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6. FUNDAMENTALS IN THE METHODS OF PERIODONTAL DISEASE

EPIDEMIOLOGY

For a comprehensive reading on this topic, please refer to CHAPTER 6 – FUNDAMENTALS IN THE
METHODS OF PERIODONTAL DISEASE EPIDEMIOLOGY in Carranza’s Clinical
Periodontology, 13th ed., 2018.

1. The Need for Epidemiology

The World Health Organization (WHO) defines epidemiology as “the study of the distribution and
determinants of health-related states or events (including disease), and the application of this study to the
control of diseases and other health problems.” Distinct study designs are employed to examine the
distribution of periodontal diseases in populations and to determine its etiology and its association with other
diseases. There are two study design categories: observational and interventional studies. Examples of
interventional studies in oral health research are randomized clinical trials and nonrandomized clinical
trials. Randomized controlled trials are study designs that assess the diagnosis, management, and prognosis
of chronic diseases and that either confirm or refute the suspected causes of disease identified in case–
control or cohort studies. Examples of observational studies are cross-sectional studies, cohort studies, and
case-control studies. Case–control studies and cohort studies are study designs that identify common causes
of chronic disease. Well-designed interventional studies generally are higher level than observational
studies.
Epidemiologic studies have had a powerful impact on reducing the incidence of some chronic
diseases by reliably identifying their primary causes. Evidence on what causes disease allows laboratory
research to focus on elucidating the causal pathways of disease, which can then lead to clinical trials.
The emerging epidemiologic evidence regarding the cause of periodontal diseases suggests that
factors such as cigarette smoking, sugar, and chronic diseases such as diabetes could be primary causes of
periodontal disease (5, 22, 64).
FLASH BACK
1.1. Measuring the Occurrence of Conditions or Diseases

Definitions

The fundamental tools of epidemiology are simple sums and divisions that reflect how many
individuals or sites either have or develop a particular condition or disease.
The prevalence is the sum of all examined individuals or sites that exhibit the condition or disease of
interest divided by the sum of the number of individuals or sites examined. The prevalence can range from
0% (no one has the condition or disease of interest) to 100% (everyone has the condition or disease of
interest).
The risk is the probability that an individual or a site will develop a particular condition or disease
during follow-up. The risk for a condition or a disease is a number that ranges between 0% and 100%. After
a follow-up period, the risk can be calculated as the proportion of persons or sites in which the clinical
outcome of interest develops during the follow-up period. Because the risk is estimated as a proportion, it is
without dimension, and it ranges between 0 and 1. When a risk is reported, it should be accompanied by a
specific time period to which it is applied. A 5% risk for death may be considered small when it refers to a
20-year period but large when it refers to a 3-month period.
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The odds for an event is the probability that an event occurred divided by the probability that an
event did not occur. Whereas probability is a value that has to range between 0 and 1, odds values range
from 0 to infinity. If the probability for observing an event is small, then the odds and the probability are
almost identical. For example, if the probability for a vertical root fracture after an endodontic procedure is
0.001, then the odds are 0.001/0.999 or 0.001001.
Incidence rates are an alternative measure to describe disease occurrence. The disease rate is a ratio
in which the numerator is the number of subjects or sites diagnosed with the disease of interest and the
denominator is the sum of the time at risk over all subjects or sites in the population.

Incidence versus Prevalence

Recall that prevalence is the proportion of a population found to have a condition at a given point in
time (e.g., 9% of the US population had severe periodontitis in the 2009-2010 NHANES survey), while
incidence is the probability that a disease will occur in a previously healthy population over a period of time
(e.g., the incidence of peri-implantitis for patients with mandibular over-dentures is 17% after 5 years).

1.2. Periodontal Measures Typically Recorded Clinically

A periodontal examination can measure various characteristics of the periodontium. Periodontal

