This document discusses various dental indices used for recording oral diseases in children. It begins by defining what a dental index is and providing examples of common indices. It then categorizes indices based on how their scores can change, the areas of the mouth they measure, and the conditions they assess. Key indices discussed include the Oral Hygiene Index, Simplified Oral Hygiene Index, Plaque Index, Gingival Index, and CPITN. The document outlines the methodology, scoring, and uses of these important indices for assessing conditions like dental caries, periodontal disease, fluorosis, and malocclusion.

1. Dental Indices
Used for recording oral diseases in children mainly dental
caries, periodontal diseases, fluorosis and malocclusion
1
Dr Darpan Nenava
Pg 3rd yr

2. Contents
1. Introduction
2. Definitions
3. Classification of index
4. Ideal requisites of an index
5. Objectives and uses of index
2
6. Oral hygiene and plaque index
• OHI
• OHI-S
• Patient Hygiene Performance
• Plaque index
• Turesky, Gilmore, Glickman
modification of the Quigley Hein plaque
index

3. 3
7. Gingival and periodontal
disease indices
• Gingival index
• Periodontal index
• CPITN
8. Caries index
• DMF
• def
• Stone’s Index
• Caries severity index
• Dental caries severity index for
primary teeth
• Functional measure index
• Tissue health index
• Dental health index
• Index by J Murray and A Shaw
• PUFA index
9. Indices used in dental fluorosis
• Deans fluorosis
• Community fluorosis index
• Thylstrup – Fejerskov Classification of
fluorosis
• Developmental defects of index

4. 4
10. Malocclusion index
• IOTN
• PAR index
11. Points to remember
12. References

5. Introduction
Unless you can count it, weigh it or express it in a quantitative fashion,
you have scarcely begun to think about the disease in a scientific
fashion.
Lord Kelvin
5

6. The teeth and their surrounding structures are so definite, so easy to
observe, and carry with them, so much of their previous disease
history, that the measurement of dental diseases is much easier than
the measurement of any other forms of the disease.
6

7. Definitions
• Index is a graduated scale having upper and lower limits , with scores
on the scale corresponding to specific criteria which is designed to
permit and facilitate comparison with other population classified by
same criteria and methods. – Russel AL
• Epidemiological indices are attempts to quantitate clinical condition
on a graduated scale, thereby facilitating comparison among
populations examined by the same criteria and methods. – Irving
Glickman
7

8. An index is an expression of clinical observation in numeric values. It is
used to describe the status of the individual or group with respect to a
condition being measured. The use of numeric scale and a standardized
method for interpreting observations of a condition results in an index
score that is more consistent and less subjective than a word
description of that condition. – Esther M Wilkins
8

9. Oral indices are essentially set of values, usually numerical with
maximum and minimum limits, used to describe the variables or a
specific conditions on a graduated scale, which use the same criteria
and method to compare a specific variable in individuals, samples or
populations with that same variables as is found in other individuals,
samples or populations. – George P Barnes
9

10. Classification of index
• Based upon the direction in which their scores can fluctuate
• Upon the extent to which the areas of oral cavity are measured
• According to the entity they measure
• General indices
10

11. Based on the direction in which their scores
can fluctuate:
• Reversible index: Measures condition that can be changed e.g.
periodontal index
• Irreversible index: Index that measures conditions that will not
change e.g. dental caries
11

12. Depending upon the extent to which areas of
oral cavity are measured :
• Full mouth indices: Patient’s entire periodontium or dentition is
measured. e.g. OHI
• Simplified indices: Measure only a representative sample of the
dental apparatus. e.g. OHI-S
12

13. According to the entity which they measure :
• Disease Index : “D” decay portion of the DMF index is the best
example of disease index
• Symptom Index : Measuring gingival or sulcular bleeding are
essentially examples of symptom indices
• Treatment Index : “F” filled portion of DMFT index is the best
example for treatment index
13

14. General Indices :
• Simple index: Index that measures the presence or absence of a
condition. E.g. plaque index
• Cumulative index: Index that measures all the evidence of a
condition, past and present. E.g. DMF index
14

15. Ideal Requisites of an Index
• Simplicity:
• Should be easy to apply so that there is no undue time lost during
field examinations.
• No expensive equipment should be needed.
• Objectivity:
• Criteria for the index should be clear and unambiguous, with
mutually exclusive categories.
15

16. • Validity:
• Must measure what it is intended to measure, so it should
correspond with the clinical stages of the disease under study at
each point.
• 2 components –
• Sensitivity : ability to detect the condition when it is present.
• Specificity: ability to not detect the condition when it is absent.
16

17. • Reliability:
• Should measure consistently at different times and under a variety
of conditions.
• 2 components-
• Inter examiner reliability: different examiners record the same result.
• Intra examiner reliability: same examiner records the same result at
repeated attempts.
• Precision:
• Ability to distinguish between small increments. 17

18. • Acceptability
• Safe and not demeaning to the subject.
• Quantifiability
• The index should be amenable to statistical analysis and
interpretable.
18

19. Objectives and Uses of Index
• For individual patient
• In research
• In community health
19

20. For Individual Patient
• Provide individual assessment to help patient recognize an oral
problem
• Reveal degree of effectiveness of present oral hygiene practices
• Motivation in preventive and professional care for control and
elimination of diseases
20

21. In Research
• Determine base line data before experimental factors are introduced
• Measure the effectiveness of specific agents for prevention control or
treatment of oral condition
• Measure the effectiveness of mechanical devices for personal care
21

