Note: this lecture includes what is mentioned in the lecture summarized by your group and the handouts

MEASURING PERIODONTAL DISEASES

In contrast to the stability of the DMF index

for caries over a 50-year period, the philosophical basis for measuring periodontal diseases has changed several times over a shorter time span

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In the early days of modern periodontal research,

periodontal disease was considered a single entity that began with gingivitis and progressed to periodontitis and tooth loss
They thought that theres a disease called periodontal disease which starts as gingivitis stage I then progresses to periodontitis stage II and then progresses to teeth loss

Gingivitis and periodontitis were seen as different stages of the same disease and it was proposed that all patients with gingivitis will progress to periodontitis a view that no longer finds
favor among periodontal researchers because we now know that gingivitis and periodontitis are two

disease entities and not all gingivitis cases progress into periodontitis

Indexes based on this earlier perception of

the condition therefore are now considered invalid

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But they have not yet been replaced by new indexes, so methods of measuring periodontal diseases remain in something of a state of flux

Gingivitis

Gingivitis index is a reversible index

The oldest reversible index for gingivitis is the

P-M-A

P stand for papillary, M stands for marginal and

A stands for attached

Anatomically we divide the gingiva into marginal,

papillary and attached gingiva

P-M-A index = an assessment tool used to measure

the severity of gingivitis based on examination and rating of the degree of involvement of the interdental papilla and the marginal and attached portions of the gingiva in each individual

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With better understanding of the inflammatory

process, Gingival Index (GI) of Loe and Silness was invented

Gingival Index (GI)

Gingival index = an assessment tool used to

evaluate the severity of gingivitis based on visual inspection of the gingivae that takes into consideration the color, firmness and swelling of gingival tissue along with the presence of blood during probing

The GI grades the gingiva on the mesial, distal, buc-

cal, and lingual surfaces of the teeth

Each area is scored on a 0 to 3 ordinal scale

according to certain criteria

Criteria for the gingival index

Score Criteria
0

Normal gingiva

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Mild inflammation slight change in

color, slight edema and No bleeding on probing

2

Moderate inflammation redness,

edema, glazing and Bleeding on probing

3

Severe inflammation marked redness

and edema, Ulceration and Tendency to spontaneous bleeding

The GI has been used on selected teeth in the

mouth as well as on all erupted teeth

Those selected teeth are: upper right 6, upper

right 1 or 2, upper left 4, lower left 6, lower left 1 or 2 and lower right 4

The GI index is an index of gingivitis that takes NO

account of deeper changes in the periodontium

and it has been proved to be useful

It is sufficiently sensitive to distinguish between

groups with little and with severe gingivitis BUT

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it may NOT discriminate as well between the middle range It can distinguish very well between 1 and 3 scores but not between 1 and 2 scores

To obtain more sensitivity at the initial stages of

gingivitis for clinical trials, the Sulcus Bleeding Index

(SBI) was invented

Sulcus bleeding index = an assessment tool used to

evaluate the existence of gingival bleeding in individual teeth and/or regions of the oral cavity upon gentle probing by assigning a score of 0-5 ordinal scale according to certain criteria

Criteria for the sulcus bleeding index

0

Normal gingiva normal color, normal

texture and NO bleeding

1

gingiva apparently normal, bleeding on

probing
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bleeding on probing, change in color, NO bleeding on probing, change in color, slight

edema
3

edema
4

bleeding on probing, change in color,

obvious edema
5

bleeding on probing and spontaneous

bleeding, change in color, severe edema

SBI index has increased sensitivity BUT reduced

diagnostic reliability

The use of gingival bleeding after gentle probing

as a measure of gingivitis by the SBI index has become accepted with further experience

Visual assessments of inflammation color,

texture and swelling by the gingival index are subjective

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The appearance of spots of blood after gentle

probing around the gingival margin by the sulcus bleeding index is more sensitive and more objective especially in sites that are difficult to view directly

The major subjective area with a sulcus

bleeding index is gentle probing force which has

been shown to vary between 3 and 130 grams with different examiners

So many bleeding indices appear after the sulcus bleeding index, and among them:
1.

