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Indices for measuring periodontitis: A literature review

Article  in  International Dental Journal · April 2011

DOI: 10.1111/j.1875-595X.2011.00018.x

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 International Dental Journal 2011; 61: 76–84
ORIGINAL ARTICLE
doi: 10.1111/j.1875-595X.2011.00018.x

Indices for measuring periodontitis: a literature review

Kunaal Dhingra1 and Kharidhi Laxman Vandana2
1
Department of Periodontics, N.S.V.K Sri Venkateshwara Dental College, Bangalore, Karnataka, India; 2Department of Periodontics, College of
Dental Sciences, Davangere, Karnataka, India.

Indices are important tools to measure, quantify and treat periodontitis both in epidemiological and clinical situations
and are based on the prevailing understanding of the pathogenesis of periodontal disease. However, there is dearth of
literature on collective information of periodontal indices formulated to date. This article collectively describes the
evolution and the present concept of formulation of periodontal indices based on the multi-factorial nature of periodontal
disease and also provides some direction for future periodontal indices. Periodontal indices have evolved from the simple
Russell’s index to the current usage of measurement of clinical attachment level in the recording of indices. The use of
dichotomous measurements and the Genetic Susceptibility Index are the new additions to the periodontal indices.
Nevertheless, an ideal would be an index that will keep pace with the ever changing concept of the pathogenesis of
periodontal disease.
Key words: Periodontal Index, periodontitis, epidemiology

Periodontitis is the inflammation of the periodontium been formulated and tried to date to measure peri-
that is accompanied by apical migration of the junc- odontal disease but there is still a lack of collective data
tional epithelium, leading to destruction of the connec- on these indices in terms of their evolution, future and
tive tissue attachment and alveolar bone loss1. The their merits and limitations. This paper aims to provide
assessment of its disease activity is important because an insight to their evolution along with the present
periodontal disease still remains a major cause of tooth concept of formulation of periodontal indices based on
loss for some segments of the population. In addition, the multi-factorial nature of periodontal disease and
periodontal infection has recently been implicated as a also some direction for future periodontal indices.
possible risk factor for serious systemic vascular
disease2.
A HISTORY OF INDICES
Lord Kelvin (1824–1907), the famous British math-
ematician and physicist, once famously remarked Until The formulation of the various indices has been rooted
you can count it, weigh it, or express it in a quantitative in the prevailing understanding of the aetiology and
fashion, you have scarcely begun to think about the progression of periodontal disease at the time. The
problem in a scientific fashion. This statement aptly following passages provide an appraisal along with the
describes the essence of the indices, which have formed shortcomings of indices used for measuring periodon-
the pillar of epidemiological studies to quantify and titis, in chronological order, which is also summarised
measure the world wide prevalent periodontal disease. in Table 1.
Epidemiologic studies are conducted to describe the
health status of populations, elucidate the aetiology of
Russell’s Periodontal Index (PI)
diseases, identify risk factors, forecast disease occur-
rence and assist in disease prevention and control3. On Realising the lack of valid indices for determining the
the other hand, an index which is an essential tool of prevalence and epidemiological characteristics of peri-
epidemiology results in a number describing the relative odontal diseases, Russell developed the first index for
status of the population on a graduated scale with periodontal disease, the Periodontal Index (PI) in 1956
definite upper and lower limits, designed to permit and to facilitate the surveillance of periodontal disease in
facilitate comparison with other populations classified concordance with the already widely used DMFT
by same criteria and methods4. Various indices have (Decayed, Missing and Filled Teeth) index5,6. Russell
76 ª 2011 FDI World Dental Federation
 Indices for measuring periodontitis

