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




viz. the gingival and supporting structures 6/5/12 .INTRODUCTION Ø Periodontal disease is a major oral disease of universal occurrence. Ø It includes all pathological conditions of the periodontium.

Ø Uses of EPIDEMIOLOGY in the study of DISEASE PERIODONTAL 6/5/12 .

studies. ü Surveys to assess periodontal 6/5/12 . ü Longitudinal experimental ü Controlled clinical trials on a small well-controlled group.Ø Studies using periodontal indices : ü Surveys on prevalence & incidence.

L.PERIODONTAL INDEX (PI) § Developed by : RUSSELL A. § Year : 1956 6/5/12 .

§ Type : ü Composite reversible irreversible ü Full mouth index 6/5/12 .

6/5/12 .§ Objective : ü Intended to estimate deeper periodontal disease. § Method : ü All the teeth present are examined.

) “0” : Negative Neither overt inflammation in the investing tissues nor loss of function due to destruction of supporting 6/5/12 tissue. .L. SCORING CRITERIA : (adapted by Russell A.

An overt area of inflammation in the free gingiva does not circumscribe the tooth. 6/5/12 . “1” : Mild gingivitis.

but there is no apparent break in the epithelial attachment. 6/5/12 .“2” : Gingivitis Inflammation completely circumscribes the tooth.

There is early notch like resorption of alveolar crest 6/5/12 .“4” : Usually used when radiographs are available.

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

There is horizontal bone loss involving the entire alveolar crest. upto half of the length of the tooth root. 6/5/12 .

may sound dull on percussion with metallic instrument. may have drifted. or may be depressible in its socket.“8” : Advanced Destruction with Loss of Masticatory Function. 6/5/12 . The tooth may be loose.

ü There may be root resorption or rarefaction 6/5/12 at the apex. .ü There is advanced bone loss involving more than half the tooth root. or a definite infrabony pocket with widening of periodontal ligament.

RUSSELL’S RULE : “When in doubt assign the lower score”. 6/5/12 .

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 6/5/12 .

GROUP PERIODONTAL INDEX SCORE AND CLINICAL MANIFESTATIONS CLINICAL CONDITION GROUP PI STAGE OF SCORES Clinically normal supportive 0-0.9 DISEASE Beginning destructive periodontal disease Established destructive periodontal disease Terminal disease 0.2 tissues Simple gingivitis 0.7-1.0 Irreversible 3.9 Reversible 1.3-0.6-5.0 Irreversible 6/5/12 .8-8.

7-1.9 disease Established destructive periodontal disease Terminal disease 1.0-8.6-4.9 Beginning destructive periodontal 0.INDIVIDUAL PERIODONTAL INDEX SCORE AND CLINICAL MANIFESTATIONS INDIVIDUAL PI SCORES CLINICAL CONDITION Clinically normal supportive tissues Simple gingivitis 0-0.2 0.9 5.0 6/5/12 .3-0.

6/5/12 .Drawbacks : ü Results tend to underestimate the true level of the periodontal disease. ü Number of pockets without obvious supragingival calculus is also underestimated.

(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 .

ü In National Health Survey (NHS) – the largest ongoing health survey in U.S. 6/5/12 . ü More data can be assembled using PI.Uses :  ü Epidemiological surveys.

Ramfjord  Year : 1959 Records the attachment level of periodontal tissues 6/5/12 relative to CEJ.PERIODONTAL DISEASE INDEX (PDI) Developed by : Sigurd P. .

PI v/s PDI 6/5/12 .

It described 3 degrees of severity for gingivitis (scores 1. The Periodontal Disease Index system as introduced by Ramfjord differed from the Periodontal Index system in several respects. 2 and 3). it measured the distance from the cementoenamel junction with a 6/5/12 periodontal probe graduated in .

and thus offered much greater potential and quantifying periodontal destruction than the Periodontal Index system.Altogether. the Periodontal Disease Index system relied on probing measurement. 6/5/12 .

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. 6/5/12 .

Objectives : I. I. Accurate basis for incidence & longitudinal studies. Assess prevalence & severity. 6/5/12 .

