CRITICAL EVALUATION OF INDICES MEASURING PERIODONTAL DISEASES

CONTENT
 INTRODUCTION
 INDICES MEASURING POCKET DEPTH AND LOSS OF ATTACHMENT
 INDICES TO ASSESS PERIODONTAL DISEASES
 INDICES FOR ASSESSMENT OF GINGIVAL RECESSION
 RADIOGRAPHIC BONE INDICES
 CONCLUSION
 REFERENCES
 INTRODUCTION
DEFINITION
 A numerical value describing the relative status of a population on a graduated scale with
definite upper and lower limits , which is designed to permit and facilitate comparison
with other populations classified by the same criteria and methods.

1) CLARITY , SIMPLICITY, OBJECTIVITY

2) VALIDITY
3) RELIABILITY

4) QUANTIFIABILITY

5) SENSITIVITY
6) ACCEPTABILITY

CLASSIFICATION OF INDICES
1. Based upon the direction in which their scores fluctuate
DMFT INDEX
IRREVERSIBLE INDEX

GINGIVAL / PERIODONTAL INDEX

REVERSIBLE INDEX

2. Based on Extent to which areas of oral cavity are measured

FULL MOUTH – Russell’s Index

SIMPLIFIED INDICES – OHI-S

3. Based on general categories according to entity to measure

DISEASE INDEX – D portion of DMFT

SYMPTOM INDEX – Gingival /Sulcular bleeding

TREATMENT INDEX – F portion of DMFT

4. Based on Special categories
 SIMPLE CUMULATIV COMPOSITE
INDEX E INDEX INDEX
Sillness and DMFT
Loe
INTRODUCTION
CRITICAL EVALUATION
 Point out any differences which are particularly significant. Give your verdict as to what
extent a statement or findings within a piece of research are true, or to what extent you
agree with them
CRITICAL REFLECTION
 It is a reasoning process to make meaning of an experience. Critical reflection is
descriptive, analytical, and critical, and can be articulated in a number of ways such as in
written form, orally, or as an artistic expression.
 Periodontal Indices are important tools to measure ,quantify and Treat Periodontitis.
 Periodontitis is inflammation of the periodontium that is accompanied by Apical
migration of the junctional epithelium, Leading to destruction of the connective tissue
attachment, Alveolar bone loss.
 Periodontal disease should be measured using loss of attachment, not pocket depth.
Case Definition by Burt & Eklund,
‘Serious’ periodontitis as reviewed by
• Four or more sites with ≥5 mm of periodontal attachment loss, with probing depths of ≥4
mm at one or more of those sites.
• Two or more sites with ≥6 mm of periodontal attachment loss, plus one or more sites
with probing depths of ≥5 mm.
• Mean periodontal attachment loss in the 20th percentile of the distribution
INDICES MEASURING POCKET DEPTH AND LOSS OF ATTACHMENT
 Russell Periodontal index
 Periodontal disease index
 Periodontal disease rate index
 Gingival periodontal index
 Gingival – bone count index
 Community periodontal index of treatment needs
 Community periodontal index
 Periodontal screening and recording index
 Periodontal index for treatment
 Extent and severity index
 Navy periodontal disease index
 Periodontitis severity index

PERIODONTAL INDEX
  Russell AL over a period of ten years in 1956 - developed the first index for periodontal
disease. (National Institute of Dental and Craniofacial Research (formerly known as
National Institute of Dental Research),
 To facilitate the surveillance of periodontal disease in concordance with the already
widely used DMFT (Decayed, Missing and Filled Teeth) index.
 Rationale of this method by data published by Sandler and stahl (1954) – Compared
Gingival Recession and Bone loss by X ray.
 It is an essential Epidemiological tool
 Used in first two national surveys in the United States
 Created the PI criteria (0, 1, 2,4, 6 and 8)
 Based upon the signs of periodontitis , i.e. inflammation, pocket formation, and loss of
function.
 Referred to as a scaled scoring system /weighted categorical scoring system.
 Mouth mirror, explorer, jacquette scaler or chip blower( Demonstartion of periodontal
pocket)
ADVANTAGES :
 Epidemiological tool, useful and valid in the field. Precise method and provide adequate
data about periodontal diseases.
 Both reversible and irreversible changes.
 Calibration of the examiner is easy
 Minimum of equipment is required

