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BPE – an update

This article explores the development of periodontal disease measurement tools over the years, and the role of the Basic Periodontal Examination in modern dental care in the UK.

It was in the 1950s that the first recorded system to measure the prevalence and severity of periodontal disease came into existence.1 Created by Albert Lee Russell who, at the time, worked at the National Institute of Dental Research, Russell’s Periodontal Index scored the severity of pocket depth and gingival bleeding.1,2

At that time, the Index was considered an effective tool, however, owing to greater understanding of the mechanisms behind periodontal disease, by the 1980s it had fallen out of favour. This was partly due to concerns about the ‘interval scale between scores’ and ‘underlying assumptions’ regarding the ‘continuity between gingivitis and periodontal disease’.1

At about the same time as Russell, Sigurd Ramjford developed the Periodontal Disease Index, which used a periodontal probe to measure the distance from the cementoenamel junction (CEJ) to the bottom of the pocket, to ascertain attachment loss.1

Next, in the 1960s, Timothy O’Leary, a military man, developed the Periodontal Screening Examination to assess recruits. It is particularly noteworthy because he introduced the concept of examining the mouth in sextants.1

The next notable change occurred in 1977, when the World Health Organization (WHO) Scientific Group met, ‘[...] to seek and consider a more realistic system of measurement than those available. […] The group concluded that the most useful information on periodontal diseases would be obtained by including gingival bleeding, the presence of calculus and periodontal pocket depth measurements, and proposed a prototype index – the TRS 621 method. This index was later renamed as the Community Periodontal Index of Treatment Needs.’1

Two modifications of the Community Periodontal Index of Treatment Needs have been cultivated in the intervening years for the purpose of clinal screening: the American Dental Association’s Periodontal Screening and Recording tool, and the British Society of Periodontology’s Basic Periodontal Examination (BPE).1

The BPE today

1986 was the year that the BPE was first introduced to the UK’s dental profession, and has been revised over the years; most recently in 2011 and then 2016.3,4

The main differences between the 2011 and 2016 guidelines are:

• Code 3 sextants should only have a 6 point pocket chart after initial therapy

• When carrying out a 6 point pocket chart only record sites of 4mm and above

• Always record bleeding on probing with a 6 point chart

• BPE should not be used around implants.5

In terms of the change to code 3, Ower (2016) wrote: ‘As expected, the revision that created the most discussion and the widest variety of views was code 3. In many ways code 3 is a crucial part of the BPE system as it has the potential to identify periodontal disease at a very early stage when it is easier to manage. At the same time, however, while a code 3 could indeed be mild and/or early disease, it could also be gingivitis without attachment loss. Discussion revolved around the management of a code 3 and whether a full mouth 6 point chart (6PPC) was required for this code; it was recognized that there was a risk that practitioners might under record BPE to avoid the need for a 6PPC in that sextant. Views surrounding this code varied from only doing a 6PPC if bone loss was apparent on a radiograph (given that the recommendation for radiographs in all code 3 and 4 sextants remains) to leaving the recommendation that all code 3 sextants should receive a 6PPC. In the end it was agreed that code 3 sextants need not receive a 6PPC at the outset but that this should be done to assess the response to initial therapy to control marginal inflammation.’4

Regarding the statement that the BPE should not be used around implants, the BSP explains it thus: ‘Similar to teeth, implants are susceptible to bacterial plaque leading to an inflammatory response in the peri-implant tissues. However, the tissues surrounding implants are not connected to the implant surface in the same way as those surrounding teeth and are less resistant to probing. This in combination with the anatomical position of the implant in relation to the bone and soft tissues may lead to deeper probing depths in healthy sites. For this reason, the BPE is not appropriate for the assessment of implants. Detailed probing (four or six points) and the presence of any bleeding or suppuration should be measured around each implant.’3

Probing depths

It is recommended that a WHO BPE probe should be used during the examination, which has a ‘ball end’ 0.5mm in diameter, and a black band from 3.5mm to 5.5mm.3 This ball tip minimises the risk of penetrating beyond the point necessary in the soft tissues, as well as helping to detect calculus.6

Light force is needed to achieve accurate measurements, suggested to be in the region of 20g to 25g, equivalent to 0.20N to 0.25N.3,6 As Preshaw (2015) states: ‘The probing force that is used during the clinical examination clearly has the potential to influence the recorded measurements, […] However, for the clinician, it is difficult to assess this amount of force [0.20N to 0.25N], which has been described alternatively as the pressure required to blanch the tissues when the probe point is placed under the thumbnail, or, as the pressure required to depress the skin on the pad of the thumb by about 1 mm.’6

The significance of screening

Addressing the overall need posed by dental health care professionals’ desire to prevent the development of periodontal disease, Preshaw (2015) wrote: ‘Assessment and diagnosis of periodontal conditions that are amenable to prevention is a complex and challenging task. It is essential, however, to undertake periodontal screening in all our patients, given that the consequences of periodontal disease (attachment loss, alveolar bone loss, and ultimately, tooth loss), are largely irreversible.’6

It would seem, therefore, that using the BPE offers an essential and effective tool to screen for periodontal disease, not only at an initial appointment but also as part of each patient’s individual, ongoing oral healthcare needs.6,7

References

  1. Beltrán-Aguilar ED et al. Recording and surveillance systems for periodontal diseases. Periodontol 2000. 2012; 60(1): 40–53
  2. Proceedings of the Board of Regents University of Michigan. Board of Regents. UM Libraries 1972