Russel’s Periodontal Index

& CPITN...

DEPARTMENT OF PUBLIC HEALTH DENTISTRY

Presented By:

Priyanka VadheraRoll No.: 6083059Batch- 2012

Under the Guidance of:

Dr. Sukhchen BaggaDr. Geetika

CONTENTS Scope & Purpose Treatment Needs Procedure for CPITN

Sextants Index Teeth Recording Data WHO Periodontal Examination

Probe - CPITN Probe→Probing Procedure

Codes & Criteria Examination Procedure

Choice of Age Groups Classification of Treatment Needs Calculation of CPITN Modification of CPITN

Introduction What is an Index? Features of an Index Ideal Requisites of an Index Criteria for Selection of an Index Classification of Indices Russel’s Periodontal Index Introduction Method Scoring Criteria Russel’s Rule Calculation of the Index Uses Drawbacks CPITN Introduction

Introduction• The simplest form of measuring a disease is by a

count of the no. of cases of its occurence, but with the oral diseases, simple counts of cases are of limited use because of the high prevalence of these conditions in many of the world’s population.

• Dental Index or indices can be considered as the main tool of epidemiological studies in dental diseases to find out the incidence, prevalence & severity of diseases, based on which preventive programmes are adopted for their control & prevention.

What is an Index?• According to Russel A.L. -

“An index is defined as a numerical value describing the relative status of a population on a graduated scale with definite upper & lower limits, which permits & facilitates comparison with other groups classified by same criteria & method.”

Features of an IndexFor an index to be accurate, following properties are needed:-

• Simplicity: Easy to use needing no expensive equipment.

• Objectivity: Unambiguous with mutually exclusive categories.

• Validity: Ability to detect the condition when present.

• Reliability: Different examiners record the same result.

• Precision: Ability to distinguish between.• Acceptabilty: Safe & not demeaning to.• Amenablity to analysis: Data should be

analysable & interpretable.

IDEAL REQUISITES OF AN INDEXIdeally an Index should possess the following properties:-• Clarity, Simplicity & Objectivity• Validity• Reliability• Quantifiablity• Senstivity• Acceptabilty

Criteria for Selection of an Index• Simple to use & calculate.• Should permit the examination of many

people in a short period of time.• Should require minimum

armamentarium & expenditure.• Should be highly reproducible in

assessing a clinical condition when used by one or more examiners.

• Should not cause discomfort to the patient & should be acceptable to the patient.

• Should define clinical conditions objectively.

• Should be equally sensitive throughout the scale, if it relates the severity of a variable.

Clas

sifica

tion

Based upon the direction in which their scores can fluctuateBased

upon the direction in which their scores can fluctuate

Irreversible IndexEg: DMFT Index

Reversible IndexEg: Loe & Silness Gingival Index

Depending upon extent to which areas of oral cavity

are measured

Full Mouth IndicesEg: Russel’s Periodontal Index

Simplified IndicesEg: OHI-S

Based on the entity which they measure

Disease Index‘D’ (decay) portion of DMFT Index.

Symptom IndexMeasuring gingival/sulcular bleeding.

Treatment IndexEg: ‘F’ (filled) portion of DMFT Index

Special Categories

Simple IndexEg: Silness & Loe Plaque Index

Cumulative IndexEg: DMFT Index for Dental Caries

RUSSEL’SPERIODONTAL

INDEX

Introduction• The Periodontal Index (PI) was developed by Russel

A.L. in 1956.• Thus index was developed over a trial period of ten

years, because of a lack of sophisticated methodologies to assess the prevalence & severity of gingivitis & destructive periodontal disease.

• The PI is a composite index because it records both the reversible changes due to gingivitis & the more destructive & presumably irreversible changes brought about by deeper periodontal disease.

• The PI is probably the most widely used periodontal index in epidemiological surveys around the world.

• It was intended to estimate deeper periodontal diseases by measuring the presence or absence of gingival inflammation & its severity, pocket formation, & masticatory fiunction.

• The scale of values range from 0-8 with increasing prevalence & severity of disease.

Method Instruments Used: Mouth mirror & Plain probe.

• All the teeth present are examined.• All of the gingival tissue circumscribing each

tooth (i.e, all of the tissue circumscribing a tooth is considered a scoring or gingival unit) is assessed for gingival inflammation & periodontal involvement.

