10.14219/jada.archive.1996.01371996;127(12):1763-1766JADA

BL Butler, O Morejon and SB Lowplaque accumulationAn accurate, time-efficient method to assess

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ARTICLE 2

AN ACCURATE, TIME-EFFICIENT METHODTO ASSESS PLAQUE ACCUMULATIONBOBBY L. BUTLER, D.D.S.; OSCAR MOREJON, D.M.D.; SAMUEL B.LOW, D.D.S., M.S., M.ED.

The authors compared the accu-

racy and time efficiency of a sim-

plified index called the Plaque

Assessment Scoring System, or

PASS, and the O'Leary Plaque

Control Record. Using both in-

dexes, they examined 35 partici-

pants. They found a strong cor-

relation between the results

achieved with each method.

They also noted that the mean

time required to complete the

PASS examination was consider-

ably less than that needed to

record the O'Leary index, 1.47

vs. 7.07 minutes, respectively.

OAt has long been established that the central etiological agent ofperiodontal disease is bacterial plaque.1'2 Without the presence ofplaque, other risk factors become inconsequential. Successful out-comes with either nonsurgical or surgical treatment must centeraround the elimination of plaque.3

Practitioners in every practice setting understand the crucialneed for oral hygiene documentation and instruction. Unfortu-nately, plaque control is not routinely evaluated. When it is ad-dressed, it usually is described in subjective terms like "good," "fair"or "poor." The obvious reason for this subjective approach to evalu-ating plaque control is that it saves time.

The literature describes many plaque index systems used in clini-cal research, but they are complicated and time-consuming. Themost frequently used is the Silness and Loe Plaque Index, which as-sesses the surface area and thickness of plaque from grades of 0 to3.45 There are four other indexes commonly used in clinical studies.The Simplified Oral Hygiene Index by Greene and Vermillion isbased on the surface area of the tooth covered with plaque.6 TheModified Plaque Index by Schick and Ash grades on the extent ofvisible plaque at the gingival margin on selected teeth.7 The NavyPlaque Index scores plaque presence on three zones of the tooth (theocclusal, middle and gingival thirds), with the gingival zone dividedinto three subcategories based on the extent of the plaque present.8The last index that has been used in many studies to quantifyplaque is the Modified Plaque Index by Turesky and coworkers.9This comprehensive index has five grades of plaque accumulation.

All of these indexes record the amount of plaque as well as the toothsurface on which the plaque is located, but their accuracy is limitedand their complexity cumbersome. For use on a routine basis, these in-dexes are not practical and cannot be used easily in a private practice.

In clinical practice, some form of the O'Leary Plaque ControlRecord'0 is commonly used when recording patient plaque scores.O'Leary's suggestion of recording only the presence or absence ofplaque on four surfaces per tooth (mesial, distal, facial and lingual)is useful at identifying oral hygiene deficiencies and is more accu-rate than trying to grade the extent of plaque on each surface.However, an average dentition with 28 teeth requires that 112 sur-faces be assessed for the presence of plaque. O'Leary reasoned that

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CLINICAL PRACTICE

"when an assistant records thefindings of the examiner, therecordings can be completed inapproximately five to six min-utes."10 In reality, the plaqueindex often is completed by thehygienist with no assistantavailable, thereby increasingthe time for an accurate plaqueindex evaluation. During a typi-cal one-hour maintenance ap-pointment, this time frame is notpractical and usually results inthe recording of a subjective ob-servation like "moderate plaqueaccumulation."

The Plaque AssessmentScoring System, or PASS, pre-sented in this study allows anexaminer to objectively recordplaque accumulation on selectedteeth in a time-efficient manner.Also, using PASS, an examineris able to assess subgingivalplaque accumulation, which isnot evaluated by other indexes.Because of its location and com-position of high levels of gram-negative anaerobic pathogens,subgingival plaque is central tothe progression of periodonti-tis.'1"2 The O'Leary index assess-es only visible supragingivalplaque.

The purpose of this study wasto compare the accuracy andtime efficiency of PASS vs. theO'Leary index so that the clini-cian may have a time-efficientand objective assessment oftheir patients' oral hygieneeffectiveness.

MATERIALS ANDMETHODS

Using the PASS and the O'LearyPlaque Control Record methods,we examined 35 adults for thepresence of plaque. Examinersfirst evaluated the participantsusing the PASS and then usingthe O'Leary index.

