Epidemiology of

Periodontal Diseases

Dr. Rana
Darwish
Epidemiology
It came from Greek words.

Epi = Upon
Demos = People
Logus = Study or Science

Literally it means Study Of People

 Definition of Epidemiology
The art and science which deals with
various factors and conditions that
determine the occurrence and
distribution of health, disease,
disability and death in a group of
population.
Definition of Epidemiology
The study of health and disease
in populations and the effect of
various biologic, demographic,
environmental and lifestyles on
these states.
 Essential Features
Focus of study groups rather
than individuals
Persons with and without a
particular disease (periodontal
disease)
Persons with and without the
exposure of interest are
included (rather than patients)
Concerns of Epidemiology

Causes and etiology of disease.

(Genetic factors, environmental

factors including lifestyle.)

Describe the health status of population

groups & describe the size and
distribution of disease problem in
human population.
 Concerns of Epidemiology

Provide the data essential to the

planning, implementation and evaluation
of services for the prevention, control,
and treatment of disease.
Develop new preventive and therapeutic
measures.
Measurements in Epidemiology

Prevalence of a disease: The total

number of cases of a specific disease in
existence In a given population at a
certain time.
 Types of Epidemiological
Studies
Observational Studies
Descriptive
Analytical

Experimental studies (intervention)

 Experimental Studies

Randomized Controlled Trials

 Observational Studies

Cross-sectional studies (Prevalence

studies)
Case control studies
Cohort studies (Follow up)
Epidemiological studies & Perio

Used a wide group of symptoms:

Gingivitis
Probing depths
Clinical attachment level scores
Radiographically assessed alveolar
bone loss
Perio Recognition in
Epidemiological Studies

Gingivitis inflammatory lesion of

marginal gingiva recognized by color, texture
change and /or by bleeding on gentle
probing within gingival sulcus.

If loss or destruction of periodontal

attachment or alveolar bone occur
condition is characterized as periodontitis.
Basic Clinical Measures

Clinical Attachment Loss

Probing Depth
Periodontal Indices

Gingival Index
Plaque Index

Debris Index
Oral hygiene Index
Calculus Index

Community Periodontal Index

Community Periodontal Index
(CPI)

Indicators. Three indicators of

periodontal status are used for this
assessment:

Gingival bleeding
Calculus
Periodontal pockets
 CPI Codes
0 Healthy
1 Bleeding observed, directly or by using
mouth mirror, after probing
2 Calculus detected during probing, but
all the black band on the probe visible
3 Pocket 4 5 mm (gingival margin within
the black band on the probe)
4 Pocket 6 mm or more (black band on
the probe not visible)
X Excluded sextant (less than two teeth
present)
9 Not recorded
35
-4
4
ye
a rs
 Cross Sectional Analysis

Periodontitis at CPI
>3 42.5%
20
CPI = 4 9.5% 06

Periodontitis at CPI >3 10.3% 9

00
CPI = 4 3.0% 2
Periodontitis increase with
age

Moderate Periodontitis (CPI=3)

17.5% in 35-44 years old
21.4% in 65-74 years old

Severe Periodontitis (> 6mm)

7.8% in 35-44 years old
18.1% in 65-74 years old
2004
 Canadian Survey 2006
35-44 years old

Quebec
Perio pockets > 4mm 73.6%
Perio Pockets > 6mm 21.4%
National Survey 1993 France

Studied age group 35-44

years
Gingivitis 80.4%
Pockets 4-5mm 26.6%
Pockets > 6mm 1.6%
Prevalence of Gingivitis

In United States:
40 to 60 % among
schoolchildren
> 82% of adolescents
> 50% of adult
population

In Saudi Arabia (2000):

100% gingivitis among
5-12 years old
14% of them
moderate to severe
 Modifiable risk factors
Environmental
Behavioral

Non-modifiable risk factors

Intrinsic to individual
Non-Modifiable risk factors

Periodontal Determinants
Periodontitis Modifiable Risk
Factors

Smoking
Diabetes
Dental plaque & oral hygiene
Specific microorganisms
Psychological factors
Obesity
Socioeconomic status
Osteoporosis
Smoking & Periodontitis

Associated with attachment loss

High risk for chronic
periodontitis
Dose-effect relationship
Heavy smokers
Longer smoking history
Smoking & Periodontitis

Twofold to sevenfold increased risk of

attachment loss
In US 42% of periodontitis
attributed to current cigarette
smoking
11% of case attributed to
former cigarette smoking

Year
2000
Smoking & Periodontitis
Sweden 2000

257 ppl aged 20 to 69

Non-smokers / former smokers/
current smokers
Full mouth clinical & radiographic
assessment
Current smokers highest
Prevalence of disease (AL >
4mm)
Heavy smokers & longer duration
AL
Diabetes & Periodontitis

Controlled vs uncontrolled
Diabetic parameters:
Glycemic control
Duration of disease
Other associated complications
Perio parameters:
Gingivitis
CAL
Alveolar bone loss
Diabetes & Periodontitis
1989 - 2006

Poor glycemic control associated with:

CAL
Gingivitis
Alveolar Bone loss
& respond less successfully to
perio therapy relative to well
controlled
NHANES III US 1988-1994
70

