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

philosophical basis for measuring periodontal diseases has changed several times over a shorter time span. In the early days of modern periodontal research (i.e., the 1950 -1960s), "periodontal disease" was considered a single entity that began with gingivitis and progressed to periodontitis and tooth loss. Gingivitis and periodontitis were seen as different stages of the same disease, a view that no longer finds favor among periodontal researchers. 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 But they have not yet been replaced by new indexes, so methods of measuring periodontal diseases remain in something of a state of flux.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 The oldest reversible index is probably the P-M- A (standing for Papillary - Marginal Attached), which dates from the immediate post-World War II period. With better understanding of the inflammatory process, it gave way to the Gingival Index (GI) of Loe and Silness in the early 1960s. The GI grades the gingiva on the mesial, distal, buccal, and lingual surfaces of the teeth. Each area is scored on a 0 to 3 ordinal scale according to the criteria shown in Table. The GI has been used on selected teeth in the mouth as well as on all erupted teeth. The GI, an index of gingivitis that takes no account of deeper changes in the periodontium, has proved to be useful. It is sufficiently sensitive to distinguish between groups with little and with severe gingivitis, though it may not discriminate as well between, the middle-range. To obtain more sensitivity at the initial stages of gingivitis for clinical trials, the Sulcus Bleeding Index (SBI) adds an extra grade of incipient gingivitis. As mentioned earlier, the tradeoff for increased sensitivity can be reduced diagnostic reliability. The use of gingival bleeding after gentle probing as a measure of gingivitis has become accepted with further experience. Visual assessments of inflammation (color, swelling) are subjective, but the appearance of spots of blood after gently running the probe around the gingival margin is more sensitive and more objective in those sites

that are difficult to view directly. Validity against the GI has also been demonstrated. The major subjective area with a gingival bleeding index is "gentle probing," which has been shown to vary between 3 and 130 grams with different examiner. A further refinement of the bleeding indexes came with the Eastman Interdental Bleeding Index, said to be more sensitive than other measures of papillary bleeding. These refined indexes based on gingival bleeding work well in clinical trials, though this degree of sensitivity is usually not required for surveys. Although it is a useful measure in the clinical management of gingival conditions bleeding on probing is a poor predictor of future periodontitis. Its use in public health programs is not yet clear either, both because of uncertain value as a discriminator in field conditions and because deliberate induction of gingival bleeding in screening programs can hardly be encouraged in light of current sensitivities about infectious diseases. The Modified Gingival Index (MG1) was developed to eliminate the use of bleeding on probing but still to provide high visual sensitivity with incipient gingivitis, although its utility remains to be demonstrated. Gingivitis is an area where valid nonclinical measures would be highly beneficial. Criteria for the gingival index Score 0 1 2 3 Criteria Normal gingiva. Mild inflammation: slight change in color, slight edema. No bleeding on probing. Moderate inflammation: redness, edema, and glazing. Bleeding on probing. Severe inflammation: marked redness and edema. Ulceration. Tendency to spontaneous bleeding.

Periodontitis Many early epidemiological studies of periodontal diseases were based on radiographic surveys of alveolar bone loss. But radiography, although a standard diagnostic procedure in periodontitis clinical trials, 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. In this group, the most widely used periodontal index for many years was the Periodontal Index (PI), described by Russell in 1956. The PI, like other periodontal indexes, developed around this time, was a composite index, meaning that it scored both gingivitis and periodontitis on the same scale. It clearly represented the thinking of its time, for Russell extensively validated his index against the clinical diagnoses of periodontists during its development, one, of the very few so tested. It was also developed as a true ratio scale, again one of the very few. The basis for stating that the PI is invalid in light of modern research can be summarized as follows: 1. Russell recommended that the PI be used without probing, a rule that reflected how firmly the gingivitis-periodontitis continuum was then accepted. Pocketing was thus often diagnosed on the severity of gingivitis (with diagnosis no doubt 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 min or deeper were scored equally unless a tooth was mobile. 2. As a composite index, the PI scored both gingivitis and periodontitis in the same weighted scale. Perceptions of the extent and age-distribution of periodontitis were distorted by what now appears as excessive statistical weight given to gingivitis, even though Russell considered the weighting "very little." 3. The PI assumed generalized distribution of disease in the mouth. When discussing how to measure disease from remaining teeth when many had already been extracted, Russell saw no problem: "If an individual has already lost teeth because of periodontal involvement, there is a strong

