Dental Indices: CM Marya

16 Dental Indices
CM Marya
Dental indices provide a quantitative method for measuring, measures conditions that can be changed, such as the amount
scoring, and analyzing dental conditions in individuals and of bacterial plaque present.
groups. An index describes the status of individuals or groups
with respect to the condition being measured. It is an objective DEFINITION
mathematical description of a disease or condition based on
carefully determined criteria under specified circumstances. An index is defined as a numerical value describing the relative
Oral health surveys depend on dental indices, as do status of a population on a graduated scale with definite
researchers and clinicians, to help in understanding trends upper and lower limits, which is designed to permit and
and patient’s needs. In epidemiological oral health surveys, facilitate comparison with other populations classified by the
an index is used to show the prevalence and incidence of a same criteria and methods (AL Russell).
particular condition, to provide baseline data, to assess the
needs of a population, and to evaluate the effects and results Professional Implications
of a community program. Researchers use indices to determine Dental professionals from the private practice clinician to the
baseline data and to measure the effectiveness of specific researcher use indices to benefit their patients. A dentist or
agents, interventions, and mechanical devices. In private hygienist might use a PI to impress upon a patient the need
practice, index scores are used to educate, motivate, and for better oral hygiene. A World Health Organization researcher
evaluate the patient. By comparing scores from the initial might use the same index to assess the home care practices
exam during a follow-up exam, the patient can measure the of a population. Indices will continue to be important and
effects of personal daily care. necessary tools for dental professionals.
The first dental index, developed by Schour and Massler,
was known as a Papilla, Marginal gingiva and Attached gingiva
PROPERTIES OF AN IDEAL INDEX
(PMA) Index. Each of those areas was examined and scored
from 0 to 5, depending on the severity of inflammation. The 1. Reliability: It should be able to measure consistently at
PMA Index, largely of historic interest now, was primarily used different times and under a variety of conditions. The
in surveys of acute gingivitis. The status of a patient’s term is synonymous with reproducibility, repeatability that
periodontal health or disease is commonly measured by an is, if a researcher examined the same patient with the
index in private practices. One of the most widely used is the same condition multiple times, each times the score or
Periodontal Screening and Recording (PSR) TM Index, adapted results would be the same.
in 1992 from a system in use in Europe called the Community 2. Validity: It should measure what it is intended to measure.
Periodontal Index of Treatment Needs. The PSRTM is an early It should accurately reflect the extent or degree to which
detection system for periodontal disease. It is not intended to the condition or disease is present.
replace full periodontal charting, but to serve as a simple and 3. Clarity, simplicity and objectivity: The examiner should
convenient screening tool. be able to remember the criteria. Index should be easy to
Today, dental indices are used to assess both individual apply. The criteria should be clear and simple.
and group oral health and disease status. They can be simple, 4. Quantifiability: The index should be amenable to statistical
measuring only the presence or absence of a condition, or analysis, so that status of a group can be expressed by a
they can be cumulative, measuring all evidence of a condition, statistical measure. For example, mean, median.
past and present. Irreversible indices measure conditions that 5. Acceptability: The use of an index should not be painful
will not change, such as dental caries. A reversible index and demeaning to the subject.
186 Section 2  Dental Public Health
6. Sensitivity: The index should be able to detect reasonably
IDEAL REQUISITES OF AN INDEX
small shifts, in either direction in the condition.
• Should be simple to use and calculate
TYPES OF INDICES • Uses a minimal amount of time to complete
Simple index: It is the one which measures the presence or • Does not cause discomfort to the patient
• Is acceptable to the patient
absence of a condition. For example, an index which measures
• Requires minimum equipment and expense
the presence of plaque without evaluating its effects on the
• Has clear-cut criteria that are easily understood
gingiva. • Is reproducible in assessing the condition by the same or
Cumulative index: It is the one which measures all the evidence different examiner
of a condition (past and present). An example is DMFT index • Should be realistic: It should relate numerically to the clinical
for dental caries. stages of the specific disease.
Irreversible index: An index which measures the conditions
that will not change. For example, a dental caries index.
In addition to measuring a patient’s periodontal status,
Reversible index: One that measures conditions that can be
dental indices can measure the amount of plaque and calculus
changed or reversed.
present or not present in a patient’s mouth, the amount of
Full mouth indices: These indices measure the patient’s entire
bleeding present in the gingiva, the amount of tooth mobility
periodontium or dentition e.g. Russell’s periodontal index.
present at a given time, the amount of fluorosis present, and
Simplified indices:These indices measure only representative the number of decayed, missing, or filled teeth present.
samples of dental apparatus e.g. Green and Vermillion’s
simplified oral hygiene index (OHI-S).
RECOMMENDED METHOD OF PERFORMANCE OF AN INDEX
Indices are also classified in general categories according
to the entity which they measure
• Explain procedure to patient/client.
1. Disease index: e.g. ‘D’ (Decay) portion of the DMF index • Drape patient/client.
is the best example for disease index. • Give patient/client protective eyewear.
2. Symptom index: e.g. measuring gingival or sulcular • Wash hands.
bleeding are essentially examples for symptom indices. • Don PPE. (Personal protective equipment)
3. Treatment index: e.g. the ‘F’ (Filled) portion of DMF index • Position patient/client in reclined position in dental chair.
is best example for treatment index. • Adjust dental light for maximum illumination.
• Apply lubricant gel to patient/client’s lips and opaque colored
PURPOSE AND USES OF AN INDEX restorations.
• Dry teeth with compressed air using recommended sequence.
Indices can be used for individual assessment, for clinical • Carry out the index.
trials or epidemiological surveys as shown in Table 16.1.
Table 16.1: Purpose and uses of an index
Type Uses
Individual assessment Evaluation and monitoring the progress and maintenance of oral health.
Measures effects of personalized disease control programs overtime.
Monitors progress of disease healing.
Patient education and motivation
Provides individual assessment to help patient to recognize an oral problem
Clinical trial Comparison of an experimental group with a control group
Determines the effect of Determines baseline data before the experimental factors are introduced
an agent or procedure Measures the effectiveness of specific agents used for prevention, control and treatment of oral
on the prevention, conditions.
progression, or control Measures the effectiveness of mechanical devices used for personal care, i.e. toothbrushes, interdental
of a disease cleaning aids.
Community health/ Not designed for evaluation of an individual patient
epidemiologic survey Measures the prevalence and incidence of a oral condition occurring within a population
Survey for the study of Provides baseline data to show existing dental health practices
disease characteristics Compares the effects of a community program and evaluates the results
of populations Finds out the needs of a community
Chapter 16  Dental Indices 187
INDICES COMMONLY USED IN DENTISTRY Contd...

(BOX 16.1) e. Gingival bone count index.
f. Navy periodontal disease index.
Periodontal Indices g. Gingivitis periodontitis missing teeth index.
h. Periodontitis severity index.
There are 4 main areas in periodontal disease for which indices i. Extent and severity index.
are required: j. Gingival sulcus measurement component of periodontal
a. Plaque or soft deposits on teeth disease index.
b. Calculus k. Periodontal screening and recording index.
c. Gingivitis 7. Indices used in assessing dental caries:
d. Periodontal destruction or loss of attachment a. DMFT index.
b. DMFS index.
• Dental caries
c. def index.
• Fluorosis d. Root caries index.
• Malocclusion e. Modified DMFT index.
f. Caries Severity index.
BOX 16.1: INDICES USED IN DENTISTRY g. Czechoslovakia caries index.
h. DMF surface percentage index.
1. Indices used in assessing oral hygiene:
i. Functional measure index.
a. Oral hygiene index.
j. Dental health index.
b. Simplified oral hygiene index.
k. WHO dentition status.
c. Modified patient hygiene performance index.
l. Restorative Index.
d. Plaque free score index.
8. Indices used in assessing dental fluorosis:
e. Plaque control record.
a. Dean’s fluorosis index.
f. Oral health status index.
b. Moller’s fluorosis index.
2. Indices used in assessing plaque and debris:
c. Chronological fluorosis assessment index.
a. Plaque component of the periodontal disease index.
d. Fluorosis risk index.
b. Schick and Ash modification of plaque criteria.
e. Young’s classification.
c. Turseky-Gilmore-Glickman modification of the
f. Al-alomsi classification.
Quigley Hein plaque index.
g. Murray and Shaw classification.
d. Plaque index.
h. The FDI index.
e. Modified navy plaque index.
i. Thylstrup Fejerskov fluorosis index.
f. Distal mesial plaque index.
j. Tooth surface index of fluorosis.
3. Indices used in assessing calculus:
9. Indices used in assessing malocclusion
a. Calculus surface index.
a. Malalignment index.
b. Calculus surface severity index.
b. Handicapping malocclusion assessment index.
c. Marginal line calculus index.
c. Occlusal feature index.
d. Calculus component of the periodontal disease index.
d. Occlusal index.
e. Probe method of calculus assessment.
e. Index of orthodontic treatment needs.
4. Indices used in assessing gingival inflammation
f. Norwegian index of orthodontic treatment needs.
a. Papillary marginal attachment index.
g. Handicapping labiolingual deviation index.
b. Gingivitis component of the periodontal disease index.
h. Massler and Frankel index.
c. Gingival index.
i. Peer assessment rating index.
d. Papillary marginal gingivitis index.
e. Modified gingival index.
f. Gingival tissue index. Some of the more widely known indices are:
g. Gingival pain index.
5. Indices used in assessing gingival bleeding: PERIODONTAL INDICES
a. Sulcus bleeding index.
b. Papillary bleeding index.
c. Gingival bleeding index.
Plaque Index (PI)
d. Interdental bleeding index. The PI as developed by Silness and Loe (1964) assesses the
e. Gingival status index.
thickness of plaque at the cervical margin of the tooth (closest
f. Bleeding points index.
g. Quantitative gingival bleeding index. to the gum). Four areas, distal, facial or buccal, mesial, and
h. Gingival fluid flow index. lingual, are examined.
6. Indices used in assessing periodontal diseases: • Each tooth is dried and examined visually using a mirror, an
a. Periodontal index. explorer, and adequate light. The explorer is passed over the
b. CPITN. cervical third to test for the presence of plaque. A disclosing
c. CPI. agent may be used to assist evaluation.
d. Periodontal disease index.
• Missing teeth are not substituted.
Contd... • Four different scores are possible.
• Each of the four surfaces of the teeth (buccal, lingual, 1.0-1.9 = Fair oral hygiene
mesial and distal) is given a score from 0 to 3. 2.0-3.0 = Poor oral hygiene
PI Score for Tooth PLAQUE CONTROL RECORD

