DENTAL CARIES - INDICES

INDICES FOR DENTAL CARIES
Presented by:
M.D.Suhail
Post Graduate
Dept of pedodontics
Guided by :
Dr.Ravindar Puppala
Professor and H.O.D
Dept of Pedodontics

• Measurement is a process of assigning values to characteristics according
to a set of rules.
• A prerequisite for any epidemiological investigation is the ability to
quantify the occurrence and severity of the disease.
2
Measuring Diseases
This is facilitated through indices: certain
methodology and criteria

1. An Index can be defined as a numerical value describing the relative status
of a population on a graduated scale with definite upper and lower limits,
which is designed to permit and facilitate comparison with other populations
classified by the same criteria and methods.
(Russal
A. L)
2. An Index is an expression of clinical observation in numerical values which
is used to describe the status of the individual or group with respect to a
condition being measured.
(Wilkins
Esther M.)

3. Dental Index is an abbreviated measurement of the amount or condition of
disease in a population; a numerical scale with a defined upper and lower
limits designed to permit and facilitate comparison with other population
classified by the same criterion and methods.
(Zarkowski
Pamela)
4. Epidemiologic Indices are attempts to quantitate clinical conditions on a
graduated scale, thereby facilitating comparison among populations
examined by the same criterion and methods.
(Glickman
Irving)

1. To increase understanding of the disease process.
2. To discover populations at high and low risk.
3. To define specific problem under investigation.

1. Clarity, Simplicity and Objectivity
2. Validity
3. Reliability
4. Quantifiability
5. Sensitivity
6. Acceptability

 CLARITY: The examiner should be able to remember the rules of the index
clearly in his mind
 SIMPLICITY: The index should be simple and easy to apply so that there is no
undue time lost during field examinations
 OBJECTIVITY: The criteria for the index should be objective and
unambiguous, with mutually exclusive criteria
 VALIDITY: The index must measure what it is intended to measure
10

 RELIABILITY: The index should measure consistently at different times and at
variety of conditions
 QUANTIFIABILITY: The index should be amenable to statistical analysis
 SENSITIVITY: The index should be able to detect reasonably small shifts, in
either direction in group condition
 ACCEPTABILITY: The use of index should not be painful or demeaning to the
subject
11

• Measures the conditions that can
be changed
• Indices for periodontal conditionsReversible
• Measures the conditions that will
not change.
• Dental caries indexIrreversible
A. Depending upon the directions in which the
scores can fluctuate

• Measures patient’s entire
periodontium or dentition
• Russel’s Periodontal index
Full
Mouth
• Measures only a representative
sample of dental apparatus
• Greene and Vermillion’s oral
hygiene index-Simplified
Simplified
B. Depending upon the extent to which areas of oral
cavity are measured

Disease Index
Symptom Index
Treatment Index
C. Depending upon the entity they measure

D. Special Category Indices
• Measures the presence or absence of a
condition.
• Index measuring presence of dental plaque
without an evaluation of its effect on
gingiva.
Simple
Index
• Measures all the evidence of a condition,
past and present.
• DMF index for dental caries
Cumulative
Index

Dental caries is an irreversible microbial disease of calcified tissues of the teeth,
characterised by demineraliasation of the inorganic portion and destruction of
the organic substance of the tooth, which often leads to cavitation
SHAFER’S
DENTAL CARIES

It is a dynamic process of demineralisation due to microbial metabolism
resulting in net mineral loss which subsequently may not always lead to
cavitation
Frejeskov 1997

Measuring Dental Caries
Statistical measurement of dental caries serves 3 broad purposes:
• For epidemiological investigation on characteristics of dental caries in
population groups
• For public health programme planning and evaluation
• For testing prevention and control procedures
20

Prevalence of Dental caries is measured in terms of:
• percentage of persons affected
• Number of teeth attacked
• Number of tooth surface involved
• Number of discrete cavities
• Size and degree of severity of carious lesion
21

HISTORICAL BACKGROUND OF
CARIES INDICES.
BODECKER CF and
BODECKER HWC
• described a Caries Index
in 1931
• Modified it later by
addition to counting of
decayed surfaces.
DEAN HT
• Counting carious teeth
visibly in the mouth
MELLANBY M
• In 1934 described the
carious lesions
depending upon the
degree of severity
• 1 = Slight caries
• 2 = Moderate caries
• 3 = Advanced caries

• First systematic description - DMF index
• Attributed to Knutson JW, Henry Klein and Carole Palmer in their studies of dental
caries in Hagerstown and Maryland (1930)
FINALLY….

MOST COMMONLY USED OTHER MIXED DENTITION
INDICES
DMFT
1. Primary Teeth (dmft & dmfs)
2. Permanent Teeth (DMFT & DMFS)
1. Stone’s Index
2. Caries Severity Index
3. Czechoslovakian Index
4. Caries Susceptibility Index
5. Modified DMFT Index
6. Functional Measure Index
7. Tissue Health Index
8. Dental Health Index
9. DMFS Percentage Index
10.Moller’s Index
11.Restorative Index
12.Significant Caries Index
INDICES FOR DENTAL CARIES

DIAGNOSING PIT AND FISSURE CARIES : -CRITERIA
 ANGLO-SAXON SYSTEM {LIBERAL}
By Horowitz H.S. In 1972
The pits and fissure on the occlusal, vestibular and lingual surfaces are carious when-
1 The explorer “catches” after insertion with moderate to firm pressure .
2. When the catch is accompanied by one or more of the following signs of decay
a) Softness at the base of the area.
b) Opacity adjacent to the area provides
evidence of undermining or demineralization.
c) Softened enamel that can be scraped by explorer.
NOTE : - Areas should be diagnosed as sound when there is apparent evidence of
demineralisation but no evidence of softness.

