1.

5 Assessment of oral
health status

1.5.1 Standard forms

Suitable standardized forms for recording clinical oral health assessments as
described in this manual are provided in Annex 1 (for adults) and Annex 2
(for children). The assessment form for children only includes the variables
relevant to young individuals. Survey planners needing to record the dentition
status by tooth surface can use the special forms designed for this purpose
(see Annex 3 and Annex 4). Investigators should arrange to have copies
reproduced locally.
A simplified assessment form for recording common oral manifestations of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is provided in Annex 5. The investigator is advised to
consult the WHO publication Guide for epidemiological studies of oral manifestations of HIV infection (17), available at who.int/oral_health. The publication includes information on practical planning and implementation of
surveys on oral lesions related to HIV/AIDS. The conditions considered
essential to record are fungal infections, bacterial infections, viral infections
and neoplasms.
Annex 6 illustrates the major oral conditions relevant to a standard oral
health survey. The conditions shown in Plates 171 may be helpful in differential diagnosis of lesions, increasing accuracy of coding during the
examination.

1.5.2 Standard codes

Standard codes must be used for all sections of the form(s). If this requirement is not observed, WHO will be unable to make recommendations for
processing the data and summarizing the results. If some of the oral health
assessments are not carried out, or are not applicable to the age group being
examined, the unused sections of the form should be cancelled with a diagonal
line, or by using code 9 in the appropriate box (= not recorded).
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Fig. 3. Clear writing prevents confusion between numbers and alphabets that
resemble each other (see text).

The forms are designed to facilitate computer processing of the observations. Each box is given an identification number (the small number in parentheses), which represents a location in a computer file. Recording codes are
shown near the appropriate boxes. To minimize the number of errors, all
entries must be clear and unambiguous. Confusing similarities in entries commonly occur while writing 1 and 7, 2 and 4, 6 and 0, and B and 8. To avoid
confusion and erroneous entries that create problems for computing processing and consequently inaccurate results, numerals should be written out
clearly (Fig. 3).
Again, clear enunciation is essential when calling out scores to recorders
to differentiate unmistakably between similar sounding codes, e.g. eight and
A. Examiners can dictate codes using common words in the local language,
for example, in English, one can use Alpha, Beta, Coast, Day, Gamma, Fire
and X-ray instead of A, B, C, D, G, F, X to facilitate clear understanding on
the part of the recording clerk.
The two-digit numbers above or below some of the boxes indicate specific
teeth according to the tooth notation system developed by WHO and FDI
(previously called Fdration Dentaire Internationale, now World Dental Federation) (18). The first digit indicates the quadrant of the mouth the tooth is
in and the second digit the actual tooth (Fig. 4). In designating a tooth, the
examiner should call the quadrant number and then the tooth number, e.g.
the upper right second incisor (12) is called out as one-two rather than
twelve; the lower left third molar (38) should be called out as three-eight
rather than thirty-eight.

1.5.3

Oral health assessment form

The standard oral health assessment form for adults (Annex 1) includes the
following sections:
identification information
survey
general
extraoralinformation
conditions

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Fig. 4. WHO/FDI tooth notation used for coding of teeth: (a) permanent tooth
notation and (b) primary tooth notation.

status (crown, root)

dentition
periodontal
status
loss of attachment
enamel fluorosis
dental erosion
dental trauma
oral mucosal lesions
denture status (fixed or removable dentures)
intervention urgency and need for referral
notes.

The corresponding standard oral health assessment form for children

(Annex 2) includes the following sections:
survey identification information
general information
dentition status
gingival status
enamel fluorosis
dental erosion
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dental trauma
oral mucosal lesions
intervention urgency.
With regard to oral mucosal lesions, if the sample consists only of children,
a decision may be made to record only those lesions that are frequently
observed in children rather than all the lesions that may occur in adults. It is
strongly recommended that the appropriate form is used when surveying
children or adults.

1.5.4

Identification and general information sections

During planning of the survey, a list of examination sites and a list of the
examiners who will be involved in the study should be made, and a code assigned to each examiner. The coding list should also include the numeric
codes to be used for other relevant information such as the fluoride content
of drinking water or use of fluoride supplements. The investigator should write
the name of the country in which the survey is being conducted in capital
letters on the original assessment form before making additional copies. Boxes
14 on the form are reserved for the WHO code for the country in which the
survey will be carried out and should not be filled in by the investigator.
Essential information includes year, month and day of examination (Boxes
510). The identification number is the unique identifier for the individual
person under examination (Boxes 1114); codes are also given to indicate
whether the examination is the original or duplicate examination (Box 15)
and by the individual examiner responsible for the examination (Boxes 16
and 17).
In the general information section, the following points are recorded: the
name (write-in response if permissible to record), sex (Box 18), date of birth
(Boxes 1924), age (Boxes 25 and 26), ethnic group (Boxes 27 and 28), other
group (Boxes 29 and 30), years attended school (Boxes 31 and 32), occupation (Box 33), geographical location/community (Boxes 34 and 35), type of
location (Box 36), and other survey specific data (Boxes 3742). Findings
from the extra-oral examination are recorded in Boxes 43 and 44.
Date of examination (Boxes 510)
The year, month and day should be recorded on the form at the time of
examination. Recording the day enables an investigator to refer back to examinations held on any particular day which may need to be reviewed or checked.
Identification number (Boxes 1114)
Each subject examined should be given an identification number. This number
should always have the same number of digits as the total number of subjects
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to be examined. Thus, if it is intended to examine 1200 subjects, the first