likelihood that his remaining teeth will show extensive disease. This statement clashes with current views on site-specificity. 4. The compression of PI data into a group mean, considered one of its advantages when first introduced, masked any statistical distribution, such as the concentration of severe disease in relatively few people, which is today considered a prime research issue. None of this was recognized in the 1960s, however, and the PI was applied in a series of epidemiological studies that correlated disease scores with clinical and social determinants. Soon became accepted as basic knowledge. The PI's major long-term contribution was to introduce the modern era of periodontal research, moving the field past the phase of pure observation toward focused research on natural history, etiology, and control. Its place in the evolution of periodontal research is thus secure, even if the view of periodontal disease that emerged from its use has since been amended. The same fundamental problem of a composite index was evident in the Periodontal Disease Index (PDI), intended as a more sensitive version of the PI for use in clinical trials. Although the PDI is also no longer used, the method of measuring loss of periodontal attachment that Ramfjord described then is still used today. The PDI also gave us the Ramfjord teeth," an examination of six teeth taken to represent the whole mouth. The "Ramfjord teeth" are the maxillary right first molar, left central incisor, and left first bicuspid, the mandibular left first molar, right central incisor, and right first bicuspid. Ramfjord chose this group of teeth to represent the dentition and to save time in clinical examinations. So we are left, in the early 1990s, with no natural successor to the PI as an index for epidemiological studies of periodontitis. Periodontitis in field studies today is usually measured by Ramfjords technique, first described over 30 years ago when he introduced the PDI and referred to as the indirect method of measuring loss of periodontal attachment (LPA). The approach is shown graphically. It consists of measuring first from the gingival crest to the base of the pocket; this gives pocket depth. Second, the cementoenamel junction (CEJ) is located and the distance from the CEJ to the gingival crest recorded. The difference between

the two gives an indirect measure of LPA. These measurements are usually carried out at between two and six sites per tooth, depending on the purposes of the study, and usually for either the "Ramfjord teeth" or the whole dentition. Measuring six sites per tooth for an intact dentition can take 30 to 40 minutes per examination, even for an experienced examiner. A more recent measure, the Extent and Severity Index (ESI), measures extent and severity of LPA, expressed as the percent of sites with LPA greater than 1 mm, and the mean LPA for the affected sites. Because it is an aggregate measure, it may receive limited use. Although the indirect method of scoring LPA is generally considered the best available measure of periodontitis in epidemiology, it is far from ideal because LPA 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, which is most likely to be found from clinical research with a microbiological or immunological marker. Despite considerable research effort, no satisfactory measure of active periodontitis has yet emerged: Periodontal Treatment Needs 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, As an example of an early effort, O'Leary used an adaptation of the PDI he called the Gingival Periodontal Index (GPI). Both gingivitis and pocket depth were scored in six segments, the worst condition found in any one segment was taken as the score for that segment. The Periodontal Treatment Need System (PTNS), which categorized patients into levels of treatment need and assigned times for the type of treatment required, received some use in Norway. In the 1977 edition of its survey procedures manual, WHO recommended something similar, though only a year later that evolved into what became known as the "621" method (from its WHO technical series publication number): examination of the "Ramfjord teeth" in four age-groups for calculus, depth of

