The P-M-A Index for the Assessment of Gingivitis

BY M A U R Y MASSLER

T H E P R I M A R Y I M P E T U S which led to
the development of the P - M - A index i n
1944-1947 was the need for some quantita-
tive method of recording readily-observable
inflammatory conditions of the gingivae to
replace the then current gross assessment of
gingivitis i n both children and adults as
mild, moderate or severe. These gross ob-
servations were naturally highly subjective
and depended a great deal upon the back-
ground and orientation of the examiner
towards gingival and periodontal diseases as
well as his "expertise" as a periodontist. A t
that time, changes i n the amount or degree
of inflammation of the gingivae after thera-
peutic treatment such as scaling, ingestion
Fig. 1. M . Massler examining.
of vitamin C or toothbrushing could not be
satisfactorily evaluated since even clinically
obvious improvements could not be docu- was intended rather to survey gingival
mented i n quantitative terms. The need for changes i n relatively large groups for epi-
some method of quantifying inflammatory demiologic purposes and study. Its use was
changes i n the gingivae became acutely intended more like that of the D - M - F index
necessary with the advent of the so-called for dental caries. The D - M - F assessment
therapeutic dentifrices since any claims does not replace the clinical radiograph
made had to be documented i n a reason- taken periodically for caries detection i n
ably objective fashion. Although the indi- the individual patient.
vidual clinician using therapeutic proce-
dures on individual patients was satisfied to The basic philosophy used i n the de-
record changes as impressions or (rarely) velopment of the P - M - A index was very
on color photographs, such evaluations similar to the D - M - F index, i.e., the num-
could not be accepted by the scientific com- ber of gingival units affected were counted
munity. Inevitably, a more objective, quan- rather than the severity of the inflamma-
titative method had to be sought to replace tion. However, as w i l l be noted below, the
the subjective, clinical impressions. severity of inflammation is also included i n
the records for other possible uses of the
It should be noted that the P - M - A index P - M - A index.
was not intended as an exact quantification
of gingivitis or to determine gingival The first task was to delineate and define
changes with sufficient accuracy to satisfy "the gingival unit." B y 1945, sufficient re-
the individual practitioner dealing with the search had accumulated to define a gingival
individual patient—although it turned out unit and its component parts ( K i n g ) . C l i n i -
to be very useful also i n this respect to cally, the gingival tissues could be easily
control his wishful thinking concerning his separated into the papillary portion be-
therapeutic effectiveness. T h e P - M - A index tween the teeth, the marginal collar sur-

Page 20/592
 A S S E S S M E N T O F GINGIVITIS
rounding the teeth, and the attached (stip-
pled) gingivae overlying the bony alveolar
process. T h e free marginal gingivae is that
portion which encircles the tooth and is
both clinically and histologically attached
to the hard tissue of the tooth (enamel
and/or cementum). It is clearly delimited
from the attached gingivae by the free gin-
gival groove.
The gingival papilla is formed by a co-
alescence of the approximal marginal col-
lars between approximal teeth. The gingival
papilla, therefore, does not exist when teeth
are widely separated by edentulous area
and its contour and morphology are modi-
fied by the distance between adjacent teeth.
It was apparent quite early i n our stud-
ies that the papillary portion of the free
gingivae constituted the first area of attack
by inflammatory changes; and that the se-
verity of the inflammation was generally
mild if the inflammation was confined to
the papillae alone. A s the inflammation i n -
creased i n intensity and duration, it was
apparent that the inflammatory process
tended to spread from the interdental pa-
pillae to the buccal and lingual marginal
collar. Thus, the severity of inflammation
could be assessed by the tissues affected,
i.e., marginal gingivitis was more severe
and/or extensive than a papillary gingivitis
alone. In general, marginal gingivitis is l i m -
ited by the free marginal groove until the
inflammatory process becomes sufficiently
chronic and severe, when it tends to break
through the free marginal groove into the
attached gingivae. W h e n the attached gin-
givae are affected, one could speak of a
true periodontitis.
Thus, i n general, m i l d gingivitis is con-
fined to the papillary area; moderate gingi-
vitis spreads to the marginal gingivae; and
a severe gingivitis is identified by its spread
to the attached gingivae.
The analogy with the D - M - F index for
caries might be helpful i n illustrating the
thinking used i n the development of the
Page 21/593
initial stages of the P - M - A index.
The gingival papillae were like the pits
and fissures of the teeth as sites of predi-
lection for the initiation of the diseases.