subject should be numbered 0001.
If possible, the identification numbers should be entered on the forms
before commencing the examinations for the day, because it is important to
ensure that each identification number is used only once. Cross-checking is
necessary when more than one examiner is participating in a survey. If a total
of 1200 subjects are to be surveyed by two examiners, examiner 1 should use
the numbers 00010600 and examiner 2 should use 06011200.
Original or duplication examination (Box 15)
If the subject will be re-examined to assess reproducibility, the first (original)
examination is scored 1 and any subsequent, duplication examinations are
coded 2, 3, 4, etc. in Box 15. For all subjects for whom duplicate
examinations have been made, data from the first examination only are
included in the survey analysis. To assess intra-examiner reproducibility, the
first (original) examination is coded 1 and the second examination performed by the same examiner is coded 2. When the findings of the survey
are analysed, the level of intra-examiner reproducibility, denoted by the percentage of agreement and the kappa statistic, can be calculated and reported.
It is important that the method selected is clearly explained to avoid misinterpretations in data entry.
Examiner (Boxes 16 and 17)
If more than one examiner is participating in the survey, each examiner should
be assigned a specific code, which should be entered in Boxes 16 and 17. If
a validating examiner is participating in the survey, he or she should also be
assigned a specific code.
Name
The name of the subject may be written in block letters, beginning with the
family name. It should be noted that, in some countries, identification of
survey subjects by name is not permitted, in which case this space should be
left blank.
Sex (Box 18)
This information should be recorded at the time of examination because it is
not always possible to tell a persons sex from the name alone (which may or
may not be recorded). The relevant code (1 = male, 2 = female) is entered in
Box 18.
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Date of birth (Boxes 1924)

Where possible, the year (Boxes 19 and 20), month (Boxes 21 and 22),
and day of birth (Boxes 23 and 24) should be entered for cross-checking
purposes.
Age (Boxes 25 and 26)
Age should be recorded as age at last birthday (e.g. a child in the thirteenth
year of life is 12 years old). If the age is less than 10 years, enter 0 in Box
25 (e.g. 6 years is coded as 06). In communities where age is expressed in
different terms, a conversion must be made. If the age of the subject is not
known, it may be necessary to make an estimate on the basis of, for instance,
status of tooth eruption or, for adults, major life events or occasions in the
community. Where age has been estimated, the manner of estimation should
be reported.
Ethnic group (Boxes 27 and 28)
In different countries, ethnic and other groups are identified in different ways,
by area or country of origin, race, colour, language, religion or tribal membership. Local health and education authorities should be consulted before
making a decision about the relevant ethnic group classification/coding scheme
to be used.
More than 10 ethnic groups may officially exist in a country; therefore a
two-digit entry code should be used. Since it is often not possible to identify
a persons ethnic origin from their name alone, ethnic group information must
be recorded at the time of the examination from information provided by the
subject/parent. In some countries, information on ethnicity may be obtained
from government agencies or school administrative data at the time of sample
selection.
Other group (Boxes 29 and 30)
Codes may be used to identify different subpopulation groups.
Number of years in school (Boxes 31 and 32)
This information is useful for assessment of the level of education, which is
important factor in the analysis of oral health. In children, the boxes may be
used for recording the school grade achieved by a child (Annex 2).
Occupation (Box 33)
A coding system should be devised according to local usage to identify different occupations and the appropriate code entered.
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Community geographical location (Boxes 34 and 35)

In these surveys, using codes to identify schools as part of the survey is important since the information obtained on oral health status can be used for
planning strategies applicable to specific age groups in a particular school.
Once the schools have been selected, the codes can be designated.
Boxes 34 and 35 should be used to record the site where the examination
is being conducted. This allows geographical locations (villages etc.) to be
identified (0198). A list giving each location and its code number should
be prepared. Usually just a few codes are needed. The code 99 should be
entered if this information is not recorded.
Community information is very useful for health administrators for planning or revising programmes or strategies. If samples of drinking water are
collected during the survey, the name of the community will be essential in
mapping of fluoride in drinking water supplies and determining whether the
concentration is below, at or above optimal levels.

Location type (Box 36)

The rationale for including these data is to obtain general information about
local environmental conditions and the availability of services at each site.
Three codes are used:
1. Urban site.
2. Periurban area: this has been included in order to indicate areas surrounding major towns that may have characteristics similar to those of
rural areas, with very few health facilities of any kind and usually with
no or limited access to oral health-care facilities.
3. Rural area or small village.

