EPIDEMIOLOGY The term epidemiology consists of the preposition epi which means among or against and the noun

demos which means people. As denoted by its etymology, epidemiology is defined as the study of the distribution of disease or a physiologic condition in human populations and of the factors that influence this distribution (Lilienfeld, 1978). A more inclusive description by Froa (1941) emphasizes that epidemiology is essentially an inductive science, concerned not merely with describing the distribution of the disease, but equally or more with fitting it into a consistent philosophy. Epidemiology is the study of the distribution and determinants of health related states or events in the populations, and the application of this study to control health related problems (Last JM and Abrams, 1995). The purpose of epidemiology includes 1. Description of the distribution of the disease in different populations (descriptive epidemiology).
2.

Elucidate

the

etiology

of

specific

disease

by

combining epidemiologic data with information from

1

other disciplines such as genetics, biochemistry and microbiology (Etiologic epidemiology). 3. Evaluate the consistency of epidemiologic data with hypotheses
4.

developed basis for

clinically

or

experimentally and health evaluating practices

(Analytical epidemiology). Provide the developing and public preventive procedures

(Experimental / interventional epidemiology). The final purpose of epidemiology is to promote, protect and restore health (Last JM and Abramson 1995). Epidemiologic measures of disease prevalence Prevalence is the proportion of persons in a population who have the disease of interest at a given period or point of time. It is calculated by dividing the number of people in the population who have the disease by the total number of persons in the population. Number of persons with the disease Prevalence = --------------------------------------------Number of persons in the population It can be reported as a proportion or percentage to denote the burden of the disease.

Prevalence incidence and

is cure.

the

dynamic

situation the more

between sensitive

the the

Ironically

diagnostic test, greater the prevalence. Incidence Risk or cumulative incidence It is the average percentage of unaffected persons in a population who will develop disease in a given period or point of time. No. of new cases Incidence = -------------------------------Number of persons at risk Specifying the period of observation in necessary in defining incidence. Epidemiologic study designs To investigate the prevalence, incidence of diseases, risk factors associated with disease and the effectiveness of interventions, epidemiologic studies are conducted. Most are observational. Observational studies include cross-sectional, cohort and care-control studies. Community intervention and randomized clinical trials are two types of experimental studies.

Cross sectional studies The presence/absence of disease and characteristics of members of the population are measured at a point in time. Uses Prevalence data Comparing characteristics Generating a hypothesis regarding the etiology. Cross sectional studies are descriptive and are referred to as disease frequency surveys or prevalence studies. There are repeated at regular intervals and can provide information on the trends of the disease. Limitations Incidence cannot be determined. Establishing a temporal relationship between a characteristic and disease is not possible. Advantages Less expensive. Quicker to conduct. Epidemiological research in periodontics must (1) fulfill the task of providing data on the prevalence of periodontal diseases in different populations, i.e., the frequency of their
4

occurrence, as well as on the severity of such conditions, i.e. the level of occurring pathologic changes; (2) elucidate aspects related to the etiology and the determinants of development of these diseases (causative and risk factors); and (3) provide documentation concerning the effectiveness of preventive and therapeutic measures aimed against these diseases on a population basis. There is an abundance of both empirical evidence and substantial theoretical justification for accepting the widespread belief that many diseases have more than one cause, i.e., that they are of multifactorial etiology. The casual inference, i.e. the procedure of drawing conclusions related to the cause(s) of a disease, is a particularly complicated issue in epidemiological research. In the 1970s, Hill (1971) formalized the criteria that have to be fulfilled in order to accept a causal relation. These included:
Strength

of

the

association:

The

stronger

the

association is between the potential (putative) risk factor and disease presence, the more likely it is that the anticipated causal relation is valid.
Dose-response effect: An observation that the frequency

of the disease increases with the dose or level of exposure to a certain factor supports a causal interpretation.

 Temporal consistency: It is important to establish that

the exposure to the anticipated causative factor occurred prior to the onset of the disease. This may be difficult in case of diseases with long latent periods or factors that change over time.
Consistency

of a

the given

findings:

If

several generate

studies similar if the

investigating
Biological

relationship It is

results, the causal interpretation is strengthened. plausibility: advantageous anticipated relationship makes sense in the context of current biological knowledge. However, it must be realized that the less that is known about the etiology of a given disease, the more difficult it becomes to satisfy this particular criterion.
Specificity

of the association: If the factor under

investigation is found to be associated with only one disease, or if the disease is found to be associated with only one factor among a multitude of factors tested, the casual relation is strengthened. However, this criterion can by no means be used to reject a causal relation, since many factors have multiple effects and most diseases have multiple causes. The principles of the risk assessment process were discussed by Beck (1994) and should consist of the following four steps:

 The identification of one or several individual factors that appear to be associated with the disease. In the case of multiple factors, a multivariate risk assessment model must be developed that discloses which combination of factors does most effectively discriminate between health and disease. The assessment step, in which new populations are screened for this particular combination of factors, with a subsequent comparison of the level of the disease assessed with the one predicted by the model. The targeting step, in which exposure to the identified factors is modified by prevention or intervention and the effectiveness of this particular regimen is evaluated. Thus, according to this flow chart, potential or putative risk factors (often also referred to as risk indicators) are first identified and thereafter tested until their significance as true risk factors is proven. Finally, distinction must be made between prognostic factors (or disease predictors), i.e. characteristics related to the progression of pre-existing disease and true risk factors; i.e. exposures related to the onset of the disease. In a study of the association between exposure to a risk factor and the occurrence of disease, confounding can occur

when as additional factor, associated with the disease, exists and is unevenly distributed among the groups under investigation. There are various ways to assess simultaneously the effect of a number of putative risk factors identified in step 1 and generate the multivariate model required for step 2. For example, the association between exposure and disease may for reasons of simplicity have the form of the following linear equation: Y = a + b 1 x 1 +b 2 x 2 + b 3 x 3 + . + b n x n Where y represents occurrence or severity of the disease, a is the intercept (a constant value), x 1 , x 2 , x n describe the different exposures (putative risk factors), and b 1 , b2, . b n are estimates defining the relative importance of each individual exposures as determinant of disease, after taking all other factors into account. Such an approach may identify factors with statistically and biologically significant effect and may eliminate the effect of confounders. Epidemiologic indices are attempts to quantitate clinical conditions on a graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods. Indices are actually underestimates of the true clinical condition.

Requirements of an index 1. Validity It must measure what it is intended to measure, so it should correspond with clinical stages of the disease under study at each point. A valid measure of disease should be both sensitive and specific. Sensitivity refers to ability to detect a high proportion of true cases, that is, to yield few false negative results. Specificity is the reverse: a specific test is one that correctly identifies the true negatives and hence yields few false positive verdicts. 2. Practicality Use of the technique should be practical in the particular circumstances of the survey, and it should be sufficiently simple and inexpensive to use to permit study of large numbers of persons. 3. Reliability The index should measure consistently at different times and under varied conditions. The term reliability is almost synonymous with reproducibility, which means the ability of the examiner or different examiners to interpret and use the index in the same way.

4. Quantifiability The index should be amenable to statistical analysis, so that the status of a group can be expressed by a number that corresponds to a relative position on a scale from zero to the upper limit. 5. Sensitivity The index should be able to detect reasonably small shifts in condition, in either direction. It should be equally sensitive throughout and indicate in a meaningful way the clinical stages of the disease process. 6. Clarity, simplicity and objectivity The examiner should be able to remember the criteria easily. It should be easy to apply and the criteria should be clear and unambiguous with mutually exclusive categories to promote accuracy and reproducibility. 7. Acceptability The use of the index should not be painful or embarrassing to the subject. Two types of dental indices the first type of index measures the number of proportion of people in a population with or without a specific condition at a specific point in time or interval of time. The second type of dental index measures
10

the number of people affected and the severity of the specific condition at a specific time or interval of time. More explicitly, the second type of index not only helps to identify the person in the population affected with a specific condition, but also assesses the condition under study on a graduated scale. Most of the indices described in this chapter are of the second type. The indices that are discussed in this chapter can, for the purposes of convenience and reason, be divided according to the following measured variables: The degree of inflammation of the gingival tissues The degree of periodontal destruction The amount of plaque accumulated The amount of calculus present In addition, indices to assess treatment needs. I. Indices used to assess gingival inflammation (Schour and Massler, 1948) 1. Papillary-Marginal-Attachment Index Originally the Papillary-Marginal-Attachment (PMA) Index was used to count the number of gingival units affected with gingivitis. This approach predicted on the belief that the number of units affected correlated with the degree or severity

