PERIODONTAL

INDICES

Epidemiological, staging & grading, extent & severity,

clinical, and treatment planning indices about periodontitis

Dr. Om Nemichand Baghele BDS, MDS, MBA

MDS (Periodontology), MBA (Hospital Management)
Professor & PG Guide, Department of Periodontology & Implantology,
Maharashtra Institute of Dental Sciences & Research,
Maharashtra Institute of Medical Sciences Campus, Latur, Maharashtra, India

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ISBN: 9798679717367

(Periodontal Indices: epidemiological, staging & grading, extent & severity, clinical, and
treatment planning indices about periodontitis)

Copyright @2020 Dr. Om Baghele

All rights reserved.

No part of this book may be reproduced in any form or by any electronic or mechanical
means, including information storage and retrieval systems, without written permission from
the author, except for the brief quotations in a book review.

Commercial use and distribution of the contents of the book are not allowed without express
and prior written consent of the author. It is illegal and a punishable offense to make media
files of the whole book (like .pdf files) and distribute them across different media.

Disclaimer:

“Periodontal Indices: epidemiological, staging & grading, extent & severity, clinical, and
treatment planning indices about periodontitis” is presented for awareness, education, and
explanation of periodontal indices so that they can be referred and used by Dentists,
Periodontists and alike. It is presented for research, academic or professional use. The
author and the publisher (or future publishers) are not offering it as professional service.
While best and dedicated efforts have been put in for preparing this book, the author and
the publisher (or future publisher) make no representations or warranties and assume no
liabilities of any kind with respect to the accuracy or completeness of the contents and
specially disclaim any implied warranties of using it for a particular purpose.

Neither the author nor the publisher (or future publisher) shall be held liable or responsible
to any person or entity concerning any loss, or incidental or consequential damages caused,
or alleged to have been caused, directly or indirectly, by the information and procedures
contained herein.

The information contained in this book may be used for research purposes, but professional
advice and thorough reference to the original journal article is advised.

Book 1 of Series: Indices in Periodontology: For Clinical & Epidemiological Research,

& Case Recording

Edition: First (2020)

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Contributors:

Prof. Dr. Suresh Kamble MDS

Principal, Professor & PG Guide,
Department of Prosthodontics & Crown & Bridge,
MIDSR, Latur

Dr. Vishnudas Bhandari MDS

Professor & Head & PG Guide, Department of Periodontology,
MIDSR, Latur

Dr. Gauri Mahesh Ugale MDS

Associate Professor & PG Guide, Department of Periodontology,
MIDSR, Latur

Dr. Vrushali Madhavrao Kathole MDS

Private Practice, Former PG Student, Department of Periodontology,
MIDSR, Latur

Dr. Khushbu Bezalwar BDS

PG Student, Department of Periodontology,
MIDSR, Latur

Dr. Shrirang Shamsundar Sangle BDS

PG Student, Department of Periodontology,
MIDSR, Latur

Dr. Kanishka Magdum BDS

PG Student, Department of Periodontology,
MIDSR, Latur

Dr. Madhura Vairagi BDS

PG Student, Department of Periodontology,
MIDSR, Latur

Dr. Raghavendra Metri MDS

Associate Professor, Department of Periodontology,
MIDSR, Latur

Dr. Mukesh Aradale MDS

Assistant Professor, Department of Periodontology,
MIDSR, Latur

Dr. Sukanya Vyawahare MDS

Assistant Professor, Department of Periodontology,
MIDSR, Latur

Dr. Poonam Kedar Bhatane MDS

Assistant Professor, Department of Periodontology,
MIDSR, Latur

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 Index

Chapter
No. Topic Page No.
1 Introduction to periodontal indices in brief
2 Radiographic alveolar bone loss index by Sheppard (1936)
3
4 Periodontal Index (PI) by Russell (1956)
5
6 Periodontal Disease Index (PDI) by Ramfjord (1959)
7
8
9

10

11

12 Periodontal assessment scoring in WHO Oral Health Surveys Basic Methods (1971)

13

14

15
16

17

18

19
20 Periodontal Status Index by WHO (1977)
21 Community Periodontal Index of Treatment Needs (CPITN) by WHO (1982)
22 The GPM/T Index by Gaengler (1984)
• The TRS 621 Methodology by WHO
23
24
25 Basic Periodontal Examination (BPE) by BSP (1986)
26
27
28 The Periodontal Control System (PCS) by Grace and Smales (1989)
29 Periodontal Screening and Recording Index (PSR) by AAP (1991)
30 Community periodontal index by WHO (1997)
Dutch Periodontal Screening Index (DPSI) by Dutch Society of Periodontology
31 (1998)
32

