Periodontal indices

Periodontal indices in detail.

1. PERIODONTAL INDICES DR BHAUMIK THAKKAR. PART -1 P.G. DEPT OF PERIODONTICS

2. INTRODUCTION Dental index or indices are devices to find out the incidence, prevalence and severity of the disease, based on which preventive programs can be adopted. An index is an expression of the clinical observation in a numerical value. It helps to describe the status of the individual or a group with respect to a condition being measured.

3. DEFINITION A n index is defined as ‘ A numerical value describing the relative status of the population on a graduated scale with definite upper and lower limits which is designed to permit and facilitate comparison with other population classified with the same criteria and the method’- Russell A.L Oral indices are essentially set of values, usually numerical with maximum and minimum limits, used to describe the variables or a specific conditions on a graduated scale, which use the same criteria and method to compare a specific variable in individuals, samples or populations with that same variables as is found in other individuals, samples or populations . – ‘’George P Barnes’’ - 1985

4. An index is an expression of clinical observation in numeric values. It is used to describe the status of the individual or group with respect to a condition being measured. The use of numeric scale and a standardized method for interpreting observations of a condition results in an index score that is more consistent and less subjective than a word description of that condition . – ‘ ’Esther M Wilkins’’ - 1987

5. IDEAL REQUISTIES OF AN INDEX CLARITY SIMPLICITY OBJECTIVITY VALIDITY RELIABILITY ACCEPTABILITY QUANTIFIBILITY SENSITIVITY INDEX

6. USES 6 FOR INDIVIDUAL PATIENT Recognize an oral problem Effectiveness of present oral hygiene practices Motivation in preventive and professional care for control and elimination of diseases I N R ESEARCH D etermine base line data before experimental factors are introduced M easure the effectiveness of specific agents for prevention control or treatment of oral condition IN COMMUNITY S hows prevalence and incidence of a condition A ssess the needs of the community. C ompare the effects of a community program and evaluate the results

7. CLASSIFICATION OF INDICES

8. TREATMENT INDEX

9. CRITERIA FOR SELECTING INDEX Simple to use and calculate. Permit the examination of many people in a short period of time. Require minimum armamentarium and expenditure. Highly reproducible in assessing a clinical condition when used by one or more examiners. Not cause discomfort to the patient and should be acceptable to the patient. Amenable to statistical analysis Strongly related numerically to the clinical stages of the specific disease under investigation.

10. Indices for assessing oral hygiene & plaque

11. ORAL HYGIENE INDEX RULES OF ORAL HYGIENE INDEX 1 Only fully erupted permanent teeth are scored. 2 . Third molars are not included The buccal & lingual calculus scores are both taken on the tooth in a segment having the greatest surface area covered by supra and subgingival calculus. Developed in 1960 by John C. Green and Jack R. Vermillion R

12. DEBRIS INDEX CRITERIA – No debris or stain present 1 – Soft debris covering not more than 1/3 rd the tooth surface, or presence of extrinsic stains without other debris regardless of the area covered. 2 – Soft debris covering more than 1/3 rd , but not more than 2/3 rd ,of the exposed tooth surface. 3 – Soft debris covering more than 2/3 rd of the exposed tooth surface.

13. CALCULUS SCORING CRITERIA SCORE CRITERIA No calculus present 1 Supragingival calculus covering not more than 1/3 of the exposed tooth surface 2 Supragingival calculus covering more than 1/3 but not more than 2/3 the exposed tooth surface or presence of individual flecks of subgingival calculus around the cervical portion of the tooth or both 3 Supragingival calculus covering more than 2/3 the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of tooth or both

14. C alculation Debris Index (DI) =( Buccal Score+ Lingual Score) / NO. OF SEG Calculus Index (CI) =( Buccal Score+ Lingual Score) / NO. OF SEG DI and CI range from 0-6 Maximum score for all segments can be 36 for debris or calculus OHI range from 0-12 Higher the OHI, poorer is the oral hygiene of patient OHI=D.I+C.I

15. SIMPLIFIED ORAL HYGIENE INDEX Developed by John C Greene and Jack R Vermillion in 1964 Only fully erupted permanent teeth are scored. Natural teeth with full crown restorations and surfaces reduced in height by caries or trauma are not scored 16 17,18 11 21 26 27,28 36 37,38 31 41 46 47,48 SURFACES TO BE EXAMINED SUBSTITUTION

