Preventive and

Community Dentistry I

Measurements in
epidemiology:

Dr. Caroline Piske de A. Mohamed

Objectives:
O Students should be able to explain and discuss:

1.
2.
3.
4.
5.
6.
7.
8.

Scales of measurement
Counts
Proportions
Ratio
Percentages
Rates
Index
Criteria of index

Measurements in Oral
Epidemiology
O The main objective of any epidemiological

investigation is the ability to measure the

ocurrence of a disease among groups of
persons.

1.Scale of Measurements:
O There

are several kinds of scale for

measuring the intensity of a condition:
1. Ordinal scale: list conditions in order of
severity without attepting to define any
mathematical relation between the
categories.

0 1 2 3 4 5 6 7 8 9 10 11 ...

O 2. Interval: in which the numbers used in the

measuring scale supose to have a

mathematical relation to each other.
O Fahrenheit and Celsius temperatures are
interval scales. ( There isnt a zero that
means no temperature)
O ...- 2, -1, 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,
11...degrees

O 3. Ratio Scale
O The ratio scale has a true ZERO point, such as

measures of height and weight.

O 1.80 cm
O 1.70
O 1.60

O 1.50
O 1.40
O 1.30
O 1.20...

O 0 cm

Methods of measuring oral

diseases:
O The

most important measurements of

disease are:

its

prevalence

(measured by counts,
proportions or percentages),

incidence (measured by rates), and

severity or intensity (measured using
indices)

2.Counts
O The simplest form of measuring the

prevalence of any disease is by counting

the number of cases of its occurence
(the n. of persons who have a particular
disease i.e. measuring the presence or
absence of a particular condition or
disease).
O Simple counts of cases are most useful
with unusual conditions of low
prevalence; they become less useful as
prevalence increases.

The simplest count

O Present

or

Absent

Count
Example:
Cases of AIDS reported in GZ in 2004.
Stomach cancer patients who were female in KLJ
Hospital.

Female: 5
Male:

Useful for allocation of health resources

Limited usefulness for epidemiologic purposes without
10
knowing size of the source population

O To investigate distribution of disease, it is

also necessary to know the size of the

source population from which affected
individuals were counted, as well as the time
period during the data is collected.

3.Proportions
O Acount can be turned into a proportion by

adding a denominator.
O In order for a count to be descriptive of a
group of a population, it must be seen in
proportion to it and must be divided by the
total number of individuals in the group.
O ( prevalence)

Proportion
The quotient of 2 numbers
Numerator NECESSARELY INCLUDED
in the denominator
Quantities have to be of same

nature

Proportion always ranges between 0 and 1

Percentage = proportion x 100

2
--- = 0.5 = 50%

4
13

O Proportion =

COUNT
Total population

O This

type of measurement allows

comparisons of disease frequencies in two
or more groups.
O The numerator is inside the denominator

( Prevalence)

Example Proportion
O What is the proportion of 20 to 30 years

libyan citizens that are diabetic?

O Total of the 20 -30 years population: 1000
000.
O Total of 20-30 years diabetics = 1 000
O Proportion= 1000
= 1 to 1000
1000000
It is 1 diabetic to 1000 citizens

4.Ratio

Ratio
The quotient of 2 numbers.
Numerator NOT necessarily INCLUDED in the
denominator.
Allows to compare quantities of different nature.
Ex: The rate between women and man that
graduate from medical school is 2.5 to 1.

= 5 / 2 = 2.5 / 1
18

Ratio
O The numerator and denominator need not

be related. Therefore, one could compare

apples with oranges or apples with number
of physician visits.

Ratio, Examples
O How is the relation between hospital beds per doctor in

Libya?
O
O

850 beds/10 doctors

R = 85 beds for 1 doctor

O How many nurses per doctor is there in Libya?

O What is the ratio between male and female in the

Libyan population in 2013?

O Sex ratio:
O Odds ratio
O Rate ratio
O Prevalence ratio

Male / Female
Female / Male

20

Method for calculating a ratio

Number or rate of events, items, persons,
etc. in one group
Number or rate of events, items, persons,
etc. in another group
O After the numerator is divided by the

denominator, the result is often expressed

as the result to one or written as the result
:1.

