17: Community Oral Health

CHAPTER 17 Community Oral Health

UTILIZATION OF DENTAL SERVICES

Use of dental services is defined as the proportion of the population who receive dental care services within given period. Factors that affect frequency include age, gender, economics, ethnicity, geographical location, general health status, acquisition of dental insurance. Factors influence and affect each other, interrelationship makes it difficult to determine exact influence of each component.

image • See CD-ROM for Chapter Terms and WebLinks.
A. Needs: perceived vs. normative:

1. Younger children with perceived needs (needs perceived by child or responsible adult) were MORE likely to be episodic users of dental care than children without perceived needs.
2. Younger children with normative needs (defined by presence of untreated caries diagnosed by dentist) were less likely to be regular users.
3. Older children with perceived or normative needs were MORE likely to be episodic users, less likely to have had previous-year visit than children with no needs.

B. National dental visits (need to know only approximate values when given for dental health concepts):

1. Only 76% of children ages 2 to 17 with dental visit in past year.
2. Only 64% of adults ages 18 to 64 with dental visit in past year.
3. Only 56% of adults ages ≥65 with dental visit in past year.

C. Use of dental services is disproportionate among population group (factors noted above):

1. Dental visits have been found to be scarcer among children with lower family incomes.
2. Access to a dental examination for Medicaid-eligible children has been improved by federal and state programs but remains worse than for those whose family incomes are above poverty (family income ≥201% of Federal Poverty Level [FPL]) (discussed later).
3. Fewer than 1 in 5 Medicaid-covered children received at least one preventive dental service in recent year; many states provide only emergency dental services to Medicaid-eligible adults.
4. BOTH groups, poor and near-poor, are considered to be at high risk for poor oral health and are similar in terms of having had “any” dental visit—visit for routine dental examinations, restorative procedures, emergency care, preventive services, or combination.
5. Poor children have ∼12 times MORE restricted-activity days because of dental-related illness than children from higher income families.

D. Currently, individual who MOST regularly uses dental services can be described as a white, college-educated woman with a higher than average income, lives in suburban area, has dental insurance, possesses the characteristics related to good to excellent general and oral health.

Payment for Dental Care

Dental services are paid for by several means, including fee-for-service; third-party plans; usual, customary, reasonable (UCR) fees; capitation plans; dental service corporation plans (e.g., Delta Dental); indemnity plans; direct reimbursement; managed care plans; public financing.

A. Fee-for-service payment: two-party plan whereby the individual who receives dental services pays the fee directly out of pocket to the provider (dentist).
B. Third-party plans:

1. Include BOTH not-for-profit and for-profit plans.

a. Involve a contract between dental office (first party), patient (second party), insurance company (third party).
b. Involve collection of premiums from patient by the third party, which in turn pays dental provider for services rendered.
c. Regard third party as the insurance company, carrier, insurer, underwriter, or administrative agent.
d. Insurance holder may be patient’s employer, union group, government agency, or welfare fund.

C. UCR fees:

1. Method of reimbursement used in prepayment plan.
2. Usual fee: fee most frequently charged by dentists for particular dental service.
3. Customary fee: maximum benefit payable under particular plan for a specific procedure; is determined by the administrator of the dental insurance benefit plan and based on submitted fees; may or may NOT correlate with patient’s submitted fee.
4. Reasonable fee: actual fee charged by dental provider for particular procedure; modified according to each patient’s specific circumstances; may or may NOT differ from dentist’s usual fee or insurance company’s customary fee.

D. Capitation plans: dentist contracts with an insurance program to provide most or all dental services covered by dental benefit program; dentist is given payment on per-capita basis.

1. Characteristics:

a. Involve fixed, monthly payments to providing dentist.
b. Payments based on the number of patients assigned to dentist by benefit program.
c. Patients are assigned to dentist to receive care.
d. Monthly payments are received by dentist whether or not patients assigned require treatment.
e. Co-payments and yearly maximums are features of these plans.

2. Insurance benefit program assumes that some members will require a significant amount of care and that others will NOT seek care.