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 33
34
35
36
37
38 Digital image analyzer and alveolar bone loss index by Teeuw et al. (2009)
39
40 Additional Periodontal Treatment Need Indices
Periodontal treatment need by Cross (1952)
Periodontal treatment need by Davies et al. (1961)
Periodontal treatment need by Heloe et al. (1973)
Periodontal treatment need by Markkanen et al. (1979)
Periodontal treatment need by Schonfeld (1981)
Periodontal treatment need by Gordon et al. (1986)
Periodontal treatment need by Oliver et al. (1989)
41 Oxidative stress index by Esen et al. (2012)
42 Modified Community Periodontal Index by WHO (2013)
43
44
45 Dysbiosis ratio of periodontitis by Meuric et al. (2017)
46 Grading based on alveolar bone loss & bleeding on probing by Liljestrand et al.
(2017)
47 Staging and grading of periodontitis by AAP & EFP (2017)
48
49
50 Immunological burden index by Liljestrand et al. (2018)
51 Periodontal indices: When, Why and How?
52 Citation analysis of periodontal indices based on Google Scholar matrix as on 25 th
August, 2020
53 References (Alphabetical)

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Chapter No. 1
Introduction to Periodontal indices in brief

Indices are very important to measure, quantify and grade, presence of disease, extent and
severity of disease, define appropriate treatment approaches, and project quality of life. Not
only for epidemiological purposes, various periodontal indexes have been found to be useful
in recording and preserving clinical patient data at multiple time-points for assessing
treatment results and medico-legal issues.
The understanding of periodontal diseases is improving over decades and because of this the
earlier proposed indices may or may not be useful in current scenario. A researcher or a
clinician should wisely choose between the available indices.
The attempts to measure periodontal disease in certain terms and units form the basis of
evolution of a periodontal index. Periodontitis is a multifactorial immuno-inflammatory
polymicrobial destructive disease of the supporting tissues of the teeth. The signs of the
disease include increased pocket depth, attachment loss, bleeding on probing, suppuration,
bone destruction, soft tissue destruction, tooth mobility, loss of teeth, etc. There are telltale
signs of the disease identified in saliva, gingival crevicular fluid and blood also. Because of
such nature, measurement strategies are varied. The attempts to characterize and measure the
disease can be classified as; morphological, radiological, molecular, genetic, immunological,
microbiological, clinical, biochemical, etc. The indices can also be classified according to
their purpose like, pertaining to definitions, extent and severity, staging and grading,
continuous variable type, etc. The indices can be invasive or non-invasive depending on the
encroachment on personal liberty for clinical examinations. They can be simple (stand-alone)
or composite, depending on number of characteristics chosen.

The main objectives of this book are:

i) To present the reader indices related to periodontitis (the indices related to plaque,
calculus, oral hygiene, staining, gingivitis, gingival enlargements, etc. are not
presented here)
ii) To present all types of periodontal indices (clinical, epidemiological, biochemical,
genetic, microbiological, anatomical, radiographical, etc.)
iii) To present all the possible indices as far back as possible (if the publication is too
old and no information apart from topic is available, it is to be excluded)
iv) To present the index in its originally described manner as much as possible
v) To present major modifications to the original index to the extent possible
vi) To present all the indices in their chronological order of appearance in the
published literature
vii) To present the index in as simple language as possible
viii) To present periodontal indices as recent as possible
ix) Critical appraisal of any of the indices is not presently considered as a part of the
book
x) To do a citation analysis of the citable periodontal indices so as to assess their
impact and usefulness by the research community at large

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Sources of information:
The primary source of information is the PubMed database. Once we finally selected the
article, the full text publication is retrieved from journal websites, online library resources or
physical libraries. The information about indices is directly referred from the original full text
articles as far as possible. We were able to retrieve all full-texts but three. The indices
published independently were also retrieved and discussed. The cross references from the
published articles is also one of the main sources of gathering information.

Expression style:
Information pertaining to only the index is tabulated, whenever possible, for easy referral.
The method of examination and other relevant details are added for each index. Each index is
expressed as a chapter for reducing confusion, and specific and easy reading.

Purpose of the book:

The research activities related to Dentistry in general and Periodontology in particular, are
very high today and they are increasing day by day. Not only students pursuing
Periodontology have to do a compulsory project, other investigators like undergraduate
students of health sciences, epidemiologists, and public health people, trusts and Non-
Governmental Organizations are also into research activities. A lot of research is also
concentrated on assessing the relationship between periodontal disease and systemic disease.
While conducting different types of research, indices are necessary, and no study is possible
without a proper suitable index. There is still a lot of confusion for application of indices
while designing a study. Many studies also get rejections from journal publishers for lack of
appropriate indices employed. The purpose of this book is to be used as a help-book for
selecting and using an index properly.

