Clinical parameters

Reassessing clinical parameters

Monitoring plaque levels

Plaque biofilm control is essential to reduce gingival inflammation during treatment and to prevent relapse in the maintenance phase of management. Low levels of plaque are associated with periodontal stability. The level of self-care required to prevent and control inflammation will differ depending on the patient’s risk profile. However, the goal should be for all patients to reach a level of self-care which promotes health and controls inflammation.

The BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)⁶ guideline includes a guide outlining the changes in plaque scores which may indicate a favourable improvement in oral hygiene and a patient who is engaged during Step 1 of therapy. These are:

• plaque levels of ≤20%, or
• ≥50% reduction in plaque from baseline measurements, or 
• targets for improvements in plaque levels can be agreed by the patient and clinician. 

Consideration of these scores can be helpful during a holistic assessment of patient engagement.

Regular, objective recording and review of plaque biofilm levels will identify areas where ongoing support for home care by the patient is required and can also inform an overall assessment of the potential value of more advanced periodontal treatments. 

Objective measuring can be performed using: 

• Plaque charts which record the levels of plaque on all teeth (see Assessing plaque biofilm and bleeding and Monitoring plaque and bleeding);
• Plaque charts which record the levels of plaque at index teeth (e.g. Ramfjord teeth; see Assessing plaque biofilm and bleeding and Monitoring plaque and bleeding). 

Monitoring gingival bleeding

Bleeding superficially from the gingival margin (marginal bleeding) rather than from the base of a periodontal pocket, is related in most cases to oral hygiene measures. Objectively measuring and recording this is useful for assessing the patient’s response to home care oral hygiene measures.
The BSP-S3 guideline⁶ includes a guide outlining the changes in bleeding scores which may indicate a favourable improvement during Step 1 of therapy. These are:

• marginal bleeding levels of ≤30%, or 
• ≥50% reduction in marginal bleeding from baseline measurements, or 
• targets for improvements in marginal bleeding levels can be agreed by the patient and clinician. 

Consideration of these scores can be helpful during holistic assessment of patient engagement.
Objective measuring can be performed using: 

• Bleeding charts which record the presence or absence of marginal bleeding around all teeth (see Assessing plaque biofilm and bleeding and Monitoring plaque and bleeding);
• Bleeding indices which record the presence or absence of marginal bleeding at index teeth (e.g. Ramfjord teeth;
• see Assessing plaque biofilm and bleeding and Monitoring plaque and bleeding). 

Monitoring periodontal probing pocket depth

Reduction in probing pocket depth following treatment is an indicator of disease resolution and maintenance of these reduced probing pocket depths during Step 4 of therapy is an indicator of disease stability. 

The BSP-S3 guideline⁶ suggests that a goal of treatment is shallow probing pocket depths of ≤4 mm with no bleeding at 4 mm sites. This corresponds to a diagnosis of periodontal stability or remission. It is recognised that this goal may not be attainable in some cases. A suitable compromise, for example for patients where persistent pocketing ≥5 mm is present but the oral conditions are not suitable for periodontal surgery or the patient does not wish further treatment, could be to move to Step 4 of treatment, with the agreement and consent of the patient.