11

of gingival inflammation. The facial surface of the gingiva around a tooth was divided into three gingival scoring units: the mesial dental papilla (P), the gingival margin (M), and the attached (A). The presence or absence of inflammation on each gingival unit was recorded as 1 or 0, respectively. The P, M and A numerical values for all teeth were totaled separately and then added together to express the PMA Index score per person. Although all of the facial tissues surrounding all of the teeth could be assessed in this manner, usually only the maxillary and mandibular incisors, the canines and the premolars were examined. 2. Massler (1967) eventually added a severity component for assessing gingivitis; the papillary units (P) were scored on a scale of 0 to 5, and the marginal (M) and attached (A) gingivae were scored on a scale of 0 to 3. The value of this index lies in its broad application to epidemiologic surveys and clinical trials and in its capacity for use in individual patients. 3. Periodontal Index - Russel (1956) The Periodontal Index (PI) was intended to estimate the extent of deeper periodontal disease than the PMA Index could measure by determining the presence or absence of gingival inflammation and its severity, pocket formation and masticatory function. Because the PI measures both reversible
12

and irreversible aspects of periodontal disease, it is an epidemiologic index with a true biologic gradient. Only a mouth mirror and no calibrated probes or radiographs are used results tend to underestimate the true level of periodontal disease, especially early bone loss, in a population.
Score Criteria and Scoring for field studies 0 Additional radiographic criteria followed in the is

clinical test Negative there is neither overt Radiographic appearance inflammation in the investing essentially normal. tissues not loss of function owing

to destruction of supporting tissues Mild gingivitis there is an overt area of inflammation in the free gingivae, but this area does not circumscribe the tooth. Gingivitis inflammation completely circumscribes the tooth, but there is no apparent

4 6

break in the epithelial attachment. (Used when radiographs are There

is

early,

notch-like

available) resorption of the alveolar crest. Gingivitis with pocket formation There is horizontal bone loss the epithelial attachment has involving the entire alveolar been broken, and there is a pocket crest up to half of the length of (not merely a deepened gingival the tooth root. crevice as a result of swelling in free ginivae). There with is no interference normal

masticatory function; the tooth is

13

firm and has not drifted. Advanced destruction with loss There is advanced bone loss of masticatory function the involving more than one half of tooth may be loose, may have the length of the tooth root or a drifted, may sound with a dull on definite infrabony pocket with of the periodontal percussion in its socket. metallic widening

instrument, or may be depressible ligament. There may be root resorption or rarefraction at the apex. RULE: When in doubt, assign the lesser scores. Sum of individual scores Periodontal index score per person = ------------------------------------Number of teeth present Clinical Condition Clinically normal supportive tissues Simple gingivitis Beginning disease Established disease Terminal disease 3.8 to 8.0 Irreversible destructive periodontal 1.6 to 5.0 destructive periodontal Group Pi Scores 0 to 0.2 0.3 to 0.9 0.7 to 1.9 Reversible Stage of Disease

4. Gingivitis component of the periodontal disease index (Ramfjord, 1959) The Periodontal Disease Index (PDI) is similar to the PI in that both are used to measure the presence and severity of periodontal disease. The PDI does so by combining the
14

assessments of gingivitis and gingival sulcus depth on six selected teeth (teeth #3, 9, 12, 19, 25 and 28). This group of teeth, frequently referred to as the Ramfjord teeth, have been tested as reliable indicators for the various regions of the mouth. Calculus and plaque are also examined to assist in formulating a comprehensive assessment of periodontal status. A numerical score for the gingival status component of the PDI (i.e. the Gingivitis Index score per person) is obtained by adding the values for all of the gingival units and dividing by the number of teeth present. The PDI has been used in epidemiologic surveys, longitudinal studies of periodontal disease and clinical trials of therapeutic or preventive procedures.

Criteria for several components of the periodontal disease index Gingival status (Gingivitis index) 0 1 2 3 = = = = Absence of signs of inflammation Mild to moderate inflammatory gingival changes, Mild to moderately severe gingivitis extending all around the tooth Severe gingivitis characterized by marked redness, swelling, tendency to bleed, and ulceration

not extending around the tooth

15

Crevicular measurements
A.

If the original margin is on the enamel, measure from the gum margin to the cemento-enamel junction and record the measurement. If the epithelial attachment is on the crown and the cemento-enamel junction cannot be felt by the probe, record the depth of the gingival sulcus of the crown. Then record the distance from the gingival margin to the bottom of the pocket if the probe can be moved apically to the cemento-enamel junction without resistance or pain. The distance from the cemento-enamel junction to the bottom of the pocket can then be found by subtracting the first from the second measurement.

