For Personal Use Only

Library of School of Dentistry, TUMS

 For Personal Use Only
Library of School of Dentistry, TUMS

A Practical Manual of
Public Health Dentistry
 For Personal Use Only
Library of School of Dentistry, TUMS
 A Practical Manual of
Public Health Dentistry
Library of School of Dentistry, TUMS
For Personal Use Only

CM Marya BDS MDS

Professor and Head
Department of Public Health Dentistry
Sudha Rustagi College of Dental Sciences and Research
Faridabad, Haryana, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • Panama City • London
 ®

Jaypee Brothers Medical Publishers (P) Ltd.

Headquarter
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]

Overseas Offices
Library of School of Dentistry, TUMS

J.P. Medical Ltd., Jaypee-Highlights Medical Publishers Inc.

83 Victoria Street London City of Knowledge, Bld. 237, Clayton
For Personal Use Only

SW1H 0HW (UK) Panama City, Panama

Phone: +44-2031708910 Phone: +507-301-0496
Fax: +02-03-0086180 Fax: +507-301-0499
Email: [email protected] Email: [email protected]

Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com

© 2012, Jaypee Brothers Medical Publishers

All rights reserved. No part of this book may be reproduced in any form or by any means
without the prior permission of the publisher.

Inquiries for bulk sales may be solicited at: [email protected]

This book has been published in good faith that the contents provided by the author
contained herein are original, and is intended for educational purposes only. While
every effort is made to ensure an accuracy of information, the publisher and the author
specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from
the use or application of any of the contents of this work. If not specifically stated, all
figures and tables are courtesy of the author. Where appropriate, the readers should
consult with a specialist or contact the manufacturer of the drug or device.

A Practical Manual of Public Health Dentistry

First Edition: 2012

ISBN 978-93-5025-709-8
Printed at
 List of Contributors

Anil Gupta MDS Hind Pal Bhatia MDS

Professor and Head Professor and Head
Department of Pedodontics Department of Pedodontics
IDST Dental College Santosh Dental College
Muradnagar, Uttar Pradesh, India Ghaziabad, Uttar Pradesh, India
Ashish Gupta MDS HL Jayakumar MDS
Professor and Head Professor and Head
Department of Oral Surgery Department of Public Health
Library of School of Dentistry, TUMS

Sudha Rustagi College of Dental Dentistry

Sciences and Research AECS Maaruti College of Dental
For Personal Use Only

Faridabad, Haryana, India Sciences

Bangalore, Karnataka, India
Avinash Jnaneswar MDS
Professor KR Indushekhar MDS
Department of Public Health Professor and Head
Dentistry Department of Pedodontics
Sudha Rustagi College of Dental Sudha Rustagi College of Dental
Sciences and Research Sciences and Research
Faridabad, Haryana, India Faridabad, Haryana, India
CS Baiju MDS Navin Anand Ingle MDS
Professor and Head Professor and Head
Department of Periodontics Department of Public Health
Sudha Rustagi College of Dental Dentistry
Sciences and Research Meenakshi Ammal Dental College
Faridabad, Haryana, India Chennai, Tamil Nadu, India
 For Personal Use Only
Library of School of Dentistry, TUMS
 Preface

“Accurate diagnosis of a disease depends on

the art of taking Case History”
The traditional approach to the diagnosis and treatment of a patient in
medicine or dentistry starts with recording of the history of the problem.
Despite major advances in investigative techniques, an analysis of history
and clinical examination of the patient remains the cornerstone of correct
diagnosis and sound treatment. Even then, many clinicians skip the
Library of School of Dentistry, TUMS

process, jump to “spot-diagnosis” and start with the treatment. Such

an approach is likely to miss coincidental pathology and co-morbidity.
For Personal Use Only

Therefore, it is imperative that a detailed dental and general medical

history is elicited and recorded on record sheets. The recording of an
accurate medical history is in the best interest of patients and dental
staff alike.
There is little information in the literature concerning the standard
of medical history recording thought to be adequate and the questions
necessary for comprehensive medical history taking. It has been
suggested that efforts need to be made by the dental profession to set
standards and formulate guidelines to establish a more standardized
medical history questionnaire. The use of a pre-printed dental/medical
history questionnaire can serve a valuable role in taking and
documenting history and clinical examination of a patient, and
formulation of a treatment plan. This manual is an effort in that
direction.
There are several books of Public Health Dentistry available in the
libraries and market but no book till date is written on how to
successfully record a case history including indices and planning of
treatment by dental students especially for the department of Public
Health Dentistry. This book, written in concise and clear language, is
intended to fill that lacuna.
 viii A Practical Manual of Public Health Dentistry

This manual takes into consideration the method of history taking,

clinical diagnosis, levels of prevention and comprehensive treatment
planning. It also highlights different questions and also tries to provide
answers. This book is intended to be used in practicals in Public Health
Dentistry. The manual would be useful for both undergraduate and
postgraduate students.
In conclusion, I hope that this manual will prove to be valuable
to staff and students of the department of Public Health Dentistry.

CM Marya
Library of School of Dentistry, TUMS
For Personal Use Only
 Acknowledgments

Many persons generously gave their time in the preparation of the

first of its kind book “Practical Manual of Public Health Dentistry”.
I would like to convey my grateful thanks to all the contributors for
their cooperation and enthusiasm for the publication of this book.
In addition, special appreciation is to be mentioned for Dr Ruchi
Nagpal, Dr Nidhi Pruthi, Dr Zohara Charania, Dr Sonal Dhingra
and Dr Sikhar Grover, who provided high quality logistical and editing
Library of School of Dentistry, TUMS

support during the preparation of this book.

My thanks also go to my colleagues at the Sudha Rustagi College
For Personal Use Only

of Dental Sciences and Research, Faridabad (Haryana), who have

given encouragement and support at key times in the development
of this book and have contributed for creating a stimulating and
congenial environment for me at work.
I would like to thank my Chairman Mr Dharamvir Gupta,
Mr Deepak Gupta, Secretary, Wing Cdr. Dr Niraj Rampal vsm,
Principal and Dr Vishal Juneja (CEO), Sudha Rustagi College of Dental
Sciences and Research, Faridabad for their encouragement and support
in this venture.
Finally, I want to acknowledge my family’s contribution, for
putting up with my absences, both mental and physical.
Very few texts would be published without the help of a publisher.
For this publication by M/s Jaypee Brothers Medical Publishers (P)
Ltd, New Delhi, I am thankful to Shri Jitendar P Vij (Chairman and
Managing Director), Mr Tarun Duneja (Director Publishing),
Samina Khan (PA to Director Publishing) and Mr KK Raman
(Production Manager), Mr Rajesh Sharma (Production Co-ordinator),
Mr Rajesh Kumar and Mr Radhey Shyam who have lent their computer
expertise.
 For Personal Use Only
Library of School of Dentistry, TUMS
 Contents

1. Introduction .............................................................. 1

2. Methods of Recording a Case History .................. 3

3. General Information ................................................. 4

Patient Registration Number ......................................... 4
Date ............................................................................. 4
Name ............................................................................ 4
Library of School of Dentistry, TUMS

Age .............................................................................. 5
Diagnosis .............................................................................. 5
For Personal Use Only

Treatment Planning ............................................................. 6

Behavior Management Techniques ........................................ 7
Sex ............................................................................... 7
Education ..................................................................... 9
Address ........................................................................ 9
Occupation ................................................................. 10
Religion ..................................................................... 11

4. Chief Complaint...................................................... 12

5. History of Present Illness...................................... 13

Detail History of Particular Symptom ......................... 14
Pain ................................................................................... 14
Swelling .............................................................................. 17
Ulcer ................................................................................... 18
Dental Hypersensitivity ....................................................... 19
Bleeding from the Gums ...................................................... 19
Dry Mouth (Xerostomia) ..................................................... 20
Burning Sensation of the Mouth ........................................... 22
Loose Teeth or Tooth Mobility ................................................. 23
Halitosis or Oral Malodor .................................................... 24
Oral Pigmentation .............................................................. 26
Delayed Tooth Eruption ....................................................... 29
Discolored Teeth ................................................................... 30
Recent Occlusal Problems ................................................... 32
 xii A Practical Manual of Public Health Dentistry

6. Previous Dental History ........................................ 34

7. Medical History ...................................................... 36

Family History ........................................................... 38

8. Personal History ..................................................... 39

Oral Habits ................................................................. 39
Thumb and Digit Sucking ........................................... 40
Diagnosis of Digit Sucking ................................................... 43
Extraoral Examination ....................................................... 43
Control of Thumb Sucking ................................................... 46
Treatment Consideration .................................................... 47
Management ...................................................................... 47
Library of School of Dentistry, TUMS

Thermoplastic Thumb Post ................................................... 48

Pacifier Habits ............................................................ 49
Tongue Thrust Habit .................................................. 50
For Personal Use Only

Definitions .......................................................................... 50
Etiology of Tongue Thrust ..................................................... 50
Clinical Manifestations of Tongue Thrust ............................ 51
Diagnosis of Tongue Thrust .................................................. 52
Treatment of Tongue Thrust ................................................ 53
Mouth Breathing Habit .............................................. 55
Definition ........................................................................... 55
Etiology ............................................................................... 55
Clinical Features ................................................................ 56
Diagnosis ............................................................................ 58
Management ...................................................................... 58
Bruxism ...................................................................... 59
Definition ........................................................................... 59
Other Minor Habits .................................................... 61
Lip Biting ........................................................................... 61
Nail Biting ......................................................................... 61
Self-Destructive Oral Habits/Masochistic Habits ................. 61
Oral Hygiene Habits ................................................... 61
Adverse Habits ........................................................... 62
Diet History ............................................................... 62
Sugar .................................................................................. 63
Classification of Sugars ....................................................... 63
Diet and Dental Caries ....................................................... 64
 Contents xiii
Diet Counseling .................................................................. 68
Isolate the Sugar Factor ........................................................ 68

9. Clinical Examination .............................................. 70

10. Extraoral Examination ........................................... 78

Skin ........................................................................... 78
Head .......................................................................... 78
Shape of the Head ................................................................ 79
Facial Form ................................................................. 79
Facial Symmetry ................................................................. 79
Facial Profile ...................................................................... 79
Nose, Paranasal Sinuses, External Ear and Nasal
Mucosa ................................................................... 80
Library of School of Dentistry, TUMS

Lips ............................................................................ 80
Cheeks ........................................................................ 80
For Personal Use Only

Lymph Nodes ............................................................. 80

Area of Lymphatic Drainage of Face .................................... 85
Temporomandibular Joint ........................................... 85
Muscles of Mastication ................................................ 86
Salivary Glands ........................................................... 88
Parotid Gland .................................................................... 88
Submandibular Gland ....................................................... 88

11. Intraoral Examination ............................................. 90

Soft Tissue Examination ............................................. 90
Examination of Lips and Labial Mucosa ............................. 90
Examination of Buccal Mucosa ........................................... 91
Examination of the Floor of the Mouth .................................. 93
Examination of the Tongue .................................................. 94
Examination of the Hard and Soft Palate ............................ 95
Periodontal Examination .................................................. 100
Furcation Assessment ........................................................ 105
Mobility Test ...................................................................... 107
Detection of Suppuration ................................................... 108
Hard Tissue Examination .......................................... 108
Dentition .......................................................................... 108
Dental Caries Assessment ................................................. 109
Malocclusion ..................................................................... 111
 xiv A Practical Manual of Public Health Dentistry

Developmental Anomalies of Teeth .................................... 111

Wasting Diseases of Teeth ................................................... 113
Enamel Hypoplasia ........................................................... 114
Dental Fluorosis ................................................................ 118
Trauma from Occlusion .................................................... 120
Tooth Fracture ................................................................... 121

12. Establishing the Diagnosis ................................. 123

13. Investigations ....................................................... 124

Radiographic Investigations ...................................... 124
Intraoral Radiographs ....................................................... 125
Extraoral Radiographs ...................................................... 127
Advanced Imaging Procedures .......................................... 128
Library of School of Dentistry, TUMS

Histopathological Investigations ............................... 129

Biopsy ................................................................................ 129
For Personal Use Only

Cytologic Smear ................................................................. 130

Exfoliative Cytology ........................................................... 130
Pulp Vitality Testing ................................................. 131

14. Final Diagnosis ..................................................... 133

15. Formulating a Comprehensive

Treatment Plan .................................................... 134
Phase I: Emergency Phase ......................................... 134
Phase II: Preventive Phase ........................................ 135
Phase III: Promotive Phase ....................................... 135
Phase IV: Curative Phase .......................................... 135
Phase V: Rehabilitation Phase ................................... 136
Phase VI: Maintenance Phase .................................... 136

16. Levels of Prevention ........................................... 138

Levels of Prevention for Dental Caries ....................... 139
Levels of Prevention for Periodontal Disease ............. 141
Prevention of Dental Trauma .................................... 143
Levels of Prevention for Oral Cancer ......................... 144
Levels of Prevention for Dental Fluorosis .................. 145
Levels of Prevention of Malocclusion ........................ 145
 Contents xv

17. Dental Indices ...................................................... 146

Definition ................................................................ 147
Professional Implications ................................................... 147
Properties of an Ideal Index ...................................... 147
Types of Indices ........................................................ 148
Purpose and Uses of an Index ................................... 148
Indices Commonly Used in Dentistry ........................ 150
Periodontal Indices ............................................................ 150
Dental Caries ................................................................... 151
Fluorosis ............................................................................ 151
Malocclusion ..................................................................... 151
Indices Used in Assessing Oral Hygiene ..................... 153
Oral Hygiene Index (OHI) ............................................... 153
Library of School of Dentistry, TUMS

The Oral Hygiene Index-Simplified (OHI-S) ..................... 156

Patient Hygiene Performance Index (PHP Index) ............ 160
For Personal Use Only

Indices Used in Assessing Plaque and Debris .............. 163

Turesky-Gilmore-Glickman Modification
of the Quigley-Hein Plaque Index ................................. 163
Modified Plaque Scoring System of Turesky et al ................. 164
Periodontal Indices ............................................................ 165
Navy Plaque Index ........................................................... 167
Plaque Control Record ...................................................... 169
Indices Used in Assessing Calculus ............................ 170
Calculus Surface Index .................................................... 170
Indices Used in Assessing Gingival
Inflammation ........................................................ 170
Papillary-Marginal-Attachment Index ............................. 170
Gingival Index (GI) ......................................................... 172
Indices Used in Assessing Gingival Bleeding .............. 174
Gingival Bleeding Index (GBI) ......................................... 174
Indices Used in Assessing Periodontal Diseases .......... 176
Periodontal Index (PI) ...................................................... 176
Scoring Criteria for Russell’s Periodontal Index ................. 177
Periodontal Disease Index (PDI) ....................................... 178
Gingival Bone Count Index .............................................. 182
The Navy Periodontal Disease Index (NPDI) .................... 183
Community Periodontal Index of Treatment
Needs (CPITN) ............................................................ 185
Community Periodontal Index (CPI) ............................... 193
 xvi A Practical Manual of Public Health Dentistry

Indices Used in Assessing Dental Caries ..................... 197

Decayed, Missing and Filled Teeth (DMFT) Index ............. 197
Decayed, Missing and Filled Surface (DMFS) Index ......... 200
Dental Caries Index for Deciduous Teeth
(dmft and dmfs) ........................................................... 200
WHO Dentition Status and Treatment Needs ................... 201
Significant Caries Index ................................................... 206
Indices Used in Assessing Dental Fluorosis ................ 207
Dean’s Fluorosis Index ...................................................... 207
Scores and Criteria for Dean’s Fluorosis Index ................... 208
Community Fluorosis Index .............................................. 208
Tooth Surface Index of Fluorosis (TSIF) .............................. 213
Indices Used in Assessing Malocclusion ..................... 214
The Index of Orthodontic Treatment Need (IOTN) ........... 214
Library of School of Dentistry, TUMS

Indices Used in Assessing Tooth Wear ........................ 217

Eccles Index for Dental Erosion of Nonindustrial
For Personal Use Only

Origin .......................................................................... 217

Tooth Wear Index (TWI) .................................................... 218
The Exact Tooth Wear Index ............................................... 219

Appendices .................................................................... 221

Index .............................................................................. 241

 1
Introduction
Library of School of Dentistry, TUMS

“Accurate diagnosis of a disease depends on the art of taking Case

History”
For Personal Use Only

Case history is an important and integral part of treatment.

Ideally case history is taken in a consultation room or a private
office in which the surroundings and the conditions are entirely
friendly and not like the dental operating room. In many occasions
a properly prepared case history alone is sufficient to diagnose the
disease without examining the patient.
Case history is defined as planned professional conversation that
enables a patient to communicate his/her feelings, fear and sequence
of events leading to the problem for which the patient seeks professional
assistance, to the clinician so that patients’ real or suspected illness
and mental attitude of the patient can be determined.
Eliciting accurate, detailed and unbiased information from a
patient is a skilled task and not simply a matter of recording the
patient’s responses to a checklist of questions. Avoid interrupting
patients, particularly as they begin to tell you the story of the
presenting features of the illness. Recognizing the patient’s need to
talk without interruption and being a good listener will greatly help
you to establish a good relationship quickly (Fig. 1.1).
A case history is of immense value in the following ways:
• To provide information regarding etiology and establish diagnosis
of oral conditions
 2 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS

Fig. 1.1: Listen to the patient

For Personal Use Only

• To reveal any medical problem necessitating precautions,

modifications during appointments so as to ensure that dental
procedures do not harm the patient and also to prevent emergency
situations
• Evaluation of other possible undiagnosed problems
• Discovery of communicable diseases
• Gives an insight into emotional and psychological factors
• For effective treatment planning
• Record maintenance for future reference and periodic follow-up
• Acts as a evidence in legal matters.
Components of Clinical Record Sheet:
• General Information
• History Recording
• Examination of the patient
• Establishment of provisional diagnosis
• Necessary investigations
• Final Diagnosis
• Treatment plan.
 2
Methods of Recording
Recording
a Case History

Establishing a good rapport with the patient is important for

Library of School of Dentistry, TUMS

recording a complete history with valid information. A sincere smile

For Personal Use Only

and being a good listener will help reassure the patient that it is
appropriate and safe to divulge personal information.
There is usually a traditional approach in the design of a case
history. The preliminary part of the case history is usually based on
questionnaires.
Sequence of case recording and evaluation:
• General Information
• Chief Complaint
• History of Present Illness
• Previous Dental History
• Medical History
• Family History
• Personal History
• General Physical Examination
• Extraoral Examination
• Intraoral Examination
• Provisional Diagnosis
• Investigations
• Final Diagnosis
• Treatment Plan.
 3
General Information

It is recorded so as to impart knowledge to the investigator regarding

Library of School of Dentistry, TUMS

important events in human life such as; births, deaths, marriage and
For Personal Use Only

migrations. Also, it makes the investigator familiar with the patient

as it does contain personal details of the patient such as; name, age,
etc.

PATIENT REGISTRATION NUMBER

It helps the investigator in:
• Record maintenance
• Billing purposes
• Medicolegal aspects
• Identification of the patient.

DATE
The date is recorded in full for the following purpose:
• Reference
• Record maintenance.

NAME
Knowing the complete name of the patient while recording history
leads to:
• Identification
• Communication
 General Information 5

• Establishing a rapport with patient

• Record maintenance
• Psychological benefit; specially in case of pediatric patient if called
by nickname
• Sense of importance and acceptance to the patient
• Information of patient such gender and religion.

AGE
Age (date of birth) has a particular significance to the investigator to
decide upon:
• Diagnosis
• Treatment planning
• Behavior management techniques.
Library of School of Dentistry, TUMS

It is also used for maintaining hospital records and to know the

For Personal Use Only

psychology/mental development of the patient which has role on

his dietary habits, oral hygiene practices and personal habits.

Diagnosis
There is a predilection of certain diseases at different age levels. Based
on the disease predilection of age patients are divided into:
• Neonatal: At Birth
• 1–3 Yrs: Infancy
• 4–14 Yrs: Child
• 15–20 Yrs: Young Adults
• 21–40 Yrs: Adults
• 40–50 Yrs: Older Adults
• Above 50 Yrs: Old Age.
So based on these age groups one can rule out some of the dental
diseases as well as medical conditions which in turn relate to dental
problems.
For example, Periodontitis is seen generally in old age, i.e. > 50 yrs.
But if the condition is seen in children and young adults one can
confirm that it is Juvenile Periodontitis.
Examples of conditions present at different ages are mentioned
as follows:
 6 A Practical Manual of Public Health Dentistry

Conditions commonly present at birth:

• Cleft lip and palate • Facial hemihypertrophy
• Ankyloglossia • Facial hemiatrophy
• Teratoma • Fissured tongue
• Hemophilia • Median rhomboid glossitis, etc.

Conditions commonly present in children and young adults:

• Papilloma
• Juvenile periodontitis
• Scarlet fever, etc.

Conditions commonly occurring in old age:

Library of School of Dentistry, TUMS

• Attrition/abrasion
• Periodontitis
For Personal Use Only

• Pulp stones
• Root resorption, etc.

Treatment Planning

• Comparison/Correlation of chronological age with dental age

will help to decide the line of treatment for a patient.
Chronological age gives information about the dento-skeletal
development of the person.
• Growth spurts: It is also important in developmental and
hereditary diseases which occur at the time of birth and grows
up to the puberty or ceases with growth.
– Infantile/childhood growth spurt
– Mixed dentition/juvenile growth spurt
– Prepubertal/adolescent growth spurt
• Calculation of child’s dosage.

Based on age
1. Young’s Rule
Age adult dose
= Dose for child
Age + 12
 General Information 7

Based on weight
2. Clark’s Rule,
Weight (in lb) adult dose
= Dose for infant
150 (average weight for adult in
n lb)
3. Fried’s Rule for Infants
Weight (in months) adult dose
= Dose for child
150

Based on body surface area (BSA)

BSA is determined from a nomogram using the child’s height and
weight.
Child s BSA
× adult dosage = Dose for child
Library of School of Dentistry, TUMS

1.73 M 2

Example: If the child has a BSA of 0.67 M2 (in meters) and the
For Personal Use Only

adult dose is 40 mg. Then dose for child would be

0.67 26.8
× 40 = = 15.8 mg
1.7 1.7
Calculation of child’s dosage by BSA is thought to be the most
reliable method.

Behavior Management Techniques

Management of patients of different age groups requires different
behavior modification methods.

SEX
Similar to age, certain dental and systemic diseases also show sex
predilection. Some diseases are more specific to females while some
are to males.
Diseases affecting them are as follows:

Females
• Iron Deficiency Anemia
• Pleomorphic Adenoma
• Sjogren’s Syndrome
 8 A Practical Manual of Public Health Dentistry

• Adeno Ameloblastoma
• Myasthenia Gravis
• Sickle Cell Anemia
• Thyroid Diseases
• Juvenile Periodontitis
• Peripheral Ossifying Fibroma
• Nasoalveolar Cyst
• Anorexia nervosa
• Parotid gland diseases
• Erosion
• Aphthous ulcers
• Oral Lichen Planus.
Library of School of Dentistry, TUMS

Males
For Personal Use Only

• Stomatitis nicotina palate

• Hemophilia
• Attrition
• Carcinoma in Situ
• Carcinoma of the buccal mucosa
• Leukoplakia
• Keratoacanthoma
• Basal Cell Carcinoma
• Verrucous Carcinoma
• Adenoid cystic Squamous cell carcinoma
• Liposarcoma
• Hodgkins Disease
• Multiple Myeloma
• Chondrosarcoma
• Herpes Simplex
• Ewings Sarcoma
• Ameloblastic fibro-odontoma
• Basal cell Adenoma.
Along with sex Predilection of the diseases, Gender also helps
to analyze the following:
1. Important for the treatment planning in case of orthodontic
patients as timing of growth spurts is different in males and females.
 General Information 9

2. Esthetic: Girls are more conscious about their esthetics.

3. Dosage of Drugs: The dosage of drug is affected by certain factors
which are discussed below:
• Females require low dosage of drugs than the Males as their
Body weight is less when compared to the males
• Extraordinary care should be taken while prescribing medicines
to patients who are in Menstruation, Pregnancy, Lactation
• Drugs given during pregnancy could affect the Fetus directly
• Long term use of Antihypertensive Drugs can lead to
Impotency in Males
• Gynecomastia may be caused in males due to some medications
like Digitalis, Ketoconazole, Chlorpromazine, etc.
4. Most of the times, sex is linked to occupation and in turn, related
Library of School of Dentistry, TUMS

to occupational hazards.
For Personal Use Only

EDUCATION
Education level of the person is recorded to determine:
• Socioeconomic status
• Intelligence quotient (IQ) for effective communication
• Attitude towards general and oral health.

ADDRESS
Full Postal Address should be taken in order for communication
and to ascertain geographic distribution.
1. For future correspondence/Recall
2. Gives a view of the socioeconomic status. For example, diseases
such as Diabetes, Hypertension and Dental caries are more
prevalent in high socioeconomic status persons and diseases such
as Tuberculosis, Chronic generalized periodontitis are more
commonly found in low socioeconomic strata.
3. To know prevalence of diseases: certain diseases are found more
in a particular area.
For example:
a. Fluorosis (as a result of increased level of fluorides in water)
is spread differently in various parts of country. It is endemic
in certain areas.
 10 A Practical Manual of Public Health Dentistry

b. Caries are more common in modern industrialized areas,

whereas periodontal diseases are more common in rural areas.
c. Filariasis common in Orissa
d. Leprosy common in West Bengal
e. Carcinoma of the Palate common in Srikakulam AP
4. For hospital records/Administrative purposes.

FACTORS RELATED TO SOCIOECONOMIC STATUS

Socioeconomic status (SES) is assessed by looking at an individual group's

housing, occupation, education and income levels in comparison to their
country's statistical averages from surveys. Socioeconomic status is typically
broken into 3 categories: high SES, middle SES and low SES to describe
the areas a family or an individual may fall into.
Library of School of Dentistry, TUMS

OCCUPATION
For Personal Use Only

It is an indicator of socioeconomic status. Also, it shows predilection

of diseases in different occupations, such as:

Oral Manifestations of Occupational Disease

according to Etiologic Agent

Occupation Specific factor Possible oral

manifestations
Cobblers, carpenters, Instruments for Localized abrasion
glass blowers, musicians prehension
Fishermen, asphalt and Tar Stomatitis, caricinoma
coal tar workers, pavers, of lip and mucosa
pitch roofers, wood
preservers
Bronzers, cement Copper, iron, Staining of teeth,
workers, electrotypers, nickel, chromium, pigmentation of
metal grinders, miners, coal, etc. gingiva, generalized
stone cutters abrasion, calculus,
gingivostomatitis,
hemorrhage
Chemical workers, Arsenic Necrosis of bone, blue
electroplaters, metal black pigmentation
refiners, rubber mixers of gingiva

Contd...
 General Information 11
Contd...

Occupation Specific factor Possible oral

manifestations
Bismuth handlers, Bismuth Blue pigmentation of
dusting powder gingiva, oral mucosa,
makers gingivostomatitis
Refiners, bakers, Sugar Caries
candy makers
Alcohol, distillery, Amyl acetate Stomatitis
explosives, shellac,
smokeless powder
and shoe factory
workers
Library of School of Dentistry, TUMS

(Adapted from I. Schour and B. G. Sarnat. Oral manifestations of occupational

origin. JAMA 1942; 120: 1197)
For Personal Use Only

Thus, occupation can be an important factor in determining the

source or cause of the disease for the further treatment of the disease.
It helps in planning appointments for the patient as per their
occupation and also determines their affordability in relation to
money and time for the treatment.
It also tells about the socioeconomic status of the patient and his
ability to afford the nutritious food and use of healthy oral hygiene
practices.

RELIGION
Religion has a particular significance to the investigator in:
• Identifying the festive periods when religious people are reluctant
to undergo treatment procedures
• Predilection of diseases in specific religions.
 4
Chief Complaint

The chief complaint is established by asking the patient to describe

Library of School of Dentistry, TUMS

the problem for which he or she is seeking help or treatment. It is

For Personal Use Only

recorded in patient’s own words as much as possible, and no

documentary or technical language should be used. It answers the
question, “Why are you here today?” It is primarily a statement of
the patient’s signs and symptoms. It is recorded in chronological
order of their appearance, and in the order of their severity. The
chief complaint aids in the diagnosis and treatment planning and
should be given the first priority.
Common chief complaints include:
• Pain
• Bad taste
• Bleeding from gums
• Loose teeth
• Hypersensitivity
• Burning sensation
• Recent occlusal problems
• Delayed tooth eruptions
• Dry mouth
• Swellings
• Paresthesia and anesthesia
• Irregular teeth
• Missing teeth
• Routine dental check-up.
 5
History of PPresent
resent
Illness
Library of School of Dentistry, TUMS

Initially, the patient may not volunteer the detailed history of the
problem, so the examiner has to elicit out the additional information
For Personal Use Only

by the possible questionnaire about the symptoms. The patient’s

response to these questions is termed history of present illness. It is
a chronological account of the chief complaint and associated
symptoms from the time of onset to the time the history is taken.
The history commences from the beginning of the first symptom
and extends to the time of the examination.
Expanding the chief complaint by filling in the dimensions of
the problem identified in the chief complaint provides a more
complete statement—the history of present illness.
• The questions can be asked in the manner:
– When did the problem start?
– What did you notice first?
– Did you have any problems or symptoms related to this?
– What makes the problem worse or better?
– Have any tests been performed before to diagnose this
complaint?
– Have you consulted any other examiner for this problem?
– What have you done to treat this problem? Etc.
• In general, the symptoms can be elaborated under:
– Mode of onset
– Cause of onset
– Duration
 14 A Practical Manual of Public Health Dentistry

– Progress and referred pain

– Relapse and remission
– Treatment
– Negative history.

DETAIL HISTORY OF PARTICULAR SYMPTOM

Pain
The International Association for the Study of Pain (IASP) gives
this definition as “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in
terms of such damage”. The IASP classification system recommends
describing pain according to five categories: duration and severity,
Library of School of Dentistry, TUMS

anatomical location, body system involved, cause, and temporal

characteristics (intermittent, constant, etc.)
For Personal Use Only

Note the following:

• Anatomical location (site)

• Origin and mode of onset
• Intensity of pain
• Nature of pain
• Progression of pain
• Duration of pain
• Movement of pain
 History of Present Illness 15

• Localization behavior
• Effect of functional activity
• Neurological signs
• Temporal behavior.

Analysis of Pain
The word pain is derived from Latin word ‘poena’ meaning penalty
or punishment. It is a very common symptom and occurs in response
to an injurious stimulus.
Four types of pain are noticed:
1. Superficial: occurs due to direct irritation of the peripheral nerve
endings.
Library of School of Dentistry, TUMS

2. Segmental: occurs due to irritation of a sensory nerve trunk or

root.
For Personal Use Only

3. Deep or visceral: occurs due to irritation of deep structures in

the body.
4. Psychogenic or central: pain arises from brain, due to an
emotional or hysterical situation.
Analysis of pain is important so as to reach to the proper diagnosis.
A careful history is an essential prerequisite; else it may confuse the
clinician to frame a wrong diagnosis. There are various factors to be
considered in pain:
• Site of pain: determining the original site of pain is important.
The clinician may ask the patient ‘where did the pain start’?
Although the site of pain may have changed after a short period,
the original site must be known.
• Origin and mode of onset: The clinician may ask the patient
‘how did the pain start’? The origin and mode of onset is
important to determine the chronicity of pain. A long continued
pain with insidious onset indicates chronic nature of the disease,
whereas a recent onset of pain with sudden impact indicates acute
nature of disease.
• Severity: The perception of pain varies in different individuals.
A mild pain may be severe to others. The severity of a pain gives
an impression of the acuteness of the symptoms felt by the patient,
thus helping in constituting a proper diagnosis.
 16 A Practical Manual of Public Health Dentistry

• Type of pain: There are various types of pain. The most common
are:
– Vague pain: It is a mild continuous pain, e.g. periodontal
pain
– Burning pain: Pain usually occurs with the burning sensation,
e.g. reflex oesophagitis.
– Throbbing pain: Type of pressured throbbing sensation is felt,
e.g. in abscesses.
– Stabbing pain: Sudden, severe, sharp and short-lived pain,
e.g. acute pulpal pain.
– Shooting pain: Pain increases in severity in a short period, e.g.
trigeminal neuralgia.
Library of School of Dentistry, TUMS

• Progression of pain: The clinician asks the patient ‘how is the

pain progressing’? The progression of pain from the time of its
For Personal Use Only

onset is to be asked.
• Duration of the pain: In terms of days/months/years. The
clinician asks ‘how long the pain lasts’? Pain can be intermittant
or continuous. A continuous pain is the one which persists for a
longer duration. An intermittent pain is the one which occurs
after short intervals of time.
• Radiation of pain: It is the extension of pain to another site,
while the original site is still painful. The radiating pain has the
same character as the original pain.
Referred Pain is a term used to describe the phenomenon of
pain perceived at a site adjacent to or at a distance from the site
of an injury’s origin. (Dorland’s Medical Dictionary)
• Precipitating or aggravating factors: different factors may
worsen the pain suggesting a specific diagnosis about the disease.
For example, the pain of cracked tooth syndrome occurs when
the patient relieves the occlusal pressure over the tooth.
• Relieving factors: factors which reduce the severity or frequency
of pain are considered important in diagnosis. For example, in
some cases, pain of chronic pulpitis gets relieved by cold
application.
• Associated symptoms: pain may occur along with nausea,
vomiting, sweating, flushing and increase in pulse rate.
 History of Present Illness 17

Swelling

• Anatomical location (site)

• Duration
• Mode of onset
• Symptoms
• Progress of swelling
• Associated features
• Secondary changes
• Impairment of function
• Recurrence of swelling.
Library of School of Dentistry, TUMS

Examination of a swelling should be accompanied by a complete

history of the patient. Following points should be noted:
For Personal Use Only

• Duration: The clinician may ask ‘when was the swelling first
noticed’? Swellings that are painful and of shorter duration are
mostly inflammatory (acute), whereas those with longer duration
and without pain are chronic, e.g. a chronic periapical abscess.
• Mode of onset: The clinician may ask ‘how did the swelling
start’? The history of any injury or trauma or any inflammation
may contribute to the diagnosis and nature of the swelling.
• Progression: The clinician should ask ‘has the lump changed in
size since it was first noticed? Benign growths such as bony
swellings grow in size very slowly and may remain static for a
long period of time. If the swelling decreases in size, this suggests
of an inflammatory lesion.
• Site of swelling: The original site where it started must be
assessed.
• Other symptoms: Pain, fever, difficulty in swallowing, difficulty
in respiration, disfigurement, bleeding or pus discharge are the
common symptoms associated with swellings in the orofacial
region.
• Recurrence of the swelling: many swellings do recur after
removal of the tissue, indicating the presence of precipitating
factor, e.g. ranula.
 18 A Practical Manual of Public Health Dentistry

Ulcer

COMMON TYPE OF ULCERS IN THE ORAL CAVITY

• Traumatic ulcer
• Recurrent aphthous ulcers
– Bacterial infection
– Immunologic abnormalities
– Iron, Vitamin B12 or Folic acid deficiency
– Hormonal conditions (premenstrual/postovulation period in females)
– Psychic factors (stress)
• Infections, e.g. Tuberculosis, Syphilis, Oral Candidiasis, HIV
• Drug-induced Aspirin burn, allergic reactions to drugs, Stevens-Johnson
syndrome
• Malignant squamous cell carcinoma
Library of School of Dentistry, TUMS

• Blood dyscrasias: Agranulocytosis, Anemia, Leukemia

• Underlying systemic diseases: Behcet’s syndrome, Reiter’s syndrome,
For Personal Use Only

Crohn’s disease, Ulcerative colitis

An ulcer is a break in the continuity of epithelium. A proper

history must be taken in case of an ulcer:
• Mode of onset: The clinician may ask ‘how has the ulcer
developed’? The patient may provide significant information
about the nature and etiology of the ulcer such as any trauma or
spontaneously.
• Duration: The clinician may ask ‘how long is the ulcer present
here’? It determines the chronicity of the ulcer. For example,
traumatic ulcers in oral cavity are acute (occurring for a short
period), but if the agent persists; it may become a chronic ulcer.
• Pain: The clinician may ask ‘is the ulcer painful’? Most of the
ulcers, being inflammatory in nature, produce pain. Painless ulcers
usually suggest nerve diseases (such as peripheral neuritis, syphilis,
etc).
• Discharge: Any blood, pus or serum discharge must be noted.
• Associated disease: Any associated generalized systemic problem
may be associated with the ulcers of oral cavity (such as
tuberculosis, squamous cell carcinoma, etc).
 History of Present Illness 19

Dental Hypersensitivity
Causes
Exposure of dentinal tubules due to
• Wasting diseases — attrition, abrasion, erosion, abfraction
• Gingival recession
• Following periodontal surgery/root planing due to removal of
cementum overradicular dentin.

Patient History
Patients often report with complaint of a sudden, short, sharp shock-
like sensation in response to cold or hot, sweet or sour substances,
or touch. This sensation is a hyperreactive pulpalgia and must be
Library of School of Dentistry, TUMS

elicited by some exciting factor. It is never spontaneous. Exciting

For Personal Use Only

factors are usually cold food or drink or cold air, contact of two
dissimilar metals that will yield a galvanic shock, or stimulation of
the exposed dentin on the root surface by cold, sweet or sour,
vegetable or fruit acid, salt, or glycerine, or often just touching the
surface with a fingernail, toothbrush, or explorer.

Bleeding from the Gums

Patients often report with problems of chronic or recurrent bleeding,
which is provoked by mechanical trauma (e.g. from toothbrushing,
toothpicks, or food impaction) or by biting into solid foods such as
apples.

History of Bleeding Gums

• Duration
• Amount/Quantity
• Ease with which bleeding can be elicited
• Associated symptoms (dull pain, sensitivity).

Causes
Chronic or recurrent bleeding: Most common cause is chronic
gingival inflammation.
 20 A Practical Manual of Public Health Dentistry

Acute bleeding
• Caused by injury or can occur spontaneously in acute gingival
disease
• Acute Necrotizing Ulcerative Gingivitis (ANUG).
Gingival bleeding associated with systemic changes
• Hemorrhagic disorders (Vitamin C deficiency, Schonlein-Henoch
purpura)
• Platelet disorders (thrombocytopenic purpura)
• Hypoprothrombinemia (Vitamin K deficiency)
• Other coagulation defects (hemophilia, leukemia, Christmas
disease)
• Deficient platelet thromboplastic factor (PF3) resulting from
Library of School of Dentistry, TUMS

uremia, multiple myeloma, postrubella purpura

• Excessive intake of drugs (salicylates, anticoagulants — dicoumarol
For Personal Use Only

and heparin).

