PD Ch4 Dental indices epidemiology
Introduction
Epidemiological indice
Russel AL
Glickman I
are a graduated scales having upper and lower limits, with scores on the scale corresponding to specific criteria which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.是具有上限和下限的分級量表，量表上的分數與特定標準相對應，該標準旨在允許並促進與通過相同標準和方法分類的其他人群進行比較。
are attempts to quantify clinical condition on a graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods.試圖以分級的方式量化臨床狀況，從而促進以相同標準和方法進行檢查的人群之間的比較。
Objectives and Uses of an Index
In research (for science and publication)
In community health(epidemiology)
For individual patient (In office)
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Provide individual assessment to help patients to recognise an oral problem
Reveal揭示 degree of treatment effectiveness
Motivation in preventive and professional care for control and elimination of diseases
(e.g. oral hygiene practices and compliance of patients)
Determine baseline data before experimental factors are introduced在引入實驗因素之前確定基線數據
Measure the effectiveness of specific agents for prevention control or treatment of oral condition
Measure the effectiveness of mechanical devices for personal care
Shows prevalence and incidence of condition
Baseline data for existing dental practice
Assess the need of the community
Compare the effect of a community program and evaluate the results
Indice Classification
- Direction in which their scores can oscillate 分數波動的方向
- According to the entity measured根據被測實體
- General indices一般指標
- Extent of measurements in oral cavity口腔測量範圍
Reversible index
Irreversible index
Measure condition that can be changed over time
EX: gingival index
Index that measure condition that will not change
EX:dental caries(DMFT)
Full mouth indices
Simplified indices
Patient’s entire periodontium or dentition is measure
EX: Oral hygiene index(OHI)
Measure only a representative sample of the dental apparatus
EX:Simplified Oral Hygiene Index(OHI-S)
Disease Index
Symptom Index
Treatment Index
“D” decay portion of the DMFT index is the best example of disease index
Measuring gingival or sulcular bleeding are essentially examples of symptom indices
“F” filled portion of DMFT index is the best exampl
Simple index
Cumulative累積 index
Index that measures the presence or absence是否存在 of a condition
EX:plaque index
Index that measures all the evidence of a condition, past and present過去和現在
EX:DMF index
Fundamentals of an Index
Objectivity客觀
Validity有效
Reability可靠性
Simplicity
Accuracy準確
Acceptability
Quantifiability可量化性
Should be easy to apply so that there is no
undue time lost during field examinations.
No expensive equipment should be needed.
Criteria for the index should be clear and unambiguous, with mutually exclusive categories.索引的標準應清晰明確，並具有獨家的類別
Must measure disease clinical stage at each point
Sensitivity (true positive rate)
Specificity (true negative rate)
the percentage of people who are correctly identified as having the condition
the percentage of healthy people who are correctly identified as not having the condition.
Should measure consistently at different times and
under a variety of conditions應該在不同時間進行一致的測量，並且在各種條件下
2 compound
Inter-examiner reliability
Intra-examiner reliability
different examiners record the same result.不同的考官記錄的結果相同
same examiner records the same result at repeated attempts.同一考官反复嘗試記錄相同結果
Ability to distinguish between small increments.能夠區分小的增量
Safe and not demanding to the subject
The index should be responsive to statistical
analysis and interpretable.
Indices指標 used for oral hygiene assessment
Oral hygiene index(OHI)
Simplified oral hygiene index(OHI-S)
Patient hygiene performance(PHP)
Turesky, Gilmore, Glickman modification of the quigley hein plaque index
2 component
Background
Developed in 1960 by John C. Green and JR. Vermillion in order to classify and assess oral hygiene status
Simple and sensitive method for assessing groups or individual oral hygiene quantitatively.
Debris/Plaque index (DI)
Calculus index (CI)
0
1
2
3
soft debris covering more than 2/3rd of the exposed tooth surface
0
1
2
3
no debris or stain present
soft debris covering not more than 1/3rd the tooth surface
soft debris covering more than 1/3rd, but not more than 2/3rd,of the exposed tooth surface
No calculus present
Supragingival calculus covering not more than 1/3 of the exposed tooth surface
Supragingival calculus covering more than 1/3 but not more than 2/3 the exposed tooth surface
Supragingival calculus covering more than 2/3 the exposed tooth surface
or presence of extrinsic stains without other debris regardless of the area covered 存在外部污漬而無其他雜物，無論覆蓋區域如何
or presence of individual flecks斑點 of subgingival calculus around the cervical portion of the tooth or both.
continuous heavy band of subgingival calculus around the cervical portion of tooth or both.
OHI index(rules of oral hygiene index)
Third molars and incompletely erupted teeth are not scored because of the wide variations in heights of clinical crowns.
