Oral Hygiene Status

The current state of oral hygiene is assessed by collecting an oral hygiene status. This incorporates indices that record the presence of plaque (microbial plaque) and signs of inflammation of the gingiva (the gums). Plaque or biofilm is the term used to describe the microbial plaque that forms on the surfaces and in the approximal spaces (interdental spaces) of teeth when dental hygiene is inadequate. Demonstration of this bacterial plaque by staining is a valuable aid for patients, allowing them to identify and target their oral hygiene deficiencies. A large number of microorganisms can be found in the oral cavity of every person, without this being a pathological (diseased) condition. The most diverse types of germs together form a balanced, self-contained ecosystem into which other germs can only penetrate with difficulty. The germs that have specialized in adhering to the hard surfaces of the teeth form the so-called plaque. The development of plaque takes place in several phases, until after seven days, if there has been no intervention, it is referred to as mature plaque. If there is an excess of carbohydrates, preferably sugar, in the mouth over a long period of time, this leads to increased growth of cariogenic (caries-causing) germs within the plaque. These are primarily mutans streptococci and lactobacilli. Sugar is rapidly and effectively metabolized by Streptococcus mutans to lactic acid. The acid, on the other hand, causes the actual damage to the tooth structure: it is demineralized. The crystal structure, which gives the tooth hardness, is gradually dissolved by the acid, so that cavitation (loss of substance, creation of a “hole”) occurs in the further course. The increase in plaque due to a longer residence time on the tooth surfaces, especially in niches and at the gum line, not only leads to an increased risk of caries: the thicker and more mature the plaque becomes, the less oxygen reaches the deeper layers. Germs thrive in the low-oxygen environment, inevitably leading to gingivitis (inflammation of the gums) within a few days. If gingivitis persists, it can turn into periodontitis (disease of the periodontium), which in turn causes tooth loosening and tooth loss.

Indications (areas of application)

Without plaque there is no caries, without gingivitis there is no periodontitis! The indication for establishing an oral hygiene status is based on this simple formula. Here, it makes sense to collect a plaque index and a gingiva index respectively and to retain once selected indices for follow-up visits. While a plaque index provides a snapshot of the success of the last tooth brushing, the gingival inflammation level provides a picture of oral hygiene over a longer period of time, as signs of inflammation only appear after several days of poor dental hygiene. Thus, both indices considered together provide a picture of the degree of oral hygiene in the recent period. The results are useful:

  • For the targeted motivation of a patient, because showing all bacterial loopholes facilitates the switch to a new and consistently performed toothbrushing technique.
  • For an objective comparison during follow-up visits, as the state of oral hygiene is recorded schematically and reproducibly.
  • To determine the frequency of preventive care appointments: with increased risk of caries and inflammatory changed gums will need to see the dentist more often than every six months to refresh or deepen knowledge of oral hygiene techniques.

Contraindications

There are no contraindications for performing an oral hygiene status. The plaque revelers (liquids for staining dental plaque) listed below are classified and approved as safe for health. The use of erythrosine is nevertheless a contraindication in the case of iodine allergy due to its iodine content. Gentianaviolet and fuchsin, on the other hand, are considered potentially carcinogenic (cancer-causing) as aniline dyes and are therefore no longer permitted for use as plaque revelers.

Before the examination

  • Patient consent to stain plaque should be obtained in advance, as lips and oral mucosa may be affected by staining for several hours.
  • Vaseline applied to the lips beforehand can largely prevent the lips from staining

The procedures

I. Gingival indices

Gingival indices are used to detect marginal (gum edge) bleeding as an important sign of inflammation. In dental practice, indices such as the less elaborate modified sulcus bleeding index (SBI) are used, as well as the somewhat more sophisticated papilla bleeding index (PBI) or the gingival bleeding index (GBI), which is more elaborate due to the number of measurement points. I.1 Modified sulcus bleeding index (according to Mühlemann and Son 1975, Lange 1990) / SBI:

It assesses the presence of bleeding in the interdental spaces without further graduation.

