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Good Morning

6/5/12

INDICES FOR ASSESSMENT OFClick to edit Master style PERIODONTAL DISEASES

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Presented by : Dr. Shivi 6/5/12 Khattri

CONTENTS
1)INTRODUCTION 2)PERIODONTAL INDEX

(PI) 3)PERIODONTAL DISEASE INDEX (PDI) 4)GINGIVAL PERIODONTAL INDEX (GPI) 6/5/12 5)GINGIVAL BONE COUNT

7) COMMUNITY PERIODONTAL

INDEX OF TREATMENT NEEDS(CPITN)

8) COMMUNITY PERIODONTAL

INDEX (CPI)
9) PERIODONTAL SCREENING &

RECORDING (PSR)
10) CONCLUSION 11) REFERENCES
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INTRODUCTION
Periodontal disease is a

major oral disease of universal occurrence.

It includes all pathological

conditions of the periodontium, viz. the gingival and supporting structures

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 Uses of EPIDEMIOLOGY

in the study of DISEASE

PERIODONTAL

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 Studies using periodontal

indices :
Surveys on prevalence &

incidence. studies.

Longitudinal experimental Controlled clinical trials on

a small well-controlled group.

Surveys to assess periodontal
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PERIODONTAL INDEX (PI)

Developed by :

RUSSELL A.L.
Year :

1956
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 Type : Composite

reversible irreversible

Full mouth index

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 Objective :
Intended to estimate

deeper periodontal disease.

Method : All the teeth present are

examined.
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 SCORING CRITERIA :

(adapted by Russell A.L.)

0 : Negative Neither overt inflammation in the investing tissues nor loss of function due to destruction of supporting 6/5/12 tissue.

 1 : Mild gingivitis.

An overt area of inflammation in the free gingiva does not circumscribe the tooth.

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2 : Gingivitis

Inflammation completely circumscribes the tooth, but there is no apparent break in the epithelial attachment.

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4 : Usually used

when radiographs are available. There is early notch like resorption of alveolar crest
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6 : Gingivitis with

Pocket Formation. The epithelial attachment has been broken and there is a pocket (not merely a deepened gingival crevice due to swelling in free gingivae). There is no interference with masticatory function; the tooth is firm in socket and 6/5/12 has not drifted.

There is horizontal bone loss involving the entire alveolar crest, upto half of the length of the tooth root.

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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.
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 There is advanced bone

loss involving more than half the tooth root, or a definite infrabony pocket with widening of periodontal ligament.
There may be root

resorption or rarefaction 6/5/12 at the apex.

RUSSELLS RULE :

When in doubt assign the lower score.

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RECORDING FORM FOR RUSSELL S PERIODONTAL INDEX

18 17 16 15 25 26 27 28 14 13 12 11 21 22 23 24

48 35

47 36

46 37

45 38

44

43

42

41 31

32

33

34

PI SCORE 6/5/12 =

Calculation :

PI Score = Sum of individual scores Number of teeth present

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GROUP PERIODONTAL INDEX SCORE AND CLINICAL MANIFESTATIONS CLINICAL CONDITION GROUP PI STAGE OF
SCORES
Clinically normal supportive 0-0.2 tissues Simple gingivitis 0.3-0.9

DISEASE

Beginning destructive periodontal disease Established destructive periodontal disease Terminal disease

0.7-1.9

Reversible

1.6-5.0

Irreversible

3.8-8.0

Irreversible 6/5/12

INDIVIDUAL PERIODONTAL INDEX SCORE AND CLINICAL MANIFESTATIONS INDIVIDUAL PI SCORES CLINICAL CONDITION
Clinically normal supportive tissues Simple gingivitis 0-0.2

0.3-0.9

Beginning destructive periodontal 0.7-1.9 disease Established destructive periodontal disease Terminal disease 1.6-4.9

5.0-8.0 6/5/12

Drawbacks : Results tend to

underestimate the true level of the periodontal disease.

Number of pockets without

obvious supragingival calculus is also underestimated.

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(Periodontology 2000)

Much information on the relative severity of periodontal destruction in the different populations of the world was generated through the 6/5/12 use of the

Uses :
Epidemiological surveys. More data can be assembled

using PI.
In National Health Survey

(NHS) the largest ongoing health survey in U.S.