Table 1 Description of periodontal indices

Serial No. Index Author and year Salient features

1. Periodontal Index Russell (1956) • First index for periodontal disease

• A weighted categorical scoring system
• No longer considered valid
2. Periodontal Disease Sandler and Stahl • Each tooth is assessed utilizing radiographs and clinical measure-
Rate Index (1959) ments
3. Periodontal Disease Ramfjord (1959) • More sensitive version of the PI for use in clinical trials
Index • Scores the gingival status first using a 0 to 3 scale while clinical
attachment level is scored on a scale from 4 to 6, on a selected group
of teeth – ‘Ramfjord teeth’
4. Gingival Bone Count Dunning and Leach • Subjective measurement of gingival status is combined with
Index (1960) proportionate measurements of bone loss from radiographs
• Time consuming, thus, not used
5. Gingival Periodontal O’Leary (1967) • Mouth is divided into six sextants and the highest score for each
Index segment either gingival (0–3) or periodontal (4–6) is recorded
• Not much used
6. Navy Periodontal Grossman and Fedi • Derived from gingival (0–2) and pocket (0, 5 and 8) scores of the six
Disease Index (1974) Ramfjord teeth
7. Community Periodontal World Health • Assesses the presence or absence of gingival bleeding on probing,
Index for Treatment Organization (1982) supra or subgingival calculus and periodontal pockets by using
Needs by Ainamo, Barmes, 0.5 mm ball tip WHO probe
Beagrie, Cutress, • Advantages include simplicity, speed and international uniformity,
Martin and Infirri hence, popular
8. Periodontitis Severity Adams and Nystrom • Assesses the presence or absence of periodontitis as product of
Index (1986) clinical inflammation and interproximal bone loss determined
radiographically using a Schei ruler
• Use limited to longitudinal studies and lacks validation
9. Extent and Severity Carlos et al. (1986) • Extent score is % of sites examined having attachment loss more
Index than 1 mm whereas, the severity score is average loss of attachment
per site among disease sites
• Simple, reproducible
10. National Institute of NIDCR (1988–1994) • Periodontal examination consisted of measurement of periodontal
Dental and supporting tissues including attachment loss, probing pocket depth
Craniofacial Research and furcation involvement
(NIDCR) protocol • Used in U.S. National Health and Nutrition Examination Survey
(NHANES III)
11. Periodontal Index for Eaton and Woodman • Clinical assessment of six teeth is done with a specially designed
Treatment (1981–1985) periodontal probe
• Simple rapid and reliable periodontal screening
12. Periodontal Screening American Academy of • Divides mouth into six sextants and greatest score in each sextant of
and Recording Index Periodontology (1991) mouth is determined and recorded by using a plastic PSR probe
• Simple, fast and preferred by patients
13. Community Periodontal World Health • Modification of CPITN index
Index Organization (1997) • Useful in periodontal research, especially to reduce the time needed
for examinations when the study population comprises a large
number of individuals
14. Periodontitis Index Albandar et al. (1999) • Classifies each person as having either mild, moderate or advanced
periodontitis, or with no periodontitis, based on the number (or
percentages) of teeth showing certain thresholds of probing depth
and attachment loss
15. Dichotomous Dye et al. (2002), Tezal • Record the presence or absence of pocket or clinical attachment loss
Periodontal Index et al. (2004), Borrell against a cut-off point
et al. (2006), Brothwell
and Ghiabi (2009),
Persson et al. (2005)
16. Genetic Susceptibility Moustakis et al. (2007) • Used for both single nucleotide polymorphisms and microbial
Index for periodontal component of periodontal disease
disease

created the PI criteria (0, 1, 2, 6 and 8) based upon the prophylaxis, 0.5–1.9 require minimal periodontal treat-
signs of periodontitis and the sequence in which they ment, 1.5–5.0 require elaborate and protracted treat-
usually appear, i.e. inflammation, pocket formation, ment while 4.0–8.0 require full mouth extraction7.
and loss of function. Although often referred to as a Since PI was the first of the periodontal indices, it was
scaled scoring system, the PI was actually a weighted extensively used in the epidemiologic surveys of numer-
categorical scoring system6. In 1967 Russell provided a ous populations, including the first two national
refinement in the form of treatment needs based on the surveys in the United States8. The major advantage of
PI; i.e. PI scores in the range of 0.1–1.0 require simple PI is that the calibration of the examiner is easy, the
ª 2011 FDI World Dental Federation 77
Dhingra and Vandana

