SUBJECT TITLE

LESSON 1: Lesson Title

FACULTY OF DENTISTRY
Doctor of Dental Surgery
Dental Public Health (2212)
By: Dr. Shilpa Gunjal (shilpa@mahsa.edu.my)
 DDS Year 4
10 October 2018

Dr. Shilpa Gunjal MDS, Ph.D

Associate Professor
Dental Public Health
MAHSA University

10/10/2018
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LESSON 1: Indices
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Dental Epidemiology

At the end of the lecture, students should be able to:

List the indices used for dental caries.
Describe DMFT Index.
List the indices used for Periodontal disease.
Describe CPITN and CPI.
List the indices used for dental fluorosis.
Describe Dean’s Fluorosis index.
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LESSON 1: Indices
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Dental Epidemiology

 Indices used for assessment of Dental caries.

 Indices used for assessment of Periodontal

disease.

 Indices used for assessment of Dental Fluorosis.

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LESSON 1: Indices
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Dental Epidemiology

 DECAYED-MISSING-FILLED TEETH INDEX (DMFT INDEX)

 DECAYED-MISSING-FILLED-TOOTH SURFACES INDEX(DMFS)
 CARIES INDICES FOR PRIMARY DENTITION
 STONE’S INDEX
 CARIES SEVERITY INDEX
 CARIES SUSCEPTIBILITY INDEX
 MODIFIED DMFT INDEX
 DENTAL CARIES SEVERITY INDEX FOR PRIMARY TEETH
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Dental Epidemiology

‘D’ – Decayed teeth

‘M’ – Missing or Extracted teeth due to caries
‘F’ – Filled teeth
The teeth not included are:
• Third molars & Unerupted teeth
• Congenitally missing & supernumerary
• Teeth removed for reasons other than caries.
• Teeth restored for reasons other than caries.
• Primary retained with the permanent successor erupted.
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Criteria for identification of dental caries.

The lesion is clinically visible and obvious.
The explorer tip can penetrate deep into soft yielding material.
There is discoloration or loss of translucency typical of
undermined or demineralized enamel.
The explorer tip in a pit or fissure catches or resists removal
after moderate to firm pressure on insertion and when there is
softness at the base of the area
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Dental Epidemiology

Principles and rules:

No tooth must be counted more than once.
Decayed, Missing, Filled teeth should be recorded separately.
While counting the number of decayed teeth, also include those
teeth which have restorations with recurrent decay.
Following should not be counted as missing:
-Unerupted teeth

- Missing due to accident

- Congenitally missing
- Teeth extracted for orthodontic reason
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Dental Epidemiology

Principles and rules:

Care must be taken to list as missing only those teeth which have
been lost due to decay. Also included should be those teeth which
are so badly decayed that they are indicated for extraction.
A tooth may have several restorations but it is counted as one
tooth.
Deciduous teeth are not included.
A tooth is considered to be erupted when the occlusal surface or
incisal edge is totally exposed or can be exposed by gently
reflecting the overlying gingival tissue with mirror or explorer.
A tooth is considered to be present even though the crown has
been destroyed and only the roots are left.
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LESSON 1: Indices
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Dental Epidemiology

WHO Modification of DMF Index (1986):

 All third molars are included

 Temporary restorations are considered as ‘D’

 Only carious cavities are considered as ‘D’, initial lesions (Chalky spots,
stained fissures, etc) are not considered as ‘D’.
 Can be applied to denote number of affected teeth (DMFT) or to
measure the surfaces affected by caries (DMFS)
Coding Criteria for DMF index

Code Criteria
E Excluded tooth or tooth space
1 Sound permanent tooth
2 Filled permanent
3 Decayed permanent tooth
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 For tooth absent:

‘0’ – Missing tooth, Unerupted, Impacted, Congenitally

missing

‘X’ – Extracted permanent tooth

 Calculation of the index:

A. Individual DMFT:

D+M+F = DMF

B. Group Average: Total DMF

Average DMF =
Total No. of subjects
examined
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Limitations :
 Values are not related to the number of teeth at risk
 Can be invalid in older adults
 Can be misleading in children, teeth have been lost
due to orthodontic reasons
 Overestimates caries experience in teeth in which
“preventive fillings”, have been placed
 Little use in studies of root caries
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Surfaces examined :
◦ for posterior teeth: facial, lingual, mesial, distal & occlusal.
◦ for anterior teeth: facial, lingual, mesial & distal

Calculations :
◦ Total No. of decayed surfaces = D
◦ Total No. of missing surfaces = M
◦ Total No. of filled surfaces =F
◦ DMFS Score = D + M+ F
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‘def ’ index: Gruebbel AO (1942)

d – decayed tooth
e - extracted tooth

f – filled tooth
Coding criteria
Code Criteria
E Excluded tooth or tooth space
P1 Sound deciduous tooth
P2 Filled deciduous tooth
P3 Decayed deciduous tooth
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 Calculation of ‘def ’ index:

A. Individual def index:

-Total each component, i.e d,e & f separately and

then total, d + e + f = def

B. Group average:
Total def
Average def =
Total No. of children
examined
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Dental Epidemiology

 Dean’s Fluorosis Index

 Community Fluorosis Index
 Thylstrup and Fejerskov Index for Fluorosis
 Fluorosis Risk Index
 Young’s classification of enamel fluorosis
 Murray and Shaw’s classification of enamel fluorosis
 Simplified fluoride mottling index
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Dental Epidemiology

 Trendley H Dean 1934

 In 1942, Dean combined “moderately severe” & “severe”
categories – 6 point ordinal scale
 Recording is based on two teeth most affected, the score
for the less affected tooth is recorded
 Start at the higher end of the index (severe) and eliminate
each score.
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 Modified criteria 1934:

Normal (0)
The enamel represents the usual
translucent semivitriform type of
structure. Smooth, glossy and
usually of a pale creamy white
color

Questionable (0.5)
Slight aberrations in the
translucency, ranging from few
white flecks to occasional white
spots (1-2 mm)
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Very mild (1)

Small, opaque, paper white areas are
scattered irregularly.
observed on the labial and buccal surfaces,
involves 25% of the tooth surface.
Mild (2)
 White, opaque areas involve at least half of
the tooth surface.
 Faint brown stains appear sometimes on the
upper incisors.
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Moderate (3)
All enamel surfaces of the teeth are affected &
surfaces subject to attrition show wear
Brown stain is frequently a disfiguring feature
Severe (4)
All enamel surfaces of the tooth are affected,
marked hypoplasia.
Discrete or confluent pitting.
Brown stain are wide spread.
“corroded” – like appearance
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Dental Epidemiology

Jukko Ainamo, David Barmes, George Beagrie, Terry Cutress, Jean

Martin, Jennifer Sardo-Infirri 1982

Scope & Purpose:

 Epidemiologic surveys of periodontal health.
 Provides guidance on the planning and monitoring of
effectiveness of periodontal care programmes and the dental
personnel required.
 Records the common treatable conditions ( periodontal pockets,
gingival inflammation , calculus & other plaque retentive factors).
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Advantages :
 Simplicity
 Speed and
 International uniformity

Limitations:
 Partial recording.
 Exclusion of some important signs of past periodontal
breakdown – notably – attachment loss and absence of any
marker of disease activity or susceptibility.
 Not a diagnostic tool and should not be used for planning of
specific clinical treatment
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Treatment needs’
intended as a guide to the level or magnitude of need for care using
accepted periodontal criteria.
provides an indication of the level of complexity of care needed if
the periodontal conditions are to improve

Procedure

i. No need for care (score 0)

ii. Bleeding gingivae on gentle probing (score 1)

iii. Presence of calculus & other plaque retentive factors (score 2)

iv. Presence of 4 or 5 mm pockets (score 3)

v. Presence of 6 mm or deeper pockets (score 4)

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Sextants

17 – 14 13 – 23 24 – 27
47 – 44 43 – 33 34 – 37

Index Teeth: (Adults aged 20 years or more)

17 16 11 26 27
47 46 31 36 37

For young people upto 19 years

16 11 26
46 31 36
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Dental Epidemiology

The WHO Periodontal Examination Probe – CPITN Probe :

Measurement of pocket depth & detection of subgingival calculus

11.5 mm

8.5 mm
5.5 mm

3.5 mm

‘CPITN-E’ – for Epidemiological probe

‘CPITN-C’ – for clinical probe (8.5, 11.5 markings)
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Dental Epidemiology

 Probing procedures :
- ‘working component’ to determine pocket depth
- ‘sensing component’ to detect subgingival calculus
- Force: Not more than 20 gms
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Codes & criteria

Code 0: No periodontal Disease
Code 1: Bleeding observed during or after
probing
Code 2: Calculus or plaque retentive
factors either seen or felt during probing
Code 3: Pathological pocket 4 or 5 mm in
depth. Gingival margin situated on black
band of the probe
Code 4: Pathological pocket 6 mm or more
in depth. Black band of the probe not
visible
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Examination Procedure :
To determine the highest score applicable to each sextant with the least
number of measurements.

Explanation of clinical criteria :

Bleeding on gentle probing.
Plaque retentive factors (calculus or overhangs of restorations) .
4 or 5 mm and 6 mm or deeper pockets.
‘Treatment Need 1’ (TN 1) : Control of bleeding by means of self-care is a
pre-requisite.
‘Treatment Need 2’ (TN-2) : Removal of calculus & other plaque-retentive
factors demands professional care.
‘Treatment Need 3’ (TN-3): Treatment of residual pockets requires
complex therapy
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Dental Epidemiology

Substitution for excluded and missing index teeth

Remember that 2 or more functioning teeth must be present
in a sextant for it to qualify for scoring.
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
examination of remaining index tooth.
If both index teeth in a posterior sextant are absent or
excluded from examination, all the remaining teeth in that
sextant are examined and the highest score is recorded
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 In the anterior maxillary sextant, if tooth 11 is excluded, substitue

21, if 21 is also excluded then identify the worst score for the
remaining teeth. Similarly, substitute tooth41 if 31 is missing.
 In subjects under 20 years of age, if the 1st molar is not present or
has to be excluded, the nearest adjacent premolar is examined.
 If all teeth in a sextant are missing or only functional tooth remains
the sextant is coded as missing.
 A single tooth in a sextant is considered as a tooth in the adjacent
sextant and subject to rules for that sextant. If the single tooth is an
index tooth, then the worst index tooth score is recorded
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 Choice of age group:

Single years – 19 , 15 – 19, 20 – 24, 25 – 29, 30 –34, 35 – 44,

45 – 54, 55 – 64, 65 –74, 75 – 84 years and over
 Classification of Treatment Needs:

TN – 0 Code 0 (healthy) or code y (missing) – indicates no

need for treatment
TN – 1 A code of 1 or higher indicates a need for improving
personal oral hygiene of that individual

TN – 2 A code of 2 or higher – Need for professional

cleaning of teeth & removal of plaque retentive
factors
Shallow to moderate pocketing (4 or 5 mm-code 3)
TN – 3 A sextant scoring code 4 (6mm or deeper pockets)
may or may not be successfully treated by deep
scaling Code 4 is therefore assigned as ‘Complex
Treatment’
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Dental Epidemiology

 Calculation of CPITN:
Step I: Count the No. of charts with different codes and add up the
codes individually (ie, codes 0,1,2,3,4)

Step II: Divide the counts of codes respectively, by the total No. of
dentate subjects examined and multiply by 100

‘ Mean No. of Sextants ‘:

- Divide the total No. of sextants with highest score of the person by
the No. of dentate subjects examined.
 Modifications :

- Simplified Periodontal Examination (SPE) later termed Basic

Periodontal Examination (BPE)

- Periodontal Screening and Recording (PSR)

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 Inclusion of measurement of “Loss of Attachment” and elimination of

“Treatment Needs” category
 Indicators:
- Gingival Bleeding
- Calculus
- Periodontal Pockets
 “CPITN – C” Probe
 Sextants

18 – 14 13 – 23 24 – 28
44 – 48 33 – 43 38 – 34
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 Sensing Gingival pockets & calculus:

- Probe as ‘sensing’ instrument
 Examination and recording
SCORE CRITERIA
0 Healthy
1 Bleeding on probing
2 Calculus detected, but all of the black band on the probe
visible
3 Pocket 4-5mm (gingival margin within the black band on the
probe visible)
4 Pocket 6mm or more (Black band not visible)
X Excluded sextant
9 Not recorded
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0 1

3 4
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Loss of attachment scores

0 Loss of attachment 0-3mm (CEJ not visible & CPI score 0-3)

If the CEJ is not visible & the CPI score is 4, or if the CEJ is visible

1 Loss of attachment is 4-5mm (CEJ within the black band)

2 Loss of attachment is 6-8mm (CEJ between the upper limit of the black band & the 8-
5mm)
3 Loss of attachment 9-12mm (CEJ between the 8.5mm & 11.5mm rings)

4 Loss of attachment 12mm or more (CEJ beyond 11.5mm rings)

X Excluded sextant (Less than two teeth present)

9 Not recorded (CEJ neither visible nor detectable)

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 Soben Peter. Essential’s of Public Health Dentistry (Community

Dentistry), 5th edition.
 O'Leary TJ, Drake RB, Naylor JE. The Plaque control record. J
Periodontol1972 Jan;43(1):38.