The scores from the four areas of the tooth are added and It was given by O’Leary, Drake TJ, and Naylor JE (1972).
divided by four in order to give the plaque index for the tooth This system measures plaque present, rather than plaque not
with the following scores and criteria: present, but no attempt is made to differentiate in the quantity
of plaque seen on each surface.
Scoring Criteria: The Plaque Index
Selection of Teeth and Surfaces
Scores Criteria
• All teeth are examined.
0 No plaque • Missing teeth are indicated on the record form as a single
1 A film of plaque adhering to the free gingival margin thick horizontal line.
and adjacent area of the tooth. The plaque may be • Four surfaces are examined: facial, lingual, mesial and distal.
seen in situ only after application of disclosing • The number of surfaces examined may be increased from
solution or by using the probe on the tooth surface.
four to six. When using six surfaces, they are facial (or
2 Moderate accumulation of soft deposits within the
gingival pocket, or the tooth and gingival margin
buccal), mesiofacial, mesiolingual, lingual, distolingual,
which can be seen with the naked eye. and distofacial.
3 Abundance of soft matter within the gingival pocket
and/or on the tooth and gingival margin. Procedure
Plaque is disclosed by either applying disclosing agent or the
The indices for the following six teeth may be grouped to patient is asked to chew disclosing tablet and swish and rub
designate the index for the group of teeth: 16, 12, 24, 36, 32, the solution over the tooth surfaces with the tongue before
and 44. (Fig. 16.1). rinsing. Each tooth surface is examined for plaque at the
gingival margin and recording is done.
PI for an Individual
Scoring
The index for the patient is obtained by summing the indices
for all six teeth and dividing by six For individual: The number of surfaces with plaque is multiplied
by 100, and divided by the number of tooth surfaces examined.
Interpretation for PI Scores Percent with plaque =
Four ratings may be assigned: The number of surfaces with plaque
0 = Excellent oral hygiene × 100
Number of tooth surfaces examined
0.1-0.9 = Good oral hygiene
For example, if an individual has 26 teeth, that equals
104 surfaces.
If eight surfaces are found to have plaque, then 800 are
divided by 104, leaving a plaque control index of 7.6 percent.
A score under 10% is considered good.
NAVY PLAQUE INDEX

The Navy Plaque Index (NPI) was developed by Grossman
FD and Fedi PF (1970) as part of the Navy Periodontal
Screening Examination, along with the Navy Periodontal
Disease Index. It reflects the plaque control status of the
patient and emphasizes plaque in the cervical portion of the
tooth which is in contact with the gingiva margins.
Teeth Examined
16 - Maxillary Right First Molar
Fig. 16.1: Teeth and surfaces scored (Silness and Loe PI) 21 - Maxillary Left Central Incisor
24 - Maxillary Left First Premolar Maximum NPI score : 18
36 - Mandibular Left First Molar Minimum NPI total : 0
41 - Mandibular Right Central Incisor
44 - Mandibular Right First Premolar ORAL HYGIENE INDEX (OHI)
Substitutions The OHI, developed by John C Greene and Jack R Vermillion

(1960), has two components, the debris index and the calculus
If 16, 24, 36 or 44 are missing, then substitute the next most index, and is an indication of oral cleanliness. The scores
posterior tooth. may be used singly or in combination. For scoring, the clinician
If 21 or 41 are missing, then substitute the nearest incisor divides the dentition into sextants and selects the facial (or
in the arch. If all incisors are missing from the arch, then buccal) and lingual tooth surface in each sextant that is
substitute a cuspid. covered with the greatest amount of debris and calculus.
Twelve surfaces, therefore, are evaluated. For this index, a
Surfaces Examined on Each Tooth surface includes half the circumference of the tooth.
The Oral Hygiene Index is composed of the combined
Facial gingival area (G) mesial proximal area (M) distal
Debris Index and Calculus index, each of these index is in
proximal area (D)
turn based on 12 numerical determinations representing the
Lingual gingival area (G) mesial proximal area (M) distal
amount of debris or calculus found on the buccal and lingual
proximal area (D).
surfaces of each of three segments of each dental arch.
The Maxillary and the Mandibular arches are each
SCORING CRITERA—NPI
composed of three segments (Fig. 16.2).
Plaque status Designated Points
SEGMENTS
Plaque in contact with gingival M 3
tissue on mesial proximal surface Maxillary
Plaque in contact with gingival tissue G 2
1. Segment 1: The segment distal to the right cuspid.
on facial or lingual surface
2. Segment 2: Upper right canine to upper left canine.
Plaque in contact with gingival tissue D 3 3. Segment 3: The segment distal to the left cuspid.
on distal proximal surface
Plaque on facial or lingual surface of R 1 Mandibular
tooth surface but not in contact with
gingival tissue 4. Segment 4: The segment distal to the left cuspid.
For Each Tooth

Facial points = (M points on facial aspect) + (G points on
facial aspect) + (D points on facial aspect)
+ (R points on facial aspect)
Lingual points = (M points on lingual aspect) + (G points on

lingual aspect) + (D points on lingual
aspect) + (R points on lingual aspect)
Calculating the NPI

Tooth score = (facial points) + (lingual points)
NPI score = MAX (all 6 tooth scores)
NPI total = SUM (all 6 tooth scores)
Interpretation
Minimum score for a surface : 0
Maximum score for a surface : 9
Minimum tooth score : 0
Maximum tooth score : 18 Fig. 16.2: Various segments of the mouth [OHI]
Total calculus score

Calculus index (CI) =
No. of segments scored
The average individual or group debris and calculus scores
are combined to obtain Oral hygiene index, as follows.
Oral hygiene index = Debris index + Calculus index

A perfect score would be 0, and the worst score possible
is 12
The Simplified Oral Hygiene Index (OHI-S)

This index was given by John C. Greene and Jack R. Vermillion
Fig. 16.3: Scoring method for debris in 1964. It offers a more rapid method for evaluation of oral
cleanliness of population groups, but lacks in degree of
5. Segment 5: Lower left canine to lower right canine. sensitivity in comparison to the original OHI index.
6. Segment 6: The segment distal to right cuspid. It differs from the original index in:
Each segment is examined for debris or calculus. From • Number of tooth surfaces scored [6 rather than 12].
each segment one tooth is used for calculating the individual • The method of selecting the tooth surfaces to be scored
index, for that particular segment. The tooth used for the • The scores which can be obtained.
calculation must have the greatest area covered by either
debris or calculus (Fig. 16.3). Selection of Tooth
The method for scoring calculus is the same as that applied
to debris, but additional provisions are made for recording The six surfaces examined for the OHI-S are selected from
subgingival deposits. four posterior and two anterior teeth.
• In the posterior teeth, the first fully erupted tooth distal to
Debris Score the second bicuspid, usually the first molar but sometimes
the second or third molar, is examined on each side of
each arch.
Scores Criteria
• In the anterior portion of the mouth upper right central
0 No debris or stain present incisor and lower left central incisor are scored.
1 Soft debris covering not more than one third of the • In the absence of either of these anterior teeth, the central
tooth surface, or presence of extrinsic stains without incisor on the opposite side of the midline is substituted.
other debris regardless of surface area covered • Only fully erupted permanent teeth are scored. A tooth is
2 Soft debris covering more than one third, but not
considered to be fully erupted when the occlusal or incisal
more than two thirds, of the exposed tooth surface.
surface has reached the occlusal plane
3 Soft debris covering more than two thirds of the
exposed tooth surface.
• Natural teeth with full crown restorations and surfaces
reduced in heights by caries or trauma are not scored.
Total debris score Instead an alternate tooth is examined.
Debris index (DI) =
No. of segments scored
Surfaces to be Seen (Fig. 16.4)
Calculus Score • Six surfaces are examined [from four posterior teeth and
two anterior teeth].
Scores Criteria Upper molars [ 6 | 6 ] : The buccal surfaces of selected
teeth is inspected.
0 No calculus present
1 Supragingival calculus covering not more than one third of Lower molars [6 | 6 ] : The lingual surfaces of the selected
the exposed tooth surface. teeth are checked.
2 Supragingival calculus covering more than one third but not Upper and Lower Central incisor 1 : labial surface is scored.
more than two thirds of the exposed tooth surface and/or
the presence of individual flecks of subgingival calculus Examination Method
around the cervical portion of the tooth.
To obtain the scores for debris and calculus, each of the six
3 Supragingival calculus covering more than two third of the
exposed tooth surface and/or a continuous heavy band of selected tooth surfaces are examined for debris and then
subgingival calculus around the cervical portion of the tooth. calculus. The surface area covered by debris is estimated by
running the side of a No. 5 explorer (Shepherd’s Crook) along
2. Insert saliva ejector into patient/client’s mouth.
3. Select teeth for examination by choosing six specific
teeth with one in each sextant.
4. Evaluate teeth.
a. Start evaluation with maxillary posterior sextant and
work way around maxillary arch.
b. Drop down to mandibular left lingual posterior sextant
and work way around to other side of mouth.
5. Evaluate teeth for soft debris by recording six debris scores
on appropriate recording form(s).
6. Evaluate teeth for calculus by recording six calculus
scores.
7. Calculate debris score by totalling debris scores and
dividing by number of teeth scored.
8. Calculate calculus score by totalling calculus scores and
dividing by number of teeth scored.
9. Calculate OHI-S score by adding debris score to calculus
score that equals OHI-S score.
10. Record OHI-S score in patient/client’s chart or on
Fig. 16.4: Six teeth and the surfaces scored (OHI-S)
appropriate recording form(s).
Scoring Criteria (Debris) (Fig. 16.5A)
Scores Criteria
0 No debris or stain present.

1 Soft debris covering not more than one third of the tooth
surface being examined or presence of extrinsic stains
without debris regardless of surface area covered.
2 Soft debris covering more than one third, but not more
than two thirds, of the exposed tooth surface.
3 Soft debris covering more than two thirds of the exposed
Fig. 16.5A: Scoring method for debris tooth surface.
Scoring Criteria (Calculus) (Fig. 16.5B)
Scores Criteria
0 No calculus present.
1 Supragingival calculus covering not more than one-
third of the exposed tooth surface being examined.
2 Supragingival calculus covering more than one-third
but not more than two thirds of the exposed tooth surface
and /or the presence of individual flecks of subgingival
calculus around the cervical portion of the tooth.
3 Supragingival calculus covering more than two third
of the exposed tooth surface or a continuous heavy
band of subgingival calculus around the cervical portion
Fig. 16.5B: Scoring method for calculus
of the tooth.
the tooth surfaces being examined (Explorer is moved from In the simplified OHI, the worst score possible is 6.
incisal/occlusal to gingival margin). The occlusal or incisal
extent of the debris is noted as it is removed. Same No. 5 Interpretation
explorer is used to estimate the surface area covered by the Individually DI-S and CI-S is scored as follows:
supragingival and subgingival calculus. 0.0 to 0.6 = Good oral hygiene
1. Spray water into patient/client’s mouth and instruct 0.7 to 1.8 = Fair oral hygiene
patient/client to swish. 1.9 to 3.0 = Poor oral hygiene
An OHI-S is scored as follows: Surfaces
0.0-1.2 = Good oral hygiene
Facial surfaces: Incisors and maxillary molars.
1.3 -3.0 = Fair oral hygiene
Lingual surfaces: Mandibular molars
3.1 -6.0 = Poor oral hygiene
Substitutions for Missing Teeth
PATIENT HYGIENE PERFORMANCE INDEX
• The second molar is used if the 1st molar
(PHP INDEX)
- Is missing
It was developed by Podshadley AG, and Haley JV (1968) to - Less than three–fourth erupted
assess the extent of plaque and debris over a tooth surface as - Has a full crown
an indication of oral cleanliness. Debris for PHP was defined - Is broken down
as the soft foreign material consisting of bacterial plaque, • The third molar is used when the second molar is missing.
material alba and food debris that is loosely attached to tooth • The adjacent incisor the of the opposite side is used, when
surfaces. the central incisor is missing.
Most useful for individual patients who have significant
plaque accumulation. Procedure
Teeth and Surfaces Examined (Fig. 16.6) • Disclosing solution is applied.
• Patient is asked to swish for 30 seconds and expectorate
Tooth Numbers in FDI System but not rinse.
16 - Upper right first molar • Examination is made using a mouth mirror.
11 - Upper right central incisor • Each tooth surface to be evaluated is subdivided into five
26 - Upper left molar sections as follows (Fig. 16.7).
36 - Lower left first molar Vertically: Three divisions mesial, middle and distal.
31 - Lower left central incisor Horizontally: The middle third is subdivided into gingival,
46 - Lower right first molar middle and occlusal or incisal thirds.
• Each area with plaque is scored a point so each tooth
score can range from 1 to 5 points.
Scoring
Debris scores for individual tooth: Add the scores for each of
the five subdivisions. The scores range from 0 to 5.
PHP for an individual: Total the scores for the individual teeth
and divide by the number of the teeth examined. The PHP
value ranges from 0 to 5.
PHP Index for a group: To obtain the average PHP score for
a group or a population, total the individual score and divide
by the number of people examined.
Fig. 16.6: PHP index: 6 tooth surfaces are scored Fig. 16.7: Subdivision of a tooth into 5 sections (PHP index)
Interpretation Interpretation: Gingival Index
Nominal scale for evaluation of scores:
Average gingival Interpretation
Rating scores
index (Score)
1. Excellent = 0 (No debris)
2. Good = 0.1-1.7 2.1 - 3.0 Poor (severe gingivitis), severe inflammation
3. Fair = 1.8-3.4 1.1 - 2.0 fair (moderate gingivitis), moderate inflammation,
0.1 - 1.0 Good (mild gingivitis), mild inflammation
4. Poor = 3.5- 5.0
< 0.1 Excellent (no gingivitis), no inflammation
GINGIVAL INDEX (GI)