Other data (Boxes 3742)

Fields are provided for entering a two-digit code for up to three conditions
or data to be recorded. Conditions and codes must be agreed prior to commencing the survey. These fields have been provided for recording other
information about the subjects examined or the survey location. Information
such as exposure to a specific oral health programme, use of tobacco or
chewing sticks, refugee status, socioeconomic status, physical environment,
and level of fluoride in drinking water can be recorded here; if sugar intake
was of interest, a coding system could be designed by the investigator whereby
the amount and frequency of intake were given suitable codes.
Additionally, two boxes are reserved for recording any abnormality identified by the examiner during extra-oral examination of the oro-facial complex.
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1.5.5 Clinical examination (Boxes 43 and 44)

The oral cavity is part of the orofacial complex and examiners should record
any evident abnormality of the tissues of the face, nose, cheek or chin. The
condition and its location are recorded using the following recommended
codes:
Condition (Box 43)
0
1
2
3
4
5
6
9

= Normal
= Ulceration, sores
= Erosions
= Fissures
= Cancrum oris
= Enlarged lymph nodes
= Any other abnormalities
= Not recorded

Location (Box 44)

1
2
3
4
5
6
7
8

= Face
= Neck
= Nose
= Cheeks
= Chin
= Commissures
= Vermillion border
= Jaws

1.5.5.1

Dentition status

(Boxes 45108 in the Oral Health Assessment Form for Adults and 4572 in the
Oral Health Assessment Form for Children)
The examination for dental caries should be conducted with a plane mouth
mirror. The use of radiography for detection of approximal caries is not recommended because the equipment is impractical to utilize in most field situations. Likewise, the use of fibreoptics is not recommended. Although it is
recognized that both these diagnostic aids reduce the underestimation of
dental caries, logistical complications and frequent objections on the part of
subjects to exposure to radiation outweigh any potential gains.
Examiners should adopt a systematic approach to the assessment of the
dentition status, bearing the following points in mind:
examination should proceed in an orderly manner from one tooth
the
or tooth space to the adjacent tooth or tooth space;
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should be considered present in the mouth when any part of it

ais tooth
visible
a permanent and primary tooth occupy the same tooth space, the
ifstatus
of the permanent tooth only should be recorded.
Permanent dentition status (crown and roots) is recorded using numbered
scores and the primary dentition status is recorded using letter scores (Table
2) in the same boxes. Boxes 4576 are used for upper teeth and Boxes 77108
for lower teeth. The corresponding boxes for the Oral Health Assessment
Form for Children are Boxes 4558 and 5972.
An entry must be made in every box pertaining to the coronal and root
status of a tooth (Annex 1). In children, root status is not assessed; therefore
the corresponding boxes have been omitted in the Oral Health Assessment
Form for Children (Annex 2).
Considerable care should be taken to identify tooth-coloured fillings,
which may be extremely difficult to detect.