16. DI – S/CI-S = Total score/No of surfaces OHI -S= DI-S+ CI-S CALCULATION INTERPRETATION DI –S and CI-S Good -0.0-0.6 Fair – 0.7-1.8 Poor – 1.9 -3.0 OHI-S Good - 0.0-1.2 Fair – 1.3- 3.0 Poor – 3.0 -6.0

17. PATIENT HYGIENE PERFORMANCE (PHP) INDEX Introduced by Podshadley A.G. and Haley JV in 1968. Assessments are based on 6 index teeth. The extent of plaque and debris over a tooth surface was determined 16 BUCCAL 11 LABIAL 26 BUCCAL 36 LINGUAL 31 LABIAL 46 LINGUAL

18. PROCEDURE Apply a disclosing agent before scoring. Patient is asked to swish for 30 sec and then expectorate but not rinse. Examination is made by using a mouth mirror. Each of the 5 subdivisions is scored for presence of stained debris: 0= No debris(or questionable) 1= Debris definitely present.

19. Debris score for individual tooth: Add the scores for each of the 5 subdivisions. PHP index for an individual= (Sum of debris score/number of debris score) SCORING CRITERIA Excellent : (no debris) Good : 0.1-1.7 Fair : 1.8 – 3.4 Poor : 3.5 – 5.0

20. PLAQUE INDEX Described by Silness P and Loe H in 1964. This index measures the thickness of plaque on the gingival one third . Good validility and reliability. Draw back is subjectivity in estimating the amount of plaque. Used as full mouth index/simplified index. INDEX TEETH : 16,12,24,36,32,44. Areas examined : Distofacial Facial Mesio-facial& lingual surface of the tooth.

21. SCORING CRITERIA : PII for a tooth = Scores of 4 areas/4 PII for individual = Total scores/ no : of teeth examined PII for group = Total score/no : of individuals.

22. TURESKY – GILMORE- GLICKMAN MODIFICATION OF THE QUIGLEY – HEIN PLAQUE INDEX Quigley G. Hein . J in 1962 , plaque measurement that focused on the gingival third of the tooth surface. They examined only the facial surfaces of the anterior teeth, using basic fuchsin mouthwash as a disclosing agent. The Quigley-Hein plaque index was modified by Turesky S, Gilmore N.D and Glickman I in 1970 .. Method: Labial, B uccal and lingual surfaces are assessed after using disclosing agent. INDEX SCORE = Total Score/ No of surfaces examined 0-1 = low >2 = High

23. SCORING CRITERIA: SCORE CRITERIA No plaque 1 Separate flecks of plaque at the cervical margin of the tooth 2 A thin continuous band of plaque at the cervical margin of the tooth 3 A band of plaque wider then 1mm covering less than 1/3rd of the crown of the tooth 4 Plaque covering at least 1/3rd but less then 2/3rd of the crown of the tooth 5 Plaque covering 2/3 rd or more of the crown of the tooth Score Criteria no plaque 1 flecks of stain of the gingival margin 2 Definitive line of plaque on gingival margin 3 Gingival third of surface 4 Two- thirds of surface 5 Greater then 2/3 rd of the surface QUIGLEY AND HEIN TURESKY et al

24. GINGIVAL INDICES

25. GINGIVAL INDEX Developed by Loe H and Silness P in 1963. For assessing severity of gingivitis,and its location by examining qualitative changes of gingival tissues. METHOD: The severity of gingivitis is scored on all teeth or on selected index teeth. INDEX TEETH: 16,36,12,32,24,44 Tissues surrounding each tooth divided into 4 gingival scoring units DISTO-FACIAL PAPILLA FACIAL MARGIN MESIO-FACIAL PAPILLA LINGUAL GINGIVAL MARGIN

26. SCORING CRITERIA Calculation and interpretation GI score for a tooth = Scores from 4 areas/4 GI score individual = Sum of indices of teeth/no.of teeth examined GI score for group = Sum of all member/Total no of individuals

27. Use : Severity of gingivitis, controlled clinical trials of preventive or therapeutic agents

28. MODIFIED GINIGVAL INDEX Lobene, Weatherford, Ross, Lamm and Menaker in 1986. Assess the prevalence and severity of gingivitis . IMPORTANT CHANGES IN GI: Elimination of gingival probing to assess the presence or absence of bleeding. Redefinition of scoring system for mild and moderate inflammation. Method: To obtain MGI , labial and lingual surfaces of the gingival margins and the interdental papilla of all erupted teeth except 3rd molars are examined and scored.

