periodontal indices

periodontal indices & their reliability - the usefulness of PSR & CPITN

1. PERIODONTAL INDICES & THEIR RELIABILITY- USEFULLNESS OF PSR & CPITN BY DR.AYUSHI SINGH MDS 1 ST YEAR

2. CONTENTS INTRODUCTION DEFINITION IMPORTANT TERMINOLOGIES IDEAL REQUISITES OF AN INDEX USES CLASSIFICATION OF INDICES CRITERIA FOR SELECTING INDEX INDICES FOR ASSESSING ORAL HYGIENE AND PLAQUE GINGIVAL INDICES PERIODONTAL INDICES CONCLUSION REFERENCES

3. INTRODUCTION Dental 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.

4. 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

5. 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

6. IMPORTANT TERMINOLOGIES MATERIA ALBA: Loosely adherent, white curds of matter composed of dead cells, food debris, and other components of the dental plaque found on the tooth which can be easily removed by air or water spray .- GPT DEBRIS: Oral debris is the soft foreign matter loosely attached to the teeth. It consists of mucin , bacteria and food, and varies in colour from greyish white to green to orange. - WHO

7. PLAQUE : Plaque is a specific but highly variable structural entity resulting from the sequential colonization and growth of micro- oraganisms on the surfaces of teeth or restorative material and consists of a number of microbial species and strains embedded in an extracellular gelatinous matrix composed of diet, saliva and serum . -WHO

8. CALCULUS: Calculus is a hard deposit that forms by mineralization of dental plaque, and it is generally covered by a layer of unmineralized plaque . - WHO

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

10. Simplicity : Should be easy to apply so that there is no undue time lost during field examinations. No expensive equipment should be needed. 1 Objectivity: Criteria for the index should be clear and unambiguous, with mutually exclusive categories. 1

11. Validity : Must measure what it is intended to measure, so it should correspond with the clinical stages of the disease under study at each point. 1

12. Reliability : Should measure consistently at different times and under a variety of conditions. 1 2 components- Inter examiner reliability : different examiners record the same result. Intra examiner reliability : same examiner records the same result at repeated attempts.

13. Acceptability: Safe and not demeaning to the subject. 1 Quantifiability : The index should be amenable to statistical analysis and interpretable. 1 Precision : Ability to distinguish between small increments. 1

14. Sensitivity Should be able to detect reasonably small shifts, in either direction in the group condition. 1

15. USES 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 IN RESEARCH Determine base line data before experimental factors are introduced Measure the effectiveness of specific agents for prevention control or treatment of oral condition

16. IN COMMUNITY Shows prevalence and incidence of a condition Assess the needs of the community. Compare the effects of a community program and evaluate the results

17. CLASSIFICATION OF INDICES IRREVERSIBLE INDEX REVERSIBLE INDEX FULL MOUTH INDICES SIMPLIFIED INDICES Based on the direction in which their scores can fluctuate: Depending upon the extent to which areas of oral cavity are measured :

18. According to the entity which they measure DISEASE INDEX SYMPTOM INDEX TREATMENT INDEX General indices SIMPLE INDEX CUMULATIVE INDEX

19. 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.

20. Indices for assessing oral hygiene & plaque

21. ORAL HYGIENE INDEX Developed in 1960 by John C. Green and Jack R. Vermillion 1 RULES OF ORAL HYGIENE INDEX Only fully erupted permanent teeth are scored. 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. 1 6 segments: dist to right cuspid on max arch, mesial to right & left 1 st bicuspid on max arch, distal to left cuspid on max arch, distal to left cuspid on mand arch, mesial to right & left 1 st bicuspid on mand arch, distal to right cuspid on mand arch.

22. DEBRIS INDEX CRITERIA 1 – 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.

23. CALCULUS SCORING CRITERIA 1 0 – No calculus present 1 – Supragingival calculus covering not more than 1/3 rd 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

24. Calculation 1 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

25. Developed by John C Greene and Jack R Vermillion in 1964 1 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 1 CALCULATION – DI –S/CI-S = Total score/No of surfaces OHI -S= DI-S+ CI-S SIMPLIFIED ORAL HYGIENE INDEX

26. Surfaces to be examined Index teeth Substitution teeth 16 17,18 11 21 26 27,28 36 37,38 31 41 46 47,48

27. INTERPRETATION 1 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

28. 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 The index teeth are 16 buccal , 11 labial, 26 buccal , 36 lingual ,31 labial & 46 lingual.

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

30. 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 : 0 (no debris) Good : 0.1-1.7 Fair : 1.8 – 3.4 Poor : 3.5 – 5.0

31. PLAQUE INDEX Described by Silness P and Loe H in 1964. 1 This index measures the thickness of plaque on the gingival one third. 2 Good validility and reliability. Draw back is subjectivity in estimating the amount of plaque. Used as full mouth index/simplified index . INDEX TEETH : 1 16,12,24,36,32,44. Areas examined : Distofacial , Facial , Mesio -facial & lingual surface of the tooth .

32. SCORING CRITERIA:

33. 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.

