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Using the BPE in dental practice

This article introduces the nature of periodontal disease, the importance of recording the features of the disease to help reach a diagnosis, why the Basic Periodontal Examination (BPE) was developed by the British Society of Periodontology, and presents a brief overview of the most recent edition.

Figures indicate that 83% of dentate adults show some evidence of periodontal disease (that is bleeding, calculus, periodontal pocketing of 4mm or more),1 suggesting that there is an unmet need in treating and managing this disease.

According to Chapple and colleagues (2017), alongside caries, periodontal disease, if left untreated, may result in, ‘[…] tooth loss, reduced masticatory function, poorer nutritional status, low self-esteem and quality of life, negative general health impacts. There is also evidence of an association with higher all-cause mortality.’2

In terms of periodontal health, they wrote, ‘[…] there is a symbiosis between a health-associated biofilm and a proportionate host immune inflammatory response. Periodontitis develops following the emergence of a dysbiosis in susceptible individuals which is associated with dysregulation of the immune-inflammatory response, and which leads to host mediated connective tissue damage and alveolar bone loss.’2

Reaching a consensus on recommendations regarding the management of periodontal disease, Chapple and colleagues (2017) stated: ‘Public Health agencies and Policy Makers should ensure that periodontal screening becomes a mandatory component of the oral health examination and consider mandatory reporting of periodontal screening to appropriate local commissioning bodies.’2

Recording periodontal disease

Various periodontal recording methods have been used since the 1960s, to measure prevalence, extent and severity among individuals and at population levels.3 In 1977, the World Health Organization (WHO) began to develop a ‘needs- assessment tool’, which is now known as the Community Periodontal Index of Treatment Needs.3

A modified version of this index is used in Britain – the Basic Periodontal Examination (BPE) – first created by the British Society of Periodontists in 1986, and was updated in 2016.3,4

As stated in the guideline document, ‘Dental practitioners have a key role to play in the early recognition and diagnosis of periodontal conditions. Careful assessment of the periodontal tissues is an essential component of patient management. 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. The 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.’4

To record an adult’s BPE, the dentition should be divided into six sextants – upper right, upper anterior, upper left, lower right, lower anterior and lower left – and the highest score for each recorded.4 Every tooth in each sextant should be examined, the exception being 3rd molars unless the 1st or 2nd molars are missing.4 A sextant must contain at least two teeth to qualify for BPE recording.4 Using a WHO (BPE) probe, a light probing force should be utilised, ‘walked around’ the sulcus/pockets in each sextant’.4

Scoring codes for the BPE are as follows:

• 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.

If a code 4 is identified in a sextant, the rest of the teeth in that sextant should also be examined, to help, ‘[…] to gain a fuller understanding of the periodontal condition and [to] make sure that furcation involvements are not missed.’4

For those under the age of 18, a simplified version of the BPE involves assessing six index teeth: UR6, UR1, UL6, LL6, LL1 and LR6.4 It is recommended that a WHO 621-style probe be used for this, as the second black band helps to identify false pocketing.4

Only codes 0 to 2 are used in 7- to 11-year olds (the mixed dentition phase), whilst for 12- to 17-year olds the full range can be used, once the permanent dentition comes through.4 The scores should be interpreted as follows:

• Healthy 1 – Bleeding following gentle probing

• Plaque or calculus retention factor

• Shallow pocket of 4mm to 5mm

• Deep pocket of 6mm or more * – Furcation.4

It is important to note that the recently revised BPE guidelines implemented some changes, and Ower (2016) highlighted the following as the main differences between the 2011 and 2016 document:

• Code 3 − initial therapy followed by a 6 point chart

• Bleeding on probing should always be recorded with 6 point chart;

• Only record 4mm and above when doing a 6 point chart.5

Practical considerations

In his article on managing patients with periodontal disease, Allen (2015) offered a number of in-practice tips, including that charting duties can be shared out among appropriate members of the dental the team.6 For example, he wrote: ‘Train your nurses in oral hygiene education and plaque scoring; they can then complete this at a separate appointment or at the beginning or end of appointments.’6

In addition, it is imperative that notes include BPE scores, diagnosis of any periodontal disease and the consent process undertaken, as note-taking will form part of a dental health care professional’s defence should any allegations of malpractice be made by a dissatisfied patient.6

As Allen (2015) wrote so succinctly: ‘In order to diagnose [periodontal] disease a thor¬ough history and clinical examination is required. […]. The BPE will help determine if periodontal assessments and radiographs are justified. These are primarily to monitor the disease however they also help provide additional diagnostic information, for example; deter¬mining extent, severity – which is deter¬mined with clinical attachment loss (CAL – pocket depth plus recession) – and identifying local risk factors.’6

References

  1. Adult Dental Health Survey 2009. Health and Social Care Information Centre 2011
  2. Chapple ILC et al. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol 2017; 44 (Suppl. 18): S39-S51
  3. Beltrán-Aguilar ED et al. Recording and surveillance systems for periodontal diseases. Periodontol 2000. 2012; 60(1): 40–53
  4. The Good Practitioner’s Guide to Periodontology. BSP 2016. https://www.bsperio.org.uk/publications/good_practitioners_guide_2016.pdf?v=3. Accessed 5 June 2017
  5. Ower P. BPE Guidelines: British Society of Periodontology Revision 2016. Dental Update 2016; 43(5): 406-408
  6. Allen G. Producing guidance for the management of patients with chronic periodontal disease in general dental practice. BDJ 2015; 218: 461-466