22. In Community Health
• Shows prevalence and incidence of a condition
• Base line data for existing dental practices
• Assess the need of the community
• Compare the effects of a community program and evaluate the
results
22

23. INDICES USED FOR ORAL HYGIENE
ASSESSMENT
• ORAL HYGIENE INDEX
• SIMPLIFIED ORAL HYGIENE INDEX
• PATIENT HYGIENE PERFORMANCE
• TURESKY, GILMORE, GLICKMAN MODIFICATION OF THE QUIGLEY HEIN
PLAQUE INDEX
23

24. ORAL HYGIENE INDEX (OHI)
• Developed in 1960
• John C. Green and Jack R. Vermillion in order to classify and assess oral
hygiene status.
• Simple and sensitive method for assessing group or individual oral
hygiene quantitatively.
• It is composed of 2 components:
• Debris index (DI)
• Calculus index (CI)
24

25. 25
RULES OF ORAL HYGIENE INDEX
1 Only fully erupted permanent teeth are
scored.
2 Third molars and incompletely erupted
teeth are not scored because of the wide
variations in heights of clinical crowns.
3 The buccal and lingual debris scores are
both taken on the tooth in a segment
having the greatest surface area covered by
debris.
4 The buccal and lingual calculus scores are
both taken on the tooth in a segment
having the greatest surface area covered by
supragingival and subgingival calculus.

26. 26
0 – no debris or stain
present
1 – soft debris covering
not more than 1/3rd the
tooth surface, or presence
of extrinsic stains without
other debris regardless
of the area covered
2 – soft debris covering
more than 1/3rd, but not
more than 2/3rd,of the
exposed tooth surface
3 – soft debris covering more
than 2/3rd of the exposed
tooth surface
DEBRIS INDEX

27. 27
SCORE CRITERIA
0 No calculus present
1 Supragingival calculus covering not
more than 1/3 of the exposed tooth
surface
2 Supragingival calculus covering more
than 1/3 but not more than 2/3 the
exposed tooth surface or presence
of individual flecks of subgingival
calculus around the cervical portion
of the tooth or both.
3 Supragingival calculus covering more
than 2/3 the exposed tooth surface
or a continuous heavy band of
subgingival calculus around the
cervical portion of tooth or both.
Supragingival
calculus
Subgingival
calculus
CALCULUS INDEX

28. Calculation
• DI = B.S + L.S / No. of seg
• CI = B.S + L.S / No. of seg
• OHI = DI + CI
• DI and CI range from 0-6
• Maximum score for all segments can be 36 for debris or calculus
• OHI range from 0-12
• Higher the OHI, poorer is the oral hygiene of patient
28

29. SIMPLIFIED ORAL HYGIENE INDEX
• John C Greene and Jack R Vermillion in 1964.
• Only fully erupted permanent teeth are scored.
• Natural teeth with full crown restorations and surfaces reduced in
height by caries or trauma are not scored.
• An alternate tooth is then examined.
29

30. 30
16 17,18
11 21
26 27,28
36 37,38
31 41
46 47,48

31. Calculation and Interpretation
• DI -S= Total score/ no of surfaces
• CI-S= Total score/ no of surfaces
• OHI -S= DI-S+ CI-S
• DI-S and CI-S range from 0-3
• OHI-S range from 0-6
31
• INTERPRETATION
• DI –S and CI-S
• Good -0.0-0.6
• Fair – 0.7-1.8
• Poor – 1.9 -3.0
• OHI –S
• Good - 0.0-1.2
• Fair – 1.3- 3.0
• Poor – 3.0 -6.0

32. Uses
• Widely used in epidemiological studies of periodontal diseases.
• Useful in evaluation of dental health education programs
• Evaluating the efficacy of tooth brushes.
• Evaluate an individual’s level of oral cleanliness.
32

33. PATIENT HYGIENE PERFORMANCE (PHP INDEX)
• Introduced by Podshadley A.G. and Haley J.V in 1968.
• Assessments are based on 6 index teeth.
• The extent of plaque and debris over a tooth surface was determined.
33
16 buccal
11 labial
26 buccal
36 lingual
31 labial
46 lingual

34. • PROCEDURE:
• Apply a disclosing agent before scoring.
• Patient is asked to swish for 30 sec and then expectorate but not
rinse.
• Examination is made by using a mouth mirror.
• Each of the 5 subdivisions is scored for presence of stained debris:
• 0= no debris(or questionable)
• 1= debris definitely present.
34
M
MI
D
M
O/I
G

35. • Debris score for individual tooth:
• Add the scores for each of the 5 subdivisions.
• PHP index for an individual :
• Total score for all the teeth divided by the number of teeth examined.
• RATING SCORES:
• Excellent : 0 (no debris)
• Good : 0.1-1.7
• Fair : 1.8 – 3.4
• Poor : 3.5 – 5.0
35
Debris score
for 1 tooth = 4/5
= 0.8
1
1
1 1
0

36. Plaque index
• Silness and Loe in 1964
• Assesses the thickness of plaque at the cervical margin of the tooth
closest to the gums
• All four surfaces are examined
• Distal
• Mesial
• Lingual
• Buccal 36
12
24
16
44
32
36

37. Scoring Criteria
Score Criteria
0 No Plaque
1
A film of plaque adhering to the free gingival margin and adjacent
area of tooth the plaque may be seen in situ only after
application of disclosing solution or by using probe on tooth
surface
2
Moderate accumulation of soft deposits within the gingival
pocket, or the tooth and gingival margin which can be seen with
the naked eye
3
Abundance of soft matter within the gingival pocket and/or on
the tooth and gingival margin
37