COMPONENTS OF PDI : I. Calculus Component III.Gingival & Periodontal component 6/5/12 . Plaque Component II.

consistency. 21.Scoring methods : ü Only 6 teeth selected: 16.Changes in : Color. depth ü Recording of crevice 6/5/12 . contour is detected. 36. form. ü For gingiva . 24. 41. 44.

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Gingival crevice in any of the four measured areas extending apically 3-6mm from the CEJ. distal. Criteria 4 Gingival crevice in any of the four measured areas (mesial. Mild to moderate inflammatory gingival changes not extending all around the tooth. characterized by marked tendency to bleed. extending apically to CEJ but not more than 3mm.Score 0 1 2 3 Scoring criteria : Absence of inflammation. Gingival crevice in any of the four measured areas 6/5/12 extending apically more than 6mm from the CEJ. and ulceration. 5 6 . Mild to moderately severe gingivitis extending all around the tooth. Severe gingivitis. buccal. lingual). redness.

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of Teeth examined 6/5/12 . Calculation of PDI score : PDI = Total of Individual Tooth Scores No.

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. 6/5/12 .

buccal and “3” 6/5/12 . and lingual erupted teeth surface of the tooth. buccal and substituted. Only fully buccal. Plaque extending over all interproximal. Missing teeth “2” Plaque present on all should not be interproximal. lingual surfaces.SCORING CRITERIA Score Criteria “0” No plaque present “1” Plaque present on some but not on all interproximal. but covering less than one half of these surfaces. should be scored.

of teeth examined 6/5/12 .Calculations : Plaque score = Total Score No.

6/5/12 . Teeth and surfaces examined : The facial (buccal/labial) and lingual surfaces of index teeth are examined.III) CALCULUS COMPONENT OF PDI Assesses the presence & extent of calculus of 6 index teeth.

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.Method : Evaluation is done using a mouth mirror and a dental explorer and/or a periodontal probe. An abundance of supra gingival 6/5/12 and sub gingival calculus ‘2’ ‘3’ .

 Calculation of the index : calculus score of individual = Total score No. of teeth examined Has high degree of examiner reproducibility. 6/5/12 . Can be performed quickly.

6/5/12 . ü Longitudinal studies in periodontal diseases.Uses : ü Epidemiological surveys.

RECORDING FORM FOR RAMJFORD’S PERIODONTAL DISEASE INDEX Plaque Component (Shick & Ash modification) F 16 L F 21 L F 24 L F L F L F L Score: 46 41 34 6/5/12 .

RECORDING FORM FOR RAMJFORD’S PERIODONTAL DISEASE INDEX Calculus Component F 16 L F 21 L F 24 L F L F L F L Score: 46 41 34 6/5/12 .

Gingival & Periodontal Component : 16 21 24 Score: 44 41 34 6/5/12 .

ü O’Leary T.J., ü Gibson W.A., ü Shannon I.L., ü Schuessler C.F. and ü Nabers C.L. ØYear : 1963


Modification of PDI. Screens the individuals

who need periodontal treatment.
Assesses three components of

periodontal disease:
ü Gingival status ü Periodontal status (crevice



Segmentation of the

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

6/5/12 . with the severest condition within each segment. Assessment is done segment wise. § Objective : To determine the tooth or its surrounding tissues.§ Method : Done on all teeth present.

recession. spontaneous hemorrhage. 6/5/12 2 3 . The above changes (Score 1) either singly or combined completely encircle one or more teeth in a segment. Slight to moderate inflammation. firm consistency with physiologic architecture. marked deviation from normal contour (such as gross thickening or enlargement covering more than onethird of the anatomic crown). Marked inflammation. loss of normal consistency. loss of faciolingual continuity or any interdental. as indicated by changes in gingival color. and clefts. but not completely surrounding any one tooth. involving one or more teeth in the same segment.Score 0 1 Gingival Status : Criteria Tissue tightly adapted to the teeth. blunting and slight enlargement of marginal or papillary gingiva. as indicated by loss of surface continuity (ulceration).

Gingival status for mouth : Sum of gingival scores No.Area with the highest score determines the gingival score for the segment. of segments 6/5/12 .

the mesio-facial line angle of every tooth erupted to the occlusal plane is probed with a Merritt type probe.Periodontal status :  Beginning in segment 1. 6/5/12 .

