A Method for Evaluating

Oral Hygiene Performance

ARLON G. PODSHADLEY, D.D.S., M.S.D., and JOHN V. HALEY, Ph.D.

RECENT INVESTIGATIONS have dem- tion comparing the Podshadley PHP method
onstrated that there is a strong positive with the well-established debris index-simpli-
correlation between poor oral hygiene and peri- fied (DI-S) aspect of the Greene and Vermillion
odontal disease (1-9) . An awareness of this rela- 011-S method.
tionship has stimulated dentists to place greater
emphasis on teaching patients the importance of Determining the PHP Score
good oral hygiene and the best methods for A mouth mirror examination of selected teeth
obtaining it. It has also stimulated additional is made after the patient has been given an
study of the role of oral debris in dental disease. erythrosin disclosing wafer which stains the
The current emphasis on patient education and oral debris a dark pink. Oral debris is defined as
on research in oral hygiene has underlined the the soft foreign material consisting of mucin,
need for a simple and accurate method for meas- bacteria, and food that is loosely attached to the
uring the oral hygiene of dental patients. tooth surface. The patient is instructed to chew
The simplified oral hygiene index (OHI-S) the disclosing wafer and to "swish" for 30
developed by Greene and Vermillion for meas- seconds. He may then expectorte but is not per-
uring oral hygiene (10) has proved a reliable mitted to rinse his mouth until after the
instrument for large epidemiologic studies. The examination.
need, however, for a simpler and more sensitive The examination is performed on the follow-
measurement device both for research and for ing teeth in this order: (a) maxillary right first
use by the dental practitioner has stimulated the molar, (b) maxillary right central incisor, (c)
development of the patient hygiene perform- maxillary left first molar, (d) mandibular left
ance (PHP) method (11, 12). first molar, (e) mandibular left central incisor,
This paper reports the results of an investiga- (f) mandibular right first molar. The tooth sur-
faces wlich are assessed are the buccal of the
Dr. Podshadley is assistant professor, department of maxillary molars, the lingual of the mandibular
community dentistry, University of Kentucky Medi- molars, and the labial of the maxillary and
cal Center, Lexington, and Dr. Haley is assistant mandibular incisors.
professor, department of behavioral science. Dr. If the first molars are'missing, are less than
Sherwin Fishman, assistant professor, and Mrs. Jean three-fourths erupted, have full-crown restora-
Shannon, research associate, department of commu- tions, or are too badly broken down to assess,
nity dentistry, assisted in the data collection phase of the second molar is substituted. If the second
the project. molar is missing or cannot be used, the third

Vol. 83. No. 3, March 1968 259

molar is then substituted. If all three molars are the patient hygiene performance score is then
missing or cannot be used, ian M is placed on the calculated by dividing the sum of the scres by
recording chart. the number of surfaces charted as shown in the
If the designated central incisor is missing or following examples.
cannot be used, the adjacent central incisor is
substituted. If both central incisors are missing Debris 8core
or cannot be used, again an M is placed on the Example 1 Example B
chart. Tooth surface
Maxillary right molar--- 3 4
To assess the debris on each surface, the ex- Maxillary right central in-
aminer must mentally divide the tooth into five cisor _- -__ 2 2
Maxillary left molar 4 5
sections (fig. 1). The clinical crown is subdi- Mandibular left molar- - - 3 3
vided longitudinally into mesial, middle, and Mandibular left central in- is 1
cisor -_-
distal thirds. The mesial and distal thirds make Mandibular right molar--- 3 M
up the first two subdivisions; each area extends Sum of scores_ 16 15
to the middle third of its adjacent proximal sur-
face. The remaining middle third is then sub- /sum of debris\
divided horizontally into the gingival, middle, PEP scores 16 , or 2.66 5, or 3.0
number of
and occlusal thirds. debris scores
Each of the subdivisions is examined for the
presence of the pink-stained oral debris. If no In example 1, the letter S indicates that a
debris is present, 0 is assigned to that section; substitute tooth was used. In example 2, M indi-
if debris is present, 1 is assigned. The value of 1 cates a missing score and that tooth is therefore
is assigned only to those areas on which debris not included in the computation. For that reason
is definitely present. The lesser score of 0 is as- the number of debris scores equals 5 instead
signed to all questionable areas. of 6.
The debris score for each tooth is detennined Survey Methods
by adding the values of each of the five subdivi-
sions. For example, in figure 1-B, debris is pres- Fifty-five sixth-grade children aged 11 to 12
ent in both proximal areas and in the gingival were examined independently by two examiners.
third; the debris score is 3. In figure 1-C, debris Each examiner performed three examinations
is present in one proximal area only; the debris on each child. First a DI-S score was calculated
score is 1. In figure 1-D, debris is present in both on the same child by each examiner. After both
proximal areas, the gingival third, and the mid- examiners had completed the DI-S, the child
dle third; the debris score is 4. was asked to chew an erythrosin dye tablet and
The debris score for the designated surface of swish saliva around all of the teeth. Each ex-
each of the six teeth is entered in a table, and aminer then calculated a patient hygiene per-

