1. It can identify and measure the importance of health problems 2. For understanding the natural history of disease 3. It is essential for disease surveillance and control 4. It contributes to the planning, monitoring and evaluation of health services (to know which disease to focus on) 5. It serves as a key instrument in the formulation of health policies

EPIDEMIOLOGY OF PERIODONTAL DISEASES Flashcards by Pauline Cabatuando

the study of the distribution of a disease or a physiologic condition in human population and of the factors that influence this distribution

epidemiology

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3 Components of Epidemiology

population
distribution
factors

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defined by
• geographic boundaries (racial)
• characteristics or attributes (age, old, or young group)

population

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normal distribution

distribution

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dependent and independent variables, confounders, exposure variables

factors

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Aim of Epidemiology

Prevention of Disease (Control of disease)
Maintenance of health (promotion of health)

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Basically organizing gathered information for it to be useful

maintenance of health

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the dilemma in epidemiology

pendulum

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Scope of Epidemiology

Part of it is research
• It can be used in every aspect of our lives

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Uses of Epidemiology

It can identify and measure the importance of health problems
For understanding the natural history of disease
It is essential for disease surveillance and control
It contributes to the planning, monitoring and evaluation of health services (to know which disease to focus on)
It serves as a key instrument in the formulation of health policies

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Demographic Factors in the Prevalence of Periodontal Disease

age
sex
race
nutrition
socioeconomic status

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Study Designs Used in Epidemiology

• Descriptive Studies
• Analytical Studies
• Observational studies
• Experimental Studies

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Epidemiologic Researches are used in Periodontics

Provide data on the prevalence of periodontal diseases in different populations
Elucidates aspects related to the etiology and the determinants of development of these diseases.
• determinants: risk or modifying
• there are risk factors that can be modified (eg. lifestyle)
Provide documentation concerning the effectiveness of preventive therapeutic measures against diseases

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• Characterizes disease occurrence

descriptive studies

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Provide clues regarding etiology

descriptive

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Useful for formulating hypothesis

descriptive

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Just describes the phenomena

descriptive

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Tools: Case Studies (simplest form), Case Series (can hypothesize), Cross Sectional Studies

descriptive

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Simply observes the natural course of events (no intervention, no control)

observational

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Tools: Cross Sectional Studies, Cohort Studies (from exposure then look for the outcome), Case-Control Studies (reverse of cohort, for rare diseases, basic problem: case definition, denominator)

observational

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May prove causal association and May lead to development of new hypothesis

experimental

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Tools: Clinical Trials (expensive, only involves a small group of people) Community Trials (succeeds clinical trials if clinical is effective)
- involves the entire community
- factors: accessibility, cost, culture

experimental

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Indices Used in Periodontal Disease Studies

• Periodontal Index by Russel (1956)
• Oral Hygiene Index (OHI) by Greene and Vermillion (1960)
• Plaque Index (PI) of Silness and Loe
• Interdental Hygiene Index (HYG)
• Hygiene Index (HI)
• Sulcus Bleeding Index (SBI)
• Gingival Index (GI)
• Gingival Index Simplified (GI-S, Lindhe 1981) and Gingival Bleeding Index (GBI, Alnamo, 1975)
• Papilla Bleeding Index (PBI)
• Ramfjord teeth
• Periodontal Disease Index (PDI)
• CPITN (Community Periodontal Index of Treatment Needs)

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Focuses in gingivitis and also considers pocketing and mobility

periodontal index

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describe the scores in periodontal index

Score 0 healthy Score 1 gingivitis but not on whole gingival margin of tooth Score 2 gingival inflammation along the cervical margin encircling the tooth Score 6 periodontal pocketing, bone loss Score 8 with excessive mobility

by Greene and Vermillion, 1960 • Concentrated on dental calculus because during that time, calculus is considered an etiologic factor for periodontal disease

oral hygiene index

scores in OHI

Score 0 no debris or calculus or plaque on tooth surface Score 1 calculus extending 1/3 of the tooth Score 2 calculus extending 2/3 of the tooth Score 3 calculus on whole coronal portion of the tooth

by Silness and Loe

plaque index

The most important consideration is the thickness of plaque along the gingival margin, because only this plaque in direct contact with the gingival tissue plays any role in the etiology of gingivitis.

plaque index

Plaque is not stained, it is visualized by air drying • Problem: subjective, what is moderate? • relatively time consuming

scores in plaque index

Score 0 no plaque Score 1 thin film of plaque at the gingival margin, visible only when scraped with an explorer Score 2 moderate amount of plaque along the gingival margin; interdental space free of plaque; plaque visible with the naked eye Score 3 heavy plaque accumulation at the gingival margin; interdental space filled with plaque

It records plaque-free surfaces as a percentage

interdental hygiene index

Usually scored with a quadrant from only one aspect. i.e.., from the facial or from the oral

interdental hygiene index

It is a sensitive index because small plaque quantity is also measured and because the index is scored in the interdental areas, which are in most cases not particularly cleaned.

interdental hygiene index

formula for interdental HI

HYG = Number of plaque free areas (-) x 100 number of examined areas

not used in epidemiological studies because it is time consuming

interdental hygiene index

• Recording plaque accumulation on all tooth surfaces

hygiene index

this most precise index involves measurement of plaque accumulation on all four tooth surfaces (facial, oral, mesial, distal)