O Note that in certain ratios, the numerator

and denominator are different categories of

the same variable, such as males and
females, or persons 2029 years and 30
39 years of age.
O In other ratios, the numerator and
denominator are completely different
variables, such as the number of hospitals
in a city and the size of the population living
in that city.

EXAMPLE: Calculating a Ratio

Different Categories of Same Variable
O Between 1971 and 1975, as part of the National

Health and Nutrition Examination Survey

(NHANES), 7,381 persons ages 4077 years
were enrolled in a follow-up study.
O At the time of enrollment, each study
participant was classified as having or not
having diabetes.
O During 19821984, enrollees were documented
either to have died or were still alive. The results
are summarized as follows.

O Of the men enrolled in the NHANES follow-

up study, 3,151 were nondiabetic and 189

were diabetic.
O Calculate the ratio of non-diabetic to
diabetic men.
O Ratio = 3,151 / 189 x 1 = 16.7:1

Ratio/proportion
O Ratio the relationship between two

measures expressed as a / b
O Proportion a type of ratio in which the
numerator is included in the denominator,
expressed as a percentage.
( X ) x 100
X+ Y

Proportion, Examples:
O What is the proportion of students from Omar

Mohtar School that brush their teeth twice a day?

27

O TOTAL of students= 200

O Students that brush their teeth twice a day = 25
O Proportion of students that brush their teeth twice

a day in relation to the total of students of the

school= 25 = 1,5 to 10
200

O Ratio of the students that brush their teeth twice a

day in relation to the students that dont brush

their teeth twice daily= 25 =
1
= 1:7
175
7

200 25=

1:6

1 to 5

5.Percentage
O Prevalence of oral disease or condition can

also be expressed in percentage, i.e.

Number per 100 persons. Ex:

O 100% of the students of the 6 th

semester are studying hard!!

What is the percentage of Omar Mohtar Schools

students that brush their teeth twice a day?

O TOTAL of students= 200

O Students that brush their teeth twice a day =

20
O Percentage of students that brush teeth 2 a
day =
25 x 100
=
200

12.5 %

6.Rates
O A

rate is a proportion that uses a

standardized denominator and includes a
time dimention.
O A standardized unit of population is often
used in the denominator of each rate.
O This is usually expressed as a power of 10;
that is, 100, 1000, 10 000, 100 000 or 1
million. ( Incidence)

O Rate = new cases/population/time

O A widely used rate in health is infant

mortality, which is measured by the

number of deaths of newborn infants
whithin the first year of life per 1000
live births.

Rate
Numerator
- number of EVENTS observed for a given time
Denominator includes time
- population in which the events occur
(Population at risk)
- Cases of anodontia of laterals in 12 years old
children of Benghazi in 2005. ( INCIDENCE)
Observed in 2005

2
----- = 0.02 / year

100
36

7.Index
Intensity ( severity- index)
O The measurement of the more prevalent

oral disease such as caries and periodontal

disease requires the assessment of the
degree of intensity or severity of the disease
in addition to its prevalence.
O The disease intensity or severity can only be
determined by the use of an INDEX.

What is an index?
O An index is a graduated numerical scale with

upper and lower limits, with scores on the

scale corresponding to specific criteria.
O Index

scores frequently are clinical

abstractions, which only make sense when
used for comparisons between individuals or
groups measured in a similar way.

Requirements of an ideal
index:
1- Validity :

measure whats intended to measure

2- Reliability: consistent at different times under a
variety of conditions
3- Clarity, simplicity & objectivity: readily
memorized after some practice
4- Quantitability: amenable to statistical analysis
5- Sensitivity: detect small shift
6- Acceptability: not painful

Properties of an INDEX
O A) Validity ( related to the instrument)
O Does it measure what it is supposed to

measure?
O The index must measure what it is intended to
measure, so it should correspond with clinical
stages of the disease under study at each point.
O Gingival Index
O Score 2
Bleeding after probing

B. Reliability
O The index should be able to measure

consistently at different times and under a

variety of conditions. ( related to the
researchers)
O The term reliability is virtually synonymous
with reproducibility, repeatability and
consistency, meaning the ability of the same
or different examiners to interpret and use
the index in the same way.

RELATIONSHIP BETWEEN
VALIDITY & RELIABILITY
O Validity

and

reliability

are

closely

related.
O A test cannot be considered valid
unless the measurements resulting
from it are reliable.
O Likewise, results from a test can be
reliable and not necessarily valid.

