recent advances in dental indices

Recent Advances in Dental Indices

Presented by:Ujwal Gautam

Roll no. 431BDS 4th year (batch

2009)

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

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• A prerequisite for any epidemiological investigation is the ability to quantify the occurrence and severity of the disease.

• Measurement is a process of assigning values to characteristics according to a set of rules. This is facilitated through indices: certain methodology and criteria

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Measuring Diseases

“A numerical value describing the relative status of a population on a graduated scale with definite upper and lower limits, which is designed to permit and facilitate comparison with other populations classified by same criteria and methods.”

-Russell A. L.

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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

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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

Ideal Requisites of an Index(contd)

Statistical measurement of dental caries serves 3 broad purposes:– For epidemiological investigation on characteristics of dental

caries in population groups– For public health programme planning and evaluation– For testing prevention and control procedures

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Measuring Dental Caries

Prevalence of Dental caries is measured in terms of:– percentage of persons affected– Number of teeth attacked– Number of tooth surface involved– Number of discrete cavities– Size and degree of severity of carious lesion

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Shortcomings of DMF Index

• DMF values are not related to the number of teeth at risk. It tends to equate desired state with treated condition

• It assesses only cavitated lesion extended into dentin• DMF index is invalid in elderly population, as teeth can be

lost for reasons other than caries• Reaches saturation level at particular point of time when

all teeth are involved and prevents registration of caries attack even when caries activity is continuing

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Shortcomings of DMF Index(contd)

• Does not give account for treatment needs• DMF index gives equal weight to missing, untreated

decayed and well restored teeth• Cannot be use to assess root caries• Rate of caries progression cannot be assessed

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Inability of D component of DMF score to define treatment needs:

– Criteria used to diagnose caries in a survey are not the same as those used by practitioners in forming patient’s treatment plan

– Patient’s own perceived needs, level of interest in their dental conditions, and ability or willingness to pay all level of treatment

– A practitioner has to judge whether a minor lesion will develop into a major lesion over time, and whether a lesion in primary tooth can safely remain untreated for the life of the tooth. A survey, whereas, scores a tooth by how it appears at the time of the survey.

– Treatment philosophies change with time

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Nyvad Caries Diagnostic Criteria

• Proposed by Nyvad in 1999• Includes manifestation of caries in the initial stages of

the disease, even before a cavity exists.• Differentiates between active and inactive caries

lesions at both the cavitated and non cavitated levels• It also measures the activity of the carious lesion,

favoring the cost–benefit relationship when treatment plans are made.

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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

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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

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• 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

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Significant caries Index (SiC)

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

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advantages

– brings attention to the individuals with the highest caries values in each population under investigation

– It tries to overcome limitation of the mean DMFT value in accurately assessing the skewed distribution of dental caries in a population especially in developed countries leading to incorrect conclusion that the caries situation for the whole population is controlled, while in reality, several individuals still have caries

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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

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• Proposed by Acharya S. in 2006• To develop a reproducible surface-specific caries index

that would provide qualitative and quantitative information about untreated dental caries, that could be used in conjunction with the DMFS index and would provide information on not only the caries prevalence but also the location and type of caries lesion in an individual based on clinical examination

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Specific Caries Index

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Calculating Specific Caries Index

The SCI score for an individual is calculated by adding the individual tooth scoresThe SCI scores for an individual can range from 0 to 192 (for 32 teeth)

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advantages

– the future manpower and material requirements and also the type and level of training of manpower, required to treat the caries in a particular population might be assessed

– The results from authors work showed the reproducibility and validity of this new index to be fair to good

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limitations

– in cases of large lesions, which cover more than one surface, only an assumption can be made regarding the originating lesion

– inability of this index, if used alone, to capture information useful for treatment planning

– lack of provision for assessing root caries– number of proximal lesions be underestimated in

absence of bitewing radiograph

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• Developed in the year 2001 by the effort of large group of researchers, epidemiologists and restorative dentists

• two-digit system; evolved with the need to detect caries at the non cavitated stage

• ICDAS is divided into sections covering – coronal caries (pits and fissures, mesial-distal, and

buccal-lingual),– root caries, and– caries-associated-with-restorations-and-sealants (CARS)

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International Caries Detection and Assessment System (ICDAS)

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

The ‘A’ in ICDAS stands for assessment of the caries process by stage (noncavitated or cavitated) and activity (active or arrested)

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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

2) The second decision that should be made for each tooth surface is the classification of the carious status on an ordinal scale

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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.

