Epidemiology

Learning Objectives
• Define Epidemiology
• Describe the uses of epidemiology
• Define and index (indices) and describe the
ideal properties of an index
• Understand the differences between dmft and
ICDAS
• Understand the terms D3, Significant caries
index, Care index
 Epidemiology

• The study of health and disease in

populations and of how these states are
influenced
• Requires that disease be measured
quantitatively in a standardised fashion
 Epidemiology

Seeks to find order among seemingly

haphazard patterns of disease in
population groups.
 Uses of epidemiology
• Describing normal biological processes
• Understanding natural history of disease
• Measuring the distribution of disease
• Identifying the determinants of disease
• Testing hypotheses for prevention & control of
disease
• Planning & evaluating health care services
 Epidemiology should drive policy
development

• Health care delivery systems

• Research priorities
• Educational systems for dental personnel
• Legislation governing dental practice
• Methods of payment
 Measuring Oral Disease

• COUNTS - simple count of the number of cases

• PROPORTIONS - add a denominator to count
• RATES - proportion using a standardized
denominator i.e. deaths per 1000
• INDICES - DMFT, dmft, CPI(TN), DAI, IOTN,
DEAN’S, DDE
 Indices

An index is a graduated, numerical scale

having upper and lower limits, with scores
on the scale corresponding to specific
criteria.
Ideal Properties of an Index

• Clarity, simplicity and objectivity

• Validity
• Reliability
• Quantifiability
• Sensitivity
• Acceptability
Burt & Eklund
Clarity, simplicity and objectivity

https://www.slideshare.net/NoorahMurad/lect
ure-56-123480633
Validity

https://slideplayer.com/slide/3588645/
Quantifiability

Something you can count

• Teeth
• Areas with periodontal pocketing

What couldn’t you count?

How people feel
Time if no recognizable measure
Temperature if no recognizable measure
Sensitivity
Acceptability
 Indices

•Caries - WHO criteria, BASCD criteria

•Root Caries Index - Katz
•CPI/CPITN - severity & extent
•Loss of attachment
•Trauma to incisors
•Tooth wear (erosion, attrition)
•Oral Mucosal Lesions
 Measuring Dental Caries

• DMFT/dmft index
• Decayed
• Missing due to decay
• Filled due to decay
• Teeth/Surfaces

• Mean values of DMFT/DMFS reported

Shortcomings of DMF Index

• DMF values are not related to the number of teeth at risk.

Ie it does not measure activity
• It assesses only cavitated lesion extended into dentin (not
enamel)
• Reaches saturation level at particular point of time when
all teeth are involved and prevents registration of caries
attack even when caries activity is continuing

17
Shortcomings of DMF Index(contd)

• Does not give account for treatment needs

• DMF index gives equal weight to missing, untreated
decayed and well restored teeth
• Cannot be use to assess root caries
• Rate of caries progression cannot be assessed

18
International Caries Detection and Assessment System
(ICDAS)
• Developed in the year 2001 by the effort of large group
of researchers, epidemiologists and restorative dentists
• two-digit system; evolved with the need to detect
caries at the non cavitated stage
• ICDAS is divided into sections covering
– coronal caries (pits and fissures, mesial-distal, and
buccal-lingual),
– root caries, and
– caries-associated-with-restorations-and-sealants (CARS)
19
 International Caries Detection and Assessment System (ICDAS)

The ‘D’ in ICDAS stands for detection of dental caries by

(i) stage of the carious process;
(ii) topography (pit-and-fissure or smooth surfaces);
(iii) anatomy (crowns versus roots);
(iv) restoration or sealant status

The ‘A’ in ICDAS stands for assessment of the caries

process by stage (noncavitated or cavitated) and activity
(active or arrested)

20
 International Caries Detection and Assessment System (ICDAS)

The detection of dental caries on coronal tooth surfaces is a two-

stage process;
1) The first decision is to classify each tooth surface on
whether it is sound, sealed, restored, crowned, or
missing
2) The second decision that should be made for each tooth
surface is the classification of the carious status on an
ordinal scale

21
 International Caries Detection and Assessment System (ICDAS)

Decision 1

0 = Sound (use with the codes for primary caries)

1 = Sealant, partial
2 = Sealant, full
3 = Tooth colored restoration
4 = Amalgam restoration
5 = Stainless steel crown
6 = Porcelain or gold or PFM crown or veneer
7 = Lost or broken restoration
8 = Temporary restoration
9 = Used for the following conditions
97 = Tooth extracted because of caries (all tooth
surfaces will be coded 97)
98 = Tooth extracted for reasons other than caries (all
tooth surfaces coded 98)
99 = Unerupted (all tooth surfaces coded 99)
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 International Caries Detection and Assessment System (ICDAS)

