A System of Periodontal Care in General Dental Practice

1. Preamble

1.1 As the concepts of periodontal care have changed with increasing

knowledge of the natural history of periodontal disease, the British
Society of Periodontology has considered it advisable to revise the
document setting out what it believes to be the best current advice on
the practice of periodontology within General Dental Practice. Special
emphasis is placed upon careful periodontal evaluation as an essential
pre-requisite in the planning and execution of all dental care.

1.2. It is intended that this policy document will be kept under continuous
review and will be updated when necessary.

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Introduction

2 The Nature of Periodontal Diseases

2.1. The traditional concept of destructive periodontal disease (now

regarded as being several diseases but collectively referred to by
convention in the singular) was that the periodontium was uniformly
affected by microbial dental plaque. This resulted in gingivitis in the
early stages and thereafter the periodontium was destroyed more or
less evenly causing severe loss of bone, and eventually necessitating
the loss of teeth. It was considered that the majority of individuals
were susceptible to periodontal disease and that in the presence of
plaque there was a continuous, gradual progression of bone loss.

2.2 Careful examination of epidemiological data show that, even in the

early stages, periodontal disease can be much more active when
associated with some teeth than with others (1, 2, 3). Furthermore, the
activity of the disease at a site is not directly proportional to the local
presence of plaque. In addition to those deviations from the simple
concept of the disease, it has also been shown that in many instances
periodontal disease is episodic and that even the destructive phases of
the disease may show apparent reversals and remissions (4,5).

2.3 It is this pattern of diversity in which the time component is so

important, that demands a special technique of care for the disease,
even in its earliest stages. In the case of the dentist or dental
hygienist, charting the distribution and progression of the disease is
needed to enable them to treat the disease and counsel the patient.
Certain aspects of the same data have to be presented to the patient in
a form which can be easily assimilated by the lay public to enable them
to direct preventive home-care techniques to the areas of periodontium
and teeth where they are required (6, 7).

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3. Prevention and Treatment

3.1 Several studies have demonstrated that under optimal conditions the
careful and regular removal of dental plaque can prevent the
occurrence and progression of early periodontal disease (8, 9, 10, 11,
12, 13). Furthermore, it has been found that plaque control techniques
can prevent occurrence of the disease after successful treatment and it
has also been demonstrated that plaque control is an important part of
periodontal treatment itself (14, 15, 16, 17, 18, 19).

3.2 Originally, these results were interpreted as implying that a brief

mention of plaque control and its significance in periodontal disease to
patients at the time of a short dental examination would constitute an
adequate preventive technique for the majority of regular dental
attenders who did not have the disease in a severe form.

3.3 The studies mentioned above, and others, suggest that such a view
represents a considerable over-simplification of the actual position.
The reality is that time-consuming techniques have to be employed by
dentists or dental auxiliaries and that frequent repetition is needed if
they are to be successful (20, 21, 22).

3.4 The conflict between the postulated simplified approach and the
observed reality arises from two assumptions about the nature of the
disease process and its prevention. Firstly, it was assumed that a
quick examination is all that is required to enable the dentist or
auxiliary to assess the extent of the disease and the distribution of
dental plaque in patients with superficial levels of disease. Secondly,
and in a related manner, it was assumed that a brief explanation of the
periodontal condition is sufficient to enable the patient to practice
successful plaque control.

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4. Recording and Diagnosis

4.1 It has long been recognised by periodontologists that the key to

successful treatment of established periodontal disease lies in the
careful assessment and diagnosis of the various features of periodontal
disease. Data related to the amount and distribution of dental plaque
and gingival inflammation are collected together with measurements of
pocket depths and loss of attachment. Tooth mobilities and special
problems such as root proximity, root concavities and grooves, and
furcation involvements are noted. Radiographs are usually necessary
to assist in diagnosis and treatment planning.

4.2 Records of the same data must also be made after the treatment has
been completed. These serve to determine the degree of improvement
achieved. Over a longer period they determine whether the
improvement is maintained.

4.3 Only a percentage (approximately 7 - 15%) of the population seeking

dental care are regarded as being susceptible to severe disease.
However, no reliable prognostic indicators for use prior to disease onset
exist at present. Consequently, examination of all patients is needed
from time to time to detect disease at an early stage of the process.
The numbers of patients involved and the frequency with which the
examinations will be required suggest that this can only be
accomplished within General Dental Practice. For this reason the
Basic Periodontal Examination (BPE) was developed by the
British Society of Perioodontology in 1986 and subsequently
modified to screen all patients and to determine the level of
examination needed by patients with differing disease levels.

