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Measuring periodontal disease

 MEASURING GINGIVITIS
 MEASURING PERIODONTITIS
 PERIODONTAL TREATMENT NEEDS
 PLAQUE AND CALCULUS
 PARTIAL-MOUTH PERIODONTAL MEASUREMENTS
MEASURING GINGIVITIS
 Gingivitis is Inflammation of the gingivae without involvement of the deeper supporting tissues

‫ دلاٌك ٌشرح اناتومً ٌلً حاب ٌرجعله ٌسمع بداٌة‬5 ‫الدكتور ضل تمرٌبا‬
)): ً‫الرٌكورد أنا مش شاٌفه الها داع‬

You can qualitatively assess the gingiva by examine the

gingiva (ex: swollen free gingival margin, plaque, calculus,
 Measures used for gingivitis BOP, etc…). All of these are subjective signs & we need to
a) Papillary-Marginal-Attached Index convert it to something measurable & quantifiable & hence
b) Gingival Index (GI) the role of indices. Quantification of ds ‘index’ is important
c) Eastman Interdental Bleeding Index (EIBI) for assessment of an individual patient & for research or
d) The Modified Gingival Index (MGI) epidemiological studies.
 Papillary-Marginal-Attached Index (PMAI)
 Principle: Inflammation commences in the interdental papilla (P) from where it spreads to the marginal
(M) and ultimately the attached gingiva (A)
,early stage ‫ بكون‬interdental papilla ‫ ٌعنً اذا كان فً الـ‬spread of inflammation ‫ حسب الـ‬level of severity ‫ بمٌس الـ‬
‫ بكون وصل مراحل متمدمة‬attached gingiva ‫ واذا وصل الـ‬intermediate stage ‫ بكون‬marginal gingiva ‫اذا وصل الـ‬
subjective rather than objective ‫ بطرٌمه‬severity level of gingivitis ‫ غٌر دلٌك ألنه بوصف الـ‬index ‫ هاد الـ‬
 Developed in 1947 and described by Massler 1967
 The oldest reversible index
 Gingival Index (GI)
 Found by LÖe and Silness in the early 1963
 Records qualitative changes in the gingiva
quantitative ‫ على شكل‬qualitative changes ‫ بسجل الـ‬
 Still used till today
 The GI grades the gingiva on the mesial, distal, buccal, and lingual surfaces of the teeth
 Each area is scored on a 0 to 3 ordinal scale
‫ لكن الفرولات بٌنهم مش بالضروره تكون متساوٌة‬3 ‫ الل من‬2 ‫ الل من‬1 ‫ الصفر الل من‬
 Takes no account of deeper changes in the periodontium subjective ‫ ٌعتبر‬BOP ‫ والـ‬GI ‫ بالـ‬BOP ‫الزم الٌس الـ‬
 Scores & Criteria for the Gingival Index (Subjective) ً‫ اكتر من التان‬pressure ‫عشان ممكن حدا ٌعمل‬
0: Normal gingiva
1: Mild inflammation-slight change in color, slight edema but no bleeding on probing
2: Moderate inflammation-redness, edema, and glazing (loss part of stippling); bleeding on probing
3: Severe inflammation-marked redness and edema; ulceration; tendency to spontaneous bleeding

