Indices for dental caries

INDICES FOR
DENTAL CARIES
Seminar – 12Seminar – 12
Dr. Nabeela BashaDr. Nabeela Basha

Contents
• Introduction
• Definition of index
• Objective of an indices
• Ideal requisites of an Index
• Uses of an index
• Indices used for dental caries
• Recent developments on caries indices
• Conclusion
• Previous year questions
• References

INTRODUCTION
• Dental diseases are the most prevalent and the most neglected
of all the chronic diseases affecting mankind. The backlog of
unmet treatment need is greater than the amount of available
treatment time.
 Indeed, the dental profession, for all the progress it has made in
techniques and instrumentation, is yet unable to provide
treatment enough to pace with the newly occurring needs for
care.

 Dental caries is a complex disease affecting the teeth, which is
mainly caused by imbalance between demineralization and
remineralization process around the tooth surface.
 To apply measures which can prevent or control caries, a
reliable picture of it in a population is prerequisite; this can
only be obtained if we have a reliable caries assessment system
(index).

 “An index 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”
- Russel A.L. 1968

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

Simplicity
Clarity and objectivity
Validity
Reliability
Acceptability
Quantifiability
IDEAL REQUISITES OF AN INDEX

For individual patients
In research
In Community Health
USES OF THE INDEX

Based on the direction in which their scores can fluctuate:
CLASSIFICATION OF INDICES

Depending upon the extent to which areas of oral cavity are measured

Depending upon the entity they measure:

DENTAL CARIES INDICES
 The number of persons affected by dental caries
 The number of teeth that need treatment
 The number of surfaces involved
 The number of teeth that have been treated
 The number of teeth missing due to caries
 Other statistical data useful in organizing and evaluating
dental health programme efforts.

HISTORICAL BACKGROUND ON
CARIES INDICES
 As early as 1931, Bodecker OF and Bodecker HWC described a
Caries Index. This Caries Index was found to be sensitive but
too complex for use in epidemiological surveys.
 Bodecker modified this Caries Index later, wherein addition to
counting the surfaces decayed, an extra count was allotted for
those surfaces that could experience multiple carious attacks.
But this also was not used in major epidemiological studies.

 The approach to measuring caries by counting the numbers of
teeth in the mouth visibly affected by caries was used in a
systematic manner, by DEAN. HT and associates in their historic
studies of the dental caries / fluoride relation.
 MELLANBY M in 1934 described the carious lesions depending
upon the degree of severity and numerically expressed it as
follows:
1 = Slight caries 2 = Moderate caries 3 = Advanced caries

 However, the first systematic description of what is now known
as the DMF index is usually attributed to Henry Klein and Carole
Palmer in their studies of dental caries in Hagerstown, Maryland
in the latter part of 1930s.

INDICES FOR DENTAL CARIES
Most commonly used:Most commonly used:
DMF
•Primary teeth (dmft &
dmfs)
•Permanent teeth (DMFT
& DMFS)
Other indices:Other indices:
•Stone’s index
•Caries severity index
•Dental caries severity index
for primary teeth
•Czechoslovakian caries
index
•Significant caries index
•Caries susceptibility index
•Moller’s index
•Root caries index

Visual criteria for diagnosing initial dental caries:Visual criteria for diagnosing initial dental caries:
•Nyvad’s criteria
•ICDAS II
•PUFA
•Caries assessment spectrum and treatment (CAST) index
Recent developments on caries indices:Recent developments on caries indices:
•Oral health status index
•Functional measure index
•Dental health index

Different criteria for diagnosing pit and fissure caries:Different criteria for diagnosing pit and fissure caries:
•Anglo-Saxon system (liberal)
•European system (conservative)

Decayed Missing and Filled Teeth
(DMFT) Index
• Henry T. Klein, Carrole E. Palmer and Knutson J.W in 1938
• Prevalence of coronal caries
• Irreversible index
• Measures lifetime caries experience

Procedure:Procedure:
•‘D’ – Decayed teeth
•‘M’ – Missing or Extracted teeth due to caries
•‘F’ – teeth that have been previously filled due to caries.
Instruments used are:Instruments used are:
•No. 3 plain mirror
•Fine-pointed pig-tail explorer

Not included:Not included:
•Third molars
•Unerupted teeth
•Congenitally missing, supernumerary teeth
•Teeth missing for other reasons
•Teeth restored for other reasons
•Primary tooth retained with permanent successor erupted.

Rules for recording:Rules for recording:
A tooth is considered to be erupted when the occlusal surface or
incisal edge is exposed.
Decayed, missing and filled should be recorded separately.
No tooth should be counted more than once.
Tooth lost or filled due to causes other than caries are not
included.

 Deciduous teeth are not taken into account.
 Tooth is considered present even when the crown is destroyed
and only the roots are left.

WHO Modification of DMF Index (1987):WHO Modification of DMF Index (1987):
 All third molars are included
 Temporary restorations are considered as ‘D’
 Only carious cavities are considered as ‘D’, initial lesions
(Chalky spots, stained fissures, etc) are not considered as ‘D’

WHO Modification of DMF Index (1997):WHO Modification of DMF Index (1997):
 The CPI probe should be used to confirm visual evidence of
caries.
 Individuals 30 years and older, M component should include
teeth missing due to caries and any other reason.
 <30 years M component includes missing due to caries only.

Advantages:Advantages:
 Simple, rapid, versatile, universally accepted, statistically
manageable and a reliable index.
 Gives total lifetime caries experience of an individual and
group of individuals.

Disadvantages:Disadvantages:
 DMF values are not related to the number of teeth at risk.
 DMF index gives equal weight to missing, untreated decayed,
or well-restored teeth.
 DMF data are of little use for estimating treatment needs.
 DMFT Index is of little use in studies of root caries.
 DMF index is invalid when teeth have been lost for reasons
other than caries.

 DMFT index can overestimate caries in teeth in which
"preventive fillings" have been placed.
 They do not account for sealed teeth since sealants and other
cosmetic restorations did not exist in the 1930s when this
method was devised.
 Rate of caries progression cannot be assessed.

Decayed Missing and Filled Tooth
Surfaces (DMFS) Index
 The DMFS is a more detailed index than the DMFT summing
the total number of decayed, missing and filled permanent
tooth surfaces.
 D - Used to describe decayed teeth surfaces.
 M- Used to describe missing teeth surfaces due to caries
 F - Used to describe teeth surfaces that have been previously
filled due to caries.

 Principles, rules and criteria for DMFS is same as that for
DMFT

Advantages:Advantages:
 The DMFS index is more sensitive and is usually the index of
choice in a clinical trial of a caries preventive agent.
 More precise.
 Gives true status of caries attack.

Disadvantages:Disadvantages:
 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.
 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.

DENTITION STATUS ANDDENTITION STATUS AND
TREATMENT NEED INDEXTREATMENT NEED INDEX
 Given by WHO in 1997.
 Boxes 66-161.
 Examination done by plane mouth mirror & CPI probe.
 Radiography and fibre-optics not recommended.
 Tooth considered present when any part of it is visible in oral cavity.
 If both primary and permanent tooth occupy the same tooth space,
the status of permanent tooth is recorded.

 Upper teeth: 66-97
 Lower teeth: 114-161

Codes for the dentition status of primary and
permanent teeth (crowns and roots)

0 (A). Sound crown:
A crown with the following defects, in the absence of other
positive criteria, should be coded as sound:
white or chalky spots.
discoloured or rough spots that are not soft to touch with a
metal CPI probe.

 stained pits or fissures in the enamel that do not have visual signs of
undermined enamel, or softening of the floor or walls detectable
with a CPI probe.
 dark, shiny, hard, pitted areas of enamel in a tooth showing signs of
moderate to severe fluorosis.
• Sound root:
A root is recorded as sound when it is exposed and shows no
evidence of treated or untreated clinical caries. (Unexposed roots
are coded 8.)

1 (B). Decayed crown
Caries is recorded as present when a lesion in a pit or fissure,
or on a smooth tooth surface, has an unmistakable cavity,
undermined enamel, or a detectably softened floor or wall
A tooth with a temporary filling, or one which is sealed (code 6
(F)) but also decayed is included in this category.

Decayed root
Caries is recorded as present when a lesion feels soft or leathery
to probing with the CPI probe. If the root caries is discrete from
the crown and will require a separate treatment, it should be
recorded as root caries.

2 (C). Filled crown, with decay.
•A crown is considered filled, with decay, when it has one or more
permanent restorations and one or more areas that are decayed.
Filled root, with decay.
•A root is considered filled, with decay, when it has one or more
permanent restorations and one or more areas that are decayed.

3 (D). Filled crown, with no decay.
•A crown is considered filled, without decay, when one or more permanent
restorations are present and there is no caries anywhere on the crown.
Filled root, with no decay.
•A root is considered filled, without decay, when one or more permanent
restorations are present and there is no caries any where on the root.

4 (E). Missing tooth, as a result of caries.
•This code is used for permanent or primary teeth that have been
extracted because of caries and is recorded under coronal status.
•The root status of a tooth that has been scored as missing because
of caries should be coded "7" or "9".

5 (-). Permanent tooth missing, for any other reason.
•This code is used for permanent teeth judged to be absent
congenitally, or extracted for orthodontic reasons or because of
periodontal disease, trauma, etc.
•The root status of a tooth scored 5 should be coded "7" or "9".

6 (F). Fissure sealant.
•This code is used for teeth in which a fissure sealant has been
placed on the occlusal surface
•If a tooth with a sealant has decay, it should be coded as 1 or B.

7 (G). Bridge abutment, special crown or veneer.
•This code is used under coronal status to indicate that a tooth forms
part of a fixed bridge, i.e., is a bridge abutment.
•Missing teeth replaced by a bridge are coded 4 or 5, under coronal
status, while root status is scored 9.

8 (-). Unerupted crown.
•Restricted to permanent teeth and used only for a tooth space with
an unerupted permanent tooth but without a primary tooth.
Unexposed root.
•This code indicates that the root surface is not exposed, i.e. there is
no gingival recession beyond the CEJ.

XT (T). Trauma (fracture).
•A crown is scored as fractured when some of its surface is missing
as a result of trauma and there is no evidence of caries.
9 (-). Not recorded.
•This code is used for any erupted permanent tooth that cannot be
examined for any reason (e.g. because of orthodontic bands, severe
hypoplasia, etc.)

MODIFIED DMFT INDEXMODIFIED DMFT INDEX
 Put forth by Joseph Z. Anaise in 1984.
 There are 4 divisions for D component.

Code Criteria
C Unfilled teeth that are carious
CF restored teeth that are either secondarily carious
around the margins of the restorations or primarily on
a tooth surface other than the restored one.
IX carious teeth that are either filled or unfilled that in the
examiner’s opinion are indicated for extraction
IRC carious teeth that are either filled or unfilled that in the
examiner’s opinion are indicated for pulp treatment

def Indexdef Index
 Described by Gruebbel A.O. – 1944
 As an equivalent index to DMF index
 For measuring dental caries in 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.

 d – Indicates the number of deciduous teeth decayed.
 e – Indicates deciduous teeth extracted due to caries &
indicated for extraction
 f – Indicates restored teeth without recurrent decay

Modifications
dmf index
• For children
over 7 years and
upto 11 – 12
years
• Primary molar
and canines are
used for dmft or
dmfs
df index
• Primary
molars
•Above 9 years
Mixed dentition
• DMFT and deft
are done
separately and
never added
• Permanent
teeth index is
done first then
deciduous

STONE’S INDEXSTONE’S INDEX
 The Stone's caries index was developed by Stone H.H,
Lawton F. E, Bransby E. R. and Hartley H.O. in 1949 to
evaluate the incidence of caries in national children’s home
aged 3-16 years.

CARIES SEVERITY INDEXCARIES SEVERITY INDEX
• The Caries Severity Index was developed by Tank Certrude
and Storvick Clara in 1960.
• This index was developed to study the depth and extent of the
caries surfaces and the extent of pulpal involvements.

DENTAL CARIES SEVERITYDENTAL CARIES SEVERITY
INDEX FOR PRIMARY TEETHINDEX FOR PRIMARY TEETH
 The caries severity index was proposed by Aubrey Chosack in
1986.
Criteria for scoring:Criteria for scoring:
1. Occlusal surfaces and pit and fissure caries on buccal and
palatal surfaces
2. Buccal-lingual & palatal smooth surfaces caries
3. Proximal surfaces of molars
4. Proximal surfaces of incisors & canines

Occlusal surfaces and pit and fissure caries on
buccal and palatal surfaces

Buccal, lingual & palatal smooth surfaces
caries

Proximal surfaces of incisors & canines

SIGNIFICANT CARIES INDEXSIGNIFICANT CARIES INDEX
 Introduced by Douglas Bratthall in 2000 and recommended by
WHO in 2005, to bring attention to those children with the
highest caries scores in each population.
 SIC index is calculated as follows:
- Individuals are sorted according to their DMFT values.
-1/3rd of the population with highest scores are selected.

 It is the mean DMF score for the third of the population that is
most affected by caries, intended to be used alongside the
mean DMF of the whole population to give a more complete
summary of its caries distribution.

RESTORATIVE INDEX (RI)RESTORATIVE INDEX (RI)
 Developed by D JACKSON in 1973.
 It can be used to measure the level of restorative care within a
community.
 It does not depend upon the DMF index. Hence it can be used
for all ages.

SPECIFIC CARIES INDEXSPECIFIC CARIES INDEX
 Proposed by Shashidhar Acharya in 2006
 This index is based on GV Black, classification of cavity
preparation.

MOLLER’S INDEXMOLLER’S INDEX
 This index system was developed by Moller J.J. in 1966 as a
standardized system for diagnosing, recording and analyzing
dental caries data.
 The basis for the development of this system was to make
available a system which could be used in many different
situations.

ROOT CARIES INDEX (RCI)ROOT CARIES INDEX (RCI)
 The Root Caries Index (RCI) was developed by Ralph V KatzRalph V Katz
in 1979, to make the simple prevalence measures for root
caries more specific by including the concept of teeth at risk
for root caries.
 Only teeth with gingival recession are examined.

The root surfaces are characterized and recorded:
R-N = Recession present; surface normal or sound
R-D = Recession present; with a decayed root surface
R-F = Recession present; with a filled root surface
No-R=No association with gingival recession
M = Root surfaces characterized as missing

RECENT DEVELOPMENTS ONRECENT DEVELOPMENTS ON
CARIES INDICESCARIES INDICES
 Oral health status index
 Functional measure index
 Dental health index

ORAL HEALTH STATUSORAL HEALTH STATUS
INDEXINDEX
 Marcus M., Koch A.L, and Gershen, J.A. developed the Oral
Health Status Index (OHSI) in 1980.
 This index includes 3 component of DMFT and 15 other
variables such as –
• Temperomandiular dysfunction,
• Degree of periodontal disease and
• Tumors

FUNCTIONAL MEASUREFUNCTIONAL MEASURE
INDEX (FMI)INDEX (FMI)
 The Functional Measure Index (FMI) was proposed by Sheiham A.,
Maizels J.and Maizels A. in 1987.
 This index is the first composite indicator index to measure dental
health and functional status rather than disease.
 In FMI, the filled and the sound teeth are weighed equally, but the
decayed and missing teeth are given zero weight.
 FMI = Filled + Sound / 28.
 The FMI scores ranges from 0 to 1.

DENTAL HEALTH INDEXDENTAL HEALTH INDEX
(DHI)(DHI)
 The Dental Health Index (DHI) was developed by Carpay J.J,
Nieman F. H, Konig K.G, Felling A.J., and Lammers J. G in
1988.
 The DHI was developed to minimize the difference between
sound and affected (or extracted) teeth.
 The sound teeth were given a score of "+1" and the affected
(or extracted) teeth were given a score of "-1".

 DHI = (Sound teeth) – Decayed + Filled + Missing teeth
Sound + Decayed + Filled + Missing teeth
 i.e., DHI is a ratio of sound teeth minus unsound teeth,
divided by the total number of teeth examined.
 DHI score ranges from –1 to +1

VISUAL CRITERIA FOR DIAGNOSINGVISUAL CRITERIA FOR DIAGNOSING
INITIAL DENTAL CARIESINITIAL DENTAL CARIES
 Nyvad’s criteria
 ICDAS II
 PUFA
 Caries assessment spectrum and treatment (CAST) index

NYVAD’S CARIES DIAGNOSTICNYVAD’S CARIES DIAGNOSTIC
CRITERIACRITERIA
 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.

INTERNATIONAL CARIES DETECTIONINTERNATIONAL CARIES DETECTION
AND ASSESSMENT SYSTEMAND ASSESSMENT SYSTEM
(ICDAS)(ICDAS)
• 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 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.

 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)

 The ‘DD’ 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 ‘AA’ in ICDAS stands for assessment of the caries process
by stage (noncavitated or cavitated) and activity (active or
arrested).

Score Criteria
0- sound There should be no evidence of caries after
prolonged air-drying (5 seconds). Surfaces with
developmental defects enamel hypoplasia,
fluorosis, attrition, abrasion and erosion, and
extrinsic or intrinsic stains will be recorded as
sound.
Score Criteria
1 – First visual
change in
enamel
When seen wet there is no evidence of any change
in colour attributable to carious activity, but after
prolonged air-drying a carious opacity or
discoloration (white or brown lesion) is visible
that is not consistent with the clinical appearance
of sound enamel.
Score Criteria
2 – Distinct
visual change
in enamel
The tooth must be viewed wet. When wet there is
a (a) carious opacity (white spot lesion) and ⁄ or
(b) brown carious discoloration which is wider
than the natural fissure ⁄ fossa that is not
consistent with the clinical appearance of sound
enamel.
Score Criteria
3 – Localized
enamel
breakdown
due to caries
with no visible
dentin or
underlying
shadow
The tooth viewed wet may have a clear carious
opacity (white spot lesion) and ⁄ or brown carious
discoloration which is wider than the natural
fissure ⁄ fossa that is not consistent with the
clinical appearance of sound enamel. Once dried
for approximately 5 seconds there is carious loss
of tooth structure at the entrance to, or within, the
pit or fissure ⁄ fossa. If in doubt, or to confirm the
visual assessment, the CPI probe was used gently
across a tooth surface to confirm the presence of a
cavity apparently confined to the enamel.
Score Criteria
4 – Underlying
dark shadow
from dentin
with or
without
localized
enamel
breakdown
This lesion appears as a shadow of discolored
dentin visible through an apparently intact enamel
surface, which may or may not show signs of
localized breakdown (loss of continuity of the
surface that is not showing the dentin).
Score Criteria
5 – Distinct
cavity with
visible dentin
Cavitation in opaque or discoloured enamel
exposing the dentin beneath.
Score Criteria
6 – Extensive
distinct cavity
with
Visible dentin.
Obvious loss of tooth structure, the cavity is both
deep and wide and dentin is clearly visible on the
walls and at the base. An extensive cavity involves
at least half of a tooth surface or possibly reaching
the pulp.

PUFA (pulp-ulcer-fistula-abscess)PUFA (pulp-ulcer-fistula-abscess)
IndexIndex
 Developed by Monse B et al in 2010.
 Assess the presence of oral conditions resulting from
untreated caries
 Upper case for permanent and lower case for primary
dentition
 Assessment is made visually without any instrument

Caries Assessment Spectrum andCaries Assessment Spectrum and
Treatment (CAST) IndexTreatment (CAST) Index
 Developed by Frencken et al in 2011
 Combines elements of the ICDAS II and PUFA indices, and
the M- and F-components of the DMF index.

INDICES FOR PIT & FISSUREINDICES FOR PIT & FISSURE
CARIESCARIES
 Anglo Saxon system (liberal)
 European system ( Conservative)

 The “Anglo –Saxon” System for diagnosing pit and fissure
caries, which consists of certain “liberal criteria”, was
described by HOROWITZ, H.S. , in 1972.
ANGLO-SAXON SYSTEMANGLO-SAXON SYSTEM

 The pits and fissures on the occlusal, vestibular and lingual surfaces
are carious when the explorer "catches" after insertion with moderate to
firm pressure and when the "catch" is accompanied by one or more of
the following signs of decay:
Softness at the base of the area.
Opacity adjacent to the area provides evidence of undermining of
demineralization.
Softened enamel adjacent to the area that may be scraped away by the
explorer.

 The "European" System, for diagnosing pit and fissure caries,
which consists of certain "conservative" criteria, was
described by BACKER-DIRKS.O , HOUWINK.B and
KWANT.G.W in 1961.
EUROPEAN SYSTEMEUROPEAN SYSTEM

Description of the system:Description of the system:
In upper molars, the mesio-occlusal and disto-occlusal palatal
fissures are assessed separately.
In lower molars, the occlusal fissures and the buccal pits are
assessed separately.
Teeth are dried, sharp new explorers are used for assessment.

Caries is diagnosed in four categories:
•C. I - Minute black line at base of fissure.
•C. II - In addition ,a white zone along margins of fissure (dark
in transmitted light)
•C. III - The smallest perceptible break in the continuity of the
enamel.
•C. IV - Large cavity , more than 3mm wide.

• Index is considered to be an ideal method to quantify the
disease.
• There is an increasing need to quantify various oral diseases
in order to prevent the disease and reduce the prevalence.
• Many new indices have been developed to assess caries but
we are far away from finding an ideal caries index which can
replace or overcome limitations of DMF index.
CONCLUSION

• Peter S. Essentials of Preventive and Community
Dentistry.3rd ed, Arya Medi Publishers; 2006.
• Hiremath SS. Textbook of Public Health Dentistry. 3rd
edition. Elsevier Publishers, New Delhi; 2016.
• CM Marya. A Textbook of Public Health Dentistry. 1st Edition
2011. Jaypee Brothers Medical Publishers, New Delhi.
REFERENCES

• Chakravathy PK. Dental Indices – Ready Reckoner. 1st edn,
CBS Publishers & Distributors Pvt. Ltd., New Delhi; 2014.
• Mehta A. Comprehensive review of caries assessment systems
developed over the last decade. RSBO. 2012 Jul-
Sep;9(3):316-21.
• Radhey Shyam et al. Newer Concept of Measuring Dental
Caries - A Review. Saudi J Oral Dent. Res. 2017;2(8):192-
196.

• Indices used for dental caries. (R.G.U.H.S M.D.S Degree
Examination – May 2009, October 2009 - 10 marks)
• Significant Caries Index. (R.G.U.H.S M.D.S Degree
Examination – May 2013- 7 marks)
PREVIOUS YEAR QUESTIONS

Indices for dental caries

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