4.4 Collection of full clinical and radiographic data as required for patients
with complex periodontal disease would not be appropriate for many of
the patients seen in General Dental Practice. A simple and rapid
method of screening is required so that time and other resources are
not misused.

The screening system would indicate which clinical and radiographic

data appropriate to the level of disease were required.

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4.5 The method of examination known as BPE provides a basis for simple
and rapid screening. Although it was developed to assess the treatment
needs, it has the advantage of summarising the periodontal condition
in a form which is useful for communicating with the lay pubic,
including patiients themselves.

4.6 It must be stressed that the index may have to be accompanied by

additional information, for example in the case of uneven distribution
of the disease, where there is severe recession of soft tissue or where
there are other factors in the mouth which influence periodontal
treatment. Furthermore, in the majority of cases in dental practice the
index will indicate that further clinical and radiographic recording is
required.

5. The Basic Periodontal Examination (BPE)

5.1 The BPE divides the full dentition into sextants. The six sextants
consist of the four groups of teeth each containing the molars
(excluding third molars) and premolars of one side of one jaw and
the two groups of teeth each containing canines and incisors of one jaw.

5.2 For a sextant to qualify for recording, it must contain at least two
functioning teeth. The observations made from only one remaining
tooth are included in the recording for the adjoining sextant.

5.3 All teeth in the sextant are examined.

5.4 The WHO 621 probe is used. This has a "ball point", 0.5 mm in
diameter, at its tip. A colour coded area extends from 3.5 to 5.5 mm.
The force used at probing should not exceed that corresponding to 20-
25 gm.

5.5 Code * is given to a sextant if there is total attachment loss at

any site is 7 mm or more, or if a furcation can be probed. The
asterisk denotes that a full periodontal examination of the
sextant is required regardless of the BPE score.

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5.6 Code 4 is given to the sextant if at one or more teeth the colour coded
area of the WHO probe disappears into the inflamed pocket indicating
pocket depth of 6 mm or more.

5.7 Code 3 is given to the sextant if the colour coded area of the probe
remains partially visible when inserted into the deepest pocket.

5.8 Code 2 is assigned to the sextant if there are no pockets exceeding 3

mm in depth (coloured area remains totally visible) but dental calculus
or other plaque retention factors are seen at, or recognised underneath,
the gingival margin.

5.9 Code 1 is given to a sextant when there are no pockets exceeding 3 mm

in depth and no calculus or overhangs of fillings but bleeding occurs
after gentle probing.

5.10 Code 0 is given to a sextant when there are no pockets

exceeding 3 mm in depth, no calculus or overhangs of fillings
and no bleeding after gentle probing.

5.11 As soon as Code 4 or * is recorded at a tooth in a sextant the

examiner passes to the next sextant. If Code 4 is not detected then it is
necessary to examine all teeth to be certain that the highest code is
recorded before passing on to the next sextant.

5.12 Collection and recording of the BPE codes should be performed at each
examination. The method is, together with radiographs, practical for
preliminary assessment of the need for further periodontal
investigation during screening of the oral health status of a patient.
Figure 1 shows a grid for recording BPE Scores.

6. Notes on the Use of the BPE

6.1 When used as a preliminary screening system the BPE may have to be
modified. Problems are encountered with false pocketing in young
individuals, with recession, and furcation involvement in older
patients. It is recommended that the following variants are applied

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6.2 In young individuals the gingival margin may be situated coronal to
the cement enamel junction by a number of millimetres. Account of
this should be taken when proposing treatment for sextants assigned
scores 3 and 4.

7. A Proposed System of Periodontal Care

in General Dental Practice.

7.1 The benefits of any system that encourages a more careful examination
of the periodontium in General Dental Practice are such that an initial
screening system involving the BPE would be beneficial.

7.2 Dentists carrying out periodontal care should be required to equip

themselves with WHO pattern periodontal probes, which are available
from several suppliers in this country and compare favourably in price
with other periodontal instruments. Dentists should familiarise
themselves with the collection and recording system.

7.3 All new patients attending dentists for the first time should have the
BPE undertaken. Codes for each sextant are recorded. A brief
explanation of the significance of the findings in terms acceptable to
the layman should be given. These and subsequent recommended
procedures require a significant and measurable period of time from
skilled personnel and this should be recognised in any system of
recompense.

7.4 The management of sextants with Codes 0, 1 and 2 is as follows:-

(a) sextants of the mouth for which Code 0 are recorded do not require
treatment;

(b) sextants scoring Code 1 can be treated by oral hygiene instruction and
prophylaxis;

(c) sextants scoring Code 2 can be treated as for sextants scoring Code 1
with the addition of supra-and subgingival scaling at selected sites.

