Oral Epidemiology

Community Periodontal Treatment Needs

Purpose : to provide an epidemiological measure of the treatment required to control and reduce the prevalence of periodontal disease. Assessment is based on the evaluation of the specified index teeth for: 1. gingival inflammation 2. depth of periodontal pockets To determine the treatment need profile for a population , the following age groups are considered: 1. 15-19 yrs 2. 20-29 yrs 3. 30-44 yrs 4. 45-64 yrs

Identification of Priority Groups

The age of the subject at the time of examination, together with the CPI recording, should give sufficient information for classification of the subject in an appropriate treatment priority group. The order of priority might be, for example as follows; 1, Young patient with deep pockets 2. Young patient with moderate pockets 3. Adult patient with deep pockets 4. Young patient with gingival bleeding. 5. Adult patient with moderate pockets. 6. Adult patient with dental calculus and gingival bleeding.

CPITN Probes : Two types : 1. Epidemiological probe 2. Clinical probe Epidemiological Probe : The probe has black band markings from 3.5 mm to 5.5 mm and having a 0.5 mm diameter ball at its tip.

5.5mm 3.5mm

0.5 mm diameter

 Clinical Probe: This probe has black band marking from 3.5 mm to 5.5 mm and 8.5 mm to 11.5 mm and having 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 the pocket .

CPITN Indicators
Three indicators of periodontal status are used for this assessment: 1. Presence or absence of gingival bleeding. 2. Supra or subgingival calculus. 3. Periodontal pockets subdivided into : a. Shallow ( 4-5 mm ) b. Deep ( 6 mm or more )

Principles
1. Last molar should not be included in CPITN. 2. The mouth is divided into sextant. 3. If second molar is removed and third molar is shifted to second molars position then it can be included for recording. 4. The teeth which are indicated for extraction should not be included. 5. Vertical mobility of the tooth with discomfort due to periodontal disease should not be included. 6. In one segment if only one tooth is there then it should be included in the next segment. 7. Two or more teeth should be there in the segment for the study purpose.

Index Teeth
For adults aged 20 years and over , the teeth to be examined are : 17 16 11 26 27 47 46 31 36 37 For young people up to the age of 19 years , only six teeth are to be examined. 16 11 26 46 31 36 This modification is made in order to avoid classifying the deepened crevices associated with eruption as periodontal pockets. For the same reason, when examining children under the age of 15 , recording for pocket should not be attempted , only bleeding and calculus should be considered.

 Probing Pockets : The probing force should not be more than 20 gms. A practical test for establishing this force is to place the probe point under the thumb nail and press until blanching occur. For sensing subgingival calculus , the lightest possible force that will allow movement of the probe ballpoint along the tooth surface should be used. When inserting the probe , the ballpoint should follow the anatomical configuration of the surface of the tooth root. If the patient feels pain during probing , this indicates the use of too much force.

Codes for Treatment Needs

Code 4 : pocket 6mm or more , when black area of the probe cannot be seen. Note : A recording of 4mm , theres no need to record the presence or absence of calculus , and gingival bleeding. Code 3 : pocket 4 or 5 mm when gingival margin is on the black area of the probe. Note : No need to examine for calculus and gingival bleeding. Code 2 : calculus present , either seen or felt during the probing. Note : No need to examine for gingival bleeding. Code 1 : bleeding observed during or after probing. Note : Gingivae of the designated tooth should be inspected for bleeding before the examinee is allowed to swallow or close his mouth. At times bleeding may occur only 10 -30 secs. after probing. Code 0 : Healthy tissue

10

 UTILIZATION OF CPI RECORDING

The CPI is designed for rapid recording of the level of periodontal treatment needs in population surveys. Average severity scores would in most population be fairly well assessed by examination of the designated index teeth. The CPI does not measure past periodontal disease experience. For Example, recession of the gingival margin of the alveolar bone is in most cases the same after treatment and although of interest in determination of periodontal status it does not indicate an actual treatment need. The time to complete a CPI assessment for the six segments should not exceed 2-3 minutes. The following samples illustrate and explain several assessments using the CPI. Case No.1

There are deep pockets in the right posterior and moderately deep pockets in the left posterior sextant of the maxilla. Three sextants have no pocket depths over 3mm but do require scaling

Case No. 2

The maxilla is edentulous. In the lower front there is need for scaling. The mandibular posterior sextants require improved personal oral hygiene.
Case No. 3

3 3

0 1

3 3

Moderate pocket depths in all posterior sextants. If this is a young patient, the possibility of juvenile periodontitis should be futher examined