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Decision 1


0 = Sound (use with the codes for primary caries)1 = Sealant, partial2 = Sealant, full3 = Tooth colored restoration4 = Amalgam restoration5 = Stainless steel crown6 = Porcelain or gold or PFM crown or veneer7 = Lost or broken restoration8 = Temporary restoration9 = Used for the following conditions

97 = Tooth extracted because of caries (all tooth surfaces will be coded 97)98 = Tooth extracted for reasons other than caries (all tooth surfaces coded 98)99 = Unerupted (all tooth surfaces coded 99)

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Decision 2


0 = Sound1 = 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 dentin4 = Non-cavitated surface with underlying dark shadow from dentin5 = Distinct cavity with visible dentin6 = Extensive distinct cavity with visible dentin. An extensive cavity involves at least half of a tooth surface and possibly reaching the pulp.7 = Tooth extracted because of caries (tooth surfaces will be coded 97)8 = Tooth extracted for reasons other than caries (tooth surfaces will be coded 98)9 = Unerupted (tooth surfaces coded 99)

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E = Excluded root surfaces (no gingival recession)0 = Sound (no caries or restoration)1 = Non-cavitated carious root surface— soft or leathery2 = Non-cavitated carious root surface— hard and glossy3 = Cavitated (greater than 0.5mm in depth) carious root surface— soft or leathery4 = Cavitated (greater than 0.5mm in depth) carious root surface—hard and glossy6 = Extensive cavity: an extensive cavity involves at least half of a tooth surface and possibly reaching the pulp.7 = Filled root with no caries9 = Used for the following conditions

97 = Tooth extracted because of caries (tooth surfaces will be coded 97)98 = Tooth extracted for reasons other than caries (all tooth surfaces coded 98)99 = Unerupted (tooth surfaces coded 99)

Root Caries

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

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Wardrobe concept

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

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limitation

– Root caries assessment criteria has not been tested in any epidemiological or clinical studies

– Data obtained are unpragmatic, non-cohesive and difficult to read

– May lead to overestimation of seriousness of Dental caries– results are difficult to compare against the widely-used

DMF index– Does not assess the very advanced stages of carious lesion

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• Assesses the presence of oral conditions resulting from untreated advance stages of cavitated carious lesions

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PUFA (pulp-ulcer-fistula-abscess) Index

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advantages

– Applicable in low- and middle- income countries as the burden of untreated cavitated lesions leads to serious consequences at tooth and surrounding tissue

– simple to record– can be used for primary and permanent teeth– results can be presented alongside with DMF index

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limitations

– stages of carious lesion progression in enamel are not being assessed

– few subjects with score “u” (ulcer)– assessment of abscess and fistula can be combined into

one code– reliability and validity of this index requires further

discussion and research.


• 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

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Caries Assessment Spectrum and Treatment (CAST) Index

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advantages

– A DMF score can easily be calculated from the CAST score, thereby enabling retention of the use of existing DMF scores

– Used only for epidemiological surveys– Visual/tactile hierarchical one digit coding system– Includes the total spectrum of stages of caries lesion

progression allows for easy communication among health professionals and policymakers

– is built on the strength of the ICDAS, DMF and PUFA indices– provide a link to the widely used DMF index

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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

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• The World Health Organization’s Global Oral Health Programme has recognized the importance of promoting “a new paradigm among dental practitioners, shifting from a restorative to preventive/health promotion model.”

• Developed by FDI Science Committee

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FDI World Dental Federation Caries Matrix

Objective

The intent of this matrix was not to establish a new caries lesion classification system, but to integrate existing systems into a framework that could be used by clinicians, researchers, educators, public health workers and decision makers

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

Separate clinical measures are now being used for gingivitis and periodontitis.

