The numbers game
Time to count up the reasons for making indices a hot topic in practice
An index is a numerical value – we use them in dentistry to measure the presence/absence or level of disease present, either in an individual site, a person or population. It needs to simple (if possible), quick, practical and easily reproducible. Quantifying how much plaque is in the mouth, recording inflammatory markers such as bleeding, loss of attachment and pocket depth, and tooth mobility are key factors in the documentation of periodontal diseases. But, sadly, indices are often overlooked or avoided because of time constraints and lack of nursing assistance, particularly when working as a DH&T. There is some irony in that we, as a professional group, really need to given the time and opportunity to carry out these investigations. Most periodontal indices were created for the purpose of collecting epidemiological data, and can be intricate at best. However, there are some ‘gems’ of the indices world that can be used in general and private hygiene practice. Repeated indices are paramount in recording and assessing patient behaviour in terms of homecare compliance and motivation.
It counts, so record:
• How much plaque is in the mouth
• Inflammatory markers such as bleeding, loss of attachment and pocket depth
• Tooth mobility
Failing to deliver
We all like a number with which to walk out of the door. This is reminiscent of our school days when a nine out of 10 of 10 out of 10 in a test meant the world! These numbers probably motivate us as human beings more than we know, especially when these numbers could keep us on the right side of good practice and avoiding unnecessary litigation 10 years down the line. When a patient claims they were never told about their gum problems, can you defend this accusation? Litigation in periodontal cases can take many years to rear its ugly head with many cases appearing 5-10 years after the patient last sought treatment. By producing and retaining accurate records, the clinician can sleep soundly at night. They do take a little time to collate, yet their weight could be valuable when faced with an accusation that you failed to deliver the correct care.
With direct access looking likely, we need to take ownership. This is our ethical responsibility as the accountability will rest even more with us in the future.
Which index is used can be debated. The Basic Periodontal Examination (BPE), formulated by the British Society of Periodontology (BSP) in 1986 (modified October 2011) is the standard screening tool for periodontal disease – but it is just that, a screening tool. Much more in-depth tools are required to assist the clinician in deciding on the correct care to be delivered to the patient; there are many to choose from but many of us tend to stick with what we know. The Löe & Silness Gingival Index (GI)(1963) is used to measure gingivitis. These two great researchers in periodontal disease also produced the Plaque Index (PI) (1964) that gives an empirical score for plaque found at margins. That said, a much more practical index for practice use is the Plaque Control Index (PCI) (1972), formulated by O’Leary, Drake, and Naylor that gives scores as a percentage. The list is large and there are modifications of many of these. The clinician should be familiar with them and be prepared to use various indices depending on the situation. A point to note is that if the clinician is varying which index they use, it may be prudent to note on the record the choice.
So, what do we need to do the job properly? Well we need to make time in the structure of appointment to carry out the data collection. Conversations may need to take place behind the scenes to make this happen; a campaign for 30-minute appointments? Everything in life comes at an investment of time and money. We also need the proper equipment in plentiful supply. A couple of probes in a drawer will not cut the mustard. We will need 8 to 10 UNC-15 and BPE (World Health Organization) probes for a morning’s work in one surgery. When all is said and done, any information collected forms part of the patient record and should be retained as such.
Many clinicians feel are unable to collect data as they lack the confidence, knowledge or skills yet we were all taught these – and, if our skills are rusty, perhaps now is the time to return to the numbers game.
Shaun Howe works in two practices full time in Nottingham and Derbyshire. Shaun started public speaking in 2005 and has spoken nationally to various groups and continues to do so.
Amanda Gallie qualified from the University of Manchester School of Dental Hygiene in 1996 and is a part-time tutor at GKT London, working in private practice in central London. Amanda lectures on communication for the dental team and has a passion for periodontics.
Email [email protected]
Shaun and Amanda will be speaking at the DH&T Conference. Their joint presentation will explore the use of indices in modern practice and the practicalities of recording these. The lecture will give an overview and update of commonly used indices that can be used to help record the patient’s oral health status. This will be the first non-association event for hygienists and therapists and is on 8 February 2013 in London.