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Copyright©2012 British Society of Periodontology
CONTENTS
Introduction .................................................................................................................................................................... 3
Classification of periodontal diseases.......................................................................................................... 4
Risk factors...................................................................................................................................................................... 6
Essentials of periodontal diagnosis................................................................................................................ 7
Radiographs .................................................................................................................................................................. 9
Patient behaviour change: Getting the periodontal health message across...................... 11
Non-surgical therapy .............................................................................................................................................. 13
Smoking and periodontal health .................................................................................................................... 15
The role of hygienists in the management of periodontal health .............................................. 16
Antimicrobials in periodontal therapy.......................................................................................................... 18
Periodontal surgery.................................................................................................................................................. 19
Teeth versus implants in periodontal patients.......................................................................................... 23
Dento-legal aspects of managing patients with periodontal diseases .................................... 25
Who to refer to, when and how ...................................................................................................................... 28
Basic Periodontal Examination (BPE)............................................................................................................ 30
Guidelines for Periodontal Screening .......................................................................................................... 32
Referral proforma...................................................................................................................................................... 34
Revised 2nd version, November 2012
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INTRODUCTION
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Copyright©2012 British Society of Periodontology
The Young Practitioners Guide to Periodontology was conceived as a digest of
what we felt was the most clinically relevant information that would be needed
by a newly qualified graduate to manage patients with periodontal diseases in
general dental practice.
The aim was to present this information in a concise, easily referenced format and to encourage
newly qualified practitioners in a general practice setting, to maintain and further develop skills in
diagnosis, treatment planning and treatment of periodontal conditions.
We hope that you will enjoy using this guide and that you will find it pertinent and usable.
This was very much a collaborative effort and we would like to thank all our contributors:
Paul Baker, Len D'Cruz, Koray Feran, Philip Greene, Mark Ide, Sarah Manton, Mike Milward,
Phil Ower, Kevin Seymour and Jeanie Suvan.
We would also like to thank Henry Schein Minerva for their unswerving support of this project over
the last two years, their endless patience and in particular the guidance and expertise of their
graphics department who designed and printed the guide.
Last but not least we would like to extend our thanks to Johnson & Johnson who very generously
sponsored the production of the first edition of this guide.
Prof Ian Needleman, Editor in Chief
Elaine Giedrys-Leeper, Editor
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4
CLASSIFICATION OF
PERIODONTAL DISEASES
CLASSIFICATION OF PERIODONTAL DISEASES
(based on the American Academy of Periodontology Classification, 1999)
NECROTISING ULCERATIVE GINGIVITIS
(NUG) AND PERIODONTITIS (NUP)
Necrotising ulcerative gingivitis is a painful ulceration of the
tips of the interdental papillae with grey necrotic tissue visible
on the surface of the ulcers. This ma y cause loss of papillae.
There is a characteristic halitosis and submandibular lymph
nodes may be tender and palpable. NUG is common among
smokers and patients wit h poor or al h ygiene. NUP is
diagnosed in the presence of attachment loss.
GINGIVITIS
Gingivitis is plaq ue-induced inflammation of t he gingivae,
recognised by erythema and oedema, bleeding on brushing
or probing, and perhaps detachment of the gingivae from
the teeth. Gingivitis may be exacerbated by various factors.
The hormonal changes associated with pregnancy produce
an incr ease in inf lammatory signs, r esulting in incr eased
bleeding that may bring it t o the attention of t he patient.
Sometimes an individual papilla ma y swell suf ficiently t o
become a pr egnancy epulis. The se verity of pr egnancy
gingivitis reduces after parturition and reverts to the previous
low level of inflammation.
GINGIVAL HYPERPLASIA
Hyperplasia is thickening of the gingivae due to proliferation
of cells wit hin the tissue. It can be induced b y irritation by
plaque and calculus, repeated friction or trauma, and by some
medications, notably calcium c hannel bloc kers used in t he
treatment of hypertension, ciclosporin (used as an anti-rejection
agent for organ transplant patients) and phenytoin, used to
control epilepsy. Mouth breathing can also lead to gingivitis
and gingival overgrowth.
Extensive loss of papillae secondary to NUG in a patient
who smokes 20 cigarettes / day
Pre existing gingivitis aggravated by mouth breathing,
tissue now hyperplastic
Untreated periodontal disease with extensive supra and
subgingival deposits.
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CLASSIFICATION OF
PERIODONTAL DISEASES
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Copyright©2012 British Society of Periodontology
CHRONIC PERIODONTITIS
For most patients, gingivitis does not progress beyond the gingival margins. However 10-15% of people are susceptible
to a mor e destructive process. Susceptibility is t hought to be par tly genetically determined, which explains why
periodontitis can af fect members of t he same f amily. In c hronic periodontitis, plaque left near t he gingival margins
causes gingivitis, which becomes periodontitis as it destroys the junctional epithelium and forms a periodontal pocket,
harbouring plaque inaccessible to the toothbrush and floss. This process usually progresses slowly and is related to
the amount of dental plaque and calculus deposits
AGGRESSIVE PERIODONTITIS
Approximately 1/1000 of susceptible patients suffer more rapid
attachment loss, a small per centage losing more than half of
the bone support by the age of 35. This is known as aggressive
periodontitis, which may be localised to some of the teeth, or
generalised, involving all the teeth. Aggressive periodontitis is
diagnosed from its rapid rate of progress or severe disease in
individuals usually under 35 years. It is characterised by vertical
bone defects on radiographs. There may be very little plaque
or calculus present in some of these patients.
PERIODONTAL ABSCESS
An acut e inf ection in a per iodontal poc ket is a common
occurrence. It is important to distinguish between a periapical
and per iodontal abscess and t his may be difficult if both
conditions are present at t he same time. A bscesses can be
acute or chronic and asymptomatic if freely draining. If there
is no endodontic component, the tooth will be vital.
PERIODONTITIS ASSOCIATED
WITH ENDODONTIC LESIONS
These lesions ma y be independent or
coalescing, and ma y or iginate eit her
from the gingiva or the apex.
Generalised aggressive periodontitis in a 30 year old
non smoker
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RISK FACTORS
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Copyright©2012 British Society of Periodontology
RISK FACTORS
Smoking
The most important known risk factor for periodontitis is cigarette smoking. This is thought to be due to a reduction in
gingival blood flow, impaired white cell function, impaired wound healing and an increased production of inflammatory
substances (cytokines) enhancing tissue breakdown. Many studies have shown that persistent smoking leads to greater
tooth loss and reduced response to periodontal therapy.
Diabetes
Poorly controlled diabetes increases the risk of periodontal diseases. Wound healing is adversely affected by diabetes,
especially if poorly controlled and this can make treatment of diabetic patients more difficult. Assessment of diabetic
control is important and communication with the patient’s doctor can be very useful. Periodontal treatment might
improve diabetic control.
Other known systemic risk factors include hormonal changes, age, stress, and leukaemias.
LOCAL RISK FACTORS
Local risk factors include calculus, enamel pearls, root grooves and concavities, malpositioned teeth, overhanging and
poorly contoured restorations, removable partial dentures, weak contact areas between the teeth resulting in chronic
food packing and deep overbite with direct gingival trauma.
