Assessment of periodontal status with CPITN and conventional periodontal indices
K. Almas^*, J. S. Buiman^ and H.N. Newman^ Departments of ^Community Dental Health and ^Periodontology, Institute of Dental Surgery, Eastman Dental Hospital, British Postgraduate Medicai Federation, University of London, UK 'Present address: Joint Department of Community Dental Health and Dentai Practice, University College London and The London Hospital Medicai Coiiege, University of London, UK
Almas K, Bulman JS and Newman HN: Assessment of periodontal status with CPITN and conventional periodontal indices. J Clin Periodontol 1991; 18: 654-659. Abstract. This study compared CPITN with plaque index (PlI), gingival index (GI), papilla bleeding index (PBI), and probeable pocket depth (PPD). 52 patients were examined, mean age 43 years. Partial mouth random recording (2 upper and 1 lower or 1 upper and 2 lower sextants) was made by CPITN of 150 sextants, and at 6 sites around each tooth in each sextant for each index using a pressuresensitive probe, with Newman tip and Williams markings, and a WHO 621 tip, probing pressure 0.25 N. Ranges of each index were compared with corresponding CPITN data. Most (71%) sextants had CPITN scores of 4, indicating periodontitis. None had CPITN scored 0 or 1. A given CPITN code was found to represent extremes of ranges for all other indices evaluated. There was no relation between CPITN and PlI or GI, nor did CPITN refiect the number of sites affected per sextant, but there was a tendency for CPITN to relate with PBI and PPD. It was concluded that CPITN may be used as a general indicator of bleeding and pocket depth, but not of plaque or gingivifis. Other indices are required to reliably assess chronic infiammatory periodontal disease status in a given mouth.
The community periodontal index of treatment needs (CPITN) was originally designed to assess chronic infiammatory periodontal disease (CIPD) in epidelniological surveys (Ainaino et al. 1982). Increasing numbers of studies suggest that the CPITN may be used as an indicator of both CIPD status and treatinent needs (Ainarno et al. 1987, Croxson 1984, Cutress et al. 1987). Recently, there has been an increasing adoption of CPITN as a diagnosis and treatment index (Ainamo et al. 1984, Aucott & Ashley 1986, Pilot & Barmes 1987), but few studies have compared CPITN with other conventional periodontal indices (Cutress et a l l 986, Life & Smales 1987, Reich et al. 1986, Watanabe et al. 1984) for the assessment of CIPD. Cutress et al. (1986) compared periodontal index and CPITN and noted that CPITN was to be preferred. Life et al. (1987) compared CPITN with plaque (presence or absence), bleeding on probing, overhanging margins, calculus (supra-subgingival), probing depth, loss of attachment, mobility and furcation involvement. They coticluded that CPITN treatment plans were comparable to those produced by the
periodontologists. Reich et al. (1986) compared CPITN with more traditional indices (periodontal index, periodontal disease index) and foutid that the results obtained with CPITN were comparable to those obtained with PDL Watanabe et al. (1984) compared CPITN and conventional indices, gingival bleeding index (BGI), probing depth and furcation involvement. They showed a significant correlation between CPITN and probing depth and GBI. While these studies show some degree of correlations of CPITN with conventional indices, there has been httle investigationof the extent to which CPITN refiects the extent of disease in a given mouth. The aim of this study was to evaluate the capacity of CPITN to refiect clinical periodontal status in comparison with conventional periodontal indices namely plaque index, gingival index, papilla bleeding index and probeable pocket depth. Material and Methods
52 patients were examined, 22 male and 30 female, referred by their general dental practitioners for treatment to the
Key words; CPiTN; piaque index; gingivai index; papiiia bleeding index; probing depth. Accepted for pubiication 31 Juiy 1990
Periodontology Department, Eastman Dental Hospital, London. None of the patients were under 20 years of age, the majority being 40-49 years, with smaller numbers in the 30-39 and 50-59 age groups. The lowest numbers were in the age group 60 + (Table 1). Plaque index (Silness & L5e 1964), gingival index (Loe & Silness 1963), papilla bleeding index (Miihlemann 1977) and probeable pocket depth (PPD) were used for assessment and comparison with CPITN (Ainamo et al. 1982), and were recorded in that order after conventional CPITN assessment. The distance from the free gingival margin to the bottom of the pocket (PPD) was obtained with a borodontic pressure-sensitive probe with a Newman tip with Williams markings (Prima, Byfleet, England). The probe tip diameter was 0.34 mm, and pressure was adjusted to 0.25 N. Pocket depth was recorded to the nearest mm. The CPITN probe used was the WHO 612 CPITN (E) probe, ball end diameter 0.5 mm (Morita Corporation, Japan). Data were recorded from 6 sites (mesio-buccal, mesio-lingual, disto-buccal, disto-lingual, mid-buccal and mid-hn-
CPITN and conventional indices Table 1. Distribution of study patients with regard to age and sex Sex male female all
20-29
30-39
Age (years) 40^9
50-59
60 +
Total
1 4 5
5 8 13
12 8 20
3 8 11
1 2 3
22 30 32
gual) around each tooth. Random selection of 3 sextants per patient (1 upper, 2 lower, or 2 upper, 1 lower) was made for recording of the conventional indices and the variable PPD, and for CPITN. Reproducibility was assessed prior to the commencement of the study. Pll, GI, PPD, PBI and CPITN were recorded twice with 30-min intervals between scoring (Table 2). Ranges and % ranges of conventional indices were used to obtain descriptive correlations of CPITN with the other indices. Results % distribution of CPITN scores
The total number of sextants examined was 150 (Table 3). The CPITN score range was from 2-4. There was no sextant with a score of 1 or 0, that is, none of the sextants presented with simple bleeding but without pockets, or was healthy. Score 2 sextants numbered 8 (5%); score 3, 36 (24%);and score 4, 106
(Table 3) showed a PBI range of 1-3. For CPITN score 4, most sextants had a PBI range 0-3, and only 5% had a range of 0-1. Frequency distribution for each levei of CPiTN (Table 4)
(71%). Extreme ranges were as follows: plaque index 0-^3, gingival index 0-3, papilla bleeding index 0-3 and probeable pocket depth 2-12. Conventional indices and the variable PPD ranged from very low to very high for any given CPITN code. Range and % range distribution for each ievel of CPiTN (Table 3)
Plaque index Just over 50% of sextants with CPITN score 2, 3, 4 were in Pll range 1-3, while approximately equal %s of sextants ranged from 0-2, 0-3 and 1-2. Only 1 sextant scoring 4 had a Pll range of 0-1. Gingival index No sextant had a coding of GI 0; most showed a range of 1-2. Papilla bleeding index For CPITN sextants scoring 2, half had a PBI range of 0-2 and half 0-3. Only 3% of sextants with a CPITN scored 3
Table 2. Investigator reproducibility for plaque index (PI), gingival index (GI), probeable pocket depth (PPD), papilla bleeding index (PBI) and community periodontal index of treatment needs (CPITN) Reproducibility
Pll
GI
PPD
PBI
CPITN
number of scores agreenient in scores disagreement in scores reproducibility (%)
246 226 20 92
246 222 24 90
246 222 24 90
246 224 22 91
36 32 4 89
Table 3. Range and % range distribution of each level of CPITN in relation to plaque, gingival and papilla bleeding indices 0-1
0-2
0-3
1-2
1-3
2-3
Plaque index 2 3 4
1 — 1
1
1 6 19
4 18 54
_ 3
12
1 4 12
— -
,3
— — 1
5 22 48
3 10 46
—
4 Papilla bleeding index 2 3 • , 4
:
L/l
CPITN score
Gingival index 2 3
•
4 14 26
4 18 68
8
4
— 1 . •-" "
-
7.