 The GI of the patient can be obtained by adding the values of each tooth and dividing by the number of
teeth examined
‫ وبمٌس لكل األسنان وباآلخر بجمعهم وبمسم على توتال عدد األسنان‬average ‫ عاألسطح األربعه للسن وباخدلهم‬GI ‫ بمٌس الـ‬
 The Gingival Index may be scored for all surfaces of all or selected teeth or for selected areas of all or
selected teeth.
M&D ‫ أو ممكن اختار اسطح معٌنه مثال‬,‫ اسطح‬4 ‫ اسطح لكل األسنان أو بختار عدد اسنان معٌنه بمٌسلهم‬4 ‫ اذا عندي ولت كافً بمٌس الـ‬
‫لكل األسنان أو ألسنان معٌنه‬
  The GI may be used for the assessment of prevalence and severity of gingivitis in populations, groups
and individuals
 It is sufficiently sensitive to distinguish between groups with little and with severe gingivitis
extremes ‫ ٌعنً بكٌز الـ‬healthy- mild -severe gingivitis ‫ بشكل عام بمٌس الفرولات بٌن الناس ٌلً عندها‬,sensitivity ‫ فٌه‬
‫ وبعبر عن وضع المرٌض‬accurate ‫وكونه انا باخد لراءه ألغلب األسنان بعتبره نوعا ما‬
 It may not discriminate between middle-range
moderate to ‫ زي الحاالت ٌلً بتكون‬scores near the middle (2) ‫ لكن ممكن ٌكون صعب تمٌز‬0, 1 & 3 ‫ ٌعنً بمٌز بٌن‬
mild to slightly moderate ‫ او‬slightly severe
 It is subjective because it depends on visual assessments of inflammation (color, swelling, BOP)
 Assessment of Severity of gingivitis using GI:
‫ لكلسن وباآلخر اخدت‬GI ‫ عادي ألنه انا اخدت‬fractions ‫ممكن ٌكون فٌها‬
0.1-1.0 = mild inflammation ‫ لكل األسنان ٌلً لستها‬average
1.1-2.0 = moderate inflammation integer ‫ الزم ٌكون‬GI per Surface ‫لكن لما بحكً عن‬
2.1-3.0 = severe inflammation
 Gingival Bleeding on Probing (BOP)
 The appearance of spots of blood after the probe is gently run around the gingival margin is more
sensitive
 The BOP is more objective in those sites that are difficult to view directly (ex:
behind the last molar)
 It is used as a standard measure of gingivitis in clinical trials
 Validity against the GI has been demonstrated
 The major area of subjectivity is gentle probing (not excessive pressure)
 Probing has been shown to vary between 3 ‘very gentle’ and 130 g for different examiners (extreme
variation)
 Eastman Interdental Bleeding Index (EIBI)
 Developed by Caton & Polson (1985)
 Wooden interdental cleaner (Not perio probe) is inserted between the teeth from the facial aspect,
depressing the interdental tissues 1 to 2 mm
 More sensitive than other measures of papillary bleeding
 BOP is not recommended in public health programs for 3 reasons:
- This degree of sensitivity is rarely required in surveys, surveillance, or screening; it may be needed
in cohort and case-control studies
‫ مثال‬cohort ‫ بالـ‬something to compare your finding with ‫؟ ألنه عندي‬case-control ‫ والـ‬cohort ‫ لٌش بستخدمها بالـ‬
periodontitis ‫ على مرٌض عنده‬probe ‫ بالـ‬pressure ‫ انا بطبك نفس الـ‬case control ‫ بالـ‬,‫عندي لراءات المرٌض السابمه‬
)‫ومرٌض تانً ما عنده (تذكروهم من اول محاضره‬
ً‫ فما اله داع‬reference ‫ ما عندي‬,‫ او غٌرها فأنا بس بشوف المرٌض كره وحده‬survey ‫ بٌنما لما بحكً عن‬
- Such indexes have uncertain discriminatory power in field conditions
BOP ‫ الـ‬,cross-sectional studies ‫ هً الدراسات المٌدانٌه ٌلً بشوف فٌها مرضى بأعداد كبٌره بـ‬field conditions ‫ الممصود بالـ‬
reference ‫ ألنه ما عندي‬people ‫بالحاله هاي ما بتفرق بٌن الـ‬
- Concerns about infection control make the deliberate inducement of gingival bleeding outside the
clinic hard to justify
‫ بٌنما بالمدارس‬,‫ وغٌرها‬gloves, mask, protective personal equipment ‫ من‬infection control ‫ انا بالعٌاده بمدر اسٌطر عالـ‬
good infection control measures ‫مثال انا ما عندي‬
 The Modified Gingival Index (MGI)
 Was developed by Lobene et al. (1986) to eliminate the use of bleeding on probing
 Non-invasive index (no probing, based on visual assessment): no risk of bleeding or tissue damage
 Still providing high visual sensitivity for incipient gingivitis
good visual sensitivity ً‫ بتعطٌن‬gingivitis ‫ بالمراحل األولى من الـ‬
 Gingivitis is an area in which the development of valid non-clinical measures would be highly beneficial
‫ بدل‬field studies ‫ وممكن ٌكونو مفٌدٌن أكتر بالـ‬,‫ ٌعطٌنً لراءات دلٌمه‬valid ‫ الزم ٌكون‬non-clinical measures ‫ اذا بدي استخدم‬
‫ لعدد كبٌر من الناس‬BOP ‫ما الٌس‬
 MEASURING PERIODONTITIS
 Periodontitis is a bacterially induced inflammation of the gingival tissues together with some loss of
both the attachment of the periodontal ligament and bony support
 The clinical manifestations of periodontitis come from the interaction between bacterial infection and
the host response.