DIAGNOSING PIT AND FISSURE CARIES : -CRITERIA
 “EUROPEAN SYSTEM {CONSERVATIVE}
By Backer-Dirks O., Houwink B., Kwant G.W. in 1961
Teeth are first dried and sharp new explorers are used
• Upper molars : Mesio-occlusal and disto-occlusal-palative fissures are assessed separately.
• Lower molars : Occlusal fissures and buccal pits are assessed separately.
C I - Minute black line at the base of fissure
C II - In addition, a white zone along margins of fissure.
C III - Smallest precipitable break in the continuity of enamel.
C IV - Large cavity, more than 3mm wide.

DECAYED-MISSING-FILLED TEETH INDEX
(DMFT INDEX)

• Developed to determine the prevalence of coronal caries.
• Is a simple, rapid, versatile, universally accepted and widely used index for several decades.
• It is used to determine total dental caries experience past and previous.
• The DMFT Index is an irreversible index (meaning that it measures total lifetime caries experience).
• The tooth either remains decayed or if treated it is extracted or filled.

Procedure
• The DMFT Index is applied only to permanent teeth is composed of three components.

Examination of DMFT Index has to be done with : -
1. Favorable lighting conditions
2. A No. 3 plain mirror
3. A Fine-pointed pig-tail explorer

Third molars and
Unerupted teeth
Congenitally,
missing and
supernumerary
teeth
Teeth removed for
reasons other than
dental caries
Teeth restored for
reasons other than
dental caries
Primary tooth
retained with
permanent
successor erupted.
• All 28 teeth are examined.
Teeth not to be included

Principles and Rules in recording
DMFT:1. No tooth must be counted more than once. It is either decayed, missing, filled or sound.
2. Decayed, missing, and filled teeth should be recorded separately since the components of
DMF are of great interest.
3. When counting the number of decayed teeth, also include those teeth which have restorations
with recurrent decay.
4. Care must be taken to list as missing only those teeth which have been lost due to decay.
5. Also included should be those teeth which are so badly, decayed that they are indicated for
extraction.

The following should not be counted as missing:
a) Unerupted teeth
b) Missing teeth due to accident
c) Congenitally missing teeth
d) Teeth that have been extracted for orthodontic reasons.
6. A tooth may have several restorations but it is counted as one tooth.
7. Deciduous teeth are not included in DMF count.
8. A tooth is considered to be erupted when the occlusal surface or incisal edge is totally,
exposed or can be exposed by gently, reflecting the overlying gingival tissue with the mirror or
explorer.
9. A tooth is considered to be present even though the crown has been destroyed and only the
roots are left.

WHO modification of DMF Index
(1986)1. All third molars are included.
2. Temporary restorations are considered as decayed
3. Only, carious cavities are considered as ‘D', the initial lesions (Chalky spots. stained
fissures, etc) are not considered as ‘D'. The DMF Index can be applied to denote the number
of affected teeth (DMFT) or to measure the surfaces affected by dental caries (DMFS).

Calculation of the Index
Individual DMFT: total D+M+F= DMF.
Group Average:
Total DMF
Total number of the subjects examined
Percent Needing Care Total number of decayed tooth
Total number examined
Percentage of teeth lost: Total number of missing teeth
Percent of filled teeth : Total number of filled teeth
Total DMFT

Missing permanent teeth/100 Total number of missing teeth X 100
The maximum possible
DMFT score is 32 ( if third molars are included )
DMFT score is 28 ( if third molars are excluded)

Advantages of DMFT index
1. Because of its wide spread use world wide over the past 60 years , it provides a
reasonably accurate historical account of changes in prevalence of dental caries.

Limitations of DMFT Index:
1.DMFT values are not related to the number of teeth at risk.
2. DMFT index can be invalid in older adults because teeth can become lost for reasons other than caries.
3. DMFT index can be misleading in children whose teeth have been lost due to the orthodontic reasons.
4. DMFT index can over estimate caries experience in teeth in which "preventive fillings" have been
placed.
5. DMFT Index is of little use in studies of root caries.

Shortcomings of DMF Index
• DMF values are not related to the number of teeth at risk. It tends to equate desired state with
treated condition
• It assesses only cavitated lesion extended into dentin
• DMF index is invalid in elderly population, as teeth can be lost for reasons other than caries
• Reaches saturation level at particular point of time when all teeth are involved and prevents
registration of caries attack even when caries activity is continuing
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Shortcomings of DMF Index(contd)
• Does not give account for treatment needs
• DMF index gives equal weight to missing, untreated decayed and well
restored teeth
• Cannot be use to assess root caries
• Rate of caries progression cannot be assessed
40

Inability of D component of DMF score to define treatment needs:
• Criteria used to diagnose caries in a survey are not the same as those used
by practitioners in forming patient’s treatment plan
• Patient’s own perceived needs, level of interest in their dental conditions,
and ability or willingness to pay all level of treatment
• A practitioner has to judge whether a minor lesion will develop into a
major lesion over time, and whether a lesion in primary tooth can safely
remain untreated for the life of the tooth. A survey, whereas, scores a
tooth by how it appears at the time of the survey.
• Treatment philosophies change with time
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OTHER METHODS OF DMF
EXMINATION
‘Shorthand' Methods
1. Intended for use in surveys where basic prevalence is assessed.
2. Based on examination of selected teeth only
3. Objective is to decrease the time taken for each examination
and still provide valid data.

