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Revisiting the BPE

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Learning outcomes

B,C,D

Aims and objectives

The aim of this article is to present the most recent main changes to the British Society of Periodontology’s Basic Periodontal Examination (BPE) guidelines, which were last revised in 2016.

On completing this CPD session, the reader will:

• Understand the role of the of BPE in relation to periodontal screening

• Understand main revisions to the BPE guidelines, published in 2016

• Understand how to use the BPE system in practice

• Understand the findings of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions

• Understand the possible need for changes to how periodontal screening is performed when looking to the future.

Revisiting the BPE

This piece presents the most recent main changes to the British Society of Periodontology’s BPE guidelines, last revised in 2016.

The first set of Basic Periodontal Examination (BPE) guidelines was published in 1986 by the British Society of Periodontology (BSP) and were most recently revised in 2016.1

The BPE is an important aspect of routine periodontal screening.2 As the BSP states: ‘The BPE is a simple and rapid screening tool that is used to indicate the level of further examination needed and provide basic guidance on treatment needed. These BPE guidelines are not prescriptive but represent a minimum standard of care for initial periodontal assessment. BPE should be used for screening only and should not be used for diagnosis.’3

Updated guidance

A working group of academics, specialists and general practitioners came together to offer a consensus opinion on whether the BPE guidelines needed to be updated, the results of which were used to create a revised document.1

The main revisions to the BPE guidelines, published in 2016, were:4

• Radiographs for all code 3 and 4 sextants as before but periapicals are recommended

• 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.

The BPE in use

A WHO periodontal probe, which has a ball-shaped tip 0.5mm in diameter and a narrow shaft marked with black a line between 3.5mm and 5.5mm from the tip, is used to record a patient’s BPE. Some probes also have a black band between 8.5mm and 11.5mm.2

To record the BPE for adults:3

1. The teeth are divided into six sextants – upper right, upper anterior, upper left, lower right, lower anterior and lower left

2. All teeth in each sextant are examined, except for 3rd molars (unless the 1st and / or 2nd molar(s) is / are missing). For a sextant to qualify for examination, at least two natural teeth must be present.

3. The probe is ‘walked’ around the pockets / sulcus in all qualifying sextants, with the clinician recording the highest score in each. A light probing force of 20-25g should be used.

It is important to note that where a BPE score of 4 is recorded, all areas in the sextant should be examined, to ensure furcation involvements are not overlooked and to gain a better understanding of the patient’s periodontal health.3

The BSP’s guidance indicates that BPE codes should be scored as follows:3

0 – pockets <3.5mm, first black band completely visible, healthy periodontal tissues, no calculus/overhangs, no bleeding on probing.

1 – pockets <3.5mm, first black band completely visible, no calculus/overhangs, presence of bleeding on probing

2 – pockets <3.5mm, first black band completely visible, supra or subgingival calculus or plaque retention factor (overhang)

3 – probing depth 3.5mm to 5.5mm, first black band partially visible, indicating pocket of 4mm to 5mm

4 – probing depth >5.5mm, first black band entirely within the pocket, indicating pocket of 6mm or more

* – furcation involvement.

In terms of interpreting scores for practical purposes, BSP guidance further suggests:3

Code 0 – no need for periodontal treatment

Code 1 – provide oral hygiene instruction

Code 2 – provide oral hygiene instruction and remove plaque retentive factors, including both supra- and sub-gingival calculus

Code 3 – provide oral hygiene instruction, remove plaque retentive factors (including both supra- and sub-gingival calculus), and perform root surface debridement if appropriate

Code 4 – provide oral hygiene instruction and perform root surface debridement where required. In addition, assess the need for more involved treatment, for which a referral may be appropriate

* – Treat in line with BPE codes 1 to 4, as well as assessing the need to perform more complex dentistry, perhaps via a referral.

Future possibilities

At the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions, working group 1 classified gingival heath and gingival conditions, as well as creating a summary table of diagnostic features for defining oral heath and gingivitis in a number of clinical situations.5

On this, Chapple and colleagues (2018) wrote: ‘The reliability and reproducibility of any case definition for health, gingival or periodontal conditions relies upon standardization of probing protocols, which is only possible with the implementation of an ISO probe. The current International Organization for Standardization (ISO) for periodontal probes is – ISO 21672, but requires updating in order to define the features of a global standard periodontal probe. These characteristics are:

1. Tip diameter 0.5 mm

2. Cylindrical tine structure

3. Constant force limiter of 0.25 N

4. 15mm scale with precise individual or banded millimetre markings

5. A taper of 1.75°.’5

The group also concluded that there are four levels of periodontal health:

1. Pristine periodontal health, with a structurally sound and uninflamed periodontium

2. Well-maintained clinical periodontal health, with a structurally and clinically sound (intact) periodontium

3. Periodontal disease stability, with a reduced periodontium

4. Periodontal disease remission/control, with a reduced periodontium.’6

Speaking to the European Federation of Periodontology in 2018, Chapple commented: ‘The new classification should provide a globally consistent approach to diagnosis and management and ultimately improve outcomes for our patients.’7

He continued: ‘Next steps include careful education of the Oral Healthcare team to ensure its simplicity is recognised as, at first glance, the classification may appear complex but it is actually quite pragmatic, and to make sure we train effectively in its implementation.’7

The BSP is in the process of considering this new guidance and will publish a consensus document in terms of its practical implementation in the near future.8

QUESTIONS: 

References

  1. Ower P. BPE Guidelines: British Society of Periodontology Revision 2016. Dental Update 2016; 43(5): 406-408

  2. Preshaw PM. Detection and diagnosis of periodontal conditions amenable to prevention. BMC Oral Health 2015; 15(Suppl 1): S5-S15

  3. The Good Practitioner’s Guide to Periodontology. BSP 2016. https://www.bsperio.org.uk/publications/good_practitioners_guide_2016.pdf?v=3. Accessed 14 August 2018

  4. Important news: Revised BPE Guidelines are now available. http://www.bsperio.org.uk/news/important-news-revised-bpe-guidelines-ar. Accessed 10 August 2018

  5. Chapple ILC et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions. J Clin Periodontol. 2018; 45(Suppl 20): S68-S77

  6. Proceedings of ground-breaking World Workshop on new classification are published. http://www.efp.org/newsupdate/world-workshop-on-classification/. Accessed 10 August 2018

  7. New classification of periodontal and peri-implant diseases and conditions. EFP press release, 2018. https://www.efp.org/press/downloads/.../EFP_PR_classification_periodontal_FINAL.pdf. Accessed 14 August 2018

  8. New classification of periodontal and peri-implant diseases and conditions. https://www.bsperio.org.uk/news/new-classification-of-periodontal-and-pe. Accessed 10 August 2018