THE METHODS OF ORAL EPIDEMIOLOGY Why do some patients have serious periodontitis while other apparently similar patients

do not? Frequently there is no obvious answer. The branch of scientific inquiry that seeks to find order among seemingly haphazard patterns of disease in population groups is known as epidemiology. It is defined as the study of health and disease in populations, and of how these states are influenced by heredity, biology, physical environment, social environment, and ways of living. EPIDEMIOLOGY-AN INTRODUCTION Although there are commonalities in the philosophy of all scientific research, physical laws are more universally true than biological laws. The set of circumstances that leads to a heart attack in one person will not necessarily do so in another person of the same age, sex, and race. The reasons for these differences between two similar individuals may be rooted in their genetic endowment, in the environment in which they live, in particular aspects of their lifestyles, or perhaps in a combination of these factors. These differences between individuals are examples of biological variation. The concept of biological variation is implicitly understood by the clinician, but the epidemiologist goes further in seeking patterns among people who can be grouped by particular characteristics. In the late 19th century, a time when the bacterial agents in many infectious diseases were being identified, the "end of disease" was confidently being predicted. The concept of disease at the time was dominated by infections; little thought was given to chronic conditions. Today we are more aware that disease is multifactorial, meaning that for any disease it is difficult to pinpoint one particular cause. Heart disease, the leading cause of death in the United States, is not a bacterial disease, but is clearly associated with genetics, stress, diet, exercise, smoking, blood pressure, and blood cholesterol. So what is the "cause" of heart disease? Dental caries is a bacterial disease, but is also associated with sugar consumption, fluoride exposure, saliva quality and quantity, and family education and income. So what is the "cause" of dental caries? Within the multifactorial tangle, epidemiology attempts to determine which associated factors are the most important for prevention and control. Early Studies Epidemiology was learned and practiced empirically long before it was named. For example, people have known for ages that malaria is a disease of wet lowlands, so they

avoided living in such places. Such customs led to improvements in living standards, but there was little true understanding about conditions that led to disease. The periodic epidemics of plague that swept Europe from the Middle Ages until fairly recent times, for instance, were often seen as, religious signs rather than as a result of filthy living conditions. It was from the more rational study of these epidemics that epidemiology evolved to its present form. Samuel Pepys, author of The Diary of Samuel Pepys, a vivid record of life in, London, used the Bills of Mortality, the forerunner of modern death certificates, to measure the progress of an outbreak of plague in London in 1665. Percival Pott's Treatise of the Chimney Sweep's Cancer, in 1775, described the unusually high occurrence of scrotal cancer among chimney sweeps, and is thus one of the first scientific descriptions of an occupational hazard. In 1854, John Snow, a medical practitioner in the Soho area of London, went so far as to control an outbreak of cholera by the application of his epidemiological conclusions. Snow began his investigations by trying to find the common features among those who died from the disease. After mapping out the residences of those who had died, his subsequent enquiries disclosed that all of the victims had used water from the same source. That source, in the days before indoor plumbing, was a pump in Broad Street (now Broadwick Street, where the site of the pump is now occupied by a public toilet). Although this investigation took place some years before the germ theory of disease was understood and generally accepted, Snow reached the rational conclusion that something in the water was responsible for the spread of the disease. Snow's simple method of preventing people from using the contaminated water was to persuade the authorities to remove the handle of the pump. The epidemic soon subsided. Snow's subsequent investigations on the relations between cholera and the source of water supply are epidemiological classics. The results of the patiently executed research of 19th-century workers such as Snow still benefit present-day society, Their investigations led to gradual but profound improvements in sanitation, personal hygiene, and the development of public health codes affecting housing, water supply, and food processing that are now taken for granted. The fact that infectious diseases such as cholera, typhoid, yellow fever, plague, and relapsing fever are now rare in developed countries is largely due to the pioneering work of these early epidemiologists. Their work continues today; the understanding of the mode of transmission of the HIV virus, and its translation into public health education to prevent AIDS, followed remarkably quickly on the first identification of the virus in 1983. That too is epidemiology.

