PERIODONTAL

INDICES

DR BHAUMIK THAKKAR.

PART -1 P.G.

DEPT OF PERIODONTICS

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.

DEFINITION

An index is defined as ‘A numerical value describing the relativestatus of the population on a graduated scale with definite upperand lower limits which is designed to permit and facilitatecomparison with other population classified with the same criteriaand the method’- Russell A.L

Oral indices are essentially set of values, usually numerical withmaximum and minimum limits, used to describe the variables or aspecific conditions on a graduated scale, which use the same criteriaand method to compare a specific variable in individuals, samples orpopulations with that same variables as is found in other individuals,samples or populations. – ‘’George P Barnes’’ - 1985

An index is an expression of clinical observation in numeric values. It isused to describe the status of the individual or group with respect to acondition being measured. The use of numeric scale and astandardized method for interpreting observations of a conditionresults in an index score that is more consistent and less subjectivethan a word description of that condition. – ‘’Esther M Wilkins’’ - 1987

IDEAL REQUISTIES OF AN INDEX

CLARITY

SIMPLICITY

OBJECTIVITY

VALIDITY

RELIABILITY

ACCEPTABILITY

QUANTIFIBILITY

SENSITIVITY INDEX

USES

6FOR 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

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

CLASSIFICATION OF INDICES

Based on the direction in which their scores can

fluctuate:

IRREVERSIBLE

INDEX

REVERSIBLE

INDEX

Depending upon the extent towhich areas of oral cavity aremeasured :

FULL MOUTH

INDICES

SIMPLIFIED

INDICES

According to the entitywhich they measure

DISEASE INDEX

SYMPTOM INDEX

General indices :

SIMPLE

INDEX

CUMULATIVE

INDEX

TREATMENTINDEX

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.

Indices for assessing

oral hygiene & plaque

ORAL HYGIENE INDEX

RULES OF ORAL HYGIENE

INDEX

1 Only fully erupted permanent teeth

are scored.

2. Third molars are not included

3. The buccal & lingual calculus scores areboth taken on the tooth in a segmenthaving the greatest surface area coveredby supra and subgingival calculus.

Developed in 1960 by John C. Green and Jack R. Vermillion

R

DEBRIS INDEX CRITERIA0 – No debris or stain present

1 – Soft debris covering not more than1/3rd the tooth surface, or presenceof extrinsic stains without other debrisregardless of the area covered.

2 – Soft debris covering more than 1/3rd, but not more than 2/3rd,of the exposed tooth surface.

3 – Soft debris covering more than 2/3rd of the exposed tooth surface.

CALCULUS SCORING CRITERIA

SCO

RE

CRITERIA

0 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

Calculation

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

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 reducedin height by caries or trauma are not scored

16 17,18

11 21

26 27,28

36 37,38

31 41

46 47,48

SURFACES TO BE EXAMINED

SUBSTITUTION

DI –S/CI-S = Total score/No of surfaces

OHI -S= DI-S+ CI-S

CALCULATION INTERPRETATION

DI –S and CI-S1. Good -0.0-0.62. Fair – 0.7-1.83. Poor – 1.9 -3.0

OHI-S1. Good - 0.0-1.22. Fair – 1.3- 3.03. Poor – 3.0 -6.0

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 BUCCAL

11 LABIAL

26 BUCCAL

36 LINGUAL

31 LABIAL

46 LINGUAL

PROCEDURE

Apply a disclosing agent before scoring.

Patient is asked to swish for 30 sec and thenexpectorate but not rinse.

Examination is made by using a mouth mirror.

Each of the 5 subdivisions is scored for presence ofstained debris:

0= No debris(or questionable)

1= Debris definitely present.

Debris score for individual tooth:

Add the scores for each of the 5 subdivisions.

PHP index for an individual= (Sum of debris score/number ofdebris score)

SCORING CRITERIA

Excellent : 0 (no debris)

Good : 0.1-1.7

Fair : 1.8 – 3.4

Poor : 3.5 – 5.0

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.

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.

TURESKY – GILMORE- GLICKMAN MODIFICATION OF THE QUIGLEY – HEIN PLAQUE INDEX

Quigley G. Hein . J in 1962, plaque measurement thatfocused on the gingival third of the tooth surface. Theyexamined only the facial surfaces of the anterior teeth,using basic fuchsin mouthwash as a disclosing agent.

The Quigley-Hein plaque index was modified byTuresky S, Gilmore N.D and Glickman I in 1970..

Method:

Labial, Buccal and lingual surfaces are assessed afterusing disclosing agent.

