Dental Indices Used for recording oral diseases in children mainly dental caries, periodontal diseases, fluorosis and malocclusion Dr Darpan Nenava Pg 3rd yr 1 Contents 1. Introduction 6. Oral hygiene and plaque index 2. Definitions 3. Classification of index 4. Ideal requisites of an index 5. Objectives and uses of index • OHI • OHI-S • Patient Hygiene Performance • Plaque index • Turesky, Gilmore, Glickman modification of the Quigley Hein plaque index 2 7. Gingival and periodontal • Functional measure index disease indices • Tissue health index • Gingival index • Dental health index • Periodontal index • Index by J Murray and A Shaw • CPITN • PUFA index 8. Caries index 9. Indices used in dental fluorosis • DMF • Deans fluorosis • def • Community fluorosis index • Stone’s Index • Thylstrup – Fejerskov Classification of • Caries severity index • Dental caries severity index for primary teeth fluorosis • Developmental defects of index 3 10. Malocclusion index • IOTN • PAR index 11. Points to remember 12. References 4 Introduction Unless you can count it, weigh it or express it in a quantitative fashion, you have scarcely begun to think about the disease in a scientific fashion. Lord Kelvin 5 The teeth and their surrounding structures are so definite, so easy to observe, and carry with them, so much of their previous disease history, that the measurement of dental diseases is much easier than the measurement of any other forms of the disease. 6 Definitions • Index is a graduated scale having upper and lower limits , with scores on the scale corresponding to specific criteria which is designed to permit and facilitate comparison with other population classified by same criteria and methods. – Russel AL • Epidemiological indices are attempts to quantitate clinical condition on a graduated scale, thereby facilitating comparison among populations examined by the same criteria and methods. – Irving Glickman 7 An index is an expression of clinical observation in numeric values. It is used to describe the status of the individual or group with respect to a condition being measured. The use of numeric scale and a standardized method for interpreting observations of a condition results in an index score that is more consistent and less subjective than a word description of that condition. – Esther M Wilkins 8 Oral indices are essentially set of values, usually numerical with maximum and minimum limits, used to describe the variables or a specific conditions on a graduated scale, which use the same criteria and method to compare a specific variable in individuals, samples or populations with that same variables as is found in other individuals, samples or populations. – George P Barnes 9 Classification of index • Based upon the direction in which their scores can fluctuate • Upon the extent to which the areas of oral cavity are measured • According to the entity they measure • General indices 10 Based on the direction in which their scores can fluctuate: • Reversible index: Measures condition that can be changed e.g. periodontal index • Irreversible index: Index that measures conditions that will not change e.g. dental caries 11 Depending upon the extent to which areas of oral cavity are measured : • Full mouth indices: Patient’s entire periodontium or dentition is measured. e.g. OHI • Simplified indices: Measure only a representative sample of the dental apparatus. e.g. OHI-S 12 According to the entity which they measure : • Disease Index : “D” decay portion of the DMF index is the best example of disease index • Symptom Index : Measuring gingival or sulcular bleeding are essentially examples of symptom indices • Treatment Index : “F” filled portion of DMFT index is the best example for treatment index 13 General Indices : • Simple index: Index that measures the presence or absence of a condition. E.g. plaque index • Cumulative index: Index that measures all the evidence of a condition, past and present. E.g. DMF index 14 Ideal Requisites of an Index • Simplicity: • Should be easy to apply so that there is no undue time lost during field examinations. • No expensive equipment should be needed. • Objectivity: • Criteria for the index should be clear and unambiguous, with mutually exclusive categories. 15 • Validity: • Must measure what it is intended to measure, so it should correspond with the clinical stages of the disease under study at each point. • 2 components – • Sensitivity : ability to detect the condition when it is present. • Specificity: ability to not detect the condition when it is absent. 16 • Reliability: • Should measure consistently at different times and under a variety of conditions. • 2 components• Inter examiner reliability: different examiners record the same result. • Intra examiner reliability: same examiner records the same result at repeated attempts. • Precision: • Ability to distinguish between small increments. 