38. Calculation
• Plaque index for area : 0-3 for each surface.
• Plaque index for a tooth : Scores added and then divided by four.
• Plaque index for group of teeth : Scores for individual teeth are added
and then divided by number of teeth.
• Plaque index for the individual : Indices for each of the teeth are added
and then divided by the total number of teeth examined.
• Plaque index for group : All indices are taken and divided by number of
individual 38

39. Interpretation of Plaque index
Rating Scores
Excellent 0
Good 0.1-0.9
Fair 1.0-1.9
Poor 2.0-3.0
39

40. Uses
• Reliable technique for evaluating both mechanical anti plaque
procedures and chemical agents.
• Used in longitudinal studies and clinical trials.
40

41. TURESKY, GILMORE, GLICKMAN MODIFICATION OF
THE QUIGLEY HEIN PLAQUE INDEX
• Quigley and Hein in 1962 reported a plaque measurement that
focused on the gingival third of the tooth surface. Only facial surfaces
of the anterior teeth were examined after using basic fuchsin
mouthwash as a disclosing agent.
• The Quigley - Hein plaque index was modified by Turesky, Gilmore
and Glickman in 1970.
41

42. 0 – no plaque
1 – separate flecks of plaque at the cervical margin of tooth.
2 – thin continuous band of plaque ( up to 1 mm)
3 – band of plaque wider than 1 mm but covering less than 1/3rd of the crown of
the tooth.
4 – plaque covering at least 1/3rd but less than 2/3rd of the crown of the tooth.
5 - plaque covering 2/3rd or more of the crown of the tooth.
42

43. • Plaque is assessed on the labial, buccal and lingual surfaces of all the
teeth after using a disclosing agent.
• The scores of the gingival 1/3rd area was also redefined.
• Provides a comprehensive method for evaluating anti plaque
procedures such as tooth brushing, flossing as well as chemical anti
plaque agents.
• The index is based on a numerical score of 0 to 5.
43

44. Gingival and periodontal disease indices
• Gingival index
• Periodontal index
• CPITN
44

45. Gingival Index
• Developed by Loe H and Silness J in 1963.
• One of the most widely accepted and used gingival indices.
• Assess the severity of gingivitis and its location in 4 possible areas.
• Mesial
• Lingual
• Distal
• Facial
• Only qualitative changes are assessed.
45

46. METHOD:
• All surfaces of all teeth or selected teeth or selected surface of all teeth or
selected teeth are scored.
• The selected teeth as the index teeth are 16,12,24,36,32,44.
• The teeth and gingiva are first dried with a blast of air and/or cotton rolls.
• The tissues are divided into 4 gingival scoring units: disto facial papilla,
facial margin, mesio facial papilla and entire lingual margin.
• A blunt periodontal probe is used to assess the bleeding potential of the
tissues.
46

47. 47
SCORE CRITERIA
0
Absence of inflammation/normal
gingiva
1
Mild inflammation, slight change in
color, slight edema, no bleeding on
probing
2
Moderate inflammation, moderate
glazing, redness, edema and
hypertrophy. bleeding on probing
3
Severe inflammation, marked
redness and hypertrophy ulceration.
Tendency to spontaneous bleeding.

48. Calculation and Interpretation
• If the scores around each tooth are totaled and divided by the number of
surfaces per tooth examined (4), the gingival index score for the tooth is
obtained.
• Totaling all of the scores per tooth and dividing by the number of teeth
examined provides the gingival index score for individual.
• Interpretation:
• 0.1 - 1.0 : Mild gingivitis
• 1.1 – 2.0 : Moderate gingivitis
• 2.1 – 3.0 : Severe gingivitis
48

49. Modified Gingival Index
• Developed by Lobene, Weatherford, Ross, Lamm and Menaker in 1986.
• Assess the prevalence and severity of gingivitis.
• Strictly based on non invasive approach i.e. visual examination only
without any probing.
• To obtain MGI , labial and lingual surfaces of the gingival margins and the
interdental papilla of all erupted teeth except 3rd molars are examined and
scored.
49

50. 50
0
• Normal (absence
of inflammation)
1
• Mild
inflammat
ion (slight
change in
color, little
change in
texture) of
any
portion of
the
gingival
unit
2
• Mild
inflammat
ion of the
entire
gingival
unit
3
• Moderate
inflammat
ion
(moderate
glazing,
redness,
edema,
and/or
hypertrop
hy) of the
gingival
unit.
4
• Severe
inflammat
ion
(marked
redness
and
edema/hy
pertrophy,
spontaneo
us
bleeding,
or
ulceration
) of the
gingival
unit.

