Survey procedures in dentistry

survey procedures in dentistry - public health dentistry

1. SURVEY PROCEDU RE S I N DENTIST R Y B . D e e p t h i r a g a s r e e B D S ( f i n a l y e a r )

2. Survey is a non-experimental type of research that attempts to gather information about the status quo for a large number of people by describing present conditions without directly analyzing their causes . D e f i n i tion

3. Types of survey A n a l y t ical s u r v e y Descriptive s u r v e y L o n g i t u dinal s u r v e y C r o s s s e c t ional s u r v e y Longitudinal s u r v e y C r o s s s e c t i o n a l s u r v e y

4. USES O F SURVEY Monitoring trends in oral health and disease: When national surveys are repeated periodically under general similar conditions, broad oral health trends over time can be estimated, provided the sampling design so permits.The WHO's pathfinder survey protocol when repeated periodically can assess trends in health and disease and it is assumed that the results are valid enough to support national policy decisions. Policy development: Survey data can be used to establish oral health strategies. Scotland has successfully used survey data to develop its oral health policy. A number of American States switched their primary preventive focus from fluoride mouth-rinsing to sealant application after statewide surveys showed mo st carious lesions to be in pits and fissur Program evaluation: Survey data are often used to evaluate programs though the principle that association does not show cause-and-effect needs to be remembered.The success of particular programs can only be inferred from survey data, though the more localized the survey and the program, then the more plausible is the inference.

5. USES O F SURVEY Assessment of dental needs: Although surveys can be used for assessment of needs, there is a clear gap between the criteria used in surveys and those applied for individual patient care. e.g. criteria for caries in surveys usually are based on cavitation, but dentists generally intervene at an earlier stage in the carious process. Providing visibility to dental issues: The visibility that oral health acquires through the mere existence of data from a national survey may be the most important of all uses of survey data.

6. METHODS OF DATA COLLECTION Health interview survey: (face- t o-face survey) It is an invaluable method of measuring subjective phenomena, such as perceived morbidity, disability and impairment; opinions, beliefs and attitudes and some behavioral characteristics. Health examination survey: This survey is carried out by teams consisting of doctors and auxiliaries. D i s a d v antages : 1 )It is expensive and cannot be carried out on an extensive scale. 2 )The method also requires consideration of providing treatment to people found suffering from certain disease .

7. METHODS OF DATA COLLECTION Health records survey : It i n v o l v e s the collection of data from health service records. This is obviously the most economical method of collecting data. D i s a d v antages : The data obtained is not population- based. Reliability is o p e n to question. Lack of uniform procedures and standardization in the recording of data. Questionnaire survey: The use of questionnaires and interviews is
a standard method of data collection in
clinical,epidemiological, psychosocial
and demographic research. It is used for
measuring subjective phenomena.
Taking a medical history is a form of
questionnaire interview and is recorded
either in a fixed protocol (medical record)
or taken as an o p e n -ended interview.

8. METHODS OF DATA COLLECTION - Q U E S T I O N A R I E S U R V E Y Types : 1 ) M a i l e d questionarie s 2 ) Telephone questionarie s 3 ) F a c e -t o - f a c e questionaries A D V A N T A GES : Simple Economical Standardization - Written instructions reduce biases from differences in administration . Anonymity -Privacy encourages candid and honest responses to sensitive questions . Disadvantages: A certain level of education and skill is expected from the respondents. There is usually a high rate of non response .

9. T h e q u estions m ay be of two types : O p e n ended questions - F r e e r e s p o n se C l o s e d e n d e d questions - f i x e d a l t e r native The subject answers in his own words. This may produce difficulties when interpreting the responses, e.g. How many cigarettes do you smoke per day? They are answered by choosing from a number of fixed alternative response . Eg: Ho w many cigarettes do you smoke per day? a. Upto - 10 b. 10-20 c. 20 - 30 d. More than 30 The 2 types of scales most commonly used are : 1 )Likert Scale: (Summative) 2 )Guttman scale: (Cumulative) (Scalogram) ? ? ? ?

