Indices for dental caries

1. INDICES FOR
DENTAL CARIES

2. What is Index?
1. An Index can be 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.
(Russal A. L 1931)

3. • An Index is an expression of clinical
observation in numerical values which is used
to describe the status of the individual or group
with respect to a condition being measured.
(Wilkins Esther M. 1934)

4. Ideal Requisites of an Index
CLARITY The examiner should be able to
remember the rules of the index clearly in
his mind
SIMPLICITY The index should be simple and easy to
apply so that there is no undue time lost
during field examinations
OBJECTIVITY The criteria for the index should be
objective and unambiguous, with
mutually exclusive criteria
VALIDITY The index must measure what it is
intended to measure

5. RELIABILITY The index should measure
consistently at different times and at
variety of conditions
QUANTIFIABILITY The index should be amenable to
statistical analysis.
SENSITIVITY The index should be able to detect
reasonably small shifts, in either
direction in group condition
ACCEPTABILITY The use of index should not be
painful or demeaning to the subject

6. CLASSIFICATION OF INDEX
Depending upon the
directions in which
the scores can
fluctuate
Reversible
Measures the
conditions that can be
changed on subsequent
examination.
Indices for periodontal
conditions
Irreversible
Measures the
conditions that will
not change.
Dental caries index

7. Depending upon the extent to which
areas of oral cavity are measured
• Measures patient’s entire
periodontium or dentition
• Russel’s Periodontal index,
DMFT index etc.
Full
Mouth
• Measures only a representative
sample of dental apparatus
• Greene and Vermillion’s oral
hygiene index-Simplified
Simplified

8. Special Category Indices
Simple
Index
Measures the
presence or
absence of a
condition.
DMFT index,
Silness and Loe
Plaque index
Cumulative
Index
Measures all the
evidence of a
condition, past
and present.
DMF index for
dental caries

9. Various Indices For
Dental Caries

10. YEAR NAME INDEX
1938 Knutson JW, Henry Klein
and Carole Palmer
DMFT/DMFS
index
1944 Gruebbel A.O. Def/dmfs index
1949 Stone H. H, Lawton F. E,
Bransby E. R. & Hartley
H.O
Stone's index
1956 Ponsova Novak and
Matena
Czechoslovakian
Caries Index
1960 Tank Certrude and Storvick
Clara
Caries severity
index

11. YEAR NAME INDEX
1961 Richardson A Caries susceptibility
index
1966 Moller I.J and
Pouslen S
Molers index
1987,
1997,
2013
World Health
Organization
WHO modification of
DMFT Index
(1987,1997, 2013)
1999 Nyvad et al., Nyvad’s System
2000 Bratthall D Significant caries Index
2006 Acharya S. Specific Caries Index

12. YEAR NAME INDEX
2002,2005 Baltimore,
Maryland,
USA
International Caries
Detection and
Assessment System
(ICDAS)
2010 Monse et al Pulpal Ulceration,
Fistula, Abscess Index
(PUFA)
2011 Frencken JE Caries Assessment and
Treatment Instrument
(CAST)

13. HISTORICAL BACKGROUND OF DENTAL
CARIES INDICES
• Bodecker C.F. And Bodecker H.W.C (1931)-
described caries index.
• It was found to be sensitive but too complex for
use in epidemiological surveys.
• Bodecker modified caries index later, with addition
to counting the surfaces decayed an extra count
was allotted for those surfaces that can experience
multiple caries attack.

