discern from this study? People who were young could have a lot of plaque but would have ____ index (low level of disease). And, people who had less plaque would have ____ disease.
◦ This does not go along with what was established at the :me
◦ You lose a lot of information within the ____ of all these parameters because you are putting a number of things together into one number
indices number russel periodontal low more variability
• The study of experimental gingivitis
◦ It was a study using ____ - gave numbers based on the extent of ____
◦ Gave numbers based on the ____ and ____ of gingival :ssues
◦ All visual indices - so, it is ____ (even when you try to calibrate)
• This proved, at the :me, that plaque accumula:on would lead to ____, at least
• At first the indices were mostly ____
◦ They would some:mes use a probe just to lightly swipe the margins just to see plaque
◦ But, there was no ____
• Also, they were ____ indices at the beginning. Because they were epidemiological studies, sometimes you use indices that only analyze certain teeth/certain sites and not the whole mouth (analyze subsets of oral cavity)
◦ Why do this? Because this is part of an epidemiological study - want to do par:al exams to try to op:mize/
streamline your ____, :me, and ____
indices plaque accumulation color consistency subjective
gingival disease visual probing partial money resources
Conclusions of the Era
1. “Linear progression” of periodontal diseases
• Conclusion of these studies up un:l 1960’s was that there was a ____ progression of periodontal disease
◦ Gave us the idea that it was a con:nuum: Gingivi:s -> chronic periodon::s -> lost teeth
◦ Also gave us the idea that it was ____ that periodontal disease would result in losing teeth
- “Gingivitis inevitably turns into ____”
- “____ and poor OH explain most of the periodontal disease variation”
• Seemed to be a ____: the older you get, the more Periodontal Disease you have. The more plaque you have, the more Periodontal Disease you have - “Plaque is the cause of gingivitis”: Loe et al 1965.
• Because of the ____: the idea that plaque is the cause of gingivi:s
• Take home message from all this: if you have plaque, you will lose all of your teeth
linear inevitable periodontitis age correlation experimental gingivitis study
1982
CPITN: Peak of the era
• Later on, there was another set of studies also using an index
◦ CPITN = ____
• Created with intent to assess ____ and ____ of ?periodontitis?
community periodontal index for treatment needs
disease prevalence
treatment needs
- The CPITN Index was rela:vely ____ to do
- Divide mouth into ____ – score certain teeth in those sextants
- The ____ tooth in each sextant would be the score for that pa:ent
- Because it was an epidemiological study seeing thousands of pa:ents, the WHO developed a specific ____.
• Used Codes:
◦ Code 0,1,2 – the black sec:on of the probe is not touching yet
◦ Code 3 - see some of the black ____
◦ Code 4 - don’t see any of the ____ sec:on anymore - ____mm or more
• You also have some level of plaque, calculus, etc. - but the major driver is ____ because that is what’s deemed as “would require treatment”
◦ Yes, some people progress to periodon::s with deep pockets. But, some people progress to periodon::s without
having deeper pockets. How? ____. This index does not assess level of ____. This is a limitation of this index - 1. that it was assuming ____ of disease; also 2. “you are assuming that in Code 2 you also have everything from ____
• The whole point of this was to try to make it ____ and simpler to calibrate people and see many individuals, and to have an idea of how extensive the treatments would be
◦ Up to Code 3 -> considered ____ treatments
◦ Up to Code 4 -> considered ____ treatments and ____-based treatments
easy sextants worst probe touching black 5.5
pocket depth recession attachment linearity code 1
faster
simple
complex
surgical
• Because the CPITN index was rela:vely ____ to use, people started using it to assess not only treatment needs, but also to assess ____
• Can see ____ of studies. Large amount of popula:ons were give 3s or 4s
• This is focusing a lot on pocket depth - you are not including ____
• Also, you are taking one sextant of oral cavity and deeming that representa:ve of everything else. May be
overes:ma:ng ____
easy disease prevalence inflation attachment level treatment needs
1982-1996:
The era of risk assessment
• Studies using CPTIN fell into ____
◦ These indices became less useful because people started to understand the need to analyze the disease in
____ methods. Because when we see pa:ents with periodontal disease, it is not something that is
completely widespread. (There are sites that have disease, and sites that do not.)