records typically contain information about the teeth that are present, missing, or impacted, as well as
measurable information such as clinical probing depth (PD), bleeding on probing (BOP), gingival recession
(REC), mobility of teeth, and the presence of furcation involvements. In addition, some clinicians may
collect information about the presence of gingivitis by evaluating the color and form of the gingival tissues,
they can record clinical attachment levels, microbiologic measures, gingival crevicular fluid volume,
biomarkers in the crevicular fluid, and indices that measure the amount of gingival inflammation or dental
plaque or debris accumulation.
Commonly used measures of periodontal tissue destruction include mean probing depth, mean
attachment loss, and mean recession level (32). These measures can be complemented with radiographic
examinations that may provide information about marginal bone levels.
Two common measures of gingival inflammation are the Gingival Index (GI) and bleeding on
probing (BOP) (25). The GI assesses for inflammation each of the four gingival areas of the tooth (i.e.,
facial, mesial, distal, and lingual). They are rated as follows: normal gingiva (a score of 0), mildly inflamed
gingiva without bleeding on probing (a score of 1), moderately inflamed gingiva with bleeding on probing (a
score of 2) or severely inflamed gingiva with a tendency to spontaneously bleed (a score of 3). The scores
can be averaged for each patient to provide patient means.
Bleeding on probing is another measure of periodontal inflammation. The tip of the periodontal
probe is inserted into, and moved along the gingival sulcus by the examiner. If bleeding occurs shortly after
probing, a positive score is given. The presence or absence of bleeding on probing is assessed on each of the
six sites of a tooth (i.e., mesial, central and distal on the facial side, as well as mesial, central and distal on
the lingual side). As all teeth are examined, this is an overall gingival bleeding index. The number of
bleeding sites is divided by the total number of sites examined and multiplied by 100, to obtain a percentage
of bleeding on probing.
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Bleeding on Probing versus Gingival Index

According to the existing nomenclature, GI is a categorical index that assesses the severity of
gingival inflammation on a scale from 0 to 3. On the other hand, BOP is a binary index (Yes/No) that
determines whether a site is bleeding on probing or not. The two should not be confused.

Sensitivity versus Specificity

Sensitivity is defined as the number of diseased patients who are correctly identified as having
disease—that is, the diagnostic marker leads to a minimum number of false negative diagnoses. Specificity is
defined as the number of healthy persons who are correctly determined to not have the disease—that is, the
diagnostic marker leads to a minimum number of false positive diagnoses.

True and Surrogate Measures of the Periodontal Condition

The epidemiology of true and surrogate endpoints of periodontal disease do not necessarily coincide.
True endpoints are tangible outcomes that directly measure how a patient feels, functions, or survives (17).
True endpoints include oral health–related quality-of-life measurements (40, 48, 68) and self-reported
problems, such as a positive answer to the following question: “When you brush or floss your teeth, do you
notice bleeding that is both regular and that involves spitting blood-stained saliva?” Surrogate endpoints are
intangible to the patient (71). Surrogate endpoints in periodontal research include anatomic measures (e.g.,
probing depth), measures of inflammation (e.g., bleeding), microbiologic measures, and immunologic
measures (13). Surrogate endpoints are often objective, because they can be measured by the clinician
(rather than relying on self-report by patients) or by laboratory methods. Surrogate endpoints can be
misleading when the goal is to provide reliable information about clinical decisions related to diagnosis,
etiology, treatment, or prognosis. One periodontal example is the use of systemic antibiotics that may have a
beneficial impact on attachment gain (19) but a potential increased risk for tooth loss (11).
Periodontal Endpoints
Examples true endpoints: Tooth loss, patient’s quality of life, and oral function
Examples surrogate endpoints: Probing depths, bleeding on probing, microbial measures

The Community Periodontal Index of Treatment Needs (CPITN)

The Community Periodontal Index of Treatment Needs (CPITN) is an epidemiologic tool developed
by the World Health Organization (WHO) for the evaluation of periodontal disease. The CPITN is based on
the examination of six segments of the dentition, from second molars to first premolars and from canines to
canines. All teeth are examined. The worst finding in each sextant is given a code. A sextant is qualified for
recording only if it comprises two or more functioning teeth. If only one tooth is present, it will be assessed
and it will be included in the adjacent sextant. There is a specially designed WHO periodontal probe to
assess the CPITN. The probe has a colour coded area between 3.5 and 5.5 mm from the ball-pointed tip of
the probe. The coloured band allows a quick estimate to be made of pocket depth and the degree of gingival
recession, eliminating the need for recording precise measurements. The probe is thus designed to rapidly
differentiate ‘normal’ from ‘abnormal’ status to provide an estimate of an individual’s periodontal treatment
needs.
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The WHO-CPITN probe