Russell’s Periodontal - Validity (interval scale between scores) and underlying

assumptions (continuity between gingivitis and periodontal diseases)

DISADVANTAGES :
 Not very useful for individual dental patient /(small groups).
 No calibrated probe or radiographic examination,and X ray needed for assess bone loss
so tends to underestimate the true level of periodontal disease
 Scoring criteria are not continuous.
 No treatment need assessment
 No specific measures of pocket depth, clinical attachment loss,radiographic assessment.
 Overlapping of scores
 Variations due to Subjective methods.
 Number of periodontal pockets without supragingival calculus is under estimated

RELIABILITY,SENSITIVITY AND STATISTICAL ANALYSIS OF RUSELL’S INDEX

 Lack of inter-examiner reliability has been demonstrated by, Davies et al; as part of an
epidemiological training course.
 In this study the index proposed by Russell was used and the results clearly indicate that
without any calibration or training the inter-examiner reliability was low.
 Smith et al., Alexander et al ; and Shaw & Murray have shown that training programs
can be effective in reducing inter-examiner as well as intra-examiner agreement in
recording gingivitis.
Sven Poulsen, Dr Odont Epidemiology and indices of gingival and periodontal disease
PEDIATRIC DENTISTRY/Copyright ° 1981 by The American Academy of Pedodontics Vol. 3,
Special Issue
  The non-parametric nature of many indices of gingival and periodontal disease prohibits
statistical analysis using regular parametric statistical methods.
 One possible solution is to apply statistical methods which have been designed to analyse
non-parametric data.
 Another possibility is to tabulate the frequency with which the different scores are found.
This type of measurement is parametric in nature and can be analysed using parametric
statistics
PERIODONTAL DISEASE INDEX
 Sigurd P. Ramfjord in 1959.
 Clinical modification of Russell’s PI index for epidemiological.
 For accurate assessment of periodontal status of individual person.
 Recording of attachment level of periodontal tissue relative to CEJ.
 Index Teeth – 16,21,24,36,41,44

Gingival and
Plaque Component Calculus Component
Periodontal Component

Ramfjord understood PRECISION issue and proposed using less precise measurements (marks
on the probe were at 3, 6 and 8 mm)
Calculus Subgingival Calculus located with a #17 probe when
probing with Michigan # O probe
Examination

Plaque
Examination Staining with Bismarck Brown
  Maximum accuracy depends on Standardized optimal and Standardized thickness of
measuring probe.
 Its is Basically combination of PMA and PI Index.
 The University of Michigan # O probe (Premises Mfg.co., Philadelphia) is used.
(Graduated 3,6,8mm from the end )

ADVANTAGES
• For both large and small population,
Easy calibration of examiners
• Accurate record of level of DISADVANTAGE
Periodontal support , So accurate for
• Does not differentiate
incidence and clinical studies,
loss of periodontal
longitudinal studies.(CAL recorded)
support by periodontitis
• Data needed for assessment of
or by atrophy.
prevalence and severity of both
gingivitis and periodontitis.
• Need of Treatment need for
Periodontitis.

Ramfjord understood PRECISION issue and proposed using less precise measurements
(marks on the probe were at 3, 6 and 8 mm)

Jamison and others that these 6 teeth provides Validation research on the

basis for a surprisingly accurate assessment of ‘Ramfjord teeth’ as

the total periodontal status of the individual as representing the entire mouth

expressed in scoring of all the teeth showed mixed results

 The Periodontal Disease Index was used by Ramfjord in one epidemiological study
among youths and young adults aged 11 to 30 from India .
  He presented these findings side-by-side with results from another five surveys,
conducted using Russell’s Periodontal Index between 1957 and 1963 in Sri Lanka, Iran,
Nigeria and Sudan.
 Later, both indices were described as reporting lower disease levels when compared with
radiographic methods
PERIODONTAL DISEASE RATE INDEX
 Sandler and Stahl in 1959.
 Number of diseased teeth are counted and then divided by total number of teeth present
in the mouth.
 Expressed as a percentage.