Classification of Treatment Needs

Score 0: Obviously a recording of code 0 (zero) for all six sextants indicated that there is no need for treatment Score 1: A maximum code of 1 without codes 2, 3 or 4 in the same dentition indicates a need for improving the personal oral hygiene of that individual. Score 2: A maximum code of 2 indicates need for professional cleaning of the teeth. Score 3: moderate pocketing (4-5mm) code 3 can also be managed with a combination of professional and personal cleaning of the teeth, the need of treatment is the same for codes 2 and 3. In addition the patient obviously also requires oral hygiene instruction. Score 4: A sextant scoring code 4 (6mm or deeper pockets) may or may not be successfully treated by means of deep scaling and efficient personal oral hygiene measures. Code 4 is therefore assigned to complex treatment which may involve deep scaling and root planing under local anesthesia, or require surgical exposure of the infected root surface in order to gain access to clean it.

DENTAL FLUOROSIS INDEX

Mottled enamel (Dental Fluorosis) is a defect of the crown portion of the teeth brought about as a result of the ingestion of excessive amount of fluoride in the dinking water during the early formative year of a child, specifically during the process of tooth development.

GROSS MANIFESTATIONS OF FLOURISIS HAVE BEEN CLASSIFIED INTO:

Questionable- cases which may suggest some doubt as whether to classify as normal early traces of mottling. These are represented by slight aberrations in the translucency of normal enamel, in the form of white flecks or occasional white spots some 1 to 2 mm in diameter.

Very mild- cases showing small opaque paper white areas scattered irregular over less than 25% of the tooth surfaces. In addition, cusps tips of the 6 years molar show small pitted white areas. Mild- cases where greater part of the tooth at least half of the tooth surfaces are involved. Generally, the surfaces of molars and bicuspids show thin white layers worn off and the bluish shades of underlying normal enamel. Occasionally, light brown or yellowish brown stains are apparent, generally on the upper incisors. Moderate- cases which manifest characteristics of mild type; in addition, however there is minute pitting on the labial and buccal surfaces of the teeth. Stains are most often seen ranging from light brown to tan and chocolate color, or almost half of the labial surfaces and buccal surfaces.

Moderately severe-cases showing discrete pitting on the greater portions of the labial surfaces and buccal surfaces. Severe cases- cases presenting very grossly discolored teeth with deep brown or almost black stains. In addition, the teeth present a coroded-like appearance such that their forms are affected.

Groups response the different fluoride concentrations rated as marked, medium, slight, borderline and negative is technically termed as community mottled enamel.
A community is given a negativemottled enamel index when less than 10% of the children show very mild or more severe types of mottled enamel.

Minimal threshold of fluoride concentration- a domestic water supply the highest concentration of fluoride incapable of producing a definite degree of mottled enamel in as much as 10% of the groups examined. Variables to Consider in Fluorosis studies

1. Discontinuities in time of exposure (continuous residence breaks in continuity of 30 days expected). 2. Changes in fluoride content (Arithmetical mean of 12 consecutive monthly samples) mean annual fluoride content) be consistent through the years. MOTTLED ENAMEL INDEX OF A COMMUNITY

Negative

: When less than 10% of the children show very mild or severe types of mottled enamel.

Border line : When 10% or more, but less than 35% show very mild mottled enamel or worse. Slight : When 35% or more show very mild or worse, but less 50% are mild or worse, and less than 35% moderate or worse.

Medium

: When 50% or more, are mild or worse, but less than 35% are moderate or worse.

Rather Marked

: When 35% or more, but less than 50% are moderately severe or worse.

Marked

: When 50% or more moderate or worse, but less than 35% are moderately severe or worse.

Very Marked

: When 35% or worse are classified as moderately severe or worse.

 Scoring: 1. Based on 28 permanent teeth only 2. Not included are third molars , unerupted, congenitally missing , supernumerary or retained primary teeth. D Recordings : 1. Used for restorable , decayed permanent teeth( or surfaces ) 2. When both dental caries and a restoration are present , the tooth is listed as D 3. The D refers to the morbidity of the disease and represents treatment needs M Recordings 1. Teeth ( or surfaces) missing or indicated for extraction due to caries only are assigned M 2. M refers to the mortality or fatality of the disease. F Recordings 1. Restored ( filled) teeth (surfaces) are listed as F 2. Used only for restorative work that is an outcome of carious lesions. 3. Tooth with a defective filling but without evidence of dental caries is recorded as F.