Table 2. Coding the dentition status primary and permanent teeth

Code
Primary
teeth

Condition/status

Permanent
teeth

Crown

Crown

Root

Sound

Caries

Filled, with caries

Filled, no caries

Missing due to caries

Missing for any other reason

Fissure sealant

Fixed dental prosthesis abutment, special

crown or veneer/implant

Unerupted tooth (crown)/unexposed root

Not recorded
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The criteria for diagnosing a tooth status and the coding are as follows
(codes applied to primary teeth are given in parentheses):
0 (A) Sound crown. A crown is coded as sound if it shows no evidence of
treated or untreated clinical caries (see Plate 1, code A, and Plate 6,
code 0). The stages of caries that precede cavitation, as well as other
conditions similar to the early stages of caries, are excluded because
they cannot be reliably identified in most field conditions in which
epidemiological surveys are conducted. Thus, a crown with the following defects, in the absence of other positive criteria, should be coded
as sound (see Plates 7 and 8):
or chalky spots; discoloured or rough spots that are not soft
towhite
touch with a metal CPI probe;
stained enamel pits or fissures that do not have visible cavitation or
softening
of the floor or walls detectable with a CPI probe;
dark,
shiny,
pitted areas of enamel in a tooth showing signs of
moderate tohard,
severe enamel fluorosis;
lesions that, on the basis of their distribution or history, or on exami nation,
appear to be due to abrasion.
Sound root. A root is recorded as sound when it is exposed and shows
no evidence of treated or untreated clinical caries (see Plate 9).
1 (B) Carious crown. Caries is recorded as present when a lesion in a pit or
fissure, or on a smooth tooth surface, has an unmistakable cavity,
undermined enamel, or a detectably softened floor or wall (see Plates
24 Primary dentition, and Plates 1012 Permanent dentition). A tooth
with a temporary filling, or one which is sealed but also decayed, should
also be included in this category. In cases where the crown has been
destroyed by caries and only the root is left, the caries is judged to have
originated in the crown and is therefore scored as crown caries only.
The CPI probe should be used to confirm visual evidence of caries on
the tooth surface(s). Where any doubt exists, caries should not be
recorded as present.
Carious root. Caries is recorded as present when a lesion feels soft or
leathery on probing with the CPI probe. If the carious lesion on the
root does not involve the crown, it should be recorded as root caries.
For single carious lesions affecting both the crown and the root, the
likely site of origin of the lesion should be recorded as the decayed site.
When it is not possible to identify the site of origin, both the crown
and the root should be coded as decayed. In general, root caries is not
recorded for children and in youth or young adults.
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2 (C) Filled crown, with caries. A crown is considered filled, with decay, when
it has one or more permanent restorations and one or more areas that
are decayed. No distinction is made between primary and secondary
caries and the same code applies regardless of whether the carious
lesions are in contact with the restoration(s) (see Plates 13 and 14).
Filled root, with caries. A root is considered filled, with caries, when it
has one or more permanent restorations and one or more areas that
are decayed. No distinction is made between primary and secondary
caries. In the case of restorations involving both the crown and the root,
identification of the site of origin is more difficult. For any restoration
involving both the crown and the root with secondary caries, the most
likely site of the primary carious lesion is recorded as filled, with decay.
When it is not possible to identify the site of origin of the primary
carious lesion, both the crown and the root should be coded as filled,
with caries.
3 (D) Filled crown, with no caries. A crown is considered filled, without caries,
when one or more permanent restorations are present and there is no
caries anywhere on the crown (see Plates 5 and 15). A tooth that has
been crowned because of previous decay is recorded in this category.
A tooth that has been crowned for reasons other than caries by means
of a fixed dental prosthesis abutment is coded 7 (G).
Filled root, with no caries. A root is considered filled, without caries, when
one or more permanent restorations are present and there is no caries
anywhere on the root. In the case of fillings involving both the crown
and the root, identification of the site of origin is more difficult. For
any restoration involving both the crown and the root, the most likely
site of the primary carious lesion is recorded as filled. When it is not
possible to identify the site of origin, both the crown and the root
should be coded as filled.
4 (E) Missing tooth, due to caries. This code is used for permanent or primary
teeth that have been extracted because of caries and are recorded under
coronal status (see Plates 16 and 17). For missing primary teeth, this
score should be used only if the subject is at an age when normal
exfoliation would not be a sufficient explanation for absence.
Note: The root status of a tooth that has been scored as missing because
of caries should be coded 7 or 9.
In some age groups, it may be difficult to distinguish between unerupted
teeth (code 8) and missing teeth (codes 4 or 5). Basic knowledge of tooth
eruption patterns, the appearance of the alveolar ridge in the area of the tooth
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space in question, and the caries status of other teeth in the mouth may
provide helpful clues in making in deciding whether a tooth is unerupted or
has been extracted. Code 4 should not be used for teeth deemed to be missing
for any reason other than caries. For convenience, in fully edentulous arches,
a single 4 should be placed in Boxes 45 and 60; and 7792, as appropriate,
and the respective pairs of numbers linked with straight lines. Such procedure
may also be applied where the record form for registration at tooth surface
level is used (Annex 3 and Annex 4).
5 () Permanent tooth missing due to any other reason. This code is used for
permanent teeth deemed to be absent congenitally, or extracted for
orthodontic reasons or because of periodontal disease, trauma, etc. (see
Plate 18). As for code 4, two entries of code 5 can be linked by a line
in cases of fully edentulous arches.
Note: The root status of a tooth scored 5 should be coded 7 or 9.
6 (F) Fissure sealant. This code is used for teeth in which a fissure sealant has
been placed on the occlusal surface, in pits or for teeth in which the
occlusal fissure has been enlarged with a rounded or flame-shaped
bur, and a composite material placed (see Plate 19). If a tooth with a
sealant has caries, it should be coded as 1 or B.
7 (G) Fixed dental prosthesis abutment, special crown or veneer. This code is used
under coronal status to indicate that a tooth forms part of a fixed bridge
abutment. This code can also be used for crowns placed for reasons
other than caries and for veneers or laminates covering the labial
surface of a tooth, on which there is no evidence of caries or a restoration (see Plate 20).
Note: Missing teeth replaced by fixed partial denture pontics are coded 4
or 5 under coronal status, while root status is scored 9.
Implant. This code is used under root status to indicate that an implant
has been placed as an abutment.
8 () Unerupted tooth (crown). This classification is restricted to permanent
teeth and used only for a tooth space with an unerupted permanent
tooth but no primary tooth. Teeth scored as unerupted are excluded
from all calculations concerning dental caries (see Plate 1 (incisors)
and Plate 21). This category does not include congenitally missing
teeth, or teeth lost as a result of trauma etc. For differential diagnosis
between missing and unerupted teeth, see code 5.
Unexposed root. This code indicates that the root surface is not exposed;
there is no gingival recession beyond the cement-enamel junction
(CEJ).
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9 () Not recorded. This code is used for an erupted permanent tooth that
cannot be examined for any reason such as orthodontic bands, severe
hypoplasia, etc.
This code is used under root status to indicate either that the tooth has
been extracted or that calculus is present to such an extent that root examination is not possible.
Dental caries indices: tooth (DMFT, dmft) and surface levels (DMFS,
dmfs)
Information on the Decayed, Missing and Filled Teeth Index (DMFT)
can be derived directly from the data in Boxes 4576 and 77108 (Annex 1).
The D component includes all teeth with codes 1 or 2. The M component
comprises teeth coded 4 in subjects under 30 years of age, and teeth coded
4 or 5 in subjects 30 years and older, i.e. missing due to caries or for any
other reason. The F component includes teeth only with code 3. The basis
for DMFT calculations is 32 teeth, i.e. all permanent teeth including
wisdom teeth. Teeth coded 6 (fissure sealant) or 7 (fixed dental prosthesis/
bridge abutment, special crown or veneer/implant) are not included in
calculations of the DMFT index. In the case of the primary teeth, the
calculation of the dmft index is similar, i.e. by deriving information
from data codes A, B, C and D and E in the oral health assessment form
(Annex 2).
When a survey is undertaken for a particular purpose, e.g. evaluation of a
disease prevention programme, planners may wish to record dentition status
by tooth surface and to calculate the DMFS and dmfs indices. Record forms
for this purpose are available in Annex 3 (for adults) and Annex 4 (for
children).
A DFT index applicable to roots can easily be calculated as data for each
tooth are collected during examination; this index is especially relevant in
older population groups.

