Causality in Dentistry Dr Sergio Uribe sergio.uribe @ gmail.

com Objectives at the end of class, the student may articulate the concept of causality to recognize the different causal models to identify types of causal state the Hill criteria of causation set forth the conc ept of confounding variables to estimate risk of tetrachoric tables sergio.uribe @ gmail.com sergio.uribe @ gmail.com Causality Cause: A causal factor is an event if its operation alters the frequency of the event A A A B B C sergio.uribe @ gmail.com B C D Classical Epidemiology Time Place Person sergio.uribe @ gmail.com Causal factors Biological factors age, sex, race, weight, size, genetic composition, nutritional status, immune st atus Psychological factors self-esteem, behavior pattern, lifestyle, stress response Factors related to the social and cultural environment global warming, pollution, demographic, lifestyle, physical activity during leis ure time, membership of a social network, access to basic services, overcrowding , drug addiction, alcoholism

Economic factors socioeconomic status, occupational status, educational level, poverty Workplace accident at work, employment, loss of employment, access to social security, job stress, noise pollution, workplace conditions Political factors wars, embargoes, external debt, globalization and invasion Factors related to the physical environment geology, climate, natural causes, chemical causes, presence of vectors, deforest ation sergio.uribe @ gmail.com Role of variable Association Independent Independent Independent Dependent Effect modifier Confusion Dependent sergio.uribe @ gmail.com Dependent Variable Types Quantitative (continuous) Qualitative (Discrete) sergio.uribe @ gmail.com Causal models sergio.uribe @ gmail.com Establishing causation group of subjects divided into two similar groups apply to a group putative fact or to measure the frequency in both groups compare frequencies Rest 52 107 patients with TB 14 + 21 17 52 streptomycin + rest 4 + 13 38 sergio.uribe @ gmail.com

Causality DeStefano et al. BMJ. 1993 Mar 13; 306 (6879) :688-91. sergio.uribe @ gmail.com Causal model of dental caries sergio.uribe @ gmail.com Causal model of dental caries Litt et al Public Health Rep. 1995 Sep-Oct, 110 (5) :607-17 sergio.uribe @ gmail.com sergio.uribe @ gmail.com Hill criteria 1) Strength of association as measured by appropriate statistical indices. 2) Co nsistency among different observers in different places, times and circumstances . 3) Specificity of the causes. 4) Time. 5) Biological gradient in the dose-resp onse relationship. 6) Biological plausibility. 7) Consistency with other knowled ge. 8) experimental evidence. 9) Analogy with other causal relationships. sergio.uribe @ gmail.com Measurement of disease Normal - - statistical criterion standard diagnostic threshold prevalence incidence forecas t

Basic measures of disease - sergio.uribe @ gmail.com Relationship between P and R Prevalence = Incidence x Duration sergio.uribe @ gmail.com Measures of Association • Useful for assessing the existence of a relationship between exposure to a spe cific risk factor and disease status • Relative risk (risk ratio) (RR) - used in cohort studies. Reason for attack rates in exposed and unexposed groups. - RR = 1 rate in both groups - RR> 1 the above is possible that disease nás - RR <1 the above is no more likely to get sick sergio.uribe @ gmail.com Risk estimation Smoking Implant failure present absent present absent 75 100 565 225 Smoke Implant failure absent present absent present ab cd

Absolute risk Relative risk sergio.uribe @ gmail.com Risks Absolute Risk Relative Risk Risk Risk Attributable Attributable%

sergio.uribe @ gmail.com As measured risks epidemiology Determine rates of disease by person, place and time - Absolute Risk (incidence, prevalence) to identify risk factors for the disease - relative risk (or odds r atio) develop ways for the prevention of disease - Risk / attributable fraction

sergio.uribe @ gmail.com Attributable Risk Risk 35 30 25 20 15 10 5 0 A B Excess risk RA = Risk between the positive risk factor on the negative risk to the risk factor Risk factor sergio.uribe @ gmail.com Attributable fraction FA = Risk among positive risk factor Risk among negative risk factor Risk among positive risk factor sergio.uribe @ gmail.com X 100% Confusion Cafe

? Periodontal Diseases Cafe Periodontal Diseases Smoking sergio.uribe @ gmail.com sergio.uribe @ gmail.com