Pregnancy gingivitis with pregnancy epulis buccal to 12 & 13
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PERIODONTAL
DIAGNOSIS
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Copyright©2012 British Society of Periodontology
ESSENTIALS OF PERIODONTAL DIAGNOSIS
LISTEN
Listen to the patient. Most of the time they will tell you what’s wrong with them. Ask open ended questions, the ones
that begin with what, when, where, why, how and who. Then just to be sure, ask the seven questions that reveal all:
1. Do your gums bleed on brushing or overnight?
2. Are any of your teeth loose?
3. Can you chew everything you want to?
4. Do you have a bad taste or smell from your mouth?
5. Do you suffer from pain, swelling, gumboils or blisters?
6. Do you smoke?
7. Is there anything else you would like to tell me?
Use your listening skills, such as observing non-verbal cues, together with attention signals and verbal indications of
understanding, such as affirmatory noises, nodding, back-tracking and clarifying, and restating to gain rapport with
the patient.
PROBE
Probing is essential for periodontal diagnosis and monitoring.
The probing depth at any site dictates the patient's ability t o maintain soft tissue healt h by optimal plaque control.
Probing depths in excess of 3mm are considered to be too deep to be controlled by plaque control with interdental
cleaning alone. These sites should be considered for active periodontal therapy.
The periodontal probe answers two questions:
Where is the base of the gingival crevice? i.e. how far below the gingival margin and how far from the amelocemental
junction? This is a measure of periodontal attachment loss, but remember that the recession is added to the
probing depth to give the clinical attachment level. This is a better parameter to measure for long-term monitoring.
Does the tissue bleed when touched?This is a measure of inflammation, not necessarily active tissue destruction.
No bleeding on probing means health (except in smokers, where it is hidden). An absence of bleeding on probing from
the bottom of the pocket/crevice predicts periodontal stability.
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PERIODONTAL
DIAGNOSIS
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Copyright©2012 British Society of Periodontology
There are different types of probe.
The BPE probe is used to screen every new and recall patient for
periodontal diseases and enables you quickly to identify patients with
periodontal diseases.
A standard periodontal probe is necessary for the detailed data
collection you need to enable you to monitor the progress of specific
sites. Popular types include the 10mm Williams probe and the 15mm
UNC probe. If the situation is not improving retreatment, different
treatment, or referral to a specialist should be considered and the
decision recorded in the patient’s notes.
RECORD
Record your findings on any pre-printed chart, computer, official GDS
perio chart, or modified dental record card. Include as a minimum:
probing depths, recession, bleeding on probing, plaque and mobility.
You need this written record to guide your therapy to the affected sites,
monitor treatment, show the patient how well they’ve done, and to
resist a com plaint that you didn’t diagnose and treat properly. Also
note the fact that you explained the problem to the patient and offered
appropriate treatment or referral.
EXPLAIN
Every time a patient willingly consults you there is a window of
opportunity for you to tell them something that will improve their dental
health. If you can find out what is important to them about their teeth
you may be able to engage t heir cooperation and change their
behaviour. Try to translate your dental knowledge into words that the
patient can underst and. For example, rather than speaking about
pocket depths, or bone-loss try offering no blood on the pillow, no
bad taste, sweeter breath, a stronger bite, keeping their teeth and not
having to wear dentures.
How much information you record will be guided by your BPE score:(see pages 30-32)
BPE 0 – 2 The BPE plus some measure of plaque will
be sufficient.
BPE 3 Probing depths of the affected sextants
before and after treatment should be
recorded to assess response.
BPE 4 and * Probing depths of all the teeth should be
recorded before treatment to guide therapy
and to assess post-treatment response.
BPE probe, 10mm Williams and UNC 15 probe
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RADIOGRAPHS
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Copyright©2012 British Society of Periodontology
RADIOGRAPHS
Appropriate radiographs form an essential part of your clinical records. They will help you to make an initial diagnosis
and to monitor the stability of periodontal health.
WHEN TO TAKE RADIOGRAPHS
This guide does not aim t o dict ate the choice of radiographs as each patient will have their own unique
clinical presentation.
Initial presentation:
Appropriate radiographs (alongside a pocket chart) should follow an initial examination such as the Basic Periodontal
Examination (BPE) and be select ed according to the clinical pr esentation. As a gener al guide, r adiographs for
periodontal assessment will be needed with BPE codes 3, 4 or *.
Recall maintenance:
Radiographs can also be useful to track changes in bone levels over time, for example in areas of furcation involvement
or in patients where you are uncertain as to the aggressiveness of the disease process. Clinical need should determine
the frequency of repeat radiographs. Bone loss is slow to become apparent on sequential radiographs. This needs to
be balanced with the need for adequate monitoring of sites that may not be stable or if you are considering more
complex periodontal or other types of treatment.
WHICH RADIOGRAPHS?
Horizontal Bitewings
These r adiographs ar e lik ely t o be t aken r outinely f or assessing car ies.
They may also give early warning of localised bone loss and the presence of
subgingival calculus. The normal positioning of the film should automatically ensure
a non-distorted view of bone levels in relation to the CEJ’s.
Vertical Bitewings
Correctly positioned, this type of radiograph should also give a non-distorted view of
bone levels in r elation t o CEJs, in opposing ar ches. However t hey can onl y be
positioned accurately in patients with quite tall palatal vaults. Selected paralleled
periapicals may be more appropriate in cases with more difficult access and where
the teeth are restored, in order to assess apical status.
Paralleled periapicals
The “gold standard” radiograph for periodontal cases. Correctly positioned this
radiograph will give an accurate, non-distorted two dimensional picture of bone levels
in relation to both CEJs and total root length. This technique involves the use of a
paralleling device, of which there are several on the market. These devices take the
guess work out of radiography and you will achieve better and more consistent results.
Visualising root anatomy in its entirety can be very useful in assessing bone le vel in
relation to total root length in:
• Assessing prognosis
• Helping to assess furcation involvements
• Identifying possible endodontic complications
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RADIOGRAPHS
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Copyright©2012 British Society of Periodontology
Panoramic radiographs
A panoramic radiograph may be indicated if there are symptomatic third molars. However, there is no case for
routine screening with panoramic films. The yield of information is low for screening given the radiation dosage.
PERIAPICAL VS. PANORAMIC RADIOGRAPHS
The choice of panoramic vs. intra-oral periodical radiographs may depend on a range of factors including preference
and availability. In general, full mouth periapical radiographs using a paralleling technique, give more accurate and
detailed assessment of periodontal bony defects. In contrast a good quality panoramic radiograph is quicker, less
uncomfortable, and may provide a useful assessment of bone levels and other pathologies. With both techniques
appropriate collimation must be considered, in order to reduce the patient received radiation dose to a minimum. Ideally
this involves using some form of rectangular collimation for periapical radiographs and field size collimation for DPT's,
designed specifically to reduce the dosage to the orbits and parotid glands.
RADIOGRAPHIC PERIODONTAL ASSESSMENT
Medico-legally it is important that you record in the clinical notes what
you have seen on the radiographs. You should make some general
comments about the image quality.
