EPIDEMIOLOGY ?

the study of the distribution and

determinants of health-related states or
events in specified populations, and the
application of this study to control health
problems.

PURPOSES OF
EPIDEMIOLOGY

To determine the amount and distribution f

a disease in a population

To investigate causes for the disease

To apply this knowledge to the control of the

disease

NOTE :
Epidemiology traditionally has been
considered a basic science of public health.
* ( public health practice emphasizes
the health of population groups. )

PREVALENCE:
Proportion of persons in a population who
have the disease of interest at a given point
in or period of time.
It measures the burden of disease in
population
It is the dynamic situation between the
addition of new cases, which increases the
prevalence and the removal of cases
through death or cure, which decreases
prevalence.

INCIDENCE:
It is the average percentage of unaffected
persons who will develop the disease of
interest during a given period of time.
It indicates the risk or probability that a
person will become a case

Incidence = no of new cases of diseases

no of persons in population at
risk

Prevalence is a measure of amount of

disease existing in a population
while,

Incidence is a measure of the occurrence of

new cases

Epidemiologic study
designs
Cross-sectional studies
Cohort studies
Case-control studies

Cross-sectional studies
Measures presence or absence of disease
Characteristics of the members of a population are
measured at a point in time.
useful for providing prevalence data on a disease
comparing the characteristics of persons with and without
disease and generating hypotheses regarding the etiology
of a disease.

Two major limitations

1.

It can only identify prevalent cases of disease but not the

incidence.

2.

Although it may show that a certain characteristic is

associated
with having the disease, determining whether the
characteristic preceded the disease is not always possible.

Cohort studies

It follows subjects over time.

Purpose:
To determine whether an exposure or characteristic
is associated with the development of a disease or
condition.

At the beginning of the study, all subjects must be free of

the disease of interest.

Subjects are classified into exposed and unexposed

groups and then followed over time and monitored for
the development of the disease.

The disadvantage of cohort study is that they can require

long periods of follow-up and can be expensive to conduct.

Case-control studies

It provide and efficient way to investigate the association

between an exposure and a disease, especially a rare disease.

Require fewer resources and can be conducted more quickly

than cohort studies.
*The prevalence or incidence of a disease cannot be
determined from a case-control study because the subjects
are recruited into study based on their disease status.

Disadvantage :
The temporal relationship between the exposure and the
onset of disease cannot be determined because the exposure
is usually assessed when the disease status is established.

INDICES

Indices are methods for quantifying the

amount and severity of diseases or
conditions in individuals or population.

TYPES OF INDICES

Plaque Index

Definition: an index for estimating the

status of oral hygiene by measuring dental
plaque that occurs in the areas adjacent to
the gingival margin.

No plaque

A film of plaque adhering to the free

gingival margin and adjacent area of
the tooth, which can not be seen with
the naked eye. But only by using
disclosing solution or by using probe.

Moderate accumulation of deposits

within the gingival pocket, on the
gingival margin and/ or adjacent tooth
surface, which can be seen with
the naked eye.

Abundance of soft matter within the

gingival pocket and/or on the tooth and
gingival
margin

DEBRIS AND CALCULUS

INDEX

The Oral Hygiene Index is composed of the

combined Debris Index and Calculus
index, representing the amount of debris or
calculus found on the tooth surface

DEBRIS INDEX
0
1

No debris or stain present

Soft debris covering not more than one third of
the tooth surface, or presence of extrinsic stains
without other debris regardless of surface area
covered
Soft debris covering more than one third, but not
more than two thirds, of the exposed tooth
surface.
Soft debris covering more than two thirds of the
exposed tooth surface.

CALCULUS INDEX
0

No calculus present

Supragingival calculus covering not more than third of

the exposed tooth surface.

Supragingival calculus covering more than one third but

not more than two thirds of the exposed tooth surface or
the presence of individual flecks of subgingival calculus
around the cervical portion of the tooth or both.
supragingival calculus covering more than two third of
the exposed tooth surface or a continuous heavy band of
subgingival calculus around the cervical portion of the
tooth or both.

PAPILLARY MARGINAL ATTACHED

GINGIVAL INDEX (PMA)

An index used for recording the prevalence

and severity of gingivitis in schoolchildren
by noting and scoring three areas: the
gingival papillae (P), the buccal or labial
gingival margin (M), and the attached
gingiva (A).

PAPILLARY
0

Normal, no inflammation

Mild papillary engorgement, slight increase

in size

Obvious increase in size of gingival papilla,

bleeding on pressure

Excessive increase in size with spontaneous

bleeding

Necrotic papilla

Atrophy and loss of papilla

MARGINAL
0

Normal, no inflammation visible

Engorgement, slight increase in size and

no bleeding

Obvious engorgement and bleeding upon

pressure

Swollen collar, spontaneous bleeding,

beginning infiltration into attached
gingiva.

Necrotic gingivitis

Recession of the free marginal gingiva

below the cemento-enamel junction as a
result of inflammatory changes

ATTACHED
0

Normal; pale rose, stippled

Slight engorgement with loss of stippling,

change in color may or may not be
present.

Obvious engorgement of attached gingiva

with marked increase in redness, pocket
formation present.

Advanced periodontitis, deep pockets

evident

Gingival index
Gingival index was proposed in 1963 as a
method of assessing the severity and quantity
of gingival inflammation in individual patients
or among subjects in large population groups.
*NOTE :
1)only gingival tissues are assessed with
GI.
2) Each of the four gingival areas of the
tooth( facial, mesial, distal and lingual) is
assessed for inflammation.

