The Epidemiology of periodontal diseases

Department of Preventive Dentistry

School & Hospital of Stomatology

Wuhan University

Minquan Du 杜民权

Periodontal diseases Gingivitis is defined as an inflammatory process of the gingiva in

which the junction epithelium, although altered by the disease, re

mains attached to the tooth at its original level

Periodontitis is also an inflammatory condition of the gingival tis

sues, characterized by loss of attachment of the periodontal ligam

ent and the bony support of the tooth

From the viewpoint of public health that periodontal diseases ar

e slowly progressing inflammatory diseases.

Periodontal diseases

Local factors: oral hygiene, dental plaque and

calculus

Systemic factors: unusual syndromes

associated with defects, malnutrition and

hormonology imbalance

The 3rd National Oral Helath Survey 2005

1212 岁组牙龈出血为岁组牙龈出血为 57.757.7%

35~4435~44 岁人群牙周炎患病率岁人群牙周炎患病率 41.0% 41.0%

65~7465~74 岁人群牙周炎患病率岁人群牙周炎患病率 52.3%52.3%

An Index is a graduated, numerical scale with

upper and lower limits, with scores in the sc

ale corresponding to specific criteria

指数 : 表明某种现象变动的程度。指标作用或

批示作用的标识。用数值级差作标准，测量和比较疾病的扩展范围和严重程度

指 数

An Ideal Index

简单 Simplicity 价廉 Acceptability 有效 Validity 可靠 Reliability 敏感 Sensitivity 能用统计学方法处理 Quantifiability

The Measurement of Periodontal Diseases

In contrast to the stability of the DMF index for caries oveIn contrast to the stability of the DMF index for caries ove

r a 50-year period, the philosophical basis for measuring pr a 50-year period, the philosophical basis for measuring p

eriodontal disease has changed several times over a shorter eriodontal disease has changed several times over a shorter

time. time.

Clinical measures used for gingivitis and periodontitis werClinical measures used for gingivitis and periodontitis wer

e first described 40 years ago.e first described 40 years ago.

Periodontal health index

1. Oral hygiene index – simplified 简化口腔卫生指数

2. Plaque Index 菌斑指数 3. Turesky Modified Quigley-Hein Plaque Index

4. Gingival Index 牙龈指数5. Sulcus bleeding index 龈沟出血指数6. Community periodontal index 社区牙周指数

Oral hygiene index – simplified (OHI-S)

Debris index 软垢指数 Calculus index 牙石指数

Oral hygiene index – simplified

o 牙面： 16 11 26 31 唇面， 36 46 舌面

o 计分方法： 牙面计分之和o 软垢、牙石计分＝

受检牙面数o 个人计分＝简化牙石计分＋简化软垢计分

o 检查方法：视诊，探诊

Criteria for DI 00 = = No debris in the surface of the teeth. No debris in the surface of the teeth. 牙面无软垢牙面无软垢 11 = = Debris covered less than one third area of the surface. Debris covered less than one third area of the surface. 软垢覆盖面积占牙面软垢覆盖面积占牙面 1/31/3 以下以下

22 = = Debris covered between one third to two third area Debris covered between one third to two third area of the surface. of the surface. 软垢覆盖面积为牙面软垢覆盖面积为牙面 1/31/3 与与 2/32/3 之间之间

33 = = Debris covered more than two third area of the Debris covered more than two third area of the surface. surface. 软垢覆盖面积占牙面软垢覆盖面积占牙面 2/32/3 以上以上

Scores and criteria for CI-S

00 = = No calculus in the surface of the teeth. No calculus in the surface of the teeth. 龈上、龈下无牙石 11 = = Calculus covered less than one third area of the surface. Calculus covered less than one third area of the surface. 龈上牙

石面积占牙面 1/3 以下

22 = = Calculus covered between one third to two third area Calculus covered between one third to two third area of the surface.of the surface. 龈上牙石面积占牙面 1/3 ～ 2/3 之间，或牙颈

部有散在的龈下牙石

33 = = Calculus covered more than two third area of the Calculus covered more than two third area of the surface.surface. 龈上牙石面积占牙面 2/3 以上，或牙颈部有连续而

厚的的龈下牙石

0 1 2 3

Plaque Index, PLI 菌斑指数 The principal difference between the PLI and OHI-

S approach is that the PLI scores plaque according to its thickness at the gingival margin rather than its coronal extent, a measure claimed to be more valid.