Limitations
Also attributed to Loe and Silness (1963), the GI assesses
the severity of gingivitis based on color, consistency, and To eliminate the need to perform probing and to better
bleeding on probing. It describes the clinical severity of gingival describe milder forms of inflammation, several subsequent
inflammation as well as its location. Mesial, lingual, distal, modifications were made.
and facial (or buccal) surface of each teeth are examined. A
probe is used to press on the gingiva to determine its degree CALCULUS SURFACE INDEX
of firmness, and to run along the soft tissue wall adjacent to
This index was developed by Ennever J, Sturzenberger CP
the entrance to the gingival sulcus.
and Radike AW (1961).
The Calculus Surface Index is a measure of dental calculus
Teeth Examined formation. It can be used to quantitate the accumulation of
1. Maxillary right first molar. dental calculus in short-term testing programs to evaluate the
2. Maxillary right lateral incisor. effectiveness of preventive care.
3. Maxillary left first bicuspid.
4. Mandibular left first molar. Method
5. Mandibular left lateral incisor. Presence or absence of supragingival and/subgingival or
6. Mandibular right first bicuspid. gubgingival calculus on the four mandibular incisor is assessed.
Each of the 4 mandibular incisors is assessed on 4 surfaces
Surfaces Examined on each Tooth (one labial, one lingual and two proximal).
The presence or absence of calculus is examined by visual
Buccal, lingual, mesial and distal.
or tactile examination using a mirror and dental explorer (sickle
Bleeding potential is based on the following criteria: type).
Each surface with calculus is scored 1 point.
Scoring Criteria: Gingival Index
Scoring
Average gingival Interpretation
index (Score) For a person
Calculus surface index = Sum total of calculus points on the
0 Normal gingiva/absence of inflammation 16 surfaces surveyed
1 Mild inflammation: Slight change in color, slight
edema. No bleeding on probing; Interpretation
2 Moderate inflammation: Redness edema and
glazing. Bleeding on probing Minimum score: 0
3 Severe inflammation: Marked redness and Maximum score: 16
edema. Ulceration and a tendency for
spontaneous bleeding PERIODONTAL INDEX (PI)
Russell [1956] developed an index for measuring periodontal
Each surface is given a score, and then the scores are disease that could be used in population surveys. It can be
totaled which gives the score for area and divided by based solely upon the clinical examination, or it can make
four gives score for the tooth. Totaling all scores and use of dental X-rays if they are available. It places greater
dividing by the number of teeth examined provides GI score emphasis on advanced disease. PI determines the periodontal
per person. disease status of populations in epidemiologic studies. Each
tooth is scored according to the condition of the surrounding PERIODONTAL DISEASE INDEX (PDI)
tissues. On examination, each tooth is assigned a score using
the following criteria: The periodontal disease index was introduced by Sigurd P
Ramfjord in 1959. It was a modification of Russell index,
Scoring particularly designed for assessing the extent of pocket
deepening below the cementoenamel junction. It combines
1. Each tooth is scored separately according to the following the evaluation of gingival status with the probed attachment
criteria. level (crevice depth measured from the cementoenamel
2. Rule: When in doubt, assign the lower score. junction).
Reasons for its Widespread Use Selection of Teeth and Surfaces

i. Ease of use
Teeth examined: (FDI system tooth numbers are in the
ii. Clarity of criteria
parenthesis)
iii. Reasonable comparability of results
1. Maxillary right first molar - (16)
Scoring values (0, 1, 2, 6, and 8) relate to the stages of
2. Maxillary left central incisor - (21)
the disease scored in an epidemiological survey to the clinical
condition observed. The jump from 2 to 6 in the scale recognizes 3. Maxillary left first bicuspid - (24)
the change in disease condition from a severe gingivitis to an 4. Mandibular left first molar - (36)
overt destructive periodontal disease with obvious loss of 5. Mandibular right central incisor - (41)
attachment. PI can be considered a true interval scale. 6. Mandibular right first bicuspid - (44)
Scores for each tooth are added, and the total is divided If any of the teeth are missing or unerupted, then only the
by the number of teeth examined. Scores can be interpreted teeth present are examined (only fully erupted teeth are used).
as follows: Substitution is not made for missing teeth.
• 0.0-0.2 = Clinically normal supportive tissues.
• 0.3-0.9 = Simple gingivitis. Procedure
• 0.7-1.9 = Beginning destructive periodontal disease. 1. Under consistent light, gingiva is dried with cotton to
• 1.6-5.0 = Established destructive periodontal observe the form.
disease.
2. Gentle pressure is applied with a probe to determine
• 3.8-8.0 = Terminal periodontal disease.
consistency.
Individual score = Average (scores for all of the teeth in
3. Michigan probe No. 0 was used originally.
the mouth)
4. Four measurements are made from each tooth, on the
Population score = Average (individual scores in population
mesial, distal, facial and lingual surfaces.
examined).
SCORING CRITERIA FOR RUSSELS (PI) INDEX
Criteria for field studies Additional X-ray criteria Score
Negative (neither overt inflammation in the investing tissues, Radiographic appearance normal 0
nor loss of function due to destruction of supporting tissues)
Mild gingivitis (overt area of inflammation in the free gingivae,
but this area does not circumscribe the tooth) 1
Gingivitis (inflammation completely circumscribes the tooth,
but there is no apparent break in the epithelial attachment) 2
(Not used in field study) Early, notchlike resorption of the alveolar crest 4
Gingivitis with pocket formation (the epithelial attachment is Horizontal bone loss involving the entire alveolar 6
broken, and there is a pocket. There is no interference with crest, up to half of the length of the tooth root
normal masticatory function, the tooth is firm in its socket, (distance from apex to cementoenamel junction)
and has not drifted).
Advanced destruction with loss of masticatory function Advanced bone loss, involving more than half of 8
(tooth may be loose, tooth may have drifted, tooth may the length of the tooth root, or a definite intrabony
sound dull on percussion with a metallic instrument, the pocket with definite widening of the periodontal
tooth may be depressible in its socket) membranes. There may be root resorption, or
rarefaction at the apex
Scoring Method: Periodontal Disease Index Calculus (PDI)
Gingivitis No signs of inflammation 0 To measure the presence and extent of calculus a subgingival
Mild to moderate inflammatory gingival explorer or a periodontal probe is used.
changes, not extending around the tooth 1
Mild to moderately severe gingivitis extending Procedure
all around the tooth 2
For each of the 6 teeth, four surfaces (mesial, distal, facial,
Severe gingivitis characterized by marked redness, lingual/palatal) are scored from 0 to 3.
swelling, tendency to bleed and ulceration 3
Gingival Gingival crevice in any of the four measured Scoring Criteria for Calculus
crevice areas (mesial, distal, buccal, lingual), extend
depth apically to the cementoenamel junction
but not more than 3 mm 4 Criteria Score
Gingival crevice in any of the four measured None 0
areas extending apically to the cemento- Supragingival calculus, extending only slightly 1
enamel junction from 3 mm to 6 mm inclusive. 5 below the free gingival margin (not more than 1 mm)
Gingival crevice in any of the four measured
Moderate amount of supra- and subgingival 2
areas extending more than 6 mm apical to the
calculus or subgingival calculus alone
cementoenamel junction. 6
An abundance of supra- and subgingival calculus 3
Scoring PDI Scoring

For individuals: Add the scores for individual teeth and divide For individual teeth: Add scores for each surface and divide
by the number of teeth examined. The PDI ranges from 0 to 6. by the number of surfaces (4).
For an individual: Add the scores for an individual tooth and
For group: Total the individual PDI scores and divide by the
divide by the number of teeth.
number of individuals examined. The average ranges from 0
to 6.
Plaque and Calculus Component of the Periodontal GINGIVAL BLEEDING INDEX (GBI)
Disease Index (PDI). Unwaxed dental floss is used to measure a GBI, developed
Although not part of PDI, a Plaque Index and Calculus by Carter and Barnes (1974). A full complement of teeth has
Index are included when making a survey hence described. 28 proximal areas to be examined. Floss is passed
interproximally, first on one side of the dental papilla, then
Dental Plaque (PDI) on the other. The clinician curves the floss around each tooth
For each of 6 teeth mentioned above 4 surfaces (facial, lingual, and passes it below the gingival margin, taking care not to
mesial and distal) are scored from 0 to 3. lacerate the gingiva. Any bleeding noted indicates the presence
of disease. The numbers of bleeding areas versus proximal
areas scored is recorded. It can be used for initial patient
Procedure
evaluation and motivation or over time to assess response to
i. Apply disclosing agent interventions to improve periodontal health.
ii. Patient is asked to expectorate and rinse with water
iii. Specific surfaces with disclosed plaque are observed. Procedure
Scoring Criteria for Plaque Selection of Teeth