Normal gingiva

Mild inflammation: slight change in color and slight

edema; no bleeding on probing

Moderate inflammation: redness, edema, and glazing;

bleeding on probing

Severe inflammation: marked redness and edema;

ulceration; tendency to spontaneous bleeding.

Modified gingival index

Introduced two important changes to the GI;
1) Elimination of gingival probing to assess
the presence or absence of bleeding
2)

Redefinition of the scoring system for mild

and moderate inflammation

absence of inflammation

Mild inflammation; slight change in color;

little change in texture of any portion of,
but not the entire, marginal and papillary
gingival unit

Mild inflammation; criteria as above, but

involving the entire marginal or papillary
gingival unit.

Moderate inflammation; glazing, redness,

edema, and/or hypertrophy of the
marginal or papillary gingival unit.

Severe inflammation; marked redness,

edema, and/or hypertrophy of the
marginal or papillary gingival unit;
spontaneous bleeding, congestion, or
ulceration

SULCUS BLEEDING INDEX

An index of gingival inflammation in which

bleeding is measured from four gingival
units (mesial and distal papillary units and
labial and lingual marginal units), using a
periodontal probe with a 0.5mm diameter
tip. The scoring range around eight anterior
teeth (four maxillary and four mandibular)

Gingiva of normal texture and color;

no bleeding

Gingiva apparently normal, bleeding on

probing

Bleeding on probing, change in color, no

edema

Bleeding on probing; change in color,

slight edema

Bleeding on probing, change in color and

obvious edema

Spontaneous bleeding and marked

edema

Periodontal index

An index that estimates the degree of

periodontal disease present in the mouth by
measuring both bone loss around the teeth
and gingival inflammation; used frequently
in the epidemiologic investigation of
periodontal disease

Each erupted tooth is examined

Russell chose the scoring values (0,1,2,6,8)

in order to relate the stages of the disease
scored in a survey to the clinical condition
observed

Low scores are given for gingival

inflammation and higher scores when the
alveolar bone has been destroyed.

An additional score 4 which is not used in

the field study, it is an xray criteria used
only for individual clinical examination

SCORE 4 = early notchlike resorption of the

alveolar crest

Limitations of PI

It does not discriminate between moderate

and severe gingivitis

It does not measure loss of attachment;

graded all pockets of 3mm or more equality

Scored gingivitis and periodontitis on the

same weighted scale

Negative : there is neither overt inflammation

in the investing tissues nor loss of function due
to destruction of supporting tissues.

Mild gingivitis: there is an overt areas of

inflammation in the free gingiva, but the area
does not circumscribe the tooth

Gingivitis : inflammation completely

circumscribes the tooth, but there is no
apparent break epithelial attachment

Gingivitis with pocket formation :the

epithelial attachment has been broken and
there is a pocket, there is no interference with
normal masticatory function, the tooth is firm
in its socket and has not drifted.

Advanced destruction with loss of

masticatory function: the tooth may be
loose; may have drifted; may sound dull on
percussion and may be depressible in its
socket.

PERIODONTAL DISEASE
INDEX
Ramfjord introduced PDI to overcome
shortcomings of other indices.
1) 6 pre selected teeth were used to examine
PDI ( max right first molar, max left central
incisor, max left first premolar, mandibular
left first molar, mandibular right central
incisor and mandibular right first premolar.
This selection of teeth became known as
the ramfjord teeth.

Another unique aspect of the PDI was the

use of the cementoenamel junction as a
fixed landmark for measuring periodontal
attachment loss.

GINGIVAL ASSESSMENT
0

Absence of inflammation

Mild to moderate inflammatory

gingival changes not extending all
around the tooth.

2
3

Mild to moderate severe gingivitis

extending all around the tooth
Severe gingivitis characterized by
marked redness, tendency to bleed
and ulceration

THE BASIC PERIODONTAL

EXAMINATION (BPE)

The Basic Periodontal Examination (BPE) is

derived from the Community Periodontal
Index of Treatment Needs (CPITN), which
was developed as a screening tool to enable
the prevalence of periodontal disease in a
community to be summarized.

CPITN

The index comprises six codes (04 and

*).An individual patients periodontal status
can be summarized by six numbers.

CPITN PROBE

The use of a CPITN probe (Figure 10.2) is

mandatory. This has a ball end 0.5 mm in
diameter. A color-coded area extends from
3.55.5mm. A probing force in the order of
2025 g is recommended. This corresponds
to gentle pressure; pain during probing
indicates that too much force is being
applied.

Code 0

Healthy gingival tissues with no bleeding

after probing.

Code 1

Bleeding on probing, plaque present, but no

calculus or
defective restoration margins, pockets <3.5mm.

Code 2

Bleeding on probing, calculus detected or

defective
restoration margins but pockets <3.5mm.

Code 3

Pocket within the color-coded area, i.e. pocket

>3.5 mm<5.5mm.

Code 4

Color-coded area disappears, indicating pocket

>5.5mm.

Code*

Denotes the presence of furcation involvement or

attachment loss >7mm.

The BPE, whilst useful as a guide to a

patients overall periodontal status, is
insufficiently sensitive for monitoring
individual patient treatment over a period of
time because only the worst score is
recorded in each sextant.

BPE codes 13 are deemed suitable for nonspecialist periodontal care.

Code 4 and * frequently suggest that the
complexity is such that the patient may
need referral for specialist periodontal care.
This is particularly so if the patient is young
and suffering from aggressive forms of
periodontitis, or has a complicating medical
history, e.g. uncontrolled diabetes.

THANKYOU