Periodontally, radiographs should be assessed for:
• Degree of bone loss: If the apex is visible then bone loss
should be measured as %.
• Type of bone loss: e.g. angular defects vs. horizontal loss;
furcation involvements.
• Other features: e.g. perio/endo lesions; noticeable calculus
deposits; widened periodontal ligament spaces; abnormal root
length or root morphology; overhanging restorations.
The radiographic information should be combined with the clinical data and patient interview for treatment planning.
The radiographs will be par ticularly helpful f or assessing expectations of treatment for you, your hygienist and f or
your patient. For example:
• If there are multiple angular defects > 3mm deep you should not expect dramatic pocket
reductions with simple non-surgical therapy.
• Furcation involvements will limit the effectiveness of non-surgical therapy alone and you and your
hygienist should consider primarily ultrasonic instrumentation in these areas, to be sure of
gaining reasonable access.
• Multiple angular defects and furcation involvement suggest a complex treatment need and
consideration for referral.
For detailed guidance on which radiographs to take see: Faculty of General Dental Practice (UK) Selection Criteria
for Dental Radiography, 2nd edn, London: Faculty of General Dental Practitioners (UK) 2004.
Paralleled periapical Film holder for paralleling periapical films
A 'furcation triangle' this may signify
furcation involvement
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PATIENT
BEHAVIOUR CHANGE
PATIENT BEHAVIOUR CHANGE:
GETTING THE PERIODONTAL HEALTH MESSAGE ACROSS
Successful treatment of periodontal diseases involves establishing a close w orking partnership with the patient. This
partnership denotes that the patient is actively involved in the therapy rather than just being a passive receiver of treatment.
Lifestyle behaviours such as tobacco use, diet, and self-performed plaque control can have a significant impact on
both healing responses to initial subgingival debridement and any subsequent treatment. Negotiating a change in
such behaviours might therefore be required. In addition, periodontal treatment plans can involve a number of
appointments or procedures over a period of months or years, so patient compliance becomes an important part of
your patient management.
Behavioural sciences research has demonstrated that lifestyle behaviour change occurs from within the patient, not the
practitioner. Motivation is not something that can be given or taught. The key is patient activation, using communication
techniques that stimulate or engage the patient to realise the required information or skills required to reach the desired
goal. For instance:
A) The use of open questions to place the patient in control of the interaction e.g.
Closed Question: How often have you managed to use the interdental brushes?
Open Question: Tell me about how you managed with the interdental brush?
(Note: This is complimentary and positive as you give the benefit of the doubt that they have used it, it is nonjudgemental
as you have asked for any information about how they are doing, giving them the freedom to share their
perception. Usually, they will give the information you are looking for, that is, how often they used it.)
B) Listening, then delivering information or instruction in small doses according to
patient requests or interest
C) The use of reflective listening to assist a patient in realizing any discrepancy
between their current behaviour and that necessary to reach a goal they agree
on e.g.
The patient may have expressed their chief concern as the whiteness of their teeth. They may mention
that they are too tired at the end of the day to go through the entire recommended routine. Reflective
listening recognises their concerns and presents back to them the discrepancy in their values:
“I can see that you have a busy schedule and are very tired at the end of the day. However, I
also see that you really care about your teeth, especially the appearance and the whiteness.
Would you agree?” The patient may respond by saying “Yes, I really wish my teeth looked
whiter”. The clinician then has the opportunity to remind the patient that with a small increase in
effort they could significantly influence the appearance of their teeth.
D) A guiding approach rather than directing, that is, coaching rather than lecturing
A patient has admitted to irregular interdental cleaning and this has been confirmed by your clinical
examination.
A directing statement:
“In order to decrease the bleeding and stop the gum disease, it will be necessary to use the
dental floss or interdental brush regularly”.
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A guiding statement:
“With the use of dental floss or interdental brushes you would have the possibility to
decrease the inflammation in your gums significantly. Are you familiar with both of these
devices? Can you imagine which one you might find easiest to give a try in your daily
routine?” OR “What has been your experience in the past with these aids? Did you find one
more convenient or easier than the other?
There are many words or statements that can be used. The importance is that a directing approach is one sided with
no allowance for choice from the patient. The guiding approach allows the patient to express a preference.
E) Maintain an adult to adult conversation, avoiding adult to child interaction styles
F) Position patient upright during discussions at or just above your eye level
A few key points to remember about behaviour change are:
1. Learning a skill can take minutes or hours, however, changing a habit takes weeks
or months
2. Instruction is meaningless and easily forgotten without understanding the context in
which it fits
3. A few appropriately selected and delivered words are more effective than a full lecture
delivered with the hope the patient will grasp the relevant details
4. Repeating instructions multiple times will not increase motivation, in fact, it may offend
and decrease motivation
5. Offering assistance, and seeking permission to give knowledge or teach skills facilitates
patient ownership of the task (Hint: The natural response to force is resistance)
6. Motivation is not static but can vary as an individual is affected by other life related
factors and stresses
Above all, remember that delivering a plaque control message, or any message directed at lifestyle behaviour, is not
a procedure but an ongoing conversation between you and your patient throughout the time they are with you in
your practice.
PATIENT
BEHAVIOUR CHANGE
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NON-SURGICAL
THERAPY
NON-SURGICAL THERAPY
Modern concepts of non-surgical therapy suggest:
Effective patient performed oral hygiene is critical to success (see: Patient behaviour change: Getting the plaque control
message across).
• The effects of oral hygiene advice are short-term and regular advice and encouragement is
needed to achieve long-term change.
• Attached plaque biofilms and non-attached microflora in the gingival sulcus and periodontal
pockets should be regularly removed.
• Plaque retentive factors such as calculus and restoration overhangs should be eliminated.
Through this, we are able to:
• Control the bacterial challenge characteristic of gingivitis or periodontitis.
• Address local risk factors.
• Minimise the effect of systemic risk factors.
This is achieved by:
• An alteration or elimination of putative periodontal pathogens.
• Resolution of inflammation.
• The creation of periodontal health.
This will ultimately decrease the likelihood of disease progression.
Non-surgical therapy, is highly effective for most patients with early to moderate disease. Many studies have shown
that disease progression is arrested so that probing depths may decrease through resolution of inflammation, often
accompanied by recession. Obviously, these results are only achieved along with the patients co-operation, particularly
with their home care and if applicable, smoking cessation.
Non-surgical debridement appears to be easy but is a difficult skill. No differences in effectiveness have been
demonstrated between hand instruments or powered scalers (ultrasonic and sonic). To achieve great results the key
elements (other than oral hygiene) are:
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Gingival
appearance
before
subgingival
debridement
Gingival
appearance
4 weeks
after
subgingival
debridement
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NON-SURGICAL
THERAPY
Good scaling skills
Next time you take out a periodontally involved tooth with plenty of
subgingival calculus on the root surface, try to scale it clean and
smooth and see how well you do, both in terms of how much you
remove and how long it takes. It’s far harder to do this in the mouth,
blind! You could make up some models like these for you and your
team to practice debridement.