E. Dental service corporations (include Delta Dental Plans, MOST common example).

1. Provided by a dental service corporation, not-for-profit organization that negotiates and provides dental care contracts.
2. Incorporated state by state and is sponsored by each state’s constituent dental society, governed by the insurance laws of each participating state.
3. Provides dental treatment for clients in private practice facilities.
4. Assists dentists in providing group purchase of dental care through traditional practice.
5. Quality assurance is provided by a committee of nonparticipating dentists who conduct posttreatment evaluations to ensure acceptable quality.
6. Payments to dentists are made through the customary fee structure.

F. Indemnity plans (commercial): operate for profit.

1. Traditional insurance plans that operate by means of a submittal and reimbursement method.
2. Require NO filing of UCR fees by dentists.
3. Based on insurance company-generated “fee profile” that reflects the fees most often charged.

G. Direct reimbursement: occurs when an employer agrees to pay for a portion of an employee’s dental treatment.

1. Allows employee to seek dental care with dentist of choice.
2. Involves direct payment of fees to dentist by employee/patient.
3. Employee/patient pays for dental service and submits record of treatment to employer.
4. Employer reimburses employee/patient according to agreed on reimbursement schedule.

H. Managed care or health maintenance organization (HMO):

1. Was designed MAINLY to help lower cost of healthcare, participants prepay “fixed” premium for healthcare services.
2. Curtails choice of providers; participants choose providers from approved list.
3. Currently operated by BOTH for- and not-for-profit organizations; NO longer has federal constraints or funding.

I. Preferred provider organization (PPO): contracts between practitioners and their insurers to provide healthcare services for lower-than-average fees (fee-for-service plan).

1. Patients may choose a participating provider to render a covered service.
2. Service subsequently is paid for by the PPO.

J. Public financing: federal, state, and tribal government provides healthcare for groups such as the military, the Coast Guard, American Indians, Native Alaskans, federal penitentiary inmates.

GOVERNMENT’s ROLE IN ORAL HEALTHCARE

Philosophy of U.S. government gives responsibility for seeking and receiving oral healthcare services to each individual. MOST health-related programs administered by federal government are conducted through Department of Health and Human Services (HHS). Federal government developed two programs for express purpose of improving nation’s capacity to provide oral health protection and oral healthcare services.

A. Group I: programs to provide improved oral health protection.

1. Biological research.
2. Disease prevention and control.
3. Planning and development of oral health programs.
4. Education and services research.
5. Regulation and compliance functions such as quality assurance and assessment.

B. Group II: programs concerned with provision of oral healthcare services.

1. Oral healthcare services rendered to specific groups by U.S. Public Health Service (PHS).
2. The PHS are commissioned officers of Dental Corps who provide services to Indian Health Service (IHS), prisoners in federal penitentiaries, personnel of the Coast Guard and U.S. Merchant Marine, and underserved populations.

C. The PHS also administers research, prevention, resource planning, and development programs by National Institutes of Health (NIH).

1. Largest single source of monetary support for health research and development.
2. Dental component of the NIH is National Institute of Dental and Craniofacial Research (NIDCR), chief sponsor of oral health research.

Federally Funded Services

Federally funded services include services for maternal and child health, Head Start programs, Medicaid, Medicare, and the National Health Service Corps.

A. Maternal and Child Health Services (MCH):

1. For women of childbearing age.
2. For children less than 21 years of age.
3. For individuals with low incomes.
4. Through grants to improve healthcare for mothers and children.
5. Dental component of MCH:

a. Maternity and infant care projects.
b. Children and youth projects.
c. Dental health projects for children.
d. Crippled children services.
e. Women, Infant, and Children (WIC) program.

B. Head Start developed by Office of Economic Opportunity:

1. Provides educational, health, and social services to low-income preschool children; enables them to enter school on a level equal to that of their peers from higher income families.
2. Required to provide dental services to all enrolled children:

a. Oral health screening.
b. Oral health education programs.
c. Sealant programs.

C. Medicaid (Title 19 of Social Security Act): federal program that distributes funds to states for provision of healthcare services to indigent.