The buccal and lingual debris scores are both taken on the tooth in a segment having the greatest surface area covered by debris
Only fully erupted permanent teeth in segments are scored
The buccal and lingual calculus scores are both taken on the tooth in a segment having the greatest surface area covered by supragingival and subgingival calculus
Calculation
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DI = Buccal.S + Lingual.S / No. of segments
CI = B.S + L.S / No. of segments
OHI = DI + CI
The higher the OHI, the poorer is the oral hygiene of patient
Maximum score for all segments can be 36 (18 each segment) for debris (plaque) or calculus
DI and CI range from 0-6
OHI range from 0-12
Background
John C Greene and JR Vermillion in 1964.
Only fully erupted permanent teeth are scored.
Natural teeth with full crown restorations and surfaces reduced in height by caries or trauma are not scored.
An alternate tooth is then examined.
Simplified
16 and/or 17,18
11 and/or 21
26 and/or 27,28
36 and/or 37,38
31and/or 41
46 and/or 47,48
Calculation and Interpretation
Calculation
Interpretation
DI-S= Total score/ no of surfaces
CI-S= Total score/ no of surfaces
OHI-S= DI-S+ CI-S: range from 0-6
range from 0-3
DI –S and CI-S
OHI –S
Good-0.0-0.6
Fair–0.7-1.8
Poor–1.9-3.0
Good-0.0-1.2
Fair–1.3-3.0
Poor–3.0-6.0
range from 0-3
Uses and applications
Widely used in epidemiological studies of periodontal diseases.
Useful in evaluation of dental health education programs
Evaluating the efficacy of tooth brushes.
Evaluate an individual’s level of oral cleanliness.
Procedure
Background
Introduced in 1968 (Podshadley A.G. and Haley J.V.)
Assessments are based on 6 index teeth.
The extent of plaque and debris over a tooth surface is determined
16 buccal
11 labial
26 buccal
36 lingual
31 labial
46lingual
Apply a disclosing agent揭密劑 before scoring.
Patient is asked to keep it for 30 sec and then expectorate but not rinse.
Examination is made by using a dental mirror.
Each of the 5 subdivisions is scored for presence of stained debris:
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PHP for an individual.
Debris score for individual tooth
PHP index for an individual
Rating score
0= no debris (or questionable)
• 1= debris definitely present.
Add the scores for each of the 5 subdivisions
Total score for all the teeth divided by the number of
teeth examined.
- Excellent : 0 (no debris)
- Fair : 1.8 – 3.4
- Poor : 3.5 – 5.0
- Good : 0.1-1.7
3 tooth debris score = 5+3+1/3 teeth= 3 (Rating score: Poor hygiene)
Plaque index
Background
Scoring criteria
Calculation
SilnessandLoein1964
Assesses the thickness of plaque at the cervical margin of the tooth closest to the gums
All 4 surface are examined
Distal
Mesial
Lingual
Buccal
0
1
2
3
No plaque
A film of plaque adhering to the free gingival margin and adjacent area of tooth the plaque may be seen in situ only after application of disclosing solution or by using probe on tooth surface
Moderate accumulation of soft deposits within the gingival pocket
or the tooth and gingival margin which can be seen
with the naked eye
Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin
Plaque index for
for Area
for a tooth
for group of teeth
for the individual
for group
0-3 for each surface
Sum of the surfaces’ scores and then divided by four (surfaces)
Scores for individual teeth are added and then divided by number of teeth
Indices for each of the teeth are added and then divided by the total number of teeth examined.
All indices are taken and divided by number of individual
Interpretation of Plaque index
Excellent
Good
Fair
Poor
0
0.1-0.9
1.0-1.9
2.0-3.0
Use
Reliable technique for evaluating both mechanical anti plaque procedures and chemical agents.
Used in longitudinal studies and clinical trials.
Background
Quigley and Hein in 1962 reported a plaque measurement that focused on the gingival third of the tooth surface
Only buccal (vestibular) surfaces of the anterior teeth are examined after using basic fuchsine disclosing agent
The Quigley - Hein plaque index was modified by Turesky, Gilmore and Glickman in 1970.
Plaque is assessed on the labial, buccal and lingual surfaces of all the teeth after using a disclosing agent.
Provides a comprehensive method for evaluating anti plaque procedures such as tooth brushing, flossing as well as chemical anti plaque agents
The scores of the gingival 1/3rd area was also redefined
The index is based on a numerical score of 0 to 5.
Score index
0 – no plaque
1 – separate flecks of plaque at the cervical margin of tooth.
2 – thin continuous band of plaque (up to 1 mm)
3 – band of plaque wider than 1 mm but covering less than 1/3rd of the crown of the tooth.
4 – plaque covering at least 1/3rd but less than 2/3rd of the crown of the tooth.
5 - plaque covering 2/3rd or more of the crown of the tooth.
Gingival & Periodontal Disease Indices
Periodontalindex(PI)
Community Periodontal Index of Treatment Needs (CPITN)
Gingival index (GI)
Calculation and Interpretation
Score index
Method
Background
Developed by Loe H. and Silness J. in 1963.
• One of the most widely accepted and used gingival Index.
Assess the severity of gingivitis and its location in 4 possible areas.
