Professional Documents
Culture Documents
Epidemiology 5
Epidemiology 5
دلاٌك ٌشرح اناتومً ٌلً حاب ٌرجعله ٌسمع بداٌة5 الدكتور ضل تمرٌبا
)): ًالرٌكورد أنا مش شاٌفه الها داع
The GI of the patient can be obtained by adding the values of each tooth and dividing by the number of
teeth examined
وبمٌس لكل األسنان وباآلخر بجمعهم وبمسم على توتال عدد األسنانaverage عاألسطح األربعه للسن وباخدلهمGI بمٌس الـ
The Gingival Index may be scored for all surfaces of all or selected teeth or for selected areas of all or
selected teeth.
M&D أو ممكن اختار اسطح معٌنه مثال, اسطح4 اسطح لكل األسنان أو بختار عدد اسنان معٌنه بمٌسلهم4 اذا عندي ولت كافً بمٌس الـ
لكل األسنان أو ألسنان معٌنه
The GI may be used for the assessment of prevalence and severity of gingivitis in populations, groups
and individuals
It is sufficiently sensitive to distinguish between groups with little and with severe gingivitis
extremes ٌعنً بكٌز الـhealthy- mild -severe gingivitis بشكل عام بمٌس الفرولات بٌن الناس ٌلً عندها,sensitivity فٌه
وبعبر عن وضع المرٌضaccurate وكونه انا باخد لراءه ألغلب األسنان بعتبره نوعا ما
It may not discriminate between middle-range
moderate to زي الحاالت ٌلً بتكونscores near the middle (2) لكن ممكن ٌكون صعب تمٌز0, 1 & 3 ٌعنً بمٌز بٌن
mild to slightly moderate اوslightly severe
It is subjective because it depends on visual assessments of inflammation (color, swelling, BOP)
Assessment of Severity of gingivitis using GI:
لكلسن وباآلخر اخدتGI عادي ألنه انا اخدتfractions ممكن ٌكون فٌها
0.1-1.0 = mild inflammation لكل األسنان ٌلً لستهاaverage
1.1-2.0 = moderate inflammation integer الزم ٌكونGI per Surface لكن لما بحكً عن
2.1-3.0 = severe inflammation
Gingival Bleeding on Probing (BOP)
The appearance of spots of blood after the probe is gently run around the gingival margin is more
sensitive
The BOP is more objective in those sites that are difficult to view directly (ex:
behind the last molar)
It is used as a standard measure of gingivitis in clinical trials
Validity against the GI has been demonstrated
The major area of subjectivity is gentle probing (not excessive pressure)
Probing has been shown to vary between 3 ‘very gentle’ and 130 g for different examiners (extreme
variation)
Eastman Interdental Bleeding Index (EIBI)
Developed by Caton & Polson (1985)
Wooden interdental cleaner (Not perio probe) is inserted between the teeth from the facial aspect,
depressing the interdental tissues 1 to 2 mm
More sensitive than other measures of papillary bleeding
BOP is not recommended in public health programs for 3 reasons:
- This degree of sensitivity is rarely required in surveys, surveillance, or screening; it may be needed
in cohort and case-control studies
مثالcohort بالـsomething to compare your finding with ؟ ألنه عنديcase-control والـcohort لٌش بستخدمها بالـ
periodontitis على مرٌض عندهprobe بالـpressure انا بطبك نفس الـcase control بالـ,عندي لراءات المرٌض السابمه
)ومرٌض تانً ما عنده (تذكروهم من اول محاضره
ً فما اله داعreference ما عندي, او غٌرها فأنا بس بشوف المرٌض كره وحدهsurvey بٌنما لما بحكً عن
- Such indexes have uncertain discriminatory power in field conditions
BOP الـ,cross-sectional studies هً الدراسات المٌدانٌه ٌلً بشوف فٌها مرضى بأعداد كبٌره بـfield conditions الممصود بالـ
reference ألنه ما عنديpeople بالحاله هاي ما بتفرق بٌن الـ
- Concerns about infection control make the deliberate inducement of gingival bleeding outside the
clinic hard to justify
بٌنما بالمدارس, وغٌرهاgloves, mask, protective personal equipment منinfection control انا بالعٌاده بمدر اسٌطر عالـ
good infection control measures مثال انا ما عندي
The Modified Gingival Index (MGI)
Was developed by Lobene et al. (1986) to eliminate the use of bleeding on probing
Non-invasive index (no probing, based on visual assessment): no risk of bleeding or tissue damage
Still providing high visual sensitivity for incipient gingivitis
good visual sensitivity ً بتعطٌنgingivitis بالمراحل األولى من الـ
Gingivitis is an area in which the development of valid non-clinical measures would be highly beneficial
بدلfield studies وممكن ٌكونو مفٌدٌن أكتر بالـ, ٌعطٌنً لراءات دلٌمهvalid الزم ٌكونnon-clinical measures اذا بدي استخدم
لعدد كبٌر من الناسBOP ما الٌس
MEASURING PERIODONTITIS
Periodontitis is a bacterially induced inflammation of the gingival tissues together with some loss of
both the attachment of the periodontal ligament and bony support
The clinical manifestations of periodontitis come from the interaction between bacterial infection and
the host response.