1. States vary on provisions; for most, dental care is option but NOT required; dental benefits, if included, typically are limited; may be limited by age and SES.
2. Early periodic screening, diagnosis, treatment program (EPSDT):

a. Oral healthcare services for individuals who are <21 years.
b. Periodic screening for health defects.
c. Any necessary diagnosis and treatment determined by screening.

D. Medicare (Title 18 of the Social Security Act): covers individuals >65 years, some disabled individuals:

1. Provides insurance protection against cost of healthcare.
2. Consists of two main parts:

a. Part A:

(1) Basic plan for hospital and related care.
(2) Dental payments for routine dental care are excluded.

b. Part B:

(1) Voluntary supplementary plan for physician services and other healthcare services.
(2) Dental payments for routine dental care are excluded.

3. Dental services are limited to those medically necessary, such as oral/maxillofacial needs related to medical condition.

E. National Health Service Corps:

1. Federal health labor deployment program.
2. Deploys commissioned officers and civil service employees of PHS to render health services in geographical areas that are underserved because of healthcare shortages.

F. State health agencies (agencies or departments headed by a state or territorial office):

1. Preventive services for children <18 years.
2. Restorative and emergency services, screening.
3. Very small number of states provide specialty services such as orthodontics, prosthetics, or correction and repair of cleft palate.

BIOSTATISTICS

Biostatistics is the tool by which research data are analyzed and results are defined.

A. Sampling: provides representation of general population, used in research to manage time and cost involved in conducting research.

1. Random sampling: every member in population has individual and equal chance of being selected.

a. Table of random numbers may be used to select sample, or participants may be chosen by lottery.
b. Prevents researcher bias.

2. Stratified sampling: modification of random selection.

a. Divides population into subgroups before selection to ensure that all subgroups are sampled.
b. Typically involves random selection within each subgroup (stratified random sampling).
c. Prevents bias because eliminates possibility that members of a subgroup will NOT be selected.

3. Convenience sampling: simplest method.

a. Involves selecting convenient group (e.g., classroom, church, club members).
b. May encourage bias because of sampling of select group; results may NOT be applicable to general population.

4. Systematic sampling: similar to, but is NOT truly, random sampling because all members of a population do NOT have the same chance of being selected.

a. Typically begins by determining that every nth member on a list will be selected.
b. Starting number is drawn and every nth member that follows starting number is selected; another method involves systematically choosing every even-numbered individual and excluding all odd-numbered individuals.

B. Descriptive statistics: used to make inferences about a population; involve frequency distribution, graphs, central tendency, and variability.

1. Frequency distribution: group of scores arranged from lowest to highest that contains frequency with which each score occurs; scores can be grouped, ungrouped, or cumulative.

a. Relative frequency: expressed as the frequency with which a specific score is earned (e.g., 15 students scored an 80 on an exam); can be expressed as a percentage.
b. Relative percent: expressed as the percentage of students who receive a particular score (e.g., three students scored 77, or 9.1% of the 33 students who took the exam).
c. Cumulative frequency: expressed as the frequency of occurrence of scores, up to and including any value in the data set; MAINLY used for data grouped by class intervals (e.g., 88 students scored in the range of 75% to 79% or below).
d. Cumulative percent: expressed as the percent frequency of occurrence of scores, up to and including any value in a data set (e.g., 96% of students scored 90 or below on the exam).

2. MOST commonly expressed as a normal (bell) curve (DING DONG, I GET IT!).

a. Exhibits a symmetrical grouping of scores around the mean or center of the curve.
b. Assumptions are made regarding the focal center of the curve.
c. Has a total area of 1 (100%); its mean, median, and mode are equal and are located in the center of the distribution.

(1) The total area is divided into segments called standard deviations.
(2) The area between the mean and one standard deviation to the right is 34.13%, and to the left is 34.13% (the total is approximately 68.26% of the total distribution).
(3) The area between the first and second standard deviations on the right is 13.59%, and on the left is 13.59% (the total is approximately 27.18% of the total distribution).
(4) The area between the second and third standard deviations on the right is 2.15%, and on the left is 2.15% (total is approximately 4.30% of the total distribution).