The mouth is divided into 6 segments (upper right, upper
Criteria Score anterior, upper left, lower left, lower anterior, lower right).
None 0 Areas involving the third molars are not scored because of
Present on some but not on all interproximal, 1
variations in arch position, access and vision.
buccal and lingual surfaces
Plaque present on all of the interproximal, 2 Method
buccal and lingual surfaces, but covering Unwaxed dental floss is alternately passed interproximally
less than half of these surfaces
into the gingival sulcus on both sides of the interdental
Plaque extends once all interproximal, 3 papillae. With the floss extended as far as possible towards
buccal and lingual suface and once more than
the buccal and lingual, the floss is carried to the bottom of
one half of these surfaces
the sulcus. The floss is then moved in an incisogingival motion
for one double stroke. Care is taken not to cause laceration PAPILLARY-MARGINAL-ATTACHED GINGIVAL
of the papillae. A new length of clean floss is used for each INDEX
interproximal unit.
Bleeding is generally immediately evident in the area or PMA index is probably the oldest reversible index which was
on the floss, but 30 seconds are allowed for reinspection of developed by Schour I and Massler M (1944).
It was used to assess the extent of gingival changes in large
each segment. If bleeding is copious, the patient should rinse
groups for epidemiological studies. It was based on the concept
between segments.
that the extent of inflammation serves as an indicator of the
An area is non-scoreable when tooth positions, diastemas
severity of the condition. The presence or absence of inflammation
or other factors compromise the desirable interproximal is recorded in three areas of gingiva around the teeth.
relationships.
Selection of Teeth and Surfaces
Bleeding Assessment
Three gingival units are examined for each tooth
No attempt is made to quantify the degree of bleeding. P = Papillary portion between the teeth
Bleeding is assessed only as present or absent. 1. Papilla is numbered by the tooth just distal to it. Papilla is
not present when teeth are separated by a diastema or
Scoring Codes for GBI there is an edentulous area.
2. Inflammation usually begins within the papilla at the col
Not bleeding : None (blank) area.
Bleeding : B Papillary changes—Mild gingivitis.
Not-scoreable : X M = Marginal collar around the teeth.
1. It is located between papillae, attached by junctional
Recording Method epithelium, and demarcated from attached gingiva by
the free gingival groove.
Interproximal areas of maxillary teeth Code
2. Papillary and marginal gingival inflammation- Moderate
17-16 –––– gingivitis.
16-15 –––– A = Attached gingiva overlying the alveolar bone
15-14 –––– 1. Stippled gingiva between the free gingival groove and the
14-13 ––––
mucogingival junction.
13-12 ––––
2. Spread of inflammation from papillary and marginal
12-11 ––––
11-21 –––– gingivitis into the attached gingiva – Severe gingivitis.
21-22 ––––
22-23 –––– Method
23-24 –––– All the teeth can be assessed starting from maxillary second
24-25 –––– molar of one side to the second molar of the other side and
25-26 –––– then mandibular second molar of the same side to the second
26-27 –––– molar of the other side. Third molars are not included. Adequate
light and mouth mirror are used. Probe usually a blunt probe is
Similarly scores are recorded for mandibular teeth. used for pressing on gingiva.
Result Scoring Criteria

Total scoreable areas = 26 - (number of non-scoreable areas) Papillary =P
Gingival Bleeding Score (total bleeding areas) = Sum of 0 = Normal, no inflammation.
number of bleeding areas 1+ = Mild papillary engorgement, slight increase in size.
2+ = Obvious increase in size of gingival papilla, bleeding
Interpretation on pressure.
3+ = Excessive increase in size with spontaneous bleeding
The fewer the number of bleeding sites, the less the extent of 4+ = Necrotic papilla.
gingivitis. Ideally the score should be 0. 5+ = Atrophy and loss of papilla (through inflammation).
If the patient is to be followed over time, previous bleeding
Marginal = M
sites are monitored to see if they become non-bleeding.
0 = Normal, no inflammation visible.
The goal of interventions is to reduce the score as much as 1+ = Engorgement, slight increase in size, no bleeding.
possible. 2+ = Obvious engorgement, bleeding upon pressure.
3+ = Swollen collar, spontaneous bleeding, beginning Bone Score
infiltration into attached gingiva.
4+ = Necrotic gingivitis. Criteria/Finding Score
5+ = Recession of the free marginal gingiva below the
cementoenamel junction as a result of inflammatory No bone loss 0
Incipient bone loss or notching of 1
changes.
alveolar crest.
Attached = A Bone loss about one fourth of root 2
0 = Normal; pale rose, stippled length, or pocket formation on one side,
1+ = Slight engorgement with loss of stippling, change in not over one half of root length.
color may or may not be present. Bone loss about one half of root 3
2+ = Obvious engorgement of attached gingiva with marked length, or pocket formation on one side, not
increase in redness, pocket formation present over three fourth root length, mobility slight
3+ = Advanced periodontitis, deep pockets evident. Bone loss about three quarters of root 4
length, or pocket formation on one side to
Scoring apex, mobility moderate
P-M-A for individual Bone loss complete, mobility marked 5
Count the number of P, M and A units scored and record
separately as: P-M-A =?-?-? Gingival bone score
Keeping the total separate, as on adding the sum will not = SUM ((gingival score) + (bone score))/
represent the area of the gingiva where the inflammation is (number of teeth examined) =
present. = (mean gingival score) + (mean bone score)
P-M-A for a group: The average of the P, M and A is computed
by totalling each for all individuals and then dividing each Interpretation
number of individuals examined.
• Minimum score: 0
• Maximum score: 8
GINGIVAL BONE COUNT INDEX The higher the score, the more serious the periodontal
The Gingival Bone Count Index was developed by Dunning disease.
JM and Leach LB (1960). It is a composite score based on
the gingival condition and degree of bone loss affecting a COMMUNITY PERIODONTAL INDEX OF
person’s teeth. This can be used to evaluate periodontal health, TREATMENT NEEDS (CPITN)
especially in epidemiologic studies.
The FDI-WHO Joint Working Group on periodontal diseases
supports the use of the CPITN as an epidemiological screening
Method
procedure for periodontal treatment needs in populations.
• The gingival score is based on the clinical examination. The Community Periodontal Index of Treatment Needs
• The bone score is based on the clinical examination and (CPITN) is an epidemiologic tool developed by the World
evaluation of dental X-rays. Health Organization (WHO) for the evaluation of periodontal
• A mean for each score is then computed for the whole mouth. disease in population surveys. It can be used to recommend
the kind of treatment needed to prevent periodontal disease.
Scoring Criteria Following extensive discussion and testing the CPITN was
finalized and described in 1982 (Ainamo Jukka, Barmes David,
A single gingival score and a single bone score is generated Beagrie George, Cutress Terry, Martin Jean and Sardo-Infirri
for each tooth studied. Jennifer).
The CPITN is primarily a screening procedure which
Gingival Score requires clinical assessment for the presence or absence of
periodontal pockets, calculus and gingival bleeding. Use of
Criteria/Finding Score
a special CPITN periodontal probe (or its equivalent) is
Negative 0 recommended.
Mild gingivitis involving the free gingiva 1 For epidemiologic purposes in adult populations, 10
(margin, papilla, or both) specified index teeth are examined. For persons under 20
Moderate gingivitis involving both free 2 years of age only, six index teeth are specified. In dental
and attached gingiva practice, all teeth are examined and the highest score for
Severe gingivitis with hypertrophy 3 each sextants noted. Only six scores are recorded. Measures
and easy hemorrhage
of gingival recession, tooth mobility, intensity of inflammation,
precise identification of pocket depths or differentiation in concept from the probes for dental caries and most other
between supra- and subgingival calculus are not included in oral care instruments in current use.
the CPITN. Individuals are assigned to one of four treatment
need categories determined from their CPITN scores.
Teeth examined: Two methods of selection
Sextants: Total six sextants
14 teeth on the maxilla and 14 teeth on the mandible, divided The Probe
into three segments on each arch with following tooth
numbers (FDI). The probe has color coding between 3.5 and 5.5 mm markings
Maxilla: at intervals from the tip. The working tip has a ball 0.5 mm
Sextant 1 : 17 to 14 in diameter. The functions of ball tip are:
Sextant 2 : 13 to 23 i. To aid in detection of calculus and other tooth surface
Sextant 3 : 24 to 27 roughness.
Mandible: ii. To facilitate assessment of the base of the pocket and
Sextant 4 : 37 to 34 reduce the risk of over measurement.
Sextant 5 : 33 to 43 A variant of this basic probe has two additional lines at
Sextant 6 : 44 to 47 8.5 mm and 11.5 mm from the working tip. The additional
Third molars are not used unless they function in place of lines may be of use when performing a detailed assessment
the second molars. and recording of deep pockets for the purpose of preparing
treatment plan for complex periodontal therapy. The two
Index Teeth instruments can be identified as:
CPITN-E for the epidemiologic probe with 3.5 and
In epidemiological surveys, for adults aged 20 years or more, 5.5 mm markings (Fig. 16.8).
only 10 index teeth are examined (5 teeth on the maxilla and CPITN-C for the clinical probe with the additional 8.5
5 teeth on the mandible). These have been identified as the and 11.5 mm markings (Fig. 16.9).
best estimators of the worst periodontal condition of the
mouth. Sensing Gingival Pockets
MAX 17 16 11 26 27
MAND 47 46 31 36 37 An index tooth should be probed, using the probe as a
“sensing” instrument to determine pocket depth and to detect
The molars are examined in pairs and only one score, the subgingival calculus and bleeding response. The sensing force
highest is recorded. Only one score is recorded for each sextant. used should be not more than 20 grams. A practical test for
For young people, up to 19 years only, six index teeth establishing this force is to place the probe point under the
MAX 16 11 26 thumb nail and press until blanching occurs. For sensing
MAND 46 31 36 subgingival calculus, the lightest possible force that will allow
The second molars are excluded as index teeth at these movement of the probe ballpoint along the tooth surface
ages because of the high frequency of false (noninflammatory should be used.
associated with tooth eruption) pocket. The ball-end should be in contact with the root surface.
For screening and monitoring purposes in dental practice When inserting the probe, the ballpoint should follow the
all teeth in a sextant are examined for adults over age 19 anatomical configuration of the surface of the tooth root. If
years. Only one score, the highest is recorded for each sextant the patient feels pain during probing, this is an indicative of
When examining children less than 15 years, pockets are the use of too much force.
not recorded although probing for bleeding and calculus are The probe tip should be inserted gently into the gingival
carried out as routine. pocket and the depth of insertion read against the color coding.
The total extent of the pocket should be explored and at least
Recording Data six points on each tooth should be examined: mesiobuccal,
midbuccal, distobuccal, and the corresponding lingual sites.
The following box chart is recommended as the epidemiologic
and dental office chart for recording CPITN data. The CODES AND CRITERIA (FIG. 16.10)
recommended periodontal probe for use with CPITN was
described in the WHO 621 report (WHO 1978). The approved The codes are listed in the descending order of treatment
basic probe is suitable for general use in epidemiology and complexity as follows:
routine screening of patients in general practice. The CPITN Code X: When only one tooth or no tooth is present in the
is particularly designed for gentle manipulation of the often sextant (third molars are excluded unless they
very sensitive soft tissues around the teeth; as such it is different function in place of second molars).
Fig. 16.8: Community periodontal index of

treatment needs (CPITN) ‘E’ probe Fig. 16.10: Community periodontal index of treatment
needs (CPITNs)
Note: If the deepest pocket is found at the

designated tooth or teeth in a sextant is 4 or
5 mm, a code 3 is recorded. There is no need to
examine for calculus or gingival bleeding.
Code 2: Calculus or other plaque retentive factors such as
ill fitting crowns or poorly adapted edges of
restoration are either seen or felt during probing.
Note: The black band remains fully visible.
Code 1: Bleeding observed during or after probing (either
immediate or delayed).
Code 0: Healthy tissue: The black band on the probe
remains fully visible. There is no bleeding after
probing. No calculus, restoration overhangs or other
plaque retention factors are present.
Treatment Needs
Fig. 16.9: Community periodontal index of

