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The Periodontal Assessment

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The Periodontal Assessment The Periodontal Assessment Sumamry This lesson will guide you through how to carry out a thorough periodontal assessment. NOTE – Please note this assessment and management criteria are indicated by the British Society of Periodontology. If you are following this lesson from another region, please check your national guidelines in regard to periodontal assessment and management. Keywords: Supracrestal attached The distance from the base of the gingival sulcus, to the alveolar tissues (previously termed bone; it includes the connective tissue and the junctional epithelium Biological width) attachment to the tooth. Plaque which has calcified due to mineral deposits such as calcium Calculus and phosphates from the saliva The area where roots separate; this can be in a bifurcation (two Furcation roots), or trifurcation (three roots) The displacement of a tooth beyond its normal physiological Mobility boundaries in a horizontal or vertical plane Periodontal Pocket A pathologically deepened gingival sulcus Is the distance between the free gingival margin and the bottom of Pocket Depth the pocket. Clinical Attachment Loss CAL is the distance between the CEJ and the bottom of the pocket. (CAL) ReviseDental.com Instruments involved in the Periodontal Assessment Basic Periodontal Exam Probe (also known as a WHO probe) Williams probe UNC 15 probe Nabers probe BPE probe A BPE probe is the standard probe used in every initial dental assessment. This probe is used to give a BPE score. Its structure has a 0.5mm ball at the end; this is ball shaped to prevent trauma to the gingivae, but also this will pick up the tactile feel of calculus subgingivally. There are 4 sections to a BPE probe, with 2 black bands. The first black band is 3.5mm - 5.5mm. The second black band is from 8.5mm – 11.5mm. ReviseDental.com BPE Probe Williams Probe A Williams probe can be used in a 6PPC to take more thorough and accurate measurements of the pocket, and the gingival recession. The Williams probe has markings at; 1, 2, 3, 5, 7, 8, 9, 10 Wiliams Probe UNC15 Probe A UNC15 probe can be used in a 6PPC also to take more thorough and accurate measurements of the pocket, and the gingival recession. This probe has black markings every 5mm. Therefore 5, 10 and 15! TheReviseDental.com UNC15 probe has markings at; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 UNC15 Nabers Probe A Nabers probe is a probe which is used to measure the extent and the depth of a furcation. A furcation is the area where tooth roots meet, so can only be used in molar teeth. The markings on a Nabers probe are; 3-6mm, 9-12mm both indicated through a black band ReviseDental.com Nabers Probe The Initial Exam - Periodontal Stages The periodontal exam is divided into multiple stages depending on findings. There are multiple parts to be considered; Clinical Appearance BPE Plaque Indices Bleeding Indices Radiographs If a person shows to have signs of periodontal disease, a further assessment is used called a 6-point pocket chart (6PPC). This is divided into several further stages. Pocket depth Gingival recession Clinical Attachment Loss (CAL) Bleeding Suppuration Mobility Furcation This lesson will guide you through the way to carry out a periodontal assessment to gain the appropriate informationReviseDental.com to make a diagnosis. Clinical Appearance When initially assessing a patient, it is important to not only take measurements, but to also evaluate clinically the health of gums. Clinical Health can be determined by; Colour - are they pink or erythematous? Contour – do they have the knife cut papilla or do they appear to have lost this contour? Swelling – do they look slightly puffy indicating inflammation? Recession – does the patient brush with a heavy hand or is there a history of gum disease? Plaque accumulation Following a clinical inspection of the gums to give you an idea of the health, it should be followed by a Basic Periodontal Exam (BPE) as indicated by the British Society of Periodontology (BSP). ReviseDental.com Healthy Clinical Appearance ReviseDental.com Basic Periodontal Exam (BPE) The BPE is the screening process for gum disease. This means exactly what it says in the name; basic. It allows dentist to check in the least invasive and discomforting manner if there is gum disease present, and also acts as a guide on where improved oral hygiene may be indicated. A BPE is conducted using a BPE probe (sounds logical?). The BPE probe is walked around all 6 surfaces of the teeth with a light probing force estimated to be 20-25g. The clinician will be watching the depth the probe goes to and always watching the black band, as well as gaining