Dental indices used in pedodontics1

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Dental indices used in pedodontics1 Powered By Docstoc


      Dental diseases are the most prevalent and most neglected of

all the chronic diseases affecting mankind, and in country after

country, the backlog of unmet treatment need is greater by far than

the   amount   of   available   treatment   time.   Indeed,   the   dental

profession, for all the progress it has made in technique and

instrumentation, is as yet unable to provide treatment enough to

pace newly occurring needs for care. We are still falling behind in

our efforts to protest out children‟s dental health, and we will

undoubtedly continue so to fail until we begin to use to the fullest

all methods available to us for the prevention of dental diseases.

      The present review attempts to provide a critical description

of the various indices used in pediatric dentistry.


According to Russel A.L.

      It is 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 population classified by same criteria and methods.
According to Glickman

      Epidemiologic indices are attempts to quantitate clinical

conditions on a graduated scale, thereby facilitating comparison

among populations examined by the same criteria and methods.

According to Wilkins

      An index is an expression of clinical observation in numerical

values which is used to describe the status of the individual or

group with respect to a condition being measured.

According to Zarkowski

      It is an abbreviated measurement of the amount or condition

of disease in a population; a numerical scale with defined upper

and lower limits designed to permit and facilitate comparison with

other populations classified by same criteria and method.


       Clarity, simplicity and objectivity: The examiner should

        be able to carry the rules of the index in his head, and the

        index should be reasonably easy to apply so that there is

        no undue time last during field examinations.
       Validity: The index must measure what it is intended to

        measure, so it should correspond with clinical stages of

        the disease under study at each point.

       Reliability: The index should measure consistently at

        different times and under a variety of conditions.

       Quantifiability:     The    index     should      be    amenable      to

        statistical analysis, so that the status of a group can be


       Sensitivity:   The    index        should    be   above     to   detect

        reasonably small shifts, in either direction in the group


       Acceptability:     The     index    should    not      be   painful   or

        deamning to the subject probably no index used in oral

        epidemiology completely meets all of these conditions, but

        choice of an index in any given situation should be made

        on the basis of how closely the index approximates them.


Based upon the direction in which their source can fluctuate

indices are classified as either reversible or irreversible.

       Irreversible index: Index that measures conditions that

        will not change. Irreversible index scores, once established
       cannot decrease in value on subsequent examinations.

       E.g., an index that measures dental caries.

      Reversible index: Index that measures condition that can

       be      changed.    Reversible      index   score    can   increase   or

       decrease on subsequent examinations. E.g., indices that

       measure periodontal conditions.

Based upon the extent to which areas of oral cavity are


      Full mouth: These indices measure the patient‟s entire

       periodontium or dentition. E.g., Russel‟s periodontal index


      Simplified         indices:   These     indices      measure   only   a

       representative       sample    of    the    dental   apparatus.   E.g.,

       Greene and Vermillian (OHI-S).

According to entity which they measure

      Disease index: E.g., the „D‟ portion of the „DMF‟ index.

      Symptom index: The indices measuring gingival/sulcular

       bleeding are essentially symptom indices.

      Treatment index: E.g., The „F‟ filled portion of the DMF

Dental indices can also be classified under special categories


       Simple      index:   Index that measures the presence or

        absence of a condition. E.g., an index that would measure

        the presence of dental plaque without an evaluation of its

        effect on gingival.

       Cumulative index: Index that measures all the evidence of

        a condition, past and present. E.g., DMF index of dental



Decayed – missing – filled index:

      Developed by Klein, Palmer and Knutson in 1938.

      Most universally employed index for measuring dental caries.

Principles and rules in recording DMFT

       No tooth must be counted more than once. It can be either

        decayed, missing, filled or sound.

       Decayed, missing and filled teeth should be recorded

        separately since the components of DMF are of great


       When counting the number of decayed teeth, also include

        those teeth which have restorations with recurrent decay.
      The following should not be counted as missing:

           Unerupted teeth.

           Missing teeth due to accident

           Congenitally missing teeth

           Teeth   that     have   been   extracted   for   orthodontic


      A tooth may have several restorations but it is counted as

       one teeth.

      Deciduous teeth are not included in DMF count.

      A tooth is considered to be erupted when the occlusal

       surface or incisal edge is totally exposed or can be exposed

       by gently reflecting the overlying gingival tissue with the

       explorer or mirror.

      A tooth is considered to be present even though the crown

       has been destroyed and only root are left.

WHO modification of DMF index (1936)

      All third molar are included.

      Temporary restorations are considered as „D‟

      Only carious cavities are considered as „D‟ the init ial

       lesions (chalky spot, stained fissure etc) are not considered

       as „D‟. The DMF index can be applied to denote the number
              of affected teeth (CMFT) or to measure the surface affected

              by dental caries (DMFS).

Coding criteria:

                   Code                   Criteria

                     E        Excluded tooth or tooth space

                     1        Sound permanent tooth

                     2        Filled permanent tooth

                     3        Decayed permanent tooth

For tooth absent:

„O‟       Missing tooth – unerupted, impacted, congenitally missing.

„X‟       Extracted permanent tooth.

Calculation of the index:

Individual DMFT: Total component i.e., D, M & F separately.

          Total D + M + F = DMF

Group average:

          =               Total DMF
                Total number of subject examined

Limitation of DMF index:

             DMF values are not related to the number of teeth at risk.
      DMF index can be invalid in order adults because teeth

       can become last for reason other than caries.

      DMF index can be misleading in children whose teeth have

       been lost due to orthodontic reasons.

      DMF index can overestimate caries experience in teeth in

       which “preventive filling” have been placed.

      DMF index is of little use in studies of root caries.

Other methods of DMF examinations

      WHO‟s half mouth technique: Half the upper arch and

       contralateral lower half arch are scored and result are

       doubled. It is done for assessments of caries prevalence in

       population which has not been previously surveyed.

      McClendon, et al., 1972

            Only first molars and upper central incisors are


            This method was described to estimate total DMF in

             groups were caries prevalence was moderate to high,

             and where the children had been exposed to little


      Viegas A.R. in 1969 described another method of DMF

       examination where only the lower left first molar and

       upper control incisors are examined.
       Grainger in 1967 suggested a method of DMF examination

        and was modified by Poulsen A. and Horowitz H.A. in

        1974. This method classifies individuals in a hierarchical

        pattern according to which site of mouth have been

        attacked. If caries is found first in approximal surfaces of

        mandibular incisors, the individual is graded in „Zone 5‟,

        the most severe zone. If caries is first found on the labial

        surfaces of lower incisors „Zone 4‟ and so on.

Decayed – missing – filled surface index (DMFS)

      When DMF index is employed to access each individual

surface of each tooth, rather than the tooth as a whole, it is termed

as DMFS index.

      The principles, rules and criteria for DMFS index is the same

as that of for DMFT index, which is described previously along with

description of DMF index. The only difference here is surface


Surface examined

       Posterior teeth: Each tooth has five surface examined and

        recorded facial, lingual, mesial, distal and occlusal.
         Anterior    teeth:     Each    tooth   has     four   surfaces   for

          evaluation facial, lingual, mesial and distal.

Total surface count for DMFS index

       If 28 teeth are examined (i.e., 3 rd molar excluded)

       46 posterior teeth (16 x 5)      = 80 surfaces.

       12 anterior teeth (12 x 4)       = 48 surfaces.

                         Total          = 128 surfaces

       If third molars are included (4 x 5) = 20 surfaces

                         Total          = 148 surfaces

Calculation of index:

       Individual DMFS

       Total No. of decayed surface          =     D

       Total No. of missing surface          =     M

       Total No. of filled surface           =     F

       DMF score = D + M + F

       The DMFS index is more sensitive and usually the index of

choice in a clinical trial of a caries preventive agent. This is

because relative incidence is more likely to be detected over the

limited time period of clinical trial.
Caries indices for primary dentition

‘def’ index:

     The „def index‟ was described by Gruebel in 19 44 as an

equivalent index to DMF index for measuring dental caries in

primary dentition.

     d = Decayed teeth

     e = Indicated for extraction

     f = Filled teeth

Examination method

‘d’ decayed: Indicates the number of deciduous teeth that are

decayed. A tooth should be counted only once. If it has been

restored and caries can be detected, count it as decayed.

‘e’ indicated for extraction: A grossly decayed teeth that are

indicated for extraction.

‘f’ filled: Primary teeth that have been attacked by caries but

which have been restored without any recurrent decay present. A

tooth may have several fillings but it is counted as one tooth. If a

tooth has a filling but shows evidence of recurrent decay, it is

counted as a decayed tooth.
Coding criteria for primary tooth dentition

               Code                     Criteria

                E           Excluded tooth/tooth space

                P1          Sound deciduous tooth

                P2          Filled deciduous tooth

                P3          Decayed deciduous tooth

When tooth absent:

‘O” Missing tooth: When unerupted, congenitally missing or

missing for any other reason.

„X‟ Extracted deciduous tooth.

Calculation of def index:

Individual def score

     d + e + f = def

Group average =               Total def
                  Total No. of the children examined

Modification of ‘def’ index:

‘dmf’ index:

     dmf index for use in children before ages of exfoliation.
      For children over 7 years and up to 11 or 12 years, the

decayed, missing and filled primary molars and canines, have been

used to determine decayed – missing – filled teeth (dmft) or decayed

– missing – filled surfaces (dmfs), when surfaces are counted.

‘df’ index:

      Another method of getting around exfoliation problem is the

„df‟ index in which the missing teeth are ignored. This is the

method of choice of the world health organization in their basic

survey technique.

      The „df‟ index can be applied to the whole tooth as the

decayed – filled - tooth (d-f-t index) or to the individual surfaces as

the („dfs‟ index).

Mixed dentition:

      A DMFT or DMFS and a „deft‟ or „defs‟ are never added

together. Each child is given a separate index for permanent teeth

and another for primary teeth. The index for the permanent teeth is

usually determined first and then the index for the primary teeth

Developmental defect of enamel index (DDE Index):

      Develoed by FDI-Commission on oral health, research and

epidemiology in 1982.


         Tooth surface should be inspected visually and defective

          areas   tactilely    explore    with    a   probe    to   determine

          abnormalities of surface contour. Natural or artificial light

          should be used depending upon the field conditions.

         Ideally, the teeth should receive a prophylaxis and be dried

          at the time of examination.

         Sometime examiner may be unsure weather the enamel is

          defective or fall within the range of normal, when in doubt,

          the tooth surface should be scored „normal‟ where an

          abnormality is obviously present can‟t readily be classified

          into one of the listed categories of defects, it should be

          scored as other defects.

Recording of data:

      A   recording    chart    has      been    identified   which   permits

identification of various types, number and location of defects on

buccal and lingual surface of all teeth.
Coding criteria:

1     -    Unerupted, missing, heavily restored, badly decayed,

           fractured teeth or tooth surfaces which any other reason

           can‟t be classified for defects must be coded as „X‟. This

           implies   that   it   will   be   disregarded   from   statistical


2     -    Type of defect: Permanent teeth are number coded and

           primary teeth are letter coded, when a defect is observed,

           it is classified with respect to the type of defect it m ost

           closely resemble.

Options and code for DDE index:

           Type of defect                     Permanent    Primary
                                                teeth       teeth
Normal                                            „0‟         „A‟

Opacity (white/cream)                             „1‟              „B‟

Opacity (yellow/brown)                            „2‟              „C‟

Hypoplasia (pits)                                 „3‟              „D‟

Hypoplasia (grooves; horizontal)                  „4‟              „E‟

Hypoplasia (grooves; vertical)                    „5‟               „F‟

Hypoplasia (missing enamel)                       „6‟              „G‟

Discolored enamel (not associated                 „7‟              „H‟
with opacity)
Other defects                                     „8‟               „J‟
All the above mentioned different categories i.e.,

          Type of defect

          Number and demarcation of defect

          Location of defect etc are given individual boxes in the

           recording chart for entering particular code used.

          Number and demarcation of defects – when the type of

           defect has been classified, the number of defect is coded.

           The options and codes used are;

         Number & demarcation                                Primary
Single                                         1                A

Multiple                                        2               B

Diffuse (fine white lines)                      3               C

Diffuse (patchy)                                4               D

          Location of defect: It is coded as in the gingival or incisal

           one-half, occlusally or cuspal. The areas designed are

           orbitrary, it is sufficient to identify the primary location.

           The option and codes are;
          Location of defect                Code
          No defect                                0

          Gingival one half                        1

          Incisal one half                         2

          Gingival and incisal halves              3

          Occlusal                                 4

          Cuspal                                   5

          Whole surface                            6

          Other combination                        7

Dental caries severity index for primary teeth:

     By Aubrey Chosack in 1985

     This index for primary teeth is based on clinical examination

only, which could be used in survey of dental caries and give

information addition to „def‟ figures, especially when investigating

preventive measures.


     Criteria for scoring of caries on each primary tooth surface;

Occlusal surfaces and pit and fissure caries on buccal and palatal

surfaces of molar:
1       -       Early pit and fissure caries where the explorer „catches‟

                or resists removal with moderate to firm pressure and is

                accompanied by either a softness at the base of the area

                or an opacity adjacent to the pit or fissure as evidence of

                undermining or demineralization or softened enamel

                adjacent to the pit or fissure which may be scrapped

                away with the explorer.

2       -       Cavitation of at least 1 mm across the smallest diameter

                at the tooth surface.

3       -       Cavitation with breakdown or undermining (as seen by

                obvious discoloration) of at least half a cusp.

Buccal-lingual and palatal smooth surface caries:

Score            Criteria

1           -    A white lesion not extending to the embrasure areas,

                 found to be soft sticky by penetration with explorer.

2           -    Cavitation of at least 1 mm but less than 2 mm across

                 the smallest diameter, or a soft sticky white lesion

                 extending into one embrasure.

3           -    Cavitation of at least 2 mm in the smallest diameter, or

                 a   soft   sticky   white   lesion   extending   into   both

Provisional surface of molars:

Score       Criteria

1       -   A discontinuity of the enamel is which explorer will

            catch and there is softness.

2       -   Cavitation with early breakdown of marginal ridge or

            obvious discoloration indicating undermining of the


3       -   Breakdown of marginal ridge with cavitation extending

            to the mesial or distal extensions of the occlusal


Proximal surfaces on incisors and canines:

Score       Criteria

1       -   A discontinuity of the enamel is which an explorer will

            catch and there is softness.

2       -   Cavitation with breakdown or obvious discoloration,

            indicating undermining for at least 1 mm as the buccal

            or lingual surfaces.

3       -   Cavitation   with     breakdown     of   the   incisal    edge   or

            undermining      of   the   edge   as    indicated   by   obvious

        A full crown restoration gives a total score of “5” for that

tooth. A total tooth score of “6” is given to a tooth extracted

because of caries.

        The caries severity index (CSI) for the population is the mean

of the scores for the carious teeth. Teeth free of caries are not

included in this calculation.


Simplified oral hygiene index (OHI-S)

        Introduced by John C. Breene and Jack R. Vermillion in


Surfaces and teeth to be examined

                     Tooth                Surface

                      16                   Buccal

                      11                   Labial

                      26                   Buccal

                      36                   Lingual

                      31                   Labial

                      46                   Lingual
Examination method and scoring criteria:

      The following criteria are used to determine the scores for

each of the surface examined.

Debris index – simplified (DI-S): It consist of mucin, bacteria, and

food and varies in color from grayish white to green or orange and

it is loosely attached to the teeth.

Scoring system:

„0‟        -    No debris or stains present.

„1‟        -    Soft debris covering not more than one third of the

                tooth surface being examined or the presence of

                extrinsic stains without debris regardless of surface

                area covered.

„2‟        -    Soft debris covering more than one third but not

                more than two thirds of the exposed tooth surface.

„3‟        -    Soft debris covering more than two thirds of the

                exposed tooth surface.

Calculus index – simplified (CI – S)

      Calculus is defined as deposition of inorganic salts composed

primarily of calcium carbonate and phosphate mixed with food

debris, bacteria and desquamated epithelial cells.
Scoring criteria:
„0‟          -   No calculus present.

„1‟          -   Supragingival calculus covering not more than one

                 third of the exposed tooth surface being examined.

„2‟          -   Supragingival calculus covering more than one

                 third, but not more than two thirds of the exposed

                 tooth surface, (or) the presence of individual flecks

                 of subgingival calculus around the cervical portion

                 of the tooth.

„3‟          -   Supragingival calculus covering more than two

                 thirds   of     the   exposed   tooth   surface   (or)   a

                 continuous heavy band of subgingival calculus

                 around the cervical portion of the tooth.

Calculation of an individual
OHI – S = DI – S + CL – S

Score for DI – S/CL – S:

      Good        =       0.0 to 0.6

      Fair        =       0.7 to 1.8

      Poor        =       1.9 to 3.0

The OHI-S value ranges from 0 to 6 as follows:
      Good        =       0.0 to 1.2
      Fair        =       1.3 to 3.0
      Poor        =       3.1 to 6.0
Use of OHI-S:
         The OHI-S has          been widely used        in studies of      the

          epidemiology of periodontal disease.

         OHI-S has been used as a standard comparison of the

          periodontal   index     in   the   world   wide   studies    of   the

          interdepartmental committee on nutrition for national


         OHI-S is useful in evaluation of dental health education

          programs in public school systems.

         It is used in evaluating the cleansing efficiency of tooth


         It is easy to use because the criteria are objective, the

          examination may be performed quickly, and a high level or

          reproducibility   is    possible   with    a   minimum      training


Plaque index (PL-I): Described by Silness and Loe in 1964.


      The surface examined are the four gingival areas of the tooth

i.e., the disto-facial, facial, mesial-facial and lingual surface. Only

plaque of the cervical third of the tooth is evaluated with no

attention to plaque that has extended to the middle/incisal thirds.

The mouth mirror, a light source, a dental explorer and air drying

of the teeth and gingiva are used in scoring the index.

Code          Criteria

„0‟       -   The gingival area of tooth surface in literally free of

              plaque. The surface is tested by running a pointed

              probe across the tooth.

„1‟       -   No plaque can be observed by the naked eye. A film

              of plaque adhering to the free gingival margin and

              adjacent area of tooth, which can be recognized

              only by running the explorer/pointed probe across

              the tooth surface or by using disclosing agent.

„2‟       -   A thin to moderate accumulation of soft deposits

              within the gingival pocket or on the tooth and

              gingival margin, which can be seen by naked eye.

„3‟       -   Abundance of soft matter within the gingival pocket

              and or in the tooth surface and gingival margin.

              The interdental area is stuffed with soft debris.

Calculation of PL-I:

PL-I for a tooth: The score from the four areas of the tooth are

added and then divided by four. This gives plaque index for the

PL-I for the individual: The indices for each tooth are added and

then divided by the total number of the teeth examined. The score

ranges from 0 to 3.

                          Rating          Scores

                   Excellent                „0‟

                   Good                  0.1 – 0.9

                   Fair                  1.0 – 1.9

                   Poor                  2.0 – 3.0

Use of PL-I:

         A reliable technique for evaluating both mechanical anti -

          plaque procedures and chemical agents.

         Used in longitudinal stages and clinical trials.

Gingival index: Developed by Loe and Silness in 1963.


      The severity of the gingivitis is scored on all surfaces of all

teeth or selected teeth or on selected surfaces of all teeth or

selected teeth. The teeth selected as the index teeth are;

16, 12, 24, 36, 32 and 44.

      The tissue surrounding each tooth are divided into four

gingival scoring units: distofacial papilla, facial margin, mesial-

facial papilla and the entire lingual gingival margin.
          A blunt instrument, such as a periodontal pocket probe, is

used to assess the bleeding potential of the tissues.

Scoring 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


Calculation of the index:

          Totaling the scores around each tooth obtains the gingival

index score for the area.

           If the scores around each tooth are totaled and divided by

            four, the gingival index score for the tooth is obtained.

           Totaling all the score per tooth and divided by the number

            of teeth examined provides the gingival index score per

                         Scores                   Condition

                         0.1 – 1.0           Mild gingivitis

                         1.1 – 2.0           Moderate gingivitis

                         2.1- 3.0            Severe gingivitis


           Used to determine prevalence and severity of gingivitis in

            epidemiologic surveys.

           For     assessment       of   gingivitis   severity   in   individual


           Used in controlled clinical trial of preventive or therapeutic


Russel periodontal index:

Score             Criteria

0       -         Negative: There is no evidence of inflammation of

                  investing tissue or loss of function resulting from

                  destruction of supporting tissue.

1       -         Mild gingivitis: Inflammation of free gingiva but does not

                  circumscribe the tooth.

2       -         Gingivitis: Inflammation completely circumscribing the

                  tooth, no break of epithelial attachment.
6        -      Gingivitis    with   pocket      formation:   The     epithelial

                attachment has been broken and there is a definite

                periodontal pocket. Tooth is firm in socket and has not


8        -      Advanced destruction: With loss of mastication the

                tooth may be loose, may have drifted or depressed in



        Distinguishing between normal gingiva and gingiva with mild


Community Periodontal Index of Treatment Needs (CPITN):

        Developed     by     WHO/FDI,     used   frequently   in    periodontal



        Dentition is divided into six parts (sextants), for assessment

of periodontal treatment needs, each sextant is given a score.

Essentially the CPITN considers the periodontal treatment needs of

each sextant with respect to;

            No need for care (score 0)

            Bleeding gingivae on gently probing (score 1)
       Presence of calculus and other plaque retentive factors

        (score 2)

       Presence of 4 or 5 mm pockets (score 3)

       Presence of 6 mm or deeper pockets (score 4)


      The mouth is divided into sextants as follows;

                    17 - 14         13 - 23     24 – 27

                    47 – 44         43 - 33     34 - 37

      Third    molars   are   not    included   except    where   they   are

functioning in place of second molars.

Index teeth:

      Adult 20 year or more

      10 index teeth are examined

                         17 16 11 26 27

                              47 46 31 36 37

      Below 19 years

      Only 6 index teeth are examined

                              16 11 26

                                    46 31 36
      When examining children below 15 years pockets are not

recorded, although probing for bleeding and calculus are carried

out as routine.

CPITN probe:


Purpose:   To     measure   the   pocket   depths   and   detection   of

subgingival calculus.

        CPITN is both thin in handle and very light weight (5 gms).

        Manufactured for gentle manipulation of very sensitive soft

         tissue around the teeth.

        Pocket depth is measured through coding with a black

         mark starting at 3.5 mm and ending at 5.5 mm.

        Probe has ball tip of 0.5 mm diameter that all ows easy

         detection of subgingival calculus and also identification of

         base of the pocket.

        A variant of this basic probe has two additional lines at 8.5

         mm and 11.5 mm from working tip. The additional lines

         may be of use when performing a detailed assessment and

         recording of deep pocket for purpose of preparing a

         treatment plan for complex periodontal therapy.

CPITN-E: Epidemiological probe with black marking from 3.5 and

5.5 mm.

CPITN-C: Clinical probe with additional 8.5 and 11.5 mm marking.

Treatment needs:

TN-0: Code 0 (Healthy) or code Y (missing)- no need for treatment.

TN-1: Code 1- need for improving the personal oral hygiene.

TN-2: a. Code 2 or higher- need for professional cleaning of teeth

          and removal of plaque.

      b. Code 3- oral hygiene and scaling will usually reduce

          inflammation and bring 4 mm of pocket to 3 mm or below.

          Thus treatment need to scaling and root planning.

TN-3: Code 4- Scaling, root planning and more complex surgical


Indices used for dental fluorosis:

     Dental fluorosis is a hypoplasia or hypomineralization of

tooth enamel or dentine produced by the chronic ingestion of

excessive amounts of fluoride during the period when teeth are

       The major determinant of the prevalence and severity of

dental fluorosis has been shown to be the concentration of fluoride

in the water consumed by infants and children during first five year

of life.

       Although both primary and permanent teeth may be affected

by fluorosis, fluorosis tend to be greater in permanent teeth than in

primary teeth.


Dean’s fluorosis index: By Trendly H. Dean in 1942.

Criteria for Dean’s classification system for dental fluorosis:

Classification     Criteria

Normal (0)         The enamel represents the usual translucent

                   semivitriform   type   structure.   The      surface   is

                   smooth, glossy and usually of a pale, creamy

                   white color.

Questionable (0.5) The enamel discloses slight aberrations from

                   translucency of normal enamel ranging from a

                   few white flecks to occasional white spots.

Very mild (1)      Small   opaque,   paper   white     areas,    scattered

                   irregularly over the tooth, but not involving as

                   much as approximately 25% of tooth surface.
Mild (2)            The white opaque areas in enamel of teeth are

                    more extensive, but do not involve as much as

                    50% tooth.

Moderate (3)        All enamel surfaces of the teeth are affected and

                    surfaces subject to attrition show wear. Brown

                    stain is frequently a distinguishing feature.

Severe (4)          All enamel surface of the tooth are affected and

                    hypoplasia is so marked that the general form of

                    the tooth may be affected. The major diagnostic

                    sign of this classification is discrete or confluent

                    pitting. Brown stains are wide spread and tooth

                    often present a corroded like appearance.

      The classification is the most widely adopted system for

classifying dental fluorosis in use since 1942.

Tooth surface index of fluorosis:

      Developed by Horowitz et al., 1984.

      It was developed in order to eliminate or reduce some of the

shortcomings of Dean‟s index TSIF was applied in a survey to

assess the prevalence of dental caries and dental fluorosis in

communities having optimal concentrations of naturally occurring

fluoride in drinking water.
Descriptive criteria and scoring system:

Score         Criteria

„0‟       -   Enamel shows no evidence of fluorosis.

„1‟       -   Enamel shows definite evidence of fluorosis namely

              areas with parchment white color that total less

              than 1/3 rd of visible enamel surface. This category

              includes fluorosis confined only to incisal edge of

              anterior teeth and cusp tip of posterior teeth (snow


„2‟       -   Parchment – white fluorosis totals at least 1/3 rd of

              the visible enamel surface but less than 2/3 rd .

„3‟       -   Parchment – White fluorosis totals at least 2/3 of

              visible enamel surface.

„4‟       -   Enamel shows staining in conjunction with any of

              the preceding levels of fluorosis.

„5‟       -   Discrete pitting of enamel exists, unaccompanied

              by evidence of staining of intact enamel.

„6‟       -   Both discrete pitting and staining of the intact

              enamel exist.

„7‟       -   Confluent pitting of the enamel surface exists large

              areas of enamel.
      With the TSIF, a separate score is given to each unrestored

tooth surface. Two scores are assigned to anterior teeth (labial,

lingual aspect) and these scores are assigned to posterior teeth

(Bucco-linguo-occlusal). Total surface index of fluorosis (TSIF)

contains     no   questionable    category.   Fluorosis   diagnosed   in

categories 1, 2 and 3 may be confined to a single area of enamel, or

may occur irregularly over an entire surface.

          When more than one category of fluorosis exists in a

           surface e.g., discrete pitting and staining (score 6) and

           confluent pitting (score 7), the highest numerical score is

           assigned to the surface.

          It is especially useful for determining the public health

           effect of fluorosis in a population.

Young’s classification of enamel fluorosis:

      By Young in 1973

      Young classified enamel fluorosis as follows:

Classification Criteria

Type A             White areas less than 2 mm in diameter

Type B             White areas of or greater than 2 mm in diameter.

Type C             Colored areas (brown) less than 2 mm in diameter,

                   irrespective of these being any white areas.
Type D          Colored (brown) areas of or greater than 2mm in

                diameter, irrespective of these being white areas.

Type E          Horizontal white lines irrespective of these being

                any white non-linear areas.

Type F          Colored (brown) or white areas of lines associated

                with pits or hypoplastic areas.


     Dental index or indices can be considered as the main tool of

epidemiological studies in dental disease, to find out the incidence,

prevalence and severity of disease, based on which preventive

programmes are adopted for their control and prevention.

Dean, H.T. (1942): “The investigation of physiological effects by the

      epidemiological method”. In Fluoride and dental health (Ed.

      F.R. Moultan) American Association for the advancement of

      science, Washington: 23-31.

Greene, J.C. and J.R. Vermillian (1964): “The simplified oral

      hygiene index”. J. Am. Dent. Assoc.; 68: 7-13.

Horowitz, H.S. et al. (1984): “A new method for assessing the

      prevalence of dental fluorosis – The tooth surface index of

      fluorosis”. J. Am. Dent. Res.; 109: 37-41.

McDonald, R.E. and D.R. Avery (1996): “Dentistry for child and

      adolescent”. 5 th Ed., C.V. Mosby Company: 466-511.

Peter, S.: “Essentials of preventive and community dentistry”. 1 st

      Ed., Arya (Medi) Publishing House, New Delhi, 2002:456-552.

Russel, A.L. (1956): “A system of classification and scoring for

      prevalence surveys of periodontal disease”. J. Dent. Res.; 35:


Silness, J. and H. Loe (1964): “Periodontal diseases in pregnancy: II

      correlation between oral hygiene and periodontal condition”.

      Acta. Odontal. Scand.; 22: 121.

Young, M.A. (!973): “An epidemiological study of enamel opacities

      and other dental conditions in children”. In Temprate and

      subtropical climate, Ph.D. thesis University of London.


   Introduction

   Ideal requirement of index

   Classification of indices

   Caries indices

    DMF index

    DMFS index

    def index

    Caries severity index for primary teeth

    Developmental defect of enamel index

   Periodontal index


    Plaque index

    Gingival index

    Russel periodontal index


   Fluorosis index

    Dean‟s fluorosis index

    Tooth surface index for fluorosis

    Young‟s fluorosis index

   Conclusion

   References