CRITERIA

• Gingival Crevice depth of 3mm or more

• Tooth Mobility greater than 1mm in any direction
• Radiographic evidence of resorption of alveolar bone extending
more than 3mm apically from CEJ.
• Gingival necrosis , Purulent exudate , Hypertrophy of Gingiva

GINGIVAL PERIDONTAL INDEX

 O’ Leary T, Gibson W, Shannon I L, Schuessler CF, Nabers CL , in 1963.
 As a part of periodontal screening examination for the needs for military dental service.
 Evaluate gingival health and status of supporting alveolar bone.
 Periodontal Screening Examination also consists of Irritant Index (II).
 Probing of Mesial surface of each tooth (94% of correct diagnosis)
 GPI score : highest gingival and periodontal score.
 Irritant index: highest plaque and other local factors.
 It introduced the idea of examination by ‘sextants’
 Six index teeth : mesial-facial or buccal line of each tooth (Merritt type Probe)

Teeth 17 to 14, 13 to 23, 24 to 27, 37 to 34, 33 to 43 and 44 to 47.

ADVANTAGES :
 Quick appraisal of the health status of each area of the patient's mouth
 The scores were helpful in determining the personal, facility and equipment needs of
patients.
DISADVANTAGES:
 GPI has not found much usage,
 A modification of the GPI has been used in an oral health survey in five countries by
measuring pocket depth instead of clinical attachment .
GINGIVAL BONE COUNT INDEX
 Dunnig JM, Leach LB in 1960.
 Records gingival condition and levels of crest of alveolar bone.
 Subjective measurement
 Gingival status: 0-3 scale, mouth mirror and no 17 explorer
 Measurements of bone loss from radiographs : 0-5 scale, probing with explorer.

GINGIVAL SCORE + BONE SCORE =GINGIVAL BONE COUNT

 Sheiham A and Striffler D.F developed an index similar to bone count component of
Gingival bone count index in 1970.

SCORE CRITERIA

0 Normal
4 Lack of continuity of cortical plate at crest
of interdental bone, with possible
widening of periodontal ligament.
5 Up to one third and up to two thirds of
supporting bone lost
7 More than two thirds of supporting bone
lost

COMMUNITY PERIDONTAL INDEX OF TREATMENT NEEDS

 OHI-S and PI were not Satisfactory to estimate the magnitude and severity of periodontal
condition.
 1977 Moscow Stomatological Institute was the Venue and produced Prototype Index –
TRS 621 method.
 “Joint working committee” (4 members from WHO and 4 of FDI )Tested the CPITN
Protype and accepted in 1981 september in Rio de Janerio.
 Jukka ainoma, David Barmes, George Beagrie, Terry Cutress, Jean Martin, Jennifer
Sardo-Infirri in 1982.
 Survey and evaluate periodontal treatment needs rather than periodontal status (Both
Community and Individuals)
 Six sextants – 17-14 , 13-23 , 24-27 , 47-44 , 43-33 , 34-37
 CPITN probe first designed in 1978 by WHO 621 report and later reported in detail by
Emsile (1980) which was designed by Jukka Ainamo.
 Weight id 4.5g , Black band between 3.5 & 5.5, and additional lines at 8.5mm and
11.5mm
ADVANTAGES :
 Scoring criteria is simple
 Minimal equipment required.
  Scoring 10 index teeth in less than 10 minutes.
 International uniformity
 Measureable and understanble goals can be set.
 Use in surveys, clinical settings.
 Records Perio pockets, Gingival Inflammation , Dental calculus and other plaque
retentive factors.
DISADVANTAGES:
 Reproducibilty and scoring score 1 is difficult.
 Does not record irreversible changes.
 Not a diagnostic tool and not be used for specific clinical treatment .
 No distinction between supragingival and subgingival plaque.
 No distinction between presence of calculus with or without bleeding
USES
 Treatment needs in population groups – Public health Planning
 Descriptive studies of periodontal disease
 Generation of data for health promotion
 Tool in Analytical Epidemiology identify the risk factors and association.
LIMITATIONS :
 Baelum and papapanou listed ,Hierachical principles underlying the use of CPITN not
being universally valid.
 Partial recording approach leads to gross underestimation of prevalence of deep pockets
and gingival and periodontal status.
 TAKAHASHI MODIFICATION OF CPITN
 Sextants given a scoring code of 2 were subdivided into code
2+ = When calculus was associated with gingival bleeding

2- = When was present without any associated bleeding

 The worst finding for each sextant was recorded.