Gingival bleeding index (GBI) = an assessment

tool used to verify the presence of gingival inflammation based on any bleeding that occurs at the gingival margin during or immediately

after flossing

Papillary Bleeding Index (PBI) = an assessment

tool used to measure and quantify bleeding in the

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papillary region of the gingiva by gentle probing

and assign a score of 0-4 ordinal scale according to certain criteria

0 no bleeding 1 one point of blood 2 line or multiple points of blood 3 triangle of blood 4 profuse bleeding
2.

Eastman Interdental Bleeding Index (EIBI) =

an assessment tool used to determine the extent of

interdental inflammation based on bleeding

that occurs within 15 seconds after a wooden

cleaning stick is inserted between the teeth

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Eastman Interdental Bleeding Index is said to

be more sensitive than other measures of

papillary bleeding

Indexes based on gingival bleeding on probing,

on flossing, on wooden stick use work well in

clinical trials, and they are highly sensitive although this degree of sensitivity is usually not required for surveys

Although bleeding on probing is a useful

measure in the clinical management of gingival conditions BUT it is a poor predictor of future periodontitis

The use of bleeding on probing in public health

programs is not highly recommended in community studies because:

-

Deliberate induction of gingival bleeding

in screening programs can hardly be encouraged in light of current sensitivities about

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infectious diseases " " - Indexes using bleeding on probing are highly sensitive and high sensitivity is not required
-

When gingival bleeding occur we wont be able to

know is it really related to gingivitis or any other condition?!

The gingival index was modified into the Modified

Gingival Index (MG1)

Modified Gingival Index (MG1) is a more sensitive

measure of gingivitis than gingival index itself and also

non-invasive because it eliminates the use of bleeding on probing but still provide high visual sensitivity with incipient gingivitis early stages of gingivitis

Modified Gingival Index only depends on

changes in color and swelling but not bleeding on probing

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Modified Gingival Index (MG1) assigns scores of

0-4 ordinal scale according to certain criteria

0 1 2 3 4

Normal, No inflammation Localized mild inflammation Generalized mild inflammation Moderate inflammation Severe inflammation

Gingivitis is an area where valid non-clinical

measures would be highly beneficial oral hygiene

instructions

Periodontitis

Many early epidemiological studies of periodontal

diseases were based on radiographic surveys of

alveolar bone loss

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Radiography is a standard diagnostic procedure in

periodontitis BUT it is not used in surveys because of its impracticability, and because it adds little to the

value of clinical measures

The attempt was therefore made to develop indexes

that were both sensitive and clinically manageable in field conditions

The most widely used periodontal index for many

years was the Periodontal Index (PI), described by Russell

All periodontal indices at that time including the

periodontal index were composite indices

Composite indices = indices scoring both gingivitis

and periodontitis on the same scale

Russell periodontal index = an index that

measures an individual's periodontal condition by adding scores based on the condition of the gingiva and dividing the sum by the number of teeth

present
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Individuals with clinically normal gingiva have an index of 0 to 0.2 and the index reaches a maximum of 8.0 in persons with severe terminal destructive periodontitis so it is 0-8 ordinal scale

Periodontal index was a composite index because it

records both of the reversible changes due to

gingivitis and the more destructive changes due to periodontitis in the same scale

With periodontal index all teeth were examined

and assessed

The criteria followed was:

0 - 0.2 clinically normal supportive tissues 0.3 - 0.9 simple gingivitis reversible 1.0 - 1.9 beginning of destructive periodontal disease reversible 2.0 4.9 established destructive periodontal disease irreversible 5.0 8.0 terminal disease irreversible

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Periodontal index for one person = sum of

individual scores/ number of teeth

The basis for stating that the Periodontal index

is invalid in light of modern research can be summarized as follows:

1.

Russell recommended that the

Periodontal index be used without probing and this rule reflects how firmly the gingivitis - periodontitis continuum was then accepted gingivitis (stage I) & periodontitis (stage II)

Pocketing was thus often diagnosed on

the severity of gingivitis while in the reality pocketing is always a sign of periodontitis The diagnosis was unconsciously influenced

by the patient's age and oral hygiene status The opportunity for serious bias is apparent

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Loss of attachment was not recorded

All pockets judged to be 3 mm or deeper were

scored equally unless a tooth was mobile

non-mobile teeth were scored having the same periodontal index score a value of 2.0 - 4.9

regardless of their individual pocket depth value, and mobile teeth were scored having the
same periodontal index score a value of 5.0 8.0 regardless of their actual pocket depth

value
2.