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 Patients whose BPE scores for all sextants are Codes 0, 1 or 2 should
be screened again after an interval of 1 year.

7.5 When patients have sextants scoring Code 3 further data will have to
be collected. Plaque distribution and gingival inflammation are
recorded and, in addition, probing depths are taken in the sextants
scoring Code 3. Treatment of sextants scoring Code 3 will be the same
as those scoring Code 2 but a longer time will be required for
completion. Patients with BPE score 3 for one or more sextants should
have pocket depth measurements taken in those sextants at not more
than yearly intervals in addition to the BPE screening of the other
sextants.

7.6 Patients with sextants scoring Code 4 or * will require extensive

periodontal assessment both at the outset and duration of treatment.
Following initial treatment, which will be as for sextants scoring Code
2, some resolution can be expected. Full probing depth charts will then
be required, together with evaluation of furcation involvements, root
concavities and grooves, and other relevant details using radiographs
when appropriate. Subsequent treatment may include root planing and
periodontal surgery, whilst emphasis on plaque control is sustained.

7.7 Many practitioners may choose to refer patients with sextants scoring
Code 4 or * for specialist care. They may, however, be responsible for
long-term maintenance upon the patients being referred back to the
General Dental Practitioner. That care should consist initially of
appointments at three month intervals for reinforcement of oral
hygiene, supragingival prophylaxis and subgingival plaque removal at
sites with persistent pockets. Collection of plaque and bleeding scores
and pocket depths should be undertaken, and these compared to the
post treatment readings. Sites showing deterioration should thus be
identified and re-treated as necessary.

7.8 It is suggested that, in addition to routine screening, assessment for all

items of advanced restorative or orthodontic treatment should include
BPE screening data. The rationale for this suggestion is the
recognition that failure of such forms of treatment is commonly due to
the presence of chronic periodontal disease and its related factors. As

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 in the case of patients who have experienced advanced periodontal
procedures, patients having other advanced forms of care must be
offered a recall programme as described in paragraph 7.7.

7.9 Possible methods for collecting and recording the periodontal data
described above, and additional to the BPE, are described in
Appendices 1, 2 and 3.

8. Notes on the Use of Radiographs in the

Proposed System

8.1 Appropriate intra-oral radiographs will be taken at the time of a BPE

examination for sextants scoring Code 3.

8.2 Additionally, in sextants scoring 4 or * individual intra-oral

radiographs will be taken to provide views of teeth with sites where
loss of attachment exceeds 7 mm or furcation involvement is detected.

9. Conclusion

9.1 Modern concepts of destructive periodontal disease require that all

patients, need regular assessment of the condition. The magnitude of
this indicates that most of this work will have to be carried out by
dentists working under the regulations of the General Dental Service.

9.2 The method of patient examination used when assessing BPE for an
individual patient, together with appropriate radiographs, forms the
basis of a suitable periodontal screening examination for use in
General Dental Practice.

9.3 The proposed screening system is not a substitute for the full
periodontal examination required for the proper diagnosis and
planning of treatment for susceptible patients.

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9.4 A series of studies could easily be undertaken to provide the necessary
validation and finalise detail of a comprehensive periodontal diagnostic
system for use in General Dental Practice.

10. Recognition of Risk Patients

10.1 Practitioners should be aware that a combination of

observations makes certain patients susceptible to a higher
risk of severe periodontal disease and may wish to refer the
patients. These may include:

(a) BPE scores of 3, 4 or * in patients under 35 years of age.

(b) Smoking 10+ cigarettes a day.

(c) A concurrent medical factor that is directly affecting the

periodontal tissues such as diabetes, periods of major stress
and use of certain medications.

(d) Root morphology that adversely affects prognosis

(e) Rapid periodontal breakdown > 2mm attachment loss in any

one year

(f) A high % of bleeding on probing in relation of a low plaque

index.

(g) A previous history of treatment for periodontal disease.

(h) A family history of early tooth loss due to periodontal disease

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Variability of Behaviour of Sites
1. Moscow, B.S. (1978)
Spontaneous arrest of advanced periodontal disease without treatment:
an interesting case report.
J. Perio. 49: 465-468.
2. Socransky, S.S., Haffajee, A.D., Goodson, J.M. and Lindhe J. (1983)
Changing concepts of destructive periodontal disease.
J. Clin. Perio. 11: 21-32.
3. Haffajee, A.D., Socransky, S.S. and Goodson, J.M. (1983)
Comparison of different data analyses for detecting changes in
attachment level.
J. Clin. Perio. 10: 513-521.