VALIDITY OF CPITN PROBE:

 Wilson et al Concluded that WHO probe is less accurate in assessing pockets of 3.5mm
-5.5mm.
 Suggested to incorporate a measure of gingival recession in epidemiological studies
involving CPITN
VALIDITY OF THE COMMUNITY PERIODONTAL INDEX OF TREATMENT
NEEDS’ (CPITN) FOR POPULATION PERIODONTITIS SCREENING
 Bassani DG et al,2006 was to validate two versions of CPITN for periodontitis
diagnosis.
 A sample of 400 individuals
 Clinical Attachment Loss, Periodontal Pocket Depth and Sub-gingival Calculus.
 Full and partial CPITN versions were derived from this exam (gold standard)
FULL CPITN:
 58% sensitivity
 80.6% Specificity
 87% Postive predictive value
 46.3% negative predivtive value
 Periodontitis prevalence -46%,
 Obtained with the gold standard was 69%.
PARTIAL VERSION CPITN:
 50% sensitivity
 87.1% specificity.
 89.6% Positive predictive value
 43.9% negative predictive value
 Estimated periodontitis prevalence, through partial CPITN, was 30.5%
COMPARISON OF THE PERIODONTAL INDEX (PI) AND COMMUNITY
PERIODONTAL INDEX OF TREATMENT NEEDS (CPITN)
 Cutress TW et al.1985
 827 eligible people were identified
 745 subjects were successfully inter- viewed and examined orally.
 Periodontal conditions were recorded for all dentate respondents using the procedures for
the PI and the CPITN
COMMUNITY PERIODONTAL INDEX OF TREATMENT NEEDS INDEX: AN
INDICATOR OF ANAEROBIC PERIODONTAL INFECTION
 S Muthukumar, R Suresh.2015
 Correlated the CPITN scores of patients with BANA test results to assess the validity of
CPITN as an indicator of anaerobic periodontal infection.
 A total of 80 sites were selected from 20 patients with generalized chronic periodontitis.
 After measuring the probing depth with CPITN C probe, the subgingival plaque samples
were collected using a sterile curette and the BANA test was performed
 Results indicated sensitivity (92.86%), specificity (80%) and agreement (91.25%);
indicating the validity of CPITN in assessing anaerobic infection.
COMMUNITY PERIODONTAL INDEX
 Modification of CPITN index (Index teeth and probing are similar to CPITN)
 Measurement of loss of attachment and Elimination of Treatment Needs
 Not recorded for children less than 15 years.

CPI Probe 0.5mm ball tip ,

black band between 3.5 to
5.5mm,ring at 8.5 to 11.5mm

ADVANTAGES:
 In periodontal research
 To reduce the time needed when in large population
 Allows the elaboration of preventive and therapeutic programmes
 Quantification of biological and environmental risk factors related to the disease onset
and progression
DISADVANTAGES:
 Old paradigm to assess disease especially among adolescents.
 The validity of the record (bleeding, calculus and periodontal pocket)is questioned
A study by Mojon et al. reported on the reliability of two examiners using the Community
Periodontal Index in individuals of 65– 80 years of age.
Unweighted kappa statistics for intraexaminer reliability were 0.39 and 0.58 for each examiner
and 0.48 when both examiners were compared with each other.
Agreement was worst in categories 1 (bleeding) and 3 (4–5 mm pocket depths) and best on
category 4 (>6 mm pocket depth).
DUTCH PERIODONTAL SCREENING INDEX
 Dutch society of periodontology as a component of periodontal diagnosis and treatment
protocol – 1998
 Initially evaluation to determine the level of additional periodontal examination and
subsequently, the treatment needs of patients with differing disease level
 Modification of CPITN
 Minor, Moderate, Severe periodontal disease
DUTCH – PERIO Protocol
 1)Patient require oral hygiene instructions (DPSI 0, 1,2 )
 2)Limited periodontal examination (DPSI 3)
 3)Extensive periodontal examination (DPSI 4,5)

DPSI 0- No pockets >3mm, No BOP

DPSI 3 – Pockets 4-5mm without Gingival
DPSI 1 - No pockets >3mm, BOP recession

DPSI 2 - No pockets >3mm, BOP, and DPSI 4 – Pockets 4-5mm with Gingival recession
presence of calculus and overhanging
DPSI 5 – Pathological pockets ≥ 6mm
restoration
BASIC PERIODONTAL EXAMINATION
 Recommended by British Society of Peridontology 1986,2001.
 Same scoring as CPITN but symbol * is added if there is attachment loss at any site
>7mm or if function loss.
 The asterisk denotes a ful periodontal examination of sexant is required regardless of the
BPE score.