17 • Acceptability • Safe and not demeaning to the subject. • Quantifiability • The index should be amenable to statistical analysis and interpretable. 18 Objectives and Uses of Index • For individual patient • In research • In community health 19 For Individual Patient • Provide individual assessment to help patient recognize an oral problem • Reveal degree of effectiveness of present oral hygiene practices • Motivation in preventive and professional care for control and elimination of diseases 20 In Research • Determine base line data before experimental factors are introduced • Measure the effectiveness of specific agents for prevention control or treatment of oral condition • Measure the effectiveness of mechanical devices for personal care 21 In Community Health • Shows prevalence and incidence of a condition • Base line data for existing dental practices • Assess the need of the community • Compare the effects of a community program and evaluate the results 22 INDICES USED FOR ORAL HYGIENE ASSESSMENT • ORAL HYGIENE INDEX • SIMPLIFIED ORAL HYGIENE INDEX • PATIENT HYGIENE PERFORMANCE • TURESKY, GILMORE, GLICKMAN MODIFICATION OF THE QUIGLEY HEIN PLAQUE INDEX 23 ORAL HYGIENE INDEX (OHI) • Developed in 1960 • John C. Green and Jack R. Vermillion in order to classify and assess oral hygiene status. • Simple and sensitive method for assessing group or individual oral hygiene quantitatively. • It is composed of 2 components: • Debris index (DI) • Calculus index (CI) 24 RULES OF ORAL HYGIENE INDEX 1 Only fully erupted permanent teeth are scored. 2 Third molars and incompletely erupted teeth are not scored because of the wide variations in heights of clinical crowns. 3 The buccal and lingual debris scores are both taken on the tooth in a segment having the greatest surface area covered by debris. 4 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. 25 DEBRIS INDEX 0 – no debris or stain present 1 – soft debris covering not more than 1/3rd the tooth surface, or presence of extrinsic stains without other debris regardless of the area covered 2 – soft debris covering more than 1/3rd, but not more than 2/3rd,of the exposed tooth surface 3 – soft debris covering more than 2/3rd of the exposed tooth surface 26 SCORE CALCULUS INDEX Supragingival calculus 0 1 No calculus present 2 Supragingival calculus covering more than 1/3 but not more than 2/3 the exposed tooth surface or presence of individual flecks of subgingival calculus around the cervical portion of the tooth or both. Supragingival calculus covering more than 2/3 the exposed tooth surface or a continuous heavy band of subgingival calculus around the cervical portion of tooth or both. 27 3 Subgingival calculus CRITERIA Supragingival calculus covering not more than 1/3 of the exposed tooth surface Calculation • DI = B.S + L.S / No. of seg • CI = B.S + L.S / No. of seg • OHI = DI + CI • DI and CI range from 0-6 • Maximum score for all segments can be 36 for debris or calculus • OHI range from 0-12 • Higher the OHI, poorer is the oral hygiene of patient 28 SIMPLIFIED ORAL HYGIENE INDEX • John C Greene and Jack R 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. 29 16 17,18 11 21 26 27,28 36 37,38 31 41 46 47,48 30 Calculation and Interpretation • DI -S= Total score/ no of surfaces • CI-S= Total score/ no of surfaces • INTERPRETATION • DI –S and CI-S • OHI -S= DI-S+ CI-S • Good -0.0-0.6 • Fair – 0.7-1.8 • Poor – 1.9 -3.0 • DI-S and CI-S range from 0-3 • OHI –S • OHI-S range from 0-6 • Good - 0.0-1.2 • Fair – 1.3- 3.0 • Poor – 3.0 -6.0 31 Uses • 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. 32 PATIENT HYGIENE PERFORMANCE (PHP INDEX) • Introduced by Podshadley A.G. and Haley J.V in 1968. • Assessments are based on 6 index teeth. • The extent of plaque and debris over a tooth surface was determined. 16 buccal 11 labial 26 buccal 36 lingual 31 labial 46 lingual 33 • PROCEDURE: • Apply a disclosing agent before scoring. • Patient is asked to swish for 30 sec and then expectorate but not rinse. • Examination is made by using a mouth mirror. G M M MI D O/I • Each of the 5 subdivisions is scored for presence of stained debris: • 0= no debris(or questionable) • 1= debris definitely present. 34 • Debris score for individual tooth: • Add the scores for each of the 5 subdivisions. • PHP index for an individual : • Total score for all the teeth divided by the number of teeth examined. • RATING SCORES: • Excellent : 0 (no debris) • Good : 0.1-1.7 • Fair : 1.8 – 3.4 • Poor : 3.5 – 5.0 Debris score for 1 tooth = 4/5 = 0.8 1 1 1 1 0 35 12 Plaque index 24 16 • Silness and Loe in 1964 • Assesses the thickness of plaque at the cervical margin of the tooth closest to the gums 36 • All four surfaces are examined • Distal 44 32 • Mesial • Lingual • Buccal 36 Scoring Criteria Score 0 1 2 3 Criteria 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 37 Calculation • Plaque index for area : 0-3 for each surface. • Plaque index for a tooth : Scores added and then divided by four. • Plaque index for group of teeth : Scores for individual teeth are added and then divided by number of teeth. • Plaque index for the individual : Indices for each of the teeth are added and then divided by the total number of teeth examined. • Plaque index for group : All indices are taken and divided by number of individual 38 Interpretation of Plaque index Rating Scores Excellent 0 Good 0.1-0.9 Fair 1.0-1.9 Poor 2.0-3.0 39 Uses • Reliable technique for evaluating both mechanical anti plaque procedures and chemical agents. • Used in longitudinal studies and clinical trials. 