Periodontal indices final

INDEX IN DENTISTRY

1. GOOD MORNING 1

2. perio dontal Indices 2 SUBMITTED BY: SHEKHAR KUMAR MANDAL Roll no: 26 BDS IV GUIDED BY : DR. NAVRAJ LAMDARI DR. LAL BABU KAMAIT DEPARTMENT OF PERIODONTICS COLLEGE OF MEDICAL SCIENCES, BHARATPUR NEPAL

3. Contents 3

4. Introduction “ Unless you can count it, weigh it or express it in a quantitative fashion, you have scarcely begun to think about the disease in a scientific fashion” -Lord Kelvin 4

5. Definitions “Epidemiological indices are attempts to quantitate clinical condition on graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods”. – Irving Glickman 5 According to Russell A.L , 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”

6. “ 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 6

7. IDEAL REQUISITES OF AN INDEX 7

8. OBJECTIVES 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 8 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 need of the community C ompare the effects of a community program and evaluate the results

9. Based on the direction in which their scores can fluctuate: 9 Classification of index

10. Depending upon the extent to which areas of oral cavity are measured : 10

11. According to the entity which they measure 11

12. General indices : 12

13. INDICES USED FOR ORAL HYGIENE ASSESSMENT Oral hygiene index Simplified oral hygiene index Patient hygiene performance Turesky , Gilmore, Glickman modification of the Quigley Hein plaque index 13

14. ORAL HYGIENE INDEX (OHI) Developed in 1960 by John C. Green and Jack R. Vermillion in order to classify and assess oral hygiene status. Simple and sensitive method for assessing group or individual oral hygiene quantitatively. Composed of 2 components: Debris index (DI) Calculus index (CI) 14

15. 15 RULES OF ORAL HYGIENE INDEX 1 Only fully erupted permanent teeth are scored. 2 Third molars and incompletely erupted teeth are not scored because of the wide variations in heights of clinical crowns . 3 The buccal and lingual debris scores are both taken on the tooth in a segment having the greatest surface area covered by debris . 4 The buccal and lingual calculus scores are both taken on the tooth in a segment having the greatest surface area covered by supragingival and subgingival calculus .

16. – 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 DEBRIS INDEX CRITERIA

17. 17 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. Supragingival calculus Subgingival calculus CALCULUS INDEX CRITERIA

18. CALCULATION Debris Index (DI) =( Buccal Score+ Lingual Score) / NO. OF SEG Calculus Index (CI) =( Buccal Score+ Lingual Score) / NO. OF SEG Oral Hygiene Index= DI+CI 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 18

19. SIMPLIFIED ORAL HYGIENE INDEX Developed by John C Greene and Jack R Vermillion in 1964 as OHI was time consuming and required more decision making 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 An alternate tooth is then examined if missing 19

20. 20 16 17,18 11 21 26 27,28 36 37,38 31 41 46 47,48 Surfaces and tooth to examined Substitution

21. 21 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 INTERPRETATION CALCULATION DI –S = Total score/No of surfaces CI-S = Total score/ No of surfaces OHI -S= DI-S+ CI-S

22. USES Widely used in epidemiological studies of periodontal diseases. Useful in evaluation of dental health education programs Evaluating the efficacy of tooth brushes. Evaluate an individual’s level of oral cleanliness.

23. 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. 23 16 Buccal 11 Labial 26 Buccal 36 Lingual 31 Labial 46 Lingual

24. 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. 24 M MI D M O/I G Procedure:

25. Debris score for individual tooth: Add the scores for each of the 5 subdivisions. PHP index for an individual= (Total score for all the teeth /the number of teeth examined) Debris score for 1 tooth = 4/5 = 0.8 1 1 1 1 Rating scores Excellent : (no debris) Good : 0.1-1.7 Fair : 1.8 – 3.4 Poor : 3.5 – 5.0

26. PLAQUE INDEX Silness and Loe in 1964 Assesses only thickness of plaque at the cervical margin of the tooth closest to the gums All four surfaces are examined Distal Mesial Lingual Buccal 12 24 16 44 32 36

27. SCORING CRITERIA Score Criteria No Plaque 1 A film of plaque adhering to the free gingival margin and adjacent area of tooth the plaque may be seen in situ only after application of disclosing solution or by using probe on tooth surface 2 Moderate accumulation of soft deposits within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eye 3 Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin 27

28. CALCULATION 28 Plaque index for area 0-3 for each surface Plaque index for a tooth Scores added and then divided by four Plaque index for group of teeth Scores for individual teeth are added and then divided by number of teeth. Plaque index for the individual Indices for each of the teeth are added and then divided by the total number of teeth examined Plaque index for group All indices are taken and divided by number of individual Rating Scores Excellent Good 0.1-0.9 Fair 1.0-1.9 Poor 2.0-3.0 INTERPRETATION