B. If the gingival margin is on the cementum, record the distance from the cemento-enamel junction to the gingival margin as a minus value. Then record the distance from the cemento-enamel junction to the bottom of the gingival sulcus as a plus value. Both loss of attachment and actual sulcus depth can easily be assessed from the scores. Periodontal Disease Index (PDI) Criteria for Surveys If the gingival sulcus in none of the measured areas extended apiclaly to the cemento-enamel junction, the recorded score for gingivitis is the PDI score for that tooth. If the gingival sulcus in any of the two measured areas extended apiclaly to the cemento-enamel junction but not more than 3mm (including 3mm in any area), the tooth is assigned a PDI score of 4. The score for gingivitis is then disregarded in the
16

PDI score for that tooth. If the gingival sulcus in either of the two recorded areas of the tooth extends apically to from 3 to 6mm (including 6mm) in relation to the cemento-enamel junction, the tooth is assigned a PDI score of 5 9again, the gingivitis score is disregarded). Whenever the gingival sulcus extends more than 6mm apically to the cemento-enamel junction in any of the measured areas of the tooth, the score of 6 is assigned as the PDI score for that tooth (again disregarding the gingivitis score). Shick-Ash Modification of Plaque Criteria 0 1 = = Absence of dental plaque Dental plaque in the interproximal area or at the gingival margin covering less than one third of the gingival half of the facial or lingual surface of the tooth. 2 = Dental plaque covering more than one third but less two thirds of the gingival half of the facial or lingual surface of the tooth. 3 = Dental plaque covering two thirds or more of the gingival half of the facial or gingival surface of the tooth. Calculus criteria 0 1 2 = = = Absence of calculus Supragingival calculus extending only slightly

below the free gingival margin (nor more than 1mm) Moderate amount of supragingival and subgingival
17

calculus or subgingival calculus alone 3 = An abundance of supragingival and subgingival calculus Gingival Index. (Loe and Silness, 1963) The Gingival Index (GI) was developed solely for the purpose of assessing the severity of gingivitis and its location in four possible areas. The tissues surrounding each tooth are divided into four gingival scoring units: the distofacial papilla, the facial margin, the mesiofacial papilla, and the entire lingual gingival margin. To minimize examiner variability in scoring, the lingual surface is not subdivided, because it will most likely be viewed indirectly with a mouth mirror. A blunt instrument, such as a periodontal pocket probe, is used to assess the bleeding potential of the tissues. Totaling the scores around each tooth yields the GI score for the area. If the scores around each tooth are totaled and divided by four, the GI score for the tooth is obtained. Totaling all of the scores per tooth and dividing by the number of teeth examined provides the GI score per person. The GI may also be used to evaluate a segment of the mouth or a group of teeth. The numerical scores of the GI are associated with varying degrees of clinical gingivitis as follows:

18

Gingival Scores 0.1 1.0 1.1 2.0 2.1 3.0

Degree of Gingivitis Mild Moderate Severe

The index can be used to determine the prevalence and severity of gingivitis in both epidemiologic surveys and in an individual. This latter attribute has contributed to making the GI the index of choice in controlled clinical trials of preventive or therapeutic agents.

Gingival Index (GI) 0 1 2 3 = = = = Normal gingiva Mild inflammation, slight change in color, slight edema, no bleeding on palpation Moderate inflammation, redness, edema and glazing, bleeding on probing Severe inflammation, marked redness and edema, ulcerations, tendency to spontaneous bleeding. Modified Gingival Index (MGI) Lobene and associates created the modified GI (MGI) by eliminating the bleeding criterion, making the MGI a noninvasive index. By redefining the criteria for mild and moderate inflammation, the MGI increases sensitivity in the lower portion of the scoring scale.
19

0 1

= =

Absence of inflammation Mild inflammation, slight change in color, little change in texture of any portion of the marginal or papillary gingival unit.

2 3

= =

Mild inflammation, criteria as above but involving the entire marginal or papillary gingival unit. Moderate inflammation, glazing, redness, edema and/or hypertrophy of the marginal of papillary gingival unit.

Severe inflammation marked redness, edema, and/or hypertrophy of the marginal or papillary gingival unit, spontaneous bleeding, congestion or ulceration.

Indices of gingival bleeding The Sulcus Bleeding Index (SBI) of Mhlemann and Mazor uses bleeding on gentle probing as the first criterion for indicating gingival inflammation. In 1971, Mhlemann and Son added an additional category to the original criteria, resulting in a 0 to 5 scale for assessing inflammation or sulcular bleeding. Mhlemann assessed sulcus bleeding on probing at the inderdental papilla. This Papillary Bleeding Index (PBI) used a scale of 0 to 4. A timing component was added to the PBI by Barnett and colleagues in an effort to make the PBI more sensitive than the GI in assessing gingival changes.