To establish a PASS score, anexaminer selects five teeth forexamination (four first molarsand one maxillary incisor). If oneof these teeth is missing, then anadjacent distal tooth or, if thattooth is missing as well, a mesialtooth is considered. If no maxil-lary incisors are present, amandibular incisor can be sub-stituted. Each tooth selected isdivided into four areas: mesial,distal, buccal and lingual.

Using a periodontal probe,the examiner sweeps each quar-ter of the tooth approximately 1

Figure 1. Example of the format used to record the presence of plaqueusing PASS. This example indicates the presence of plaque on 10 sur-faces, representing a 50 percent PASS score.

millimeter into the sulcus to de-tect plaque. If plaque is visibleon the probe, the surface iscounted as positive for plaqueaccumulation. There are 20 pos-sible plaque surfaces. The PASSscore is the percentage of sur-faces positive for plaque accumu-lation (Figure 1).

After the PASS examination,participants rinsed for 30 sec-onds with a disclosing solution.The O'Leary index consisted ofrecording the presence or ab-sence of disclosed plaque on themesial, distal, buccal and lin-gual surfaces of all teeth. Thepercentage of disclosed plaquewas then calculated for eachparticipant.

All of the participants hadbeen diagnosed as having re-fractory periodontitis. Each hadreceived periodontal surgeryand antibiotic therapy, and wason a long-term frequent mainte-nance program.

The study was conducted intwo phases.

In the first phase, all pa-tients were examined once foreach index and both indexeswere performed by the same ex-aminer. An assistant recordedthe number of plaque-coveredsurfaces as they were called outby the examiner, which pre-vented the examiner from com-paring the indexes as he or sherecorded them. The scores werecalculated after both indexeswere complete.

In the second phase, exam-iners used both methods torecord the presence of plaque ineight new participants. We con-ducted the second phase to de-termine the amount of time re-quired to perform each of theplaque-assessment methods.Unlike the first phase, duringwhich an assistant recorded thedata, the second phase required

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-CLINICAL PRACTICE -

TABLE

PLAQUE MEAN SD* SEWt MINIMUM MAXIMUM RANGE TIMEINDEX (MINUTES)

IRASS ('3o) 33.29 12.83 2.17 15 60 45 1.47

O'Leary(to) 34.91t 11.14 1.88 14 58 44 7.07

Standard deviation.t Standard error of the mean.t A correlation of r = 0.7, which is significant at P = .0001, was found between the two indexes.

that the examiners record thedata themselves to simulate aprivate practice setting. Usinga stopwatch, an observerrecorded the number of min-utes required for each examina-tion. The practitioners were un-aware of the amount of timethat elapsed.We used the Pearson Corre-

lation Coefficient to determinethe agreement between the twoplaque-assessment methods.

RESULTS

Overall, we found a strong posi-tive correlation between themean PASS and the meanO'Leary Plaque Control Recordscores (r = 0.7, P = .0001),which indicates that the mea-surements recorded were con-sistent between the two meth-ods. In considering correlationsbetween the scores for individu-al participants, however, wefound some isolated instancesin which the correlation waspoor (Figure 2).

The mean plaque index (± SD)recorded with the PASS was33.29 percent (± 12.83) comparedwith a mean of 34.91 percent(± 11.14) recorded with theO'Leary index (Table).We found that examiners

took an average time of 7.07minutes to record the O'Learyindex and 1.47 minutes torecord the PASS index.

DISCUSSION

The results from this studydemonstrate an overall agree-ment between the PASS andO'Leary Plaque Control Record.However, as seen in Figure 2,there were some instances inwhich the correlation was poor.These results resemble those re-ported by Greene and Vermil-lion in comparing the SimplifiedOral Hygiene Index with theoriginal Oral Hygiene Index;

the means were similar but thestandard deviations were high.6Individual variations alwayswill exist unless the samemethod and index is used atevery examination.We expected to detect some

disagreement between the mea-sures achieved with the tech-niques used in this study becauseof the differences in methodology.Examiners using the PASS indexmeasured plaque accumulationat the supragingival and subgin-

Figure 2. A graph of the PASS and O'Leary index scores for each participantshows that, although there was a strong correlation between the mean data, therewere instances in which the plaque indexes varied between the methods.

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gC INICAL PHACIICE

gival margin by sweeping a probealong the surface ofthe tooth and1 mm below the gingival margin.This is unlike the O'Leary index,in which only disclosed supragin-gival plaque is counted. The dif-ference in techniques would ac-count for significant error and ispossibly why the correlation wasnot ideal.

Differences also were ampli-fied because all of the partici-pants had low to moderateplaque scores for both indexes.Also, the participants were en-rolled in a rigid periodontalmaintenance program. Perhapsselecting patients with a broad-er range of scores would haveelicited different results.