Code 0 – No treatment is needed

Code 4 – Extensive periodontal assessment

PERIODONTAL SCREENING AND RECORDING INDEX

 In 1988 when the American Academy of Periodontology (AAP) approved the
development of a Periodontal Disease Detection Day , PERIODONTAL SCREENING
AND RECORDING INDEX in collaboration with the American Dental Association
(ADA).
 For assessing the periodontal status of patients in US in Oct 6 1993
 Derived from Basic Periodontal Examination.(1984-1990)
 Six sextants – Greatest probe depth
 Plastic PSR probe – 0.5mm ball tip , Color-coded band extending 3.5mm to 5.5mm from
the tip.
 Apart from one difference (Asterisk code) PSR is identical to CPITN.
PERIODONTAL SCREENING AND RECORDING (PSR) INDEX SCORES PREDICT
PERIODONTAL DIAGNOSIS
 Primal KS, Esther SR and Boehm TK .2014.
 Significant correlations have been found between the PSR and periodontal disease
diagnosis
 Inter - examiner agreement was very good (examiners agreed 95% on diagnosis, kappa
was 0.936.
ADVANTAGES:
 Simple, similar to CPITN except for the asterick mark.
 It is average nine times faster than a conventional evaluation.(Piazinni in 1994 )
 PSR score has significant associations with probing depths and attachment levels in
comparison to radiographs.
DISADVANTAGES:
 Underestimate the level of periodontal involvement.
 The asterisk code does not specify Which method is to be used for detection of the
periodontal abnormalities
EXTENT AND SEVERITY INDEX
 James P Carlos, Mary D Wolfe and Albert Kingman in 1986.
 Due to lack of satisfaction with previous indices and by the newer conceptual model of
periodontal diseases by Socransky et al.
 Gives estimates of loss of attachment by subtracting the probing distance (mm) from the
gingival crest to the CEJ. When Gingival crest located below the CEJ , first measurement
is recorded as negative value (Ramfjord 1974)
 ESI – bivariate statistics : Percentage of sites exhibits disease and Mean attachment loss
in mm. Disease is defined as 1mm of attachment loss
 Gives the distribution of the diseases unlike other indices.
 The ESI is a simple, reproducible method.
 Yields an informative description of the periodontal disease status of a population.
 It requires only minimal training of examiners.
 The index is intended to per direct comparisons among epidemiologic studies of different
populations ; by different investigators.
NAVY PERIODONTAL DISEASE INDEX
 Grossman FD, Fedi PF in 1974.
 Gingival score – Inflammation determined by color, consistency , density and bleeding (0
–Normal Gingiva 1- Inflammatory status present not encircle the tooth , 3- Encircle the
tooth
 Pocket score – Tissue destruction by pocket depth

0 – Less than 3mm of pocket , 1- 3-5mm 2- more than 5mm

Scores obtained from 6 selected

teeth( 16,21,24,36,41,44)

Gingival Score + Pocket score = NPDI

Treatment Recommendations Scores

0-2 = Oral prophylaxix, Plaque

control

5-7= Complete oral examination,

Perio treatment

8-10 = COE , Refer to periodontist

PERIODONTAL TREATMENT NEED SYSTEM
 Johansen JR, Gjermo P ,Bellini HT in 1973.
 Periodontal therapeutic needs in a population.
 Estimate manpower and costs needed to address the problem found in examination.

