Bleeding on probing as it relates to probing pressure and gingival health in patients with a reduced but healthy periodontium
A. Karayiannis, N. P, Lang, A, Joss & S. Nyman University of Berne School of Dental Medicine, Berne, Switeerland
A clinical study Karayiannis A, Lang NP, JCKSS A and Nyman S: Bleeding ort probing as it relates to probing pressure and gingival health tn patients with a reduced but healthy periodontium. A clinical study. J Clin Periodontol 1992: 19: 471^75. Abstract. A previous study demonstrated that the bleeding on probing (BOP) test using uncontrolled forces may result in a proportion of false positive readings when used as a parameter for inflammation, A strong possibility exists for the traumatization of clinically healthy gingival tissues if a probing force exceeding 0,25 N is applied. While these results originated form young dental hygienists exhibiting excellent oral hygiene, the aim of the present study was to evaluate the relationship between probing pressures and gingival conditions in patients with a history of treated periodontal disease, i,e,, in situations with a reduced but healthy periodontium, 10 patients who had been enrolled in a periodontai maintenance program foliowing treatment of moderate to advanced chronic inflammatory periodontal disease consented to participate in the study. They were ail selected on the basis of a record of excellent oral hygiene practices for at least 2-6 years and almost complete absence of clinical inflammation following sucessful periodontal therapy. Applying a probing force of 0,125, 0,25, 0,375 and 0,5 N in the 4 jaw quadrants, respectively, at 2 different occasions with an interval of 10 days, bleeding on probing was assessed. Oral hygiene and gingival conditions were determined using the criteria of the plaque and gingival index systems. All subjects showed significant increases in mean BOP/u with increasing probing force applied (2,5%-7,9%), Regression analysis revealed an almost linear correlation and a significant correlation coefficient between BOP % and probing force. Almost identical slope inclinations were found when the 6 subjects with the lowest mean BOP "/a at 0,25 N were compared with the regression analysis of the total group. The results of the present study support the findings of the previous study in healthy dental hygiene students with normal gingival anatomy, namely that the BOP test using uncontrolled forces may result in a proportion of false positive readings for the presence of gingival inflammation, A strong possibility also e,Kists for the traumatization of clinically healthy gingival tissues with reduced support if probing forces exceeding 0,25 N are applied.
Probing is the most commonly used clinical method to assess pocket depth and connective tissue attachment level. Also, probing is frequently used as a means to distinguish between healthy and inflamed periodontal tissues. In this respect, bleeding upon probing is interpreted to represent the presence of inflammation in the periodontal tissues, while the absence of bleeding on probing has been shown to be indicative of absence of inflammation (Lang et al.
1990), However, several factors such as the dimension of the probe used, the probing force applied, the angulation of the probe during probing and the gingival morphology substantially affect the outcome of the scorings (for review, see Lang & Bragger (1991)), For clinical purposes, attempts have been made to standardize several of these factors. For example, the placement of acrylic stents with grooves was advocated to standardize the alignment of
Key words; bleeding on probing; clinical trial: girtgivat health: proving pressure. Accepted tor publication 6 June 1991
the probe (Rosling et al, 1975), Periodontal probes with well-defined tip diameters were manufactured (Ramijord 1967), Also, periodontal probes yielding standardized pressures were developed (Van der Velden & de Vries 1978. Vitek et al, 1979), However, the correct probing pressure to be applied in order to distinguish between healthy and inflamed gingival tissues has not been determined as yet, A recent study (Lang et al, 1991) has
472
Karaviannis et al.