34. 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, Buccal and lingual surfaces are assessed after using disclosing agent. INDEX SCORE= Total Score/ No of surfaces examined 0-1 = low >2 = High

35. SCORING CRITERIA: 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 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 QUIGLEY AND HEIN TURESKY et al

36. 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 : 16,12,24,32,36,44 Tissues surrounding each tooth divided into 4 gingival scoring units DISTO-FACIAL PAPILLA ,FACIAL MARGIN , MESIO-FACIAL PAPILLA & LINGUAL GINGIVAL MARGIN

37. 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

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

39. 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.

40. 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

41. 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.

42. SCORING CRITERIA score criteria Normal 1 Mild papillary enlargement 2 Obvious increase in size , BO Pressue 3 Excessive inc in size, spontaneous bleeding 4 Necrotic papilla 5 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

43. 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

44. 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

45. 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.

46. 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

47. PERIODONTAL INDICES

48. RUSELL’S PERIODONTAL INDEX Developed by Rusell AI in 1956 . 1 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. 1 The Russell’s rule states that “ when in doubt assign the lesser score .”

49. 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.

50. CALCULATION AND INTERPRETATION 1 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

51. LIMITATIONS In field surveys radiographic are not practicable & hence sore 4 cannot be used . Index scores from 2 onwards jump to 4, 6, 8 only to signify the severity & nature of destruction of periodontium, which are not recordable, & most of them are reversible. Most time consuming This index is not sensitive to minor changes in periodontium It does not give past periodontal experience ( Subbappa A, Ganganna A et al Russell’s periodontal index: to score or not to score , IJIRR 2019 ; 06 (12) ; 6647-6649 )

52. 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. 1 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. 1 Treatment needs implies that the CPITN assesses only those conditions potentially responsive to treatment, but not non treatable or irreversible conditions.

53. 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 .

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

55. 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

56. PERIODONTAL SCREENING AND RECORDING (PSR) INDEX Apart from one major difference (the asterisk Code), the PSR Index is virtually identical to CPITN. The two indices use a common evaluation method based on the following three periodontal disease indicators: gingival bleeding on probing; calculus accumulation; and probing depth. 4 In addition, the PSR Index provides a more detailed picture of periodontal status by recording the presence of furcation involvement, tooth mobility, muco - gingival problems, and gingival recessions exceeding 3.5mm. 4 When at least one of the above conditions is present, an asterisk (*) is recorded with the PSR score for that given sextant. 4

57. THE INTERDENTAL PRESSURE INDEX T he interdental pressure index (IPI) is introduced to specifically evaluate clinical interproximal-tissue conditions and assess the effect of interproximal hygiene stimulation. T his index scores clinical responses of periodontal tissues to the apical pressure of a horizontally placed periodontal probe . It is negative when gingival tissues are firm , bleeding-free, and slightly ischemic by the stimulation ; otherwise it is positive . (Luigi C, Marco M et al A Proposed New Index for Clinical Evaluation of Interproximal Soft Tissues: The Interdental Pressure Index Int J Dent 2014)

58. SCORES CLINICAL SIGNS JUDGEMENT POSITIVE Consistency : spongy and unstable Color : relevant ischemia Bleeding Tissues are not correctly stimulated NEGATIVE Consistency : tonic and firm Color : slight ischemia or stable Tissues are correctly stimulated (Luigi C, Marco M et al A Proposed New Index for Clinical Evaluation of Interproximal Soft Tissues: The Interdental Pressure Index Int J Dent 2014)

59. Many practical advantages result from a properly stimulated periodontium . Considering the surgical aspects ; smoothened inflammation, and edema reduce bleeding during incision, improving operator visibility; a better incision design is also achieved as the blade moves in more stable tissues . Consistency of tissues helps to raise flaps without leaving abundant soft-tissue remnants t he increased tonicity of the gingiva and specifically of the interdental tissues allows the periodontist to better manage and suture the tissues (Luigi C, Marco M et al A Proposed New Index for Clinical Evaluation of Interproximal Soft Tissues: The Interdental Pressure Index Int J Dent 2014)

60. 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.

61. MILD(2) White opaque areas in enamel are more extensive,but do not involve as much as 50% of tooth. MODERATE(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.

62. 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.

63. REFERENCES Soben peter – essentials of public health dentistry 5 th edition Carranza’s textbook of clinical periodontology 10 th edition MK Jeffcoat , M McGuire and MG Newman “Evidence-based periodontal treatment. Highlights from the 1996 World Workshop in Periodontics” JADA 1997;128;713-724 Landry R.G, Jean M Periodontal Screening and Recording (PSR) Index : precursors, utility and limitations in a clinical setting International Dental Journal (2002) 52. 35-40

64. Subbappa A, Ganganna A et al Russell’s periodontal index: to score or not to score , IJIRR 2019 ; 06 (12) ; 6647-6649 Luigi C, Marco M et al A Proposed New Index for Clinical Evaluation of Interproximal Soft Tissues: The Interdental Pressure Index Int. J Dent 2014. Dhingra K and Vandana K L. Indices for measuring periodontitis : A literature review, International Dental Journal 2011; 61: 76–84