29. SCORING CRITERIA Calculation: Mesial and distal for papilla , labial and lingual for marginal and then adding the two and then dividing with no. Of teeth. Uses: Clinical trials of therapeutic agents SCORE CRITERIA Normal 1 Mild inflammation, slight change in color, little change in texture of any portion of gingival unit 2 Mild inflammation of entire gingival unit 3 Moderate inflammation of gingival unit 4 Severe inflammation of gingival unit

30. PAPILLARY – MARGINAL ATTACHMENT INDEX ( PMA) MAURY MASSLER AND SCHOUR .L 1944 . No. of gingival units effected were counted rather then the severity of inflammation METHOD A gingival unit is divided into three compartments – Papillary gingiva, Marginal gingiva, Attached gingiva Presence or absence of inflammation on each gingival unit is recorded and usually only maxillary and mandibular incisors, canines and premolars were examined.

31. SCORING CRITERIA score criteria Normal 1 Mild papillary enlargement 2 Obvious increase in size , BO Pressue 3 Excessive inc in size, spontaneous bleeding 4 5 Necrotic papilla Atrophy and loss of papilla score criteria Normal 1 Engorgement, slight inc in size, no bleeding 2 Obvious engorgement , bleeding on pressure 3 Swollen collar, spontaneous bleeding , beginning infiltration 4 Necrotic gingiva 5 Recession of the free marginal gingiva below CEJ due to inflammatory changes. PAPILLARY COMPONENT MARGINAL COMPONENT

32. Calculation of the Index USES: Clinical trials On individual patients Epidemiologic surveys PMA = P+M+A score criteria Normal 1 Slight engorgement with loss of stippling, changes in color may or may not be present 2 Obvious engorgement with marked inc in redness and pocket formation . 3 Advanced periodontitis ATTACHED COMPONENT

33. GINGIVAL BLEEDING INDEX (AINAMO and BAY,1975) Gingival bleeding index is based on recordings from all four tooth surfaces of all teeth. Recorded as Bleeding present + Bleeding absent - A minus recording is equivalent to gingival index scores 0 & 1 A plus recording is equivalent to gingival index scores 2 & 3. Gingival bleeding index is calculated as a percentage of affected sites. USES: In Experimental Studies Routine Basis In Individual Patients

34. SULCUS BLEEDING INDEX Developed by MUHLEMANN H.R AND SON.S in 1971 . Modification of PAPILLARY – MARGINAL INDEX of MUHLEMANN and MAZOR Z SCORING CRITERIA Score 0 – healthy looking papillary and marginal gingiva no bleeding on probing; Score 1 – healthy looking gingiva, bleeding on probing; Score 2 – bleeding on probing, change in color, no edema; Score 3 – bleeding on probing, change in color, slight edema; Score 4 –bleeding on probing, change in color, obvious edema; Score 5 –spontaneous bleeding, change in color, marked edema . Four gingival units are scored systematically for each tooth: the labial and lingual marginal gingival (M units) and the mesial and distal papillary gingival (P units). Scores for these units are added and divided by four gives the sulcus bleeding index.

35. MODIFIED SULCULAR BLEEDING INDEX Developed by MOMBELLI,VAN OOSTEN & S.CHURCH ET.AL IN 1987. Scoring criteria : SCORE 0 – No bleeding when probe is passed along the gingival margin SCORE 1 – Isolated bleeding , spots visible SCORE 2 – Blood forms a confluent red line on margins SCORE 3 – Heavy or profuse bleeding

36. ORAL PIGMENTATION INDEX (DUMMET 1966) CALCULATION: Maxillary DOPI/number of teeth examined Mandibular DOPI/number of teeth examined. MEAN=maxillary DOPI + mandibular DOPI/2 SCORE CRITERIA PINK TISSUE(no pigmentation) 1 Mild brown(light) tissue(mild pigmentation) 2 Moderate brown/mixed pink and brown tissue(moderate clinical pigmentation) 3 Deep brown/blue/black tissue(heavy clinical pigmentation)

37. INTERPRETATION : 0 - NO PIGMENTATION 0.03-1.0 - MILD PIGMENTATION 1.O3-2.0 - MODERATE PIGMENTATION 2.03-3.0 - SEVERE PIGMENTATION

