Recent advances in dental indices

Recent Advances in
Dental Indices

Presented by:
Ujwal Gautam
Roll no. 431
BDS 4th year (batch
2009)

Contents
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Dental Indices- an Introduction
Measuring Dental Caries
Measuring Periodontal Diseases
Measuring tooth erosion
Measuring Dental Fluorosis and Enamel Defects
Measuring Malocclusion
Measuring OHRQoL

2

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

3

“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 same
criteria and methods.”
-Russell A. L.

4

Ideal Requisites of an Index
 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
5

Ideal Requisites of an Index

(contd)

 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
6

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

7

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

8

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

9

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

10

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

11

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.
12


13


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
14


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

15

Significant caries Index (SiC)
• 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

16


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

17


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

18


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

19

Specific Caries Index
• 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

20


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)

22


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

23


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

24

International Caries Detection and Assessment System
(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 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)
25

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)

26


The detection of dental caries on coronal tooth surfaces is a twostage 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

27


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 noncavitated 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.

28


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)
29


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)
30


31


32

Root Caries


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)
33


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

34


Wardrobe concept
The users can decide at what stage (noncavitated or cavitated) and
severity they wish to measure dental caries.
The only stipulation is the requirement that the ICDAS definitions are
used for whatever stage of dental caries is chosen for a specific study.
The configuration of surfaces chosen for use in any study and the
stage used to measure dental caries may be determined for each
study using the ‘wardrobe’ concept.
For example, in a national study that aims to compare dental caries
prevalence over time, the number and configuration of tooth
surfaces may be selected to match previous surveys. Also, the stage
of caries detection may be adjusted to match previous studies
conducted in a country.
35


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

36

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

37


38


advantages
– Applicable in low- and middle- income countries as the
burden of untreated cavitated lesions leads to serious
consequences at tooth and surrounding tissue
– simple to record
– can be used for primary and permanent teeth
– results can be presented alongside with DMF index

39


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.

40

Caries Assessment Spectrum and Treatment (CAST) Index

• developed by J. E. Frencken, Rodrigo G. de Amorim,
Jorge Faber and Soraya C. Leal in 2011
• Combines elements of the ICDAS II and PUFA indices, and
the M- and F-components of the DMF index

41


42


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
43


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

44

FDI World Dental Federation Caries Matrix
• 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

45


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

46


47

Measuring Periodontal Disease
“Periodontal disease” was viewed as a single entity that
began with gingivitis and progressed to periodontitis and
tooth loss. This view is now obsolete, so that indices based
on it are now invalid.
Separate clinical measures are now being used for gingivitis
and periodontitis.

48

requires;

o What depth of Clinical attachment loss(CAL) at any site
constitutes evidence of disease processes?
o How many such sites need to be present in a mouth to
establish disease presence
o How probing depth and Bleeding on probing are to be
included in the case definition

49

Even the introduction of computerized, constant-force
probes has little difference in the reliability of
measurements.
The problems inherent in the clinical measurement have led
researchers to look for markers of periodontitis.

50

Role of Inflammatory cytokines as markers
in measuring periodontitis
The most promising candidates are inflammatory cytokines expressed
in gingival crevicular fluid (GCF) as part of the host response to
inflammation, a number of which has been associated with active
disease. These cytokines include PGE2, TNF α, Interleukin-1α,
interleukin-1β, and others. However, quantifying these associations
and determining the sensitivity of the measures is proving difficult.
To date, measurement of periodontitis by means of inflammatory
cytokines in GCF is still experimental.

51

Shortcomings of CPITN
• The hierarchical principles underlying its use are not
universally valid.
• The partial recording approach of the CPITN may grossly
underestimate the prevalence of deep pockets
• CPITN yields extensively distorted estimates of the
prevalence and severity of periodontal destruction in a
population
• Measuring treatment need has become obsolete as the
standard treatment for periodontal pocket has shifted
considerably from surgical removal of pockets to scaling
and root planing
52

Basic Periodontal Examination (BPE) Index
• Developed by British Society of Periodontology in 1986
• derived from the Community Periodontal Index of Treatment
Needs (CPITN)
• simple and rapid screening tool that is used to indicate the
level of examination needed and to provide basic guidance on
treatment need
• Not a diagnostic tool

53


 Both the number and the * should be recorded if a furcation is detected

54


•

As a general rule, radiographs to assess alveolar bone levels should be obtained for
teeth or sextants where BPE codes 3 or 4 are found.

55

Genetic Susceptibility Index for Periodontal disease
Etiology of periodontitis is multifactorial and involves
infectious components, environmental factors and genetic
susceptibility.
Genetic markers denote susceptibility toward disease
manifestation and it would be useful to exploit the
information hidden into them and to derive a genetic
susceptibility index (GSI)
56

Genetic Susceptibility Index for Periodontal disease

• shows direct and indirect association between the
susceptibility index, selected microbial values and disease
presence
• Single nucleotide polymorphisms (SNP’s) in genes encoding
molecules of the host defense system are assessed and an
association is established between SNP and disease status

57

Periodontal Screening and Recording (PSR) Index
• Introduced in 1992 by American Academy of
Periodontology(AAP) and American Dental
Association(ADA)
• endorsed by the World Health Organization (WHO)
• adaptation of the Community Periodontal Index of
Treatment Needs (CPITN)
• used to measure gingival bleeding upon probing, calculus
on a tooth, and periodontal pocket depth in each sextant
of the oral cavity
58


Calculating PSR
• highest score in a sextant is recorded as the PSR score for the
sextant.
• Only one score is recorded for each sextant of the oral cavity.
• A WHO/CPITN/PSR probe is used to examine each tooth
individually

59


Score

Criteria

0

pocket depth is < 3.5 mm, no bleeding upon probing, and no calculus

1

pocket depth is < 3.5 mm, bleeding on probing and no calculus

2

pocket depth is < 3.5 mm, bleeding on probing and calculus present

3

pocket is 3.5 – 5.5 mm in depth

4

pocket is > 5.5 mm in depth

*

clinical abnormalities
such as furcation involvement, tooth mobility, mucogingival
involvement, or 3.5 mm or more of recession in that sextant

X

edentulous sextant

60


advantages

– Introducing a simplified screening method that met legal
dental recording requirements.
– early detection of periodontal disease and it serves as an
aid in monitoring the periodontal status of patients
– fast method to screen patients as only six scores are
recorded
– Its documented use also assists with the record keeping
of a patient’s periodontal history
– Can be used with a large population during oral health
screenings.
61


limitations

– not intended to replace a full-mouth periodontal
examination. Those patients who have received
treatment for periodontal diseases and/or are in a
maintenance phase of care should receive
comprehensive periodontal examinations
– limited use of the PSR system in children due to inability
to differentiate pseudo-pockets
– does not measure epithelial attachment, the severity of
periodontal disease may be underestimated with its use

62

Measuring Tooth Wear
• The objective of tooth wear indices is to classify and
record the severity of tooth wear or dental erosion in
prevalence and incidence studies.
• different researchers have developed indices which suit
their own research needs but do not allow comparison
to assess the prevalence of tooth wear between
countries and regions. Therefore, a need of new scoring
system is deemed necessary to allow existing and
hopefully future indices to be collapsed and re-analysed
63

Basic Erosive Wear Examination (BEWE)
• Developed by Bartlett, Ganss and Lussi in 2007
• The aim of the BEWE is to be a simple, reproducible and
transferable scoring system for recording clinical findings
and for assisting in the decision-making process for the
management of erosive tooth wear that can be used
with the diagnostic criteria of all existing indices

64


The BEWE is a partial scoring system recording the most
severely affected surface in a sextant and the cumulative
score guides the management of the condition for the
practitioner

The result of the BEWE is not only a measure of the severity
of the condition for scientific purposes but, when transferred
into risk levels, also a possible guide towards management

65


66


67


68


advantages
– by removing the clear distinction between “enamel loss”
and “dentine” exposed, it will not only evade diagnostic
uncertainties but will open a broad applicability beyond
the clinical situation
– can be used with study models or photographs
– particular value in cross-sectional and incidence studies as
well as for the monitoring of individual cases
– avoid an overestimate of the problem
– as a model to increase awareness

69

Measuring Dental Fluorosis
Two distinct groups of indexes have been proposed for
measuring dental fluorosis:
• Specific fluorosis indexes - specifically measures the fluoride
induced enamel changes in order to reflect increasing severity
of fluorosis of lesions
• Descriptive indexes - including all types of defects. These
indexes includes all defects of enamel are recorded based
solely on descriptive criteria, regardless of causative factors. It
is based on the principle that examiner should record what he
sees and do not presume the etiology
70

Shortcoming of Dean’s Index

• Single score is given to a tooth rather than, a separate score to
each tooth surface. Hence differences in the severity of
fluorosis in different tooth surfaces cannot be ascertained
• An individual has been classified according to the tooth most
affected by fluorosis which may be located in the mouth that
has little cosmetic value
• Questionable diagnostic category (score 0.5) in Dean’s Index is
difficult to define and interpret precisely
• The distinctions between some of the diagnostic categories in
Dean’s system are unclear, imprecise or lack sensitivity.
71

Thylstrup and Fejerskov Index (TFI)

• Developed by Thylstrup A. and Fejerskov O. in 1978 to assess
the prevalence and severity of dental fluorosis
• It was developed to refine, modify, and extend the original
concepts established by Dean. The primary aim was to
develop a more sensitive classification system for recording
enamel changes associated, with increasing level of fluoride in
water
72

Thylstrup and Fejerskov Index (TFI)

advantages
– more appropriate than Dean's Index for use in clinical trials
or analytical epidemiologic studies
– increased sensitivity because teeth are dried and fluorosis
can be identified in its milder forms.
– provides statistical and practical advantages from the
possible detection of effects with smaller samples when
potential fluoride effects are small, or when the exposure
may be widespread
73

Fluorosis Risk Index (FRI)
• Introduced by David G Pendrys in 1990
• to permit a more accurate identification of associations
between age-specific exposures to fluoride sources and
the development of enamel fluorosis
• developed for use in analytical epidemiologic studies

74

Fluorosis Risk Index (FRI)

FRI divides the enamel surfaces of the permanent dentition into
two developmentally related groups of surface zones, designated
either as
– having begun formation during the first year of life (classification I) or
– during the third through sixth years of life (classification II)

Data are found to illustrate the high reliability of the index, its
validity, and its unique utility for the identification of risk factors
of enamel fluorosis.

75

Modified Developmental Defects of Dental Enamel Index
(modified DDE)
• Developed by Clarkson J.J. and O’Mullane D.M. in 1989
• Access developmental enamel defects without the need
for diagnosing fluorosis before recording enamel opacities
• Simple and flexible compared to DDE Index

76

Modified Developmental Defects of Dental Enamel Index (modified DDE)

Scoring Criteria
Normal
Demarcated opacity
Diffuse opacity
Hypoplasia
Other defects
Demarcated and Diffuse
Demarcated and Hypoplasia
Diffuse and Hypoplasia
All three defects

:
:
:
:
:
:
:
:
:

0
1
2
3
4
5
6
7
8

77

Measuring malocclusion
Recording or measuring malocclusion is important for
documentation of prevalence and severity of malocclusion in
population groups and provide a basis for planning orthodontic
treatment.
Methods of recording and measuring malocclusion can be
divided as;
Qualitative
Quantitative
78

Index of Complexity, Outcome and Need (ICON)
• Developed by Richmond and Daniels in 2000
• Assess treatment need, complexity, treatment
improvement and outcome based on international
orthodontic professional opinion, intended for use in the
context of specialist practice
• Intended to use in late mixed dentition onwards
• Simple with relatively fewer trait to measure
• Quick and takes approximately 1 minute for a case
79

Measuring
Oral Health-Related Quality of Life
(OHRQoL)
The impact of oral diseases and disorders on aspects of
everyday life that a patient or person values, that are of
sufficient magnitude, in terms of frequency, severity or
duration to affect their experience and perception of their life
overall
Locker and Allen, 2007

80

Why measure health??
Although philosophically, it is desirable to measure health rather than
disease; in practice the epidemiology concerns with measuring
disease as health is difficult to define in operational terms and hence
difficult to measure.
Due to limitations in measurements of the levels of
dysfunction, discomfort and disability associated with oral
disorders, measurement of the social impact of oral disorders seems
justifiable.

Empirical approach to develop an index for oral health. Though
subjective assessment in done and correlated with clinical measures
81

• Paradigm shift – from biomedical to biopsychosocial model
of oral health
• Expanded understanding of oral disorders: functional and
psychosocial consequences
• Legitimacy of the patients’ perspective –needs for and
outcomes of therapy

82

Involves measurement of:
– Group differences for public health purposes.
To do this we need instrument that are reliable and valid

– Changes in OHRQoL as a time effect or in response to
treatment and preventive procedures.
To do this we need instruments where the sensitivity to change
(responsiveness) is established

83

Instruments to measure OHRQoL

The OHIP-14 (Oral Health Impact Profile) comprises 14 items that
explore sevenis concerned of impact (functional limitation, pain,
The OHIP-49 dimensions with impairment and three functional
The OIDP (Oral Impacts onpsychological and physical) which
psychological discomfort, physical disability, psychological
status dimensions (social, Daily Performances) questionnaire
assesses socialof the seven conditions 16 questions, which takes
disability,the impacts of oral quality of life dimensions. of respond
The OHQoL-UK consists ofand handicap) and participants
represent four disability, a battery of on the abilities
individuals toboth 'effect' and frequency of impact on a 5-point
to each item accordingeight daily activities eating, speaking,
into account perform to the 'impact' of oral health on life
hygiene,incorporating dimensions and relations, sleeping-relaxing,
Likert scale ranging from never to veryan individualised weighting
quality, occupational activities, social often (never = 0, hardly
smiling, occasionally = 2, fairly often = 3, very often = 4), using
ever = 1,and emotional state; using a severity-based approach a
system.
twelve-months recall period

84

Instruments to measure OHRQoL

85

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).
2005. Available from: URL: http://www.icdas.org.
 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.
86

References
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proposal for a new oral health goal for 12-year-olds. Int Dent J.
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References
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review. International Dental Journal. 2011; 61:76-84
 Burt BA, Eklund SA. Dentistry, Dental practice, and the Community; 5/e;
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Journal of Dentistry. Jan-Mar 2012; 3(1):77-86

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