Uses of Epidemiology The various ways in which the results, of epidemiological studies are used can be grouped as follows:

1. 2.

Collecting of data to describe normal biological processes. Examples are height at various stages of growth, blood groups, and times and order of tooth eruption. Understanding the natural history of diseases. Observations of disease progression and outcome in populations have enabled investigators to distinguish those diseases that are fatal or disabling from those that will resolve satisfactorily. The diagnosis of most forms of cancer requires intervention that of chicken pox does not.

3.

Measuring the distribution of diseases in population. Surveys demonstrate how diseases are distributed by age, gender, race, geographic region, and socioeconomic status. Comparisons of cross-sectional surveys conducted at different times demonstrate trends in disease prevalence and distribution. It was the comparison of survey results in the early 1980s which first clearly showed that caries experience had declined among children of the United States.

4.

Identifying the determinants of disease. Within the multifactorial causes of disease referred to earlier, specific study designs can identify the determinants and risk factors associated with a disease. Even if the causal pathway of a disease is. not fully understood, knowledge of risk factors can lead to intervention strategies, sometimes highly effective, for the prevention and control of the disease.

5.

Testing hypotheses for the prevention and control of disease through special studies in populations. This use refers to the clinical trial, in which potential agents, regimens, or procedures for the prevention and control of disease are experimentally tested. As a dental example, the various uses of fluoride to reduce caries incidence have been subject to numerous field trials in human populations.

6.

Planning and evaluating health care services. This application is a relatively recent development. Data that describe (a) the distribution of disease, both treated and untreated, in the population under study, (b) the population's utilization of health care services, and (c) the availability and productivity of health care services, can all be employed to assist planning decisions on services and types of personnel required. A related application is validating the effectiveness of treatment techniques, both new and traditional, and determining the quality of treatment provided.

Epidemiology and the Practitioner Practitioners may still ask how knowledge of health and disease tendencies in a particular group of people can help them to diagnose and treat the individual patient. After all, biological variation being what it is, the individual patient may or may not be typical of the group. A broad response is that epidemiology joins the basic sciences and clinical studies to increase our understanding of diseases to the extent that they can be controlled or alleviated. In the more immediate sense, the practitioner can bring the knowledge of risk factors into diagnosis and treatment planning decisions, meaning that a patient is more likely to exhibit a particular disease if he or she exhibits certain characteristics. For example, a man who smokes may or may not have lung cancer, but he certainly runs more risk of developing lung cancer than if he does not smoke. Similarly, an elderly man who both smokes and drinks heavily is more at risk of oral cancer than one who does not. The examining dentist should include such details from the health history in diagnosis and treatment planning. Another immediate use of epidemiology for the practitioner is application of results from clinical trials, which have given dentistry its scientific basis for preventive procedures. Although not every member of a test group in a clinical trial necessarily benefits from the tested procedure, the probabilities are high that a given patient will benefit from a procedure that has been successfully tested. Biological variation also applies the other way: a practitioner cannot generalize from the results of an individual patient's treatment to the population at large. Successful treatment can result from a practitioner's personality, from serendipitous characteristics of the particular patient, or from outside influences, as well as from the treatment itself. Only with controls and the appropriate design can effective prevention and treatment be determined. Measuring Disease The good clinician thinks in qualitative terms. During a diagnostic examination the dental practitioner not only looks for existing disease but also tries to look ahead for possible areas of future disease. Measuring oral disease in a population, however, requires a more standardized and objective approach to the oral examination of the group members. Standard diagnostic criteria, written explicitly for clinical, radiographic, microbiological, or pathological examination, replace the judgment of the practitioner. These criteria, meaning objective standards on which diagnostic judgment can be based, are applied to judge the condition of the oral tissues as they are at examination time, not on how they might be in the future. This objective application of