TN 0: A recording of code 0 (health) or X (missing) for all six
treatment needs (CPITN) ‘C’ probe sextant indicates that there is no need for treatment.
TN 1: A code of 1 or higher indicates that there is need for
improving the personal oral hygiene of that individual.
Code 4: Pathological pocket of the 6 mm or more, that is, TN 2: a. Code of 2 or higher indicates a need of
the black area of the CPITN probe is not visible. professional cleaning of the teeth and removal of
Note: If the designated tooth or teeth are found plaque retentive factors. Patient require oral
to have a 6 mm or deeper pocket in the sextant hygiene instructions
being examined, a code of 4 is given to the sextant. b. Shallow to moderate pocketing (4 or 5 mm,
Recording of Code 4 makes further examination code 3). Oral hygiene and scaling will reduce
of that sextant unnecessary. There is no need to inflammation and bring 4 or 5 mm pockets to
record the presence or absence of pathological values of or below 3 mm. Thus, sextants of these
pockets of 4 or 5 mm, calculus or bleeding. pockets are placed in the same treatment category
Code 3: Pathological pocket of 4 or 5 mm that is when the as scaling and root planning, i.e. Treatment Needs
gingival margin is on the black area of the probe. 2 (TN2)
TN 3: A sextant scoring code 4 (6 mm or deeper pockets) 6. If all teeth in a sextant are missing or only one functional
may or may not be treated successfully by means of tooth remains, the sextant is coded as missing
deep scaling and efficient personal oral hygiene 7. A single tooth in a sextant is considered as a tooth in the
measures. Code 4 is therefore assigned as complex adjacent sextant and subject to the rules for that sextant.
treatment which can involve deep scaling, root If single tooth is an index tooth, then the worst index
planning and more complex procedures. tooth score is recorded.
Explanation of the Clinical Criteria and Examination Procedure

Treatment Needs
The aim is to determine the highest score applicable to each
Bleeding on gentle probing, plaque retentive factors (calculus sextant with least number of measurements.
or overhangs of restoration), 4 or 5 or 6 mm or deeper pockets First decide whether the sextant can be validly scored. More
are basic indicators if treatment needs. These criteria were than one functional tooth should be present.
chosen for the following reason. If ‘no’, then give a score X and move to the next sextant.
1. TN 1: Bleeding is sign of a early disease which can be If ‘yes’, examine index teeth (epidemiological) or all teeth (in
over come by self care following suitable oral health care clinical screening procedure) in the order of presence of 6
educations and instructions. Control of gingival bleeding mm or deeper pockets; 4 to 5 mm pockets, calculus or other
is a prerequisite for all periodontal therapy. This treatment plaque retentive factors and bleeding only.
is recognized as treatment need 1 (TN1). The control or Determine appropriate highest score for each sextant. As
elimination of gingival bleeding should be the prime goal soon as the highest score criteria has been determined there
even if further treatment is not available. is no need to examine for the presence of lower score criteria.
2. TN 2: Although not pathological in themselves, Calculus
and other plaque retentive factors favor plaque retention Number of Probings Per Sextant
and inflammation. Unlike plaque that can be eliminated
by self care, the removal of calculus demands the The tip of the CPITN probe is gently inserted between tooth
professional care defined as treatment need 2 (TN2). and gingiva to the full depth of the sulcus or pocket and the
3. TN 3: In patient with deep pocket even after scaling, root probing depth read by the observation of the position of the
planning and control of bleeding by oral hygiene methods black band. Recommended sites for probing are mesial, midline
there will generally be residual pockets. The treatment of and distal on both facial and lingual surfaces. The probing
these conditions may require complex therapy for which may be done by withdrawing the probe between each probing
skilled and trained dental professionals are needed. This or alternatively with probe tip remaining in the sulcus the
treatment is recognized as TN 3. probe may be ‘walked’ around the tooth. Sites in addition to
the recommended one should be probed, if there is suspicion
Substitution for Excluded and Missing that a higher scoring condition is present.
Index Teeth
Explanation of the Clinical Criteria
The ten CPITN index teeth are first molar and second molars
in the posterior sextant and a central incisor in each of the Bleeding on gentle probing, plaque retentive factors (calculus
two anterior sextant. When one or more index teeth are missing or over hangs of restoration), 4 or 5 or 6 mm or deeper pockets
at the time of examination, substitute teeth are selected using are basic indicators if treatment needs. These criteria were
the following rules: chosen for the following reason.
1. Two or more functioning teeth must be present in a sextant 1. TN 1: Bleeding is sign of a early disease which can be
for it to qualify for scoring. over come by self care following suitable oral health care
2. If in posterior sextant, one of the two index teeth is not educations and instructions. Control of gingival bleeding
present or has to be excluded, then the recording is based is a pre requisite for all periodontal therapy. This treatment
on the examination of remaining index tooth. is recognized as treatment need 1 (TN1). The control or
3. If both index teeth in posterior sextant are absent or elimination of gingival bleeding should be the prime goal
excluded from examination, all the remaining teeth in even if further treatment is not available.
that sextant are examined and highest score recorded. 2. TN 2: Although not pathological in themselves, Calculus
4. In the anterior maxillary sextant, if tooth 11 is excluded, and other plaque retentive factors favor plaque retention
substitute 21. If 21 is also excluded, then identify the and inflammation. Unlike plaque that can be eliminated
worst score for the remaining teeth. Similarly substitute by self care the removal of calculus demands the
tooth 41 if 31 is missing. professional care defined as treatment need 2 (TN 2).
5. In subjects under 20 years of age, if the first molar is not 3. TN 3: In patient with deep pocket even after scaling, root
present or has to be excluded the nearest adjacent planning and control of bleeding by oral hygiene methods
premolar is examined. there will generally be residual pockets. The treatment of
these conditions may require complex therapy for which When the probe is inserted, the ball tip should follow the
skilled and trained dental professionals are needed. This anatomical configuration of the surface of the tooth root. If
treatment is recognized as TN 3. the patient feels pain during probing, this is an indicative of
the use of too much force.
COMMUNITY PERIODONTAL INDEX (CPI) The probe tip should be inserted gently into the gingival
sulcus or pocket and the total extent of the sulcus or pocket
Indicators explored. For example, the probe is placed in the pocket at
Three indicators of periodontal status are used for this the distobuccal surface of the second molar, as close as
assessment: possible to the contact point with the third molar, keeping the
1. Gingival bleeding probe parallel to the long axis of the tooth. The probe is then
2. Calculus moved gently, with short upward and downward movements,
3. Periodontal pockets along the buccal sulcus or pocket to the mesial surface of the
A specially designed lightweight CPI probe with a second molar, and from the distobuccal surface of the first
0.5 mm ball tip is used, with a black band between 3.5 and molar towards the contact area with the premolar. A similar
5.5 mm and rings at 8.5 and 11.5 mm from the ball tip. procedure is carried out for the lingual surfaces, starting
distolingually to the second molar.
Sextants
Examination and Recording
The mouth is divided into sextants defined by tooth numbers:
18-14, 13-23, 24-28, 38-34, 33-43, and 44-48. A sextant The index teeth, all remaining teeth in a sextant where there
should be examined only if there are two or more teeth present is no index tooth, should be probed and the highest score is
and not indicated for extraction. (Note: This replaces the recorded in the appropriate box. The codes are:
former instruction to include single remaining teeth in the 0 Healthy
adjacent sextant.)
1 Bleeding observed, directly or by using mouth mirror, after
Selection of teeth: For adults aged 20 years and over, the
probing
teeth to be examined are:
2 Calculus detected during probing, but all the black band
17 16 11 26 27 on the probe visible
47 46 31 36 37 3 Pocket 4 to 5 mm (gingival margin within the black band
The two molars in each posterior sextant are paired for on the probe)
recording, and if one is missing, there is no replacement. If 4 Pocket 6 mm or more (black band on the probe not visible)
no index teeth or tooth is present in a sextant qualifying for X Excluded sextant (less than two teeth present)
examination, all the remaining teeth in that sextant are 9 Not recorded
examined and the highest score is recorded as the score for
the sextant. In this case, distal surfaces of third molars should Loss of Attachment (Fig. 16.11)
not be scored.
For subjects under the age of 20 years, only six teeth - 16, Information on loss of attachment gives an estimate of the
11, 26, 36, 31 and 46 - are examined. This modification is lifetime accumulated destruction of the periodontal
made in order to avoid scoring the deepened sulci associated attachment. Loss of attachment should not be recorded for
with eruption as periodontal pockets. For the same reason, children under the age of 15.
when examining children under the age of 15 are examined, Highest score recorded in the appropriate box.
pockets should not be recorded, i.e. only bleeding and calculus The codes are:
should be considered. 0 Loss of attachment 0 to 3 mm (CEJ not visible and CPI
score 0-3).
Sensing Gingival Pockets and Calculus 1 Loss of attachment 4 to 5 mm (CEJ within the black
band).
An index tooth should be probed, using the probe as a “sensing” 2 Loss of attachment 6 to 8 mm (CEJ between the upper
instrument to determine pocket depth and to detect subgingival limit of the black band and the 8.5 mm ring).
calculus and bleeding response. The sensing force used should 3 Loss of attachment 9 to 11 mm (CEJ between 8.5 mm
be not more than 20 grams. A practical test for establishing and 11.5 mm ring).
this force is to place the probe point under the thumb nail and 4 Loss of attachment 12 mm or more (CEJ beyond the
press until blanching occurs. For sensing subgingival calculus, 11.5 mm ring).
the lightest possible force that will allow movement of the probe X Excluded sextant (less than two teeth present)
ball tip along the tooth surface should be used. 9 Not recorded (CEJ neither visible nor detectable).
Plaque Scoring System for Quigley and Hein
Scoring criteria Score
No plaque 0
Flecks of stain at the gingival margin 1
Definite line of plaque at the gingival margin 2
Gingival third of surface 3
Two thirds of surface 4
Greater than two thirds of surface 5
This was modified by Turesky S, Gilmore ND and

Fig. 16.11A: Community periodontal index codes
Glickman I to more explicitly describe mild to moderate plaque
Code 0. Healthy periodontal tissues. Entire black band of the probe deposits in 1970.
is visible.
Code 1. Entire black band is visible, but bleeding is present after
gentle probing.
Scoring by the Turesky Modification
Code 2. Entire black band is visible, but calculus is present. (Bleed- i. All teeth assessed except third molars (maximum number
ing may or may not be present.)
28)
Code 3. 4 to 5 mm pocket depth. (Black band on probe partially
hidden by gingival margin.)
ii. A staining solution is used to show plaque deposits (Quigley
Code 4. 6 mm or greater pocket depth. (Black band of the probe is and Turesky used basic fuchsin, Gordon used erythrosine)
completely hidden by the gingival margin.) iii. Both the facial and lingual surfaces examined (maximum
number 56)
iv. A score is assigned to each facial and lingual non-restored
surface.
MODIFIED PLAQUE SCORING SYSTEM OF