I. WORLD HEALTH ORGANISATION (WHO) has
described a shorthand method
1. Recommends the use of "half-mouth" DMF in its basic survey techniques.
2 Objective is to obtain assessments of caries prevalence in a population
which has not been previously surveyed.
3. Half the upper arch only is scored. then the contra lateral lower half arch
and the results doubled. It is Quicker and easier than full-mouth DMF
Index.

Henry T. Klein, Carrole. E. Palmer and
Knutson J.W 1938.

 More sensitive
 Usually the index of choice in a clinical trial of caries preventive agent.
 Used to determine total dental caries experience past and present by recording tooth
surface invloved instead of teeth.

• DMFS is a more detailed index than the DMFT by summing the total number of
decayed, missing and filled permanent tooth surfaces.
• As in the case of the DMFT Index, the DMFS index is simple and versatile and
more sensitive, has practically, universal acceptance. and is one of the best-known
dental indices today.

1. For Posterior teeth: Five surfaces examined and recorded:
facial, lingual Mesial, distal and occlusal
2. For Anterior teeth: Four surfaces examined and recorded:
facial, Lingual, mesial and distal.

Calculation of DMFS Index:
1. Individual DMFS Index : DMFS score = D+M+F
2. Total surface count for a DMFS
Index
(If 28 teeth are examined)
• 16 posterior teeth (16*5=80)
• 12 Anterior teeth (12*4=48)
• Total= 128 surfaces
3. Total surface count for a DMFS
Index
(If 32 teeth are examined)
• If third molars are included
(4*5)=20surfaces
• Total = 128 + 20 = 148 surfaces

Established modification:
• Procedural modifications can be made to the DMFS index to allow for factors
such as secondary caries , crowned teeth , bridge pontics , and any other
particular attribute required for study.
• To save time in large surveys, the DMFS can be used half-mouth , applied to
opposite diagonal quadrants and the score doubled an approach that assumes
that caries incidence is bilateral.

Disadvantages
1. DMFS examination takes a longer time and is more likely to produce
inconsistencies in diagnosis and may require the use of radiographs to be fully
accurate.
2. To save time in larger surveys, the DMFS can be used half- mouth , applied to
opposite diagonal quadrants and the score doubled.
3. This is based on the assumption that caries incidence is bilateral.
4. A tooth scores exactly the same under extremes of clinical conditions; a tooth with
small restoration in one pit rates the same as a tooth that has been extracted.

5. One of the difficulties encountered in use of this surface index is the score to be allocated
to teeth indicated for extraction, which may have been attacked on one surface only,
although its extraction results in the loss of four or five surfaces , according to the tooth.
6. Another difficulty is the score to be given to two surface fillings in posterior teeth, where
the initial attack was probably on one proximal surface and the occlusal surface was
involved later, to provide an adequate class II type of cavity or restoration.

CARIES INDICES FOR PRIMARY DENTITION

The Caries Indices used for primary dentition are 'deft' index and 'defs' index equivalent to the
DMFT and DMFS indices used for permanent dentition.
The basic principles and rules for def index are the same as that for DMF index.

‘d’ decayed
Indicates the number of deciduous teeth that are decayed. In counting the number of decayed
deciduous teeth - a tooth can only be counted once.
It cannot be counted as filled and decayed. If it has been restored and caries can be detected
count it as decayed.
The explorer should fall into carious tooth substance and not just in a deep groove before
counting occlusal caries.

'e' extraction
 Indicates those deciduous teeth which have been extracted due to caries or which are so
badly, decayed that they are indicated for extraction. Because of the wide variation in the time
of exfoliation of deciduous teeth.
 It is difficult to determine whether a tooth missing from the deciduous dentition was normal,
exfoliated or was extracted because of advanced caries.
 If it can be accurately established that a missing deciduous tooth has been lost due to caries.
include it with those indicated for extraction

‘f’ filled
 Indicates the number of deciduous teeth that have been attacked by caries but which
have been restored without a recurrent decay present.
 A tooth may have several fillings but it is counted as one tooth. If a tooth has a filling
but shows evidence of recurrent decay.
 It is counted as a decayed tooth.

Modifications of def index
 dmf index
For use in children before ages of exfoliation i.e. children over 7 years and upto 11 or 12
years
 df index
In this index the missing teeth are ignored. df index can be applied –
to whole tooth as : decayed –filled- tooth (dft index) or
to individual surfaces as : decayed filled surfaces (dfs index)

Disadvantages (def and dmf
indices)
1. It is difficult to determine whether the primary tooth has been extracted or shed
naturally, by this index.

• The D1-D3 Scale was first published by WHO in 1979 as an aid to diagnosing
coronal caries.
• Traditionally used among European investigators who diagnose dental caries from
the earliest detectable non-cavitated lesion through to pulpal involvement ,said to be
of extreme value in research studies because it permits identification of lesion
progression as well as initiation.
• Involves a lengthy & detailed examination, requires meticulous examiner training
DENTAL CARIES SEVERITY
CLASSIFICATION SCALE

0-surface sound : no evidence of treated or untreated clinical caries.
D1-initial caries : no clinically detectable loss of substance For pits & fissures, there may be
significant staining, discolouration, rough spots in the enamel that do not catch the explorer
but loss of substance cannot be positively diagnosed.
D2-Enamel caries : demonstrable loss of tooth substance in pits, fissures or on smooth
surfaces, but no softened floor or wall or undermined enamel. The texture of the material
within the cavity may be chalky or crumbly, but there is no evidence that cavitation has
penetrated the dentin.