Good, well maintained instruments
Universal and Gracey curettes are excellent but to use them you will
need to be skilled in sharpening them and have a knowledge of which
instrument works best in which area.
Most instrument manufacturers can help you with this. A wide variety of sonic and ultrasonic tips are now available
for access to deep pockets and furcations and you will need to keep the device tuned for optimum efficiency.
TIME
It is impossible to give rigid guidance but for moderate to deep pockets, skilled clinicians can expect to achieve good
results spending about 3-5 minutes per tooth on debridement. Furcation involvements, root grooves and infrabony
pockets will make debridement more difficult. Whether using ultrasonic or hand instruments carrying out all the
necessary debridement in one or two long appointments can be as effective as spreading the treatment over
4 appointments, although operator and patient fatigue need to be considered.
SIDE-EFFECTS
The patient should also be made aware of any potential downsides of the treatment e.g. increasing gingival recession,
increased sensitivity and food packing and the expected cost of the treatment should be included in the overall
treatment plan.
CHEMOTHERAPEUTICS
Antiplaque agents e.g. chlorhexidine, delmopinol or essential oils are useful to manage acute periods when
cleaning is difficult but are not needed as a routine. Subgingival irrigation with chlorhexidine does not appear to have
any clinical benefit.
Some patients value the ‘cosmetic’ effect of mouthrinses and there is little harm in using them for such a purpose.
However, there can be side ef fects such as er osion. Effective subgingival debridement is t he mainstay of activ e
periodontal therapy and as you will see in figures 15 & 16 can produce reliably good results in patients who practice
good plaque control.
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Copyright©2012 British Society of Periodontology
Tip of mini Gracey curette neatly engaging
distal root groove and calculus
Site specific mini Gracey and universal
curettes with Arkansas stone
Variety of ultrasonic tips for furcations
and different sized pockets
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SMOKING AND
PERIODONTAL HEALTH
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SMOKING AND PERIODONTAL HEALTH
Tobacco use is directly related to a number of medical problems including cancer, low birth weight babies, pulmonary
and cardiovascular problems. As health care professionals, therefore, we should be prepared to grasp any
opportunity to encourage patients in our care to quit smoking. The provision of periodontal care can provide a
perfect opportunity for delivery of this sort of health care message as you and your hygienist will be interacting with
your patients over several appointments and over an extended period of time.
Smoking is one of the most significant risk factors in the development and progression of periodontal diseases. Smokers
are up to six times more likely to show periodontal destruction than non-smokers.
There is a dose related effect.
Smoking cigars shows a similar risk. Smoking cannabis regularly carries a similar risk to that of cigarettes.
A number of studies have shown that smokers do not show as good a response to periodontal treatment even in the
presence of good oral hygiene as non-smokers and that smokers who have regular professional periodontal
maintenance are twice as likely to lose teeth over a five year period. If patients stop smoking there is some evidence
to show that the periodontium will be back to normal in terms of its response to treatment after three years.
PERIODONTAL MANAGEMENT
Setting patient expectations
You should make your patients fully aware of the effects that smoking will ha ve on their periodontal care and most
importantly long-term tooth mortality.
Quit smoking encouragement
How you and your hygienist approach this will depend on whether your patient is a contented smoker, is contemplating
quitting or whether they have tried and failed to quit in the past. Many PCT’s have quit smoking services who would
be happy to provide practical guidance in quitting or you can direct patients to the NHS smoking helplines.
Stopping smoking is a pr ocess no t a single e vent and ma y r equire se veral ser ious att empts bef ore success.
Every failed attempt, therefore should not be viewed as a failure but simply another mile post on what may be a
lengthy journey.
You should note down your patient’s current self-reported smoking status at every regular recall appointment.
Periodontal treatment
The mainstay remains regular, high quality supra- and subgingival debridement with adjunctive local anaesthesia as
required and ongoing encour agement with maintaining good plaq ue control. Remember, smokers with gingival
recession are at increased risk of developing root caries, so careful monitoring of diet and the caries status together
with the provision of appropriate fluoride adjuncts may also be important for this group of patients.
Given the reduced healing capacity of the periodontal tissues in smokers, periodontal management of these patients
tends to avoid any surgical intervention and in particular any form of hard or soft tissue grafting. You should consider
referral for non-responding patients.
Apart from your local PCT, other organisations that offer help, advice and resources are:
http://smokefree.nhs.uk Free NHS quit smoking specialist services
http://www.dh.gov.uk “Smokefree and smiling: helping dental patients to quit tobacco” May 2007
http://www.nice.org.uk Summary of smoking cessation guidance March 2006
http://www.gasp.org.uk/
http://www.quit.org.uk/
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HYGIENISTS IN THE MANAGEMENT
OF PERIODONTAL HEALTH
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THE ROLE OF HYGIENISTS IN THE MANAGEMENT
OF PERIODONTAL HEALTH
Periodontal treatment can be very successful and your dental hygienist is the most important resource that you have
to help make this happen. But remember that he/she can only work to the treatment plan and prescription that you
have formulated for the patient. Highlighting areas that your hygienist will need to concentrate upon will be very useful
when it comes t o their organising how they are going to spend t heir time at an y one appointment, and ho w many
appointments may be needed to achieve the treatment objectives. A simple proforma that you can fill in for the hygienist
will help to save time. An example of a treatment prescription could be as follows:
Diagnosis Localised advanced periodontitis
General prognosis Questionable, more bone loss than expected for age
Risk factors Smoking 15 / day. 10 pack years
Oral hygiene instruction Single tuft interspace tb, subgingivally to all 5mm + pd. Electric
toothbrush. Appropriate sized interproximal tb and /or brushsticks
Preventive advice Twice daily use of desensitising toothpastes with occluding agents to
reduce dentine hypersensitivity and reduction of soft acidic drinks
Smoking cessation
encouragement Y
Debridement Full mouth subg debride all pd 5mm or greater with LA. Ultrasonics
to furcations. Root grooves mesial 14, 24. 2 long appointments not
more than 3 weeks apart.
Reassess 3 months after debride complete.
If you and your hygienist are both measuring pocket depths then be aware that any change < 2mm could be due to
measurement error. However, the consequence of a 2mm loss of attachment could affect the management of a patient
if a furcation is involved, or if attachment loss is already advanced.
For clinical results that work, good lines of communication need to be established between the dentist and the hygienist,
otherwise the objectives and benefits of any therapy may not be realised. It is important that the hygienist understands
the expectations of the dentist for the patient and, conversely, that the hygienist lets the dentist know how the patient
has responded to treatment as well as the level of compliance. Good record keeping on both sides is vital. An entry
just saying ‘scale and polish’ does not tell the dentist anything about the level of oral hygiene, or the health of the
gingival/periodontal tissues.
The patient should understand why he/she has been referred to the hygienist and the benefits that might reasonably
be expected from the treatment e.g. less bleeding on brushing; reduction in halitosis; reduction in tooth mobility;
appreciation of why good oral hygiene is important to maintain subgingival health.
