4 Epidemiology

7/22/2019 4 Epidemiology

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MEASURING PERIODONTAL DISEASES

Introduction: In contrast to the stabil ity of the DMF indexfor caries over a 50-year period, the philosophical

basis for measuring periodontal diseases has changed several timesover 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 gingivitisstageIthen progresses to periodontitis stage IIand then progresses to teeth loss

- Gingivitis and periodontitis were seen as different stages of the same disease and it wasproposed 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 intoperiodontitis

Indexes based on this earlier perception of the condition therefore are now consideredinvalidBut they have not yet been replaced by new indexes, so methods of measuring periodontal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 oldestreversible index for gingivitis is the P-M-A Pstand for papillary,Mstands for marginal and Astands 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 gingivitisbased 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 Silnesswas invented

Gingival Index (GI):o

Gingival index =an assessment tool used to evaluate the severity of gingivitis based onvisual inspectionof the gingivae that takes into consideration the color, firmness and

swellingof 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 teetho Each area is scored on a 0 to 3 ordinal scaleaccording to certain criteriao Criteria for the gingival index (Score Criteria):

0 Normal gingiva1 Mild inflammationslight change in color, slight edema and No bleeding onprobing

2 Moderate inflammationredness, edema, glazing and Bleeding on probing


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3 Severe inflammationmarked redness and edema, Ulceration and Tendency tospontaneous bleeding

o The GI has been used on selected teethin the mouth as well as on all erupted teetho 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 theperiodontium and it has been proved to be useful

o It is sufficiently sensitiveto distinguish between groups with l i ttle and with severe gingivi ti sBUT i t may NOT discriminate as wel l between the middle range

o It can distinguish very well between 1 and 3 scores but not between 1 and 2 scoreso To obtain more sensitivityat 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 probingby

assigning a score of 0-5 ordinal scaleaccording to certain criteria

o Criteria for the sulcus bleeding index (Score Criteria):0 Normal gingivanormal color, normal texture and NO bleeding1 gingiva apparently normal, bleeding on probing2 bleeding on probing, change in color, NO edema3 bleeding on probing, change in color, slight edema4 bleeding on probing, change in color, obvious edema5 bleeding on probing and spontaneous bleeding, change in color, severe edema

o SBI index has increased sensitivityBUT reduced diagnostic reliabilityo The use of gingival bleeding after gentle probingas a measure of gingivitis by the SBI

indexhas become accepted with further experience

o Visual assessments of inflammation color, texture and swelling by the gingival indexare subjective

o The appearance of spots of blood after gentle probingaround the gingival margin by thesulcus bleeding indexis more sensitiveand 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 hasbeen shown to vary between 3 and 130 gramswith 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 bleedingthat occurs at the gingival margin during

or immediately after flossing


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2. Papillary Bleeding Index (PBI) =an assessmenttool used to measure and quantify bleeding in the

papillary regionof the gingiva by gentl e probing

and assign a score of 0-4 ordinal scaleaccording to

certain criteria0no bleeding

1one point of blood

2line or multiple points of blood

3triangle of blood

4profuse bleeding

3. Eastman Interdental Bleeding Index (EIBI) =an assessment tool used to determine theextent of interdental inflammationbased on bleeding that occurs within 15 seconds

after a wooden cleaning stickis inserted between the teethEastman Interdental Bleeding Index is said to be more sensitivethan other measures of

papillary bleeding

o Indexes based on gingival bleedingon probing, on flossing, on wooden stick useworkwell in clinical trials, and they are highly sensitivealthough this degree of sensitivity is

usually not required for surveys

o Although bleeding on probing is a useful measure in the clinical management of gingivalconditions BUT it is a poor predictor of future periodontitis

o The use of bleeding on probingin public health programs is not highly recommendedincommunity studies because:

- Deliberate induction of gingival bleedingin screening programscan hardly be encouraged in light of current sensitivities about infectious diseases " "

- Indexes using bleeding on probing are highly sensitive andhigh 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 sensitivemeasure of gingivitis than gingival

index itself and also non-invasivebecause it eliminates the use of bleeding on probingbut

still provide high visual sensitivity with incipient gingivitisearly stages of gingivitis

o Modified Gingival Index only depends on changes in color and swelling but notbleeding on probing

o Modified Gingival Index (MG1) assigns scores of 0-4 ordinal scaleaccording to certaincriteria


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o Criteria for the Modified Gingival Index (Score Criteria):

