Indices of Periodontal disease

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 Periodontal Index (PI) (1, 2, 3, 5, 6)
This Index was developed by Russell A.L. (1956). It took him ten years to develop this index because of a lack of sophisticated methodologies to assess the prevalence and severity of gingivitis and destructive periodontal disease. (1) In earlier times, clinical appearance of the tissues of the anterior teeth was taken as the only basis for segregating individuals for epidemiologic studies of gingival and periodontal disease in large populations. These observations permitted evaluation of only relative proportions of affected and unaffected individuals in the populations under consideration. So, according to WHO the PI has made great strides to the epidemiology of periodontal disease due to its definition that very quickly achieved wide international acceptance. (WHO, 1999) 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 Criteria (1, 2) Russell chose the scoring values (0,1,2,4,6,8) in order to relate the stages of the disease in an epidemiological survey to the clinical conditions observed. Russell’s rule (1, 2, 5) According to Russell’s rule “When in doubt assign the lower score”. Calculation of the index The PI score per individual is obtained by adding all of the individual scores and dividing by the number of teeth present or examined. i.e. PI score per person = Sum of individual scores/number of teeth. PI score per group = Sum of scores of all individuals/number of individuals Scoring (1)

Score

Criteria (for field studies)

Additional radiographic criteria for clinical studies

0

Negative. No overt inflammation, nor loss of function due to destruction of supporting tissues Mild Gingivitis. An overt area of inflammation in the free gingiva, not circumscribing the tooth. Gingivitis. Inflammation completely circumscribing the tooth. No apparent break in the epithelial attachment. Used only when radiographs available

Normal appearance

1

2

4

Early notch like resorption of alveolar crest Horizontal bone loss in whole of the alveolar crest, up to half of the length of the tooth root Advanced bone loss involving >1/2 of tooth root or a definite infrabony pocket with widening of Periodontal ligament. There may be root resorption or rarefaction of apex

6 Gingivitis with pocket formation. The epithelial attachment has been broken & there is a true pocket. There is no interference in mastication. 8 The tooth is firm & not drifted. Advanced destruction with loss of masticatory function. The tooth may be loose, drifted with dull sound on percussion or may be depressible in its socket.

Group Periodontal Index score & Clinical manifestations Clinical Condition Clinically normal supportive tissues Simple gingivitis Beginning destructive periodontal disease Irreversible Established destructive periodontal disease Terminal disease 3.8 – 8.0 1.6 – 5.0 0.3 -0.9 0.7 – 1.9 Group PI scores 0 – 0.2 Stage of disease Reversible

Individual Periodontal Index (PI) score & clinical conditions Clinical Condition Clinically normal supportive tissues Simple gingivitis Beginning destructive periodontal disease Established destructive periodontal disease Terminal disease Individual PI scores 0 – 0.2 0.3 -0.9 1.0 – 1.9 2.0 – 4.9 5.0 – 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 Disease Index
Introduction: (3) As a consultant to the World Health Organization for a 1957 study o periodontal disease in India, Ramfjord was faced with the inadequacies of

the available indices for measuring periodontal disease. Taking the most valuable features of existing indices and adding new features to compensate for their shortcomings, Ramfjord developed his own system for measuring periodontal disease. This system became known as the Periodontal Disease Index (PDI). The Periodontal Disease Index (PDI) was developed by Siguard P. Ramfjord in 1959. (1) The PDI is a clinician’s modification of Russell’s Periodontal Index. As in the case of the PI, the PDI was developed due to a lack of methodologies to determine prevalence and severity and with the intent to be a more sensitive version of the PI for use in clinical trials. The PDI has been framed to be accurate for use in longitudinal studies. The PDI is primarily concerned with an accurate assessment of the periodontal status of the individual person. (1) Objectives (1, 2)
1. To assess prevalence and severity of gingivitis and Periodontitis within the

individual dentitions and in population groups. 2. To provide an accurate basis for longitudinal studies of periodontal disease. 3. To provide a meaningful basis for estimate of need for periodontal therapy in selected population groups. 4. To provide accurate recordings for clinical trials of preventive and therapeutic procedures in periodontics.
5. To provide measurable reference data for assessment of correlations with

factors of potential significance in the etiology of periodontal disease. The most important feature of PDI is measurement of the level of the periodontal attachment related to the CEJ of the teeth. Components of Periodontal Disease Index The PDI comprises of three components, namely: 1. Plaque component 2. Calculus component 3. Gingival and Periodontal component

