PEDIATRICDENTiSTRY/Copyright e 1981 by TheAmerican Academy of Pedodontics/Vol.3 No. 4 CURRENT TOPICS n []

Periodontal epidemiological indices for children and adolescents: I. gingival and periodontal health assessments

Stephen H. Y. Wei, DDS, MS, MDS Klaus P. Lang, DDS, MS, Dr Med Dent This paper is the first in a three-part series, with parts two and three appearing in the March, 1982 issue of Pedi- atric . Abstract high degree of intraexaminer reproducibility and are reve~ible and pedodontitis usually should be simple, accurate and meaningful tools in as- conditions in children and should be detected early and sessing,9 the status of oral health or disease? treatment renderedpromptly. Henceappropriate clinical indices must be available to record these conditions The purposes of this paper are to review the exist- accurately and to assess treatment success or failure. This ing gingival and periodontal indices, assessing their paperreviews the existing gingival and periodontal indices potential as indices for use in children, and to focus and discuesestheir potential for clinical use in children. greater attention on the gingival and periodontal health of children and adolescents. The international Introduction designations for numbers have been used in the Gingivitis and periodontitis are generally thought paper in compliance with W.H.O. recommendations. of as diseases of adulthood. Pedodontists and general practitioners have traditionally paid little attention to Classification and Characteristics the1 gingival and periodontal health status of children. Indices may be classified into four categories; 1) Due to the widespread use of water fluoridation, topi- gingival indices, 2) periodontal indices, 3) cal fluoride, fluoride dentifrices and other preventive indices, and 4) miscellaneous indices such as retention measures, the prevalence of dental caries has shown a index, alveolar bone loss and mobility index. dramatic drop in countries that traditionally had very According to Russell, 9 an index is a numerical value high caries levels -- Switzerland, Australia and New describing the relative status of the population on a Zealand2 for example. In the United States, where the scale with a definitive upper and lower level. By using dental caries rate has been moderate, there are indica- indices which have been carefully defined, compari- tions that the caries rate in 1980 is considerably lower sons can be made between different population groups than two decades ago.s,4 However,the incidence of gin- of the severity of a disease since the same criteria and givitis in children has shown a significant increase. methodologies have been adopted. An adequate index Similarly, gingival health in adults in Switzerland and is both reliable and has validity. Unfortunately many other countries has shown little if any improvement disease entities are not easily quantifiable by objective despite efforts of the public health and dental profes- means. Consequently the results of clinical trials are sions.5 not only affected by the shortcomings of the indices Although6,7 plaque indices such as the simplified themselves, but are also subject to examiner varia- oral hygiene index have been used for some time, a de- tions such as training, and clinical experience. Fur- finitive recording of the gingivai and periodontal thermore, the analysis of data is complicated by the health~ in children has not usually been carried out in fact that most index systems follow an ordinal scale pedodontic clinics or in private dental practices. Most and are non-parametric in nature. clinical indices have been developed in order to assess the gingivai and periodontal health in experimental or Gingivitis epidemiological studies. Recordings of gingival and PMA~’) Index (Schour and MassleV periodontal health in clinical practice may require a One of the first quantitative gingival indices is the

