Public Health Dentistry

By:
Muthukumaran. L. R
Final year BDS(Aug batch)
Dental Indices
 Contents

● Introduction
● Definition
● Requirements
● Objectives and Uses
● Indices
○ DMFT/DMFS index
○ Russell's periodontal index
○ Dean’s fluorosis index
○ IOTN index
○ CPITN index
○ CPI index
● Conclusion
 Introduction

An index is a numerical expression of a clinical situation. It is

helpful in describing the condition of an individual or a group in
respect to a disease or condition that is being measured. An index
score is more consistent and less subjective when compared to the
word description of the situation.
Dental indices are the devices to find the incidence, prevalence,
severity and other factors of a disease, based on which preventive
programs can be adopted.
 Definition
Index is defined as a numerical value describing the relative position of a population in a
graduated scale with definite upper and lower limits, which is designed to permit and
facilitate comparison with other population, classified by same criteria and methods.

- Russel A L (1969)

Epidemiological indices are attempts to quantate clinical conditions on a graduated scale,

thereby facilitating comparison among populations examined by the same criteria and
methods.

- Irving Glickman
 Requirements

1. Simplicity

2. Objectivity

3. Validity

4. Reliability

5. Quantifiability
 Requirements (Cont.)

1. Simplicity:
● Should be easy to apply, without losing more time than necessary
● No expensive equipments should be needed.

2. Objectivity:

Criteria for the index should be clear and unambiguous, with mutually exclusive
categories.
 Requirements (Cont.)

3. Validity:
It should correspond with the clinical stages of the disease under study at each stage.

Two components:
Sensitivity: To detect the disease when it is present.
Specificity: To not detect the disease when it is not present.
 Requirements (Cont.)

4. Reliability:
It should measure consistently at different times and under various conditions.

Two components:

Interexaminer reliability: Different examiners should get the same results on

examination.

Intraexaminer reliability: Same examiner should get the same results at different
times.

5. Quantifiability:

Should be amenable to statistical analysis and interpretation.

 Objectives and Uses

1. To the individual patient:

● To assess and recognise the oral problems of the patient.
● To evaluate the effectiveness of a oral hygiene practice in the patient.

2. In Research:
● To form a base line of data for the research before adding any variable to the examination.
● To assess the effectiveness of a oral hygiene practice or a treatment method towards a certain disease.

3. In Community health:
● In assessing and evaluating the prevalance and incidence of a condition in a community.
● To compare the effects of community programs and evaluate the results.
 Indices

1. DMFT index

2. DMFS index

3. Russell's periodontal index

4. Dean's fluorosis index

5. IOTN index

6. CPITN index

7. CPI index
 DMFT Index
(Decay-Missing-Filled teeth index)

This index was given by Henry T. Klein , Carole E. Palmer and Knutson. J. W in 1938.
This index was formed based on the fact that the dental hard tissues are not self healing and have
scars of past established caries.
It is a irreversible index which records lifetime caries experience.

Instruments used:
1. Mouth mirror
2. Explorer

Procedure:
This index is only for permanent dentition.
It has 3 components:
3. D - used to describe the decayed tooth
4. M - used to describe the teeth missing due to caries
5. F - used to describe teeth that has been filled due to caries.
 DMFT index (cont.)

Criteria for deciding dental caries:

Exclusions:
● The third molars.
● Lesion should be clinically visible and
● Unerupted teeth
obvious.
● Congenitally missing and Supernumerary teeth
● Explorer should penetrate into soft yielding
● Teeth removed for reasons other than dental
material.
caries, like impaction and orthodontic purpose.
● Discoloration or loss of translucency typical
● Teeth restored for reasons other than dental
to demineralization enamel.
caries, like trauma, cosmetic reasons or as
● Explorer tip should resist removal after
abutment.
moderate to firm pressure on insertion.
● Retained primary teeth with erupted permanent
successor. The permanent tooth is evaluated.
 DMFT index (cont.)

Principles and rules:

● No tooth must be counted more than once.
● All Decayed, Missing, and Filled tooth should be recorded seperately.
● The tooth which are restored but have recurrent decay are to be included in the decayed
tooth segment.
● Single tooth with multiple restorations are counted as one tooth.
● Deciduous tooth are not counted in DMF count.
● The teeth which are missing only due to caries are to be included in the missing tooth
segment. Also include those teeth which are badly damage and indicated for extraction.
● The tooth is considerednto be erupted if the occousal or incisal surface is totally
exposed or can be exposed by reflecting the overlying gingival tissue.
● The tooth is considered to be present even if the crown is destroyed and only root is
present.
DMFT index (cont.)