40 TURESKY, GILMORE, GLICKMAN MODIFICATION OF THE QUIGLEY HEIN PLAQUE INDEX • Quigley and Hein in 1962 reported a plaque measurement that focused on the gingival third of the tooth surface. Only facial surfaces of the anterior teeth were examined after using basic fuchsin mouthwash as a disclosing agent. • The Quigley - Hein plaque index was modified by Turesky, Gilmore and Glickman in 1970. 41 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. 42 • Plaque is assessed on the labial, buccal and lingual surfaces of all the teeth after using a disclosing agent. • The scores of the gingival 1/3rd area was also redefined. • Provides a comprehensive method for evaluating anti plaque procedures such as tooth brushing, flossing as well as chemical anti plaque agents. • The index is based on a numerical score of 0 to 5. 43 Gingival and periodontal disease indices • Gingival index • Periodontal index • CPITN 44 Gingival Index • Developed by Loe H and Silness J in 1963. • One of the most widely accepted and used gingival indices. • Assess the severity of gingivitis and its location in 4 possible areas. • Mesial • Lingual • Distal • Facial • Only qualitative changes are assessed. 45 METHOD: • 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 a blast of air and/or cotton rolls. • The tissues are divided into 4 gingival scoring units: disto facial papilla, facial margin, mesio facial papilla and entire lingual margin. • A blunt periodontal probe is used to assess the bleeding potential of the tissues. 46 SCORE CRITERIA 0 Absence of inflammation/normal gingiva 1 Mild inflammation, slight change in color, slight edema, no bleeding on probing 2 Moderate inflammation, moderate glazing, redness, edema and hypertrophy. bleeding on probing 3 Severe inflammation, marked redness and hypertrophy ulceration. Tendency to spontaneous bleeding. 47 Calculation and Interpretation • If the scores around each tooth are totaled and divided by the number of surfaces per tooth examined (4), the gingival index score for the tooth is obtained. • Totaling all of the scores per tooth and dividing by the number of teeth examined provides the gingival index score for individual. • Interpretation: • 0.1 - 1.0 : Mild gingivitis • 1.1 – 2.0 : Moderate gingivitis • 2.1 – 3.0 : Severe gingivitis 48 Modified Gingival 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. 49 0 1 2 3 4 • Normal (absence of inflammation) • Mild inflammat ion (slight change in color, little change in texture) of any portion of the gingival unit • Mild inflammat ion of the entire gingival unit • Moderate inflammat ion (moderate glazing, redness, edema, and/or hypertrop hy) of the gingival unit. • Severe inflammat ion (marked redness and edema/hy pertrophy, spontaneo us bleeding, or ulceration ) of the gingival unit. 50 Periodontal Index • 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. 51 • 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.” 52 FIELD STUDIES CLINICAL STUDIES / RADIOGRAPHIC FINDINGS 0 Negative. Neither overt inflammation in the investing Radiographic appearance is essentially normal. tissues nor loss of function due to destruction of supporting bone. 1 Mild gingivitis. An overt area of inflammation in the free gingiva does not circumscribe the tooth 2 Gingivitis. Inflammation completely circumscribe the tooth, but there is no apparent break in the epithelial attachment 4 Used only when radiographs are available. 6 Gingivitis with pocket formation. The epithelial There is horizontal bone loss involving the entire attachment is broken and there is a pocket. There is no alveolar crest, up to half of the length of the tooth root. interference with normal masticatory function; the tooth is firm in its socket and has not drifted. 