_ • '•
1
655
• • •
-
Table 4 gives the actual frequency distribution (FD) of sites for each level of CPITN and for conventional variables. Plaque index Only 2.5% of sites had a Pll of 0, 33.5% had a score of 1, 47% a score of 2 and 17% a score of 3. There was an approximately even frequency distribution and % of sites with Pll 1 and 2, except for CPITN 4 sextants. Approximately Yj the sites with a CPITN scored 4 had Pll score of 2 and '/3 had a PII score of 1. A minority of sites had Pll 3 and very few Pll 0. Gingival index About 1/2 the sextants with a CPITN score of 2 had a score of GI 2, and 43% a score of 1. In sextants with CPITN scores of 3 and 4, again about 90% of sites had a GI score of 1 or 2. Only 13 sites (0.5%) had a GI score of 0 in sextants with a CPITN score of 4. Papilla bleeding index PBI data indicated a trend towards a smaller % of sites that did not bleed when related to a higher level of CPITN (CPITN 2, 43%, CPITN 3, 40%, CPITN 4, 28%). All these also had a GI score of 0. There were higher %s of bleeding sites with PBI scores of 2 and 3 in sextants with CPITN scores of 4 than in sextants with CPITN scores of 2 or 3. Probeable pocket depth (Fig. 1) The shallowest pocket measured was 2 mm and the deepest 13 mm. There was a clear tendency for a higher % of deeper pockets to occur in CPITN 4 sextants, and similarly for a higher % of shallow pockets to occur in sextants graded 2 or 3. Overall, only about 25% sites had pockets greater than or equal to 6 mm deep. Although 70% of sextants had a CPITN score of 4, only approximately 33% of the sites in CPITN 4 sextants had PPD greater than or equal to 6 mm, and about 48% greater than or equal to 5 mm (Fig. 1). It was observed that 11 % of sites in sextants with CPITN score of 2 had 5 mm pockets, while there were 5 sites
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Almas ei al.
Table 4. Frequency distribution and % frequency distribution of sites for each index and each level of CPITN Papilla bleeding Gingival index index AT ••" • Plaque index CPITN 1 2 3 0 1 2 3 0 1 2 3 0 (sextants) FD score - 110 125 17 109 65 62 16 7 118 114 13 8 FD 2 - 312 533 100 385 253 249 58 432 182 302 36 FD 29 13 829 1671 310 805 687 995 336 FD 62 928 1360 473 106 4 ' • FD = sites.
with 6 mm pockets and 1 with a 7 mm pocket. For CPITN 3 sextants, the corresponding figures were 13.6% with 5 mm, 4.2% with 6 mm, and 3 sites with 7 mm pockets (Fig. 1). Discussion
In this study, the subjects were from the Periodontal Department of a teaching dental hospital. The majority of the patients were between 40-49 years of age. There was ari equal distribution of female but not of male patients between the ages of 30-39, 40-49, 50-59 years. The standardised pressure (0.25 N) used with the probe tips has been recommended by WHO (1978) for CPITN work. The more parallel-sided and thinner probe, and the constant probing force used, may have aided in the recording of probeable pocket depth. Lower readings obtained with the WHO probe in several instances may have been due to the ball tip contacting an obstruction, for example, calculus. It is therefore possible that the
CPITN probe may underestimate pocket depth. Similarly, there are several possible explanations for the observation of sites with pockets equal to or greater than 4 mm in sextants with CPITN scores of 2 or 3. The probe tip diameter was 0.5 mm for the CPITN probe, but only 0.34 mm for the conventional probe. Calculus may have obstructed the CPITN probe and CPITN probing being a screening process may be more rapid, and therefore less precise than conventional probing. In this study, variables were recorded at the 6 sites around each tooth as recommended by Ainamo & Ainamo (1985) and Aucott et al. (1986). Random selection of 3 sextants per patient was representative of a whole mouth according to Ainamo (1983), calculated on the basis of the 6 Ramfjord (1959) teeth. In another study by Ainamo et al. (1982) in which variables were monitored in relation to 6 surfaces of each tooth,using either (1) all teeth, (2) the 6 Ramfjord teeth, examination of only the latter was found to give a fair-to-
1000-T
n u m b e r
800
600-
CPITN 2 CPITN 3
o f 3
CPITN 4
400-
I t
e s
200
Q JJ
J
—r™"
r
6 6 7 pocket depth in mm
8
Fig. ]. Frequency distribution of sites by CPITN score and PPD.
9-12
13
good estimate of severity and prevalence of supra- and subgingival calculus and of gingival bleeding tendency after gentle pocket probing. While the plaque index enables a rough estimate of the principal (supragingival) causative factor, calculus recording would have enabled more accurate correlation with sites in sextants coded CPITN 2. Proportions of sites affected, with ranges of the given variables, were used for descriptive analysis, since proportions may be used for both quantitative and quahtative variables. In other studies, the results have been obtained through determination of the mean of the scores of all teeth (Russell 1956) or of the selected index teeth (Ramfjord 1959) of the individual, and then by calculating the mean of all individualmeans within the study population. Such data have been very useful for comparison of chronic infiammatory periodontal disease levels in different parts of the world. Mean severity scores, however, give no information about the actual proportion of individuals affected within the population. From the range distribution of conventional indices in relation to CPITN, it is obvious, regardless of CPITN scores, that there was supragingival plaque present from extremely low to extremely high levels, and that CPITN did not relate to the amount of plaque present. Papilla bleeding index and GI, particularly the former, also gave the same extreme ranges irrespective of the CPITN code. As regards probeable pocket depth, the shallowest pocket recorded was 2 mm and the deepest 12 mm. As 2 mm pockets were observed regardless of CPITN code, it may be that the index is not helpful in identifying shallower pockets, but the fact that the higher the code, the deeper the extreme pocket depth, would indicate some direct correlation of CPITN with probeable pocket depth (Fig. 1). Because the majority of sextants (about 50%), whether CPITN 2, 3 or 4, had a PII range of 1-3, it would seem that there is little relationship between supragingival plaque level as represented by PII and CPITN code.It was noted that out of a total of 150 sextants, only 2 had PII scores of 0-1, even though there was a 6-point recording around each tooth. As only one of these had a CPITN score of 2 and the other a CPITN score of 4, it again indicates little guidance from CPITN as to level
CPITN and conventional indiees of supragingivalplaque. For the gingival index, it was observed that there was no sextant with a GI score of 0-1, again regardless of CPITN code, and that nearly all the sextants were in the GI ranges of 1-2 and 1-3. This shows again, that, irrespective of CPITN code, the sextant could have had mild, moderate or severe gingival inflammation. However, none of the sextants with a CPITN code of 2 had a GI range of 2-3 and none of those with a CPITN score of 2 or 3 had GI ranges of 0-2 or 0-3. Similarly only a small % of sextants with a CPITN code of 4 had a GI range of 0-3. This too indicates no direct relation of GI to CPITN score. From the range and % range distribution of each level of papilla bleeding index compared with CPITN, it is obvious that the majority ofthe sextants had corresponding PBI ranges of 0-2 and 0-3, suggesting a poor correlation with the CPITN code. While it might have been expected that range 0-1 would be associated with sextants with CPITN codes 1 or 2, in fact only sextants with CPITN codes of 3 or 4 (8 in total) were in this PBI range. However, some slight relation of CPITN to PBI might be considered on the basis of PBI ranges 1-3 • having been observed only in sextants coded CPITN 3 (1 sextant) and 4 (7 sextants). The frequency distribution of sites for each level of PlI compared with each level of CPITN indicates that the majority of sites were in the range of PlI 1-2, with a very small number of sites with PlI scores 0 and 3. This suggests that, irrespective of the CPITN code, there is approximately the same % distribution of sites, particularly for PlI scores 0, 1 and 2. Plainly, CPITN code does not indicate a direct relation to the amount of plaque or numbers of sites affected. There was a similar pattern noted for site distribution as regards gingival index, also indicating a lack of relation between CPITN code and GI, including number of sites affected. There is no clear explanation for the finding that the only sites with a GI score of 0 had a CPITN score of 4, but this also indicates the lack of association of CPITN and GI. The finding of increasing numbers of sites affected with increasing PBI, and vice versa would suggest a direct association with CPITN code. Clearly, there was a tendency for iower PPD to be associated with lower CPITN and vice versa, and for increas-