10. Likert Scale: (Summative) Commonly used to quantify attitudes and behavior. Respondents are asked to select a response that best represents the rank or degree of their answer. E.g. The respondent may be asked to indicate whether he strongly agrees, agrees, neither, disagrees or strongly disagrees with the statement. Each response is assigned a number. The points of each item is added. Guttman scale: (Cumulative) (Scalogram) These contain a series of statements that express increasing intensity of a characteristic. The respondent is asked to agree or disagree with each statement. The respondents score is the total number of items with which he agrees or disagrees.

11. S T E P S I N SURVEYING Establishing the objective D e s i g n i n g t h e i n v e s tigation Selecting t h e s a m p l e C o n d u c t i n g t h e e x a m i n ation s Analyzing t h e d a t a Drawing the c o n c l u sion s P u b l i s h i n g t h e results 1 3 2 4 5 6 7

12. 1 ) Establishing the objectives: The objectives can either be stated in the form of a hypothesis which is to be tested, or, the objective ma y be stated by describing what is to be measured . The starting point of a study is frequently an expression of a null hypothesis, which states that there is no difference between the groups. Eg : There is no difference in the periodontal status of males and females aged 35-44 years in Mangalore. The objective of the study is then to test this hypothesis Eg : To determine the prevalence of dental caries among 12 year old school children in Mangalore.

13. 2 ) Designing the investigation: Survey protocol: It is important to prepare a written protocol for the survey, which should contain , Main objective and purpose of the survey, A description of the type of information to be collected and of the methods to be used. A description of the sampling methods to be used. Personnel and physical arrangements. Statistical methods to be used in analyzing the data. A provisional budget. A provisional time-table of main activities and responsible staff.

14. 1 ) Obtaining approval from authorities: Permission to examine population groups must usually be obtained from a local, regional or national authority. E.g. If school populations are to be examined, schoolauthorities and the parents should be approached for obtaining permission. 2 ) Emergency care and referral: All survey teams should be equipped for and ready to provide emergency care if required. It is also the responsibility of the examiner to ensure an appropriate care f acility is made. 3 ) Budgeting : A budget for the survey should be prepared which should include all the resources required to carry out the survey.

15. 3 ) Selecting the sample: S a m p l e C o l l e c t i n f o r m ation f r o m these p e o p l e t o f i n d a n s w e rs t o y o u r Research q u e s t i o n s S t u d y p o p u l a tion : S a m p l ing units M a k e a n e s t i m ate o f t h e i r prevalence i n t h e study p o p u l ation f r o m s a m p l e findings Select a f e w s a m p l i n g units f r o m the study p o p u l a tion Reference o r p a r e n t p o p u l a tion

16. METHODS O F SAMPLING : 1 ) Simple random s a m p l i n g It is a technique whereby each sampling unit has the same probability of being selected. E v e r y item i n p o p u l ation h a s a n e q u a l chance o f b e i n g i n c l u ded . Basic procedure: • Prepare a sampling frame • Decide on the size ofthe sample • Select the required number of unit

17. 1 ) Simple random s a m p l i n g L O T T E R Y M E T H O D T A B L E O F R A N D O M N U M B E R S Here the population units are numbered on separate slips of paper of identical size and shape These slips are then shuffled and blind fold selection of the number of slips is made to constitute the desired sample size Random numbers are haphazard collection of certain numbers, arranged in a cunning manner to eliminate personal selection or the unconscious bias in taking out the sample

18. The first unit is chosen at random and then, other units are chosen in a systematic way. E'.g. Every third patient visiting the dentist. ( 2 ) Systematic s a m p l i n g

19. ( 3 ) Stratified s a m p l i n g The population is first divided into subgroups or strata according to certain common characteristics. Then random or systematic sampling is performed independently in each stratum: Stratified random sampling Stratified systematic sampling

20. ( 4 ) C l u s t e r s a m p l i n g A simple random sampling is selected, not of individual subjects, but of groups or clusters of individuals. T he sampling units are clusters and the sampling frame is a list of these clusters