29. USES Reliable technique for evaluating both mechanical anti plaque procedures and chemical agents Used in longitudinal studies and clinical trials 29

30. 30 ADVANTAGE Good validity and reproducibility Can be used as full mouth or simplified DRAWBACK Subjectivity in estimating plaque

31. Turesky , Gilmore, Glickman modification of the Quigley-Hein plaque index Quigley and Hein in 1962 reported a plaque measurement that focused on the gingival third of the tooth surface. Only facial surfaces of the anterior teeth were examined after using basic fuchsin mouthwash as a disclosing agent. Quigley - Hein plaque index was modified by Turesky , Gilmore and Glickman in 1970. 31

32. 32 SCORE CRITERIA No plaque 1 Separate flecks of plaque at the cervical margin of tooth 2 Thin continuous band of plaque ( up to 1 mm 3 Band of plaque wider than 1 mm but covering less than 1/3rd of the crown of the tooth. 4 Plaque covering at least 1/3rd but less than 2/3rd of the crown of the tooth 5 Plaque covering 2/3rd or more of the crown of the tooth

33. Plaque is assessed on the labial, buccal and lingual surfaces of all the teeth after using a disclosing agent. The scores of the gingival 1/3rd area was also redefined. Provides a comprehensive method for evaluating anti plaque procedures such as tooth brushing, flossing as well as chemical anti plaque agents. The index is based on a numerical score of 0 to 5 33

34. O’LEARY INDEX ( plaque control record) O' leary T, Drake R, Naylor in1972 Method of recording the presence of the plaque on individual tooth surfaces Suitable disclosing solution such as Bismarck brown, Diaplac or similar is painted on all exposed tooth surfaces.. The operator (using an explorer or a tip of a probe) examines each stained surface for soft accumulations at the dentogingival junction. When found, they are recorded by making a dash/red colour in the appropriate spaces on the record form

35. Calculation PLAQUE INDEX = The number of plaque containing surfaces The total number of available surfaces Since plaque is stained ,identification and record making is easy Also aids in patient education Drawback Records only the presence or absence of plaque

36. BLEEDING POINT INDEX Provides an evaluation of gingival inflammation around each tooth in patient’s mouth Bleeding on probing recorded on distal ,facial ,mesial and gingival surface Calculation=(no of bleeding surface/total no of tooth surface)*100 Demonstrates gingival inflammation characterized by gingival bleeding rather than presence of microbial plaque

37. GINGIVAL AND PERIODONTAL DISEASE INDICES GINGIVAL INDEX PERIODONTAL INDEX CPITN COMMUNITY PERIODONTAL INDEX 37

38. GINGIVAL INDEX Developed by Loe and Silness in 1963. One of the most widely accepted and used gingival indices. Assess the severity of gingivitis and its location in 4 possible areas. Mesial Lingual Distal Facial 0nly qualitative changes are assessed. 38

39. : All surfaces of all teeth or selected teeth or selected surface of all teeth or selected teeth are scored. The selected teeth as the index teeth are 16,12,24,36,32,44. The teeth and gingiva are first dried with a blast of air and/or cotton rolls. The tissues are divided into 4 gingival scoring units: Disto facial papilla, Facial margin, Mesio facial papilla and Entire lingual margin. A blunt periodontal probe is used to assess the bleeding potential of the tissues. 39 METHOD

40. SCORE CRITERIA Absence of inflammation/normal gingiva 1 Mild inflammation, slight change in color, slight edema, no bleeding on probing 2 Moderate inflammation, moderate glazing, redness, edema and hypertrophy. bleeding on probing 3 Severe inflammation, marked redness and hypertrophy ulceration. Tendency to spontaneous bleeding. 40

41. CALCULATION AND INTERPRETATION If the scores around each tooth are totaled and divided by the number of surfaces per tooth examined (4), the gingival index score for the tooth is obtained. Totaling all of the scores per tooth and dividing by the number of teeth examined provides the gingival index score for individual. 41 INTERPRETATION: 0.1 - 1.0 : mild gingivitis 1.1 – 2.0 : moderate gingivitis 2.1 – 3.0 : severe gingivitis

42. MODIFIED GINGIVAL INDEX Developed by Lobene , Weatherford, Ross, Lamm and Menaker in 1986. Assess the prevalence and severity of gingivitis. Strictly based on non invasive approach i.e. visual examination only without any probing. 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. 42

43. 43 SCORE CRITERIA

44. RUSELL’S PERIODONTAL INDEX Developed by Rusell AI in 1956. It was once widely used in epidemiological surveys but not used much now because of introduction of new periodontal indices and refinement of criteria. The RPI is reported to be useful among large populations, but it is of limited use for individuals or small groups. 44