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Measuring Periodontal Disease

requires;

o What depth of Clinical attachment loss(CAL) at any site constitutes evidence of disease processes?

o How many such sites need to be present in a mouth to establish disease presence

o How probing depth and Bleeding on probing are to be included in the case definition

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Even the introduction of computerized, constant-force probes has little difference in the reliability of measurements.

The problems inherent in the clinical measurement have led researchers to look for markers of periodontitis.

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Role of Inflammatory cytokines as markers in measuring periodontitis

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

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Shortcomings of CPITN• The hierarchical principles underlying its use are not

universally valid.• The partial recording approach of the CPITN may grossly

underestimate the prevalence of deep pockets• CPITN yields extensively distorted estimates of the

prevalence and severity of periodontal destruction in a population

• Measuring treatment need has become obsolete as the standard treatment for periodontal pocket has shifted considerably from surgical removal of pockets to scaling and root planing

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• Developed by British Society of Periodontology in 1986• derived from the Community Periodontal Index of Treatment

Needs (CPITN)• simple and rapid screening tool that is used to indicate the

level of examination needed and to provide basic guidance on treatment need

• Not a diagnostic tool

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Basic Periodontal Examination (BPE) Index

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

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

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Etiology of periodontitis is multifactorial and involves infectious components, environmental factors and genetic susceptibility.

Genetic markers denote susceptibility toward disease manifestation and it would be useful to exploit the information hidden into them and to derive a genetic susceptibility index (GSI)

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Genetic Susceptibility Index for Periodontal disease

• shows direct and indirect association between the susceptibility index, selected microbial values and disease presence

• Single nucleotide polymorphisms (SNP’s) in genes encoding molecules of the host defense system are assessed and an association is established between SNP and disease status

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Genetic Susceptibility Index for Periodontal disease

• Introduced in 1992 by American Academy of Periodontology(AAP) and American Dental Association(ADA)

• endorsed by the World Health Organization (WHO)• adaptation of the Community Periodontal Index of

Treatment Needs (CPITN)• used to measure gingival bleeding upon probing, calculus

on a tooth, and periodontal pocket depth in each sextant of the oral cavity

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Periodontal Screening and Recording (PSR) Index

Calculating PSR

• highest score in a sextant is recorded as the PSR score for the sextant.

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

individually

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Score Criteria

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

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

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

3 pocket is 3.5 – 5.5 mm in depth

4 pocket is > 5.5 mm in depth

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

X edentulous sextant

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advantages

– Introducing a simplified screening method that met legal dental recording requirements.

– early detection of periodontal disease and it serves as an aid in monitoring the periodontal status of patients

– fast method to screen patients as only six scores are recorded

– Its documented use also assists with the record keeping of a patient’s periodontal history

– Can be used with a large population during oral health screenings.

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limitations

– not intended to replace a full-mouth periodontal examination. Those patients who have received treatment for periodontal diseases and/or are in a maintenance phase of care should receive comprehensive periodontal examinations

– limited use of the PSR system in children due to inability to differentiate pseudo-pockets

– does not measure epithelial attachment, the severity of periodontal disease may be underestimated with its use

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Measuring Tooth Wear

• The objective of tooth wear indices is to classify and record the severity of tooth wear or dental erosion in prevalence and incidence studies.

• different researchers have developed indices which suit their own research needs but do not allow comparison to assess the prevalence of tooth wear between countries and regions. Therefore, a need of new scoring system is deemed necessary to allow existing and hopefully future indices to be collapsed and re-analysed

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• Developed by Bartlett, Ganss and Lussi in 2007• The aim of the BEWE is to be a simple, reproducible and

transferable scoring system for recording clinical findings and for assisting in the decision-making process for the management of erosive tooth wear that can be used with the diagnostic criteria of all existing indices

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Basic Erosive Wear Examination (BEWE)

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

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

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advantages

– by removing the clear distinction between “enamel loss” and “dentine” exposed, it will not only evade diagnostic uncertainties but will open a broad applicability beyond the clinical situation