1.5.5.2

Periodontal status: Community Periodontal Index (CPI) modified

Two indicators of periodontal status are used for this assessment: gingival
bleeding and periodontal pockets. A specially designed, lightweight CPI metallic probe with a 0.5-mm ball tip is used, with a black band between 3.5 and
5.5 mm, and rings at 8.5 and 11.5 mm from the ball tip (Fig. 5) (19). All
teeth present in the mouth are examined for absence or presence of gingival
bleeding and absence or presence of periodontal pockets; pocket depth is
measured with the WHO CPI periodontal probe.
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11.5 mm
3.0 mm
8.5 mm
3.0 mm
5.5 mm
2.0 mm
3.5 mm

3.5 mm

5.5 mm

0.5 mm

Fig. 5. The WHO Community Periodontal Index probe recommended for clinical
examination.

Assessing for gingival bleeding and measuring periodontal pockets

Gingivae of all teeth present in the mouth should be examined by carefully
inserting the tip of the WHO CPI probe between the gingiva and the tooth
to assess absence or presence of bleeding response (Fig. 6). The sensing force
used should be no more than 20 g. A practical test for establishing this force
is to ask examiners to place the probe point under their thumbnail and press
until blanching occurs. Alternatively, examiners can use a mirror and insert
the probe into the gingival sulcus of their own anterior teeth using the lightest
possible force that will allow movement of the probe ball tip along the tooth
surface. These exercises should be conducted as part of the training when
examiners are calibrated for reliability and consistency.
When the probe is inserted, the ball tip should follow the anatomical configuration of the surface of the tooth root. If the subject being examined feels
pain during probing, this is indicative of the use of too much force. The probe
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Fig. 6. Coding of periodontal status consistent to the modi ed Community Periodontal Index (CPI modi ed), showing the correct positioning of the WHO CPI
probe.

tip should be inserted gently into the gingival sulcus or pocket and the full
extent of the sulcus or pocket explored. For example, place the probe in the
pocket at the distobuccal surface of the second molar, as close as possible to
the contact point with the third molar, keeping the probe parallel to the long
axis of the tooth. Move the probe gently, with short upward and downward
movements, along the buccal sulcus or pocket, to the mesial surface of the
second molar. A similar procedure is carried out for lingual surfaces, starting
on the distolingual aspect of the second molar.
All teeth present should be probed and scored in the corresponding box.
Periodontal pockets are not recorded in individuals younger than 15 years of
age. The codes for scoring bleeding and pocketing are given below.
Gingival bleeding scores
(Boxes 109124 and 141156 in the Oral Health Assessment Form for Adults;
Boxes 7386 and 87100 in the Oral Health Assessment Form for Children)
0 = Absence of condition (see Plate 22, adult).
1 = Presence of condition (see Plate 23 child; Plate 24 adolescent; Plate
25 adult).
9 = Tooth excluded (see Plate 28, Tooth 16).
X = Tooth not present (see Plates 16 and 17, posterior areas in adults).
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Pocket scores
(Boxes 125140 and 157172)
0 = Absence of condition (see Plate 22).
1 = Pocket 45 mm (see Plate 26).
2 = Pocket 6 mm or more (see Plate 27).
9 = Tooth excluded (see Plate 28, Tooth 16).
X = Tooth not present (see Plates 16 and 17, posterior regions).
1.5.5.3 Loss of attachment (Boxes 173178 Oral Health Assessment Form
for Adults)
Information on loss of attachment may be collected from the index teeth (Fig.
7). The CPI system is designed to obtain an estimate of the lifetime accumulated destruction of the periodontal attachment and thereby permits comparisons between population groups. It is not designed to describe the full extent
of loss of attachment in an individual. Loss of attachment is recorded by
dividing the mouth in sextants, defined by tooth numbers: 1814, 1323,
2428, 3834, 3343, and 4448. The most reliable method of examination
for loss of attachment in each sextant is to record this immediately after
recording the gingival status and pocket scores. As mentioned above, loss of
attachment should not be recorded for individuals under the age of 15.
Index teeth.
The index teeth, which are the teeth to be examined, are shown in Figure 7.
The two molars in each posterior sextant are paired for recording and, if
one is missing, there is no replacement. If no index tooth is present in a sextant
qualifying for examination, all the teeth that are present in that sextant are
examined and the highest score is recorded as the score for the sextant.

Fig. 7. The index teeth for recording loss of attachment in subjects aged 15 and
over.
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Fig. 8. Examples of coding for loss of attachment with a WHO CPI

probe (4).