45. 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 lower score .” 45 METHOD

46. FIELD STUDIES CLINICAL STUDIES / 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. 46

47. CALCULATION AND INTERPRETATION RPI score per person = Sum of individual scores No of teeth present 47 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

48. 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. 48

49. 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. The treatment need in a sextant is recorded only if there are 2 or more teeth present in a sextant and not indicated for extraction. If only one tooth remains in a sextant, then the tooth is included in the adjoining sextant. 49 Procedure :

50. Probing depth is recorded either on all the teeth in a sextant or only on certain indexed teeth as recommended by who for epidemiological surveys . For adults aged > 20 yrs: 10 index teeth are taken into account : 17 16 11 26 37 47 46 31 36 37 . The molars are examined in pairs and only one score the highest score is recorded. 50

51. For young people up to 19 yrs : Only 6 index teeth are examined : 16 11 26 46 31 36 The second molars are excluded at these ages because of the high frequency of false pockets (non inflammatory tooth eruption associated). When examining children less than 15 yrs, pockets are not recorded although probing for bleeding and calculus are carried out as a routine. 51

52. First described by WHO. Designed for 2 purposes : measurement of pockets. detection of sub-gingival calculus. Weighs : 5 gms Working force: 20-25 gms 52 CPITN probe CPITN-E PROBE CPITN-C PROBE

53. 53 CODE CRITERIA TREATMENT NEEDS Healthy periodontium TN-0 No need of treatment 1 Bleeding observed during / after probing TN-1 Self care 2 Calculus or other plaque retentive factors seen or felt during probing TN-2 Professional care 3 Pathological pocket 4-5 mm. gingival margin situated on black band of the probe. TN-2 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

54. ADVANTAGE Simplicity Speed I nternational uniformity LIMITATIONS Doesnot record the position of gingiva D oesn’t provide assessment of past periodontal breakdown 54

55. Community Periodontal Index (CPI) Based on modification of CPITN Modification is done by including “loss of attachment” and eliminating “treatment needs” category . CPI scoring criteria is same as CPITN and done with CPITN-C probe

56. 56 Code Criteria 0 loss of attachment 0-3 mm, CEJ not visible 1 loss of attachment 4-5mm 2 loss of attachment 6-8mm 3 loss of attachment 9-11mm 4 loss of attachment 12mm or more X excluded sextant 9 not recorded Codes and Criteria for Loss of attachment includes:

57. by Schour & Massler, (1944) To count number of gingival unit affected with gingivitis that is correlated with severity of gingival inflammation. The facial surface of gingiva around a tooth divided into three units: Papillary gingiva (P), Marginal gingiva (M), and Attached gingiva (A). Usually central incisor to second premolars are examined. PAPILLARY MARGINAL ATTACHMENT INDEX(PMA)

58. Papillary Component (P) = Normal; no inflammation. 1+= Mild papillary engorgement; slight increase in size . 2+= Obvious increase in size of gingival papilla; hemorrhage on pressure . 3+= Excessive increase in size with spontaneous hemorrhage . 4+= Necrotic papilla . 5+= Atrophy and loss of papilla ( through inflammation ).

59. MARGINAL COMPONENT(M) 0= Normal ; no inflammation visible . 1+= Engorgement ; slight increase in size; no bleeding. 2+= Obvious engorgement; bleeding upon pressure. 3+= Swollen collar; spontaneous hemorrhage; beginning infiltration into attached gingivae . 4+= Necrotic gingivitis. 5+= Recession of the free marginal gingiva below the CEJ due to inflammatory changes.

60. Attached Component(A) 0= Normal; pale rose; stippled. 1+= slight engorgement with loss of stippling; change in color may or may not be present. 2+=obvious engorgement of attached gingivae with marked increase in redness. Pocket formation present. 3+=advanced periodontitis. Deep pockets evident.

61. Calculation : P M A index Score per person = P + M + A 61 USES : On clinical trails O n individual patient F or epidemiological surveys

62. first introduced by Ramfjord in 1959 composed of three components: plaque COMPONENT, Calculus COMPONENT and gingival & periodontal componenet . All the three components will be scored separately using six Ramfjord selected teeth . 16 21 24 44 41 36 PERIODONTAL DISEASE INDEX (PDI)

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

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

65. Calculus component : Scoring criteria : SCORE CRITERIA No calculus 1 Supragingival calculus extending only slightly below the free gingival margin (not more than 1 mm 2 Moderate amount of supragingival and sub gingival calculus or sub- gingival calculus alone. 3 An abundance of supra gingival and sub gingival calculus

66. Calculation : CALCULUS SCORE = Total scores No . of surfaces examined

67. 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.