method is quick and a minimum of equipment is cumulative index. Since it combines clinical examina-
required4. However, the PI was flawed, conceptually tion with reading of radiographs, it is one of the most
and methodologically, in that gingivitis is no longer time consuming of all the methods, and is thus not
considered to be the equivalent of early periodontitis extensively used4,9,13.
and the index did not measure features specific for
periodontitis (in contrast to gingivitis), such as pocket
O’Leary Gingival Periodontal Index
depth, clinical attachment level, and radiographic bone
loss. Consequently, the index is no longer considered The next index was the O’Leary Gingival Periodontal
valid although its modification (periodontal sites were Index formulated in 1967, in which the mouth was
probed, and gingivitis and periodontitis were reported divided into six sextants and the highest score for each
separately) was used in the third US national survey in segment either gingival (0–3) or periodontal (4–6) was
19818. recorded and the sum was divided by the number of
segments to give the GPI score for the individual. For
periodontal score, the clinical attachment level was
Periodontal Disease Rate Index and Periodontal
recorded at the mesial facial line angle. The main
Disease Index
advantages of this index were quick appraisal of the
In 1959, Sandler and Stahl formulated the Periodontal health status of each area of the patient’s mouth and the
Disease Rate (PDR) Index in which each tooth was scores were helpful in determining the personal, facility
assessed utilising radiographs and clinical measure- and equipment needs of patients14. GPI has not found
ments like mobility, pocket depth and appearance of much usage, but the methodology of the index has been
gingiva, to be classified as affected or not affected. used in some studies15,16 and even a modification of the
According to the authors, PDR appeared to have a GPI has been used in an oral health survey in five
fairly good relationship to Russell’s PI when measuring countries by measuring pocket depth instead of clinical
the incidents of disease9. In the same year, Ramfjord attachment level17.
came out with the Periodontal Disease Index (PDI),
intended as a more sensitive version of the PI for use in
Navy Periodontal Disease Index
clinical trials. The PDI scored the gingival status first
using a 0–3 scale (based upon Russell’s PI and Schour In 1974, Grossman and Fedi developed the Navy
and Massler’s Papillary Marginal Attachment gingival Periodontal Disease Index (NPDI) under the navy
index) while the clinical attachment level was scored on periodontal screening examination to aid the general
a scale from 4 to 6, on a selected group of teeth called practitioner in the early recognition and diagnosis
‘Ramfjord teeth’6. Its main advantages were easy of periodontal disease and in particular for screening
calibration of examiners and it was an accurate tool of periodontal disease in the navy dental corps. The
to assess periodontal status as it was based on NPDI was derived from the gingival (0–2) and pocket
measurements rather than estimation4. However, it scores (0, 5 and 8) of the six Ramfjord teeth. The highest
was time consuming due to a high requirement of combined gingival and pocket score for any one tooth is
precision and also in primitive populations with many the patient’s NPDI score while NPDI total is the total
middle aged and older people, much time has to be score for all the six teeth18. Hancock and Wirthlin on
spent on removing calculus to determine the location of examination of 98 young adult patients with the NPDI,
cementoenamel junction4. Although the PDI was never found that the NPDI total offered a wider range of
used for national estimates of periodontal disease in the scores (than NPDI score) that would give the clinician a
USA, it was used for various epidemiological surveys in better indication of the extent of involvement19.
India and Michigan and various clinical trials of
therapeutic or preventive procedures6,10–12. The revo-
Community Periodontal Index for Treatment Needs
lutionary concepts of clinical attachment level and
Ramfjord teeth, i.e. partial mouth recording are now The Community Periodontal Index for Treatment
being used for USA national oral health surveys6. Needs (CPITN) was developed in 1982 as a World
Health Organisation (WHO) initiative. When the WHO
Global Oral Data Bank was initiated in 1969, Russell’s
Gingival Bone Count Index
PI and Greene and Vermillion’s Simplified Oral Hygiene
In 1960, Dunning and Leach formulated the Gingival Index were the two preferred methods for data accu-
Bone (GB) Count Index, in which the subjective mulation. It became clear that these two indices were
measurement of gingival status is combined with not wholly satisfactory and in 1977, a WHO Scientific
proportionate measurements of bone loss from radio- Group meeting was convened in Moscow which
graphs to produce a composite score. The GB count produced a prototype index, the Technical Report
may be used as a composite index, morbidity or Series (TRS) 62120. Following extensive discussions
78 ª 2011 FDI World Dental Federation
 Indices for measuring periodontitis