C. Graphs: visually represent distribution of scores along the Y– and X-axes.

1. The Y-axis typically represents the frequency of scores and typically is vertical.
2. The X-axis typically represents the scale that measures a specific variable.
3. Types (see CD-ROM for discussion): image

a. Bar graph: two-dimensional representation of discrete data.
b. Histograph: representation formed directly from a frequency distribution.

D. Central tendency: measure of the average score; summary or typical score of a distribution.

1. Mean: arithmetic value that is computed by dividing the total by its members (e.g., 450 students/3 schools = 150; the mean is 150 students per school); can be influenced by extreme scores.
2. Median: point that divides a score distribution into two equal parts, with 50% of the scores falling below and 50% of the scores falling above that point (e.g., 22, 56, 57, 78, 79, 80, 83, 84, 85, 90, 100; the median is 80 because 5 scores fall below it and 5 fall above it); is LEAST influenced by extreme scores.
3. Mode: value that occurs with the MOST frequency in a distribution (e.g., 1, 1, 3, 3, 3, 3, 3, 4, 5, 6, 7, 7, 7, 7, 8, 9; the mode is 3); MORE than one mode can occur; used MAINLY for quick computation.

E. Variability: BEST used for describing the spread, range, or distribution of scores.

1. Range: difference or distance between highest and lowest scores (e.g., range is 4 when scores range from 8 to 12); is NOT stable with extreme scores because ONLY uses the highest and lowest scores.
2. Variance: measure of average spread of scores around the mean; the greater the dispersion around the mean, the greater the variance; MORE useful than the range because considers all scores.
3. Standard deviation: positive square root of variance; the greater dispersion around the mean, the greater the standard deviation; MOST useful measure of variability in descriptive statistics; considers all scores in a distribution.

F. Inferential statistics: used to make generalizations from the statistical sample to the general population; effective sampling techniques make the inferences MORE accurate.

1. Student’s t-test: procedure that is used MAINLY to make comparisons between the means of two different studies; determines the probability that the differences in the two means are real, and NOT caused by chance.
2. ANOVA: used in place of the t-test whenever more than two means MUST be compared.
3. Chi-square test: compares the observed measurement of a given characteristic with the expected measurement for a sample; chi-square statistic is a measure of the difference between the observed and expected measurements; used MAINLY when studying categorical information.
4. Correlation analysis: involves the study of two variables and their effects on each other; MOST useful when the number of pairs of variables is large (>30); correlation coefficient is the number that summarizes the strength of the relationship between two variables; is denoted as r = +1 or −1; the closer the correlation coefficient is to 1, the stronger the relationship between two variables.

COMMUNITY HEALTH STUDY

Scenario: A junior high school counselor contacted local dental and medical professionals regarding a perceived increase in the number of girls with eating disorders in her school. Several local dental hygienists decided to develop a program for raising the awareness of the dangers of eating disorders for this population of students. To determine the current level of awareness, the dental hygienists developed a pretest that elicited information regarding facts and fallacies related to eating disorders; it also asked students whether they had an eating disorder and whether they knew of a classmate with an eating disorder.

The pretest was voluntarily taken by 410 girls in grades 7 through 9. One week later, the participants gathered in an auditorium, where they listened to information about different eating disorders, their treatment, and the dental and medical effects of the disorders. The participants subsequently watched a 20-minute video of personal accounts of battles against anorexia and bulimia. One week after the presentation, the 410 participants were given a posttest that covered the information on the pretest. Participants scored significantly higher on the facts and fallacies section of the posttest than they did on the pretest.

1. What type of sampling was used in this study?
2. What type of research does this project involve?
3. What are the oral signs of eating disorders?
4. The results of the study showed that students scored much higher on the posttest than on the pretest. What does this indicate?