CLASS 0-No sign of Inflammation

CLASS 1 – All patients needing any kind of Periodontal treatment
CLASS 2 – Each quadrant with one or more pocket but less than 5mm
CLASS 3 – More than 5mm

Class 0 – No treatment
Class 1 -Motivation and oral hygiene instruction
Class 2 - Scaling and elimination of overhangs
Class 3 - Surgery

PERIODONTITIS SEVERITY INDEX

 Adam RA, Nystorm GP in 1985.
 Assesses the presence or absence of periodontitis as the product of clinical inflammation
and interproximal bone loss determined radiographically using a Modified Schei ruler.
 Full mouth Periapical radiograph –Long cone technique
 The rules are changed from that originally described in that it acknowledges the enamel
junction in ideal health and is divided into tenths , permitting analysis of the percentage
of bone loss in 10% increments.
 CALCULATION = CIS * BLS

CLINICAL INFLAMMATION SCORE BONE LOSS SCORE

0 – Absence of Inflammation in marginal gingiva 0%=0
1- Presence 1-10% = score 1
No inflammation , CIS = 0 So PSI VALUE =O 90-100% = Score 2
When CIS=1 , Then PSI directly to BLS
When BLS =0 So PSI =0
Finally PSI ranges from 0-10
 ADVANTAGES :
 Healthy sites can be distinguished from diseased sites.
 Ratio data can be produced
 Avoidance of the arbitrarily weighted clinical observations
 Direct measurements of periodontitis severity can be made.
DISADVANTAGES:
 Radiographs are necessary
 Radiographs do not permit buccal or lingual PSI calculations.
 Limited to longitudinal studies and

Recording and surveillance systems for periodontal diseases

Eugenio D. Beltrán-Aguilar, Paul I. Eke, Gina Thornton-Evans, and Poul E. Petersen
doi:  10.1111/j.1600-0757.2012.00446.x Periodontol 2000. 2012 Oct; 60(1): 40–53.

Index Develo Type Time Premise Use Advantages Disadvantage

ped by

Periodonta Russell Periodo 1956 Continuity Epidemiologic First index to Underestimate

l Index ntal between al assess s disease
composi gingival and periodontal levels
te periodontal disease at the
involvement epidemiologi
cal level

Periodonta Ramfjo Periodo 1959 Full mouth or Epidemiologic  1)First use Partial
l Disease rd ntal selected teeth al, clinical of a assessment of
Index trials calibrated teeth and sites
periodontal could lead to
probe 2) underestimati
Explicit need on of disease 
to train Coding based
examiners  on ‘zones’ in
Flexible in the probe is
number of less sensitive
teeth and than
sites to be measuring at a
examined precision of 1
mm in loss of
periodontal
attachment
Gingival O’Lear Compos Early Little Screening Introduces Not
Periondont y ite 1960s agreement individuals the concept considered a
al among who need of ‘sextants‘ ‘diagnostic
Index(Peri general periodontal tool‘
odontal practitioners treatment Not widely
screening without used
examinati training, and
on) impractical to
examine all
teeth
Communit World Compos 1982 Uses World Epidemiologic Simplicity, Assesses only
y Health ite Health al surveys speed and pocket depth 
Periodonta Organiz Organization international Questionable
l Index of ation probe uniformity  extension into
Treatment sextants and Provides an treatment
Needs index teeth overview of needs 
the Underestimati
magnitude of on of disease
periodontal levels
care
services 
Widely used
Periodonta Americ Compos 1993 Same as Clinical An Assesses only
l an ite Community screening adaptation of pocket depth 
Screening Dental Periodontal the Questionable
and Associa Index of Community extension into
Recording tion / Treatment Periodontal treatment
Index Americ Needs Index of needs 
an Treatment Underestimati
Acade Needs with on of disease
my of six sites levels
Periodo measured
ntology around each
index tooth
Communit World Compos Late
Elimination Epidemiologic A measure Assesses only
y Health ite 1990s
of the al of loss of pocket depth 
Periodonta Organiz treatment periodontal Questionable
l Index ation needs attachment / extension into
(90) component of Modified in treatment
the CPITN 5th edition to needs 
Included in include all Underestimati
the 4th teeth in each on of disease
Edition of sextant levels
Oral Health
Surveys
DERIVED MEASURES FOR PERIODONTAL DISEASES
 Derived community Attachment loss index
periodontal index

Attachment loss
Attachment loss
extent index
extent index

DERIVED COMMUNITY PERIODONTAL INDEX

 Based on WHO scoring criteria and was derived from worst tooth condition observed for
each quadrant.
 dCPI scoring guidelines: probing depth measurements as Ainamo in 1994 as in CPITN
and CPI 1997.
 A dCPI subject level score was determined by the selection of the worse of the two
quadrant scores.