Scoring methods Only six selected teeth are scored for assessment of the periodontal status of the mouth; however, for short term clinical trials and where a limited number of patients are available, one may concern all of the teeth in the mouth. The six selected index teeth are (according to FDI notation 16, 21, 24, 36, 41, 44). These are known as Ramfjord’s teeth. The gingival status is scored first. The gingivae around the teeth to be scored are first dried superficially by gently touching with absorbing cotton. Changes in colour are evaluated by observing the colour of the gingivae around the tooth to be scored and comparing the colour corresponding to the buccal, lingual and interproximal surfaces with each other, as well as comparing it with the colour of the gingiva around the adjacent teeth. Change in form is initially a blunting or rounding of the margin of the gingivae and thickening of papillae. However slight contour change alone is never scored as gingivitis. Presence or absence of stippling is not considered as related to gingival inflammation. Change in consistency is checked by applying gentle pressure with the side of periodontal probe against the gingiva to determine if there is a soft or spongy consistency. Any minor change either in contour, stippling or consistency alone is not considered to be a definite manifestation of gingivitis. Evidence of ulceration of the gingiva with bleeding is considered, if the gingiva is touched gently with the side of a periodontal probe, of if there is severe redness and marked change in contour. The next step is recording of crevice depth related to the CEJ. For this purpose, a “University of Michigan” number O probe is used. The end of the probe should be placed against the enamel surface coronally to the margin of the gingiva so that the angle formed by the working end of the probe and long axis

of the crown of the tooth is approximately 45°. Minimal force should be used to pass the probe in apical direction maintaining contact with the tooth. The probe should always be pointed towards the apex of the tooth or the central axis of multirooted teeth. After the distance from the free gingival margin to the CEJ has been measured, an attempt should be made to move the probe along the cemental surface. This can be achieved only if there has been loss of periodontal attachment. The University of Michigan number O probe is graduated at 3, 6 and 8 mm, making it necessary to estimate intervening measurements. The buccal measurements should be made at the middle of the buccal surfaces. The mesial measurement should be made at the buccal aspect of the interproximal contact area with the probe touching both teeth if there is a neighbour tooth present and the probe pointing in the direction of the long axis of the tooth to be scored. (1) Later on it was simplified by taking the score at the mesial surface of the tooth as representative of all surfaces. (6) The following criteria is used for crevicular measurements:1. If the gingival margin is on enamel, measure from gum margin to CEJ

and record the measurement. Then record the distance from the gingival margin to the bottom of the pocket. The distance from the CEJ to the bottom of the pocket can then be found by subtracting the first from the second measurement.
2. If the gingival margin is on cementum, record the distance from the

CEJ to the gingival margin as a minus value (a) then record the distance from the CEJ to the bottom of the gingival crevice as a positive value (b). Both loss of attachment and actual crevice depth can easily be assessed from these scores. (1, 2) Ramfjord’s method for measureing this distance is often referred to as the “Indirect method for measuring periodontal attachment loss” (3)