21. ( 5 ) M u l t i p h a s e s a m p l i n g This is used to take basic data from a large sample and details from a subsample. It is a sub-sampling within groups chosen as cluster samples. The first stage is to select the groups or clusters. Then sub-samples are taken in as many subsequent stages as necessary to obtain the desired sample siz e E g : Nutritional status o f t h e c o u n t r y ( 6 ) Multistage sampling

22. ( 7 ) P anels They are useful for studying trends. A sample is randomly selected and the n data are collected from the sample on several occasions. E.g. Every person is interviewed every 6 months. A small sample is tested in order to answer certain questions about the population. If the questions are not answered, the number of subjects or units in the sample is increased gradually until the conclusions may be drawn. ( 8 ) Sequential sampling

23. The examination should be as automatic as possible to obviate excessive intrusion of subjective thought. Therefore it should be performed quickly. T he object of epidemiological surveys is to examine subjects in fairly large numbers. Excessive time spent on each individual necessitates a reduction in the number of individuals seen. 4 . C o n d u c t i n g t h e E x a m i n a tion : B A S I C O R A L H E A L T H E X A M I N A T ION 5 - 1 m i n u t e s 1 5 - 2 m i n u t e s

24. • P l ane mouth mirrors - 30 per examiner • P e r iodontal probes - 30 per examiner • S e veral pair of tweezers • C o ntainers and concentrated sterilizing solution. • A wash basin • C loth or paper hand towels • G a u ze. Instruments & s u p p l i e s I n f e c t ion c o n t r o l : Current national recommendations and standards should be followed for • Infection control • Waste disposal • Disposable masks, gloves, protective eyewear recommended.

25. CHAIR : P r e ferable with a head rest. Most comfortable situation is for the subject to be on a table/bench, and examiner to sit behind the subject’s head. ILLUMINATION : A s eparate unit lamp attached to head of the examiner fibre optic light source . CLEANING : M e thod to remove loose debris where necessary. ASSESSMENT FORMS: A d equate supply. Avoidance of crowding and noise around the examiner. RECORDER: L i v e or tape for receiving information called by the examiner. ORGANIZING CLERK: T o maintain constant flow of subjects and to enter general descriptive info on forms. E X A M I N A TION A R E A :

26. It is used to calculate intra and inter examiner reproducibility. It is an index which compares the agreement against that which might be expected by chance. Kappa can be thought of as the chance-corrected proportional agreement, and possible values range from + 1 (perfect agreement) via 0 (no agreement above that expected by chance) to -1 (complete disagreement). K A P P A S T A T I S T I C : K A P P A VALUE I N T E R P R E T A T ION 1 Total a g r e e m e nt > . 8 G o o d agreement . 6 - . 8 Substantial a g r e e m e n t . 4 - . 6 M o d e r a t e a g r e e m e nt

27. C L A S S I F I CATION OF T Y P E S O F I N S P E CTION AND E X A M I N ATION : TYPE 1: Complete examination using mouth mirror , explorer , good illumination, full mouth radiographs, & additional diagnostic methods (pulp testing, study models, transillumination etc.) TYPE 2: Limited examination, using m o u t h mirror and explorer, bitewing radiographs. P e r i a p i cal radiographs if indicated. TYPE 3: Inspection using mouth mirror , explorer & good illumination. TYPE 4: Screening procedure - tongue depressor, available illuminati on .

28. ( 5 ) ANALYZING DATA : Once the examination procedures of a survey have been completed, the work of assembling the material and interpreting it begins. 01 2 The analysis of findings has t w o components: Data processing (statistical analysis) Interpretation of result

29. ( 6 ) Drawing the conclusions and publishing the report: The conclusions are specifically related to the investigation that has been carried out and The final step in a survey procedure should be the construction of a report with or without a set of recommendations. Clearness and simplicity should be sought .

30. The WHO outline for a formal written report is: 1. Statement of the purposes of the survey. 2. Material and methods. A) Description of area and population served. B) Types of information collected C) Methods of collecting data D) Sampling method E) Examiner personnel and equipment F) Statistical analysis and computational procedure G) Cost analysis H) Reliability and reproducibility of results. 3. Results: They should be tabulated and illustrated appropriately. 4. Discussion and conclusions: The investigations, its findings and its conclusions are discussed. 5. Summary .