Dry Mouth (Xerostomia)

The subjective feeling of oral dryness is termed xerostomia. It is a
symptom, not a diagnosis or a disease.

Causes of Xerostomia

• Developmental (Aplasia and hypoplasia of the salivary glands)

• Drugs (Tricyclic antidepressants, antipsychotics, antihistaminics,
atropine, β-lockers)
• Radiation therapy of head and neck
• Oncologic chemotherapy
• Infections and inflammatory conditions (Parotitis, Mumps)
• Benign or malignant tumors of the salivary glands
• Systemic diseases
– Sjogren’s syndrome
– Granulomatous diseases (Sarcoidosis, Tuberculosis)
– Graft-versus-host-disease
– Cystic fibrosis
– Bell’s palsy
 History of Present Illness 21

– Diabetes
– Amyloidosis
– HIV infection
– Thyroid disease
– Late stage liver disease
– Patients on hemodialysis for end-stage renal disease
• Psychological factors (affective disorders)
• Malnutrition (anorexia, bulimia, dehydration)
• Idiopathic disorders
• Smoking, use of smokeless tobacco products, alcoholism and
caffeine can aggravate dry mouth.

Diagnosis and Evaluation of Xerostomia

Library of School of Dentistry, TUMS

• Patient history: Patient complains of dryness of all oral mucosal

For Personal Use Only

surfaces, particularly at night, or of difficulty chewing, swallowing

and speaking, mucosa may be sensitive to spicy or coarse foods.
• Past and present medical history: Assess for medical conditions
or medications known to cause dry mouth.
• Clinical features: The oral mucosa may be dry and sticky, lips
are often cracked, peeling and atrophic, buccal mucosa may be
pale and corrugated or erethamatous due to an overgrowth of
Candida albicans. There may be little or no pooled saliva in the
floor of the mouth, and the tongue may appear dry with loss of
papillation. The saliva may appear stringy, ropy or foamy. There
is often a marked increase in erosion and dental caries, particularly
root caries and even cusp tip involvement.

Two Additional Indications of Oral Dryness

“Lipstick sign” — Lipstick adheres to the facial surface of maxillary
anterior teeth.
“Tongue-blade sign” — Tongue blade adheres to the buccal
mucosa.
Clinical examination should also include bimanual palpation of
major salivary glands to assess the size, consistency and tenderness
of the glands, and also to determine if saliva can be expressed via the
 22 A Practical Manual of Public Health Dentistry

main excretory ducts. Enlarged, painful glands are indicative of

infection or acute inflammation. The consistency should be slightly
rubbery, but not hard, and distinct masses within the body of the
gland may be indicative of a salivary gland tumor.
Several office tests and techniques can be utilized to ascertain
the function of salivary glands. Sialometr y, or salivar y flow
measurement can determine the salivary output from the individual
major salivary glands or from the whole saliva. Unstimulated whole
saliva flow rates of < 0.1 mL/min and stimulated whole saliva flow
rates of < 1.0 mL/min are considered abnormally low and indicative
of marked salivary gland hypofunction.
Salivary gland imaging can provide information on salivary
function, anatomic alterations, and space-occupying lesions within
Library of School of Dentistry, TUMS

the glands. Various salivary gland imaging modalities include plain-

film radiography, Sialography, Ultrasonography, Radionuclide
For Personal Use Only

Salivary Imaging, Computed Tomography and Magnetic Resonance

Imaging. Minor salivary gland biopsy is often used in the diagnosis
of Sjögren’s syndrome (SS), human immunodeficiency virus-salivary
gland disease, sarcoidosis, amyloidosis and graft-vs-host disease.
Biopsy of major salivary glands is an option when malignancy is
suspected.

Burning Sensation of the Mouth

Burning sensations accompany many inflammatory or ulcerative
diseases of the oral mucosa, but term Burning Mouth Syndrome is
reserved for describing oral burning that has no detectable cause.
• Local causes
– Stomatitis
– Ulcers
– Infections (e.g. Candidiasis)
– Dry mouth, salivary gland hypofunction
– Mucosal disorders (Geographic tongue, lichen planus, etc.)
– Trauma to oral mucosa (e.g. Poorly fitting dentures)
– Gastroesophageal reflux disease.
• Systemic causes
– Vitamin B-12, folate, iron deficiencies
– Medication (e.g. ACE inhibitors such as Captopril)
 History of Present Illness 23

– Immunologically mediated diseases (e.g. Sjogren’s disease)

– Psychogenic disorders (e.g. Anxiety, depression, fear of cancer)
– Psychosocial stress
– Diabetes mellitus
– Menopause/hormonal disturbances.

Diagnosis and Evaluation of Burning Mouth

• History: When questioned, 10 to 15 percent of postmenopausal
women are found to have a history of oral burning sensations,
and these symptoms are most prevalent 3 to 12 years after
menopause. Burning may be intermittent or constant, but eating,
drinking, or placing candy or chewing gum in the mouth
Library of School of Dentistry, TUMS

characteristically relieves the symptoms. Tongue is most frequently

involved, followed by lips and palate. These patients usually are
For Personal Use Only

anxious, they may also have symptoms suggestive of depression.

• Clinical features and laboratory studies can help eliminate other
causes of burning symptoms of oral mucosa from burning mouth
syndrome. Patients with unilateral symptoms require thorough
evaluation of trigeminal and other cranial nerves to eliminate a
neurological source of pain. Oral examination for lesions resulting
from Candidiasis, lichen planus or other mucosal diseases should
be performed. Salivary gland assessment should be done for
patients complaining of a combination of xerostomia and burning.
When indicated, laboratory tests should be carried out to detect
undiagnosed diabetic neuropathy, anemia or iron, folate or
Vitamin B12 deficiencies.

Loose Teeth or Tooth Mobility

Causes
• Loss of tooth support (bone loss) due to periodontal disease
• Trauma (physical trauma from a fall or blow to the teeth)
• Trauma from occlusion
• Abnormal occlusal habits (bruxism, clenching)
• Hypofunction
• Extension of inflammation from the gingival or periapex into
the periodontal ligament results in changes that increase mobility.
 24 A Practical Manual of Public Health Dentistry

For example, spread of inflammation from an acute periapical

abcess may increase tooth mobility in the absence of periodontal
disease
• Periodontal surgery temporarily increases tooth mobility
• Mobility may be increased in pregnancy, or sometimes may be
associated with menstrual cycle or use of contraceptive pills
• Osteomyelitis of the alveolar bone
• Cysts/tumors of the jaw.

Symptoms and Diagnosis of Tooth Mobility

Patient complains of discomfort while chewing of food, pain may
accompany the mobility of teeth; the tissues around a mobile tooth
are invariable red, swollen and damaged. At times, patient may report
Library of School of Dentistry, TUMS

with complaint of the loose tooth without any accompanying symptom.

For Personal Use Only

Halitosis or Oral Malodor

“Halitosis may rank only behind dental caries and periodontal disease
as the cause of the patient’s visit to the dentist.”
Origin may be either –

Oral
• Poor oral hygiene
– Retention of odoriferous food particles on and between the
teeth
– Coated tongue
– Artificial dentures
• Acute Necrotizing ulcerative gingivitis
• Pericoronitis
• Abscesses
• Dehydration states
• Ulceration in the oral cavity
• Hyposalivation/Xerostomia
• Bone disease (Dry socket, Osteomyelitis, Osteonecrosis and
malignancy)
• Smoker’s breath
• Healing oral wounds
• Chronic periodontitis with pocket formation.
 History of Present Illness 25

Extraoral (Conditions that can Contribute

to Presence of Oral Malodor)
• Sinusitis and other bacterial infections
• Dry nasal mucosa
• Blocked nose (which can cause mouth breathing)
• Tonsillitis/tonsil stones
• Various carcinomas
• Infections of the respiratory tract (bronchitis, pneumonia,
bronchiectasis)
• Alcoholic breath
• Uremic breath of kidney dysfunction
Library of School of Dentistry, TUMS

• Acetone odor of Diabetes

When a patient presents to the dental office with the complaint
For Personal Use Only

of halitosis, it is important for the dental professional to eliminate

systemic conditions that may be contributing to the presence of oral
malodor. For this reason, it is important to have an up-to-date medical
history of the patient, which should help the dental professional
eliminate any systemic causes for the presence of oral malodor.
The clinical assessment of oral malodor is either subjective or
objective. Subjective assessment is based on smelling the exhaled air
of the mouth and nose and comparing the two (organoleptic
assessment). Various scoring systems, such as a 0- to 5-point scale
(Table 1), and a 0- to 10-point scale can be used to estimate the
intensity of exhaled oral odor, tongue odor and nasal odor, among
others.

ORGANOLEPTIC SCORING SCALE

• Absence of odor
• Questionable to slight malodor. Odor is deemed to exceed the threshold
of malodor detection
• Moderate malodor. Odor is definitely detected
• Strong malodor. Malodor is objectionable but examiner can tolerate
• Severe malodor. Overwhelming malodor. Examiner cannot tolerate.
 26 A Practical Manual of Public Health Dentistry

Methods for objective measurement of the breath include:

• Detection of sulphides with an appropriate monitor—simple, but
may fail to detect oral malodour caused by nonsulphide
components. Halimeter is a instrument that can be used chair-
side to measure volatile sulfur compounds in the exhaled air.
• Gas chromatography—not applicable for routine clinical practice.
• Bacterial detection (such as benzoylarginine- naphthylamide test
(BANA test), polymerase chain reaction, dark field microscopy)—
not applicable for routine clinical practice.

Oral Pigmentation
Pigmented lesions are commonly found in the mouth. Such lesions
Library of School of Dentistry, TUMS

represent a variety of clinical entities, ranging from physiologic

changes to manifestations of systemic illnesses and malignant
For Personal Use Only

neoplasms.
Oral pigmentation may be exogenous or endogenous in origin.
Exogenous pigmentation is commonly due to foreign-body
implantation in the oral mucosa. Endogenous pigments include
melanin, hemoglobin, hemosiderin and carotene.

Classification of Oral Pigmented Lesions

Exogenous
• Accidental pigmentation (e.g. Graphite tattoos — due to pencil
points broken off in gingival tissue, if not completely removed
can cause permanent discoloration)
• Iatrogenic pigmentation (e.g. Amalgam tattoo)
• Pigmentation due to drugs and metals (e.g. Bismuth line,
Burtonian (lead) line, Mercurialism, Argyria)
• Localized pigmentation (e.g. Chlorhexidine stains, hairy tongue,
tobacco stains).

Endogenous
• Kaposi’s Sarcoma
• Hereditary hemorrhagic telangiectasia
 History of Present Illness 27

• Brown melanotic lesions

– Melanotic macule
– Melanoplakia
a. due to racial pigmentation
b. may occur due to smoker’s melanosis
c. Peutz-Jegher’s syndrome
d. Addison’s disease
– Nevi
– Melanoma
• Physiological pigmentation
• Cyanosis
• HIV oral melanosis
• Brown heme-associated lesions
Library of School of Dentistry, TUMS

– Ecchymosis and petechiae

– Hemochromatosis
For Personal Use Only

– Caratonemia
– Jaundice
– Early hematoma.

Guide to Diagnosis and Evaluation of Oral

Pigmented Lesions
Evaluation of a patient presenting with a pigmented lesion should
include a full medical and dental history, extraoral and intraoral
examinations, and laboratory tests. The history should include the
onset and duration of the lesion, the presence of associated skin
hyperpigmentation, the presence of systemic signs and symptoms (e.g.
malaise, fatigue, weight loss), use of prescription and nonprescription
medications, and smoking habits. Pigmented lesions on the face,
perioral skin and lips should be noted. The number, distribution, size,
shape and color of intraoral pigmented lesions should be assessed.
In general, benign pigmented lesions show regular borders and
are small, symmetric and uniform in color. They may be either at
surface or slightly elevated. In contrast, irregular borders, color
variation, and surface ulceration suggest malignancy.
The following algorithm can be used as a guide to the assessment
of pigmented lesions of the oral cavity on the basis of history, clinical
examination and laboratory investigations:
 For Personal Use Only
Library of School of Dentistry, TUMS

28

[Kauzman A, Pavon M, Blanas N, Bradley G. Pigmented Lesions of the Oral Cavity: Review, Differential Diagnosis,
and Case Presentations. J Can Dent Assoc 2004; 70(10):682–3]
A Practical Manual of Public Health Dentistry
 History of Present Illness 29

Delayed Tooth Eruption

Delayed tooth eruption (DTE) is the emergence of a tooth into the
oral cavity at a time that deviates significantly from norms established
for different races, ethnicities, and sexes.
Conditions associated with Delayed Tooth Eruption:

LOCAL

• Mucosal barriers-scar • Lack of resorption of

tissue: trauma/surgery deciduous tooth
• Gingival bromatosis/gingival • Apical periodontitis of
hyperplasia deciduous teeth
• Supernumerary teeth • Regional odontodysplasia
Library of School of Dentistry, TUMS

• Odontogenic tumors (e.g. • Impacted primary tooth

adenomatoid odontogenic • Ectopic eruption
For Personal Use Only

tumors, odontomas) • Arch-length deficiency and

• Nonodontogenic tumors skeletal pattern
• Enamel pearls • Radiation damage
• Injuries to primary teeth • Oral clefts
• Ankylosis of deciduous teeth • Segmental odontomaxillary
• Premature loss of primary dysplasia
tooth

SYSTEMIC

• Nutrition • Anemia
• Vitamin D-resistant rickets • Celiac disease
• Endocrine disorders • Prematurity/low birth weight
• Hypothyroidism (cretinism) • Ichthyosis
• Hypopituitarism • Other systemic conditions:
• Hypoparathyroidism renal failure, cobalt/lead or
• Pseudohypoparathyroidism other heavy metal
• Long-term chemotherapy intoxication, exposure to
• HIV infection hypobaria
• Cerebral palsy • Genetic disorders
• Dysosteosclerosis • Familial/inherited
• Drugs: Phenytoin • Idiopathic
 30 A Practical Manual of Public Health Dentistry

Diagnosis
History: When teeth do not erupt at the expected age (mean ±
2 SD), a careful evaluation should be performed to establish the
etiology and the treatment plan accordingly. It is important for the
dentist to rule out underlying medical conditions as a cause. Family
information and information from affected patients about unusual
variations in eruption patterns should be investigated.
Clinical evaluation: Should be done methodically and must begin
with the overall physical evaluation of the patient. Although the
presence of syndromes is usually obvious, in the mild forms, only a
careful examination will reveal the abnormalities. Right-left variations
in eruption timings are minimal in most patients, but significant
Library of School of Dentistry, TUMS

deviations might be associated with for example tumors or hemifacial

microsomia or macrosomia and should alert the clinician to perform
For Personal Use Only

further investigation. Intraoral examination should include

inspection, palpation, percussion, and radiographic examination.

Discolored Teeth
Knowledge of the aetiology of tooth staining is of importance to
dental surgeons in order to enable a correct diagnosis to be made
when examining a discolored dentition and allows the dental
practitioner to explain to the patient the exact nature of the condition.

Classification of Tooth Discoloration

Historically, tooth discolouration has been classified according to
the location of the stain, which may be either intrinsic or extrinsic.
It may also be of merit to consider a further category of internalized
stain or discoloration:

Intrinsic Discoloration
Intrinsic discoloration occurs following a change to the structural
composition or thickness of the dental hard tissues. A number of
metabolic diseases and systemic factors are known to affect the
developing dentition and cause discoloration as a consequence. Local
factors such as injury are also recognized.
 For Personal Use Only
Library of School of Dentistry, TUMS

History of Present Illness

Diagnostic algorithm for delayed tooth eruption

[Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis, diagnosis, and treatment. A
31

literature review. Am J Orthod Dentofacial Orthop 2004;126:432-45]

 32 A Practical Manual of Public Health Dentistry

• Alkaptonuria
• Congenital erythropoietic porphyria
• Congenital hyperbilirubinemia
• Amelogenesis imperfecta
• Dentinogenesis imperfecta
• Tetracycline staining
• Fluorosis
• Enamel hypoplasia
• Pulpal hemorrhagic products
• Root resorption
• Aging.

Extrinsic Discoloration
Library of School of Dentistry, TUMS

Extrinsic discoloration is outside the tooth substance and lies on the

For Personal Use Only

tooth surface or in the acquired pellicle. The origin of the stain may
be:
• Metallic
• Nonmetallic

Internalized Discoloration
Internalized discoloration is the incorporation of extrinsic stain within
the tooth substance following dental development. It occurs in
enamel defects and in the porous surface of exposed dentine. The
routes by which pigments may become internalized are:
• Developmental defects
• Acquired defects:
– Tooth wear and gingival recession
– Dental caries
– Restorative materials.

Recent Occlusal Problems

A physiologic occlusion is present when no signs of dysfunction or
disease are present and no treatment is indicated. A nonphysiologic
(or traumatic) occlusion is associated with dysfunction or disease
due to tissue injury, and treatment may be indicated.
 History of Present Illness 33

Causes
• Missing or shifting teeth, leading to alterations in arch form and
alignment.
• Acute occlusal changes—due to iatrogenic changes induced by
faulty restorative dentistry, prosthetic appliances that interfere
with or alter the direction of occlusal forces on teeth.
• Parafunctional habits—bruxism.
Signs and symptoms of a nonphysiologic occlusion include
damaged teeth and restorations, abnormal mobility, fremitus,
widened periodontal ligament, pain and a subjective sense of bite
discomfort.
Clinical evaluation procedures include a screening evaluation
Library of School of Dentistry, TUMS

for temporomandibular disorders and intraoral occlusal evaluation.

This includes assessment of:
For Personal Use Only

• Intercuspal Position stability

– Light or absent anterior contacts
– Well-distributed posterior contacts
– Coupled contacts between opposing teeth
– Cross tooth stabilization
– Forces directed towards long axis of each tooth
• Excursive movements—smooth excursive movements without
interferences
• Tooth mobility
• Attrition.
 6
Previous Dental
History

It tells the investigator about the attitude of the patient towards

Library of School of Dentistry, TUMS

dentistry. It often provides the dentist with valuable prognostic as

For Personal Use Only

well as diagnostic information. A dental history should be performed

that includes the frequency of past dental visits, a history of dental
sensitivity, pain, infection, soft tissue lesions, bleeding, swelling, age
and condition of existing dental prostheses, and a history of oral
and periodontal surgery or any other dental treatment.
• Frequency of visit to a dentist: It provides the examiner with
information regarding the interest of the patient in his dental
health.
• Frequency of dental prophylaxis: It may be valuable guide in
evaluating periodontal conditions which are present as well as
provides the dentist with prognostic information.
• Past experience during and following local anesthesia: It may
alert the dentist to the necessity for investigation into possible
allergy to the anesthetic agent. It may also allow him to anticipate
possible syncope during the administration of LA in future
appointments.
• Past periodontal therapy: Type of treatment and the time in
the past it was received, will help to evaluate the present status of
periodontal structure and planning of future periodontal
treatment for a patient.
• Past orthodontic treatment: The condition which was treated,
the length of time of active treatment, the nature of the appliance
 Previous Dental History 35

used, whether a retainer was used appropriately and is still required

can be evaluated.
• Fixed Bridges: The comfort level of the bridge.
• Surgical procedures in the mouth other than extraction:
Nature of the tissue removed. Manner in which it was removed
and its recurrence should be enquired.
Obtaining past dental records, including radiographs, and
consultation with other dentists involved in the patient’s care should
be considered, especially if the dentist performing the pretreatment
dental evaluation is not the patient’s usual dental provider.
The dental history can also give insight into the patient’s level of
dental awareness and motivation to maintain optimum oral health.
Inquiry into the patient’s perceived reasons for lack of dental care
Library of School of Dentistry, TUMS

may be predictive of future compliance.

Previous dental history gives a general view about how the patient
For Personal Use Only

is aware about pursuing oral health.

• It provides a basis for the determination of the caries rate, the
rate of plaque and calculus formation, the susceptibility to
periodontal diseases, the resorption rate of edentulous ridges.
• If history of previous bad experience (pain, rude attitude of
dentist, etc.) is present then moulding of behavior is done using
behavior management technique.
• Significant knowledge can be drawn about the patient’s previous
treatment procedures and can be helpful towards the present
situation.
• Also the information regarding any complication faced during
the previous treatment/visit can be noted.
If this is the patient’s first visit to a dental clinic then reasons for
not visiting the dentist should be enquired:
Patient feels that he/she has:
• No problem
• had some problem but thinks it will get corrected by itself
• due to other reasons, like time factor/no facilities/lack of
affordability, etc.
 7
Medical History
Library of School of Dentistry, TUMS

‘Medical history is the description of the relevant features of the

patient’s health status which influence the oral health from birth to
For Personal Use Only

the moment that the patient enters the office’.

Medical history includes:
• Diseases or conditions that contraindicate certain kind of dental
treatment.
• Diseases that require special precautions or premedication prior
to dental treatment. For eg myocardial infarction, hemophilia,
radiation, etc.
• Diseases under treatment of a physician with medication that
contraindicates the use of additional medication. For example,
Anticoagulants, steroid therapy, tranquilizers.
• Allergies/untoward r eaction towards penicillin/local
anesthesia.
• Diseases that endanger the dentist/other patients. For eg.
Infectitious diseases like hepatitis, tuberculosis
• Physiological state of patient. For example, Pregnancy, aging.
Recording of past medical history includes history of past
illnesses, health care experiences, immunization, known allergy,
current treatment including medications hospitalizations and
evaluation of the patient’s health based on the history provided by
the patient.
 Medical History 37

CHECKLIST FOR MEDICAL HISTORY BY SCULLY AND CAWSON

• Anemia
• Bleeding disorders
• Cardiorespiratory disorders
• Drug treatment and allergies
• Endocrine disorders
• Fits and faints
• Gastroinstestinal disorders
• Hospital admissions and surgeries
• Infections
• Jaundice
• Kidney diseases

All diseases suffered by the patient should be recorded in

Library of School of Dentistry, TUMS

chronological order.
For Personal Use Only

Patient should be evaluated for:

• Cardiovascular diseases • Respiratory diseases
• Gastrointestinal • Genitourinary
• Endocrine • Neurological
• Hematological • Psychiatric
• Allergic reactions • Extremities and joints

Patient should be assessed by the questionnaire:

• Whether he is suffering or has suffered before from any major
systemic disease?
• What is the duration and treatment of the disease?
• Is he on any medication?
• History of all the hospitalizations and their purpose should be
assessed.
Some important examples of diseases (conditions) affecting the
treatment includes:
• Postpone treatment if suffering from acute illness like mumps or
chickenpox
• Patient with cardiac defects needs to get a physician’s report
• Patient on anticoagulant therapy
• If Asthmatic then Nonsteroidal Antiinflammator y Drugs
(NSAIDs) are contraindicated
• Juvenile diabetes mellitus.
 38 A Practical Manual of Public Health Dentistry

FAMILY HISTORY
Family history is asked to assess the presence of any inherited disease
pattern or trait. The reason a family history can help predict risk is
that families share their genes, as well as other factors that affect
health, like environment, lifestyles and habits.
• It includes:
– Number of siblings and their age.
This gives an idea of:
- Size of family and socioeconomic status.
- Whether patient can afford for the time and treatment.
- To know the child’s psychology which has an effect on
his behavior.
Library of School of Dentistry, TUMS

Children from larger families are more adjustable, co-

operative, willing to face the crisis/face challenges on their
For Personal Use Only

own.
- To study the peer influence of dietary and oral hygiene
practice.
– History of any disease running in the family. For example,
Diseases like hemophilia, diabetes, and hypertension recur in
families’ generation after generation.
– Prenatal, Natal and postnatal history should be taken in case
of pediatric patients.
 8
Personal History

It includes:
Library of School of Dentistry, TUMS

• Oral habits
For Personal Use Only

• Oral hygiene habits

• Adverse habits
• Diet history.

1. ORAL HABITS

Habit
Definition
• A habit can be defined as the tendency towards an act that has
become a repeated performance, relatively fixed, consistent and
easy to perform by an individual (Boucher O.C.).
• A habit can be defined as fixed or constant practice established
by frequent repetition (Dorland, 1957).
• Buttersworth (1961): Defined a habit as a frequent or constant
practice or acquired tendency, which has been fixed by frequent
repetition.
• Mathewson (1982): Defines it as oral habits are learned patterns
of muscular contractions.

Various Habits are

• Thumb sucking
• Finger sucking
 40 A Practical Manual of Public Health Dentistry

• Tongue thrusting
• Pacifier or dummy sucking
• Lip biting
• Nail biting
• Cheek biting
• Pencil or foreign object sucking
• Lip sucking
• Clenching
• Mouth breathing
• Bruxism
• Occupational habits.

THUMB AND DIGIT SUCKING

Library of School of Dentistry, TUMS

It makes up the majority of oral habits. About two thirds are ended
by 5 years of age.
For Personal Use Only

• The types of dental changes that a digit habit may cause vary
with the intensity, duration, and frequency of the habit as well as
the manner in which the digit is positioned in the mouth.
• Clinical and experimental evidence suggests that 4 to 6 hours of
force per day are probably the minimum necessary to cause tooth
movement.
• A child who sucks intermittently with high intensity may not
produce much tooth movement at all, whereas a child who sucks
continuously (for more than 6 hours) can cause significant dental
change.

DEFINITION
Thumb sucking is the childhood habit of putting the thumb in the
mouth for comfort or to relieve stress.
Thumb sucking is defined as placement of the thumb or one or
more fingers in varying depths into the mouth (Gellin 1978).
Fig. 8.1 shows a child with thumb sucking habit.
Thumb sucking is considered normal during the first and second
year of life. It does not generate any malocclusion.
Abnormal thumb sucking persists beyond the preschool period,
i.e. after the age of 3 to 4 years.
 Personal History 41
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 8.1: A child sucking thumb

• Psychological: deep rooted emotional reason (insecurity, neglect,

loneliness)
• Habitual: no psychological bearing; act out of a habit.

Sucking Reflex
The process of sucking is a reflex occurring in the oral stage of
development and is seen even at 29 weeks of intrauterine life,
and may disappear during normal growth between the ages one
and three and half. It is the first coordinated muscular activity of
the infant.
Finger sucking and tongue thrusting habits are normal when the
child is one and a half year of age and will disappear spontaneously
by the second year with proper attention to nursing. If it continues
beyond three years, malocclusion will result.

Causative Factors
• Parent’s occupation
• Working mother
• Number of siblings
• Order of birth of the child
 42 A Practical Manual of Public Health Dentistry

• Social adjustment and stress

• Feeding practices
• Age of the child
Parents Occupation: It relates to the socioeconomic status of the family.
Families living in a high socioeconomic status are blessed with ample
sources of nourishment. Mothers belonging to low socio-economic
group are unable to provide the infant with sufficient breast milk.
Working Mother: Sucking habits are commonly observed to be present
in children with working parents. Such children brought-up in the
hands of care taker may have feelings of insecurity.
Number of Siblings: The development of the habit can be indirectly
Library of School of Dentistry, TUMS

related to the number of siblings.

Order of the Birth of Child : It has been noticed that the later the
For Personal Use Only

sibling rank of a child, greater the chance of having an oral habit.

Social Adjustment and Stress : Digit sucking has also been proposed
as an emotion based behavior related to the difficulty with the social
adjustment or with stress.
Feeding Practices: A negative relation is also seen between the breast-
feeding and the development of dummy or finger sucking.
Age of the Child:
• In the Neonate: Primitive demands as hunger
• During the first week of life: Feeding problems
• During the eruption of the primary molar: As a teething device
• Still Later: Release of emotional tension.

Phases of Development of Thumb Sucking

Phase I: Normal/subclinically significant sucking—seen during first
three years of life is considered normal during this phase.
Phase II: Clinically significant sucking—seen during three to six
and half year of age indicates that child is under great anxiety.
Phase III: Intractable sucking—any thumb sucking that persists
beyond fourth or fifth year of life.
 Personal History 43

Diagnosis of Digit Sucking

History: It determines the psychological component involved—
Question regarding the frequency, intensity and duration of habit.
Enquire the feeding patterns, and parental care of the child.
Presence of other habits should be evaluated.

Extraoral Examination
Various key areas to be noted include the following:

The Digit
The digits that are involved in habit will appear reddened, clean,
Library of School of Dentistry, TUMS

chapped, short finger nail and with callus formation on the thumb
(Fig. 8.2).
For Personal Use Only

The Lip
Chronic thumb suckers are having short, hypotonic upper lip.
Upper lip is passive or incompetent during sucking and lower lip
is hyperactive and this leads to a further increase in the proclination
of the upper anteriors due to its thrust on these teeth.

Fig 8.2: Callus formation on the thumb as a result of sucking habit

 44 A Practical Manual of Public Health Dentistry

Facial form analysis: Check for the mandibular retrusion, maxillary

protrusion, high mandibular plane angle and profile.
Other Features: Active thumb sucker also have higher incidence
of middle ear infections.

Intraoral Examination
Tongue: Examine the oral cavity for size and position of tongue at
rest and tongue action during swallowing.

Dentoalveolar Structure
Individuals with severe finger or thumb sucking habit, where the
digit is applied as anterior superior vector to the upper dentition and
Library of School of Dentistry, TUMS

palate, will have flared and proclined maxillary anteriors with

diastemas and retroclined mandibular anteriors. (Fig. 8.3).
For Personal Use Only

Other Symptoms are constriction of buccal musculature and

tendency to narrow palates.
Gingiva: Look for the evidence of mouth breathing, gum line
etching, decayed or excessive staining on labial surface of upper central
and lateral incisors.

Fig. 8.3: Forces acting on the teeth while thumb sucking

 Personal History 45

Effects of Non-nutritive Thumb Sucking

Effects of non-nutritive thumb sucking habits on developing teeth are
minor in infants or children under age three.

Effects of Thumb Sucking Depends On

Library of School of Dentistry, TUMS

• Intensity is the amount of force that is applied to the teeth during

sucking.
For Personal Use Only

• Duration is defined as the amount of time spent sucking a digit

• Frequency is the number of times the habit is practiced
throughout the day.

Features
• Increased overjet due to proclined maxillary anterior teeth
(Fig. 8.4).
• Lingual tipping of mandibular anterior teeth.

Fig 8.4: Proclination of the upper anterior teeth and anterior open bite
 46 A Practical Manual of Public Health Dentistry

• Supraeruption of buccal teeth

• Posterior crossbite due to overactivity of buccinator compressing
the maxilla.
• Narrow and high palatal vault.
• Hypotonic upper lip with the lower part of the face exhibiting
hyperactive mentalis activity.
There is a significant association between the prevalence of Class
II malocclusion and persisting digit sucking in the different age groups.
As the duration of the habit increases, the probability of a child’s
developing a Class II malocclusion increases.
Emotional difficulties: Some preschoolers who suck their thumbs
may feel ashamed if they are teased by other children. Parents can
Library of School of Dentistry, TUMS

cause low self-esteem by ridiculing or punishing their child for this

behavior.
For Personal Use Only

Speech problems: The most common speech problems that develop

because of thumb sucking include mispronouncing Ts and Ds, lisping,
and thrusting out the tongue when talking.

Control of Thumb Sucking

Prevention
• Motive based approach: Its prevention should be directed towards
the motive behind the habit.
• Child’s engagement in various activities: Parents can be consulted
on keeping the child engaged in various activities.
• Parent’s involvement in prevention: When the parents are at home
they should be advised to spend ample time with the child so as
to put away his feelings of insecurity.
• Duration of breastfeeding: Duration of feeding should be adequate.
• Mother’s presence and attention during bottle feeding: It will
promote close emotional union between the mother and the baby.
• Use of psychological nipple: Size and number of hole should be
standardized to regulate a slow and steady flow of milk.
• Use of dummy or pacifier: Thumb sucking can be prevented by
encouraging the baby to suck a dummy instead.
 Personal History 47

Treatment Consideration
• Psychological status of the child: Frequency, duration and intensity
of oral habit are important in evaluating the psychological status
of the child.
• Age factor: The child having thumb sucking habit at
– 3 Years of age:
- Effect — Damage incurred such as open bite. No
treatment provided in this age group.
– 4 to 5 years of age :
- Effect — Self correction can be expected.
– 6 years of age:
- Effect — It will not self correct.
Library of School of Dentistry, TUMS

• Motivation of the child to stop the habit: It is also important to

assess the maturity of child in response to new situation and to
For Personal Use Only

observe the child’s reaction to any suggestion.

• Parental concern regarding the habit: Negative reinforcements in
the form of threats, nagging and ridicule would only entrench
the habit.
• Other factors: Self correction again depends on severity of
malocclusion, anatomic variation in the perioral soft tissue, and
presence of other oral habits such as tongue thrusting, mouth
breathing, and lip biting habits.

Management
• Psychological approach: The parents should be consulted to provide
the child with adequate love and affection. They should be advised
to divert the child’s attention to the other things such as play
and toys.
Dunlop’s beta hypothesis: This hypothesis is the best way to break
a habit.
Child should be asked to sit in front of a mirror and to suck his
thumb, observing himself as he indulges in the habit.
• Reminder therapy:
a. Extraoral approaches:
It employs hot tasting, bitter flavoured preparations are
distasteful agents that are applied to thumb example cayenne,
 48 A Practical Manual of Public Health Dentistry

pepper, quinine, asafoetida. This is effective only when the

habit is not formally entrenched.

Thermoplastic Thumb Post

A thumb device is usually made of nontoxic plastic and is worn over
the child’s thumb (Fig. 8.5).
It is held in place with straps that go around the wrist. A thumb
device prevents a child from being able to suck his or her thumb and
is worn all day.
It is removed after the child has gone 24 hours without trying to
suck a thumb. The device is put back if the child starts to suck his or
her thumb again. Thumb devices need to be fitted by a health
Library of School of Dentistry, TUMS

professional.
• Intraoral approaches : Removable appliances: These are palatal
For Personal Use Only

crib, rakes, palatal arch, lingual spurs, Hawley’s retainer with or

without spur (Fig. 8.6).
• Fixed appliances: Upper palatal tongue screens appear to be more
effective in breaking these habits.

Fig 8.5: Thermoplastic thumb post

 Personal History 49
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.6: Habit crib appliance

Mechanotherapy
Fixed Intraoral Antithumb Sucking Appliances
• Bands fitted to the primary second molar or first permanent molar.
A lingual arch forms the base of the appliances to which are added
interlacing wires in the anterior portion in the area of the anterior
part of hard palate.
• This prevents the patient from putting the palmer surface of the
thumb in contact with palatal gingiva.

Quad Helix (Fig. 8.7)

It prevents the thumb from being inserted and also corrects
malocclusion by expanding the arch.

PACIFIER HABITS
Dental changes created by pacifier habits are largely similar to changes
created by thumb habits, and no clear consensus indicates a
therapeutic difference. Anterior open bite and maxillary constriction
occur consistently in children who suck pacifiers. Pacifier habits
appear to end earlier than digit habits.
 50 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS

Fig 8.7: Quad helix

For Personal Use Only

TONGUE THRUST HABIT

Definitions
Tongue thrusting is defined as a condition in which the tongue makes
contact with any teeth anterior to the molars during swallowing.
A tongue thrust is said to be present if the tongue is observed
thrusting between and the teeth do not close in centric occlusion
during deglutition. — Brauer (1965)
Tongue thrust is the forward movement of the tongue tip between
the teeth to meet the lower lip during deglutition and in sounds of
speech, so that the tongue becomes interdental. — Tulley (1969)
Tongue thrust is an oral habit pattern related to the persistence
of an infantile swallow pattern during childhood and adolescence
and thereby produces an open bite and protrusion of the anterior
tooth segments. — Barber (1975)
Tongue thrust is a forward placement of the tongue between the
anterior teeth and against the lower lip during swallowing.
— Schneider (1982)

Etiology of Tongue Thrust

• Retained infantile swallow
• Upper respiratory tract infection
 Personal History 51

• Mouth breathing
• Chronic tonsillitis
• Neurological disturbances
– Hyposensitive palate
– Moderate motor disability
– Disruption of sensory control
• Due to transient change in anatomy
– Tongue can protrude when the incisors are missing
• Bottle feeding
• Thumb and finger sucking
• Hypertonic orbicularis oris
• Macroglossia.
Library of School of Dentistry, TUMS

Clinical Manifestations of Tongue Thrust

For Personal Use Only

• Clinical manifestations depend on:

– Intensity
– Duration
– Frequency and
– Type of tongue thrust.

Extraoral Findings
• Lip separation
• More erratic mandibular movements
• Speech disorders such as:
– Sibilant distortions
– Lisping distortions
– Problem in articulation of s/n/t//d/l/th/z/v/sounds
– Increase in anterior face height.

Intraoral Findings
• Jerky and irregular tongue movements
• Lowered tongue tip because of :
– Anterior open bite
– Longer period of time required for tongue tip elevation
 52 A Practical Manual of Public Health Dentistry

• Malocclusion:
– Proclination of maxillary anterior results in increased overjet
– Generalized spacing between teeth
– Retroclination or proclination of mandibular teeth
– Anterior and posterior open bite (depends on posture of
tongue)
– Posterior teeth crossbite.

Diagnosis of Tongue Thrust

A. Take History
• Ask about swallow pattern of siblings and parents to check
for etiologic factor
Library of School of Dentistry, TUMS

• Get information about upper respiratory tract infection,

sucking habits and neuromuscular problems.
For Personal Use Only

B. Examine
• Detect perverted swallowing habit and correct it to facilitate
normal development of the palate and dentitions
• Study the tongue posture
• Observe tongue movements during swallow.

Treatment Considerations of Tongue Thrust

1. Age: Tongue thrust often corrects itself by 8 or 9 years of age.
Self-correction is due to improved musculature balance during
swallowing.
2. Presence/absence of associated manifestation: Treatment is
not recommended when tongue thrust is present without mal-
occlusion or a speech problem.
3. Tongue thrust with malocclusion and without speech defect:
Orthodontic treatment may be carried out.
4. Speech defect with tongue thrust:
• Speech therapy is indicated.
• Surgery may be done to reduce the size of pharyngeal
lymphoid masses.
5. Treatment of associated habit first: If an associated habit like
thumb sucking is present, it must be treated first.
 Personal History 53

Treatment of Tongue Thrust

I. Training the tongue for correct swallow and posture:
a. Myofunctional exercise:
1. The child is asked to place the tip of the tongue in the rugae
area for 5 minutes.
2. Orthodontic elastic and sugarless fruit drop exercise.
3. 4s exercise.
Includes:
• Identifying the spot
• Salivating
• Squeezing the spot
• Swallowing.
Library of School of Dentistry, TUMS

4. Ask the child to perform a series of exercises like

For Personal Use Only

• whistling
• reciting the count from 60 to 69
• gargling or yawning, to tone the respective muscles.
b. Use of appliances to correct position of tongue:
1. Preorthodontic trainer for myofunctional training (Fig. 8.8).
• Nance palatal arch appliance
II. Speech therapy:
• Not indicated before the age of 8 years.
III. Mechanotherapy: Fixed (Fig. 8.9) and removable appliances
can be fabricated to restrain the anterior tongue movements during
swallowing.
• Force the tongue downward and backward during swallowing
• Re-educates tongue position.