diagnostic criteria is the most important philosophical, difference between the epidemiological examination and that carried out for treatment planning. Measurement, the quantifying of observations, is the crux of science, and is a fascinating study in itself. Measurement variability is inherent in all fields of science; it is one reason why experiments are repeated before their findings can be accepted. In studies of oral disease, it can be demonstrated that a true count of lesions in a population is almost never achieved; a repeat examination of the same group of patients nearly always results in a different total number of lesions. Any one count of disease in a group is therefore an estimate of conditions, rather than absolute truth. So long as criteria are applied consistently, however, valid estimates will still result because diagnostic "drifts" in one direction will be balanced by drifts the other way. Acute diseases, such as measles, are characterized by a sudden onset of symptoms, so that, the patient rapidly progresses from a state in which the disease is clearly absent to one in which the disease is clearly present. Remission of the acute phase of the disease is equally rapid, so there is little time spent in the "gray areas." At any given time, therefore, measles is likely to be either clearly absent or clearly present in the members of a population group, thus making its quantification fairly straightforward. Chronic diseases, however, are usually characterized by a much slower time of onset. It is difficult to establish exactly when arthritis, alcoholism, mental illness, dental caries, and periodontitis become definitely established; as shown in Figure 6 - 2, there is a considerable gray area where it cannot be stated with certainty whether the disease is established or not. A dental example is the stained fissure, which may or may not be actively carious, This problem is handled by counting as lesions only those defects that meet specific criteria. The Human Populations Studied We are not going deeply into the many facets of sampling from human populations; these are well-detailed in many texts on epidemiology and biostatistics. There are, however, several fundamentals about groups seen in epidemiological studies that need to be understood when interpreting results. The first concerns representative populations, meaning the degree to which the results from a sample in fact represent the base population from which the sample was chosen. An example comes with surveys of the population of the United States. Obviously, no study is going to examine or ask questions of all 250 million or so people, so samples are chosen. The process itself is complicated and requires specialized training, but sampling precision is such that the 122,310 persons interviewed in the 1988 National Health Interview

Survey represented the whole country very closely. In a probability sample such as this one, meaning that the chance of each person being chosen in the sample is known, the degree of sampling error can be calculated. Sampling error is an estimate of the error that may result from the sample not perfectly representing the base population, and with modern statistical methods it can be remarkably small. The degree of sampling error, however, cannot be calculated for non-probability samples, and interpretive problems arise when the sample studied is not a true probability sample. For example, the National Survey of Oral Health in US Employed Adults and Seniors in 1985 - 1986 sought to obtain a profile of oral health in American adults by examining employed adults and seniors who visited senior centers. This was a feasible way of getting an adequate profile, but results have to be interpreted with some caution. For example, the survey found that only 4.2% of persons under age 65 were edentulous, but this is almost certainly an underestimate-because by definition the survey excluded the unemployed, persons in agriculture and mining, the military, and persons not employed outside the home. It requires major efforts to draw a truly representative sample of US adults, whereas the problem is much less acute with children because they can be sampled from schools. Analytical studies in epidemiology, however, usually do not require probability samples. In fact, case-control and cohort studies, as well as clinical trials, are usually conducted on convenience populations, meaning groups that are of the desired age, are accessible, exhibit both the disease and the exposures under study, and include enough individuals willing to participate. In analytical study designs, the critical issue is the categorization of participants as cases or controls; in clinical trials, it is the allocation of participants to test or control group. Although risk factors can be identified in a single study, there is always the possibility that selection bias limits the generalizability of the conclusions. If other such studies are carried out with similar results, however, then conclusions that the risk factors are real become much stronger. Replication is also important when generalizing from the results of clinical trials. If a weekly fluoride mouthrinse is found to reduce dental caries by 22% over 30 months among 12-year-old children in fluoridated Des Moines, what does that mean for the children of the United States? Even assuming experimental conditions could be identical, (which they never are), results need not necessarily be the same for children of different ethnic background, living in different climatic zones, and with differing exposure to fluoridated water. But when additional studies are carried out by different researchers in different places with fairly similar results, then the weight of evidence is such that the observed effect is likely to be real and general.