TURESKY ET AL (Fig. 16.12)
Criteria Score
No plaque 0
Separate flecks of plaque at the cervical margin 1
of the tooth
Fig. 16.11B: CPI: Lost of attachment codes A thin continuous band of plaque 2
(up to 1 mm) at the cervical margin of the tooth
Code 0. 0 to 3 mm loss of attachment. (Cementoenamel junction
[CEJ] is covered by the gingival margin and the CPI score A band of plaque wider than 1 mm coercing less 3
is 0 to 3.) If the CEJ is visible, or if CPI score is 4, LOA than one-third of the crown of the tooth
codes 1 to 4 are used. Plaque covering at least one-third but less 4
Code 1. 3.5 to 5.5 mm loss of attachment. (CEJ is within the black than two thirds of the crown of the tooth
band on the probe.) Plaque covering two-thirds or more of the 5
Code 2. 6 to 8 mm loss of attachment. (CEJ is between the top of crown of the tooth
the black band and the 8.5 mm mark on the probe.)
Code 3. 9 to 11 mm loss of attachment. (CEJ is between the 8.5 Total score = Sum (scores for all facial and lingual surfaces)
and the 11.5 mm marks on the probe.)
Index = (total score) / (number of surfaces examined)
Code 4. 12 mm or greater loss or attachment. (CEJ is beyond the
highest [11.5 mm] mark on the probe.)
Interpretation
A score of 0 or 1 is considered low.
TURESKY-GILMORE-GLICKMAN MODIFICATION A score of 2 or more is considered high.
OF THE QUIGLEY-HEIN PLAQUE INDEX
Quigley G and Hein J (1962) proposed a system for scoring THE NAVY PERIODONTAL DISEASE INDEX
dental plaque. They examined only the facial surfaces (gingival (NPDI)
third) of the anterior teeth using basic fuchsin as a disclosing The Navy Periodontal Disease Index Index (NPDI) was
agent, and scoring 0 to 5. developed as part of the Navy Periodontal Screening
Pocket Score
With a calibrated periodontal probe, take six measurements
of each designated tooth:
1. Mesial facial surface
2. Middle facial surface
3. Distal facial surface
4. Mesial lingual surface
5. Middle lingual surface
6. Distal lingual surface
Scoring Criteria
Fig. 16.12: Tooth areas graded by the Pocket measurements Points

Turesky et al modified Quigley Hein plaque index
Probing reveals sulcular depth not over 0
3 mm.
Examination, along with the Navy Plaque Index. It is Probing reveals pocket depth greater 5
composed of a gingival and a pocket scores. The NPDI score than 3 mm but not over 5 mm
can be used to determine the level of treatment required by Probing reveals pocket depth greater 8
the individual patient. than 5 mm
Teeth examined
16 - Maxillary Right First Molar Pocket score = Maximum score taken at the 6 probing sites
21 - Maxillary Left Central Incisor Calculating the NPDI
24 - Maxillary Left First Premolar Tooth score = Gingival score + pocket score
36 - Mandibular Left First Molar NPDI score = Maximum of all six tooth scores
41 - Mandibular Right Central Incisor NPDI total = Sum of all six tooth scores
44 - Mandibular Right First Premolar
Interpretation
Substitutions
• Minimum tooth score : 0
If 16, 24, 36 or 44 are missing, and then substitute the next
• Maximum tooth score : 10
most posterior tooth.
• Minimum NPDI score : 0
If 21 or 41 are missing, then substitute the nearest incisor
• Maximum NPDI score : 10
in the arch. If all incisors are missing from the arch, then
• Minimum NPDI total : 0
substitute a cuspid.
• Maximum NPDI total : 60
Gingival Score Mobility Index
Each tooth is examined for evidence of inflammatory change, The mobility index, developed by Grace and Smales, can be
which constitutes one or more of the following findings: useful to track the amount of mobility in teeth over a period
• Any change from normal gingival color of time. Grade 0 indicates no apparent mobility. Grade 1 is
• Loss of normal density and consistency assigned to a tooth in which mobility is perceptible, but less
• Slight enlargement or blunting of the papilla or gingiva than 1 mm buccolingually. Grade 2 mobility is between 1 to
• Tendency to bleed upon palpation or probing 2 mm, and Grade 3 mobility exceeds 2 mm buccolingually
or vertically.
Scoring Criteria
Evaluation of Tooth Mobility
Gingival Score Points
Tooth mobility may be present due to hyperfunction or loss
Gingival tissue is normal in color and 0 of attachment. Figure 16.13 illustrates how to assess for tooth
tightly adapted to the tooth. Tooth is firm mobility by using the index finger and the handle of a probe.
and no exudate is present. Class I: 0.5 to 1.0 mm facial lingual tooth movement.
Inflammatory changes are present but do 1 Class II: 1 to 2 mm facial lingual tooth movement.
not completely encircle the tooth.
Class III: Over 2 mm facial lingual tooth movement and
Inflammatory changes completely encircle 2
apical coronal depressibility (can be depressed in
the tooth.
socket).
Selection of Teeth
All 28 teeth are examined (based on 28 teeth).
Teeth not included are:
• Third molars
• Unerupted teeth (a tooth is considered as erupted when
the occlusal surface or incisal edge is totally exposed)
• Supernumerary and congenitally missing teeth
• Teeth removed for reasons other than dental caries such
as for orthodontic reasons and impactions
• Teeth restored for reasons other than dental caries, such as
trauma, use as a bridge abutment and cosmetic purposes
• Retained primary tooth when the successor permanent is
present. The permanent tooth is considered.
Procedure
Each tooth is examined using a mouth mirror, an explorer
and adequate light. The teeth should be observed by visual
Fig. 16.13: Classification of mobility means as much as possible and only questionable small lesions
should be checked by using an explorer.
INDICES FOR DENTAL CARIES Rules for Scoring DMFT

Diagnosis of dental caries is difficult in initial stages. Early • No tooth should be counted more than once.
approximal lesions are readily revealed by a radiograph but • Decayed (D), Missing (M) and Filled (F) teeth should be
may not be detected by an explorer. There always exists inter recorded separately
examiner variations. • Tooth lost or filled due to reasons other than caries are
not included
Decayed, Missing and Filled Teeth • Deciduous teeth are not considered in DMFT index
(DMFT) Index • A tooth with several filling is counted as one tooth.
This index was developed by Henry Klein, Carrole E Palmer Criteria for Recording
and Knutson JW in 1938. This index was based on the fact
that the dental hard tissues are not self healing and established i. Decayed (D) recording:
caries leaves a scar. The tooth either remains decayed and if • When dental caries and a restoration are present on
treated may be extracted or filled. It is an irreversible index the same tooth, the tooth is recorded as D
• When a crown is broken due to caries, it is recorded
DMFT describe the amount (the prevalence) of dental
as D.
caries in an individual. DMFT numerically expresses the caries
• Tooth with temporary restoration are recorded as
prevalence and is obtained by calculating the number of teeth
decayed.
(T) which are:
ii. Missing (M) recording:
• Decayed (D)
• When a tooth has been extracted because of dental
• Missing (M) caries
• Filled (F). • When a tooth is carious, cannot be restored and is
It is thus used to get an estimation illustrating how much indicated for extraction.
the dentition until the day of examination has become affected iii. Filled (F) recording:
by dental caries • Permanent restorations are recorded as F
Thus:
• How many teeth have caries lesions (incipient caries not Criteria for Identification of Dental Caries
included)?
• Lesion is clinically visible and obvious
• How many teeth have been extracted?
• Discoloration or loss of translucency typical of undermined
• How many teeth have fillings or crowns? or demineralized enamel
• Definite catch and the explorer tip can penetrate into soft Surfaces Examined
yielding material.
Anterior teeth: Four surfaces are examined; Facial, Lingual,
Mesial and Distal.
DMFT Scores
Posterior teeth: Five surfaces are examined; Facial, Lingual,
The sum of the three figures forms the DMFT value. For Mesial, Distal and Occulusal.
example: DMFT of 4 + 3 + 9 = 16 means that 4 teeth are
Maximum value for DMFS comes to 128 for 28 teeth.
decayed, 3 teeth are missing and 9 teeth have fillings. It also
means that 12 teeth are intact Posterior teeth: 16 with 5 surface, each: 16 × 5 = 80
Anterior teeth: 12 with 4 surface, each: 12 × 4 = 48
Individual DMFT Total = 128 surfaces.
Total each component separately ie total D, total M, total F.
Total D + M + F = DMF SCORE Calculating the DMFS
Individual
Group Average
Total number of decayed surfaces =
D
• Total the D, M and F for each individual
Total number of missing surfaces =M
• Divide the total DMF by the number of individuals
Total number of filled surfaces =
F
examined.
Total DMFS score for an individual =D +M+ F
Average DMF =
(surfaces)
Total DMF It is a more precise index but takes a longer time to
Total Number of Individuals Examined perform.
Treatment Needs WHO MODIFICATION OF DMF INDEX

Percentage needing restorations (%) = 1. Third molars are included.
2. Teeth with temporary restorations are considered as
Total Number of D Tooth decayed (D).
× 100
Total Number Examined 3. Initial caries is not regarded as decayed.
LIMITATIONS OF DMFT INDEX DENTAL CARIES INDEX FOR DECIDUOUS

