Periodontal Indices

Gingival Periodontal CPITN BPE PSR indices periodontology

1. GINGIVAL AND PERIODONTAL INDICES DR JAFFAR RAZA LECTURER KMUIDS KOHAT

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

5. USES FOR INDIVIDUAL PATIENT I N RESEARCH IN COMMUNITY  Recognize an oral • Determine base line data • Shows prevalence and incidence of a condition problem before experimental factors are introduced  Effectiveness of present • Assess the needs of the oral hygiene practices community. • Measure the effectiveness of specific agents for  Motivation in preventive and professional care for control and elimination of diseases • Compare the effects of prevention control or a community program treatment of oral condition and evaluate the results

6. 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.

7. Indices for assessing oral hygiene & plaque

8. ORAL HYGIENE INDEX Developed in 1960 by John C. Green and Jack R. Vermillion RULES OF ORAL HYGIENE INDEX R 1 Only fully erupted permanent teeth are scored. 2 . Third molars are not included 3. 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.

9. DEBRIS INDEX CRITERIA 0 – 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.

10. CALCULUS SCORING CRITERIA SCO CRITERIA RE 1 No calculus present 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

11. Calculation  Debris Index (DI) =( Buccal Score+ Lingual Score) / NO. OF SEG  Calculus Index (CI) =( Buccal Score+ Lingual Score) / NO. OF SEG OHI=D.I+C.I  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

12. 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 SUBSTITUTION 16 17,18 21 SURFACES TO BE EXAMINED 11 26 36 31 46 27,28 37,38 41 47,48

13. CALCULATION INTERPRETATION DI –S and CI-S 1. Good -0.0-0.6 2. Fair – 0.7-1.8  DI –S/CI-S = Total score/No of surfaces 3. Poor – 1.9 -3.0 OHI-S 1. Good - 0.0-1.2 2. Fair – 1.3- 3.0 3. Poor – 3.0 -6.0 OHI -S= DI-S+ CI-S

14. 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 11 26 36 31 46 BUCCAL LABIAL BUCCAL LINGUAL LABIAL LINGUAL

15. 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.

16.  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 :  Poor : 1.8 – 3.4 3.5 – 5.0

17. 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.

18. 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.

19. GINGIVAL INDICES

20. 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

21. 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

22.  Use:  Severity of gingivitis, controlled clinical trials of preventive or therapeutic agents

23. 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.

24. SCORING CRITERIA CRITERIA SCOR E 1 Normal Mild inflammation, slight change in color, little change in texture of any portion of gingival unit 2 Mild inflammation of entire gingival unit Moderate inflammation of gingival unit Severe inflammation of gingival unit 3 Calcula 4 tion: 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

25. 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.

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

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

28. 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

29. 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.

30. MODIFIED SULCULAR BLEEDING INDEX Developed by MOMBELLI,VAN OOSTEN & S.CHURCH ET.AL IN 1987. Scoring criteria :  SCORE – 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

31. PERIODONTAL INDICES

32. 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 . ”

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

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

35. PERIODONTAL DISEASE INDEX (PDI) • FIRST INTRODUCED BY RAMFJORD IN 1959 • COMPOSED OF THREE COMPONENTS: I. PLAQUE COMPONENT, II. CALCULUS COMPONENT AND III. GINGIVAL & PERIODONTAL COMPONENET . • ALL THE THREE COMPONENTS WILL BE SCORED SEPARATELY USING SIX RAMFJORD SELECTED TEETH. 16 21 41 24 44 36

36. PLAQUE COMPONENT: Scoring is done after staining with Bismark Brown solution. Score Criteria No plaque Plaque present on some but not on all interproximal, buccal, and lingual surfaces of the tooth Plaque present on all interproximal, buccal, and lingual surfaces,but covering less than one half of these surfaces Plaque extending over all interproximal, buccal and lingual surfaces, and covering more than one half of these surfaces 1 2 3

37. CALCULATION: Plaque Score = Total scores No. of teeth examined

38. CALCULUS COMPONEN T : SCORING CRITERIA : SCO CRITERIA RE No calculus 1 2 Supragingival calculus extending only slightly below the free gingival margin (not more than 1 mm Moderate amount of supragingival and sub gingival calculus or sub- gingival calculus alone. 3 An abundance of supra gingival and sub gingival calculus

39. CALCULATION: CALCULUS SCORE = TOTA L SCORES NO. OF SURFACES EXAMINED

40. GINGIVAL AND PERIODONTAL COMPONENT . • Gingival status is scored first. • Gingival status and crevice depth is recorded in relation to CEJ • All areas (m, d, b, l) is scored . • Only fully erupted teeth are scored . • There is no substitution for excluded teeth.

41. SCORE CRITERIA 1 Absence of signs of inflammation Mild to moderate inflammatory gingival changes not extending around the tooth 2 Mild to moderately severe gingivitis extending all around the tooth 3 4 5 6 severe gingivitis characterized by marked redness, swelling, tendency to bleed, and ulceration gingival crevice in any of 4 measured areas(M,D,B,L) extending apically to CEJ but not more than 3mm gingival crevice in any of 4 measured areas(M,D,B,L) extending apically to CEJ between 3-6mm gingival crevice in any of 4 measured areas(M,D,B,L) extending apically more than 6mm from CEJ

42. CALCULATION PDI score = Total of individual tooth scores (PS+CS+GPS) Number of tooth examined

43. 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.

44.  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 .

45. 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

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

47. RECENT ADVANCES IN PERIODONTAL INDICES • BASIC PERIODONTAL EXAMINATION (BPE) INDEX • GENETIC SUSCEPTIBILITY INDEX FOR PERIODONTAL DISEAS • PERIODONTAL SCREENING AND RECORDING (PSR) INDEX 70

48. BASIC PERIODONTAL EXAMINATION (BPE) INDEX • Developed by British Society of Periodontology in 1986 • Derived from the community periodontal index of treatment needs (cpitn) • Simple and rapid screening tool that is used to indicate the level of examination needed and to provide basic guidance on treatment need • Not a diagnostic tool

49. PERIODONTAL SCREENING AND RECORDING (PSR) INDEX • Introduced in 1992 by American Academy of Periodontology (AAP) and American Dental Association(ADA) • Endorsed by the World Health Organization (WHO) • Adaptation of the Community Periodontal Index of Treatment needs (CPITN) • Used to measure gingival bleeding upon probing, calculus on a tooth, and periodontal pocket depth in each sextant of the oral cavity

50. CALCULATING PSR • Highest score in a sextant is recorded as the PSR score for the sextant. • Only one score is recorded for each sextant of the oral cavity. • A WHO/CPITN/PSR probe is used to examine each tooth individually 75

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