657
ing numbers of deeper pockets to be previously, they noted a direct correassociated with increasing CPITN code, lation with all three. showing, therefore, an obvious direct association beteen CPITN and PPD Conclusions (Fig. 1). There has recently been an increasing NNO direct associations were found beadoption of CPITN as an epidemio- tween CPITN and plaque index or ginlogical index.Although the clinical gival index. rationale behind the recommended There appeared to be an association basic criteria, and parfial recording pro- between CPITN and papilla bleeding cedure explains its ready acceptance, it index, and between CPITN and PPD. is necessary that the advantages of the Comparison of CPITN score with the index be identified (Cutress et al. 1986). plaque index and the gingival index Several epidemiological studies have gives no indication as to numbers of been carried out using CPITN or PTNS sites affected in a sextant by a given (Bellini & Gjermo 1973, Christensen et level of plaque or inflammation, as indial. 1983, Markhanen et al. 1983, cated by PlI and GI. Croxson 1984, Ishikawa et al. 1984, AiComparison of CPITN score with namo et al. 1986, Barmes & Leous 1986, PBI and PPD indicated that there was Brauer et al. 1986, Manji & Sheiham a tendency for a greater number of sites 1986, Pilot et al. 1986, Tervonen & Ain- in a sextant to be affected by more amo 1986, Garcia & Cutress 1986, bleeding and deeper pockets as repreBrown et al. 1987, Pilot et al. 1987, Siv- sented by these indices, the higher the aneswaran & Barnard 1987). All these CPITN code. studies have evaluated treatment needs From the above conclusions, it would for populations. Thus, most ofthe work seem that CPITN is a poor guide to has been carried out after acceptance gingivitis, but a good indicator of the of the CPITN as a screening index for irreversible stage of CIPD, chronic treatment need, and it has been proved periodontitis, as represented by PBI and to be useful for epidemiological pur- PPD, at least in a hospital periodontal poses and for treatment needs and man- population without unusual forms of power planning. Few studies have com- periodontitis, and which may, therefore, pared CPITN with other, conventional have had a relatively even distribution indices for the assessment of CPID. In of lesions, representative of the usual Japan, Watanabe et al. (1984) compared "horizontal" pattern of bone loss asCPITN and conventional indices, in- sociated with routine chronic adult cluding the gingival bleeding index periodontitis. (GBI), probing depth and furcation inIn spite of these positive findings, exvolvement. They showed a significant tremes of ranges of all indices may be correlation between CPITN and prob- observed in a sextant, regardless of ing depth and GBI. There was a direct CPITN code. Low levels of inflamcorrelation of CPITN code with increas- mation, plaque, pocketing, and bleeding ing PPD and this correlation has also may be observed in sites of sextants been suggested by the present study. Cu- coded 4, and high levels of plaque, tress et al. (1986) compared periodontal bleeding and inflammation and ocindex and CPITN as epidemiological casional early pockets may be observed screening procedures. The CPITN index in sextants of lower code. was assessed on the basis of only 10 While CPITN is a guide, there is no teeth while all teeth were assessed for substitute for site recording of data for PI. They used a WHO 621 probe for accurate periodontal diagnosis and CPITN, and a PI examination was car- specifically for treatment planning. Ignoring the above might lead to ovried out with the aid of a mouth mirror. er-treatment of code 4 sextants and failAlthough the findings cannot be ure to diagnose with accompanying incompared directly with those of the adequate treatment of code 2 sextants. present study, they noted that for assessment of periodontol conditions and treatment needs, the CPITN was to be Zusammenfassung preferred to the PI. Only Watanabe et al. (1984) appear Die Beurteilung des parodontalen Status mit dem CPITN und konventlonellen, parodontato have compared CPITN with conven- len Indizes tional indices, namely GBI, PPD and In dieser Studie with der CPITN (Communifurcation involvement, and, as stated ty Periodontal Index of Treatment Needs) mit
658
Almas et al.
dem Plaqueindex (Pll), dem Gingivalindex (GI), dem Papillenblutungsindex (PBI) und der sondierbaren Taschentiefe (PPD) verglichen, Untersucht wurden 52 Patienten mit einem Altersdurchschnitt von 43 Jahren, Mit der CPITN-Methode wurde an 150 Sextanten eine partielle Erhebung iiber die oralen Verhaltnisse (an 2 oberen oder 1 oberen und 2 unteren Sextanten) durchgefuhrt, Mit einer druckempfmdiichen Sonde mit der Newmanspitze und Markierungen nach Williams und einer WHO 621 Spitze wurden 6 Stellen eines jeden Zahnes der Sextanten bei einem Sondierungsdruck von 0.25 N sondiert. Die Variationsbreiten eines jeden Index wurden mit den entsprechenden CPITN-Werten verglichen. Bei den meisten Sextanten (71%) lagen CPITN-scores in einer Hohe von 4 vor, was Parodontitis bedeutet. Eine Beurteilungseinheit (score) von 0 oder 1 wurde in keinem Sextanten registriert, Man fand einen bestimmten CPITN-Kode, der die Extremwerte der Variationsbreiten aller anderen untersuchten Indizes darstellte. Zwischen dem CPITN und dem Pll und GI bestand weder eine Beziehung noch gab der CPITN die Anzahl befallener Stellen pro Sextant wieder es lag aber eine Tendenz zur Beziehung zwischen CPITN und PBI sowie PPD vor. Man folgerte, dass der CPITN als allgemeiner Indikator fijr das Zahnfleischbluten und die Taschentiefe gelten kann, nicht hingegen fiJr die Plaque oder die Gingivitis, Es bedarf anderer Indizes, um den Stand der chronischentziindlichen Parodontalkrankheit in einem Munde verlasslich zu beurteilen. Resume Evaluation de I'etat parodontal avec les indices CPITN et converitionels
Cette etude a compare I'indice parodontal communautaire des besoins en traitement (CPITN) avec I'indice de plaque (Pll), I'indice gingival (GI), I'indice de saignement papillaire (PBI) et la profondeur de poche au sondage (PPD), Cinquante-deux patients, d'un age moyen de 43 ans, ont ete examines, Un enregistrement partiel a ete effectue au hasard, soit au niveau d'un sextant superieur et de deux inferieurs soit au niveau de deux sextants superieurs et un inferieur, par CPITN au niveau de 150 sextants, L'examen utiiisant les autres indices ont ete menes au niveau de six sites autour de chaque dent de chaque sextant a l'aide d'une sonde sensible a la pression, avec une pointe de Newman et les marquages de Williams, et une pointe OMS 621, en utiiisant une pression de 0,25 N. La repartition de chaque indice a ete comparee aux donnees CPITN correspondantes. La plupart des sextants (71%) avaient des scores CPITN de 4, indiquant la presence de parodontite, alors qu'aucun n'avait de score 0 ou 1. Un code CPITN donne representait les extremes de la repartition de tous les autres indices evalues. II n'y avait aucune relation entre le CPITN et le Pll ou le GI. De plus le CPITN n'indiquait pas le nombre de sites atteints par sextant, Cependant Ie CPITN semblait
quelque peu en relation avec le PBI et le PPD, Le CPITN peut done etre utilise comme indicateur general de saignement et de profondeur de poche mais pas de plaque ou de gingivite. D'autres indices sont necessaires pour estimer de maniere sure le niveau de la maladie parodontale inflammatoire chronique dans une bouche donnee.
