Periodontal Screening and Recording (PSR)

Background, history
Periodontal disease continues to be a significant health problem and is one of the major
causes of tooth loss in adults in the United States and throughout the world (Oliver et al
1998; Sheiham and Ong, 1998). There have been a number of screening systems that
have been developed to detect periodontal disease such as the Periodontal Index (Russell,
1956), Peridontal Disease Index (Ramfjord, 1959), Periodontal Treatment Needs System
(Johansen et al 1973) Community Periodontal Index of Treatment Needs (Ainamo, et al,
1982) and the Extent and Severity Index (Carlos et al, 1986). None of these, however,
have been universally accepted or are routinely used by most general practitioners
(Covinton et al, 2003).

To help, the American Dental Association (ADA) with the endorsement of the American
Academy of Peridontology (AAP) introduced the Periodontal Screen and Recording
IndexTM(PSR) as the system recommended for the early detection of patients with
periodontal disease in the US on October 6, 1993. Two years later, the Canadian Dental
Association (CDA) and the Canadian Periodontist Association (CPA) followed suit and
adopted the index. Apart from one major difference (the asterisk Code), the PSR Index is
virtually identical to the Community Periodontal Index of Treatment Needs which is
endorsed by the World Health Organization (WHO) (Landry and Jean, 2002). The
asterisk is utilized to indicate the presence of furcation involvement, tooth mobility,
mucogingival problems and gingival recession exceeding 3.5mm.

References:
Ainamo J, Barnes D, Beagrie G, et al. Development of the World Health Organization
(WHO)

Community Periodontal Index of Treatment Needs (CPITN). International Dental

Journal Journal 1982 (32): 281-291.

Carlos JP, Wolf MD, Kingman A. The extent of severity index: a simple method for use
in epidemiologic studies of periodontal disease. J Clin Periodontol 1986; 3:500.

Covinton LL, Breault L, Hokett S. The application of Periodontal Screening and

Recording on a military population. J Contemp Dent Pract 2003; (3):2-10.

Johansen JR, Gjermo P, Bellini HT. A system to classify the need for periodontal
treatment. Acta Odontol Scand. 1973; 31(5):297-305.
Oliver RC, Brown LJ, Loe H. Periodontal diseases in the United States population.
Journal of Periodontology 1998; 69:269-78.

Ong G. Periodontal disease and tooth loss. International Dental Journal 1998; 48: 233-
238.

Ramfjord SP. Indices for prevalence and incidence of periodontal disease. J Periodontol
1959;30: 350-359.

Russell AL. A system of classification and scoring for prevalence surveys of periodontal
disease. J Dent Res 1956;35: 350-58.

Sheiham A, Netuveil G. Periodontal disease in Europe. Periodontology 2000; 29:104-

121.

How administered
The PSR index divides the mouth into 6 segments (sextants) and the greatest probe depth
in each sextant of the mouth is determined and recorded. Probing is accomplished by a
plastic PSR probe that has a .5mm diameter ball tip and a color-coded band extending
3.5mm to 5.5 mm from the tip. The probe is gently inserted into the gingival sulcus until
resistance is met and then explored by “walking” around the tooth or implant. At least
six areas in each tooth or implant should be examined: mesiofacial, midfacial, distofacial,
and the corresponding lingual/palatal areas.

Scale scoring and normative values

Codes range from 0-4 where code 0 indicates that there is probing depth that is less than
3.5mm in the deepest crevice in the sextant with no calculus or defective margins or
bleeding on probing detected. Code 1 only differs from code 0 in that bleeding is present.
Code 2 only differs from Code 0 in that there is supra- or subgingival calculus and/or
defected margins present. Code 3 indicates that the probing depth is greater than 3.5mm
but less than 5.5mm. Code 4 indicates that the probing depth is greater than 5.5mm.
Sextants with fewer than two teeth are scored with an X and are not considered in the
overall evaluation. Each code can have an asterick * placed depending on clinical
abnormalities including but not limited to furcation invasion, mobility, mucogingival
problems, or recession extending to the colored area of the probe (3.5 mm or grater).