SCORING CRITERIA The scoring criteria for the Periodontal Disease Index is as follows: Score 0 1 2 3 4 5 6 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 redness, tendency to bleed & ulcerate Gingival crevice in any of the measured areas extending apical to the CEJ but not more than 3mm Gingival crevice in any of the measured areas of the tooth 3-6 mm apical to the CEJ. Gingival crevice in any of the measured areas more than 6mm apical to the CEJ. Calculation of the PDI score (1) The PDI score can be calculated for an individual and a group For Individual = Total of individual tooth scores/ Number of teeth examined For group = Total individual PDI score/ Number of people examined Either of the PDI score ranges from 0 – 6. (1, 2) If any of the six index teeth is missing, another tooth is not substituted in its place. (3) Uses: (1) 1. Epidemiologic surveys 2. Longitudinal studies in periodontal diseases Drawbacks: 1. Values marked on probe are 3, 6, 8 mm. Hence in between scores need to be estimated, hence leading to inter examiner bias.
2. It is more time consuming as compared to Russell’s Index. (6)

Although the PDI is rarely used nowadays, two aspects of the index are often used: Selection of the six Ramfjord teeth and the method for measuring pocket depth and loss of periodontal attachment. Ramfjord’s technique for measuring pocket depth and periodontal attachment loss (3, 4) has been used in national surveys (e.g. NHANES) (3)

Gingival Periodontal Index
Developed by O’Leary T J, Gibson W A, Shannon I L, Schuessler C F and Nabers C L, in 1963. This index is also known as “Periodontal Screening Examination” The GPI is a modification of the PDI of the Ramfjord for the purpose of screening individuals to determine who needs periodontal treatment. The GPI assesses three components of periodontal disease: gingival status; periodontal status (crevice depth); and collectively material alba, calculus and overhanging restoration. The latter triad is independently called as the “Irritation index”. Segmentation of the mouth The Dentition is divided into six segments: (According to FDI notation) 18 to 14, Method: Scoring is done on all teeth present. The assessment is done segment wise. Each segment is assessed for each of the three components of periodontal disease. The primary objective in using the index is to determine the tooth or its surrounding tissues, with the severest condition within each segment. Gingival status The specific criteria for the gingival status component of the GPI are as follows: Score Criteria 0 Tissue tightly adapted to the teeth, firm consistency with physiologic 1 architecture Slight to moderate inflammation, as indicated by changes in gingival colour, loss of normal consistency, blunting and slight enlargement of 13 to 23, 24 to 28, 38 to 34, 33 to 43, 44 to 48

marginal or papillary gingiva, involving one or more teeth in the same 2 3 segment, but not completely surrounding any one tooth. The above changes 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 papilla, marked deviation from normal contour (such as gross thickening or enlargement covering more than one third of the anatomic crown), recession, and clefts. The area with the highest score determines the gingival score for the entire segment, and the gingival status for the mouth is obtained by dividing the sum of the gingival scores by the number of segments. 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 5 6

Probe extends up to 3 mm apical to CEJ of any tooth in segment Probe extends from 3mm to 6mm apical to CEJ of any tooth in segment 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

Gingival Bone (GB) Count Index (1,2)
The GB count index was given by Dunning J M and Leach L B (1960) This index records the gingival condition and the level of the crest of the alveolar bone. This index permits differential recording of both gingival and bone conditions. The bone level is assessed by clinical examination but radiographs are recommended for greater accuracy. Subjective measurement of gingivitis is made on an arbitrary scale of 0 to 3 for each tooth, and proportionate measurement of bone loss is made on a 0 to 5 scale. Scoring

Gingival Score One score is assigned to each tooth studied, and a mean is computed for the whole mouth. Score 0 1 2 3 Criteria Negative Mild gingivitis involving free gingiva (margin, papilla or both) Moderate gingivitis involving both free and attached gingivae Severe ginigivitis with enlargement and easy hemorrhage.

