THE METHODS OF ORAL EPIDEMIOLOGY Why do some patients have serious periodontitis while other apparently similar patients

do not? Frequently there is no obvious answer. The branch of scientific inquiry that seeks to find order among seemingly haphazard patterns of disease in population groups is known as epidemiology. It is defined as the study of health and disease in populations and of how these states are influenced by heredity biology physical environment social environment and ways of living. EPIDEMIOLOGY-AN INTRODUCTION !lthough there are commonalities in the philosophy of all scientific research physical laws are more universally true than biological laws. The set of circumstances that leads to a heart attack in one person will not necessarily do so in another person of the same age se" and race. The reasons for these differences between two similar individuals may be rooted in their genetic endowment in the environment in which they live in particular aspects of their lifestyles or perhaps in a combination of these factors. These differences between individuals are e"amples of biological variation. The concept of biological variation is implicitly understood by the clinician but the epidemiologist goes further in seeking patterns among people who can be grouped by particular characteristics. In the late #$th century a time when the bacterial agents in many infectious diseases were being identified the %end of disease% was confidently being predicted. The concept of disease at the time was dominated by infections& little thought was given to chronic conditions. Today we are more aware that disease is multifactorial, meaning that for any disease it is difficult to pinpoint one particular cause. 'eart disease the leading cause of death in the (nited )tates is not a bacterial disease but is clearly associated with genetics stress diet e"ercise smoking blood pressure and blood cholesterol. )o what is the %cause% of heart disease? *ental caries is a bacterial disease but is also associated with sugar consumption fluoride e"posure saliva quality and quantity and family education and income. )o what is the %cause% of dental caries? Within the multifactorial tangle epidemiology attempts to determine which associated factors are the most important for prevention and control. Early Studies +pidemiology was learned and practiced empirically long before it was named. For e"ample people have known for ages that malaria is a disease of wet lowlands so they

avoided living in such places. )uch customs led to improvements in living standards but there was little true understanding about conditions that led to disease. The periodic epidemics of plague that swept +urope from the ,iddle !ges until fairly recent times for instance were often seen as religious signs rather than as a result of filthy living conditions. It was from the more rational study of these epidemics that epidemiology evolved to its present form. )amuel -epys author of The Diary of Samuel Pepys, a vivid record of life in .ondon used the /ills of ,ortality the forerunner of modern death certificates to measure the progress of an outbreak of plague in .ondon in #001. -ercival -ott2s Treatise of the Chimney Sweep's Cancer, in #331 described the unusually high occurrence of scrotal cancer among chimney sweeps and is thus one of the first scientific descriptions of an occupational hazard. In #415 6ohn )now a medical practitioner in the )oho area of .ondon went so far as to control an outbreak of cholera by the application of his epidemiological conclusions. )now began his investigations by trying to find the common features among those who died from the disease. !fter mapping out the residences of those who had died his subsequent enquiries disclosed that all of the victims had used water from the same source. That source in the days before indoor plumbing was a pump in /road )treet 7now /roadwick )treet where the site of the pump is now occupied by a public toilet8. !lthough this investigation took place some years before the germ theory of disease was understood and generally accepted )now reached the rational conclusion that something in the water was responsible for the spread of the disease. )now2s simple method of preventing people from using the contaminated water was to persuade the authorities to remove the handle of the pump. The epidemic soon subsided. )now2s subsequent investigations on the relations between cholera and the source of water supply are epidemiological classics. The results of the patiently e"ecuted research of #$th9century workers such as )now still benefit present9day society Their investigations led to gradual but profound improvements in sanitation personal hygiene and the development of public health codes affecting housing water supply and food processing that are now taken for granted. The fact that infectious diseases such as cholera typhoid yellow fever plague and relapsing fever are now rare in developed countries is largely due to the pioneering work of these early epidemiologists. Their work continues today& the understanding of the mode of transmission of the 'I: virus and its translation into public health education to prevent !I*) followed remarkably quickly on the first identification of the virus in #$4;. That too is epidemiology.