Episodic Behaviour of Sites

4. Selikowitz, H-S, Sheiham, A., Albert, D. and Williams, G.M. (1981)
Retrospective longitudinal study of the rate of alveolar bone loss in
humans using bitewing radiographs.
J. Clin. Perio. 8: 431-438.
5. Goodson, J.M., Tanner, A.C.R., Haffajee, A.D., Somberger, G.C. and
Socransky, S.S. (1982)
Patterns of progression and regression of advanced destructive
periodontal disease.
J. Clin. Perio. 9: 472-481

Patients and Dentist Aw areness of Disease

Distribution
6. Glavind, L. and Attström, R. (1979)
Periodontal self-examination - A motivational tool in periodontics.
J. Clin. Perio. 6: 238-251
7. Glavind, L., Christensen, H., Pedersen, E., Rosendahl, H. and
Attström, R. (1985)
Oral hygiene instruction in general dental practice by means of self-
teaching manuals.
J. Clin. Perio. 12: 27-34

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Prevention
8. Axelsson, P. and Lindhe, J. (1977)
The effect of a plaque control programme on gingivitis and dental
caries in school children.
J. Dent. Res. Special Issue C: 142-148
9. Axelsson, P and Lindhe, J. (1978)
Effect of controlled oral hygiene procedures on caries and periodontal
disease in adults.
J. Clin. Perio. 5: 133-151
10. Badersten, A., Egelberg, J. and Koch, G. (1975)
Effect of monthly prophylaxis on caries and gingivitis in school
children.
Comm. Dent. Oral Epidemiol. 3: 1-4
11 Agerbaek, N., Paulsen, S., Nelson, B. and Glavind L. (1977)
Effect of professional tooth-cleaning every third week on gingivitis and
dental caries in children.
Comm. Dent. Oral Epidemiol. 6: 40-41
12. Hamp, S.E., Lindhe, J., Farrell, J., Johansson, L.A. and Karlsson, R.
(1978)
Effect of a field programme based on systematic plaque control on
caries and gingivitis in school children after three years.
Comm. Dent. Oral Epidemiol. 6: 17-23
13. Ashley, F.P. and Sainsbury, R.H. (1981)
The effect of a school-based plaque control programme on caries and
gingivitis - a three-year study in 11-14 year old girls.
Brit. Dent. J. 150: 41-45

Maintenance
14. Suomi, J.D., Greene, J.C., Vermillion, J.R., Doyle, J., Change, J.J. and
Leatherwood, E.C. (1971)
The effect of controlled oral hygiene procedures on the progression of
periodontal disease in adults. Results after third and final year.
J. Clin. Perio. 42: 152-160
15. Axelsson, P. and Lindhe, J. (1981)
The significance of maintenance care in the treatment of periodontal
disease.
J. Clin. Perio. 8: 281-295

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16. Ramfjörd, S.P., Morrison, E.C., Bergett, F.G., Nissle, R.R., Shick, R.A.,
Zann, G.J. and Knowles, J.W. (1982)
Oral hygiene and maintenance of periodontal support.
J. Perio. 53: 26-30

Treatment
17. Nyman, S., Rosling, B. and Lindhe, J. (1975)
Effect of professional tooth-cleaning after periodontal surgery.
J. Clin. Perio. 2: 80-86
18. Lindhe, J. and Nyman S. (1975)
The effect of plaque control and surgical elimination on the
establishment of periodontal health. A longitudinal study of
periodontal therapy in cases of advanced disease.
J. Clin. Perio. 2: 67-79
19. Badersten, A., Nilveus, R. and Egelberg, J. (1981)
Effect of non-surgical periodontal therapy. I. Moderately advanced
periodontitis.
J. Clin. Perio. 8: 57-72

Time Taken for Treatment

20. Bellini, H.T. and Gjermo, P. (1973)
Application of the Periodontal Treatment Need System (PTNS) in a
group of Norwegian industrial employees.
Comm. Dent. and Oral Epidemiol. 1: 22-29
21. Johansen, J.R., Germo, P. and Bellini, H.T. (1973)
A system to classify the need for periodontal treatment.
Acta Odont. Scand. 31: 297-305
22. Ekanayaka, A.N.I. and Sheiham, A. (1979)
Assessing the periodontal treatment needs of a population.
J. Clin. Perio 6: 150-159