Bone Score (Bone loss) (One tooth is assigned to each tooth studied visually or by radiographs and a mean is computed for the whole mouth.) Score 0 1 2 3 4 5 Criteria No bone loss Incipient bone loss or notching of alveolar crest Bone loss approximating 1/4th of root length or pocket formation on one side not over one half root length Bone loss approximate one half of root length or pocket formation on one side not over three fouth root length; mobility – slight Bone loss approximating three fourths of root length or pocket formation on one side to apex; mobility –moderate Bone loss – Complete; Mobility – marked

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 4 5 6 7

Normal Lack of continuity of cortical plate at the crest of interdental bone, with possible widening of Periodontal Ligament. Up to 1/3rd of supporting bone lost More than 1/3rd and up to 2/3rd of supporting bone lost More than 2/3rd of supporting bone lost

Extent and Severity Index (ESI)
This index was developed by J P Carlos, M D Wolfe and A Kingman (1986) to assess the extent (i.e. number of sites affected within the mouth) and severity (i.e. stage of advancement) of loss of Periodontal attachment (LPA) by determining the percentage of sites within the mouth with LPA greater than 1 millimeter (i.e. extent) and the mean LPA for affected sites (i.e. severity). The ESI utilizes the Ramfjord’s method to measure loss of periodontal attachment. The ESI was developed because of a lack of satisfaction with the previous indices of periodontal disease and because of the emergence of a newer conceptual model of periodontal disease by “Socransky and associates” The PI was based on a model in which periodontal disease was a slowly progressing, continuous disease process. It dealt with gingivitis as part of the biologic gradient that extended from health to advanced periodontal disease. In the newer model, periodontal disease is a chronic process, with intermittent periods of activity and remission that affects individual teeth and sites around teeth at different rates within the same mouth. (2) Some consider the ESI not to be a true index since it summarizes data and is descriptive rather than analytical. The ESI is considered to be a simple and reproducible procedure requiring minimal examiner training. It can be used in a variety of survey types such as cross sectional surveys and longitudinal studies. Furthermore, the ESI has

demonstrated relatively the same level of reliability in partial mouth examinations versus full mouth examinations. 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.

Community Periodontal Index of Treatment Needs (CPITN)
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) Scope and Purpose The CPITN procedure is recommended for epidemiological surveys of periodontal health. Also, it provides guidance on the planning and monitoring of the effectiveness of periodontal care programmes and the dental personnel required. The CPITN is a procedure which uses clinical parameters and criteria relevant to planning for the prevention and control of periodontal diseases. The CPITN is not intended as a comprehensive assessment of total past and present periodontal disease experience. The CPITN records the common treatable conditions, namely periodontal pockets, gingival inflammation (identified by bleeding of gentle probing) and dental

calculus and other plaque retentive factors. It does not record irreversible changes such as recession or other deviations from periodontal health such as tooth mobility or loss of periodontal attachment. The major advantages of CPITN are: 1. Simplicity 2. Speed, and 3. International uniformity Its limitations include partial recording, exclusion of some important signs of past periodontal breakdown – notably attachment loss and absence of any marker of disease activity or susceptibility. CPITN is therefore not a diagnostic tool and should not be used for planning of specific clinical treatment of individual patients. Primarily the CPITN is a screening procedure for identifying actual and potential problems posed by periodontal diseases both in the community and by the individual. With this information appropriate oral care services can be planned for populations and for individuals. 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)

Procedure for CPITN The dentition is divided into six parts (sextants) for assessment of periodontal treatment needs. Each sextant is given a score. For epidemiological purposes, the score is identified by examination of specific index teeth. For clinical practice, the highest score in each sextant is identified after examining all teeth. Sextants Six sextants (depicted based on FDI notation) 17 – 14 47 – 44 13 – 23 43 -33 24 – 27 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.

