modified plaque and bleeding scores

Question 1

Ramfjord’s teeth

Answer 1

6 index teeth
6 1 4
4 1 6

Question 2

how are Ramfjord’s teeth distributed?

Answer 2

to best reflect the condition of the whole mouth

Question 3

what does modified bleeding score measure and what does this reflect?

Answer 3

marginal bleeding (immediate) rather than BOP from base of pocket
reflects how well pt is able to carry out effective plaque control daily rather than disease activity and PD breakdown

Question 4

modified bleeding score procedure

Answer 4

on each of Ramfjord’s teeth run a probe gently at 45 degrees around the gingival sulcus in a continuous sweep
- for up to 30s after probing check for bleeding
keep probe moving at all times

Question 5

modified bleeding score scoring

Answer 5

each tooth split into 4 surfaces
 - M
 - D
 - B
 - L/P
for each surface
 - 1 = bleeding
 - 0 = no bleeding
add to get total score then divide by max score possible

score/max x100 = %

Question 6

modified plaque score

Answer 6

split each tooth into 3 surfaces
- IP
- buccal
- palatal/lingual
for each surface
- 2 = visible plaque without use of probe
- 1 = no visible plaque but a probe skimmed over tooth surface reveals plaque
- 0 = no plaque
add score for each surface
total score then divide by max plaque score possible for a pt
score/max x100 = %

Question 7

what if one of Ramfjord’s teeth is missing?

Answer 7

is there an appropriate alternative tooth?

• yes = use this tooth for charting
• no = code N used (changes the max score)

Question 8

when to record?

Answer 8

not recorded at initial consultant clinic

recorded at every tx and review clinic

Question 9

what do the scores mean?

Answer 9

indication of pt engagement - should not be used in isolation as other patient factors must be considered
threshold levels for an engaging pt
- <30% plaque score AND <35% bleeding score
- OR >50% improvement in both

Question 10

sensitivity

Answer 10

ability of a test to correctly identify pts with a disease

Question 11

specificity

Answer 11

ability of a test to correctly identify pts without the disease

Question 12

engaging pt tx

Answer 12

should receive site specific repeated RSI or more advanced tx as necessary

Question 13

threshold scores have been set higher than the accepted standard

Answer 13

partial mouth recording systems tend to underestimate disease
site specific repeated RSI has not yet been carried out

Question 14

non-engaging pt tx

Answer 14

not usually suitable for site-specific repeated RSI or more advanced tx

• communicate to pt
• barriers to engagement identified
• may delay further RSI until sufficient engagement
• pts continue to receive supportive care with further OHE, motivation and behaviour change

Question 15

additional advice re engagement

Answer 15

some pts will not be able to achieve these levels of OH and plaque control due to factors e.g. manual dexterity, mental health problems etc
should be noted that these pts may be ‘engaging’ pts who are doing their best, and may not be able to achieve 30 and 35%

Question 16

interpreting scores

Answer 16

plaque score - snapshot of OH at that moment
marginal bleeding - how well pt is brushing on a daily basis
so bleeding is more important when assessing engagement in non-smokers
interpret both together in smokers

Question 17

need for further research

Answer 17

evaluate use of other index teeth
need for larger cohort and multicentre
need to test engaging pt threshold to pt outcomes following site specific repeated RSI

Question 18

how can these scores improve our current practice?

Answer 18

a more objective way of assessing OH - esp when used with marginal bleeding
simle and Buick
clear objective results that can be easily presented to pts
allows objective assessment of OH over a period of time
identify engaging pts

Question 19

reasons to continue tx if they do not fit ‘engaging’

Answer 19

v high risk for disease progression
young pt
PDD compromising QOL
teeth difficult to clean given mobility

non-engaging pts should not necessarily be discharged if there are complicating RFs
- exceptions to the usual pathways should be made for pts with complicating medical RFs