8 Advanced destruction with loss of masticatory function. The tooth may be loose, may have drifted, may sound dull on percussion with metallic instrument, or may be depressible in its socket. There is early notch like resorption of alveolar crest. There is advanced bone loss involving more than half of the tooth root, or a definite intrabony pocket with widening of periodontal ligament. There may be root resorption or rarefaction at the apex. 53 Calculation and Interpretation • PI score per person = sum of individual scores no of teeth present Clinical Condition Individual Scores Clinical normally supportive tissue 0.0-0.2 Simple gingivitis 0.3-0.9 Beginning destructive periodontal diseases 1.0-1.9 Established destructive periodontal disease 2.0-4.9 Terminal disease 5.0-8.0 54 Community Periodontal Index of Treatment Needs • The community periodontal index of treatment needs was developed by the joint working committee of the WHO and FDI in 1982. • Developed primarily to survey and evaluate periodontal treatment needs rather than determining past and present periodontal status i.e. recession of the gingival margin and alveolar bone. 55 • Treatment needs implies that the CPITN assesses only those conditions potentially responsive to treatment, but not non treatable or irreversible conditions. • Procedure : • The mouth is divided into sextants : 17- 14 13- 23 24- 27 47 – 44 43- 33 34 – 37 • 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. 56 • 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. • FOR ADULTS AGED > 20 yrs: • 10 index 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. • For young people up to 19 yrs: • 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). 57 • When examining children less than 15 yrs pockets are not recorded although probing for bleeding and calculus are carried out as a routine. • CPITN PROBE : • First described by WHO. • Designed for 2 purposes : • Measurement of pockets. • Detection of sub-gingival calculus. 58 59 Codes and Criteria CODE CRITERIA TREATMENT NEEDS 0 Healthy periodontium TN-0 No need of treatment 1 Bleeding observed during / after probing TN-1 Self care 2 Calculus or other plaque retentive factors seen or felt during probing TN-2 Professional care 3 Pathological pocket 4-5 mm. gingival margin situated on black band of the probe. TN-2 Scaling and root planning 4 Pathological pocket 6mm or more. Black band of the probe not visible TN-3 Complex therapy by specially trained personnel 60 Caries Indices • Dmf • Functional measure index • def • Tissue health index • Stone’s Index • Dental health index • Caries severity index • Index by J Murray and A Shaw • Dental caries severity index for • PUFA index primary teeth 61 DMF Index • Bodecker CF and Bowdecker HWC 1931 gave term caries • Henry Klein, Carrole E Palmer and JW Knutson 1938 gave DMF index • Only permanent teeth • 28 teeth are included 62 • Exclusion Criteria • 3rd molar • Teeth extracted • Filled for any other reason than • D – decayed • M – missing due to caries • F – filled teeth caries • Teeth restored for cosmetic reason • Supernumerary teeth 63 Features of DMF • • • • • • • • • • Tooth is counted only once Decayed, missing and filled teeth should be recorded separately Recurrent caries is also counted as decay Extraction indicated teeth are included in missing Many restoration is counted as one score Root stump is also scored 1986 WHO modification includes 3rd molars Cant be used in children Not accurate Overestimate caries 64 65 Limitations • DMFT values are not related to the number of teeth at risk • Can be invalid in older patients because teeth can become lost for reasons other than caries • Can be misleading in children whose teeth lost due to orthodontic reasons • Can overestimate caries experience in teeth in which preventive filling have been placed • Little use in root caries 66 def Index • Gruebbel AD 1944 as an equivalent index to DMF for measuring dental caries in primary dentition • d – Indicates the number of deciduous teeth decayed. • e – Indicates deciduous teeth extracted due to caries & indicated for Xn • f – Indicates restored teeth without recurrent decay 67 68 Modifications • dmf index • For children over 7 years and upto 11 – 12 years • Decayed, missing and filled primary molar and canines have being used to determine dmft • df index • • • • Exfoliation problem df is used missing are ignored WHO in survey dft index • Mixed dentition • DMFT and deft are done separately and never added • Permanent teeth index is done first then deciduous separately 69 Stone’s Index • Introduced by HH Stone, FE Lawton, ER Bransby and HO Hartley in 1949 70 Caries Severity Index • Tank Certrude and Storvick Clara 1960 71 Dental Caries Severity Index for primary teeth • Designed by Aubrey Chosack 1985 Occlusal surface Proximal surfaces of molar Score Criteria Score Criteria 1 Early pit and fissure caries 1 Discontinuity of enamel 2 Cavitation of 1mm 2 Cavitation with breakdown of marginal ridge 3 Cavitation with breakdown of half tooth 3 Break down of marginal ridge to proximal extensions of occlusal surface Buccal-lingual and palatal smooth surface Proximal surfaces of Incisors Score Criteria Score Criteria 1 White lesion not extending to embrasure 1 Discontinuity of enamel 2 Cavitation of 1-2mm extending to one embrasure 2 3 Cavitation of 2 mm extending to both embrasures Cavitation with breakdown of buccal and