and need for periodontal treatment in a representative sample of 35-44 year olds in Copenhagen. In: Public Health Aspects of Periodontal Disease in Europe, ed. Frandsen, A,, Berlin. Quintessence pp, 47-57. Croxson, L, J. (1984) A simplified periodontal screening examination: the Community Periodontal Index of Treatment Needs (WHO) in general practice. InternaReferences tional Dental Journal 34, 28-34. Ainamo, J,, Barmes, D., Beagrie, G,, Cutress, Cutress, T. W, Ainamo, J, & Sardo-Infirri, T, Martin, J. & Sardo-Infirri, J. (1982) J. (1987) The Community Periodontal InDevelopment of the World Health Organdex of Treatment Needs (CPITN) proization (WHO) community periodontal incedure for population groups and individdex of treatment needs (CPITN), Internauals. International Dental Journal 37, tional Dental Journal 32, 281-291, 222-223. Ainamo, J. (1983) Assessment of periodontal Garcia, M. L. & Cutress, T W. (1986) A treatment needs: Adaptation of the WHO national survey of periodontal treatment Community Periodontal Index of Treatneeds of the adults in Philippines. Comment Needs (CPITN) to European conmunity Dentistry and Oral Epidemiology ditions. In: Public Health Aspects of Perio14, 313-316. dontal Disease in Europe, ed. Frandsen, A,, Gjermo, P. B,, Bellini, J, T. & Marcos, B, Berlin. Quintessenz, pp, 35-45, (1983). Application of the community Ainamo, J., Norblad, A, & Kallio, P (1984) periodontal needs in a population of young Use of CPITN in populations under 20 Brazilians, Community Dentistry and Oral years of age. International Dental Journal Epidemiology 11, 342-346. 34, 285-291, Ishikawa, L, Honma, S., Hagiwara, S,, Asai, Ainamo, J, & Ainamo, A. (1985) Partial indiH,, Osada, Y., Ixumi, Y., Watanabe, J,, ces as indicators for severity and prevaIsumizawa, K, & Noguchi, T. (1984) Epilence of periodontal disease. International demiological survey on periodontal disease Dental Journal 35, 322-326, in the employees of two banks with Ainamo, J,, Tervonen, T & Ainamo, A, CPITN, Journal Japan Association of (1986) CPITN assessment of periodontal Periodontologists lf>, 161-11%. treatment needs among adults in OstroLife, J, S. C, & Smales, F, C, (1987) An bothinia, Finland, Community Dental investigation into the ability of CPITN to Healths, 153-161, indicate appropriate basic periodontal Ainamo, J,, Tervonen, T, Norblad, A. & Kaltherapy for individual patients. Journal of lio, P, (1987) Use of CPITN cross-tabuDental Research 66, (abstr, 30), 904, lations - a research perspective. InternaLoe, H, & Silness, J. (1963) Periodontal distional Dental Journal 37, 173-178, ease in pregnancy (1). Prevalence and sevAucott, D, M. & Ashley, F, P (1986) Assesserity, Acta Odontologica Scandinavica 21, ment of the WHO partial recording ap533-563, proach in identification of individuals Manji, F & Sheihan, A, (1986) CPITN findhighly susceptible to periodontitis. Comings and the manpower implications of munity Dentistry and Oral Epidemiology periodontal treatment needs for Kenyan 14, 152-155, children. Community Dental Health 3, Barmes,D, E. & Leous, P A. (1986) Assess143-151, ment of periodontal status by CPITN and Markkanen, J,, Rajala, M, & Paunio, K, its applicability to the development of (1983) Periodontal treatment need of the longerm goals on periodontal health of the Finnish population aged 30 years and over. population. International Dental Journal Community Dentistry and Oral Epidemi36, 177-181, ology 11, 25-32. Bellini, H, T, & Gjermo, P (1973) Application Muhlemann, H. R, (1977) Psychological and of the Periodontal Treatment Need system chemical mediators of gingival health. (PTNS) in a group of Norwegian industrial Journal Preventive Dentistry 4, 6-16, employees. Community Dentistry and Oral Pilot, T, & Barmes, D, E, (1987) An update Epidemiology 1, 22-29, on periodontal conditions in adults, measBrauer, L,, Bessermann, M., Frijs Madsen, ured by CPITN, International Dental JourB. & Brauer, E. (1986) Oral health status nal, 169-172, and needs for dental treatment in geriatric Pilot, T., Barmes, D, E,, Leclercq, M, H., patients in a Danish district hospital. ComMcCombie, B. J. & Sardo-Infirri, J. (1986) munity Dentistry and Oral Epidemiology Periodontal conditions in adults, 35-44 14, 132-135. years of age; an overview of CPITN data Brown, E, H., Edwards, J. L. & Spears, G, F, in the WHO Global Oral Data Bank. ComS, (1987) Periodontal and tooth treatment munity Dentistry and Oral Epidemiology needs in dentate elderly people in Dunedin. 14, 310-312. New Zealand Dental Journal 83, 42-45. Pilot, T., Effendi, I., Sunu, N. P, Wibowo, Christensen, J., Skougaard, M. R. & Stoltze D. J., Rihatinah, R. & Lima,Y, S, (1987) (1983) Prevalence of periodontal disease Periodontal profiles in different regions in
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ease in pregnancy (II). Correlation between oral hygiene and periodontal condition. Acta Odontologica Seandinavica 11, 121-135. Sivaneswaran, S, & Barnard, P. D. (1987) Periodontal assessment using the Community Periodontal Index of Treatment Needs of Westmead Hospital, Sydney, 1984. Australian Dental Journal 31, 11-16. Tervonen, T. & Ainamo, J. (1986) Relative influence of calculus and overhangs of fillings on the frequency of score 2 of the CPITN. Community Dentistry and Oral Epidemiology 14, 136-137.