The probe extend from 3mm to 6mm. 6/5/12 . 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. 4 5 6 The probe extends 6mm or more apical to the CEJ of any tooth in the segment.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.

Compiling the GPI : GPI score = Sum of the highest scores for each dentulous segment The number of segments 6/5/12 .

GINGIVAL BONE (GB) COUNT INDEX Developed by : Dunning J. & Leach L. 6/5/12 .B. Year : 1960 Records the gingival condition and the level of the crest of the alveolar bone.M.

Scoring criteria : Gingival Score (Gingivitis): (One score is assigned to each tooth studied. and a mean is computed for the whole mouth) 6/5/12 .

6/5/12 2 3 * Maximum score = 3 . Severe gingivitis with enlargement and easy hemorrhage.Score Criteria 0 1 Negative (no gingivitis) Mild gingivitis involving free gingiva (margin. Moderate gingivitis involving both free and attached gingivae. papilla or both).

Bone Score (Bone Loss): (One score is assigned to each tooth studied visually or by x–ray. and a mean is computed for the whole mouth.) 6/5/12 .

Mobility – marked. Mobility moderate Bone loss complete. 6/5/12 3 4 5 * Maximum score = 5 .Score 0 Criteria No incipient bone loss. Bone loss approximating one-half of root length or pocket formation one side not over three-fourths of root length. Bone loss approximating three-fourths of root length or pocket formation one side to apex. 1 Incipient bone loss or notching of crest. Mobility – slight. alveolar 2 Bone loss approximating one-fourth of root length or pocket formation one side not over one-half root length.

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


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


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

Uses : 1) Periodontal epidemiology. 6/5/12 . 4) For monitoring changes in periodontal needs of individuals.Objective : To evaluate periodontal treatment needs. 2) In a promotional role in developing periodontal health problems. 3) For initial screening.

ü Limitations : 1) Partial recording.ü Advantages : 1) Simplicity 2) Speed 3) International uniformity. 2) Exclusion of important signs of periodontal breakdown. 6/5/12 .

ØTreatment needs ØProcedure for CPITN ØSextants ØIndex teeth ØRecording data 6/5/12 .

6/5/12 . and shank and handle include angles of 90° and 30° respectively.WHO Periodontal Examination Probe CPITN Probe : Tip and shank.

“Walking” of the probe 6/5/12 .

No signs of disease..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. 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. when the gingival margin is on the black area of the probe. the black area of CPITN probe is not visible.e. “CODE 4” “CODE 3” Pathological pocket of 4mm or 5mm present i..e. 6/5/12 “CODE 2” “CODE 1” “CODE 0” . Healthy tissue.

Gingival margin situated on black band of the probe 6/5/12 . 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.

ØExamination procedure. ØExplanation of clinical criteria. 6/5/12 .

ØSubstitution for excluded and missing teeth. in a sextant. then the recording is based on examination of remaining index teeth. ØIf both index teeth in posterior 6/5/12 sextant are missing or excluded . ØPresence of two more teeth ØIf in a posterior sextant. one of the two index teeth are not present or has to be excluded.

if 1st molar is not present or has to be excluded. Similarly substitute 41 if tooth 31 is missing. nearest adjacent premolar is examined. identify the worst score for the remaining teeth. substitute 21. ØIn subjects age < 20 yrs. ØIf all the teeth in a sextant are missing or only one functional 6/5/12 tooth remains the sextant is coded . If 21 is also missing.ØIf 11 is missing/excluded.

TN = 2 A Code of 2 or higher indicates need for professional cleaning of teeth and removal of plaque retentive factors. Thus sextants with these pockets are placed 6/5/12 in the same treatment category . In addition.ØClassification 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. the patient the requires oral hygiene instructions. TN = 1 A Code of 1 or higher indicates a need for improving the personal oral hygiene of that individual. Oral hygiene and scaling will usually reduce inflammation & bring 4-5mm pocket values of 3mm or below 3mm. . Shallow to moderate pocketing (4-5mm – Code 3).