Uses o E!ide"iolo#y The various ways in which the results of epidemiological studies are used can be grouped as follows<

1. 2.

Collecting of data to describe normal biological processes. +"amples are height at various stages of growth blood groups and times and order of tooth eruption. Understanding the natural history of diseases. =bservations of disease progression and outcome in populations have enabled investigators to distinguish those diseases that are fatal or disabling from those that will resolve satisfactorily. The diagnosis of most forms of cancer requires intervention that of chicken po" does not.

3.

easuring the distribution of diseases in population. )urveys demonstrate how diseases are distributed by age gender race geographic region and socioeconomic status. >omparisons of cross9sectional surveys conducted at different times demonstrate trends in disease prevalence and distribution. It was the comparison of survey results in the early #$4?s which first clearly showed that caries e"perience had declined among children of the (nited )tates.

4.

!dentifying the determinants of disease. Within the multifactorial causes of disease referred to earlier specific study designs can identify the determinants and risk factors associated with a disease. +ven if the causal pathway of a disease is. not fully understood knowledge of risk factors can lead to intervention strategies sometimes highly effective for the prevention and control of the disease.

5.

Testing hypotheses for the prevention and control of disease through special studies in populations. This use refers to the clinical trial in which potential agents regimens or procedures for the prevention and control of disease are e"perimentally tested. !s a dental e"ample the various uses of fluoride to reduce caries incidence have been sub@ect to numerous field trials in human populations.

6.

Planning and evaluating health care services. This application is a relatively recent development. *ata that describe "a# the distribution of disease both treated and untreated in the population under study 7b8 the population2s utilization of health care services and 7c8 the availability and productivity of health care services can all be employed to assist planning decisions on services and types of personnel required. ! related application is validating the effectiveness of treatment techniques both new and traditional and determining the quality of treatment provided.

E!ide"iolo#y a$d t%e Pra&titio$er -ractitioners may still ask how knowledge of health and disease tendencies in a particular group of people can help them to diagnose and treat the individual patient. !fter all biological variation being what it is the individual patient may or may not be typical of the group. ! broad response is that epidemiology @oins the basic sciences and clinical studies to increase our understanding of diseases to the e"tent that they can be controlled or alleviated. In the more immediate sense the practitioner can bring the knowledge of risk factors into diagnosis and treatment planning decisions meaning that a patient is more likely to e"hibit a particular disease if he or she e"hibits certain characteristics. For e"ample a man who smokes may or may not have lung cancer but he certainly runs more risk of developing lung cancer than if he does not smoke. )imilarly an elderly man who both smokes and drinks heavily is more at risk of oral cancer than one who does not. The e"amining dentist should include such details from the health history in diagnosis and treatment planning. !nother immediate use of epidemiology for the practitioner is application of results from clinical trials which have given dentistry its scientific basis for preventive procedures. !lthough not every member of a test group in a clinical trial necessarily benefits from the tested procedure the probabilities are high that a given patient will benefit from a procedure that has been successfully tested. /iological variation also applies the other way< a practitioner cannot generalize from the results of an individual patient2s treatment to the population at large. )uccessful treatment can result from a practitioner2s personality from serendipitous characteristics of the particular patient or from outside influences as well as from the treatment itself. =nly with controls and the appropriate design can effective prevention and treatment be determined. Measuri$# Disease The good clinician thinks in qualitative terms. *uring a diagnostic e"amination the dental practitioner not only looks for e"isting disease but also tries to look ahead for possible areas of future disease. ,easuring oral disease in a population however requires a more standardized and ob@ective approach to the oral e"amination of the group members. )tandard diagnostic criteria, written e"plicitly for clinical radiographic microbiological or pathological e"amination replace the @udgment of the practitioner. These criteria meaning ob@ective standards on which diagnostic @udgment can be based are applied to @udge the condition of the oral tissues as they are at e"amination time not on how they might be in the future. This ob@ective application of