The WHO Periodontal Examination Probe – CPITN Probe Figure - CPITN Probe The recommended periodontal probe for use with CPITN was first described by WHO (TRS -621 – 1978). This probe was designed for two purposes, namely measurement of pocket depth and detection of subgingival calculus. The CPITN probe is both thin in the handle and is of very light weight (5 gms). This probe is particularly designed for gentle manipulation of the often very sensitive soft tissues around the teeth. The pocket depth is measured through colour coding with a black band starting at 3.5 mm and ending at 5.5 mm. The probe has a ball tip of 0.5 mm diameter that allows easy detection of subgingival calculus. This feature combined with the light probe weight facilitates the identification of the base of the pocket, thus decreasing the tendency for false reading by over measurement. A variant of this basic probe has two additional lines at 8.5 mm and 11.5 mm from the working tip. The additional lines may be of use when performing a detailed assessment and recording of deep pockets for the purpose of preparing a treatment plan for complex periodontal therapy. The Joint Working Committee of WHO/ FDI have advised the manufacturers of CPITN probes to identify the instruments as either ‘CPITN–E’ for the

epidemiological probe with 3.5 mm and 5.5 mm markings, or ‘CPITN–C’ for the clinical probe with additional 8.5 mm and 11.5 mm markings. 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. Codes and Criteria (1) The appropriate code for each sextant is determined with respect to the following criteria. The codes are listed in descending order of treatment complexity as follows: Code “X” When only one tooth or no teeth are present in a sextant (third molars are excluded unless they function in place of second molars) Code “4” Pathological pocket of 6 mm or more present i.e. the black area of CPITN probe is not visible. Recording of code 4 makes further examination of that sextant unnecessary. Code “3” Pathological pocket of 4 mm or 5mm present, i.e. when the gingival margin is on the black area of the probe. Note:- If the deepest pocket found at the designated tooth or teeth in a sextant is 4 or 5 mm, a code of 3 is recorded – there is no need to examine for calculus or gingival bleeding. Code “2” Calculus or other retentive factors such as ill fitting crowns or poorly adapted edges of restorations are either seen or felt during probing. Note:- If code 2 is attained, there is no need to examine for gingival bleeding.

tors such as ill fitting crowns or poorly adapted edges of restorations are either seen or felt during probing. Note:- If code 2 is attained, there is no need to examine for gingival bleeding. Code “1” Bleeding observed during or after probing. Note:- If neither pathological pocket nor calculus is observed, but bleeding occurs after gentle probing, a code of 1 is recorded for the sextant. Code “0” Healthy tissue; No signs of disease is observed. Examination procedure (1) The aim is to determine the highest score applicable to each sextant with the least number of measurements. First decide whether the sextant can be validly scored. The requirement is that more than one functional tooth is present. If ‘no’, then score ‘x’ and move to next sextant. If ‘yes’, examine index teeth (in epidemiological procedure), or examine all teeth (for clinical screening procedure), for presence of 6mm or deeper pockets, 4 or 5 mm deep pockets, calculus or other plaque retentive factor, bleeding only, in that order. Determine appropriate highest score for each sextant. As soon as the highest scored criterion has been determined there is no need to examine for the presence of lower score criteria. Classification of treatment needs (TN) A recording of Code 0 (healthy) or code X (missing) for all six sextants indicates that there is no need for treatment (TN - 0) Bleeding is a sign of early disease which can be overcome by self care following suitable oral health education and instruction. Control of bleeding by means of self care is a pre- requisite for all periodontal therapy. This treatment is recognized as “Treatment need 1” (TN -1)

The control or elimination of gingival bleeding should be a prime goal even if further treatment is not available. Although not pathological in themselves, calculus and other plaque retentive factors favour plaque retention and inflammation. Unlike plaque that can be eliminated through self care, the removal of calculus and other plaque – retentive factors demands the professional care defined as ‘Treatment need 2’ (TN -2)

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. * Therefore, a CPITN code of 2 or 3 means 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” A sextant scoring code 4 also will fall in “Treatment need 3” Substitution for excluded and missing Index teeth The index (and substitute) teeth are excluded from the CPITN scoring when the decision has been made to go for extraction due to any cause. (1) The indication for extraction because of periodontal involvement is that the tooth has vertical mobility and causes discomfort to the patient. (2) The ten CPITN index teeth are the first and second molars in the posterior sextants and a central incisor in each of the two anterior sextants. When one or more of the (TN -3) (TN -3) (TN -2)