A S. c I.D

I
3
..,

I
3

t
1 1 I

Figure 1. The subdivisions of a tooth used in PHP (patient hygiene performance) method, with
examples of scoring by this method: A. Five subdivisions, B. debris score of 3, C. debris
score of 1, and D. debris score of 4

260 Public Health Reports

Table 1. Interexaminer comparisons for the DI-S method and for the PHP method with dye
tablet and with liquid dye
Mean score Standard deviation Difference between Correlation
Number of mean scores coefficient
Method children (examiner 1
examined Examiner Examiner Examiner Examiner t scores Probabil- to examiner
1 2 1 2 ity1 2)

DI-S -55 1.435 1.359 ±0.335 ±0.447 1.82 0.074 0.72

PHP with dye tab-
let-first exami-
nation -55 3.367 3.391 ±.638 ±.547 .531 .597 .85
PHP with dye tab-
let-second ex-
amination 55 3.337 3.365 ±.612 i.599 .692 .492 .87
PHP with liquid
dye -55 3.559 3.592 ±.560 ±.528 1.06 .291 2.91
I No significant difference between mean scores at the method when liquid dye was used was significantly
0.05 level of confidence in any comparison. higher than the correlation coefficient of 0.72 for the
2 The correlation coefficient of 0.91 for the PHP DI-S method (P=<0.001).

formance score for the child. The child was throsin in 6 cc. of water) around all of his teeth
then returned to his classroom but instructed for approximately 15 seconds. The DI-S was not
not to brush his teeth, eat, or in any way disturb calculated, and the children were not re-
the stain on the teeth. He was returned to the examined after 1 hour. Except for these differ-
examination room 1 hour later and again asked ences, this examination was conducted in the
to chew and swish another dye tablet. The PHP same manner as when the dye tablet was used.
score was again calculated by each examiner.
We conducted the examination in the school Analysis of Data
auditorium, using portable dental chairs and Pearson's product moment correlation co-
lights. To assure completely independent scor- efficients were used to determine the inter-
ing, the dental chairs were placed so that the examiner and intraexaminer relationships. The
examiners could not overhear each other. The interexaminer correlations were considerably
examiners in this investigation had been trained higher with the PHP method than with DI-S
in the DI-S techniques, and each examiner had (table 1). This result indicates a greater con-
had previous experience in using both methods. sistency between examiners using the PHP
Since the DI-S method requires the use of an method than between those using the DI-S.
explorer to detect debris, the examiners took Although the correlations were quite high when
special precautions to avoid any unnecessary dis- the dye tablet was used, the interexaminer corre-
turbance of the debris when using this method. lation improved when the liquid dye was
We had some minor difficulty in getting the substituted.
debris in all of the children's mouths to stain A test for significance using Fisher's Z
uniformly well with the dye tablet; occasionally transformation was applied to the difference be-
a child had to repeat the staining procedure be- tween the interexaminer correlation coefficient
fore an accurate PHP score could be calcu- of 0.91 for the PHP with liquid dye and the
lated. For this reason, we calculated the patient
hygiene performance score again on another 0.72 for the DI-S. This difference was found to
group, using liquid dye instead of the dye tablet. be highly significant; the probability that it
This group also numbered 55 sixth-grade chil- could have occurred by chance was less than 1
dren aged 11 to 12; all were from the same school in 1,000. The PHP method with liquid dye was
as those on whom the dye tablet had been used. tested at a different time and with a different
In this part of the investigation, each child was group of children, but in the same school on the
instructed to swish the erythrosin solution (4 same age group. For this reason we believe that
drops of a 6 percent aqueous solution of ery- the results can be directly compared with the