Scoring Criteria

Russel chose the scoring values (0,1,2,6,8) in order to relate the stages of the disease in an epidemiological survey to the clinical conditions observed.

Scoring Criteria Table

Clinical Condition Group PI scores Stage of DiseaseClinically normal supportive tissues

0-0.2

Simple gingivitis 0.3-0.9Beginning destructive periodontal disease

0.7-1.9 Reversible

Established destructive periodontal disease

1.6-5.0 Irreversible

Terminal disease 3.8-8.0 Irreversible

Clinical Condition Individual PI ScoreClinical normal supportive tissues

0-0.2

Simple gingivitis 0.3-0.9Beginning destructive periodontal disease

1.0-1.9

Established destructive periodontal disease

2.0-4.9

Terminal disease 5.0-8.0

Group Periodontal Index (PI) Score & Clinical Manifestations:

Individual Periodontal Index (PI) Score & Clinical Manifestations:

Russel’s RuleThe Russel’s Rule states that-

“When in doubt, assign the lower score.”

Calculation of the Index• The PI score per individual is obtained

by adding all of the individual scores & dividing by the no. of teeth present oe examined. i.e,

PI score per person =

Uses • Used in epidemiological surveys.• More data can be assembled using PI

than any other index of periodontal disease.

• Used in National Health Survey, the largest ongoing health survey in United States.

Drawbacks• Since only a mouth mirror & no calibrated

probe or radiograph is used, when performing the PI examination, the results tend to underestimate the true level of periodontal disease, especially early bone loss, in a population.

• The number of periodontal pockets without obvious supragingival calculus is underestimated in the PI.

CPITN

Introduction• The “Community Periodontal Index of Treament

Needs” (CPITN) was developed for the “joint working family” of the “WHO”& “FDI” by Jukka Ainamo, David Barmes, George Beagrie, Terry Cutress, Jean Martin & Jeniffer Sardo-Infirri in 1982.

• It was developed primarily to survey & evaluate periodontal treatment needs rather than determining past &B present periodontal status i.e, the recession of gingival margin & alveolar bone.

Scope & Purpose• The CPITN procedure is recommended for epidemiological surveys of

periodontal health.• It provides guidance on the planning & monitoring of the effectiveness

of periodontal care programme & dental personnel required• The CPITN records the common treatable conditions, namely– Periodontal Pockets– Gingival Inflammation– Dental Calculus– Other Plaque Retentive Factors• It doesn’t record irreversible changes such as recession or other

deviations from periodontal health such as tooth mobilty or loss of periodontal attachment.

AdvantagesMajor advantages of CPITN are:• Simplicity• Speed• International uniformity

Limitations Limitations of CPITN are:-• Partial recording• Exclusion of spome important signs of past periodontal

breakdown- notably attachment loss• Absence of any marker of disease activity or susceptibilty

Procedure for CPITN• The dentition is divided into six parts called

Sextants.• Each sextant is given a score.• For epidemiololgical purposes, the score is

identified by examination of specified Index teeth.

• For clinical practice, the highest score in each sextant is identified after examining all teeth.

• Essentially the CPITN considers the periodontal treatment needs of each sextant with respect to:-

i. No need for care (score 0)ii. Bleeding gingivae on gentle probing (score 1)iii. Presence of calculus & other plaque retentive

factors (score 2)iv. Presence of 4-5mm pockets (score 3)v. Presence of 6mm or deeper pockets (score 4)

• The mouth is divided into six sextants defined by tooth numbers as shown below:-

• The third molars are not included, except where they arer functioning in place of second molars.

• The treatment need in a sextant is recorded only if there atre two or more teeth present & not indicated for extraction.

• When only one tooth is present in a sextant, it is included in the adjacent sextant.

Sextant

Index Teeth• In epidemiological surveys for adults, aged 20

years or more, only 10 teeth, known as the Index Teeth are examined.

• The ten specified index Teeth are:-

• The molars are examined in pairs & only one score, the highest is recorded. Only one score is recorded for each sextant.

17 16 11 26 27

47 46 31 36 37

• For young people upto 19 years, only six Index Teeth are examined. The second molars are excluded as Index Teeth at these ages because of the high frequency of false pockets.

• The six Index Teeth selected are:-

• When examining children less than 15 years, pockets are not recorded although probing for bleeding & calculus are carried out as a routine.