• D3-caries of dentin : detectably softened floor, undermined enamel or a softened wall, or
the tooth has a temporary filling. On proximal surfaces, the explorer point must enter a lesion
with certainty
• D4-pulpal involvement : deep cavity with probable pulpal involvement. pulp should not
be probed (usually included with D3 in data analysis)

STONE'S INDEX
Stone H. H, Lawton F. E, Bransby E. R. and Hartley H.O.
1949.

Score Criteria
1 One point to one or more cavities in the same tooth detectable by sharp
probe where the lesion has not penetrated through the enamel to involve the
dentine.
2 Two points to one or more cavities in the same tooth where the dentine is
involved, where a total of less than a Quarter of the crown is estimated to
have been destroyed
3 Three points to one or more cavities in the same tooth resulting in a total
destruction of more than a Quarter of the crown
Scoring Criteria

CARIES SEVERITY INDEX
Tank Certrude and Storvick Clara in 1960

a. This index was developed to study the depth and extent of the caries
surfaces and the extent of pulpal involvements.
b. The progress of the dental caries in stages as described by Massier and
Schour in 1952 were modified and this caries severity index was devised to
measure the extent and depth of decayed surfaces and pulpal involvements
based on clinical and radiographic examinations.

Score Criteria
1 Superficial (caries in enamel)
2 Moderate (caries in enamel and superficial dentine)
3 Moderately severe (enamel undermined)
4 Severe (approaching pulp,enamel,collapsed)
5 Pulpitis(caused either by deep seated caries or by trauma without
caries)
6 Death of pulp (caused either by deep seated caries or by trauma
without caries)
7 Periapical infection (caused either by deep seated caries or by trauma
without caries)
Scoring Criteria

CZECHOSLOVAKIAN
CARIES INDEX
Poncova, Novak and Matena in 1956.

• This index is mainly used to compare caries experience in one group with that of
the other groups with a similar population density but living in different
environments.
• In this index the "variables" seems to be controlled. In all examination studies and
tests in which this index is used, the average number of teeth, tooth surfaces and
tooth areas and the condition of previously extracted or crowned teeth were
considered.

 The proposed formula can be applied as a basis for an individual or a collective index.
 In individual examination. the "Base" is given by the amount of teeth in adult dentition (32) and
in collective studies, the "Base" is the number of persons examined multipled by 32 to establish
the correct base figure. The average index value will then be between 0 to I. The nearer, the
index is to 1 the higher the caries frequency.
The following formula serves as the basis for this caries index (in adults):
1- C - FC - 4/ 5 E - 2 / 3 AT
Base
(C- Caries: FC - Fillings and Crowns; E Extractions; and AT - Anchorage teeth).

CARIES SUSCEPTIBILITY
INDEX
Richardson A. in 1961

1. This index is based on Bodecker and Mellanby caries indices.
2. There are 2 factors involved in measuring caries susceptibility using the
dynamic survey, namely
a) Amount of tooth surface at risk.
b) Amount of caries developing during the period of observation.

Method:
• Each tooth is divided into various surfaces, to use one caries tooth surface as the unit of
measurement.
Susceptible surfaces are scored as follows:
• Incisors - Mesial. Distal. Lingual. labial = 4
• Canine - Mesial, Distal, lingual, labial = 4
• Premolar - Mesial, Distal, Lingual. Buccal Occlusal = 5
• Molar - Mesial, Distal, Lingual. Buccal, Occlusal = 5
Full permanent dentition thus would have 148 susceptible surfaces and full deciduous dentition
would have 88 susceptible surfaces.

D-M-F SURFACE
PERCENTAGE INDEX
Jagger CL in 1963

Method :
 All the teeth are given surface values (SV)
-The incisors and canines are given ‘four’ values.
-The premolars and molars are given ‘five’ values.
1. Deciduous and permanent teeth are treated alike and a mixed dentition does not upset this
index.
2. Caries teeth are allotted ‘ONE’ carious surface value (CSV) for every surface attacked by
caries.
3. Missing teeth are allotted equivalent to their total surface values (missing teeth lost other
than caries are not included).
4. Restored teeth are treated as carious teeth.
5. Inter proximal cavities of incisors are given 3 (CSV) values and of premolars and molars are
given 2 (CSV)

In the suggested DMFS percentage index:
• The age of the subject is considered,since different numbers of surfaces are present at different ages
• The simplified age factors for different age groups are as follows:
AGE AGE FACTOR
6 to 71/2 months 6
7 to 9 months 3
12 to 14 months 2
16 to 18 months 1.5
20 months to 5 years 1
6 to 11 years 0.9
12 to 16 years 0.8
17 years 0.7

• Calculation:
To determine the DMFS percentage caries index of an individual, total the carious
surface values and multiply by the age factor for the particular individuals age
group.

RESTORATIVE
INDEX
D. Jackson in 1973

a) RI=F/F+D
b) Measures the proportion of attached teeth(F+D) which are filled(F)
c) Does not depend on DMF index & hence can be used at all ages
d) RI is not a weighted index,it is a simple proportion with a definite meaning
e) It is the objective of the unmet restorative treatment needs (UTN) used by Glick et al in
1972,which is D/F+D%
f) The restorative index as a community index:
The RI can be used to measure the level of restorative care in any community and for any
subsection of a community at any age

MODIFIED DMFT
INDEX
Joseph Z. Anaise in 1983.