PEDIATRIC DENTISTRY: Volume 3, Number 4 353 P-M-A Index developed by Schour and Massler in Modified PMA-I (Miildemann and MazoVO. Mfih- 1944-1947, probably derived from the index suggested lemann and Mazor, in a study on the prevalence of by King.~4 The degree of gingivitis for each of the pap- gingivitis in a population of Zurich school children illary (P), marginal (M) and attached (A) gingival measured gingivitis by concentrating on l~he P and M units was defined as in Table 1. units and discarding the A units. In addition, the severity of gingivitis was evaluated (Table 2). TableI.m~ PMAIndex of Schourand Massler. Table 2.6 Modified PMA-Iof Miihlemannand Mazor? P 0= Normal; no inflammation. 1+= Mild papillary engorgement; slight I: Bleedingfrom the on gentle probing, increase in size. the P-Mshowing no changeof color and no swelling. 2+ = Obvious increase in size of gingival papilla; The papillary and marginal gingivae have a "normal hemorrhage on pressure. appearance." 3+ -- Excessive increase in size with II. Bleedingfrom the gingival sulcus on probing plus spontaneous hemorrhage. change of color due to inflammatorydisturbances of 4+ -- Necrotic papilla. P-MUnits. Noswelling or miscroscopic edema. 5+= Atrophy and loss of papilla (through III. Bleedingplus changeof color plus edematousswelling inflammation). of P-MUnits. For example: P(I) means]healthy M 0= Normal; no infiammation visible. papilla. PM(II): papilla and marginal gingivae, 1+ -- Engorgement;slight increase in size; no bleeding and hyperemic. A(II) Attached gingivae with bleeding. inflanm~atorycolor change. 2+= Obvious engorgement; bleeding upon DegreeI was the criterion of beginninggingivitis and pressure. an individual showinga single P(I) or M(I) unit 3+= Swollen collar; spontaneous hemorrhage; classified as havinglocalized gingivitis. beginning infiltration into attached gingivae. Sulcus Bleeding Index (SBI, Miihlemann and Necrotic gingivitis. Son~O. More than a decade later, Miihlemann and Son Recession of the free marginal gingiva modified the index and suggested the use of a "sulcus below the CEJ due to inflammatory bleeding index" (SBI) because they believe that bleed- changes. ing from the sulcus is the earliest clinical symptomof A 0= Normal; pale rose; stippled. gingivitis and that it even precedes discoloration and Slight engorgementwith loss of ; swelling. The major characteristics of the iSBI were: change in color may or may not be present. 1. For all severity scores, diagnosis of inflammation 2+= Obvious engorgement of attached gingivae is made only if bleeding occurs upon gentle prob- with marked increase in redness. Pocket ing of the sulcus. formation present. 2. Apparently healthy gingival units without color 3+= Advanced periodontitis. Deep pockets changes or swelling are diagnosed as inflammed evident. -- score 1 if bleeding occurs upon gentle probing. 3. The SBI uses 8 maxillary and mandibular ante- rior teeth, and 4 gingival units are scored for each The index was designed primarily for the examina- tooth: Mlabial, Mlingual, P mesial, P distal. tion of gingivitis in children. It was developed with Papillary Bleeding Index (PBI, Miihlemann~). The the purpose of quantifying the number of gingival SBI was further modified in 1977 when Mfihlemann" units affected in the mandibular and maxillary incisor suggested the use of a papillary bleeding index (PBI) areas. as an effective index to motivate patients for improv- Moditications of the PMAIndex. Several modifica- ing their gingival health (Table 3). tions of the PMAIndex have been suggested. For ex- The rationale of this index is that marginal perio- ample, Parfitt TM added the buccal and lingual gingivae dontitis and alveolar bone loss begin interproximally and divided the degree of inflammation into five arbi- and the effectiveness of preventive procedures are trary levels. The severity of inflammation in each gin- more easily related to the presence or absence of inter- gival area for both buccal and lingual aspects were . The results are translated into numeri- evaluated separately. cal scores which are easily comprehensible by the Further modifications of the P-M-A Index have patient. been described by Miihlemann and Mazor)6 Arno, et Gingivitis Index (Suomi and Barban~). Another al.)7~ Heylings)8 Jackson)0 and othem. modification of the P-M-A Index was described by