lingual surface 3 Break down of incisal edge 72 Functional measure Index • Sheiham, Maizels A, Maizels J in 1987 • Filled and sound teeth are measured while decayed and missing teeth is given zero FMI = (Filled + Sound) / 28 73 Tissue health Index • Sheiham, Maizels A, Maizels J in 1987 1 – decayed 2 – filled 4 – sound Tissue health index (THI) = ¼(1*decayed+2*filled+4*sound)/28 Third molars are excluded Score ranges from 0 – 1 74 Dental health Index • JJ Carpay, FHM Nieman, KG Konig, AJA Felling and JGM Lammers in 1968 • Sound teeth were given a score of +1 affected teeth a score of -1 DHI = sound teeth – (decayed + filled +missing teeth)/ sound teeth + decayed + filled + missing teeth Score ranges from – 1 to + 1 75 Clinical and radiographic Index by J Murray and A Shaw in 1975 76 PUFA Index • Jindal M and Khan S in 2012 • Assess the presence of oral conditions resulting from untreated caries both in primary and permanent dentition • Upper case for permanent and lower case for primary dentition • Assessment is made visually without any instrument 77 Denotation Criteria P/p Pulp exposure is recorded when an opening of pulp chamber is visible (grossly decayed) U/u Ulceration of soft tissue of tongue or mucosa by sharp edges of dislocated decayed carious tooth F/f Fistula is recorded with pus releasing sinus in relation to exposed tooth A/a Abscess is recorded with pus containing swelling in relation to exposed tooth 78 Calculation and Interpretation PUFA/pufa = (filled + sound)* 100 /D+d Higher scores indicates dental treatment is neglected either due to lack of knowledge, facility available, cost and importance of dentition. Advantages • Easy to use • No instruments required • Used for planning monitoring and implementing oral health programs keeping in view cause of negligence 79 Dental Fluorosis Index • DENTAL FLUOROSIS : is a hypoplasia or hypo-mineralisation of tooth enamel or dentine produced by the chronic ingestion of excessive amounts of fluoride during the period when teeth are developing. 80 CLASSIFICATION OF FLUOROSIS MEASURING INDICES • DEVELOPMENTAL DEFECTS OF ENAMEL INDEX DESCRIPTIVE FLUOROSIS SPECIFIC • THYLSTRUP AND FERJESKOV • DEAN’S INDEX 81 DEAN’S FLUOROSIS INDEX • 1934; TRENDLEY H.DEAN devised an index for assessing the presence and severity of mottled enamel. 82 The fluorosis index set criteria for categorization of dental fluorosis on a 7point scale. Under his classification all those showing hypoplasia other than mottling of enamel were placed in normal category SALIENT FEATURES Children who had not lived in the community continuously or had obtained domestic water from other than public supply are eliminated Although no numbers were used it was considered to be on ordinal scale. 83 METHOD ( as implied by DEAN) Each individual receives a score corresponding to clinical appearance of two most affected teeth • Examinations are made in good natural light with the subject sitting facing the window No specific information as to whether the teeth were cleaned or dried before examination is given • Mouth mirror and probes were utilized for examination. 84 CLASSIFICATION AND CRITERIA NORMAL • The enamel represents the usual translucency semi-vitriform type of structure • The surface is smooth, glossy and usually of pale creamy white color QUESTIONABLE • Slight aberrations in translucency of normal enamel ranging from few white flecks to occasional white spots, 1-2mm in diameter. VERY MILD • Small, opaque, paper white areas are scattered irregularly or streaked over the tooth surface • Observed on labial and buccal surfaces ; <25% of teeth surface involved. • Small pitted white areas are frequently found on summits of cusps • No brown stain MILD • White opaque areas involve half of tooth surface. • Surfaces of cuspids n bicuspids prone to attrition show thin white layers worn off and bluish shades of normal enamel • Faint brown stains are apparent MODERATE • No change in form of tooth but all surfaces are involved • Surfaces subjected to attrition are definitely marked • Minute pitting is present on buccal n labial surfaces MODERATELY SEVERE • Smoky white appearance • Pitting is more frequent and generally seen on all surfaces • Brown stain if present has more hue and involves all surfaces SEVERE • Form of teeth are affected. • Pits are deeper and confluent • Stains are widespread and range from chocolate brown to almost black Based on this index, Dean. Dixon and Cohen(1935) proposed that their classification should determine a mottled enamel index of a community for epidemiological purpose Negative Borderline Slight Medium Rather marked Very marked 87 88 USES • Most widely used index to measure dental fluorosis. • Helped to indicate prevalence of moderate to severe fluorosis in many communities as Sweden by Forsman in 1974 Austria by Binder in 1973 England by Murray et al(1956), Forrest (1965), Goward (1976) USA by Galagan and Lamson (1953) India by Nanda et al (1974) 89 • The National Survey of Children’s Dental Health in Ireland in 1984 measured fluorosis using Dean’s index to provide baseline data for future reference. ( Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM;2004) • National Fluorosis Survey in USA in 1986-87 to note baseline values was done using Dean’s index. 