Assessment of Oral Health Status Using Dental Indices

r
,tr,ECAYED MISSING FILLED (DMF) INDEX
Introduction
Dental caries is one of the major diseases of
mankind. By the age of 25-years-old 95% of
the people in the most population groups
will be affected by dental caries. The dental
caries is widespread. Adversely affects the
total health conditions of the individual
and results is unnecessarily expense and
discomfort if left untreated. Dental caries
can be prevented and most dental public
health programs are concerned about it.
The dental health program administrator
needs to known the patterns of dental
caries occurrence in various communities
or in special groups under his jurisdiction in
order to plan, conduct and evaluate various
activities directed towards prevention and
control of dental caries.
In early twentieth century, measurement
of intensity of dental caries was done by the
proportion of first molars lost dues to dental
caries, and percentage of permanent teeth
affected by dental caries have been used. But
both these methods provided little useful
comparative information and not sensitive.
As early as 1931 Bodeker CF and Bodeker
HWC described a caries index "Bodeker's
Index", which was found to be sensitive
but for complex to use in epidemiological
surveys. Bodeker modified this caries
index later where in addition to counting
the surfaces for decayed, an extra count
was allotted for those surfaces that could
experience multiple caries attacks. But this
also was not used in major epiderniologica.3
studies.
 Clinical Manual for Public Health Dentistry and Practical Record Book
:c:-;::ept of DMF Index
:-:-.e original concept of DMF index was
.::e·.·eloped O\'er 70 years age. The first
:eystematic description of DMF index is
c.Lt1ibuted to Henry Klein, Carrolle. Palmer
ai,d Jl,V Knutson in their studies of dental
caries in Hagerstown, Maryland in 1938.
The first publication presenting DMF index
"·as an article in the public health bulletin
in 1937, entitled "Dental caries in American
Indian children" by Henry Klein and Carroll
E Palmer.
Subsequent to the initial work, many
dental investigators have used the concept,
modified criteria and methods on occasions
or otherwise changed the original classi­
fication system. The experimentation and
modification have made the comparison of
data from surveys by different investigators
difficult and the various modifications pose
a particular problem in the training of public
health dentists to perform a survey examina­
tion.
The approach to measuring caries
by counting the number of teeth in the
mouth visibly affected by caries was used
in a systematic manner by Dean HT and
colleagues in their historic studies of the
dental caries/fluoride relation.
The characteristics of dental caries in
children and young adults can be estimated
from a survey using "DMF Index" such a
survey can provide information on:
• The number of persons affected by
dental caries
• The number of teeth that need treatment
for dental caries
• Proportion of teeth that have been
treated and
• Other statistical data that are useful in
e\·aluating and directing dental health
:=-rogram efforts.
A survey using "DMF Index" can also
provide data useful in assessing the value of
various preventive activities, examples are.
• Fluoridation of public water supplies
• Topical application of fluorides
• Plaque control programs and
• Other preventive programs.
The information can be useful to pro­
fessional groups, the public and governing
bodies in assessing the need for additional
resources and preventive measures needed
in the community.
What Does DMF Index Describe?
The DMF index has received practically
universal acceptance and probably the best
known in all dental indices. DMF index is
the most universally employed index for
measuring dental caries. DMF index is based
on the fact that the dental hard tissues are
not self healing; established caries leaves a
scar of some sort. The tooth either remains
decayed or if treated it is extracted or filled.
The DMF index is therefore an irreversible
index, used to measure past and present
lifetime caries experience of a population
with permanent teeth.
Definition
The DMF index is defined as quantitative
expression of a person's lifetime caries
experience in permanent teeth. It describes
numerically the results of dental caries
attacks on permanent teeth of a population
group. An average DMF score expresses
the mean caries prevalence in a group of
individuals. DMF can therefore be defined
as irreversible index on a ratio scale. The
DMF score for any individual can range
from O to 32 in whole numbers. DMF value
for a group studies in an epidemiological
survey constitute the total of the individual
 Assessment of Oral Health Status Using Dental Indices
values divided by the number of subjects
examined, so the DMF group score can have
decimal values.
In permanent dentition, the upper
case letters for permanent teeth are used to
designate the DMF index. (The symbol "D"
refers to the number of teeth present with
unrestored carious lesions). The symbol "M"
refers to the number of teeth that are missing
(extracted) due to caries. The symbol "F"
refers to the number of teeth that have been
attacked by caries but have been restored
and are now free from caries.