51. Periodontal Index
• Developed by Rusell AI in 1956.
• It was once widely used in epidemiological surveys but not used much
now because of introduction of new periodontal indices and
refinement of criteria.
• The PI is reported to be useful among large populations, but it is of
limited use for individuals or small groups.
51

52. • All the teeth are examined in this index.
• Russell chose the scoring values as 0,1,2,6,8 in order to relate the
stage of the disease in an epidemiological survey to the clinical
conditions observed.
• The Russell’s rule states that “ when in doubt assign the lower score.”
52

53. 53
FIELD STUDIES CLINICAL STUDIES / RADIOGRAPHIC FINDINGS
0 Negative. Neither overt inflammation in the investing
tissues nor loss of function due to destruction of
supporting bone.
Radiographic appearance is essentially normal.
1 Mild gingivitis. An overt area of inflammation in the free
gingiva does not circumscribe the tooth
2 Gingivitis. Inflammation completely circumscribe the
tooth, but there is no apparent break in the epithelial
attachment
4 Used only when radiographs are available. There is early notch like resorption of alveolar crest.
6 Gingivitis with pocket formation. The epithelial
attachment is broken and there is a pocket. There is no
interference with normal masticatory function; the tooth
is firm in its socket and has not drifted.
There is horizontal bone loss involving the entire
alveolar crest, up to half of the length of the tooth root.
8 Advanced destruction with loss of masticatory function.
The tooth may be loose, may have drifted, may sound dull
on percussion with metallic instrument, or may be
depressible in its socket.
There is advanced bone loss involving more than half of
the tooth root, or a definite intrabony pocket with
widening of periodontal ligament. There may be root
resorption or rarefaction at the apex.

54. Calculation and Interpretation
• PI score per person = sum of individual scores
no of teeth present
54
Clinical Condition Individual Scores
Clinical normally supportive tissue 0.0-0.2
Simple gingivitis 0.3-0.9
Beginning destructive periodontal
diseases
1.0-1.9
Established destructive periodontal
disease
2.0-4.9
Terminal disease 5.0-8.0

55. Community Periodontal Index of Treatment
Needs
• The community periodontal index of treatment needs was developed
by the joint working committee of the WHO and FDI in 1982.
• Developed primarily to survey and evaluate periodontal treatment
needs rather than determining past and present periodontal status
i.e. recession of the gingival margin and alveolar bone.
55

56. • Treatment needs implies that the CPITN assesses only those conditions
potentially responsive to treatment, but not non treatable or irreversible
conditions.
• Procedure :
• The mouth is divided into sextants :
17- 14 13- 23 24- 27
47 – 44 43- 33 34 – 37
• The 3rd molars are not included, except where they are functioning in place of 2nd
molars.
• The treatment need in a sextant is recorded only if there are 2 or more teeth present in
a sextant and not indicated for extraction. If only one tooth remains in a sextant, then
the tooth is included in the adjoining sextant.
56

57. • Probing depth is recorded either on all the teeth in a sextant or only on
certain indexed teeth as recommended by WHO for epidemiological
surveys.
• FOR ADULTS AGED > 20 yrs:
• 10 index teeth are taken into account :17 16 11 26 37 47 46 31 36 37.
• The molars are examined in pairs and only one score the highest score is recorded.
• For young people up to 19 yrs:
• Only 6 index teeth are examined : 16 11 26 46 31 36
• The second molars are excluded at these ages because of the high frequency of false
pockets (non inflammatory tooth eruption associated).
57

58. • When examining children less than 15 yrs pockets are not recorded
although probing for bleeding and calculus are carried out as a routine.
• CPITN PROBE :
• First described by WHO.
• Designed for 2 purposes :
• Measurement of pockets.
• Detection of sub-gingival calculus.
58

59. 59

60. Codes and Criteria
60
CODE CRITERIA TREATMENT NEEDS
0 Healthy periodontium TN-0 No need of treatment
1 Bleeding observed during / after probing TN-1 Self care
2 Calculus or other plaque retentive factors
seen or felt during probing
TN-2 Professional care
3 Pathological pocket 4-5 mm. gingival margin
situated on black band of the probe.
TN-2 Scaling and root planning
4 Pathological pocket 6mm or more. Black
band of the probe not visible
TN-3 Complex therapy by specially
trained personnel

61. Caries Indices
• Dmf
• def
• Stone’s Index
• Caries severity index
• Dental caries severity index for
primary teeth
61
• Functional measure index
• Tissue health index
• Dental health index
• Index by J Murray and A Shaw
• PUFA index

62. DMF Index
• Bodecker CF and Bowdecker HWC 1931 gave term caries
• Henry Klein, Carrole E Palmer and JW Knutson 1938 gave DMF index
• Only permanent teeth
• 28 teeth are included
62

63. • Exclusion Criteria
• 3rd molar
• Teeth extracted
• Filled for any other reason than
caries
• Teeth restored for cosmetic reason
• Supernumerary teeth
• D – decayed
• M – missing due to caries
• F – filled teeth
63

64. Features of DMF
• Tooth is counted only once
• Decayed, missing and filled teeth should be recorded separately
• Recurrent caries is also counted as decay
• Extraction indicated teeth are included in missing
• Many restoration is counted as one score
• Root stump is also scored
• 1986 WHO modification includes 3rd molars
• Cant be used in children
• Not accurate
• Overestimate caries
64

65. 65

66. Limitations
• DMFT values are not related to the number of teeth at risk
• Can be invalid in older patients because teeth can become lost for
reasons other than caries
• Can be misleading in children whose teeth lost due to orthodontic
reasons
• Can overestimate caries experience in teeth in which preventive filling
have been placed
• Little use in root caries
66

67. def Index
• Gruebbel AD 1944 as an equivalent index to DMF for measuring dental
caries in primary dentition
• d – Indicates the number of deciduous teeth decayed.
• e – Indicates deciduous teeth extracted due to caries & indicated for Xn
• f – Indicates restored teeth without recurrent decay
67

68. 68

69. Modifications
• dmf index
• For children over 7 years and upto
11 – 12 years
• Decayed, missing and filled
primary molar and canines have
being used to determine dmft
• df index
• Exfoliation problem
• df is used missing are ignored
• WHO in survey
• dft index
69
• Mixed dentition
• DMFT and deft are done separately and never added
• Permanent teeth index is done first then deciduous separately