 Periodontitis is:
- a family of related diseases that differ in natural history and response to therapy
- but that are characterized by a common underlying chain of events
- These commonalities, and their clinical expression, permit valid clinical measurement by similar
procedures, basically measurement of clinical attachment loss (CAL) and probing depth
 Many early epidemiologic studies of periodontal diseases were based on radiographic surveys of
alveolar bone loss
 However, radiography is impractical and probably unethical in field studies
not the only source of data for measuring ‫؟ هأل هً مهمه لكن‬radiographic data ‫ هل ممكن اعتمد فمط على‬
CAL & ‫ بعبر عنه بـ‬soft tissue attachment ‫ لكن فٌه‬bone level ‫ انا باخدها عشان الٌم الـ‬,ً‫ لحالها ما بتكف‬,periodontitis
more important indicator ‫ وهدول بعتبرهم‬Probing depth
field ‫ فبالـ‬unjustifiable radiation ‫ وبعرضهم لـ‬unethical ‫ للبٌشنت بدل ما افحصهم هاد‬X-ray ‫ انه آخد‬field studies ‫ كمان بالـ‬
‫ و األشعه عند الحاجه‬clinical examination ‫ بعتمد عالـ‬study
field study ‫ تعتبر مشكله بلـ‬portability of X-ray machines ‫ الـ‬
 The attempt was therefore made to develop reversible indexes that were both sensitive and clinically
manageable in field conditions
 The most widely used periodontal index for many years was the periodontal index (PI)
 Periodontal index (PI)
 Described by Russell in 1956
 Scores:
0: Absence of signs of Inflammation
1: Mild to moderate inflammatory gingival changes not extending around the tooth
2: Mild to moderately severe gingivitis extending all around the tooth
3: severe gingivitis characterized by marked redness, swelling, tendency to bleed, and ulceration
>> Form 0 to 3: Gingival disease so it has the advantage about including gingival condition
4: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically to CEJ but not more than
3mm
5: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically to CEJ between 3-6 mm
6: gingival crevice in any of 4 measured areas (M, D, B, L) extending apically more than 6mm from CEJ
 PI is composite index which scored both gingivitis and periodontitis in the same scale (some of people
consider it as disadvantage since we have gingival index so no need to include gingival conditions in PI)
 The PI was viewed as an ideal field index in the 1960s
 It was used in a series of epidemiologic studies that correlated disease scores with clinical and social
determinants.
 These correlations soon became accepted as base knowledge
 Modern understanding has shown the PI to be invalid because:
- It does not include evaluation of CAL (it measures tissue extension from CEJ. What about false
pocket or if free gingiva is bulging?)
- Grades all pockets  3 mm equally so it’s not sensitive (score 5 in the index)
 - Scores gingivitis and periodontitis on the same weighted scale
- Its compression of all information into a group mean also fails to illuminate the disease distribution
distribution ‫ و‬mean ‫ الزم اعبر عنها ب‬data ‫ احنا حكٌنا انه أي‬
- Fails to illuminate why some people have no disease and others have severe disease
chronic periodontitis ‫ و‬rapidly progressing periodontitis ‫ ما بمٌز بٌن‬
 Periodontal Disease Index (PDI)
 Same fundamental problem of a composite index
Ramfjord teeth ‫ انه بختار عٌنه من األسنان اسمها‬PI ‫بفرق عن الـ‬
 PDI is also no longer used
 Periodontal Disease Index (PDI) - Ramfjord teeth
- Ramfjord teeth are a set of six teeth taken to represent the whole mouth during
examination
- Ramfjord teeth are the 16, 12, 24, 36, 32, 44 (What if the patient have one of them
extracted??? It’s a drawback)
- Ramfjord chose this group of teeth to save time in clinical examinations
 Indirect measurement of CAL
 These measurements are usually carried out to 2-6 sites per tooth (record the
worst measurement)
 Either used the “Ramfjord teeth" or the whole dentition
 Measuring six sites per tooth for an intact dentition can take 30-40 minutes per
examination