90 LIMITATIONS • Does not give sufficient information on distribution of fluorosis within the dentition. • Isolated defects are not recorded. • The distinction amongst the categories is unclear, indistinct and lacking sensitivity. • Even though Dean’s scale is ordinal , it involves averaging of the scores which is inappropriate. (A. Rizan Mohamed,W. Murray Thomson;Timothy D. Mackay, An epidemiological comparison of Dean’s index and the Developmental Defects of Enamel (DDE) index; JPHD ISSN 0022-4006) 91 COMMUNITY FLUOROSIS INDEX • 1942 , based on the revised fluorosis index scale , he developed a scoring system so as to derive a COMMUNITY FLUOROSIS INDEX . • On basis of the number and distribution of individual scores, a community index for dental fluorosis (Fci) can be calculated by the formula Fci = sum of no. of individuals * statistical weights)/ no. of individuals examined 92 RANGE OF SCORES FOR CFI SIGNIFICANCE 0.0 – 0.4 • Negative 0.4 – 0.5 • Borderline 0.5 – 1.0 • Slight 1.0 – 2.0 • Medium 2.0 – 3.0 • Marked 3.0 – 4.0 • Very Marked 93 • It gives an indication of public health significance of fluorosis. • It was used by Galagan and Lamson (1953) in their investigation of climate and endemic fluorosis. • Minoguchi (1970) refined the above analysis to take into account the total fluoride content from the diet by a community. • Myers(1978) suggested a graphic method of obtaining optimal fluoride concentration by comparing CFI against water fluoride content at different temperatures. 94 THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS • 1978 ; Thylstrup and Frejeskov suggested a 10point classification system designed to categorize the degree of fluorosis affecting buccal/lingual and occlusal surfaces. 95 Plane mirror n probes are used Prior to examination the teeth are dried with cotton wool rolls Examination is done on a portable chair out in daylight. SALIENT FEATURES 96 THYLSTRUP – FEJERSKOV CLASSIFICATION OF FLUOROSIS 97 Advantages • It attempts to validate the visual appearance against the histological defect. • Most sensitive of all fluorosis measuring indices. • Granath et al. (1985), comparing the DEAN and T-F indexes, concluded that the latter was more detailed and sensitive because it was based on biological aspects where there is an increase in hypo mineralization with a simultaneous increase in the depth of the enamel surface in direction of the amelo-dentin junction. 98 • Cleaton-Jones and Hargreaves (1990) compared the two fluorosis indexes (DEAN and T-F) in deciduous dentition, reporting that the prevalence of fluorosis in individual teeth was more frequently diagnosed with the T-F index. They concluded that the T-F index is the most indicated for work where detailed information about the problem is required. 99 USES • To assess the impact of enamel fluorosis in three communities examined in project FLINT.( Sigourjon’s H et al 2004) • Burger et al. (1987), recommended the T-F index for future field studies, due to the facility of use and better defined criteria. 100 Disadvantages • Clarkson (1989) reported that in TF index drying of teeth creates an unnatural situation due to which changes in score 1 and 2 are very minor. The aesthetic significance of these changes are questionable. 101 DEVELOPMENTAL DEFECTS OF INDEX • The developmental defects of enamel was developed by “ FDI – Commission on Oral Health, Research and Epidemiology” in 1982 to avoid need for diagnosing fluorosis before recording enamel opacities. 102 PROCEDURE Tooth surface is inspected visually and defective areas are tactilely explored with a probe. Natural or artificial light Teeth should receive a prophylaxis and be dried at time of examination 103 CODING AND CRITERIA • Un-erupted, missing, heavily restored , grossly decayed , fractured teeth and teeth or tooth surfaces which for any other reason cannot be classified with defects must be coded ‘X’. • Permanent teeth are number coded. • Primary teeth are letter coded. • When in doubt the tooth surface should be scored ‘normal’. • When an abnormality is present but cannot be classified into listed categories, it should be scored as ‘other defects’. 