DMFT index by Klein and Palmer
 Is simple and most widely used in epidemiological surveys of dental caries
 It quantifies dental health status based on the number of decayed missing and filled teeth.
Drawbacks of DMFT index
 Does not provide an accurate description of previous dental care.
 Does not provide information regarding severity of carious attack or the indicated
treatment.
 To overcome these drawbacks of DMFT index the modified DMFT index was developed.

• Basically this modified DMFT index involves the same operational procedures as common
DMFT index. The only difference is in the scoring criteria for ‘D’ component of index ,
which is divided into 4 separate categories as follows : -
• C = Unfilled teeth that are carious
• CF = Teeth that are carious around the margins of restorations or primarily on a tooth
surface other than restored one.
• IX - Carious teeth either filled or unfilled that in the examiners opinion are indicated for
extraction
• IRC - Carious teeth either filled or unfilled that in the examiners opinion are indicated for
pulp treatment or RCT.

• Advantages
1. The index remains simple and yet provides description of previous dental experience.
2. It further shows the extent of dental services needed by the population, which can be
interpreted in terms of treatment hours and costs.
3. In addition to these four categories, the remaining two categories of DMFT index (F- filled
teeth with no decay and M- Missing teeth) are recorded as usual according to the WHO
criteria.
4. The DMFT score is then, the summation of all six categories and the calculation of the
individual components as well as sum remains essentially the same as the original DMFT
index.

DENTAL CARIES SEVERITY
INDEX FOR PRIMARY TEETH
Aubrey Chosack in 1985.

METHOD
• Caries seen on the buccal, lingual and palatal surfaces or proximal caries is only
scored for these surfaces when normal pits or fissures of these surfaces are affected
or included, or when the caries extends along atleast half the gingival third of these
surfaces

• Only the largest caries involment is scored for any one surface. Scores of two or more lesions
on one surface are not combined
• A filled surface is given a score of “1”, secondary caries at the margin of restoration is given a
score of “2”
• A full crown restoration gives a total score of 5 for that tooth and the total tooth score of 6 is
given to a tooth extracted because of caries.
• These scores are based on the clinical experience of the earlier levels of caries severity
resulting in these types of treatment

• Score for each tooth is total of the scores of all the surfaces
• Although a theoretical score of 15 is possible for molars and 12 for canines and incisors,
part of the tooth material loss may have occurred because of fracture of unsupported surface,
rather than caries of that surface.

A ) Occlusal surfaces & pit and fissure caries
on buccal or palatal surfaces of molars:
1 -
2 -
3 -
early pit and fissure caries where explorer catches or resists removal with moderate
or firm pressure, and is accompanied by either a softness at the base of the areas or
an opacity adjacent to the pit or fissure as evidence of undermining or
demineralization or softened enamel adjacent to the pit or fissure which may be
scraped away with the explorer.
cavitation of atleast 1mm across the smallest diameter at the tooth surface
cavitation with breakdown or undermining (as seen by obvious discolouration) of
atleast half a cusp

B) Buccal,lingual and palatal smooth caries
1 a white lesion not extending to the embrasure areas,found to be soft and sticky
by penetration with the explorer
2 cavitation of atleast 1mm but less than 2mm across the smallest diameter, or a
soft sticky white lesion extending into one embrassure
3 cavitation of atleast 2mm in the smallest diameter or a soft sticky white lesion
extending into both embrasures

C) Proximal surfaces of molars:
1 a discontinuity of the enamel in which an explorer will catch and there is
softness
2 cavitation with early breakdown of marginal ridge or obvious discolouration
indicating undermining of the ridge
3 breakdown of the marginal ridge with cavitation extending to mesial or dental
extensions of occlusal fissures

D. Proximal surfaces on incisors and canine
1 a discontinuity of the enamel in which an explorer will catch and if there is
softness
2 cavitation with breakdown or obvious discolouration, indicating undermining for
atleast 1mm on the buccal or lingual surfaces
3 cavitation with breakdown of incisal edge or undermining of the edge is
indicated by obvious discolouration

• Thus a maximum of 12 is scored for molars and a maximum of 9 for canines and
incisors
• If caries has resulted in complete breakdown of the crown,leaving only roots,the
maximum score is recorded for this tooth
• The CSI for the population is the mean of the scores for the caries teeth.Teeth free of
caries are not included in this calculation.

MOLLER’S INDEX
Moller IJ and Poulsen S 1966

Advantages
1. The basis for the development of this system was to make available a system which could
be used in many different situations .
2. It is flexible in meeting the various needs of different types of clinical studies on dental caries.
3. The diagnostic criteria are specified for
* pit and fissure surfaces
* smooth surfaces
* radiographic evaluation of proximal surfaces
4. Untreated carious lesions are divided into 4 types Type 1 ,2,3,4 which makes it possible to
exclude certain types of carious lesions in either diagnosis or during the analysis.

Disadvantages
1. It involves use of radiographs.

RECENT ADVANCES
3. Oral Health Status Index
4. Functional Measure Index

1.Oral health status
index
Marcus M, Koch AL, Gershen JA in
1980.
The index includes –
3 component of DMFT and 15 other variables such as –
• Temperomandiular dysfunction,
• Degree of periodontal disease and
• Tumors.