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The Community Periodontal Index of Treat
Need
23. Ainamo, J., Barmes, D., Beagrie, G., Cutress, T., Norton, J. and Sardo-
Infirri, J. (1982)
Development of the World Health Organisation (WHO) Community
Periodontal Index of Treatment Needs (CPITN).
Int. Dent. J. 32: 281-291
24. Croxson, L.J. (1984)
A simplified periodontal screening examination: the Community
Periodontal Index of Treatment Needs (WHO) in general practice.
Int. Dent. J. 34: 28-34
25. Emslie, R.D. (1980)
The 621 periodontal probe.
Int. Dent. J. 30: 287

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Appendix 1

The Plaque Distribution Chart

1. The chart showing the distribution of dental plaque adjacent to the

gingival margin is a time-honoured method used in treatment planning
and periodontal monitoring. It is also of value in the process of patient
motivation.

2. It employs the dichotomous scoring principle, presence or absence of

plaque on the four surfaces of each tooth being recorded in full on a
grid (Fig. 2). The system can be employed with the deciduous and
mixed dentitions and special modifications are not required when teeth
are missing.

3. The patient must be disclosed so that all plaque-involved tooth areas

can be detected. Because the disclosing is for recording purposes, the
intensity of staining can generally be less than that used for patient
education.

4. Excess stain is flushed away, conveniently with a 3-in-1 syringe. The

presence of a continuous band of dental plaque adjacent to the gingival
margin is recorded as positive. A positive score for either of the buccal
or lingual aspects of a proximal surface is recorded as positive.

5. The plaque score is calculated by expressing as a percentage the

number of surfaces harbouring plaque related to the total number of
tooth surfaces.

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Appendix 2

The Bleeding Point Chart

1. It is now generally recognised that gingival inflammation should be

estimated by gingival bleeding, as changes in colour and swelling are
difficult to reconcile with the dichotomous scoring principle.

2. Accordingly, the presence or absence of bleeding on probing of the

gingiva associated with each tooth surface is recorded in full on a grid
of the type used to measure plaque distribution (Fig. 2). The system
can be employed with deciduous and mixed dentitions and special
modifications are not required when teeth are missing.

3. A periodontal probe, graduated or WHO pattern is inserted to the base

of the pocket. A force not exceeding 20-25 gm is recommended.
Bleeding occurring within 30 seconds is recorded as positive.

4. Where teeth are in a contact point relationship, bleeding on either side

of the proximal surface causes the gingiva associated with that surface
to be recorded as positive.

5. The bleeding score is calculated by expressing as a percentage the

number of gingival units which bleed related to the total number of
units.

6. It is possible to combine the collection of a bleeding point chart with

pocket depth recording. Pockets are measured on a group of three or
four teeth and the bleeding recorded subsequently, before passing on to
the assessment of the next group of pockets.

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Appendix 3

The Probing Depths Chart

1. Probing depth is defined as the depth to which a periodontal probe can

be inserted between the tooth and gingival tissues, using a force not
exceeding 20-25 gm in a direction parallel to the long axis of the tooth.

2. The measurement is usually taken at six points on the tooth surface so

that a chart which includes a stylised representation of the periodontal
condition (Fig. 3) can be completed. The representation is of value in
patient orientation and motivation.

3. To achieve operator agreement, standardisation of various aspects of

the collection procedure is required. That includes attention to probe
graduation, probe diameter and force and angulation during the
application of the probe.

4. With regard to probe graduation, irregular markings are easier to

detect than regular ones. It is found, however, that any irregular
pattern tends to influence the frequency of scoring of certain depths.
The Williams graduated probe is in common usage (graduations at 1, 2,
3, 5, 7, 8, 9 and 10 mm).

5. In consistency with the probe used for CPITN, a probe diameter

0.5 mm is recommended. This is about 50 per cent greater than
previously suggested.

6. The interpretation of probing depths requires some care, especially

because it is now recognised that some values in the later stages of
treatment may be due to long epithelial attachments occurring because
of resolution of gingival inflammation. During the early stages of
treatment, however, probing depths are of considerable value as
indicators of the extent of the lesion which is inaccessible to the
patient.

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Acknow ledgements

The preparation of this document was co-ordinated by Mr. R.F. Mosedale, Mr.
P.D. Floyd and Dr. F.C. Smales. The many valuable contributions made by
members of the British Society of Periodontology are gratefully
acknowledged.

The Society is very grateful to Dr. R.M. Palmer for his revision of the
document in 1994, and to Dr R.F. Mosedale and Dr W.S. McLaughlin for their
revision of the document in 2000.

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