Examination method:
● D-Decayed : Indicating the permanent teeth that are decayed. It includes teeth with
dental caries and restored teeth with recurrent caries. The explorer should catch
into the deep grooves for occlusal caries.
● M-Missing : Indicates the teeth that are missing due to decay. The teeth that are
badly decayed abd indicated for extraction are also counted as missing. Proper
history should be taken to ensure the teeth are marked correctly.
● F-Filled : Indicates the number of permanent teeth that are affected and restored to
its previous healthy condition. Tooth with multiple restorations is evaluated as one
tooth. Any teeth with restoration and recurrent caries is not counted as filled tooth,
but as decayed tooth.
 DMFT index (cont.)

Scoring format:

17 16 15 14 13 12 11 21 22 23 24
25 26 27

47 46 45 44 43 42 41 31 32 33 34
35 36 37

DT _____ MT _____ FT _____ DMFT score :

 DMFT index (cont.)

Calculation:

Individual DMFT:
Maximum score: 28

DMFT score = D + M + F

Group average:
Total DMF
Average DMFT =
Total number of the subjects examined
 DMFT index (cont.)

Modifications:

WHO modification: (1987)

● All third molars are included.
● Teeth with temporary restorations are considered as ‘decay’.
● Teeth with remarkable cavitation, undermined enamel or softened wall are
considered as decay.
● Teeth missing due to car8es only are recorded.

WHO modification: (1997)

● Instruments used: mouth mirror, CPI probe
● For individuals above 30 years of age, the M-component should include all
missing teeth without regarding the reason for loss.
● For individuals below 30 years of age, M-component includes teeth missing only
due to caries.
DMFT index (cont.)

Limitations:
● DMFT values are not related to number of teeth at risk.
● It can be invalid in older patients since teeth czn be lost due to many reasons
other than caries.
● DMFT indexncan overestimate the caries experience of tooth with preventive
restorations.
● It cannot be used in cases of root caries.
 DMFS index
(Decay-Missing-Filled surface index)

This index was developed by Henry T. Klein, Carole E. Palmer and Knutson. J. W in 1938, along
with the DMFT index.
This index was formed to evaluate the prevalance of the coronal caries.

Procedure:
It is applied only to the permanent dention.
It has 3 components:
D - used to describe the decayed teeth surface.
M - used to describe the teeth surfaces missing due to caries.
F - used to describe the surfaces that has been previously filled due to caries.

Instruments used:
Mouth mirror
Explorer
DMFS index (cont.)

Surfaces examined:
For posterior teeth: Facial, Lingual, Mesial, Distal, Occlusal.
For anterior teeth: Facial, Lingual, Mesial, Distal.

If 28 teeth are examined, (third molars excluded)

16 posterior teeth: 16×5 = 80 surfaces

12 anterior teeth: 12×4 = 48 surfaces
Total = 128 surfaces

The principle, rules, criteria, and calculations are all same as the DMFT index.
 DMFS index (cont.)
Scoring format:

17 16 15 14 13 12 11 21 22 23 24 25 26 27

47 46 45 44 43 42 41 31 32 33 34 35 36 37

DS_____ MS_____ FS_____ DMFS score =

DMFS index (cont.)

Advantages:
The DMFS index is more sensitive and it is the preferred index in clinical trial of a
caries-preventive agents.

Limitations:
● DMFS examinations take longer.
● It is more likely to produce inconsistencies in diagnosis.
● Radiographs may be required for accurate diagnosis.
 Russell’s periodontal index

Founded by Russell A L in 1956

Purpose:

Estimate deeper periodontal diseases by measuring presence or absence of gingival

inflammation and its severity, pocket formation and masticatory function.

Instruments used:

Mouth mirror

Blunt probe

Russell’s rule: When in doubt assign the lesser score.

 Periodontal pocket

The periodontal pocket is defined as

a pathologically deepened gingival
sulcus. Deepening of gingival sulcus
may occur by coronal movement of
the gingiva margin, apical
displacement of gingival attachment
or combination of both.
 Russell’s periodontal index (cont.)