A s the disease became more severe and
chronic, it spread into the surrounding tis-
sues. I n the beginning, we felt it more de-
sirable to count the number of units af-
fected rather than to identify the degree of
gingivitis i n each unit, since previous expe-
rience had taught that counting the number
of D - M - F teeth was almost as accurate as
counting the number of surfaces affected
when these data were used for epidemio-
logical purposes.
Although the private practitioner is great-
ly concerned with the size and depth of the
carious cavity, such measurements would
not be appropriate to the epidemiological
method nor towards the ultimate goal of
preventing disease rather than the repair of
the ravages of disease.
In spite of this philosophy, we did define
the degree of gingivitis for each gingival
unit as follows:
p 0 = N o r m a l ; no inflammation.
l + = M i l d p a p i l l a r y engorgement;
slight increase i n size.
2 + = Obvious increase i n size of gin-
gival papilla; hemorrhage on
pressure.
3 + = Excessive increase i n size with
spontaneous hemorrhage.
4 + = Necrotic papilla.
5 + = A t r o p h y and loss of papilla
( through inflammation ). *
M 0 = N o r m a l ; no inflammation visible.
1+ = Engorgement; slight increase i n
size; no bleeding.
2 + = Obvious engorgement; bleeding
upon pressure.
3 + = Swollen collar; spontaneous hem-
orrhage; beginning infiltration i n -
to attached gingivae.
*Loss of tissue by recession due to ischemia and
atrophy is recorded separately as "recession" (see
chart) usually confined to the marginal gingivae and
does not affect gingival papilla often associated with
erosion (idiopathic or due to excessive toothbrushing).
Page 22/594
4-h = Necrotic gingivitis.
5 + = Recession of the free marginal
gingivae below the C E J due to
inflammatory changes.
A 0 = N o r m a l ; pale rose; stippled.
1 + = Slight engorgement with loss of
stippling; change i n color may or
may not be present.
2 + = Obvious engorgement of attached
gingivae with marked increase in
redness. Pocket formation pres-
ent.
3+ = Advanced periodontitis. Deep
pockets evident.
F r o m the above it can be seen that:
1. The intent of this index is to examine
and record only one aspect of the perio-
dontal disease problem, namely, the gin-
giva itself. It does not attempt to evaluate
the status of the gingival pockets by direct
examination or measurement nor the epi-
thelial attachment and, therefore, is not
really an index of periodontal disease. The
Russell index does this much better and
more directly. Changes i n the underlying
bone are also not evaluated since no at-
tempt was made to correlate the x-ray ex-
amination with the clinical appearance.
2. It is, therefore, apparent that the
major usefulness of the index was i n the
examination of children i n w h o m the early
stages of gingivitis were usually seen with-
out obvious changes i n the other perio-
dontal tissues.
N o attempt was made to relate the in-
flammatory process to such factors as erup-
tion gingivitis, crowding gingivitis, plaque
and plaque accumulation, etc. T h e Oral
Hygiene index, especially when disclosing
dyes are used, would evaluate plaque for-
mation. The intent was to provide a re-
producible quantitative measure of the
gingivitis itself for future research i n the
relationship between gingival inflamma-
tions and tooth-accumulated materials (soft
or hard).
MASSLER
The question has often been raised as to
the distinction between an acute transitory
gingivitis which, i n general, is self-repara-
tive i n children and the more common
variety of chronic gingivitis i n adults which
progresses towards degeneration of the af-
fected tissues unless etiologic factors are
removed by the dentist. Although we did
record whether the inflammation was acute
or chronic, I feel that this requires further
investigation, since clinical evaluation and
distinction on a subjective basis might lead
to erroneous relationships. The need for a
clinically useful and objective method of
distinguishing among the varieties of i n -
flammatory processes i n order to validate
prognoses is evident. The only method
which we have found useful to date is the
taking of a standardized color photograph
at intervals from the same patient over
long periods of time, with and without
therapeutic interventions. This type of re-
cording and documentation is no longer
difficult or even expensive and is as useful
to the private practitioner who follows the
progress of his individual case, as the x-ray
of the hard tissue. F o r epidemiological re-
search, we have found that the color photo-
graph obtained i n large groups and exam-
ined by three or four examiners post hoc
was more accurate and time-saving than the
usual single examination and recording of
each P - M - A unit affected. It is, therefore,
suggested that if objectivity is essential for
valid data accumulation, that the photo
recording device might be superior to the
visual examiner recording procedure cur-
rently i n use. The method is faster and, in
our experience, more accurate and ob-
jective.
