Professional Documents
Culture Documents
Contents
1. Introduction
2. Definition
a. Index
b. Periodontal disease
3. Various Indices of Periodontal disease
a. Periodontal Index
b. Periodontal Disease Index
c. Gingival Periodontal Index
d. Gingival Bone Count Index
e. Extent and Severity Index
f. Community Periodontal Index of Treatment Needs
g. Community Periodontal Index
h. Navy Periodontal Disease Index
i. Gingivitis Periodontitis Missing Teeth index
j. Periodontitis Severity Index
k. Periodontal Screening & Recording
4. Conclusion
5. References
Introduction
Health examination is not completer without the oral health assessment. Regular
assessment of dental diseases have been seen to be important as they keep on
varying in occurrence and severity. This has to be measured both qualitatively and
quantitatively and the measure of these parameters are taken by an ‘Index’ (plural
– Indices). It is a very important tool in the branch of dental public health and in
the study of epidemiology. (2)
Definitions
An ‘Index’ has been defined by ‘Russell’ as “A numerical value describing the
relative status of a population on a graduated scale with definite upper and lower
limits, which is designed to permit and facilitate comparison with other
populations classified by the same criteria and methods.” (2)
“Periodontal disease” means disease involving either or all of the attachment
apparatus of a tooth. Many researchers place gingival diseases also under the
heading of Periodontal diseases while others differentiate the two.
Periodontitis is a bacterially induced inflammation of the gingival tissues together
with loss of both the attachment of the periodontal ligament and bony support. (4)
Various Indices of Periodontal disease
However nowadays this index in not used much in epidemiologic surveys because
of the introduction of new periodontal indices and refinement of criteria amid
increasing periodontal research. (1)
The PI was intended to estimate deeper periodontal disease by measuring the
presence or absence of gingival inflammation and its severity, pocket formation,
and masticatory function. (1, 2) The scale of value for the PI ranges from 0 – 8 with
increasing prevalence and severity of disease. The PI is a composite index
because it records both the reversible changes due to gingivitis and the more
destructive and presumably irreversible changes brought by deeper periodontal
disease. (1) Because of this, it is an epidemiological index with a true biological
gradient. (8)
Method
All the teeth present are examined. Gingival tissue is assessed for gingival
inflammation and periodontal involvement. (1, 2) Third molars are not taken into
consideration. (5)
Instruments used (3, 9)
Mouth mirror and explorer are supplemented occasionally by straight jaquette
scaler or the chip blower for demonstration of a periodontal pocket. (9) Periodontal
probing was not recommended because, according to Russell, it added little and
proved to be a troublesome focus of examiner disagreement. (3)
Scoring (1)
Score
Criteria (for field studies) Additional radiographic
criteria for clinical studies
Reversible
Clinically normal supportive 0 – 0.2
tissues
Simple gingivitis 0.3 -0.9
Irreversible
Established destructive 1.6 – 5.0
periodontal disease
Terminal disease 3.8 – 8.0
Uses of PI (1, 3)
1. Used in epidemiological surveys.
2. More data can be assembled using PI than most other indices of periodontal
disease.
3. Used in the national Health Survey (NHS), the largest ongoing health
survey in the United States. (1)
4. The PI is fast and easy to use. (3)
5. Use of the PI requires a minimum of equipment: a light source, a plane
mouth mirror and an explorer. (3)
6. PI serves well for making an overall assessment of the periodontal status of
a population. It is also important because a number of epidemiological
surveys have been conducted world over using this index. (5)
Drawbacks of PI
1. Since no caliberated probe or essentially radiographs are used when
performing the PI examination, the results tend to underestimate the true
level of periodontal disease, especially early bone loss in a population.
2. The number of periodontal pockets without obvious supragingival calculus
is also underestimated in the periodontal index. (1, 2)
3. It doesn’t indicate the degree of periodontal tissue destruction. (5)
4. Modern understanding has shown the PI to be invalid because it does not
include evaluation of Clinical Attachment Loss (CAL), grades all pockets
of 3 mm or more equally and scores gingivitis and Periodontitis on the
same weighted scale. (4)
Periodontal status
Beginning in segment one, the mesiofacial line angle of every tooth erupted to the
occlusal plane is probed with a Merritt type probe. (1) (It is round, single bend to
shank) (7)
1. In probing, the distance from the gingival margin to the Cemento Enamel
Junction (CEJ) is noted. Then the probe is advanced to the depth of the
pocket and this depth from the gingival margin is noted. Subtracting the
first reading from the second one gives the amount of loss of periodontal
attachment.
2. The recording is made at the mesiofacial or buccal line angle with the probe
directed in the long axis of the tooth.
3. The probe tip is directed along the crown toward the CEJ at a 45° angle
until the junction is located.
The criteria for scoring periodontal status are as follows:
Score Criteria
0 Probe doesn’t extend 1mm apical to the CEJ of any tooth in the segment &
no exposure of CEJ.
4 Probe extends up to 3 mm apical to CEJ of any tooth in segment
5 Probe extends from 3mm to 6mm apical to CEJ of any tooth in segment
6 Probe extends from 6mm or more apical to CEJ of any tooth in segment
The highest score found on any tooth in a segment is recorded as the periodontal
score for the segment.
Compiling the Gingival Periodontal Index
The highest score (either gingival or periodontal) found for each dentulous
segment is recorded and the sum is divided by the number of segments to give the
GPI score for the individual.
Uses (2)
1. To monitor patient progress
2. For epidemiologic surveys
The average Gingival score (G) per person is added to the average bone (B) score
per person to yield the GB count per person = 8 (maximum)
Shetham A and Striffler D F developed an index similar to the Bone count
component index similar to the Bone count component of the Gingival Bone count
index in 1970. The criteria used for evaluating radiographs are as follows:
Score Criteria
0 Normal
4 Lack of continuity of cortical plate at the crest of interdental bone,
with possible widening of Periodontal Ligament.
5 Up to 1/3rd of supporting bone lost
6 More than 1/3rd and up to 2/3rd of supporting bone lost
7 More than 2/3rd of supporting bone lost
Procedure
To obtain the ESI, use a random procedure (e.g., a coin toss) to select which upper
quadrant to examine. The contralateral quadrant in the lower arch is then
automatically decided. Afterwards, mid-buccal and the mesio-buccal aspects of
each tooth using the Ramfjord procedure. This results in a maximum of 28
measurements (i.e. a maximum of 14 measurements in each quadrant) for each
subject.
Third molars are not examined.
For the ESI, a tooth site is considered diseased only when loss of attachment
exceeds 1 mm. So as stated earlier, disease extent, E, is expressed as the
percentage of sites among examined sites with an LPA greater than 1 mm. Disease
severity, S, is expressed as the mean loss of attachment, in excess of 1 mm, for
affected or diseased sites. So, the ESI is written as follows where E is rounded off
to the nearest whole number.
ESI = (E, S)
An ESI expressed as (27, 1.34) means, on average, 27% of sites examined showed
evidence of disease, with an average severity of 1.34 mm loss of attachment per
diseased site.
In addition, for interpretation, an ESI of (60, 2.0) suggests a generalized but mild
form of periodontal disease whereas an ESI of (20, 6.0) suggests a severe localized
form of periodontal involvement.
This index was developed for the “Joint Working Committee” of the World Health
Organization” and “Federation Dentaire Internationale” (WHO/ FDI) by Jukka
Ainamo, David Barmes, George Beagrie, Terry Cutress, Jean Martin and Jennifer
Sardo-infirri in 1978 (2)
This index was developed primarily to survey and evaluate periodontal treatment
needs rather than determining past and present periodontal status, i.e., the
recession of the gingival margin and alveolar bone. The CPITN is an evolution of
the “621” method, named for the WHO Technical Report Series (TRS) publication
number in which this method was first featured. (1)
Having accepted that periodontal disease is one of the most wide spread diseases
of mankind, the Oral health unit of the World Health Organization (WHO) took
the initiative to organize a group of experts from 14 member countries to examine
and advise on the epidemiology, etiology and prevention of periodontal diseases.
The assessment of gingivitis, pathological pockets and numbers of erupted teeth
were considered basic to data requirements. For population studies and field trials,
having the objective of developing a method for the evaluation of treatment needs,
recording of plaque was considered less important than the assessment of its
consequences, gingival bleeding and pocket formation. Gingival recession and
tooth mobility were also excluded from the recordings. As far as calculus is
concerned, it was included as being necessary to any study of treatment need. (2)
Treatment needs
It implies that CPITN assesses only those conditions potentially responsive to
treatment, but not non-treatable or irreversible conditions (i.e. recession,
attachment level).
Reasons for attempting to control periodontal disease and promote good
periodontal care include, improved quality of life, enhanced general well-being
and appearance, reduced halitosis, elimination of bleeding from the gums, reduced
potential threat to longevity of teeth, and improved mastication. (1)
In order to determine periodontal disease status, the group supported the use of a
partial mouth recording system with scores being taken with the aid of a probe
from two surfaces of six teeth. Originally, in the maxilla, these were the facial and
mesial aspects of the right first molar (16 – FDI notation), left central incisor (21)
and left first premolar (24) and in the mandible, the lingual and mesial aspects of
the left first molar (36), right central incisor (41) and right first premolar (44).
This selection of teeth was as proposed by Ramfjord (1959) for partial mouth
recording of periodontal disease.
The recordings were made in the following order, for the presence or absence of:
1. Supragingival calculus
2. Subgingival calculus
3. Pocket depths of 4 or 5 mm
4. Pocket depths of 6 mm or more
5. Gingival bleeding after probing
6. Recession (eventually recession scores were discarded). (2)
Sextants
Six sextants (depicted based on FDI notation)
17 – 14 13 – 23 24 – 27
47 – 44 43 -33 34 – 37
The third molars are not included, except where they are functioning in place of
second molars. The treatment need in a sextant is recorded only if there are two or
more teeth present and not indicated for extraction. When only one tooth remains
in a sextant, it is included in the adjacent sextant.
Index teeth
In epidemiological surveys assessing the periodontal treatment needs of a
population, the recordings per sextant are based on findings from specified index
teeth.
In epidemiological surveys for adults, aged 20 years or more, only ten teeth,
known as the “Index teeth” are examined. These teeth have been identified as the
best estimators of the worst periodontal condition of the mouth.
The ten specified index teeth are: (according to FDI notation)
17, 16, 11, 26, 27
47, 46, 31, 36, 37
The molars are examined in pairs and only one score, the highest is recorded. Only
one score is recorded for each sextant.
For young people up to 19 years, only six ‘Index teeth’ are examined. The second
molars are excluded as index teeth at these ages because of the high frequency of
false (non-inflammatory, associated with tooth eruption) pockets. The six ‘index
teeth’ selected are:
16, 11, 26,
46, 31, 36
When examining children less than 15 years pockets are not recorded although
probing for bleeding and calculus are carried out as routine.
For use in a clinical setting, all teeth are examined per sextant and the CPITN
recording is based on the worst finding from all teeth in that sextant. This method
is also suitable for adult populations with a history of high caries prevalence and
extensive restorative treatment. In contrast, research states that full mouth
examination based on sextant has little advantage over partial examination of the
index teeth for age groups up to 20 years (Ainamo, Barmes, Beagrie, Cutress,
Martin, and Sardo-infirri, 1982)
Whenever feasible, the findings in every tenth or twentieth subject should be
recorded both by examination of index teeth and by the worst finding per sextant
so that the results obtained by partial examination can be subjected to analysis of
reliability. (2)
There is no rule specifying the number of separate probings to be made. This will
depend on the condition of the tissues surrounding the tooth. When only the index
tooth or teeth are being examined or when the recording is based on the worst
finding in all teeth of the sextant, it would be rare to exceed four probings per
sextant. (2)
Recording Data
The following box chart is recommended as the epidemiological and dental office
chart for recording CPITN data.
Probing procedure
A tooth is probed to determine pocket depth and to detect subgingival calculus and
bleeding response. The probing force can be divided into a ‘working component’ –
to determine pocket depth and a ‘sensing component’ – to detect subgingival
calculus. The working force should not be more than 20 grams – a practical test
for establishing this force is to gently insert the probe point under the finger nail
without causing pain or discomfort.
FIGURE – NAIL
The probe is inserted between the tooth and the gingiva, and the sulcus depth or
pocket depth is noted against the colour code or measuring lines. The ball end of
the probe should be kept in contact with the root surface. The direction of the
probe during insertion should, whenever possible be in the same plane as the long
axis of the tooth. For ‘sensing’ subgingival calculus, the lightest possible force
which will allow movement of the probe ball point along the tooth surface is used.
Pain to the patient during probing is in most cases indicative of the use of a too
heavy probing force.
Recommended sites for probing are mesial, mid line and distal, both on facial and
lingual/ palatal surfaces. The probing may be done by withdrawing the probe
between each probing or alternatively, with the probe tip remaining in the sulcus,
the probe may be ‘walked’ around the tooth. Sites in addition to the recommended
ones should be probed if there is suspicion that a higher scoring condition is
present.
When gently inserting the probe into the gingival pocket, the ball tip should follow
the anatomic configuration of the tooth root surface. The probing may be done by
withdrawing the probe between each probing or by the probe tip remaining in the
sulcus or pocket in order to walk the probe around each surface (i.e. buccal and
lingual) of the tooth (Cutress, Ainamo and sardo-infirri, 1987). “Walking” the
probe should be done with short upward and downward movements.
After probing, the gingiva or gum of the examined tooth should be inspected for
the presence or absence of bleeding before the subject is allowed to swallow or
close their mouth. Bleeding may be delayed for up to 10 – 30 seconds after
probing.
The depth of a pocket is not necessarily related to the amount of attachment loss.
The CPITN differentiates between pockets of 4 or 5 mm and 6 mm or deeper
because of the currently accepted different approach to their treatment. Oral
hygiene and scaling will usually reduce inflammation and bring a 4 or 5 mm
sulcus depth or below 3 mm. Sextants with such pockets are placed in the same
treatment category as calculus and other plaque retentive factors i.e., scaling and
root plaining. (TN -2)
On the other hand, for patients with deep pockets even after scaling, root plaining
and control of bleeding by oral hygiene, there will generally be residual pockets.
The treatment of these conditions may require “complex therapy” for which
skilled clinically trained and experienced dental personnel are needed. This need
for complex treatment is recognized as “Treatment need 3” (TN -3)
A sextant scoring code 4 also will fall in “Treatment need 3” (TN -3)