TEETH (dmft and dmfs)
• DMF values are not related to the number of teeth at risk.
A DMF score does not directly gives an indication of the This index for primary teeth was given by Grubbel in 1944. It
intensity of attack in any one individual, e.g. a child of is used for the primary dentition, consisting of maximum 20
8-year-old may have DMF score of 3 with only nine teeth.
permanent teeth in mouth (one-third of teeth have been Designations are “deft” or “defs”:
already affected by caries), whereas an adult may have a Where d = decayed primary teeth
DMF score of 8 (more than the child score) out of 32 e = extracted tooth/indicated for
teeth (only one fourth of the teeth have been affected) extraction (due to caries)
• The DMF index is invalid when teeth have been removed f = filled teeth/surfaces
or lost due to other reasons, e.g. periodontal reasons
• The index gives equal weight to all the three components, Selection of Teeth or Surfaces
i.e. missing decayed and well-restored teeth dmft: 20 teeth are evaluated (all the primary teeth are
• Does not tell about the treatment needs of a person included).
• The DMF index can overestimate caries experience in cases
having teeth with preventive restorations
For Surfaces
• Cannot be used for root caries.
dmfs: 88 surfaces are evaluated.
Decayed, Missing, Filled Surface Index (DMFS) Posterior teeth: 8 teeth × 5 surfaces = 40 surfaces
DMFS index assesses the total no of tooth surfaces affected Anterior teeth: 12 teeth × 4 surfaces = 48 surfaces
rather than the tooth. It is a more detailed index in which
DMF is calculated per tooth surface. DMFS
Teeth not Counted
Rules, method and criteria are same as that of DMFT index • Missing teeth, including unerupted and congenitally missing
except that all tooth surfaces are examined in DMFS index. teeth.
• Teeth restored for reasons other than dental caries are not • 1: One indicates a tooth with caries. A tooth or root with
counted as f. a definite cavity, undermined enamel, or detectably
• Supernumerary teeth softened or leathery area of enamel or cementum can be
designated as 1. A tooth with a temporary filling, and
Procedure and Criteria teeth that are sealed but decayed, are also termed 1.
Score 1 is not assigned to any tooth in which caries is
Same as for DMFT only suspected. In cases where the crown of a tooth is
entirely decayed, leaving only the root, score 1 is assigned
Calculating the def to both crown and root. Where only the root is decayed,
only the root is termed as 1. In cases, where both the
Total def score = d + e + f
crown and root are involved with decay, whichever site is
Total defs score = d + e + f surfaces.
judged the site of origin is recorded as 1. These criteria
apply to all numbers.
MIXED DENTITION • 2: Filled teeth, with additional decay, are termed 2. No
In mixed dentition, DMFT or DMFS and a deft and defs distinction is made between primary caries which is not
index are done separately and never added together. Separate associated with a previous filling, and secondary caries,
index is done for each child for permanent teeth and primary adjacent to an existing restoration.
teeth starting with permanent teeth first. • 3: It indicates a filled tooth with no decay. If a tooth has
been crowned because of previous decay, that tooth is
judged 3. When a tooth has been crowned for another
WHO INDEX FOR DENTAL CARIES reason such as aesthetics or for use as a bridge abutment,
7 is used.
CODES GIVEN BY WHO • 4: It indicates a tooth that is missing as a result of caries.
Only crowns are given 4 status. Roots of teeth that have
Permanent Condition / status Primary tooth
been scored as 4 are recorded as 7 or 9. When primary
tooth code code
teeth are missing, the score should be used only if the
0 Sound A tooth is missing prematurely. Primary teeth missing because
1 Decayed B of normal exfoliation needs no recording.
2 Filled, with decay C • 5: A permanent tooth missing for any other reason than
3 Filled, no decay D decay is given as 5. Examples are teeth extracted for
4 Missing, as a result of caries E orthodontia or because of periodontal disease, teeth that
5 Missing, any other reason –
are congenitally missing, or teeth missing because of
6 Sealent, varnish F
trauma. The 5 is assigned to the crown, the root is given
7 Bridge abutment or special crown G
8 Unerupted tooth –
a 7 or 9. Knowledge of tooth eruption patterns is helpful
9 Excluded tooth – to determine whether teeth are missing or not yet erupted.
10 Trauma T Clues to help in the determination include appearance of
the alveolar ridge in the area in question, and caries status
To assess dental caries in a population, a DMFT index is of other teeth in the mouth.
used. During a systematic examination with a mirror and • 6: A 6 is assigned to teeth on which sealants have been
CPI Probe that includes the crown and exposed root of every placed. Teeth on which the occlusal fissure has been
primary and permanent tooth, each crown and root are enlarged and a composite material placed should also be
assigned a number based on the result of that exam. The termed 6.
numbers are recorded in boxes corresponding to each tooth • 7: A 7 is used to indicate that the tooth is part of a fixed
to provide a DMFT chart. It is recommended, that care should bridge. When a tooth has been crowned for a reason
be taken to record all tooth-colored fillings, which may be other than decay, this code is also used. Teeth that have
veneers or laminates covering the facial surface are also
difficult to detect.
termed 7 when there is no evidence of caries or restoration.
Numbers are assigned as follows: A 7 is also used to indicate a root replaced by an implant.
Teeth that have been replaced by bridge pontics are scored
• 0: A zero indicates a sound crown or root, showing no 4 or 5; their roots are scored 9.
evidence of either treated or untreated caries. A crown • 8: This code is used for a space with an unerupted
may have defects and still be recorded as 0. Defects that permanent tooth, where no primary tooth is present. The
can be disregarded include white or chalky spots; discolored category does not include missing teeth. Code 8 teeth are
or rough spots that are not soft; stained enamel pits or excluded from calculations of caries. When applied to a
fissures; dark, shiny, hard, pitted areas of moderate to root, an 8 indicates the root surface is not visible in the
severe fluorosis; or abraded areas. mouth.
• 9: Erupted teeth that cannot be examined because of Steps to Calculate Significant Caries Index
orthodontic bands, e.g. are coded a 9. When applied to a
root, a 9 indicates the tooth has been extracted. The • Sort the individuals according to their DMFT
crown of that tooth would be scored a 4 or 5. • Select the one third of the population with the highest
• T: Indicating trauma, a T is used when a crown is fractured, caries values
with some of its surface missing but with no evidence of • Calculate the Mean DMFT for this subgroup, suppose the
decay. DMFT of 15 students was calculated as
The “D” of DMFT refers to all teeth with codes 1 and 2. e.g. 0, 1, 5, 0, 0, 2, 1, 7, 0, 9, 0, 4, 1, 0, 5
The “M” applies to teeth scored 4 in subjects under age Arranged in increasing order the DMFT Scores are 0,
30, and teeth scored 4 or 5 in subjects over age 30. The 0, 0, 0, 0, 0, 1, 1, 1, 2, 4, 5, 5, 7, 9
“F” refers to teeth with code 3. Those teeth coded 6, 7, 8,
9, or T are not included in DMFT calculations. The highest 1/3rd scores are - 0, 0, 0, 0, 0, 0, 1, 1, 1,
To arrive at a DMFT score for an individual patient's 2, 4, 5, 5, 7, 9
mouth, three values must be determined: the number of teeth Thus, the SiC Index is - 4 + 5 + 5 + 7 + 9 / 5 = 30/
with carious lesions, the number of extracted teeth, and the 5 = 6.0
number of teeth with fillings or crowns. A patient who has
two areas of decay, six missing teeth and 11 filled or crowned DMFT - 0 + 0+ 0 + 0 + 0 + 0 + 1 + 1 + 1 + 2 +
teeth, e.g. has a DMFT score of 19. Teeth that include both 4 + 5 + 5 + 7 + 9 / 15 = 35 / 15 = 2.33.
decay and fillings or crowns, are only given one point, a D.
Thirteen teeth (based on a full dentition of 32) remain intact. Viewpoints
It is also possible to determine more detailed DMFS Researchers all over the world develop dental indices to suit
(decayed, missing, or filled surface) scores. As anterior teeth their particular needs, resulting in some duplication. There
have four surfaces and posterior teeth have five, a full dentition are at least six indices that measure the presence or absence
of 32 teeth includes 148 surfaces. A patient with seven decayed of plaque. Indices have become flexible, able to be adapted,
surfaces, 20 surfaces from which teeth are missing, and 42 modernized, or simplified to fit different needs. They will
surfaces either filled or included in a crown, the DMFS score continue to develop as those needs change again.
is 69. 79 surfaces are intact.
For primary dentition, scoring is referred to as “deft” or
Professional Implications
“defs” (decayed, extracted, or filled).
Dental professionals from the private practice clinician to the
SIGNIFICANT CARIES INDEX researcher use indices to benefit their patients. A dentist or
hygienist might use a PI to impress upon a patient the need
In 2000, the World Health Organization developed the for better oral hygiene. A World Health Organization researcher
significant caries index (SiC) to be used when studying DMFT might use the same index to assess the home care practices
scores on a global basis. A single population may include a of a population. Indices will continue to be important and
number of individuals with low DMFT scores, as well as those necessary tools for dental professionals.
with high scores. A mean DMFT value would not accurately
reflect the status of the population. The SiC Index isolates
FLUOROSIS INDEX
and highlights those individuals with the highest caries values
in a particular population.
Dean’s Fluorosis Index
To calculate a SiC Index, individuals are sorted according to
DMFT values. The third of the population with highest caries HT Dean's fluorosis index was developed in 1942 and is
scores is isolated, and a mean DMFT for this subgroup is currently the most universally accepted classification system.
calculated. The resulting value is the SiC Index. An individual's fluorosis score is based on the most severe
DMFT score show that there is a skewed distribution of form of fluorosis found on two or more teeth. Dean’s is used
caries prevalence. Clearly, the mean DMFT value does not to score the amount of dental fluorosis (discoloration) present
accurately reflect this skewed distribution leading to incorrect on teeth. Fluorosis generally appears as a horizontal striated
conclusion that the caries situation for the whole population pattern across a tooth. Molars and bicuspids are most
is controlled while in reality several individuals still have caries. frequently affected, followed by upper incisors. The mandibular
A new index called the 'Significant Caries Index' (SiC) was incisors are usually least affected. Fluorosis tends to be
proposed by Bratthall D in the year 2000, in order to bring bilaterally symmetrical. Defects may appear as fine white or
attention to those individuals with the highest caries scores in frosted lines or patches near the incisal edges or cusp tips. A
each population. The SiC Index is the Mean DMFT of the one score is given, based on the two teeth most affected. If the
third of the study group with the highest caries score. The index teeth are not equal in appearance, the less affected tooth is
is used as a complement to the mean DMFT value. the one scored.
Scores and Criteria for Dean’s Fluorosis Index Contd...
Score Criteria Score Criteria
Normal (0) The enamel represents the usually translucent 2 Smooth surfaces: More pronounced lines of opacity that follow
semivitriform type of structure. The surface is the perikymata. Occasionally confluence of adjacent lines.
smooth, glossy, and usually a pale creamy white Occlusal surfaces: Scattered areas of opacity <2 mm in
color. diameter and pronounced opacity of cuspal ridges.
Questionable (0.5) The enamel discloses slight aberrations from 3 Smooth surfaces: Merging and irregular cloudy areas of opacity.
the translucency of normal enamel, ranging Accentuated drawing of perikymata often visible between
from a few white flecks to occasional white spots. opacities.
This classification is utilized when a definite Occlusal surfaces: Confluent areas of marked opacity. Worn
diagnosis of the mildest form of fluorosis is not areas appear almost normal but usually circumscribed by a
warranted and a classification of "normal" is rim of opaque enamel.
not justified.
4 Smooth surfaces: The entire surface exhibits marked opacity
Very mild (1) Small, opaque, paper white area scattered
or appears chalky white. Parts of surface exposed to attrition
irregularly over the tooth but not involving as
appear less affected.
much as approximately 25% of the tooth
Occlusal surfaces: Entire surface exhibits marked opacity.
surface. Frequently included in this classification
Attrition is often pronounced shortly after eruption.
are teeth showing no more than 1 to 2 mm of
white opacity at the tip of the summit of the 5 Smooth surfaces and occlusal surfaces: Entire surface displays
cusps of the bicuspids or second molars. marked opacity wtih focal loss of outermost enamel (pits)
Mild (2) The white opaque areas in the enamel of the < 2 mm in diameter.
teeth are more extensive but do not involve as 6 Smooth surfaces: Pits are regularly arranged in horizontal
much as 50% of the tooth. bands < 2 mm in vertical extension.
Moderate (3) All enamel surfaces of the teeth are affected, Occlusal surfaces: Confluent areas < 3 mm in diameter
and surfaces subject to attrition show marked exhibit loss of enamel. Marked attrition.
wear. Brown stain is frequently a disfiguring 7 Smooth surfaces: Loss of outermost enamel in irregular areas
feature. involving < 1/2 of entire surface.
Severe (4) All enamel surfaces are affected and hypoplasia Occlusal surfaces: Changes in the morphology caused by
is so marked that the general form of the tooth merging pits and marked attrition.
may be altered. The major diagnostic sign of 8 Smooth and occlusal surfaces: Loss of outermost enamel
this classification is the discrete or confluent involving > 1/2 of surface.
pitting. Brown stains are widespread and teeth 9 Smooth and occlusal surfaces: Loss of main part of enamel
often present a corroded appearance. with change in anatomic appearance of surface. Cervical rim
Source: Dean 1942. American Association for the Advancement of of almost unafffected enamel is often noted.
Science.
THYLSTRUP-FEJERSKOV INDEX OF TOOTH SURFACE INDEX OF FLUOROSIS

FLUOROSIS (TF) (TSIF)
This index has a stronger biological basis than Dean's index This index was developed in 1984 by Horowitz HS, Driscoll
because the index scores were developed by relating them to WS, Meyers RJ and used by researcher in the National Institute
histologic features of affected enamel. As the procedure of Dental Research. It is probably more sensitive than Dean's
includes drying of tooth it is the most sensitive of the existing index specially for the mildest forms of fluorosis. Each tooth
indices. Also it requires assessment of only one surface per surface is seen and scored on a 0-7 scale, whereas Dean's
tooth because fluorosis affects all tooth surfaces equally. It index applies only to two worst teeth in the mouth.
can be used on selected teeth or entire dentition.
Selection of Teeth
Clinical Criteria and Scoring for the TF
All the teeth are assessed.
(Thylstrup-Fejerskov) Index
Score Criteria Surface