The question has also been raised as to
whether the anterior gingivae, which are
more easily inspected and/ or photographed,
might not serve adequately i n epidemio-
logical studies for the assessment of gingi-
val disease i n large groups i n a manner
similar to the use of the first permanent
molar as an index to the incidence of den-
tal caries for large group evaluation of
caries attack rates.
 ASSESSMENT O F GINGIVITIS
Experiences of investigators who have
used the P - M - A index for total mouth ex-
amination indicate that the anterior seg-
ments reflect the total picture with sufficient
accuracy for large-scale studies. It is abun-
dantly clear that the area of initial and
most severe gingivitis are the labial anterior
segments, particularly the lower anterior
gingivae. Therefore, when time permits, we
examine the entire mouth and record visual
observations and collect photographic rec-
ords. When time is limited, the anterior
segment alone can be inspected. A n d for
more objective evaluation of therapeutic
effects i n relatively small groups, we believe
that standardized color photographs pro-
vide better documentation than visual in-
spection and recording alone.
The question has also been raised as to
other gingival diseases which are non-
inflammatory i n nature. These are recorded
but not included i n the P - M - A index be-
cause the incidence is low i n children.
However, some method of evaluating the
ischemic diseases, such as gingival atrophy
with or without recession, and gingivosis,
needs to be considered. T o the present time,
the intraoral color photograph is most use-
ful, especially when used for longitudinal
studies.
Finally, we are concerned with the fact
that the term "periodontal disease" is used
to designate a wide variety of conditions
affecting the periodontal tissues. Clinical
research has also progressed sufficiently to
indicate that diseases of the gingivae may
occur without affecting the underlying bone
and periodontal ligament, and that diseases
of the attachment apparatus (bone, liga-
ment, and cementum) might occur without
obvious involvement of the gingival tissue.
Surely diseases initiated by ischemia (idio-
pathic marginal recession) differ from loss
of tissue following chronic inflammation! It
is apparent that the acute gingivitis seen i n
the child differs markedly i n the appearance
and prognosis from the chronic degenera-
tive form seen i n adults; and that the two
are not necessarily related (although in- Figure 2.
Page 23/595
ferred). It is suggested by those who ques-
tion these inferences that breakdown of the
attachment apparatus i n the juvenile (ju-
venile periodontosis?) is quite different i n
terms of clinical criteria and rate of prog-
ress from the so-called "periodontitis com-
plex" of the adult. The process of aging
modifies the appearance and progress of all
disease processes. F o r example, mumps in
the child differs from mumps i n the adult.
Streptococcal infections i n children are dif-
ferent from those i n adults, although the
etiologic agent appears to be similar. L i k e -
wise, giving a name to a condition such as
gout does not correctly identify the etiol-
ogy of the diseases i n the adult or i n the
child (abnormal uric acid metabolism in
infants leads to brain damage).
It should be noted that the original i n -
tent of the P - M - A index was to show how
to count the number of gingival units af-
fected by disease which it still does better
than any other system yet devised. It did
not, at that time, indicate what was being
counted other than inflamed gingivae. A n
important modification of the P - M - A index
would be to designate the quality of the i n -
flammation as acute or chronic and to add
the category of noninflammatory recession
of the gingivae as indicated i n the attached
figure ( F i g . 2 ) .
Page 24/596 MASSLER
It is hoped that this conference w i l l see
fit to attempt a more clear definition of the
variety of periodontal diseases so that the
use of the singular w i l l not continue to be-
cloud the issue and that the use of the
plural may stimulate a more accurate defi-
nition of the differences among the different
varieties of periodontal diseases. A review
of the different indices using different cri-
teria for assessment suggests that each may
define different diseases. T h e question is
not which is better but what diseases are we
measuring?
Procedures for Examination
INSTRUMENTS
C h a i r with headrest (dental chair not es-
sential). G o o d lighting extraorally. (Natu-
ral lighting is best.)
Intraoral light desirable, but not essen-
tial. (Flashlight w i l l do for questionable
areas. )
M o u t h mirrors—one per patient. C o l d
sterilization acceptable.
Pediatric size tongue blades acceptable,
since direct vision is used.
Explorers—one per patient. These should
be blunted (or o l d ) , since the back end is
usually used for pressing on gingivae. The
exploring end is used only occasionally to
test for presence of pockets.