The extent of loss of attachment is recorded using the CPI probe and
applying the following codes (Fig. 8):
0 = 03 mm
1 = 45 mm (CEJ within black band) (see Plate 26)
2 = 68 mm (CEJ between upper limit of black band and 8.5 mm ring)
3 = 911 mm (CEJ between 8.5 mm and 11.5 mm ring)
4 = 12 mm or more (CEJ beyond 11.5 mm ring) (see Plate 28, tooth 16)
X = Excluded sextant
9 = Not recorded
1.5.5.4

Enamel fluorosis

(Box 179 in the Oral Health Assessment Form for Adults; Box 101 in the Oral
Health Assessment Form for Children)
Fluorotic lesions are usually bilaterally symmetrical and tend to show a
horizontal striated pattern across the tooth. The premolars and second molars
are most frequently affected, followed by the maxillary incisors. The mandibular incisors are least affected.
The examiner should note the distribution pattern of any defects, using
Deans index criteria (20), and make a decision as to whether they are typical
of fluorosis. Defects falling into the questionable to mild categories the
conditions most likely to be encountered may consist of fine white lines or
patches and tend to fade into the surrounding enamel. To facilitate differentiating fluorosis lesions from other opacities not related to fluoride, it is
important to remember that fluorosis lesions are usually observed near the
edges of incisors or cusp tips; however, depending on severity, the lesions may
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be readily apparent on other areas of the tooth and be readily visible in premolars and molars. Non-fluoride related opacities can be localized to the centre
of the smooth surface, although they can affect the entire crown. Fluorosis
lesions generally appear as fine lines, frosted in appearance and non-fluoride
opacities appear round or oval in shape. Fluorosis lesions also can be more
easily observed with the light directed in a tangential direction whereas nonfluoride opacities can be easily observed with the light directed perpendicularly to the tooth surface.
Coding is done on the basis of the two most severely affected teeth. If the
two teeth are not equally severely affected, the score is based on the appearance of the less affected tooth. When the teeth are scored, the examiner should
start at the higher end of the index, severe, and eliminate each score until
he or she arrives at the condition present. If there is any doubt, the lower score
should be given.
The codes and criteria are as follows:
0 = Normal. Enamel surface is smooth, glossy and usually a pale creamywhite colour (see Plate 29)
1 = Questionable. The enamel shows slight aberrations in the translucent
normal enamel and which may range from a few white flecks to occasional spots (see Plates 3033)
2 = Very mild. Small, opaque, paper-white areas scattered irregularly over
the tooth but involving less than 25% of the labial tooth surface (see
Plates 34 and 35)
3 = Mild. White opacities of the enamel involving more than 25% (see
Code 2) but less than 50% of the tooth surface (see Plates 36 and 37)
4 = Moderate. The enamel surfaces show marked wear, and brown staining
is frequently a disfiguring feature (see Plates 38 and 39)
5 = Severe. The enamel surfaces are severely affected and the hypoplasia
is so marked that the general form of the tooth may be affected. There
are pitted or worn areas and brown stains are widespread; the teeth
often have a corroded appearance (see Plates 40 and 41)
8 = Excluded (e.g. a crowned tooth)
9 = Not recorded

1.5.5.5

Dental erosion

(Boxes 180182 in the Oral Health Assessment Form for Adults; Boxes 102104 in
the Oral Health Assessment Form for Children)
Data on prevalence, severity and number of teeth affected by dental
erosion would assist public health administrators in estimating whether this
condition is a public health problem. Dental erosion results from the progressive loss of calcified dental tissue by chemical processes not associated with
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Assessment of oral health status

bacterial action. Enamel tissue is lost by exposure to acids which may come
from dietary sources or may be intrinsic, i.e. in individuals suffering from
bulimia, gastro-oesophageal reflux or heavy alcohol consumption and chronic
vomit.
The following codes 13 are used where the crown of a tooth shows an
erosion lesion at different levels:
0
1
2
3

=
=
=
=

No sign of erosion (see Plate 42)

Enamel lesion (see Plate 43)
Dentinal lesion (see Plate 43, 44 and 46)
Pulp involvement (see Plates 4446)

Severity of dental erosion is recorded according to the tooth with the

highest score of erosion. In addition, the number of teeth involved is recorded.
1.5.5.6 Traumatic dental injuries
(Boxes 183185 in the Oral Health Assessment Form for Adults; Boxes 105107 in
the Oral Health Assessment form for Children)
Teeth affected by dental trauma are coded as follows:
0
1
2
3
4
5
6
9

= No sign of injury
= Treated injury
= Enamel fracture only (Plate 47)
= Enamel and dentine fracture (Plate 48)
= Pulp involvement (Plate 49)
= Missing tooth due to trauma (Plate 50)
= Other damage
= Excluded tooth

In addition to the degree/status of trauma, the severity of dental trauma

can be measured in terms of the number of teeth involved.
1.5.5.7

Oral mucosal lesions

(Boxes 186191 in the Oral Health Assessment Form for Adults; Boxes 108113 in
the Oral Health Assessment Form for Children)
The oral mucosa and soft tissues in and around the mouth should be
examined in every subject. The examination should be thorough and systematic, and performed in the following sequence:
1. labial mucosa and labial sulci (upper and lower)
2. labial part of the commissures and buccal mucosa (right and left)
3. tongue (dorsal and ventral surfaces, margins)
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4. floor of the mouth