To detect pathological conditions without producing pain or false results, a maximum probing force
of 20 g is recommended. A simple and practical way of estimating the force to be used is to insert the probe
gently under a finger nail without causing pain or discomfort. (Landry & Jean, 2002)
Each tooth is scored from Code 0 to Code 4, but only the highest score of the sextant is recorded.
The CPITN codes are assigned as follows: absence of any sign of disease in a sextant is indicated
with code 0. Code 1 is recorded if the probing depth is 3 mm or less and there is no calculus but bleeding on
gentle probing of the sulcus occurs. If the entire coloured band of the probe remains visible, code 2 is given
if supragingival and/or subgingival calculus is present, or if there are other microirritation factors, such as
incorrect restorations. If the colour coded area remains partly visible, the pocket depth is 4 or 5 mm and code
3 is given. If the colour coded area disappears into the pocket during probing, the pocket depth is 6 mm or
more and gives a sextant a code of 4. In the currently used version of CPITN, if there are furcation lesions,
loss of attachment greater than 7 mm or mucogingival conditions, a code x is assigned. This currently-used x
code differs from the X code that appears in the original paper (Cuttress et al. 1987)(see below).
Disease status codes are converted into four treatment categories: for code 0 there is no need for
additional treatment; oral hygiene instructions (OHI) are provided for code 1; scaling, root planing, OHI and
removal of all microirritation factors for codes 2 or 3; complex periodontal treatment for codes 4 or x.

The Periodontal Screening and Recording (PSR) method

Apart from one major difference (the asterisk Code), the PSR Index is virtually identical to CPITN.
The two indices use a common evaluation method based on the following three periodontal disease
indicators: gingival bleeding on probing; calculus accumulation; and probing depth. In addition, the PSR
Index provides a more detailed picture of periodontal status by recording the presence of furcation
involvement, tooth mobility, mucogingival problems, and gingival recessions exceeding 3.5 mm. When at
least one of the above conditions is present, an asterisk (*) is recorded with the PSR score for that given
sextant. Information is collected and scored by dividing the mouth in to six sextants. The first sextant
includes teeth 1.8 to 1.4 according to the WHO classification, the second, teeth 1.3 to 2.3, and so forth. Each
tooth in a sextant is probed at six different sites: mesiobuccal, midbuccal, distobuccal, and the corresponding
lingual and palatal sites.
PSR code definitions and recommended treatment plans:
Clinical Signs: Code 0 - Absence of clinical signs, Code 1 - Bleeding on probing, Code 2 - Supra
and/or subgingival calculus and/or defective margins, Code 3 - Periodontal pocket 4 mm to 5.5 mm deep
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(colored band on probe partially visible), Code 4 - Periodontal pocket 6 mm deep (colored band no longer
visible), Code * - Periodontal abnormalities present, Code X - Sextant absent or fewer than 2 teeth.
Treatment Plan: Code 0 - No treatment required, Code 1 - Oral hygiene instructions, Code 2 -
Removal of calculus, Correction of plaque retentive margins, Code 3 - Removal of calculus, Root planing,
Detailed periodontal examination of sextant or entire mouth if more than 2 sextants receive a Code 3 score,
Code 4 - Detailed periodontal examination of entire mouth, Complex treatment, Code * - Detailed
periodontal examination of affected sextant.
The periodontal examinations recommended for Codes 3, 4, and * should include radiographs,
(preferably bite-wings), of the affected regions and detailed measurements of the following parameters:
actual probing depth, attachment levels, tooth mobility, gingival recession, muco-gingival problems,
furcation involvement.
The results of the evaluation in the CPITN and PSR systems, as they appear in the original sources:

Index CPITN PSR

T.W. Cutress, J.Ainamo, J. Sardo-Infirri, R.G. Landry and M. Jean, Periodontal
Source

The community periodontal index of Screening and Recording (PSR)

treatment needs (CPITN) procedure for Index: precursors, utility and
population groups and individuals, limitations in a clinical setting,
International Dental Journal (1987) vol. International Dental Journal signs,
(2002) 52.
theResults of

Code 0: healthy tissue Code 0: absence of clinical

Code 1: bleeding observed during or after Code 1: bleeding on probing,
probing Code 2: supra and/or subgingival
Code 2: calculus or other plaque retentive calculus and/or defective margins,
factors such as ill-fitting crowns or poorly Code 3: periodontal pocket 4 mm to
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The treatment indications in the CPITN and PSR systems, as they appear in the original sources:

Index CPITN PSR

T.W. Cutress, J.Ainamo, J. R.G. Landry and M. Jean, Periodontal Screening
Source

Sardo-Infirri, The and Recording (PSR) Index: precursors, utility

community periodontal and limitations in a clinical setting, International
index of treatment needs Dental Journal (2002) 52. 35-40.
(CPITN) procedure for
population groups and
individuals, International
Dental Journal (1987) vol.
37 nr. 4
Treatmen Code 0 or code X for all six Code 0 No treatment required,
t sextants – there is no need Code 1 Oral hygiene instructions, Code 2
indication for treatment Removal of calculus, correction of plaque
Code 1 or higher – the need
retentive margins,
for improving the personal
oral hygiene of that Code 3 Removal of calculus, Root planing,
individual Detailed periodontal examination of sextant or
Code 2 or higher – a need entire mouth if more than 2 sextants receive a
for professional cleaning of Code 3 score;
the teeth and removal of Code 4 Detailed periodontal examination of
plaque retentive factors + entire mouth, Complex treatment,
oral hygiene instructions
Code * Detailed periodontal examination of
Code 3 –scaling and root
planing and oral hygiene affected sextant.
instructions
Code 4 – complex The periodontal examinations recommended for
treatment Codes 3, 4, and * should include radiographs,
preferably bite-wings, of the affected regions and
detailed measurements of the following
parameters:
- actual probing depth,
- attachment levels,
- furcation involvement,
- gingival recessions,
- mucogingival problems,
- tooth mobility.

The overall (Full Mouth) Plaque Index

The Plaque Index (PlI) is useful to assess the compliance of the patient with the oral hygiene
instructions provided by the practitioner. The tip of the periodontal probe is moved along the cervical area of
the crown in order to detect plaque deposits. The presence or absence of plaque is assessed on each of the
six sites of one tooth (i.e., mesial, central and distal on the facial side, as well as mesial, central and distal on
the lingual side). As all teeth are examined, the number of sites showing plaque deposits is then divided by
the total number of sites examined and multiplied by 100, to obtain a percentage.
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2. Causes

Human chronic diseases such as diabetes and destructive periodontal disease have complex causes.
The terms necessary cause, component cause, and sufficient cause help to define the cause of a disease (62).
The set of causes that initiate a chronic disease is referred to as a sufficient cause. Each sufficient
cause consists of multiple component causes. As an example, a sufficient cause for periodontal disease
includes the following component causes: smoking, dental plaque, and an unspecified gene defect (Fig. 6.2).
All component causes of a sufficient cause need to be present for the disease process to be initiated. Multiple
sufficient causes may be responsible for a given disease.
A component cause, which is an element of all the sufficient causes for a given disease, is referred to
as a necessary cause. For example, fermentable carbohydrates are a necessary cause for dental caries. The
elimination of necessary causes could eradicate a disease.
The proportion of disease that results from different component causes does not add up to 100%. The
component cause “smoking” is responsible for 80% of destructive periodontal disease cases; plaque is
responsible for 100%, and diabetes is responsible for 10%.

2.1. Suspected Modifiable Causative Factors for Periodontal Disease

- Tobacco Smoking: Tobacco smoking is recognized by several organizations as one of the primary
drivers of periodontal disease epidemiology (5). Smoking cessation has been shown to slow the
progression of periodontal disease (38, 39, 57).
- Nutrition: There are relationships between periodontal disease and a variety of medical conditions
that center on carbohydrate metabolism, including intake of dietary carbohydrates, exercise, obesity,
prediabetes, and diabetes.
- Dental Plaque: There is evidence that chemotherapeutic and mechanical plaque control will reduce
gingival inflammation.
- The Cause of Periodontal Disease for the "Patient Sitting in Your Chair": In clinical epidemiology,
uncertainty regarding the “cause” is an important consideration when discussing causality. One can
almost never determine with certainty what caused a particular condition or disease to appear in a
patient; all one can do is assign probabilities to the likelihood that a particular causal factor was
responsible for the disease diagnosed in the patient.

3. Diagnosis: Periodontal Conditions Versus Periodontal Diseases

Disease is defined as an attribute or a characteristic of a person, and diagnosis is the clinician’s belief
that the person has the attribute (70). The World Health Organization defined disease as "those adverse
health consequences that include physical or psychological impairment, activity restrictions, and role
limitations" (70). Certain periodontal conditions have been associated with such adverse consequences, and
thus certain periodontal conditions qualify as diseases, according to the WHO’s definition. Gingival
conditions (e.g., necrotizing ulcerative gingivitis) similarly have an impact on oral health–related quality of
life (44).
An important thing to consider during periodontal diagnosis is to determine which periodontal
conditions can be diagnosed as “diseased.” Can a patient with a couple of sites with 1 or 2 mm of attachment
loss be classified as diseased? Disagreement regarding such questions is one of the reasons that the
prevalence of gingivitis and destructive periodontal disease can range widely, depending on which reference
levels are considered to be the cutoff for normal as compared with diseased.