Removable Appliance Therapy

• For posterior open bite modified habit crib is used
• Oral screen
– Modified acrylic plate
– Used to control muscle forces both inside and outside the
dental arches
– Reduces development of malocclusion.
 54 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.8: Preorthodontic trainer

IV. Correction of Malocclusion

V. Surgical Treatment
• For retained infantile swallow tongue thrust
• For reduction of lymphoid tissue size improves abnormality to
tongue thrust.
 Personal History 55
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.9: Habit breaking appliance

MOUTH BREATHING HABIT

Definition
Sassouni (1971): Defined mouth breathing as habitual respiration
through the mouth instead of the nose.
Merle (1980): Suggested the term oronasal breathing instead of
mouth breathing.

Etiology
• Nasal Obstruction
– Nasal obstruction may be due to
- Enlarged turbinates
- Deviated nasal septum
- Allergic rhinitis
- Nasal polyps
- Enlarged adenoids
- Chronic inflammation of nasal mucosa.
• Abnormally short upper lip preventing proper lip seal
• Obstruction in the bronchial tree or larynx
• Obstructive sleep apnea syndrome
 56 A Practical Manual of Public Health Dentistry

• Genetically predisposed individuals: Ectomorphic children having

a genetic type of tapering face and nasopharynx are prone for
nasal obstruction.
• Thumb sucking or other oral habits can be the instigating agent.

Clinical Features
• General effects:
– Pigeon chest
– Low grade esophagitis
– Blood gas constituents.
• Effects on dentofacial structures:
– Facial form:
Library of School of Dentistry, TUMS

- A large face height

- Increased mandibular plane angle
For Personal Use Only

- Retrognathic mandible and maxilla.

– Adenoid faces–characterized by:
- Long narrow face
- Narrow nose and nasal passage
- Flaccid lips with upper lip being short
- Dolicocephalic skeletal pattern (Fig. 8.10)
- Nose is tipped superiorly in front
- Expressionless face
- V shaped maxillary arch and high palatal vault.
– Dental defects:
- Upper and lower incisors are retroclined.
- Posterior cross bite

Fig 8.10: Dolicocephalic skeletal pattern

 Personal History 57

- Anterior open bite

- Narrow palatal and cranial width.
- Flaring of incisors (Fig. 8.11)
- Decrease in vertical overlap of anterior teeth.
– Speech defects:
- Nasal tone in voice
– Lips:
- Short thick incompetent upper lip
- Voluminous curled over lower lip
- Gummy smile
- External Nares
- Slit like external nares with a narrow nose due to atrophy
Library of School of Dentistry, TUMS

of lateral cartilage.
– Gingiva
For Personal Use Only

- Inflammed and irritated gingival tissue in the anterior

maxillary arch.
- Classic rolled marginal gingiva and enlarged interdental
papilla.
- Interproximal bone loss and presence of deep pockets.
– Other Effects
- Otitis Media
- Dull sense of smell and loss of taste.

Fig 8.11: Flaring of incisors

 58 A Practical Manual of Public Health Dentistry

Diagnosis
• History of patient.
• Clinical examination.
• Mirror test — Double-sided mirror is held between nose and
mouth. Fogging on nasal side indicates nasal breathing while
fogging towards oral side indicates oral breathing.
• Cotton test — A butterfly shaped piece of cotton is placed over
upper lip below nostrils.
If cotton flutters down,it indicates nasal breathing.
• Water test — Patient is asked to fill his mouth with water and
retain it for a period of time.
While nasal breathers accomplish with ease, mouth breathers
Library of School of Dentistry, TUMS

find task difficult.

• Observation — In nasal breathers, external nares dilate during
For Personal Use Only

inspiration.
• Cephalometric examination.
• Rhinomanometry.

Management

Elimination of the Cause

Symptomatic Treatment
Interception of the habit: If the habit continues even after removal
of obstruction, then it should be corrected. Correction can be
done by:
• Physical exercise
• Lip exercises
• Maxillothorax myotherapy
• Oral screen
Oral Screen (Fig. 8.12): Most effective way to re-establish nasal
breathing is to prevent air from entering the oral cavity.
Oral screen should be constructed with a material compatible
with the oral tissues.
Reduction in the anterior open bite is obtained after treatment
for 3 to 6 months.
 Personal History 59
Library of School of Dentistry, TUMS

Fig 8.12: Oral screen

For Personal Use Only

Preorthodontic Trainer
It is used in mouth breathers, tongue thruster and thumb suckers.

Correction of the Malocclusion

Mechanical appliances
• Children with class I occlusion and anterior spacing — oral shield
appliance.
• Class II div. I dentition without crowding — Monobloc Activator
can be used.
• Class III malocclusion — chin cap can be used.

BRUXISM

Definition
Defined as the clenching or grinding of teeth when not masticating
or swallowing (Poselt and Wolff).
Habitual grinding of teeth when the individual is not chewing or
swallowing (Ramfjord 1966).
Nonfunctional contact of teeth which may include clenching,
gnashing, grinding and tapping of teeth (Rubina 1986).
 60 A Practical Manual of Public Health Dentistry

Etiology
• Psychological and emotional stresses
• Occlusal interference or discrepancy between centric relation and
centric occlusion
• Genetics
• Magnesium deficiency
• Allergies
• Occupational factors.

Clinical Features
• Occlusal wear facets
Library of School of Dentistry, TUMS

• Fractures of teeth and restorations

• Mobility of teeth
For Personal Use Only

• Tenderness and hypertrophy of masticatory muscles

• TMJ pain and discomfort.

Diagnosis

• History and clinical examination are sufficient to diagnose

• Occlusal prematurities can be diagnosed by use of articulating
papers
• Electromyographic examination to check for hypertrophy of
masticatory muscles.

Treatment

• Appropriate psychological counseling

• Hypnosis, relaxing exercises and massage can help relieve muscle
tension.
• Occlusal adjustments need to be carried out to eliminate
prematurities
• Night guards can be given which cover the occlusal surfaces of
teeth and prevent interferences and wear
• Biofeedback—utilizes positive feedback to enable the patient to
learn tension reduction.
 Personal History 61

OTHER MINOR HABITS

Lip Biting
Lip biting most often involves the lower lip which is turned inwards
and pressure is exerted on the lingual surfaces of maxillary anteriors.

Features
• Proclined upper anteriors and retroclined lower anteriors
• Hypertrophic and redundant lower lip
• Cracking of lips.

Interception
Library of School of Dentistry, TUMS

Lip bumpers can be used that not only keep the lips away but also
improve the axial inclination of anterior teeth due to unrestrained
For Personal Use Only

action of tongue.

Nail Biting
It does not produce any gross malocclusion.
Minor local tooth irregularities such as rotation, wear of incisal
edge and minor crowding can occur.
Nut notch is seen which is wear of teeth in the form of notch. It is
seen due to cracking open of hard nuts using incisal edge of anteriors.

Self-Destructive Oral Habits/Masochistic Habits

Include picking at the gingiva with fingers and finger nails, chewing
the inside of the cheek, lip or tongue.
• Associated with Lesch—Nyhan and de Lange’s syndromes
• Diverting the child’s attention each time habit is observed can
solve the problem
• Restraints, protective padding, sedation can be used in mentally
retarded children.

2. ORAL HYGIENE HABITS

• It is important so as to:
– Assess the knowledge of dental care the patient possesses.
– To determine the level of hygiene maintained by the patient.
 62 A Practical Manual of Public Health Dentistry

• It includes: Regularity of brushing

– Frequency and method of brushing
– Use of fluoridated and nonfluoridated tooth pastes
– Type of brush and how often it is changed
– Use of other oral hygiene aids.

3. ADVERSE HABITS
• It includes:
– Smoking: Record the type, frequency and duration
– Alcohol consumption: Record the amount, frequency and
duration
– Tobacco chewing Arecanut chewing/Paan chewing: Record
Library of School of Dentistry, TUMS

the type, amount, frequency and duration.

For Personal Use Only

4. DIET HISTORY

Diet Recording
List the sweets and sugar-sweetened foods and the frequency with
which they are consumed in a typical day.
A 5-day diet diary is recommended.
The diary is kept for 5 consecutive days including a weekend or
holiday, to provide a more representative sample of the food intake.

DIET-DIARY
Name:
Date:
Instructions
1. Each detail about what you eat or drink in the order in which it is eaten
should be recorded with time.
2. The frequency of eating is an important consideration; therefore between
meal-snacks, candies, gum, etc. should also be included alongwith meals.
3. The following information is essential:
The amount in household measurements such as 8 oz, 1 serving,1/2 cup,1
teaspoon should be recorded.
The food and method of preparation such as fried chicken, baked apple,
raw carrots etc should be mentioned.

Contd...
 Personal History 63
Contd...

The addition of sugar, syrup or milk to cereal, beverages such as 1 bowl of

cornflakes with 2 teaspoon of sugar and ½ cup of milk
4. Example:
Wrong Right
Juice ½ cup tomato juice
Sandwich 1 chicken sandwich
Dessert 1 slice chocolate cake
Coffee 1 cup coffee with milk and 2 teaspoon sugar

Place a checkmark in the frequency column for each item as long

as they are eaten at least 20 minutes apart.
Library of School of Dentistry, TUMS

(This time is based on the Stephan’s curve that the pH of the

plaque drops and remains below critical level for an average 20
For Personal Use Only

minutes after introduction of sucrose into the mouth).

Form Frequency Points

Liquid —×5
Solid and sticky — × 10
Slowly dissolving — × 15

Sweet Score
5 or less excellent
10 good
15 or more “watch out zone”

Diet Analysis
Sugar
The generic term “sugar” usually means sucrose, the disaccharide
caloric white granular substance that is processed from sugar cane or
beets.

Classification of Sugars
• Committee on medical aspects of food policy (COMA)
– Intrinsic Sugars
 64 A Practical Manual of Public Health Dentistry

– Extrinsic Sugars
- Milk Extrinsic Sugars
- Nonmilk Extrinsic Sugars (NMES)

Pattern of Sugar Consumption

Sugar first became inexpensive and available on a mass scale in the
United States in the mide- 9th century, when tariffs on sugar imports
were lifted.
When food distribution methods in the United States became
more efficient after World War I, sugar consumption increased.
Since then, the rate of sugar consumption has continued to rise;
the taste for sweets seems to be insatiable.
Library of School of Dentistry, TUMS

The food industry spends large amount of money each year on

the promotion and advertising of sweetened products (Nielsen 1998).
For Personal Use Only

Diet and Dental Caries

Dental caries is accepted as being caused by the ingestion of
fermentable carbohydrates particularly sucrose.
Cariogenic potential of food containing sucrose depends on many
variables such as the ability to:
• Be retained by the teeth
• Form acids
• Dissolve enamel
• Neutralize or buffer acids
– The solid and retentive sucrose are more cariogenic than liquid
and nonretentive sugars.
– The frequency and time of ingestion of foods are also
important. The sucrose containing foods becomes more
dangerous if, it is eaten more frequently. Food eaten at meals
produces less caries than the same eaten between meals does.
– In decreasing order of cariogenicity, the food is grouped as:
- Adherent, sucrose-containing foods eaten frequently
between meals.
- Adherent, sucrose-containing foods eaten during meals.
 Personal History 65

- Nonretentive (liquid) sucrose-containing beverages

consumed frequently between meals.
- Nonretentive (liquid) sucrose-containing foods consumed
during meals.

Consensus View on Diet and Caries

(Cannon 1992; Deptt. of Health 1989; Rugg-Gunn 1993; Sheiham
2001; WHO 1990).
• The influence of the diet is more important after the teeth have erupted.
The preeruptive effect of diet on caries development is minimal.
• NMES are highly cariogenic.
• Frequency of eating/drinking NMES is important in caries
Library of School of Dentistry, TUMS

development. However, frequency of intake and amount con-

sumed are closely related.
For Personal Use Only

• Intrinsic sugars, as found in for example, fresh fruits and vegetables

and cooked staple starchy foods such as rice and potatoes, are of low
cariogenicity. Milk extrinsic sugars, for example milk, are virtually
noncariogenic.
• Alternatives or nonsugar sweeteners (bulk and intense) are non-
cariogenic.

Classify each sweet into:

• Liquid
• Solid and sticky
• Slowly dissolving category.
 66 A Practical Manual of Public Health Dentistry

Sugar in Liquid Form (Fig. 8.13)

• Cold drinks, soda pop, powdered drink mixes, fruit drinks
• Sweetened condensed milk, syrup
• Sweetened sauces like chocolate, butterscotch
• Chocolate milk, hot chocolate
• Milk shakes and malts.
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.13: Sugar in liquid form

Solid and Sticky Sugar (Fig. 8.14)

• Cakes, doughnuts, cookie
• Candies, chocolates
• Pastries, puddings,sweet rolls, pies
• Sugar-containing cereals sugar coated gums
• Dry fruits— raisins, dates, apricots
• Food cooked in sugar
• Ice cream, jam jellies
• Sugar containing chewing gums, caramels.
 Personal History 67
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.14: Solid and sticky sugar

Slowly Dissolving Sugars (Fig. 8.15)

• Hard candies
• Mints, lollipops, jelly beans
• Frosting honey, cough syrups, drops.
 68 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS
For Personal Use Only

Fig 8.15: Slowly dissolving sugar

Diet Counseling

Educate the Patient in the Role of Sugar in Decay Process

The plaque that forms in the teeth every day contain bacteria. This
changes the sugar present in the food in to acids.
SUGAR (in food) + PLAQUE/BACTERIA (germs)
⎯→

TOOTH + ACIDS = DECAY

• The grand total of time of exposure to acid is used here to give the
patient a rough idea of the risk that his diet is imposing on his teeth.

Isolate the Sugar Factor

The patient is aided in identification of these foods, whether they are
healthy or harmful choices. Interviewer and patient together code
 Personal History 69

the record with different colors like Red Cross for harmful choices
and time and blue cross for good choice and meal time. Taking this as
a game, child is asked to count the total number of red Xs which are
harmful for teeth.
Next, ask the child which X marked food he can eliminate. Tell
him to reduce number of red Xs when he come next time. It is not
fair to cut down all sugar from the diet. Sugar during meal time and
after proper oral hygiene measures is okay. Substitute should be
acceptable to dentist in terms of cariogenicity as well as to patient as
far as taste and preference is concerned. List of substitute food should
be made by the joint effort of dentist and patient.

List of Substitutes
Library of School of Dentistry, TUMS

• Peanuts, walnuts, pea cans, almonds, other types of nuts

For Personal Use Only

• Popcorn, corn chips

• Whole wheat biscuits
• Unsweetened dry cereals
• Cold cuts of meats (unsweetened)
• Cubes of cheese
• Fresh fruits, salads
• Vegetables such as carrot slices, celery sticks, cucumber slices
• Baked potatoes
• Unsweetened fruit juices
• Freshly squeezed fruit juices
• Sugarless chewing gum.

Recall Visits
Evaluate patient’s performance at regular intervals by means of:
• Patient’ comments
• New diet diary
• Susceptibility tests like Snyder’s test and
• Clinical judgment
• Reinforce patient by praising his efforts.
 9
Clinical Examination
Library of School of Dentistry, TUMS

The ability to perform a thorough clinical examination of the superficial

structures of the head, neck and oral cavity is essential for all dentists.
For Personal Use Only

The examination should be carried out on all the patients, and every
dentist must be trained to effectively diagnose and evaluate the disease.
To perform the examination, a dentist should have:
• Adequate knowledge of the anatomy and physiology of the region
• A well practiced technique for examination providing minimal
discomfort to the patient
• Knowledge of the disease process affecting the head and neck
region.
The basic techniques of diagnosis are visual inspection, palpation,
olfaction, auscultation, percussion and aspiration.
• Visual inspection: It is a standardized observation of the anatomical
landmarks of the head and neck region to ensure the completeness
and accuracy of the examination. Visual inspection involves
evaluating the bilateral completeness of the facial structures.
• Palpation: It is used to determine the size, texture, consistency,
symmetry, temperature, etc. which are sensed by touch. Palpation
may be done by either hand or by both hands (bimanual
palpation). Findings related with the palpation techniques are
confirmed with percussion and auscultatory techniques.
• Olfaction: Some odors can be associated with conditions of the
patient such as smoking habits, poor oral hygiene, sinusitis,
metabolic disorders, gastrointestinal disorders, etc.
 Clinical Examination 71

• Auscultation: It is the listening to sounds. It is performed by the

unaided ear or by the assistance of a stethoscope. A dentist should
evaluate the sounds of crepitus or popping like in case of TMJ,
blood pressure sounds, etc.
• Percussion: It is performed by gentle tapping over the area with
fingers or an instrument to determine the relative consistency of
the structure with its surroundings. Patient may even feel pain
while the procedure providing valuable information about the
area percussed.
• Aspiration: It is the removal of whole or a part of fluid from a
body cavity. The area aspirated is usually a soft tissue or a bony
lesion having a fluid filled cavity. The aspirated fluid is thus
Library of School of Dentistry, TUMS

evaluated for its consistency and components.

The examination includes the following par ts: General
For Personal Use Only

examination, Local examination.

Local examination further includes extraoral examination and
intraoral examination.
General examination includes:
• Gait
• Posture
• Built
• Blood pressure
• Pulse
• Temperature
• Respiratory rate
• Pallor
• Cyanosis
• Edema
• Icterus
• Body mass index (BMI).
Gait: Gait is the pattern of movement of the limbs of animals,
including humans, during locomotion over a solid substrate. Different
gaits are characterized by differences in limb movement patterns,
overall velocity, forces, kinetic and potential energy cycles, and
changes in the contact with the surface (ground, floor, etc.).
 72 A Practical Manual of Public Health Dentistry

Antalgic Gait: Painful gait, a limp is adopted to avoid pain on weight

bearing structures (hip, knee, ankle).
Ataxic Gait: An unsteady, uncoordinated walk, a wide base of support
is seen. normally due to cerebellar disease.
Festinating Gait: Short, accelerating steps are used to move forward,
often seen in people with Parkinson’s disease.
Four Point Gait: Utilized by crutch users, first on crutch, then the
opposite leg followed by the other crutch and then the other leg.
Hemiplegic Gait: Involves flexion of the hip because of inability to clear
the toes from the floor at the ankle and circumduction at the hip.
Spastic Gait: Walk in which the legs are held close together and move
in a stiff manner. often due to central nervous system injuries.
Library of School of Dentistry, TUMS

Posture: In humans, posture can provide important nonverbal

For Personal Use Only

communication. Posture deals with how the body is positioned in

relation to another person or group of persons (for example, leaning
stance posture, standing, sitting, etc.) and how they are positioned
relative to each other various body parts.
Built: It is how the body looks like. There are three extremes of
body types.
Endomorph (Fig. 9.1)

Fig. 9.1: Endomorph body type

• A pear shaped body

• A rounded head
• Wide hips and shoulders
 Clinical Examination 73

• Wider front to back rather than side to side

• A lot of fat on the body, upper arms and thighs.
Mesomorph (Fig. 9.2)
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 9.2: Mesomorph body type

• A wedge shaped body

• A cubical head
• Wide broad shoulders
• Muscled arms and legs
• Narrow hips
• Narrow from front to back rather than side to side
• A minimum amount of fat.
Ectomorph (Fig. 9.3)

Fig. 9.3: Ectomorph body type

 74 A Practical Manual of Public Health Dentistry

• A high forehead
• Receding chin
• Narrow shoulders and hips
• A narrow chest and abdomen
• Thin arms and legs
• Little muscle and fat.
Blood Pressure: It is useful to determine:
• The stroke volume of the heart and stiffness of the arterial vessels.
• To assess severity of hyper and hypotension and aortic incompetence.
(normal level of blood pressure is 120/80 lbmm of Hg).
Pulse: It is an important index of severity of the vascular system and
heart abnormalities.
Library of School of Dentistry, TUMS

It is useful to record:
• Rate: Fast or slow (normal rate is 60–100/min)
For Personal Use Only

• Rhythm: Regular or irregular

• Volume: High, normal or low pulse pressure (normal pulse
pressure is 40–60 mm hg)
• Tension and force
• Character: Some vascular diseases may show different pulse
character such as ‘water hammer’ pulse in aortic regurgitation,
‘pulsus paradoxicus’ in pericardial effusion, etc.
Body Temperature: The normal core body temperature of a healthy,
resting adult human being is stated to be at 98.6 degrees fahrenheit
or 37.0 degrees celsius.
Respiration: A respiratory rate, or breathing rate, is the number of
breaths a person takes in 1 minute while at rest. Respiratory rate can
be measured by counting the number of times a person’s chest rises
and falls within a minute.
The normal respiratory rate for babies from birth to 6 months is
30 to 60 breaths per minute; after the age of 6 months, breathing
has slowed to 24 to 30 breaths per minute. For children from the
age of 1 to 5 years old, normal respiration is 20 to 30 breaths per
minute. Children who are from 6 to 12 years old should have a
normal respiratory rate that ranges from 12 to 20 breaths per minute.
The normal respiratory rate for adults and children over the age of
12 ranges from 14 to 18 breaths per minute.
 Clinical Examination 75

Pallor: Pallor is a reduced amount of oxyhemoglobin in skin or

mucous membrane, a pale color which can be caused by illness,
emotional shock or stress, stimulant use, lack of exposure to sunlight,
anemia or genetics.
Pallor is more evident on the face and palms. It can develop
suddenly or gradually, depending on the cause. It is not usually
clinically significant unless it is accompanied by a general pallor (pale
lips, tongue, palms, mouth and other regions with mucous
membranes). It is distinguished from similar symptoms such as
hypopigmentation.
Possible causes:
• Migraine attack or headache
Library of School of Dentistry, TUMS

• Natural genetics
• Excess estradiol and/or estrone
For Personal Use Only

• Vitamin D deficiency
• Weight gain
• Osteoporosis
• Emotional response, due to fear, embarrassment, grief
• Anemia, due to blood loss, poor nutrition, or underlying disease
such as sickle cell anemia
• Shock, a medical emergency caused by illness or injury
• Frostbite
• Cancer
• Hypoglycemia
• Leukemia
• Albinism
• Panic attack
• Heart disease
• Peripheral vascular disease
• Hypothyroidism
• Hypopituitarism
• Scurvy
• Tuberculosis
• Sleep deprivation
• Depression
• Pheochromocytoma
 76 A Practical Manual of Public Health Dentistry

• Squeamishness
• Visceral larval migrans
• High doses or chronic use of amphetamines
• Reaction to ethanol and/or other drugs such as cannabis
• Lead poisoning.
Edema: It is an abnormal accumulation of fluid beneath the skin or
in one or more cavities of the body. Generally, the amount of
interstitial fluid is determined by the balance of fluid homeostasis,
and increased secretion of fluid into the interstitium or impaired
removal of this fluid may cause edema.
Cutaneous edema is referred to as “pitting” when, after
pressure is applied to a small area, the indentation persists for
Library of School of Dentistry, TUMS

sometime after the release of the pressure. Peripheral pitting

edema is the more common type, results from water retention.
For Personal Use Only

It can be caused by systemic diseases, pregnancy in some women,

either directly or as a result of heart failure, or local conditions
such as varicose veins, thrombophlebitis, insect bites, and
dermatitis.
Nonpitting edema is observed when the indentation does not
persist. It is associated with such conditions as lymphedema,
Lipoedema and myxedema.
Cyanosis: Cyanosis is a physical sign causing bluish discoloration of
the skin and mucous membranes. Cyanosis is caused by a lack of
oxygen in the blood. It is due to the presence of greater than, or
equal to, 2.5 g/dL of deoxygenated hemoglobin in blood vessels
near the skin surface.
Icterus: It is defined as a yellow discoloration of mucous membranes
and skin due to high concentrations of bilirubin in blood and tissues.
It is seen in the condition of jaundice.
Jaundice is often seen in liver disease such as hepatitis or liver
cancer.
Body mass index: Body Mass Index (BMI) is a number calculated
from a person’s weight and height. BMI provides a reliable indicator
of body fatness for most people and is used to screen for weight
categories that may lead to health problems.
 Clinical Examination 77

Calculation of BMI: BMI is calculated the same way for both adults
and children. The calculation is based on the following formula:

Weight (in kg)/[height (in m)]2

With the metric system, the formula for BMI is weight in

kilograms divided by height in meters squared.
Interpretation of BMI:
BMI WEIGHT STATUS
• Below 18.5 Underweight
• 18.5–24.9 Normal
• 25.0–29.9 Overweight
• 30.0 and Above Obese
Library of School of Dentistry, TUMS
For Personal Use Only
 10
Extraoral Examination

It includes the examination of skin, head, face, nose, paranasal sinuses,

Library of School of Dentistry, TUMS

external ear, nasal mucosa, lips, cheeks, lymph nodes, TMJ, muscles
For Personal Use Only

of mastication and salivary glands.

SKIN
Note the general appearance of the individual and the changes in
appearance or any rashes, sores or ulcerations. If present, is questioned.
Also note for the change in color of the skin as it signifies anemia
and jaundice. Generalized pallor is seen in severe anemia. Yellowness
of skin is seen in carotenemia. Pallor is seen in hypopituitarism, shock,
syncope and left heart failure.
Check out for texture of the skin. Skin becomes dry and inelastic
in dehydration and becomes greasy in acromegaly. Skin gets atrophied
with age and with steroid medications.
Also note for the abnormal signs such as petechial hemorrhages
(e.g. in blood dyscrasias), any eruptions, erosions, pigmentations
(e.g. in Addison’s disease, in Von Recklinghausen’s disease) or any
swelling or edema if present. The positive findings denote a specific
sign of characteristic abnormality which is to be questioned.

HEAD
Patient should be evaluated for head region in terms of its appearance,
its circumference, etc.
(Hydrocephalus is suspected when the growth of the head is
abnormal as compared to age and sex of the patient)
 Extraoral Examination 79

Shape of the Head

The head can be classified into one of the following three types:
1. Mesocephalic: Average shape of head. Patient usually possesses
normal shaped dental arches.
2. Dolichocephalic: Long and narrow shaped head. Patients usually
have narrow dental arches.
3. Brachycephalic: Broad and short shaped head. Patients usually
have a broad dental arch.

FACIAL FORM
The overall shape of the face is generally classified into following
three types:
Library of School of Dentistry, TUMS

1. Mesoprosopic: It is an average or normal facial form.

2. Euryprosopic: This type of face is broad and short.
For Personal Use Only

3. Leptoprosopic: It is a long and narrow form.

Facial Symmetry
Diagnosis of the symmetry of patients face is important so as to
determine the disproportions of face in transverse and vertical planes.
No face is ideally symmetrical on both the sides. Some degree of
asymmetry is always considered normal.
Asymmetries that are gross and identifiable should be noted and
recorded. Gross facial abnormalities can occur as a result of:
• Congenital defects
• Hemifacial hypertrophy/hypotrophy
• Unilateral condylar ankylosis/hyperplasia
• Chronic abscesses/presence of a large cyst/space infections (facial
swellings)
• Facial fractures, etc.

Facial Profile
Profile of the patient is determined by visualizing the patient from
the side. Profile assessment helps in diagnosing gross deviations in
the maxillomandibular relationship.
Three types of facial profiles have been classified:
1. Straight profile: an imaginary line is drawn from the forehead to
the upper lip and another line from the upper lip to the anterior
 80 A Practical Manual of Public Health Dentistry

point of chin. Both these lines when joined form a nearly straight
line.
2. Convex profile: the two imaginary lines form an angle with the
concavity facing the tissue. This type of profile is seen in a
prognathic maxilla or a retrognathic mandible.
3. Concave profile: the two imaginary lines form an angle with the
convexity towards the tissue. This type of profile s associated
with a prognathic mandible or a retrognathic maxilla.

NOSE, PARANASAL SINUSES, EXTERNAL EAR AND

NASAL MUCOSA
The nasal area should be examined for any sinus pain, discharge,
Library of School of Dentistry, TUMS

obstruction, continuous sneezing, periorbital swelling or

inflammation.
For Personal Use Only

Some of the common examples are:

• An apical abscess of upper tooth may lead to acute sinusitis.
• Nasal obstruction may lead to mouth breathing habit
• Epistaxis (nasal bleeding) is seen in severe conditions like cerebral
hemorrhage.

LIPS
Note the lip color, texture, and any surface abnormalities as well as
angular or vertical fissures, sores, ulcers, nodules, plaques, scars and
swellings. Notice the vermillion border and the presence of fordyce’s
granules.

CHEEKS
Note any changes in pigmentation and linea alba, any hyperkeratotic
or any hyperpigmented patch, swellings, nodules, scars or ulcers.

LYMPH NODES (FIG. 10.1)

Examination of neck nodes is important, particularly in head and
neck malignancies and a systematic approach should be followed.
Neck nodes are better palpated while standing at the back of the
patient. Neck is slightly flexed to achieve relaxation of muscles.
 Extraoral Examination 81
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 10.1: Lymph nodes of head and neck

When a node or nodes are palpable, look for the following

points:
• Location of nodes
• Number of nodes
• Size—Abnormal Nodes
– Greater than 1.5 cm in jugulo digastric area (level I, II, III)
– Greater than 1cm elsewhere
• Consistency. Metastatic nodes are hard; lymphoma nodes are firm
and rubbery; hyperplastic nodes are soft. Nodes of metastatic
melanoma are also soft
• Discrete or matted nodes.
• Tenderness. Inflammatory nodes are tender.
• Fixity to overlying skin or deeper str uctures. Mobility
should be checked both in the vertical and horizontal planes
(Fig. 10.2).
 82 A Practical Manual of Public Health Dentistry

The lymph nodes of head and neck region

are classified according to their position level:

Level I includes
• IA Submental nodes, which lie in the
submental triangle, i.e. between right and
left anterior bellies of diagastric muscles and
the hyoid bone.
• IB Submandibular nodes, lying between Fig. 10.2: Examination
of the neck nodes
anterior and posterior bellies of diagastric
muscle and the body of mandible.

Level II Upper Jugular Nodes

Library of School of Dentistry, TUMS

• They are located along the upper third of jugular vein, i.e. between
the skull base above, and the level of hyoid bone (or bifurcation
For Personal Use Only

of carotid artery) below.

Level III Middle Jugular Nodes

• They are located along the middle third of jugular vein, from the
level of hyoid bone above, to the level of upper border of cricoid
cartilage.

Level IV Lower Jugular Nodes

• They are located along the lower third of jugular vein; from upper
border of cricoid cartilage to the clavicle.

Level V Posterior Cervical Group

• They are located in the posterior triangle, i.e. between posterior
border of sternocleidomastoid(anteriorly), anterior border of
trapezius (posteriorly), and the clavicle below. They include lymph
nodes of spinal accessary chain, transverse cervical nodes and
supraclavicular nodes.

Level VI Anterior Compartment Nodes

• They are located between the medial borders of sternocleido-
mastoid muscles (or carotid sheaths) on each side, hyoid bone
 Extraoral Examination 83

above and suprasternal notch below. They include prelaryngeal,

pretracheal, paratracheal nodes.

Level VII
They are located below the suprasternal notch and include nodes of
the upper mediastinum.
Examination of Various Lymph Nodes
• Submental Nodes (Fig. 10.3)
Roll the fingers below the chin with patient’s head tilted forwards.
• Submandibular Nodes (Fig. 10.4)
Roll your fingers against inner surface of mandible with patient’s
head gently tilted on one side.
Library of School of Dentistry, TUMS

• Parotid (Preauricular) Nodes (Fig. 10.5)

Roll your finger in front of the ear, against the maxilla
For Personal Use Only

• Postauricular (Mastoid Nodes) (Fig. 10.6)

Roll the fingers behind the ear
• Internal Jugular Chain (Fig. 10.7)
Examine the upper, middle and lower groups.
Many of them lie deep to sternomastoid muscle which may
need to be displaced posteriorly.
• Transverse Cervical Nodes
• Supraclavicular (Scalene Nodes) (Fig. 10.8)
Roll your fingers gently behind the clavicles.

Fig. 10.3: Examination of submental Fig. 10.4: Examination of sub-

nodes mandibular nodes
 84 A Practical Manual of Public Health Dentistry

Fig. 10.5: Examination of Fig. 10.6: Examination of postauricular

Library of School of Dentistry, TUMS

preauricular nodes nodes

For Personal Use Only

Fig. 10.7: Examination of internal Fig. 10.8: Examination of

jugular chain supraclavicular chain

Instruct the patient to cough or to bear down like they are having
a bowel movement. Occasionally an enlarged lymph node may pop
up.
A normal lymph node cannot be felt. If a node is palpable, it
must be abnormal.
If a node is palpable, record the:
• Site
• Size-measure using vernier calipers
 Extraoral Examination 85

• Texture-soft (in case of infection), rubbery hard (in case of

Hodgkin’s disease), stony hard (in case of secondary carcinoma)
• Tenderness to palpation-in case of infection
• Fixation to surrounding tissues may suggest metastatic cancer
• Coalescence in case of tuberculosis
• Number of nodes-multiple in case of glandular fever,
leukemia, etc.
Palpable node characteristics:
• Acute infection—large, soft, painful, mobile, discrete, rapid onset
• Chronic infection—large, firm, less tender, mobile
• Lymphoma—rubbery hard, matted, painless, multiple
• Metastatic cancer—stony hard, fixed to underlying tissues, painless.
Library of School of Dentistry, TUMS

Area of Lymphatic Drainage of Face

For Personal Use Only

The face has three lymphatic territories:

a. The upper territory: Including the greater part of the forehead,
the lateral halves of the eyelids, the conjunctiva, the lateral part
of the cheek and the parotid area, drains into the preauricular
(parotid) nodes.
b. The middle territory: Including a strip over the median part of
the forehead, the external nose, the upper lip, the lateral part of
the lower lip, the medial halves of the eyelids, the medial
part of the cheek and the greater part of the lower jaw, drains
into the submandibular nodes.
c. The lower territory: Including the central part of the lower lip
and chin, drains into the submental nodes.

TEMPOROMANDIBULAR JOINT
The importance is to determine deviation of jaw from the midline
during the opening and closing of the jaws.
Causes of jaw deviation:
• Traumatic injuries of the joint
• Infection of the jaw
• Fractures of the jaw
• Muscular hypertrophy and hypotrophy.
 86 A Practical Manual of Public Health Dentistry

The lateral mandibular range of motion or movement is assessed

“normal 8 to 10 mm” by having the patient to occlude the teeth
and then slide the jaw in both directions. The range of movement
from midline and any pain, location and severity is recorded.
Maximum interincisal opening: As a general guide, mobility is
considered to be reduced if the subject is unable to open his or her
jaw to the width of two fingers (< 30 mm).

Palpation: (Figs 10.9A to C)

• Palpation of TMJ may be bimanual and bidigital palpation; may
be extra-auricular or intra-auricular.
• The palpation may reveal pain and irregularities during condylar
Library of School of Dentistry, TUMS

movement, described as clicking or crepitus. Clicking reveals the

internal derangement of TMJ.
For Personal Use Only

• The lateral pole of condyle is most accessible for palpation during

mandibular movements.
• Palpation just anterior and posterior to the lateral pole detects
pain associated with TMJ capsular ligament.
• The comparison between both condyles must be assessed by
palpation.

MUSCLES OF MASTICATION (FIGS 10.10A TO G)

• The patient is asked to clench their teeth and, using both hands,
the practitioner palpates the masseter muscles on both sides, making
sure that the patient continues to clench during the procedure.

A B C

Figs 10.9A to C: TMJ examination: A. Measuring maximum interincisal opening;

B. Palpation of the pretragus area, lateral aspect of the TMJ; C. Intra-auricular
palpation, the posterior aspect of TMJ
 Extraoral Examination 87

A B C
Library of School of Dentistry, TUMS

D E
For Personal Use Only

F G

Figs 10.10A to G: Examination of muscles of mastication: A. Palpation of the

masseter muscles; B. Bimanual palpation of the masseter muscles; C. Palpation of
the lateral pterygoid muscles; D. Palpation of the medial pterygoid muscle;
E. Palpation of the temporalis muscle; F. Palpation of the sternocleidomastoid;
G. Palpation of the trapezius muscles

• Palpate the origin of the masseter along the zygomatic arch and
continue to palpate down the body of the mandible where the
masseter is attached.
• Parafunctions such as bruxism and clenching also gives rise to
masseter pain that is frequently associated with pain in the
temporalis muscle.
• The temporalis is palpated in much the same manner to detect
lateral interferences.
• The lateral pterygoid muscle is sometimes painful on the
contralateral side in patients with nonworking side interferences.
 88 A Practical Manual of Public Health Dentistry

• In addition, this muscle will be painful whenever there is a centric

slide with an anterior component and the patient is bruxing or
clenching in this anterior position.
• The lateral pterygoid, despite its commonality in displaying a
spasm, cannot be palpated intraorally.
• The medial pterygoid muscle is not usually involved in gnathic
dysfunctions but when they are hypertonic, the patient is usually
conscious of a feeling of fullness in the throat and an occasionally
pain on swallowing.

SALIVARY GLANDS

Parotid Gland
Library of School of Dentistry, TUMS

• Check for any swelling over the region. Note the extent, size
For Personal Use Only

shape and consistency of the gland over the area. The position
determination is vital so as to rule out the lymph node swellings
that may be confused with parotid swellings.
• In case of parotid abscess, the skin over the area becomes
edematous with pitting on pressure.
• Examine the area for presence of any fistula, and enlargement of
lymph nodes or involvement of facial nerves.
The parotid gland duct (stenson’s duct) opens in the buccal
mucosa opposite to the crown of maxillary second molar. Retract
the cheek for its proper examination.