INDEX SCORE= Total Score/ No of surfaces examined

0-1 = low

>2 = High

SCORING CRITERIA:

SCORE CRITERIA

0 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 2/3rd or more of

the crown of the tooth

Score Criteria

0 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 2/3rd of the

surface

QUIGLEY AND

HEIN

TURESKY et al

GINGIVAL INDICES

GINGIVAL INDEX

Developed by Loe H and Silness P in 1963.

For assessing severity of gingivitis,and its location by examiningqualitative changes of gingival tissues.

METHOD:

The severity of gingivitis is scored on all teeth or on selected indexteeth.

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

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

Use:

Severity of gingivitis, controlled clinical trials ofpreventive or therapeutic agents

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 orabsence of bleeding.

Redefinition of scoring system for mild and moderateinflammation.

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.

SCORING CRITERIA

Calculation:

Mesial and distal for papilla , labial and lingual formarginal and then adding the two and then dividing withno. Of teeth.

Uses:

Clinical trials of therapeutic agents

SCOR

E

CRITERIA

0 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

PAPILLARY – MARGINAL ATTACHMENT INDEX (PMA)

MAURY MASSLER AND SCHOUR .L 1944.

No. of gingival units effected were counted ratherthen 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 eachgingival unit is recorded and usually only maxillaryand mandibular incisors, canines and premolars wereexamined.

SCORING CRITERIA

score criteria

0 Normal

1 Mild papillary

enlargement

2 Obvious increase in

size , BO Pressue

3 Excessive inc in size,

spontaneous bleeding

4

5

Necrotic papilla

Atrophy and loss of

papilla

score criteria

0 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

Calculation of the Index

USES:

Clinical trials

On individual patients

Epidemiologic surveys

PMA = P+M+A

score criteria

0 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

GINGIVAL BLEEDING INDEX(AINAMO and BAY,1975)

Gingival bleeding index is based on recordings from all fourtooth 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 ofaffected sites.

USES:

In Experimental Studies

Routine Basis In Individual Patients

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.

MODIFIED SULCULAR BLEEDING INDEX

Developed by MOMBELLI,VAN OOSTEN & S.CHURCH ET.AL IN1987.

Scoring criteria :

SCORE 0 – No bleeding when probe is passed along thegingival margin

SCORE 1 – Isolated bleeding , spots visible

SCORE 2 – Blood forms a confluent red line on margins

SCORE 3 – Heavy or profuse bleeding

ORAL PIGMENTATION INDEX(DUMMET 1966)

CALCULATION:

Maxillary DOPI/number of teeth examined

Mandibular DOPI/number of teeth examined.

MEAN=maxillary DOPI + mandibular DOPI/2

SCORE CRITERIA

0 PINK TISSUE(no pigmentation)

1 Mild brown(light) tissue(mild pigmentation)

2 Moderate brown/mixed pink and brown tissue(moderate clinical pigmentation)

3 Deep brown/blue/black tissue(heavy clinical pigmentation)

INTERPRETATION:

0 - NO PIGMENTATION

0.03-1.0 - MILD PIGMENTATION

1.O3-2.0 - MODERATE PIGMENTATION

2.03-3.0 - SEVERE PIGMENTATION

GINGIVAL PIGMENTATION INDEXBY PEERAN ET AL 2014

CLASS CRITERIA OF CLASSIFICATION

I Coral pink/salmon pink colored gingiva

II Localized/isolated spots/areas of gingival melanin pigmentation which does not involve all the three parts of gingiva,that is attached,free and papillary gingiva Mild to moderate pigmentation Severe/intense pigmentation

III Localized/isolated unit/of melanin pigmentation which involve all the three parts of gingiva Mild to moderate pigmentation Severe/intense pigmentation

IV Generalized diffuse pigmentation

Mild to moderate pigmentation

Severe/intense pigmentation.

V Tobacco associated pigmentation like smoker’s melanosis

VI

Gingival pigmentation due to exogenous pigments eg:-Amalgam tattoos, Cultural

gingival tattooing, Drinks, Food colors, Habitual betelnut/khat chewing, Lead-

Burtonian line, Mercury, Silver, Arsenic, Bismuth, Graphite, Other foreign bodies,

Topical medications, Idiopathic.

VII Gingival pigmentation due to endogenous pigments like Bilirubin, Blood breakdown

products, Ecchymosis, Petechiae, Hemochromatosis, Hemosiderin.

VIII Drug-induced gingival pigmentation like ACTH, Antimalarial drugs,

Chemotherapeutic agentbusulfan and doxorubicin, Minocycline, Oral

contraceptives, Phenothiazines.