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PERIODONTAL DISEASE INDEX (PDI)

Developed by :

Sigurd P. Ramfjord
Year :

1959
Records the attachment level

of periodontal tissues 6/5/12 relative to CEJ.

PI v/s PDI

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 The Periodontal Disease

Index system as introduced by Ramfjord differed from the Periodontal Index system in several respects.

It described 3 degrees of

severity for gingivitis (scores 1, 2 and 3); it measured the distance from the cementoenamel junction with a 6/5/12 periodontal probe graduated in

Altogether, the Periodontal

Disease Index system relied on probing measurement, and thus offered much greater potential and quantifying periodontal destruction than the Periodontal Index system.
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The question was raised

(Loe H.) as to whether the quality (of the gingiva) and quantity (of destruction or attachment loss) were compatible components in a single statistical entity.

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Objectives : I. Assess prevalence & severity.

I. Accurate basis for

incidence & longitudinal studies.

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COMPONENTS OF PDI : I.

Plaque Component

II. Calculus Component III.Gingival & Periodontal

component

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Scoring methods : Only 6 teeth selected:

16, 21, 24, 36, 41, 44.

For gingiva - Changes in :

Color, form, consistency, contour is detected. depth Recording of crevice 6/5/12

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Score 0 1 2 3

Scoring criteria :
Absence of inflammation. Mild to moderate inflammatory gingival changes not extending all around the tooth. Mild to moderately severe gingivitis extending all around the tooth. Severe gingivitis, characterized by marked tendency to bleed, and ulceration. redness,

Criteria

Gingival crevice in any of the four measured areas (mesial, distal, buccal, lingual), extending apically to CEJ but not more than 3mm. Gingival crevice in any of the four measured areas extending apically 3-6mm from the CEJ. Gingival crevice in any of the four measured areas 6/5/12 extending apically more than 6mm from the CEJ.

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 Calculation of PDI score

: PDI =

Total of Individual Tooth Scores No. of Teeth examined

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II) Plaque component of PDI

The index was the first

one that used a numerical scale to assess the extent of plaque covering the surface area of the tooth.

Selection of teeth Method : Done after staining with

Bismarck Brown solution.

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SCORING CRITERIA
Score Criteria 0 No plaque present 1 Plaque present on some but not on all interproximal, Only fully buccal, and lingual erupted teeth surface of the tooth. should be scored. Missing teeth 2 Plaque present on all should not be interproximal, buccal and substituted. lingual surfaces, but covering less than one half of these surfaces. Plaque extending over all interproximal, buccal and

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Calculations : Plaque score = Total Score No. of teeth examined

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III) CALCULUS COMPONENT OF PDI Assesses the presence

& extent of calculus of 6 index teeth.

Teeth and surfaces examined :

The facial (buccal/labial) and lingual surfaces of index teeth are examined.

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Method : Evaluation is

done using a mouth mirror and a dental explorer and/or a periodontal probe.
Score 0 1 Criteria Absence of calculus. Supra gingival calculus extending only slightly below the free gingival margin (not more than 1mm) Moderate amount of supra gingival and sub gingival calculus or sub gingival calculus alone. An abundance of supra gingival 6/5/12 and sub gingival calculus

 Calculation of the

index : calculus score of individual = Total score No. of teeth examined

Has high degree of examiner

reproducibility.

Can be performed quickly.

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Uses : Epidemiological surveys. Longitudinal studies in

periodontal diseases.

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RECORDING FORM FOR RAMJFORDS PERIODONTAL DISEASE INDEX

Plaque Component (Shick & Ash

modification)
F

16

21
L

24

L Score:

46

41

34
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RECORDING FORM FOR RAMJFORDS PERIODONTAL DISEASE INDEX

Calculus Component

16

21
L

24

L Score:

46

41

34
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Gingival & Periodontal

Component : 16 21 24

Score: 44 41 34

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GINGIVAL PERIODONTAL INDEX (GPI) : Developed by

OLeary T.J., Gibson W.A., Shannon I.L., Schuessler C.F. and Nabers C.L. Year : 1963

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Modification of PDI. Screens the individuals

who need periodontal treatment.

