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 Dentistry. Abstract high degree of intraexaminer reproducibility and are reve~ible Gingivitis 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 tooth 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) oral hygiene 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 gingival sulcus 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 stippling; 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 dental plaque. 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