Future of the book:

We hope the book will be used to its fullest dimensions. We do have plans to not only update
the book on regular basis, but also to upgrade it. Once data on new indices is available or we
get to know about old indices which are not mentioned here, we will go on updating it. We
have plans to upgrade it by introducing sections on critical appraisal of the indices and
chapters on selecting indices for a particular project with examples. There are various other
upgrading proposals, which can’t be disclosed now.

Indices discussed:
Following are the various periodontal indices, 56 in number, presented in this book:
1. Radiographic alveolar bone loss index by Sheppard (1936)

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Chapter No. 2
Radiographic alveolar bone loss index by Sheppard (1936)

Irving Sheppard from New York, USA, while studying the relationship between diabetes
mellitus and alveolar bone destruction, used intraoral radiographs and graded the bone loss on
a scale so as to classify the patients on the basis of severity. He also classified diabetic
patients based on daily insulin requirements.

For further information read the published book.

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Chapter No. 31
Dutch Periodontal Screening Index (DPSI) by DSP (1998)

In the Netherlands, a periodontal diagnosis and treatment protocol was introduced in 1998 by
the Dutch Society of Periodontology (DSP). A component of this protocol is the Dutch
periodontal screening index (DPSI), a procedure that functions as an initial evaluation to
determine the level of additional periodontal examination and subsequently, the treatment
needs of patients with differing disease levels (Van der Velden U, 2009).

Table No. 32: Description of clinical criteria per score of the Dutch periodontal
screening index (DPSI, 1998), to apply per sextant based on the site with the highest
score
Score Clinical criteria for the score per sextant

0 No pockets >3mm in depth, no calculus, no overhanging restorations and no

bleeding on probing to the bottom of the pocket
1 No pockets >3mm in depth, no calculus, no overhangs of restorations, but
presence of bleeding on probing to the bottom of the pocket
2 No pockets >3mm in depth, presence of bleeding on probing to the bottom
of the pocket, and presence of calculus or overhanging restorations
3 Presence of pathological pockets of 4–5mm without gingival recession
4 Presence of pathological pockets of 4–5mm with gingival recession
5 Presence of pathological pockets ≥ 6mm.

This index is also a modification of the CPITN and aims to screen for subjects with minor,
moderate and severe periodontal disease. To achieve this, the original CPITN codes 0, 1, 2
remained unchanged, i.e. now written as DPSI 0,1, 2, respectively. CPITN code 3 was
differentiated into 3 minus, that is pathological pockets of 4–5mm without gingival recession
(DPSI 3) and 3 plus that is pathological pockets of 4–5mmwith gingival recession now DPSI
4, CPITN code 4 was recorded into DPSI5. It is also referred to as the “Dutch perio-
protocol”. It recognizes three categories of patients mentioned in the Table No. 33.
Table No. 33: The DPSI treatment need scoring criteria
Treatment need Criteria
Scores
DPSI 1 & 2 Patients that require only oral hygiene instruction and calculus
removal
DPSI 3 Patients that require a limited periodontal examination in order to
be able to make a proper treatment plan
DPSI 4 & 5 Patients that require an extensive periodontal examination in order
to be able to make a proper treatment plan

It is then adopted by the Dutch Govt. and made it compulsory for all the dentists to record
and report.

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Chapter No. 51
Periodontal indices- When, Why and How?