60

50

40

30

Diabetics
20 Column1

10

0
o ss t h
io
n
i ng
ntl D ep e ss dd
e ec e
m ng lR Bl
ac
h bi va al
t Pr
o
gi gv
At in ni
m m G Gi
5 m
> 5m m
m
> 3
>
Diabetes & Periodontitis

Type 2 Diabetes & elderly

Evidence suggest that Periodontal
disease is associated with poor
glycemic control. ADA 2007
Treatment of Periodontal disease
improves glycemic control in
Diabetic patients. ADA 2007
Dental Plaque & Perio disease

Strongly linked to gingivitis

irrespective of age / gender
Oral hygiene influence ecology
of microbes in shallow to
moderate pockets
Plaque & supragingival
calculus correlate poorly with
severe periodontitis
Obesity & Perio disease
2000 - 2005

+ve association btw BMI . 30 &

periodontitis
Lipid metabolism pathway to
insulin resistance
National Heealth Survey in US
2003 waist to hip ratio, BMI, fat
free mass significantly correlated
to periodontitis
Obesity reduce blood flow to perio
tissues
May enhance immunological &
inflammatory disorder
Psychological Factors 2002 - 2003

Ppl under stress more

likely develop CAL &
alveolar bone loss
Mechanism complex
Poor oral hygiene & more
smoking
A 1996 study low SES,
lower job satisfaction,
irritable personality
attachment loss
Studies according to perio
Diseases Classification AAP

Gingival diseases
Chronic periodontitis
Aggressive periodontitis
Periodontitis as a
manifestation of systemic
disease
Necrotizing periodontal
diseases
Prevalence and risk indicators of gingivitis
and periodontitis in North Jordan

595 patients
Probing depth
CAL
Plaque index
Gingival index
Oral hygiene habits,
smoking, BMI
Prevalence and risk indicators of gingivitis
and periodontitis in North Jordan

76% gingivitis
2.2% aggressive
periodontitis
5.5% chronic periodontitis
Males more than females
Poor oral hygiene & BMI
>30 & smokers higher
prevalence of
periodontitis
Periodontitis Non-Modifiable Risk
Factors

Age
Gender
Race
Genetic factors
Age & Periodontal Disease
1995-2000

Early studies prevalence & severity of

periodontitis increase with older age.
Increased AL with age but the effect on
pocket depth is minimal & no extensive
loss of function in affected teeth.
Hypothesis more susceptible ppl
those whom periodontitis begins in
youth.
Old age associated with
systemic diseases related to PD
Age & Periodontal Disease

Periodontal conditions in 35-44 and

65-74 year old adults in Denmark.
2006
Among 65-74 years old:
2.4% healthy
93.1% bleeding on probing
62.1% pockets 4-5mm
20% pockets > 5mm
 Age & Periodontal Disease

The effect of age on attachment loss

is reduced after adjustments in oral
hygiene levels & access to dental
care services.

Findings in a study Global risk factors &

risk indicators for periodontal diseases:
By Albandar J.M. 2002
 Institutionalized Older Adults

Oral hygiene is worse than the

general population.
Prevalence of edentulism &
unmet dental needs.
Studies in Japan & Australia
showed (2002/3):
Poor oral health status
Increased periodontal disease
Increased tooth loss
 Gender & Periodontal Disease
2000-2005

Males have higher prevalence &

severity of perio destruction.
Suggestions: sociobehavioral
Poorer oral hygiene
Less positive attitude to oral
health
Fewer dental visits
 Race & Periodontal Disease
1999-2003

African Americans

Mexican Americans

Non Hispanic white ppl

Genetic Factors (1997 2004)

Several gene polymorphisms

associated with increased risk
of periodontitis.
IL-1 gene severe periodontitis
IL-1 & smoking risk
Other IL 2, 4, 6, 10
Periodontal disease &risk for
systemic diseases

Cardiovascular/ CHD
Cerebrovascular disease
Pregnancy complications
Diabetes
 CVD & Periodontal Disease

Ppl with periodontitis 25%

increased risk for CHD when
compared to perio free ppl.
Among men younger than 50
years ppl with
periodontitis were 70% more
likely to develop CHD than
men without perio disease
CVD & Periodontal Disease

2005 US cohort study

Increased systemic levels to
periodontal microbes are related to
increased prevalence of coronary
heart disease & subclinical
atherosclerosis.non-smokers
 CVD & Periodontal Disease
Oral infections and Vascular
Disease Epidemiology Study
2005:
Measured bac quantitatively
in perio plaque samples
Researchers analyzed 5000
subgingival plaque samples
for known perio bac
including:
Porphyromonas gingivalis
Tannerella forsythensis
Treponima denticola
 CVD & Periodontal Disease

Findings Oral Infections and

Vascular Disease Epidemiology
Study 2005:
Carotid atherosclerosis increased
with higher levels of periodontal
bacteria after adjusting other
risk factors.
Stroke & Periodontal Disease

First National Health &

Nutrition Examination
Survey NHANES 2001
Among participants
<55 years strong
positive associations
between periodontal
disease and stroke.
Also 2003 study found
positive association
for stroke.
Stroke & Periodontal Disease

Study: Periodontal disease

as a risk factor for
ischemic stroke. 2004
Case control study
Men <60 years with severe
periodontitis had a 4.3
times higher risk of
experiencing stroke than
did patients with same age
who had mild or no
periodontitis.