14. • 1934- Mallanby M
• Described the carious lesions depending
upon the degree of severity and
numerically expressed as:
• Slight caries
• Moderate caries
• Advanced caries

15. DMFT index
• Knutson JW, Henry Klein and Carole Palmer 1938.
• All the 28 teeth are examined
EXCLUSION
Third molars, Un-erupted teeth, Congenitally missing,
Supernumerary
Teeth removed for any other reason than caries
Teeth restored for any other reason other than caries
Primary tooth retained with the permanent successor erupted

16. PRINCIPELS AND RULES
• No tooth is counted more than once.
• D, M or F teeth should be recorded separately
• When counting the decayed teeth, also count
those teeth which have restorations with recurrent
decay
• Care must be taken to list the missing teeth if
missing due to caries

17. • A tooth may have many restorations but is
counted as ONE
• Deciduous teeth are not included
• A tooth is considered to be erupted when the
occlusal surface or incisal edge is totally
exposed or can be exposed be gently reflecting
the gingival tissue

18. CODING FOR DMF /DMFS INDEX
Code Criteria
E Excluded tooth or tooth space
1 Sound permanent tooth
2 Filled permanent tooth
3 Decayed permanent tooth
0 Missing tooth, unerupted, congenitally
missing
X Extracted permanent tooth

19. Calculation of index
• 1:Individual DMFT
• Identify each component separately
• Add each component separately than add all
subgroups.
• Then add them
• D+M+F = DMFT

20. • 2:Group Average
• Total D, M ,F for each individual , then divide
the total DMF by the no of individuals in the
group i.e
Average DMFT= total DMFT
total no of persons

21. LIMITATIONS
• Doesn’t indicate the no of teeth that are at risk
• Can be invalid in older patients because
become lost for the reasons other than caries
• Can be misleading in children because teeth
may be lost for orthodontic reason

22. DMFS
• Applied only to permanent teeth
• D= Decayed teeth surfaces
• M= Missing teeth surfaces
• F= Filled teeth surfaces

23. ADVANTEGES DISADVANTEGES
More sensitive
Takes longer time
May require radiographs
for accurate assessment.

24. SURFACES EXAMINED
• For Posterior Teeth: Five Surfaces
Facial, Lingual, Mesial, Distal and Occlusal
• For Anterior Teeth: Four Surfaces
Facial, Lingual, Mesial, Distal

25. CALCULATIONS
If Third Molars are not included
• Total surfaces for posterior teeth= 80
• Total Surfaces for anterior teeth =48
• Total=128
Rest of the calculations are similar to DMFT
index

26. RECORDING FORMAT FOR
DMFS

27. dmf/dmfs index
• Gruebbel AD 1944 as an equivalent index to
DMF for measuring dental caries in primary
dentition
• d – Indicates the number of deciduous teeth
decayed.
• e – Indicates deciduous teeth extracted due to
caries & indicated for extraction
• f – Indicates restored teeth without recurrent
decay

28. RECORDING CRITERIA FOR dmfs
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75

29. WHO modification of DMFT Index
(1987)
• All third molars were included.
• Temporary restorations are considered as ‘D’.
• Earlier only teeth missing due to caries were
included for its M-component.

30. WHO modification of DMFT Index
(1997)
• WHO stated that for individuals 30 years or
older, M-component should comprise teeth
missing due to caries or any other reason.
• For subjects less than 30 years of age, the M-
component should only include teeth missing
due to caries

31. WHO CODES

33. Stone's index
• Introduced by HH Stone, FE Lawton, ER
Bransby and HO Hartley in 1949
Score Criteria
1 One or more cavities in the same tooth restricted to
enamel
2 One or more cavities in the same tooth with dentin
involvement
3 One or more cavities in the same tooth resulting in a
total destruction of more than a quarter of the crown

34. Czechoslovakian Caries Index
• Ponsova and Matena 1956
• Used to compare experience in one group with
that of other groups with a similar population
density but living in different environments.
• In this index, the ‘variables’ seem to be
controlled.