检查方法 : 视诊 + 探诊 检查时用探针轻划牙面，根据菌斑的量和厚度记

分 PLI 可以检查全口牙面，也可检查指数牙 每颗牙检查 4 个牙面： mesial, distal, buccal, and

lingua surfaces

Criteria for use of the Plaque Index

0 = 0 = no plaque in the gingival area . no plaque in the gingival area . 龈缘区无菌斑龈缘区无菌斑

1 1 = a film of plaque adhering to the free gingival margin and adjacent area of th= a film of plaque adhering to the free gingival margin and adjacent area of the tooth, the plaque may be recognized only by running a probe across the toe tooth, the plaque may be recognized only by running a probe across the tooth surface. oth surface. 龈缘区的牙面有薄的菌斑，但视诊不可见，若用 探针尖的龈缘区的牙面有薄的菌斑，但视诊不可见，若用 探针尖的侧面可刮出菌斑侧面可刮出菌斑

2 = 2 = moderate accumulation of soft deposits within the gingival pocket, on the gimoderate accumulation of soft deposits within the gingival pocket, on the gi

ngival margin and/or adjacent tooth surface, which can be seen by the naked ngival margin and/or adjacent tooth surface, which can be seen by the naked

eye. eye. 在龈缘或邻面可见中等量菌斑在龈缘或邻面可见中等量菌斑

3 = 3 = abundance of soft matter within the gingival pocket and/or on the gingival abundance of soft matter within the gingival pocket and/or on the gingival

margin and adjacent tooth surface margin and adjacent tooth surface 龈沟内或龈缘区及邻面有大量软垢龈沟内或龈缘区及邻面有大量软垢

0 1 2 3

Turesky Modified Quigley-Hein Plaque Index

Quigly & Hein, 1962

Turesky, 1970

Ramfjord 指数牙： 16, 21, 24, 36, 41, 44

检查方法 : 菌斑染色剂使菌斑染色，根据面积记分

Scores and criteria for QT

0 ＝牙面无菌斑 1 ＝牙颈部龈缘处有散在的点状菌斑 2 ＝牙颈部连续薄带状菌斑宽度 <1mm 3 ＝牙颈部菌斑面积 1mm ～牙面 1/3 4 ＝菌斑覆盖面积占牙面 1/3 ～ 2/3 5 ＝菌斑覆盖占面积 2/3 或以上

0 1 2 3 4 5

Gingival Index, GI 牙龈指数

Loe and Silness, in the early 1960s

观察牙龈情况，检查牙龈颜色和质的改变，以及出血倾向

检查方法：钝头牙周探针，结合视诊和探诊 全口牙或指数牙， 4 个牙周围的牙龈

Scores and criteria for the Gingival Index 0 = Normal gingiva 牙龈健康

1 = Mild inflammation: slight change in color, slight edema.

No bleeding on probing 牙龈的色有轻度改变并轻度水 肿，探诊不出血

2 = Moderate inflammation: redness, edema, and glazing.

Bleeding on probing. 牙龈中等炎症：牙龈色红 , 水肿光 亮，探诊出血

3 = Severe inflammation: marked redness and edema.

Ulceration. Tendency to spontaneous bleeding. 牙龈明 显红肿或有溃疡 , 并有自动出血倾向

0 1 2 3

群体患牙龈炎程度的衡量标准 牙龈指数 牙龈炎流行程度牙龈指数 牙龈炎流行程度

0.1-1.00.1-1.0 轻度轻度

1.1-2.01.1-2.0 中度中度

2.1-3.02.1-3.0 重度重度

由于牙龈指数能反映牙龈炎症的有无与程度由于牙龈指数能反映牙龈炎症的有无与程度 ,,且临床应用简便且临床应用简便 ,, 无论在牙周疾病的现况调查无论在牙周疾病的现况调查中或实验流行病学研究中中或实验流行病学研究中 ,, 多采用此标准多采用此标准