20

The Bleeding Points Index was developed to assess a patients oral hygiene performance. It determines the presence or absence of gingival bleeding interproximally and on the facial and lingual surfaces of each tooth. A periodontal probe is drawn horizontally through the gingival crevice of a quadrant, and the gingiva is examined for bleeding after 30 seconds. The Gingival Bleeding Index also assesses the presence or absence of gingival bleeding, but only at the interproximal spaces and using unwaxed dental floss. The floss is thought to assess a larger area more quickly than a periodontal probe, and it can be used by both the professional and the patient when the latter is instructed to perform self evaluation in a control program. The Interdental Bleeding Index, also referred to as the Eastman Interdental Bleeding Index, utilizes a triangle-shaped toothpick made of soft, pliable wood to stimulate the interproximal gingival tissue. The presence or absence of bleeding with a specific stimulus permits the dentist and, perhaps more important, the patient to monitor interproximal gingival health. The interproximal cleaner is inserted horizontally between the teeth from the facial surface, depressing the interproximal papilla by up to 2mm. The wooden cleaner is inserted and removed four times, and the presence or absence of bleeding within 15 seconds is noted.
21

The Interdental Bleeding Index score is determined by dividing the number of bleeding sites by the number of sites evaluated. The Gingival Bleeding Index (GBI) of Ainamo and Bay was developed as an easy and suitable way for the practitioner to assess a patients progress in plaque control. The presence or absence of gingival bleeding is determined by gentle probing of the gingival crevice with a periodontal probe. The appearance of bleeding within 10 seconds indicates a positive score, which is expressed as a percentage of the total number of gingival margins examined. Criteria used by the NIDR to assess gingival inflammation and calculus Gingival inflammation (Bleeding index) 0 1 = = No bleeding present Bleeding results after probe is placed in gingival sulcus up to 2mm and drawn along the inner surface of the gingival sulcus. Indices used to measure periodontal destruction 1. Gingival sulcus measurement component of the PDI The technique developed by Ramfjord for determining gingival sulcus depth with a calibrated periodontal probe involves measuring the distance from the cemento-enamel
22

junction to the free gingival margin and the distance from the free gingival margin to the bottom of the gingival sulcus or pocket. The difference between the two measurements yields the clinical attachment level. This is considered the most important clinical measurement (i.e. the gold standard in determining the status of the periodontium. Ramfjords technique is considered useful in epidemiologic surveys, longitudinal studies of periodontal disease, and clinical trials of preventive and therapeutic agents. The PDI score for the individual is obtained by totaling the scores of the teeth and dividing by the number of teeth examined (a maximum of six). 2. Extent and severity index The Extent and Severity Index (ESI) was developed because of a lack of satisfaction with previous indices of periodontal disease and because of the emergence of a newer conceptual model of periodontal disease pathogenesis developed by Socransky and associates. The ESI uses a periodontal probe (the NIDR periodontal probe) to determine attachment levels. The ESI score is a bivariate statistic. It expresses the percentage of sites that exhibit disease (E for Extent) and measures mean attachment loss in millimeters (S for Severity). Hence the ESI = (E, S). Disease is defined arbitrarily as any site with more than 1mm of attachment loss. Unlike the PI, which examines the tissues surrounding all teeth present, the
23

ESI is based on probe measurements (at the mesio-buccal interproximal and mid-buccal locations on all teeth excluding molars and at the mesio-buccal interproximal and mid-buccal of the mesial root of molars) at 14 sites in half of the maxillary Currently, arch the is NIDR made randomly. Attachment includes level the measurements are made using the criteria of Ramfjord. diagnostic criterion methodology of the ESI but has modified the definition of disease to be more than 3mm of attachment loss.
Dunning and Leach (the Gingival-Bone Count Index),

which records the gingival condition on a scale of 0 to 3 and the level of the crest of the alveolar bone, and a similar index by Sheiham and Striffler.
The Periodontitis Severity Index (PSI) assesses the

presence or absence of periodontitis as the product of clinical inflammation (CIS) and interproximal bone loss (BLS) determined radiographically using a modified Schei ruler. Because of the need for periapical radiographs, the PSI is limited to longitudinal studies and lacks validation. Indices used to measure plaque accumulation Plaque component of the PDI The first index that attempted to use a numerical scale to assess the extent of plaque covering the surface area of a tooth was developed by Ramfjord. The plaque component of the PDI
24