31. O R A L HEALTH S U R V E Y S PATH F I N D E R SURVEYS The special factors associated with the most common oral diseases w h i c h have enabled a practical economic survey sampling method o l o g y to be defined, called the " pathfinder method " . The "pathfinder method" is a stratified cluster sampling technique, which aims to include the most important population subgroups likely to have differing disease levels.

32. C L A S S I F I CATION OF P A T H F I N D E R P A T H F I N D E R NATIO N A L P A T H F I N D E R S U R V E Y P I L O T SURVEY

33. P I L O T SURVEY NATIONAL PATH F I N D E R SURVEY O n l y the most i m portant s u b g r oups i n the p o p u lation . O n e o r t w o index ages 1 2 y e a r s a n d o n e other a g e group . P r o v i d e s t h e m a x i m u m a m o u nt of data n e e d e d t o c o m m e n c e p l a n n i ng Incorporat e s sufficient examination sites t o cover a l l important s u b g r o u ps o f t h e population Atleast t h r e e o f t he i n d e x a g e groups . S u i t a b l e for c o l l e c t ion o f d a t a f o r p l a n n i ng p u r poses & monitoring o f o r a l h e a lth programmes i n a l l countries r e g a r d l ess o f the l e v e l of d i s e a s e , availability of r e s o u rces / c o m p l e x i t y o f c a r e .

34. I N D E X A G E GROUPS 5 years 1 2 years 1 5 years 3 5 - 4 4 years 6 5 - 7 4 years

35. 5 Y E A R S I N D E X A G E G R O U P C hildren should be examined b e t w e e n 5th - 6th birthdays. Caries levels in Primary dentition Exhibit changes over a short span of time than in permanent dentition at other index ages In some countries, 5 years is also the age at which children begin primary school.

36. 1 2 YEARS I N D E X A G E G R O U P • Children leave primary school. • Last age at which a reliable sample may be obtained easily through school system. • All permanent teeth (except 3rd molars) are likely to have erupted. • Chosen as “global indicator age group for international comparisons and surveillance of disease trends”

37. 1 5 YEARS I N D E X A G E G R O U P • Permanent teeth - exposed to oral environment for 3-9 years. • Assessment of caries prevalence and periodontal disease in adolescents. (15-19yrs) • In countries where it is difficult to obtain a reliable sample of this age group, it is customary to examine individuals in two-three areas

38. 3 5 - 4 4 YEARS I N D E X A G E G R O U P Standard age group for surveillance of oral health conditions in adults. • Planners & decision-makers can assess the full effect of dental caries, level of severe periodontal involvement, & general effects of oral health care provided. • Samples can be derived from organized groups - office, factory workers etc. • Care must be taken to avoid obvious selection bias.

39. 6 5 - 7 4 YEARS I N D E X A G E G R O U P • Has become important with the changes in age distribution of populations and the worldwide increase in lifespan. • Estimate the manifestation of oral disease from a life course perspective. • Data needed : planning appropriate interventions for older people and for assessment of the ultimate effect of oral health programmes • Sampling - care should be taken to sample adequately both house bound & active members of this age group.

40. N U M B E R OF S U B J ECTS The number of subjects in each index age group to be examined ranges from a minimum of 25 to 50 for each cluster or sampling site, depending on the expected prevalence and severity of oral diseas e s . If this cluster distribution is applied to four index ages in the population under study, the total sample is 4 x 300 = 1200. P ermits the identification of differences - between urban and rural group. - between socioeconomic groups. - areas where prevalence is much higher or lower.

41. THE WHO ORAL HEALTH AS SESSMENT FORM (1997) The WH O Oral Health Assessment Form 1997 is a universally accepted and used recording methodology for oral health surveys. S T A N D ARD C O D E S If some of the oral health assessments are not carried out, or are not applicable to the age group being examined, the unused sections of the form should be canceled with a diagonal line, or by using code 9 . The forms are designed to facilitate computer processing of the result . The two-digit numbers above or below some of the boxes indicate specific teeth, according to the system used by the International Dental Federation (FDI).