0 Normal translucency of enamel remains after prolonged air Anterior teeth: Separate score is given for every intact labial
drying. or lingual surface of anterior teeth.
1 Narrow white lines corresponding to the perikymata. Posterior teeth: Every buccal, occlusal and lingual surface
Contd... are given a separate score.
Scoring Criteria Contd...
Clinical Criteria and Scoring System for the Tooth Weighting Diagnosis Clinical criteria
Surface Index of Fluorosis 0.5 mm in diameter) directly on the cusp
tips, while the rest of the tooth is
Score Criteria completely normally mineralised. The
features of these opaque lines and spots
0 Enamel shows no evidence of fluorosis. are so fine that they are often confused
1 Enamel shows definite evidence of fluorosis, namely areas with perichymata. This fine feature shows
with parchment-white color that total less than 1/3rd of the more clearly with drying the tooth, a
visible enamel surface. This category includes fluorosis confined procedure which should always be done
only to incisal edges of anterior teeth and cusp tips of posterior while diagnosing.
teeth (“snow capping”). 0.25-1 Very Mild Clearer opaque, paper-white, trans-
2 Parchment-white fluorosis totals at least 1/3rd of the visible versely oriented striations or spots, found
surface but less than 2/3rd. spread especially on the upper incisors’
3 Parchment- white fluorosis totals at least 2/3rd of the visible labial surfaces and most concentrated
surface. in the incisal third. In the back teeth are
4 Enamel shows staining in conjunction with any of the seen opaque regions (< 1 mm in
preceding levels of fluorosis. Staining is defined as an area of diameter) directly on the cusp tips.
definite discoloration that may range from light to very dark Opaque, paper-white, narrow, trans-
brown. versely running lines reach down over
5 Discrete pitting of enamel exists, unaccompanied by evidence the cusp, while the rest of the tooth is
of staining of intact enamel. A pit is defined as a definite normal. The opaque regions cover
physical defect in the enamel surface with a rough floor that is almost a fourth of the surface of the tooth.
surrounded by a wall of intact enamel. The pitted area is When viewed from a distance, the tooth
usually stained or differs in color from the surrounding enamel. seems to have a slightly mother-of-pearl
6 Both discrete pitting and staining of the intact enamel exists. sheen. The lower grades of very mild
7 Confluent pitting of the enamel surface exists. Large areas of dental fluorosis are rated 0.5 and the
enamel may be missing and the anatomy of the tooth may be worst 1.0.
altered. Dark-brown stain is usually present. 1.5-2 Mild The mainly transversely running opaque
lines and spots are more clear and stretch
Dental Fluorosis Index by Moller (1965) further down over the tooth’s surface
towards the outer circumference. One
can detect that the opaque lines begin to
Weighting Diagnosis Clinical criteria
merge together into diffuse regions, so
0 Normal The enamel shows the usual that the tooth seen at a distance (40-50
translucency. The surface is smooth, cm) seems whiter - more opaque - than
shiny and usually of a pale, creamy white a normally mineralised tooth. Seen close
to grey white colour. In this group are to these opaque areas take up, however,
also opacities, which are not considered at most half of the tooth’s surface.
to be of fluorotic character. Changes in the front teeth’s lingual
0 Optimal The enamel is on clinical inspection surfaces are considerably less obvious
completely homogeneously mineralised than on the labial. As far as the back
without hypomineralisation of any sort. teeth are concerned, the changes in labial
The enamel is smooth and mirror-like, and lingual surfaces are of more or less
and has a shiny. “Varnished” look. The the same degree. On the cusps of
colour is creamy white to yellowish canines, premolars and molars there are
white. cases where the cusp tips are worn, so
0.25 Questionable In areas with relatively low fluoride that the wear facets peripherally are
content in drinking water, there are cases bordered by a narrow, opaque ring (an
which even the most experienced expression of the fluorotic surface layer)
researchers cannot classify as either surrounded by the clearer underlying
normal or very mild. These cases show enamel. In pronounced cases the
mainly labially in the upper front teeth development of pigment can be seen,
as very narrow, opaque, paper-white, especially in the upper incisors. Lower
horizontal lines in the tooth’s incisal third grades of mild dental fluorosis are scored
especially. In back teeth are now and 1.5 and the worst 2.0.
then seen small, opaque spots (about
Contd... Contd...
Contd... Where:
Diastema = the space between 2 adjacent teeth on
Weighting Diagnosis Clinical criteria
the same dental arch
2.5-3 Moderate The opaque regions take up practically
all the tooth’s surface. Tooth shape is DAI score = SUM((finding) * (weight))
normal, but a weak “pit” development
can be found, especially on premolar Interpretation
buccal and palatal surfaces, as well as Minimum score: 13
upper incisor labial surfaces. Pigment
Further the score falls from the norm of most acceptable
where present can vary in color from
yellow to brown. The lower grades of
dental appearance, the more the occlusal condition may be
moderate dental fluorosis are rated 2.5 judged socially or physically handicapping if left untreated.
and the worst 3.0.
3.5-4 Severe The shape of the tooth can be changed. THE INDEX OF ORTHODONTIC TREATMENT
The development of pits is pronounced. NEED (IOTN)
Merging of pits is often seen. Sometimes
the outer layer of enamel is parlty or Overview
completely missing, and the tooth has a
corroded look. Pigmentation varies in The Index of Orthodontic Treatment Need (IOTN) was
color from brown, to dark brown, to developed as a means to objectively measure a person's need
black. Lower degrees of severe dental for orthodontic treatment.
fluorosis score 3.5 and the worst 4.0.
Components
INDICES FOR MALOCCLUSION 1. Dental health: 5 grades from none to very great
2. Aesthetics: attractiveness of the patient's labial aspect
The Dental Aesthetic Index (DAI) ranked from 1 (close to normal) to 10.
The Dental Aesthetic Index (DAI) is an orthodontic index
which incorporates socially defined aesthetic standards. In Dental Health Component Grade 1: None
addition, it provides a severity measure for psychologic and • Extremely minor malocclusions including displacements
functional impairment. It consists of 10 components < 1 mm.
multiplied by weights based on regression coefficients, plus a
constant. Dental Health Component Grade 2: Little
Component Finding Weight • Increased overjet 3.6 to 6.0 mm, with competent lips.
Constant 13 • Reverse overjet 0.1 to 1.0 mm
Missing teeth Number of missing incisor, 6 • Anterior to posterior crossbite with up to 1 mm discrepancy
canine and premolar teeth between retruded contact position and intercuspal position.
Crowding in incisal Number of segments 1 • Displacement of teeth 1.1 to 2.0 mm
segments crowded • Anterior or posterior openbite 1.1 to 2.0 mm
Spacing in incisal Number of segments spaced 1 • Increased overbite ≥ 3.5 mm, without gingival contact.
segments
• Pre-normal or post-normal occlusions with no other
Diastema In millimeters 3
anomalies. Includes up to half a unit discrepancy.
Anterior irregularity in Largest irregularity in mm 1
maxilla
Anterior irregularity in Largest irregularity in mm 1 Dental Health Component Grade 3: Moderate
mandible
• Increased overjet 3.6 to 6.0 mm, with incompetent lips.
Anterior maxillary overjet In millimeters 2
Anterior mandibular In millimeters 4 • Reverse overjet 1.1 to 3.5 mm
overjet • Anterior or posterior crossbites with 1.1 to 2.0 mm
Vertical anterior openbite In millimeters 4 discrepancy.
Anteroposterior molar Largest deviation from 3 • Displacement of teeth 2.1 to 4.0 mm
relation normal 0.5 cusp=1 • Lateral or anterior crossbite 2.1 to 4.0 mm
>=1 cusp=2 • Increased and complete overbite without gingival trauma.
Dental Health Component Grade 4: Great Dental Health Component Grade 5: Very Great
• Increased overjet 6.1 to 9.0 mm • Increased overjet > 9 mm
• Reversed overjet > 3.5 mm with no masticatory or speech • Extensive hypodontia with restorative implications (more
difficulties than 1 tooth missing in any quadrant) requiring pre-
• Anterior or posterior crossbites with > 2 mm discrepancy restorative orthodontics
between retruded contact position and intercuspal position • Impeded eruptions of teeth (with the exception of the
• Severe displacement of teeth, > 4 mm third molars) due to crowding, displacement, the presence
• Extreme lateral or anterior openbites, > 4 mm of supernumerary teeth, retained deciduous teeth, and
• Increased and complete overbite with gingival or palatal any pathological cause
trauma • Reverse overjet > 3.5 mm with reported masticatory and
• Less extensive hypodontia requiring pre-restorative speech difficulties
orthodontic space closure to obivate the need for a • Defects of cleft lip and palate
prosthesis • Submerged deciduous teeth.
• Posterior lingual crossbite with no functional occlusal
contact in one or both buccal segments Aesthetic Component
• Reverse overjet 1.1 to 3.5 mm with recorded masticatory
and speech difficulties • A patient’s score is based on matching his or her dental
• Partially erupted teet, tipped and impacted against appearance with one of a series of 10 photographs
adjacent teeth showing the labial aspect of different Class I or Class II
• Supplemental teeth malocclusions ranked according to their attractiveness.

Dental Indices: CM Marya

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16 Dental Indices

Table 16.1: Purpose and uses of an index

INDICES COMMONLY USED IN DENTISTRY Contd...

PI Score for Tooth PLAQUE CONTROL RECORD

NAVY PLAQUE INDEX

Substitutions The OHI, developed by John C Greene and Jack R Vermillion

For Each Tooth

Lingual points = (M points on lingual aspect) + (G points on

Calculating the NPI

Total calculus score

Oral hygiene index = Debris index + Calculus index

The Simplified Oral Hygiene Index (OHI-S)

Scoring Criteria (Debris) (Fig. 16.5A)

0 No debris or stain present.

Scoring Criteria (Calculus) (Fig. 16.5B)

GINGIVAL INDEX (GI)

Reasons for its Widespread Use Selection of Teeth and Surfaces

SCORING CRITERIA FOR RUSSELS (PI) INDEX

Criteria for field studies Additional X-ray criteria Score

Scoring PDI Scoring

Scoring Criteria for Plaque Selection of Teeth

Result Scoring Criteria

Fig. 16.8: Community periodontal index of

Note: If the deepest pocket is found at the

Fig. 16.9: Community periodontal index of

Explanation of the Clinical Criteria and Examination Procedure

Scoring criteria Score

This was modified by Turesky S, Gilmore ND and

MODIFIED PLAQUE SCORING SYSTEM OF

Fig. 16.12: Tooth areas graded by the Pocket measurements Points

INDICES FOR DENTAL CARIES Rules for Scoring DMFT

Treatment Needs WHO MODIFICATION OF DMF INDEX

LIMITATIONS OF DMFT INDEX DENTAL CARIES INDEX FOR DECIDUOUS

Scores and Criteria for Dean’s Fluorosis Index Contd...

Score Criteria Score Criteria

THYLSTRUP-FEJERSKOV INDEX OF TOOTH SURFACE INDEX OF FLUOROSIS

Score Criteria Surface

Scoring Criteria Contd...

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