diagnostic criteria is the most important philosophical difference between the epidemiological e"amination and that carried out for treatment planning. ,easurement the quantifying of observations is the cru" of science and is a fascinating study in itself. ,easurement variability is inherent in all fields of science& it is one reason why e"periments are repeated before their findings can be accepted. In studies of oral disease it can be demonstrated that a true count of lesions in a population is almost never achieved& a repeat e"amination of the same group of patients nearly always results in a different total number of lesions. !ny one count of disease in a group is therefore an estimate of conditions rather than absolute truth. )o long as criteria are applied consistently however valid estimates will still result because diagnostic %drifts% in one direction will be balanced by drifts the other way. !cute diseases such as measles are characterized by a sudden onset of symptoms so that the patient rapidly progresses from a state in which the disease is clearly absent to one in which the disease is clearly present. Aemission of the acute phase of the disease is equally rapid so there is little time spent in the %gray areas.% !t any given time therefore measles is likely to be either clearly absent or clearly present in the members of a population group thus making its quantification fairly straightforward. >hronic diseases however are usually characterized by a much slower time of onset. It is difficult to establish e"actly when arthritis alcoholism mental illness dental caries and periodontitis become definitely established& as shown in Figure 0 9 B there is a considerable gray area where it cannot be stated with certainty whether the disease is established or not. ! dental e"ample is the stained fissure which may or may not be actively carious This problem is handled by counting as lesions only those defects that meet specific criteria. T%e Hu"a$ Po!ulatio$s Studied We are not going deeply into the many facets of sampling from human populations& these are well9detailed in many te"ts on epidemiology and biostatistics. There are however several fundamentals about groups seen in epidemiological studies that need to be understood when interpreting results. The first concerns representative populations meaning the degree to which the results from a sample in fact represent the base population from which the sample was chosen. !n e"ample comes with surveys of the population of the (nited )tates. =bviously no study is going to e"amine or ask questions of all B1? million or so people so samples are chosen. The process itself is complicated and requires specialized training but sampling precision is such that the #BB ;#? persons interviewed in the #$44 Cational 'ealth Interview

)urvey represented the whole country very closely. In a probability sample such as this one meaning that the chance of each person being chosen in the sample is known the degree of sampling error can be calculated. )ampling error is an estimate of the error that may result from the sample not perfectly representing the base population and with modern statistical methods it can be remarkably small. The degree of sampling error however cannot be calculated for non9probability samples and interpretive problems arise when the sample studied is not a true probability sample. For e"ample the Cational )urvey of =ral 'ealth in () +mployed !dults and )eniors in #$41 9 #$40 sought to obtain a profile of oral health in !merican adults by e"amining employed adults and seniors who visited senior centers. This was a feasible way of getting an adequate profile but results have to be interpreted with some caution. For e"ample the survey found that only 5.BD of persons under age 01 were edentulous but this is almost certainly an underestimate9because by definition the survey e"cluded the unemployed persons in agriculture and mining the military and persons not employed outside the home. It requires ma@or efforts to draw a truly representative sample of () adults whereas the problem is much less acute with children because they can be sampled from schools. !nalytical studies in epidemiology however usually do not require probability samples. In fact case9control and cohort studies as well as clinical trials are usually conducted on convenience populations meaning groups that are of the desired age are accessible e"hibit both the disease and the e"posures under study and include enough individuals willing to participate. In analytical study designs the critical issue is the categorization of participants as cases or controls& in clinical trials it is the allocation of participants to test or control group. !lthough risk factors can be identified in a single study there is always the possibility that selection bias limits the generalizability of the conclusions. If other such studies are carried out with similar results however then conclusions that the risk factors are real become much stronger. Aeplication is also important when generalizing from the results of clinical trials. If a weekly fluoride mouthrinse is found to reduce dental caries by BBD over ;? months among #B9year9old children in fluoridated *es ,oines what does that mean for the children of the (nited )tates? +ven assuming e"perimental conditions could be identical 7which they never are8 results need not necessarily be the same for children of different ethnic background living in different climatic zones and with differing e"posure to fluoridated water. /ut when additional studies are carried out by different researchers in different places with fairly similar results then the weight of evidence is such that the observed effect is likely to be real and general.