Healthy Gums Do Matter

Question 1

what are useful tools in assessing oral hygiene and patient compliance

Answer 1

Full mouth plaque (with or without disclosing agents) and bleeding scores are useful tools in assessing oral hygiene and patient compliance

Question 2

what are ramfjord’s teeth

Answer 2

6 index teeth, distributed in order to best reflect the condition of the whole mouth
○ Upper right 6
○ Upper left 1
○ Upper left 4
○ Lower left 6
○ Lower right 1
○ Lower right 4

Question 3

explain the modified plaque score

Answer 3

• Visualisation of plaque on each surface of the tooth and where necessary use of a probe to detect presence of plaque

• Each of the six Ramfjord teeth is split into 3 surfaces
○ Interproximal
○ Buccal
○ Palatal / lingual

• For each surface there are 3 possible scores
○ 2 = visible plaque without use of probe
○ 1 = no visible plaque but a probe skimmed over tooth surface reveals plaque
○ 0 = no plaque

• Scores for each surface should be added to get a total

• This total score is then divided by the maximum plaque score possible for a patient
Ie a score of 2 on all surfaces then this value is 36
This value remains a constant unless a code N is used

Question 4

how do you work out the modified plaque score

Answer 4

1. work out the total score from all the 3 surfaces of each of ramfjord’s teeth (add the scores together)
2. work out the maximum plaque score possible for the patient (most cases it will be 36 [ie a score of 2 on every surface] unless there is a code N)
3. place the patient’s plaque score over the maximum plaque score and multiply by 100 to get your percentage

Question 5

when should the modified plaque score be repeated

Answer 5

at every review appointment to keep records of patient engagement

Question 6

explain the modified bleeding score

Answer 6

• To carry out the modified bleeding score (MBS), each of the 6 Ramfjord’s teeth should have a periodontal probe run gently at 45 degrees around the gingival sulcus in a continuous sweep

○ For up to 30 seconds after probing check for presence or absence of bleeding

○ It is important to not apply pressure at any one particular point and to keep the probe moving at all times

• Each of Ramfjord's teeth is split into 4 surfaces
○ Mesial 
○ Distal
○ Buccal
○ Lingual / palatal

• For each surface there are 2 possible scores
○ 1 = bleeding present
○ 0 = no bleeding

• Scores for each surface should be added to get a total score

• This total score is then divided by the maximum bleeding score possible for a patient
Ie a score of 1 on all surfaces = value is 24
This value of 24 would usually remain a constant unless one of Ramfjord’s teeth are missing

Question 7

what does the modified bleeding score measure

Answer 7

Modified bleeding score measures marginal bleeding rather than bleeding on probing from the base of the pocket

Question 8

what is marginal bleeding

Answer 8

Marginal bleeding reflects how well the patient is able to carry out effective plaque control daily

Question 9

what does bleeding on probing show

Answer 9

Bleeding on probing from the base of the pockets indicates disease activity and periodontal breakdown

Question 10

how do you work out a patient’s modified bleeding score

Answer 10

1. work out the total score from all the 4 surfaces of each of ramfjord’s teeth (add the scores together)
2. work out the maximum bleeding score possible for the patient (most cases it will be 24 [ie a score of 1 on every surface] unless there is a code N)
3. place the patient’s bleeding score over the maximum bleeding score and multiply by 100 to get your percentage

Question 11

when should the modified bleeding score be repeated

Answer 11

at every review appointment so to keep records of patient engagement

Question 12

what do you do if one of ramfjord’s teeth are missing?

Answer 12

if there is an apporpriate alternative tooth than use that tooth for charting
for example if a central incisor is missing then this can be substituted for a lateral incisor or the alternative central incisor

if there is no appropriate alternative tooth then code N is used
for example if the patient is missing all the lower left teeth (5-8) teeth then there is no appropriate substitute so code N is used

Question 13

what happens to the maximum modified plaque / bleeding scores if code N is used for one of ramfjord’s teeth

Answer 13

you need to take away the total number of surfaces that are missing from the maximum score

for example for modified plaque scores, if code N is used to replace one of ramfjord’s teeth then there are 3 surfaces not be recorded and these 3 surfaces have a maximum score of 6 so that is removed from the total of 36

then instead the patient’s score is placed over 30 instead of 36 and multiplied by 100

Question 14

when do you record modfied plaque score and modified bleeding score for patients

Answer 14

Initial plan for implementation at GDH&S
○ Not recorded at initial consultant clinic
○ Subsequently, record at every treatment and review visit

Question 15

where do you record the modified plaque score and the modified bleeding score

Answer 15

there is a plan to have a ‘booklet’ in the patient notes that includes ALL perio charts
This should be kept with the patient’s notes

Question 16

what do the scores mean

Answer 16

Indication of patient engagement (These should not be used in isolation as other patient factors must be considered)

The threshold levels for an engaging patient have been validated as follows:
○ Less than 30% plaque score and
○ Less than 35% bleeding score or
○ Greater than 50% improvement in both

Question 17

what is the accurate threshold score for assesing patient engagement based on MPS

Answer 17

The modified plaque score has a sensitivity of 66.10% and specificity of 100% when compared against the Full Mouth Plaque Index at 30% level for patient engagement for both

A modified plaque score of 30% has therefore been deemed the most accurate threshold score for assessing patient engagement

Question 18

what is the accurate threshold score for assessing patient engagement based on MBS

Answer 18

The modified bleeding score has sensitivity of 100% and specificity of 95% at 35% levels for patient engagement when compared to 30% levels for full mouth bleeding score

Therefore, a modified bleeding score of 35% would be most appropriate as a threshold for site specific repeated root surface instrumentation

Question 19

what is the difference for an engaging patient and a non-engaging patient

Answer 19

An engaging patient should receive site specific repeated root surface instrumentation - or more advanced treatment - as necessary

A non-engaging patient is usually not suitable for site specific repeated root surface instrumentation - or more advanced treatment - this should be communicated to the patient, barriers to engagement identified, and consideration of further treatment options may include delay in further RSI until there is sufficient engagement
These patients would continue to receive ‘supportive care’ with further oral health education, motivation and behaviour change

Question 20

why are these threshold scores higher than those published elsewhere

Answer 20

These scores have been set higher than the accepted standard for 2 main reasons:

i. Partial mouth recording systems tend to under estimate disease
ii. Site specific repeated root surface has not been carried out yet

Question 21

why can some engaging patient’s not be able to achieve plaque and bleeding scores below 30% and 35%?

Answer 21

Some patients will not be able to achieve these levels of oral hygiene and plaque control due to factors such as manual dexterity, mental health problems, etc
It should be noted that these patients may in fact be ‘engaging’ patients, who are engaging to the best of their ability, and they may not be able to achieve plaque and bleeding scores below 30% and 35% respectively

Question 22

how can we interpret these score

Answer 22

• A plaque score will only give us a snap shot of the oral hygiene of the patient at that moment in time, whereas marginal bleeding will inform us how well the patient is brushing on a daily basis
• Therefore, bleeding is the more important determining factor when assessing engagement in non-smokers
• Both bleeding and plaque should be interpreted together for patients who smoke

Question 23

how can these scores improve our current practice

Answer 23

• A more objective way of assessing OH - in particular when used with marginal bleeding
• Simple and quick to use - good screening tool
• Clear, objective results that can be easily presented to patients
• Allows objectively assessment of a patient’s OH over a longer period of time
• Objectively identifies patients who are engaging