– can be used with study models or photographs– particular value in cross-sectional and incidence studies as

well as for the monitoring of individual cases– avoid an overestimate of the problem– as a model to increase awareness

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Measuring Dental Fluorosis

Two distinct groups of indexes have been proposed for measuring dental fluorosis:• Specific fluorosis indexes - specifically measures the fluoride

induced enamel changes in order to reflect increasing severity of fluorosis of lesions

• Descriptive indexes - including all types of defects. These indexes includes all defects of enamel are recorded based solely on descriptive criteria, regardless of causative factors. It is based on the principle that examiner should record what he sees and do not presume the etiology

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Shortcoming of Dean’s Index

• Single score is given to a tooth rather than, a separate score to each tooth surface. Hence differences in the severity of fluorosis in different tooth surfaces cannot be ascertained

• An individual has been classified according to the tooth most affected by fluorosis which may be located in the mouth that has little cosmetic value

• Questionable diagnostic category (score 0.5) in Dean’s Index is difficult to define and interpret precisely

• The distinctions between some of the diagnostic categories in Dean’s system are unclear, imprecise or lack sensitivity.

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• Developed by Thylstrup A. and Fejerskov O. in 1978 to assess the prevalence and severity of dental fluorosis

• It was developed to refine, modify, and extend the original concepts established by Dean. The primary aim was to develop a more sensitive classification system for recording enamel changes associated, with increasing level of fluoride in water

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Thylstrup and Fejerskov Index (TFI)

advantages

– more appropriate than Dean's Index for use in clinical trials or analytical epidemiologic studies

– increased sensitivity because teeth are dried and fluorosis can be identified in its milder forms.

– provides statistical and practical advantages from the possible detection of effects with smaller samples when potential fluoride effects are small, or when the exposure may be widespread

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Thylstrup and Fejerskov Index (TFI)

• Introduced by David G Pendrys in 1990• to permit a more accurate identification of associations

between age-specific exposures to fluoride sources and the development of enamel fluorosis

• developed for use in analytical epidemiologic studies

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Fluorosis Risk Index (FRI)

FRI divides the enamel surfaces of the permanent dentition into two developmentally related groups of surface zones, designated either as

– having begun formation during the first year of life (classification I) or – during the third through sixth years of life (classification II)

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

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Fluorosis Risk Index (FRI)

• Developed by Clarkson J.J. and O’Mullane D.M. in 1989• Access developmental enamel defects without the need

for diagnosing fluorosis before recording enamel opacities• Simple and flexible compared to DDE Index

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Modified Developmental Defects of Dental Enamel Index(modified DDE)

Scoring Criteria

Normal : 0Demarcated opacity : 1Diffuse opacity : 2Hypoplasia : 3Other defects : 4Demarcated and Diffuse : 5Demarcated and Hypoplasia : 6Diffuse and Hypoplasia : 7All three defects : 8

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Modified Developmental Defects of Dental Enamel Index (modified DDE)

Measuring malocclusion

Recording or measuring malocclusion is important for documentation of prevalence and severity of malocclusion in population groups and provide a basis for planning orthodontic treatment.

Methods of recording and measuring malocclusion can be divided as;

QualitativeQuantitative

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• Developed by Richmond and Daniels in 2000• Assess treatment need, complexity, treatment

improvement and outcome based on international orthodontic professional opinion, intended for use in the context of specialist practice

• Intended to use in late mixed dentition onwards• Simple with relatively fewer trait to measure• Quick and takes approximately 1 minute for a case

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Index of Complexity, Outcome and Need (ICON)

Measuring Oral Health-Related Quality of Life

(OHRQoL)

The impact of oral diseases and disorders on aspects of everyday life that a patient or person values, that are of sufficient magnitude, in terms of frequency, severity or duration to affect their experience and perception of their life overallLocker and Allen, 2007

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Although philosophically, it is desirable to measure health rather than disease; in practice the epidemiology concerns with measuring disease as health is difficult to define in operational terms and hence difficult to measure.

