The inflammatory diseases of gingiva and periodontium, as well as their symptoms and the etiologic agents of these conditions (microbial plaque/biofilm) can be assessed clinically using qualitative and/or quantitative indices. In most instances, indices are used in epidemiologic studies, but they can also be useful during clinical examination of individual patients.

Indices are expressed numerically to describe defined diagnostic criteria: A disease process or its severity is described or classified using numbers (1, 2, 3 etc.). Simple indices record only the presence or absence of a symptom or an etiologic agent with “yes or no” entries, e.g., after sulcus probing: (+) = “bleeding,” (−) = “no bleeding.”

An appropriate index permits quantitative and qualitative statements about the criteria under investigation (disease, disease etiology), and is simple, objective, reproducible, rapid and practical. It should also be amenable for use by auxiliary personnel. Indices must provide data that are amenable to statistical evaluation.

Although indices for the most part were developed for epidemiologic studies, international standardization among various research groups has proven to be impossible: Many investigators use various indices or employ no indices whatever in periodontitis studies, rather they collect data on pocket probing depth and/or attachment loss in millimeters, which are then attributed to certain degrees of severity. Severity grades I–III: for probing depths up to 3 mm (I), between 4 and 6 mm (II) and those of 7 mm and greater (III). Other epidemiologists may assess these three severity grades using different millimeter measurements. Therefore it is scarcely possible to precisely compare the results of various studies to each other. Nevertheless, approximate conclusions can be drawn, e.g., concerning the worldwide incidence of periodontitis (p. 75).

Indices are also used in the private practice with individual patients: Especially plaque and gingivitis can be readily assessed in numerical fashion.

Repeated determination of an index during the course of preventive or active therapy can help ascertain the degree of patient motivation/compliance and treatment success or failure.

In this chapter, only a few of the many indices will be briefly described, primarily those which have been used for international epidemiologic studies, as well as some that are indicated for use on individual patients in private practice.

Plaque Indices

  • Plaque index (PI)—O’Leary et al. 1972

  • Approximal plaque index (API)—Lange 1986

  • Plaque index (PI)—Silness & Löe 1964

Gingivitis Indices

  • Bleeding on probing (BOP)—Ainamo & Bay 1975

  • Papilla bleeding index (PBI)—Saxer & Mühlemann 1975

  • Gingival index (GI)—Löe & Silness 1963

Periodontal Indices

  • Periodontal disease index (PDI)—Ramfjord 1959

  • Community periodontal index of treatment needs (CPITN)—WHO 1978

  • Periodontal screening and recording (PSR)—ADA/AAP 1992

“Gingival Recession Index”

  • Recession is measured in mm from the cementoenamel junction to the gingival margin (Jahnke et al. 1993, p.162) or classified according to Miller (1985, pp. 162–163).

Plaque Indices

125 Plaque Index simplified, PI—Plaque Control Record, PCR (PI; PCR—O’Leary et al. 1972) This precise index records the presence of supragingival plaque on all four tooth surfaces. For this test, the plaque is disclosed. The presence (+) or absence (−) of plaque is recorded in a simple chart, and the plaque incidence in the oral cavity is expressed as an exact percentage. • PI is an index for the practice.
126 Approximal Plaque Index—API (Lange 1986) Following application of disclosing solution, a simple yes/no decision is made concerning whether the examined interproximal surfaces are covered by plaque (+) or not (−). The proportion of plaque-covered interproximal spaces is expressed as a percentage. Usually, analogous to the papilla bleeding index (PBI, Fig. 129), in a given quadrant the interproximal spaces are scored from only one aspect, i.e., from the facial (Q2 and Q4) or from the oral aspect (Q1 and Q3). The API is indicated for individual patient data collection and for motivation. It correlates with the PBI and is calculated as shown in the following formula: Right: The problem of missing teeth (dark): If only one tooth is missing (above), the measurement site remains intact; if two adjacent teeth are missing (below) one measurement site is lost. In the depicted quadrants (2 and 3) the API is 69%.
127 Plaque Index (PI; Silness & Löe 1964) This index ascertains the thickness of plaque along the gingival margin; only this plaque plays any role in the etiology of gingivitis. To visualize plaque, teeth are dried with air. Plaque is not stained. The PI is indicated for epidemiologic studies in which the gingival index (GI) is recorded simultaneously. It is less useful for routine dental office charting.

Gingival Indices

128 Bleeding on Probing–BOP (Ainamo & Bay 1975) As in the PI (Fig. 125), all four surfaces of all teeth are assessed with regard to whether probing elicits bleeding (+) or not (−). The severity of gingivitis is expressed as a percentage. Because more than 100 sites must be measured, the BOP is indicated only for individual patient examinations (e.g., data collection, recall).
129 Papilla Bleeding Index—PBI (Saxer & Mühlemann 1975) The PBI discriminates four different degrees (intensities) of bleeding subsequent to careful probing of the gingival sulcus in the papillary region (see p. 70). Probing is performed in all four quadrants. To simplify the recording of the PBI, quadrant 1 is probed only from the oral aspect, quadrant 2 from the facial, 3 again from oral, and from the facial in quadrant 4 (see black arrows in diagram). Bleeding scores are entered into the chart (middle). The PBI can be reported as the bleeding number (= sum of all values) or as an index (average severity, as in this formula: • The PBI is valuable for the practitioner, who can compare values over time (patient motivation, risk factors). Left: In this example (quadrants 2 and 3), the PBI is 2. 1; the bleeding number is 27. Missing teeth? Compare Fig. 126, right.
130 Gingival Index—GI (Löe & Silness 1963) The GI records gingival inflammation in three grades. It is measured on six selected teeth (16, 12; 24 and 36, 32; 44; cf. Fig. 127)) on facial, oral, mesial and distal sites. The symptom of bleeding comprises a score of 2. • The GI was developed for epidemiologic studies. It is less applicable for individual patients because the differences between the scoring levels are too gross.

Papilla Bleeding Index—PBI

The PBI was developed for use in the private practice and not for epidemiologic studies. It is a sensitive indicator of the severity of gingival inflammation in individual patients. The PBI does not require a great amount of time, since only 28 measurement sites in the complete dentition are evaluated (Saxer & Mühlemann 1975).

The PBI has proven to be particularly useful for assessing inflammation in the interdental papillae by recording bleeding on probing in the interdental areas during the course of treatment. The index therefore offers an excellent means for patient motivation (p. 222). While the patient watches in a mirror, the practitioner can score the intensity of papillary inflammation. The patient can see when the gingival tissue bleeds, which helps him to realize where the diseased sites in the mouth are located.

The patient will realize and experience the reduction in inflammation during the course of therapy as the index is repeated at each visit, and this is a good motivator for thorough and continuing patient compliance.

131 Grade 1—Point 20–30 seconds after probing the mesial and distal sulci with a periodontal probe, a single bleeding point is observed.
132 Grade 2—Line/Points A fine line of blood or several bleeding points become visible at the gingival margin.
133 Grade 3—Triangle The interdental triangle becomes more or less filled with blood.
134 Grade 4—Drops Profuse bleeding. Immediately after probing, blood flows into the interdental area to cover portions of the tooth and/or gingiva.

Recording the PBI

Bleeding is provoked by sweeping the sulcus using a blunt periodontal probe under light finger pressure from the base of the papilla to its tip along the tooth’s distal and mesial aspects. After 20–30 seconds, when a quadrant has been completely probed, the intensity of bleeding is scored in four grades and recorded on the chart.

The sum of the recorded scores gives the “bleeding number.” The PBI is calculated by dividing the bleeding number by the total number of papilla examined.

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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Indices
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