Sulcus bleeding index, SBI 龈沟出血指数 Muheman & Son, 1971

反映牙龈炎活动状况 检查方法：视诊 + 探诊 检查时观察牙龈颜色和形状，牙周探针轻探龈

沟，观察出血情况 不用菌斑染色

Scores and criteria For SBI

0 = 龈缘和龈乳头外观健康，轻探龈沟后不出血 1 = 龈缘和龈乳头外观健康，轻探龈沟后出血 2= 牙龈因炎症而有颜色改变，无肿胀或水肿 , 探

诊后出血 3= 牙龈有颜色改变和轻度水肿，探诊后出血 4= 牙龈不但有色的改变并明显肿胀，探诊后出血 5= 牙龈有色的改变，明显肿胀，有时有溃疡，探

诊后出血或自动出血

Community periodontal index, CPI

社区牙周指数

WHO, 1982, worldwide use

不仅反映牙周组织的健康状况，也反映牙周的治疗需要情况

操作简便，重复性好，适合于大规模的口腔流行病学调查

A specially designed lightweight CPI A specially designed lightweight CPI

probe with a 0.5 mm ball tip is used, wprobe with a 0.5 mm ball tip is used, w

ith a black band between 3.5 to 5.5 anith a black band between 3.5 to 5.5 an

d rings at 8.5 and 11.5 mm from the bad rings at 8.5 and 11.5 mm from the ba

ll tip.ll tip.

Community Periodontal Index

检查方法：探诊为主、结合视诊 检查项目：牙龈出血

牙石

牙周袋深度

指数牙 17－14 13－23 24－27

47－44 43－33 34－37

17 16 11 26 27

47 46 31 36 37

16 11 26

46 31 36

检查顺序：按顺时针方向检查每一颗功能牙

探诊力量：应在 20g 以下，简单测试方法是将 CPI 探针插入拇指甲沟内，轻轻压迫显示指盖发白且不造成疼痛和不舒服的感觉为适宜力量

Community Periodontal Index

WHOWHO 规定：规定： A sextants should be examined only if there are two or A sextants should be examined only if there are two or

more teeth present which are not indicated for extractiomore teeth present which are not indicated for extraction.n.

每个区段内必须有每个区段内必须有 22 颗或颗或 22 颗以上功能牙，并颗以上功能牙，并 且无拔牙指征，该区段才做检查。检查区段且无拔牙指征，该区段才做检查。检查区段 内以最重情况记分内以最重情况记分

Community Periodontal Index

成年人的后牙区段，有时缺失一颗指数牙或有拔牙指 征，则只检查另一颗指数牙。

如果一个区段内的指数牙全部缺失或有拔牙指征时，则检查此区段内的所有其余牙齿，以最重情况记分。

每颗指数牙的所有龈沟或牙周袋都须检查到。

每个区段两颗功能牙检查结果，以最重情况记分。

六个区段中记分最高区段的记分则作为个人 CPI 记分。

Codes and criteria used in the CPI

0 – 0 – Healthy Healthy 健康健康 1 - Bleeding observed, directly or by using a mouth mirror, after probing. 1 - Bleeding observed, directly or by using a mouth mirror, after probing. 牙牙

龈探诊后出血（直接或口镜观察）龈探诊后出血（直接或口镜观察）2 - Calculus detected during probing, but all of the black band on the probe vi2 - Calculus detected during probing, but all of the black band on the probe vi

sible sible 探诊有牙石存在，但探针黑区全部可见探诊有牙石存在，但探针黑区全部可见3 - Pocket 4-5 mm (gingival margin within the black band on the probe 3 - Pocket 4-5 mm (gingival margin within the black band on the probe 牙周牙周

袋袋 4-54-5 毫米（探针黑区部分在龈下） 毫米（探针黑区部分在龈下） 4 - Pocket 6 mm or more (black band on the probe not visible ).4 - Pocket 6 mm or more (black band on the probe not visible ). 牙周袋牙周袋 66 毫毫米或以上（探针黑区全部在龈下）米或以上（探针黑区全部在龈下）

X - Excluded sextant (less than two teeth present). X - Excluded sextant (less than two teeth present). 除外区段（余留牙不足除外区段（余留牙不足22 颗） 颗）