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Watanabe, U., Hayashi, J., Wakao, N. & Kamoi, K. (1984) Epidemiological surveys of periodontal disease (Report 3). Comparison between CPITN and conventional methods. Journal of the Japanese Association of Periodontology 26, 532-541. Address:
• ''? /,^ •• -
"•. 'f\.
j ,f ••'
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H. N. Newman "' " "' ' ' ' ""'" '-'"'I Department of Periodontology Institute of Dental Surgery . 'f'..,^ •''"'•. C} 256 Gray's Inn Road '..' ; ' -.' i London WCIX 8LD UK
K. Almas^*, J. S. Buiman^ and H.N. Newman^ Departments of ^Community Dental Health and ^Periodontology, Institute of Dental Surgery, Eastman Dental Hospital, British Postgraduate Medicai Federation, University of London, UK 'Present address: Joint Department of Community Dental Health and Dentai Practice, University College London and The London Hospital Medicai Coiiege, University of London, UK
Almas K, Bulman JS and Newman HN: Assessment of periodontal status with CPITN and conventional periodontal indices. J Clin Periodontol 1991; 18: 654-659. Abstract. This study compared CPITN with plaque index (PlI), gingival index (GI), papilla bleeding index (PBI), and probeable pocket depth (PPD). 52 patients were examined, mean age 43 years. Partial mouth random recording (2 upper and 1 lower or 1 upper and 2 lower sextants) was made by CPITN of 150 sextants, and at 6 sites around each tooth in each sextant for each index using a pressuresensitive probe, with Newman tip and Williams markings, and a WHO 621 tip, probing pressure 0.25 N. Ranges of each index were compared with corresponding CPITN data. Most (71%) sextants had CPITN scores of 4, indicating periodontitis. None had CPITN scored 0 or 1. A given CPITN code was found to represent extremes of ranges for all other indices evaluated. There was no relation between CPITN and PlI or GI, nor did CPITN refiect the number of sites affected per sextant, but there was a tendency for CPITN to relate with PBI and PPD. It was concluded that CPITN may be used as a general indicator of bleeding and pocket depth, but not of plaque or gingivifis. Other indices are required to reliably assess chronic infiammatory periodontal disease status in a given mouth.
The community periodontal index of treatment needs (CPITN) was originally designed to assess chronic infiammatory periodontal disease (CIPD) in epidelniological surveys (Ainaino et al. 1982). Increasing numbers of studies suggest that the CPITN may be used as an indicator of both CIPD status and treatinent needs (Ainarno et al. 1987, Croxson 1984, Cutress et al. 1987). Recently, there has been an increasing adoption of CPITN as a diagnosis and treatment index (Ainamo et al. 1984, Aucott & Ashley 1986, Pilot & Barmes 1987), but few studies have compared CPITN with other conventional periodontal indices (Cutress et a l l 986, Life & Smales 1987, Reich et al. 1986, Watanabe et al. 1984) for the assessment of CIPD. Cutress et al. (1986) compared periodontal index and CPITN and noted that CPITN was to be preferred. Life et al. (1987) compared CPITN with plaque (presence or absence), bleeding on probing, overhanging margins, calculus (supra-subgingival), probing depth, loss of attachment, mobility and furcation involvement. They coticluded that CPITN treatment plans were comparable to those produced by the
periodontologists. Reich et al. (1986) compared CPITN with more traditional indices (periodontal index, periodontal disease index) and foutid that the results obtained with CPITN were comparable to those obtained with PDL Watanabe et al. (1984) compared CPITN and conventional indices, gingival bleeding index (BGI), probing depth and furcation involvement. They showed a significant correlation between CPITN and probing depth and GBI. While these studies show some degree of correlations of CPITN with conventional indices, there has been httle investigationof the extent to which CPITN refiects the extent of disease in a given mouth. The aim of this study was to evaluate the capacity of CPITN to refiect clinical periodontal status in comparison with conventional periodontal indices namely plaque index, gingival index, papilla bleeding index and probeable pocket depth. Material and Methods
52 patients were examined, 22 male and 30 female, referred by their general dental practitioners for treatment to the
Key words; CPiTN; piaque index; gingivai index; papiiia bleeding index; probing depth. Accepted for pubiication 31 Juiy 1990
Periodontology Department, Eastman Dental Hospital, London. None of the patients were under 20 years of age, the majority being 40-49 years, with smaller numbers in the 30-39 and 50-59 age groups. The lowest numbers were in the age group 60 + (Table 1). Plaque index (Silness & L5e 1964), gingival index (Loe & Silness 1963), papilla bleeding index (Miihlemann 1977) and probeable pocket depth (PPD) were used for assessment and comparison with CPITN (Ainamo et al. 1982), and were recorded in that order after conventional CPITN assessment. The distance from the free gingival margin to the bottom of the pocket (PPD) was obtained with a borodontic pressure-sensitive probe with a Newman tip with Williams markings (Prima, Byfleet, England). The probe tip diameter was 0.34 mm, and pressure was adjusted to 0.25 N. Pocket depth was recorded to the nearest mm. The CPITN probe used was the WHO 612 CPITN (E) probe, ball end diameter 0.5 mm (Morita Corporation, Japan). Data were recorded from 6 sites (mesio-buccal, mesio-lingual, disto-buccal, disto-lingual, mid-buccal and mid-hn-
CPITN and conventional indices Table 1. Distribution of study patients with regard to age and sex Sex male female all
20-29
30-39
Age (years) 40^9
50-59
60 +
Total
1 4 5
5 8 13
12 8 20
3 8 11
1 2 3
22 30 32
gual) around each tooth. Random selection of 3 sextants per patient (1 upper, 2 lower, or 2 upper, 1 lower) was made for recording of the conventional indices and the variable PPD, and for CPITN. Reproducibility was assessed prior to the commencement of the study. Pll, GI, PPD, PBI and CPITN were recorded twice with 30-min intervals between scoring (Table 2). Ranges and % ranges of conventional indices were used to obtain descriptive correlations of CPITN with the other indices. Results % distribution of CPITN scores
The total number of sextants examined was 150 (Table 3). The CPITN score range was from 2-4. There was no sextant with a score of 1 or 0, that is, none of the sextants presented with simple bleeding but without pockets, or was healthy. Score 2 sextants numbered 8 (5%); score 3, 36 (24%);and score 4, 106
(Table 3) showed a PBI range of 1-3. For CPITN score 4, most sextants had a PBI range 0-3, and only 5% had a range of 0-1. Frequency distribution for each levei of CPiTN (Table 4)
(71%). Extreme ranges were as follows: plaque index 0-^3, gingival index 0-3, papilla bleeding index 0-3 and probeable pocket depth 2-12. Conventional indices and the variable PPD ranged from very low to very high for any given CPITN code. Range and % range distribution for each ievel of CPiTN (Table 3)
Plaque index Just over 50% of sextants with CPITN score 2, 3, 4 were in Pll range 1-3, while approximately equal %s of sextants ranged from 0-2, 0-3 and 1-2. Only 1 sextant scoring 4 had a Pll range of 0-1. Gingival index No sextant had a coding of GI 0; most showed a range of 1-2. Papilla bleeding index For CPITN sextants scoring 2, half had a PBI range of 0-2 and half 0-3. Only 3% of sextants with a CPITN scored 3
Table 2. Investigator reproducibility for plaque index (PI), gingival index (GI), probeable pocket depth (PPD), papilla bleeding index (PBI) and community periodontal index of treatment needs (CPITN) Reproducibility
Pll
GI
PPD
PBI
CPITN
number of scores agreenient in scores disagreement in scores reproducibility (%)
246 226 20 92
246 222 24 90
246 222 24 90
246 224 22 91
36 32 4 89
Table 3. Range and % range distribution of each level of CPITN in relation to plaque, gingival and papilla bleeding indices 0-1
0-2
0-3
1-2
1-3
2-3
Plaque index 2 3 4
1 — 1
1
1 6 19
4 18 54
_ 3
12
1 4 12
— -
,3
— — 1
5 22 48
3 10 46
—
4 Papilla bleeding index 2 3 • , 4
:
L/l
CPITN score
Gingival index 2 3
•
4 14 26
4 18 68
8
4
— 1 . •-" "
-
7.
