Indices IN DENTAL

EPIDEMIOLOGY

UNDER THE GUIDANCE OF :

PRESENTED BY :
DR. SHITANSHU MALHOTRA
HAMMAD ULLAH
DR. SHIKHA CHAUDHARY BDS FINAL YEAR
DR. OMVEER SINGH POSTING BATCH - C
DR. CHAMAN ZEHRA
 Contents

1. Introduction 6. Oral hygiene and plaque index

2. Definitions • OHI
• OHI-S
3. Classification of index
• Patient Hygiene Performance
4. Ideal requisites of an index
• Plaque index
5. Objectives and uses of 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

• DMFT • Deans fluorosis
• DMFS • Community fluorosis index
• Dental caries severity index for • Thylstrup – Fejerskov Classification of
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 CRITERIA

0 No calculus present
CALCULUS
INDEX 1 Supragingival calculus covering not
more than 1/3 of the exposed tooth
surface

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.

3 Supragingival calculus covering more

than 2/3 the exposed tooth surface
Supragingival Subgingival or a continuous heavy band of
calculus calculus subgingival calculus around the
cervical portion of tooth or both.
27
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 • INTERPRETATION

• DI –S and CI-S
• CI-S= Total score/ no of surfaces
• Good -0.0-0.6
• OHI -S= DI-S+ CI-S • 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
31
• Poor – 3.0 -6.0
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.

M
MI
M
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.
Debris score
for 1 tooth = 4/5
• RATING SCORES: 1 = 0.8

• Excellent : 0 (no debris) 1 1 1

• Good : 0.1-1.7
• Fair : 1.8 – 3.4
0
• Poor : 3.5 – 5.0
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 44

• Distal 32

• Mesial

• Lingual

• Buccal 36
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 37
Uses

• Reliable technique for evaluating both mechanical anti plaque

procedures and chemical agents.

• Used in longitudinal studies and clinical trials.

38
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. 39
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.
40
• 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.

41
Gingival and periodontal disease
indices
• Gingival index

• Periodontal index

• CPITN

42
 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.

43
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.

44
SCORE CRITERIA

Absence of inflammation/normal
0
gingiva

Mild inflammation, slight change in

1 color, slight edema, no bleeding on
probing

Moderate inflammation, moderate

2 glazing, redness, edema and
hypertrophy. bleeding on probing

Severe inflammation, marked

3 redness and hypertrophy ulceration.
Tendency to spontaneous bleeding.

45
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

46
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.
47
0 1 2 3 4
• Normal (absence • Mild • Mild • Moderate • Severe
of inflammation) inflammat inflammat inflammat inflammat
ion (slight ion of the ion ion
change in entire (moderate (marked
color, little gingival glazing, redness
change in unit redness, and
texture) of edema, edema/hy
any and/or pertrophy,
portion of hypertrop spontaneo
the hy) of the us
gingival gingival bleeding,
unit unit. or
ulceration
) of the
gingival
unit.

48
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.
49
• 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.”

50
 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. There is early notch like resorption of alveolar crest.

6 Gingivitis with pocket formation. The epithelial There is horizontal bone loss involving the entire alveolar
attachment is broken and there is a pocket. There is no 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. There is advanced bone loss involving more than half of
The tooth may be loose, may have drifted, may sound dull the tooth root, or a definite intrabony pocket with
on percussion with metallic instrument, or may be widening of periodontal ligament. There may be root
depressible in its socket. resorption or rarefaction at the apex.

51
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 1.0-1.9
diseases
Established destructive periodontal 2.0-4.9
disease
Terminal disease 5.0-8.0

52
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.

53
• 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.

54
• 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).

55
• 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.