Gingivitis is an area where valid non-clinical measureswould be highly beneficial oral hygieneinstructions

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 clinicallymanageable in field conditions

The most widely used periodontal index for many years was the Periodontal Index (PI),describedby Russell

All periodontal indices at that time including the periodontal index were composite indices** Composite index =index scoring both gingivitis and periodontitison 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 gingivaand dividing the sum by the number of

teeth present

o Individuals with clinically normal gingivahave an index of 0 to 0.2and the index reaches amaximum of 8.0in persons with severe terminal destructive periodontitisso it is 0-8

ordinal scaleo Periodontal index was a composite indexbecause 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 assessedo Criteria for the Russell periodontal index (Score Criteria):

0 - 0.2clinically normal supportive tissues

0.3 - 0.9simple gingivitis reversible

1.0 - 1.9beginning of destructive periodontal disease reversible

2.04.9established destructive periodontal disease irreversible

5.08.0terminal disease irreversible

0 Normal, No inflammation

1 Localized mild inflammation

2 Generalized mild inflammation

3 Moderate inflammation

4 Severe inflammation


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o Periodontal index for one person = sum of individual scores/ number of teetho The basis for stating that the Periodontal index is invalidin light of modern research can

be summarized as follows:

1. Russell recommended that the Periodontal index be used without probingand this rulereflects how firmly the gingivitis - periodontitis continuum was then acceptedgingivitis(stage I) & periodontitis (stage II)

- Pocketing was thus often diagnosed on the severity of gingivitiswhile in the realitypocketing is always a sign of periodontitis

- The diagnosis was unconsciously influenced by the patient's age and oral hygienestatus

- The opportunity for serious biasis 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 teethwere scored having the same periodontal index score a value

of 2.0 - 4.9regardless of their individual pocket depth value, and mobile teethwere

scored having the same periodontal index score a value of 5.0 8.0regardless of

their actual pocket depth value

2. As a composite index, the Periodontal index scored both gingivitis and periodontitis inthe same weighted scale

** Perceptions of the extent and age-distributions of periodontitis were distorted by

excessive statistical weight given to gingivitismost PI scores describe gingivitis

3.The Periodontal index assumed generalized distribution of the disease in the mouth andthis 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 arevery sitespecific

o The periodontal index was based on a model in which periodontal disease was slowlyprogressing 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 Ramfjordand was

intended as a more sensitive modification of the Periodontal Indexfor use in clinical trials

o Periodontal disease index is acomposite indextooo Periodontal disease index is a 0-6 ordinal scaleo Criteria for the Periodontal Disease Index (Score Criteria):

0no inflammation

1mild-moderate gingivitisnot circumscribing the tooth

2mild-moderately severe gingivitiscircumscribing the whole tooth

3severe gingivitis with bleeding on probing

4pocket extending apical to CEJ not more than 3 mm

5pocket extending apical to CEJ by 3-6 mm

6pocket extending apical to CEJ by more than 6 mm

o The most important feature of Periodontal Disease Index is the fact it measures the clinicalattachment loss relative to the CEJwhich was NOT recorded by Periodontal Index

o In periodontal disease index a periodontal probe was usedto measure the clinical attachmentlossunlike periodontal index

o The PDI also gave us the Ramfjord teeth" an examination of six teeth taken to represent thewhole mouth

o The Ramfjord teeth are:the upper right 6, upper left 1 or 2, upper left 4, lower left 6, lowerright 1 or 2 and lower right 4

o Ramfjord chose this group of teeth to represent the dentition and to save time in clinicalexaminations

o Although the Periodontal Disease Index is no longer used, BUT the selection of the sixRamfjord 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 techniqueof measuring periodontalattachment 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 pocketthis 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, dependingon the purposes of the study, and usually for either the Ramfjord teethor the whole dentition

o Measuring six sites per toothfor an intact dentition can take 30 to 40 minutes perexamination,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 mouthand

severity stage of advancementof loss of periodontal attachment by determining the

percentage of sites within the mouth with Loss of Periodontal Attachment greater than 1

mmextentand the mean Loss of Periodontal Attachment for the affected sitesseverity

o Extent and severity index uses the Ramfjords indirect method of measuring theperiodontal attachment loss indirect LPA

o Extent and severity index is an aggregate measureand thats why it may receive limited useo 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 bestavailable measure of periodontitis in epidemiologyBUT it is still considered far from ideal

because it records past rather than present disease

What would be more usefulwould be to combine these measures of past disease with ameasure of active disease