Submandibular Gland
• History of the patient is to be noted, e.g. swelling with pain at
the time of meals suggests obstruction in submandibular duct.
Calculi are more common in submandibular gland as compared
to others major salivary glands.
• Check for any nodal swelling, it may suggest of lymph node
enlargement.
Inspection over the area of the gland should be done to check
the overlying skin color and distension of the mucosa and the
orifice of the Wharton’s duct.
 Extraoral Examination 89

• Bimanual palpation — in the open mouth, the physician’s finger

of one hand is placed on the floor of the mouth and pressed as
far as possible. The finger of the other hand is placed on the
exterior at the inferior margin of the mandible. These fingers are
pushed upwards and palpation is achieved.
If the gland or duct is infected, slight pressure over the gland
will exudates pus from its orifice.
If any obstruction is suspected, it is checked by placing dry cotton
over both the orifices, and the patient is asked to suck lemon juice
for 2 minutes. After 2 minutes, both the rolls are taken out. The
gland that is obstructed will not wet the cotton on its side.
Library of School of Dentistry, TUMS
For Personal Use Only
 11
Intraoral Examination

SOFT TISSUE EXAMINATION

Library of School of Dentistry, TUMS

Examination of Lips and Labial Mucosa

For Personal Use Only

Logically, the intraoral examination begins with the examination of

the lips. The exposed red portion of the lips, or the vermillion border,
forms a transition between the external skin and the moist mucous
membrane of the oral mucosa.
Because the overlying epithelium is thin, a normal lip shows the
characteristic reddish color. Several folds and sulci over the epithelium
of the lip may crease the skin. The thick, pink labial mucosa that
lines the internal surfaces of the lips may appear mildly lumpy or
nodular on visual inspection. This is due to the presence of accessory
salivary glands found just beneath the mucosal surface.
Both the upper and lower lips have a flap of tissue called a frenum
or frenulum, which attaches to the midline mucosa of the maxillary
and mandibular alveolar processes.
The clinical features of normal lips and labial mucosa are:
• Reddish color over the area
• Folds and sulci over the surface of lips
• Absence of any plaque or patchy area
• Absence of any erosive areas
The lips and the labial mucosa are examined by the observation of
the patient at rest. The lips are normally in contact or slightly apart.
The lip line, the level of the edge of the lip should be noted, both at
 Intraoral Examination 91

rest and when the patient smiles. Any abnormalities should be carefully
noted and recorded. A careful evaluation of the lip by bidigital palpation
is done using the index finger and the thumb to gently squeeze the lip
mass. Any abnormalities to sight or feel are carefully recorded.
The lips are thus recorded for:
• Competency
• Color
• Texture
• Fissuring
• Shape
• Presence of any lump or hard tissue.
Some of the common conditions that manifest as lip
Library of School of Dentistry, TUMS

abnormalities are:
1. Lip pits and commissural pits: These are congenital defects of lip
For Personal Use Only

and labial mucosa that result in unilateral or bilateral depression

or pit that may occur on the lip region or on the commissures
(angles of mouth).
2. Cleft lip: These are one of the most common developmental
malformations. The incidence of cleft lip varies from 1:500 to
1:2500 in Asians. It presents a unilateral or bilateral deficiency
over the lip area, extending up to the nasal area. Cleft lip is most
common in upper lip. Cleft lip is also commonly associated with
cleft palate (Figs 11.1A and B).
3. Angular cheilitis: Inflammatory lesion at the labial commissure,
or corner of the mouth, and often occurs bilaterally. The condition
manifests as deep cracks or splits.
4. Angioedema: Diffuse edematous swelling occurring as a result of
allergic reactions. Spreads to other tissues very rapidly and should
be treated instantly.

Examination of Buccal Mucosa

Buccal mucosa is the internal lining of the cheek region. The mucous
membrane often varies considerably in thickness from one area to
another but it is generally thick and pink like the labial mucosa with
which it is continuous.
 92 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS

A
For Personal Use Only

Figs 11.1A and B: (A) Unilateral cleft lip, (B) bilateral cleft lip

Occasionally, there is seen a white line running anteroposteriorly

at the occlusal level, termed as Linea Alba. This line is produced by
continuous pressing of buccal mucosa by the teeth due to the action
of buccinators. Also, a frequent observation of small yellow nodules
is seen at the posterior parts of buccal mucosa. These are actually the
ectopic sebaceous glands, termed as Fordyce’s Granules.
 Intraoral Examination 93

Clinically, a normal buccal mucosa presents:

• Pink to slight reddish surface
• Occasionally, Linea alba may be present
• Occasional occurrence of Fordyce’s granules.
The buccal mucosa can be best visualized when the patient
partially opens the mouth. A mouth mirror or clinicians finger can
be used to retract the cheek to expose all the areas. Gauze should be
used to dry the surface of buccal mucosa when required. Any
abnormal finding should be carefully noted and recorded.
Some of the common conditions in buccal mucosa that mani-
fest as abnormalities are:
1. White lesions of oral cavity: Such as hyperkeratosis, leukoplakia,
actinic keratosis, candidiasis, chewer’s mucosa, white sponge
Library of School of Dentistry, TUMS

nevus, lichen planus, etc.

2. Red lesions of oral cavity: Hemangiomas, varix, erythroplakia,
For Personal Use Only

ecchymosis, etc.
3. Ulcerative lesions of oral cavity: Trauma, apthous stomatitis,
herpangina, behcet’s syndrome, etc.

Examination of the Floor of the Mouth

The floor of the mouth is a narrow, horse shoe shaped depression
lying between the base of the tongue and alveolar processes of the
mandible. There is present in the midline a Lingual Frenulum,
connecting the inferior surface of the tongue with the floor of the
mouth.
Clinically, a normal floor of mouth presents:
• Shiny pink surface
• Presence of normal lingual frenal attachments
• Absence of any patchy or ulcerated lesion.
The best view of the floor of the mouth is seen by asking the
patient to raise the tongue to the roof of the mouth and then using
a mouth mirror to further retract the tongue away from the medial
sides of the mandible. The mucosa is gently dried with gauze.
Palpation is done by gently pressing the floor of the mouth by
index finger of one hand and the opposite hand palpating from
outside of the jaw extra orally, gently pressing up.
 94 A Practical Manual of Public Health Dentistry

Some of the common conditions of floor of mouth that mani-

fest as abnormalities are:
• Mandibular tori: A physiologic enlargement of alveolar process
on the lingual surface that can be seen while examining the floor
of the mouth.
• Ranula: A traumatic swelling that occurs on the floor of mouth
as a result of calculi in the duct of salivary gland or obstruction
of minor salivary glands on the surface.

Examination of the Tongue

The dorsum of a healthy tongue is covered by a mucous membrane,
which is rough due to the presence of thousands of papillae projecting
onto the surface. There are three types of papillae present on the surface:
Library of School of Dentistry, TUMS

1. Filiform papillae: these are the most numerous type of papilla,

with small, spikelike projections covering most of the surface of
For Personal Use Only

tongue. This papilla does not contain taste buds and are
responsible for surface roughness.
2. Fungiform papillae: these are the second most numerous papillae,
containing taste buds, having mushroom shaped projections, most
commonly on the lateral borders and on the tip of tongue.
3. Circumvallate papillae: these are 7 to 14 in number, distinctively
present slightly anterior to the sulcus terminalis (a v-shaped groove
on the posterior part of tongue), running parallel to it. Each
circumvallate papilla is surrounded by a trough or crypt, into
which numerous taste buds open.
A normal tongue presents the following characteristics:
• A moist, reddish mucosa over the dorsal surface
• Roughness over the dorsal surface indicating the presence of papilla
• Absence of any plaque or ulcer.
The dorsal and lateral surfaces of the tongue are best examined
by asking the patient to open his mouth wide and the tongue thrust
forward. A piece of gauze is wrapped around the tip of the tongue,
enabling the clinician to manually move the tongue by itself, for
examining the lateral borders.
All surfaces of the tongue should be carefully inspected and palpated
by running a finger firmly over the surfaces. Care must be taken not
to stimulate the patient’s gag reflex by touching the soft palate.
 Intraoral Examination 95

Some of the conditions of tongue that manifest as abnormalities

are:
• Aglossia: Absence of tongue
• Microglossia: Decrease in size of tongue
• Macroglossia: Increase in size of tongue
• Ankyloglossia: Also known as ‘tongue-tie’. A condition, where
lingual frenum attaches overly to the bottom of the tongue and
restricts its free movement (Fig. 11.2)
• Sprue: A common condition seen in malabsorption syndrome
where tongue becomes severly ulcerated and inflamed with a
painful, burning sensation
• Iron deficiency anemia: Tongue presents depapillated areas with
erosive lesions
Library of School of Dentistry, TUMS

• Fissured Tongue
• Geographic Tongue
For Personal Use Only

• Ulcers
• Squamous Cell Carcinoma
• Median rhomboid glossitis.

Examination of the Hard and Soft Palate

The hard palate forms two third of the palatal region, lying between
the alveolar processes of the maxilla and palatine bones. The soft palate

Fig. 11.2: Ankyloglossia

 96 A Practical Manual of Public Health Dentistry

is just the posterior one third of the palatal region, and is formed by a
group of small palatal muscles covered by a mucous membrane.
The hard palate consists of an incisive papilla, a soft tissue portion
overlying the incisive canal, a median palatine raphe, which can be
distinguished by a shallow depression or a low ridge extending to
the soft palate and palatine rugae, which are dense ridges of mucosa
present on anterior hard palate. The soft palate consists of a soft
tissue projection in the midline termed as the uvula.
The hard and soft palates can be best visualized when the patient’s
head is tilted back as the patient lies in a supine position with the
mouth wide open. A mouth mirror may be used for additional help.
In addition, the patient is asked to say ‘ahhh’ as the examiner gently
Library of School of Dentistry, TUMS

depresses the tongue, visualizes the soft palate function.

Some of the common conditions of palate that manifest as
For Personal Use Only

abnormalities are:
• Cleft palate: A common developmental anomaly resulting in
incomplete fusion of the two lateral processes creating a gap in
the palatal shelf. Cleft palate may be complete (involving the
hard and soft palate) or incomplete (involving only the hard palate
or only the soft palate) (Fig. 11.3).

Fig. 11.3: Cleft Palate

 Intraoral Examination 97

• Torus palatinus: A slow growing, physiologic, bony protuberance

occurring in the midline area of the palate.
• Smoker’s palate: A common condition where multiple petechiae
are seen over the hard palate, as a result of inflammation of minor
salivary glands and hyperkeratosis in response to tobacco smoking
(Fig. 11.4).

Examination of Swelling
• Inspection: A good observation of the lump is important for
determining the nature of the swelling. A few points must be
considered:
– Site of the swelling
Library of School of Dentistry, TUMS

– Shape of the swelling

– Size of the swelling
For Personal Use Only

– Surface mucosa
– Edges
– Number

Fig. 11.4: Smoker’s Palate

 98 A Practical Manual of Public Health Dentistry

– Movement with deglutition

– Movement with protrusion of tongue.
• Palpation: This is the most important part of the physical
examination of the swelling, giving many clues about the diagnosis.
The swelling must be gently palpated to avoid producing any
associated problems. Following points must be noticed:
– Surface temperature: localized temperature may be raised in
cases of increased vascularity as in inflammatory swellings.
– Tenderness: If the patient complains of pain while touching
the swelling, it is considered as tender. The inflammatory
swellings are mostly tender.
– Consistency: The consistency of a swelling indicates the
contents of the swelling and the clue to which anatomical
Library of School of Dentistry, TUMS

structure it is derived from. A soft swelling may indicate a

For Personal Use Only

cyst or an acute abscess and a hard swelling may indicate of a

neoplasm or a chronic abscess.
– Size, shape and extent: On palpation, a general idea can be
taken about the deeper dimensions of the swelling inside the
oral cavity which is not evident from inspection.
– Fluctuation: to determine a fluctuant swelling, a sudden
pressure is applied at one end of the swelling, and vibrations
are felt at the other end. When a swelling fluctuates, it indicates
the presence of a liquid or a gas, e.g. in case of lipoma, irritation
fibroma, etc.
– Translucency: The amount of clear fluid (such as water, serum,
plasma, fat globules) present in a swelling decides the amount
of light to pass through it. It is mostly used to analyze extra-
oral swellings. A torch is used to produce light to be
transmitted through the swelling, e.g. Ranula, Mucocele.
– Fixity to the skin: pedunculated swellings (such as papilloma)
or sessile swellings (such as sebaceous cyst) are assessed.
– Relation to surrounding structures: The clinician must try to
assess the anatomical structure from which the swelling has
originated and must assess whether it is confined to that
structure or has invaded to other structures. This is mostly
done to rule out malignancies in the orofacial region.
 Intraoral Examination 99

• State of the regional lymph nodes: The lymph nodes associated

with the area of swelling should be assessed for determining
chronicity and tenderness.

Examination of Ulcer
• Inspection: following points should be considered:
– Size and shape: different diseases produce a variety of ulcers
(for example, syphilitic ulcers are circular or semilunar,
carcinomatous ulcers are irregular in shape, traumatic ulcers
take the shape of the injurious agent, etc).
– Number: ulcers of neoplastic origin, tuberculous ulcers, etc.
are solitary while other are numerous in number. For example,
Library of School of Dentistry, TUMS

recurrent apthous ulcers.

– Position: position of the ulcer over the face or in the oral cavity
For Personal Use Only

itself gives an important clue about the diagnosis (ulcers of

squamous cell carcinoma reside mostly in the middle third of
face, position of traumatic ulcers in denture wearers gives the
idea of the offending artificial tooth, etc.)
– Edges: It suggests of both the diagnosis and the condition of
the ulcer. Five common types of ulcer edges are seen:
- Undermined edge: seen in tubercular ulcers. The ulcer
spreads and destroys the subcutaneous tissue faster than
skin.
- Punched out edge: mostly seen in gummatous or recent
traumatic ulcers. The edge is seen at right angles to the
base of ulcer.
- Sloping edge: healing ulcers mostly present this edge. It
suggests that the disease is confined within the ulcer itself,
not beyond that.
- Raised edge: is a feature of rodent ulcer.
- Rolled out (averted) edge: suggests neoplastic diseases.
The fast growing cellular matter heaps up and spills over
the normal skin to produce an everted edge.
– Floor: This is the major portion of the ulcer and is exposed to
the environment. The presence of granulation tissue over the
 100 A Practical Manual of Public Health Dentistry

base indicates a healing ulcer. A smooth and shiny base

indicates a growing, inflamed ulcer.
– Discharge: The amount and nature of discharge from the ulcer
should be noted. A spreading and inflamed ulcer will produce
a purulent discharge. Discharge may also be associated with
the etiologic organism associated with the disease.
– Surrounding area: Generally, the surrounding of an acute ulcer
is inflamed. Wrinkling around the ulcer may indicate a healing
ulcer which may produce a scar.
• Palpation: Following points should be kept in mind:
– Tenderness: Acute ulcers are usually found to be more tender
than the chronic ones.
– Depth: Depth of an ulcer is to be noted.
Library of School of Dentistry, TUMS

– Bleeding: clinician must see whether the ulcer bleeds on

For Personal Use Only

touching or not. It is a common feature of a malignant ulcer.

– Surrounding skin: increased temperature and tenderness of
the adjoining skin is seen in an acute ulcer.
– Relation with deeper structures.
• Examination of lymph nodes: The regional lymph nodes
relating to the area of the ulcer must be assessed. In acutely
inflamed ulcers, the lymph nodes become large and tender. A
chronic nonhealing ulcer may too produce an enlarged lymph
node. In malignant ulcers, the nodes are stony hard and fixed to
the surrounding structures.

Periodontal Examination
The periodontal assessment is typically done after the extraoral and
intraoral assessment, and mostly after the dental assessment. In this
way, a number of periodontal abnormalities can be directly associated
to dental hard tissue problems such as faulty restorations, open
contacts, malpositioned teeth, anatomical variations, etc.
The visual examination of periodontium is difficult because the
appearance of periodontal disease varies widely. Instruments such as
mouth mirror, periodontal probe, furcation probe, explorer, etc. are
necessary for the complete assessment of the periodontium.
 Intraoral Examination 101

The components of the periodontal examination include:

• Visual characteristics of gingiva
– Color
– Contour
– Consistency
– Surface Texture
– Shape
– Size
• Periodontal pocket assessment
• Assessment of gingival recession and the level of gingival attachment
• Detection of bleeding while probing
• Detection of suppuration
• Detection and measurement of furcations.
Library of School of Dentistry, TUMS

Gingival Characteristics
For Personal Use Only

• Color: Healthy gingiva has always been described as being coral

pink, although variable melanin pigmentation between individuals
may differ its appearance. An inflamed gingiva may appear
erythematous or cyanotic or both. Capillary dilation due to
inflammation make the gingiva appear red and shiny. Gingival
color is not a good indicator of its health as normal colored gingiva
may exhibit deep pockets too.
• Contour: A healthy gingival contour follows the margin of
underlying bone. In an inflamed gingiva, the connective tissue is
destroyed and hence, the accumulation of extracellular fluid
occurs in it. This edema, swells up the tissue and normal contour
is lost. A rimlike enlargement of gingival margin is also observed
and noted as rolled or rounded.
• Consistency: Healthy gingiva is firmly bound to underlying bone
and tooth. Inflamed gingiva, being edematous, the gingiva here
loses its firmness and resiliency. The papilla can be seen retractable,
the tissue becomes loose.
• Surface Texture: Normal gingiva shows an orange peel like
appearance which is termed stippling. Histologically, stippling is
formed by intersection of epithelial rete pegs and the interspersing
penetration of connective tissue papillae. Loss of stippling occurs
when gingival loses its resiliency, i.e. it becomes edematous.
 102 A Practical Manual of Public Health Dentistry

• Size: A healthy gingiva is flat and not enlarged, fitting snugly

around the tooth. The fitting is because of the attached gingiva
that varies among patients and in different areas of the mouth
from 1 to 9 mm.
In an inflamed gingiva, the size becomes enlarged, either
localized to specific areas or generalized throughout the gingiva.
The amount of false pocket depth also increases.
Size of gingiva increases in:
– Chronic gingival inflammations
– Pregnancy associated gingivitis
– Puberty associated gingivitis
– Drug induced gingival reactions.
• Position: The actual position of the gingiva is at the level of the
Library of School of Dentistry, TUMS

attached periodontal tissue, but it can only be determined by

For Personal Use Only

probing. In a fully erupted tooth in and adult, the apparent

position of gingival margin is normally at the level of, or slightly
below, the enamel contour or prominence of the cervical third
of the tooth.
In a diseased gingiva, the margins of gingiva may be high on
the enamel or at a lower level exposing a part of the cervical area
and the root surface.
Conditions producing a high margin:
– Gingival enlargements
– Short clinical crowns.
Conditions producing a lower margin:
– Gingival recessions
– Trauma from occlusion
– Supraeruption
– long clinical crowns.
• Bleeding on probing: The insertion of probe to the bottom of the
pocket elicits bleeding if the gingiva is inflamed, atrophic or
ulcerated. In most cases, bleeding on probing is an earlier sign of
inflammation than gingival color changes.
To test for bleeding, a blunt periodontal probe is carefully
introduced to the bottom of the pocket along the long axis of
the tooth and is gently moved with a weight ranging from
 Intraoral Examination 103

20 to 25 grams. The clinician should wait for at least 30 seconds

to check the presence of any bleeding (Figs 11.5A and B).
Bleeding on probing occurs when:
• Gingiva is inflamed
• Ulcerated
• Necrosed.
• Exudate: In a clinically healthy gingiva, there is no exudation
from the gingival sulcus except a slight gingival sulcular fluid,
Library of School of Dentistry, TUMS
For Personal Use Only

Figs 11.5A and B: Bleeding on probing

 104 A Practical Manual of Public Health Dentistry

which cannot be seen by visual observation. But in an inflamed

gingiva, the amount of sulcular fluid is increased and there may
be an evidence of suppurative exudation from the gingival sulcus.
Although exudation is an important sign of inflammation, it does
not give any information about the depth of periodontal pockets.

Periodontal Pocket Assessment

A periodontal pocket occurs as a result of apical migration of the
junctional epithelium in the presence of disease from the CEJ.
A calibrated periodontal probe must be used to both detect and
measure the depth of pocket. The periodontal probe consists of a
handle connected to a tapered shank with a working end marked in
millimeters, terminating in a blunt tip.
Library of School of Dentistry, TUMS

The most common probes used for measuring pocket depth

For Personal Use Only

are:
• Michigan ‘O’ probe: markings are at 1-2-3-5-7-8-9-10 mm
• The WHO/CPITN probe: markings are at 0.5-3.5-5.5-8.5-
11.5 mm (Fig. 11.6).
• William’s periodontal probe: markings are at 1-2-3-5-6-
8-9 mm (Fig. 11.7).

Fig. 11.6: CPITN probe

 Intraoral Examination 105
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 11.7: William’s periodontal probe

Probing is done by gently inserting the probe into the sulcus parallel
to the long axis of the tooth with a mild force of 20 to 25 gms. At the
‘col’ space, the probe is tilted slightly (up to 10 degrees) to ensure an
accurate reading. Measurements for a tooth are usually made at all the
surfaces individually. The tendency to probe gently in the anterior
region and more forcefully in the posterior region leads to inaccurate
measurements and patient discomfort. A clinically acceptable healthy
gingiva may have a sulcus depth ranging from 1 to 3 mm.

Attachment Loss and Gingival Recession

Probing depth alone does not indicate the amount of periodontal
destruction, assessing the loss of attachment is also vital. Loss of
attachment, the distance between the CEJ and the base of the pocket,
is the true clinical measure of the amount of destruction.

Furcation Assessment
The point at which the root trunk on a multirooted tooth diverges
to form more than one root is called a furcation or furca. Bone loss
 106 A Practical Manual of Public Health Dentistry

during the periodontal disease may progress to the level that results
in involvement of the furcation area. Once a furcation gets involved,
the prognosis of the tooth decreases significantly.
Naber’s probe is the probe of choice for detecting and measuring
furcation areas (Fig. 11.8). It is a double-ended curved probe with
alternate 3 mm markings. While examination, the tip of the Nabers
probe should be held as parallel as possible to the long axis of the
tooth and the furcation is explored as the probe is moved with a
horizontal walking stroke apically and laterally into the furca.
In 1953, Irving Glickman graded furcation involvement into the
following four classes:
Grade I: Incipient furcation involvement, with any associated
pocketing remaining coronal to the alveolar bone; primarily affects
Library of School of Dentistry, TUMS

the soft tissue. Early bone loss may have occurred but is rarely
For Personal Use Only

evident radiographically.
Grade II: There is a definite horizontal component to the bone
loss between roots resulting in a probeable area, but bone remains

Fig. 11.8: Naber’s probe

 Intraoral Examination 107

attached to the tooth so that multiple areas of furcal bone loss, if

present, do not communicate.
Grade III: Bone is no longer attached to the furcation of the tooth,
essentially resulting in a through-and-through tunnel. Because of
an angle in this tunnel, however, the furcation may not be able to
be probed in its entirety; if cumulative measurements from different
sides equal or exceed the width of the tooth, however, a grade III
defect may be assumed. In early grade III lesions, soft tissue may
still occlude the furcation involvement, though, making it difficult
to detect.
Grade IV: Essentially a super grade III lesion, grade IV describes
a through-and-through lesion that has sustained enough bone
loss to make it completely probeable.
Library of School of Dentistry, TUMS

Mobility Test
For Personal Use Only

The periodontal attachment surrounding the tooth is evaluated by

using the test. The test is performed by moving the tooth laterally in
its socket either by using a back end of a mirror and a finger or by
using the handles of two instruments.
Mobility is of two types:
1. Pathologic mobility: resulting from destruction of attachment
apparatus around the tooth, or by parafunctional habits.
2. Adaptive mobility: resulting from anatomic factors such as short
root-crown ratio, or short roots, etc.
Tooth mobility is measured by:
1. According to Glickman:
a. Grade I–Slightly more than normal
b. Grade II–Moderately more than normal
c. Grade III–Severe mobility also in the lateral sides combined
with vertical depression
2. According to Miller in 1950:
0 – It denotes no detectable movement when force is applied
except for the normal (physiologic) mobility.
1 – Mobility greater than normal
2 – Mobility upto 1 mm in buccolingual direction
3 – Mobility greater than 1 mm in buccolingual direction with
the ability to depress the tooth.
 108 A Practical Manual of Public Health Dentistry

Check for the presence of any root stump, filled tooth,

defective restorations, the areas devoid of teeth (missing teeth
areas), any supernumerary teeth or any other abnormality present
in the dentition.

Detection of Suppuration
Suppuration is the formation or secretion of PUS. Pus is an exudate,
resulting from inflammatory products consisting of leukocytes and
debris of dead cells and tissue elements. The presence of suppuration
indicates the presence of inflammation of the periodontium, but does
not signify its severity. Notably, suppuration is not related to pocket
depth too.
Library of School of Dentistry, TUMS

HARD TISSUE EXAMINATION

For Personal Use Only

A proper hard tissue evaluation involves more than just reporting

the positive findings over the area. Condition presented in the
intraoral examination should be comprehensively recorded and
compared to the results of history. The way and order of the
comprehensive recording depends on dentist’s preference.

Dentition
There are different nomenclature systems proposed for naming each
tooth in the oral cavity:
FDI (two digit system): This is the most commonly used
system. The first digit in the system indicates the quadrant
number and the second digit denotes the number of tooth
in the quadrant.
Permanent teeth:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Primary teeth: 55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Zsigmondy and palmer system: The oldest method, divides the
oral cavity into four quadrants.
 Intraoral Examination 109

The deciduous teeth are named by the formula

E D C B A A B C D E
E D C B A A B C D E
The permanent teeth are named by the formula
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Universal system: The entire dentition is named by continuous
alphabets/numbers after dividing the quadrants.
Deciduous teeth: A B C D E F G H I J
T S R Q P O N M L K
Permanent teeth:
Library of School of Dentistry, TUMS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
For Personal Use Only

Dane system:
For permanent teeth:
8+ 7+ 6+ 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 +6 +7 +8
8– 7– 6– 5– 4– 3– 2– 1– –1 –2 –3 –4 –5 –6 –7 –8
For primary teeth:
05+ 04+ 03+ 02+ 01+ +01 +02 +03 +04 +05
05– 04– 03– 02– 01– –01 –02 –03 –04 –05

Dental Caries Assessment

Dental caries: It is an infectious, microbiological disease of teeth that
results in localized dissolution and destruction of the calcified tissue.
Any type of carious exposure to the patient is examined and
recorded. The caries below an existing restoration are also carefully
checked and recorded.

Classification of Caries
According to EXTENT of lesion:
• Incipient caries (Initial or primary): Carious lesion appears as a
white opaque region (white spot lesion)
• Cavitated caries: The enamel surface is broken (not intact) and
the lesion has advanced into enamel/dentin. No remineralization
is possible at this stage.
 110 A Practical Manual of Public Health Dentistry

According to RAPIDITY of caries progression

• Acute caries (active): spreads rapidly invading almost the entire
dentition. It involves several teeth. The carious lesion is soft and
light-colored. For example, Rampant caries appears suddenly in
the dentition and progresses rapidly with early pulp involvement.
• Chronic caries (slow): caries spreading slowly over the tooth
surface. The carious lesion is darker in colour and harder in
consistency due to repeated phases of demineralization and
remineralization.
According to PREVIOUS treatment
• Primary caries: Primary caries is the original carious lesion of the
tooth
Library of School of Dentistry, TUMS

• Recurrent caries (secondary): Occurs at the interface of tooth

and restorative material.
For Personal Use Only

According to the INVOLVING SITES and SURFACES to be

treated:
GV BLACK’S classification:
CLASS 1: Cavities on occlusal surface of premolars and molars,
on occlusal two-thirds of the facial and lingual
surfaces of molars, and on lingual surfaces of molars.
CLASS 2: Cavities on proximal surfaces of posterior teeth.
CLASS 3: Cavities on proximal surfaces of anterior teeth that
do not involve the incisal angle.
CLASS 4: Cavities on proximal surfaces of anterior teeth that
do involve the incisal edge.
CLASS 5: Cavities on the gingival third of the facial and lingual
surface of all teeth.
CLASS 6: Cavities on the incisal edge of the anterior teeth or
occlusal cusp heights of posterior teeth.
Based on LOCATION of caries:
• Pit and fissure caries
• Smooth surface caries
• Root surface caries
– Check out for any defective restoration or recurrent caries.
 Intraoral Examination 111

Percussion Test
This test evaluates the status of periodontium around the tooth. It is
done by two methods: vertical percussion and horizontal percussion
test. The percussion test is done by striking the tooth with a quick,
moderate blow, first on the teeth adjacent to the suspected teeth
and then in succession to the last teeth.
If vertical percussion test comes positive, it indicates periapical
pathology and if horizontal percussion test is positive, it indicates
periodontium pathology. Also, the patient’s response over the striking
of the tooth is noted.

Malocclusion
Library of School of Dentistry, TUMS

Edward Angle gave the classification for permanent dentition

For Personal Use Only

(1890):
• Class I—Arch in normal mesiodistal relationship, the mesio-
buccal cusp of the maxillary first permanent molar coincides
with the buccal groove of the mandibular permanent first
molar (Fig. 11.9).
• Class II—The distobuccal cusp of the upper first permanent molar
coincides with the buccal groove of the lower first permanent
molar (Figs 11.10A and B).
• Class III—The mesiobuccal cusp of maxillary first permanent
molar coincides with the interdental space between the
mandibular first and second permanent molar (Fig. 11.11).

Developmental Anomalies of Teeth

Developmental anomalies of teeth are not very rare and can occur at
various stages of tooth development:
• Dental Lamina formation stage: Anodontia (no teeth)
• Initiation and Proliferation (during the formation of tooth bud):
Partial anodontia, supernumerary, geminated/fused teeth
• Histo-differentiation: Odontodysplasia
• Morpho-differentiation: Macro/micro size, dans invaginatus,
dens evaginatus, Hutchinson’s Incisors, talon cusp, taurodon-
tism, dilacerations
 112 A Practical Manual of Public Health Dentistry

Fig. 11.9: Class I

malocclusion
Library of School of Dentistry, TUMS

Figs 11.10A and B:

Class II malocclusion:
For Personal Use Only

A. Class II Div. 1;
B. Class II Div. 2

B
 Intraoral Examination 113
Library of School of Dentistry, TUMS

Fig. 11.11: Class III malocclusion

For Personal Use Only

• Apposition–matrix formation
– Amelogenesis imperfecta
– Dentinogenesis imperfecta
– Enamel Hypoplasia (Fig. 11.12)
• Calcification–mineralization of the matrix
– Fluorosis
– Amelogenesis Imperfecta.

Wasting Diseases of Teeth

Tooth wear describes the noncarious loss of tooth tissue as a result
from the interaction of four processes which may occur in isolation
or in combination; attrition, erosion, abrasion and abfraction.
Erosion is a chemical process in which the tooth surface is
removed in the absence of plaque. Erosive factors may be either
intrinsic or extrinsic. Extrinsic sources include drinks such as fresh
fruit juices, carbonated drinks and alcoholic beverages; and some
foods and industrial processes. Intrinsic sources include gastro-
esophageal reflux and eating disorders (Fig. 11.13).
Abrasion refers to the loss of tooth structure due to external
agents which have an abrasive effect on the teeth for example,
toothbrush bristles and dietary factors (Figs 11.14A and B).
 114 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS

Fig. 11.12: Enamel Hypoplasia

For Personal Use Only

Attrition is a process in which tooth tissue is removed as a result

of opposing tooth sur faces contacting during function or
parafunction. Such direct contact occurs at proximal areas, on
supporting cusps and on guiding surfaces during empty grinding
movements (Figs 11.15A and B).
Abfraction (stress lesions) has been suggested to be as a conseque-
nce of eccentric forces on the natural dentition. Cusp flexure causes
stress at the cervical fulcrum and results in loss of the overlying tooth
structure. The lesion is typically wedge shaped with sharp line angles,
but occlusal abfractions may present as circular invaginations
(Figs 11.16A and B).
Bruxism: It is defined as the grinding of teeth during nonfunctional
movements of the masticatory system. The wear is usually uniform
when opposing teeth are affected. Bruxism can also be associated with
muscle spasm, fractured teeth and restorations (Figs 11.17A and B).

Enamel Hypoplasia
Enamel hypoplasia is a defect that occurs when dental enamel doesn’t
form completely, usually because of malnutrition or disease. Enamel
hypoplasia is identified as a horizontal line, a series of pits or grooves
 Intraoral Examination 115

Fig. 11.13: Dentition showing erosion

Library of School of Dentistry, TUMS
For Personal Use Only

Figs 11.14A and B: Abrasion (marked by arrow)

 116 A Practical Manual of Public Health Dentistry

A
Library of School of Dentistry, TUMS
For Personal Use Only

Figs 11.15A and B: Attrition

along the outer surface of the tooth. These lines mark points at which
the tooth’s growth was resumed after it had stopped.
Hypoplasia is most common in the permanent teeth and
represents episodes of arrested growth in infancy or childhood while
these teeth were still developing. Once the enamel forms, it can no
longer be affected (Figs 11.18A and B).
This type of defect may cause tooth sensitivity, may be unsightly
or may be more susceptible to dental cavities. Some genetic disorders
cause all the teeth to have enamel hypoplasia.
 Intraoral Examination 117
Library of School of Dentistry, TUMS

A
For Personal Use Only

Figs 11.16A and B: Abfraction (marked by arrows)

Environmental and genetic factors that interfere with tooth

formation are thought to be responsible for enamel hypoplasia.
This includes trauma to the teeth and jaws, infections during
pregnancy or infancy, poor prenatal and postnatal nutrition,
hypoxia, exposure to toxic chemicals and a variety of hereditary
disorders.
 118 A Practical Manual of Public Health Dentistry

A
Library of School of Dentistry, TUMS
For Personal Use Only

Figs 11.17A and B: Bruxism

Dental Fluorosis
It is important to diagnose the condition. It is difficult to differentiate
between dental fluorosis and other enamel disturbances. Dental
fluorosis is generalized within the dentition and over the entire tooth
surface which makes it easy to distinguish fluoride-induced enamel
changes from other enamel defects (nonfluoride origin) which may
be symmetrically distributed in the oral cavity.
Due to excessive fluoride intake, enamel loses its lustre. In its
mild form, dental fluorosis is characterized by white, opaque areas
 Intraoral Examination 119
Library of School of Dentistry, TUMS
For Personal Use Only

Figs 11.18A and B: Enamel hypoplasia

on the tooth surface and in severe form, it is manifestated as yellowish

brown to black stains and severe pitting of the teeth. This
discoloration may be in the form of spots or horizontal streaks.
Normally, the degree of dental fluorosis depends on the amount
of fluoride exposure up to the age of 8 to 10 years, as fluoride stains
 120 A Practical Manual of Public Health Dentistry

only the developing teeth while they are being formed in the jawbones
and are still under the gums.
The effects of dental fluorosis may not be apparent if the teeth
are already fully grown prior to the fluoride over exposure. Therefore,
the fact that an adult shows no signs of dental fluorosis does not
necessarily mean that his or her fluoride intake is within the safety
limit.
The levels of prevention for dental fluorosis and Indices for scoring
dental fluorosis are discussed in subsequent chapters
(Chapters 16 & 17).

Trauma from Occlusion

Library of School of Dentistry, TUMS

It can be defined as pathologic or adaptive changes which develop

in the periodontium as a result of undue force produced by the
For Personal Use Only

masticatory muscles.
Stillman (1917): A condition where injury results to the
supporting structures of the teeth by the act of bringing the jaws
into a closed position
WHO (1978): Damage in the periodontium caused by stress on
the teeth produced by the teeth of the opposing jaw.
Trauma from occlusion [TFO] is classified into two categories:
Primary: A tissue reaction, which is elicited around a tooth with
normal of the periodontium, thus no attachment loss is seen.
Secondary: This is related to situations in which occlusal forces
cause damage in a periodontium of reduced height (attachment
loss present).
The clinical signs that are seen are:
• Pain
• Tooth migration
• Attrition
• Muscle/joint pain
• Fractures, chipping
• Fremitus.
 Intraoral Examination 121

Etiology of TFO
• Occlusal disharmony
• Tooth drifting, tipping and overeruption following extraction of
neighboring teeth results in occlusal interference
• Failure to contour the cusps of restorations
• Occlusal interference following orthodontic tooth movement
• Excessive occlusal stress as badly designed partial denture
• Parafunctional activity, e.g bruxism
• Decreased adaptive capacity of the tissues to occlusal forces.

Tooth Fracture (Figure 11.19)

Tooth fracture is the break in the continuity of a tooth with or
Library of School of Dentistry, TUMS

without any displacements of the fragments. It may be pathological

or by the result of an injury of an already diseased tooth or a healthy
For Personal Use Only

one. Tooth fracture can be as a result of many causes including;

sport injuries, automobile accidents, bicycle falls, physical fighting
and chewing of very hard items.
Ellis and Davey have classified tooth fracture according to the
level and severity of fracture:
Class I Simple fracture of crown involving enamel.
Class II Fracture of crown involving dentin but no pulp

Fig. 11.19: Tooth fracture

 122 A Practical Manual of Public Health Dentistry

Class III Extensive fracture of crown involving dentin and pulp

exposure
Class IV Traumatized tooth becomes nonvital (with or without
loss of tooth structure)
Class V Tooth lost due to trauma
Class VI Fracture of root with or without loss of crown structure
Class VII Displacement of the tooth without crown or root
fracture
Class VIII Fracture of crown en mass
Class IX Fracture of deciduous tooth.

Classification by Garcia Godoy

Library of School of Dentistry, TUMS

0– Enamel crack
1– Enamel fracture
For Personal Use Only

2– Enamel, dentin fracture without pulp exposure

3– Enamel, dentin fracture with pulp exposure
4– Enamel, dentin, cementum fracture without pulp exposure
5– Enamel, dentin fracture with pulp exposure
6– Root fracture
7– Concussion
8– Luxation
9– Lateral displacement
10– Intrusion
11– Extrusion
12– Avulsion.
 12 Establishing the
Diagnosis

The diagnosis of patient’s symptoms and other significant disease

Library of School of Dentistry, TUMS

processes leads to sometimes a self-evident conclusion. The diagnosis

For Personal Use Only

is usually established by:

• Reviewing the patient’s history and examination data
• Listing those items that may suggest the possibility of a significant
health problem
• Grouping items into primary and secondary, acute and chronic,
high priority versus low priority, etc.
• Categorizing the disease on the basis of this grouping.
For an effective treatment and insurance and medicolegal
purposes, it is essential that the diagnosis should be written into the
patient’s record after the detailed history and examination data.
Although, there is no universal accepted system for identifying
and classifying diseases, the diagnosis are often written for the purpose
of accurate understanding of the disease. Some of the standardization
has been done by WHO under ‘International Classification of
Diseases (ICD)’ system, continuously revised by it.
A definite diagnosis cannot be always made, despite possessing
full examination and history data. In such cases, a descriptive term
may be used for describing the probable health problem, termed as
the ‘provisional diagnosis’. The clinician should always keep in mind
about the differential diagnosis. The ‘provisional diagnosis’ indicates
to list those items that indicate an abnormality or suggest the
possibility of significant health problems.
 13
Investigations

It helps to come to the final diagnosis. These are adjuvant methods

Library of School of Dentistry, TUMS

of examining the patient for further confirmation of the provisional

For Personal Use Only

diagnosis.
The common methods are:
• Radiographic investigations
• Biochemical investigations
• Histopathological investigations
• Pulp vitality testing
• Hematological investigations
• Urine analysis
• Microbiological investigations
• Special investigations like MRI, CT Scan, etc.