354 PERIODONTALEPIDEMIOLOGICAL INDICES: Wei and Lang Table 3.= Papillary Bleeding Index of Miihlemann. difference between the SBI (Mfihlemann and Son21) or the PBI (Miihlemann~) is that there is a score (1) for Score Bleedingon gentle probing initial color and texture change in the tissues without the development of bleeding on gentle probing. The GI has gained wide acceptance as a simple, accurate Nobleeding. and reproducible method for evaluating gingival Only one bleeding point appearing. health or disease in epiderniological and clinical Several isolated bleedingpoints or a small blood research. area appearing. Gingival~) Periodontal Index (GPI, O’Leary Interdental triangle filled with bloodsoon after The GPI was developed to screen the need for per- probing. iodontal treatment. Probing is restricted to the mesial-faeial line angle of each tooth. The mouth is Profuse bleeding whenprobing, blood spreads divided into six segments, and the highest score found towards the marginal gingiva. for any one of the teeth in a segment is recorded as the score for that segment (Table 6). =.u Suorni, Suomi and Barbano. Initially the facial and = lingual surfaces of all teeth were measured but were Table 5. The Gingival Index of L~ and Silness. subsequently modified to include only tooth numbers 16, 21, 24, 26, 36, 31, 44, and 46. A scale of 0-2 was used 0 = Normalgingiva. (Table 4). 1 = Mild inflammation -- slight change in color, slight edema. Nobleeding on probing. Table 4. Gingivitis index of Suomiand BarbanoY 2 -- Moderateinflammation -- redness, edemaand glaz- ing. Bleedingon probing. 0 ffi Absenceof inflammation-- gingiva is pale pink in color and firm in texture. Swellingis not evident and 3 -- Severe inflammation -- marked redness and edema. stippling can usually be noted. Ulceration. Tendencyto spontaneousbleeding. i ffi Presenceof inflammation-- a distinct color change to red or magentais evident. There maybe swelling and loss of stippling. The gingiva maybe spongyin Table6. Gingival Periodontal Index (GPI, 0’Leary). texture.

2 ffi Presenceof severe inflammation-- a distinct color 0 ffi Tissue tightly adaptedto the teeth, firm consistency changeto red or magentais evident. Thereis with physiologic architecture. swelling, loss of stippling and a spongyconsistency. Thereis either gingival bleeding upongentle probing 1--Slight to moderate inflammation as indicated by with the side of an explorer or the inflammationhas changes in color and consistency, involving one or spread to the attached gingiva. more teeth in the same segment but not completely surrounding any one tooth. ~) 2 ffi The above changes singularly or combined com- Gin~yal Index (G.I., LSe-Silness pletely encircle one or moreteeth in a segment. One of the most commonlyused indices for assess- 3 ffi Markedinflammation as indicated by loss of surface ing the status of gingival health or inflammation is the continuity (ulceration), spontaneous hemorrhage, Gingival Index (G.I.) by LSe and Silness (Table loss of facio-lingual continuity or any interdental pa- While all the indices published prior to 1963 were pilla, markeddeviation from normalcontour, such as based on the single tooth as a unit, the GI was the gross thickening or enlargement covering more than first index to evaluate every single tooth surface. one third of the anatomic , recession, and Each of the buccal, mesial, lingual and distal sur- clefts. faces of the gingival tissues is given a score of 0-3. This Scores of 4, 5, and 6 are given to seg- then constitutes the GI for the area, and scores from ments. the 4 areas of the tooth are added and divided by four to give the GI for the tooth. Scores for individual 4 ffi Whenthe probe extends up to 3 mmapical to the teeth may be grouped to designate the GI for the CEJof any tooth in the segment. group of teeth such as incisors, premolars and molars. 5 -- Whenthe probe extends from 3 to 6 mmapical to The scores may be added and divided by the number the CEJof any tooth in the segment. of teeth examined to derive the GI for the individual. 6 ffi Whenthe probe extends 6 mmor moreapical to the Usually all tooth surfaces are included or designated CEJof any tooth in the segment. and single tooth surfaces may be selected. The major

PEDIATRICDENTISTRY: Volume 3, Number4 355 The highest score found for each dentulous segment A blunt is passed along the gin- is recorded and the sum divided by the number of seg- gival crevice and if bleeding occurs within 10 to 15 sec- ments to give the GPI score for the individual. onds, a positive score is given. The number of positive Gingival~) Bleeding Index ( G.B.L, Ainamo a~d Bay units is divided by the number of gingival margins ex- Because of the subjective nature of many of the amined and the result is multiplied by 100 to express earlier indices, and observations that bleeding is a the index as a percentage. This index has been adopted simple reliable indicator of gingival inflammation, in several epidemiological and clinical studies in Scandi- Ainamo and Bay~ simply used the presence or absence navia with a relatively high degree of reliability. of bleeding on gentle probing as the only criterion for Gingival~) Exudate (LSe and Holm-Pealer, sen their index. The flow of fluid from the gingival crevice has been

Table7. Indices developedby various investigators to measuregingival inflammation.