5. hard and soft palate
6. alveolar ridges/gingiva (upper and lower).
Either two plane mouth mirrors or one mirror and the handle of the periodontal probe can be used to retract the tissues. Boxes 186188 (108110 in
children) should be used to record the absence, presence, or suspected presence
of the conditions coded 17. Examiners should be alert to, and can make a
tentative diagnosis for, these conditions during clinical examination. Code 8
should be used to record a condition not mentioned in the list; for example,
hairy leukoplakia or Kaposi sarcoma. Whenever possible, the tentative diagnosis should be specified in the space provided, for up to three conditions.
The following codes apply for adults:
0
1
2
3
4
5
6
7
8

=
=
=
=
=
=
=
=
=

No abnormal condition
Malignant tumour (oral cancer) (see Plate 51)
Leukoplakia (see Plate 52)
Lichen planus (see Plate 53)
Ulceration (aphthous, herpetic, traumatic) (see Plates 5457)
Acute necrotizing ulcerative gingivitis (ANUG; see Plate 58)
Candidiasis (see Plates 59 and 60)
Abscess (see Plates 61 and 62).
Other condition (specify if possible) (e.g. keratosis, see Plate 63; and
Koplick spots, see Plate 64)
9 = Not recorded
Recording of leukoplakia and lichen planus is not considered important in
children.
In addition, all the main locations of the oral mucosal lesion should be
recorded in Boxes 189191 for adults and Boxes 111113 for children, as
follows:
0
1
2
3
4
5
6
7
8
9

= Vermillion border
= Commissures
= Lips
= Sulci
= Buccal mucosa
= Floor of the mouth
= Tongue
= Hard and/or soft palate
= Alveolar ridges/gingiva
= Not recorded

For example, if an adult subject has leukoplakia on both the buccal mucosa
and the commissures, the coding would be done as shown in Figure 9.
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Assessment of oral health status

Fig. 9. Coding for leukoplakia in two main locations.

Fig. 10. Coding for more than two oral lesions.

Similarly, where an adult subject has oral cancer on the commissures and
the lower lip, and candidiasis on the tongue, the coding should be done as
shown in Figure 10.
1.5.5.8

Denture status

(Boxes 192 and 193 in the Oral Health Assessment Form for Adults)
The presence of removable dentures should be recorded for each jaw (Box
192, upper jaw; Box 193, lower jaw). The codes are as follows:
0
1
2
9

=
=
=
=

1.5.5.9

No denture
Partial denture
Complete denture
Not recorded
Intervention urgency

(Box 194 in the Oral Health Assessment Form for Adults; Box 114 in the Oral
Health Assessment Form for Children)
It is the responsibility of the examiner or team leader to ensure that referral
to an appropriate health-care facility is made, if needed. There is a need for
immediate care if pain, infection or serious illness is present or is likely to
occur unless treatment is provided within a certain period of time. This period
may vary from a few days to a month, depending on the availability of oral
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Oral Health Surveys Basic Methods

health services. Examples of conditions that require immediate attention are

periapical abscess and ANUG. Advanced dental caries and chronic alveolar
abscesses may also be recorded in this box. A life-threatening condition (oral
cancer or precancerous lesions) or any other severe condition that is a clear
oral manifestation of a systemic disease should have been recorded in the oral
mucosa section and a code should also be entered in Box 194 in the form for
adults or in Box 114 in the form for children.
The following intervention urgency codes are recommended:
0
1
2
3

=
=
=
=

No treatment needed (see Plate 65)

Preventive or routine treatment needed (see Plate 66)
Prompt treatment including scaling needed (see Plate 67)
Immediate (urgent) treatment needed due to pain or infection of
dental and/or oral origin (see Plates 6870)
4 = Referred for comprehensive evaluation or medical/dental treatment
(systemic condition) (see Plate 71)

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Annex 6

Dentition status

Plate 2
Plate 1

Plate 4
Plate 3

Explanatory notes
Plate 1

Plate 2
Plate 3
Plate 4

Plate 5
Plate 5

Code A: sound primary

dentition; Code 8: unerupted
maxillary incisors; and Code
0: sound first permanent
molars
Code B: caries primary
dentition
Code B: caries teeth 52,
51, 61 and 62
Code B: caries teeth 51
and 61; code D: filled no
caries tooth 64
Code D: filled with no caries
teeth 75 and 85

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Plate 7

Plate 6

Plate 8

Plate 9

Plate 11

Plate 10
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Plate 13

Plate 12

Plate 14

Explanatory notes
Plate 6
Plate 7
Plate
Plate
Plate
Plate
Plate
Plate
Plate

8
9
10
11
12
13
14

Code A and code 0: sound primary and permanent dentitions

Code 0: Sound stained pits or fissures in the enamel that do not have
visual signs of undermined enamel
Code 0: sound crown with dark pitted areas/fluorosis
Code 0: sound root
Code 1: caries permanent dentition
Code 1: caries teeth 22 and 23
Code 1: caries teeth 34 and 35
Code 2: filled with caries tooth 36
Code 1: Caries Tooth 37; Code 3: Filled with no decay Tooth 36