42. 1. Survey identification information 2. General information 3. Extra-oral examination 4. Temporomandibular joint assessment 5. Oral mucosa 6. Enamel opacities/hypoplasia 7. Dental fluorosis 8. CPI (periodontal status, formerly called Community Periodontal Index of Treatment Needs or CPITN) 9. Loss of attachment 10.Dentition status and treatment need 11 .Prosthetic status 12.Prosthetic need 13.Dentofacial anomalies 14.Need for immediate care a n d r e f e r r a l 15. Notes ORAL HEALTH AS SESSMENT FORM S H O U L D INCLUDE

43. ORAL HEALTH AS SESSMENT FORM - 1 9 9 7

44. ORAL HEALTH AS SESSMENT FORM - 1 9 9 7

45. ORAL HEALTH AS SESSMENT FORM - 1 9 9 7

46. ORAL HEALTH AS SESSMENT FORM - 1 9 9 7

47. • During planning - a list of examination sites & of the examiners involved in the study should be made & a code assigned to each examiner. • The coding list should also include the numeric codes to be used for other relevant information such as the fluoride content of drinking water or use of fluoride supplements. Identification and general information sections of the form

48. • Country in which the survey is carried out. • Should not be filled by the investigator. BOX 1 - 4 WHO code for the country

49. • Should be recorded at the time of examination. • Enables an investigator to refer back to examinations held on any particular day which may need to be reviewed or checked. BOX 5 - 8 Essential info: year, month, date

50. • Each subject examined should be given an identification number. • Should always have the same number of digits as the total number of subjects. • e.g : 1200 subjects . . . first subject - 0001. • If possible, ID no.s be entered before commencing the examinations. BOX 1 1 - 1 4 Identification number

51. • If more than one examiner is participating in the survey. • Each examiner should be assigned a specific code. BOX 1 5 E X A M I N A R

52. • If the subject will be re-examined to assess reproducibility, original examination is scored “1” & any subsequent examinations are coded “2”, “3”, “4” etc. • For all subjects for whom duplicate examinations are made, data from the 1st examination only are included in the survey analysis . BOX 1 6 Original / Duplicate examination

53. • I n Block letters. • In some countries, identification of survey subjects by name is not permitted, in such case - space should be left blank. N A M E

54. • Year, month and day of birth • For cross-checking purposes. • age at last birthday. • 6 years is coded as “06”. • when age is not known - ‘estimated age’: eruption status, major life events etc. • Manner of estimation should be reported. Date of birth ( 1 7 - 2 ) Age (2 1 - 2 2 ) S E X - 2 3 • Must always be recorded, because it is not always possible to tell a person’s sex from the name alone. • 1 = Male, 2 = Female.

55. • In different countries, ethnic groups may be identified in different ways, by area or country of origin, race, color, language, religion or tribal membership. • local health & education authorities should be consulted. • May be obtained from govt. agencies or school administrative data at the time of sample selection. Other Group: To identify different subpopulation groups. BOX 2 4 Ethnic group

56. A coding system should be devised according to local usage to identify different occupations and appropriate code entered. BOX 2 5 O C C U P A T ION B O X 2 6 - 2 7 Geographical location: • To record the site where examination is being conducted. • 01 - 98 • ’99’ entered if this information is not recorded. • Community information is useful for health administrators for planning or revising programs or strategies.

57. • General information about the local environmental conditions & availability of services at each site. 1 Urban site 2 Periurban area: areas surrounding major towns with very few health facilities & limited access. 3 Rural area or small village. BOX 2 8 LOCATION

58. • use of tobacco, SES, physical environment, levels of fluoride etc. • Frequency of sugar intake. BOX 2 9 - 3 OTHER D A T A

59. Examiners should use their judgement in matter. The following codes are used ; 0 - No contraindication 1 - Contraindication BOX 3 1 Contraindication to examination

60. In order, to ensure that all conditions are detected and diagnosed, it is recommended that the clinical examination follows the order of the assessment form. C L I N I CAL AS S E S SMENT