38. GINGIVAL PIGMENTATION INDEX BY PEERAN ET AL 2014 CLASS CRITERIA OF CLASSIFICATION I Coral pink/salmon pink colored gingiva II Localized/isolated spots/areas of gingival melanin pigmentation which does not involve all the three parts of gingiva ,that is attached,free and papillary gingiva Mild to moderate pigmentation Severe/intense pigmentation III Localized/isolated unit/of melanin pigmentation which involve all the three parts of gingiva Mild to moderate pigmentation Severe/intense pigmentation IV Generalized diffuse pigmentation Mild to moderate pigmentation Severe/intense pigmentation. V Tobacco associated pigmentation like smoker’s melanosis

39. VI Gingival pigmentation due to exogenous pigments eg:-Amalgam tattoos, Cultural gingival tattooing, Drinks, Food colors, Habitual betelnut/khat chewing, Lead-Burtonian line, Mercury, Silver, Arsenic, Bismuth, Graphite, Other foreign bodies, Topical medications, Idiopathic. VII Gingival pigmentation due to endogenous pigments like Bilirubin, Blood breakdown products, Ecchymosis, Petechiae, Hemochromatosis, Hemosiderin. VIII Drug-induced gingival pigmentation like ACTH, Antimalarial drugs, Chemotherapeutic agentbusulfan and doxorubicin, Minocycline, Oral contraceptives, Phenothiazines. IX Gingival pigmentation associated with systemic diseases and syndromes like Addison’s disease, Albright’s syndrome, Basilar melanosis with incontinence, Beta thalassemia; Healed mucocutaneous lesions-Lichen planus, Pemphigus, Pemphigoid; Hereditary hemorrhagic telangiectasia; HIV-associated melanosis, Neurofibromatosis, Peutz-Jeghers and other familial hamartoma syndromes, Pyogenic granuloma/Granulomatous epulis. X Pigmented benign and malignant lesions involving the gingival like Angiosarcoma, Hemangioma, Kaposi’s sarcoma, Malignant melanoma, Melanocytic nevus, Pigmented macule.

40. PERIODONTAL INDICES

41. RUSELL’S PERIODONTAL INDEX Developed by Rusell AI in 1956. METHOD: All the teeth are examined in this index. Russell chose the scoring values as 0,1,2,4,6,8 in order to relate the stage of the disease in an epidemiological survey to the clinical conditions observed. The Russell’s rule states that “ when in doubt assign the lesser score .”

42. CRITERIA RADIOGRAPHIC FINDINGS Negative. Neither overt inflammation in the investing tissues nor loss of function due to destruction of supporting bone. Radiographic appearance is essentially normal. 1 Mild gingivitis. An overt area of inflammation in the free gingiva does not circumscribe the tooth 2 Gingivitis. Inflammation completely circumscribe the tooth, but there is no apparent break in the epithelial attachment 4 Used only when radiographs are available. There is early notch like resorption of alveolar crest. 6 Gingivitis with pocket formation. The epithelial attachment is broken and there is a pocket. There is no interference with normal masticatory function; the tooth is firm in its socket and has not drifted. There is horizontal bone loss involving the entire alveolar crest, up to half of the length of the tooth root. 8 Advanced destruction with loss of masticatory function. The tooth may be loose, may have drifted, may sound dull on percussion with metallic instrument, or may be depressible in its socket. There is advanced bone loss involving more than half of the tooth root, or a definite intrabony pocket with widening of periodontal ligament. There may be root resorption or rarefaction at the apex.

43. CALCULATION AND INTERPRETATION CLINICAL CONDITION INDIVIDUAL SCORES Clinical normally supportive tissue 0.0-0.2 Simple gingivitis 0.3-0.9 Beginning destructive periodontal diseases 1.0-1.9 Established destructive periodontal disease 2.0-4.9 Terminal disease 5.0-8.0 PI score per person = Sum of individual scores No of teeth present

44. COMMUNITY PERIODONTAL INDEX OF TREATMENT NEEDS The community periodontal index of treatment needs (CPITN) was introduced by Jukka Ainamo for joint working committee of the WHO and FDI in 1982. Developed primarily to survey and evaluate periodontal treatment needs rather than determining past and present periodontal status i.e. recession of the gingival margin and alveolar bone. Treatment needs implies that the CPITN assesses only those conditions potentially responsive to treatment, but not non treatable or irreversible conditions.

45. Procedure: The mouth is divided into sextants : 17- 14 13- 23 24- 27 47 – 44 43- 33 34 – 37 The 3rd molars are not included, except where they are functioning in place of 2nd molars . For adults aged > 20 yrs: 10 index teeth are taken into account : 17/16 11 26/27 47/46 31 36/37 .