1. This study used convenience sample (all female students in a school were chosen). Random study is one in which every element in a population has an equal chance of selection. Stratified sample involves selecting members from the subpopulations of a group. Single-subject sampling involves one or a few subjects who exhibit a special condition.
2. This study is an example of educational or behavioral research because it (a) assesses and evaluates the application of an educational or behavioral technique in dentistry or dental hygiene to an individual or group; (b) focuses on knowledge, attitudes, behaviors regarding oral health and disease; (c) was conducted during a short period of time. Unlike this study, educational or behavioral studies typically involve smaller populations than experimental studies.
3. Oral signs or manifestations of eating disorders include enamel erosion (perimolysis), cheilitis, parotid gland enlargement, palatal bruising, thermal sensitivity, enlarged interdental papillae.
4. Fact that students scored much higher on posttest than on pretest indicates that learning occurred as a result of the information presented. However, increase in knowledge may not always lead to a change in behavior.

EPIDEMIOLOGY AND PREVALENCE

Epidemiology is the study of disease prevalence. It is conducted through systematic observation and is used in medicine, social and computer science, biology, and statistics. Epidemiological methods can be applied in dentistry to evaluate the specific disease patterns and needs of a community. Comparisons can be made between groups of a defined population.

A. Incidence: rate at which a disease occurs.

1. Expressed as the number of new cases during a specific time.
2. Incidence rate = The number of cases divided by individuals and time.
3. Ir = Cases/Individuals and time
4. Example: 50 individuals in a community of 250,000 died of oral cancer during 2008; Ir = 50 deaths/250,000 individuals per year for the incidence of oral cancer in that community.

B. Prevalence: total number of cases of disease in existence in a given population at a given time.

1. Prevalence = The number of cases divided by population multiplied by 100.
2. P = Cases/Population × 100
3. Example: in 2008 there were 300 reported cases of gingivitis among 1000 20-year-old students examined; 300 gingivitis cases/1000 students × 100% = 30% prevalence of gingivitis among the student population.

C. Rate of disease: expressed as a ratio (fraction, numerator/denominator).

1. Numerator is occurrences of a disease; denominator is possible occurrences of a disease.
2. Rate = Actual occurrences/Possible occurrences
3. Example: in 2008 there were 25 cases of gingivitis among 250 teenagers examined; 25 actual/250 possible = 10% rate of gingivitis among the student population (must be very good brushers!).

D. Morbidity (disease) can be expressed as a rate: morbidity rate is number of actual diseases divided by number of possible diseases.
E. Mortality (death) can be expressed as a rate: mortality rate is number of actual deaths divided by number of possible deaths.
F. Epidemic: significantly greater-than-normal incidence of disease.

1. Describes a disease that spreads rapidly through particular segment of the population.
2. Describes a disease with MORE cases than expected.

G. Endemic: disease with expected (typical) number of cases that continues over time; may be specific to particular geographical area or population.
H. Pandemic: disease that occurs throughout population of a country, people, or the world.
I. Index (plural, indices): systematic way of collecting and arranging data gathered from observations so that they can be quantified, analyzed, understood (specific dental indices discussed later).

1. Accomplished under specifically defined criteria and conditions.
2. Example: record of data collected from periodontal probing.
3. Characteristics of effective index: reliable; reproducible; valid; easily understood and explained.

Epidemiology of Caries

A 2005 report, “The Centers for Disease Control Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis—United States, 1988-1994 and 1999-2002,” used the National Health and Nutrition Examination Survey (NHANES), ongoing survey of representative samples of population.

A. Background concerning caries:

1. Common chronic disease that causes pain and disability across ALL age groups.
2. Although dental caries (tooth decay) is LARGELY preventable, remains MOST common chronic disease of children aged 5 to 17 years, four times MORE common than asthma (42% versus 9.5%).
3. If left untreated, dental caries can lead to pain and infection, tooth loss, edentulism (total tooth loss); pain and suffering resulting from untreated tooth decay can lead to problems in eating, speaking, and attending to learning.
4. Enamel (dental) sealants are effective in preventing dental caries in occlusal (chewing) and other pitted and fissured surfaces of teeth.
5. Enamel fluorosis is hypomineralization of enamel related to fluoride exposure during tooth formation (first 6 years for MOST permanent teeth); exposure to fluoride throughout life is effective in preventing dental caries.