Periodontitis is:
- a family of related diseases that differ in natural history and response to therapy
- but that are characterized by a common underlying chain of events
- These commonalities, and their clinical expression, permit valid clinical measurement by similar
procedures, basically measurement of clinical attachment loss (CAL) and probing depth
Many early epidemiologic studies of periodontal diseases were based on radiographic surveys of
alveolar bone loss
However, radiography is impractical and probably unethical in field studies
not the only source of data for measuring ؟ هأل هً مهمه لكنradiographic data هل ممكن اعتمد فمط على
CAL & بعبر عنه بـsoft tissue attachment لكن فٌهbone level انا باخدها عشان الٌم الـ,ً لحالها ما بتكف,periodontitis
more important indicator وهدول بعتبرهمProbing depth
field فبالـunjustifiable radiation وبعرضهم لـunethical للبٌشنت بدل ما افحصهم هادX-ray انه آخدfield studies كمان بالـ
و األشعه عند الحاجهclinical examination بعتمد عالـstudy
field study تعتبر مشكله بلـportability of X-ray machines الـ
The attempt was therefore made to develop reversible indexes that were both sensitive and clinically
manageable in field conditions
The most widely used periodontal index for many years was the periodontal index (PI)
Periodontal index (PI)
Described by Russell in 1956
Scores:
0: Absence of signs of Inflammation
1: Mild to moderate inflammatory gingival changes not extending around the tooth
2: Mild to moderately severe gingivitis extending all around the tooth
3: severe gingivitis characterized by marked redness, swelling, tendency to bleed, and ulceration
>> Form 0 to 3: Gingival disease so it has the advantage about including gingival condition
4: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically to CEJ but not more than
3mm
5: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically to CEJ between 3-6 mm
6: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically more than 6mm from CEJ
PI is composite index which scored both gingivitis and periodontitis in the same scale (some of people
consider it as disadvantage since we have gingival index so no need to include gingival conditions in PI)
The PI was viewed as an ideal field index in the 1960s
It was used in a series of epidemiologic studies that correlated disease scores with clinical and social
determinants.
These correlations soon became accepted as base knowledge
Modern understanding has shown the PI to be invalid because:
- It does not include evaluation of CAL (it measures tissue extension from CEJ. What about false
pocket or if free gingiva is bulging?)
- Grades all pockets 3 mm equally so it’s not sensitive (score 5 in the index)
- Scores gingivitis and periodontitis on the same weighted scale
- Its compression of all information into a group mean also fails to illuminate the disease distribution
distribution وmean الزم اعبر عنها بdata احنا حكٌنا انه أي
- Fails to illuminate why some people have no disease and others have severe disease
chronic periodontitis وrapidly progressing periodontitis ما بمٌز بٌن
Periodontal Disease Index (PDI)
Same fundamental problem of a composite index
Ramfjord teeth انه بختار عٌنه من األسنان اسمهاPI بفرق عن الـ
PDI is also no longer used
Periodontal Disease Index (PDI) - Ramfjord teeth
- Ramfjord teeth are a set of six teeth taken to represent the whole mouth during
examination
- Ramfjord teeth are the 16, 12, 24, 36, 32, 44 (What if the patient have one of them
extracted??? It’s a drawback)
- Ramfjord chose this group of teeth to save time in clinical examinations
Indirect measurement of CAL
These measurements are usually carried out to 2-6 sites per tooth (record the
worst measurement)
Either used the “Ramfjord teeth" or the whole dentition
Measuring six sites per tooth for an intact dentition can take 30-40 minutes per
examination
فهو عباره عن المسافه بٌن الـpocket depth هأل بالنسبه للـ,Gingival crest وCEJ و المسافه بٌن الـpocket depth بنمٌس
) زيsevere gingivitis( false pocket هأل المشكله انه المرٌض ممكن ٌكون عندهbase of the pocket والـgingival crest
فبصٌر عندهمdrug-induced gingival enlargement due to cyclosporine, Ca-channel blockers الناس ٌلً عندها
periodontitis بس ما عنده7 او6 بطلع عنديpocket depth ولما بمٌس الـovergrowth
صارتgingival crest واذا الـ,gingival crest to CEJ ) ٌلً هً المسافه بٌن الـB عشان هٌن بعتمد على نمطه تانٌه (المسافه
3 بتصٌر المراءات بالسالب زي صورهapical to CEJ
CAL (C) = A – B
Extent and Severity Index (ESI)
Records the % of sites with a CAL 1 mm and the mean CAL for those affected sites
Give extent & severity
ESI is a method of summarizing data rather than a true index
Its measurements are made by the Ramfjord method.