RADIOGRAPHIC INVESTIGATIONS
Clinical situations for which radiographs may be indicated are:
• Positive historical findings
– Previous periodontal or endodontic therapy
– History of pain or trauma
– Familial history of dental anomalies
– Postoperative evaluation of healing
– Presence of implants.
• Positive clinical signs/symptoms
– Clinical evidence of periodontal disease
– Large or deep restorations
 Investigations 125

– Deep carious lesions

– Malposed or clinically impacted teeth
– Swelling
– Evidence of facial trauma
– Mobility of teeth
– Fistula or sinus tract infection
– Clinically suspected sinus pathology
– Growth abnormalities
– Oral involvement in known or suspected systemic disease
– Positive neurologic findings in the head and neck
– Evidence of foreign objects
– Pain and/or dysfunction of the temporomandibular joint.
– Facial asymmetry
Library of School of Dentistry, TUMS

– Abutment teeth or fixed or removable partial prosthesis

– Unexplained bleeding
For Personal Use Only

– Unexplained sensitivity of teeth

– Unusual eruption, spacing, or migration of teeth
– Unusual tooth morphology, calcification, or color
– Missing teeth with unknown reason.
The radiographs used in dentistry are:
• Intraoral periapical radiographs
• Bitewing radiographs
• Occlusal radiograph
• Panoramic radiographs (orthopantomogram).
In choosing the type of radiograph to be examined, the dentist
should consider the anatomic relationships, the size of the field, and
the radiation dose from each view.
Radiographic examination is categorized under: Intraoral
radiographs and Extraoral radiographs.

Intraoral Radiographs
Intraoral radiographs are examinations made by placing the X-ray
film within the patient’s mouth during the exposure. Intraoral films
provide more detailed information but a significantly higher radiation
dose per unit area exposed.
 126 A Practical Manual of Public Health Dentistry

They are of three types:

A. Periapical Radiograph (Fig. 13.1)

Periapical views show all of a tooth and the surrounding bone and
are very useful for revealing caries and periodontal and periapical
disease. These views may be made of a specific tooth or region or as
part of a full mouth examination.

B. Interproximal Radiograph (Fig. 13.2)

Interproximal views (bitewings) show the coronal aspects of both
the maxillary and mandibular dentition in a region, as well as the
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 13.1: Periapical radiograph

Fig. 13.2: Interproximal radiograph

 Investigations 127

Fig. 13.3: Occlusal radiograph

Library of School of Dentistry, TUMS
For Personal Use Only

surrounding crestal bone. These views are most useful for revealing
proximal caries and evaluating the height of the alveolar bony crest.

C. Occlusal Radiograph (Fig. 13.3)

Occlusal views are intraoral radiographs in which the film is positioned
in the occlusal plane. They are often used in lieu of periapical views
in children because the small size of the patient’s mouth limits film
placement. In adults, occlusal radiographs may supplement periapical
views, providing visualizations of a greater area of teeth and bone.
They are useful for demonstrating impacted or abnormally placed
maxillary anterior teeth or visualizing the region of a palatal cleft.
Occlusal views may also demonstrate buccal or lingual expansion of
bone or presence of a sialolith in the submandibular duct.

Extraoral Radiographs
These are examinations made of the orofacial region using films
located outside the mouth. The panoramic radiograph has the most
common use for general dental patients.

Panoramic Radiograph (Fig. 13.4)

These radiographs provide a broad view of the jaws, teeth, maxillary
sinuses, nasal fossa and TMJs. They show which teeth are present,
 128 A Practical Manual of Public Health Dentistry

Fig. 13.4: Panoramic radiograph

Library of School of Dentistry, TUMS

their relative state of development, presence or absence of dental

For Personal Use Only

abnormalities, and many traumatic and pathologic lesions in bone.

Panoramic radiographs are the technique of choice for initial
examinations of edentulous patients. Panoramic radiographs are also
susceptible to artifacts from improper patient positioning that
negatively affect the image. This system is considered inadequate for
independent diagnosis of caries, root abnormalities, and periapical
changes.

Advanced Imaging Procedures

A variety of advanced imaging procedures such as CT.
CT scanning (sometimes called CAT scanning) is a noninvasive
medical test that helps physicians diagnose and treat medical
conditions. CT scanning combines special X-ray equipment with
sophisticated computers to produce multiple images or pictures of
the inside of the body. These cross-sectional images of the area being
studied can then be examined on a computer monitor, printed or
transferred to a CD. CT scans of internal organs, bones, soft tissue
and blood vessels provide greater clarity and reveal more details than
regular X-ray exams (Fig. 13.5).
MRI, Ultrasonography, and nuclear medicine scans may be
required in specific diagnostic situations. For these techniques, the
 Investigations 129

Fig. 13.5: CT scan

Library of School of Dentistry, TUMS

dentist refers the patient to a hospital or other imaging center, rather

For Personal Use Only

than performing them in the dental office.

Type of examination Detectable disease

Intraoral radiographs
Periapical Caries, periodontal disease, occult disease
Bitewings Caries, periodontal bone level
Full–mouth periapical Caries, periodontal disease, dental
anomalies, occult disease
Occlusal Dental anomalies, occult disease, salivary
stones, expansion of jaw
Extraoral radiographs
Panoramic Dental anomalies, occult disease,
extensive caries, periodontal disease,
periapical disease, TMJ
Conventional Tomography/ Slice TMJ, implant site assessment
CT/Head Extent of craniofacial pathology, fracture,
implants
MRI Soft tissue disease, TMJ

HISTOPATHOLOGICAL INVESTIGATIONS

Biopsy
Biopsy is the removal and examination of a section of tissue or other
material from the living body for the purposes of diagnosis.
 130 A Practical Manual of Public Health Dentistry

Indications for biopsy:

• Any unusual oral lesion that cannot be identified with clinical
certainty must be biopsied.
• Any lesion that has not shown evidence of healing in 2 weeks
should be considered malignant until proven otherwise.
• A persistent, thick, white, hyperkeratotic lesion and any mass that
does not break through the surface epithelium should be biopsied.
• Any tissue surgically removed must be submitted for microscopic
examination.

Cytologic Smear
The cytologic smear technique is a diagnostic aid in which surface
Library of School of Dentistry, TUMS

cells of a suspicious lesion are removed for microscopic evaluation.

Indications for smear technique:
For Personal Use Only

• In general, a lesion for which biopsy is not planned may be

examined by smear. An exception is a keratotic lesion that is not
suitable for exfoliative cytology.
• A lesion that looks like potential cancer should be examined be
smear if the patient refuses to have a biopsy specimen taken.
• The smear technique is used for follow-up examination of patients
with oral cancer treated by radiation. The treated tissue may heal
inadequately and cause persistent ulceration.
• Cytology is useful for identifying Candida Albicans organisms in
patients with suspected candidiasis.
• Cytology may be useful in identifying herpes virus by taking a
smear from an intact vesicle.
• In mass screening programs for cancer detection, smears may be
taken.
• Research studies to show changes in surface cells, for example,
the effects of topical agents, may use a smear technique.

Exfoliative Cytology
Stratified squamous epithelial cells are constantly growing towards
the surface of the mucous membrane, where they are exfoliated.
Exfoliated cells and cells beneath them are scraped off, and when
these cells are prepared on a slide, changes in the cells can be detected
 Investigations 131

by staining and studying them microscopically. The malignant cells

stain differently from normal cells and take on unusual, abnormal
forms.

PULP VITALITY TESTING

Dental pulp tests are investigations that provide valuable diagnostic
and treatment planning information. Pulp testing combined with
information taken from the histor y, examination, and other
investigations such as radiographs leads to the diagnosis of the
underlying disease. Pulp sensibility tests include thermal and electric
tests, which extrapolate pulp health from sensory response. With all
pulp tests, the results need to be carefully interpreted as false results
Library of School of Dentistry, TUMS

can lead to misdiagnosis leading to incorrect, inappropriate, or

unnecessary treatment.
For Personal Use Only

Cold tests: Ethyl chloride and ice have been popular in the past,
but CO 2 snow and other refrigerants such as dichlorodifluo-
romethane (DDM) have been shown to be effective and superior to
ice and ethyl chloride. Ice is the most common and easiest way for
cold test. A common way to make ice in useful sizes and dimensions
involves freezing water in empty local anesthetic cartridges.
Heat test: Typical methods used include gutta-percha or
compound material heated to melting temperature and directly
applied to the tooth being tested with lubricant in order to facilitate
removal of the material. Heated ball-ended metallic instruments
placed near the tooth (without touching the tooth surface), battery-
powered controlled heating instruments such as ‘Touch n Heat’ and
hot water bathing with the tooth isolated by rubber dam are other
alternative methods.
Electric pulp test: Electric pulp testing (EPT) works on the
principle that electrical stimuli cause an ionic change across the neural
membrane, thereby inducing an action potential with a rapid hopping
action at the nodes of Ranvier in myelinated nerves. The pathway
for the electric current is thought to be from the probe tip of the
test device to the tooth, along the lines of the enamel prisms and
dentine tubules, and then through the pulp tissue. The circuit is
completed with the patient wearing a lip clip or by touching the
 132 A Practical Manual of Public Health Dentistry

probe handle with his/her hand; alternatively, the operator can touch
the patient’s skin with one “gloveless” hand. A tingling sensation
will be felt by the patient once the increasing voltage reaches the
pain threshold. This threshold level varies between patients and teeth,
and is affected by individual age, pain perception, tooth surface
conduction, and resistance.
Test cavity: The preparation of a test cavity has been suggested as
a last resort in a tooth where no other means can ascertain the pulp
status. Cutting into dentine using a high or low speed bur without
local anesthetic may give some indication of whether the sensory
element of the pulp is still functioning. This method is considered
invasive and irreversible. It is unlikely that this procedure would
provide any more information than thermal and electric pulp
Library of School of Dentistry, TUMS

sensibility tests. The defect made in the tooth can be repaired with
restorative dental materials.
For Personal Use Only
 14
Final Diagnosis

All the records, clinical findings, the provisional diagnosis and

Library of School of Dentistry, TUMS

investigations are clubbed together to frame the final diagnosis on

For Personal Use Only

which treatment is planned. The final diagnosis is first made on the

chief complaint of the patient and then other problems are
considered.
Patients must be informed of their diagnosis and the results of
the various examination and tests performed on it. Also, the patient
should be informed of the nature, significance and treatment of the
health problem that has been clearly diagnosed.
 15 Formulating a
Comprehensive
Treatment Plan

The goal of treatment planning is to devise the best treatment for the
Library of School of Dentistry, TUMS

patient. The diagnostic procedures help the clinician in establishing a

For Personal Use Only

suitable treatment plan for the respective patient. The plan of treatment
should also be included in the record of the patient and explained to the
patient in detail. If the patient has a compromising medical health situation,
the risks for the treatment should be assessed and informed to the patient.
The decision for or against a medically compromised patient is
usually arrived by the dentist requesting the patient’s physician to
‘clear the patient for dental treatment’. The plan of treatment is
usually directed towards the severity of patient’s symptoms, referring
to as rational or scientific treatment planning.
COMPREHENSIVE TREATMENT PLAN MAY BE DIVIDED INTO THE
FOLLOWING PHASES

Phase I: Emergency phase

Phase II: Preventive phase
Phase III: Promotive phase
Phase IV: Curative phase
Phase V: Rehabilitation phase
Phase VI: Maintenance phase

A treatment plan that works effectively in a private practice as

well as teaching institute can be divided into following phases:
PHASE I: EMERGENCY PHASE
It includes the procedures which eliminate pain and manage the acute
infections. The effort should be made to include the chief complaint
in this phase as it addresses the main dental problem of the patient.
 Formulating a Comprehensive Treatment Plan 135

Procedures in this phase include:

• Treatment of pulpally involved teeth by emergency endodontics
or extraction
• Treatment of painful oral conditions such as ANUG, etc.
• Placement of temporary restorations in case of deep caries
threatening pulp exposure
• Drainage of abscess.

PHASE II: PREVENTIVE PHASE

In this phase, the effort is made to control the disease process rather
than to provide therapy.
Procedures undertaken in this phase include:
Library of School of Dentistry, TUMS

• Pit and fissure sealants

• Topical fluoride application
For Personal Use Only

• Oral screens and other habit breaking appliances

• Space maintainer and Preventive orthodontics.

PHASE III: PROMOTIVE PHASE

Oral health promotion aims to improve the oral hygiene and dental
awareness of the patient.
Procedures undertaken in this phase include:
• Oral hygiene instruction
• Diet advice/counseling
• Oral health education.

PHASE IV: CURATIVE PHASE

This phase aims to eliminate all the dental problems of the patient.
This phase is also called as therapeutic phase.
Procedures undertaken in this phase include:
• Oral prophylaxis and root planing
• Restoration
• Endodontic therapy
• Periodontal therapy
• Extraction of teeth
• Oral surgical procedures.
 136 A Practical Manual of Public Health Dentistry

PHASE V: REHABILITATION PHASE

In this phase, the goal is to restore the mouth to full function using
restorative and prosthodontic procedures.
Procedures undertaken in this phase include:
• Crowns and Bridges
• Implant supported prosthesis
• Complete or removable partial dentures
• Reconstruction prosthesis.

PHASE VI: MAINTENANCE PHASE

It includes the steps such as recall, review and reassessment of the
Library of School of Dentistry, TUMS

oral conditions of the patient after the treatment.

The recall interval is indeed an important step in dental care as it
For Personal Use Only

helps the clinician to assess the effectiveness of the treatment and

preventive advice provided previously.
The recommended interval for recall should be determined
specifically for each patient and tailored to meet his or her needs, on
the basis of an assessment of disease levels and risk of or from dental
disease.
• The beneficial effects of oral hygiene, diet, fluoride use.
• The ill effects of tobacco, alcohol and pan chewing on oral health.
• The risk factors that may influence the patient’s oral health, and
their implications for deciding the appropriate recall interval.
• The outcome of previous care episodes and the suitability of
previously recommended intervals.
• The patient’s ability or desire to visit the dentist at the
recommended interval.
• The financial costs to the patient of having the oral health review
and any subsequent treatments.
– The interval before the next oral health review should be
chosen, either at the end of an oral health review if no further
treatment is indicated, or on completion of a specific
treatment.
– According to National Institute for Health and Clinical
Excellence, the patient should be assigned a recall interval of
 Formulating a Comprehensive Treatment Plan 137

3, 6, 9 or 12 months if he or she is younger than 18 years, or

3, 6, 9, 12, 15, 18, 21 or 24 months if he or she is aged 18
years or older.
During a recall visit, the patient record can be updated in terms
of his or her previous treatment/s, new lesions, reinforcement of
prevention advice, etc.
Periodic maintenance is infact of more importance than seeking
a treatment. If regular evaluation of patient is done then the need
for complex, invasive or surgical procedures can be eliminated with
the help of preventive and promotive procedures only.
Library of School of Dentistry, TUMS
For Personal Use Only
 16 Levels of PPrevention
revention

In modern day concept of prevention has become ‘Broad Based’.

Library of School of Dentistry, TUMS

Four levels of prevention can be identified in relation to natural

For Personal Use Only

history of disease:
• Primordial prevention
• Primary prevention
• Secondary prevention
• Tertiary prevention.

Levels of Primordial Primary Secondary Tertiary

prevention
Priorities of Before Disease Disease Loss of
prevention disease Initiation progression function
initiation and
recurrence
Taxonomy of Prepathosis Prepathosis Intervention Replacement
prevention
Preventive Individual Health Early Disability
services and mass promotion diagnosis limitation
education Specific and prompt
protection treatment Rehabilitation

Primordial prevention consists of actions and measures that

inhibit the emergence of risk factors in the form of environmental,
economic, social, and behavioral conditions and cultural patterns
of living, etc.
 Levels of Prevention 139

Primary prevention is defined as action taken prior to onset of

disease which removes the possibility that a disease will ever occur.
Secondary prevention is defined as action which halts the
progress of disease in its incipient stage and prevent compli-
cations.
Tertiary prevention is defined as all measures available to reduce
or limit impairments and disabilities, minimize suffering caused by
existing departures from good health to promote patients adjustment
to irremediable conditions.

LEVELS OF PREVENTION FOR DENTAL CARIES

Library of School of Dentistry, TUMS

Levels of Primary prevention Secondary Tertiary prevention

prevention prevention
For Personal Use Only

Preventive Health Specific Disability Rehabilitation

services promotion protection Early limitation
diagnosis
and prompt
treatment

Services Diet Appropriate Self Utilization Utilization of

provided planning. use of examination of dental dental services
by the Demand for fluoride. and referral. services
individual preventive Ingestion Utilization
services. of of dental
Periodic fluoridated services.
visits to water.
the dental Use of
office. fluoridated
dentifrice.
Oral
hygiene
practices.

Services Dental Community Periodic Provision Provision of

provided health or school screening of dental dental services
by the education water and services
community programs. fluoridation. referral.

Contd...
 140 A Practical Manual of Public Health Dentistry

Contd...

Levels of Primary prevention Secondary Tertiary prevention

prevention prevention
Preventive Health Specific Disability Rehabilitation
services promotion protection Early limitation
diagnosis
and prompt
treatment

Promotion School Provision

of lobby fluoride of dental
efforts tablet services
program.
School
Library of School of Dentistry, TUMS

sealant
program
For Personal Use Only

Services Patient Topical Complete Complex Removable

provided education. application examination. restorative and fixed
by the Plaque of fluoride. Prompt dentistry. prosthodontics.
dental control Fluoride treatment Pulpotomy. Minor tooth
professional program. supple- of incipient RCT, movement.
Diet ments/rinse- lesions. extraction. Implants.
counseling. preparation. Preventive Rehabilitation of
Recall re- Pit and resin decayed teeth with
inforcement. fissure restorations. further preventive
Caries sealants. Simple care
activity Assessing restorative
tests. the clinical dentistry.
Assessing evidence Pulp
the Dietary of previous capping.
habits, disease. Limiting the
especially impact of
frequency caries at
of sugary an early
food and age.
drink con-
sumption.
 For Personal Use Only
Library of School of Dentistry, TUMS

LEVELS OF PREVENTION FOR PERIODONTAL DISEASE

Levels of Primary prevention Secondary Tertiary prevention

prevention prevention
Preventive Health Specific Disability Rehabilitation
services promotion protection Early limitation
diagnosis
and prompt
treatment
Services Demand for Oral hygiene Self-examination Utilization of Utilization of dental
provided preventive practices. and referral. dental services services
by the services. Utilization of
individual Periodic visits dental services.
to the dental
office.
Levels of Prevention

Services Dental health Supervised school Periodic screening Provision of Provision of dental
provided education brushing programs and referral. dental services services
by the programs. Provision of dental
community Promotion of services
lobby efforts.
Promotion of
research efforts.
Provision of oral
hygiene aids.
Contd...
141
 For Personal Use Only
Library of School of Dentistry, TUMS

Contd...
142
Levels of Primary prevention Secondary Tertiary prevention
prevention prevention
Preventive Health Specific Disability Rehabilitation
services promotion protection Early limitation
diagnosis
and prompt
treatment
Services Patient education. Correction of tooth Complete Procedures that Removable/fixed
provided by Plaque control malalignment. examination. limit the impact prosthodontics.
the dental program. Recall Prophylaxis. Scaling and of established Minor tooth
professional reinforcement. Immunization curettage. disease (for movement
against specific Corrective, example,
plaque pathogens. restorative and resection of
This should be occlusal services. deep periodontal
done especially Treatment of pockets to
in patients with gingivitis. reduce nidi
periodontal for plaque
disease; accumulation.
pregnant women; Deep curettage.
diabetic patients; Root planing.
patients infected Splinting.
A Practical Manual of Public Health Dentistry

with the human Periodontal

immunodeficiency surgery. Selective
virus; patients extractions
with neutrophil
defects, etc.
 Levels of Prevention 143

PREVENTION OF DENTAL TRAUMA

Primary prevention Secondary Tertiary

prevention prevention
Four components of the thoroughly Prompt Provision
tested, easy-to-implement SAFE intervention of dental
model: following services
National Program for Playground dental trauma (Pulp care
Safety (NPPS) recommends: can reduce and
complications restoration,
Supervision—adults must be trained of injury and Prosthesis)
in appropriate active supervision also improves
techniques. the prognosis.
Library of School of Dentistry, TUMS

Age-appropriate design—children of
varying age groups need equipment
designed for their specific developmental
For Personal Use Only

characteristics.

Fall surfacing—the type and depth

of ground materials must be adequate
for cushioning falls.

Equipment—plastic, wooden, and metal

equipment must be maintained, repaired,
and replaced.

Playground surfaces:
Most government rules for play equipment
recommends that an impact absorbing
surface be provided around the items from
which children are most likely to fall.

Early treatment of large overjets

(mixed dentition)
Studies have shown that the incidence of
accidental trauma to permanent incisors
significantly increases with overjets greater
that 9 mm.
 For Personal Use Only
Library of School of Dentistry, TUMS

LEVELS OF PREVENTION FOR ORAL CANCER 144

Levels of Primary prevention Secondary Tertiary prevention
prevention prevention
Preventive Health Specific Disability Rehabilitation
services promotion protection Early limitation
diagnosis
and prompt
treatment
Services Demand for Avoidance of Self examination Utilization of Utilization of dental
provided preventive known irritants. and referral. dental services services
by the services. Utilization of
individual Periodic visits to dental services.
the dental office.
Services Dental health Periodic screening Provision of Provision of dental
provided education and referral. dental services services
by the programs. Provision of dental
community Promotion of services
lobby efforts.
Promotion of
research efforts.
Services Patient education Removal of known Complete Chemotherapy, Maxillofacial
A Practical Manual of Public Health Dentistry

provided irritants in the oral examination, radiation and removable

by the cavity. biopsy, therapy, prosthesis.
dental oral cytology, surgery Plastic surgery,
professional complete speech therapy,
excision counseling.
 For Personal Use Only
Library of School of Dentistry, TUMS

LEVELS OF PREVENTION FOR DENTAL FLUOROSIS

Primary prevention Secondary prevention Tertiary prevention

Specific guidelines on the use and Improve the nutritional status, especially Treat the discolored/ disfigured
appropriate dose levels of fluoride of expecting mothers, newborns and dentition by appropriate aesthetic
supplements, and use of fluoride tooth children up to the age of 12 years. treatment such as bleaching, micro-
paste for young children. abrasion, laminate veneers, etc.
In high fluoride areas: Treat other causes of fluoride toxicity
• Provide an alternate supply of such as kidney and thyroid diseases,
drinking water etc.
• Employ defluoridation techniques at
the community or individual level

LEVELS OF PREVENTION OF MALOCCLUSION

Levels of Prevention

Primary prevention Secondary prevention Tertiary prevention

This includes control of harmful oral Habit-breaking appliances should be Corrective orthodontic treatment
habits, and preservation and restoration used. Serial extractions, space includes the use of fixed and removal
of primary and permanent dentition. maintainers/regainers, and functional appliances and surgical orthodontics in
appliances to correct jaw relations are cases of severe malocclusion
other modalities.
Frenectomies and simple appliances
can be used to correct anterior cross
bites.
145
 17
Dental Indices

Dental indices provide a quantitative method for measuring, scoring,

Library of School of Dentistry, TUMS

and analyzing dental conditions in individuals and groups. An index

For Personal Use Only

describes the status of individuals or groups with respect to the

condition being measured. It is an objective mathematical description
of a disease or condition based on carefully determined criteria under
specified circumstances.
Oral health surveys depend on dental indices, as do researchers
and clinicians, to help in understanding trends of a disease and patient’s
needs. In epidemiological oral health surveys, an index is used to show
the prevalence and incidence of a particular condition, to provide
baseline data, to assess the needs of a population, and to evaluate the
effects and results of a community program. Researchers use indices
to determine baseline data and to measure the effectiveness of specific
agents, interventions, and mechanical devices. In private practice, index
scores are used to educate, motivate, and evaluate the patient. By
comparing scores from the initial exam during a follow-up exam, the
patient can measure the effects of personal daily care.
The first dental index, developed by Schour and Massler, was known
as a Papilla, Marginal gingiva and Attached gingiva (PMA) Index.
Each of those areas was examined and scored from 0 to 5, depending
on the severity of inflammation. The PMA Index, largely of historic
interest now, was primarily used in surveys of acute gingivitis. The
status of a patient’s periodontal health or disease is commonly measured
by an index in private practices. One of the most widely used is the
Periodontal Screening and Recording (PSR) Index, adapted in 1992
from a system in use in Europe called the Community Periodontal
 Dental Indices 147

Index of Treatment Needs. The PSR is an early detection system for

periodontal disease. It is not intended to replace full periodontal
charting, but to serve as a simple and convenient screening tool.
Today, dental indices are used to assess both individual and group
oral health and disease status. They can be simple, measuring only
the presence or absence of a condition, or they can be cumulative,
measuring all evidence of a condition, past and present.

DEFINITION
An index is 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
Library of School of Dentistry, TUMS

(AL Russell, 1969).

Professional Implications
For Personal Use Only

Dental professionals from the private practice clinician to the

researcher use indices to benefit their patients. A dentist or hygienist
might use a PI to impress upon a patient the need for better oral
hygiene. A World Health Organization researcher might use the same
index to assess the home care practices of a population. Indices will
continue to be important and necessary tools for dental professionals.

PROPERTIES OF AN IDEAL INDEX

Reliability: It should be able to measure consistently at different
times and under a variety of conditions. The term is synonymous
with reproducibility, repeatability that is, if a researcher examined
the same patient with the same condition multiple times, each times
the score or results would be the same.
Validity: It should measure what it is intended to measure. It should
accurately reflect the extent or degree to which the condition or
disease is present.
Clarity, simplicity and objectivity: The examiner should be able to
remember the criteria. Index should be easy to apply. The criteria
should be clear and simple.
Quantifiability: The index should be amenable to statistical analysis,
so that status of a group can be expressed by a statistical measure.
For example, mean, median.
 148 A Practical Manual of Public Health Dentistry

Acceptability: The use of an index should not be painful and

demeaning to the subject.
Sensitivity: The index should be able to detect reasonably small shifts,
in either direction in the condition.

TYPES OF INDICES
Simple index: It is the one which measures the presence or absence
of a condition. For example, an index which measures the presence
of plaque without evaluating its effects on the gingiva.
Cumulative index: It is the one which measures all the evidence of a
condition (past and present). An example is DMFT index for dental
caries.
Library of School of Dentistry, TUMS

Irreversible index: An index which measures the conditions that will

not change. For example, a dental caries index.
For Personal Use Only

Reversible index: One that measures conditions that can be changed

or reversed.
Full mouth indices: These indices measure the patient’s entire
periodontium or dentition, e.g. Russell’s periodontal index.
Simplified indices: These indices measure only representative samples
of dental apparatus, e.g. Green and Vermillion’s simplified oral
hygiene index (OHI-S).
Indices are also classified in general categories according to the
entity which they measure
• Disease index, e.g. ‘D’ (Decay) portion of the DMF index is the
best example for disease index.
• Symptom index, e.g. measuring gingival or sulcular bleeding are
essentially examples for symptom indices.
• Treatment index, e.g. the ‘F’ (Filled) portion of DMF index is
best example for treatment index.

PURPOSE AND USES OF AN INDEX

Indices can be used for individual assessment, for clinical trials or
epidemiological surveys as shown in Table 17.1.
In addition to measuring a patient’s periodontal status, dental
indices can measure the amount of plaque and calculus present or
not present in a patient’s mouth, the amount of bleeding present in
 For Personal Use Only
Library of School of Dentistry, TUMS

Table 17.1: Purpose and uses of an index

Type Uses
Individual assessment Evaluation and monitoring the progress and maintenance of oral health
Measures effects of personalized disease control programs overtime
Monitors progress of disease healing
Patient education and motivation
Provides individual assessment to help patient to recognize an oral problem
Clinical trial Comparison of an experimental group with a control group
Determines the effect of Determines baseline data before the experimental factors are introduced
an agent or procedure Measures the effectiveness of specific agents used for prevention, control and treatment of oral
Dental Indices

on the prevention, conditions

progression, or control Measures the effectiveness of mechanical devices used for personal care, i.e. toothbrushes,
of a disease interdental cleaning aids
Community health/ Not designed for evaluation of an individual patient
epidemiologic survey Measures the prevalence and incidence of a oral condition occurring within a population
Survey for the study of Provides baseline data to show existing dental health practices
disease characteristics Compares the effects of a community program and evaluates the results
of populations Finds out the needs of a community
149
 150 A Practical Manual of Public Health Dentistry

IDEAL REQUISITES OF AN INDEX

• Should be simple to use and calculate

• Uses a minimal amount of time to complete
• Does not cause discomfort to the patient
• Is acceptable to the patient
• Requires minimum equipment and expense
• Has clear-cut criteria that are easily understood
• Is reproducible in assessing the condition by the same or different examiner
• Should be realistic: It should relate numerically to the clinical stages of
the specific disease.

the gingiva, the amount of tooth mobility present at a given time,

the amount of fluorosis present, and the number of decayed, missing,
Library of School of Dentistry, TUMS

or filled teeth present.

For Personal Use Only

RECOMMENDED METHOD OF PERFORMANCE OF AN INDEX

• Explain procedure to patient

• Drape patient
• Give patient protective eyewear
• Wash hands
• Don PPE (Personal protective equipment)
• Position patient in reclined position in dental chair
• Adjust dental light for maximum illumination
• Apply lubricant gel to patient lips and opaque colored restorations
• Dry teeth with compressed air using recommended sequence
• Carry-out the index.

INDICES COMMONLY USED IN DENTISTRY

(BOX 17.1)

Periodontal Indices
There are 4 main areas in periodontal disease for which indices are
required:
a. Plaque or soft deposits on teeth
b. Calculus
c. Gingivitis
d. Periodontal destruction or loss of attachment.
 Dental Indices 151

Dental Caries

Dental Fluorosis

Malocclusion

BOX 17.1: INDICES USED IN DENTISTRY

1. Indices used in assessing oral hygiene:

a. Oral hygiene index.
b. Simplified oral hygiene index.
c. Patient hygiene performance index.
2. Indices used in assessing plaque and debris:
Library of School of Dentistry, TUMS

a. Plaque component of the periodontal disease index.

b. Shick and Ash modification of plaque criteria.
For Personal Use Only

c. Turseky-Gilmore-Glickman modification of the Quigley Hein plaque

index.
d. Plaque index.
e. Navy plaque index.
f. Distal mesial plaque index.
g. Glass Index.
h. Plaque free score index.
i. Plaque control record.
j. Oral health status index.
3. Indices used in assessing calculus:
a. Calculus surface index.
b. Calculus surface severity index.
c. Marginal line calculus index.
d. Calculus component of the periodontal disease index.
e. Probe method of calculus assessment.
f. Calculus component of OHI-S.
4. Indices used in assessing gingival inflammation:
a. Papillary marginal attachment index.
b. Gingivitis component of the periodontal disease index.
c. Gingival index.
d. Papillary marginal gingivitis index.
e. Modified gingival index.
f. Gingival tissue index.
g. Gingival pain index.
5. Indices used in assessing gingival bleeding:
a. Sulcus bleeding index.

Contd...
 152 A Practical Manual of Public Health Dentistry

Contd...

b. Papillary bleeding index.

c. Gingival bleeding index.
d. Interdental bleeding index.
e. Gingival status index.
f. Bleeding points index.
g. Quantitative gingival bleeding index.
h. Gingival fluid flow index.
6. Indices used in assessing periodontal diseases:
a. Periodontal index.
b. Periodontal disease index.
c. Gingival bone count index.
d. Navy periodontal disease index.
e. Community periodontal index of treatment needs.
f. Community periodontal index.
Library of School of Dentistry, TUMS

g. Gingivitis periodontitis missing teeth index.

h. Periodontitis severity index.
For Personal Use Only

i. Extent and severity index.

j. Gingival sulcus measurement component of periodontal disease
index.
k. Periodontal screening and recording index.
7. Indices used in assessing dental caries:
a. DMFT index.
b. DMFS index.
c. def index.
d. Root caries index.
e. Modified DMFT index.
f. Caries Severity index.
g. Czechoslovakia caries index.
h. DMF surface percentage index.
i. Functional measure index.
j. Dental health index.
k. WHO dentition status & treatment needs index.
l. Restorative Index.
m. Stone’s index.
n. Significant Caries index.
8. Indices used in assessing dental fluorosis:
a. Dean’s fluorosis index.
b. Moller’s fluorosis index.
c. Chronological fluorosis assessment index.
d. Fluorosis risk index.
e. Young’s classification.
f. Al-alousi classification.

Contd...
 Dental Indices 153
Contd...

g. Murray and Shaw classification.

h. DDE index & modified DDE index.
i. Thylstrup Fejerskov fluorosis index.
j. Tooth surface index of fluorosis.
9. Indices used in assessing malocclusion:
a. Malalignment index.
b. Handicapping malocclusion assessment index.
c. Occlusal feature index.
d. Occlusal index.
e. Index of orthodontic treatment needs.
f. Norwegian index of orthodontic treatment needs.
g. Handicapping labiolingual deviation index.
h. Massler and Frankel index.
i. Peer assessment rating index.
Library of School of Dentistry, TUMS

j. Dental Aesthetic index (DAI).

10. Indices used in assessing tooth wear:
For Personal Use Only

a. Eccles index of non-industrial origin.

b. Tooth wear index.
c. Exact tooth wear index.

Some of the more widely known indices are:

INDICES USED IN ASSESSING ORAL HYGIENE

Oral Hygiene Index (OHI)

The OHI, developed by John C Greene and Jack R Vermillion
(1960), has two components, the debris index and the calculus index,
and is an indication of oral cleanliness. The scores may be used singly
or in combination. For scoring, the clinician divides the dentition
into segments and selects the facial (or buccal) and lingual tooth
surface in each segment that is covered with the greatest amount of
debris and calculus. Twelve surfaces, therefore, are evaluated. For
this index, a surface includes half the circumference of the tooth.
The Oral Hygiene Index is composed of the combined Debris
Index and Calculus index, each of these index is in turn based on 12
numerical determinations representing the amount of debris or
calculus found on the buccal and lingual surfaces of each of three
segments of each dental arch.
 154 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 17.1: Various segments of the mouth (OHI)

The Maxillary and the Mandibular arches are each composed of

three segments (Fig. 17.1).

Segments
Maxillary
1. Segment 1: The segment distal to the right cuspid.
2. Segment 2: Upper right canine to upper left canine.
3. Segment 3: The segment distal to the left cuspid.
Mandibular
4. Segment 4: The segment distal to the left cuspid.
5. Segment 5: Lower left canine to lower right canine.
6. Segment 6: The segment distal to right cuspid.
 Dental Indices 155

Fig. 17.2: Scoring method for debris

Library of School of Dentistry, TUMS

Each segment is examined for debris or calculus. From each

segment one tooth is used for calculating the individual index, for
For Personal Use Only

that particular segment. The tooth used for the calculation must
have the greatest area covered by either debris or calculus (Fig. 17.2).
The method for scoring calculus is the same as that applied to
debris, but additional provisions are made for recording subgingival
deposits.

Debris Score

Scores Criteria
0 No debris or stain present
1 Soft debris covering not more than one third of the tooth
surface, or presence of extrinsic stains without other 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.

Total debris score

Debris index (DI) =
No. of segments scored
 156 A Practical Manual of Public Health Dentistry

Calculus Score

Scores Criteria
0 No calculus present
1 Supragingival calculus covering not more than one third of
the exposed tooth surface.
2 Supragingival calculus covering more than one-third but not
more than two thirds of the exposed tooth surface and/or the
presence of individual flecks of subgingival calculus around
the cervical portion of the tooth.
3 Supragingival calculus covering more than two-third of the
exposed tooth surface and/or a continuous heavy band of
subgingival calculus around the cervical portion of the tooth.
Library of School of Dentistry, TUMS

Total calculus score

Calculus index (CI) =
No. of segments scored
For Personal Use Only

The average individual or group debris and calculus scores are

combined to obtain oral hygiene index, as follows.
Oral hygiene index = Debris index + Calculus index
A perfect score would be 0, and the worst score possible is 12.

The Oral Hygiene Index-Simplified (OHI-S)

This index was given by John C. Greene and Jack R. Vermillion in
1964. It offers a more rapid method for evaluation of oral cleanliness
of population groups, but lacks in degree of sensitivity in comparison
to the original OHI index.
It differs from the original index in:
• Number of tooth surfaces scored [6 rather than 12]
• The method of selecting the tooth surfaces to be scored
• The scores which can be obtained.

Selection of Tooth
The six surfaces examined for the OHI-S are selected from four
posterior and two anterior teeth.
• In the posterior teeth, the first fully erupted tooth distal to the
second bicuspid, usually the first molar but sometimes the second
or third molar, is examined on each side of each arch.
 Dental Indices 157

• In the anterior portion of the mouth upper right central incisor

and lower left central incisor are scored.
• In the absence of either of these anterior teeth, the central incisor
on the opposite side of the midline is substituted.
• Only fully erupted permanent teeth are scored. A tooth is
considered to be fully erupted when the occlusal or incisal surface
has reached the occlusal plane.
• Natural teeth with full crown restorations and surfaces reduced
in heights by caries or trauma are not scored. Instead an alternate
tooth is examined.

Surfaces to be Seen (Fig. 17.3A)

Library of School of Dentistry, TUMS

• Six surfaces are examined [from four posterior teeth and two
anterior teeth].
For Personal Use Only

Upper molars [6|6]: The buccal surfaces of selected teeth is

inspected.
Lower molars [6|6]: The lingual surfaces of the selected teeth
are checked.
Upper and Lower Central incisor 1: labial surface is scored.