2. Functional measure
index
Sheiham A, Maizels J, and Maizels A in 1987
FIRST ALTERNATIVE TO DMFT
Definition-
Is defined as the aggregate of healthy restored (i.e filled) teeth (otherwise sound) and
sound teeth with no decay.
Was the first composite indictor index to measure dental health and functional status
rather than disease.
 In FMI the filled and sound teeth are weighted equally, while the decayed and the
missing teeth are given zero weight .

Formula-
FMI = Filled + Sound
28
The FMI score ranges from - 0 to 1
Advantage Disadvantage
1. More reliable indicator of dental health
status than conventional DMFT
2. More efficient at revealing the antecedent
and behavioural facts that are associated
with dental health status.
1. Very little research can be found utilizing
this index.
2. According to some it is a sound approach to
measuring dental health and function rather
than the disease hat probably deserves
more attention.

Sheiham A, Maizels J and Maizels A in 1987
second alternative to DMFT index.
Definition - defined as the weighted average of decayed teeth, filled (other wise sound) teeth
and sound teeth.
Purpose - To assess dental health status rather than dental disease in relation to caries.

Principle
The weights represents the relative amount of sound tissue surrounding these three
categories of teeth. that means-
• Sound teeth contains- more sound tissue
• Filled tooth contains – more sound tissue compared to decayed tooth.
• Missing tooth – contains no sound tissue
• In THI selective weights are given to the 3 components as follows
1 – Decayed
2- Filled
4- Sound

Formula to calculate THI
THI = 1/4( 1X decayed + 2 X filled + 4X sound)
28
Third molars are not considered.

Advantages
1. More reliable indicator of dental health than the conventional DMFT.
2. More efficient at revealing the preliminary and behavioural factors that are associated with
the dental health status.
For example-
categories of decayed, filled and missing teeth are each assigned equal weights to derive
DMFT score.
3. So the transformation of decayed tooth into a filled tooth by restoration has no effect on
the DMF value.
4. In addition, the DMF value, specifically the number of filled teeth, distorts the
disease experience score of those who have regular dental checkups and who
observe a preventive approach to their dental health.

(DHI)
Carpay JJ , Nieman FHM, Konig KJ, Felling AJ
and Lammers JGM in 1988.
 This index uses selected teeth for developing the index.
 Any number of teeth may be examined and the denominator is adjusted
accordingly.
 This index was developed to minimize the difference between sound and
affected (or extracted )teeth .

• Formula-
DHI = (Sound teeth)- (decayed +filled+ missing teeth)
Sound+ decayed+ filled+ missing teeth
DHI – is the ratio of sound teeth minus unsound teeth divided by the
total number of teeth examined.
•SCORE
Sound teeth given score of +1
Affected (extracted teeth) of - 1

ROOT CARIES INDEX
(RCI)
Ralph V Katz in 1979

1. This was to make the simple prevalence measures for root caries more specific by including
the concept of teeth at risk for root caries.
2. This index is specifically designed for analytical epidemiological studies in which risk factors
and causes of diseases are being studied.
3. This index can be computed for an individual, for a particular tooth types, or for a population
at large.
4. An RCI of 7% means that all of the teeth with gingival recession, 7% were decayed or filled
on the root surface.

Procedure:
 To obtain the RCI each of the four surfaces the mesial, distal, buccal (labial), and lingual of a
root are examined for a single tooth.
 All teeth are examined in both the lower and upper arch.
 It is the suggested rule that when multiple root surfaces are exposed, the most severely
affected root surface be recorded for that tooth even though this occurrence is judged to be
rare.

 A designation of missing (M) is made for the whole tooth and not for a single surface.
The root surfaces are characterized and
recorded as missing
M
Showing no association with gingival
recession
NoR
Recession present, surface decayed R-D
Recession present, surface filled R-F
Recession present, surface normal or
sound
R-N

• Therefore, once a tooth is observed to be missing, all the root surfaces are recorded as
missing.
• A judgement of no recession (NoR) is made if the cemento-enamel junction (CEJ) cannot be
observed.
• In addition, if calculus is present in the absence of any other findings on a recessed root
surface. a judgement of sound (R-N) is made on the assumption that decay is not found
underneath the band of calculus.
• Once the above information is collected and recorded, as illustrated in the following formula,
the RCI is obtained by adding the number of root lesions and restorations and dividing that
number by number of root surfaces with gingival recession in decayed. filled, and sound
teeth.

• The data collected is entered on a format for each tooth examined, as
given below:
M D B L
R-N
R-F
R-D
NOR

Diagnostic conventions proposed for
RCI
Ralph V Katz in 1986 presented the following conventions for
RCI
• Convention Number 1 : If the diagnosis of caries or of filled is uncertain, score the
surface as 'sound'.
• Convention Number 2 : All caries detected on root surfaces near the Cemento-
EnamelJunction (CEJ) shall be scored as 'decayed' regardless of the adjacent enamel
condition.
• Convention Number 3 : For any coronal filling which extends on to a root surface, the
filling material must extend more than 3 mm, beyond the CEJ in order to score that root

• Convention Number 4 :
In order to score a filling as involving multiple surfaces, the filling must extend
across at least 1/3 rd of each additional surface.
• Convention Number 5a : Recurrent decay associated with a root surface
filling should be recorded as an independent disease category called
"Recurrent Root Decay“

• Convention Number 5b :
Recurrent decay associated with a coronal filling (i.e. a coronal filling extending less
than 3 mm onto the root surface) or a crown should be recorded as an independent
disease category called "Root Decay Contiguous with Coronal Filling".
• Convention Number 6 :
For any root surface that is decayed. the events of an additional but
separate root lesion is recorded as an independent disease category
called" Additional Root Caries Lesion".