Now after going through several indices on measuring periodontitis incidence and
prevalence, extent and severity, staging and grading, and treatment planning, it becomes more
and more complex and confusing to select an appropriate index for a particular study or
clinical recording. Apart from the problem of selection from many, several indices have been
used or modified as per convenience by the researchers. The modifications included, but not
restricted to, using the same index partly in the mouth, or on index teeth, or even full mouth.
Again, there are variations in taking measurements only on few selected sites on teeth under
observation.
‘’’’’’’’’’’’’’’’’’’’
‘’’’’’’’’’’’’’’’’’’
When?
It is mandatory for a post-graduate student to do research for the partial fulfillment to get the
degree of Master of Dental Surgery, MS, MPH, MClinDent or any other as per the country of
residence. Many interns and UG students also conduct various short term or long-term studies
for making their curriculum vitae stronger for opening multiple channels of education abroad
and in other fields. Studies on various aspects of periodontal diseases are the mainstay for
PGs pursuing studies in Periodontology and Public Health Dentistry.
PGs in Pediatric & Preventive Dentistry also can conduct research on, e.g.
• Prevalence of periodontitis in children visiting a dental hospital
• Prevalence of periodontitis in special and disabled children
• Extent and severity of periodontitis in mixed dentition phase
• Periodontitis prevalence in a locality, school, factory, special group etc., like
school for deaf and dumb
• Comparison between different periodontal indices amongst children and
adolescents
The PGs in Orthodontics also can think of doing a periodontal related study, e.g.
• Prevalence of periodontitis in orthodontic patients undergoing buccal orthodontics
versus lingual orthodontics
• Periodontally accelerated orthodontic therapy and crestal bone loss after
orthodontic therapy
• Various force application matrices and alveolar bone loss and periodontitis
• Types of malocclusions as related to extent and severity of periodontitis in adult
population
The PGs in Conservative Dentistry & Endodontics can also design an interdisciplinary
research topic, e.g.
• Prevalence of periodontitis and presence of class II lesions or fillings
• Cervical perforations/ cervical accessory canals and alveolar bone loss
• Extent and severity of periodontitis and pulpal problems

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 • Level of attachment loss and need for root canal therapy
The PGs in other branches and also the interns can think of these lines to extract various
different research projects. All such studies definitely require an index, a periodontal index to
be specific.
Irrespective of which type of study you are doing, whether clinical, epidemiological,
radiographical, surgical, or linkage and association; you will require a corresponding
periodontal index for designing and executing your project. You can use a radiographical
index for finding out associations between periodontitis and diabetes mellitus, but it would be
much appropriate if you are using an extent and severity index for the same if your objective
is to correlate micromolecular aspects.
So, when periodontal index, almost every time when you are considering a project on
periodontal disease.
Why?
Let’s consider you are doing a research for establishing the association between periodontitis
and secondary infection in knee replacement surgeries. You are checking for DNA strands of
periodontal bacteria in washings of infected joints. Now there are two patients, the sample
size will be obviously more this is just an example, one with only one periodontal pocket of 6
mm and the other person has 10 pockets of 6 mm and 8 pockets of 8 mm. Do you feel these
two patients can be compared? Obviously, no. Even if they can be classified as periodontitis
patients, they can’t be compared for influence on infected joints. The influence on induced
bacteremia quotient of the first patient will be much lower than that of the second patient.
Therefore, you require a system where individuals of similar characteristics can be grouped
together for better comparisons. Every level will have a definite upper and lower limit. It will
have specific definitions. It will be realistic, easy to use, complementing rigorous scientific
methodology, repeatable, universal in application, amenable to statistical analysis, etc. This
system is referred to as an ‘Index’, and when it is application to periodontal disease, a
‘periodontal index’.
How?
Once you have selected a particular periodontal index suitable for your research, you should
know how to use it properly. Make tables, charts or recording systems appropriate for the
selected index for each patient/ individual. Write down the methods of calculations for each
patient on the same page.
Often times it becomes confusing where the disease extent and severity looks the same for
two different levels. This happens when the patient values or clinical findings are near the
upper value of lower level and lower values of upper level. Be clear about such doubts in the
beginning and assign clearly in which level you are going to place that patient.
Implementation of a selected index is also one of the most important steps.

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Chapter No. 52
Citation analysis of periodontal indices based on Google Scholar matrix as on
25th August, 2020

Author: Baghele Om N.

How to cite this manuscript: Baghele O. N. Citation analysis of periodontal indices based on
Google Scholar matrix as on 25th August, 2020. In Baghele Om, ed., Periodontal Indices:
epidemiological, staging & grading, extent & severity, clinical, and treatment planning
indices about periodontitis. 2020 Amazon Kindle (ASIN: B08FYH3HPN): Amazon.
www.amazon.com.

Abstract:

Background: The use of a periodontal index is a prerequisite for a vast majority of studies,
especially epidemiological research. The citations to a published periodontal index article
may represent its popularity and use in the literature. As of now there are no citation
analysis studies on articles of periodontal indices.

Objective: To conduct a bibliometric citation analysis study on periodontal index articles to

estimate the overall impact on the publication trends based on their utilization.

Materials & Methods: Individual searches were executed on PubMed database using
various terms, like ‘periodontal index’, ‘periodontitis index’, ‘periodontal AND index’, etc.
The cross references of the published articles were ultimately becoming the chosen mode
for further search on PubMed or otherwise. All the 54 indices discussed in the
corresponding book are considered for citation analysis.

The citable and non-citable articles from the selected manuscripts were identified and
Google Scholar citation companion used for noting down number of citations to individual
articles. Citation analyses then conducted using simple mathematical formulae.