70. Stone’s Index
• Introduced by HH Stone, FE Lawton, ER Bransby and HO Hartley in
1949
70

71. Caries Severity Index
• Tank Certrude and Storvick Clara 1960
71

72. Dental Caries Severity Index for primary teeth
• Designed by Aubrey Chosack 1985
72
Score Criteria
1 Early pit and fissure caries
2 Cavitation of 1mm
3 Cavitation with breakdown of half tooth
Occlusal surface
Score Criteria
1 White lesion not extending to embrasure
2 Cavitation of 1-2mm extending to one embrasure
3 Cavitation of 2 mm extending to both embrasures
Buccal-lingual and palatal smooth surface
Score Criteria
1 Discontinuity of enamel
2 Cavitation with breakdown of marginal ridge
3 Break down of marginal ridge to proximal
extensions of occlusal surface
Proximal surfaces of molar
Score Criteria
1 Discontinuity of enamel
2 Cavitation with breakdown of buccal and lingual
surface
3 Break down of incisal edge
Proximal surfaces of Incisors

73. Functional measure Index
• Sheiham, Maizels A, Maizels J in 1987
• Filled and sound teeth are measured while decayed and missing teeth
is given zero
FMI = (Filled + Sound) / 28
73

74. Tissue health Index
• Sheiham, Maizels A, Maizels J in 1987
1 – decayed
2 – filled
4 – sound
Tissue health index (THI) = ¼(1*decayed+2*filled+4*sound)/28
Third molars are excluded
Score ranges from 0 – 1
74

75. Dental health Index
• JJ Carpay, FHM Nieman, KG Konig, AJA Felling and JGM Lammers in
1968
• Sound teeth were given a score of +1 affected teeth a score of -1
DHI = sound teeth – (decayed + filled +missing teeth)/ sound teeth +
decayed + filled + missing teeth
Score ranges from – 1 to + 1
75

76. Clinical and radiographic Index by J Murray
and A Shaw in 1975
76

77. PUFA Index
• Jindal M and Khan S in 2012
• Assess the presence of oral conditions resulting from untreated caries
both in primary and permanent dentition
• Upper case for permanent and lower case for primary dentition
• Assessment is made visually without any instrument
77

78. 78
Denotation Criteria
P/p
Pulp exposure is recorded when an opening of pulp chamber is
visible (grossly decayed)
U/u
Ulceration of soft tissue of tongue or mucosa by sharp edges of
dislocated decayed carious tooth
F/f
Fistula is recorded with pus releasing sinus in relation to exposed
tooth
A/a
Abscess is recorded with pus containing swelling in relation to
exposed tooth

79. Calculation and Interpretation
PUFA/pufa = (filled + sound)* 100 /D+d
Higher scores indicates dental treatment is neglected either due to
lack of knowledge, facility available, cost and importance of dentition.
Advantages
• Easy to use
• No instruments required
• Used for planning monitoring and implementing oral health
programs keeping in view cause of negligence 79

80. Dental Fluorosis Index
• DENTAL FLUOROSIS : is a hypoplasia or hypo-mineralisation of
tooth enamel or dentine produced by the chronic ingestion of
excessive amounts of fluoride during the period when teeth are
developing.
80

81. CLASSIFICATION OF FLUOROSIS MEASURING
INDICES
FLUOROSIS SPECIFIC
•THYLSTRUP AND
FERJESKOV
•DEAN’S INDEX
DESCRIPTIVE
•DEVELOPMENTAL
DEFECTS OF ENAMEL
INDEX
81

82. DEAN’S FLUOROSIS INDEX
• 1934; TRENDLEY H.DEAN devised
an index for assessing the
presence and severity of mottled
enamel.
82

83. SALIENT
FEATURES
The fluorosis index set
criteria for categorization
of dental fluorosis on a
7point scale.
Although no numbers
were used it was
considered to be on
ordinal scale.
Children who had not
lived in the community
continuously or had
obtained domestic water
from other than public
supply are eliminated
Under his classification all
those showing hypoplasia
other than mottling of
enamel were placed in
normal category
83

84. METHOD ( as implied by DEAN)
Each individual receives a score corresponding to
clinical appearance of two most affected teeth
• Examinations are made in good natural light with the subject
sitting facing the window
No specific information as to whether the teeth
were cleaned or dried before examination is given
• Mouth mirror and probes were utilized for examination.
84

85. CLASSIFICATION AND CRITERIA
•The enamel represents the usual translucency semi-vitriform type of structure
•The surface is smooth, glossy and usually of pale creamy white color
NORMAL
•Slight aberrations in translucency of normal enamel ranging from few white flecks to occasional white
spots, 1-2mm in diameter.
QUESTIONABLE
•Small, opaque, paper white areas are scattered irregularly or streaked over the tooth surface
•Observed on labial and buccal surfaces ; <25% of teeth surface involved.
•Small pitted white areas are frequently found on summits of cusps
•No brown stain
VERY MILD

86. • White opaque areas involve half of tooth surface.
• Surfaces of cuspids n bicuspids prone to attrition show thin white layers worn off and bluish
shades of normal enamel
• Faint brown stains are apparent
MILD
• No change in form of tooth but all surfaces are involved
• Surfaces subjected to attrition are definitely marked
• Minute pitting is present on buccal n labial surfaces
MODERATE
• Smoky white appearance
• Pitting is more frequent and generally seen on all surfaces
• Brown stain if present has more hue and involves all surfaces
MODERATELY SEVERE
• Form of teeth are affected.
• Pits are deeper and confluent
• Stains are widespread and range from chocolate brown to almost black
SEVERE