_ • '•
1
655
• • •
-
Table 4 gives the actual frequency distribution (FD) of sites for each level of CPITN and for conventional variables. Plaque index Only 2.5% of sites had a Pll of 0, 33.5% had a score of 1, 47% a score of 2 and 17% a score of 3. There was an approximately even frequency distribution and % of sites with Pll 1 and 2, except for CPITN 4 sextants. Approximately Yj the sites with a CPITN scored 4 had Pll score of 2 and '/3 had a PII score of 1. A minority of sites had Pll 3 and very few Pll 0. Gingival index About 1/2 the sextants with a CPITN score of 2 had a score of GI 2, and 43% a score of 1. In sextants with CPITN scores of 3 and 4, again about 90% of sites had a GI score of 1 or 2. Only 13 sites (0.5%) had a GI score of 0 in sextants with a CPITN score of 4. Papilla bleeding index PBI data indicated a trend towards a smaller % of sites that did not bleed when related to a higher level of CPITN (CPITN 2, 43%, CPITN 3, 40%, CPITN 4, 28%). All these also had a GI score of 0. There were higher %s of bleeding sites with PBI scores of 2 and 3 in sextants with CPITN scores of 4 than in sextants with CPITN scores of 2 or 3. Probeable pocket depth (Fig. 1) The shallowest pocket measured was 2 mm and the deepest 13 mm. There was a clear tendency for a higher % of deeper pockets to occur in CPITN 4 sextants, and similarly for a higher % of shallow pockets to occur in sextants graded 2 or 3. Overall, only about 25% sites had pockets greater than or equal to 6 mm deep. Although 70% of sextants had a CPITN score of 4, only approximately 33% of the sites in CPITN 4 sextants had PPD greater than or equal to 6 mm, and about 48% greater than or equal to 5 mm (Fig. 1). It was observed that 11 % of sites in sextants with CPITN score of 2 had 5 mm pockets, while there were 5 sites
656
Almas ei al.
Table 4. Frequency distribution and % frequency distribution of sites for each index and each level of CPITN Papilla bleeding Gingival index index AT ••" • Plaque index CPITN 1 2 3 0 1 2 3 0 1 2 3 0 (sextants) FD score - 110 125 17 109 65 62 16 7 118 114 13 8 FD 2 - 312 533 100 385 253 249 58 432 182 302 36 FD 29 13 829 1671 310 805 687 995 336 FD 62 928 1360 473 106 4 ' • FD = sites.
with 6 mm pockets and 1 with a 7 mm pocket. For CPITN 3 sextants, the corresponding figures were 13.6% with 5 mm, 4.2% with 6 mm, and 3 sites with 7 mm pockets (Fig. 1). Discussion
In this study, the subjects were from the Periodontal Department of a teaching dental hospital. The majority of the patients were between 40-49 years of age. There was ari equal distribution of female but not of male patients between the ages of 30-39, 40-49, 50-59 years. The standardised pressure (0.25 N) used with the probe tips has been recommended by WHO (1978) for CPITN work. The more parallel-sided and thinner probe, and the constant probing force used, may have aided in the recording of probeable pocket depth. Lower readings obtained with the WHO probe in several instances may have been due to the ball tip contacting an obstruction, for example, calculus. It is therefore possible that the
CPITN probe may underestimate pocket depth. Similarly, there are several possible explanations for the observation of sites with pockets equal to or greater than 4 mm in sextants with CPITN scores of 2 or 3. The probe tip diameter was 0.5 mm for the CPITN probe, but only 0.34 mm for the conventional probe. Calculus may have obstructed the CPITN probe and CPITN probing being a screening process may be more rapid, and therefore less precise than conventional probing. In this study, variables were recorded at the 6 sites around each tooth as recommended by Ainamo & Ainamo (1985) and Aucott et al. (1986). Random selection of 3 sextants per patient was representative of a whole mouth according to Ainamo (1983), calculated on the basis of the 6 Ramfjord (1959) teeth. In another study by Ainamo et al. (1982) in which variables were monitored in relation to 6 surfaces of each tooth,using either (1) all teeth, (2) the 6 Ramfjord teeth, examination of only the latter was found to give a fair-to-
1000-T
n u m b e r
800
600-
CPITN 2 CPITN 3
o f 3
CPITN 4
400-
I t
e s
200
Q JJ
J
—r™"
r
6 6 7 pocket depth in mm
8
Fig. ]. Frequency distribution of sites by CPITN score and PPD.
9-12
13
good estimate of severity and prevalence of supra- and subgingival calculus and of gingival bleeding tendency after gentle pocket probing. While the plaque index enables a rough estimate of the principal (supragingival) causative factor, calculus recording would have enabled more accurate correlation with sites in sextants coded CPITN 2. Proportions of sites affected, with ranges of the given variables, were used for descriptive analysis, since proportions may be used for both quantitative and quahtative variables. In other studies, the results have been obtained through determination of the mean of the scores of all teeth (Russell 1956) or of the selected index teeth (Ramfjord 1959) of the individual, and then by calculating the mean of all individualmeans within the study population. Such data have been very useful for comparison of chronic infiammatory periodontal disease levels in different parts of the world. Mean severity scores, however, give no information about the actual proportion of individuals affected within the population. From the range distribution of conventional indices in relation to CPITN, it is obvious, regardless of CPITN scores, that there was supragingival plaque present from extremely low to extremely high levels, and that CPITN did not relate to the amount of plaque present. Papilla bleeding index and GI, particularly the former, also gave the same extreme ranges irrespective of the CPITN code. As regards probeable pocket depth, the shallowest pocket recorded was 2 mm and the deepest 12 mm. As 2 mm pockets were observed regardless of CPITN code, it may be that the index is not helpful in identifying shallower pockets, but the fact that the higher the code, the deeper the extreme pocket depth, would indicate some direct correlation of CPITN with probeable pocket depth (Fig. 1). Because the majority of sextants (about 50%), whether CPITN 2, 3 or 4, had a PII range of 1-3, it would seem that there is little relationship between supragingival plaque level as represented by PII and CPITN code.It was noted that out of a total of 150 sextants, only 2 had PII scores of 0-1, even though there was a 6-point recording around each tooth. As only one of these had a CPITN score of 2 and the other a CPITN score of 4, it again indicates little guidance from CPITN as to level
CPITN and conventional indiees of supragingivalplaque. For the gingival index, it was observed that there was no sextant with a GI score of 0-1, again regardless of CPITN code, and that nearly all the sextants were in the GI ranges of 1-2 and 1-3. This shows again, that, irrespective of CPITN code, the sextant could have had mild, moderate or severe gingival inflammation. However, none of the sextants with a CPITN code of 2 had a GI range of 2-3 and none of those with a CPITN score of 2 or 3 had GI ranges of 0-2 or 0-3. Similarly only a small % of sextants with a CPITN code of 4 had a GI range of 0-3. This too indicates no direct relation of GI to CPITN score. From the range and % range distribution of each level of papilla bleeding index compared with CPITN, it is obvious that the majority ofthe sextants had corresponding PBI ranges of 0-2 and 0-3, suggesting a poor correlation with the CPITN code. While it might have been expected that range 0-1 would be associated with sextants with CPITN codes 1 or 2, in fact only sextants with CPITN codes of 3 or 4 (8 in total) were in this PBI range. However, some slight relation of CPITN to PBI might be considered on the basis of PBI ranges 1-3 • having been observed only in sextants coded CPITN 3 (1 sextant) and 4 (7 sextants). The frequency distribution of sites for each level of PlI compared with each level of CPITN indicates that the majority of sites were in the range of PlI 1-2, with a very small number of sites with PlI scores 0 and 3. This suggests that, irrespective of the CPITN code, there is approximately the same % distribution of sites, particularly for PlI scores 0, 1 and 2. Plainly, CPITN code does not indicate a direct relation to the amount of plaque or numbers of sites affected. There was a similar pattern noted for site distribution as regards gingival index, also indicating a lack of relation between CPITN code and GI, including number of sites affected. There is no clear explanation for the finding that the only sites with a GI score of 0 had a CPITN score of 4, but this also indicates the lack of association of CPITN and GI. The finding of increasing numbers of sites affected with increasing PBI, and vice versa would suggest a direct association with CPITN code. Clearly, there was a tendency for iower PPD to be associated with lower CPITN and vice versa, and for increas-