◦ This created the no:on that you need to look at the oral cavity with ____ view, as opposed to having an overall composite. Also, this allows you to see individual ____ separately
disuse
site-specific
site-specific
parameters
Legacy of the Era
• Concept of ____ disease should be questioned
• Disease sites may undergo cycles of ____ or spontaneous
____
• Significant progression of disease is infrequent event among untreated periodontally diseased subjects
continuous
exacerbation
remission
Legacy of the Era
- Some of first people that looked at periodontal data from site-specific level: Socransky, Haffajee, Goodson, Tanner, and Lindhe
- Coming to these conclusions was only possible because we moved to analyzing the data in a different way - at the ____ level
◦ They started to ques:on whether this disease is ____ (Plaque->Gingivi:s->Periodon::s->Tooth loss) ◦ Why do you think it’s not con:nuous?
• If it is true that this disease is not con:nuous, something need to happen that you have the disease ____. It even ____ a liDle bit. That was a concept that came from this study.
◦ Only a ____ of sites on a ____ of individuals showed progression. It was not as widespread and generalized as
one would expect
site-specific continuous stop regresses subset subset
Continuous Progression x Burst Hypothesis
Continuous Progression Model
Random Burst Model (current)
• Current hypothesis is that disease progression follows the ____
• If you are studying an individual’s periodontal disease, these models allow us to compare ____ sites and their
progression
Able to study prevalence, extent, and severity at a different level
◦ Can see the prevalence of moderate, mild, and severe disease - to understand a disease that is ____ or ____
◦ Able to focus on specific ____ of disease - ex: compare just pocket depth, just aDachment level, etc.
◦ All concepts that no one men:oned when doing ____, etc.
random burst model multiple generalized localized parameters composites, indices, scores
• 1. Looking at individuals in diff ages that have sites of aDachment loss of 1 mm or more
If you wanted a base level of 1mm to be a clinical parameter of disease, this isn’t telling you much because, in
some segments, ____ of the popula:on is having that problem. So then, that is not a problem, that is the ____.
- With ____, you weed out a lot of the loss that is probably not due to the disease.
• 3. To be even a liDle more stringent and go to a level of aDachment loss of 7mm or more: ◦ ____ individuals do not even have 7mm of loss - they do not show up here
◦ You are able to see that 7mm of loss only occurs in a ____ of the popula:on
• If you use a criteria that is too loose - ____ will be considered to have the disease. If you use a criteria that is too stringent, only a subset has the disease. That is part of the challenge - deciding where the ____ is.
• 4. Same data as #1-3, but includes BOP (Bleeding on Probing)
◦ Why is BOP important in that context? BOP typically gives you more confidence that the disease is ____
(especially when combined with pocket depth or aDachment level)
• 5. Same idea - includes CAL, BOP, and PD
◦ If you use CAL, PD, and BOP like we do in the clinic - you have a more ____ view of the extent of the disease
in a popula:on
100% norm 4mm young subset everybody cutoff active realistic
Intra‐oral pattern of distribution of clinical attachment loss according to tooth type and age
• Another u:lity of epidemiological studies is that it allows us to see intraoral ____ of disease development.
• Looking at loss of aDachment in the ____ and ____ and comparing to interproximal – what do you see in these
individuals (ages 15-24)?
◦ See more loss of aDachment in ____ and ____ than we see in interproximal in these individuals
• Same goes for these guys (ages 25-34). More loss of aDachment in buccal and lingual than we see in interproximal
• Why do you think more loss of aDachment in buccal and lingual than in interproximal for these 2 groups?
◦ Could be due to ____
◦ Could be when you are ____, much easier to measure Buccal/Lingual than Interproximal – this is part of the issue
- Lot of loss of aDachment in ____ and ____
- Can see that clinical aDachment loss grows with ____
patterns buccal lingual buccal lingual brushing assessing
central incisor
lateral incisor
time