Fig. 17.3A: Six teeth and the surfaces scored (OHI-S)

 158 A Practical Manual of Public Health Dentistry

Examination Method
To obtain the scores for debris and calculus, each of the six selected
tooth surfaces are examined for debris and then calculus. The surface
area covered by debris is estimated by running the side of a No. 5
explorer (Shepherd’s Crook) along the tooth surfaces being examined
(Explorer is moved from incisal/occlusal to gingival margin). The
occlusal or incisal extent of the debris is noted as it is removed
(Fig. 17.3B). Same No. 5 explorer is used to estimate the surface
area covered by the supragingival and subgingival calculus.
• Spray water into patient/
client’s mouth and
instruct patient/client to
Library of School of Dentistry, TUMS

swish.
• Insert saliva ejector into
For Personal Use Only

patient/client’s mouth.
• Select teeth for examina-
tion by choosing six
specific teeth with one in
each sextant. Fig. 17.3B: Examination method
• Evaluate teeth. for OHI-S

– Start evaluation with maxillary posterior sextant and work

way around maxillary arch.
– Drop down to mandibular left lingual posterior sextant and
work way around to other side of mouth.
• Evaluate teeth for soft debris by recording six debris scores on
appropriate recording form(s).
• Evaluate teeth for calculus by recording six calculus scores.
• Calculate debris score by totalling debris scores and dividing by
number of teeth scored.
• Calculate calculus score by totalling calculus scores and dividing
by number of teeth scored.
• Calculate OHI-S score by adding debris score to calculus score
that equals OHI-S score.
• Record OHI-S score in patient/client’s chart or on appropriate
recording form(s).
 Dental Indices 159

Scoring Criteria (Debris) (Fig. 17.4A)

Scores Criteria
0 No debris or stain present.
1 Soft debris covering not more than one third of the tooth
surface being examined or 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.

Scoring Criteria (Calculus) (Fig. 17.4B)

Library of School of Dentistry, TUMS

Scores Criteria
0 No calculus present.
For Personal Use Only

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 and /or the
presence of individual flecks of subgingival calculus around
the cervical portion of the tooth.
3 Supragingival calculus covering more than two-third of the
exposed tooth surface or a continuous heavy band of
subgingival calculus around the cervical portion of the tooth.

In the simplified OHI, the worst score possible is 6.

Interpretation
Individually DI-S and CI-S is scored as follows:
0.0 to 0.6 = Good oral hygiene
0.7 to 1.8 = Fair oral hygiene
1.9 to 3.0 = Poor oral hygiene
An OHI-S is scored as follows:
0.0–1.2 = Good oral hygiene
1.3–3.0 = Fair oral hygiene
3.1–6.0 = Poor oral hygiene
 160 A Practical Manual of Public Health Dentistry

Fig. 17.4A: Scoring method for debris

Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 17.4B: Scoring method for calculus

Patient Hygiene Performance Index (PHP Index)

It was developed by Podshadley AG, and Haley JV (1968) to assess
the extent of plaque and debris over a tooth surface as an indication
of oral cleanliness. Debris for PHP was defined as the soft foreign
material consisting of bacterial plaque, material alba and food debris
that is loosely attached to tooth surfaces.
Most useful for individual patients who have significant plaque
accumulation.
 Dental Indices 161

Teeth and Surfaces Examined (Fig. 17.5)

Tooth Numbers in FDI System
16 - Upper right first molar
11 - Upper right central incisor
26 - Upper left molar
36 - Lower left first molar
31 - Lower left central incisor
46 - Lower right first molar
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 17.5: PHP index: 6 tooth surfaces are scored

 162 A Practical Manual of Public Health Dentistry

Surfaces
Facial surfaces: Incisors and maxillary molars.
Lingual surfaces: Mandibular molars.

Substitutions for Missing Teeth

• The second molar is used if the 1st molar
– Is missing
– Less than three–fourth erupted
– Has a full crown
– Is broken down/exposed surface area is reduced
• The third molar is used when the second molar is missing.
• The adjacent incisor of the opposite side is used, when the central
Library of School of Dentistry, TUMS

incisor is missing.

Procedure
For Personal Use Only

• Disclosing solution is applied.

• Patient is asked to swish for 30 seconds and expectorate but not
rinse.
• Examination is made using a mouth mirror.
• Each tooth surface to be evaluated is subdivided into five sections
as follows (Fig. 17.6).
Vertically: Three divisions mesial, middle and distal.
Horizontally: The middle third is subdivided into gingival, middle
and occlusal or incisal thirds.
• Each area with plaque is scored a point so each tooth score can
range from 1 to 5 points.

Fig. 17.6: Subdivision of a tooth into 5 sections (PHP index)

 Dental Indices 163

Scoring
Debris scores for individual tooth: Add the scores for each of the five
subdivisions. The scores range from 0 to 5.
PHP for an individual: Total the scores for the individual teeth
and divide by the number of the teeth examined. The PHP value
ranges from 0 to 5.
PHP Index for a group: To obtain the average PHP score for a
group or a population, total the individual score and divide by the
number of people examined.

Interpretation
Nominal scale for evaluation of scores:
Library of School of Dentistry, TUMS

Rating scores
1. Excellent = 0 (No debris)
For Personal Use Only

2. Good = 0.1–1.7
3. Fair = 1.8–3.4
4. Poor = 3.5–5.0

INDICES USED IN ASSESSING PLAQUE AND DEBRIS

Turesky-Gilmore-Glickman Modification of the

Quigley-Hein Plaque Index
Quigley G and Hein J (1962) proposed a system for scoring dental
plaque. They examined only the facial surfaces (gingival third) of
the anterior teeth using basic fuchsin as a disclosing agent, and scoring
0 to 5.

Plaque Scoring System for Quigley and Hein

Scoring criteria Score

No plaque 0
Flecks of stain at the gingival margin 1
Definite line of plaque at the gingival margin 2
Gingival third of surface 3
Two-thirds of surface 4
Greater than two-thirds of surface 5
 164 A Practical Manual of Public Health Dentistry

This was modified by Turesky S, Gilmore ND and Glickman I to

more explicitly describe mild to moderate plaque deposits in 1970.

Scoring by the Turesky Modification

• All teeth assessed except third molars (maximum number 28)
• A staining solution is used to show plaque deposits (Quigley and
Turesky used basic fuchsin, Gordon used erythrosine)
• Both the facial and lingual surfaces examined (maximum number
56)
• A score is assigned to each facial and lingual nonrestored surface.

Modified Plaque Scoring System of Turesky

et al (Fig. 17.7)
Library of School of Dentistry, TUMS

Criteria Score
For Personal Use Only

No plaque 0
Separate flecks of plaque at the cervical margin of the tooth 1
A thin continuous band of plaque 2
(up to 1 mm) at the cervical margin of the tooth
A band of plaque wider than 1 mm coercing less 3
than one-third of the crown of the tooth
Plaque covering at least one-third but less 4
than two-thirds of the crown of the tooth
Plaque covering two-thirds or more of the 5
crown of the tooth

Fig. 17.7: Tooth areas graded by the Turesky et al

modified Quigley Hein plaque index
 Dental Indices 165

Total score = Sum (scores for all facial and lingual surfaces)
Index = (total score)/(number of surfaces examined)
Interpretation
A score of 0 or 1 is considered low.
A score of 2 or more is considered high.

Periodontal Indices

Plaque Index (PI)

The PI as developed by Silness and Loe (1964) assesses the thickness
of plaque at the cervical margin of the tooth (closest to the gum).
The scoring is done on the entire dentition or on selected teeth. If it
Library of School of Dentistry, TUMS

is done on selected teeth, then index teeth will be 16, 12, 24, 36, 32
For Personal Use Only

& 44. Four gingival areas, i.e. distofacial, facial, mesiofacial and lingual
surfaces are examined.
• Each tooth is dried and examined visually using a mirror, an
explorer, and adequate light. The explorer is passed over the
cervical third to test for the presence of plaque. A disclosing agent
may be used to assist evaluation.
• Missing teeth are not substituted.
• Four different scores are possible.
• Each of the four surfaces of the teeth (buccal, lingual, mesial and
distal) is given a score from 0 to 3.

PI Score for Tooth

The scores from the four areas of the tooth are added and divided
by four in order to give the plaque index for the tooth with the
following scores and criteria:

Scoring Criteria: The Plaque Index

The indices for the following six teeth may be grouped to designate
the index for the group of teeth: 16, 12, 24, 36, 32, and 44.
(Fig. 17.8).
 166 A Practical Manual of Public Health Dentistry

Scores Criteria
0 No plaque
1 A film of plaque adhering to the free gingival margin and
adjacent area of the tooth. The plaque may be seen in situ
only after application of disclosing solution or by using the
probe on the tooth surface.
2 Moderate accumulation of soft deposits within the gingival
pocket, or the tooth and gingival margin which can be seen
with the naked eye.
3 Abundance of soft matter within the gingival pocket and/or
on the tooth and gingival margin.
Library of School of Dentistry, TUMS
For Personal Use Only

Fig. 17.8: Teeth and surfaces scored (Silness and Loe PI)
 Dental Indices 167

PI for an Individual
The index for the patient is obtained by summing the indices for all
six teeth and dividing by six.

Interpretation for PI Scores

Four ratings may be assigned:
0 = Excellent oral hygiene
0.1–0.9 = Good oral hygiene
1.0–1.9 = Fair oral hygiene
2.0–3.0 = Poor oral hygiene

Navy Plaque Index

Library of School of Dentistry, TUMS

The Navy Plaque Index (NPI) was developed by Grossman FD and

For Personal Use Only

Fedi PF (1970) as part of the Navy Periodontal Screening Examination,

along with the Navy Periodontal Disease Index. It reflects the plaque
control status of the patient and emphasizes plaque in the cervical
portion of the tooth which is in contact with the gingiva margins.

Teeth Examined
16 - Maxillary Right First Molar
21 - Maxillary Left Central Incisor
24 - Maxillary Left First Premolar
36 - Mandibular Left First Molar
41 - Mandibular Right Central Incisor
44 - Mandibular Right First Premolar.

Substitutions
If 16, 24, 36 or 44 are missing, then substitute the next most posterior
tooth.
If 21 or 41 are missing, then substitute the nearest incisor in the
arch. If all incisors are missing from the arch, then substitute a cuspid.

Surfaces Examined on Each Tooth

Facial gingival area (G) mesial proximal area (M) distal proximal area (D)
 168 A Practical Manual of Public Health Dentistry

Lingual gingival area (G) mesial proximal area (M) distal proximal
area (D).

Scoring Critera—NPI

Plaque status Designated Points

Plaque in contact with gingival M 3
tissue on mesial proximal surface
Plaque in contact with gingival tissue G 2
on facial or lingual surface
Plaque in contact with gingival tissue D 3
on distal proximal surface
Plaque on facial or lingual surface of R 1
tooth surface but not in contact with
gingival tissue
Library of School of Dentistry, TUMS

For Each Tooth

For Personal Use Only

Facial points = (M points on facial aspect) + (G points on facial

aspect) + (D points on facial aspect) + (R points
on facial aspect)
Lingual points = (M points on lingual aspect) + (G points on
lingual aspect) + (D points on lingual aspect) +
(R points on lingual aspect)
Calculating the NPI
Tooth score = (facial points) + (lingual points)
NPI score = MAX (all 6 tooth scores)
NPI total = SUM (all 6 tooth scores).
Interpretation
Minimum score for a surface : 0
Maximum score for a surface : 9
Minimum tooth score : 0
Maximum tooth score : 18
Maximum NPI score : 18
Minimum NPI total : 0
 Dental Indices 169

Plaque Control Record

It was given by O’Leary TJ, Drake RB and Naylor JE (1972). This
system measures plaque present, rather than plaque not present, but
no attempt is made to differentiate in the quantity of plaque seen on
each surface.

Selection of Teeth and Surfaces

• All teeth are examined.
• Missing teeth are indicated on the record form as a single thick
horizontal line.
• Four surfaces are examined: facial, lingual, mesial and distal.
• The number of surfaces examined may be increased from four to
Library of School of Dentistry, TUMS

six. When using six surfaces, they are facial (or buccal), mesiofacial,
mesiolingual, lingual, distolingual, and distofacial.
For Personal Use Only

Procedure
Plaque is disclosed by either applying disclosing agent or the patient
is asked to chew disclosing tablet and swish and rub the solution
over the tooth surfaces with the tongue before rinsing. The operator
uses an explorer or the tip of probe, examines each stained surface
for soft accumulations at the dento gingival junction. Those surfaces
which do not have soft accumulations at the dentogingival junction
are not scored.

Scoring
For individual: The number of surfaces with plaque is multiplied by
100, and divided by the number of tooth surfaces examined.
Percent with plaque =
The number of surfaces with plaque
× 100
Number of tooth surfaces examined
For example, if an individual has 26 teeth, that equals 104 surfaces.
If eight surfaces are found to have plaque, then 800 are divided by
104, leaving a plaque control index of 7.6 percent.
A score under 10 percent is considered good.
 170 A Practical Manual of Public Health Dentistry

INDICES USED IN ASSESSING CALCULUS

Calculus Surface Index

This index was developed by Ennever J, Sturzenberger CP and Radike
AW (1961).
The Calculus Surface Index is a measure of dental calculus
formation. It can be used to quantitate the accumulation of dental
calculus in short-term testing programs to evaluate the effectiveness
of preventive care.

Method
Presence or absence of supragingival and/subgingival or subgingival
Library of School of Dentistry, TUMS

calculus on the four mandibular incisor is assessed.

Each incisor is divided into four scoring units. The facial surface
For Personal Use Only

is considered as one unit, and the lingual surface is divided

longitudinally into three subsections, the distal-lingual, middle-
lingual and the mesial-lingual.
The presence or absence of calculus is examined by visual or tactile
examination using a mirror and dental explorer (sickle type).
Each surface with calculus is scored 1 point.

Scoring
For a person
Calculus surface index = Sum total of calculus points on the 16
surfaces surveyed.

Interpretation
Minimum score: 0
Maximum score: 16

INDICES USED IN ASSESSING GINGIVAL

INFLAMMATION

Papillary-Marginal-Attachment Index
PMA index is probably the oldest reversible index which was
developed by Schour I and Massler M (1944).
 Dental Indices 171

It was used to assess the extent of gingival changes in large groups

for epidemiological studies. It was based on the concept that the
extent of inflammation serves as an indicator of the severity of the
condition. The presence or absence of inflammation is recorded in
three areas of gingiva around the teeth.

Selection of Teeth and Surfaces

Three gingival units are examined for each tooth
P = Papillary portion between the teeth
• Papilla is numbered by the tooth just distal to it. Papilla is not
present when teeth are separated by a diastema or there is an
edentulous area.
Library of School of Dentistry, TUMS

• Inflammation usually begins within the papilla at the col area.

Papillary changes—Mild gingivitis.
For Personal Use Only

M = Marginal collar around the teeth

• It is located between papillae, attached by junctional epithelium,
and demarcated from attached gingiva by the free gingival groove.
• Papillary and marginal gingival inflammation- Moderate gingivitis.
A = Attached gingiva overlying the alveolar bone
• Stippled gingiva between the free gingival groove and the
mucogingival junction.
• Spread of inflammation from papillary and marginal gingivitis
into the attached gingiva — Severe gingivitis.

Method
All the teeth can be assessed starting from maxillary second molar of
one side to the second molar of the other side and then mandibular
second molar of the same side to the second molar of the other side.
Third molars are not included. Adequate light and mouth mirror
are used. Probe usually a blunt probe is used for pressing on gingiva.

Scoring Criteria
Papillary = P
0 = Normal, no inflammation.
1+ = Mild papillary engorgement, slight increase in size.
 172 A Practical Manual of Public Health Dentistry

2+ = Obvious increase in size of gingival papilla, bleeding on pressure.

3+ = Excessive increase in size with spontaneous bleeding.
4+ = Necrotic papilla.
5+ = Atrophy and loss of papilla (through inflammation).
Marginal = M
0 = Normal, no inflammation visible.
1+ = Engorgement, slight increase in size, no bleeding.
2+ = Obvious engorgement, bleeding upon pressure.
3+ = Swollen collar, spontaneous bleeding, beginning infiltration
into attached gingiva.
4+ = Necrotic gingivitis.
5+ = Recession of the free marginal gingiva below the
cementoenamel junction as a result of inflammatory changes.
Library of School of Dentistry, TUMS

Attached = A
0 = Normal; pale rose, stippled.
For Personal Use Only

1+ = Slight engorgement with loss of stippling, change in color

may or may not be present.
2+ = Obvious engorgement of attached gingiva with marked
increase in redness, pocket formation present.
3+ = Advanced periodontitis, deep pockets evident.
Scoring
P-M-A for individual
Count the number of P, M and A units scored and record separately
as: P-M-A =?-?-?
Keeping the total separate, as on adding the sum will not represent
the area of the gingiva where the inflammation is present.
P-M-A for a group: The average of the P, M and A is computed by
totalling each for all individuals and then dividing each number of
individuals examined.

Gingival Index (GI)

Also attributed to Loe and Silness (1963), the GI assesses the severity
of gingivitis based on color, consistency, and bleeding on probing.
It describes the clinical severity of gingival inflammation as well as
its location. The scoring is done on the entire dentition or on selected
 Dental Indices 173

teeth. If it is done on selected teeth, then index teeth will be 16, 12,
24, 36, 32 & 44. Four gingival areas, i.e. distofacial, facial, mesiofacial
and lingual surfaces are examined. A probe is used to press on the
gingiva to determine its degree of firmness, and to run along the
soft tissue wall adjacent to the entrance to the gingival sulcus.

Teeth Examined
• Maxillary right first molar
• Maxillary right lateral incisor
• Maxillary left first bicuspid
• Mandibular left first molar
• Mandibular left lateral incisor
Library of School of Dentistry, TUMS

• Mandibular right first bicuspid.

For Personal Use Only

Surfaces Examined on each Tooth

Distofacial, facial, mesiofacial and lingual surfaces.
Scoring is based on the following criteria:

Scoring Criteria: Gingival Index

Average gingival Interpretation

index (Score)
0 Normal gingiva/absence of inflammation
1 Mild inflammation: Slight change in color, slight
edema. No bleeding on probing;
2 Moderate inflammation: Redness edema and
glazing. Bleeding on probing
3 Severe inflammation: Marked redness and
edema. Ulceration and a tendency for
spontaneous bleeding

Each surface is given a score, and then the scores are totaled
which gives the score for area and divided by four gives score for the
tooth. Totaling all scores and dividing by the number of teeth
examined provides GI score per person.
 174 A Practical Manual of Public Health Dentistry

Interpretation: Gingival Index

Average gingival Interpretation

index (Score)
2.1 – 3.0 Poor (severe gingivitis), severe inflammation
1.1 – 2.0 fair (moderate gingivitis), moderate inflammation,
0.1 – 1.0 Good (mild gingivitis), mild inflammation
< 0.1 Excellent (no gingivitis), no inflammation

INDICES USED IN ASSESSING GINGIVAL BLEEDING

Gingival Bleeding Index (GBI)

Unwaxed dental floss is used to measure a GBI, developed by Carter
Library of School of Dentistry, TUMS

and Barmes (1974). A full complement of teeth has 28 proximal

areas to be examined. Floss is passed interproximally, first on one
For Personal Use Only

side of the dental papilla, then on the other. Although this involves
two sulci, they are scored as one interdental unit. The clinician curves
the floss around each tooth and passes it below the gingival margin,
taking care not to lacerate the gingiva. Any bleeding noted indicates
the presence of disease. The numbers of bleeding areas versus
proximal areas scored is recorded. It can be used for initial patient
evaluation and motivation or overtime to assess response to
interventions to improve periodontal health.

Procedure
Selection of Teeth
The mouth is divided into 6 segments (upper right, upper anterior,
upper left, lower left, lower anterior, lower right).
Areas involving the third molars are not scored because of
variations in arch position, access and vision.
Method
Unwaxed dental floss is alternately passed interproximally into the
gingival sulcus on both sides of the interdental papillae. With the floss
extended as far as possible towards the buccal and lingual, the floss is
carried to the bottom of the sulcus. The floss is then moved in an
 Dental Indices 175

incisogingival motion for one double stroke. Care is taken not to cause
laceration of the papillae. A new length of clean floss is used for each
interproximal unit.
Bleeding is generally immediately evident in the area or on the
floss, but 30 seconds are allowed for reinspection of each segment.
If bleeding is copious, the patient should rinse between segments.
An area is nonscoreable when tooth positions, diastemas or other
factors compromise the desirable interproximal relationships.
Bleeding Assessment
No attempt is made to quantify the degree of bleeding.
Bleeding is assessed only as present or absent.
Library of School of Dentistry, TUMS

Scoring Codes for GBI

Not bleeding : None (blank)
For Personal Use Only

Bleeding : B
Notscoreable : X

Recording Method

Interproximal areas of maxillary teeth Code

17–16 ––––
16–15 ––––
15–14 ––––
14–13 ––––
13–12 ––––
12–11 ––––
11–21 ––––
21–22 ––––
22–23 ––––
23–24 ––––
24–25 ––––
25–26 ––––
26–27 ––––

Similarly scores are recorded for mandibular teeth.

Result
Total scoreable areas = 26 – (number of nonscoreable areas)
 176 A Practical Manual of Public Health Dentistry

Gingival Bleeding Score (total bleeding areas) = Sum of number of

bleeding areas.

Interpretation
The fewer the number of bleeding sites, the less the extent of
gingivitis. Ideally the score should be 0.
If the patient is to be followed overtime, previous bleeding sites
are monitored to see if they become nonbleeding. The goal of
interventions is to reduce the score as much as possible.

INDICES USED IN ASSESSING PERIODONTAL

DISEASES
Library of School of Dentistry, TUMS

Periodontal Index (PI)

For Personal Use Only

Russell [1956] developed an index for measuring periodontal disease

that could be used in population surveys. It can be based solely upon
the clinical examination, or it can make use of dental X-rays if they
are available. It places greater emphasis on advanced disease. PI
determines the periodontal disease status of populations in
epidemiologic studies. Each tooth is scored according to the
condition of the surrounding tissues. On examination, each tooth is
assigned a score using the following criteria:

Scoring
• Each tooth is scored separately according to the following criteria.
• Rule: When in doubt, assign the lower score.

Reasons for its Widespread Use

• Ease of use
• Clarity of criteria
• Reasonable comparability of results
Scoring values (0, 1, 2, 6, and 8) relate to the stages of the disease
scored in an epidemiological survey to the clinical condition observed.
The jump from 2 to 6 in the scale recognizes the change in disease
condition from a severe gingivitis to an overt destructive periodontal
 For Personal Use Only
Library of School of Dentistry, TUMS

Scoring Criteria of Russell’s Periodontal Index

Criteria for field studies Additional X-ray criteria Score

Negative (neither overt inflammation in the investing tissues, Radiographic appearance normal 0
nor loss of function due to destruction of supporting tissues)
Mild gingivitis (overt area of inflammation in the free gingivae,
but this area does not circumscribe the tooth) 1
Gingivitis (inflammation completely circumscribes the tooth,
but there is no apparent break in the epithelial attachment) 2
(Not used in field study) Early, notchlike resorption of the alveolar crest 4
Gingivitis with pocket formation (the epithelial attachment is Horizontal bone loss involving the entire alveolar 6
broken, and there is a pocket. There is no interference with crest, up to half of the length of the tooth root
normal masticatory function, the tooth is firm in its socket, (distance from apex to cementoenamel junction)
and has not drifted).
Dental Indices

Advanced destruction with loss of masticatory function Advanced bone loss, involving more than half of 8
(tooth may be loose, tooth may have drifted, tooth may the length of the tooth root, or a definite intrabony
sound dull on percussion with a metallic instrument, the pocket with definite widening of the periodontal
tooth may be depressible in its socket) membranes. There may be root resorption, or
rarefaction at the apex
177
 178 A Practical Manual of Public Health Dentistry

disease with obvious loss of attachment. PI can be considered a true

interval scale.
Scores for each tooth are added, and the total is divided by the
number of teeth examined. Scores can be interpreted as follows:
• 0.0–0.2 = Clinically normal supportive tissues.
• 0.3–0.9 = Simple gingivitis.
• 0.7–1.9 = Beginning destructive periodontal disease.
• 1.6–5.0 = Established destructive periodontal
disease.
• 3.8–8.0 = Terminal periodontal disease.
Individual score = Average (scores for all of the teeth in the
mouth)
Population score = Average (individual scores in population
Library of School of Dentistry, TUMS

examined).
For Personal Use Only

Periodontal Disease Index (PDI)

The periodontal disease index was introduced by Sigurd P Ramfjord
in 1959. It was a modification of Russell index, particularly designed
for assessing the extent of pocket deepening below the
cementoenamel junction. The PDI comprises of three components
namely: Plaque component, Calculus component, Gingival &
periodontal component. It combines the evaluation of gingival status
with the probed attachment level (crevice depth measured from the
cementoenamel junction).

Selection of Teeth and Surfaces

Teeth examined: (FDI system tooth numbers are in the parenthesis)
• Maxillary right first molar - (16)
• Maxillary left central incisor - (21)
• Maxillary left first bicuspid - (24)
• Mandibular left first molar - (36)
• Mandibular right central incisor - (41)
• Mandibular right first bicuspid - (44)
If any of the teeth are missing or unerupted, then only the teeth
present are examined (only fully erupted teeth are used).
Substitution is not made for missing teeth.
 Dental Indices 179

Scoring Method
For Gingival Status: The gingiva around the teeth to be scored is
first dried superficially by gently touching with absorbing cotton.
Changes in color are evaluated by observing the color of the gingiva
around the tooth to be scored and comparing the color corresponding
to the buccal, lingual and interproximal surfaces with each other.
Change in form is initially a blunting or rounding of the margin of
the gingiva and thickening of papilla. Change in consistency is detected
by applying gentle pressure with the side of periodontal probe against
the gingiva to determine if there is soft or spongy consistency.
For Crevicular measurements: To measure crevice depth related
to cementoenamel junction, a University of Michigan #O Probe is
Library of School of Dentistry, TUMS

used. The end of the probe should be placed against the enamel
surface coronally to the margin of the gingiva so that the angle formed
For Personal Use Only

by the working end of the probe and long axis of the crown of the
tooth is approximately 45°. Minimal force should be used to pass
the probe in apical direction maintaining contact with the tooth.
The probe should always be pointed towards the apex of the tooth
or the central axis of multirooted teeth. After the distance from the
free gingival margin to the CEJ has been measured, an attempt should
be made to move the probe along the cemental surface. This can be
achieved only if there has been loss of periodontal attachment.
The University of Michigan number O probe is graduated at 3, 6
and 8 mm, making it necessary to estimate intervening measurements.
The following criteria are used for crevicular measurements:
1. If the gingival margin is on enamel, measure from gum margin to
CEJ and record the measurement. Then record the distance from
the gingival margin to the bottom of the pocket. The distance
from the CEJ to the bottom of the pocket can then be found by
subtracting the first from the second measurement.
2. If the gingival margin is on cementum, record the distance from
the CEJ to the gingival margin as a minus value (a) then record
the distance from the CEJ to the bottom of the gingival crevice
as a positive value (b) Both loss of attachment and actual crevice
depth can easily be assessed from these scores.
Ramfjord’s method for measuring this distance is often referred to
as the “Indirect method for measuring periodontal attachment loss”.
 180 A Practical Manual of Public Health Dentistry

Scoring Criteria: Periodontal Disease Index

Gingivitis No signs of inflammation 0

Mild to moderate inflammatory gingival
changes, not extending around the tooth 1
Mild to moderately severe gingivitis
extending all around the tooth 2
Severe gingivitis characterized by marked
redness, swelling, tendency to bleed and ulceration 3
Gingival Gingival crevice in any of the two measured
crevice areas (mesial, buccal), extend
depth apically to the cementoenamel junction
but not more than 3 mm 4
Gingival crevice in any of the two measured
areas extending apically to the cemento-
enamel junction from 3 to 6 mm inclusive. 5
Library of School of Dentistry, TUMS

Gingival crevice in any of the two measured

areas extending more than 6 mm apical to the
For Personal Use Only

cementoenamel junction. 6

Scoring PDI
For individuals: Add the scores for individual teeth and divide by
the number of teeth examined. The PDI ranges from 0 to 6.
For group: Total the individual PDI scores and divide by the number
of individuals examined. The average ranges from 0 to 6.
Plaque and Calculus Component of the Periodontal Disease Index
(PDI).
Although not part of PDI, a Plaque Index and Calculus Index
are included when making a survey hence described.

Dental Plaque
For each of 6 teeth mentioned above 4 surfaces (facial, lingual, mesial
and distal) are scored from 0 to 3.
Procedure
• Apply disclosing agent
• Patient is asked to expectorate and rinse with water
• Specific surfaces with disclosed plaque are observed.
 Dental Indices 181

Scoring Criteria for Plaque

Criteria Score
None 0
Present on some but not on all interproximal, 1
buccal and lingual surfaces
Plaque present on all of the interproximal, 2
buccal and lingual surfaces, but covering
less than half of these surfaces
Plaque extends once all interproximal, 3
buccal and lingual suface and covering more than
one half of these surfaces
Library of School of Dentistry, TUMS

Total score
Plaque score of an individual =
For Personal Use Only

Number of teeth examined

Calculus
To measure the presence and extent of calculus a subgingival explorer
or a periodontal probe is used.
Procedure
For each of the 6 teeth, the presence and extent of calculus on facial
and lingual surfaces is scored from 0 to 3.

Scoring Criteria for Calculus

Criteria Score
None 0
Supragingival calculus, extending only slightly 1
below the free gingival margin (not more than 1 mm)
Moderate amount of supra- and subgingival 2
calculus or subgingival calculus alone
An abundance of supra- and subgingival calculus 3

Scoring
For individual teeth: Add scores for each surface and divide by the
number of surfaces (4).
 182 A Practical Manual of Public Health Dentistry

For an individual: Add the scores for an individual tooth and divide
by the number of teeth.

Gingival Bone Count Index

The Gingival Bone Count Index was developed by Dunning JM
and Leach LB (1960). It is a composite score based on the gingival
condition and degree of bone loss affecting a person’s teeth. This
can be used to evaluate periodontal health, especially in epidemiologic
studies.

Instruments Used
• Mouth mirror
Library of School of Dentistry, TUMS

• No. 17 Probe
• Two no. 3 posterior bitewing radiographs.
For Personal Use Only

Method
• The gingival score is based on the clinical examination.
• The bone score is based on the clinical examination and evaluation
of dental X-rays
• A mean for each score is then computed for the whole mouth.

Scoring Criteria
A single gingival score and a single bone score is generated for each
tooth studied.

Gingival Score

Criteria/Finding Score
Negative 0
Mild gingivitis involving the free gingiva 1
(margin, papilla, or both)
Moderate gingivitis involving both free 2
and attached gingiva
Severe gingivitis with hypertrophy 3
and easy hemorrhage
 Dental Indices 183

Bone Score

Criteria/Finding Score
No bone loss 0
Incipient bone loss or notching of 1
alveolar crest.
Bone loss about one fourth of root 2
length, or pocket formation on one side,
not over one half of root length.
Bone loss about one half of root 3
length, or pocket formation on one side, not
over three-fourth root length, mobility slight
Bone loss about three quarters of root 4
length, or pocket formation on one side to
apex, mobility moderate
Library of School of Dentistry, TUMS

Bone loss complete, mobility marked 5

For Personal Use Only

Gingival bone score

= SUM ((gingival score) + (bone score))/
(number of teeth examined) =
= (mean gingival score) + (mean bone score)
Interpretation
• Minimum score: 0
• Maximum score: 8
The higher the score, the more serious the periodontal disease.

The Navy Periodontal Disease Index (NPDI)

The Navy Periodontal Disease Index (NPDI) was developed as part
of the Navy Periodontal Screening Examination, along with the Navy
Plaque Index. It is composed of a gingival and a pocket scores. The
NPDI score can be used to determine the level of treatment required
by the individual patient.
Teeth examined
16 - Maxillary Right First Molar
21 - Maxillary Left Central Incisor
24 - Maxillary Left First Premolar
36 - Mandibular Left First Molar
 184 A Practical Manual of Public Health Dentistry

41 - Mandibular Right Central Incisor

44 - Mandibular Right First Premolar

Substitutions
If 16, 24, 36 or 44 are missing, and then substitute the next most
posterior tooth.
If 21 or 41 are missing, then substitute the nearest incisor in the
arch. If all incisors are missing from the arch, then substitute a cuspid.

Gingival Score
Each tooth is examined for evidence of inflammatory change, which
constitutes one or more of the following findings:
Library of School of Dentistry, TUMS

• Any change from normal gingival color

• Loss of normal density and consistency
For Personal Use Only

• Slight enlargement or blunting of the papilla or gingiva

• Tendency to bleed upon palpation or probing.

Scoring Criteria

Gingival Score Points

Gingival tissue is normal in color and tightly adapted to 0
the tooth. Tooth is firm and no exudate is present.
Inflammatory changes are present but do 1
not completely encircle the tooth.
Inflammatory changes completely encircle the tooth. 2

Pocket Score
With a calibrated periodontal probe, take six measurements of each
designated tooth:
1. Mesial facial surface
2. Middle facial surface
3. Distal facial surface
4. Mesial lingual surface
5. Middle lingual surface
6. Distal lingual surface
 Dental Indices 185

Scoring Criteria

Pocket measurements Points

Probing reveals sulcular depth not over 3 mm 0
Probing reveals pocket depth greater 5
than 3 mm but not over 5 mm
Probing reveals pocket depth greater than 5 mm 8

Pocket score = Maximum score taken at the 6 probing sites

Calculating the NPDI
Tooth score = Gingival score + pocket score
NPDI score = Maximum of all six tooth scores
NPDI total = Sum of all six tooth scores
Library of School of Dentistry, TUMS

Interpretation
• Minimum tooth score : 0
For Personal Use Only

• Maximum tooth score : 10

• Minimum NPDI score : 0
• Maximum NPDI score : 10
• Minimum NPDI total : 0
• Maximum NPDI total : 60

Community Periodontal Index of Treatment

Needs (CPITN)
The FDI-WHO Joint Working Group on periodontal diseases supports
the use of the CPITN as an epidemiological screening procedure for
periodontal treatment needs in populations. The Community
Periodontal Index of Treatment Needs (CPITN) is an epidemiologic
tool developed by the World Health Organization (WHO) for the
evaluation of periodontal disease in population surveys. It can be used
to recommend the kind of treatment needed to prevent periodontal
disease. Following extensive discussion and testing the CPITN was
finalized and described in 1982 (Ainamo Jukka, Barmes David, Beagrie
George, Cutress Terry, Martin Jean and Sardo-Infirri Jennifer).
The CPITN is primarily a screening procedure which requires
clinical assessment for the presence or absence of periodontal pockets,
calculus and gingival bleeding. Use of a special CPITN periodontal
probe (or its equivalent) is recommended.
 186 A Practical Manual of Public Health Dentistry

For epidemiologic purposes in adult populations, 10 specified index

teeth are examined. For persons under 20 years of age only, six index
teeth are specified. In dental practice, all teeth are examined and the
highest score for each sextants noted. Only six scores are recorded.
Measures of gingival recession, tooth mobility, intensity of
inflammation, precise identification of pocket depths or differentiation
between supra- and subgingival calculus are not included in the
CPITN. Individuals are assigned to one of four treatment need
categories determined from their CPITN scores.
Teeth examined: Two methods of selection
Sextants: Total six sextants
14 teeth on the maxilla and 14 teeth on the mandible, divided
into three segments on each arch with following tooth numbers (FDI).
Library of School of Dentistry, TUMS

Maxilla:
Sextant 1 : 17 to 14
For Personal Use Only

Sextant 2 : 13 to 23
Sextant 3 : 24 to 27
Mandible:
Sextant 4 : 37 to 34
Sextant 5 : 33 to 43
Sextant 6 : 44 to 47
Third molars are not used unless they function in place of the
second molars.

Index Teeth
In epidemiological surveys, for adults aged 20 years or more, only
10 index teeth are examined (5 teeth on the maxilla and 5 teeth on
the mandible). These have been identified as the best estimators of
the worst periodontal condition of the mouth.
MAX 17 16 11 26 27
MAND 47 46 31 36 37
The molars are examined in pairs and only one score, the highest
is recorded. Only one score is recorded for each sextant.
For young people, up to 19 years only, six index teeth
MAX 16 11 26
MAND 46 31 36
The second molars are excluded as index teeth at these ages because
of the high frequency of false (noninflammatory associated with tooth
eruption) pocket.
 Dental Indices 187

For screening and monitoring purposes in dental practice all teeth

in a sextant are examined for adults over age 19 years. Only one
score, the highest is recorded for each sextant
When examining children less than 15 years, pockets are not recorded
although probing for bleeding and calculus are carried out as routine.

Recording Data

The following box chart is recommended as the epidemiologic and

dental office chart for recording CPITN data. The recommended
periodontal probe for use with CPITN was described in the WHO
621 report (WHO 1978). The approved basic probe is suitable for
Library of School of Dentistry, TUMS

general use in epidemiology and routine screening of patients in

general practice. The CPITN is particularly designed for gentle
For Personal Use Only

manipulation of the often very sensitive soft tissues around the teeth;
as such it is different in concept from the probes for dental caries
and most other oral care instruments in current use.

The Probe

The probe is both thin in the handle and is of very light weight (5
gms). The probe has a black band starting at 3.5 mm and ending at
5.5 mm a ball tip of 0.5 mm diameter.
The functions of ball tip are:
• To aid in detection of calculus and other tooth surface roughness.
• To facilitate assessment of the base of the pocket and reduce the
risk of over measurement.
A variant of this basic probe has two additional lines at 8.5 mm
and 11.5 mm from the working tip. The additional lines may be of
use when performing a detailed assessment and recording of deep
pockets for the purpose of preparing treatment plan for complex
periodontal therapy. The two instruments can be identified as:
CPITN-E for the epidemiologic probe with a black band from
3.5 and 5.5 mm (Fig. 17.9).
CPITN-C for the clinical probe with the additional 8.5 and
11.5 mm markings (Fig. 17.10).
 188 A Practical Manual of Public Health Dentistry
Library of School of Dentistry, TUMS

Fig. 17.9: Community periodontal

index of treatment needs (CPITN)
For Personal Use Only

‘E’ probe

Fig. 17.10: Community

periodontal index of
treatment needs
(CPITN) ‘C’ probe
 Dental Indices 189

Sensing Gingival Pockets

An index tooth should be probed, using the probe as a “sensing”
instrument to determine pocket depth and to detect subgingival calculus
and bleeding response. The sensing force used should be not more than
20 grams. A practical test for establishing this force is to place the probe
point under the thumb nail and press until blanching occurs. For sensing
subgingival calculus, the lightest possible force that will allow movement
of the probe ballpoint along the tooth surface should be used.
The ball-end should be in contact with the root surface. When
inserting the probe, the ballpoint should follow the anatomical
configuration of the surface of the tooth root. If the patient feels pain
during probing, this is an indicative of the use of too much force.
Library of School of Dentistry, TUMS

The probe tip should be inserted gently into the gingival pocket
and the depth of insertion read against the color coding. The total
For Personal Use Only

extent of the pocket should be explored and at least six points on

each tooth should be examined: mesiobuccal, midbuccal, distobuccal,
and the corresponding lingual sites.