A ball burnisher is handy to have, to test
for edema i n severe cases.
PERSONNEL
T w o examiners should be used, one do-
ing the examination while the other records
and checks from time to time. This tends
to reduce examiner variability.
Examiners change roles every tenth pa-
tient to reduce fatigue and further reduce
examiner variability.
It is essential that all examiners be
trained prior to field study. This is best
done i n concert by use of color transparen-
cies projected on a fiat paper screen. The
enlarged image more clearly defines what is
meant by P 1+, P 2 + , P 3 + , etc. than
naked-eye examination (1:1) in vivo.
Examiners are then tested for accuracy,
validity and consistency by each examining
the same ten patients and comparing their
own records with "buddy" examiner and
with other examiners.
C o l o r transparencies of patients exam-
ined are then projected on a screen and
each examiner i n the group self-corrects
his "decisions" while the tutor calls out his
evaluation of each gingival papilla and la-
bial margin. Evaluation of attached gingivi-
tis is made after concurrence is achieved
on the papillary and marginal gingivitis.
Training of examiners for the P - M - A
index is essential. It is more difficult than
training examiners for consistency i n the
D - M - F index because of very variable
backgrounds and clinical orientation of ex-
aminers. Periodontists tend to see more and
overrate the severity. Y o u n g dental gradu-
ates and nondental assistants tend to under-
rate or even miss attached gingivitis.
Furthermore, the distinction between a
0 and a 1 + ; between a 1 + and a 2 + and a
3 + is not easily made consistently, even by
the same examiner one day later, although
the distinction between a 1 + and a 3 + has
a high degree of agreement among exam-
iners.
F o r this reason, the P & M ' s which are
marked 2 + by a "severe" examiner com-
pare to the 1 + category of a more "permis-
sive" examiner. Since severity per se is not
necessarily included i n the final P - M - A i n -
dex, the "cut-off point" can be easily de-
termined by the statistician by having an
occasional child i n the series examined by
two different examiners. This helps to
achieve consistency i n the data.
 A S S E S S M E N T O F GINGIVITIS
A dental assistant can be used as the re-
corder, while the second examiner stands
by as an observer and roving assistant.
METHOD
Examine buccal-labial surfaces only.
Begin from patient's upper left posterior
tooth (second molar is # 2 ) to the last
tooth on the right side ( 1 5 ) . Shift to lower
right and proceed to left i n a continuous
arc. (Third molars are omitted.) C a l l out
to recorder:
Second molar: M 0; P 2; A 0.
First molar: M 1; P 2; A 0, etc.
Note: The marginal gingivae is examined
first on left side, since the papilla mesial to
the tooth is counted as belonging to that
tooth.
The papilla between the two centrals is
common to both. O n the right side, call out
the papilla first and marginal area second:
Right central: M 2; A 1.
Lateral: P 3; M 2; A 1.
Cuspid: P 1 ; M 1; A O .
1st Bicuspid: P 0; M 0; A 0.
When categories 4 + or 5 + are seen, the
second examiner should confirm. Special
notes can be added at the bottom of the
sheet, ad libitum (i.e. oral hygiene, poor,
fair; good; calculus 1 + 2 + 3 + ; acute her-
petic stomatitis; sore throat; dry cracked
lips; etc.).
STATISTICAL METHODS
1. The number of affected Papillary
units, Marginal units, and Attached units
are counted for each patient and recorded
as follows :
P - M - A = 10-5-0 (15)
Preference has been given to recording
these numbers separately rather than as a
sum, since the same sum can have differ-
ent meanings:
P - M - A = 5-5-5 (15)
Page 25/597
2. The degree of inflammation can be
used to weight a final "score" or merely as
a "cut-off" device. Its best use is to keep
the examiner's evaluation consistent.
COMMENTS A N D DISCUSSION
1. Essential to consider that periodontal
diseases are multiple and not singular—or
at least multivariate. Therefore more exact
criteria must be established before indexes
can be improved or compared.
2. P - M - A index was intended to desig-
nate how to count (quantitate) gingival
units and not what is being counted (other
than "inflammation"). It is now time to
add qualitative descriptions of the inflam-
mation (or ischemia) causing the disease
(or diseases).
3. Methods of recording should be i m -
proved. V i s u a l examination at 1:1 eye-
power by a highly variable and even i n -
consistent observer should be improved.
V i s u a l examination should be improved by
using consistent, objective and much more
reliable recording devices.