index teeth are missing or excluded at the time of examination, substitute teeth are selected, using the following rules. 1. Remember that 2 or more functioning teeth must be present in a sextant for it to qualify for scoring. 2. If in a posterior sextant, one of the two index teeth is not present or has to be excluded, then the recording is based on the examination of the remaining index tooth. 3. If both index teeth in a posterior sextant are absent or excluded from the examination, all the remaining teeth in that sextant are examined and the highest score is recorded. 4. In the anterior maxillary sextant if tooth 11 is excluded, substitute 21 for it. If 21 is also excluded then identify the worst score for the remaining teeth. Similarly, substitute for mandibular teeth. 5. In subjects under 20 years of age, if the first molar is not present or has to be excluded, the nearest adjacent premolar is examined. 6. If all teeth in a sextant are missing or only one functional tooth remains, the sextant is coded as missing. 7. A single tooth in a sextant is considered as a tooth in the adjacent sextant and subject to the rules for that sextant. If the single tooth is an index tooth, then the worst index tooth score is recorded. Choice of age groups (1) While applying the CPITN, the WHO standard are grouping should be used, i.e. single years to 19 but including a group 15 – 19 years then 20 – 24 years, 25 – 29 years, 30 – 34 years, 35 – 44 years, 45 – 54 years, 55 – 64 years and 75 – 84 years and over. It is recommended that age groups 15 – 19 (or 15 years), 35 – 44 years and 65 – 74 years be the age groups for data collection for international comparison and for planning and monitoring. Where resources allow, or if a high prevalence of disease appears present at an early age, examination of age groups 7 – 11 years and 12 -14 years may be justified.

Calculation of CPITN (1) The CPITN for a population group can be calculated as follows: Step 1: Count the number of charts with different codes and add up the codes individually (i.e. codes 0, 1, 2, 3, 4) Step 2: 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 and multiply by 100. To obtain the ‘mean number of sextants’ (MNS) for each condition per person, divide the total number of sextants with highest score for the person by the number of dentate subjects examined. Modifications of CPITN (1) Besides the slight changes to the CPITN since it was first described, there have been very few changes to the index for epidemiological and public health purposes. Utilization of CPITN recordings (2) The CPITN is designed for rapid and practical assessment of various periodontal treatment needs in population surveys and for initial screening of patients attending for regular dental care. For patients requiring oral hygiene instruction and scaling only, the CPITN recordings are sufficient for treatment planning. However, a finding of the need for complex treatment necessitates a more precise identification of the teeth and tooth surfaces affected before starting the actual therapy required by the individual patient. The time needed for the CPITN in recording the codes for the six segments should not exceed 1 – 2 minutes.

Community Periodontal index

This index is based on a modification of the earlier used CPITN. The modification is done by the inclusion of measurement of “Loss of attachment” and elimination of the “Treatment Needs” category. Indicators:- Three indicators of periodontal status are used for this assessment; gingival bleeding, calculus and periodontal pockets. For this “CPITN – C” probe is used. Procedure: The mouth is divided into sextants as in the case of CPITN. A sextant should be examined only if there are two or more teeth present which are not indicated for extraction. (Note: this replaces the former instruction to include single remaining tooth in the adjacent sextant). Index teeth: For adults aged 20 years and over, the teeth to be examined are: 17 47 16 46 11 41 26 36 27 37

The two molars in each posterior sextant are paired for recording and, if one is missing, there is no replacement. If no index teeth or tooth is present in a sextant qualifying for examination, all the remaining teeth in that sextant are examined and the highest score is recorded as the score for the sextant. In this case, distal surfaces of third molars should not be scored. For subjects under the age of 20 years, only six index teeth 16, 11, 26, 36, 31 and 46 are examined. This modification is made in order to avoid scoring the deepened sulci associated with eruption as periodontal pockets. For the same reason, when children under the age of 15 are examined, pockets should not be recorded i.e., only bleeding and calculus should be considered. The probing for sensing gingival pockets and calculus is same as for CPITN. Examination and recording