Vol. 83, No. 3, March 1968 261

interexaminer correlation obtained for the judgments required in the PHP method. This
DI-S examinations. The same test for signifi- ease is important because the increased number
cance was applied to the difference between the of subdivisions in the PHP method places more
interexaminer correlations of 0.72 for the DI-S emphasis on the proximal and gingival areas-
and 0.85 for the PHP with dye tablets. the most important areas in peridontal disease
Although this difference was not significant at etiology.
the 0.05 level of confidence, it approached sig- The significance of the difference between the
nificance; the probability that it could have means of the scores recorded by examiner 1 and
occurred by chance was only 8 in 100. examiner 2 in each group was determined by
The intraexaminer correlation coefficients be- the t test for correlated measures. The t scores
tween the first and second PHP examinations and prdbabilities are tabulated in table 1. The
were 0.85 for the first examiner and 0.80 for the difference between the means was not significant
second (table 2). These high correlations dem- at the 0.05 level of confidence in any comparison.
onstrate that an examiner can repeatedly use Although the difference between the means of
the PHP score with a high degree of accuracy. the scores of the two examiners was not sig-
The intraexaminer correlations were slightly nificant in either the DI-S or the PHP method,
lower than the interexaminer. This result is the difference between the means with the DI-S
probably explained by the hour between the method approaches a point of significance, the
first and second examinations, a period in which probability that this difference could have oc-
the children were returned to their classroom curred by chance being 7 in 100.
and were not directly supervised by the investi- The t test for significance was also applied
gators. Although the children were asked not to to the difference between the means of the scores
eat or to otherwise disturb their teeth in any obtained by each examiner on the first and
way, this advice was probably not followed second PHP examination (table 2). Again the
precisely. The investigation with liquid dye difference was not significant for either of the
was not designed to provide intraexaminer examiners at the 0.05 level of confidence.
comparisons. The standard deviations are somewhat higher
The consistently high correlations achieved with the PHP than with the DI-S method
with the PHP method demontstrate that the (table 1). The very high interexaminer and
examiners were able to make the necessary intraexaminer correlations achieved with the
judgments consistently. This ability could have PHP method indicate that these higher values
resulted from the division of the tooth into five are probably the result of the different possible
parts, the use of dye, or a combination of the range of scores for the two methods-0-3 for
two procedures. Making the debris visible with the DI-S and 0-5 for the PHP.
the dye was probably the most important factor. The raw DI-S scores were separated into the
It is important to note, however, that the high ranges of 0-1.0, 1.01-2.0, and 2.01-3.0, and the
correlations demonstrate that examiners had means of the scores listed in each range were
no difficulty in making the increased number of calculated, along with the means of the compa-

Table 2. Intraexaminer comparisons of mean scores for first and second examinations by
PHP method with dye tablet
Mean scores Difference between mean
Number of scores Correlation
Examiner children coefficient (first
examined PHP with dye PHP with dye examination to
tablet- first tablet-second t scores Probability 1 second)
examination examination

1 55 3.367 3.337 0.646 0.521 0.85

2 55 3.391 3.365 .532 .597 .80
1 No significant difference between mean scores at the 0.05 level of confidence for either examiner.

262 Public Health Reports

Figure 2. Means of DI-S (debris index-sim- third and fourth steps of evaluation and re-
plified) scores and of the comparable PHP instruction.
(patient hygiene performance) scores for The high intraexaminer correlations obtained
55 sixth-grade school children 11 to 12 with the PHP method suggest that the effec-
years old tiveness of oral hygiene instruction can be
evaluated with reasonable accuracy by this
5r r measurement. An important advantage of the
DI-S PHP method for this purpose is its ability to
PHP
detect changes in -the critical proximal and
gingival areas. Moreover, since current tooth-
4 brushing instruction includes use of the dye
tablet, the preinstruction calculation of a PHP
score and the subsequent periodic recalculation
require little additional time for the dentist-
3 teacher.
4)
0
The interexaminer correlations of 0.85 and
0.87 for the PHP method with the dye tablet are
0 sufficiently high to justify its use for research
4)
investigations. However, since the interexaml-
2 -
iner correlation for the PHP method with
liquid dye was even higher and the difference
between this 0.91 correlation and the 0.72 correl-
ation for the DI-S proved to be significant, we
I suggest using the liquid dye for research when-
ever possible. When the liquid dye was used,
none of the children's teeth required restaining,
and both examiners were better satisfied with
O L_-.
the more uniform and positive staining.
2.u 1-30 The PHP method was originally developed
DI-S range to provide dental students at the University
of Kentucky with an instrument for assessing
rable PHP scores for children in each group. the effectiveness of the patient's education in
These mean scores are illustrated graphically in oral hygiene (11, 12). In the method's original
figure 2. The mean PHP scores, although higher form, the premolars were examined rather than
in each range, parallel the mean DI-S scores. the molars because the premolars were con-
sidered somewhat easier for dental students to
Discussion assess visually. In our investigation, however,
Dentists and dental health educators have we modified the original method in order to
often taught dental health concepts without fol- examine the same teeth that Greene -and Vermil-
lowing the basic educational structure which has lion assessed in the OHI-S method (10). This
proved effective for the classroom teacher. This modification made possible a more accurate
structure includes (a) determination of pre- comparison with the DI-S method. Also, the
cisely what is to be taught (preparing objec- tooth surfaces examined were those whicl
tives), (b) design of the necessary learning Greene and Vermillion have shown to be repre-
experiences to fulfill these objectives, (c) design sentative of all tooth surfaces (10) .
of a method for determining to what extent In our investigation, the PHP survey was
the objectives have been fulfilled (evaluation), somewhat more complicated to conduct than
and (d) reinstruction based on results of the the DI-S because an additional person was re-
evaluation. To be sure, dentists and dental quired to administer the dye. Nevertheless, the
health educators have used the first two steps PHP method definitely saved time. Partici-
of this educational structure, but seldom the pants in the investigation estimated that the