Dental Indexes Caries Index DMFT and DMFS

Prevalence of Dental caries/Periodontal disease

COMPUTATION/ANALYSIS

no. of persons w/ 1 or more DMF or w/periodontal disease. _______________________________________________x 100 total number of persons examined Dental caries DMFT = Total D,M, F No. of persons examined

% component of D,M,F :

D =
M = F =

D x100 DMF
M x100 DMF F x100 DMF

Oral Hygiene Index-Simplified (OHI-S) (Greene and Vermillion)

2 Components : Debris Index Calculus Index Index teeth : 16 /11/26 46/31/36 In the posterior of the dentition, the first erupted tooth distal to the second bicuspid, usually the first molar but sometimes the second or third molar , is examined if the first molar is missing. In the anterior portion of the mouth , the labial surface of the upper right and the lower left central incisors are scored. In the absence of either of these anterior teeth , the central incisor of the opposite side of the midline is substituted.

Calculus Index
Types of Calculus : 1. Supragingival calculus deposits usually white to yellowish brown in color coronal to free gingival margin. 2. Subgingival calculus deposits apical to the free gingival margin. These deposits usually are light brown to black in color because of the inclusion of blood pigments. Scores and Criteria : 0 No calculus. 1 Supra gingival calculus covering less than 1/3rd of the exposed tooth surface 2 Supra gingival calculus covering more than 1/3rd but less than 2/3rd of the exposed tooth surface or individual isolated flakes of subgingival calculus or both. 3 Supra gingival calculus covering more than 2/3rd of the exposed tooth surface , or subgingival continuous band of calculus around the neck of the tooth or both.

Debris Index
Debris oral debris is the soft foreign matter loosely attached to the teeth. It consists of mucin , bacteria and food and varies in color from grayish white to green orange. Scores and Criteria : 0 No soft debris 1 - Soft debris covering less than 1/3rd of the exposed tooth surface or presence of extrinsic stains regardless of the tooth surface area covered or both. 2 - Soft debris covering more than 1/3rd and less than 2/3rd of the exposed tooth surface. 3 - Soft debris covering more than 2/3rd of the exposed tooth surface. Total Debris Scores of all surfaces Debris Index = No. of Surfaces Examined Interpretation of the Debris Index : Good - 0.0 - 0.6 Fair - 0.7 - 1.8 Poor - 1.9 - 3.0

Oral Hygiene Index (OHI-S) Individual OHI where CI DI Community OHI Oral Hygiene Status : Good - 0.0 - 1.2 Fair - 1.3 - 3.0 Poor - 3.1 - 6.0 = = = = CI + DI Total calculus score total # of teeth examined Total debris score total # of teeth examined Total OHI scores total persons examined

Russells Periodontal Index

Purpose : 1. To assess and score the periodontal status of population in epidemiologic studies. 2. It is best known for diagnosis and recording of periodontal diseases. Gingival tissues around each tooth , is scored numerically according to the clinical condition.

Scores and Criteria

0 Negative - there is neither overt nor inflammation in the investing tissues nor loss of function due to destruction of supporting tissues. 1 - Very Mild - there is an overt area of inflammation in the free gingiva , but this area does not circumscribe the tooth. 2 - Mild - Gingival inflammation completely circumscribes the tooth , but there is no apparent break in the epithelial attachment, 6 - Early - With pocket formation. The epithelial attachment has been broken and there is pocket. There is no interference with normal mastication the tooth is firm and has not drifted. 8 Advanced Destruction with loss of masticatory function . The tooth may be loose, drifted , may sound dull on percussion with a metallic instrument or may be depressible in its socket. Radiographic appearance is essentially normal

There is horizontal periodontitis , bone loss involving up to of the length of the root. Advanced bone loss involving more than of the length of the root or definite infra-bony pocket with widening of periodontal ligament. there may be root resorption or rarefaction at the apex.

 Rule : if in doubt assign a lesser score. Russell chose the scoring values (0,1,6,8) in order to relate the stages of the disease score in an epidemiological survey to the clinical conditions observed , thus the jump from 2-6 in the scale , to recognize the changes in disease condition from severe gingivitis to an overt destructive periodontal diseases with obvious loss of attachment.

Grading ( Russells )
0.0 to 0.2 Clinically normal tissue reversible 0.1 to 1.0 Gingivitis Reversible 0.5 to 1.6 Incipient destructive periodontal disease Reversible 1.6 to 5.0 Established destructive disease Irreversible 4.0 to 8.0 Terminal periodontal diseaseIrreversible. Total Scores Periodontal Index = No. of teeth examined