and testing the CPITN index was developed from TRS Index (ESI). Under this index, in two designated
621 by exclusion of Ramfjord’s teeth and inclusion of quadrants, loss of attachment is determined in two
use of the WHO probe, and was thus described in 1982 periodontal sites, i.e. mid-buccal and mesio-buccal of
by Ainamo and colleagues and accepted by WHO in each tooth except the third molars. This results in 28
1983 for inclusion in oral health surveys basic meth- measurements for each subject. For an individual, the
ods21. CPITN assesses the presence or absence of extent score is the percentage of sites examined that have
gingival bleeding on probing, supra or subgingival attachment loss more than 1 mm whereas, the severity
calculus and periodontal pockets by using a 0.5 mm score is the average loss of attachment per site among the
ball tip WHO probe. In epidemiological surveys, 10 disease sites. The ESI for a population is the average
index teeth are examined, but only the worst finding extent and severity scores for the individuals examined.
from the index teeth is recorded per sextant of teeth. In Its advantages are that it is simple, reproducible method
determining the individual’s treatment needs, only the which appears to yield informative description of
worst finding from all the teeth in a sextant is recorded, periodontal disease status of a population and requires
resulting in six scores22. The main advantages include only minimal training of examiners27. However, as the
simplicity, speed and international uniformity, due to ESI measures attachment loss in only 28 sites in contra-
which CPITN had worldwide usage and CPITN results lateral quadrants, it has the same potential for inaccu-
are now included in over 500 publications21,23. How- racy as other partial measurements28. Also, Hunt and
ever, there are several weaknesses, as compiled by Fann29 found that in a scenario with increasing severity
Baelum and Papapanou24 which include: and lower prevalence, the proportional underestimation
• The hierarchical principles underlying its use are not by ESI becomes larger.
universally valid.
• The partial recording approach of the CPITN may
National Institute of Dental and Craniofacial Research
grossly underestimate the prevalence of deep pockets.
(NIDCR) protocol
• CPITN yields extensively distorted estimates of the
prevalence and severity of periodontal destruction in During the third USA National Health and Nutrition
a population. Examination Survey (NHANES III) conducted from
Based on the limitations identified by several authors 1988 to 1994, the National Institute of Dental and
during years of research, the WHO proposed some Craniofacial Research (NIDCR) protocol for periodon-
changes to the CPITN in 1987 and again in 199725. tal disease assessment was used. In this, the periodontal
examination consisted of measurement of attachment
loss, probing pocket depth and furcation involvement.
Periodontitis Severity Index
The periodontal examination was carried out in two
Adams and Nystrom developed the Periodontitis Sever- randomly selected quadrants, one maxillary and one
ity Index (PSI) in 1986 which assesses the presence or mandibular. All fully erupted teeth in these two
absence of periodontitis as the product of clinical quadrants were assessed, excluding third molars. The
inflammation and interproximal bone loss determined assessment of the attachment loss and probing pocket
radiographically using a Schei ruler22. The reported depth was done at two sites per tooth, the mesiobuccal
advantages of the PSI are that healthy sites can be and mid-buccal surfaces by using the NIDCR peri-
distinguished from diseased sites, ratio data can be odontal probe30. A third site (distal-facial) for peri-
produced, avoidance of the arbitrarily weighted clinical odontal assessment was added in 20016. Assessment of
observations and also direct measurements of peri- furcation involvement was made on five posterior teeth
odontitis severity can be made. The disadvantages are using explorer number 17 (maxillary molars and
that in order to recalculate the PSI over time, further premolars) and explorer number 3 (mandibular
radiographs are necessary and also, radiographs do not molars). Partial furcation involvement (grade I) was
permit buccal or lingual PSI calculations26. Due to these scored in sites where the explorer was definitely
limitations the PSI is limited to longitudinal studies and catching into, but did not pass though, the furcation.
lacks validation22. Total furcation involvement (grade II) was used when
the explorer could be passed between the roots and
through the entire furcation. In fact, NHANES III was
Extent and Severity Index
the first national survey to assess the periodontal
In 1986, Carlos et al.27, with the aim of devising a involvement of the furcation area of teeth30.
method that would achieve maximum data reduction
while remaining sensitive to both the extent of disease
Periodontal Index for Treatment
(the number of sites affected within the mouth) and the
severity of disease (the stage of advancement of peri- Further, Eaton and Woodman (1981–1985) developed
odontal destruction), formulated the Extent and Severity the Periodontal Index for Treatment (PIT) in which the
ª 2011 FDI World Dental Federation 79
Dhingra and Vandana