35. • The average number of teeth or teeth surfaces
and tooth areas and condition of previously
extracted or crowned teeth were considered.
Formula for caries index
= 1- C- Fc-4/5E – 2/3AT
Base
C= Caries
Fc= Filling and Crown
E= Extraction
AT= Anchorage teeth

36. • In case of individual examination the ‘Base’ is
amount of teeth in adult dentition i.e. 32
• In case of collective studies the ‘Base’ is
number of persons examined multiplied by 32.
• Average index value – 0 to 1
• If caries index is 1- higher caries frequency

37. Caries severity index
• Tank Certrude and Storvick Clara in 1960
a. This index was developed to study the depth and extent
of the caries surfaces and the extent of pulpal
involvements.
b.Massier and Schour in 1952 -The progress of the
dental caries in stages was modified and this caries
severity index was developed .
c. This index is used to measure the extent and depth of
decayed surfaces and pulpal involvements based on
clinical and radiographic examinations.

38. Scoring Criteria
Score Criteria
1 Superficial (caries in enamel)
2 Moderate (caries in enamel and superficial dentine)
3 Moderately severe (enamel undermined)
4 Severe (approaching pulp, enamel, collapsed)
5 Pulpitis (caused either by deep seated caries or by trauma without caries)
6 Death of pulp (caused either by deep seated caries or by trauma without
caries)
7 Periapical infection (caused either by deep seated caries or by trauma
without caries)

39. Caries susceptibility index
• Richardson A. in 1961
1. This index is based on Bodecker and Mellanby caries
indices.
2. There are 2 factors involved in measuring caries
susceptibility using the dynamic survey, namely
a) Amount of tooth surface at risk.
b) Amount of caries developing during the period of
observation.
c) B/A= measure of susceptibility

40. Method
• Each tooth is divided into various surfaces, to use one
caries tooth surface as the unit of measurement.
Susceptible surfaces are scored as follows:
• Incisors & Canine - Mesial. Distal. Lingual, labial = 4
• Premolar & Molar- Mesial, Distal, Lingual. Buccal,
Occlusal = 5
148 susceptible surfaces permanent dentition
88 susceptible surfaces deciduous dentition

41. • Each individual examined initially for tooth
surfaces with caries and restored surfaces are
noted.
• Each individual is re-examined after observation
period of 6 months and 12 months.
• New carious lesion on any surface noted,
previously restored surfaces and initiation of
secondary carious lesion checked and noted.
• Number of susceptible surfaces calculated from
initial examination.

42. • Tooth that is caries free and not restored is
considered susceptible.
• Susceptibility ratio (SR)=
No. of caries surfaces developed during period of
observation
No. of susceptible surfaces determined in the first
inspection or initial examination
• Susceptibility Index (SI)= Susceptibility ratio ×100
or
SI=SR ×100

43. MOLLER’S INDEX
• Developed by Moller I.J and Pouslen in 1966.
• Standardized system for diagnosing, recording
and analyzing dental caries.
• Scoring criteria specified for:
• Pit and fissure sealants.
• Smooth surfaces
• Radiographic evaluation and proximal surfaces

44. 0- Pit & fissure caries
sound
Smooth surface caries
sound
Proximal surface
caries Enamel surface
contrains distinct and
unbroken
1- Discoloration &
definite sticking of
probe
White opaque area
with loss of lusture, no
loss of tooth structure
Enamel surface
contour is broken a
shallow between the
enamel and border not
more than ¼ thru the
enamel
2- Definite sticking of
probe with or without
discoloration. No
dentine involvement
Discontinuity of
enamel, dentine not
involved
Shadow has reached
DEJ
3- Definite cavity with
dentine involvement
Dentine involvement A shadow between the
DEJ and a border not
more than half way
thru the dentin

45. • All teeth examined except third molars.
• A tooth is erupted when any part of it projects
through gingiva
• Canine and incisor- 4 surfaces
• Premolars and Molars- 5 surfaces
• For primary examination method same as that
for permanent

46. Scoring Criteria
0 Sound tooth
1 Type 1 caries
2 Type 2 caries
3 Type 3 caries
4 Type 4 caries
5 Filled tooth
6 Missing due to caries
7 Tooth/tooth surface not erupted
8 Tooth missing for reasons other than caries
9 Congenitally missing

47. Nyvad’s System
• Proposed by Nyvad in 1999
• Includes manifestation of caries in the initial
stages of the disease, even before a cavity exists.
• Differentiates between active and inactive caries
lesions at both the cavitated and non cavitated
levels
• It also measures the activity of the carious lesion,
favoring the cost–benefit relationship when
treatment plans are made.