C. Clarity, simplicity, and

objectivity.
O The criteria should be clear. Ideally, it should

be readily memorized by an examiner after

some practice.

D. Quantifiability
O The index must be amenable to statistical

analysis.

E. Sensitivity
O The index should be able to detect clinically-

relevant but small shifts, in either direction,

in the condition.

Who has
the
disease?

Who
doesnt
have the
disease?

Dr. Caroline Mohamed

50

F. Acceptability
O The

use of the index should not be

unnecessarily painful or demeaning to the
subject.

Types of indices
( classification)
A. Indices used for epidemiological surveys:

DMF/ ICDAS/ CPITN.

B. Indices used for clinical trials: Plaque Index
and Patient Hygiene Performance, Gingival
Index.
C. Indices used for individual clinical score:
Plaque-free score in which the patient is
able to measure the effects of personal
daily care efforts by the changes in the
scores. ( motivation)

ICDAS - International Caries Detection &

Assessment System

Descriptive Categories of
index:
1. General Categories:
a) Simple Index:
O Measures the presence or absence of a

condition.
O Example: Plaque Index. ( it evaluates the
presence of plaque without an evaluation of
its effects on the gingiva.)

O b) Cumulative Index:
O Measures all the evidence of a condition,

past and present. Ex: DMF

Types of
indices:
Reversible
(GI)

Complex
(PI)

Irreversible
(DMF)

Types of simple and

cumulative indices
O An index may be reversible or irreversible.
O A) Irreversible index: DMF

Measures cumulative conditions that cannot

be reversed, for ex. Dental caries which is
regarded as an irreversible condition.
Once the lesion of caries has reached a
clinically evident stage, it either continues or is
treated by restoration or extraction, therefore
leaves a permanent scar.

Permanent teeth index:

Decayed-Missing-Filled Index ( DMF )
Klein, Palmer and Knutson,1938 and modified by WHO:

The DMF is an irreversible index, applied only to

permanent teeth. And always significant by upper
case letters.
1-DMF teeth index (DMFT) measures the
prevalence of dental caries/Teeth.
2- DMF surfaces index (DMFS) which measures the
severity of dental caries.

D Caroline Mohamed

58

Superior teeth D..4 M..2 F..5

Decayed

Restored

Restored

Restored
Decayed

Restored
Restored
Missed
D Caroline Mohamed

Missed
59

Inferior teeth D..0 M..2 F..4

Missed
Filled

Missed
Filled

Filled

Filled

D Caroline Mohamed

60

B) A reversible Index
O It

is designed to measure reversible

conditions that can return to a state of
health again, for example: Gingivitis Index.

Gingival Index: GI
0

C) Compound or complex
Index.
O It is designed to measure both reversible

and irreversible conditions.

O CPITN

Scoring criteria for Russels ( CPTI)

0: normal
l: bleeding observed, directly or by using mouth mirror,
after sensing
2: calculus felt during probing but all the black area is
visible
3: pocket 4 or 5 mm (gingival margin situated on black
area of probe
4: pocket > 6 mm (black area of probe not visible)
D Caroline Mohamed

21/07/2014

64

Treatment Needs
Score CPITN

TN

Score Treatment Needs

0 or X (missing teeth)

TN 0

There is no need for treatment

TN 1

Need to improve Oral Hygiene OH

For control or elimination of bleeding

TN 2

OH; Scalling and polishing

For the removal of calculus

3/ 4

TN 3

Complex therapy : OH; Root planning;

surgery

D Caroline Mohamed

21/07/2014

65

Purposes and uses of an

index
O A) For individual patients
O An index can:
1. Provide individual assessment to help a

patient recognize an oral problem.

2. Reveal the degree of effectiveness of
present OH practices.

O 3) Motivate the person in preventive and

professional care.
O 4) Evaluate the success of individual and
professional treatment by comparing index
scores ( past and present).

B) In research
O An Index is used to:
1) Determine the baseline data.
2) Measure

the effectiveness of specific

agents for the prevention.
3) Measure the effectiveness of mechanical
devices for personal care.

C) In Community health
O An index show:
1) The prevalence and trends of incidence of

a particular condition
2) Provide baseline data
3) Assess the needs of a community
4) Compare the effects of a community
program and evaluate the results.

Thank you