shown that probing forces exceeding 0,25 N and applied by means of a periodontal probe with a tip diameter of 0,4 mm may traumatize healthy tissues, or, in other words, may provoke bleeding in non-inflamed sites. This study was carried out in young dental hygienist students exhibiting clinically perfect healthy tissues as assessed by gingival index scores oi close to 0, In these subjects a force of 0,25 N did not provoke bleeding, but bleeding could be provoked in an almost linear relationship (r = 0,87) when applying increasing probing forces to these healthy gingival units. It shouid be realized, however, that these individuals presented with a complete absence of clinical and radiographic signs or symptoms of periodontal destruction (i,e, no loss of attachment, no probing depths exceeding 3 mm, and no loss of alveolar bone). The question therefore arises whether or not the relationship between probing pressures and gingival conditions are similar or identical in patients with a history of treated chronic inflammatory periodontal disease, i,e,, in situations with reduced height and altered morphology of the periodonta! tissues resulting from disease and treatment, but with regained periodontal health. The aim of the present study was to address this question. Material and Methods 10 patients (aged 36 to 69 years and with a dentition including a minimum of 20 teeth), who had been enrolled in a periodontal maintenance care program following treatment of moderate to advanced chronic inflammatory periodontai disease, were selected on the basis of their optimal standard in oral hygiene practices, Periodontal therapy had comprised a hygienic phase which included motivation for and instruction in oral hygiene measures and in addition, thorough scaling and root planing. Thereafter, periodontal surgery (the modified Widman flap (Ramfjord & Nissle (1974)) was carried out in areas where residual probing depths following the hygienic phase exceeded 4 mm. The maintenance program following therapy included professional tooth cleaning and repeated root instrumentation once every 3-6 months in accordance with the regimen described by Axelsson & Lindhe (1978), All 10 patients had been subjected to this maintenance program for 2-6 years. During these
Supervisad Oral Hygiene
BOP%
14 12 -
^ T ^
10 -
s6-
Fig. 1. Study design.
42•
years, the patients presented continuously with a very high standard of oral hygiene as documented by low plaque scores (O'Leary et al, 1972) and extremely low gingival bleeding indices according to the GBI system (Ainamo & Bay 1975), In addition, during these years of maintenance, the patients had not suffered any further loss of supporting tissues as evaluated by ciinical measurements of pocket depth and attachment level and by radiographic analysis of the alveolar bone level. Prior to the start of the study, the patients were informed of the purpose, benefits and risks of the study and signed consent forms to participate. In addition, they all received a further prophylaxis procedure including a thorough tooth cleaning with rubber cups and polishing paste. On days 0 and 14 (Fig, 1), oral hygiene standards were assessed according to the criteria of the plaque index system (PII: Silness & Loe 1964), Gingival conditions were evaluated using the gingival index system (GI; Loe & Silness 1963), Furthermore, on day 0, probing pocket depths and chnical attachment levels were assessed. All sites with reconstruction margins interfering with the gingival tissues were identified. On days 2 and 12 (Fig, 1), bleeding on probing (BOP) to the bottom of the clinical sulcus or pocket was evaluated using different probing forces which were controlled by an electronic pressure sensitive probe with a point diameter of 0,4 mm (Vineland Mfg, Comp,), Since the periodontal probes, used in
1
4 7%
5,1%
0,25
0,375
7,9%
f 2,5% I 0 125
0,5
N
Fig. 2. Individual mean BOP % of the 4 quadrants with the differenE probing forces for all subjects.