61. E X T R A O R A L E X A M I N ATION - B O X - 3 2

62. The extra-oral examination should be performed in the following sequence : a) general overview of exposed skin areas- (head, neck, limbs) b) perioral skin areas (nose, cheeks, chin) c) lymph nodes (head, neck) d) cutaneous parts of upper & lower lips e) vermilion border and commissures f) temporomandibular joint & P a r o t i d gland region The following codes and criteria are used; - Normal extra-oral appearance, 1 - Ulceration, sores, eriosions, fissures 2 - Ulceration , sores, erosions, fissures , nose, cheeks, chin. 3 - Ulceration , sores, erosions, fissures , commissures 4 - Ulceration , sores, erosions, fissures , vermilion border. 5 - Cancrum oris. 6 - Abnormalities of upper and lower lips (e.g., clefts) 7 - Enlarged lymph nodes - head, neck 8 - Other swelling of the face & jaws . 9 - Not recorded.

63. Temporomandibular joint assessment: (boxes 33 - 36)

64. Symptoms (box 33). The following codes and criteria are used; - No symptoms 1 - Occurrence of clicking, pain or difficulties in opening or closing the jaw once or more per week. 9 - Not recorded. Signs (boxes 34 - 36). The following codes and criteria are used; - No signs 1 - Occurrence of clicking, tenderness (on palpation) or reduced jaw mobility (opening < 30 mm). 9 - Not recorded. Clicking (box 34) of one or both temporomandibular joints. Tenderness (on palpation) (box 35) of the anterior temporalis and/or masseter muscles on one or both sides. Reduced jaw mobility (box 36) - opening of < 30 mm , taken as the distance between the incisal tips of the central maxillary and mandibular incisors

65. Oral mucosa: (boxes 37 - 42) The examination should be thorough and systematic and be performed in the following sequence : a) Labial mucosa and labial sulci (upper and lower) b) Labi a l p a r t of the commissures and buccal muc o s a (rightand left). c) Tongue (dorsal and ventral surfaces, margins) d) Floor of the mouth e) Hard and soft palate f) Alveolar ridges/ gingiva (upper and lower).

66. The codes and criteria are : - No abnormal condition 1 - Malignanttumor (oral cancer). 2 - Leukoplakia 3 - Lichenplanus 4 - Ulceration (aphthous, herpetic, traumatic) 5 - Acute necrotizing gingivitis 6 - Candidiasis 7 - Abscess. 8 - Other condition (specify if possible) 9 - Not recorded. The main location of the oral mucosal lesion(s) should be recorded in boxes 40 - 42 as follows; - Vermilion border 1 - Commissures 2 - Lips 3 - Sulci 4 - Buccal mucosa 5 - Floor of the mouth 6 - Tongue 7 - Hard and/or soft palate 8 - Alveolar ridges/gingiva. 9 - Not recorded.

67. Enamel opacities / hypoplasia: boxes ( 43 - 52) T h e codes a n d c r i t e r ia a r e a s f o l l o ws : - N o r m a l 1 - Demarcated o p a c i t y 2 - Diffuse o p a c i t y 3 - H y p o p l asia 4 - Otherdefects 5 - Demarcated and diffuse opacities 6 - Demarcated opacities and hypoplasia 7 - Diffuse opacity and hypoplasia 8 - All three conditions 9 - Not recorded

68. Dental fluorosis: (box 53) Fluorotic lesions are usually B/L symmetrical. Horizontal striated pattern across the tooth. Premolars > 2nd molars > Maxillary incisors. • Criteria: Dean’s Index : 0= NORMAL - smooth enamel surface, glossy, pale-creamy white color. 1= QUESTIONABLE - slight aberrations in translucency of enamel, few white flecks. 2= VERY MILD - small, opaque, paper-white areas scattered irregularly. 3= MILD - white opacities >25% but <50%. 4= MODERATE - marked wear, brown staining. 5= SEVERE - marked hypoplasia. Pitted or worn areas, widespread brown stains. 8= EXCLUDED 9= NOT RECORDED