49. Advantages
–Can identify incipient caries lesion, hence can
be used for planning prevention programmes.
–Underestimation of prevalence and severity of
caries with def index can be omitted as it
measures only cavitation state.
–Reduce the need of treatment on a long term
basis because diagnosis of initial lesions can
stop the progression of lesion

50. Limitations
Difficult to make exact diagnosis of precavitated
active lesion over occlusal surface than over
facial surface.
Physiological wear of occlusal surface during
mastication can lead to disappearance of the
lesions

51. Significant caries Index
• Proposed by Bratthall D in 2000
• Using DMF and SiC together helps to
highlight oral health inequalities more
accurately among different population groups
within the community in order to identify the
need for special preventive oral health
interventions

52. Calculating SiC Index
SiC is calculated by sorting individuals according to
their DMFT values, than one third of the population
with the highest caries scores is selected and the
mean DMFT for this subgroup is calculated. This
value is the SiC Index

53. Advantages
– Brings attention to the individuals with the highest
caries values in each population under
investigation
– It tries to overcome limitation of the mean DMFT
value in accurately assessing the distribution of
dental caries in a population especially in
developed countries leading to incorrect
conclusion that the caries situation for the whole
population is controlled, while in reality, several
individuals still have caries

54. Limitations
–It is just an extension of DMF index as it
follows same criteria for assessing dental
caries and will have same limitations in
assessing caries in a population as DMF
index
–More of significance in population where
caries prevalence is low and has a skewed
distribution

55. Specific Caries Index
• Proposed by Acharya S. in 2006
• To developed surface-specific caries index that
would provide information about untreated dental
caries.
• Used in conjunction with the DMFS index and
would provide information on not only the caries
prevalence but also the location and type of caries
lesion in an individual based on clinical
examination

57. Calculating Specific Caries Index
The SCI score for an individual is calculated by
adding the individual tooth scores
The SCI scores for an individual can range from
0 to 192 (for 32 teeth)

58. Limitations
–In cases of large lesions, which cover more
than one surface, only an assumption can be
made regarding the originating lesion
–Lack of provision for assessing root caries
–Number of proximal lesions be
underestimated in absence of bitewing
radiograph

59. • Potlia et al., (2016)
• Compared caries status and the amount of time
taken for caries status evaluation using DMFT,
ICDAS II and CAST index.
• 253dental students were selected randomly and
examined.
• Examination was done by a single calibrated
examiner according to principles of DMFT, ICDAS
II and CAST index.
• Evaluation of teeth status was performed in dry and
wet situations according to codes of the system.

60. • When comparing the indices on the amount of
time taken, it was noticed that CAST Index took
the least time for evaluating a patient followed
by DMFT and ICDAS II respectively and this
difference was statistically significant(p =
0.001).
• Conclusion: CAST, the newer index, amongst
the three is less time consuming and more useful
for investigators in large epidemiological
surveys.

61. • De Souza et al., (2014)
• Conducted a study for assessing caries status
according to the CAST instrument and WHO
criterion in epidemiological studies.
• An epidemiological survey was carried out in
Brazil among 6-11-year-old schoolchildren.
• Time of examinations was recorded.