657
ing numbers of deeper pockets to be previously, they noted a direct correassociated with increasing CPITN code, lation with all three. showing, therefore, an obvious direct association beteen CPITN and PPD Conclusions (Fig. 1). There has recently been an increasing NNO direct associations were found beadoption of CPITN as an epidemio- tween CPITN and plaque index or ginlogical index.Although the clinical gival index. rationale behind the recommended There appeared to be an association basic criteria, and parfial recording pro- between CPITN and papilla bleeding cedure explains its ready acceptance, it index, and between CPITN and PPD. is necessary that the advantages of the Comparison of CPITN score with the index be identified (Cutress et al. 1986). plaque index and the gingival index Several epidemiological studies have gives no indication as to numbers of been carried out using CPITN or PTNS sites affected in a sextant by a given (Bellini & Gjermo 1973, Christensen et level of plaque or inflammation, as indial. 1983, Markhanen et al. 1983, cated by PlI and GI. Croxson 1984, Ishikawa et al. 1984, AiComparison of CPITN score with namo et al. 1986, Barmes & Leous 1986, PBI and PPD indicated that there was Brauer et al. 1986, Manji & Sheiham a tendency for a greater number of sites 1986, Pilot et al. 1986, Tervonen & Ain- in a sextant to be affected by more amo 1986, Garcia & Cutress 1986, bleeding and deeper pockets as repreBrown et al. 1987, Pilot et al. 1987, Siv- sented by these indices, the higher the aneswaran & Barnard 1987). All these CPITN code. studies have evaluated treatment needs From the above conclusions, it would for populations. Thus, most ofthe work seem that CPITN is a poor guide to has been carried out after acceptance gingivitis, but a good indicator of the of the CPITN as a screening index for irreversible stage of CIPD, chronic treatment need, and it has been proved periodontitis, as represented by PBI and to be useful for epidemiological pur- PPD, at least in a hospital periodontal poses and for treatment needs and man- population without unusual forms of power planning. Few studies have com- periodontitis, and which may, therefore, pared CPITN with other, conventional have had a relatively even distribution indices for the assessment of CPID. In of lesions, representative of the usual Japan, Watanabe et al. (1984) compared "horizontal" pattern of bone loss asCPITN and conventional indices, in- sociated with routine chronic adult cluding the gingival bleeding index periodontitis. (GBI), probing depth and furcation inIn spite of these positive findings, exvolvement. They showed a significant tremes of ranges of all indices may be correlation between CPITN and prob- observed in a sextant, regardless of ing depth and GBI. There was a direct CPITN code. Low levels of inflamcorrelation of CPITN code with increas- mation, plaque, pocketing, and bleeding ing PPD and this correlation has also may be observed in sites of sextants been suggested by the present study. Cu- coded 4, and high levels of plaque, tress et al. (1986) compared periodontal bleeding and inflammation and ocindex and CPITN as epidemiological casional early pockets may be observed screening procedures. The CPITN index in sextants of lower code. was assessed on the basis of only 10 While CPITN is a guide, there is no teeth while all teeth were assessed for substitute for site recording of data for PI. They used a WHO 621 probe for accurate periodontal diagnosis and CPITN, and a PI examination was car- specifically for treatment planning. Ignoring the above might lead to ovried out with the aid of a mouth mirror. er-treatment of code 4 sextants and failAlthough the findings cannot be ure to diagnose with accompanying incompared directly with those of the adequate treatment of code 2 sextants. present study, they noted that for assessment of periodontol conditions and treatment needs, the CPITN was to be Zusammenfassung preferred to the PI. Only Watanabe et al. (1984) appear Die Beurteilung des parodontalen Status mit dem CPITN und konventlonellen, parodontato have compared CPITN with conven- len Indizes tional indices, namely GBI, PPD and In dieser Studie with der CPITN (Communifurcation involvement, and, as stated ty Periodontal Index of Treatment Needs) mit
658
Almas et al.
dem Plaqueindex (Pll), dem Gingivalindex (GI), dem Papillenblutungsindex (PBI) und der sondierbaren Taschentiefe (PPD) verglichen, Untersucht wurden 52 Patienten mit einem Altersdurchschnitt von 43 Jahren, Mit der CPITN-Methode wurde an 150 Sextanten eine partielle Erhebung iiber die oralen Verhaltnisse (an 2 oberen oder 1 oberen und 2 unteren Sextanten) durchgefuhrt, Mit einer druckempfmdiichen Sonde mit der Newmanspitze und Markierungen nach Williams und einer WHO 621 Spitze wurden 6 Stellen eines jeden Zahnes der Sextanten bei einem Sondierungsdruck von 0.25 N sondiert. Die Variationsbreiten eines jeden Index wurden mit den entsprechenden CPITN-Werten verglichen. Bei den meisten Sextanten (71%) lagen CPITN-scores in einer Hohe von 4 vor, was Parodontitis bedeutet. Eine Beurteilungseinheit (score) von 0 oder 1 wurde in keinem Sextanten registriert, Man fand einen bestimmten CPITN-Kode, der die Extremwerte der Variationsbreiten aller anderen untersuchten Indizes darstellte. Zwischen dem CPITN und dem Pll und GI bestand weder eine Beziehung noch gab der CPITN die Anzahl befallener Stellen pro Sextant wieder es lag aber eine Tendenz zur Beziehung zwischen CPITN und PBI sowie PPD vor. Man folgerte, dass der CPITN als allgemeiner Indikator fijr das Zahnfleischbluten und die Taschentiefe gelten kann, nicht hingegen fiJr die Plaque oder die Gingivitis, Es bedarf anderer Indizes, um den Stand der chronischentziindlichen Parodontalkrankheit in einem Munde verlasslich zu beurteilen. Resume Evaluation de I'etat parodontal avec les indices CPITN et converitionels
Cette etude a compare I'indice parodontal communautaire des besoins en traitement (CPITN) avec I'indice de plaque (Pll), I'indice gingival (GI), I'indice de saignement papillaire (PBI) et la profondeur de poche au sondage (PPD), Cinquante-deux patients, d'un age moyen de 43 ans, ont ete examines, Un enregistrement partiel a ete effectue au hasard, soit au niveau d'un sextant superieur et de deux inferieurs soit au niveau de deux sextants superieurs et un inferieur, par CPITN au niveau de 150 sextants, L'examen utiiisant les autres indices ont ete menes au niveau de six sites autour de chaque dent de chaque sextant a l'aide d'une sonde sensible a la pression, avec une pointe de Newman et les marquages de Williams, et une pointe OMS 621, en utiiisant une pression de 0,25 N. La repartition de chaque indice a ete comparee aux donnees CPITN correspondantes. La plupart des sextants (71%) avaient des scores CPITN de 4, indiquant la presence de parodontite, alors qu'aucun n'avait de score 0 ou 1. Un code CPITN donne representait les extremes de la repartition de tous les autres indices evalues. II n'y avait aucune relation entre le CPITN et le Pll ou le GI. De plus le CPITN n'indiquait pas le nombre de sites atteints par sextant, Cependant Ie CPITN semblait
quelque peu en relation avec le PBI et le PPD, Le CPITN peut done etre utilise comme indicateur general de saignement et de profondeur de poche mais pas de plaque ou de gingivite. D'autres indices sont necessaires pour estimer de maniere sure le niveau de la maladie parodontale inflammatoire chronique dans une bouche donnee.