The index teeth, or all remaining teeth in a sextant where there is no index tooth, should be probed and the highest score recorded in the appropriate box. The scoring criteria are as follows: • • • • • • • ‘0’ – Healthy ‘1’ – Bleeding observed ‘2’ – Calculus detected, but black band on probe is visible. ‘3’ – Pocket 4 - 5 mm (gingival margin within black band) ‘4’ – Pocket 6 mm or more ( black band not visible) ‘X’ – Less than 2 teeth present ‘9’ – Not recorded

Loss of attachment Information on loss of attachment may be collected from index teeth in order to obtain an estimate of the lifetime accumulated destruction of the periodontal attachment. This permits comparisons between population groups but is not intended to describe the full extent of loss of attachment in an individual. The most reliable way of examining for loss of attachment in each sextant is to record this immediately after recording the CPI score for that particular sextant. The highest scores for CPI and loss of attachment may not necessarily be found on the same tooth in a sextant. Loss of attachment should not be recorded for children under the age of 15. Probing pocket depths gives some indication of the extent of loss of attachment. This measurement is unreliable when there is gingival recession, i.e. when the CEJ is visible. When the CEJ is not visible and the highest CPI score for a sextant is less than 4 ( probing depth less than 6 mm) and loss of attachment for that sextant is estimated to be less than 4 mm (loss of attachment =0). The extent of loss of attachment (LA) recorded using the following codes is shown below.

‘0’ – LA 0-3mm (CEJ not visible and CPI score 0-3)

‘1’ – If the CEJ is not visible and the CPI score is 4 or if the CEJ is visible and loss of attachment 4 -5 mm (CEJ within black band) ‘2’ – LA 6-8 mm (CEJ between the upper limit of the black band and the 5 – 8 mm rings). ‘3’ – LA 9-12 mm (CEJ between the 8.5 mm and 11.5 mm rings) ‘4’- LA 12mm or more (CEJ beyond the 11mm ring) ‘X’ – excluded sextant (Less than 2 teeth present) ‘9’ – not recorded (CEJ neither visible nor detectable).

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Navy Periodontal Disease Index (NPDI) (2)
The NPDI was introduced by Grossman F D and Fedi P F in 1974, as a part of their “Navy Periodontal Screening Examination” (NSPE) The NPDI has two parts: 1. A gingival score which assesses inflammation as determined by colour, consistency, dentisty, enlargement and bleeding; and 2. A pocket score which measures tissue destruction as determined by pocket depth. Method The gingival and pocket score is done on six selected teeth. The six selected teeth are:- (according to FDI notation) 16, 21, 24, 36, 41, 44 The gingival scores are determined by examining the gingival tissues and the pocket scor3es by probing sulcular or pocket depth. The gingival examination is for colour, consistency, contour and bleeding. The pocket examination includes six probing measurements of the depth of the gingival sulcus or pocket on each of the six designated teeth using a calibrated probe. These measurements are taken on the mesial, middle and distal areas of both facial and lingual surfaces. The mesial and distal areas are measured at the

facial and lingual line angles. The greatest single measurement determines the pocket score for the tooth. If any of the selected posterior tooth is missing, substitute the next most posterior tooth and if the central incisor is missing substitute the nearest incisor in the same arch. Scoring Criteria

‘0’ – Gingival tissue is of normal colour, has firm consistency, and no exudate is present. ‘1’ – Inflammatory changes are present, but do not completely encircle the tooth. Changes may include, any colour change, loss of normal dentisty and consistency, slight enlargement and/or blunting of papilla or gingiva and tendency to bleed on palpation.

‘2’ - Inflammatory changes completely encircling the tooth. ‘0’ – pocket depth not over 3 mm ‘5’- pocket depth greater than 3mm but less than 5mm ‘8’ – pocket depth greater than 5mm Calculation of NPDI score Gingival & pocket scores – added & divided by no of index teeth

Pocket Score •
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