62. • dmft, dmfs, DMFT and DMFS counts and dental
caries prevalence were obtained according to
the WHO criterion and the CAST instrument, as
well the correlation coefficient between the two
instruments.
• 419 children were examined
• dmft and dmfs counts were 1.92 and 5.31
(CAST), 1.99 and 5.34 (WHO)

63. • Mean time spent on applying CAST and WHO
were 66.3 and 64.7 sec.
• The prevalence of dental caries using CAST
(codes 2, 5-8) and the WHO criterion for the
primary dentition were 63.0% and 65.9%,
respectively, and for the permanent dentition
they were 12.7% and 12.8%, respectively

64. • The CAST instrument provided similar
prevalence of dental caries values and dmf/DMF
counts as the WHO criterion in this age group.
• Time spent on examining children was identical
for both caries assessment methods.
• Presentation of results from use of the CAST
instrument, in comparison to WHO criterion,
allowed a more detailed reporting of stages of
dental caries, which will be useful for oral health
planners.

65. International Caries Detection and
Assessment System (ICDAS)
• Developed in the year 2001 by the effort of
large group of researchers, epidemiologists and
restorative dentists from Baltimore, Maryland,
USA.
• Two -digit system; evolved with the need to
detect caries at the non cavitated stage

66. • ICDAS is divided into sections covering
–coronal caries (pits and fissures, mesial-distal,
and buccal-lingual), root caries, and
–caries-associated-with-restorations-and-
sealants (CARS)

67. The ‘D’ in ICDAS stands for detection of dental caries
by
(i) stage of the carious process;
(ii) topography (pit-and-fissure or smooth
surfaces);
(iii) anatomy (crowns versus roots);
(iv) restoration or sealant status
The ‘A’ in ICDAS stands for assessment of the caries
process by stage (noncavitated or cavitated) and activity
(active or arrested)

68. The detection of dental caries on coronal tooth
surfaces is a two-stage process;
1) The first decision is to classify each tooth
surface on whether it is sound, sealed,
restored, crowned, or missing
1) The second decision that should be made
for each tooth surface is the classification
of the carious status on an ordinal scale

69. ICDAS-I was meant to
include detection (D) of caries
by stage of carious process,
topography and anatomy,
assessment (A) of caries
process (whether cavitated or
non-cavitated and active or
arrested caries). But the
ultimate index included
detection of coronal caries and
the assessment of lesion
activity and root caries were
not included due to lack of
consensus and need for further
discussions.
ICDAS coordinating
committee came up with
ICDAS-II in the year 2009
which describes both coronal
caries and caries associated
with restorations and sealants
(CARS) and root caries. The
advantages of the ICDAS-II is
that it has found to be a valid
and reliable caries assessment
system especially for clinical
trials assessing effectiveness
of caries preventive/ control
agents.

70. Decision 1
• 0 = Sound (use with the codes for primary caries)
• 1 = Sealant, partial
• 2 = Sealant, full
• 3 = Tooth colored restoration
• 4 = Amalgam restoration
• 5 = Stainless steel crown
• 6 = Porcelain or gold or PFM crown or veneer
• 7 = Lost or broken restoration
• 8 = Temporary restoration
• 9 = Used for the following conditions
– 97 = Tooth extracted because of caries
– 98 = Tooth extracted for reasons other than caries
– 99 = Unerupted

71. Decision 2
• 0 = Sound
• 1 = First visual change in enamel (whitespot seen after 5 seconds
air drying).
• 2 = Distinct visual change in enamel (whitespot seen without air
drying).
• 3 = Localized enamel breakdown due to caries with no visible
dentin
• 4 = Non-cavitated surface with underlying dark shadow from
dentin
• 5 = Distinct cavity with visible dentin
• 6 = Extensive distinct cavity with visible dentin. An extensive
cavity involves at least half of a tooth surface and possibly
reaching the pulp.