9 - Not recorded 9 - Not recorded 不做记录不做记录

CPI

4 2 3

2 2

0 1 0

1 0 1

4

1

Community Periodontal Index

优点：操作简便，容易掌握

缺点： （ 1 ）牙龈出血和牙石被高估 （ 2 ）没有记录牙周附着丧失的程度 牙周袋有真性牙周袋和假性牙周袋两种 有时候牙周探针深度不能真实反映牙周组织

的破坏程度 , 牙周组织的附着水平是客观反映牙周炎的指标

Community Periodontal Index of Treatment Needs

计分标准 0= 不需要治疗 1= 需要口腔卫生指导以改进个人口 腔卫生状况 2= 需要口腔卫生指导及洁治 3= 需要口腔卫生指导、洁治和复杂 牙周治疗

The epidemic characteristics of periodontal diseases

流行特征

WHO criteria for perodontal conditions WHO criteria for perodontal conditions (15-year-old(15-year-old ））

牙石检出平均区段数牙石检出平均区段数 等级等级

0.0 – 1.50.0 – 1.5 很低很低

1.6 – 2.51.6 – 2.5 低低

2.6 – 3.52.6 – 3.5 中中

3.6 – 4.53.6 – 4.5 高高

4.6 – 6.04.6 – 6.0 很高很高

More than 70% of adults in all parts of the world h

ave some degree of gingivitis and periodontitis.

Gingivitis and calculus are more prevalent and sev

ere in developing countries.

There are fewer global differences in the prevalenc

e and severe periodontitis.

Global distribution

几个国家 15 ～ 19 岁学生牙周状况 (WHO)

非工业化国家 工业化国家

国家 年 牙结石平均区段数

国家 年 牙结石平均区段数

泰国塞拉利昂印度尼西亚约旦

1986198919861982

4.23.53.63.8

法国德国日本美国

1987198719861986

2.3

3.0

1.8

1.5

Geographic distribution

在我国，牙周病的流行情况农村比城市严重

牙石平均检出区段数农村高于城市所有年龄组软垢指数都较高，但仍然是农村高于城市

Geographic distribution

性别 受检人数

牙龈出血 检出率%

牙龈出血 均数

牙结石检出率%

牙结石 均数

城市 540 85.7 7.8（ 7.3）

78.0 5.8（ 5.9）

农村 540 89.4 7.6（ 6.6）

83.3 6.6（ 5.8）

合计 1080 87.6 7.7（ 6.9）

80.6 6.2（ 5.9）

湖北省 15 岁年龄组牙龈出血和牙结石情况 2005

工业化国家的儿童、青少年在 60年代初，牙龈炎的患病率也相当高；

70年代后，由于牙科公共卫生学的发展，人群中的牙病不但得到控制，且预防工作的开展逐年有所提高，青、少年儿童的龋病、牙龈炎患病情况持续下降，然后扩大到成年人

Distribution of time

Distribution of time 全国 15岁年龄组牙结石平均检出区段数（ 1995 ） ––––––––––––––––––––––––––––––––––––––––––––

––––––– 城市 1983 1995

–––––––––––––––––––––––––––––––––––––––––––––––––––

北京 3.07 2.73 上海 1.98 2.39 天津 2.11 1.80 辽宁 1.32 2.60 山东 1.78 1.30 浙江 2.05 1.88 湖北 3.23 2.99 广东 2.48 1.96 甘肃 1.52 0.75 四川 3.03 1.91 云南 2.29 2.38

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––

The severity of the disease increased with advancing

age

Periodontitis is not a disease of aging

The prevalence and severity of gingivitis from 5~6 y

ears old begin, then progressed to periodontitis.