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HYGIENISTS IN THE MANAGEMENT
OF PERIODONTAL HEALTH
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Copyright©2012 British Society of Periodontology
SUPPORTIVE MAINTENANCE
In general practice you should expect that most of your non-susceptible patients (BPE 0 – 2) will remain periodontally
stable and healthy with a visit to the hygienist once every 1 – 2 years. For those patients whom you have diagnosed
with per iodontitis, maint enance af ter t he initial per iodontal t herapy can be cr ucially im portant in maint aining
periodontal stability.
Evidence shows that even with good home care, a potentially pathogenic bacterial flora can re-establish itself at the
base of a 5mm + poc ket three months after a thorough subgingival debridement. This is one r ationale for the three
monthly recall interval in at-risk periodontal patients. Another motive is the need for oral hygiene coaching because
of the short-term effects for most people.
Remember that certain sites will be more difficult to manage than others:
• furcations
• pockets associated with infrabony defects
• pockets associated with root grooves, enamel projections, chronic food impaction
Over time, in patients with good compliance and with demonstrably stable supra- and subgingival environments,
maintenance intervals may be extended. This implies that you, with your hygienist, are monitoring both the patient (have
they stopped smoking?/ what have the general plaque levels been like over a series of appointments?), and specific
sites of concern (has there been repeated bleeding on probing at a specific site?/ has the probing depth increased by
2mm at a specific site?).
Team working in the practice will help you gain maximum benefits from your staff for your patients.
The British Society of Dental Hygiene and Therapy at www.bsdht.org.uk is the parent organisation for dental hygienists
and if you need to, you can remind yourself of the tasks that hygienists can undertake for you by viewing this website.
Long shanked gracey curette in action
subgingivally
Single tuft interspace toothbrush used with
a subgingival toothbrushing action
Electric brush in action
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ANTIMICROBIALS IN
PERIODONTAL DISEASE
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ANTIMICROBIALS IN PERIODONTAL THERAPY
Antimicrobials have very little place in periodontal therapy. It is important to be aware that bacterial antibiotic resistance
has been increasing in the population over the last few decades. As prescribing clinicians it is essential that we limit
the use of antibiotics to situations where a clear evidence base exists that patients with specific conditions will benefit.
Wherever possible the old principals of ‘drainage of infection’ and ‘removal of cause’ are still pertinent, and if this can
be achieved then the use of antibiotics can be avoided in the management of patients that are systemically well.
In terms of periodontal disease there are actually few indications for using systemic or local delivery antibiotics.
However there are certain limited circumstances where their use is appropriate and will assist in periodontal
disease management.
SYSTEMIC ANTIBIOTICS
There is no indication for using systemic antibiotics to manage chronic periodontitis.
Aggressive periodontitis: Systemic antibiotics may be used alongside conventional subgingival debridement.
However, treatment without antibiotics can be successful and should be tried first. If non–surgical treatment without
antibiotics has been unsuccessful you should consider referral for specialist care. A number of antibiotic regimes have
been proposed but recent data suggests amoxycillin 250mg TDS with metronidazole 200mg TDS for 7-10 days is
the combination of choice starting on the day of the first debridement and covering the patient for any other
debridement appointments.
Necrotising periodontal diseases: These conditions are relatively rare, but when diagnosed part of the management
regime should include the use of metronidazole 200mg TDS for 3 days as well as removal of risk factors associated
with the disease (e.g. smoking, poor oral hygiene, poor diet). Metronidazole is used for its spectrum of action against
the fuso-spirochaetal anaerobes associated with this disease.
Periodontal abscess: It should be stressed that single periodontal abscess should be managed by drainage of the
abscess (either with subgingival debridement or incision) and no t by use of antibio tics. However if there is systemic
involvement (fever, malaise) and facial swelling antibiotics may be helpful in initial management but only when
combined with debridement.
Local delivery antibiotics
There are a range of local delivery antibiotic systems available. However their
clinical benefits are unclear. Use of these systems should only be considered after
a course of non-surgical treatment, and certainly not as first line periodontal
treatment. Local delivery antimicrobials are an adjunct to conventional subgingival
debridement and not a substitute for it.
Their use can be consider ed in a case wher e isolated periodontal pockets have
failed to respond to conventional non-surgical treatment on a number of occasions,
there is no de tectable calculus at t he site, and where the patient is maint aining
good levels of plaq ue control. However, t he benef it resulting from t heir use
appears modest. If a site is not responding despite good plaque control, referral
should also be considered.
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PERIODONTAL
SURGERY
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Copyright©2012 British Society of Periodontology
PERIODONTAL SURGERY
PERIODONTAL SURGERY IN THE TREATMENT OF CHRONIC PERIODONTITIS
Periodontal flap surgery
The principles of management of chronic periodontitis revolve around the control of bacterial plaque. The two key
aspects of this are supragingival plaque control undertaken by the patient and subgingival plaque control performed
by the dental professional. Periodontal surgery is another tool in the armamentarium of the clinician in achieving
such aims.
Periodontal flap surgery is almost invariably performed after a course of thorough non-surgical treatment. It can only
be considered in the presence of optimal plaque control by the patient, and an associated healthy superficial gingiva.
Following a course of non-surgical treatment in cases of moderate to advanced disease, these two prerequisites may
be present where there are still residual increased probing depths and signs of inflammation within the depths of the
pocket, specifically bleeding on probing. Most patients requiring periodontal surgery should be referred for specialist
care unless you have the relevant expertise and experience.
The principle aims of periodontal flap surgery are:
Access for debridement
Removal of subgingival root surface deposits may be difficult where the pockets are deep or where the access is poor,
in particular molar teeth with complex root anatomy or furcation involvement. With a periodontal flap raised, the root
surface can be visualised and cleaned until free of deposits. Secondly, there is scope for pocket reduction or elimination
by means of reshaping the bone and soft tissues during surgery. The aim is to leave the patient with a mouth that is
easier to maintain, both by them and by the professional during maintenance.
Inaccessible mesial furcation 26
Grade 2 mesial furcation on 26 fully
visualised via an appropriate flap
Appropriate bone recontouring to eliminate
the bone crater
Mesial aspect of 26 and furcation now
accessible to the hygienist and the patient
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PERIODONTAL
SURGERY
Regenerative surgery
Regenerative surgical procedures aim to promote the regeneration of the periodontal tissues that have been lost
through periodontal disease. Conventional periodontal flap surgery heals primarily by the formation of a long junctional
epithelium. The aim of regenerative surgery is to promote the re-growth of cementum, periodontal ligament and alveolar
bone. Several regenerative approaches are currently in use. Products are available which involve the use of various
filler materials to ‘graft’ the defect or enamel matrix proteins to stimulate the formation of new attachment.
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Copyright©2012 British Society of Periodontology
Infrabony defect distal to 36 after
thorough open debridement
Filler covered with membrane
Before and after radiographs of a regeneration surgery
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PERIODONTAL
SURGERY
Crown Lengthening
Crown lengthening surgery involves the removal of the periodontal tissues to expose more clinical crown. This may be
limited to the soft tissues where the thickness of the tissues is excessive. In such cases this can be performed by scalpel,
electrosurgery or soft tissue lasers.