Due to limitations in measurements of the levels of dysfunction, discomfort and disability associated with oral disorders, measurement of the social impact of oral disorders seems justifiable.

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

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Why measure health??

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• Paradigm shift – from biomedical to biopsychosocial model of oral health

• Expanded understanding of oral disorders: functional and psychosocial consequences

• Legitimacy of the patients’ perspective –needs for and outcomes of therapy

Involves measurement of:

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

– Changes in OHRQoL as a time effect or in response to treatment and preventive procedures.

To do this we need instruments where the sensitivity to change (responsiveness) is established

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Instruments to measure OHRQoL

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The OHIP-49 is concerned with impairment and three functional status dimensions (social, psychological and physical) which represent four of the seven quality of life dimensions.

The OHIP-14 (Oral Health Impact Profile) comprises 14 items that explore seven dimensions of impact (functional limitation, pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap) and participants respond to each item according to the frequency of impact on a 5-point Likert scale ranging from never to very often (never = 0, hardly ever = 1, occasionally = 2, fairly often = 3, very often = 4), using a twelve-months recall period

The OHQoL-UK consists of a battery of 16 questions, which takes into account both 'effect' and 'impact' of oral health on life quality, incorporating dimensions and an individualised weighting system.

The OIDP (Oral Impacts on Daily Performances) questionnaire assesses the impacts of oral conditions on the abilities of individuals to perform eight daily activities eating, speaking, hygiene, occupational activities, social relations, sleeping-relaxing, smiling, and emotional state; using a severity-based approach

Instruments to measure OHRQoL

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References Peter S., Essentials of Preventive and Community Dentistry, 4/e,

Arya(Medi) Publishing House, 2009 Frencken JE, De Amorim RG, Faber J, Leal SC. The caries assessment

spectrum and treatment (CAST) index rational and development. Int Dent J. 2011;61:117-23.

ICDAS Coordinating Committee (ICDAS CC). Rationale and evidence for the international caries detection and assessment system (ICDAS-II). 2005. Available from: URL: http://www.icdas.org.

Ismail AI, Sohn W, Tellez M, Amaya A, Sen A, Hasson H et al. The International Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries. Community Dent Oral Epidemiol. 2007;35:170-8.

Acharya S. Specific caries index: a new system for describing untreated dental caries experience in developing countries. J Public Health Dent. 2006;66(4):285-7.

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http://www.icdas.org/

Bratthall D. Introducing the Significant Caries Index together with a proposal for a new oral health goal for 12-year-olds. Int Dent J. 2000;50:378-84.

Mehta A. Comprehensive review of caries assessment systems developed over the last decade. RSBO. 2012 jul-sep;9(3):316-21

Nyvad B, Machiulskiene V, Baelum V. Reliability of a new caries diagnostic system differentiating between active and inactive caries lesions. Caries Research. 1999;33:252-260.

Sikri V, Sikri P. Community dentistry. CBS Publishers and Distributors; 1999 Moustakis VS, Laine ML, Koumakis L et al. Modeling genetic susceptibility:

a case study in periodontitis. In: Combi C, Tucker A, editors. Proceedings of IDAMAP-2007: Intelligent Data Analysis in Biomedicine and Pharmacology. Amsterdam, The Netherlands: Artificial Intelligence

Fisher J, Glick M; A new model for caries classification and management- The FDI World Dental Federation Caries Matrix. Journal of American Dental Association. Jun 2012; 143(6):546-51

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References

Dhingra K, Vandana K L; Indices for measuring periodontitis: a literature review. International Dental Journal. 2011; 61:76-84

Burt BA, Eklund SA. Dentistry, Dental practice, and the Community; 5/e; WB Saunders; 2007

Locker D, Conceptual development of “oral health-related quality of life”; PEF Symposium: A critical review of oral health-related quality of life: Where are we now?; Sept 2008

Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997

Agarwal A, Mathur R; An Overview of Orthodontic Indices. World Journal of Dentistry. Jan-Mar 2012; 3(1):77-86

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References

recent advances in dental indices

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