clinical assessment of six teeth (all first molars and ment levels in comparison to radiographs34. Patients
maxillary right and mandibular left central incisors) is seem to relate better to the numerical values used in the
completed with a specially designed periodontal probe PSR system, especially when the patient receives the
(PIT probe with markings at 4, 6, 8 and 11 mm and a PSR colour brochure following the examination. The
0.5 mm ball tip). The maxillary sites are probed on the brochure provides photos and detailed explanations of
palatal side while the mandibular sites are probed on each PSR score to further enhance the patient’s
the buccal side, and scores are given from 0 to 3. The understanding of their periodontal condition35. How-
overall patient score (PIT score) is recorded as the ever, PSR can underestimate the level of periodontal
highest score of the six test teeth. Eaton and Woodman involvement and also the asterisk code does not specify
examined 406 UK Royal Navy and Royal Air force which method is to be used for detection of the
personnel in 1989 using this index with and without periodontal abnormalities33.
bitewing radiographs and concluded that the PIT
technique when used in conjunction with bitewing
Community Periodontal Index
radiographs provided simple rapid and reliable peri-
odontal screening31. In 1997, the CPITN index was modified to the
Community Periodontal Index (CPI) by inclusion of
measurement of ‘Loss of attachment’ and elimination of
Periodontal Screening and Recording Index
‘Treatment needs’ categories and is now included as a
The next periodontal index to be developed was the part of WHO – Oral Health Surveys. In this index, the
Periodontal Screening and Recording Index (PSR). The periodontal status is assessed with a 0.5 mm ball tip
concept of periodontal screening first arose in 1988 periodontal probe with black band markers at 3.5, 5.5,
when the American Academy of Periodontology (AAP) 8.5 and 11.5 mm. This index takes into consideration
approved the development of a Periodontal Disease 10 teeth in the oral cavity i.e. 17, 16, 11, 26, 27, 37, 36,
Detection Day, in collaboration with the American 31, 46 and 47 and subsequently evaluates the occur-
Dental Association (ADA). The AAP committee rence of gingival bleeding, presence of supra- and
decided to use a modified CPITN procedure for subgingival calculus, periodontal pockets with probing
periodontal screening and a position statement on the depths between 3.5–6.0 mm, as well as clinical attach-
use of this screening procedure was developed which ment loss. Although this system analyses a limited
later evolved into the professional education brochure number of teeth, it has been shown to be representative