Where there is a normal dento-gingival anatomy, the position of the soft tissue is, to a large degree, dictated by the
position of the underlying bone. Soft tissue removal alone will result in healing by secondary intention and tissue
rebound, losing the amount of crown that was surgically exposed. In such cases a lasting response can only be achieved
by shifting the entire dento-gingival complex apically. This requires bone removal, and to access the bone a periodontal
flap must be raised.
Crown lengthening can be performed to facilitate restorative dentistry. Subgingival margins may result from oblique
vertical fracture of a cusp or from the removal of extensive caries. Such situations provide a challenge to achieve high
quality restorative dentistry. Isolation for bonding adhesive dental restorative materials or impression taking may be
hampered by bleeding from the sulcus, or adequate coronal tissue for mechanical retention of extracoronal restorations
may not be present. This may also occur following significant amounts of tooth wear.
Aesthetic crown lengthening uses the same techniques but applied to a different situation.
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Copyright©2012 British Society of Periodontology
Final restoration with adequate height for
abutment/pontic joint + space for an
interproximal brush
16 with inadequate resistance and retention
form mesially
Increased crown height achieved by
internally thinning the flap and appropriate
bone recontouring/removal
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PERIODONTAL
SURGERY
In patient's who have a high smile line and wher e the anatomical crown is still par tially hidden by an excess of soft
tissues (as in cases with delayed passive eruption) a simple gingivectomy may be enough to achieve the desired result.
In patient's where there is an excess of both soft and hard tissue (as in cases of tooth wear with compensatory over
eruption) careful planning with diagnostic wax ups and a periodontal flap procedure with appropriate bone removal
may be required to achieve correct tooth and gingival dimensions. If crowns or veneers are required as part of this
treatment you will need to wait four to six months for the new gingival contour to stabilise.
Management of recession. Mucogingival surgery.
There are a number of reliable periodontal surgical techniques available to manage mucogingival problems such as
gingival recession. The surgery is technically demanding but can improve aesthetics and long-term stability.
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Copyright©2012 British Society of Periodontology
Excess soft
tissues 33-
43. Alveolar
bone at adult
level
Apically
repositioned
flap with
internal
thinning of
the flap to
preserve a
good zone of
attached
keratinised
tissue
1 year
healing
Buccal flap
coronally
repositioned
to cover
underlying
graft
Precision cut
buccal flap +
connective
tissue graft
harvested
from palate
Buccal
recession
with minimal
attached
keratinised
gingivae
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TEETH VS
IMPLANTS
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Copyright©2012 British Society of Periodontology
TEETH VERSUS IMPLANTS IN PERIODONTAL PATIENTS
Periodontal treatment in adults that suffer from chronic periodontal disease should be aimed at maintaining a healthy,
functional and aesthetic dentition as far as possible. It is desirable both physiologically and psychologically to maintain
the patient's own natural teeth to function throughout their life. Good quality non-surgical and surgical treatment should
be attempted first where possible.
However, where teeth are not treatable, dental implants may be one replacement option. The decision as to when to
make the transition from periodontal treatment and maintenance to implant treatment is a complex one.
Patient selection.
Motivating patients to maintain the required degrees of oral hygiene is still one of the great challenges in modern
dentistry. Patients unable or unwilling to maintain their oral hygiene when they have natural teeth present are unlikely
to consistently improve their oral hygiene habits in the presence of implants. Implants are as susceptible to peri-implant
inflammation and tissue breakdown as teeth. The transition to implants in these patients is unlikely to meet with great
long-term success if plaque-induced inflammation cannot be controlled. Implant integration failures and long-term bone
loss are higher in patients with uncontrolled periodontal disease around remaining teeth.
In patients wit h good or al hygiene and r egular att endance t he f ollowing should be consider ed as r easons t o
replace teeth:
Individual teeth where periodontal treatment and regeneration techniques are impossible
These might include deeper pockets with complex anatomy e.g. furcations; deep infrabony defects which are showing
progressive attachment loss and sym ptoms. Clinically this may be seen as incr easing bone loss on r adiographs,
increasing mobility or fremitus in function, or progression to a perio/endo lesion.
Be aware that in cases where there has already been periodontal bone loss grafting techniques may be required to
allow implant placement later.
Posterior bite collapse with loss of posterior teeth or loss of anterior
guidance through migration of incisors and canines
In such cases implants can provide a solid occlusal platform and guidance mechanism.
Timing in these cases is important but difficult. Periodontal splinting after therapy is usually a first line of treatment in
such cases but medium t o long-term instability might call f or replacement of the posterior teeth to maintain a stable
occlusal scheme.
Extensive bone loss throughout the whole dentition requiring a clearance
This may be seen in cases of advanced or aggressive periodontitis or long-term neglect. In young adult patients showing
extensive bone loss early, specialist-level comprehensive periodontal treatment should be attempted first. Refractory
cases pose a difficult decision where clearance and hence elimination of the pocket flora coupled with maintenance
of remaining bone for future implants may be the correct early treatment in extreme cases. However it should also be
remembered that all implants and especially their superstructures do not last for ever.
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TEETH VS
IMPLANTS
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Copyright©2012 British Society of Periodontology
Patient with generalised aggressive periodontitis and multiple perio/endo lesions
Clinical presentation with composite
temporary splinting
DPT on completion of treatment
Completed case with selective extractions and
implant supported metal ceramic superstructures
Rules of thumb:
• You should consider referral for a specialist opinion on options for periodontal therapy unless
you are very clear that it will not be effective. The patient should also understand the
implications of this and you should document these discussions and agreements.
• An implant is not a substitute for a tooth. It is a substitute for NO tooth.
• Prefer teeth over implants unless time and cost of maintenance is prohibitive and function,
stability and aesthetics deteriorate despite good treatment.
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DENTO-LEGAL ASPECTS
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Copyright©2012 British Society of Periodontology
DENTO-LEGAL ASPECTS OF MANAGING PATIENTS WITH
PERIODONTAL DISEASES
Good documentation is essential for effective periodontal care and record keeping should be designed primarily
to facilitate patient management. An additional benefit of such documentation will be compliance with medicolegal
requirements.
Left untreated, periodontal disease is t he source of one of t he fastest-growing allegations in t he dento-legal field.
Currently there is a level of expectation that tooth loss is avoidable. There can be strong emotional implications to
losing teeth.
Inadvertent criticism
Legal problems are particularly likely to occur when a patient who has regularly attended the same dental practitioner
over many years, for one reason or another, sees a second dentist.
Sometimes the second dentist may simply make an inadvertent comment:
• ‘It must have been present for years’
• ‘More teeth might well be lost in the foreseeable future’
An accurate presentation of your patient’s periodontal condition is important. However, unless you are in possession
of all the facts, framing the description of your patient’s current condition in a more circumspect way might avoid
problems. For example:
• ‘It’s very difficult to say how long you have had gum problems as they progress at different
rates in different people. When gum disease first appears and how fast it progresses can
depend on other medical conditions that you may have, certain medicines you may be taking
and smoking can all affect your gums and sometimes it may just be a genetic risk factor. We
can talk about your current oral and general health right now based on my thorough
examination and diagnosis. Then we can talk about how we can bring your mouth back to a
state of health.’
• ‘Of course you want to be sure that you have had proper dental care in the past. However
gum disease appears at different times in different people and progresses at different rates in
people and at differing rates over a person’s lifespan. It’s impossible for me to say when
your gum disease may have first become apparent. What I can tell you is what I can see
today and what we can do about it to achieve the best dental health possible for you.’
Whilst it is important to relate the facts of a patients presenting condition to them honestly and openly it is equally
important not to be judgemental or comment about care and treatment you have yourself not directly provided.
In your own practice there are a number of ways in which you can reduce the risk of having to face an allegation of
sub standard periodontal care in the future.
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DENTO-LEGAL ASPECTS
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Clinical records
It is vit al t o sho w fr om t he patient ’s records and
radiographs, that any periodontal disease present in
their mouth has been identified, recorded and
monitored appropriately. Alongside this, the records
should show clearly that the patient has been informed
of the nature and extent of their periodontal disease.
If some teeth have a doubtful prognosis, then this too,
should be explained carefully to the patient in terms
appropriate to their level of understanding, and this
fact recorded in the notes. Options for care should be
discussed and documented together with their benefits
and risks.
The extent and content of the records should reflect
the severity of the case as discussed in the section on
diagnosis. Documentation should be designed to allow
adequate monitoring of periodontal health and oral
hygiene needs and responses.
Identifying and recording risk factors
There are a number of well known risk factors that can effect the progression of periodontal disease, notably smoking,
diabetes and certain medications. It is important that these are recorded in a comprehensive medical history and
monitored over time – remember that the interplay of these factors is dynamic .
When they are identified, the record also needs to show that they were discussed with the patient and acted upon.
Referrals
Specialist advice or treatment should be considered from the outset in severe cases or after an inadequate response
to initial therapy or in cases involving more complex restorative planning (see “When to Refer”). Bear in mind that
in cases of severe periodontal disease, it is much easier for patients to allege, after the event, that they would have
preferred a referral for specialist care. Similarly, one should minimise any delay in a referral. Record carefully any
discussions with the patient or referral practitioners including telephone conversations. Always keep copies of
referral correspondence.
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DENTO-LEGAL ASPECTS
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Copyright©2012 British Society of Periodontology
Expectations and responsibilities
Whilst periodontal treatment is usually highly successful in the long-term for early-moderate disease, some localised
recurrence is not unusual. Furthermore, accurate determination of prognosis is unreliable at initial presentation. The
limitations and uncertainties of periodontal therapy should be communicated to your patient to achieve appropriate
expectations. In addition, where appropriate, your patient should be advised of the less welcome effects of achieving
periodontal health including recession, sensitivity and food packing.
Some patients show poor compliance with treatment visits or their home care and it is important to note this fact in the
patient’s record card. In many cases, this helps to demonstrate that the periodontal disease has arisen or progressed
because of failings on the part of the patient, rather than the dentist.
Summary:
Record information
appropriate to your patient’s
presenting problems,
periodontal condition,
treatment options, risk factors
and responsibilities.
Summarise discussion with
patients and other involved
team members.
Produced with the support of Dental Protection Ltd.
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WHO TO REFER TO,
WHEN AND HOW
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Copyright©2012 British Society of Periodontology
WHO TO REFER TO, WHEN AND HOW
INTRODUCTION
As a new graduate there will certainly be cases which you will feel uncomfortable managing on your own, either
because of t he extent or t he complexity of t he problems facing you. In t erms of patient management, ac hieving
predictable outcomes and for medicolegal reasons, you should consider referring such patients to a colleague for
help and support.
It is the responsibility of the dentist to screen patients for periodontal diseases, to make a diagnosis and institute a
treatment plan with defined therapeutic goals.
WHEN TO REFER PATIENTS
The British Society of Periodontology (BSP) has created guidelines for referral, which are available from the BSP
website http://www.bsperio.org.uk/ or regional representatives. These are summarized below.
Remember these are for guidance and should not be viewed as prescriptive.
Complexity 1 cases may be treated in general practice
These would basically be: BPE Score 1 - 3 in any sextant
Complexity 2 cases either referred or treated by the GDP
These would basically be: BPE Score of 4 in any sextant
Surgery involving the periodontal tissues
Complexity 3 cases mostly referred
These would basically be: BPE score of 4 in any sextant and including one or more
of the following factors:
Patients under the age of 35
Smoking 10+ cigarettes daily
A concurrent medical/oral factor that is affecting the periodontal tissues
Root morphology that adversely affects prognosis
Rapid periodontal breakdown >2mm attachment loss in any one year
Surgical procedures with implants
Surgical procedures periodontal tissue augmentation and/or bone removal
(e.g. Regeneration or Crown lengthening surgery)
WHO TO REFER PATIENTS TO
Dentists with a special interest in Periodontology (DwSI)
Who are they?
DwSI are general dentists who have a contract with local PCTs to provide periodontal services to NHS patients. They
may have had some extra training in periodontology beyond BDS level and should have presented evidence of
competency in basic per iodontal treatments to the PCTs in q uestion. They may have been trained in more complex
periodontal management or surgical procedures.
How can I contact them?
Some PCTs have contracts with DwSIs. You should enquire with your local PCT .
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WHO TO REFER TO,
WHEN AND HOW
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Copyright©2012 British Society of Periodontology
Specialists in Periodontology
Who are they?
These pr actitioners ar e dentists who ha ve been r ecognised b y t he Gener al Dent al Council as specialists in
Periodontology They will have achieved this either by following a recognised formal training programme in the UK or
in Europe or by virtue of their experience and previous training.
They generally work at secondary care level, taking referrals from other dentists.
How can I contact them?
• BSP or GDC websites
• PCTs some of whom have contracts with specialists or know who they are
• Recommendations from colleagues
Consultants in Restorative Dentistry
Who are they?
These are dentists who have gone through a formal 5 year training programme within a teaching hospital, in restorative
dentistry, including periodontology. Consultants work within the Health Service or in salaried services, often dealing
with patients with complex needs. Most ar e based in hospit als or clinics and while some will ha ve the resources to
provide treatment others will only be able to provide advice and detailed treatment planning.
How can I contact them?
• PCT
• Local teaching hospital
• Community Dental Services
The BSP also contains a significant number of general practitioner members who have an interest in periodontology,
and these people may be able and happy to help you if you cannot identify or access any of the other groups above.
HOW TO REFER PATIENTS
Whilst an initial telephone call to a practice may be helpful, referrals should be made formally in writing. It is wise to
keep a copy of the referral letter with the patient’s notes, and to make a dated entry in the notes that the patient has
been referred, and why. The referral letter should contain:
• Patient’s name, date of birth and contact details
• Reason for referral and any emergency problems
• Relevant medical history including smoking history
• Details of any periodontal treatment already carried out
• Relevant radiographs (particularly old ones) and charts
Many NHS funded services have a high demand for services, and patients may be have a greater chance of being
accepted in some teaching hospitals if as much relevant information as possible is provided.
(See referral proforma at back of this guide)
WHAT IF MY PATIENT DECLINES TO BE REFERRED?