Despite considerable research effort,no satisfactory measure of active periodontitis has yetemerged

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 factorsthat 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 formany years


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O'Learyused an adaptation of the Periodontal Disease Index of Ramfjordhe called theGingival 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 depthby dividing the whole dentition into 6 segments, and then the worstcondition 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 right 3 to upper left 3- Upper left 4 to upper left 8 - Lower left 8 to lower left 4- Lower left 3 to lower right 3 - Lower right 4 to lower right 8

Then came the Periodontal Treatment Need System (PTNS)which received some use inNorway

Periodontal Treatment Need System (PTNS):o Periodontal Treatment Need Systemcategorized patients into levels of treatment need and

assigned times for the type of treatment required

Then came the "621" method "621" method:

o 621 methodinvolves examination of the "Ramfjord teeth" in four age groupsforcalculus, depth of pocket and presence and absence of bleeding

o Within a few years later, the "621" methodwas converted into the Community PeriodontalIndex 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 Needsdiffers from earlier indexes in several

ways:

The special disposable plastic periodontal probe it uses- Which is characterized by being lighter than most probesand 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 disappearedand the whole black

area is visiblethen pocket depth is less than 3.5

- If the probe gets inside the pocket so that half of the black area disappearedthenpocket depth is between 3.5 and 5.5

- If the probe gets inside the pocket so that the whole black area disappeared thenpocket depth is more than 5.5


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- The purpose of the ballis to assist in feeling subgingival calculus and to prevent theprobe 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 asmean valuesmembers 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 sextantso The sex sextants are: Upper right 7 to upper right 4 - upper right 3 to upper left 3 Upper left 4 to upper left 7 - lower left 7 to lower left 4 Lower left 3 to lower right 3 - 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 molarsare examined in the four posterior sextantsthe upper right

central incisorin the upper anterior sextant, and the lower left central incisorin the lower

anterior sextant

- These 10 teeth are called index teetho For persons aged 19 or under, we measure the CPITN in 6 teeth 4 posterior and 2 anterior

- The second molars are not examinedo

Codes 0 to 4 are ascribed to the sextants examined according to the clinical criteria, andfrom 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 ofthe black area is still visible

- Code 4 = pocketing of 6 mm or morethe 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 itstill awaits universal acceptanceo Some periodontists have criticized its measurement of pockets rather than loss of

attachment and somedo 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 oftreatment 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 measureof 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 calculusoccurring on six representative tooth

surfaces in the mouth

o The sex teeth surfaces are: Facial of upper right 6 - facial surface of upper right 1 Facial of upper left 6 - lingual of lower left 6 Lingual of lower left 1 - lingual of lower right 6

o Simplified oral hygiene index includes simplified dental plaque index DI-S andsimplified calculus index CI-S

oThe OHI-S scores calculus and plaque together by 0-3 ordinal ordinal scales,bothsupragingivally and subgingivally

o Simplified oral hygiene index is quick and practical, though its lack of sensitivitymakes itless 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 onsubgingival rather than supragingival, plaque and calculus as etiological agents

Then come the Patient Hygiene Performance Index (PHP),intended for monitoring of oralhygiene 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 Loeto 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 teethand they are 0 to 3 ordinal

scale

o The principal difference between the PI and the OHI-S approach is that: The plaque indexscores the plaque present according to its thickness at the gingival

margin

The simplified oral hygiene indexscores the coronal extent of plaqueo Plaque index doesnt use a disclosing agentand its measurement is claimed to be more valido 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 surface2 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 subgingivalcalculus as part of CPITN where Soft plaque deposits are ignored

Because calculus appears to be the oral hygiene measure most closely associated withperiodontitis, 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 intrials to test agents for plaque control and calculus inhibitionmouth washes for example

o Volpe-Manhold index scores new deposits of supragingival calculus following remove of allcalculus by prophylaxis in clinical trials

o Volpe-Manhold index scores calculus deposits on three planes of each of the lower sixanterior teeth: gingival, distal and mesial

o A probe is used to measure the linear extent of calculus in increments of 0.5mmo 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 bleedingdepending 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 themouth, 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 mouthrecording is valid for plaque and gingivitis

because of the generalized nature of plaque deposits and gingivitis

Unfortunately, partial mouthrecording is less satisfactory for Loss of Periodontal Attachmentand pocketing

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4 Epidemiology