Scoring format:

28 27 26 25 24 23 22 21 11 12 13 14 15 16
17 18

38 37 36 35 34 33 32 31 41 42 43 44 45
46 47 48
Russell’s periodontal index (cont.)

SCORE CRITERIA

0 NEGATIVE: There is neither inflammation nor attachment loss due to

destruction of supporting tissues.

1 MILD GINGIVITIS: There is inflammation in the gingiva which does not

circumscribe the tooth.

2 GINGIVITIS: Inflammation circumscribing the teeth, no apparent break in

the epithelial attachment.

4 Used only when radiographs are available.

6 GINGIVITIS WITH POCKET FORMATION: Attachment loss and pocket

formation present. No loss of function and firm in the socket.

8 ADVANCED DESTRUCTION WITH LOSS OF FUNCTION: Tooth may be

drifted, may be loose and depressible in the socket.
Russell’s periodontal index (cont.)
Calculations:
Sum of individual scores
Pi score per person =
Number of teeth present

Interpretation:

PI score Clinical condition

0 - 0.2 Normal

0.3 - 0.9 Simple gingivitis

1.0 - 1.9 Beginning destructive periodontal disease

2.0 - 4.9 Established destructive periodontal disease

5.0 - 8.0 Terminal disease

 Dean’s Fluorosis Index

Introduced by Trendley H. Dean in 1934.

Also known as ‘Dean’s classification system for dental fluorosis’ .

Procedure:
The recording of this index is based on the two most affected teeth.
If the two teeth are not equally affected, the score of the less
affected tooth is recorded. When scoring, the examiner starts at
highest or severe score and eliminates each score till the right score
arrives.
When in doubt, lower scores should be recorded.

Trendley H. Dean
(1893 - 1962)
 Dean’s Fluorosis Index (cont.)
Scoring format:

18 17 16 15 14 13 12 11 21 22 23 24 25
26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35
36 37 38
Fluorosis score:

Description of enamel mottling:

 Dean’s Fluorosis Index (cont.)
Criteria:

Dean’s Fluorosis Index- Original criteria was given in Dean’s Fluorosis Index- Modified criteria was given in
1934, it was based on a 7 point ordinal scale:
● 1942, it is based on a 6 point ordinal scale:
Normal
● Questionable ● Normal
● Very mild ● Questinable
● Mild
● Very mild
● Moderate
● Moderately severe ● Mild
● Severe ● Moderate
● Severe
Dean’s Fluorosis Index (cont.)
Modified criteria (1942):

Level Score Criteria

Normal 0 Smooth, glossy with pale creamy white color.

Questionable 0.5 Slight aberrations with few white flecks or occational spots.

Very mild 1 Small opaque white spots involving approx 25% of tooth surface.

Mild 2 White opaque area involving 25-50% tooth surface.

Moderate 3 Brown stains are present. All tooth surfaces affected.

Severe 4 Widespread staining with hypoplasia and corroded appearance.

 IOTN Index
(Index of Orthodontic Treatment Needs)

The Index of Orthodontic Treatment Needs was given by P.H. Brook and W.C. Shaw in
1989.
This index was given to assess the need for orthodontic treatment from an anatomical and
aesthetic perspective.

IOTN consists of two components:

● Functional and Dental Health Component (DHC)
● The Aesthetic Component (AC)
IOTN Index (cont.)

Dental Health Component: (DHC)