the present study, were standardized in size and dimensions, only the probing force varied in order to test the effect of different probing pressures. The reason for assessing BOP on different days (days 2 and 12) than the PU and GI (days 0 and 14) was to avoid traumatic effects on the gingiva by these ciinical scorings. Furthermore, in order not to jeopardize the clinical scorings, the patients were asked to refrain from oral hygiene practices for 4 h prior to the scoring sessions. The forces, used to assess BOP in the 4 quadrants of each dentition, were 0,125, 0,25, 0,375, 0,5 N, respectively. In each individual, the quadrants were randomly assigned to one of the standardized probing forces. The same probing forces were applied at both the 1st (day 2) and the 2nd (day 12) assessments of BOP, All clinical parameters, i,e,, PII, GI and BOP were assessed at the mid-buccal and mid-oral surfaces and, for the approximai surfaces, at the buccal aspect of the mesial and distal contact areas of all teeth excluding third molars. In addition, surfaces with restoration margins interfering with the gingival tissues were excluded, BOP was calculated as the percentage number of bleeding gingival units out of the total num-
30-1
BOP%
/ - 0,85 + 13,4
A. Karayiannis, N. P, Lang, A, Joss & S. Nyman University of Berne School of Dental Medicine, Berne, Switeerland
A clinical study Karayiannis A, Lang NP, JCKSS A and Nyman S: Bleeding ort probing as it relates to probing pressure and gingival health tn patients with a reduced but healthy periodontium. A clinical study. J Clin Periodontol 1992: 19: 471^75. Abstract. A previous study demonstrated that the bleeding on probing (BOP) test using uncontrolled forces may result in a proportion of false positive readings when used as a parameter for inflammation, A strong possibility exists for the traumatization of clinically healthy gingival tissues if a probing force exceeding 0,25 N is applied. While these results originated form young dental hygienists exhibiting excellent oral hygiene, the aim of the present study was to evaluate the relationship between probing pressures and gingival conditions in patients with a history of treated periodontal disease, i,e,, in situations with a reduced but healthy periodontium, 10 patients who had been enrolled in a periodontai maintenance program foliowing treatment of moderate to advanced chronic inflammatory periodontal disease consented to participate in the study. They were ail selected on the basis of a record of excellent oral hygiene practices for at least 2-6 years and almost complete absence of clinical inflammation following sucessful periodontal therapy. Applying a probing force of 0,125, 0,25, 0,375 and 0,5 N in the 4 jaw quadrants, respectively, at 2 different occasions with an interval of 10 days, bleeding on probing was assessed. Oral hygiene and gingival conditions were determined using the criteria of the plaque and gingival index systems. All subjects showed significant increases in mean BOP/u with increasing probing force applied (2,5%-7,9%), Regression analysis revealed an almost linear correlation and a significant correlation coefficient between BOP % and probing force. Almost identical slope inclinations were found when the 6 subjects with the lowest mean BOP "/a at 0,25 N were compared with the regression analysis of the total group. The results of the present study support the findings of the previous study in healthy dental hygiene students with normal gingival anatomy, namely that the BOP test using uncontrolled forces may result in a proportion of false positive readings for the presence of gingival inflammation, A strong possibility also e,Kists for the traumatization of clinically healthy gingival tissues with reduced support if probing forces exceeding 0,25 N are applied.
Probing is the most commonly used clinical method to assess pocket depth and connective tissue attachment level. Also, probing is frequently used as a means to distinguish between healthy and inflamed periodontal tissues. In this respect, bleeding upon probing is interpreted to represent the presence of inflammation in the periodontal tissues, while the absence of bleeding on probing has been shown to be indicative of absence of inflammation (Lang et al.
1990), However, several factors such as the dimension of the probe used, the probing force applied, the angulation of the probe during probing and the gingival morphology substantially affect the outcome of the scorings (for review, see Lang & Bragger (1991)), For clinical purposes, attempts have been made to standardize several of these factors. For example, the placement of acrylic stents with grooves was advocated to standardize the alignment of
Key words; bleeding on probing; clinical trial: girtgivat health: proving pressure. Accepted tor publication 6 June 1991
the probe (Rosling et al, 1975), Periodontal probes with well-defined tip diameters were manufactured (Ramijord 1967), Also, periodontal probes yielding standardized pressures were developed (Van der Velden & de Vries 1978. Vitek et al, 1979), However, the correct probing pressure to be applied in order to distinguish between healthy and inflamed gingival tissues has not been determined as yet, A recent study (Lang et al, 1991) has
472
Karaviannis et al.