is used on the six teeth selected by Ramfjord (teeth #3, 9, 12, 19, 25 and 28) after staining with Bismarck brown solution. Shick and Ash modified the original criteria of Ramfjord by excluding consideration of the interproximal areas of the teeth and restricting the scoring of plaque to the gingival half of the facial and lingual surfaces of the index teeth. The plaque score per person is obtained by totaling all of the individual tooth scores and dividing by the number of teeth examined. Simplified oral hygiene index (Greene and Vermillion) Greene and Vermillion developed the Oral Hygiene Index (OHI) in 1960 and later simplified it to include only six tooth surfaces that were representative of all anterior and posterior segments of the mouth. This modification was called the Simplified OHI (OHI-S). The OHI-S measures the surface area of the tooth that is covered by debris and calculus. The imprecise term debris was used because it was not practical to distinguish among plaque, debris, and materia alba. In addition, the practicality of determining the weight and thickness of the soft deposits prompted the assumption that the dirtier the mouth is, the greater is the tooth surface area covered by debris. This assumption also implied a time factor, because the longer oral hygiene practices are neglected, the

25

greater the likelihood that the surface area of the tooth will be covered by debris. The OHI-S consists of two components: a Simplified Debris Index (DI-S) and a Simplified Calculus Index (CI-S). Each component is assessed on a scale of 0 to 3. Only a mouth mirror and a shepherds crook or sickle type dental explorer, and no disclosing agent, are used for the examination. The six tooth surfaces examined in the OHI-S are the facial surfaces of teeth #3, 8, 14 and 24 and the lingual surfaces of teeth #19 and 30. Each tooth surface is divided horizontally into gingival, middle and incisal thirds. For the DI-S a dental explorer is placed on the incisal third of the tooth and moved toward the gingival third. The DI-S score per person is obtained by totaling the debris score per tooth surface and dividing by the number of the surfaces examined. The CS-I assessment is performed by gently placing a dental explorer into the distal gingival crevice and drawing it subgingivally from the distal contact area to the mesial contact area (one half of a tooths circumference is considered a scoring unit). The CI-S score per person is obtained by totaling the calculus scores per tooth surface and dividing by the number of surfaces examined. The OHI-S score per person is the total of the DI-S and CI-S scores per person.

26

Criteria for scoring the oral debris (DI-S) and calculus (CI-S) components of the simplified oral hygiene index (OHI-S) Oral Debris Index (DI-S) 0 1 = = No debris or stain present Soft debris covering not more than one third of the tooth surface or the presence of extrinsic stains without other debris, regardless of surface area covered. 2 3 = = Soft debris covering more than one third but not more than two thirds of the exposed tooth surface Soft debris covering more than two thirds of the exposed tooth surface Calculus Index (CI-S) 0 1 2 tooth = = = No calculus present Supragingival calculus covering not more than one third of the exposed tooth surface Supragingival calculus covering more than one surface or the presence of individual flecks of third of the tooth not more than two thirds of the exposed subgingival calculus around the cervical portion of the tooth, or both. 3 = Supragingival calculus covering more than two thirds of the exposed tooth surface or a continuous heavy band

27

of subgingival calculus around the cervical portion of the tooth, or both. The clinical levels of oral cleanliness for debris that can be associated with group DI-S scores are as follows: Good Fair Poor 0.0 0.6 0.7 1.8 1.9 3.0

The clinical levels of oral hygiene that can be associated with group OHI-S scores are as follows: Good Fair Poor 0.0 1.2 1.3 3.0 3.1 6.0

Turesky-Gilmore-Glickman modification of the QuigleyHein plaque index In 1962 Quigley and Hein reported a plaque measurement that focused on the gingival third of the tooth surface. They examined only the facial surfaces of the anterior teeth, using a basic fuchsin mouthwash as a disclosing agent and a numerical-scoring system of 0 to 5. Turesky and colleagues strengthened the objectivity of the Quigley-Hein criteria by redefining the scores of the gingival third area. Plaque was assessed on the facial and lingual surfaces of all of the teeth after using a disclosing agent. A plaque score per person was obtained by totaling all of the plaque scores and dividing by the number of surfaces examined. The Turesky-Gilmore28

Glickman

modification

of

the

Quigley-Hein

criteria

is

considered one of the two indices of choice when assessing plaque in clinical trials. 0 1 2 3 4 5 = = = = = = No plaque Separate flecks of plaque at the cervical margin of the tooth A thin, continuous band of plaque (up to 1mm) at the cervical margin A band of plaque wider than 1mm but covering less than one third of the crown Plaque covering at least one third but less than two thirds of the crown Plaque covering two thirds or more of the crown

