1. Chapter Dental Public Health & Research Contemporary Practice for the Dental Hygienist Copyright ©2011 by Pearson Education, Inc. All rights reserved. Third Edition Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Oral Epidemiology 16

2. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Objectives After studying this chapter, the dental hygiene student should be able to: Define oral epidemiology and describe the uses of epidemiology. Relate epidemiology to evidence-based practice. Define common epidemiologic terms.

3. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Objectives (cont'd) Relate measurements to epidemiology. List and describe various publications that report oral epidemiology in the United States. Describe ways to increase validity of epidemiologic research methods.

4. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Competencies After studying this chapter and participating in accompanying course activities, the dental hygiene student should be competent to do the following: Use evidence-based decision making to evaluate and incorporate emerging treatment modalities. Assume responsibility for dental hygiene actions and care based on accepted scientific theories and research as well as the accepted standard of care.

5. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Introduction An understanding of oral epidemiology and the methodology used in epidemiologic research is essential to evidence-based practice.

6. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Epidemiology This has been defined by Timmreck as the study of the nature, cause, control, and determinants of the frequency and distribution of disease, disability, and death in human populations. Populations can be as large as the human globe or as small as a school. Epidemiology involves the process of characterizing the distribution of disease and various related factors such as age, sex, race, socioeconomic status, time, place, person, and behavior.

7. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Epidemiology Triangle

8. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe What is epidemiology used for? Epidemiology is used to describe the health status of populations, to identify multiple factors associated with disease and conditions and explain their etiology, to predict the occurrence of disease and conditions, and to control the distribution of disease and conditions within the population.

9. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Common Terms Used to Describe the Distribution of Disease Endemic—the relatively low but constant presence of disease in a particular geographic region Epidemic—the occurrence of disease in excess of normal in a specific community or region, usually occurring suddenly and spreading rapidly; “outbreak” Pandemic—an epidemic in which the disease may cross international borders to affect several countries or continents

10. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

11. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

12. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

13. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

14. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

15. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Oral Epidemiology This is simply epidemiology in relation to oral diseases and conditions. This allows us to be aware of risk factors and to understand how diseases are associated to one another.

16. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Multifactorial

17. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe The Multifactorial Nature of Disease Host—the genetic or social factors of individuals that contribute to their susceptibility or resistance (i.e., tooth morphology, salivary flow) Agent—the biologic or mechanical cause of the disease or condition (i.e., specific bacteria that cause dental caries or periodontal disease)

18. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe The Multifactorial Nature of Disease (cont'd) Environment—refers to the physical, social, sociocultural, sociopolitical, and economic circumstances that are required for the disease to thrive, survive, and spread (i.e., nutrition, sugar intake, and smoking)

19. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe FIGURE 16-1 The Epidemiology Triangle in Relation to Periodontitis Source: Adapted from Merrill RM, Timmreck TC. An Introduction to Epidemiology. 4th ed. Boston, MA: Jones & Bartlett; 2006; Timmerman MF, van der Weijden GA. Risk factors for periodontitis. Int J Den Hyg. 2006;4:2–7. http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1601-5037.2006.00168.x. Accessed June 7, 2008; Van Dyke TE, Dave S. Risk factors for periodontitis. J Int Acad Periodont. 2005;7(1):3–7. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1351013. Accessed June 7, 2008.

20. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Measurement in Epidemiology Morbidity—is the extent of disease, injury, or disability in a defined population Mortality—refers to the death rate resulting from a specific disease or condition

21. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Measurement in Epidemiology (cont'd) Prevalence—the numerical expression of the number of all existing cases of a disease or health condition measured at a given point Incidence—refers to the development of new cases of a disease or condition over a given period of time, or its progress over time

22. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Expressing Measurement in Epidemiology Count—number of cases of the disease or condition in a population Proportion—provides more information about the extent of the disease in a population; prevalence is expressed as a proportion Ratio—expresses the magnitude of one occurrence in relation to another

23. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Expressing Measurement in Epidemiology Rate—expression of disease in a population using a standardized denominator and including a time dimension; incidence is rate Index—reports more detailed information than a count, proportion, or rate by providing a standardized measurement of the amount or severity of the disease or condition in a population

24. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Surveillance

25. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Oral Epidemiology Reports Used to collect data to determine the presence of disease, injury, disability, and related factors

26. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe National Oral Health Surveillance System (NOHSS) Monitors the burden of oral disease, utilization of the oral health care delivery system, and community water fluoridation in the nation and states Uses eight oral health indicators: dental visits, cleanings, complete tooth loss, loss of six or more teeth, fluoridation status, sealants, caries, untreated caries, and oral cancer Several state-level surveys collect data for NOHSS

27. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Morbidity and Mortality Weekly Report (MMWR) The MMWR publishes events of public health interest and importance to state and local health departments as quickly as possible. Many of these health-related conditions are used in dental hygiene: herpes, hepatitis, asthma, fluoridation, and tobacco use.

28. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Healthy People 2010 Objectives Ten indicators identify the attainment of these objectives: physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care. Oral health is a specific area of focus for Healthy People 2010.

29. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

30. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

31. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

32. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

33. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Surgeon General’s Report Recent reports have provided scientific information on the oral, dental, and craniofacial diseases and conditions that affect the U.S. population. There have been invitations to expand plans, activities, and programs designed to promote oral health and prevent disease, especially to those who have limited access to care, special needs, and those of low socioeconomic status.

34. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

35. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

36. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Global Oral Health Data Bank The global oral health data bank is managed by the World Health Organization (WHO). Data are provided for dental caries, periodontal disease, tobacco, oral cancer, and other oral conditions. Data are typically from large groups from the most populous parts of a country, but they may not be fully representative.

37. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Concepts of Epidemiological Studies Risk of disease Causes of disease Effectiveness and efficacy of treatment modalities

38. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Risk and Causality Risk is used to infer or suggest causality. Criteria must be in place to support causality, but the more that are present, the stronger the case for causality of a risk factor in relation to the disease or condition. Three types of attributes that are associated with disease and condition are: risk factors, risk indicators, and risk markers.

39. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

40. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

41. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

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43. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Effectiveness Versus Efficacy Trials Clinical trials are either efficacy or effectiveness Efficacy trial: a test to determine whether an agent or treatment regimen works; it is conducted on a population that is susceptible to the disease or condition being studied Effectiveness trial: a test to determine how an agent or treatment regimen works in everyday conditions after its efficacy has been established; it is conducted on a broad community population with varying degrees of the disease or condition under study

44. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe

45. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Internal Validity Refers to the accuracy of the results of the study Enhanced by controlling sources of error and extraneous variables in the conduct of the research, increasing subject retention, achieving compliance of study participants, enhancing data quality, and applying appropriate methods for statistical data analysis

46. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Internal Validity (cont'd) The length of the study affects its internal validity. Size affects internal validity. The validity of the statistical procedures used affects internal validity.

47. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe External Validity The accuracy of inferring (generalizing) the results from the sample to the population at large Affected by how well a sample represents the population

48. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe External Validity (cont'd) Sampling must be precise for survey research. Other factors that affect external validity are the dependent variable and pretests.

49. Copyright ©2011 by Pearson Education, Inc. All rights reserved. Dental Public Health & Research: Contemporary Practice for the Dental Hygienist, 3/e Christine Nielsen Nathe Summary Evidence-based practice requires an understanding of epidemiologic research methods in order to be able to interpret research results and apply them to dental hygiene practice.