Decision 2

0 = Sound
1 = First visual change in enamel (whitespot seen after 5 seconds air
drying).
2 = Distinct visual change in enamel (whitespot seen without air drying).
3 = Localized enamel breakdown due to caries with no visible dentin
4 = Non-cavitated surface with underlying dark shadow from dentin
5 = Distinct cavity with visible dentin
6 = Extensive distinct cavity with visible dentin. An extensive cavity
involves at least half of a tooth surface and possibly reaching the pulp.
7 = Tooth extracted because of caries (tooth surfaces will be coded 97)
8 = Tooth extracted for reasons other than caries (tooth surfaces will
be coded 98)
9 = Unerupted (tooth surfaces coded 99)

23
 DMFT versus ICDAS
Dmft; Icdas
Widely used Only recently used
Large numbers of studies nationally and internationally Only a small number of studies nationally and
that use DMFT internationally

Lacks sensitivity More sensitive

Activity or rate of lesions not able to be measured Has six different classifications for measuring activity

Enamel lesions are not included Includes enamel lesions

Gives an equal weight to missing teeth, untreated caries Has different classification/codes for missing teeth,
or restored teeth untreated caries or restored teeth

Secondary caries not counted Different classification/code for secondary caries

Can be confusing for Fissure sealants or cosmetic Different classification/code for fissure sealants or
restorations cosmetic restorations

Doesn’t estimate treatment needs Can measure treatment needs

Cant access root caries Different classification/code for root caries
   
Dental Caries in Ireland
1960s, 1984 & 2002
dmft/DMFT values

9
8
7
6 1961-63
5
4 1984 F
3 1984 Non F
2 2002 F
1 2002 Non F
0
5 yrs 8yrs 12yrs 15yrs
Age

O’Mullane et al 1986
Whelton et al 2002
N. Ireland & Republic of Ireland

Northern Ireland Republic of Ireland

Age
Mean DMFT Mean DMFT
1963 1983 2002 1961-63 1984(F) 2002(F)
8 2.0 1.5 0.3 1.7 0.6 0.3

12 5.5 4.4 1.5 4.7 2.6 1.1

15 9.4 8.5 3.6 8.2 4.1 2.1

Differences were found by country, with Wales (22% at ages
5 and 15) and Northern Ireland (19% at age 5 and 36% at
age 15) showing
a higher proportion with
a severe or extensive decay burden than
England (13% at age 5 and 14% at age 15).
Obvious Decay (D3)
This is when the disease process clinically
appears to have penetrated dentine (i.e. the
layer below the outer white enamel of the
teeth) on a tooth surface.

This is described internationally as decay at the

D3 level and includes pulpal decay (i.e. decay
into the deeper dental pulp).

This is a different diagnostic level from that

used by many dentists when examining
patients in a dental surgery, i.e. for dental
check-ups.

REF NDIP PUBLICATION

Obvious Decay Experience (D3MFT)

The sum of teeth which have decay into

dentine (including teeth with fillings which
require further treatment), filled teeth and
teeth that are missing (extracted) due to decay.

Thus no obvious decay experience has

D3MFT=0.

REF NDIP PUBLICATION

Care Index

The percentage of teeth with obvious decay

experience in a population that have been
treated restoratively (filled).

This is calculated as follows: number of filled

teeth number of obvious decayed, missing and
filled teeth × 100
Or simply FT D3MFT × 100.

REF NDIP PUBLICATION

Significant Caries Index (SiC)

Used to bring attention to the individuals with

the highest caries values in each population
under investigation.

The Significant Caries Index is calculated as

follows:
• Individuals are sorted according to their
D3MFT values.
• The third of the population with the highest
caries scores is selected.
• The mean D3MFT for this subgroup is
calculated. This value is the SiC Index.