DHC is categorised into 5 grades from grade-1 (no need) to grade-5 (very great
need).
This evaluation is done based on 5 occl7sal traits:
● Missing teeth
● Overjet
● Crosbite
● Contact point displacement
● Overbite
For DHC, the measurements are done either directly in patient or from study models.
The grading is based on the most severe traints indicating the priority and need of
treatment
 IOTN Index (cont.)
DHC grading:
Grade-5 : Very great
● Cleft lip/palate
● Overjet more than 9mm
● Reverse overjet more than 3.5mm with
speech ans masticatory difficulties.
● Impeded eruption of tooth due to any
reason
● Extensive hypodontia with restorative
implication requiring pre-restorative
orthodontic trestment.
Grade-4 : Great
● Overjet: 6-9mm
● Reverse overjet more than 3.5mm with no
difficulties in speech and mastication.
● Severe drifting of teeth more than 4mm
● Increased and complete overbite
● Patient refered b by another dentist for
collaborative care
● Less extensive hypodontia that require pre-
restorative orthodontics or orthodontic space
closeure to avoid prosthetic treatment.
 IOTN Index (cont.)
Grade-3 : Moderate
● Overjet: 3.5-6 mm with incompetent
lips at rest.
● Reverse overjet: 1-3.5 mm
● Moderate lateral or anterior openbite: 2-
4mm
● Moderate displacement of tooth: 2-4
mm
● Increased or complete overbite with no
indentation or signs of trauma.
● Anterior or posterior crossbite of 1-2
mm.
Grade-2 : Little
● Overjet: 3.5-6 mm with competent lips at
rest.
● Reverse overjet: 0-1 mm
● Overbite: greater than 3.5mmw8th no
gingival contact.
● Small lateral or anterior openbite of 1-2
mm.
● Pre-normal or Post-normal occlusion
with no other anomalies.
● Mild displacement of teeth: 1-2 mm.
Grade-1 : None
● Other variations in teeth including
displacemnt less than 1mm.
IOTN Index (cont.)

Aesthetic component: (AC)

● A scale name Standardized Continuum of Aesthetic Needs (SCAN) was used for
the development of the Aesthetic Component.
● Examination can be done directly on the patient or using study models.
● Only the aesthetic part of the teeth is observed.
● The AC is a 10 point visual scale and conducted by matching the patient's with one
of the 10 photographs.
● It could either be rated by an orthodontist or by the patient themselves .
● Evaluation using plaster model or black and white photograph to prevent the
influence of oral hygiene, condition and color of gingiva.
 IOTN Index (cont.)

Grading of aesthetic componet:

● Grade- 1 : Most aesthetic arrangement of the
dentition
● Grade- 1-4 : Little or no treatment required
● Grade- 5-7 : Moderateor borderline
treatment required
● Grade- 8-10 : Treatment required

DHC score less than 4 and AC score less than 7, do not

justify treatment by a hospital based consultancy except
for teaching and research purpose.
Guide image
 CPITN Index
(Community Periodontal Index of Treatment Needs)

Introduced by Jukka Ainamo, David Barmes, George Beagrie, Terry Cutress, Jean Martin
and Jennifer Sardo-Infirri for joint committee of WHO and FDI in 1982.

Developed to evaluate the periodontal treatment needs rather than the past and present
periodontal health status.

It can be used in both in both individual and community level.

It assesses only conditions that are responsive to treatments, but not the non-treatable or
irreversible conditions.

This index provides guidance on planning and monitoring the effectiveness of periodontal care
programme and dental personal required.
 CPITN index (cont.)
Procedure:

The entire dentition is divided into 6 parts called sextants.

Each sextant is given a score

For Clinical practice the highest score in each sextant is identified after examining all teeth.

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

For Epidemiological purposes the score is identified by examination of specific index teeth.

17/16 11 26/27
INDEX
47/46 31 36/37 TEETH
CPITN index (cont.)

Instruments used:

1. Mouth mirror
2. CPITN probe
a. CPITN-E probe
b. CPITN-C probe

CPITN probe: (WHO-1978)

Purpose:

● Measurement of pocket depth

● Detection of subgingival calculus

It has a 0.5mm ball at the tip and mm

markings at 3.5, 5.5, 8.5 and 11.5mm.

Working force: 20 - 25 gms. CPITN-E probe CPITN-C probe

CPITN index (cont.)
Probing procedure:
● The tooth is probed to
○ Check pocket depth
○ Detect subgingival calculus
○ Bleeding response
● Probing force is divided into
○ Working component – to identify the pocket depth
○ Sensing component – to identify the subgingival calculus
● Probe is inserted in between the tooth and gingiva to detect the pocket depth.
● While probing, the probe should be parallel to the long axis of the tooth and the ball
should be in contact with the root surface.
● For sensing, only minimal force must be applied to move the probe along the tooth
surface. Presence of pain during probing indicated use of excessive force.
Recommended force is about 20gms.
● The probe should be walked around the tooth and the tooth should be checked on six
points – Mesiobuccal, Midbuccal, Distobuccal, Mesiolingual, Midlingual, Distolingual.
CPITN index (cont.)