Thus, the DMF index is the sum of
decayed (D), missing (extracted) because
of caries (M) and filled because of caries (F)
permanent teeth (T) or tooth surfaces (5).
Each tooth or tooth surface is counted only
once, either under DM or F. Thus the DMF
index is expressed as DMFT or DMFS.
The symbol "T" is used to indicate that
unit of count for the index is the number of
permanent teeth affected, rather than the
number of affected surfaces on the tooth or
the number of carious lesions in the mouth.
The symbol "S" is used to indicate that
unit of count for the index is the number
of surfaces affected by carious lesions in
permanent teeth.
Thus, the DMF index can be applied to
whole tooth or to surfaces of teeth.
The DMF can also be used in a "half
mouth fashion" or "shorthand method" of
DMF examination as recommended by WHO
in which apposite diagonal quadrants of the
mouth are examined. Here the objective is to
obtain assessments of caries prevalence in a
population which has not been previously
surveyed. This technique means that half
the upper arch only is scored, then the
contralateral lower half arch and the results
doubled. This is quicker and easier than full
mouth DMF index.
The "DMFf" index is generally expr�E-2'.::
as "the average numb€r of DMF teeth re=­
person" in the population being studied. The
average is usually computed separately for
each'age' and 'sex' grouping since there nm
factors are important in correctly interpreting
the data. As we know for example:
1. The girls acquire their permanent teeth
at a slightly earlier age than boys.
Therefore, we expect a slightly higher
DMF average for girls than boys when
the age is same.
2. We also know that the older the child,
the higher the DMF average. The older
child has more permanent teeth that
are subject to attack by caries and he
also has permanent teeth that have
been vulnerable to a caries attack for
a longer period of time. In addition to
the "average number of DMF teeth"
it is possible to compute a number of
other statistical measures from the
information collected on a DMFT Index
surveys.
Decayed missing filled-surfaces (DMFS) Index
The DMF index is employed to assess
individual surface of each tooth rather than
the teeth as a whole, it is termed as "decayed,
missing filled-surfaces index. (DMFS index).
The "S" symbol is used to indicate that the
unit of count for the index is the number
of surfaces affected by caries in permanent
teeth, rather than the number of affected
permanent teeth.
In studies, in which DMF surfaces are
ascertained, it is necessary to decide hmv
many affected surfaces to assign to teeth tl,at
have been extracted because of caries.
In epidemiological sh,dies or suITeys
for DMFS, it is decided to assign the affected
surfaces, i.e. facial, lingual, mesial, distal and
occlusal to posterior permanent tooth and
 .......

Clinical Manual for Public Health Dentistry and Practical Record Book

:'c:c.a�. !ingual, mesial and distal to anterior The equivalent index for measuring
-;-e::-:nanent tooth, that has been extracted caries in the primary dentition is the "DEF­
::iecause of caries, i.e. U component. In index" described by Gruebbel in 1944
root shunps the D component it is decided in his study. A measurement of dental
to assign 5 affected surfaces to posterior caries prevalence and treatment service for
permanent anterior tooth. deciduous teeth as defined by Gruebbel.
Total surfaces count for DMF(S) = D(S) "D" stands for decayed deciduous teeth.
+ M(S) + F(S) "E" stands for indicated for extraction of
Total surfaces count for DMF(S) index� deciduous teeth.
Total number of surfaces examined, if only "F" stands for filled deciduous teeth
28 teeth are examined (i.e. third molars are because of caries.
excluded). It should be noticed that in DEF index
16 posterior teeth (16 x 5) = 80 surfaces deciduous teeth missing due to caries are
12 anterior teeth (12 x 4) = 48 surfaces not recorded because of difficulty in many
Total number of surfaces examined children of distinguishing between extracted
= 128 surfaces and naturally exfoliated primary teeth. The
Calculation of DMFS index for an DEF index does not take into account teeth
individual: that have been extracted or exfoliated because
Total no. of decayed surfaces= D of past caries experience.
Total no. of missing surfaces = M
Total no. of filled surfaces = F What does "DEF-Index" describe?