shown that probing forces exceeding 0,25 N and applied by means of a periodontal probe with a tip diameter of 0,4 mm may traumatize healthy tissues, or, in other words, may provoke bleeding in non-inflamed sites. This study was carried out in young dental hygienist students exhibiting clinically perfect healthy tissues as assessed by gingival index scores oi close to 0, In these subjects a force of 0,25 N did not provoke bleeding, but bleeding could be provoked in an almost linear relationship (r = 0,87) when applying increasing probing forces to these healthy gingival units. It shouid be realized, however, that these individuals presented with a complete absence of clinical and radiographic signs or symptoms of periodontal destruction (i,e, no loss of attachment, no probing depths exceeding 3 mm, and no loss of alveolar bone). The question therefore arises whether or not the relationship between probing pressures and gingival conditions are similar or identical in patients with a history of treated chronic inflammatory periodontal disease, i,e,, in situations with reduced height and altered morphology of the periodonta! tissues resulting from disease and treatment, but with regained periodontal health. The aim of the present study was to address this question. Material and Methods 10 patients (aged 36 to 69 years and with a dentition including a minimum of 20 teeth), who had been enrolled in a periodontal maintenance care program following treatment of moderate to advanced chronic inflammatory periodontai disease, were selected on the basis of their optimal standard in oral hygiene practices, Periodontal therapy had comprised a hygienic phase which included motivation for and instruction in oral hygiene measures and in addition, thorough scaling and root planing. Thereafter, periodontal surgery (the modified Widman flap (Ramfjord & Nissle (1974)) was carried out in areas where residual probing depths following the hygienic phase exceeded 4 mm. The maintenance program following therapy included professional tooth cleaning and repeated root instrumentation once every 3-6 months in accordance with the regimen described by Axelsson & Lindhe (1978), All 10 patients had been subjected to this maintenance program for 2-6 years. During these
Supervisad Oral Hygiene
BOP%
14 12 -
^ T ^
10 -
s6-
Fig. 1. Study design.
42•
years, the patients presented continuously with a very high standard of oral hygiene as documented by low plaque scores (O'Leary et al, 1972) and extremely low gingival bleeding indices according to the GBI system (Ainamo & Bay 1975), In addition, during these years of maintenance, the patients had not suffered any further loss of supporting tissues as evaluated by ciinical measurements of pocket depth and attachment level and by radiographic analysis of the alveolar bone level. Prior to the start of the study, the patients were informed of the purpose, benefits and risks of the study and signed consent forms to participate. In addition, they all received a further prophylaxis procedure including a thorough tooth cleaning with rubber cups and polishing paste. On days 0 and 14 (Fig, 1), oral hygiene standards were assessed according to the criteria of the plaque index system (PII: Silness & Loe 1964), Gingival conditions were evaluated using the gingival index system (GI; Loe & Silness 1963), Furthermore, on day 0, probing pocket depths and chnical attachment levels were assessed. All sites with reconstruction margins interfering with the gingival tissues were identified. On days 2 and 12 (Fig, 1), bleeding on probing (BOP) to the bottom of the clinical sulcus or pocket was evaluated using different probing forces which were controlled by an electronic pressure sensitive probe with a point diameter of 0,4 mm (Vineland Mfg, Comp,), Since the periodontal probes, used in
1
4 7%
5,1%
0,25
0,375
7,9%
f 2,5% I 0 125
0,5
N
Fig. 2. Individual mean BOP % of the 4 quadrants with the differenE probing forces for all subjects.
the present study, were standardized in size and dimensions, only the probing force varied in order to test the effect of different probing pressures. The reason for assessing BOP on different days (days 2 and 12) than the PU and GI (days 0 and 14) was to avoid traumatic effects on the gingiva by these ciinical scorings. Furthermore, in order not to jeopardize the clinical scorings, the patients were asked to refrain from oral hygiene practices for 4 h prior to the scoring sessions. The forces, used to assess BOP in the 4 quadrants of each dentition, were 0,125, 0,25, 0,375, 0,5 N, respectively. In each individual, the quadrants were randomly assigned to one of the standardized probing forces. The same probing forces were applied at both the 1st (day 2) and the 2nd (day 12) assessments of BOP, All clinical parameters, i,e,, PII, GI and BOP were assessed at the mid-buccal and mid-oral surfaces and, for the approximai surfaces, at the buccal aspect of the mesial and distal contact areas of all teeth excluding third molars. In addition, surfaces with restoration margins interfering with the gingival tissues were excluded, BOP was calculated as the percentage number of bleeding gingival units out of the total num-
30-1
BOP%
/ - 0,85 + 13,4