Currently, no index tries toquantify the extent of subgingi-val plaque present. The PASSindex is not proposed as beingan exact method of quantifyingsubgingival plaque, but it doesprovide a gross estimate of ad-herent subgingival plaque. Iflarge masses of gram-positive,adherent, subgingival microbesare seen, then the resulting col-onization for gram-negative,anaerobic, nonadherent subgin-gival plaque is increased." ThePASS index is a possible indica-tor of cumulative subgingivalplaque qualities.

The PASS system also makesthe use of disclosing agents un-necessary. Disclosing agents areundesirable to most patients andcamouflage the gingival tissues,making it more difficult to identi-fy inflammation. They not onlydisclose bacterial deposits butalso the dental pellicle, increas-ing the false detection of plaque.In this study, disclosing agentsalso increased the time in exam-ining patients with the O'LearyPlaque Control Record, which ex-plains part of the difference

noted in the mean times of 1.47minutes to complete the PASSexamination and 7.07 minutesfor the O'Leary index.

Selecting the four first mo-lars and one maxillary incisorallows the examiner to identifyproblem areas in all four quad-rants without identifying theplaque-covered surfaces on allteeth. In a similar approach,Ramfjord selected "the Ram-fjord teeth" that would repre-sent the periodontal health ofthe entire dentition.13

Like the Simplified OralHygiene Index or Ramfjord'sPeriodontal Disease Index,PASS cannot be totally accu-rate, but it does appear to bewithin an acceptable limit andcan be completed quickly. Timeis a limiting factor in everypractice, and techniques thatare accurate and performed eas-ily likely will be used.

The PASS system has beenused in both academic and pri-vate sector environments. Thesystem has been met with over-whelming approval. Patients areassessed at every appointment,which makes accurate long-termoral hygiene observation feasible.Ramford has stated, "Plaque

control is thealpha and

* ~~omega of pre-vention, heal-ing and main-tenance ofperiodontal

Dr. Butler Is in pry- health."3 Whenvate periodontalpractice. He also la practitionerson the auxiliary Mini- fail to objective-cal faculty, Depart- ly record theirment of Perlodon-tology, University of patients' effec-Washington College tiveness atof Dentistry, Seattle.Address reprint re. plaque removal,quests to Dr. Butler, important diag-500 Olive Way, Suite nostic informano. 1524.Seattle,Wash. 98101. tion is lost.

CONCLUSION

Lengthy and time-consumingplaque indexes during a one-hour maintenance appointmentare unrealistic. This duty isusually delegated to the dentalhygienist, who often mustrecord the scores without an as-sistant. The PASS method isideal for the solo examiner.We conclude that PASS

demonstrates statistical relia-bility when compared with theO'Leary Plaque Control Recordand is a time-efficient methodto assess plaque control. E

Dr. Morejon is in private periodontal prac-tice, Daytona Beach, Fla.

Dr. Low is a professor and associate dean,Department of Periodontology, University ofFlorida College of Dentistry, Gainesville, Fla.

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3. Ramfjord SP. Maintenance care for treat-ed periodontitis patients. J Clin Periodontol1987;14:433-7.

4. Fischman SL. Current status of indices ofplaque. J Clin Periodontol 1986;13:371-4.

5. Lbe H, Silness J. Periodontal disease inpregnancy: correlation between oral hygieneand periodontal condition. Acta Odontol Scand1964;22:121-35.

6. Greene JC, Vermillion JR. Simplified oralhygiene index. JADA 1964;68(1):7-13.

7. Schick RA, Ash MM. Evaluation of thevertical method of toothbrushing. J Periodon-tol 1961;32:346-53.

8. Elliott JR, Bowers GM, Clemmer BA,Rovelstad GH. Evaluation of an oral physio-therapy center in the reduction of bacterialplaque and periodontal disease. J Periodontol1972;43:221-4.

9. Turesky S, Gilmore ND, Glickman I. Re-duced plaque formation by the chloromethyl ana-log ofvictamine C. J Periodontol 1970;41:41-3.

10. O'Leary TJ, Drake RB, Naylor JE. Theplaque control record. J Periodontol 1972;43:38.

11. Listgarten MA. Structure of the micro-bial flora associated with periodontal healthand disease in man. A light and electron micro-scopic study. J Periodontol 1976;47(1):1-18.

12. Slots J. Subgingival microflora and peri-odontal disease. J Clin Periodontol 1979;6:351-82.

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