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Plate 16

Plate 15

Plate 17
Plate 18

Plate 19
Plate 20
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Plate 21

Explanatory notes
Plate
Plate
Plate
Plate
Plate
Plate
Plate

15
16
17
18
19
20
21

Code
Code
Code
Code
Code
Code
Code

3: filled with no caries permanent dentition

4: missing due to caries
1: caries; code 4 missing due to dental caries
5: missing due to any other reason
6: fissure sealant
7: special crowns teeth 11 and 21
8: unerupted tooth

Periodontal status

Plate 23
Plate 22

Explanatory notes
Plate 22 Gingival bleeding score 0: absence of condition
Plate 23 Gingival bleeding score 1: presence of condition (child)
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Plate 24

Plate 25

Plate 26

Plate 27

Plate 28

Plate
Plate
Plate
Plate
Plate

24
25
26
27
28

Gingival bleeding score 1: presence of condition (adolescent)

Gingival bleeding score 1: presence of condition (adult)
Pocket depth score 1: 45 mm
Pocket depth score 2: 6 mm or more
Gingival bleeding score 9: excluded tooth 16
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Annex 6

Enamel fluorosis

Plate 30

Plate 29

Plate 32

Plate 31

Plate 33

Plate 34

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Plate 35

Explanatory notes
Plate
Plate
Plate
Plate
Plate
Plate
Plate

29
30
31
32
33
34
35

Code 0: normal/no sign of fluorosis

Score 1: questionable fluorosis
Score 1: questionable fluorosis
Score 1: questionable fluorosis
Score 1: questionable fluorosis
Score 2: very mild fluorosis
Score 2: very mild fluorosis

Plate 36

Plate 37

Plate 38

Plate 39
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Annex 6

Plate 41

Plate 40

Explanatory notes
Plate
Plate
Plate
Plate
Plate
Plate

36
37
38
39
40
41

Score
Score
Score
Score
Score
Score

3: mild fluorosis
3: mild fluorosis
4: moderate fluorosis
4: moderate fluorosis
5: severe fluorosis
5: severe fluorosis

Dental erosion

Plate 42

Plate 43

Plate 44

Plate 45
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Plate 46

Explanatory notes
Plate 42 Code 0: no sign of erosion
Plate 43 Code 1: enamel lesion tooth 11; score 2: dentinal lesion tooth
21
Plate 44 Code 3: pulp involvement teeth 11 and 21
Plate 45 Code 3: pulp involvement teeth 11, 21, 22 and 23
Plate 46 Code 2: dentinal lesion teeth 51 and 52; code 3: pulp involvement
tooth 61

Traumatic dental injuries

Plate 47

Plate 48

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Annex 6

Plate 49

Plate 50

Explanatory notes
Plate
Plate
Plate
Plate

47
48
49
50

Code
Code
Code
Code

2: enamel fracture only teeth 11 and 21

3: enamel and dentine fracture teeth 11 and 21
4: pulp involvement tooth 12
5: missing due to trauma teeth 11, 21 and 22

Oral mucosal lesions

Plate 51

Plate 52

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Plate 53

Plate 54

Plate 55

Plate 56

Explanatory notes
The first code is for the condition and the second for the location.
Plate
Plate
Plate
Plate
Plate
Plate

51
52
53
54
55
56

Code
Code
Code
Code
Code
Code

1
2
3
4
4
4

and
and
and
and
and
and

code
code
code
code
code
code

2: carcinoma of the lip

6: leukoplakia
4: lichen planus
6: aphthae on the tongue
1: recurrent aphthous ulceration
5: recurrent aphthous ulceration

Plate 57

Plate 58
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Annex 6

Plate 59
Plate 60

Plate 62

Plate 61

Plate 63

Plate 64
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Explanatory notes
The first code is for the condition and the second for the location.
Plate
Plate
Plate
Plate
Plate
Plate
Plate
Plate

57
58
59
60
61
62
63
64

Code
Code
Code
Code
Code
Code
Code
Code

4
5
6
6
7
7
8
8

and code 2: herpetic ulceration

and code 8: acute necrotizing ulcerative gingivitis (ANUG)
and code 6: candidiasis
and code 7: candidiasis (thrush)
and code 7: abscess
and code 9: abscess
and code 8: keratosis
and code 6: Koplick spots

Intervention urgency

Plate 66

Plate 65

Plate 68

Plate 67
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Annex 6

Plate 69
Plate 70

Plate 71

Explanatory notes
Plate
Plate
Plate
Plate
Plate
Plate
Plate

65
66
67
68
69
70
71

Code
Code
Code
Code
Code
Code
Code

0: no treatment needed
1: preventive or routine treatment needed (scaling)
2: prompt treatment needed
3: immediate (urgent) treatment needed
3: immediate (urgent) treatment needed
3: immediate (urgent) treatment needed
4: referred for comprehensive evaluation

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Annex 3

World Health Organization

Oral Health Assessment Form
for Adults (by tooth surface), 2013

87

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Annex 3

World Health Organization

Oral Health Assessment Form
for Adults, 2013

88

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Annex 4

World Health Organization

Oral Health Assessment Form for
Children (by tooth surface), 2013

89

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Annex 4

World Health Organization

Oral Health Assessment Form
for Children, 2013

90

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