As a composite index, the Periodontal index

scored both gingivitis and periodontitis in the

same weighted scale Perceptions of the extent and age-distribution of periodontitis were distorted by excessive statistical weight given to gingivitis most PI
scores describe gingivitis

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3.

The Periodontal index assumed generalized

distribution of the disease in the mouth and this doesnt show the real distribution of the disease
Russell stated that if an individual has already lost teeth because of periodontal involvement, there is a strong likelihood that his remaining teeth will show extensive disease So Russell considered diagnosis of teeth remaining after the extraction of others very easy and straightforward BUT this is not the real case because

periodontal diseases are very site - specific

The periodontal index was based on a model in which

periodontal disease was slowly progressing continuous disease process

It dealt with gingivitis as part of the biological

gradient that extended from health to advanced periodontal disease

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In the newer models, periodontal disease is a

chronic process with intermittent periods of activity and remission that affects individual teeth and sites around teeth at different rates within the same mouth

Then came the Periodontal Disease Index (PDI)

which was invented by Ramfjord and was intended as a more sensitive modification of the Periodontal

Index for use in clinical trials

Periodontal disease index is a composite index

too

Periodontal disease index is a 0-6 ordinal scale

Scoring criteria was followed:

0 no inflammation 1 mild-moderate gingivitis not circumscribing the tooth 2 mild-moderately severe gingivitis circumscribing the whole tooth

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3 severe gingivitis with bleeding on probing 4 pocket extending apical to CEJ not more than 3 mm 5 pocket extending apical to CEJ by 3-6 mm 6 pocket extending apical to CEJ by more than 6 mm

The most important feature of Periodontal Disease

Index is the fact it measures the clinical attachment loss relative to the CEJ which was NOT recorded by Periodontal Index

In periodontal disease index a periodontal

probe was used to measure the clinical attachment loss unlike periodontal index

The PDI also gave us the Ramfjord teeth "an

examination of six teeth taken to represent the whole mouth

The Ramfjord teeth are: the upper right 6, upper

left 1 or 2, upper left 4, lower left 6, lower right 1 or 2 and lower right 4

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Ramfjord chose this group of teeth to represent the

dentition and to save time in clinical examinations

Although the Periodontal Disease Index is no longer

used, BUT the selection of the six Ramfjord teeth

and the method of measuring loss of periodontal attachment that Ramfjord described then is still used today

Periodontitis today is usually measured by Ramfjords

technique of measuring periodontal attachment loss is often referred to indirect method of measuring loss

of periodontal attachment (LPA) Indirect method of measuring loss of periodontal attachment consists of: Recording the distance from the gingival crest

to the base of the pocket this gives pocket

depth

Locating the cementoenamel junction (CEJ) Recording the distance from the CEJ to the

gingival crest
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Then measure the distance from the base of the

pocket to the CEJ

These measurements are usually carried out at

between two and six sites per tooth, depending on the purposes of the study, and usually for either the

Ramfjord teeth or the whole dentition

Measuring six sites per tooth for an intact dentition

can take 30 to 40 minutes per examination, even for an experienced examiner

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A more recent measure is the Extent and Severity

Index (ESI)

Extent and severity index = measures extent

number of sites affected in the mouth and severity stage of advancement of loss of
periodontal attachment by determining the

percentage of sites within the mouth with Loss of Periodontal Attachment greater than 1 mm extent and the mean Loss of Periodontal Attachment for the affected sites severity

Extent and severity index uses the Ramfjords

indirect method of measuring the periodontal attachment loss indirect LPA

Extent and severity index is an aggregate

measure and thats why it may receive limited use What does extent = 20% and severity = 5% mean?!
20% 20% of the examined sites have attachment loss
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5% the average clinical attachment loss for the sites examined

Indirect method of scoring Loss of Periodontal

Attachment is generally considered the best available measure of periodontitis in epidemiology BUT it is still considered far from ideal because it records past rather than present disease

What would be more useful would be to combine

these measures of past disease with a measure of active disease

Despite considerable research effort, no

satisfactory measure of active periodontitis has yet emerged

Periodontal Treatment Needs

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Treatment need = determined by the practitioner Treatment demand = determined by the patient