Results: Out of a total of 55 articles we considered 52 for citation analysis. On further

analysis 3 articles were found non-citable, so in total 49 articles were found to be citable.
The total number of citations received to these 49 citable articles is 14907, the average
turns out to be 304 citations/ citable article. Only 4 indices received more than 1000
citations each. The top cited publication is related to the Community Periodontal Index-
Modified by WHO published in 2013 with 6,600 citations. The topmost journal favored by
the authors for their publication is the Journal of Periodontology with maximum 8 articles
and received 2654 citations. The topmost journal receiving maximum citations per article is
Journal of Dental Research with 343 citations/ article for its quota of 3 articles.

Conclusion: Contrary to belief, the citations received by the most important manuscripts on
ways of conducting research is abysmal apart from the indices proposed by the apex
healthcare body, the World Health Organization. There is lack of citable articles for clinical

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periodontal indices like Basic Periodontal Examination and Periodontal Screening &
Recording.

Key words:

Periodontal index; periodontitis measurement; periodontal treatment need; bibliometric

analysis; citation analysis; periodontal epidemiology

Introduction

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Chapter No. 53
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Further reading:
1. Baltacioglu, E., Yuva, P., Aydin, G., Alver, A., Kahraman, C., Karabulut, E., et al. Lipid
peroxidation levels and total oxidant/antioxidant status in serum and saliva from patients
with chronic and aggressive periodontitis. Oxidative stress index: a new biomarker for
periodontal disease?J Periodontol. 2014; 85:1432–1441. doi: 10.1902/jop.2014.130654
2. Beck James D, Moss Kevin L, Morelli Thiago, Offenbacher Steven. In search of appropriate
measures of periodontal status: The Periodontal Profile Phenotype (P 3) system. J
Periodontol 2018; Feb;89(2):166-175. doi: 10.1002/JPER.17-0424. Epub 2018 Feb 22.
3. Buhlin K, et al., Periodontitis is associated with angiographically verified coronary artery
disease, J Clin Periodontol 2011; 38:1007e1014.
4. Dhingra K, Vandana KL. Indices for measuring periodontitis; a literature review. International
Dental Journal 2011; 61:76-84. Doi: 10.1111/j.1875-595X.2011.00018.x
5. Hodges KO. Concepts in nonsurgical periodontal therapy. Albany, NY. Delmar Publishers.
1998.
6. Khoury W, Glogauer J, Tenenbaum HC, Glogauer M. Oral inflammatory load: Neutrophils as
oral health biomarkers. J Periodont Res 2020;00:1–8. https://doi.org/10.1111/jre.12758
7. Kose, O., Arabaci, T., Kara, A., Yemenoglu, H., Kermen, E., Kizildag, A., et al. Effects of
melatonin on oxidative stress index and alveolar bone loss in diabetic rats with periodontitis.
J Periodontol 2016; 87, e82–e90. doi: 10.1902/jop.2016.150541
8. Sharma Vinoda, Hanafi Ahmed, Overgaard Christopher, et al. Oral inflammatory load in
patients with coronary artery disease. Journal of Oral Science 2019; Vol. 61, No. 3, 412-417.
9. Weinberg MA, Fine JB. Comprehensive periodontics for the dental hygienist. Upper Saddle
River, NJ. Pearson Education. 2010.

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About the Author:

Dr. Om Nemichand Baghele, currently, is a Professor & PG Guide in the Department of

Periodontology& Oral Implantology at Maharashtra Institute of Dental Sciences &
Research, Latur, Maharashtra, India. He has completed BDS in 1998 from the prestigious
Government Dental College, Nagpur, Maharashtra and then MDS in Periodontology in
2002 from the illustrious Government Dental College, Mumbai, Maharashtra. He has 18
years of rich teaching and research experience at India’s best Dental Institutes. He has
various National & International publications to his credit. He worked as Assistant Editor
for few years for Dental Dialogue Journal and Journal of Indian Dental Association. He
also has an MBA in Hospital Management as an additional degree. He also works as a
Clinical Consultant in Periodontology & Implantology at various clinics. He is a life
member of various professional societies, like, Indian Society of Periodontology, Indian
Society for Dental Research (IADR- India Chapter), Indian Dental Association, Indian
Society of Oral Implantologists, Indian Academy of Aesthetic & Cosmetic Dentistry, etc.
He has few National & International presentations to his credit.

www.ombaghele.com

For any issue in the book, please write to ombaghele@gmail.com, we are eager to
correct and revise any wrong or inappropriate information in the book.

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