87. Based on this index, Dean. Dixon and Cohen(1935)
proposed that their classification should determine a
mottled enamel index of a community for epidemiological
purpose
Negative Borderline Slight Medium
Rather
marked
Very
marked
87

88. 88

89. USES
• Most widely used index to measure dental fluorosis.
• Helped to indicate prevalence of moderate to severe fluorosis in
many communities as
Sweden by Forsman in 1974
Austria by Binder in 1973
England by Murray et al(1956), Forrest (1965), Goward (1976)
USA by Galagan and Lamson (1953)
India by Nanda et al (1974)
89

90. • The National Survey of Children’s Dental Health in Ireland in 1984
measured fluorosis using Dean’s index to provide baseline data for
future reference.
( Whelton HP;Ketley CE;Mcsweeny F;O’Mullane DM;2004)
• National Fluorosis Survey in USA in 1986-87 to note baseline values
was done using Dean’s index.
90

91. LIMITATIONS
• Does not give sufficient information on distribution of fluorosis within
the dentition.
• Isolated defects are not recorded.
• The distinction amongst the categories is unclear, indistinct and
lacking sensitivity.
• Even though Dean’s scale is ordinal , it involves averaging of the
scores which is inappropriate.
(A. Rizan Mohamed,W. Murray Thomson;Timothy D. Mackay, An epidemiological comparison of Dean’s index and the Developmental Defects
of Enamel (DDE) index; JPHD ISSN 0022-4006)
91

92. COMMUNITY FLUOROSIS INDEX
• 1942 , based on the revised fluorosis index scale , he developed a
scoring system so as to derive a COMMUNITY FLUOROSIS INDEX .
• On basis of the number and distribution of individual scores, a
community index for dental fluorosis (Fci) can be calculated by the
formula
Fci = sum of no. of individuals * statistical weights)/ no. of
individuals examined
92

93. 0.0 – 0.4
0.4 – 0.5
0.5 – 1.0
1.0 – 2.0
2.0 – 3.0
3.0 – 4.0
• Negative
• Borderline
• Slight
• Medium
• Marked
• Very Marked
RANGE OF SCORES FOR CFI
SIGNIFICANCE
93

94. • It gives an indication of public health significance of fluorosis.
• It was used by Galagan and Lamson (1953) in their investigation of
climate and endemic fluorosis.
• Minoguchi (1970) refined the above analysis to take into account the
total fluoride content from the diet by a community.
• Myers(1978) suggested a graphic method of obtaining optimal
fluoride concentration by comparing CFI against water fluoride
content at different temperatures.
94

95. THYLSTRUP – FEJERSKOV CLASSIFICATION OF
FLUOROSIS
• 1978 ; Thylstrup and Frejeskov suggested a 10point classification
system designed to categorize the degree of fluorosis affecting
buccal/lingual and occlusal surfaces.
95

96. SALIENT
FEATURES
Examination is
done on a
portable chair
out in daylight.
Plane mirror n
probes are used
Prior to
examination the
teeth are dried
with cotton wool
rolls
96

97. THYLSTRUP – FEJERSKOV CLASSIFICATION OF
FLUOROSIS
97

98. Advantages
• It attempts to validate the visual appearance against the histological defect.
• Most sensitive of all fluorosis measuring indices.
• Granath et al. (1985), comparing the DEAN and T-F indexes, concluded that
the latter was more detailed and sensitive because it was based on
biological aspects where there is an increase in hypo mineralization with a
simultaneous increase in the depth of the enamel surface in direction of
the amelo-dentin junction.
98

99. • Cleaton-Jones and Hargreaves (1990) compared the two fluorosis
indexes (DEAN and T-F) in deciduous dentition, reporting that the
prevalence of fluorosis in individual teeth was more frequently
diagnosed with the T-F index. They concluded that the T-F index is the
most indicated for work where detailed information about the
problem is required.
99

100. USES
• To assess the impact of enamel fluorosis in three communities
examined in project FLINT.( Sigourjon’s H et al 2004)
• Burger et al. (1987), recommended the T-F index for future field
studies, due to the facility of use and better defined criteria.
100

101. Disadvantages
• Clarkson (1989) reported that in TF index drying of teeth creates an
unnatural situation due to which changes in score 1 and 2 are very
minor.
The aesthetic significance of these changes are questionable.
101

102. DEVELOPMENTAL DEFECTS OF INDEX
• The developmental defects of enamel was developed by “ FDI –
Commission on Oral Health, Research and Epidemiology” in 1982 to
avoid need for diagnosing fluorosis before recording enamel
opacities.
102

103. PROCEDURE
Tooth surface is
inspected visually
and defective areas
are tactilely explored
with a probe.
Natural or artificial
light
Teeth should receive
a prophylaxis and be
dried at time of
examination
103

104. CODING AND CRITERIA
• Un-erupted, missing, heavily restored , grossly decayed , fractured
teeth and teeth or tooth surfaces which for any other reason cannot
be classified with defects must be coded ‘X’.
• Permanent teeth are number coded.
• Primary teeth are letter coded.
• When in doubt the tooth surface should be scored ‘normal’.
• When an abnormality is present but cannot be classified into listed
categories, it should be scored as ‘other defects’.
104