69. Community Periodontal Index (CPI): (boxes 54 - 59) The s c o r i n g c r i t e r i a : - H e a l t h y 1 - B l e e d i n g observed directly o r b y using m o u t h mirror after probing 2 - calculus detec t ed d uring p ro b ing but all o f t he bl ack band o n the p rob e is visible . 3 - pocket 4 - 5 m m ( g in giv al m a rgin w ithin the black on the prob e ) 4 - pocket 6 mm o r more ( bl a ck b and on the p ro b e n ot visible ) X - E x c lu ded s e x t a n t ( l e ss th a n tw o t eeth p re sent ) 9 N ot re co rded L o ss of attach m ent : - L os s of attachme n t - 3 mm ( C E J n ot v i si ble a n d C P I s core - 3 ) 1 - L o ss of attachmen t 4 - 5 mm ( CEJ within the bla ck band ) 2 - Lo ss of atta c h m en t 6 - 8 mm ( C E J between th e upped li mit o f the bla ck band an d 8 . 5 mm ring ) 3 - Lo s s o f atta chm ent 9 - 1 1 mm ( C E J between the 8 . 5 mm & 1 1 . 5 mm rings ) 4 - Loss a tt a chme n t 1 2 mm / more ( C E J beyond the 1 1 . 5 mm rings ) X - e x l uded se xtant ( l e ss than two t ee th present ) 9 - No t r e c o rded ( C E J nei th er visible n o r d e tect abl e

70. Community Periodontal Index (CPI): (boxes 54 - 59) L O S S O F ATTA C H M E N T BOXES ( 6 - 6 5 )

71. Dentition status and treatment need: (boxes 66-161) • Examination for dental caries - plane mouth mirror. • Use of radiography for detection of proximal caries is not recommended impractical in most filed situations. • Examiners should adopt a systematic approach. • Proceed in orderly manner from one tooth to adjacent tooth or tooth space. • A tooth should be considered present in the mouth when a n y part of it is visible. • If a permanent & primary tooth occupy the same space, t h e status of permanent tooth should be recorded.

72. Dentition status and treatment need: (boxes 66-161) • An entry must be made in every box pertaining to the coronal & root status of a tooth. • In children, root status is not assessed, so the corresponding boxes have been omitted.

73. Dentition status and treatment need: (boxes 66-161) ( A ) - S o u n d cro w n N o evidence o f t r e a t e d / u n t r e a t e d caries Early s t a g e s o f c a r i e s W h i t e / c h a l k y s p o t s S t a i n e d e n a m e l p i t s & f i s s u r e s D a r k , shiny , h a r d , p i t t e d a r e a s o f e n a m e l S o u n d r o o t : when it is exposed and showed no evidence of treated clinical caries. 1 ( B ) D e c a y e d c r o w n U n d e r m i n d e n a m e l D e t e c t a b l e s o f t e n e d f l o o r I f c a r i o u s l e s i o n o n r o o t , doesn't involve c r o w n , i t s h o u ld b e recorded a s r o o t c a r i e s , t e m p o r a r y f i l l i ng . Decayed root: I f the root caries is discrete from the crown and will require a separate treatment, it should be recorded as root' caries. 2 (C) Filled crown, with decay : A c r o w n that h a s o n e / m o r e permanent r e s t o r ations & one / m o r e a r e s a r e d e c a y e d Filled root, with decay: A root is considered filled, with decay, when it has one or more permanent restorations and one or more areas that are decayed.

