MEASURING PERIODONTAL DISEASES Introduction: In contrast to the stability of the DMF index for caries over a 50-year period,

d, the philosophical basis for measuring periodontal diseases has changed several times over a shorter time span 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Indexes based on this earlier perception of the condition therefore are now considered invalid But they have not yet been replaced by new indexes, so methods of measuring periodontal diseases remain in something of a state of flux Gingivitis Gingivitis index is a reversible index The oldest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 With better understanding of the inflammatory process, Gingival Index (GI) of Loe and Silness was invented Gingival Index (GI): o 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 o The GI grades the gingiva on the mesial, distal, buccal, and lingual surfaces of the teeth o Each area is scored on a 0 to 3 ordinal scale according to certain criteria o Criteria for the gingival index (Score Criteria): 0 Normal gingiva 1 Mild inflammation slight change in color, slight edema and No bleeding on probing 2 Moderate inflammation redness, edema, glazing and Bleeding on probing

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3 Severe inflammation marked redness and edema, Ulceration and Tendency to spontaneous bleeding o The GI has been used on selected teeth in the mouth as well as on all erupted teeth o 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 o 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 o It is sufficiently sensitive to distinguish between groups with little and with severe gingivitis BUT it may NOT discriminate as well between the middle range o It can distinguish very well between 1 and 3 scores but not between 1 and 2 scores o To obtain more sensitivity at the initial stages of gingivitis for clinical trials, the Sulcus Bleeding Index (SBI) was invented Sulcus bleeding index: o 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 o Criteria for the sulcus bleeding index (Score Criteria): 0 Normal gingiva normal color, normal texture and NO bleeding 1 gingiva apparently normal, bleeding on probing 2 bleeding on probing, change in color, NO edema 3 bleeding on probing, change in color, slight edema 4 bleeding on probing, change in color, obvious edema 5 bleeding on probing and spontaneous bleeding, change in color, severe edema o SBI index has increased sensitivity BUT reduced diagnostic reliability o The use of gingival bleeding after gentle probing as a measure of gingivitis by the SBI index has become accepted with further experience o Visual assessments of inflammation color, texture and swelling by the gingival index are subjective o 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 o 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 o 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

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2. Papillary Bleeding Index (PBI) = an assessment tool used to measure and quantify bleeding in the 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 3. 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 Eastman Interdental Bleeding Index is said to be more sensitive than other measures of papillary bleeding o 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 o Although bleeding on probing is a useful measure in the clinical management of gingival conditions BUT it is a poor predictor of future periodontitis o 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 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?! Modified Gingival Index (MG1): o The gingival index was modified into the Modified Gingival Index (MG1) o 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 o Modified Gingival Index only depends on changes in color and swelling but not bleeding on probing o Modified Gingival Index (MG1) assigns scores of 0-4 ordinal scale according to certain criteria

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o Criteria for the Modified Gingival Index (Score 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 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 index = index scoring both gingivitis and periodontitis on the same scale Russell periodontal index: o 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 o 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 o 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 o With periodontal index all teeth were examined and assessed o Criteria for the Russell periodontal index (Score Criteria): 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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o Periodontal index for one person = sum of individual scores/ number of teeth o 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 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-distributions of periodontitis were distorted by excessive statistical weight given to gingivitis most PI scores describe gingivitis 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 o 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 ** 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

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 Periodontal Disease Index (PDI): o 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 o Periodontal disease index is a composite index too o Periodontal disease index is a 0-6 ordinal scale o Criteria for the Periodontal Disease Index (Score Criteria): 0 no inflammation 1 mild-moderate gingivitis not circumscribing the tooth 2 mild-moderately severe gingivitis circumscribing the whole tooth 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 o 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 o In periodontal disease index a periodontal probe was used to measure the clinical attachment loss unlike periodontal index o The PDI also gave us the Ramfjord teeth "an examination of six teeth taken to represent the whole mouth o 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 o Ramfjord chose this group of teeth to represent the dentition and to save time in clinical examinations o 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 o 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) o 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 Then measure the distance from the base of the pocket to the CEJ

o 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 o 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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 Extent and Severity Index (ESI): o A more recent measure is the Extent and Severity Index (ESI) o 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 o Extent and severity index uses the Ramfjords indirect method of measuring the periodontal attachment loss indirect LPA o Extent and severity index is an aggregate measure and thats why it may receive limited use o What does extent = 20% and severity = 5% mean?!

20% 20% of the examined sites have attachment loss 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: 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

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 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 (GPI): o Gingival periodontal index = an index that assesses both gingival status and periodontal 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 o The 6 segments were:

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

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

Then came the Periodontal Treatment Need System (PTNS) which received some use in Norway Periodontal Treatment Need System (PTNS): o 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 "621" method: o 621 method involves examination of the "Ramfjord teeth" in four age groups for calculus, depth of pocket and presence and absence of bleeding o 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: o 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 mar 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 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 If the probe gets inside the pocket so that the whole black area disappeared then pocket depth is more than 5.5

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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

o In Community Periodontal Index of Treatment Needs the mouth is divided into sextants o The sex sextants are:

Upper right 7 to upper right 4 Upper left 4 to upper left 7 Lower left 3 to lower right 3

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

o 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 The second molars are not examined

o For persons aged 19 or under, we measure the CPITN in 6 teeth 4 posterior and 2 anterior o Codes 0 to 4 are ascribed to the sextants examined according to the clinical criteria, and from those findings the patient is categorized into 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

o Although CPITN has now received wide use and has led to some impressive contributions it still awaits universal acceptance o Some periodontists have criticized its measurement of pockets rather than loss of attachment and some do not like the "feel" of the probe o 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 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 (OHI-S): o 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 o The sex teeth surfaces are:

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

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

o Simplified oral hygiene index includes simplified dental plaque index DI-S and simplified calculus index CI-S o The OHI-S scores calculus and plaque together by 0-3 ordinal ordinal scales, both supragingivally and subgingivally o 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 o 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 (PHP) o 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 o Patient Hygiene Performance Index divides each tooth into 5 subdivisions: 2 interproximal, 1 coronal, 1 middle and 1 cervical o Patient Hygiene Performance Index is also not used much at present Then come the Plaque Index (PI) which was developed by Silness and Loe to be used along with their gingival index (GI) Plaque Index (PI): o Both PI and GI are scored for the same surfaces of the same teeth and they are 0 to 3 ordinal scale o 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 The simplified oral hygiene index scores the coronal extent of plaque

o Plaque index doesnt use a disclosing agent and its measurement is claimed to be more valid o Criteria for the plaque index (Score Criteria): 0 No plaque in the gingival area 1 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 Abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface A simple and useful measure of oral hygiene status is based on the measure of subgingival calculus as 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 o Volpe-Manhold index scores new deposits of supragingival calculus following remove of all calculus by prophylaxis in clinical trials o Volpe-Manhold index scores calculus deposits on three planes of each of the lower six anterior teeth: gingival, distal and mesial o A probe is used to measure the linear extent of calculus in increments of 0.5mm o The tooth score = the sum of the scores in the three planes o The patient total score = is the sum of the tooth scores

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 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 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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