Vol. 83, No. 3, March 1968 263

PHP examinations were conducted in one-half 3. The PHP method is sufficiently sensitive to
of the time required for the DI-S. Moreover, justify its use in dental health education and
both examiners considered the visual examina- research.
tions in the PHP method considerably easier REFERENCES
to accomplish than the DI-S examinations. (1) Greene, J. C.: Periodontal disease In India: re-
Although the interexaminer correlation of port of an epidemiological study. J Dent Res 39:
0.72 for the DI-S method is sufficiently high for 302-312, March-April 1960.
use in a large epidemiologic study, the higher (2) Greene, J. C.: Oral hygiene and periodontal dis-
correlations obtained with the PHP method ease. Amer J Public Health 53: 6, June 1963.
(3) Lovdal, A., Arno, A., and Waerhaug, I.: Inci-
suggest that it is a more sensitive measure and dence of clinical manifestations of periodontal
can serve a useful purpose in dental health edu- disease in light of oral hygiene and calculus for-
cation and research. mation. J Amer Dent Assoc 56: 21-33, January
1958.
Summary and Conclusions (4) Lovdal, A., Arno, A., Schel, O., and Waerhaug,
I.: Combined effect of subgingival scaling and
The PHP (patient hygiene performance) controlled oral hygiene on the incidence of gingi-
method for assessing oral debris was compared vitis. Acta Odont Scand 19: 537-555, December
with the DI-S (debris index-simplified) as- 1961.
pect of the Greene and Vermillion OHI-S (oral (5) Lovdal, A., Schei, O., Waerhaug, I., and Arno,
hygiene index-simplified). In the PHP A.: Tooth mobility and alveolar bone resorbtion
as a function of occlusal stress and oral hygiene.
method, erythrosin dye is used to stain the Acta Odont Scand 17: 61-77, May 1959.
debris, and the tooth surface is subdivided into (6) Ramfjord, S. P.: The periodontal status of boys
five sections, each of which is assessed for the 11 to 17 years old in Bombay, India. J Periodont
presence of debris. 32: 237-248, July 1961.
Two examiners calculated the DI-S and PHP (7) Russell, A. L., and Ayers, P.: Periodontal disease
and socioeconomic status in Birmingham, Ala-
scores for 55 children 11 to 12 years old. The in- bama. Amer J Public Health 50: 206-214, Feb-
vestigation was structured to determine the in- ruary 1960.
terexaminer relationship for the DI-S scores (8) Russell, A. L.: A system of classification and
and the interexaminer and intraexaminer rela- scoring for prevalence surveys of periodontal dis-
ease. J Dent Res 35: 350-359, June 1956.
tionship for the PHP scores when the teeth were (9) Schei, O., Waerhaug, J., Lovdal, A., and Arno,
stained with a dye tablet. In addition, the inter- A.: Alveolar bone loss as related to oral hygiene
examiner relationship was determined for the and age. J Periodont 30: 7-16, January 1959.
PHP method when liquid dye was substituted (10) Greene, J. C., and Vermillion, J. R.: The simpli-
for the dye tablet. fied oral hygiene index. J Amer Dent Assoc 68:
The results of all methods were subjected to 7-13, January 1964.
(11) Podshadley, A. G.: Preventive dentistry clinical
statistical analysis, and the following conclu- procedures. University of Kentucky, Lexington,
sions were drawn: 1966. Mimeographed.
1. The examiners' results were more consist- (12) Podshadley, A .G.: The implementation of basic
ently alike when they used the PHP method educational concepts in a preventive dentistry
than when they used the DI-S method. teaching program. Proceedings of Workshop on
the Teaching of Preventive Dentistry and Com-
2. Each examiner was able to repeat the PHP munity Health. University of Kentucky, Lexing-
examination with a high degree of consistency. ton, 1967.