104 TYPE OF DEFECT • OPACITY • HYPOPLASIA • DISCOLORATION NUMBER • SINGLE • MULTIPLE DEMARCATION • DEMARCATED • DIFFUSE LOCATION OF DEFECTS • GINGIVAL OR INCISAL HALF • OCCLUSAL • CUSPAL • WHOLE SURFACE 105 MODIFICATIONS • Clarkson J.J and O’Mullane D.M in 1985 modified the DDE to be used in one of the two manners General purpose epidemiology studies Screening surveys 106 General purpose epidemiological studies • NORMAL • DEMARCATED OPACITY • White/cream • Yellow/brown • DIFFUSE OPACITY • Diffuse lines • Diffuse patchy • Diffuse confluent • Code 0 • Code 1 • Code 2 • Code 3 • Code 4 • Code 5 • Confluent +Staining+loss Of • Code 6 Enamel • HYPOPLASIA • Pits • Missing enamel • ANY OTHER DEFECTS • Code 7 • Code 8 • Code 9 107 Extent of defect • Normal • < 1/3rd • At least 1/3rd < 2/3rd • At least 2/3rd • Code 0 • Code 1 • Code 2 • Code 3 108 Screening surveys • NORMAL • DEMARCATED OPACITY • DIFFUSE OPACITY • HYPOPLASIA PITS • OTHER DEFECTS • CODE 1 • CODE 2 • CODE 3 • CODE 4 • CODE 5 109 Dental Developmental Index modified in 1989 110 Malocclusion Indices • Index for Orthodontic Treatment Needs (IOTN) • Peer Assessment Rate Index (PAR) 111 Index For Orthodontic Treatment Needs (IOTN) • P.H. Brook and W.C. Shaw 1989 • Two components • Functional and dental health component (DHC) • Aesthetic component (AC) 112 Dental Health component (DHC) Grade 5 – Very Great • Defects of CLCP • Over jet more than 9mm • Reverse over jet >3.5mm speech problem • Impeded eruption • Extensive hypodontia Grade 4 – Great • Over jet 6-9mm • Reverse over jet >3.5mm no speech problem • Cross bites with 2mm displacement between contact and retruded position • Severe displacement of teeth >4mm • Lateral or open bite >4mm • Overbite causing indentation on the palate or labial gingivae • Referred by colleague for collaborative care • Less extensive hypodontia 113 Grade 3 – Moderate Grade 2 – Little • Over jet >3.5mm <6mm incompetent lips • Over jet >3mm ≤6mm competent lips • Reverse over jet >1mm ≤3.5mm • Reverse over jet >0mm ≤1mm • Overbite without indentation or signs of • Increased over bite >3.5mm no gingival trauma • Cross bite with ≤2mm and >1mm displacement between retruded and intercuspal position • Open bite >2mm but ≤4mm • Moderate displacement of teeth with >2mm but ≤ 4mm contact • Cross bite ≤1mm displacement between retruded and intercuspal position • Open bites >1mm ≤2mm • Pre or post normal occlusion with no abnormalities • Mild displacement of teeth >1mm ≤2mm 114 Aesthetic Component (AC) 0.5 most attractive 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 least attractive • A patient score is based on matching his/her dental appearance with one of a series of 10 photographs showing labial aspect of different class 1 class 2 malocclusion ranked according to there attractiveness • 0.5 being the most attractive and 5.0 being the least attractive. 115 Peer Assessment Rating Index (PAR) • Index of treatment standards • S Richmond, W.C. Shaw, K.D. O’Brien, I.B. Buchanan, R Jones, C.D. Stephens, C.T. Roberts, M Andrews in 1992 • To measure the malocclusion assess the outcome of orthodontic treatment at any stage 116 It has 11 components 1. 2. 3. 4. 5. 6. Upper right segment Upper anterior segment Upper left segment Lower right segment Lower anterior segment Lower left segment 7. Right buccal occlusion 8. Over jet 9. Over bite 10. Centre line 11. Left buccal occlusion 117 Procedure • Pre and post treatment cast are taken • PAR ruler specially designed ruler to facilitate scoring 118 Anterior and buccal segments • Arches divided into three segments scores recorded for both upper and lower arch • Buccal recording zone is from mesial anatomical contact point of the 1st permanent molar to the distal contact point of the canine. • Anterior recording zone is mesial contact point of canine to the mesial point on other side • Occlusal traits recorded are crowding, spacing, and impacted teeth • A tooth is considered and scored “impacted” when the space is ≤ 4mm • Impacted canines are recorded in anterior segment • Displacement and impacted scores are added to obtain an overall score for each recording segment • In mixed dentition if there is potential for crowding average mesio-distal width are used to calculate space deficiency 119 Anterior and buccal segments displacement scores Score Discrepancy 0 0mm to 1mm 1 1.1mm to 2mm 2 2.1mm to 4mm Upper Canine 8mm First molar 7mm Second molar 7mm Total = 22mm (impaction ≤ 18mm) 3 4 5 4.1mm to 8mm Greater than 8mm Lower Canine 7mm First molar 7mm Second molar 7mm Impacted teeth Mixed dentition crowding assessment using average mesio-distal widths Total = 21mm (impaction ≤ 17mm) 120 Buccal occlusion • The recording zone is from canine to last molar present Transverse : Antero-posterior : Score Discrepancy Score Discrepancy 0 Good interdigitation class 1,2 and 3 0 No cross bite 1 Cross bite tendency 2 Single tooth in cross bite 3 More than one tooth in cross bite 4 More than one tooth in scissor bite 1 Less than half unit discrepancy 2 Half unit discrepancy cusp to cusp Vertical : Score Discrepancy 0 No discrepancy in inter cuspation 1 Lateral open bite on at least two teeth >2mm 121 Over jet measurements • Include positive over jet and cross bite • Recording zone is from left lateral incisor to right lateral