Name of Index Tissues Noted Author/Year Locationor Criteria References

PM papilla/marginal King, 1945 Incisor and canine regions 14 PMA papilla/marginal/ Schour & Massler, Labial gingiva of anterior teeth 10, 11, alveolar mucosa 1947, 1948, 1950 12, 13 PI gingival part of PI Russel, 1956, 1967 all teeth 32, 33 PMA buccal and lingual P, M Parfitt, 1957 buccal,maxillary incisors only 15 (modified) & A MOD PMA-I papilla, marginal MiLhlemann& anterior t~th, labial gingiva, 16 gingiva mainly Mazor, 1958 PM-index? Arno, Waerhaug, all teeth or selected 17 surfaces Lovdal, $chei, 1958 PDI gingival margin Ramfjord, 1959, 1967 select~ teeth 34, 35 tooth is unit PMA papilla/marginal Heylings, 1961 anterior teeth 18 alveolar mucosa labial gingiva PM papilla/marginal Jackson, 1962, 1965 anterior teeth labial gingiva 19, 20 GI gingival margin LSe& Silness, 1963 all tooth surfaces or selected 25 surface is unit surfaces PMA papilla, marginal Lobene, 1964 all teeth, buccal and lingual 21 (simplified) and alveolar mucosa surfaces included Gingival pocket exudate on LSe & Holm-Pederson, all teeth or selected 29, 30 Exudate strips in mm 1965 teeth Oliver, Holm- Pedersen, LSe, 1969 GPI marginal gingivae of O’Leary,1963, 1967 mouthdivided into six 26, 27 mesialfacial line segments,all teeth are angle of each tooth measured GI facialand lingual Suomi& Barbano, all 124 marginal and 23, 24 (gingivitismarginal,papilla 1968, papillary units of 32 teeth index) & attachedgingivae Suomi,1969 SBI sulcusbleeding Miihlemann& Son, 8 maxillary and mandibular 21 4 surfaces/tooth 1971 anterior teeth GBI marginal gingival Ainamo & Bay, all teeth or selected 28 crevice 1975 teeth PBI Miihlemann, 1977 interdental papillae 22 only bleeding only.

356 PERIODONTALEPIDEMIOLOGICAL INDICES: Wei and Lang used as an indication of gingival inflammation. Using The scoring intervals of 0, 1, 6, and 8 have been pro- filter paper strips placed over the labial surfaces or at posed in order to fit a linear correlation betweenperio- the orifice of the sulcus of the maxillary teeth, gingival dontal disease and aging. Scoring for each tooth is car- exudates have been sampled intra- and extracrevicu- ried out and the scores are totaled and divided by the larly. The strips are collected after a defined time pe- number of teeth present to obtain the average GI for riod (usually three minutes) and stained. LSe and each patient. According to Russell a mean PI score Holm-Pedersen~ demonstrated that healthy gingivae ranging from 0 to 0.2 may be obtained for clinically did~ not exhibit any crevicular flow while Oliver, et al. normal gingival tissue. Persons with simple gingivitis showed that the gingival index score (GI) of LSe and usually register with 0.3 to 0.9. Subjects with signifi- Silness ~1 was strongly correlated with the amount of cant gingivitis ranging upwards towards incipient de- gingival exudate flow rate. Furthermore, with increas- structive disease usually score in the range of 0.7 to ing GI scores, there is a corresponding increase in the 1.9. Those persons with established destructive perio- density and the area of inflammatory cells in histolo- dontal disease should score approximately 1.6 to 3.0, gic specimens. whereas those in the terminal stages of periodontal This type of evaluation of the buccal gingiva is time disease wouldregister a score of 3.8 to 8.0. consuming but rather objective. Hence it is most often The Russell’s PI has been used extensively in epi- used in small selected sample numbers for research demiological studies for large populations and for all purposes, particularly if gingival biopsy specimens are age groups. This simple index uses the tooth as the included. unit of measure. No special equipment is needed and it Table 7 lists the various indices cited previously can be applied rather quickly since pocket depths do with others less commonlyused. not have to be assessed accurately. Periodontal~) Disease Index (PDI, Ramfjord Periodontal Indices The periodontal disease index (PDI) of Ramfjord Periodontal~) Index (PI, Russell has, like the PI, a gingival and periodontal compo- The periodontal index (PI) of Russell was devel- nent. Only six selected teeth, namely numbers 16, 21, oped for epidemiological purposes and assumes a pro- 24, 36, 41, and 44 are used. For the gingival status of gression of gingivitis to pocket formation leading to health or disease, the assigned value represents essen- advanced destruction with loss of masticatory func- tialiy a combination of the P-M-A(without the part of tions with age. The scoring and criteria for the perio- the attached gingiva) and the PI index. Again the dontal index of Russell are presented in Table 8. tooth represents the unit evaluated (Table 9).