56
57
 Codes and Criteri

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 TN-2 Professional care
seen or felt during probing

3 Pathological pocket 4-5 mm. gingival margin TN-2 Scaling and root planning
situated on black band of the probe.

4 Pathological pocket 6mm or more. Black TN-3 Complex therapy by specially

band of the probe not visible trained personnel
58
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

59
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

60
• Exclusion Criteria
• 3rd molar
• D – decayed
• Teeth extracted
• M – missing due to caries
• Filled for any other reason than • F – filled teeth
caries
• Teeth restored for cosmetic reason

• Supernumerary teeth

61
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
62
63
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

64
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

65
66
Modifications
• dmf index • df index
• For children over 7 years and upto • Exfoliation problem
11 – 12 years • df is used missing are ignored
• Decayed, missing and filled • WHO in survey
primary molar and canines have • dft index
being used to determine dmft
• Mixed dentition
• DMFT and deft are done separately and never added
• Permanent teeth index is done first then deciduous separately

67
Stone’s Index
• Introduced by HH Stone, FE Lawton, ER Bransby and HO Hartley in
1949

68
Caries Severity Index
• Tank Certrude and Storvick Clara 1960

69
 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 Cavitation with breakdown of buccal and lingual
surface
3 Cavitation of 2 mm extending to both embrasures 3 Break down of incisal edge 70
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

71
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

72
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

73
Clinical and radiographic Index by J
Murray and A Shaw in 1975

74
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

75
Denotation Criteria

Pulp exposure is recorded when an opening of pulp chamber is

P/p visible (grossly decayed)

Ulceration of soft tissue of tongue or mucosa by sharp edges of

U/u dislocated decayed carious tooth

Fistula is recorded with pus releasing sinus in relation to exposed

F/f tooth

Abscess is recorded with pus containing swelling in relation to

A/a exposed tooth

76
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

77
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.

78
CLASSIFICATION OF FLUOROSIS
MEASURING INDICES
• DEVELOPMENTAL
DEFECTS OF ENAMEL
INDEX

DESCRIPTIVE

FLUOROSIS SPECIFIC

• THYLSTRUP AND
FERJESKOV
• DEAN’S INDEX

79
DEAN’S FLUOROSIS INDEX
• 1934; TRENDLEY H.DEAN devised
an index for assessing the
presence and severity of mottled
enamel.

80
 The fluorosis index set
criteria for categorization
of dental fluorosis on a
7point scale.

Under his classification all

Although no numbers
those showing hypoplasia
other than mottling of SALIENT were used it was
FEATURES considered to be on
enamel were placed in
ordinal scale.
normal category

Children who had not

lived in the community
continuously or had
obtained domestic water
from other than public
supply are eliminated 81
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.

82
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

Rather Very
Negative Borderline Slight Medium
marked marked

85
86
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)

87
• 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.

88
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)

89
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

90
 RANGE OF SCORES FOR CFI

SIGNIFICANCE

0.0 – 0.4 • Negative

0.4 – 0.5
• Borderline
0.5 – 1.0
1.0 – 2.0 • Slight
2.0 – 3.0
• Medium
3.0 – 4.0
• Marked

• Very Marked

91
• 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.

92
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.

93
 Plane mirror n
probes are used

Prior to
Examination is
examination the
done on a
teeth are dried
portable chair
with cotton wool
out in daylight.
rolls

SALIENT
FEATURES

94
THYLSTRUP – FEJERSKOV
CLASSIFICATION OF FLUOROSIS

95
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.
96
• 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.

97
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.

98
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.

99
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.

100
PROCEDURE

Tooth surface is
Teeth should receive
inspected visually
Natural or artificial a prophylaxis and be
and defective areas
light dried at time of
are tactilely explored
examination
with a probe.

101
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’.