Assesses three components of

periodontal disease:
Gingival status Periodontal status (crevice

depth)

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Segmentation of the

mouth : 18 to 14 13 to 23 24 to 28 38 to 34 33 to 43 44 to 48
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 Method :

Done on all teeth present. Assessment is done segment wise.

Objective :

To determine the tooth or its surrounding tissues, with the severest condition within each segment.
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Score 0 1

Gingival Status :
Criteria Tissue tightly adapted to the teeth, firm consistency with physiologic architecture. Slight to moderate inflammation, as indicated by changes in gingival color, loss of normal consistency, blunting and slight enlargement of marginal or papillary gingiva, involving one or more teeth in the same segment, but not completely surrounding any one tooth. The above changes (Score 1) either singly or combined completely encircle one or more teeth in a segment. Marked inflammation, as indicated by loss of surface continuity (ulceration), spontaneous hemorrhage, loss of faciolingual continuity or any interdental, marked deviation from normal contour (such as gross thickening or enlargement covering more than onethird of the anatomic crown), recession, and clefts.
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Area with the highest score determines the gingival score for the segment. Gingival status for mouth : Sum of gingival scores No. of segments
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Periodontal status : Beginning in segment 1, the mesio-facial line angle of every tooth erupted to the occlusal plane is probed with a Merritt type probe.

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Score
0

Criteria

The probe does not extend 1mm apical to the CEJ of any tooth in the segment and there is no exposure of the CEJ on any surface of any tooth in the segment. The probe extends up to 3mm apical to CEJ of any tooth in the segment. The probe extend from 3mm to 6mm, apical to the CEJ of any tooth in the segment.

The probe extends 6mm or more apical to the CEJ of any tooth in the segment.

The highest score on any tooth in the segment is the periodontal score for the segment.

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Compiling the GPI :

GPI score = Sum of the highest scores for each dentulous segment The number of segments

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GINGIVAL BONE (GB) COUNT INDEX

Developed by :

Dunning J.M. & Leach L.B.

Year : 1960 Records the gingival

condition and the level of the crest of the alveolar bone.

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Scoring criteria :

Gingival Score (Gingivitis): (One score is assigned to each tooth studied, and a mean is computed for the whole mouth)

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Score Criteria 0 1 Negative (no gingivitis) Mild gingivitis involving free gingiva (margin, papilla or both). Moderate gingivitis involving both free and attached gingivae. Severe gingivitis with enlargement and easy hemorrhage.
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* Maximum score = 3

Bone Score (Bone Loss):

(One score is assigned to each tooth studied visually or by xray, and a mean is computed for the whole mouth.)

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Score 0

Criteria No incipient bone loss.

Incipient bone loss or notching of crest.

alveolar

Bone loss approximating one-fourth of root length or pocket formation one side not over one-half root length. Bone loss approximating one-half of root length or pocket formation one side not over three-fourths of root length; Mobility slight. Bone loss approximating three-fourths of root length or pocket formation one side to apex; Mobility moderate Bone loss complete; Mobility marked.
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* Maximum score = 5

The average Gingival

(G)score per person is added to the average bone (B) score per person to yield the GB count per person. Maximum possible GB count per person = 8

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EXTENT AND SEVERITY INDEX (ESI) Developed by :

J.P. Carlos, M.D. Wolfe, A. Kingman.
Year : 1986

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COMMTUNITY PERIODONTAL INDEX OF TREATMENT NEEDS Developed for the Joint (CPITN) working committee of the
W.H.O. & F.D.I. by : Jukka Ainamo., David Barmes., George Beagrie., Terry Cutress., Jean Martin., Jennifer SardoInfirri.
Year : 1982
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Objective : To evaluate

periodontal treatment needs.

Uses :

1) Periodontal epidemiology. 2) In a promotional role in developing periodontal health problems. 3) For initial screening. 4) For monitoring changes in periodontal needs of individuals.
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 Advantages :

1) Simplicity 2) Speed 3) International uniformity.

Limitations :

1) Partial recording. 2) Exclusion of important signs of periodontal breakdown.