incisor and is scored from most prominent feature of any one incisor when assessing over jet PAR ruler is placed parallel is placed parallel to occlusal plane and radial to the line of arch scores for over jet and cross bite are totaled for the over all over jet scores. Over jet measurements Anterior Cross-Bite Score Discrepancy Score Discrepancy 0 0 – 3 mm 0 No discrepancy 1 3.1 – 5 mm 1 One or more teeth edge to edge 2 5.1 – 7 mm 2 One single tooth in cross bite 3 7.1 – 9 mm 3 2 teeth in cross bite 4 > 9mm 4 >2 teeth in cross bite 122 Over bite measurements • It is a vertical overlap or open bite of anterior teeth in relation to coverage of lower incisors or the degree of open bite • Recording zone includes lateral incisors and the tooth with greatest overlap is recorded • Cross bites including canines are recorded in anterior segments Over bite measurements Over bite Score Discrepancy Score Discrepancy 0 No open bite 0 No discrepancy 1 Open bite ≤ 1mm 1 One or more teeth edge to edge 2 1.1 – 2 mm 2 One single tooth in cross bite 3 2.1 – 3 mm 3 2 teeth in cross bite 4 ≥ 4 mm 4 >2 teeth in cross bite 123 Centre line Assessments • The Centre line assessment is the centre line discrepancy in relation to the lower central incisors • If a lower central incisor has been extracted the measurement is not recorded Centre line Assessments Score Discrepancy 0 Coincident and up to one quarter lower incisor width 1 One quarter to one half lower incisor width 2 Greater than one half of lower incisor width 124 • Once the total score is obtained for all 11 segments the scores are summed to calculate the over all PAR score • 0 indicates excellent alignment and occlusion and higher scores rarely beyond 50, would indicate increasing levels of alignment and malocclusion • For determining outcome of the treatment, change indicates degree of improvement and success of treatment • Degree of improvement may also be determined using a nomogram • A nomogram is divided into three segments • Upper (worse or no change) • Middle (improved) • Lower (greatly improved) 125 PAR Index Guidelines • General • • • • Scoring is accumulative No maximal cut off. Occlusion should be scored disregarding functional displacement. Contact points are not recorded between 1st 2nd 3rd molar however severe deviations will produce a cross bite and will be noted in the buccal occlusion • If a contact point displacement is due to poor restorative work then not included • Contact point between deciduous teeth not included • Extraction spaces not included if patient will receive prosthetic replacement, however if space closure is intended then adjacent teeth are noted 126 • Canines • Where there are missing canines displacements resulting from discrepancies between the mesial contact point to the 1st premolar and the distal of the lateral incisor should be recorded in the anterior segment. • Canine cross bites should be recorded in the over jet segment • Contact points between canines and premolars are scored as follows • The distal contact point of canine to the midpoint on the mesial surface of the adjacent premolar. • Impaction • Unerupted or displaced from the line of the arch either buccally or palatally due to insufficient space this is regarded as impaction • If erupted n displaced displacement score is recorded 127 • Incisors • Lost due to agenesis/ trauma/caries • If for prosthesis adjacent teeth are not recorded • If space is to be closed adjacent teeth are recorded • In over jet when falling on line lower grade is recorded • Lower incisor is extracted or missing centre line is not recorded • Molars • Contact points between 1st and 2nd molar are not recorded • If 1st molar is extracted contact point of 2nd molar is recorded 128 Points to Remember • Russel AL defines Index as a graduated scale having upper and lower limits , with scores on the scale corresponding to specific criteria which is designed to permit and facilitate comparison with other population classified by same criteria and methods. • Index used for evaluation of caries in primary dentition is ‘deft’ where ‘e’ stands for those deciduous teeth which are extracted due to caries or even those teeth that are indicated for extraction 129 • Caries indices for permanent teeth and deciduous teeth have to be done separately • OHI-S most commonly used index • Dean’s fluorosis index most commonly used index for fluorosis 130 Thank you 131 References • Soben Peter. Indices in dental epidemiology. Essentials Of Preventive and Community Dentistry 3ed.123-231. • Nikhil Marwah. Textbook of pediatric dentistry 3ed.1009-1018 • Kinane DF, Lindhe J. Pathogenesis of periodontitis. In: Lindhe J, Karring T, Lang NP, Eds. Clinical Periodontology and Implant Dentistry, 3rd ed. Copenhagen: Munksgaard, 1997, 189- 225. • Brook, P.H.; Shaw, W.C. The development of an index of orthodontic treatment priority. Eur. J. Orthod. 1989, 11, 309-320 132