B. Trends in caries:

1. NO change in prevalence of dental caries in primary teeth among children aged 2 to 11 years.
2. Reduction in prevalence of caries in permanent teeth of up to 10% among persons aged 6 to 19 years and up to 6% among dentate adults aged >20 years.
3. Increase of 13% in dental sealants among persons aged 6 to 19 years.
4. A 6% reduction in total tooth loss (edentulism) among persons >60 years.

C. Statistic on caries in United States:

1. Among children aged 2 to 11 years, 41% had dental caries in primary teeth.
2. Among children and adolescents aged 6 to 19 years, 42% had dental caries in permanent teeth, and ∼90% of adults did.
3. Among children aged 6 to 19 years, 32% had received enamel sealants.
4. Adults aged ≥20 years retained a mean of 24/28 natural teeth and 8% were edentulous.
5. Among persons aged 6 to 39 years, 23% had enamel fluorosis (very mild or greater).
6. Disparities were noticed across ALL age groups; MAINLY among racial and ethnic groups, in persons with lower education and income, and by smoking status.

Epidemiology of Periodontal Disease

The American Academy of Periodontology (AAP) Research, Science and Therapy Committee (2005) reviewed evidence concerning periodontal disease and formed conclusions. National prevalence of moderate and severe periodontal diseases among dentate adults aged 20 years and older was estimated from the 1999-2004 National Health and Nutrition Examination Survey conducted by NHANES.

• See Chapters 11, Clinical Treatment: charting and assessment of periodontal disease; 13, Periodontology: risk factors for periodontal disease.
A. Background concerning periodontal disease:

1. Interpreting results of epidemiological studies of gingivitis, and particularly those of periodontitis, is extremely difficult.
2. Prevalence of disease must be measured in terms of specific definition of each disease and age group affected.

a. Example: although periodontitis may be defined in one study as an attachment loss of 2 mm, it may be defined in another study as attachment loss of 4 mm.
b. Therefore describing prevalence of periodontal disease in statistical terms can be difficult and misleading.
c. Definition of disease must be determined before statistics are interpreted.

B. Trends concerning gingivitis:

1. Dental biofilm (dental plaque) is closely correlated with gingivitis, relationship long considered one of cause and effect.
2. Gingivitis is found in early childhood, is MORE prevalent and severe in adolescence, then tends to level off in older age groups.
3. Gingivitis, associated with widespread dental biofilm and calculus deposits, is standard in adults.
4. Relatively FEW sites with gingivitis go on to develop periodontitis; even so, prevention of gingivitis, in individual patients and in populations, is still FIRST step toward preventing periodontitis.

C. Trends concerning periodontitis:

1. Periodontitis results from a complex interplay between bacterial infection and host response, often modified by behavioral factors.
2. Host response is KEY factor in clinical expression of periodontitis, with only some 20% of periodontal diseases now attributed to bacterial variance.
3. Some 50% of periodontal diseases have been attributed to genetic variance and >20% to tobacco use.
4. While there is a clear causal relationship between poor oral hygiene and gingivitis, relationship of oral hygiene to periodontitis is LESS straightforward; in populations with poor oral hygiene, dental biofilm and supragingival calculus accumulations correlate poorly with severe periodontitis.
5. Oral hygiene can favorably influence ecology of microbial flora in shallow-to-moderate pockets but does NOT affect host response; oral hygiene alone has little effect on subgingival microflora in deep pockets.
6. Some 5% to 20% of any population suffers from generalized severe periodontitis, although slight to moderate periodontitis affects majority of adults; for those who are MOST susceptible, periodontitis becomes MOST evident in teenage and early adult years rather than the later years.

D. Statistics for periodontal disease in United States:

1. Overall, prevalence of moderate and severe periodontal disease ranged from 0.82% to 18.3% for adults aged 20 to 34 years and 0.06% to 2.9% for adults aged 75 years and older.
2. Moderate disease was MOST prevalent in males, non-Hispanic blacks, group with lowest family poverty ratio (<100%), persons with less than high school education.
3. Severe disease was MOST prevalent among males for all age groups (EXCEPT those aged 75 years and older), persons with a family poverty income ratio between 100% to 200%, those with less than high school education.
4. Overall, moderate and severe periodontitis was still prevalent; moderate disease, which is MOST open to preventive measures, was MOST prevalent in non-Hispanic black males, the poorest, and the least educated.