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Treatment needs Procedure for CPITN Sextants Index teeth Recording data

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WHO Periodontal Examination Probe CPITN Probe :

Tip and shank, and shank and handle include angles of 90 and 30 respectively.
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Walking of the probe

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Codes CODE X

Criteria When only one tooth or no teeth are present in a sextant (third molars are excluded unless they function in place of second molars ) Pathological pocket of 6mm or more present i.e., the black area of CPITN probe is not visible.

CODE 4

CODE 3

Pathological pocket of 4mm or 5mm present i.e., when the gingival margin is on the black area of the probe. Calculus or other plaque retentive factors such as ill fitting crowns or poorly adapted edges of restorations are either seen or felt during probing. Bleeding observed during or after probing. Healthy tissue; No signs of disease.
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CODE 2

CODE 1 CODE 0

 Code 0 No Periodontal

Disease (Healthy Periodontium)

Code 1 Bleeding

observed during or after probing

Code 2 Calculus or

other plaque retentive factors either seen or felt during probing

Code 3 Pathological

pocket 4-5mm in depth. Gingival margin situated on black band of the probe

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Examination procedure. Explanation of clinical

criteria.

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Substitution for excluded

and missing teeth.

in a sextant.

Presence of two more teeth

If in a posterior sextant, one of

the two index teeth are not present or has to be excluded, then the recording is based on examination of remaining index teeth.
If both index teeth in posterior
6/5/12 sextant are missing or excluded

If 11 is missing/excluded,

substitute 21. If 21 is also missing, identify the worst score for the remaining teeth. Similarly substitute 41 if tooth 31 is missing.
In subjects age < 20 yrs, if 1st

molar is not present or has to be excluded, nearest adjacent premolar is examined.

If all the teeth in a sextant are

missing or only one functional 6/5/12 tooth remains the sextant is coded

Classification of Treatment Needs

TN = 0 A recording of Code 0 (Healthy) or Code Y (missing) for all six sextants indicates that there is no need for treatment. TN = 1 A Code of 1 or higher indicates a need for improving the personal oral hygiene of that individual. TN = 2 A Code of 2 or higher indicates need for professional cleaning of teeth and removal of plaque retentive factors. In addition, the patient the requires oral hygiene instructions. Shallow to moderate pocketing (4-5mm Code 3). Oral hygiene and scaling will usually reduce inflammation & bring 4-5mm pocket values of 3mm or below 3mm. Thus sextants with these pockets are placed 6/5/12 in the same treatment category .

Calculation of CPITN :

Step I - Count the number of charts obtained with different codes individually (i.e., codes 0,1,2,3,4). Step II To obtain the prevalence (percentage) of subjects with codes 0,1,2,3,4 as their score, divide the counts of codes respectively, by the total number of dentate subjects examined.
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Modifications of CPITN : Simplified Periodontal

Examination (SPE) later termed as Basic Periodontal Examination (BPE).

Periodontal Screening and

Recording (PSR).
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COMMUNITY PERIODONTAL INDEX (CPI)Three Indicators.

indicators of periodontal status are used for this assessment: gingival bleeding calculus periodontal pockets

A specially designed

lightweight CPI probe6/5/12 with a

Sextants. The mouth is

divided into sextants defined by tooth numbers: 18-14, 13-23, 24-28, 38-34, 33-43, and 44-48.

A sextant should be examined

only if there are two or more teeth present and not indicated for extraction.

(Note: This replaces the 6/5/12 former instruction to include

 Index teeth. For adults

aged 20 years and over, the teeth to be examined are:

17 16 11 26 27 47 46 31 36 37

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Sensing gingival pockets and calculus.

An index tooth should be

probed, using the probe as a sensing instrument to determine pocket depth and to detect subgingival calculus and bleeding response.