Total DMFS of an individual score The DEF index is a variation of DMF index, is
= D(S) + M(S) + F(S) used to measure observable caries experience
In some studies, this number has in primary tooth.
been chosen arbitrarily, e.g. 3 surfaces for
posterior teeth and 2 surfaces for anterior Definition: DEF index is defined as "It is a
teeth. In clinical trials, it has been shown that qualitative expression of the observable
it is best to use an arbitrary number for three caries experience or caries prevalence in
surfaces if a tooth is absent on the baseline the primary dentition. It is the sum of
but, for teeth that are extracted during the number of primary teeth or surfaces that
course of the trial, one should use the number are decayed (D), decayed beyond repair,
of affected surfaces determined at the most i.e. those that need to be extracted (E) and
recently completed examination. filled (F)". WHO, Oral Health Surveys,
Basic Methods, (1971) substitutes "i" for "e"
to designate teeth indicated for extraction.
Mixed Dentition The DEF index differs from the DMF index
Assessment of Caries in Primary Teeth in that primary teeth missing at the time of
"DEF-Index": When a survey is made of the examination are ignored in the former.
a population of children having a mixed Caries indices used for primary dentition
dentition, DEF index is used to describe the DEFT index and DEFS index equivalent to
caries experience of deciduous teeth (pri­ DMFJ and DMFS indices used for permanent
mary dentition). dentition. The DMFT and DMFS indices as

I
 Assessment of Oral Health Status Using Dental Indices
applied to the permanent dentition is always
designated or signified by upper case letter,
i.e. capital letters. The equivalent index for
primary dentition is the DEFT and DEFS is
always designated or signified by lower case
letter, i.e. small letters.
Modification of DEF Index
It should be noticed that in DEF index
deciduous teeth missing due to caries are not
recorded because of the difficulty in many
children of distinguishing between extracted
and naturally exfoliated primary teeth. By
giving due considerations to these two facts,
DEF is modified into:
1. DMFindex
2. DF index.
Decayed missing filled Index
Definition: DMF index is a quantitative ex­
pression of the caries experience or caries
prevalence in the primary teeth. It is the
sum of decayed (d), missing due to caries
(m) and filled (f) because of caries primary
tooth (t), It is DMFT or tooth surfaces (s),
it is DMFS. It is used in the same way as
DMF index. Only those teeth which should
be present according to the subject (patient)
age at the time of examination are assessed
in the missing component. For example, it
may be decided to classify missing decidu­
ous canines and molars as missing (m) only
in children less than nine years of age, be­
cause beyond that age it may be impossi­
ble to determine whether a given missing
tooth has been extracted or has exfoliated.
If all missing primary teeth not replaced by
a permanent successor are considered as
m-teeth regard less of age, an overestima­
tion of the DMFI index results. Therefore,
the DMFT is used for children before age
of exfoliation and DMF applied only to the
primary molar teeth.
DECAYED FILLED (DF) Index
Definition
The DF index is a quantitative expression
of a person's or groups number of decayed
and filled deciduous teeth or tooth surfaces.
When a survey is made of a population
of children having a mixed dentition, "DF
index" is also used to describe the caries
experience of deciduous teeth.
The symbol (d) stands for the number of
deciduous teeth present that are caries and
not restored. The symbol (f) stands for the
number of restored deciduous teeth because
of caries. The missing teeth are ignored. This
is the method of choice of the WHO, Oral
Health Surveys, Basic Methods.
The DF index can be applied to the whole
tooth as the decayed-filled-tooth-DPT
index or to the individuals surfaces as the
decayed-filled-surfaces-DPS index.
When a survey is made of the population
of children between the age groups of 6 to 12
years having a mixed dentition, a DMFT in­
dex or DMFS index used for permanent teeth
along with DFI index and DFSindex to describe
the caries e>..-perience of deciduous teeth.
The average should be computed
separately for each age and sex grouping
for children under 12 years of age. The
DMFT index or DMFS index for permanent
dentition and DFT index or DFS index for
deciduous dentition, the data should be
computed separately to describe caries
experience in permanent and deciduous
teeth respectively.
Close observation shows that DF index
and DMF index should be numerically the
same: DEF index allow for two grades of
caries and neither count missing. Both D\1F
index and DF index may therefore under
state the true extent of the carious attack
and thus lose validity. For comprehens:Ye
purpose, however the greater ,·ariab�:::::
 Clinical Manual for Public Health Dentistry and Practical Record Book
gained by ignoring missing tooth can make
i::>ot.li. indices more useful.
The DMF Classification System
\Vhen a sunrey is made to a population of
children by using DMF and DF indices to
describe the caries experience of permanent
and deciduous teeth, the examination
criteria, coding and tabulating procedures
and methods presented in this clinical
manual and record book may differ in one
or more features from WHO criteria for 3.
caries index (1986). However, the following
considerations are called to the reader's
attention.