46. CPITN PROBE First described by WHO Designed for 2 purposes : measurement of pockets. detection of sub-gingival calculus . Weighs:5 gms Working force:20-25 gms. CPITN-E PROBE CPITN-C PROBE

47. SCORING CRITERIA CODE CRITERIA TREATMENT NEEDS Healthy periodontium TN-0 No need of treatment 1 Bleeding observed during / after probing TN-1 Self care 2 Presence of supra or subgingival calculus TN-2 Professional care Scaling 3 Pathological pocket 4-5 mm. gingival margin situated on black band of the probe. TN-2 Scaling and root planning 4 X Pathological pocket 6mm or more. Black band of the probe not visible When only one tooth or no teeth are present in sextant TN-3 Complex therapy by specially trained personnel

48. ASSESSMENT OF TOOTH MOBILITY MILLER(1985 ) – has described the most common clinical method in which tooth is held between handles of the two instruments & moved back and forth or with metallic instrument and one finger . Criteria: SCORE 0- no detectable mobility SCORE 1- distinguishable tooth mobility SCORE 2- crown of tooth moves more than 1mm in any direction SCORE 3 – movement of more than 1mm in any direction GLICKMAN/ CARRANZA F.A (1972)– GRADE 1- slightly more then normal GRADE 2- moderately more than normal GRADE 3 – severe mobility faciolingually and or mesiodistally combined with vertical displacement.

49. WASERMAN ET.AL 1973 1- normal 2- slight- > ¾ mm of bucco-lingual movement 3- moderate- up to approximately 2mm movement bucco-lingually 4- severe- more than 2 mm. LINDHE 1997: Degree 1 – movability of crown of tooth less than 1mm in horizontal direction Degree 2 – movability of crown of tooth more than 1mm in horizontal direction Degree 3 – movability of crown of tooth in vertical as well.

50. FURCATION The furcation is the point at which the two roots divide. A pocket measuring probe is used (naber’s probe ) . RAMFJORD AND ASH FURCATION INDEX: GRADE MOBILITY Grade 0 No clinical furcation involved Grade 1 Bone loss up to 1/3 width Grade 2 Bone loss up to 2/3 width Grade 3 Through and through defect

51. DEANS FLUOROSIS INDEX-MODIFIED By TRENDLEY H DEAN 1942 To obtain index,examiner’s recording is based on two teeth most affected. CLASSIFICATION CRITERIA NORMAL(0) The enamel represents the usual translucent semivitriform type of structure.the surface is smooth,glossy and usually of a pale,creamy white colour. QUESTIONABLE(0.5) The enamel discloses slight abberations from the translucency of normal enamel,ranging from few white flecks to occasional white spots. VERY MILD(1) Small,opaque paper white areas scattered irregularly over the tooth,but not involving as much as 25% of tooth surface.usually 1-2mm of opacity at the tips cusps of bicuspids or second molars.

52. MILD(2) White opaque areas in enamel are more extensive,but do not involve as much as 50% of tooth. MODERATOR(3) All enamel surfaces of the teeth are affected and surfaces subject to attrition show wear.brown stain is frequently a disfiguring feature. SEVERE(4) All enamel surfaces of the tooth are affected and hypoplasia is so marked that the general form of the tooth may be affected.major diagnostic sign is discrete or confluent pitting.brown stains are wide spread and teeth often present a corroded like appearance.

53. TRAUMA FROM OCCLUSION BY JIM AND CAO 1992 No tooth mobility during habitual centric closure and excessive mandibular movements. 1 Tooth mobility detected only in centric closure or excessive movements. 2 Significant tooth mobility detected during centric closure and excessive movements.

54. WOUND HEALING INDEX BY HUANG et.al 2005 SCORE DESCRIPTION 1 Uneventful wound healing with no gingival edema,erythema,suppuration,patient discomfort or flap dehiscence. 2 Uneventful wound healing with slight gingival edema,erythema,patient discomfort,or flap dehiscence,but no suppuration 3 Poor wound healing with significant gingival edema,erythema,patient discomfort,flap dehiscence or any suppuration

55. CONCLUSION Dental diseases are the most prevalent and most neglected of all the chronic diseases of mankind. One of the major problems in studying dental diseases and its factors is the development of a suitable and practicable method for recording and classifying the occurrence and severity of the disease. Dental indices and scoring methods are used in clinical practice and community programs to determine and record the state of health of individual and group.

56. THANK YOU