The sensing force used should

be no more than 20 grams. A 6/5/12 practical test for

Score 0 1 2 3 4 X 9

Criteria Healthy. Bleeding observed, directly or by using mouth mirror, after probing. Calculus detected during probing, but all the black band on the probe visible. Pocket 4 - 5 mm (gingival margin within the black band on the probe). Pocket 6 mm or more (black band on the probe not visible). Excluded sextant (less than two teeth present). Not recorded.
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Score 3 Score 4 Score 0 Score 2 Score 1

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of Attachment Scores

Score Criteria 0 Loss of attachment 0-3 mm (CEJ not visible and CPI score 0-3) If CEJ is not visible and the CPI score is 4, or if the CEJ is visible. Loss of attachment 4-5mm (CEJ within the 6/5/12 black band)

Score 3

Criteria Loss of attachment 9-12mm (CEJ between the 8.5 mm and 11.5 mm rings) Loss 12 mm or more (CEJ beyond the 11.5 mm rings) Excluded sextant (Less than two teeth present) Not recorded (CEJ neither visible nor 6/5/12 detectable)

PERIODONTAL SCREENING AND RECORDING and effective It is a rapid

way to screen patients for periodontal diseases and summarizes necessary information with minimum documentation.
PSR is an adaptation of the

CPITN, which is endorsed by WHO and FDI for periodontal screening.

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 The American Dental

Association and the American Academy of Periodontology recommend that PSR to be conducted by dentists for all patients as an integral part of oral examinations.

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The objective of this

screening system is to examine every tooth individually. Implants are examined in the same manner as naturally occurring teeth. For screening, the dentition is divided into sextants.
The use of a periodontal

probe is mandatory. The recommended probe has a ball end 0.5mm in diameter. A 6/5/12 color-coded area extends from

 The probe tip is gently

inserted into the gingival crevice until resistance is met. The depth of insertion is read against the colorcoding. The total extent of the crevice should be explored by "walking" the probe around the crevice.

At least six areas in each

6/5/12 tooth should be examined:

3.5 to 5.5 mm mark

0.5 mm ball-tip

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PSR CODES :

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CODE X: Denotes edentulous sextant.

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CODE * Example: Recession This sextant exhibits gingival recession and mucogingival problems and therefore should include the * symbol next to the sextant code.

CODE * Example: Recession This sextant exhibits gingival recession and mucogingival problems and therefore should include the * symbol next to the sextant code 6/5/12

CODE * Example: Mucogingival Problems This sextant exhibits mucogingival problems and calculus and therefore should include the * symbol next to the sextant code.

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A special form is

used to document the PSR codes for each sextant.

For example, the PSR

3 2 1 3 3 4* Sexta nt score 0 5 14 2 0 0 4
Month Day Year

box chart would look like the chart shown below, for a PSR completed on May 14, 2004.
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On the sample PSR

Implications of PSR Codes

Code Code 0 Code 1 Further Clinical Documentation Reinforce daily plaque control habits. Reinforce daily plaque control habits. Provide appropriate treatment, including debridement of subgingival plaque.

Code 2

All above + debridement of supra- and subgingival calculus, and correction of plaque retentive margins of restorations. Code 3 If a single sextant scores Code 3, a comprehensive periodontal examination is indicated for that sextant. If two or more sextants score Code 3, a comprehensive periodontal examination is indicated for entire mouth. Code 4Comprehensive periodontal examination is indicated for entire mouth. 6/5/12 Code *If an abnormality is present in a sextant with a Code 0, 1, or 2 score note the

 Benefits :
Early detection Speed Simplicity Cost-effectiveness Recording ease Risk management
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CONCLUSION

If it is not in the chart, it didnt happen!!

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References :

Preventive and Community Dentistry, 3rd edition Soben Peter. Clinical Periodontology, 10th edition Carranza. Fundamentals of Periodontal Instrumentation, 3rd edition. Jill S. Nield-Gehrig, Ginger A. Houseman. Methodological issues in epidemiological studies of periodontitis - how can it be improved? - Biomed Central Oral Health. Roos 6/5/12 Leroy, Kenneth A Eaton, Amir Savage.

www.Google.com www.pubmed.org PERIODONTAL PROBING, Critical Reviews in Oral Biology & Medicine.

Epidemiological principles in studying

periodontal diseases. JAMES D. BECK& HARALDLO E Periodontology 2000, 1993, volume 2.

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Than k You !!
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A doctor who cannot take a good history and a patient who cannot give one are in
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