16 11 26

46 31 36

Recording Data• The following ‘box chart’ is

recommended as the epidemiological & dental office chart for recording the CPITN Data:

WHO-CPITN Probe• It has a 0.5mm ball at the tip & millimeter

markings at 3.5, 5.5, 8.5 & 11.5 and color coding from 3.5 to 5.5.

• Used for measurement of CPITN.• Introduced by WHO in 1978.• Weight: 5gms• Designed for two purposes:i. Measurement of pocket depth.ii. Detection of subgingival calculus.

Probing Procedure• A tooth is probed to determine pocket depth & to detect

subgingival calculus & bleeding response.

• Working force shouldn’t exceed 20gms – a practical test for establishing this force is to gently insert the probe point under the finger nail without causing pain or discomfort.

• Pain to the patient during probing is in most cases indicative of the use of a too heavy probing force.

Probing Force

Working Component

Determines pocket depth

Sensing Component

Determines subgingival calculus

• The probe is inserted between the tooth & gingiva, & the sulcus depth is noted against the color code or marking.

• The ball end of the probe should be kept in contact with the root surface.

• Direction of probe during insertion should be whenever possible in the same plane as the long axis of the tooth.

• Recommended sites for probing: mesial, mid-line & distal on both facial & lingual/palatal surfaces.

• The total extent of the pocket should be examined in at least six points on each tooth, the mesio-buccal, mid-buccal, disto-buccal & corresponding lingual sites.

• After probing, the gingiva or gum of the examined tooth should be inspected for the presence or absence of bleeding before the subject is allowed to swallow or close their mouth. Bleeding may be delayed for upto 10-30secs after probing.

Codes & CriteriaCODE TREATMENT COMPLEXITY

CODE-0 No periodontal disease.CODE-1 Bleeding observed during or after probing.CODE-2 Calculus or other plaque retentive features either seen or felt during

probing.CODE-3 Pathological pocket 4-5mm in depth. Gingival margin situated on black

band of the probe.CODE-4 Pathological pocket 6mm or more in depth. Black band of the probe is not

visible.CODE-X When only one or no teeth are present in a sextant (thord molars are

excluded unless they function in place of second molars).

Examination Procedure• The aim is to determine the highest

score applicable to each sextant wit the least no. of measurements.

• For a sextant to be validly scored, the requirement is that more than one functional tooth should be present.

• If ‘no’, then score ‘X’ & move to next sextant.

• If ‘yes’, examine index teeth (in epidemiological procedure) or all teeth (in clinical screening procedure) for presence of 6mm or deeper pockets, 4 or 5mm pockets, calculus or other plaque retentive facors, bleeding only, in that order.

Choice of Age Groups• While applying CPITN, the

WHO standard age grouping should be used, i.e, single years to 19 but including a group of 15-19 years, 20-24 years, 25-29years, 30-34 years, 35-44years, 45-54tears, 55-64years, 65-74 years, & 75-84years & over.

Classification Of Treatment NeedsTreatment

NeedsCode Interpretation

TN-0 CODE-0 No treatment is needed.

TN-1 CODE-1 Improvement of personal oral hygiene.

TN-2 CODE-2 Professional cleaning of teeth & removal of plaque retentive factors along with oral hugiene instructions.

CODE-3 Scaling & root planning along with oral hygiene instructions.

TN-3 CODE-4 Complex treatment like deep scaling, root planing & more complex surgical procedures.

Calculation of CPITN• CPITN for a population group can be

calculated as follows:• Step 1: Count the no. of charts with

different codes & add up the codes individually (i.e, codes 0,1,2,3,4).

• Step 2: To obtain the prevalence (percentage) of subjects with codes 0,1,,2,3,4 as their score, divides the counts of codes respectively, by the total no. of dentate subjectsexamined & multiply by 100.

• To obtain the ‘mean no. of sextants’ (MNS) for each condition per person, divide the total no. of sextants with highest score for ther person by the no. of dentate subjects examined.

Modifications of CPITN• These include: Simplified

Periodontal Examination (SPE), later termed the Basic Periodontal Examination (BPE), & the Periodontal Screening & Recording (PSR).

• The PSR that has attachment loss incorporated into its procedurial method is predominantly used in the United States & Canada & is promoted by the American Academy of Periodontology & the American Dental Association.

THANK YOU..!