INDICES USED TO MEASURE PERIODONTAL DESTRUCTION

RESOURCE FACULTY:

Dr Shiva lal Sharma

Dr Sajeev Shrestha

Dr khushboo Goel

CONTENTS :

• INTRODUCTION

• PLAQUE INDEX , O’LEARY INDEX

• GINGIVAL INDEX , BLEEDING POINT INDEX

• PMA INDEX

• CPITN/CPI INDEX

• PERIODONTAL DISEASE INDEX

• RUSSELL’S PERIODONTAL INDEX

According to Russell, 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.’

Use to access The amount of plaque accumulated . The amount of calculus present The degree of inflammation of the gingival tissues The degree of periodontal destruction. In addition, indices are developed to assess the treatment needs

plaque and debris assessment:

*Plaque Index (PlI) … (Silness and Loe in 1964)Fully described by loe in 1967

--Surface examined: 4 gingival areas - distofacial, facial, mesiofacial &

lingual surfaces.

-This index measures the thickness of plaque on the gingival one third.

index teeth

Score Criteria0 No plaque

1 A film of plaque adhering to the free gingival margin and adjacent area of the tooth, which can not be seen with the naked but only by using probe.

2 Moderate accumulation of deposits within the gingival pocket, on the gingival margin and/ or adjacent tooth surface, 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.

INSTRUMENT USED: MOUTH MIRROR

DENTAL EXPLORER

AIR DRYING MACHINE/COTTON

CALCULATION:

• 1) INDIVIDUAL: 2) POPULATION:

• PII = TOTAL SCORES PII = TOTAL SCORES

NO. OF SURFACES EXAMINED NO. OF SUBJECTS EXAMINED

• INTERPRETATION:

• EXCELLENT 0

• GOOD 0.1 - 0.9

• FAIR 1.0 – 1.9

• POOR 2.0 – 3.0

Advantage

Good validity and reproducibility

Can be used as full mouth or simplified

Drawback

Subjectivity in estimating plaque

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

Calculation The number of plaque containing surfaces) / The total number of available surfaces

Since plaque is stained ,identification and record making is easyAlso aids in patient education

Drawback:records only the presence or absence of plaque

Gingival Index by Loe H and Sillness J (1963)

The severity of gingivitis is scored on all surfaces of all teeth, or selected teethInstrument-mouth mirror,periodontal probe

The tissues surrounding each tooth are divided into four gingival scoring units: • Distal facial papillae, • Facial margin, •Mesial facial papillae, • Entire lingual gingival margin.

Scoring criteria: 0 — No inflammation /normal gingiva1 — Mild inflammation,slight change in color,slight edema,no bleeding on probing2-Moderate inflammation, glazing ,redness ,edema ,hypertrophy bleeding on probing 3 — Severe inflammation ,marked redness,hypertrophy,ulcerationSpontaneous bleeding Inference 0.1 to 1.0 — Mild gingivitis 1.1 to 2.0 — Moderate gingivitis 2.1 to 3.0 — Severe gingivitis

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

PAPILLARY MARGINAL ATTACHMENT INDEX(PMA)…… 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 COMPONENT (P)

• 0= 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).

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.

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.

• CALCULATION: P M A SCORE = P + M + A

Community Periodontal Index of Treatment Needs (CPITN)……

which was introduced by Jukka Ainamo et all for joint working committee of WHO / FDI in 1982

· Was developed primarily to survey and evaluate periodontal treatment needs rather than determining past & present periodontal status.

· mouth is divided into six parts (sextants).

· examination done by special probe (WHO probe)

• LIMITATION

• Does not record position of gingival margin

• Does not provide assessment of past periodontal breakdown

• SEXTANTS: 17 – 14 13 - 23 24 – 27

47 – 44 43 - 33 34 – 37

INDEX TEETH: (FOR ADULTS, AGED 20 YRS. OR MORE)

7/6 1 6/7

7/6 1 6/7

For people upto 19 yrs., 2nd molars are excluded because of high frequency of false pocket.

For children less than 15 yrs., Pockets not recorded although probing for bleeding and calculus are carried out

WHO – PROBE

WEIGHS : 5 GMS

WORKING FORCE: 20 GMS (PRACTICAL TEST- GENTLY INSERT PROBE POINT UNDER

FINGER NAIL WITHOUT CAUSING

PAIN/DISCOMFORT)

INSTRUMENT USED : MOUTH MIRROR AND

CPITN PROBE

C P I SCORE CRITERIA

• 0 NO PERIODONTAL DISEASE.

• 1 BLEEDING ON PROBING.

• 2 CALCULUS WITH PLAQUE SEEN OR FELT BY PROBING.

• 3 PATHOLOGICAL POCKET 4 – 5 MM.

• 4 PATHOLOGICAL POCKET 6 MM OR MORE.

• X WHEN ONLY 1 TOOTH OR NO TOOTH ARE PRESENT.