Dental Indices

Dental indices are used in studying BOTH caries and periodontal disease and helping to create preventive programs or to understand individual needs for oral health.

A. O’Leary plaque index: does NOT quantify dental biofilm; monitors oral hygiene performance, indicates location of dental biofilm.

1. Assists in visualization of homecare progress, thus assisting clinicians in emphasizing specific areas of need and tailoring homecare with alternative dental biofilm control aids.
2. Directions for use:

a. Cross out all missing teeth; divide the teeth into four parts (facial, lingual, distal, mesial) and the mouth into four quadrants; apply disclosing solution and have patient rinse; evaluate presence of dental biofilm using air, mouth mirror, explorer.
b. Number of dental biofilm surfaces present/Total number of tooth surfaces examined × 100 = % dental biofilm.

B. Oral hygiene index, simplified (OHI-S): developed by Greene and Vermillion, used MAINLY for large populations.

1. Two components, debris index (dental biofilm, materia alba, food) and calculus index, BOTH added together to obtain single score.
2. ONLY facial and lingual surfaces are scored; includes facial surfaces of teeth #3, #8, #14, and #24, and lingual surfaces of teeth #19 and #30.
3. Scoring criteria:

a. 0 = No debris or stain present.
b. 1 = Soft debris covering not more than one third of tooth surface.
c. 2 = Soft debris covering more than one third but not more than two thirds of tooth surface.
d. 3 = Soft debris covering more than two thirds of tooth surface.
e. Debris and calculus scores are combined, and total is divided by number of surfaces examined to obtain average OHI-S.

C. Personal hygiene performance index–modified (PHP-M): developed by Podshadley and Haley, modified by Martens and Meskin; used MAINLY to provide patients with information about dental biofilm that will assist in improvement of oral health.

1. Teeth that are selected during the initial visit are used for comparison during subsequent visits.
2. Criteria for use:

a. Select six teeth, divide each of them into five areas, and label areas a, b, c, d, and e on BOTH facial and lingual surfaces.
b. Record presence of dental biofilm in each of lettered areas and give one point for each area of dental biofilm; scores range from 0 to 60 (best to worst).

D. Plaque index (PI): developed by Silness and Loe, used MAINLY in conjunction with gingival index (GI) by same authors; assesses thickness of dental biofilm on teeth at gingival margin.

1. Specific teeth and entire dentition can be assessed using the distal, mesial, facial, lingual surfaces.
2. Scoring criteria: visually examine dental biofilm or probe to swipe along cervical third; disclosing agent can be used.

a. 0 = no dental biofilm adheres or visible at gingival third.
b. 1 = dental biofilm adheres at gingival third; visible with explorer.
c. 2 = moderate amounts of dental biofilm visible in sulcus or at gingival margin.
d. 3 = heavy amounts of dental biofilm visible in sulcus or at gingival margin.

3. Criteria for use:

a. For individual teeth: total the score for each of the four surfaces and divide by four; for groups of teeth, total individual scores for all teeth in the group and divide by number of teeth in the group; used MAINLY for comparing areas of the mouth.
b. For individual dentition: total the individual scores for all teeth and divide by the number of teeth; for groups of individuals, total individual dentition scores and divide by number of members in the group.

E. Gingival index (GI; Loe and Silness): index MOST frequently used to evaluate gingivitis; bleeding is MOST critical factor; also assesses tissue bleeding, color, contour, ulceration.

1. Scoring: use on all or six selected teeth; divide the teeth into four areas (facial, lingual, distal, and mesial).

a. Total scores from these four areas and divide by number of surfaces examined.
b. 0 = Normal gingiva.
c. 1 = Mild inflammation, slight change in color, slight edema, and no bleeding on probing.
d. 2 = Moderate inflammation, redness, edema, glazing, and bleeding on probing.
e. 3 = Severe inflammation, marked redness, edema, ulceration, and a tendency toward spontaneous bleeding.