68. 68 SCORE CRITERIA Absence of signs of inflammation 1 Mild to moderate inflammatory gingival changes not extending around the tooth 2 Mild to moderately severe gingivitis extending all around the tooth 3 severe gingivitis characterized by marked redness, swelling, tendency to bleed, and ulceration 4 gingival crevice in any of 4 measured areas(M,D,B,L) extending apically to CEJ but not more than 3mm 5 gingival crevice in any of 4 measured areas(M,D,B,L) extending apically to CEJ between 3-6mm 6 gingival crevice in any of 4 measured areas(M,D,B,L) extending apically more than 6mm from CEJ

69. CALCULATION PDI score = T otal of individual tooth scores (PS+CS+GPS) Number of tooth examined

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

71. D eveloped by B ritish S ociety of Periodontology in 1986 D erived from the community periodontal index of treatment needs ( cpitn ) S imple and rapid screening tool that is used to indicate the level of examination needed and to provide basic guidance on treatment need N ot a diagnostic tool 71 BASIC PERIODONTAL EXAMINATION (BPE) INDEX

72. 72

73. G enetic markers denote susceptibility toward disease manifestation and it would be useful to exploit the information hidden into them and to derive a Genetic S usceptibility I ndex (GSI) S ingle N ucleotide P olymorphisms (SNP’s) in genes encoding molecules of the host defense system are assessed and an association is established between SNP and disease status 73 GENETIC SUSCEPTIBILITY INDEX FOR PERIODONTAL DISEASE

74. Introduced in 1992 by A merican A cademy of Periodontology (AAP) and A merican Dental Association(ADA) E ndorsed by the World H ealth O rganization (WHO) A daptation of the Community Periodontal I ndex of Treatment needs (CPITN) U sed to measure gingival bleeding upon probing, calculus on a tooth, and periodontal pocket depth in each sextant of the oral cavity 74 PERIODONTAL SCREENING AND RECORDING (PSR) INDEX

75. Calculating PSR H ighest score in a sextant is recorded as the PSR score for the sextant. O nly one score is recorded for each sextant of the oral cavity. A WHO/CPITN/PSR probe is used to examine each tooth individually 75

76. advantages I ntroducing a simplified screening method that met legal dental recording requirements. E arly detection of periodontal disease and it serves as an aid in monitoring the periodontal status of patients 76

77. limitations L imited use of the PSR system in children due to inability to differentiate pseudo-pockets D oes not measure epithelial attachment, the severity of periodontal disease may be underestimated with its use 77

78. U sed to measure pocket depths. A pocket measuring probe/ W illiams probe is used. M ain components to record: - Pocket depth (mm) - Mobility - Recession (mm) - Bleeding on probing - Furcation DPC – Detailed Periodontal Chart

79. Two blunt instruments are used to asses a tooth’s mobility. e.g end of mirror and probe T o quantify mobility, M illers index of mobility is used: Mobility GRADE MOBILITY Grade 0 Normal physiological mobility (<1mm) Grade 1 Movement up to 1mm in horizontal plane Grade 2 Movement greater than 1mm in horizontal plane Grade 4 Severe mobility greater than 2mm or vertical mobility

80. T he furcation is the point at which the two roots divide. A pocket measuring probe is used ( naber’s probe) R amfjord and Ash furcation index: Furcation 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 4 Through and through defect

81. Recession To measure the recession of a individual tooth, a pocket measuring probe must be used. The probe is placed onto the tooth and the distance between the cemento -enamel junction and the gingival margin is measured. This is the amount of recession that has occurred on that tooth.

82. The pocket measuring probe is inserted into the gingival crevice. The distance from the base of the pocket and the gingival margin is measured. In addition, if the site bleeds on probing, circle the score in red and if the site has suppuration (pus) circle the score in blue or black. Baseline Pocket Depth BASELINE POCKET DEPTH + RECESSION = CAL

83. T he DPC allows the operator to find sites in the mouth requiring attention. S ites with pockets greater than 5mm will require RSD. S ubsequent pocket depths and cal can be measured after treatment to assess the success of treatment. What happens from the results of the DPC??

84. 84 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 CONCLUSION

85. REFERENCES E ssentials of Public health dentistry 5E, Soben Peter Carranza's Clinical Periodontology, 12E (2015) , Newman, Takei, Klokkevold, Carranza H ttps://www.mah.se/capp/methods-and-indices/oral-hygiene-indices/simplified-oral-hygiene-index--ohi-s/ Dhingra k, vandana k l; indices for measuring periodontitis: a literature review. international dental journal. 2011; 85

86. THANK YOU 86