105. TYPE OF DEFECT
• OPACITY
• HYPOPLASIA
• DISCOLORATION
NUMBER
• SINGLE
• MULTIPLE
DEMARCATION
• DEMARCATED
• DIFFUSE
LOCATION OF
DEFECTS
• GINGIVAL OR
INCISAL HALF
• OCCLUSAL
• CUSPAL
• WHOLE
SURFACE
105

106. MODIFICATIONS
• Clarkson J.J and O’Mullane D.M in 1985 modified the DDE to be used
in one of the two manners
General purpose epidemiology studies
Screening surveys
106

107. General purpose epidemiological studies
• NORMAL
• DEMARCATED OPACITY
• White/cream
• Yellow/brown
• DIFFUSE OPACITY
• Diffuse lines
• Diffuse patchy
• Diffuse confluent
• Confluent +Staining+loss Of
Enamel
• Code 0
• Code 1
• Code 2
• Code 3
• Code 4
• Code 5
• Code 6
107
• HYPOPLASIA
• Pits
• Missing enamel
• ANY OTHER DEFECTS
• Code 7
• Code 8
• Code 9

108. Extent of defect
• Normal
• < 1/3rd
• At least 1/3rd < 2/3rd
• At least 2/3rd
• Code 0
• Code 1
• Code 2
• Code 3
108

109. Screening surveys
• NORMAL
• DEMARCATED OPACITY
• DIFFUSE OPACITY
• HYPOPLASIA PITS
• OTHER DEFECTS
• CODE 1
• CODE 2
• CODE 3
• CODE 4
• CODE 5
109

110. Dental Developmental Index modified in 1989
110

111. Malocclusion Indices
• Index for Orthodontic Treatment Needs (IOTN)
• Peer Assessment Rate Index (PAR)
111

112. Index For Orthodontic Treatment Needs (IOTN)
• P.H. Brook and W.C. Shaw 1989
• Two components
• Functional and dental health component (DHC)
• Aesthetic component (AC)
112

113. Dental Health component (DHC)
Grade 5 – Very Great
• Defects of CLCP
• Over jet more than 9mm
• Reverse over jet >3.5mm speech problem
• Impeded eruption
• Extensive hypodontia
Grade 4 – Great
• Over jet 6-9mm
• Reverse over jet >3.5mm no speech
problem
• Cross bites with 2mm displacement
between contact and retruded position
• Severe displacement of teeth >4mm
• Lateral or open bite >4mm
• Overbite causing indentation on the
palate or labial gingivae
• Referred by colleague for collaborative
care
• Less extensive hypodontia
113

114. Grade 3 – Moderate
• Over jet >3.5mm <6mm incompetent lips
• Reverse over jet >1mm ≤3.5mm
• Overbite without indentation or signs of
trauma
• Cross bite with ≤2mm and >1mm
displacement between retruded and
intercuspal position
• Open bite >2mm but ≤4mm
• Moderate displacement of teeth with >2mm
but ≤ 4mm
Grade 2 – Little
• Over jet >3mm ≤6mm competent lips
• Reverse over jet >0mm ≤1mm
• Increased over bite >3.5mm no gingival
contact
• Cross bite ≤1mm displacement between
retruded and intercuspal position
• Open bites >1mm ≤2mm
• Pre or post normal occlusion with no
abnormalities
• Mild displacement of teeth >1mm ≤2mm 114

115. Aesthetic Component (AC)
• A patient score is based on matching his/her dental appearance with
one of a series of 10 photographs showing labial aspect of different
class 1 class 2 malocclusion ranked according to there attractiveness
• 0.5 being the most attractive and 5.0 being the least attractive.
0.5 most
attractive
1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
5.0 least
attractive
115

116. Peer Assessment Rating Index (PAR)
• Index of treatment standards
• S Richmond, W.C. Shaw, K.D. O’Brien, I.B. Buchanan, R Jones, C.D.
Stephens, C.T. Roberts, M Andrews in 1992
• To measure the malocclusion assess the outcome of orthodontic
treatment at any stage
116

117. It has 11 components
1. Upper right segment
2. Upper anterior segment
3. Upper left segment
4. Lower right segment
5. Lower anterior segment
6. Lower left segment
7. Right buccal occlusion
8. Over jet
9. Over bite
10. Centre line
11. Left buccal occlusion
117

118. Procedure
• Pre and post treatment cast are taken
• PAR ruler specially designed ruler to facilitate scoring
118

119. 119
Anterior and buccal segments
• Arches divided into three segments scores recorded for both upper and lower arch
• Buccal recording zone is from mesial anatomical contact point of the 1st permanent molar
to the distal contact point of the canine.
• Anterior recording zone is mesial contact point of canine to the mesial point on other
side
• Occlusal traits recorded are crowding, spacing, and impacted teeth
• A tooth is considered and scored “impacted” when the space is ≤ 4mm
• Impacted canines are recorded in anterior segment
• Displacement and impacted scores are added to obtain an overall score for each
recording segment
• In mixed dentition if there is potential for crowding average mesio-distal width are used
to calculate space deficiency

120. Anterior and buccal segments displacement scores
Score Discrepancy
0 0mm to 1mm
1 1.1mm to 2mm
2 2.1mm to 4mm
3 4.1mm to 8mm
4 Greater than 8mm
5 Impacted teeth
Mixed dentition crowding assessment using average
mesio-distal widths
120
Upper
Canine 8mm
First molar 7mm
Second molar 7mm
Total = 22mm (impaction ≤ 18mm)
Lower
Canine 7mm
First molar 7mm
Second molar 7mm
Total = 21mm (impaction ≤ 17mm)