If a tooth with
bleeding and no If tooth had any probing
calculus, probing depth more than 6mm
depth of 4mm was was scored - 4
scored - 1

ATTACHMENT LOSS INDEX

 These criteria were established to reflect a previously published AL extent and severity
Index (Carlos et al 1986)
 For AL score ,Clinical AL measured in mm at each dental sites examined and calculate
mean AL score.

Five groups - 0 -1 mm , 1.1 – 1.5mm,1.6-2.0mm,2.1-2.5mm, more

than 2.6mm Average Clinical AL

ATTACHMENT LOSS EXTENT INDEX

  Number of dental sites per person affected by clinical attachement loss was summed ,
divided by number of dental sites and multiplies by 100.

0-4 % of sites affected

5-24% of sites affected
25-49% of sites affected
50-74% of sites affected
75% of more sites affected

PERIODONTAL STATUS MEASURES

 Derived based on worst tooth condition observed for each quadrant.
 Overal PSM score was determined by selection of worse of the two quadrants scores..
 PSM scoring range 0-4 is similar to CPI but unlike CPI the PSM incroporates clinical
AL and dental furcation status into the index.
 dCPI. and PSM identify the worst periodontal site assessd to derive a subject level scores
whereas ALEI and AL index identify the summary measures representing a proportion of
all sites.
INDICES FOR ASSESSMENT OF GINGIVAL RECESSION

Sullivan and atkins Mlinek et al Millers index

Mahajans modification
Index of recession
of miller

SULLIVAN AND ATKINS

 Sullivan and Atkins 1968.
 Classified recession involving mandibular incisor teeth.
 Narrow, wide, shallow, and deep .
CRITICAL EVALUATION
 This classification though simple is subjected to open interpretation of the examiner and
interexaminer variability and is therefore not reproducible.
 Sanjeev Jain, Harjit Kaur, Ridhi Aggarwal Classification systems of gingival recession:
An update DOI: 10.4103/0976-4003.201632, Vol 9 issue 1, 2017

MLINEK ET AL 1973
Defects as :
 Shallow – narrow clefts as being < 3mm.
 Deep wide - > 3mm
This modification reduced subjective variation, but it does not specify the landmark for
horizontal measurement as variable measurement may be present at variable distances.

MILLER 1985
4 classes of marginal tissue recession based on:
1. Level of underlying bone
2. Involvement of Mucogingival junction.
Class 1 – Narrow or wide recession do not extend MG line
Class 2 – Narrow or wide, Recession extend MG line
Class 3 – Broad recession extend MG line
Class 4 – Loss of Periodontal Hard and Soft tissues around the tooth
MAHAJAN’S MODIFICATION OF MILLER
 Class I: Gingival recession defects (GRD)not extending to mucogingival junction(MGJ)
 Class II:GRD extending to MGJ/ beyond it.
 Class III: GRD with bone or soft tissue loss in interdental area upto cervical one third of
root surface and / or malposition of teeth.
 Class IV: GRD with severe bone or soft tissue loss in the interdental area greater than
cervical one third of root surface and or severe malpositioning of the teeth

BEST – Class 1,2 with thick Gingival profie

GOOD – Class 1, 2 with thin

FAIR – Class 3 with thick

POOR – Class 3,4 with thin

CRITICAL EVALUATION
 This modification still does not accommodate all clinical conditions. For example, a tooth
with gingival recession not extending up to MGJ but with interdental soft and hard tissue
loss can neither be placed in Class I nor in Class III since there is no mention of
involvement of MGJ in Class II.
INDEX OF RECESSION
 Smith RG in 1997.
 IR consists of two digits separated by a dash .(F2-4*).
 First digit denotes – horizontal component
 Second – vertical component
 Prefix F/L – facial or lingual
 Asterisk* - involvement of mucogingival junction.