  • A standardized periodontal probe (WHO probe) is used to scour out the gingival sulcus toward the papilla tip. The depth of penetration into the gingival pocket should not exceed 0.5 mm.
  • 10-30 seconds after provocation, it is assessed whether there is bleeding or not.
  • Readings are taken vestibularly in the first and third quadrants, orally in the second and fourth quadrants (in the maxillary right and mandibular left on the cheek side, in the maxillary left and mandibular right on the tongue side).
  • A table is used to determine the percentage of affected interdental spaces.
  • The goal of oral hygiene is an SBI of less than 10%.

I.2. papilla bleeding index (according to Saxer and Mühlemann 1975) / PBI:

Probing corresponds to the method of the modified SBI. However, the PBI records not only the presence of bleeding in the interdental spaces, but also the intensity of bleeding by further graduation:

  • Grade 1: single point of blood
  • Grade 2: bloodline or multiple blood points
  • Grade 3: interdental triangle (space between two adjacent teeth and the underlying gingival papilla) fills with blood
  • Grade 4: profuse (more extensive) bleeding, immediately after probing, a drop flows over the tooth and gum

The PBI is read contralateral to the SBI, i.e., oral in the first and third quadrants, vestibular in the second and fourth quadrants. The index is the total number of degrees measured in relation to the total number of all interdental spaces measured. I.3. gingival bleeding index (according to Ainamo and Bay 1975) / GBI:

  • The gingival sulcus is smoothed out with a standardized periodontal probe (WHO probe).
  • After 10 seconds, the presence of bleeding is read at four to six measuring points per tooth. A graduation as with the PBI does not take place.
  • The index value results from the number of bleeding measuring points in relation to the total number of measuring points.

II. plaque indices

The approximal spaces (interdental spaces) are problem areas for toothbrushing technique and thus predestined (predetermined) for the adhesion of plaque (biofilm, dental plaque). By staining the plaque that remains even after ambitious oral hygiene – before visiting the dentist – the patient receives important feedback. Using liquid plaquerevelators, plaque is stained as follows:

  • The Revelator is applied to the tooth surfaces dabbing, not wiping, with a soaked cotton or foam pellet.
  • The patient then removes excess stain by rinsing twice with water. On the teeth, the color of the Revelator remains only in the plaque, but not on cleaned surfaces.
  • In the mirror, the patient is explained all the findings relevant to him and is specifically made aware of the areas that he must include in his future brushing technique.
  • The findings are recorded in a plaque index.

Substances used as revelators include the following:

  • Erythrosine (tetraiodo-fluorescin-Na, E 127, red coloring).
  • Patent blue (brilliant blue, food coloring, E 133, blue coloring).
  • Two-phase revelators (eg Mira-2 clay erythrosine-free): the young plaque of the initialization phase is colored pink, mature plaque appears blue. Through this effect can be targeted permanent cleaning deficiencies.
  • Sodium fluorescein (e.g. PlaqueTest Vivadent) shimmers yellow, but only when illuminated with blue light (e.g. polymerization lamp).

II.1. approximal space plaque index (according to Lange 1975) / API:

  • Staining the plaque (the dental plaque).
  • Rinse with water
  • The reading in the interdental spaces is contralateral (located on the opposite side or half of the body) to the SBI, i.e., oral in the first and third quadrants, vestibular in the second and fourth quadrants (on the right side of the tongue in the maxilla and on the left side of the mandible, on the left side of the cheek in the maxilla and on the right side of the mandible).
  • Assessed only the presence of plaque, but not its amount.
  • The reading of the index value can be based on a table and results from the ratio of plaque-positive to assess approximal spaces (interdental spaces).
  • The goal of oral hygiene is an API of less than 35%.

II.2 Plaque Control Record (after O’Leary et al. 1972) / PCR:

  • Staining of the plaque
  • Rinsing with water
  • The reading is taken at the gingival margin (gum line) at four to six locations per tooth. So, unlike the API, the PCR detects the presence of plaque not only in the interdental spaces, but also on the tongue and cheek side of the teeth near the gum line
  • The amount of plaque is not recorded by further graduation.
  • The PCR is the number of plaque-positive areas relative to the total number of areas assessed.
  • The goal of oral hygiene is a PCR of less than 10%.

After the examination

The use of plaquerevelators, with the exception of sodium fluorescein, requires professional dental cleaning, which removes the color deposits not only from the teeth, but also from the mucosa of the lips and tongue.