264 Public Health Reports

 1iAsynopses

ROMANI, JOHN H. (School of Public Health, University of Michigan): partment's work.

How public health administrators perceive their constituencies. Public Both the variations and similari-
Health Reports, Vol. 83, March 1968, pp. 239-244. ties in perceptions may possibly be
explained by differences in the career
Interviews with 29 health admin- organizations as the top management patterns of the administrators and
istrators from two State health of their units. in the formally defined relationships
departments and one Provincial (Ca- Sixteen of the 29 respondents sug- between their agencies and the chief
nadian) health department in 1964- gested that their department's con- executive of the State or Province.
65 revealed varying perceptions of cerns focused on the public at large. These propositions, however, could
the relationship of the administra- Three of the 13 other respondents not be tested fully with the data
tor's organization to the public which indicated that their department's ac- available. Such testing must await
that organization served. The ad- tivities primarily affected the clien- more extensive study in which vari-
ministrators had widely differing tele it served, and 10 held that the ous factors, such as level of govern-
administrative responsibilities but health professionals were the persons ment, type of function, and political
were considered by their respective most directly affected by their de- setting, are held constant.

FOX, RUTH I. (Westchester County Department of Health), GOLDMAN, one to care for the other children,
JACK J., and BRUMFIELD, WILLIAM A., Jr.: Determining the target and transportation difficulties were
population for prenatal and postnatal care. Public Health Reports, the four chief reasons accounting for
Vol. 83, March 1968, pp. 249-257. late prenatal care.
This study pointed out that socio-
Based upon health priority reasons among this high-risk group of fami- economic factors were as important
or socioeconomic criteria, or both, lies 17 mothers or 3 percent received as health reasons in selecting the
555 mothers and their newborn in- no prenatal care at all, 134 women target population for prenatal and
fants were selected and referred to or 24 percent did not get early pre- postnatal care. The number of
public health nurses for interviews natal care, and frequency of pre- mothers and infants who needed and
and for evaluation by physicians and natal visits averaged two a month obtained the department's post par-
nurses for admission to the West- per mother only during the eighth tum followup care and supervision
chester County Health Department's and ninth month of pregnancy. was doubled when families were
program of post partum followup The mothers' lack of recognition of chosen from the lower social class in
care and supervision. the importance of early care com- addition to identification for health
The survey results indicated that bined with denial of pregnancy, no considerations alone.

PODSHADLEY, ARLON G. (University of Kentucky Medical Center), when liquid dye was substituted for
and HALEY, JOHN V.: A method for evaluating oral hygiene perform- the dye tablet.
ance. Public Health Reports, Vol. 83, March 1968, pp. 259-264. The results of all methods were
subjected to statistical analysis, and
The PHP (patient hygiene per- Two examiners calculated the the following conclusions were
formance) method for assessing oral DI-S and PHP scores for 55 children drawn.
debris was compared with the DI-S 11 to 12 years old. The investigation 1. The examiners' results were
(debris index-simplifled) aspect of was structured to determine the more consistently alike when they
the Greene and Vermillion OHI-S interexaminer relationship for the used the PHP method than when
(oral hygiene index-simplified). In DI-S scores and the interexaminer they used the DI-S method.
2. Each examiner was able to re-
the PHP method, erythrosin dye is and intraexaminer relationship for peat the PHP examination with a
used to stain the debris, and the tooth the PHP scores when the teeth were high degree of consistency.
surface is subdivided into five sec- stained with a dye tablet. In addition, 3. The PHP method is sufficiently
tions, each of which is assessed for the interexaminer relationship was sensitive to justify its use in dental
the presence of debris. determined for the PHP method health education and research.

Vol. 83, No. 3, March 1968 265