on a Periodontal Screening and Recording system. of full mouth records. For this reason, the CPI is useful
Subsequently, in 1990, the PSR was reviewed and in periodontal research, especially to reduce the time
further modified by ADA committee and in 1991 it was needed for examinations when the study population
endorsed by the ADA as a useful tool for assessing the comprises a large number of individuals. In addition,
periodontal status of patients. In 1992, Procter and this method allows the elaboration of preventive and
Gamble Company (P&G) became the official sponsor therapeutic programmes as well as the quantification of
of PSR system and helped in active distribution of PSR biological and environmental risk factors related to the
training programme kits and promotion of the PSR disease onset and progression. Also, it has been shown
system among the dentists in USA from 1992 to 199432. that in periodontally healthy young individuals, CPI
Subsequently, the PSR system became highly popular in teeth could be an appropriate source of samples for the
the USA and the Canadian Dental Association and subgingival detection of Actinobacillus actinomycetem-
Canadian Periodontist Association also adopted the comitans in comparison to randomly selected teeth36.
index in August, 199533. However, the CPI has been criticised for being an old-
The PSR index divides the mouth into six sextants fashioned paradigm to assess disease. Especially among
and the greatest score in each sextant of the mouth is adolescents, the validity of the hierarchical record of
determined and recorded by using a plastic PSR probe conditions of interest (bleeding, calculus and periodon-
that has a 0.5 mm diameter ball tip and a colour-coded tal pocket) is questioned37.
band extending 3.5–5.5 mm from the tip. The scores
range from 0 to 4. Each code can have an asterisk (*)
Periodontitis Index
placed depending on the presence of periodontal
abnormalities such as furcation involvement, mobility, More recently, Albandar et al. described the Periodon-
mucogingival problems, or recession. Code X is given titis Index to measure the prevalence and severity of
for sextants with fewer than two teeth. Its merits periodontitis in the US population. This index classifies
include simplicity, and also Piazinni in 1994 found PSR each person as having either mild, moderate or
to be on an average nine times faster than a conven- advanced periodontitis, or with no periodontitis, based
tional evaluation33. Additionally, the PSR score showed on the number (or percentages) of teeth showing certain
significant associations with probing depths and attach- thresholds of probing depth and attachment loss. The
80 ª 2011 FDI World Dental Federation
 Indices for measuring periodontitis