1. The examination is performed to
determine the classification of 28 teeth
or tooth surfaces. The third molars
are excluded from the system for two
reasons:
i. In surveys of children under 15 years
of age (the group most commonly
surveyed) the recording of four
additional decisions by the examiner
constitutes little new information,
because the third molars erupt at the
age of between �8 to 25 years.
ii. For surveys of young adults, 15 to
35 years variations in the eruption
pattern and the frequent removal 5.
of the third molars because of
impactions or for other reasons, not
related to caries makes an accurate
classification of the reason for an
absent tooth unlikely. Even careful
questioning of the patient does not
always provide a sound basis for the
dentist to reach a decision.
2. This classification system does not use
a category. "Indicated for extraction"
for teeth that are present in the mouth
but are decayed to the extent that they
are counted as teeth absent because of
caries. Professional opinions can very
widely in the determination of when a
tooth should be extracted, particularly
when a decision is based upon a rapid
visual inspection using a mirror and an
explorer. The numerical value of the
DMF number does not change when
the category is eliminated but the 'M'
component may be less when compared
to data obtained by a different method.
The category, "indicated for extraction"
is not used for deciduous teeth for the
same reasons as described above. The
numerical value of the "DF index",
is identical with the "DEF index",
deciduous teeth affected by caries are
classified into two categories rather
than three.
4. A separate category for a tooth that is
both decayed and filled is not used. It
has been customary. When a separate
"DF" or df" category has been used,
II
to tabulate these teeth with the count of
11
the D 11 or "d" teeth respectively. The
additional statistic describing carious
teeth that have been filled at some
in the post appeared to be of limited
usefulness in most DMF surveys.
A separate category and a code designa­
tion for teeth that should be excluded
from consideration in a study of the
caries experience of a population group
has been included. In other systems of
classification, a special notation is made
on the record from requiring additional
tabulation procedures.
6. The classification system and code
does not include a method of obtaining
statistics on other oral condition that
may be observed during the DMFT
examinations. If statistics on other
 Assessment of Oral Health Status Using Dental Indices
oral conditions are needed, a separate
classification and recording system
should be used.
7. The code designations used in this
classification are numerical designations
selected, because:
i. They are easy to learn
ii. Resemble a word used in the criteria
iii. Easy to tabulate manually or by
punch card
iv. They are also different in sound
when spoken verbally and therefore,
easier for the recorder to hear.
Note: Other types of code designation have
been used or could be used.
Rational for the DMFT Classification
The examiner's task, during the survey
examination is to classify the condition
of each of the 28 tooth spaces for each
patient examined. To arrive at the proper
classification for each tooth space, the
examiner must make:
• Four decisions if a tooth is present or
• Three decisions if a tooth is absent.
The examiner's final decision for each
tooth or tooth space is expressed as a code.
The special rules to be followed in making
decisions and the definition for each category
of the code are included in the next section.
The decision process that forms the basis for
the coding system is expressed schematically
(Figure 4.10).
Examination Criteria and Rule for Coding
Special Rules
1. A tooth is considered erupted when the
occlusal surface or incisal edge is totally
exposed or can be exposed by gently
reflecting any overlying gingival tissue
with the mirror or explorer.
2. A tooth is considered to be present e':e::-.
through the crown has been destro::e..:
and only the roots are left.
3. Supernumerary teeth are not to be
classified, if a primary tooth is retained
and its permanent successor is present,
classify the permanent tooth.
Note: The following points should be noted
clearly for just to make the student to
understand the examination and coding
criteria and to avoid any confusion and doubts
to eliminate the errors in survey procedures.
General Rules
The general rules for examination and coding
criteria are as follows:
1. No tooth or tooth space or tooth surface
should be counted more than once. It
may be either decayed, missing, filled
or sound.
2. The decayed, missing and filled tooth
or tooth surface or tooth space should
be recorded separately since the compo­
nents of DMF index are great interest.
3. A tooth may have several restorations
but it is counted as one filled tooth.
Note: In DMFS index if the tooth shows
fillings on different surfaces, i.e. mesial,
distal and occlusal, lingual (or palatal)
and buccal. The filled tooth surfaces
should be counted separately in DMFS
index.
4. The tooth treated with pit and fissure
sealant and shows carious lesion.
5. Third molars are not included in DMF
index.
6. Naturally exfoliated tooth should not be
taken into considerations.
7. Measurement of caries statu s for
deciduous and permanent teeth should
be recorded separately. The deciduous
teeth are not included in DMF count.