Plaque Index. (Silness and Loe, 1963) The Plaque Index (P1I) is unique among the indices described so far because it ignores the coronal extent of plaque on the tooth surface area and assesses only the thickness of plaque at the gingival area of the tooth. Because it was developed as a component to parallel the GI of Le and Silness, it examines the same scoring units of the teeth: distofacial, facial, mesiofacial, and lingual surfaces. a mouth mirror and a dental explorer are used after air drying of the teeth to assess plaque. Unlike most indices, the P1I does not

29

exclude or substitute for teeth with gingival restorations or crowns. The P1I score for the area is obtained by totaling the four plaque scores per tooth. If the sum of the P1I score for the tooth is obtained. The P1I score per person is obtained by adding the P1I scores per tooth and dividing by the number of teeth examined. Plaque Index (PI) 0 1 = = No plaque in the gingival area A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be recognized only by running a probe across the tooth surface. 2 = Moderate accumulation of soft deposits within the gingival pocket and on the gingival margin and/or adjacent tooth surface that can be seen by the naked eye. 3 = Abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface.

Other plaque indices The Modified Navy Plaque Index records the presence or absence of plaque with a score of 1 or 0, respectively, on
30

nine area of each tooth surface of the six index teeth used by Ramfjord. Like the Patient Hygiene Performance (PHP) Index of Podshadley and Haley, the Modified Navy Plaque Index is of value in assessing health education programs and the ability of individuals to perform oral hygiene practices. A variation of the Modified Navy Plaque Index is the Distal Mesial Plaque Index (DMPI), which places more emphasis on the gingival and interproximal areas of a tooth. Plaque in one of the two factors measured in the Irritants Index, which is a component of the Gingival periodontal Index (GPI) of OLeary and associates. The presence and coronal extent of plaque are scored on a scale of 0 to 3. Other factors that contribute to the Irritants Index are supragingival and subgingival calculus and subgingival irritants, such as overhanging or deficient restorations. PHP Index (Podshadley and Haley) The PHP Index was the first index developed for the sole purpose of assessing an individuals performance in removing debris after tooth brushing instruction. It records the presence or absence of debris as 1 or 0, respectively, using the six surfaces of the six OHI-S teeth. The PHP Index is more sensitive than the OHI-S because it divides each tooth surface into five areas: three longitudinal thirds, with the middle third subdivided horizontally into thirds. Scoring is preceded by the
31

use of a disclosing agent. The index is easy to use because its criteria and dichotomous and it can be performed quickly. Its value lies chiefly in its application to individual patient education. Indices used to measure calculus 1. Calculus component of the simplified oral hygiene index The Simplified Calculus Index (CI-S) component of the OHI-S was previously discussed with indices used to measure plaque accumulation because it is less separable from the combined scoring system than are any of the other indices that include several component measures. The value of the CI-S component is its application to epidemiologic surveys and longitudinal studies of periodontal disease. 2. Calculus component of the periodontal disease index The calculus component of the PDI assesses the presence and extent of calculus on the facial and lingual surfaces of Ramfjords six index teeth (i.e. teeth #3, 9, 12, 19, 25 and 28) on a numerical scale of 0 to 3. A mouth mirror and a dental explorer and/or a periodontal probe are used in the examination. The calculus scores per tooth are totaled and then divided by the number of teeth examined to yield the calculus score per person. 3. Probe method of calculus assessment (Volpe Manholde) The developed Probe for Method longitudinal of Calculus studies
32

Assessment the quantity

was of

of

supragingival calculus formed. A periodontal probe graduated in millimeter divisions is used to measure the deposits of calculus on the lingual surfaces of the six mandibular anterior teeth. The Probe Method of Calculus Assessment has been shown to possess a high degree of inter- and intraexaminer reproducibility. 4. Calculus surface index (Muhlemann) The Calculus Surface Index (CSI) is one of two indices that are used in short-term (e.g. less than 6 weeks) clinical trials of calculus inhibiting agents. The objective of this type of study is to determine rapidly whether a specific agent has any effect on reducing or preventing surpagingival or subgingival calculus. The CSI assesses the presence or absence of supragingival and/or subgingival calculus on the four mandibular incisors. The index has also been applied to the six mandibular anterior teeth. The presence or absence of calculus is determined by visual examination or by tactile examination using a mouth mirror and a sickle type dental explorer. 5. A companion index to the CSI is the Calculus Surface

Severity Index (CSSI). The CSSI measures the quantity of calculus present on the surfaces examined for the CSI. 6. Marginal line calculus index 7. Calculus index used by NIDR Calculus Assessment (Calculus Index)
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0 1 2