TN score criteria 0 No need for treatment. (code0 / X)

1 Personal plaque control (OHI).(code1).

2 Professional plaque control (scaling and polishing). (code2- 3).

3 Deep scaling , root planning, surgical procedure. ( code4).

• Advantage-simplicity

speed

international uniformity

• Limitations-doesnot record the position of gingiva

doesn’t provide assessment of past periodontal

breakdown

*COMMUNITY PERIODONTAL INDEX (CPI) ……

• MODIFICATION IS DONE BY INCLUDING “LOSS OF ATTACHMENT” AND ELIMINATING

“TREATMENT NEEDS” CATEGORY.

• CPI SCORING CRITERIA IS SAME AS CPITN AND

• CODES AND CRITERIA FOR LOSS OF ATTACHMENT INCLUDES:

CODE CRITERIA

0 LOSS OF ATTACHMENT 0-3 MM

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

FOR PERIODONTAL DISEASE ASSESSMENT:

*PERIODONTAL DISEASE INDEX (PDI)…… WHICH WAS INTRODUCED BY RAMFJORD IN 1959

• WHICH IS COMPOSED OF THREE COMPONENTS.

• ALL THE THREE COMPONENTS WILL BE SCORED SEPARATELY USING SIX RAMFJORD SELECTED TEETH.

6 1 4 4 1 6

PLAQUE COMPONENT:

1-THE CRITERIA RANGED FROM 0 - 3 .

SCORING CRITERIA:

0 - 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.

4 - There is no substitution for excluded teeth.

5 - Instruments :mouth mirror, dental explorer, Bismarck Brown soln., Richmond cotton pellets and disclosing agents

Calculation: Total scores

No. of teeth examined

• - CALCULUS COMPONENT:

SCORING CRITERIA:

0 - ABSENCE OF 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.

• This index measured the extension of calculus.

• Facial and lingual surfaces are evaluated, and scored separately.

• Can be performed quickly.

CALCULATION:

TOTAL SCORES

NO. OF SURFACES EXAMINED

-GINGIVAL AND PERIODONTAL COMPONENT.

• Gingiva is scored 1st .

• Gingival status and crevice depth is recorded in relation to CEJ

• Instrument used: mouth mirror & university of michigan no. 0 prob(graduated at 3,6,8mm from the end)

• All areas (m, d, b, l) is scored .

• Only fully erupted teeth are scored .

• There is no substitution for excluded teeth.

• THE CRITERIA RANGED FROM O 1 2 3 4 5 6

0 NORMAL GINGIVITIS PERIODONTITIS

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

Russell’s Periodontal Index by Russell AL (1956)

-To estimate deeper periodontal disease by measuring the presence or absence of the gingival inflammation and its severity, -pocket formation and masticatory function. -All the teeth present are examined.

• CRITERIA ADDITIONAL

•

•

0=negative :neither overt inflammation in nevesting tissue nor loss of function due to destruction of supporting tissue 1= mild gingivitis :overt area of inflammation in free gingiva which donot circumscribe the tooth2 =gingivitis: inflammtion completely circumscribe the tooth but no break in the epithelial attachment4 =used only when radiograph are available

0=radiographic features essentially nrmal

4= early notch like resorption of alveolar crest

• 6 =GINGIVITIS WITH POCKET FORMATION:THE EPITHELIAL ATTACHMENT IS BROKEN AND THERE IS POCKET,NO INTERFERENCE IN MASTICATORY FUNCTION ,TOOTH IS FIRM IN TIS SOCKET AND HASNOT DRIFTED

• 8= ADVANCED DESTRUCTION WITH LOSS OF MASTICATORY FUNCTION:,TOOTH MAY BE LOOSE,MAY HAVE DRIFTED ,DULL ON PERCUSSION AND DEPRESSIBLE IN ITS SOCKET

• 6=HORIZONTAL BONE LOSS INVOLVING THE

ENTIRE ALVEOLAR CREST, UPTO HALF THE

LENGTH OF THE TOOTH ROOT

• 8=ADVANCED BONE LOSS INVOLVING

MORE THAN ONE-HALF OF THE LENGTH OF

TOOTH ROOT, INFRABONY DEFECTS,

WIDENING OF PERIODONTAL LIGAMENT,

ROOT RESORPTION

• 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

38

Periodontal Screening and Recording (PSR) Index

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 39

Score Criteria0 pocket depth is < 3.5 mm, no bleeding

upon probing, and no calculus1 pocket depth is < 3.5 mm, bleeding on

probing and no calculus2 pocket depth is < 3.5 mm, bleeding on

probing and calculus present3 pocket is 3.5 – 5.5 mm in depth4 pocket is > 5.5 mm in depth* clinical abnormalities

such as furcation involvement, tooth mobility, mucogingival involvement, or 3.5 mm or more of recession in that sextant

X edentulous sextant40

ADVANTAGE• Early detection of periodontal

disease and it serves as an aid in monitoring the periodontal status of patients

• Fast method to screen patients as only six scores are recorded

• Its documented use also assists with the record keeping of a patient’s periodontal history

41

LIMITATIONSLimited use of the PSR system in children due to inability to differentiate pseudo-pockets

Does not measure epithelial attachment, the severity of periodontal disease may be underestimated with its use

• REFERENCES:

• CARRANZA’S CLINICAL PERIODONTOLOGY-11TH EDITION

- ESSENTIALS OF PREVENTIVE AND COMMUNITY DENTISTRY.

- INTERNET SOURCES.