information through tactile feedback for calculus or overhangs. In a BPE, the teeth are sectioned into sextants. All the teeth in that sextant, excluding wisdom teeth, are included. The highest score is then taken as the recording for the sextant. Surfaces to Examine Disto-Lingual Lingual Mesio-Lingual Disto-Buccally Buccally Mesio-Buccal Teeth to Check 7,6,5,4 3,2,1,1,2,3 4,5,6,7 7,6,5,4 3,2,1,1,2,3 4,5,6,7 ReviseDental.com A full BPE should be conducted on all patients over the age of 18. A simple BPE should be conducted on patients over the age of 7, when they have their first permanent molars, and their permanent central incisors. More information regarding this can be found later in the lesson. The meaning of the band height, and the BPE it is therefore scored can be found below. Pocket BPE Band Meaning Measurement score No gingival bleeding First black band completely 0 - 3.5mm 0 No calculus or plaque retentive visible factors Gingival bleeding First black band completely 0 - 3.5mm 1 No calculus or plaque retentive visible factors First black band completely Presence of calculus or/and plaque 0 – 3.5mm 2 visible retentive factors First black band is partially Indicates a pocket depth between 3.5mm - 5.5mm 3 visible 4-5mm First black band is entirely Indicates a pocket depth above >5.5mm 4 in the pocket 6mm This means a furcation can be felt. - - * This is added onto the BPE score eg 4* Image to show how the BPE probing depth screens Periodontal Disease ReviseDental.com Additional Information for the BPE: For a sextant to qualify, there must be at least two teeth present The score for the sextant is represented by the worst site If there is only one tooth in the sextant, it should be added to the adjacent sextant If no teeth are qualifying for the sextant, it should be marked with a X The wisdom teeth (8's) aren't included in a BPE unless it allows for the sextant to be included, for example only one other tooth is present in the sextant Example: UR6 disto-palatally the black band is completely within the pocket and furcation involvement UR1 there is bleeding present UL7 buccally there is partial coverage of the black band, and general calculus deposits buccally LL7 mesio-lingual there is partial coverage of the black band LL3-LR3 shows to have supragingival calculus lingually. LR sextant only shows to have a LR5, therefore this is included in the BPE for the lower anterior sextant. Therefore, the BPE for this patient would be: 4* 1 3 X 2 3 Clinical Management Pathways based on the BPE scores BPE Management Additional Investigations No investigations required. 0 No further guidance required ReviseDental.comReassess BPE at next checkup. Plaque and Bleeding Indices. 1 Oral Hygiene Instruction Reassess BPE at next checkup. Oral Hygiene Instruction, and removal of the plaque Plaque and Bleeding indices. 2 retentive factors eg. Supra/Subgingival calculus Reassess BPE at next checkup. Plaque and Bleeding indices. Radiographs should be Oral Hygiene Instruction, removal of the plaque retentive considered. 3 factors, and Root Surface Debridement (RSD) if necessary 6PPC indicated in only the sextants of 3 after initial therapy. Plaque and Bleeding indices. Radiographs taken to indicate Oral Hygiene Instruction, and RSD. Consider referral to a 4 attachment loss. specialist for more complex treatment. 6PPC before and after treatment. Treat based on the BPE code. Consider referral to a 6PPC before and after * specialist for more complex treatment. treatment. The Simplified BPE; for Children Only The BPE on a child can feel strange to do, especially as they are so young that having a probe in their gums is going to feel very weird and can be uncomfortable. This means that an alteration to the BPE is used, termed the simple BPE, until they are older and therefore more accustomed to the gum exams a dentist might do! A Simple BPE should be conducted on patients over the age of 7 when their first permanent molars, and permanent central incisors have erupted. It is especially important to recognise the scoring and the teeth noted as it is very common for false pocketing during the mixed dentition phase, which can falsely indicate the need for treatment. Differences: Only 6 teeth are checked in the BPE for a child UR6, UR1, UL6, LL6, LL1 and LL6 A child between the ages of 7-12 should only be scored a BPE between 0-2 A childReviseDental.com between the age of 12-17 can be scored normally however using only the 6 teeth Bleeding Indices Bleeding on probing (BoP) helps to give dentists an idea of the gum health, as inflamed gums will bleed. This means that active disease is occurring. During the process of periodontal treatment, it is very important to repeat these bleeding indices as it gives the patient a goal.
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