reason for using both the number and percentages of variable, either not present or at least one dental site
teeth with a given criterion in this classification system with a pocket depth of 5 mm or more, because the
is because the NHANES III examined only two distribution of advanced pocketing did not produce a
randomly selected quadrants (half-mouth), and the stable variable to support the development of an extent
use of percentages has the potential to reduce index. The value 5 mm was selected as the cut-off point
the underestimation due to this partial recording. The as the periodontal probing depths in the range of 5 mm
index also assesses the extent of furcation involvement will generally classify an individual as a chronic
of teeth for assessment of the periodontal status of the periodontitis case with moderate destruction.
person30. Because this index does not combine param- Tezal et al.41 conducted a cross sectional study on
eters of different diseases, it does not endure some of relationship between alcohol consumption and peri-
the validity limitations found in the other indices odontal disease during NHANES III survey, in which
mentioned earlier. In the absence of periodontal the severity of periodontal disease was represented by
inflammation and pocketing, the Periodontitis Index clinical attachment loss (CAL) dichotomised using
does not regard the presence of attachment loss alone as 1.5 mm as the cut-off point, which is the upper quartile
a measure of periodontitis3. of its distribution in the NHANES III population. Using
In an excellent review on epidemiology and risk this same cut off point of 1.5 mm dichotomous CAL,
factors of periodontal diseases, Albandar3 noted that Akhter et al.42 conducted a study to identify a possible
because of lack of resources or the desire to simplify the relationship between stress and periodontal disease in
examination process, many epidemiological studies of residents of a rural area in Japan.
periodontal diseases have used partial recording meth- Also, Borrell et al.43 conducted a prospective study to
ods to assess the occurrence and severity of disease. examine whether individual- and neighborhood-level
Partial recording protocols, however, systematically socioeconomic characteristics were associated with
underestimate periodontal disease prevalence, and the periodontal disease. Severe periodontitis was defined
degree of underestimation is influenced by the type of as a combination of at least two interproximal sites
protocol used. It is important to note that the EAS with clinical attachment levels of 6 mm or above and at
survey and the NHANES III used partial-mouth least one interproximal site with pocket depths of 5 mm
examinations whereby only the midbuccal and mesio- or above. This dichotomous definition was chosen
buccal tooth surfaces of one maxillary and one rather than a continuous definition because the former
mandibular quadrants were examined3. Kingman and would be more relevant to clinicians and public health
Albandar38 showed that this method significantly professionals.
underestimates the prevalence of attachment loss and Recently, Brothwell and Ghiabi44 conducted a survey
suggested an inflation factor (ratio of true prevalence of to determine the distribution and determinants of
a condition based on the full mouth score to the periodontal health in adult members of the Sandy Bay
prevalence of the condition based on partial recording First Nation in Manitoba, Canada. They used Bivariate
protocol) to adjust for the bias in these estimates. Using analysis to find variables significantly associated with
this inflation factor for the prevalence rates, it was two outcome variables: dichotomous mean CAL (£2.5
found that United States seniors have a very high level and >2.5 mm) and the dichotomous severe periodonti-
of chronic periodontitis and tissue loss comparable to tis (one or more sites with >5 mm CAL). Persson
the rates reported in the EAS survey and the NHANES et al.45 conducted a study to assess if a history of
III3. smoking is associated with chronic periodontitis and
medical history in older subjects. In this study, the
dichotomous radiographic evidence of alveolar bone
INDICES AND THEIR CURRENT TRENDS
loss (defined as the distance between the bone level and
the cement-enamel junction ‡4.0 mm) was assessed by
Dichotomous Periodontal Index
using the score ‘0’ as no evidence of alveolar bone loss
Currently, apart from regular periodontal indices, and score ‘1’as any other condition.
various dichotomous measurements of periodontitis in
the form of presence or absence of pocket or clinical
Genetic Susceptibility Index for periodontal disease
attachment loss against a cut-off point have been
assessed. Currently, terms such as molecular epidemiology and
Dye et al.39,40 conducted two studies on the rela- genetic epidemiology have been coined to depict the
tionship between blood lead levels and periodontal change from ‘traditional epidemiology’ concerned with
bone loss and also the relationship between periodontal disease determinants at the community or social level
disease attributes and Helicobacter pylori infection (upstream) over to ‘modern epidemiology’ which is
among adults in the US. In these studies, the periodon- concerned with determinants operating at individual
tal pocket depth was expressed as a dichotomous level or even below i.e. at the organ, tissue, cell or
ª 2011 FDI World Dental Federation 81
Dhingra and Vandana