pocket, and presence and absence of bleeding. Within a few years, the "621" method metamorphosed into the Community Periodontal Index of Treatment Needs (CPITN), which also incorporates remnants of O'Leary's method and the PTNS. The CPITN was first described in 1982 and with some promotion from WHO it soon became used in much of the world. It differs from earlier indexes in several ways: the most obvious to an examiner is its own periodontal probe, which is characterized by being lighter than most probes (it has been used in a disposable plastic version), marked at 3.5 mm and 5.5 mm, and having a 0.5 mm. diameter ball at its tip. 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 (described as the pressure at which the probe can be inserted under a fingernail without discomfort). Another point of difference is that CPITN 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. For a treatment need survey, the mouth is divided into sextants. For adults aged 20 or more, 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. For persons aged 19 or under, the second molars are not examined. Codes 0 to 4 are ascribed to the sextants examined according to the clinical criteria, and from those findings the patient is categorized into one of four treatment groups on the basis of the most severe condition found. The four treatment categories and a graphic representation of the conditions fitting each category are shown in Figure.

Although it has now received wide use and has led to some impressive contributions to WHO's Global Oral Data Bank, the CPITN still awaits universal acceptance. Although a number of national dental associations have encouraged the use of CPITN by its practitioner members, the American Dental Association is not one of them. The US Indian Health Service, however, has used CPITN in its treatment planning. Some periodontists have criticized its measurement of pockets rather than loss of attachment, and some do not like the "feel" of the probe. The Federation Dentaire Internationale (FDI) developed a detailed "manual" for use of the CPITN. It has to be remembered that CPITN is not an index for determining periodontal status, but rather of treatment need. Time will ultimately determine its value. It seems likely to remain in use in much of the world at least until something clearly superior is developed. 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 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. Indexes for plaque and calculus are also employed in clinical trials for plaque control and anti-calculus agents. One index of oral hygiene that has had wide use in surveys is the OHI-S, the Simplified Oral Hygiene Index. It is quick and practical, though its lack of sensitivity

makes it less useful in the individual patient than in a group. The OHI-S scores calculus and plaque together, both supra and subgingivally. It has not been used much in recent years, especially with the current focus on subgingival, rather than supragingival, plaque and calculus as etiological agents. The Patient Hygiene Performance Index (PHP), intended for monitoring of oral hygiene performance by patients in the dental practice, is also not used much at present. It 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. Silness and Loe developed a Plaque Index (PlI) designed to be used along with their GI. The same surfaces of the same teeth are scored as in the GI and a 0 to 3 scale is again used. The principal difference between the PlI and the OHI-S approach is that the plaque index scores the plaque present according to its thickness at the gingival margin rather than its coronal extent, a measure claimed to be more valid. The PlI is still used in the 1990s. WHO, after several earlier efforts to develop a simple though useful measure of oral hygiene status, settled for its measure of subgingival calculus as part of CPITN. 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. As always, however, the index chosen depends on the purpose of a survey and how the data are to be used. The Volpe- Manhold Index, or VMI, has been widely used in the United States in trials to test agents for plaque control and calculus inhibition. It is intended to score new deposits of supragingival calculus, following a prophylaxis to remove all calculus, in clinical trials. (The reasoning is that all new calculus over a three-month period, the approximate length of a clinical trial to test calculus-inhibiting products, will be supragingival.) The VMI scores calculus deposits on three planes of each of the lower six anterior teeth: gingival, distal, and mesial. A probe is used to measure the linear extent of calculus in increments of 0.5 mm., from 0 to 5.0 mm. The tooth score is the sum of the scores in the three planes; patient total score is the sum of the tooth scores.

Partial-Mouth Periodontal Measurements Because full-mouth examinations for gingival bleeding, LPA, 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 PDI in 1959, and the CPITN uses it today. There seems to be agreement that partial mouth recording is valid for plaque and gingivitis, though one study reported underestimation in the low range of scores and overestimation in the high range. Given the generalized nature of plaque deposits and gingivitis, validity of partial-mouth recording is to be expected. Unfortunately, partial-mouth recording is less satisfactory for LPA and pocketing, where systematic underreporting occurs. Partial-mouth recording is satisfactory for some surveys, but it is not recommended for clinical trials, nor for any other situation that demands a high degree of precision in the data. Criteria for plaque index 0 1 No plaque in the gingival area. A film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may only be recognized by running a probe across the tooth surface. 2 3 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. Abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface.