Sir,- I was interested in the paper Evaluation of an oral health scoring system by dentists in general dental practice (BDJ 2003; 194: 215–218).

It seems to me, on the information given, that there is a glaring gap in the criteria used for the oral health assessment. According to Table 1 the presence and extent of existing restorations appears not to play a part in the scoring system apart from where recurrent caries is recorded.

However skilfully performed, the placing of a restoration in itself creates an increased risk of future dental problems and must be considered to compromise the patient's oral health. Even small fillings greatly raise the chances of tooth fracture and deep fillings, crowns and bridges are well known to increase the risk of pulpitis and pulp necrosis leading to root canal treatment or extraction.

In general practice today problems caused by the failure and limitations of previous restorative work have now outstripped the problems caused by primary caries. I am astonished that any oral health scoring system could pay so little heed to this factor.

Could this glaring omission be due to a mind set in which a filling is regarded as a perfect 'restoration' which implies a tooth is restored to its original healthy condition? An adequately filled tooth is therefore as healthy as an unfilled one. This is clearly nonsense. We should drop the term 'restoration' completely. A more realistic description would be 'repair'.

The authors respond: We thank Dr Reekie for his comments. The Oral Health Score and its precursor the Oral Health Index are intended to provide a snapshot of the state of a patient's mouth at the time of examination. They are not intended to provide any estimates of the patient's future dental problems. We acknowledge that large cavities and restorations may predispose to tooth fracture1 but we do not agree that small fillings 'greatly raise' the chance of tooth fracture. We agree that a perfect restoration does not restore a tooth to its original healthy state. Nevertheless, the score does reflect failing restorations against the criteria set by Ryge2 and SAMS3.

We feel that the addition of factors which would estimate the chance of failure of a restoration would unnecessarily complicate a scoring system which has recently undergone reproducibility tests which were satisfactory4. To our knowledge, only one index, the Tissue Health Index (THI) in 1987, has attempted to weight the relative amounts of sound tissue in teeth5, and this has not yet found use.

F. J. T. Burke, M. Busby, R. Matthews, S. McHugh, A. Mullins.