Periodontitis progressed with age

Distribution of Age

全国 12 ～ 74 岁年龄组不同性别 CPITN 最高记分的百分数（ 1995 ）––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

–––– 年龄 0 1 2 3 4–––––––––––––––––––––––––––––––– 12 31.01 16.30 52.03 - - 15 21.58 10.41 67.72 0.22 0.00 18 14.82 6.50 77.98 0.03 35 ～ 44 2.85 1.69 81.89 11.15 2.06 65 ～ 74 0.63 1.42 61.06 17.86 4.26––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

–––––

Distribution of Age

Epidemiologic evidence is that there are no inherent diff

erences between men and women in susceptibility to peri

odontitis

Usually Men have poorer periodontal health than women

Smoking for men

women usually exhibit better oral hygiene than do men

Distribution Gender

性别 受检人数

牙周袋 检出率%

牙周袋 均数

附着丧失检出率%

附着丧失 均数

男 540 45.2 3.3 （ 5.9 ）

50.0 2.8 （ 4.9 ）

女 540 31.7 2.1 （ 4.8 ）

40.6 1.7 （ 3.2 ）

合计 1080 38.4 2.7 （ 5.4 ）

45.3 2.3 （ 4.2 ）

湖北省 35 ～ 44 岁牙周袋和附着丧失情况 2005

Race and ethnicity in themselves cannot be

considered demographic risk factors for peri

odontitis

Distribution of Race

Gingivitis and poorer oral hygiene are clearly related to lower

SES, but the relationship between periodontitis and SES is less

direct.

The widely observed relation between SES levels and gingival

health is a function of better oral hygiene among the more edu

cated, and a greater frequency of dental visits among the more

dentally aware and those with dental insurance.

Socioeconomic status

Oral Hygiene

Tobacco use

Nutrition

Systemic conditions

Risk factors for periodontal diseases

Oral Hygiene the relation between plaque deposits and gingivitis to be on

e of cause and effect.

less calculus, both supragingival and subgingival, as a resul

t of better oral hygiene and more professional dental care.

Plaque and calculus deposits correlate poorly with severe p

eriodontitis

Plaque control is vital to the maintenance of periodontal hea

lth

The etiologic role of oral hygiene in periodonttitis might be si

milar to that of sugar in dental caries

Tobacco use Smoking is a major risk factor for periodontitis

The relative risk is twice as smokers than nonsm

okers

Smoking is thought to suppress the vascular reac

tion that follows gingivitis

There is some evidence that smoking could incre

ase the dental deposits and calculus accumulati

on and gingival inflammation

Nutrition

营养缺乏将造成牙周组织功能降低。蛋白质缺乏可使牙周结缔组织变性，牙槽骨疏松

还可影响抗体蛋白合成，免疫能力下降维生素与牙周组织胶原合成有关，它们的缺乏会造成牙周组织创伤愈合困难

Systemic conditions

Diabetes

Cardiovascular diseases

Adverse pregnancy outcomes

Diabetes Type I (insulin-dependent diabetes mellotus)

Type II (non-insulin-dependent diabetes mellotus)