Table 8. Periodontal Index (PI, Russell=). Table 9. Periodontal Disease Index (PDI, RamfjordS).

Score Criteria 0 ffi Absenceof signs of inflammation. 1 -- Mild to moderateinflammatory changes not 0 Negative. There is neither overt inflammation extending around the tooth. in the investing tissues nor loss of function due 2 ffi Mildto moderatelysevere gingivitis extendingall to destruction of supportingtissue. around the tooth. Mildgingivitis. Thereis an overt area of 3 ffi Severegingivitis characterized by markedredness, inflammationin the free gingivae whichdoes swelling, tendencyto bleed and ulceration. not circumscribe the tooth. Gingivitis. Inflammationcompletely circumscribesthe tooth, but there is no apparent break in the epithelial attachment. Most of the criteria are based on subjective evalua- tions. The gingival tissues are first gently dried and Gingivitis with pocket formation. The epithelial changes in color are measured by comparing the color attachment has been broken and there is a pocket (not merely a deepenedgingival crevice corresponding to the buccal, lingual and interproximal due to swelling in the free gingivae). Thereis no surfaces of adjacent teeth. Emphasis is placed on the interference with normal masticatory function, uniformity or lack of uniformity of color rather than the tooth is firm in its socket, and has to the different shades of color hues. Color changes are not drifted. usually towards redness, however severe inflammatory changes may lead to a blueish or purplish hue. Con- Advanceddestruction with loss of masticatory function. The tooth maybe loose; mayhave tour changes in the papilla such as blunting or round- drifted; maysound dull on percussion with a ing of the margin of the gingivae and thickening of the metallic instrument; maybe depressible in papilla are also recorded. The score of 3 is usually used its socket. only when there is ulceration with bleeding upon