Recent Advances in
Dental Indices

Nyvad Caries Diagnostic Criteria
• Proposed by Nyvad in 1999
• Includes manifestation of caries in the initial stages of
the disease, even before a cavity exists.
• Differentiates between active and inactive caries lesions
at both the cavitated and non cavitated levels
• It also measures the activity of the carious lesion,
favoring the cost–benefit relationship when treatment
plans are made. 118

Nyvad Caries Diagnostic
Criteria
119

Criteria
Advantages
• Can identify incipient caries lesion, hence can be used for planning
prevention programmes
• Underestimation of prevalence and severity of caries with def index
can be omitted as it measures only cavitation state
• Reduce the need of treatment on a long term basis because diagnosis
of initial lesions can stop the progression of lesion
120

Criteria
Limitations
• Difficult to make exact diagnosis of precavitated active lesion over
occlusal surface than over facial surface. Physiological wear of
occlusal surface during mastication can lead to disappearance of the
lesions
121

• Proposed by Bratthall D in 2000
• Using DMF and SiC together helps to highlight oral health inequalities more
accurately among different population groups within the community in order
to identify the need for special preventive oral health interventions
122
Significant caries Index (SiC)

Calculating SiC Index
SiC is calculated by sorting individuals according to their DMFT
values, than one third of the population with the highest caries
scores is selected and the mean DMFT for this subgroup is
calculated. This value is the SiC Index
123
In 15 communities, 11 with 0 DMFT and 4 with 5,10,15,20. mean dmft=3.3;
SIC=10(in 5)

Advantages
• Brings attention to the individuals with the highest caries values in each population under
investigation
• It tries to overcome limitation of the mean DMFT value in accurately assessing the
skewed distribution of dental caries in a population especially in developed countries
leading to incorrect conclusion that the caries situation for the whole population is
controlled, while in reality, several individuals still have caries
124

limitations
• It is just an extension of DMF index as it follows same criteria for assessing dental caries
and will have same limitations in assessing caries in a population as DMF index
• more of significance in population where caries prevalence is low and has a skewed
distribution
125

• Proposed by Acharya S. in 2006
• To develop a reproducible surface-specific caries index that
would provide qualitative and quantitative information
about untreated dental caries, that could be used in
conjunction with the DMFS index and would provide
information on not only the caries prevalence but also the
location and type of caries lesion in an individual based on
clinical examination
126
Specific Caries Index

Calculating Specific Caries Index
The SCI score for an individual is calculated by adding the
individual tooth scores
The SCI scores for an individual can range from 0 to 192 (for
32 teeth)
128

Advantages
• The future manpower and material requirements and also the type and
level of training of manpower, required to treat the caries in a particular
population might be assessed
• The results from authors work showed the reproducibility and validity
of this new index to be fair to good
129

Limitations
• In cases of large lesions, which cover more than one surface, only
an assumption can be made regarding the originating lesion
• inability of this index, if used alone, to capture information useful
for treatment planning
• lack of provision for assessing root caries
• number of proximal lesions be underestimated in absence of
bitewing radiograph
130

• Developed in the year 2001 by the effort of large group
of researchers, epidemiologists and restorative dentists
• two-digit system; evolved with the need to detect caries
at the non cavitated stage
• ICDAS is divided into sections covering
• coronal caries (pits and fissures, mesial-distal, and
buccal-lingual),
• root caries, and
• caries-associated-with-restorations-and-sealants (CARS) 131
International Caries Detection and Assessment
System (ICDAS)

The ‘D’ in ICDAS stands for detection of dental caries by
(i) stage of the carious process;
(ii) topography (pit-and-fissure or smooth surfaces);
(iii) anatomy (crowns versus roots);
(iv) restoration or sealant status
The ‘A’ in ICDAS stands for assessment of the caries
process by stage (noncavitated or cavitated) and activity
(active or arrested)
132
International Caries Detection and Assessment System (ICDAS)

The detection of dental caries on coronal tooth surfaces is a two-
stage process;
1) The first decision is to classify each tooth surface on whether it is
sound, sealed, restored, crowned, or missing
2) The second decision that should be made for each tooth surface is the
classification of the carious status on an ordinal scale
133

ICDAS-I was meant to include
detection (D) of caries by stage of
carious process, topography and
anatomy, assessment (A) of caries
process (whether cavitated or non-
cavitated and active or arrested caries).
But the ultimate index included
detection of coronal caries and the
assessment of lesion activity and root
caries were not included due to lack of
consensus and need for further
discussions.
ICDAS coordinating committee came
up with ICDAS-II in the year 2009
which describes both coronal caries
and caries associated with restorations
and sealants (CARS) and root caries.
The advantages of the ICDAS-II is that
it has found to be a valid and reliable
caries assessment system especially for
clinical trials assessing effectiveness of
caries preventive/ control agents.
134

135
Decision 1
0 = Sound (use with the codes for primary caries)
1 = Sealant, partial
2 = Sealant, full
3 = Tooth colored restoration
4 = Amalgam restoration
5 = Stainless steel crown
6 = Porcelain or gold or PFM crown or veneer
7 = Lost or broken restoration
8 = Temporary restoration
9 = Used for the following conditions
97 = Tooth extracted because of caries (all tooth surfaces
will be coded 97)
98 = Tooth extracted for reasons other than caries (all
tooth surfaces coded 98)
99 = Unerupted (all tooth surfaces coded 99)