CRITICAL EVALUATION
   In cases of extensive vertical component further horizontal component may be allotted at
an intermediate distance between CEJ and base of the defect, which is not clearly
specified.
 Separate values can be assigned for multirooted teeth, which make it more complex. It
may lead to overestimation of the condition as it utilizes subjective awareness of
sensitivity.
 It is also difficult to detect the midpoints of mesial and distal surfaces, in the presence of
intact interdental papilla.
RADIOGRAPHIC BONE CRITERIA INDICES

HULL PS, HILLAM DG

SHEPPARD INDEX
AND BEAL JF INDEX

SHEIHAMINDEX
SHEPPARD A AND STRIFFLER DF BLANKENSTEIN R, MURRAY JJ AND
INDEX LIND OP INDEX
 Sheppard graded the degree of bone resorption from zero to ten visible on radiographs.
 Score 1 : enough loss to be visible on the radiograph.
 Score 5: loss of half the alveolar bone.
 Score 10 : complete loss of alveolar support
 Also evaluated radiographically in Six regions of the Dental arches, average of six region
as the index score.
SHEIHAM AND STRIFFLER INDEX
 Sheiham A and Striffler DF in 1970.
 Radiographic index.
 To assess the bone loss
 0 – Normal
 4 –Loss of continuity of cortical plate , widening of PDL
 5- Supporting bone loss up to 1/3
 6- 1/3 to 2/3 supporting bone loss
 7 – More than 2/3 supporting bone loss
HULL , HILLAM AND BEAL 1975
 Radiographic evidence of periodontitis were recorded as present or absent for
interproximal spaces of Mesial and distal to each of upper and lower first permanent
molars.
Periodontitis present:
 when alveolar crest was irregular with lss of continuity of its surface.
 Widening of PDL space.
 Bone crest was greater than 3mm from CEJ
Bone loss absent:
 Bone crest was approximately 1.5mm from the CEJ.
 Alveolar crest was flat to CEJ
BLANKENSTEIN R, MURRAY JJ, LIND OP,1978
  Radiographic technique was standardized according to Moller, 1966 by using stationary
x ray units.
 Disposable bitewings holders were used.
 Interproximal crest of 17-16,16-15.47-46,46-45,25-26,26-27,35-36,36-37.
Features recorded:
 Irregularity and notching of alveolar crest.
 Linear distance greater than 3mm between the CEJ and bone crest.
 Widening of the periodontal ligament space at its alveolar crest.
 The radiographs were enlarged to 13 fold magnification and distance from inner surface
of alveolar crest to the cementum was measured with dividers.
CONCLUSION
 The major concerns of using these tools to measure periodontal diseases are number of
teeth to be examined (i.e. full mouth or index teeth only) / number of sites ,Precision of
the measurements,Pocket depth vs. loss of attachment,Summarization of site-specific
information and case definition, Reliability of periodontal disease measures.
 These summary measures are needed for continued periodontal disease surveillance in
populations .These factors are to be combined with appropriate index to measure and
report the prevalence, severity and treatment needs in a population.
REFRENCES
 Preventive and community dentistry, Soben Peter, 4 th edition, Arya medi publishing
house .
 Dental Indices Ready Reckoner , P Kalyana Chakravarthy , 1st edition, CBS publishers
 Recording and surveillance systems for periodontal diseases
Eugenio D. Beltrán-Aguilar, Paul I. Eke, Gina Thornton-Evans, and Poul E.
Petersen doi:  10.1111/j.1600-0757.2012.00446.x Periodontol 2000. 2012 Oct; 60(1):
40–53.
 Sanjeev Jain, Harjit Kaur, Ridhi Aggarwal Classification systems of gingival recession:
An update DOI: 10.4103/0976-4003.201632, Vol 9 issue 1, 201.
 Sven Poulsen, Dr Odont Epidemiology and indices of gingival and periodontal disease
The American Academy of Pedodontics Vol. 3, Special Issue.
 Jukka Ainamo et al Development of the World Health Organization (WHO) Community
Periodontal \ Index of Treat ment Needs (CPITN) volume no 32. WHO INDEX OF
TREAMENT NEEDS.
 Primal KS1 , Esther SR2 and Boehm TK ,Periodontal Screening and Recording (PSR)
Index Scores Predict Periodontal Diagnosis , J Dent App - Volume 1 Issue 1 - 2014 ISSN
: 2381-9049
 Sigurd P. Ramfjord The Periodontal Disease Index (PDI) Page 30/602 The University of
Michigan School of Dentistry, Ann Arbor, Michigan.
 A. L. RUSSELL A System Of Classification And Scoring For Prevalence Surveys Of
Periodontal Disease Volume no 35, issue no 3 1954