74. ROOT CARIES
• E = Excluded root surfaces (no gingival recession)
• 0 = Sound (no caries or restoration)
• 1 = Non-cavitated carious root surface— soft or leathery
• 2 = Non-cavitated carious root surface— hard and glossy
• 3 = Cavitated (greater than 0.5mm in depth) carious root surface—
soft or leathery
• 4 = Cavitated (greater than 0.5mm in depth) carious root surface—
hard and glossy
• 6 = Extensive cavity: an extensive cavity involves at least half of a
tooth surface and possibly reaching the pulp.
• 7 = Filled root with no caries
• 9 = Used for the following conditions
– 97 = Tooth extracted because of caries
– 98 = Tooth extracted for reasons other than caries
– 99 = Unerupted

75. Advantages
– Designed to detect 6 stages of carious process
ranging from early clinical changes to extensive
cavitation
– the system meets the requirements of validity and
reliability
– reliable in permanent teeth and acceptable in
primary teeth
– Very suitable for use in clinical trials assessing the
efficacy and/or effectiveness of caries control
agents

76. Limitation
– Root caries assessment criteria has not been tested
in any epidemiological or clinical studies
– May lead to overestimation of seriousness of
Dental caries
– Results are difficult to compare against the widely-
used DMF index
– Does not assess the very advanced stages of
carious lesion

77. Pulpal, Ulceration, Fistula, Abscess
Index (PUFA)
• Jindal M and Khan S in 2012
• Assess the presence of oral conditions resulting from
untreated caries both in primary and permanent
dentition
• Upper case for permanent and lower case for primary
dentition
• Assessment is made visually without any instrument

78. Denotation Criteria
P/p
Pulp exposure is recorded when an opening
of pulp chamber is visible (grossly decayed)
U/u
Ulceration of soft tissue of tongue or mucosa
by sharp edges of dislocated decayed carious
tooth
F/f
Fistula is recorded with pus releasing sinus in
relation to exposed tooth
A/a
Abscess is recorded with pus containing
swelling in relation to exposed tooth

79. Calculation and Interpretation
PUFA/pufa = (filled + sound)* 100 /D+d
Higher scores indicates dental treatment is
neglected either due to lack of knowledge,
facility available, cost and importance of
dentition.

80. Caries Assessment and Treatment
Instrument (CAST)
• Developed by J. E. Frencken, Rodrigo G. de
Amorim, Jorge Faber and Soraya C. Leal in
2011
• Combines elements of the ICDAS II and
PUFA indices, and the M- and F-components
of the DMF index

82. Advantages
– DMF score can easily be calculated from the
CAST score, thereby enabling retention of the use
of existing DMF scores
– Used only for epidemiological surveys
– Visual/tactile hierarchical one digit coding system
– Includes the total spectrum of stages of caries
lesion progression allows for easy communication
among health professionals and policymakers
– is built on the strength of the ICDAS, DMF and
PUFA indices
– provide a link to the widely used DMF index

83. Limitations
–It does not record active and inactive carious
lesions
–It has not been validated, nor has its
reliability been tested
–It is not suggested for use in clinical trials
–it does not provide data on treatment or
preventive measures required for each code

84. References
• "Indices For Dental Caries/ Dental Implant Courses By
Indian Dental Academy". issuu. N.p., 2017. Web. 19
Apr. 2017.
• "Tooth Status - Malmö University". Mah.se. N.p., 2017.
Web. 20 Apr. 2017.
• Soben Peter. Essentials Of Prevention And Community
Dentistry. 5th ed. New Delhi: Arya (Medi), 2004. Print.
• Shiva Kumar, M. S. Muthu. 1st ed. Elsevier India, 2009.
Print.

85. • MARYA, CM. A Textbook Of Public Health
Dentistry. 1st ed. JP Medical Ltd, 2011. Print.
• Potlia et al. Comparison of the caries status using
dmft, icdas ii and cast index system. Int. J. Adv.
Res. 2016; 4(10):364-371
• de Souza et al.: Assessing caries status according
to the CAST instrument and WHO criterion in
epidemiological studies. BMC Oral
Health.2014;14:119.