IX Gingival pigmentation associated with systemic diseases and syndromes like

Addison’s disease, Albright’s syndrome, Basilar melanosis with incontinence, Beta

thalassemia; Healed mucocutaneous lesions-Lichen planus, Pemphigus,

Pemphigoid; Hereditary hemorrhagic telangiectasia; HIV-associated melanosis,

Neurofibromatosis, Peutz-Jeghers and other familial hamartoma syndromes,

Pyogenic granuloma/Granulomatous epulis.

X Pigmented benign and malignant lesions involving the gingival like Angiosarcoma,

Hemangioma, Kaposi’s sarcoma, Malignant melanoma, Melanocytic nevus,

Pigmented macule.

PERIODONTAL INDICES

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.”

CRITERIA RADIOGRAPHIC FINDINGS

0 Negative. Neither overt inflammation in the investingtissues nor loss of function due to destruction ofsupporting bone.

Radiographic appearance isessentially normal.

1 Mild gingivitis. An overt area of inflammation in the freegingiva 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 likeresorption of alveolar crest.

6 Gingivitis with pocket formation. The epithelial attachmentis broken and there is a pocket. There is no interferencewith normal masticatory function; the tooth is firm in itssocket and has not drifted.

There is horizontal bone lossinvolving the entire alveolarcrest, up to half of the length ofthe tooth root.

8 Advanced destruction with loss of masticatory function.The tooth may be loose, may have drifted, may sound dullon percussion with metallic instrument, or may bedepressible in its socket.

There is advanced bone lossinvolving more than half of thetooth root, or a definiteintrabony pocket with wideningof periodontal ligament. Theremay be root resorption orrarefaction at the apex.

CALCULATION AND INTERPRETATION

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 scoresNo of teeth present

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.

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.

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

SCORING CRITERIA

CODE CRITERIA TREATMENT NEEDS

0 Healthy periodontium TN-0 No need of treatment

1 Bleeding observed during /after probing

TN-1 Self care

2 Presence of supra orsubgingival calculus

TN-2 Professional careScaling

3 Pathological pocket 4-5 mm.gingival margin situated onblack band of the probe.

TN-2 Scaling and root planning

4

X

Pathological pocket 6mm ormore. Black band of theprobe not visible

When only one tooth or noteeth are present in sextant

TN-3 Complex therapy by specially trained personnel

ASSESSMENT OF TOOTH MOBILITY

MILLER(1985) – has described the most common clinical method inwhich tooth is held between handles of the two instruments & movedback and forth or with metallic instrument and one finger.

Criteria:

SCORE 0- no detectable mobility

SCORE 1- distinguishable tooth mobility

SCORE 2- crown of tooth moves more than 1mm in any direction

SCORE 3 – movement of more than 1mm in any direction

GLICKMAN/ CARRANZA F.A (1972)–

GRADE 1- slightly more then normal

GRADE 2- moderately more than normal

GRADE 3 – severe mobility faciolingually and or mesiodistallycombined with vertical displacement.

WASERMAN ET.AL 1973

1- normal

2- slight- > ¾ mm of bucco-lingual movement

3- moderate- up to approximately 2mm movement bucco-lingually

4- severe- more than 2 mm.

LINDHE 1997: Degree 1 – movability of crown of tooth less than 1mm in

horizontal direction Degree 2 – movability of crown of tooth more than 1mm

in horizontal direction Degree 3 – movability of crown of tooth in vertical as well.

FURCATION

The furcation is the point at which the two roots divide.

A pocket measuring probe is used (naber’s probe).

RAMFJORD AND ASH FURCATION INDEX:

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 3 Through and through defect

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.

MILD(2) White opaque areas in enamel are more extensive,but

do not involve as much as 50% of tooth.

MODERATOR(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.

TRAUMA FROM OCCLUSION

BY JIM AND CAO 1992

0 No tooth mobility during habitual centric closure and

excessive mandibular movements.

1 Tooth mobility detected only in centric closure or

excessive movements.

2 Significant tooth mobility detected during centric closure

and excessive movements.

WOUND HEALING INDEX

BY HUANG et.al 2005

SCORE DESCRIPTION

1 Uneventful wound healing with no gingival

edema,erythema,suppuration,patient

discomfort or flap dehiscence.

2 Uneventful wound healing with slight gingival

edema,erythema,patient discomfort,or flap

dehiscence,but no suppuration

3 Poor wound healing with significant gingival

edema,erythema,patient discomfort,flap

dehiscence or any suppuration

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.

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