PEDIATRICDENTISTRY: Volume 3, Number4 357 gentle touching with the side of a periodontal probe or fected by periodontal disease, and b is the redness or change in gingival contour is very equal to the number of unaffected severe. teeth. For the periodontal component of the PDI the loss The following criteria are used to indicate whether of periodontal attachment is classified into three cate- the tooth is affected by periodontal dise~e or not: gories. In order to assign a tooth into the correct cate- 1. Gingival necrosis, hypertrophy, or inflammation gory, the distance from the free gingival margin to the encircling the teeth or a purulent exudate from the CEJ and the distance from the free gingival margin to gingival crevice. the bottom of the gingival crevice or pocket have to be 2. A gingival crevice depth of 3 mmor more. recorded for the mesial, buccal, distal, and lingual 3. greater than 1 mmin any direction. aspects of each tooth examined. The interproximal re- 4. Radiographic evidence of resorption of alevolar cording has to be secured at the buccal aspect of the bone extending more than 3 mmepically from the interproximal contact areas with the probe pointing in CEJ. the direction of the long axis of the tooth Pocket Depth and Loss of Attachment (Glavind A. If the gingival margin is on enamel: and U6e~ ) 1. Measure from gum margin to CEJ and record Both Russell’s PI and Ramfjord’s PDI have quali- the measurement on the crown of the schematic tative and quantitative criteria and a gingival and a tooth. If the epithelial attachment is on the periodontal component. The pocket depth and loss of crown and the CEJ cannot be felt by the probe, attachment in relation to the CEJ as a fixed point of record the depth of the gingival crevice on the reference are expressed in millimeters. The criteria of CrOWn. pocket depth and loss of attachment measurements 2. Measure from the gingival margin to the bottom are defined as follows. of the pocket when the crevice extends epically to Pocket deptl~ refers to the distance from the gingival the CEJ -- the measurement should be recorded margin to the bottom of the clinical pocket. Mesial and on the root of the schematic tooth. (The distance distal pockets are measuredfrom the buccal aspect and from the CEJ to the bottom of the pocket can as close as possible to the contact points. Facial and oral then be found by subtracting measurement num- pockets were measuredat the midline of the roots. Buc- cal and lingual pockets of multirooted teeth were meas- ber 1 from measurement number 2.) ured at the mesial roots in order to avoid the furcation B. If the gingival margin is on : areas. Efforts were madeto insert the probe parallel to 1. Measure from the CEJ to the gingival margin. the axes of the roots. A force of approximately10 grams Record as minus value on the root of the sche- was used during the introduction of the probe to the bot- matic tooth. tom of the pocket. 2. Measure from the CEJ to the bottom of the gin- Lo~s 0£ agtachmeat refers to the distance from the gival crevice. Record value on the root. CEJto the bottomof the clinical pocket. The loss of at- The first part of this index is reversible and scores tachment was asee~u~don the same surfaces of the same of 1, 2, and 3 represents a measurement of gingivitis teeth and with the same probe as used for pocket depth with little or no periodontal involvement. On the assessments. Following the recognition of the CEJ, the distance other hand, scores of 4-6 are used to measure loss of from the gingival margin to the CEJ was measured. periodontal attachment and are essentially irrevers- Whenthe CEJ was located apical to the gingival margin, ible. A score of 4 is assigned if the loss of attachment the loss of attachment would be the difference between is 3 mmor less, a score of 5 is assigned if the loss of the previously recorded depth of the pocket (A) and the attachment is greater than 3 mmbut less than 6 mm. distance (B) from the gingival margin to the CEJ: A - If the loss of attachment is 6 mmor more, a score of 6 -- loss of attachment. is given to a particular tooth. In cases where the marginal gingiva had been subject Periodontal Disease Rate (PDR, Sandier and to recession and the CEJwas exposed, the loss of attach- ment equaled the sum of the pocket depth and the dis- StabS) tance from the gingival margin to the CEJ: A + B = loss The periodontal disease rate is a relatively simple of attachment. index where the number of diseased teeth are counted The measurements were carried out with a 0.8 mm and then divided by the total number of teeth present thick pocket probe which was marked at each mmfrom 1 in the mouth. It is expressed as a percentage. The to 12. Pocket depth or loss of attachment of I mmor less authors claim that the simple index gives a very high was recorded as 1 ram, measurementsexc~.~ling 1 mm, correlation with Russell’s PI. It is expressed by the but less than 2mm,were recorded as 2 mm,et~. formula: Navy~) Periodontal Disease Index (NPDI As for the Ramfjord PDI, this index consists of two PDRffi a a+b components, a gingival score and a pocket score of six Where a is the number of teeth af- selected teeth, namely tooth numbers16, 21, 24, 36, 41,