3.2.e.2. divide the counts of codes respectively.Count the number of charts obtained with different codes individually (i. codes 0.. by the total number of dentate subjects examined.1. 6/5/12 . Step II – To obtain the prevalence (percentage) of subjects with codes 0.1.4 as their score.3.ØCalculation of CPITN : Step I .4).

6/5/12 . ü Periodontal Screening and Recording (PSR).ØModifications of CPITN : ü Simplified Periodontal Examination (SPE) later termed as Basic Periodontal Examination (BPE).

ü ü ü indicators of periodontal status are used for this assessment: gingival bleeding calculus periodontal pockets A specially designed lightweight CPI probe6/5/12 with a .COMMUNITY PERIODONTAL INDEX (CPI)Three Indicators.

and 44-48.Sextants. 38-34. 33-43. 24-28. 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 . 13-23. The mouth is divided into sextants defined by tooth numbers: 18-14.

For adults aged 20 years and over. the teeth to be examined are: 17 16 11 26 27 47 46 31 36 37 6/5/12 .§ Index teeth.

A 6/5/12 practical test for . using the probe as a “sensing” instrument to determine pocket depth and to detect subgingival calculus and bleeding response. Ø An index tooth should be probed.Sensing gingival pockets and calculus. Ø The sensing force used should be no more than 20 grams.

Not recorded. Excluded sextant (less than two teeth present). Pocket 4 .5 mm (gingival margin within the black band on the probe). directly or by using mouth mirror. but all the black band on the probe visible. Pocket 6 mm or more (black band on the probe not visible). Calculus detected during probing. after probing.Score 0 1 2 3 4 X 9 Criteria Healthy. 6/5/12 . Bleeding observed.

Score 3 Score 4 Score 0 Score 2 Score 1 6/5/12 .

Loss of attachment 4-5mm (CEJ within the 6/5/12 black band) 1 .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.

5 mm and 11.5 mm rings) Excluded sextant (Less than two teeth present) Not recorded (CEJ neither visible nor 6/5/12 detectable) 4 X 9 .Score 3 Criteria Loss of attachment 9-12mm (CEJ between the 8.5 mm rings) Loss 12 mm or more (CEJ beyond the 11.

6/5/12 . which is endorsed by WHO and FDI for periodontal screening.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.

6/5/12 .§ 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.

The use of a periodontal probe is mandatory. For screening. A 6/5/12 color-coded area extends from .5mm in diameter. The recommended probe has a ball end 0.The objective of this screening system is to examine every tooth individually. the dentition is divided into sextants. Implants are examined in the same manner as naturally occurring teeth.

• 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: .

5 mm mark 0.3.5 to 5.5 mm ball-tip 6/5/12 .

PSR CODES : 6/5/12 .

6/5/12 .

CODE X: Denotes edentulous sextant. 6/5/12 .

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 .

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.

for a PSR completed on May 14. 2004.A special form is used to document the PSR codes for each sextant. 6/5/12 On the sample PSR . 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.

and subgingival calculus. If two or more sextants score Code 3. including debridement of subgingival plaque. Code 4Comprehensive periodontal examination is indicated for entire mouth. Reinforce daily plaque control habits. and correction of plaque retentive margins of restorations. 6/5/12 Code *If an abnormality is present in a sextant with a Code 0. a comprehensive periodontal examination is indicated for that sextant. Provide appropriate treatment.Implications of PSR Codes Code Code 0 Code 1 Further Clinical Documentation Reinforce daily plaque control habits. Code 2 All above + debridement of supra. a comprehensive periodontal examination is indicated for entire mouth. or 2 score – note the . Code 3 If a single sextant scores Code 3. 1.

 Benefits : Ø Early detection Ø Speed Ø Simplicity Ø Cost-effectiveness Ø Recording ease Ø Risk management 6/5/12 .

it didn’t happen!! 6/5/12 .CONCLUSION If it is not in the chart.

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

Ø PERIODONTAL PROBING. JAMES D. 1993. Ø Ø Ø Epidemiological principles in studying periodontal www. 6/5/12 . Critical Reviews in Oral Biology & Medicine. volume 2. BECK& HARALDLO E Periodontology 2000.pubmed.Google.

Than k You !! 6/5/12 .

A doctor who cannot take a good history and a patient who cannot give one are in 6/5/12 .