molecular level (downstream). The inability of individ- status. Similarly, GSI scores linked with microbial
ual life-style factors to explain disease occurrence at the values (all microbial percentage values were added
population level has led to a firm belief that further and formed an m metric) to elucidate the probability of
explanations are found in biological variation between an individual being periodontal healthy was formulated
individuals, i.e. in the biochemical, molecular and and is shown in Table 3. The GSI scores correlate well
genetic make-up of individuals46. with the sum percentage of the periodontitis associated
Recently, Moustakis et al.47 formulated a Genetic bacteria. For example, when the susceptibility index is
Susceptibility Index (GSI) for both single nucleotide £1, the individual can harbour a high percentage
polymorphisms (SNPs) and microbial components of (£35%) of the seven microbial species and still be
periodontal disease. The researchers took 850 records periodontal healthy. Conversely, when susceptibility
of 675 Caucasian periodontitis and control patients. increases (>4) even at low percentage (£35%) of
The records incorporated genotypes of SNPs (sixty two bacteria, the probability of healthy status is low, only
triplets) like CARD15 (Caspase recruitment domain- 12%47.
15) and TGFB (Transforming growth factor-b), records According to the authors, genetic susceptibility to
of seven bacterial species (Actinobacillus actinomyce- disease manifestation is already confirmed and in
temcomitans, Porphyromonas gingivalis, Prevotella particularly for periodontal disease, various studies
indermedia, Tannerella forsythensis, Peptostreptococ- provide sufficient evidence. However, what is missing is
cus micros, Fusobacterium nucleatum and Campylo- an operational tool which will take research results a
bacter rectus), ethnic origin as well as age, gender, step forward. Once, genetic susceptibility profile
smoking status, periodontal status (pocket depth and reaches the clinical practice level then it will become
attachment loss), and severity assessment (valued over a part of the patient’s records. The clinician will be able
nominal scale: healthy = 0, mild periodontitis = 1, and to use the genetic profile of the patient, and via concrete
severe periodontitis = 2). A statistical process of Asso- and valid models and procedures incorporate genetics
ciation Rule Mining (ARM) was used to derive GSI into medical decision-making and reasoning. Thus, GSI
from genotypes of SNPs. points towards the integration of genotype and pheno-
The GSI derived from genotypes of SNPs is shown in type information and the improvement of clinical
Table 2. GSI scores correlate well with disease pres- practice and decision-making47. However, further stud-
ence. When the overall score is <1, the predisposition ies are required to validate and apply GSI for peri-
toward healthy status is 85% and when it is higher than odontal screening and prevention programmes.
4, the predisposition toward disease is 88%. In
addition, when score value ranges between 1 and 2,
FUTURE PERIODONTAL INDICES – A PROSPECTIVE
there is a 50 ⁄ 50 chance toward either disease or healthy
VIEW
The prevalence of periodontitis has historically been
Table 2 Genetic Susceptibility Index (GSI) values and measured using the extent and severity of loss of
disease status47 attachment and ⁄ or probing pocket depth in millime-
No. of Health Disease tres, and represents an accretion of the manifestations
GSI records (%) (%) of past disease with little or no indication of present
GSI £ 1 206 85 15
disease activity. To best assess present disease activity, a
1 < GSI £ 2 102 50 50 dependable method of quantifying periodontal disease
2 < GSI £ 3 169 29 71 incidence is essential2. Each periodontal index formu-
3 < GSI £ 4 130 23 77
GSI > 4 68 12 88
lated to date has its own merits and limitations.
The following are the possible options available to
the dental community to move closer towards formu-
lating an ideal periodontal index. Firstly, radiographic
Table 3 Genetic Susceptibility Index (GSI) values bone levels are closely related to clinical attachment
linked with microbial values (m metric)47 level which is the gold standard for scoring periodon-
Probability of healthy status
titis. With the advent of digital radiographic systems
like computer assisted subtraction radiography in the
m (%) value range field of periodontics, it is possible to detect bone level
GSI values 0, £3 (%) >3, £35 (%) >35 (%) differences as small as 0.5 mm between an initial and a
follow-up radiograph taken during periodontal exam-
GSI £ 1 97 44
1 < GSI £ 2 63 32 ination48. Thus, the combination of measurement of
2 < GSI £ 3 36 4 clinical attachment level and digital radiographic sys-
3 < GSI £ 4 67 22 3 tems into a single periodontal screening method will
GSI > 4 12 0
prove to be a useful tool for scoring periodontitis in
82 ª 2011 FDI World Dental Federation
 Indices for measuring periodontitis

clinical trials. However, digital radiographic techniques 5. Russell AL. A system of classification and scoring for prevalence
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