Codes and Criteria (Fig. 17.11)

The codes are listed in the descending order of treatment complexity
as follows:
Code X: When only one tooth or no tooth is present in the
sextant (third molars are excluded unless they function
in place of second molars).
Code 4: Pathological pocket of the 6 mm or more, that is, the
black area of the CPITN probe is not visible.
Note: If the designated tooth or teeth are found to have
a 6 mm or deeper pocket in the sextant being examined,
a code of 4 is given to the sextant. Recording of Code 4
makes further examination of that sextant unnecessary.
There is no need to record the presence or absence of
pathological pockets of 4 or 5 mm, calculus or bleeding.
Code 3: Pathological pocket of 4 or 5 mm that is when the
gingival margin is on the black area of the probe.
Note: If the deepest pocket is found at the designated
tooth or teeth in a sextant is 4 or 5 mm, a code 3 is
 190 A Practical Manual of Public Health Dentistry

Fig. 17.11: Community periodontal index of treatment needs (CPITN)

Library of School of Dentistry, TUMS
For Personal Use Only

recorded. There is no need to examine for calculus or

gingival bleeding.
Code 2: Calculus or other plaque retentive factors such as ill
fitting crowns or poorly adapted edges of restoration
are either seen or felt during probing.
Note: The black band remains fully visible.
Code 1: Bleeding observed during or after probing (either
immediate or delayed).
Code 0: Healthy tissue: The black band on the probe remains
fully visible. There is no bleeding after probing. No
calculus, restoration overhangs or other plaque retention
factors are present.

Treatment Needs
TN 0: A recording of code 0 (health) or X (missing) for all six
sextant indicates that there is no need for treatment.
TN 1: A code of 1 or higher indicates that there is need for
improving the personal oral hygiene of that individual.
 Dental Indices 191

TN 2: a. Code of 2 or higher indicates a need of professional

cleaning of the teeth and removal of plaque retentive
factors. Patient require oral hygiene instructions
b. Shallow to moderate pocketing (4 or 5 mm,
code 3). Oral hygiene and scaling will reduce
inflammation and bring 4 or 5 mm pockets to values
of or below 3 mm. Thus, sextants of these pockets
are placed in the same treatment category as scaling
and root planning, i.e. Treatment Needs 2 (TN 2)
TN 3: A sextant scoring code 4 (6 mm or deeper pockets) may
or may not be treated successfully by means of deep
scaling and efficient personal oral hygiene measures.
Code 4 is therefore assigned as complex treatment which
Library of School of Dentistry, TUMS

can involve deep scaling, root planning and more

complex procedures.
For Personal Use Only

Explanation of the Clinical Criteria and

Treatment Needs
Bleeding on gentle probing, plaque retentive factors (calculus or
overhangs of restoration), 4 or 5 or 6 mm or deeper pockets are
basic indicators if treatment needs. These criteria were chosen for
the following reason:
1. TN 1: Bleeding is sign of a early disease which can be overcome
by self-care following suitable oral health care educations and
instructions. Control of gingival bleeding is a prerequisite for all
periodontal therapy. This treatment is recognized as treatment
need 1 (TN 1). The control or elimination of gingival bleeding
should be the prime goal even if further treatment is not available.
2. TN 2: Although not pathological in themselves, Calculus and
other plaque retentive factors favor plaque retention and
inflammation. Unlike plaque that can be eliminated by self-care,
the removal of calculus demands the professional care defined as
treatment need 2 (TN 2).
3. TN 3: In patient with deep pocket even after scaling, root planning
and control of bleeding by oral hygiene methods there will generally
be residual pockets. The treatment of these conditions may require
complex therapy for which skilled and trained dental professionals
are needed. This treatment is recognized as TN 3.
 192 A Practical Manual of Public Health Dentistry

Substitution for Excluded and Missing Index Teeth

The ten CPITN index teeth are first molar and second molars in the
posterior sextant and a central incisor in each of the two anterior
sextant. When one or more index teeth are missing at the time of
examination, substitute teeth are selected using the following rules:
• Two or more functioning teeth must be present in a sextant for
it to qualify for scoring.
• If in posterior sextant, one of the two index teeth is not present
or has to be excluded, then the recording is based on the
examination of remaining index tooth.
• If both index teeth in posterior sextant are absent or excluded
from examination, all the remaining teeth in that sextant are
examined and highest score recorded.
Library of School of Dentistry, TUMS

• In the anterior maxillary sextant, if tooth 11 is excluded, substitute

21. If 21 is also excluded, then identify the worst score for the
For Personal Use Only

remaining teeth. Similarly substitute tooth 41 if 31 is missing.

• In subjects under 20 years of age, if the first molar is not
present or has to be excluded the nearest adjacent premolar is
examined.
• If all teeth in a sextant are missing or only one functional tooth
remains, the sextant is coded as missing.
• A single tooth in a sextant is considered as a tooth in the adjacent
sextant and subject to the rules for that sextant. If single tooth is
an index tooth, then the worst index tooth score is recorded.

Examination Procedure
The aim is to determine the highest score applicable to each sextant
with least number of measurements.
First decide whether the sextant can be validly scored. More than
one functional tooth should be present.
If ‘no’, then give a score X and move to the next sextant. If ‘yes’,
examine index teeth (epidemiological) or all teeth (in clinical screening
procedure) in the order of presence of 6 mm or deeper pockets; 4 to 5
mm pockets, calculus or other plaque retentive factors and bleeding only.
Determine appropriate highest score for each sextant. As soon as
the highest score criteria has been determined there is no need to
examine for the presence of lower score criteria.
 Dental Indices 193

Number of Probings Per Sextant

The tip of the CPITN probe is gently inserted between tooth and
gingiva to the full depth of the sulcus or pocket and the probing
depth read by the observation of the position of the black band.
Recommended sites for probing are mesial, midline and distal on
both facial and lingual surfaces. The probing may be done by
withdrawing the probe between each probing or alternatively with
probe tip remaining in the sulcus the probe may be ‘walked’ around
the tooth. Sites in addition to the recommended one should be
probed, if there is suspicion that a higher scoring condition is present.

Community Periodontal Index (CPI) (Fig. 17.12A)

Library of School of Dentistry, TUMS

This index is based on a modification of the earlier used CPITN.

The modification is done by the inclusion of measurement of “Loss
For Personal Use Only

of attachment” and elimination of the “Treatment Needs” category.

The CPI was proposed by World Health Organization in 1997.

Fig. 17.12A: Community periodontal index codes

Code 0. Healthy periodontal tissues. Entire black band of the probe is visible.
Code 1. Entire black band is visible, but bleeding is present after gentle probing.
Code 2. Entire black band is visible, but calculus is present. (Bleeding may or
may not be present.)
Code 3. 4 to 5 mm pocket depth. (Black band on probe partially hidden by gingival
margin.)
Code 4. 6 mm or greater pocket depth. (Black band of the probe is completely
hidden by the gingival margin.)
 194 A Practical Manual of Public Health Dentistry

Indicators
Three indicators of periodontal status are used for this assessment:
1. Gingival bleeding
2. Calculus
3. Periodontal pockets
A specially designed lightweight CPI probe with a
0.5 mm ball tip is used, with a black band between 3.5 and 5.5 mm
and rings at 8.5 and 11.5 mm from the ball tip.

Sextants
The mouth is divided into sextants defined by tooth numbers: 18-
14, 13-23, 24-28, 38-34, 33-43, and 44-48. A sextant should be
Library of School of Dentistry, TUMS

examined only if there are two or more teeth present and not
indicated for extraction. (Note: This replaces the former instruction
For Personal Use Only

to include single remaining teeth in the adjacent sextant.)

Selection of teeth: For adults aged 20 years and over, the teeth to
be examined are:
17 16 11 26 27
47 46 31 36 37
The two molars in each posterior sextant are paired for recording,
and if one is missing, there is no replacement. If no index teeth or
tooth is present in a sextant qualifying for examination, all the
remaining teeth in that sextant are examined and the highest score is
recorded as the score for the sextant. In this case, distal surfaces of
third molars should not be scored.
For subjects under the age of 20 years, only six teeth: 16, 11, 26,
36, 31 and 46 are examined. This modification is made in order to
avoid scoring the deepened sulci associated with eruption as periodontal
pockets. For the same reason, when examining children under the age
of 15 are examined, pockets should not be recorded, i.e. only bleeding
and calculus should be considered.

Sensing Gingival Pockets and Calculus

An index tooth should be probed, using the probe as a “sensing”
instrument to determine pocket depth and to detect subgingival
 Dental Indices 195

calculus and bleeding response. The sensing force used should be

not more than 20 grams. A practical test for establishing this force is
to place the probe point under the thumb nail and press until
blanching occurs. For sensing subgingival calculus, the lightest
possible force that will allow movement of the probe ball tip along
the tooth surface should be used.
When the probe is inserted, the ball tip should follow the anatomical
configuration of the surface of the tooth root. If the patient feels pain
during probing, this is an indicative of the use of too much force.
The probe tip should be inserted gently into the gingival sulcus or
pocket and the total extent of the sulcus or pocket explored. For example,
the probe is placed in the pocket at the distobuccal surface of the second
Library of School of Dentistry, TUMS

molar, as close as possible to the contact point with the third molar,
keeping the probe parallel to the long axis of the tooth. The probe is
For Personal Use Only

then moved gently, with short upward and downward movements, along
the buccal sulcus or pocket to the mesial surface of the second molar,
and from the distobuccal surface of the first molar towards the contact
area with the premolar. A similar procedure is carried out for the lingual
surfaces, starting distolingually to the second molar.

Examination and Recording

The index teeth, all remaining teeth in a sextant where there is no

index tooth, should be probed and the highest score is recorded in
the appropriate box. The codes are:
0– Healthy
1– Bleeding observed, directly or by using mouth mirror, after probing
2– Calculus detected during probing, but all the black band on the
probe visible
3– Pocket 4 to 5 mm (gingival margin within the black band on the
probe)
4– Pocket 6 mm or more (black band on the probe not visible)
X– Excluded sextant (less than two teeth present)
9– Not recorded
 196 A Practical Manual of Public Health Dentistry

Loss of Attachment (Fig. 17.12B)

Information on loss of attachment gives an estimate of the lifetime
accumulated destruction of the periodontal attachment. Loss of
attachment should not be recorded for children under the age of 15.
The most reliable way of examining for loss of attachment in
each sextant is to record this immediately after recording the CPI
score for that particular sextant.
The highest scores for CPI and loss of attachment may not
necessarily be found on the same tooth in a sextant.
Highest score recorded in the appropriate box.
The codes are:
0– Loss of attachment 0 to 3 mm (CEJ not visible and CPI score 0-3)
Library of School of Dentistry, TUMS

If the CEJ is visible, or if CPI score is 4, LOA codes 1 to 4 are used.

1– Loss of attachment 4 -5 mm (CEJ within black band)
For Personal Use Only

2– Loss of attachment 6 to 8 mm (CEJ between the upper limit of

the black band and the 8.5 mm ring)
3– Loss of attachment 9 to 11 mm (CEJ between 8.5 mm and
11.5 mm ring)

Fig. 17.12B: CPI: Lost of attachment codes

Code 0. 0 to 3 mm loss of attachment. (Cementoenamel junction [CEJ] is covered

by the gingival margin and the CPI score is 0 to 3.) If the CEJ is visible,
or if CPI score is 4, LOA codes 1 to 4 are used.
Code 1. 3.5 to 5.5 mm loss of attachment. (CEJ is within the black band on the
probe.)
Code 2. 6 to 8 mm loss of attachment. (CEJ is between the top of the black band
and the 8.5 mm mark on the probe.)
Code 3. 9 to 11 mm loss of attachment. (CEJ is between the 8.5 and the 11.5 mm
marks on the probe.)
Code 4. 12 mm or greater loss or attachment. (CEJ is beyond the highest [11.5
mm] mark on the probe.)
 Dental Indices 197

4– Loss of attachment 12 mm or more (CEJ beyond the 11.5 mm

ring)
X– Excluded sextant (less than two teeth present)
9– Not recorded (CEJ neither visible nor detectable).

INDICES USED IN ASSESSING DENTAL CARIES

Diagnosis of dental caries is difficult in initial stages. Early approximal
lesions are readily revealed by a radiograph but may not be detected
by an explorer. There always exists interexaminer variations.

Decayed, Missing and Filled Teeth (DMFT) Index

This index was developed by Henry Klein, Carrole E Palmer and
Library of School of Dentistry, TUMS

Knutson JW in 1938. This index was based on the fact that the
dental hard tissues are not self-healing and established caries leaves a
For Personal Use Only

scar. The tooth either remains decayed and if treated may be extracted
or filled. It is an irreversible index.
DMFT describe the amount (the prevalence) of dental caries in
an individual. DMFT numerically expresses the caries prevalence and
is obtained by calculating the number of teeth (T) which are:
• Decayed (D)
• Missing (M)
• Filled (F).
It is thus used to get an estimation illustrating how much the dentition
until the day of examination has become affected by dental caries.
Thus:
• How many teeth have caries lesions (incipient caries not included)?
• How many teeth have been extracted?
• How many teeth have fillings or crowns?

Selection of Teeth
All 28 teeth are examined (based on 28 teeth).
Teeth not included are:
• Third molars
• Unerupted teeth (a tooth is considered as erupted when the
occlusal surface or incisal edge is totally exposed)
• Supernumerary and congenitally missing teeth
 198 A Practical Manual of Public Health Dentistry

• Teeth removed for reasons other than dental caries such as for
orthodontic reasons and impactions
• Teeth restored for reasons other than dental caries, such as trauma,
use as a bridge abutment and cosmetic purposes
• Retained primary tooth when the successor permanent is present.
The permanent tooth is considered.

Procedure
Each tooth is examined using a mouth mirror, an explorer and adequate
light. The teeth should be observed by visual means as much as possible
and only questionable small lesions should be checked by using an explorer.

Rules for Scoring DMFT

Library of School of Dentistry, TUMS

• No tooth should be counted more than once

For Personal Use Only

• Decayed (D), Missing (M) and Filled (F) teeth should be recorded
separately
• Tooth lost or filled due to reasons other than caries are not included
• Deciduous teeth are not considered in DMFT index
• A tooth with several filling is counted as one tooth.

Criteria for Recording

i. Decayed (D) recording:
• When dental caries and a restoration are present on the same
tooth, the tooth is recorded as D
• When a crown is broken due to caries, it is recorded as D
• Tooth with temporary restoration are recorded as decayed.
ii. Missing (M) recording:
• When a tooth has been extracted because of dental caries
• When a tooth is carious, cannot be restored and is indicated
for extraction.
iii. Filled (F) recording:
• Permanent restorations are recorded as F.

Criteria for Identification of Dental Caries

• Lesion is clinically visible and obvious
• Discoloration or loss of translucency typical of undermined or
demineralized enamel
 Dental Indices 199

• Definite catch and the explorer tip can penetrate into soft yielding
material.

DMFT Scores
The sum of the three figures forms the DMFT value. For example,
DMFT of 4 + 3 + 9 = 16 means that 4 teeth are decayed, 3 teeth are
missing and 9 teeth have fillings. It also means that 12 teeth are intact

Individual DMFT
Total each component separately ie total D, total M, total F.
Total D + M + F = DMF SCORE

Group Average
Library of School of Dentistry, TUMS

• Total the D, M and F for each individual

For Personal Use Only

• Divide the total DMF by the number of individuals examined.

Total DMF
Average DMF =
Total Number of Individuals Examined

Treatment Needs
Total Number of D Tooth
Percentage needing restorations (%) = × 100
Total Number Examined
Limitations of DMFT Index
• DMF values are not related to the number of teeth at risk. A
DMF score does not directly gives an indication of the intensity
of attack in any one individual, e.g. a child of 8-year-old may
have DMF score of 3 with only nine permanent teeth in mouth
(one-third of teeth have been already affected by caries), whereas
an adult may have a DMF score of 8 (more than the child score)
out of 32 teeth (only one fourth of the teeth have been affected)
• The DMF index is invalid when teeth have been removed or lost
due to other reasons, e.g. periodontal reasons
• The index gives equal weight to all the three components, i.e.
missing decayed and well-restored teeth
• Does not tell about the treatment needs of a person
• The DMF index can overestimate caries experience in cases having
teeth with preventive restorations
• Cannot be used for root caries.
 200 A Practical Manual of Public Health Dentistry

Decayed, Missing and Filled Surface (DMFS) Index

DMFS index assesses the total no. of tooth surfaces affected rather
than the tooth. It is a more detailed index in which DMF is calculated
per tooth surface.
Rules, method and criteria are same as that of DMFT index except
that all tooth surfaces are examined in DMFS index.

Surfaces Examined
Anterior teeth: Four surfaces are examined; Facial, Lingual, Mesial
and Distal.
Posterior teeth: Five surfaces are examined; Facial, Lingual, Mesial,
Distal and Occlusal.
Library of School of Dentistry, TUMS

Maximum value for DMFS comes to 128 for 28 teeth.

Posterior teeth: 16 with 5 surface, each: 16 × 5 = 80
For Personal Use Only

Anterior teeth: 12 with 4 surface, each: 12 × 4 = 48

Total = 128 surfaces.

Calculating the DMFS

Individual
Total number of decayed surfaces = D
Total number of missing surfaces = M
Total number of filled surfaces = F
Total DMFS score for an individual = D +M+ F (surfaces)
It is a more precise index but takes a longer time to perform.
WHO Modification of DMF Index
1. Third molars are included.
2. In persons below 30 years of age, teeth lost due to caries are
considered missing. In persons above 30 years, teeth lost for any
reasons are considered as missing.
3. Initial caries is not regarded as decayed.

Dental Caries Index for Deciduous Teeth

(dmft and dmfs)
This index for primary teeth was given by Grubbel in 1944. It is
used for the primary dentition, consisting of maximum 20 teeth.
 Dental Indices 201

Designations are “deft” or “defs”:

Where d = decayed primary teeth
e = extracted tooth/indicated for extraction (due to caries)
f = filled teeth/surfaces

Selection of Teeth or Surfaces

dmft: 20 teeth are evaluated (all the primary teeth are included).
For Surfaces
dmfs: 88 surfaces are evaluated.
Posterior teeth: 8 teeth × 5 surfaces = 40 surfaces
Anterior teeth: 12 teeth × 4 surfaces = 48 surfaces
Library of School of Dentistry, TUMS

Teeth not Counted

For Personal Use Only

• Missing teeth, including unerupted and congenitally missing

teeth.
• Teeth restored for reasons other than dental caries are not counted
as f.
• Supernumerary teeth.

Procedure and Criteria

Same as for DMFT

Calculating the def

Total def score = d + e + f
Total defs score = d + e + f surfaces.

Mixed Dentition
In mixed dentition, DMFT or DMFS and a deft and defs index are
done separately and never added together. Separate index is done
for each child for permanent teeth and primary teeth starting with
permanent teeth first.

WHO Dentition Status and Treatment Needs

Dentition Status and Treatment Needs was proposed by the World
Health Organization in the year 1997.
 202 A Practical Manual of Public Health Dentistry

The index is used to determine the treatment needs in relation to

dental caries.

Method
The examination is conducted with a mouth mirror. Radiography
for the detection of approximal caries is not recommended because
of the impracticability of using the equipment in all situations.
The examination is conducted for the assessment of dentition status
and treatment needs. The examination should proceed in a systematic
manner from one tooth or tooth space to the adjacent tooth or tooth
space. A tooth should be considered present when any part of it is
visible. If a permanent and primary tooth occupy the same tooth space,
Library of School of Dentistry, TUMS

the status of the permanent tooth should be scored.

Dentition Status: An entry is made pertaining to the coronal or
For Personal Use Only

root status. The same boxes are used for recording both primary and
permanent teeth. In case of surveys of children, where root status is not
assessed, a code 9 is entered in the box pertaining to the root status.
It is recommended, that care should be taken to record all tooth-
colored fillings, which may be difficult to detect.

Scoring Criteria

Code
Primary Teeth Permanent Teeth Condition/Status
Crown Crown Root
A 0 0 Sound
B 1 1 Decayed
C 2 2 Filled, with decay
D 3 3 Filled, without decay
E 4 – Missing as a result of caries
– 5 – Missing, any other reason
F 6 – Fissure sealant
G 7 7 Bridge abutment, special crown or
veener/ implant
– 8 8 Unerupted tooth (crown)/
unexposed root
T T – Trauma
– 9 9 Not recorded
 Dental Indices 203

The criteria for diagnosis and coding are:

• 0: A zero indicates a sound crown or root, showing no evidence
of either treated or untreated caries. A crown may have defects
and still be recorded as 0. Defects that can be disregarded include
white or chalky spots; discolored or rough spots that are not
soft; stained enamel pits or fissures; dark, shiny, hard, pitted areas
of moderate to severe fluorosis; or abraded areas.
• 1: One indicates a tooth with caries. A tooth or root with a definite
cavity, undermined enamel, or detectably softened or leathery
area of enamel or cementum can be designated as 1. A tooth
with a temporary filling, and teeth that are sealed but decayed,
are also termed 1. Score 1 is not assigned to any tooth in which
caries is only suspected. In cases where the crown of a tooth is
entirely decayed, leaving only the root, score 1 is assigned to
Library of School of Dentistry, TUMS

both crown and root. Where only the root is decayed, only the
root is termed as 1. In cases, where both the crown and root are
For Personal Use Only

involved with decay, whichever site is judged the site of origin is

recorded as 1. These criteria apply to all numbers.
• 2: Filled teeth, with additional decay, are termed 2. No distinction
is made between primary caries which is not associated with a
previous filling, and secondary caries, adjacent to an existing
restoration.
• 3: It indicates a filled tooth with no decay. If a tooth has been
crowned because of previous decay, that tooth is judged 3. When
a tooth has been crowned for another reason such as aesthetics
or for use as a bridge abutment, 7 is used.
• 4: It indicates a tooth that is missing as a result of caries. Only
crowns are given 4 status. Roots of teeth that have been scored
as 4 are recorded as 7 or 9. When primary teeth are missing, the
score should be used only if the tooth is missing prematurely.
Primary teeth missing because of normal exfoliation needs no
recording.
• 5: A permanent tooth missing for any other reason than decay is
given as 5. Examples are teeth extracted for orthodontia or
because of periodontal disease, teeth that are congenitally missing,
or teeth missing because of trauma. The 5 is assigned to the
crown, the root is given a 7 or 9. Knowledge of tooth eruption
patterns is helpful to determine whether teeth are missing or not
yet erupted. Clues to help in the determination include appearance
 204 A Practical Manual of Public Health Dentistry

of the alveolar ridge in the area in question, and caries status of

other teeth in the mouth.
• 6: A 6 is assigned to teeth on which sealants have been placed.
Teeth on which the occlusal fissure has been enlarged and a
composite material placed should also be termed 6.
• 7: A 7 is used to indicate that the tooth is part of a fixed bridge.
When a tooth has been crowned for a reason other than decay,
this code is also used. Teeth that have veneers or laminates
covering the facial surface are also termed 7 when there is no
evidence of caries or restoration. A 7 is also used to indicate a
root replaced by an implant. Teeth that have been replaced by
bridge pontics are scored 4 or 5; their roots are scored 9.
• 8: This code is used for a space with an unerupted permanent
Library of School of Dentistry, TUMS

tooth, where no primary tooth is present. The category does not

include missing teeth. Code 8 teeth are excluded from calculations
For Personal Use Only

of caries. When applied to a root, an 8 indicates the root surface

is not visible in the mouth.
• 9: Erupted teeth that cannot be examined because of orthodontic
bands, e.g. are coded a 9. When applied to a root, a 9 indicates
the tooth has been extracted. The crown of that tooth would be
scored a 4 or 5.
• T: Indicating trauma, a T is used when a crown is fractured, with
some of its surface missing but with no evidence of decay.
The “D” of DMFT refers to all teeth with codes 1 and 2. The
“M” applies to teeth scored 4 in subjects under age 30, and teeth
scored 4 or 5 in subjects over age 30. The “F” refers to teeth
with code 3. Those teeth coded 6, 7, 8, 9, or T are not included
in DMFT calculations.

Treatment Needs of Individual Teeth

Treatment requirements should be assessed for the whole tooth, including
both coronal and root caries. Immediately after the status of a tooth is
recorded, and before proceeding to the next tooth or tooth space, the
type of treatment required, if any, should be recorded. If no treatment is
required, code “0” should be placed in the appropriate treatment box.
(If this is not done it will be impossible to determine later, when the data
are processed, whether no treatment was necessary, or whether the
examiner or recorder omitted to make an appropriate entry.)
 Dental Indices 205

Scoring Criteria
The codes and criteria for treatment needs are:
0. None (no treatment). This code is recorded if a crown and a
root are both sound, or if it is decided that a tooth should not
receive any treatment.
P. Preventive, caries-arresting care
F. Fissure sealant
1. One surface filling
2. Two or more surface fillings.
One of the codes P, F, 1 or 2 should be used to indicate the
treatment required to:
• Treat initial, primary or secondary caries;
Library of School of Dentistry, TUMS

• Treat discoloration of a tooth, or a developmental defect;

• Treat lesions due to trauma, abrasion, erosion or attrition;
For Personal Use Only

• Replace unsatisfactory fillings or sealants.

A sealant is considered unsatisfactory if partial loss has extended
to exposure of a fissure, pit, or junction or surface of the dentine
which, in the examiner’s opinion, requires resealing.
A filling is considered unsatisfactory if one or more of the
following conditions exist:
• A deficient margin to an existing restoration that has leaked
or is likely to permit leakage into the dentine. The decision as
to whether a margin is deficient should be based on the
examiner’s clinical judgment, on evidence gained from the
insertion of a CPI probe at the margin, or on the presence of
severe staining of the tooth structure.
• An overhanging margin of an existing restoration that causes
obvious local irritation to the gingiva and cannot be removed
by recontouring of the restoration.
• A fracture of an existing restoration that either causes it to be
loose or permits leakage into the dentine.
• Discoloration.
3. Crown for any reason.
4. Veneer or laminate (may be recommended for aesthetic purposes).
5. Pulp care and restoration: This code is used to indicate that a
tooth probably needs pulp care prior to restoration with a filling
 206 A Practical Manual of Public Health Dentistry

or crown because of deep and extensive caries, or because of

tooth mutilation or trauma.
Note: A probe should never be inserted into the depth of a cavity
to confirm, the presence of a suspected pulp exposure.
6. Extraction: A tooth is recorded as “indicated for extraction”,
depending on the treatment possibilities available, when:
• Caries has so destroyed the tooth that it cannot be restored;
• Periodontal disease has progressed so far that the tooth is
loose, painful or functionless and, in the clinical judgment of
the examiner, cannot be restored to a functional state;
• A tooth needs to be extracted to make way for a prosthesis; or
• Extraction is required for orthodontic or cosmetic reasons,
Library of School of Dentistry, TUMS

or because of impaction.
7/8. Need for other care: The examiner should specify the types of
For Personal Use Only

care for which codes 7 and 8 are used. The use of these two
codes should be kept to a minimum.
9. Not recorded.

Significant Caries Index

In 2000, the World Health Organization developed the significant
caries index (SiC) to be used when studying DMFT scores on a
global basis. A single population may include a number of individuals
with low DMFT scores, as well as those with high scores. A mean
DMFT value would not accurately reflect the status of the population.
The SiC Index isolates and highlights those individuals with the
highest caries values in a particular population.
DMFT score show that there is a skewed distribution of caries
prevalence. Clearly, the mean DMFT value does not accurately reflect
this skewed distribution leading to incorrect conclusion that the caries
situation for the whole population is controlled while in reality several
individuals still have caries.
A new index called the 'Significant Caries Index' (SiC) was
proposed by Bratthall D in the year 2000, in order to bring attention
to those individuals with the highest caries scores in each population.
 Dental Indices 207

The SiC Index is the Mean DMFT of the one third of the study
group with the highest caries score. The index is used as a complement
to the mean DMFT value.

Steps to Calculate Significant Caries Index

• Sort the individuals according to their DMFT
• Select the one third of the population with the highest caries
values
• Calculate the Mean DMFT for this subgroup, suppose the DMFT
of 15 students was calculated as, e.g. 0, 1, 5, 0, 0, 2, 1, 7, 0, 9, 0,
4, 1, 0, 5
Arranged in increasing order the DMFT scores are 0, 0, 0, 0,
Library of School of Dentistry, TUMS

0, 0, 1, 1, 1, 2, 4, 5, 5, 7, 9
The highest 1/3rd scores are - 0, 0, 0, 0, 0, 0, 1, 1, 1, 2, 4, 5,
For Personal Use Only

5, 7, 9
Thus, the SiC Index is - 4 + 5 + 5 + 7 + 9 / 5 = 30/5 = 6.0
DMFT - 0 + 0+ 0 + 0 + 0 + 0 + 1 + 1 + 1 + 2 + 4 + 5 + 5 + 7
+ 9 / 15 = 35 / 15 = 2.33.

INDICES USED IN ASSESSING DENTAL FLUOROSIS

Dean’s Fluorosis Index

HT Dean's fluorosis index was originally given in 1934 and later
modified in 1942 and is currently the most universally accepted
classification system. An individual's fluorosis score is based on the
most severe form of fluorosis found on two or more teeth. Dean’s is
used to score the amount of dental fluorosis (discoloration) present
on teeth. Fluorosis generally appears as a horizontal striated pattern
across a tooth. Molars and bicuspids are most frequently affected,
followed by upper incisors. The mandibular incisors are usually least
affected. Fluorosis tends to be bilaterally symmetrical. Defects may
appear as fine white or frosted lines or patches near the incisal edges
or cusp tips. A score is given, based on the two teeth most affected. If
the teeth are not equal in appearance, the less affected tooth is the
one scored.
 208 A Practical Manual of Public Health Dentistry

Scores and Criteria for Dean’s Fluorosis Index

Score Criteria
Normal (0) The enamel represents the usually translucent
semivitriform type of structure. The surface is
smooth, glossy, and usually a pale creamy white
color.
Questionable (0.5) The enamel discloses slight aberrations from the
translucency of normal enamel, ranging from a few
white flecks to occasional white spots. This
classification is utilized when a definite diagnosis of
the mildest form of fluorosis is not warranted and a
classification of "normal" is not justified.
Very mild (1) Small, opaque, paper white area scattered
irregularly over the tooth but not involving as much
Library of School of Dentistry, TUMS

as approximately 25 percent of the tooth surface.

Frequently included in this classification are teeth
showing no more than 1 to 2 mm of white opacity at
For Personal Use Only

the tip of the summit of the cusps of the bicuspids

or second molars.
Mild (2) The white opaque areas in the enamel of the teeth
are more extensive but do not involve as much as
50 percent of the tooth.
Moderate (3) All enamel surfaces of the teeth are affected, and
surfaces subject to attrition show marked wear.
Brown stain is frequently a disfiguring feature.
Severe (4) All enamel surfaces are affected and hypoplasia is
so marked that the general form of the tooth may
be altered. The major diagnostic sign of this
classification is the discrete or confluent pitting.
Brown stains are widespread and teeth often present
a corroded appearance.
Source: Dean 1942. American Association for the Advancement of Science.

Community Fluorosis Index

In 1942, Dean modified his index by reducing the number of
categories and developed a scoring system to derive the Community
Fluorosis Index (CFI).
In a given population, the proportion in each category is
multiplied by the weight given to derive a score for the community.
n w
Fci =
N
 Dental Indices 209

Where,
Fci – Community fluorosis index
n – Number of children in each category (frequency)
w – The weighing for each category
N – Total population
The index, weights ranging from 0 to 4, is defined mathematically
as the average weighted score per person surveyed.

Interpretation

Range of scores Public health significance

0.0–0.4 Negative
0.4–0.6 Borderline
Library of School of Dentistry, TUMS

0.6–1.0 Slight
1.0–2.0 Medium
2.0–3.0 Marked
For Personal Use Only

3.0–4.0 Very marked

The use of the CFI results in the familiar “S” curve, displaying
the relationship of the index plotted against the fluoride content of
the water supplies of communities with various levels of fluoride.
The shape of this relationship probably reflects the lower weight
assigned to questionable cases which represent a high percentage of
cases at low levels of fluoride exposure, and to a lack of sensitivity of
index criteria at higher levels of exposure.

Advantages
• It gives an indication of the public health significance of fluorosis.

Disadvantages
• The statistical basis for using arithmetic mean to calculate CFI is
questionable on the grounds that the classification is based on
an ordinal scale and not an interval scale.
• The CFI, because of its method of calculation, may not give a
true reflection of the severity of fluorosis within the community.
• The CFI is an average; it provides little information about the
variation within a population, particularly if measures of variance
are not provided.
 210 A Practical Manual of Public Health Dentistry

• The index may misrepresent the dose response relationship

between fluoride and fluorosis.

Dental Fluorosis Index by Moller (1965)

Weighting Diagnosis Clinical criteria

0 Normal The enamel shows the usual translucency. The
surface is smooth, shiny and usually of a pale,
creamy white to gray white color. In this group
are also opacities, which are not considered to
be of fluorotic character.
0 Optimal The enamel is on clinical inspection completely
homogeneously mineralised without hypomine-
ralization of any sort. The enamel is smooth and
mirror-like, and has a shiny, “Varnished” look.
Library of School of Dentistry, TUMS

The colour is creamy white to yellowish white.

0.25 Questionable In areas with relatively low fluoride content in
For Personal Use Only

drinking water, there are cases which even the

most experienced researchers cannot classify
as either normal or very mild. These cases show
mainly labially in the upper front teeth as very
narrow, opaque, paper-white, horizontal lines in
the tooth’s incisal third especially. In back teeth
are now and then seen small, opaque spots
(about 0.5 mm in diameter) directly on the cusp
tips, while the rest of the tooth is completely
normally mineralized. The features of these
opaque lines and spots are so fine that they
are often confused with perichymata. This fine
feature shows more clearly with drying the tooth,
a procedure which should always be done while
diagnosing.
0.25–1 Very Mild Clearer opaque, paper-white, transversely ori-
ented striations or spots, found spread especially
on the upper incisors’ labial surfaces and most
concentrated in the incisal third. In the back teeth
are seen opaque regions (< 1 mm in diameter)
directly on the cusp tips. Opaque, paper-white,
narrow, transversely running lines reach down
over the cusp, while the rest of the tooth is nor-
mal. The opaque regions cover almost a fourth of
the surface of the tooth. When viewed from a dis-

Contd...
 Dental Indices 211
Contd...

Weighting Diagnosis Clinical criteria

tance, the tooth seems to have a slightly mother-

of-pearl sheen. The lower grades of very mild
dental fluorosis are rated 0.5 and the worst 1.0.
1.5–2 Mild The mainly transversely running opaque lines and
spots are more clear and stretch further down over
the tooth’s surface towards the outer
circumference. One can detect that the opaque
lines begin to merge together into diffuse regions,
so that the tooth seen at a distance (40–50 cm)
seems whiter, more opaque than a normally
mineralized tooth. Seen close to these opaque
areas take up, however, at most half of the tooth’s
Library of School of Dentistry, TUMS

surface. Changes in the front teeth’s lingual

surfaces are considerably less obvious than on
For Personal Use Only

the labial. As far as the back teeth are concerned,

the changes in labial and lingual surfaces are of
more or less the same degree. On the cusps of
canines, premolars and molars, there are cases
where the cusp tips are worn, so that the wear
facets peripherally are bordered by a narrow,
opaque ring (an expression of the fluorotic surface
layer) surrounded by the clearer underlying
enamel. In pronounced cases the development
of pigment can be seen, especially in the upper
incisors. Lower grades of mild dental fluorosis are
scored 1.5 and the worst 2.0.
2.5–3 Moderate The opaque regions take-up practically all the
tooth’s surface. Tooth shape is normal, but a
weak “pit” development can be found, especially
on premolar buccal and palatal surfaces, as well
as upper incisor labial surfaces. Pigment where
present can vary in color from yellow to brown.
The lower grades of moderate dental fluorosis
are rated 2.5 and the worst 3.0.
3.5–4 Severe The shape of the tooth can be changed. The
development of pits is pronounced. Merging of pits
is often seen. Sometimes, the outer layer of enamel
parlty or completely missing, and the tooth has a
corroded look. Pigmentation varies in color from
brown, to dark brown, to black. Lower degrees of
severe dental fluorosis score 3.5 and the worst 4.0.
 212 A Practical Manual of Public Health Dentistry

Thylstrup-Fejerskov Index of Fluorosis (TF)

This index was developed by A. Thylstrup & O. Fejerskov in 1978
and has a stronger biological basis than Dean's index because the
index scores were developed by relating them to histologic features
of affected enamel. As the procedure includes drying of tooth it is
the most sensitive of the existing indices. Also, it requires assessment
of only one surface per tooth because fluorosis affects all tooth
surfaces equally. It can be used on selected teeth or entire dentition.

Clinical Criteria and Scoring for the TF

(Thylstrup-Fejerskov) Index

Score Criteria
Library of School of Dentistry, TUMS

0 Normal translucency of enamel remains after prolonged air drying.

1 Narrow white lines corresponding to the perikymata.
For Personal Use Only

2 Smooth surfaces: More pronounced lines of opacity that follow

the perikymata. Occasionally confluence of adjacent lines.
Occlusal surfaces: Scattered areas of opacity <2 mm in diameter
and pronounced opacity of cuspal ridges.
3 Smooth surfaces: Merging and irregular cloudy areas of opacity.
Accentuated drawing of perikymata often visible between opacities.
Occlusal surfaces: Confluent areas of marked opacity. Worn areas
appear almost normal but usually circumscribed by a rim of opaque
enamel.
4 Smooth surfaces: The entire surface exhibits marked opacity or
appears chalky white. Parts of surface exposed to attrition appear
less affected.
Occlusal surfaces: Entire surface exhibits marked opacity. Attrition
is often pronounced shortly after eruption.
5 Smooth surfaces and occlusal surfaces: Entire surface displays
marked opacity wtih focal loss of outermost enamel (pits) < 2 mm
in diameter.
6 Smooth surfaces: Pits are regularly arranged in horizontal bands
< 2 mm in vertical extension.
Occlusal surfaces: Confluent areas < 3 mm in diameter exhibit
loss of enamel. Marked attrition.
7 Smooth surfaces: Loss of outermost enamel in irregular areas
involving < 1/2 of entire surface.
Occlusal surfaces: Changes in the morphology caused by merging
pits and marked attrition.
8 Smooth and occlusal surfaces: Loss of outermost enamel involving
> 1/2 of surface.
9 Smooth and occlusal surfaces: Loss of main part of enamel with
change in anatomic appearance of surface. Cervical rim of almost
unafffected enamel is often noted.
 Dental Indices 213

Tooth Surface Index of Fluorosis (TSIF)

This index was developed in 1984 by Horowitz HS, Driscoll WS, Meyers
RJ and used by researcher in the National Institute of Dental Research.
It is probably more sensitive than Dean's index specially for the mildest
forms of fluorosis. Each tooth surface is seen and scored on a 0-7 scale,
whereas Dean's index applies only to two worst teeth in the mouth.

Selection of Teeth
All the teeth are assessed.

Surface
Anterior teeth: Separate score is given for every intact labial or lingual
Library of School of Dentistry, TUMS

surface of anterior teeth.

Posterior teeth: Every buccal, occlusal and lingual surface are given a
For Personal Use Only

separate score.

Scoring Criteria
Clinical Criteria and Scoring System for the Tooth Surface Index of
Fluorosis
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 1/3rd of the visible enamel
surface. This category includes fluorosis confined only to incisal
edges of anterior teeth and cusp tips of posterior teeth (“snow
capping”).
2 Parchment-white fluorosis totals at least 1/3rd of the visible surface
but less than 2/3rd.
3 Parchment- white fluorosis totals at least 2/3rd of the visible surface.
4 Enamel shows staining in conjunction with any of the preceding
levels of fluorosis. Staining is defined as an area of definite
discoloration that may range from light to very dark brown.
5 Discrete pitting of enamel exists, unaccompanied by evidence of
staining of intact enamel. A pit is defined as a definite physical defect
in the enamel surface with a rough floor that is surrounded by a wall
of intact enamel. The pitted area is usually stained or differs in color
from the surrounding enamel.
6 Both discrete pitting and staining of the intact enamel exists.
7 Confluent pitting of the enamel surface exists. Large areas of enamel
may be missing and the anatomy of the tooth may be altered. Dark-
brown stain is usually present.
 214 A Practical Manual of Public Health Dentistry

INDICES USED IN ASSESSING MALOCCLUSION

The Index of Orthodontic Treatment Need (IOTN)

This index was put forward by Peter H. Brook and William C. Shaw
in 1989.

Overview
The Index of Orthodontic Treatment Need (IOTN) was developed
as a means to objectively measure a person's need for orthodontic
treatment.

Components
Library of School of Dentistry, TUMS

• Dental health: 5 grades from none to very great

• Aesthetics: attractiveness of the patient's labial aspect ranked from
For Personal Use Only

1 (close to normal) to 10.

Dental Health Component Grade 1: None

• Extremely minor malocclusions including displacements < 1 mm.

Dental Health Component Grade 2: Little

• Increased overjet 3.6 to 6.0 mm, with competent lips
• Reverse overjet 0.1 to 1.0 mm
• Anterior to posterior cross bite with up to 1 mm discrepancy
between retruded contact position and intercuspal position
• Displacement of teeth 1.1 to 2.0 mm
• Anterior or posterior openbite 1.1 to 2.0 mm
• Increased overbite ³ 3.5 mm, without gingival contact
• Prenormal or postnormal occlusions with no other anomalies.
Includes up to half a unit discrepancy.

Dental Health Component Grade 3: Moderate

• Increased overjet 3.6 to 6.0 mm, with incompetent lips
• Reverse overjet 1.1 to 3.5 mm
• Anterior or posterior cross bites with 1.1 to 2.0 mm discrepancy.
• Displacement of teeth 2.1 to 4.0 mm
 Dental Indices 215

• Lateral or anterior cross bite 2.1 to 4.0 mm

• Increased and complete overbite without gingival trauma.

Dental Health Component Grade 4: Great

• Increased overjet 6.1 to 9.0 mm
• Reversed overjet > 3.5 mm with no masticatory or speech difficulties
• Anterior or posterior cross bites with > 2 mm discrepancy between
retruded contact position and intercuspal position
• Severe displacement of teeth, > 4 mm
• Extreme lateral or anterior openbites, > 4 mm
• Increased and complete overbite with gingival or palatal trauma
• Less extensive hypodontia requiring prerestorative orthodontic
space closure to obivate the need for a prosthesis
Library of School of Dentistry, TUMS

• Posterior lingual crossbite with no functional occlusal contact in

one or both buccal segments
For Personal Use Only

• Reverse overjet 1.1 to 3.5 mm with recorded masticatory and

speech difficulties
• Partially erupted teet, tipped and impacted against adjacent teeth
• Supplemental teeth.

Dental Health Component Grade 5: Very Great

• Increased overjet > 9 mm
• Extensive hypodontia with restorative implications (more than 1
tooth missing in any quadrant) requiring prerestorative orthodontics
• Impeded eruptions of teeth (with the exception of the third molars)
due to crowding, displacement, the presence of supernumerary
teeth, retained deciduous teeth, and any pathological cause
• Reverse overjet > 3.5 mm with reported masticatory and speech
difficulties
• Defects of cleft lip and palate
• Submerged deciduous teeth.

Aesthetic Component
• A patient’s score is based on matching his or her dental appearance
with one of a series of 10 photographs showing the labial aspect
of different Class I or Class II malocclusions ranked according
to their attractiveness.
 216 A Practical Manual of Public Health Dentistry

The Dental Aesthetic Index (DAI)

The Dental Aesthetic Index (DAI) is an orthodontic index which
incorporates socially defined aesthetic standards. This index was given
by the WHO in 1997. This index is recommended for use in age
groups where, there are no longer primary teeth, i.e. 12 year onwards.
In addition, it provides a severity measure for psychologic and
functional impairment. It consists of 10 components multiplied by
weights based on regression coefficients, plus a constant.

Component Finding Weight

Constant 13
Missing teeth Number of missing incisor, 6
canine and premolar teeth
Library of School of Dentistry, TUMS

Crowding in incisal Number of segments 1

segments crowded
For Personal Use Only

Spacing in incisal Number of segments spaced 1

segments
Diastema In millimeters 3
Anterior irregularity in Largest irregularity in mm 1
maxilla
Anterior irregularity in Largest irregularity in mm 1
mandible
Anterior maxillary overjet In millimeters 2
Anterior mandibular In millimeters 4
overjet
Vertical anterior openbite In millimeters 4
Anteroposterior molar Largest deviation from 3
relation normal 0.5 cusp=1
>=1 cusp=2
Where:
Diastema = the space between 2 adjacent teeth on the same dental arch
DAI score = SUM((finding) * (weight))

Interpretation
Minimum score: 13
Further the score falls from the norm of most acceptable dental
appearance, the more the occlusal condition may be judged socially
or physically handicapping if left untreated.
 Dental Indices 217

INDICES USED IN ASSESSING TOOTH WEAR

Eccles Index for Dental Erosion of Nonindustrial

Origin
Eccles in 1979 originally classified lesions broadly as early, small and
advanced, with no strict criteria definitions, thus allowing wide
interpretation.

Classification of Dental Erosion

Class I Superficial lesions-involving enamel only

Class II Localized lesions-involving dentin for less than one-third of
the surface
Class III Generalized lesions-involving dentin for more than one-third
Library of School of Dentistry, TUMS

of the surface
a. Facial surfaces
For Personal Use Only

b. Lingual and palatal surfaces

c. Incisal and occlusal surfaces
d. Severe multisurface involvement

Later, the index was refined and expanded, with greater emphasis
on the descriptive criteria. It was presented as a comprehensive
qualitative index, grading both severity and site of erosion due to
nonindustrial causes, and is considered as one of the cardinalindices
from which others have evolved. In essence, it breaks down into
three classes of erosion, denoting the type of lesion, assigned to four
surfaces, representing the surface where erosion was detected.

Eccles Index for Dental Erosion of Nonindustrial Origin

Class Surface Criteria

Class I Early stages of erosion, absence of developmental
ridges, smooth, glazed surface occurring mainly
on labial surfaces of maxillary incisors and canines
Class II Facial Dentine involved for less than one-third surface;
two typesType 1 (commonest): ovoid–crescentic
in outline, concave in cross-section at cervical
region of surface. Must differentiate from wedge
shaped abrasion lesionsType 2: irregular lesion
entirely within crown. Punched out appearance,
where enamel is absent from floor

Contd...
 218 A Practical Manual of Public Health Dentistry

Contd...
Class Surface Criteria
Class IIIa Facial More extensive destruction of dentine, affecting
anterior teeth particularly. Majority of lesions
affect a largepart of the surface, but some are
localized and hollowed out
Class IIIb Lingual or Dentine eroded for more than one-third of the
palatal surface area. Gingival and proximal enamel
margins have white, etched appearance. Incisal
edges translucent due to loss of dentine. Dentine
is smooth and anteriorly is flat or hollowed out,
often extending into secondary dentine
Class IIIc Incisal or Surfaces involved into dentine, appearing flattened
occlusal or with cupping. Incisal edges appear translucent
due toundermined enamel; restorations are raised
Library of School of Dentistry, TUMS

above surrounding tooth surface

Class IIId All Severely affected teeth, where both labial and
For Personal Use Only

lingual surfaces are extensively involved. Proximal

surfaces may be affected; teeth are shortened

Tooth Wear Index (TWI)

Smith and Knight in 1984 took Eccles’ ideas a stage further, producing
the tooth wear index (TWI), a comprehensive system whereby all four
visible surfaces (buccal, cervical, lingual and occlusal-incisal) of all teeth
present are scored for wear, irrespective of how it occurred.

Smith and Knight Tooth Wear Index

Score Surface Criteria
0 B/L/O/I/C No loss of enamel surface characteristics No loss
of contour
1 B/L/O/I/C Loss of enamel surface characteristics. Minimal
loss of contour
2 B/L/O/I/C Loss of enamel exposing dentine for less than one
third of surface. Loss of enamel just exposing
dentine. Defect less than 1 mm deep
3 B/L/O/I/C Loss of enamel exposing dentine for morethan one
third of surfaceLoss of enamel and substantial loss
of dentine. Defect less than 1–2 mm deep
4 B/L/O/I/C Complete enamel loss–pulp exposure–secondary
dentine exposure Pulp exposure or exposure of
secondary dentine. Defect more than 2 mm deep–
pulp exposure– secondary dentine exposure

(B-Buccal; L-Lingual; O-Occlusal; I-Incisal; C-Cervical)

 Dental Indices 219

The Exact Tooth Wear Index

A modified tooth wear index was developed by J. Fares, S. Shirodaria,
K. Chiu, N. Ahmad, M. Sherriff, D. Bartlett in 2009 according to
the basic principles of the Smith and Knight Index.
The wear on teeth was graded separately for enamel and dentine
using 5- and 6-point scales, respectively. Any surface change resulting
from wear, irrespective of the aetiology, was scored on the cervical,
buccal, occlusal/incisal and palatal/lingual surfaces of the upper first
molar to the contralateral first molar in both arches. In cases of doubt
the lower score was recorded.
A separate score was given to the area around the cervical margin
and to the buccal/facial surface following the protocols defined by
Library of School of Dentistry, TUMS

Smith and Knight. In brief, the area around the enamel/cemental

junction or the zone just above the gingival margin, if this was not
For Personal Use Only

visible, was considered as the cervical area. Any part of the tooth
coronal to this area was considered to be on the facial/buccal surface.
Restorations covering more than 25 percent of any tooth surface
(cervical, buccal, occlusal/incisal and palatal/lingual surfaces) and
missing teeth were recorded separately.

The Exact Tooth Wear Index

Exact Tooth Wear Index for Enamel

0 No tooth wear: no loss of enamel characteristics or change in contour
1 Loss of enamel affecting less than 10 percent of the scored surface
2 Enamel loss affecting between 10 percent and one third of the scored
surface
3 Enamel loss affecting at least one-third but less than two-thirds of
the scored surface
4 Enamel loss affecting two-thirds or more of the scored surface
Exact Tooth Wear Index for Dentine
0 No dentinal tooth wear: no loss of dentine
1 Loss of dentine affecting less than 10 percent of the scored surface
2 Dentine loss affecting between 10 percent and one third of the scored
surface
3 Dentine loss affecting at least one-third but less than two-thirds of
the scored surface
4 Dentine loss affecting two-thirds or more of the scored surface, no
pulpal exposure
5 Exposure of secondary dentine formation or pulpal exposure
 Appendices

Appendix 1: Case History

History Taking Clinical Examination Treatment Planning

• Demographic • General examination • Comprehensive
treatment plan
details • Local examination
– Emergency phase
• Chief complaint – Extraoral
– Preventive phase
Library of School of Dentistry, TUMS

• History of – Intraoral: soft

tissue, hard tissue – Promotive phase
present illness
For Personal Use Only

• Making a provisional – Curative phase

• Medical history
diagnosis
– Rehabilitation
• Past dental
• Appropriate phase
history investigations
– Maintenance
• Family history • Final diagnosis phase
• Personal history • Community
treatment plan
 222 A Practical Manual of Public Health Dentistry

Appendix 2: Case History Proforma

Date: __________ OPD No. _________ Student’s Name: ______________

Patient’s Name: __________________________ Age/Sex: ______________
Date and Place of Birth: __________________________________________
Education: ___________________ Occupation: _______________________
Total Income of Family per Month: _________________________________
Address: ________________________________________________________
_______________________________ Contact No: _____________________

I. Chief Complaint:
Library of School of Dentistry, TUMS
For Personal Use Only

II. History of Present Illness:

III. Medical History:

Diabetes:
Hypertension:
Blood Dyscrasias:
Hospitalizations:
Blood Transfusions:
Medications:
Asthma:
 Appendices 223
Drug Allergies:
Others:
IV. Dental History:

V. Family History:
a. Siblings: Number __________ Age ___________
Library of School of Dentistry, TUMS

Does any member in your family suffer from similar problem?

For Personal Use Only

Do you know of any illness that runs in your family?

b. Marital Status: Married

Unmarried

c. Children (if any) Number Age: ____________

VI. Personal History:

a. Personal Habits: Number Frequency Duration
1. Smoking:
2. Smokeless Tobacco:
(with/without Pan Chewing)
3. Pan Chewing:
4. Alcoholism:
b. Habits related to Oral Cavity:
Mouth Thumb Tongue Bruxism Lip/Nail/Pencil
Breathing Sucking Thrusting Biting

Duration: _________________________________________________
 224 A Practical Manual of Public Health Dentistry

c. Oral Hygiene Practices:

1. Type of Cleaning:

Toothbrush Finger

Stick Any Other (specify)

2. Method of Cleaning:

Vertical Horizontal Circular

3. Materials Used:

Toothpaste Tooth Powder Charcoal

Others
Library of School of Dentistry, TUMS

4. Frequency of Cleaning:
For Personal Use Only

Once Twice Thrice

5. Time of Brushing:

Before Meals After Meals

6. Frequency of changing the Toothbrush: __________________
____________________________________________________
7. Use of other Oral Hygiene Aids:

Flossing Other Interdental Aids

Oral Mouth Rinse

d. Dietary Habits:

1. Vegetarian Mixed
2. Dietary Chart: (Staple Diet)
Time Item Sugar Exposure
__________ ________________________ __________
__________ ________________________ __________
__________ ________________________ __________
__________ ________________________ __________
__________ ________________________ __________
 Appendices 225
3. Sugar Consumption (per day):
• Type:

Fermentable Less Fermentable

• Frequency:

Once Twice Thrice

Please Specify If More: ______________________________
• Time of Intake: With Meals Without Meals
• Form and Consistency:

Solid Liquid
Library of School of Dentistry, TUMS

Sticky Non sticky

VII. General Examination:
For Personal Use Only

Gait: _____________________ Pallor: _______________________

Posture: __________________ Cyanosis: _____________________
Built: ____________________ Edema: ______________________
Blood Pressure: ___________ Icterus: ______________________
Pulse: ____________________ Height: ______________________
Temperature: _____________ Weight: ______________________
Respiratory Rate: __________ BMI: ________________________
VIII. Local Examination:
A. Extraoral:
Symmetry: _____________________________________________
T.M.J: _________________________________________________
Lymph Nodes: _________________________________________
B. Intraoral:
1. Soft Tissue: __________________________________________
• Tongue __________________________________________
• Buccal Mucosa ____________________________________
• Labial Mucosa ____________________________________
 226 A Practical Manual of Public Health Dentistry

• Gingiva: __________________________________________
Color ____________________________________________
Contour _________________________________________
Consistency _______________________________________
Size _____________________________________________
Shape ____________________________________________
Texture __________________________________________
Position __________________________________________
Bleeding on Probing _______________________________
• Palate ____________________________________________
Library of School of Dentistry, TUMS

• Floor of Mouth ___________________________________

For Personal Use Only

• Alveolar Mucosa ___________________________________

2. Hard Tissue:

Dentition: Deciduous Mixed Permanent

Number of Teeth Present:
Teeth Absent and Reason for Loss:
Root Stumps:
Dental Caries:
Noncavitated:
Cavitated:
Filled Teeth:
Any Prosthesis: (Mention Tooth)
Crown
Bridge
RPD/Implant
Wasting Disease: Generalized Localized (mention tooth)
Attrition:
Abrasion:
Erosion:
 Appendices 227
Enamel Hypoplasia:

Generalized Localized (Mention Tooth)

Fluorosis:

Generalized Localized (Mention Tooth)

Supernumerary Teeth:
Any Other Anomaly Please Specify:
Malocclusion:
Trauma from Occlusion:
Fractured/Nonvital Tooth:
Library of School of Dentistry, TUMS

Stains: Extrinsic Intrinsic

3. Periodontal Status:
For Personal Use Only

Generalized Localized (Mention Tooth)

Gingivitis
Periodontal Pocket
Mobility of Teeth
Gingival Recession
4. Oral Hygiene Status:
Dental Deposits:

Plaque Stains Calculus

Good Fair Poor

Halitosis :
IX. Provisional Diagnosis:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
 228 A Practical Manual of Public Health Dentistry

X. Investigation:
_________________________________________________________
_________________________________________________________
_________________________________________________________
XI. Diagnosis:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Library of School of Dentistry, TUMS

XII. Treatment Plan:

For Personal Use Only

1. Emergency Phase
______________________________________________________
______________________________________________________
______________________________________________________
2. Preventive Phase
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
3. Promotive Phase
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
4. Curative or Therapeutic Phase
______________________________________________________
______________________________________________________
 Appendices 229
______________________________________________________
______________________________________________________
______________________________________________________
5. Rehabilitation
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
6. Maintenance Phase
a. Recall
Library of School of Dentistry, TUMS

____________________________________________________
For Personal Use Only

____________________________________________________
b. Review
____________________________________________________
____________________________________________________
c. Reassessment
____________________________________________________
____________________________________________________
XIII. Community Treatment Plan:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

_________________
Teacher’s Signature
 230 A Practical Manual of Public Health Dentistry

Appendix 3: Oral Hygiene Index (OHI)

Described by John C. Greene and Jack R. Vermillion in 1960

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -
Diet - Sugar exposure -
DEBRIS INDEX (DI)
Right Anterior Left
Library of School of Dentistry, TUMS
For Personal Use Only

(Total of upper and lower buccal scores) +

(Total of upper and lower lingual scores)
DI = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
(The no. of segments scored)
DI =
CALCULUS INDEX (CI)
Right Anterior Left

(Total of upper and lower buccal scores) +

Total of upper and lower lingual scores)
CI = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
(The no. of segments scored)
CI =
OHI= DI + CI =
_____________
Staff Signature
 Appendices 231

Oral Hygiene Index-Simplified (OHI-S)

Described by John C. Greene and Jack R. Vermillion in 1964

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -
Diet - Sugar exposure -
DEBRIS INDEX–SIMPLIFIED (DI-S)
Library of School of Dentistry, TUMS

16 11 26
For Personal Use Only

46 31 36
DI-S = Total score/no. of surfaces scored
= Interpretation = __________
CALCULUS INDEX–SIMPLIFIED (CI-S)
16 11 26

46 31 36
CI-S = Total score/no. of surfaces scored
= Interpretation = __________

OHI-S = DI-S + CI-S

= Interpretation = __________

_____________
Staff Signature
 232 A Practical Manual of Public Health Dentistry

Decayed-Missing-Filled Teeth Index (DMFT and deft)

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

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -
Diet - Sugar exposure -

55 54 53 52 51 61 62 63 64 65
Library of School of Dentistry, TUMS
For Personal Use Only

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

85 84 83 82 81 71 72 73 74 75

D= d=
M= e=
F= f=

DMF-T = D + M + F = def-t = d + e + f =

_____________
Staff Signature
 Appendices 233

Decayed-Missing-Filled Tooth Surfaces Index (DMFS and defs)

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

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -
Diet - Sugar exposure -

55 54 53 52 51 61 62 63 64 65
Library of School of Dentistry, TUMS
For Personal Use Only

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

85 84 83 82 81 71 72 73 74 75

D-S = d-s =
M-S = e-s =
F-S = f-s =

DMF-S = D-S + M-S + F-S = def-s = d-s + e-s + f-s =

_____________
Staff Signature
 234 A Practical Manual of Public Health Dentistry

Community Periodontal Index (CPI)

Described by WHO/FDI in 1982

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -

Periodontal Status
Library of School of Dentistry, TUMS

17/16 11 26/27
For Personal Use Only

47/46 31 36/37

Loss of Attachment
17/16 11 26/27

47/46 31 36/37

_____________
Staff Signature
 Appendices 235

Periodontal Index (PI)

Described by Rusell AL in 1956

Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Income - Brushing -
Education - Agent -
Occupation - Frequency -
Diet - Sugar exposure -
Library of School of Dentistry, TUMS

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
For Personal Use Only

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Sum of score of all individual tooth examined

PI for an individual = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
No. of teeth examined

Score: _______________

Inference: _______________

_____________
Staff Signature
 For Personal Use Only
Library of School of Dentistry, TUMS

Gingival Index (GI) 236

Described by Loe H and Silness P in 1963
Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Socioeconomic status - Brushing - Brush/ Finger/ Neem/ Other
Agent - Frequeny -
Diet - Sugar exposure -
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

B
A Practical Manual of Public Health Dentistry

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
 For Personal Use Only
Library of School of Dentistry, TUMS

Calculations:
Sum of score of four areas of tooth
GI for a tooth = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
4
Sum of score of all the individual tooth examined
GI for an individual = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
No. of teeth examined
Score: ___________
Interpretation:
0.1–1.0 Mild Gingivitis
1.1–2.0 Moderate Gingivitis
2.1–3.0 Severe Gingivitis
Appendices

_____________
Staff Signature
237
 For Personal Use Only
Library of School of Dentistry, TUMS

Plaque Index (PII) 238

Described by Silness P and Loe H in 1964
Name ___________________ Date__/__/____
Age/Sex _________________ Case No. ______
Socioeconomic status - Brushing - Brush/ Finger/ Neem/ Other
Agent - Frequeny -
Diet - Sugar exposure -
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

B
A Practical Manual of Public Health Dentistry

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
 For Personal Use Only
Library of School of Dentistry, TUMS

Calculations:
Sum of score of four areas of tooth
PII for a tooth = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
4
Sum of score of all the individual tooth examined
PII for an individual = ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯
No. of teeth examined
Score: ___________
Interpretation:
0 Excellent
0.1–0.9 Good
1.0–1.9 Fair
Appendices

2.0–3.0 Poor

_____________
Staff Signature
239
 Index

Page numbers followed by f refer to figure

A B
Abnormal occlusal habits 23 Bacterial infection 18
Acetone odor of diabetes 25 Bad taste 12
Acquired defects 32 Basal cell
Acute adenoma 8
caries 110 carcinoma 8
necrotizing ulcerative gingivitis Behavior management techniques 7
Library of School of Dentistry, TUMS

20 Behcet’s syndrome 18
Addison’s disease 27 Bell’s palsy 20
Adeno ameloblastoma 8 Bilateral cleft lip 92f
For Personal Use Only

Adenoid cystic squamous cell Biopsy 129

carcinoma 8 Bleeding 100
Aesthetic component 215 from gums 12, 19
Aglossia 95 on probing 102
Agranulocytosis 18 points index 152
Al-Alousi classification 152 Blood
Alcoholic breath 25 dyscrasias 18
Alkaptonuria 32 gas constituents 56
Allergic rhinitis 55 pressure 71, 74
Ameloblastic fibro-odontoma 8 Body
Amelogenesis imperfecta 32 mass index 71, 76
Amyloidosis 21 temperature 74
Analysis of pain 15 Bone
Anemia 18, 29 disease 24
Angioedema 91 score 183
Angular cheilitis 91 Bottle feeding 51
Ankyloglossia 6, 95, 95f Brown
Ankylosis of deciduous teeth 29 heme-associated lesions 27
Anorexia nervosa 8 melanotic lesions 27
Antalgic gait 72 Bruxism 40, 59, 114
Anterior Burning
compartment nodes 82 mouth 23
open bite 51 pain 16
Apical periodontitis of deciduous sensation 12
teeth 29 of mouth 22
Aphthous ulcers 8
Arch-length deficiency 29 C
Aspiration 71
Ataxic gait 72 Calculating DMFs 200
Auscultation 71 Calculation of BMI 77
 242 A Practical Manual of Public Health Dentistry

Calculus 150, 181 Cotton test 58

score 156 Cumulative index 148
surface index 151, 170 Cyanosis 27, 71, 76
surface severity index 151 Cystic fibrosis 20
Cancer 75 Cytologic smear 130
Carcinoma
in situ 8 D
of buccal mucosa 8
Caries severity index 152 Dean’s fluorosis index 152, 207
Causes of xerostomia 20 Debris score 155
Cavitated caries 109 Deep carious lesions 125
Celiac disease 29 Delayed tooth eruption 12, 29
Cerebral palsy 29 Dental
Cheek biting 40 aesthetic index 153, 216
Child sucking thumb 41f caries 32, 109, 151
Chondrosarcoma 8 index for deciduous teeth
Chronic 200
Library of School of Dentistry, TUMS

caries 110 fluorosis 118, 151

gingival inflammations 102 index by Moller 210
inflammation of nasal mucosa health index 152
For Personal Use Only

55 hypersensitivity 19
tonsillitis 51 indices 146
Chronological fluorosis assessment plaque 180
index 152 Dentinogenesis imperfecta 32
Circumvallate papillae 94 Dentoalveolar structure 44
Clark’s rule 7 Depression 75
Classification of Development of thumb sucking 42
caries 109 Developmental anomalies of teeth
dental erosion 217 111
oral pigmented lesions 26 Deviated nasal septum 55
sugars 63 Diabetes 21
tooth discoloration 30 mellitus 23
Cleft Discolored teeth 30
lip 6, 91 Distal
palate 6, 96, 96f facial surface 184
Clenching 40 lingual surface 184
Cold tests 131 mesial plaque index 151
Community Dolicocephalic skeletal pattern 56f
fluorosis index 208 Drug induced
periodontal index 152, 193 aspirin burn 18
codes 193f gingival reactions 102
of treatment needs 152, 185, Dry
188f, 190f mouth 12, 20, 22
Congenital nasal mucosa 25
erythropoietic porphyria 32 socket 24
hyperbilirubinemia 32 Dummy sucking 40
Control of thumb sucking 46 Dunlop’s beta hypothesis 47
Correct position of tongue 53 Duration of pain 14, 16
Correction of malocclusion 59 Dysosteosclerosis 29
 Index 243
E Festinating gait 72
Filariasis 10
Early hematoma 27 Filiform papillae 94
Ectopic eruption 29 Finger sucking 39
Edema 76 Fissured tongue 95
Effects of non-nutritive thumb Fixed bridges 35
sucking 45 Flaring of incisors 57f
Electric pulp test 131 Fluctuation 98
Enamel hypoplasia 32, 114, 114f, Fluorosis 32
119f index 208
Endocrine disorders 29 Folic acid deficiency 18
Endogenous 26 Fractures of teeth and restorations
Enlarged 60
adenoids 55 Frequency of dental prophylaxis 34
turbinates 55 Fried’s rule for infants 7
Erosion 8 Frostbite 75
Etiology of Full mouth indices 148
TFO 121
Library of School of Dentistry, TUMS

Functional measure index 152

tongue thrust 50 Fungiform papillae 94
Ewings sarcoma 8
For Personal Use Only

Exact tooth wear index 153, 219

Examination of
G
buccal mucosa 91 Gastroesophageal reflux disease 22
floor of mouth 93 Geographic tongue 22
hard and soft palate 95 Gingiva 44
internal jugular chain 84f Gingival
lips and labial mucosa 90 bleeding index 152, 174
lymph nodes 100 bone count index 152, 182
neck nodes 82f enlargements 102
postauricular nodes 84f fluid flow index 152
preauricular nodes 84f index 151, 172, 173
sub-mandibular nodes 83f pain index 151
submental nodes 83f recession 19, 105
supraclavicular chain 84f score 182, 184
swelling 97 status index 152
tongue 94 tissue index 151
ulcer 99 Gingivitis 150
Exfoliative cytology 130 periodontitis missing teeth index
Exogenous 26 152
Extent and severity index 152 Glass index 151
Extrinsic Graft-versus-host-disease 20
discoloration 32 Granulomatous diseases 20
sugars 64
H
F
Habit
Facial breaking appliance 55f
asymmetry 125 crib appliance 49f
symmetry 79 Handicapping
trauma 125 labiolingual deviation index 153
 244 A Practical Manual of Public Health Dentistry

malocclusion assessment index Internal jugular chain 83

153 Internalized discoloration 32
Healing oral wounds 24 Intrinsic
Heart disease 75 discoloration 30
Heat test 131 sugars 63
Hemiplegic gait 72 Iron deficiency anemia 7, 95
Hemochromatosis 27 Irregular teeth 12
Hemophilia 6, 8 Irreversible index 148
Hemorrhagic disorders 20 Isolate sugar factor 68
Hereditary hemorrhagic
telangiectasia 26 J
Herpes simplex 8
HIV Jaundice 27
infection 21, 29 Jerky and irregular tongue
oral melanosis 27 movements 51
Hodgkins disease 8 Juvenile periodontitis 6, 8
Hypertonic orbicularis oris 51
Library of School of Dentistry, TUMS

Hypofunction 23 K
Hypoglycemia 75
Hypoparathyroidism 29 Kaposi’s sarcoma 26
For Personal Use Only

Hypopituitarism 29, 75 Keratoacanthoma 8

Hypoprothrombinemia 20
Hyposensitive palate 51 L

I Late stage liver disease 21

Leprosy 10
Ichthyosis 29 Leukemia 75
Icterus 76 Leukoplakia 8
Idiopathic disorders 21 Levels of prevention for
Impacted primary tooth 29 dental
Incipient caries 109 caries 139
Index fluorosis 145
of orthodontic treatment need oral cancer 144
153, 217, 214 periodontal disease 141
teeth 186 Lip 80
Indices biting 40, 61
used in assessing exercises 58
calculus 170 pits and commissural pits 91
dental caries 197 separation 51
dental fluorosis 207 sucking 40
gingival bleeding 174 Liposarcoma 8
gingival inflammation 170 Lipstick sign 21
malocclusion 214 Lisping distortions 51
oral hygiene 153 Loose teeth 12, 23
periodontal diseases 176 Low grade esophagitis 56
plaque and debris 163 Lower
tooth wear 217 jugular nodes 82
Infections 22 left
Intensity of pain 14 central incisor 161
Interdental bleeding index 152 first molar 161
 Index 245
right first molar 161 Milk extrinsic sugars 64
Lymph nodes 80 Mirror test 58
of head and neck 81f Missing
Lymphatic drainage of face 85 index teeth 192
teeth 12, 162
M Mixed dentition 201
Mobility
Macroglossia 51, 95 of teeth 60, 125
Magnesium deficiency 60 test 107
Malalignment index 153 Moderate motor disability 51
Malignant Modified gingival index 151
squamous cell carcinoma 18 Moller’s fluorosis index 152
tumors of salivary glands 20 Mouth breathing 40, 51
Malocclusion 111, 151 habit 55
Mandibular Movement of pain 14
left Mucosal disorders 22
first molar 167, 173, 178, 183 Multiple myeloma 8
Library of School of Dentistry, TUMS

lateral incisor 173 Murray and Shaw classification 153

right Muscles of mastication 86
central incisor 167, 178, 184 Myasthenia gravis 8
For Personal Use Only

first bicuspid 173, 178 Myofunctional exercise 53

first premolar 167, 184
Marginal line calculus index 151 N
Massler and Frankel index 153
Mastoid nodes 83 Naber’s probe 106f
Maxillary Nail biting 40, 61
left Nasal
central incisor 167, 178, 183 obstruction 55
first bicuspid 173, 178 polyps 55
first premolar 167, 183 Nasoalveolar cyst 8
right Nature of pain 14
first molar 167, 173, 178, 183 Navy
lateral incisor 173 periodontal disease index 152,
Maxillothorax myotherapy 58 183
Mechanotherapy 49 plaque index 151, 167
Median rhomboid glossitis 95 Nonmilk extrinsic sugars 64
Melanoma 27 Nonodontogenic tumors 29
Melanoplakia 27 Nonsteroidal antiinflammatory
Melanotic macule 27 drugs 37
Menopause 23 Nutrition 29
Mesial
facial surface 184 O
lingual surface 184
Michigan ‘O’ probe 104 Occlusal
Microglossia 95 disharmony 121
Middle feature index 153
facial surface 184 index 153
jugular nodes 82 Occupational habits 40
lingual surface 184 Odontogenic tumors 29
 246 A Practical Manual of Public Health Dentistry

Oral free score index 151

clefts 29 index 151, 165
habits 39 Platelet disorders 20
health status index 151 Pleomorphic adenoma 7
hygiene Pocket score 184
habits 39, 61 Pregnancy associated gingivitis 102
index 151, 153 Premature loss of primary tooth 29
lichen planus 8 Preorthodontic trainer 54f, 59
pigmentation 26 Prevention of dental trauma 143
Osteomyelitis 24 Primary caries 110
Osteoporosis 75 Progress of swelling 17
Progression of pain 14, 16
P Properties of ideal index 147
Psychological status of child 47
Pain 12, 14 Psychosocial stress 23
Palpation 70, 86 Pulp
Papillary stones 6
Library of School of Dentistry, TUMS

bleeding index 152 vitality testing 131

marginal-attachment index 170 Pulpal hemorrhagic products 32
Papilloma 6 Purpose and uses of index 148
For Personal Use Only

Parotid
gland 88 Q
diseases 8
nodes 83 Quad helix 49, 50f
Past periodontal therapy 34
Patient hygiene performance index R
151, 160
Peer assessment rating index 153 Radiation
Percussion test 111 of pain 16
Pericoronitis 24 therapy of head and neck 20
Periodontal Ranula 94
destruction 150 Recurrent
disease index 152, 178, 180 aphthous ulcers 18
index 152, 176 caries 110
pocket assessment 104 Red lesions of oral cavity 93
screening and recording index Regional odontodysplasia 29
152 Removable appliance therapy 53
Periodontitis 6 Respiration 74
severity index 152 Respiratory rate 71
Peripheral Restorative
ossifying fibroma 8 index 152
vascular disease 75 materials 32
Peutz-Jegher’s syndrome 27 Reversible index 148
Pheochromocytoma 76 Rhinomanometry 58
PI score for tooth 165 Root
Pigeon chest 56 caries index 152
Plaque resorption 6, 32
component of periodontal Routine dental check-up 12
disease index 151 Rules for scoring DMFT 198
 Index 247
S Sugar in liquid form 66
Sulcus bleeding index 151
Salivary gland 88 Surrounding skin 100
hypofunction 22 Sweet score 63
Scalene nodes 83 Swelling 12, 17, 125
Scarlet fever 6 Systemic diseases 20
Scoring
criteria for
T
calculus 181
plaque 181 Temporomandibular joint 85
Russels periodontal index 176 Teratoma 6
method 179 Test cavity 132
for debris 155f Tetracycline staining 32
PDI 180 Thermoplastic thumb post 48
Scurvy 75 Throbbing pain 16
Segmental odontomaxillary Thrombocytopenic purpura 20
dysplasia 29 Thumb
Library of School of Dentistry, TUMS

Selection of teeth 197, 213 and digit sucking 40

and surfaces 169, 171, 178 and finger sucking 51
Sensing gingival pockets 189, 194 sucking 39
For Personal Use Only

Shooting pain 16 Thylstrup-Fejerskov

Short clinical crowns 102 fluorosis index 153, 212
Sibilant distortions 51 index 212
Sickle cell anemia 8 Thyroid disease 8, 21
Significant caries index 152, 206 Tongue
Simple index 148 blade sign 21
Simplified thrust habit 50
indices 148 Tonsil stones 25
Tonsillitis 25
oral hygiene index 151
Tooth
Six teeth and surfaces scored 157
fracture 121, 121f
Sjogren’s syndrome 7, 20, 22
migration 120
Sleep deprivation 75
mobility 23, 24
Slowly dissolving
surface index of fluorosis 213
category 65
wear index 153, 218
sugar 67, 68f
Torus palatinus 97
Smith and Knight tooth wear index Transverse cervical nodes 83
218 Traumatic ulcer 18
Solid and sticky sugar 66, 67f Treatment of tongue thrust 53
Squamous cell carcinoma 95 Tuberculosis 18, 75
Stabbing pain 16 Turesky
State of regional lymph nodes 99 Gilmore-Glickman modification
Stomatitis 22 of Quigley-Hein plaque index
nicotina palate 8 163
Stone’s index 152 modification 164
Submandibular Two digit system 108
gland 88 Type of
nodes 83 indices 148
Submental nodes 83 pain 16
Sucking reflex 41 tongue thrust 51
 248 A Practical Manual of Public Health Dentistry

U D
deficiency 75
Ulcer 18, 22, 95 resistant rickets 29
Ulcerative lesions of oral cavity 93 K deficiency 20
Unilateral cleft lip 92f
Upper W
jugular nodes 82
left molar 161 Wasting diseases 19
right of teeth 113
central incisor 161 Water test 58
first molar 161 White lesions of oral cavity 93
William’s periodontal probe 104,
105f
V
Vague pain 16 X
Various segments of mouth 154f
Xerostomia 20, 21
Verrucous carcinoma 8
Library of School of Dentistry, TUMS

Visceral larval migrans 76

Visual inspection 70
Y
Vitamin Young’s
For Personal Use Only

B12 18, 22 classification 152

C deficiency 20 rule 6