358 PERIODONTALEPIDEMIOLOGICAL INDICES: Wei and Lang Tables 10. Criteria for the Navy Periodontal Disease Index. and 44 (Table 10). The periodontal disease index is based on the sum Gin$4val of the gingival score and the pocket to derive the Score tooth score. 0 Gingival tissue is normal in color and tightly Table 11 is summary of the periodontal indices adapted to the tooth -- tissue is firm and no described above. exudate is present. 1 Inflammatory changes are present, but do not completely encircle the tooth. Changes Dr. Weiis professor and head, departmentof pedodontics, College may include one or a combination of of Dentistry, University of Iowa, Iowa City, Iowa52242. Dr. Langis the following: professor and chairman, School of Dental Medicine, University of Any change from normal gingival color, Berne, Freiburgstraese 7, CH-3010Berne, Switzerland. Requests for Loss of normal density and consistency, reprints shouldbe sent to Dr. Wei. Slight enlargement or blunting of the papilla or gingiva, Tendency to bleed upon palpation References or probing. 1. Wei, S. H. Y. Opening Remarks-- in International Symposium on the Prevention of Periodontal Disease in Children and Ado- 2 Inflammatory changes listed above lescent, Ed. S. H. Y. Wei, Pediatr Dent, 3:79 (Special Supple- completely encircle the tooth. ment), 1981. 2. Infirri, J. S. and Barmes,D. E. Epidemiologyof oral diseases -- Pocket With calibrated periodontal probe take six differences in national problems,Int DentJ, 29:183-189,1979. Score measurements of each designated tooth -- 3. Glass, R. Increases in caries prevalence, Fourth annual Confer- mesial, middle, and distal areas of the facial ence on Foods, Nutrition and Dental Health. (FNDH),October 1-3, 1980.Proceedings, In Press. and lingual surfaces. The greatest single 4. Hughes,J. T., Rozier, R. G. and Bawden,J. W. A survey of per- measurement determines the pocket score for iodontal disease in a state population -- an emphasison chil- the tooth. dren. In Special Supplementto Pediatr Dent, Ed. S. H. Y. Wei, Probing reveals sulcular depth not over Vol. 3,1981. In Press. 3mm. 5. Curilovic, Z. Gingivitis bei ziircher vorschulkinder."Acta Paro- dontiologica" in SchweitMschr Zahnheilk, 85:1105-1111,1975. Probing reveals pocket depth greater than 6. Greene, J. C. and Vermillion, J. R. Oral Hygiene Index: A 3 ram, but not over 5 ram. methodfor classifying oral hygiene status, JADA,61:172-179, 1960. Probing reveals pocket depth greater than 7. Greene,J. C. and Ven-nillion, J. R. The simplified oral hygiene 5mm. index. JADA,68:7-13, 1964.

Table 11. Commonlyused periodontal indices.

Name of Index Tooth Surfaces Author and Year Comment References

PI all teeth Russell, 1956 revisible/irreversible 32, 33 tooth is unit when in doubt, lower score PDI selected teeth Ramfjord, 1959 first part reversible 34, 35 tooth is unit second part irreversible PDR periodontal disease rate Sandier & Stahl, 1959 reversible/irreversible 36 percentage of teeth affected with periodontal disease Pocket depth all teeth or selected Glavind & LSe, 1967 irreversible 37 & Loss of teeth surface is unit attachment in mm NPDI six selected teeth Glossman, 1974 pocket score, irreversible, 38 gingival portion of score reversible