= = =

Calculus is absent Supragingival calculus, but no subgingival calculus Supragingival and subgingival calculus, or sungingival calculus only is present

is present

Indices used to assess treatment needs 1. GPI (O Leary) The GPI is a modification of the PDI of Ramfjord for the purpose of screening disease: persons gingival to determine who needs status periodontal treatment. The GPI assesses three components of periodontal status; periodontal (crevice depth); and, collectively, materia alba, calculus and overhanging restorations. The latter triad is independently called the Irritation Index. Only the criteria for the gingival status component are described. The maxillary and mandibular arches are each divided into three segments: the six anterior teeth, the left posterior teeth and the right posterior teeth. The primary objective in using the index is to determine the tooth or surrounding tissues with the severest condition within each of the six segments. Each segment is assessed for each of the three components of periodontal disease described previously. The specific criteria for the gingival status component of the GPI are as follows:

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0 1

= =

tissue tightly adapted to the teeth; firm consistency with physiologic architecture. slight to moderate inflammation, as indicated by changes in color and consistency, involving one or more teeth in the same segment but not completely surrounding any one tooth.

the above changes either singly or combined completely encircling one or more teeth in a segment.

marked inflammation as indicated by loss of surface continuity (ulceration) spontaneous hemorrhage, loss of faciolingual continuity or any interdental papilla, marked deviation from normal contour (such as gross thickening or enlargement covering more than one third of the anatomic crown), recession and clefts.

The area with the highest score determines the gingival score for the entire segment, and the gingival status for the mouth is obtained by dividing the sum of the gingival scores by the number of segments.

2. Periodontal Treatment Needs system The next index to evolve with the purpose of assessing treatment needs was the Periodontal Treatment Need System
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(PTNS), which has been used with interesting results. It attempts to place individuals into one of four classes based on treatment procedures relative to time requirements. It considers the presence or absence of gingivitis and plaque and the presence of pockets 5mm or deeper in each quadrant of the mouth. 3. Community Periodontal Index of Treatment Needs In appointed index that 1977, an the expert resulted World Health to Organization review field the (WHO) methods by committee after

available to assess periodontal status and treatment needs. The extensive testing investigators from the WHO and the International Dental Federation (FDI) was called the Community Periodontal Index of Treatment Needs (CPITN). The CPITN was primarily designed to assess periodontal treatment needs rather than periodontal status. CPITN assesses the presence or absence of gingival bleeding on gentle probing; the presence or absence of supragingival or subgingival calculus, and the presence or absence of periodontal pockets, subdivided into shallow and deep. A specially designed periodontal probe with a 0.5mm ball tip and gradations corresponding to shallow and deep pockets was developed to probe for bleeding and calculus and to determine pocket depth. 10 index teeth are examined, but only the worst finding from the index teeth is recorded per sextant of teeth.

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Criteria for the community periodontal index of treatment needs Periodontal status 0 1 2 3 4 = = = = = Healthy periodontium Bleeding observed, directly or by using mouth mirror,after sensing Calculus felt during probing, but the entire black area of the probe is visible Pocket 4 or 5mm (gingival margin is situated on black area of probe) Pocket > 6mm (black area of probe not visible)

Treatment needs 0 I II III = = = = No treatment needed Oral hygiene needs improvement I + professional scaling I + II + complex treatment

Conclusion One of the issues still debated is whether the worldwide prevalence of periodontal disease is increasing or decreasing. Unfortunately, no simple answer can be given for a number of reasons. First, no universal answer is possible, since the prevalence of periodontal disease appears to vary with race and geographic region. Second, the quality of the data available from the developing and the developed countries is clearly not comparable. High quality studies do exist; no

37

earlier studies of comparable quality are usually available from the same populations. Future research is expected to further elucidate these issues, provided that an adequate and consistent epidemiological methodology is utilized. The principal task of future epidemiological research should, therefore, be the identification of risk factors for disease development. The impact of the intervention with such factors on the state of periodontal health has yet to be documented. To assess the magnitude of the clinical benefit achieved by such modulation detailed examinations of the periodontal tissues must be adopted in prospective, long-term epidemiological surveys. These studies underscore that the oral cavity is an integral part of the human body, and that systemic health must encompass oral and periodontal health as well. Last but certainly not least, these studies have provided a unique opportunity for us oral health researchers to expand our investigative sphere, interact fruitfully with our colleagues in medicine, and acquire more knowledge. Irrespective of the definitive byproducts conclusions may of these research efforts, their as the prove to be just as important

elucidation of the research task per se.

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