SUGGESTIONS
a) Improved intraoral photography using
panoramic lens (or stereo) and controlled
processing.
b) I n t r a o r a l p a n o r a m i c x - r a y d e v i c e
modified for field use. C o u l d a radiopaque
rinse be perfected to visualize gingival
pockets, without probing?
c) Selective staining of tooth accumu-
lated materials to distinguish among sali-
vary pellicle, bacterial plaque, infected
plaque, calcifying plaque, calcified plaque
(calculus) and scale.
d) The more efficient periodontal probe
in the form of a fiber-optic tool is already
available (but not used) to transilluminate
gingival pockets and disclose pocket con-
tents visually (instead of by tactile sense
alone).
Page 26/598
4. Longitudinal studies to more exactly
define and depict the natural history of
each periodontal disease or diseases
essential, if further progress i n the under-
DISCUSSION*
Dr. I. I. Ship: A recession examination was
performed by Dr. A . L . Russell in addition to
the Periodontal Index examination. Perhaps
Dr. Russell could tell us about the recession
index.
Dr. A. L. Russell: The Recession Score devel-
oped by Stahl and Morris** is a very simple
count of the number of teeth in the mouth
where recession has exposed cementa. It is
interpreted as the means percent per man of
teeth showing recession. This was the subject
matter of the first table I showed. It provides
a rough idea of bone loss and readily gotten
into comparability between different exam-
iners. Calibration is necessary but it is a rea-
sonably simple method to apply. The Recession
Index complements the Periodontal Index in
that there is nothing in PI, we think, which
actually indicates the extent of the past dis-
ease. The elements in PI are reversible, in
order to get some good idea of what had hap-
pened to this patient, up to the time we saw
him, we have routinely employed the reces-
sion score along with PI and with O H I in the
series I described.
Dr. Paul Goldhaber: How did you arrive at a
score of eight for the last category in the Peri-
odontal Index? I have always been puzzled
about this feature of the Russell Periodontal
Index: Does this mean that eight is eight times
as bad as one?
Dr. A. L. Russell: No, this was actually a mat-
ter of trial and error until scores from multiple
examinations correlated in an even progression
with the increasing gravity of the clinical con-
dition. We found that PI scores in American
populations had a straight line relation with
ages. This has been shown many times. As a
*The authors have made every effort to transcribe
the taped discussions accurately. We hope that any
errors in context or content have not altered the sub-
stance of the proceedings.
**Stahl, S. S., and Morris, A . L . Oral health condi-
tions among Army personnel at the Army Engineer
Center. J. Periodont., 26:180-5, July 1955.
DISCUSSION
standing of etiology and pathogenesis of
these diseases is to be expected. Such
understanding is essential to further im-
are provements in epidemiologic studies or in-
dexes.
matter of fact we once assigned a score of ten
to represent a tooth previously extracted be-
cause of periodontal disease based on the pa-
tient's history. We found out that this was un-
necessary and that including it made the PI
index a hybrid index, partly reversible, and
partly irreversible. It was much simpler just
to work with one thing. Therefore this value
might have been seven or nine or eleven; what-
ever value was needed to make PI plot a
straight line with age of the group, and to re-
flect the gravity of the clinical condition.
Dr. John Greene: Would you amplify a point
which you touched on briefly and which I
think is quite important. The periodontal In-
dex was not intended for nor should it be used
for diagnostic purposes or treatment planning
and should not be used to estimate treatment
needs of a population group.
Dr. A. L. Russell: You can get a very rough
idea of the treatment needs of a population
group from the Periodontal Index, but by and
large this is not a good, or intended to be a
good, screening device. Dr. Löe and I were
talking last night about PI as a screening meas-
ure. We have accepted knowingly the fact that
one serious case in ten must be overlooked in
going through a population. Since we are not
required to treat this patient or even to iden-
tify him, this is not disturbing. It does not
have any true effect on our population aver-
ages. The Periodontal Index values are always
underestimations from the standpoint of any
half-way decent clinical approach. When we
started a longitudinal clinical study two or
three years ago we used the Ramfjord index
to record our findings. This was because in
these cases a point by point difference involv-
ing one tooth may be all the changes over this
period of observation. This was not intended
nor ever used by us as a clinical trial pro-
cedure or as a diagnostic procedure. There is
no diagnostic nomenclature involved in the
criteria. When this is needed, pick a more ap-
propriate index. It should be obvious, I think,
that this is not a clinical measure in that sense.