PEDIATRICDENTISTRY: Volume 3, Number4 359 8. Davies, G. N., Kruger, B. J., and Homan,B. T. An epidemiologi- -- 23. Suomi, J. D. and Barbano, J. P. Patterns of gingivitis, J Perio- cal training course, Aust Dent J, 7:17-28, 1967. dontol, 39:71-74, 1968. 9. Russell, A. L. Epidemiology and the rational bases of dental 24. Suomi, J. D. Periodontal disease and oral hygiene in an institu- public health and dental practice, in The , His Practice, tionalized population: report of an epidemiological study, J Per- and His Community, Young and Striffler, Philadelphia, London, iodontol, 40:5-10, 1969. Toronto: W. B. Saunders Company, 1969, pp 35-62. 25. L~e, H. and Silnese, J. Periodontal disease in . I. 10.Schour, I. and Massler, M. in postwar Italy Prevalence and severity, Acta Odont Scand, 21:533-551, 1963. (1945). I. Prevalence of gingivitis in various age groups, JADA, 26. O’Leary, T. J., Gibson, W. A., Shannon, I. L., Schueseler, C. F., 35:475-482, 1947. and Nabers, C. L. A screening examination for detection of gin- 11.Schour, I. and M~ler, M. Prevalence of gingivitis in young gival and periodontal breakdown and local irritants, Periodon- adults, J Dent Res, 27:733-734, 1948. tics, 1:167-174, 1963. 12.Massler, M., Schour, I. and Chopra, B. Occurrence of gingivitis 27. O’Leary, T. The periodontal screening examination, J Periodon- in suburban Chicago ~chool children, J Periodontol, 21:146-164, tol, 38:617-624, 1967. 1950. 28. Ainamo, J. and Bay I. Problems and proposals for recording gin- 13.Massler, M. The P-M-A Index for the asse~ment of gingivitis, givitis and plaque, Int Dent J, 25:229-235, 1975. Part II, J Periodontol, 38:592-598, 1967. 29. L~e, H. and Holm-Pederson, P. Absence and presence of fluid 14. King, J. D. Gingival ~ in Dundee, Dent Record, 65:9, 32, from normal and inflammed gingivae, Periodontics, 3:171-177, 55, 1945. 1965. 15. Parfitt, G. J. A five-year longitudinal study of the gingival con- 30. Oliver, R. C., Holm-Pederson, P., and L~e, H. The correlation dition of a group of children in England, J Periodontol 28:26-32, between clinical scoring, exudate measurements and microscopic 1957. evaluation of inflammation in the gingivae, J Periodontol, 40: 16.M~l~lemann, H. R. and Mazor, Z. S. Gingivitis in Zurich school 201-209, 1969. children, Helv Odont Acta, 2:3-12, 1958. 31. Lobene, R. R. The effect of an automatic on gingival 17.Axno, A., Waerhaug, J., Lovdal, A., and Schei, O. Incidence of health, J Per/odontol, 35:137-139, 1964. gingivitis as related to sex, occupation, tobacco consumption, 32. Russell, A. L. A system of classification and scoring for preva- toothbrushing and age, Oral Surg, 11:587-595, 1958. lence surveys of periodontal disease, J Dent Res, 35:350-359, 18. Heyling~, R. T. A study of the prevalence and severity of gingivi- 1956. tis in undergraduate~ at Leed~ University (1960), Dent Pract, 33. Russell, A. L. The Periodontal Index, J Periodontol, 38:586-591, 12:129-132, 1961. 1967. 19.Jackson, D. The efficacy of 2 percent sodium ricinoleate in 34. Ram0ord, S. P. Indices for prevalence and incidence of perio- to reduce gingival inflammation, Brit Dent J, 112: dontal disease, J Periodontol, 30:51-59, 1959. 487-493, 1962. 35. Ramfjord, S. P. The Periodontal Diesase Index (PDI), J Perio- 20. Jackson, D. The measurement of gingivitis, Brit Dent J, 118: dontol, 38:602-610, 1967. 521-527, 1965. 36. Sandler, H. C. and Stahl, S. S. The measurement of periodontal 21. M~hlernann, H. R. and Son. Gingival sulcus bleeding -- a lead- disease prevalence, JADA,58:93-97, 1959. ing symptomin initial gingivitis, Helv Odont Acta, 15:107-113, 37. Glavind, L. and L~e, H. Errors in the clinical assessment of per- 1971. iodontal destruction, 3 Periodont Res, 2:180-164, 1967. 22. M/~lemann, H. R. Psychological and chemical mediators of gin- 38. Groesman, Navy Periodontal Screening Exam, J Am Soc Prev gival health, J Prey Dent, 4:6-17, 1977. Dent, 3:41-45, 1974.

Quotable Quote One Saturday morning last winter the three networks carried 154 commercials: 72 for sugared cereals, 35 for candy, 23 for fast-food restaurants, five each for cookies, powdered soft drinks and toaster tarts... Now everyone knows that sugary foods promote ; they also caa help a kid along to obesity. And a Yale clinician, Dr. Robert Abramovitz, has pointed out that such commercials intensify the tendency toward instant self-gratifica- tion, just what kids of this age are supposed to be learning to control. This issue may be resolved soon when the Federal Trade Commission rules on TV ads for kids, but, in the mean- time, America’s fat children with rotten teeth, rendered dumber than needed by society’s acts, might well look up at society and say, "Gee, thanks Dad and Morn." From: Page, James K. Jr., Smithsonian, Vol. 10, #6, September, 1979.

360 PERIODONTALEPIDEMIOLOGICAL INDICES: Wei and Lang