and need for periodontal treatment in a representative sample of 35-44 year olds in Copenhagen. In: Public Health Aspects of Periodontal Disease in Europe, ed. Frandsen, A,, Berlin. Quintessence pp, 47-57. Croxson, L, J. (1984) A simplified periodontal screening examination: the Community Periodontal Index of Treatment Needs (WHO) in general practice. InternaReferences tional Dental Journal 34, 28-34. Ainamo, J,, Barmes, D., Beagrie, G,, Cutress, Cutress, T. W, Ainamo, J, & Sardo-Infirri, T, Martin, J. & Sardo-Infirri, J. (1982) J. (1987) The Community Periodontal InDevelopment of the World Health Organdex of Treatment Needs (CPITN) proization (WHO) community periodontal incedure for population groups and individdex of treatment needs (CPITN), Internauals. International Dental Journal 37, tional Dental Journal 32, 281-291, 222-223. Ainamo, J. (1983) Assessment of periodontal Garcia, M. L. & Cutress, T W. (1986) A treatment needs: Adaptation of the WHO national survey of periodontal treatment Community Periodontal Index of Treatneeds of the adults in Philippines. Comment Needs (CPITN) to European conmunity Dentistry and Oral Epidemiology ditions. In: Public Health Aspects of Perio14, 313-316. dontal Disease in Europe, ed. Frandsen, A,, Gjermo, P. B,, Bellini, J, T. & Marcos, B, Berlin. Quintessenz, pp, 35-45, (1983). Application of the community Ainamo, J., Norblad, A, & Kallio, P (1984) periodontal needs in a population of young Use of CPITN in populations under 20 Brazilians, Community Dentistry and Oral years of age. International Dental Journal Epidemiology 11, 342-346. 34, 285-291, Ishikawa, L, Honma, S., Hagiwara, S,, Asai, Ainamo, J, & Ainamo, A. (1985) Partial indiH,, Osada, Y., Ixumi, Y., Watanabe, J,, ces as indicators for severity and prevaIsumizawa, K, & Noguchi, T. (1984) Epilence of periodontal disease. International demiological survey on periodontal disease Dental Journal 35, 322-326, in the employees of two banks with Ainamo, J,, Tervonen, T & Ainamo, A, CPITN, Journal Japan Association of (1986) CPITN assessment of periodontal Periodontologists lf>, 161-11%. treatment needs among adults in OstroLife, J, S. C, & Smales, F, C, (1987) An bothinia, Finland, Community Dental investigation into the ability of CPITN to Healths, 153-161, indicate appropriate basic periodontal Ainamo, J,, Tervonen, T, Norblad, A. & Kaltherapy for individual patients. Journal of lio, P, (1987) Use of CPITN cross-tabuDental Research 66, (abstr, 30), 904, lations - a research perspective. InternaLoe, H, & Silness, J. (1963) Periodontal distional Dental Journal 37, 173-178, ease in pregnancy (1). Prevalence and sevAucott, D, M. & Ashley, F, P (1986) Assesserity, Acta Odontologica Scandinavica 21, ment of the WHO partial recording ap533-563, proach in identification of individuals Manji, F & Sheihan, A, (1986) CPITN findhighly susceptible to periodontitis. Comings and the manpower implications of munity Dentistry and Oral Epidemiology periodontal treatment needs for Kenyan 14, 152-155, children. Community Dental Health 3, Barmes,D, E. & Leous, P A. (1986) Assess143-151, ment of periodontal status by CPITN and Markkanen, J,, Rajala, M, & Paunio, K, its applicability to the development of (1983) Periodontal treatment need of the longerm goals on periodontal health of the Finnish population aged 30 years and over. population. International Dental Journal Community Dentistry and Oral Epidemi36, 177-181, ology 11, 25-32. Bellini, H, T, & Gjermo, P (1973) Application Muhlemann, H. R, (1977) Psychological and of the Periodontal Treatment Need system chemical mediators of gingival health. (PTNS) in a group of Norwegian industrial Journal Preventive Dentistry 4, 6-16, employees. Community Dentistry and Oral Pilot, T, & Barmes, D, E, (1987) An update Epidemiology 1, 22-29, on periodontal conditions in adults, measBrauer, L,, Bessermann, M., Frijs Madsen, ured by CPITN, International Dental JourB. & Brauer, E. (1986) Oral health status nal, 169-172, and needs for dental treatment in geriatric Pilot, T., Barmes, D, E,, Leclercq, M, H., patients in a Danish district hospital. ComMcCombie, B. J. & Sardo-Infirri, J. (1986) munity Dentistry and Oral Epidemiology Periodontal conditions in adults, 35-44 14, 132-135. years of age; an overview of CPITN data Brown, E, H., Edwards, J. L. & Spears, G, F, in the WHO Global Oral Data Bank. ComS, (1987) Periodontal and tooth treatment munity Dentistry and Oral Epidemiology needs in dentate elderly people in Dunedin. 14, 310-312. New Zealand Dental Journal 83, 42-45. Pilot, T., Effendi, I., Sunu, N. P, Wibowo, Christensen, J., Skougaard, M. R. & Stoltze D. J., Rihatinah, R. & Lima,Y, S, (1987) (1983) Prevalence of periodontal disease Periodontal profiles in different regions in
CPITN and conventional indices Indonesia. Journal of Dental Researeh 66, (abstr. 14), 958. Ramfjord, S. P. (1959) Indices for prevalence and indices of periodontal disease. Journal of Periodontology 30, 51-59. Reich, E., Schmalz, G. & Reith, A. (1986) Vergleich des CPITN mit gebrauchlichen Parodontalindizes. Deutsehes Zahndrztliches Zeitung 41, 610-612. Russell, A. L. (1956) A systemof classification and scoring for prevalence surveys of periodontal disease. Journal of Dental Researeh 35, 350-359. Silness, J. & Loe, H. (1964) Periodontal dis-
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Watanabe, U., Hayashi, J., Wakao, N. & Kamoi, K. (1984) Epidemiological surveys of periodontal disease (Report 3). Comparison between CPITN and conventional methods. Journal of the Japanese Association of Periodontology 26, 532-541. Address:
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H. N. Newman "' " "' ' ' ' ""'" '-'"'I Department of Periodontology Institute of Dental Surgery . 'f'..,^ •''"'•. C} 256 Gray's Inn Road '..' ; ' -.' i London WCIX 8LD UK