Patients have more gingivitis and more deep pock

ets than nondiabetis

Peiodontitis progresses more rapidly in poorly cont

rolled diabetics

Vascular changes, PMN dysfuntion, abnormal coll

agen synthesis and genetic predisposition

Cardiovascular diseases

Aa has been involved with endocarditis

Bacteria adhere to damaged heart values

Adverse pregnancy outcomes

Preterm low weight birth

PLBW: 10% in China

Relative risk is 7

IL-1β,IL-6, PGE2, TNF-α, MMPs

2005 年第三次全国口腔健康流行病学调

查牙周病状况调查

1. 指标 牙龈出血、牙结石、牙周袋、附着丧失（ LOA）

牙龈出血是牙龈炎的指征 牙结石反映口腔卫生状况 牙周袋是牙周炎最重要的病理改变之一 附着丧失是反映累积的牙周附着破坏的情况

2. 检查项目 12岁组：检查牙龈出血、牙结石 35-44岁组：检查牙龈出血、牙结石、

牙周袋、附着丧失 65-74岁组：检查牙龈出血、牙结石、

牙周袋、附着丧失

3. 检查的牙齿各年龄组受检者的全口牙齿都要进

行牙龈出血、牙结石、牙周袋的检查

35-44岁组和 65-74岁组受检者按照 ID号的单双数对 1 ， 3 象限或 2 ，4 象限的牙进行附着丧失的检查

4. 记分方法（ 1 ）牙龈出血：0——探诊后牙龈没有出血1——探诊后牙龈有出血9——不作记录（大量牙石覆盖牙面、残根或有不良修复体而无法检查）X——缺失牙

（ 2 ）牙石：0——没有牙石1——有龈上牙石或龈下牙石9——不作记录（残根或有不良修复体而

无法检查）X——缺失牙

3 ）牙周袋：0——没有牙周袋 （探诊时第一段黑区全部可见）1——牙周袋 4-5mm（探诊时龈缘在探针的第一段黑区

内）2——牙周袋 6mm或以上（探诊时龈缘超过探针的第一

段黑区的上限）9——不作记录（大量牙石覆盖牙面、残根、或有不良修复体而无法检查） X——缺失牙

（ 4 ）附着丧失：0——附着丧失 0-3mm（未见 CEJ并且牙周袋记分为 0

或 1； CEJ可见，在第一段黑区下限）1——附着丧失 4-5mm（ CEJ在第一段黑区内）2——附着丧失 6-8mm（ CEJ在第一段黑区上限和第二段黑区下限之间）

3——附着丧失9-11mm（ CEJ在第二段黑区内）4——附着丧失 12mm或以上（ CEJ 超过第二段黑区上限）

9——不作记录（大量牙石覆盖牙面、残根或有不良修复体而无法检查）

X——缺失牙

5. 检查方法（ 1 ）检查顺序：先检查牙龈出血，然后检查

牙周袋、牙结石和附着丧失。牙龈出血按照象限检查，牙结石、牙周袋和附着丧失按牙检查

（ 2 ）探诊力量：应在 20g 以下，简单测试方法是将 CPI 探针插入拇指甲沟内，轻轻压迫显示指盖发白且不造成疼痛和不舒服的感觉为适宜力量

（ 3 ）具体方法1 ）牙龈出血 检查顺序：分四个象限，每个象限从后牙舌面检

查到前牙舌面，然后观察该象限内每颗牙齿舌面的牙龈出血情况。若牙齿的舌面已经有了出血，这颗牙齿的唇颊面可以不再检查。若牙齿的舌面没有出血，则需要从该象限后牙的颊面检查到前牙的唇面，然后再观察该象限牙齿唇颊面的牙龈出血情况

探诊的角度：探针与牙面成 45 度角，沿着龈缘轻轻地从牙齿舌面或颊面的远中探查到近中，避免深探

注意事项：检查每一象限牙齿的唇颊面时，一定要拉开颊粘膜，以避免颊粘膜与牙齿接触而影响牙龈出血的观察

2 ）牙周袋深度（指龈缘到牙周袋底的距离） 每颗牙齿检查 6个位点，唇颊面的近中点、正

中点、远中点，舌腭面的近中点、正中点、远中点。在近远中位点探查时，探针尽量靠近牙齿的邻面接触点。

探诊的角度：探针与牙长轴平行。 探诊的力度不大于 20克。 每颗牙齿的牙周袋以六个位点中最重的情况记分

牙周袋记分图示：

3 ）牙结石 肉眼可见到的龈上牙石。 检查牙龈出血或牙周袋深度时可探及的

龈下牙石

4 ）附着丧失 （ 指 CEJ 到牙 周 袋底的距离）

每颗指数牙齿检查 6个位点，唇颊面的近中点、正中点、远中点，舌腭面的近中点、正中点、远中点。在近远中位点探查时，探针尽量靠近牙齿的邻面接触点

在进行 LOA检查前，不做洁治。如果牙面有大量牙结石，只要有一个点能够检查，则以该点的检查结果记录。如果6个位点都无法检查，记录为 9。

在探查牙周袋深度的同时记录每颗指数牙附着丧失的情况

牙齿的 CEJ 未暴露，牙周袋深度记分为0 或 1 时，则该牙的附着丧失记分是 0 。

深牙周袋但牙齿的 CEJ 又没有暴露的情况下，尽量轻轻推移牙龈寻找 CEJ，计算附着丧失程度。如果仍然找寻不到 CEJ，记录为 9

附着丧失记分图示

CEJ 未暴露，龈缘在 CEJ 冠方时，附着丧失＝牙周袋深度－龈缘到 CEJ的距离，若牙周袋深度与龈缘到 CEJ的距离一样，则没有附着丧失