Listen to the reason for declining referral and if there are any misunderstandings which have led to the decision, you
should discuss these. Otherwise, ensure the details are documented in the clinical notes and ask the patient if they wish
to discuss any referral, again, at their next recall examination.
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Careful assessment of the periodontal tissues is an essential com ponent of patient management. The BPE is a sim ple
and rapid screening tool that is used to indicate the level of examination needed and to provide basic guidance on
treatment need. Please note; the BPE does not provide a diagnosis.
How to record the BPE
1. The dentition is divided into 6 sextants:
upper right (17 to 14), upper anterior (13 to 23), upper left (24 to 27)
lower right (47 to 44), lower anterior (43 to 33), lower left (34 to 37)
2. All teeth in each sextant are examined (with the exception of 3rd molars).
3. For a sextant to qualify for recording, it must contain at least 2 teeth. (If only 1 tooth is present in a sextant, the score
for that tooth is included in the recording for the adjoining sextant).
4. A WHO BPE probe is used (World Health Organisation probe). This has a “ball end” 0.5 mm in diame ter, and a
black band from 3.5 to 5.5 mm. Light probing force should be used (20-25 grams).
5. The probe should be “walked around” the sulcus/pockets in each sextant, and the highest score recorded. As soon
as a code 4 is identified in a sextant, the clinician may then move directly on to the next sextant, though it is better to
continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition,
and will make sure that furcation involvements are not missed. If a code 4 is not detected, then all sites should be
examined to ensure that the highest score in the sextant is recorded before moving on to the next sextant.
Scoring codes
0 No pockets >3.5 mm, no calculus/overhangs, no bleeding after probing (black band completely visible)
1 No pockets >3.5 mm, no calculus/overhangs, but bleeding after probing (black band completely visible)
2 No pockets >3.5 mm, but supra- or subgingival calculus/overhangs (black band completely visible)
3 Probing depth 3.5-5.5 mm (black band partially visible, indicating pocket of 4-5 mm)
4 Probing depth >5.5 mm (black band entirely within the pocket, indicating pocket of 6 mm or more)
* Furcation involvement
Both the number and the * should be recorded if a furcation is detected - e.g. the score for a sextant could be 3*
(e.g. indicating probing depth 3.5-5.5 mm PLUS furcation involvement in the sextant).
An example BPE score grid might look like:
4 3 3*
- 2 4*
BASIC PERIODONTAL EXAMINATION
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BASIC PERIODONTAL EXAMINATION
31
When to record the BPE
• All new patients should have the BPE recorded
• For patients with codes 0, 1 or 2, the BPE should be recorded at least annually
• For patients with BPE codes of 3 or 4, more detailed periodontal charting is required:- Code 3: record full
probing depths (6 sites per tooth) in the sextant(s) where the code 3 was recorded, in addition to recording the
BPE in those sextants with scores 0, 1 or 2
• - Code 4: if there is a code 4 in any sextant, then record full probing depths (6 sites per tooth) throughout the
entire dentition
• BPE cannot be used to assess the response to periodontal therapy because it does not provide information
about how sites within a sextant change after treatment. To assess the response to treatment, probing depths
should be recorded at 6 sites per tooth pre- and post-treatment
• For patients who have undergone initial therapy for periodontitis (i.e. who had pre-treatment BPE scores of 3
or 4), and who are now in the maintenance phase of care, then full probing depths throughout the entire
dentition should be recorded at least annually
Guidance on interpretation of BPE scores
Interpreting the BPE score depends on many factors that are unique to each patient. The clinician should use their skill,
knowledge and judgement when interpreting BPE scores. General guidance is indicated below. The BPE scores should
be considered together with other factors when making decisions about whether to refer (as outlined in the companion
BSP document “Referral Policy and Parameters of Care”).
0 No need for periodontal treatment
1 Oral hygiene instruction (OHI)
2 OHI, removal of plaque retentive factors, including all supra- and subgingival calculus
3 OHI, root surface debridement (RSD)
4 OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
* OHI, RSD. Assess the need for more complex treatment; referral to a specialist may be indicated.
As a general r ule, radiographs to assess alveolar bone levels should be obtained f or teeth or sextants where
BPE codes 3 or 4 are found.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date first published: October 2011
Revised: September 2012
Review date: October 2016
Prepared by: Council of the British Society of Periodontology
The BPE was first developed by the British Society of Periodontology in 1986. Previous versions of this document were
produced in 1986, 1994 and 2000. The main changes in this 2011 version are (i) that * should now be used to denote
only the presence of a furcation, and (ii) that both the BPE code and the * should be recorded for each sextant where
furcation involvement is found.
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EXECUTIVE SUMMARY - GUIDELINES FOR PERIODONTAL SCREENING AND
MANAGEMENT OF CHILDREN AND ADOLESCENTS UNDER 18 YEARS OF AGE
Professor Valerie Clerehugh (BSP) and Dr Susan Kindelan (BSPD)
Dental practitioners have a key role to play in the early recognition and diagnosis of gingival and periodontal diseases.
Following the British Society of Periodontology (BSP) Policy Statement in 2001 relating to the screening and
management of periodontal problems in adults seen in primary dental care and the update to the Basic Periodontal
Examination (BPE) in 2011 (www.bsperio.org.uk), the need for a document pertaining to the child and adolescent
population has been recognized (Clerehugh 2008). These Guidelines have been formulated to set out the
recommendations of the BSP and the British Society of Paediatric Dentistry (BSPD) for the periodontal screening and
management of children and adolescents under 18 years of age in the primary dental care setting.
The aims of these Guidelines are: 1) To outline a method of screening children and adolescents for periodontal
diseases during the routine clinical dental examination. 2) To provide guidance on when it is appropriate to treat in
practice or refer to specialist services.
Periodontal screening for children and adolescents assesses six index teeth (UR6, UR1, UL6, LL6, LL1 and LR6) using
a simplified BPE to avoid the problem of false pockets (Ainamo et al 1984). The WHO 621 style probe with a
0.5 mm ball end, black band at 3.5 to 5.5 mm, and additional markings at 8.5 mm and 11.5 mm is used.
BPE codes 0-2 are used in the 7- to 11-year-olds while the full range of codes 0, 1, 2, 3, 4 and * can be used in the
12- to 17- year-olds (Figures 1 and 2).
Cases that may warrant referral for specialist care are shown in Table 1.
Figure 1. Simplified BPE codes for under 18 year Figure 2. Examination of index teeth
Table 1. When to refer to a specialist References
GUIDELINES FOR
PERIODONTAL SCREENING
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NOTES
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PATIENT
Name
Date of birth
Address
Tel H
W
M
REFERRING DENTIST
Name
Address
Tel W
M
CHIEF CONCERN
BPE
RELEVANT MEDICAL HISTORY
SMOKER Y / N PACK YEARS
RADIOGRAPHS / CHARTS ENCLOSED SIGNATURE
OTHER PERIODONTAL FINDINGS / TREATMENT
PERIODONTAL REFERRAL DATE:
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British Society of Periodontology
PO BOX 228
BUBWITH
SELBY
YO8 1EY
Tel/Fax 0844 335 1915
www.bsperio.org.uk
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