As to findings on 6,723 patients utilizing this index, Salkin, Cuder and Rush (1993) had
only 4.4% of their patients who screened 0 in all sextants; 12.9 % screened 1; 41.9%
screened a 2; 24.3% had a score of 3 and 16.6 % screened a 4 in all sextants. Therefore
59.2 % who had a code 0, 1 and 2 did not require a partial or full mouth comprehensive
exam while 40.9 % showed need for a partial or full mouth comprehensive periodontal
examination.
Some authors had suggested in a military population (Covington, Breault, Hakett)
that codes 1 or 2 with not more than one code 3 would best be described as gingivitis and
that codes 3 in two or more sextants or at least one PSR code 4 would be periodontitis.

Modification for COHRA

It is important to note that our COHRA protocol utilizes a modification of the PSRTM
index. For this study, Code 1 indicates probing depth that is less than 3.5 mm. Code 2
indicates that the depth is from 3.5- 5.5mm while Code 3 denotes that the depth in the
sextant is greater than 5.5mm. We further document if there is bleeding in the deepest
site and if the recession is greater than 3 mm as opposed to the 3.5mm for the PSR. We
also do not note any supra-gingival or sub-gingival calculus and/or defective margins
present as well as mobility or mcogingival problems. Finally in contrast to the traditional
PSR index, we screen sextants with one or two teeth which is not the case with the
traditional test.

Reliability and Validity

There have been a number of studies that have established correlations of varying degree
between CPITN or PSR scores for probing depth, clinical attachment loss, bleeding, and
gingival indexes. These include the below four investiagions.

Baelum V, Manji F, Wanzala P et al. Relationship between CPITN and periodontal

attachment loss in an adult population. J Clin Periodont 1995 22: 1-6

Lewis JM, Morgan MV, Wright, FA. The validity of the CPTN scoring and presentation
method for measuring periodontal conditions. J Clin Periodont 1994, 21: 1-6.

Holmgren CJ, Corbet EF. Relationship between periodontal parameters and CPITN
scores. Copmmunity Dentistry and Oral Epidemiology 1990; 18:322-323.

(Takahashi, et al, 1988; Baelum et al, 1995; Lewis et al, 1994; Holmgren and Corbet,
1990).

When it comes specifically to the PSR, probably the two best studies are by Khocht et al.
The first evaluated how PSR scores reflected periodontal status as compared to a
conventional periodontal examination on 24 patients. The second investigated the
relationship between bone levels as detected on radiographs and PSR scores vs. other
periodontal parameters such as gingival indexes, probing depths and attachment levels.
In this study the PSR score showed significant associations with probing depths and
attachment levels.
Khocht, A, Zohn, J, Deasy, M, Huang-Min, C. Assessment of periodontal status with
PSR and traditional clinical periodontal examination. Journal of the American Dental
Association. 1995; 126:1658-1665.
This study attempted to evaluate how PSR scores reflected periodontal status as
compared to a conventional periodontal examination on 24 patients. A PSR exam
was followed 30 minutes later with a traditional clinical periodontal examination.
Based on the PSR criteria, a computer program was written in SAS/STAT to
enable the investigators to review the clinical data from the conventional
periodontal examination and generate computed PSR scores. The program
scanned data in every sextant and selected the highest value for each parameter
evaluated as the score for that particular sextant. Then the computer used an
algorithm to generate a computed PSR or PSRc value for each sextant according
to the definitions presented in the PSR program kit. Results revealed that the
percent agreement between actual PSR scores derived from the conventional
periodontal examination and the PSR index to be 58.8% overall. Agreement
tended to increase with pathology. Kendall correlation analysis showed
significant correlation between actual PSR and computed PSR scores (r=.63, p≤
0.0001). Risks of underdetection were noted. There were 7 sextants that had a
PSR score of 1 and 5 sextants with a score of 2 where the PSRc score was 3.
Thus 12 sextants (19%) of the 63 sextants with a PSRc score of 3 would not have
received further periodontal evaluation and would have remained underdiagnosed.
Sensitivity and specificity of PSR in detecting additional abnormalities revealed
that the PSR only detected 6 sextants had furcation involvement as compared to
24 by conventional means (specificity = 8%; sensitivity = 93%). When it came to
recession, 25 sextants had gingival recession compared to 25 detected by the
conventional examination (specificity = 36%, sensitivity = 93%). The authors
conclude that possible improvements in the PSR examination should be
considered to minimize false negative results. Despite its shortcomings they feel
that the moderate degree of association with results of conventional periodontal
examinations, as reflected by Kendall correlation and percentage agreement,
indicates that the PSR is a useful screening tool that will enhance identification of
patients with periodontal disease.
Khocht, A, Zohn, J, Deasy, M, Huang-Min, C. Screening for periodontal disease:
radiographs vs. PSR. Journal of the American Dental Association 1996; 127:749-756.
In this study, the authors investigated the relationship between bone levels as
detected on radiographs and PSR scores vs. other periodontal parameters such as
gingival indexes, probing depths and attachment levels. Twelve patients were
included who had had a full-moth radiographic series, including PA and BW
views taken within six months of the clinical examination. Eleven participants
had radiographs on file that had been taken more than 6 months before the clinical
examinations. The authors did not detect any statistically significant differences
between the bone levels measured on PA radiographs and those measured on BW
radiographs. When comparing probing depth and attachment levels with clinical
 measurements of gingival indexes and PSR scores or bone levels detected on the
radiographs, the authors found the best correlation between probing depths and
PSR scores (rs = .704, P = .0001). A low but significant correlation was found
between attachment level and bone levels on BW radiographs (rs = .285, P = .01).
In summary, the authors concluded that overall, radiographs are not highly
reflective of periodontal status. PSR scored, by contrast, showed significant
associations with probing depths and attachment levels. These results support use
of PSR as a screening tool for periodontal disease
Other studies of interest included the following:

Person R, Svendsen J, Daubert K. A longitudinal evaluation of periodontal therapy using

the CPITN index. J Clin Periodontol 1989;16: 569-574.
In a 3 year longitudinal evaluation of periodontal therapy using the CPITN index
in 123 patients who also had pocket probing depth measurements performed, the
outcome was comparable to other studies utilizing mean pocket depth and
attachment levels.

Landry RG, Jean M. Periodontal Screening and Recording (PSR) index: precursors,
utility and limitations in a clinical setting. International Dental Journal 2002; 52:36-40.
This review describes both the PSR and its counterpart, CITPN, in order to
evaluate its usefulness and establish its limitations in a clinical setting. They
conclude that the PSR, the successor of to the CITPN, is a simple, reliable, and
reproducible periodontal index for screening purposes.
Lo Frisco C, Cutler C, Bramson J. Periodontal screening and recording: perceptions and
effects on practice. JADA 1993; 124:226-9, 231-2.
The authors utilized two surveys developed to gather national data regarding
dentists’ attitudes toward PSR and determine patterns in its usage. The surveys
were mailed to general dentists and periodontists who were randomly generated
from a database. Response rates included (224/400) a 56% for periodontists and
(184/663) and 28 % for general dentists. When asked to give their overall
opinion of the screening tool as a method of monitoring and assessing periodontal
health, 77 % of the general dentists rated the PSR good to excellent overall rating.
Eighty-eight percent of all periodontists surveyed believed the PSR to be a good
to excellent method for the overall monitoring and assessing periodontal health.
Additional perceived benefits from general practitioners included effective
recordkeeping (82 % believe PSR to be at least as effective as other methods;
5.1% think it is better); periodontal health (72% think the PSR is as good or better
as an assessment of disease status); risk management (72 % believe PSR affords
practitioners the same level or better risk management opportunities);
incorporation (87 % believe it to be as easy as or easier than current methods of
periodontal disease assessment to incorporate into their regular oral exam; 56 %
believe it to be easier than present methods; cost-effectiveness (84 % consider the
screening tool at least as cost effective as current methods; 46 % consider it more
cost effective. When it came to patient education, general practitioners and
periodontists believe the PSR is an effective tool to help educate patients and
facilitate communication between dentist and patient. This was one of the most
frequently noted benefits of the PSR for those who rated it good to excellent
overall.