• A simple yes/no decision: dichotomous

Problem: loss of information because it can’t determine the degree of plaque accumulation which can tell who is more prone or susceptible

Was developed solely for use in individual patients

Muhlemann and Son, 1971 • Considers bleeding from the sulcus after probing, as well as erythema, swelling and edema

Sulcus Bleeding Index (SBI)

Used as an indicator of gingival health, no bleeding (healthy)

Sulcus Bleeding Index (SBI)

Has been used in various clinical studies but is also applicable to individual patients in a private practice setting

SBI

Generally scored separately from both the papilla (P) and margin (M)

SBI

grade in SBI

Grade 0 no bleeding on probing Grade1 bleeding on probing, no changes in color or contour Grade 2 bleeding on probing, eryhtema Grade 3 bleeding on probing, erythema, mild edema Grade 4 bleeding on probing, erythema, severe edema Grade 5 bleeding on probing/spontaneous hemorrhage, severe edema with or without ulceration

Silness and Loe, 1963 • Scores gingival inflammation on the facial, lingual, and medial surfaces of all teeth

gingival index

The symptom of bleeding comprises a score of 2

Used worldwide in epidemiological studies and scientific investigations

Less applicable for individual patients because the differences between the scoring levels are too gross

GI scores

Grade 0 Normal gingiva, no inflammation, no discoloration, no bleeding Grade 1 Mild inflammation, slight color change, mild alteration of gingival surface, no bleeding Grade 2 Moderate inflammation, erythema, swelling, bleeding on probing or when pressure is applied Grade 3 Severe inflammation, severe erythema and swelling, tendency toward spontaneous hemorrhage, some ulceration

All four tooth surfaces are scored as (+) or (-) for bleeding on probing.

Gingival Index Simplified (GI-S, Lindhe 1981) and Gingival Bleeding Index (GBI, Ainamo, 1975)

Negative observations are not entered into the chart.

Gingival Index Simplified (GI-S, Lindhe 1981) and Gingival Bleeding Index (GBI, Ainamo, 1975)

Gingivitis incidence is calculated as a percentage of affected (bleeding) units.

GI-S,GBI

Suited only for individual practice application on a routine basis.

GI-S,GBI

by Saxer and Muhlemann, 1975 • permits both immediate evaluation of the patient’s gingival condition and his motivation, based upon the actual bleeding tendency of the gingival papillae.

papilla bleeding index

PBI grades

Grade 1 - point 20-30 seconds after probing, the medial and distal sulcus with a periodontal probe, a single bleeding is observed Grade 2 - linear/multiple pinpoint A fine line of blood or several bleeding points become visible at the gingival margin Grade 3 - Triangular bleeding The interdental triangle becomes more or less filled with blood Grade 4 - Drops/pooling Profuse bleeding. Immediately after probing, blood flows into the interdental area to cover portions of the tooth or gingiva.

For epidemiological purposes, six teeth could be taken as representative of the entire dentition (sextant)

Ramfjord teeth

Use partial assessment • Take the worst condition to represent the sextant • Less time consuming

ramfjord teeth

Contains a gingivitis index in scores 1, 2, and 3, and a measure of attachment loss independent of gingivitis, in scores 4, 5, and 6

periodontal disease index

Designed for use in epidemiological studies, not for clinical practice

PDI

Development using the Ramfjord teeth

PDI

PDI SCORES

Score 0 No inflammation, no alterations in the gingiva Gingiva Score 1 Mild to moderate gingivitis at some locations on the gingival margin Score 2 Mild to moderate gingivitis of the entire gingival margin surrounding the tooth Score 3 Advanced gingivitis with severe erythema, hemmorage, ulceration Periodontium Score 4 Up to 3mm of attachment loss, measured from CEJ Score 5 3-6mm of attachment loss Score 6 More than 6mm of attachment loss

Developed by Ainamo et.al. (1982) at the initiative of WHO

Community Periodontal Index of Treatment Needs (CPITN)

Divide dentition into sextants with at least 2 teeth present on each sextant

CPITN

Probing assessments are performed with the most severe measurement chosen to represent the sextant.

CPITN

CPITN code for periodontal conditions

Code 0 - gingival health Code 1 - no pockets, overhangs and calculus but with bleeding after probing Code 2 - pockets not exceeding 3mm, but with plaque retaining factors seen located gingival Code 3 - with 4 to 5mm deep pockets Code 4 - with pockets 6mm deep or greater

Treatment needs are scores based on the most severe score in dentition

TN 0 - gingival health TN 1 - need for improved oral hygiene (Code 1) TN 2 - need for scaling and removal of overhangs and improved oral hygiene (Code 2 and 3) TN 3 - indicating complex treatment (Code 4)

designed to determine the treatment for a community

CPITN

was used to determine prevalence

CPITN

Disputed by Baelum

CPITN

reasons of dispute by baelum

1. calculus was the etiology 2. Code 4 - surgery aided, treatment was constricted to specifics resulting to over treatment 3. Use of index teeth - doesn’t represent all dentition. - overestimates for young people in prevalences

pocket depth- not stable. measures soft tissue. Affected by: marginal inflammation, force applied, size of probe, etc., It is reversible CEJ to attachment base - a more stable measure

CPITN