F. Gingival bleeding index (Ainamo and Bay): assesses bleeding of gingival margin in response to probing.

1. Used MAINLY as indicator of gingival health and disease.
2. Scoring: positive score indicates percentage of all gingival areas explored that bleed in response to probing.

a. Divide the total number of areas that bleed by the number of gingival margins examined; then multiply the result by 100 to arrive at a score (percentage).
b. (+) = bleeding within 10 seconds after gentle probing.
c. (−) = absence of bleeding after 10 seconds following probing.

G. Russell’s periodontal index (PI): assesses progressive stages of periodontal disease and amount of attachment loss.

1. Easy to use and understand; results are comparative, used MAINLY for major population groups.
2. Criteria for use:

a. Tissues are examined for gingival inflammation, pocket formation (with noncalibrated probe), and masticatory function and given a score.

3. Scoring:

a. 0 = Negative: no overt inflammation in investing tissues or loss of function from destruction of supporting tissues.
b. 1 = Mild gingivitis: overt area of inflammation is present in free gingiva but the area does not circumscribe the tooth.
c. 2 = Gingivitis: inflammation completely circumscribes tooth; no apparent break in epithelial attachment.
d. 6 = Gingivitis with pocket formation: epithelial attachment has been breached and pocketing exists; no interference with normal masticatory function; tooth is firm in its socket, no drifting is discernible.
e. 8 = Advanced destruction with loss of masticatory function: tooth may be loose, drifting, or dull on percussion or may be depressed in its socket.

4. Findings:

a. For individuals: PI = Sum of individual scores/Number of teeth scored
b. For groups: Group PI = Total of individual scores/Number of individuals examined

5. Clinical conditions and group PI score ranges:

a. Indicates clinically normal tissues (0.0 to 0.2).
b. Indicates simple gingivitis (0.3 to 0.9).
c. Indicates incipient destructive periodontal disease (0.7 to 1.9).
d. Indicates established destructive periodontal disease (1.6 to 5.0).
e. Indicates terminal stages of periodontal disease (3.8 to 8.0).

H. Ramfjord’s periodontal disease index (PDI): evaluates gingival health, probing depths, dental biofilm and calculus deposits.

1. Used for the Ramfjord teeth (#3, #9, #12, #19, #25, and #28); MOST often are used in clinical studies as a representative sample of the entire dentition.
2. Gingiva is given a score between 0 and 3, depending on the severity of inflammation; pockets are probed on the mesial and facial surfaces and are given a score between 4 and 6.
3. Critical measurement is the distance from the CEJ to the base of the sulcus.
4. Scoring:

a. 0 = Absence of inflammatory signs.
b. 1 = Mild to moderate inflammatory gingival change that does not extend around the tooth.
c. 2 = Mild to moderately severe gingivitis that extends around the tooth.
d. 3 = Severe gingivitis characterized by marked redness, swelling, and the tendency to bleed and ulcerate.
e. 4 = Gingival crevice extends apically past the CEJ but not more than 3 mm.
f. 5 = Gingival crevice extends apically 3 to 6 mm past the CEJ.
g. 6 = Gingival crevice extends apically more than 6 mm from the CEJ.
h. Combined gingival and pocket scores reflect an individual’s periodontal status.

I. Plaque Assessment Scoring System (PASS): evaluates subgingival dental biofilm, UNLIKE O’Leary plaque index, which only evaluates supragingival dental biofilm.

1. Selects five teeth for examination: four first molars and maxillary incisor; if not available, teeth near the lost molars are used, first distal, then mesial, then mandibular incisor is used.
2. Each tooth selected is divided into areas (mesial, distal, buccal, lingual) and a periodontal probe is swept around 1 mm into the sulcus; if dental biofilm is visible on the probe, recorded as positive score.
3. There are 20 possible sites for dental biofilm surfaces to be evaluated per mouth; score is percentage of surfaces positive for subgingival dental biofilm accumulation.
4. Ideal for the solo clinician and statistically reliable compared to the O’Leary PI.

J. Community periodontal index of treatment needs (CPITN): evaluates pockets, bleeding, and dental biofilm retention factors; de/>

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Jan 1, 2015 | Posted by in Dental Hygiene | Comments Off on 17: Community Oral Health

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