Schulich Dentistry

- D5170 Oral Diseases

Cariology

Schulich Dentistry
- D5170 Oral Diseases
Cariology

Cariology: Epidemiology
Thursday 4th February 2016

Today
1.
2.
3.
4.
5.

What is epidemiology?
Why consider epidemiology?
Some epidemiological principles
How is dental caries measured
Caries in populations what is the size of the problem?

Today
6. Epidemiological evidence of causative factors
7. Evidence for caries treatments
8. Caries trends and associations
9. Current demographic changes affecting dentistry

1. What is Epidemiology?

Study of..
health and/ or disease states of populations
What is measured?.....
Normally frequency and severity of disease
What is this measurement related to?....
Any number of factors.

Age; sex; socio-economic status; geography; race; etc

2. Why consider epidemiology?

What can epidemiological data tell us?...

How many people are affected (size of the problem)
To what extent they are affected (numbers of teeth)
Can look for associations and risk factors
Age; daily sugar intake; oral hygiene habits..

This gives us possible ways to combat disease

Can examine the effect of such (usually public health) measures

Most tests follow this general format

What is the difference between an epidemiological

study and a clinical trial??

Epidemiological studies focus on

populations or population groups
Clinical trials focus on treatments
Many of the features are essentially similar

3. Some epidemiological principles.

Measurement of disease and collection of factors of interest (demographic data)

PREVALENCE..
The proportion of the population affected by a given disease at a particular time

INCIDENCE..
The number of new cases arising over a given time period
Requires TWO measurements over a period of time

3. Some epidemiological principles.

TWO types of epidemiological study.

OBSERVATIONAL

INTERVENTIVE

4. How is dental caries measured?

How do we measure disease in general?

Ideally

Valid
Reliable
Clear, simple and objective
Quantifiable
Sensitive (able to detect small shifts)
Acceptable

4. How is dental caries measured?

There are many indices of dental health but by far the most common is.
Decayed, missing and filled teeth (DMF)
This can either count whole teeth (DMFT)
OR it can measure surfaces (DMFS)
Slightly modified for children (def)

This measures cumulative disease experience in a subject

4. How is dental caries measured?

Advantages of DMF index.

Valid because effects of caries are irreversible*

Simple and reliable
Fairly objective
Quantifiable
Acceptable (visual examination)

4. How is dental caries measured?

Disadvantages of the DMF index.

Meaningless for severity without age being quoted
Gives equal weight to D, M & F
Teeth may be lost for other reasons (M)
The F component depends upon the dentist placing the filling (so is not standardized)
Restorations may be done for reasons other than caries
Cannot really account for fissure sealants

4. How is dental caries measured?

One major disadvantages of the DMF index.

THE D COMPONENT

Caries detection is very variable

When do you call a tooth carious?
Remember caries is a spectrum of disease
Not standardized therefore not really amenable to meta analyses and the like

4. How is dental caries measured?

D COMPONENT:

Separated into.

D1 Initial caries
D3 Caries into dentine
D2 Between 1 and 3

DMF more a measure of disease + treatment

experience

5. Caries in the population

How may people are affected..

Depends where you look..
Varies from country to country and from region to region

Epidemiological data for large groups are fraught with difficulty . .

Cant measure everyone
This can either count whole teeth or surfaces (DMFT or DMFS)
The way you derive your sample is all-important

5. Caries in the population

You first have to go look

Stats Canada apparently has not
No co-ordinated national picture of caries prevalence, but.
Multiple regional and sub-population studies
Picture looks broadly similar to elsewhere in the developed world

Numbers of dentate elderly

Canada
Total Pop. edentulous
1990: 16%
2003: 9%

Prop. >65 edentulous

1990: 48%
2003: 30%

Health Reports, Vol. 17, No. 1,

November 2005

UK
Total Pop. Edentulous
1968: 37%
1998: 14%

Prop. >65 edentulous

1998: 42%

6. Epidemiological evidence for cause of caries

observational studies:

Little or no caries before the middle ages

Caries found to increase thereafter
Expansion of trade in 19th Century linked to huge increase in caries.
this led to the profession of dentistry around the same time
Observed to fall in periods of short supply (e.g. WW 2 sugar rationing)

6. Epidemiological evidence for cause of caries

Interventive studies:

Vipeholm study (Gustaffson et al) 1945-52

Controlled sugar intake of in-patients
6 groups from no added sugar with meals to consumption of 24 large toffees between meals
Found that amount and frequency of intake of sugar had a profound effect on caries rates
BUT
This was during a time before Fluoride and of high caries prevalence

6. Epidemiological evidence for cause of caries

More modern studies

Show that frequency correlates poorly to caries incidence

Absolute amount of sugar did not equate directly to caries incidence (US:UK studies)
Other factors seem to be playing a part
Correlation mostly weak or moderate but rarely strong from 36 studies since 1980

7. Epidemiological evidence caries treatments

Both observational and interventive

The anti-caries effect of fluoridated water

First discovered by pure observation 1910-1930s in USA.
In areas of fluorosis (Colorado Brown Stain McKay & Black) people were less susceptible to caries
Then looked at caries and F levels in 21 cities (H.T.Dean 1940s USA) + measured decay rates
Interventive study effect of deliberately adding fluoride to water (Grand Rapids)

8a. Caries Trends and associations

Who is getting the disease globally nowadays?

Kenya

V
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8a. Caries Trends and associations

National and regional associations:

Higher-income countries have shown a decline

Lower-income countries have shown an increase
Regional variations within countries observed

What happens when we take a closer look..

Change in disease patterns

High levels of disease much
less common
Caries free much more
common
Greater proportion of
disease in a smaller section
of the population

8b. Caries Trends and associations

Age:

Caries measured by DMFT is CUMULATIVE

This means that DMFT can ONLY increase with age
(DMFT without age almost meaningless)
Children are heavily studied
..Why?
Adults less so.

8c. Caries Trends and associations

Sex:

Do you think there is a male /female difference in DMF?

Girls higher than boys..
.W hy might that be?

Earlier tooth eruption

Main difference is in the F component
(probably reflects more frequent dental visits(!)

8d. Caries Trends and associations

Genectics (also race & ethnicity):

Do bad teeth run in the family

Yes they do..

Caries rates in siblings correlate well
Population sub-groups have different caries rates
Regional & ethnic variations ARE found

8d. Caries Trends and associations

Genectics (also race & ethnicity):
Has nothing to do with genetics or race
Caries rates in siblings correlate well but so do caries rates between husbands and wives
Ethnic sub-groups do have different caries rates but depend heavily on social circumstances
Regional & ethnic variations ARE found but there are normally major environmental differences.
General decline in caries refutes genetic basis
TAKE CARE WHEN INTERPRETING DATA

8e. Caries Trends and associations

Socio-economic status

Global pattern suggests this IS a factor

USA

UK - DEPCAT

D
M
F

Increasing deprivation

2006 USA

8e. Caries Trends and associations

Socio-economic status

Correlates HIGHLY with socio-economic status

Not a simple matter of salary..
W here you live (parks / recreation)
W hat you do for a living (if)
Level of mothers education
Independent of access to dental services

CARIES CAN BE CONSIDERED A DISEASE OF POVERTY & SOCIAL DEPRIVATION

9. Current demographic trends affecting Dentistry

9. Current demographic trends affecting Dentistry

Effect increasing age and improving dental health..

Large proportion of our treatment will be on older age groups 65+

Older individuals retaining more teeth
Become susceptible to root caries and toothwear (harder to treat)
More problems with debilitation/ medical issues
Change in emphasis from young to old

10. Summary of Epidemiology

Epidemiology CAN:

Study populations NOT individuals

Tells us the general size of the problem
Can give information on subgroups who suffer greater disease
May allow targeting of public health measures and government spending (!)
May Illuminate ways to combat the disease
Gives us useful association that we can incorporate into a patients caries risk

10. Summary of Epidemiology

Epidemiology CANNOT:

Allow us to make decisions about treatments for individuals

Generally children are heavily studied
How a sample is created will determine the outcome importance of sampling (complex)
May tell us associations and risk factors

As you have seen, caries epidemiological data can be presented in a myriad of ways take care when evaluating and interpreting data!

10. Summary of Epidemiology

Epidemiology, associations and risk:

Risk factor = a factor that, if present, increases the probability of disease

Risk factors are ONLY PART of the causal chain, or expose the patient to the causal chain
When disease occurs, removal of risk factor may not result in cure

ASSOCIATION CAUSE & EFFECT!!!!!