‫ فهو عباره عن المسافه بٌن الـ‬pocket depth ‫ هأل بالنسبه للـ‬,Gingival crest ‫ و‬CEJ ‫ و المسافه بٌن الـ‬pocket depth ‫بنمٌس‬ 
‫) زي‬severe gingivitis( false pocket ‫ هأل المشكله انه المرٌض ممكن ٌكون عنده‬base of the pocket ‫ والـ‬gingival crest
‫ فبصٌر عندهم‬drug-induced gingival enlargement due to cyclosporine, Ca-channel blockers ‫الناس ٌلً عندها‬
periodontitis ‫ بس ما عنده‬7 ‫ او‬6 ‫ بطلع عندي‬pocket depth ‫ ولما بمٌس الـ‬overgrowth
‫ صارت‬gingival crest ‫ واذا الـ‬,gingival crest to CEJ ‫) ٌلً هً المسافه بٌن الـ‬B ‫عشان هٌن بعتمد على نمطه تانٌه (المسافه‬ 
3 ‫ بتصٌر المراءات بالسالب زي صوره‬apical to CEJ
 CAL (C) = A – B
 Extent and Severity Index (ESI)
 Records the % of sites with a CAL  1 mm and the mean CAL for those affected sites
 Give extent & severity
 ESI is a method of summarizing data rather than a true index
 Its measurements are made by the Ramfjord method.
Measurement of any disease is based on a case definition
 A case definition for periodontitis needs to establish the following:
- What depth of CAL at any one site constitutes evidence of disease processes?
‫ مثال؟‬2 ‫ أو اكتر من‬1 ‫ ٌكون اكتر من‬CAL ‫ ببلش لما الـ‬ds ‫ٌعنً هل بدي اعتبر انه الـ‬ 
- How many such sites need to be present in a mouth to establish disease presence?
disease ‫ حتى احكً انه عندي‬CAL ‫ الزم ٌكون فٌه‬site ‫كم‬ 
- How probing depth and BOP are to be included in the case definition?
 What depth of CAL at any one site constitutes evidence of disease processes?
- At least 2 mm because of examiner variation (1 mm)
perio ds ‫ حتى احكً انه المرٌض عنده‬CAL ‫ مم‬2 ‫ اعتمدو‬examiner ‫ بٌن الـ‬variation ‫هأل ألنه عندي‬ 
 - CAL progression of at least 3 mm over a given time period has been the criterion for change in some
studies
ً‫ والزم اعمله ش‬ds ‫ وٌضل مستمر لفتره معٌنه حتى احكً انه وهللا هاد المرٌض عنده الـ‬CAL 3 ‫ فٌه دراسات بتحكً انه الزم ٌكون الـ‬
- Introduction of computerized, constant force probes has not changed examiner variation much
‫ ما انحلت‬examiner variation ‫ مشكلة الـ‬,‫ مع كل التمدم والتكنولوجٌا‬
Markers of Periodontitis
Cytokines
measures of periodontitis ‫ كـ‬cytokines ‫ فٌه ناس بعتمدو على الـ‬
 Include prostaglandin E2, tumor necrosis factor , interleukin-1 , interleukin-1 β
 Expressed in gingival crevicular fluid (GCf)
 Associated with active disease
 To date, measurement of periodontitis by means of inflammatory cytokines in GCf is still experimental
+ it’s expensive
Periodontal Treatment Needs
Treatment plans are subjective
 Often depending on some dentist-patient factors that are not part of a clinical examination
‫ بختلف من مجتمع آلخر وحسب رغبة المرٌض وشو بده أو مثال شو الطبٌب بمدر ٌمدم عالج ضمن خبرته‬
 Treatment for a given condition can change quickly as knowledge develops
- Treatment of periodontal pockets has shifted from surgical removal of pockets to scaling and root
planning
 Community Periodontal Index of Treatment Needs (CPITN)
 The CPITN was first described in 1982
 Received some promotion by the WHO
 It requires use of a special periodontal probe
 Probing pressure is recommended to be no more than 20 g
CPITN probe
 Has a 0.5 mm diameter ball at its tip (to avoid bleeding & damage)
- To assist in feeling subgingival calculus
- Prevent the probe from being pushed through inflammatory tissue at the
base of a pocket
 A black band for visibility between 3.5 mm and 5.5 mm
 Circular markings at 8.5 mm
 Circular markings at 11.5 mm.
 CPITN code:
0: Healthy gingiva.
1: Bleeding observed, directly or by using the mouth mirror, after gentle probing.
2: Calculus felt during probing but all the black area of the probe visible (3.5-5.5
mm from ball tip). “Not more than 3.5 mm”
3: Pocket 4 or 5 mm (gingival margin situated on black area of probe, i.e., 3.5-5.5
mm from probe tip). “Part of black area is hidden”
4: Pocket >6 mm (black area of probe not visible).
X: Excluded segment (less than two teeth present).
X ‫ ٌلً فٌها الل من سنٌن بعطوها‬segment ‫ هأل الـ‬,)‫ (نفس األورثو‬6 sextant ‫ بتمسم لـ‬mouth ‫ الـ‬
9: Not recorded.

‫ حسب‬treatment ‫هأل هاد الجدول بحكً عن الـ‬

CPITN code ‫الـ‬
 CPTIN Followed a workshop on the index in Manila in 1994
 The index is now referred to as the Community Periodontal Index, or CPI
 Treatment need codes were eliminated because they had become obsolete in view of current
treatment methods