121. Buccal occlusion
• The recording zone is from canine to last molar present
121
Antero-posterior :
Score Discrepancy
0 Good interdigitation
class 1,2 and 3
1 Less than half unit
discrepancy
2 Half unit discrepancy
cusp to cusp
Vertical :
Score Discrepancy
0 No discrepancy in inter
cuspation
1 Lateral open bite on at
least two teeth >2mm
Transverse :
Score Discrepancy
0 No cross bite
1 Cross bite tendency
2 Single tooth in cross bite
3 More than one tooth in
cross bite
4 More than one tooth in
scissor bite

122. Over jet measurements
• Include positive over jet and cross bite
• Recording zone is from left lateral incisor to right lateral incisor and is scored from most
prominent feature of any one incisor when assessing over jet PAR ruler is placed parallel is
placed parallel to occlusal plane and radial to the line of arch scores for over jet and cross
bite are totaled for the over all over jet scores.
122
Over jet measurements
Score Discrepancy
0 0 – 3 mm
1 3.1 – 5 mm
2 5.1 – 7 mm
3 7.1 – 9 mm
4 > 9mm
Anterior Cross-Bite
Score Discrepancy
0 No discrepancy
1 One or more teeth edge to edge
2 One single tooth in cross bite
3 2 teeth in cross bite
4 >2 teeth in cross bite

123. Over bite measurements
• It is a vertical overlap or open bite of anterior teeth in relation to coverage of lower incisors
or the degree of open bite
• Recording zone includes lateral incisors and the tooth with greatest overlap is recorded
• Cross bites including canines are recorded in anterior segments
123
Over bite measurements
Score Discrepancy
0 No open bite
1 Open bite ≤ 1mm
2 1.1 – 2 mm
3 2.1 – 3 mm
4 ≥ 4 mm
Over bite
Score Discrepancy
0 No discrepancy
1 One or more teeth edge to edge
2 One single tooth in cross bite
3 2 teeth in cross bite
4 >2 teeth in cross bite

124. Centre line Assessments
• The Centre line assessment is the centre line discrepancy in relation to the lower
central incisors
• If a lower central incisor has been extracted the measurement is not recorded
124
Centre line Assessments
Score Discrepancy
0 Coincident and up to one quarter lower incisor width
1 One quarter to one half lower incisor width
2 Greater than one half of lower incisor width

125. • Once the total score is obtained for all 11 segments the scores are summed to calculate the
over all PAR score
• 0 indicates excellent alignment and occlusion and higher scores rarely beyond 50, would
indicate increasing levels of alignment and malocclusion
• For determining outcome of the treatment, change indicates degree of improvement and
success of treatment
• Degree of improvement may also be determined using a nomogram
• A nomogram is divided into three segments
• Upper (worse or no change)
• Middle (improved)
• Lower (greatly improved)
125

126. PAR Index Guidelines
• General
• Scoring is accumulative
• No maximal cut off.
• Occlusion should be scored disregarding functional displacement.
• Contact points are not recorded between 1st 2nd 3rd molar however severe
deviations will produce a cross bite and will be noted in the buccal occlusion
• If a contact point displacement is due to poor restorative work then not
included
• Contact point between deciduous teeth not included
• Extraction spaces not included if patient will receive prosthetic replacement,
however if space closure is intended then adjacent teeth are noted
126

127. • Canines
• Where there are missing canines displacements resulting from discrepancies between
the mesial contact point to the 1st premolar and the distal of the lateral incisor should
be recorded in the anterior segment.
• Canine cross bites should be recorded in the over jet segment
• Contact points between canines and premolars are scored as follows
• The distal contact point of canine to the midpoint on the mesial surface of the adjacent
premolar.
• Impaction
• Unerupted or displaced from the line of the arch either buccally or palatally due to
insufficient space this is regarded as impaction
• If erupted n displaced displacement score is recorded
127

128. • Incisors
• Lost due to agenesis/ trauma/caries
• If for prosthesis adjacent teeth are not recorded
• If space is to be closed adjacent teeth are recorded
• In over jet when falling on line lower grade is recorded
• Lower incisor is extracted or missing centre line is not recorded
• Molars
• Contact points between 1st and 2nd molar are not recorded
• If 1st molar is extracted contact point of 2nd molar is recorded
128

129. Points to Remember
• Russel AL defines Index as a graduated scale having upper and lower
limits , with scores on the scale corresponding to specific criteria
which is designed to permit and facilitate comparison with other
population classified by same criteria and methods.
• Index used for evaluation of caries in primary dentition is ‘deft’ where
‘e’ stands for those deciduous teeth which are extracted due to caries
or even those teeth that are indicated for extraction
129

130. • Caries indices for permanent teeth and deciduous teeth have to be
done separately
• OHI-S most commonly used index
• Dean’s fluorosis index most commonly used index for fluorosis
130

131. Thank you
131

132. References
• Soben Peter. Indices in dental epidemiology. Essentials Of Preventive
and Community Dentistry 3ed.123-231.
• Nikhil Marwah. Textbook of pediatric dentistry 3ed.1009-1018
• Kinane DF, Lindhe J. Pathogenesis of periodontitis. In: Lindhe J, Karring
T, Lang NP, Eds. Clinical Periodontology and Implant Dentistry, 3rd ed.
Copenhagen: Munksgaard, 1997, 189- 225.
• Brook, P.H.; Shaw, W.C. The development of an index of orthodontic
treatment priority. Eur. J. Orthod. 1989, 11, 309-320
132