74. Dentition status and treatment need: (boxes 66-161) 3 ( D ) F i l l e d c r o w n w i t h n o c a r i e s : A crown that h a s o n e / m o r e p e r m a n ent restorations a r e p r e s e n t & there i s n o caries a n y w h e re . Filled root, with no decay: A root is considered filled, without decay, when one or more permanent restorations are present and there is no caries anywhere on the root. 4 ( E ) M i s s i n g tooth , d u e t o c a r i e s : P e r m a n ent / p r i m a r y teeth e x t r acted because of c a r i e s . R e c o r d e d u n d e r coronal s t a t u s 5 ( - ) Permanent t o o t h m i s s i n g d u e to a n y o t h e r r e a s o n : A b s e n t c o n g e n i t a l l y e x t r a c t e d f o r o r t h o d ontic r e a s o n s , periodo n t a l d i s e a s e , t r a u m a e t c 6 ( F ) F i s s u r e s e a l a nt : A f i s s u r e s e a l a n t h a s b e e n p l a c e d o n o c c l u s a l s u r f a c e 7 ( G ) F i x e d d e n t a l p r o s t h e sis abutmen t , c r o w n / vene e r 8 ( - ) Unerupted t o o t h : Teeth scor e d a s Unerupted a r e e x c l u d e d f r o m a l l calculations c o n c e r n i n g c a r i e s . U n e x p o s e d r o o t - 8 9 ( - ) N o t Recorded : U s e d f o r a n erupted p e r m a n ent t o o t h t h a t c a n n o t b e e x a m i n e d F o r any r e ason s u c h a s o r t h o dontic b a n d s , s e v e r e Hypoplasia , c a l c u l u s etc

75. Prosthetic need: (boxes 164 and 165) 0- No prosthesis needed. 1- Need for one-unit prosthesis (one tooth replacement). 2- Need for multi-unit prosthesis (more than one tooth replacement) 3- Need for a combination of one-and /or multi-unit prosthesis. 4- Need for full prosthesis (replacement of all teeth). 5- Not recorded. Prosthetic status : (boxes 162 and 163) The presence of prostheses should be recorded for each jaw (box 162, upper jaw; box 163, lower jaw). The following codes are provided for this: 0- No prosthesis. 1 - Bridge. 2- More than one bridge. 3- Partial denture. 4- Both bridge(s) and partial denture (s) 5- Full removable denture. 9- Not recorded.

76. Dentofacial anomalies : (boxes 166- 176 ) The number of missing teeth in the upper and lower arches should be recorded in boxes 166 and 167 of the assessment form . Crowding in the incisal segments (box 168) Crowding in the incisal segments is recorded as follows: 0- No crowding. 1- One segment crowded. 2- Two segments crowded. Spacing in the incisal segments (box 169) Spacing in the incisal segments is recorded as follows: 0- No spacing. 1- One segment spaced. 2- Two segments spaced.

77. Dentofacial anomalies : (boxes 166- 176 ) Diastema (box 170) Largest anterior maxillary irregularity (box 171) Largest anterior mandibular irregularity (box 1 7 2 ) Anterior maxillary overjet (box 173) Anterior mandibular overjet (box 174) Vertical anterior openbite (box 175 ) Antero-posterior molar relation (box 176) The right and left sides are assessed with the teeth in occlusion and only the largest deviation from the normal relation is recorded. The following codes are used: 0-Normal. 1 -Half cusp. The lower first molar is half a cusp mesial or distal to its normal relation. 2 -Full cusp. The lower first molar is one cusp or more mesial or distal to its normal r elation.

78. Need for immediate care and referral: (boxes 177-180) It is the responsibility of the examiner or team leader to ensure that referral to an appropriate care facility is made, if needed . Examples of conditions that require immediate attention include periapical abscess and acute necrotizing ulcerative gingivitis. Gross caries and chronic alveolar abscesses may also be recorded in box 178. Three boxes are provided for the recording of the presence (code 1) of the following condition: A life threatening condition (oral cancer or precancerous lesion) or other severe condition with clear oral manifestation (box 177); pain or infection that needs immediate relief (box l78); O ther conditions, specify (box 1 79). If the subject is referred for care, a "1" should be recorded in ( box 180 )

79. Space i s provided a t the b o t t om of the assessment form for the examiner/recorder to note, for his or her own reference, any additional information that might be pertinent to the subject being examined.

80. Oral Health Surveys, Basic Methods, 4th Edition ,World Health Organization , 1997. Oral Health Surveys, Basic Methods, 5th Edition , World Health Organization, 2013. https://apps.who.int/iris/bitstream/handle/10665/97035/9789241548649_eng.pdf?sequence=1 Soben Peter . Essentials of Public Health Dentistry, 5th edition Hiremath SS, Textbook of Public Health Dentistry, 3rd edition Marya CM. A textbook of public health dentistry. JP Medical Ltd; 2011 Mar 14. Referenc e s

81. Than k you