Mesial
Lingual
Distal
Facial
Only qualitative changes are assessed.
All surfaces of all teeth or selected teeth or selected surface of all teeth or selected teeth are scored.
The selected teeth as the index teeth are 16,12,24,36,32,44.
The teeth and gingiva are first dried with air and/or cotton rolls.
The tissues are divided into 4 gingival scoring units
facial-margin
mesial-facial papilla
entire lingual margin
disto-facial papilla
A blunt periodontal probe is used to assess the bleeding potential of the tissues.
1
2
0
3
Absence of inflammation/normal gingiva
Mild inflammation, slight change in color, slight edema, no bleeding on probing
Moderate inflammation, moderate glazing, redness, edema and hypertrophy. bleeding on probing
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Severe inflammation, marked redness and hypertrophy ulceration.
Tendency to spontaneous bleeding.
Calculation
Interpretation
If the scores around each tooth are summed and divided by the number of surfaces per tooth examined (4), the gingival index score for the tooth is obtained.
Summing all of the scores per tooth and dividing by the number of teeth examined provides the gingival index score for individual.
0.1 - 1.0 : Mild gingivitis
1.1 – 2.0 : Moderate gingivitis
2.1–3.0:Severegingivitis
Modified Gingival Index (MGI)
Background
Score index
Developed by Lobene, Weatherford, Ross, Lamm and Menaker in 1986.
Assess the prevalence and severity of gingivitis.
Strictly based on non-invasive approach i.e. visual examination only, without any probing.
To obtain MGI , labial and lingual surfaces of the gingival margins and the interdental papilla of all erupted teeth except 3rd molars are examined and scored
0
1
2
3
4
Normal
Low inflammation
(absence of inflammation)
(slight change in color, little change in texture) of any portion of the gingival unit
Mild inflammation
of the entire gingival unit
Moderate inflammation
(moderate glazing, redness, edema, and/or hypertrophy) of the gingival unit.
Severe inflammation
(marked edema /hypertrophy, spontaneous bleeding, or ulceration) of the gingival unit.
Periodontal Index (clinical and XR)
Background
Developed by Rusell AI in 1956.
It was once widely used in epidemiological surveys but not used much now because of introduction of new periodontal indices and refinement of criteria
The PI is reported to be useful among large populations, but it is of limited use for individuals or small groups
All the teeth are examined in this index.
Russell chose the scoring values as 0,1,2,6,8 in order to relate the stage of the disease in an epidemiological survey to the clinical conditions observed.
The Russell’s rule states that “ when in doubt assign the lower score.”
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Calculation and Interpretation
PI score per person=sum of individual scores/no of teeth
Interpretation
Beginning destructive periodontal diseases:1.0-1.9
Simple gingivitis :0.3-0.9
stablished destructive periodontal disease:2.0-4.9
Terminal disease:5.0-8.0
Clinical normally supportive tissue:0.0-0.2
Cpitn prob
Procedure
Background
Developed primarily to survey and evaluate periodontal treatment needs rather than determining past and present periodontal status 主要用於調查和評估牙周治療需求，而不是確定過去和現在的牙周狀態
Treatment needs implies that the CPITN assesses only those conditions potentially responsive to treatment, but not
non-treatable or irreversible conditions.
The community periodontal index of treatment needs was developed by the joint working committee of the WHO and FDI in 1982.
recession of the gingival margin
alveolar bone
The 3rd molars are not included, except where they are functioning in place of 2nd molars
The treatment need in a sextant is recorded only if there are 2 or more teeth present in a sextant and not indicated for extraction. If only one tooth remains in a sextant, then the tooth is included in the adjoining sextant.包含在相鄰的
The mouth is divided into sextants
13-23
24-27
17-14
47-44
43-33
34-37
Probing depth is recorded either on all the teeth in a sextant or only on certain indexed teeth as recommended by WHO for epidemiological surveys.
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for adult >20years
For young people up to 19year
10 teeth are taken into account: 17, 16, 11, 26, 37, 47, 46, 31, 36, 37.
The molars are examined in pairs and only one score the highest score is recorded.
Only 6 index teeth are examined : 16, 11, 26, 46, 31, 36.
The second molars are excluded at these ages because of the high frequency of false pockets (non inflammatory tooth eruption associated)
For Children<15 years
pockets are not recorded although probing for bleeding and calculus are carried out as a routine.
first described by WHO
Design for 2 purposes
Measurement of pockets.
Detection of sub-gingival calculus.
0.5mm--> inflammation,3.5mm--> periodontal disease
Codes and criteria
0
1
2
3
4
Healthy periodontium
TN-0 No need of treatment
Bleeding observed during / after probing
TN-1 Self care
Calculus or other plaque retentive factors seen or felt during probing
TN-2 Professional care
Pathological pocket 4-5 mm. gingival margin situated on black band of the probe.
TN-2Scaling and root planning
Pathological pocket 6mm or more. Black band of the probe not visible
TN-3 Complex therapy by specially trained personnel
DMFT
Very important for exam
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