Treatment need is always stronger than treatment demand

Any assessment of periodontal treatment needs has

the same limitations seen with caries

Treatment plans are subjective, depending on some

dentist-patient factors that are not part of a clinical examination, and standard treatment for a given condition can change as the field develops

Despite these limitations, methods for assessing

periodontal treatment needs have been used for many years

O'Leary used an adaptation of the Periodontal Disease

Index of Ramfjord he called the Gingival Periodontal

Index (GPI) to assess periodontal treatment needs

Gingival periodontal index = an index that

assesses both gingival status and periodontal

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status pocket depth by dividing the whole dentition into 6 segments, and then the worst
condition found in any one segment was taken as the score for that segment

The 6 segments were: - Upper right 8 to upper right 4

upper left 3 - Upper right 3 to - Lower left 8 to - Lower right 4 to

- Upper left 4 to upper left 8

lower left 4

- Lower left 3 to lower right 3

lower right 4

Then came the Periodontal Treatment Need

System (PTNS) which received some use in Norway

Periodontal Treatment Need System categorized

patients into levels of treatment need and assigned times for the type of treatment required

Then came the "621" method

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621 method involves examination of the

"Ramfjord teeth" in four age groups for calculus,

depth of pocket and presence and absence of bleeding

Within a few years later, the "621" method was

converted into the Community Periodontal Index of

Treatment Needs (CPITN) which also incorporates

remnants of O'Leary's method and the Periodontal Treatment Needs System

Community Periodontal Index of Treatment

Needs differs from earlier indexes in several ways: - The special disposable plastic periodontal probe it uses
Which is characterized by being lighter than most probes and has a clear black area in the center for accuracy marked at 3.5 mm and 5.5 mm Having a 0.5 mm diameter ball at its tip and the ball height extends to the 3.5 mark
o

If the probe gets inside the pocket so that the

ball disappeared and the whole black area is visible then pocket depth is less than 3.5
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If the probe gets inside the pocket so that half

of the black area disappeared then pocket depth is between 3.5 and 5.5 o If the probe gets inside the pocket so that the whole black area disappeared then pocket depth is more than 5.5 The purpose of the ball is to assist in feeling subgingival calculus and to prevent the probe from being pushed through inflammatory tissue at the base of a pocket. Probing pressure is recommended to be no more than 20 grams

- Another point of difference is that data are

presented in categorical form rather than as mean values members of an examined group are placed into treatment categories according to the most severe finding in the mouth

In Community Periodontal Index of

Treatment Needs the mouth is divided into sextants The sex sextants are:
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- Upper right 7 to upper right 4

to upper left 3

- upper right 3 - lower left 7 to - lower right 4

- Upper left 4 to upper left 7

lower left 4

- Lower left 3 to lower right 3

to lower right 7

For adults aged 20 or more, we measure the

CPITN in 10 teeth 8 posterior and 2 anterior The first and second molars are examined in the four posterior sextants the upper right central incisor in the upper anterior sextant, and the lower left central incisor in the lower anterior sextant These 10 teeth are called index teeth

For persons aged 19 or under, we measure the

CPITN in 6 teeth 4 posterior and 2 anterior The second molars are not examined

Codes 0 to 4 are ascribed to the sextants

examined according to the clinical criteria, and

from those findings the patient is categorized into

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one of four treatment groups on the basis of the most severe condition found
Code 0 = healthy tissue Code 1 = bleeding on probing + No pocketing Code 2 = bleeding on probing + calculus + No pocketing the whole black area of the probe is still visible Code 3 = pocketing of 4-5 mm half of the black area is still visible Code 4 = pocketing of 6 mm or more the black area is not visible anymore Code 0 treatment need 0 no treatment but prevention Code 1 treatment need 1 oral hygiene instructions Code 2 treatment need 2 oral hygiene instructions + removal of calculus

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Code 3 treatment need 2 oral hygiene instructions + removal of calculus Code 4 treatment need 3 oral hygiene instructions + removal of calculus + complex treatment