136
Decision 2
0 = Sound
1 = First visual change in enamel (whitespot seen after 5 seconds air
drying).
2 = Distinct visual change in enamel (whitespot seen without air drying).
3 = Localized enamel breakdown due to caries with no visible dentin
4 = Non-cavitated surface with underlying dark shadow from dentin
5 = Distinct cavity with visible dentin
6 = Extensive distinct cavity with visible dentin. An extensive cavity
involves at least half of a tooth surface and possibly reaching the
pulp.
7 = Tooth extracted because of caries (tooth surfaces will be coded 97)
8 = Tooth extracted for reasons other than caries (tooth surfaces will be
coded 98)
9 = Unerupted (tooth surfaces coded 99)

137

138
E = Excluded root surfaces (no gingival recession)
0 = Sound (no caries or restoration)
1 = Non-cavitated carious root surface— soft or leathery
2 = Non-cavitated carious root surface— hard and glossy
3 = Cavitated (greater than 0.5mm in depth) carious root surface— soft
or leathery
4 = Cavitated (greater than 0.5mm in depth) carious root surface— hard
and glossy
6 = Extensive cavity: an extensive cavity involves at least half of a
tooth surface and possibly reaching the pulp.
7 = Filled root with no caries
9 = Used for the following conditions
97 = Tooth extracted because of caries (tooth surfaces will be
coded 97)
98 = Tooth extracted for reasons other than caries (all tooth surfaces
coded 98)
99 = Unerupted (tooth surfaces coded 99)
Root Caries

advantages
• Designed to detect 6 stages of carious process ranging from early
clinical changes to extensive cavitation
• the system meets the requirements of validity and reliability
• reliable in permanent teeth and acceptable in primary teeth
• Very suitable for use in clinical trials assessing the efficacy and/or
effectiveness of caries control agents
139

limitation
• Root caries assessment criteria has not been tested in any
epidemiological or clinical studies
• Data obtained are unpragmatic, non-cohesive and difficult to read
• May lead to overestimation of seriousness of Dental caries
• results are difficult to compare against the widely-used DMF index
• Does not assess the very advanced stages of carious lesion
140

• Assesses the presence of oral conditions resulting from
untreated advance stages of cavitated carious lesions
141
PUFA (pulp-ulcer-fistula-abscess) Index

142
PUFA (pulp-ulcer-fistula-abscess)
Index

143
limitations
– stages of carious lesion progression in enamel are not
being assessed
– few subjects with score “u” (ulcer)
– assessment of abscess and fistula can be combined into
one code
– reliability and validity of this index requires further
discussion and research.
PUFA (pulp-ulcer-fistula-abscess)
Index

• The World Health Organization’s Global Oral Health
Programme has recognized the importance of promoting
“a new paradigm among dental practitioners, shifting from
a restorative to preventive/health promotion model.”
• Developed by FDI Science Committee
144
FDI World Dental Federation Caries Matrix

Objective
The intent of this matrix was not to establish a new caries lesion
classification system, but to integrate existing systems into a framework
that could be used by clinicians, researchers, educators, public health
workers and decision makers
145

146

caries assessment spectrum and
treatment index
• CAST, a new caries assessment and treatment index was developed based on
the strengths of the ICDAS II and PUFA indices and provides a link to the
widely used DMF index.

148
Caries Assessment Spectrum and Treatment (CAST)
Index

advantages
• A DMF score can easily be calculated from the CAST score, thereby
enabling retention of the use of existing DMF scores
• Used only for epidemiological surveys
• Visual/tactile hierarchical one digit coding system
• Includes the total spectrum of stages of caries lesion progression allows
for easy communication among health professionals and policymakers
• is built on the strength of the ICDAS, DMF and PUFA indices
• provide a link to the widely used DMF index
149
Index

limitations
• It does not record active and inactive carious lesions
• It has not been validated, nor has its reliability been tested
• It is not suggested for use in clinical trials
• it does not provide data on treatment or preventive measures required for each code
150
Index

References
 Peter S., Essentials of Preventive and Community Dentistry, 4/e,
Arya(Medi) Publishing House, 2009
 Frencken JE, De Amorim RG, Faber J, Leal SC. The caries assessment
spectrum and treatment (CAST) index rational and development. Int Dent
J. 2011;61:117-23.
 ICDAS Coordinating Committee (ICDAS CC). Rationale and evidence for
the international caries detection and assessment system (ICDAS-II).
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 Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H et al. The
International Caries Detection and Assessment System (ICDAS): an
integrated system for measuring dental caries. Community Dent Oral
Epidemiol. 2007;35:170-8.
 Acharya S. Specific caries index: a new system for describing untreated
dental caries experience in developing countries. J Public Health Dent.
2006;66(4):285-7.
151

 Bratthall D. Introducing the Significant Caries Index together with a
proposal for a new oral health goal for 12-year-olds. Int Dent J.
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over the last decade. RSBO. 2012 jul-sep;9(3):316-21
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diagnostic system differentiating between active and inactive caries lesions.
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 Sikri V, Sikri P. Community dentistry. CBS Publishers and Distributors;
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 Moustakis VS, Laine ML, Koumakis L et al. Modeling genetic
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References

 Burt BA, Eklund SA. Dentistry, Dental practice, and the Community;
5/e; WB Saunders; 2007
 Locker D, Conceptual development of “oral health-related quality of
life”; PEF Symposium: A critical review of oral health-related quality of
life: Where are we now?; Sept 2008
 Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill:
University of North Carolina, Dental Ecology 1997
 Agarwal A, Mathur R; An Overview of Orthodontic Indices. World
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References

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