102
 LOCATION OF
TYPE OF DEFECT NUMBER DEMARCATION
DEFECTS
• OPACITY • SINGLE • DEMARCATED • GINGIVAL OR
• HYPOPLASIA • MULTIPLE • DIFFUSE INCISAL HALF
• DISCOLORATION • OCCLUSAL
• CUSPAL
• WHOLE
SURFACE

103
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

104
 General purpose
epidemiological studies
• NORMAL • Code 0

• DEMARCATED OPACITY
• White/cream • Code 1
• Yellow/brown • Code 2

• DIFFUSE OPACITY • Code 3

• Code 4
• HYPOPLASIA
• Diffuse lines
• Diffuse patchy
• Pits • Code 7
• Code 5
• Diffuse confluent • Missing enamel • Code 8
• ANY OTHER DEFECTS • Code 9
• Code 6
• Confluent +Staining+loss Of Enamel 105
Extent of defect
• Normal • Code 0
• < 1/3rd • Code 1
• At least 1/3rd < 2/3rd • Code 2
• At least 2/3rd • Code 3

106
Screening surveys
• NORMAL • CODE 1
• DEMARCATED OPACITY • CODE 2
• DIFFUSE OPACITY • CODE 3
• HYPOPLASIA PITS • CODE 4
• OTHER DEFECTS • CODE 5

107
Dental Developmental Index
modified in 1989

108
Malocclusion Indices

• Index for Orthodontic Treatment Needs (IOTN)

• Peer Assessment Rate Index (PAR)

109
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)

110
Dental Health component (DHC)

Grade 5 – Very Great Grade 4 – Great

• Over jet 6-9mm
• Defects of CLCP
• Reverse over jet >3.5mm no speech
• Over jet more than 9mm problem
• Cross bites with 2mm displacement
• Reverse over jet >3.5mm speech between contact and retruded position
problem • Severe displacement of teeth >4mm
• Impeded eruption • Lateral or open bite >4mm
• Extensive hypodontia • Overbite causing indentation on the palate
or labial gingivae
• Referred by colleague for collaborative care
• Less extensive hypodontia

111
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 contact

• Cross bite with ≤2mm and >1mm • Cross bite ≤1mm displacement between
displacement between retruded and retruded and intercuspal position
intercuspal position • Open bites >1mm ≤2mm
• Open bite >2mm but ≤4mm
• Pre or post normal occlusion with no
• Moderate displacement of teeth with >2mm abnormalities
but ≤ 4mm • Mild displacement of teeth >1mm ≤2mm 112
 Aesthetic Component (AC)

0.5 most 5.0 least

1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
attractive 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.
113
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

114
It has 11 components

1. Upper right segment 7. Right buccal occlusion

2. Upper anterior segment 8. Over jet
3. Upper left segment 9. Over bite
4. Lower right segment 10. Centre line
5. Lower anterior segment 11. Left buccal occlusion
6. Lower left segment

115
Procedure
• Pre and post treatment cast are taken
• PAR ruler specially designed ruler to facilitate scoring

116
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
117
 Anterior and buccal segments displacement
scores
Score Discrepancy Upper

0 0mm to 1mm Canine 8mm

First molar 7mm

1 1.1mm to 2mm
Second molar 7mm
2 2.1mm to 4mm
Total = 22mm (impaction ≤ 18mm)
3 4.1mm to 8mm
Lower
4 Greater than 8mm
Canine 7mm
5 Impacted teeth
First molar 7mm
Mixed dentition crowding assessment using average
mesio-distal widths Second molar 7mm

Total = 21mm (impaction ≤ 17mm) 118

 Buccal occlusion
• The recording zone is from canine to last molar present
Antero-posterior : Transverse :
Score Discrepancy Score Discrepancy
0 Good interdigitation 0 No cross bite
class 1,2 and 3
1 Cross bite tendency
1 Less than half unit
discrepancy 2 Single tooth in cross bite

2 Half unit discrepancy 3 More than one tooth in

cusp to cusp cross bite

Vertical : 4 More than one tooth in

scissor bite
Score Discrepancy
0 No discrepancy in inter
cuspation

1 Lateral open bite on at

least two teeth >2mm
119
 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
120
 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
121
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
122
• 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)

123
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

124
• 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
125
• 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

126
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
127
• 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

128
Thank
you 129
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

130