Examination procedure:
● Aim : To record the highest score in each quadrant with least number of
measurements.
● The sextant can be scored only if more than one functional tooth is present.
● If ‘no’, the score is marked ‘X’ and move on to next sextant.
● If ‘yes’, the teeth are examined for pocket of 6mm or deeper, 4 or 5mm
● pockets, calculus and bleeding in the same order.
● Once the highest score has been recorded, there is no need to check for the
lower scores in the same sextant.
● In epidemiological studies, only the index teeth are checked. While for
clinical examination, all teeth are examined.
CPITN index (cont.)

Rules to be examination:
● Two or more functional teeth must be present in a sextant for it to be scored.
● In posterior sextant, if one of two index teeth is absent or excluded, then the scoring is
done based on the remaining index teeth.
● If both the index teeth are absent or excluded, all remaining teeth in the sextant are
examined and the highest score is recorded.
● In anterior sextant, if 11 is excluded, its is substituted with 21. If 21 is also excluded l,
remaining teeth are examined and the worst score is recorded. This applies for both maxilla
and mandible.
● In subjects of age 20 or below, if the first molar is absent or excluded, the nearest adjacent
premolar is examined.
● Single tooth in a sextant is considered to be part of adjacent sextant, if it is an index tooth,
then the worst index tooth score is recorded.
● Third molar are excluded unless they are functioning in place of second molar.
 CPITN index (cont.)
Scoring format:

CPITN score:
17/16 11
26/27

47/46 31
36/37
Treatment needs:

17/16 11
26/27

47/46 31
36/37
 CPITN index (cont.)

Codes and criteria:

CODE CRITERIA

Code X When only one or no teeth is present in the sextant.

Code 4 Pathological pocket formation of 6mm or more. (Band in probe not visible)

Code 3 Pathological picket formation of 4mm - 5mm is present.

Code 2 Presence of supragingival or subgingival calculus.

Code 1 Gingival bleeding after gentle probing.

Code 0 No signs of disease.

 CPITN index (cont.)
Treatment needs classification:

TN 0 A recording of code 0 or code X for all sextants indicate there is no need for periodontal treatment.

TN 1 A recording of code 1
Indicating the need for improving personal oral hygiene habits of the individual.

TN 2a A recording of code 2
Indicates need for scaling and root planing.
Indicating the need for improving personal oral hygiene habits of the individual.

TN 2b A recording of code 3
Indicates need for scaling and root planing.
Indicating the need for improving personal oral hygiene habits of the individual.

TN 3 A recording of code 4
Complex treatment which could involve deep scaling, root planning, and more complex surgical
procedures.
 CPI Index
( Community Periodontal Index)

The CPI index is based on the modification of CPITN index by WHO in 1997.
This modification is done by inclusion of measurement of “Attachment loss” and
elimination of the “Treatment needs” category.

Instruments used:
Mouth mirror
The CPITN-C probe.

Procedure:
The teeth to be examined, the procedure of probing and examination are same
as CPITN index.
 Attachment loss

Clinical attachment loss is defined as

the extent of periodontal support that
has been destroyed around the tooth.
It is measured from the Cemento-
Enamel Junction(CEJ) to the depth
of the pocket.
CPI Index (cont.)

Scoring format:

17/16 11
26/27

47/46 31
36/37
CPI Index (cont.)

Scoring criteria for CPI index:

Score Criteria

0 Healthy.

1 Bleeding observed after probing, either directly or by using mouth

mirror.

2 Calculus detected while probing.

3 Periodontal pocket of 4-5 mm persent.

4 Periodontal pocket of 6mm or more is present.

X Excluded sextant.

9 Not recorded.
CPI Index (cont.)

Measurement of loss of attachment:

● The measurement of Loss of attachment may be collected from the index teeth
to obtain the estimation of lifetime accumulation destruction of periodontal
attachment.
● This helps in comparing the population but does not provide full information
about the extent of attachment loss in an individual.
● The best way is to record attachment loss in a segment immediately after
recording CPI score in the sextant.
Loss of attachment is not recorded for children under 15 years of age.
CPI Index (cont.)
Codes and Criteria:

Score Criteria

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

If the CEJ is not visible and the CPI score is 4 or CEJ is visible

1 Loss of attachment 4 - 5mm

2 Loss of attachment 6 - 8mm

3 Loss of attachment 9 - 11mm

4 L9ss of attachment 12mm or more

X Excluded sextant (Less than 2 teeth present)

9 Not recorded (CEJ neither visible not detectable)