Although CPITN has now received wide use and has

led to some impressive contributions it still awaits universal acceptance

Some periodontists have criticized its measurement

of pockets rather than loss of attachment and

some do not like the "feel" of the probe

It has to be remembered that CPITN is NOT an index

of periodontal status BUT an index of treatment need

Plaque and Calculus

Oral hygiene status is closely associated with

gingivitis, and it is a useful expression of oral health awareness in the community

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Oral hygiene indexes should be a basic part of

evaluating dental health in education programs

Practitioners also benefit from using an objective

measure of oral hygiene status so that patients'

progress in oral hygiene improvement can be recorded

One index of oral hygiene that has had wide use in

surveys is the simplified oral hygiene index (OHI-S)

Simplified oral hygiene index = An index that

measures the current oral hygiene status based upon the amount of debris and calculus occurring on six representative tooth surfaces in the mouth

The sex teeth surfaces are: - Facial of upper right 6

right 1 - facial surface of upper - lingual of lower left 6 - lingual of lower right 6

- Facial of upper left 6 - Lingual of lower left 1

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Simplified oral hygiene index includes simplified

dental plaque index DI-S and simplified calculus index CI-S

The OHI-S scores calculus and plaque together by 0-

3 ordinal ordinal scales, both supragingivally and subgingivally

Simplified oral hygiene index is quick and

practical, though its lack of sensitivity makes it less useful in the individual patient than in a group

OHI-S has not been used much in recent years, especially with the current focus on subgingival rather than supragingival, plaque and calculus as etiological agents

Then come the Patient Hygiene Performance

Index (PHP), intended for monitoring of oral hygiene performance by patients in the dental practice

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Patient Hygiene Performance Index requires a

disclosing stain, which can be messy, and was

probably more useful at a time when oral hygiene standards were generally lower than they are today

Patient Hygiene Performance Index divides each

tooth into 5 subdivisions: 2 interproximal, 1 coronal, 1 middle and 1 cervical

Patient Hygiene Performance Index is also not

Then come the Plaque Index (PI) which was

used much at present

developed by Silness and Loe to be used along with their gingival index (GI)

Both PI and GI are scored for the same surfaces of the

same teeth and they are 0 to 3 ordinal scale

The principal difference between the PI and the

OHI-S approach is that: - The plaque index scores the plaque present
according to its thickness at the gingival

margin
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- The simplified oral hygiene index scores the coronal extent of plaque

Plaque index doesnt use a disclosing agent and

its measurement is claimed to be more valid

Criteria for plaque index

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 only be recognized by running a probe across the tooth surface 2 Moderate accumulation of soft deposits within the gingival pocket, on the gingival margin, and/or adjacent tooth surface, which can be seen by the naked eye 3 surface

Abundance of soft matter within the gingival

pocket and/or on the gingival margin and adjacent tooth

A simple and useful measure of oral hygiene status is

based on the measure of subgingival calculus as

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part of CPITN where Soft plaque deposits are ignored

Because calculus appears to be the oral hygiene

measure most closely associated with periodontitis, a simple measure of its presence or
absence would be sufficient for most purposes

Then come the Volpe-Manhold Index (VMI) which

has been widely used in the United States in trials to

test agents for plaque control and calculus inhibition mouth washes for example

Volpe-Manhold index scores new deposits of

supragingival calculus following remove of all calculus by prophylaxis in clinical trials

Volpe-Manhold index scores calculus deposits on

three planes of each of the lower six anterior teeth: gingival, distal and mesial
A probe is used to measure the linear extent of

calculus in increments of 0.5mm

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The tooth score = the sum of the scores in the three planes The patient total score = is the sum of the tooth scores

Partial-Mouth Periodontal Measurements

Because full mouth examinations for gingival bleeding

depending on the loss of periodontal attachment, plaque and calculus can be time consuming, investigators have tried using various indexes on a subset of teeth to save time

The expectation is that the subset of teeth will act as

a "representative sample" of all teeth in the mouth, yielding information that can be applied to the

whole mouth but taking much less time to do it

Partial mouth recording was pioneered by Ramfjord

with his Periodontal Disease Index

There seems to be agreement that partial mouth

recording is valid for plaque and gingivitis because

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of the generalized nature of plaque deposits and gingivitis

Unfortunately, partial mouth recording is less

satisfactory for Loss of Periodontal Attachment and pocketing

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