Measurement of any disease is based on a case definition
A case definition for periodontitis needs to establish the following:
- What depth of CAL at any one site constitutes evidence of disease processes?
مثال؟2 أو اكتر من1 ٌكون اكتر منCAL ببلش لما الـds ٌعنً هل بدي اعتبر انه الـ
- How many such sites need to be present in a mouth to establish disease presence?
disease حتى احكً انه عنديCAL الزم ٌكون فٌهsite كم
- How probing depth and BOP are to be included in the case definition?
What depth of CAL at any one site constitutes evidence of disease processes?
- At least 2 mm because of examiner variation (1 mm)
perio ds حتى احكً انه المرٌض عندهCAL مم2 اعتمدوexaminer بٌن الـvariation هأل ألنه عندي
- CAL progression of at least 3 mm over a given time period has been the criterion for change in some
studies
ً والزم اعمله شds وٌضل مستمر لفتره معٌنه حتى احكً انه وهللا هاد المرٌض عنده الـCAL 3 فٌه دراسات بتحكً انه الزم ٌكون الـ
- Introduction of computerized, constant force probes has not changed examiner variation much
ما انحلتexaminer variation مشكلة الـ, مع كل التمدم والتكنولوجٌا
Markers of Periodontitis
Cytokines
measures of periodontitis كـcytokines فٌه ناس بعتمدو على الـ
Include prostaglandin E2, tumor necrosis factor , interleukin-1 , interleukin-1 β
Expressed in gingival crevicular fluid (GCf)
Associated with active disease
To date, measurement of periodontitis by means of inflammatory cytokines in GCf is still experimental
+ it’s expensive
Periodontal Treatment Needs
Treatment plans are subjective
Often depending on some dentist-patient factors that are not part of a clinical examination
بختلف من مجتمع آلخر وحسب رغبة المرٌض وشو بده أو مثال شو الطبٌب بمدر ٌمدم عالج ضمن خبرته
Treatment for a given condition can change quickly as knowledge develops
- Treatment of periodontal pockets has shifted from surgical removal of pockets to scaling and root
planning
Community Periodontal Index of Treatment Needs (CPITN)
The CPITN was first described in 1982
Received some promotion by the WHO
It requires use of a special periodontal probe
Probing pressure is recommended to be no more than 20 g
CPITN probe
Has a 0.5 mm diameter ball at its tip (to avoid bleeding & damage)
- To assist in feeling subgingival calculus
- Prevent the probe from being pushed through inflammatory tissue at the
base of a pocket
A black band for visibility between 3.5 mm and 5.5 mm
Circular markings at 8.5 mm
Circular markings at 11.5 mm.
CPITN code:
0: Healthy gingiva.
1: Bleeding observed, directly or by using the mouth mirror, after gentle probing.
2: Calculus felt during probing but all the black area of the probe visible (3.5-5.5
mm from ball tip). “Not more than 3.5 mm”
3: Pocket 4 or 5 mm (gingival margin situated on black area of probe, i.e., 3.5-5.5
mm from probe tip). “Part of black area is hidden”
4: Pocket >6 mm (black area of probe not visible).
X: Excluded segment (less than two teeth present).
X ٌلً فٌها الل من سنٌن بعطوهاsegment هأل الـ,) (نفس األورثو6 sextant بتمسم لـmouth الـ
9: Not recorded.