REF NDIP PUBLICATION

Scotland P1 children (6 years approx)
 Reporting Caries in Adults

• Mean number of teeth - adults

• 20+ natural teeth
• 18+ SUNT - adults
• Percentage of population edentulous
• Root Caries Index
 Dental Caries in Irish Adults 1989-
90 and 2000-01
16-24 years 35-44 years 65+ years

1989- 2000-01 1989-90 2000-01 1989-90 2000-01

90

Mean 7.4 5.7 19.0 15.4 27.3 25.9

DMFT
%D 19% 14% 6% 6% 4% 2%
%M 35% 30% 56% 38% 90% 88%
%F 46% 54% 38% 55% 6% 10%
 Oral health of Irish adults aged 35-44 in
1989-90 & 2000-01

Medical card No medical card

Male Female Male Female

1989-90 2000-01 1989-90 2000-01 1989-90 2000-01 1989-90 2000-01

20+ 77% 81% 66% 79% 67% 93% 56% 91%

teeth

18 + 32% 32% 19% 44% 20% 40% 10% 32%

SUNT
 Oral health of Irish adults aged 65+ in
1989/90 & 2000-01

Medical Card No Medical Card

Male Female Male Female
1989-90 2000-01 1989-90 2000-01 1989-90 2000-01 1989-90 2000-01

Edentulous 48% 40% 72% 49% 17% 24% 43% 35%

Mean no 8.3 8.1 3.1 6.6 12.3 13.3 8.1 9.8

teeth
Percentage of subjects with more than 20
natural teeth 1989-90

Age Non Fluoridated

Fluoridated
1989-90 2000-01 1989-90 2000-01

24-34 72.2 NA 95 NA
35-44 53.1 83.2 71.3 92.4
45-54 22.7 NA 39.6 NA
55-64 8.6 NA 29.4 NA
65+ 7.5 13.3 16.7 13.8
 Percentage of subjects edentulous by
fluoridation status 1989-90 & 2000-01
Age Non Fluoridated Fluoridated
1989-90 2000-02 1989-90 2000-02
25-34 3.3 NA 0.0 NA
35-44 6.1 1.2 2.4 0.3
45-54 29.5 NA 10.8 NA
55-64 47.1 NA 33.8 NA
65+ 54.2 41.5 42.3 41.8
 Trends in Edentulousness

Age Group 1979 1989-90 2002

65+ 72% 48% 41%

35-44 12% 4% 1%
 Edentulousness by Medical Card 2002

Year Medical Card No Medical

Card

2002 46% 29%

1989-90 62% 31%

 Percentage of Subjects by CPITN Score
& Age 1989/90 and 2002
CPITN = 0 CPITN = 1 CPITN = 2 CPITN = 3 CPITN = 4

1989 2002 1989 2002 1989 2002 1989 2002 1989 2002
/90 /90 /90 /90 /90

16-24 23% 18% 21% 19% 1% 12% 1% 12% 0% 0.4%

years

35-44 6% 8% 5% 5% 73% 45% 12% 34% 1% 6%

years
• Oral cancer is the 14th most common cancer in the UK
(2012).
• A fifth (20%) of cases of oral cancer are diagnosed in people
aged 75 and over. 
• The 50-74 age group contributes around 7 in 10 male oral
cancer cases, and around 6 in 10 female cases. 
• Over the last decade, oral cancer incidence rates have
increased by around a third (34%) in the UK.
• Most oral cancers occur in the tonsils.
•  1 in 75 men and 1 in 150 women will be diagnosed with
oral cancer during their lifetime
91% are linked to major lifestyle and other risk factors.
Increases with
1. Increasing age
2. Genetic risk factors
3. Smoking (65% of oral cancer cases in the UK)
4. alcohol (30% of oral cancer cases in the UK),
5. and infections (13%)
6. Betel quid,
7. smokeless tobacco,
8. ionising radiation
9. certain occupational exposures
10. insufficient fruit and vegetables intake (linked to 56% of oral
cancer cases in the UK)
11. Environmental tobacco smoke and solar radiation may relate
to higher risk of some oral cancer types, but evidence is
unclear
Human papillomavirus (HPV) type 16 is classified by the International Agency for
Research on Cancer (IARC) as a cause of oral cavity, tonsil and pharynx cancers,
and HPV type 18 as a probable cause of oral cancer.
• An estimated 8% of oral cavity cancers and 14% of oropharyngeal cancers in
the UK are linked to HPV infection.
• 73% of oropharyngeal cancer cases in Europe are HPV-positive, a meta-
analysis showed; this proportion has increased over time.
• 12% of oral cavity, hypopharynx and larynx cancer cases in Europe are HPV-
positive, with no change over time.
• Oropharyngeal, tonsil, and base of tongue cancer risk is higher in people with
more past sex partners (particularly oral sex partners), and those who started
having sex at a younger age
• Reflects the sexual route of HPV transmission.