bleeding on probing

monitoring disease during supportive periodontal treatment by bleeding on probing

1. Monitoring disease during supportive periodontal treatment by bleeding on probing PRESENTED BY : SONAL GOYAL 1 st YEAR POSTGRADUATE DEPARTMENT OF PERIODONTOLOGY A.E.C.S. MAARUTI COLLEGE OF DENTAL SCIENCES

2. index Introduction What is SPT? Gingival bleeding Bleeding on probing Rationale of using BOP as a diagnostic aid Bleeding indices Subject risk assessment Percentage of sites with BOP

3. Site risk assessment Standardization of probing technique Reliability of BOP% Assessment of implants Limitation of BOP assessment Conclusion Reference

4. Periodontal therapy in the absence of a carefully designed maintenance program invariably results in the relapse of the disease condition. Accordingly, periodontal care provided without a maintenance program deal with significant patient management and disease management issues. introduction Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

5. Hence maintenance therapy forms an integral part of periodontal therapy, with all treatment accomplishments channelled into achieving a healthy periodontal status that can be effectively maintained. In this regard, periodontal maintenance therapy becomes the most decisive aspect of dental treatment. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

6. The diagnosis of periodontal disease, the response to treatment and the perceived need for additional treatment are based upon clinical criteria. Therefore, clinical parameters are needed which reliably portray pathologic changes. The most commonly used clinical parameters to detect periodontal disease are pocket depth measurements, visual signs of inflammation (redness and swelling) and bleeding upon probing. Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

7. What is spt ? The Supportive periodontal therapy is the phase of the periodontal treatment during which the periodontal diseases and conditions are monitored and etiological factors reduced or eliminated. The maintenance and recall phase was renamed “supportive periodontal therapy” at the 3 rd World workshop in clinical periodontics in 1989. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

8. This phase of therapy expresses the essential need for therapeutic measures to support the patient’s own efforts to control periodontal infection and avoid re-infection. An integral part of SPT is the continuous diagnostic monitoring of the patient in order to intercept with adequate therapy and to optimize the therapeutic interventions tailored to the patient’s needs. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

9. In most cases, it is initiated after completion of active periodontal treatment and continued at regular intervals for the life of the dentition. Phase I Re-evaluation Phase IV ( maintenance) Phase II( periodontal surgery) Phase III (restorative)

10. SPT COMPRISES OF …. Part I : Examination Part II : Treatment Part III: Next Schedule PERIODONTAL RISK ASSESSMENT Oral hygiene Reinforcement Recall Further Perio treatment Restorative/Prosthetic Treatment MULTI RISK ASSESSMENT TOOTH RISK ASSESSMENT SITE RISK ASSESSMENT

11. The time required for a recall visit for patients with multiple teeth in both arches is approximately one hour ( Schallhorn and snider,1981). Periodontal care at each recall visit comprises of three parts: Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development . 2013;2:392-398.

12. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development . 2013;2:392-398.

13. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development . 2013;2:392-398.

14. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development . 2013;2:392-398.

15. RECALL INTERVALS: After 1yr well maintenance Merin’s classification Characteristics Recall interval First year Routine 3 months Difficult cases with complicated prosthesis, furcation involvement, questionable patient cooperation. 1-2 months Class A Excellent result well maintained for 1 year or more, patient displays good oral hygiene, minimal calculus, no occlusal problems, no complicated prosthesis, no remaining pockets, no teeth with less than 50% alveolar bone remaining. 6 months to 1 year

16. Class- B Generally good results maintained for 1 year or more but patient displays some of the factors: Inconsistent / poor oral hygeiene Heavy calculus Systemic disease that predispose to periodontal breakdown Occlusal problems Complicated prosthesis Same teeth with less than 50% of alveolar bone support 3-4 months {recall interval based on the number and severity of negative factors}

17. Class- C Generally poor results following periodontal therapy and/or several negative factors from the following: Inconsistent/ poor oral hygiene Heavy calculus formation Systemic diseases that predisose to periodontal breakdown Remaining pockets Occlusal problems Many teeth with less than 50% of alveolar bone support, condition too advanced to be improved by periodontal surgery. 1-3 months (recall interval based on the number and severity of negative factors)

18. Recall intervals Re-evaluation of the periodontal case should be made in no less than 1-3 months, wherein Re-probing of the entire mouth is done, and Persistent inflammation (present/absent). The initial gross clinical results of therapeutic procedures are established 4-6 weeks after therapy completion. Here, the results of therapy can be improved by SRP every 2 weeks for first 6 months, thereafter, once every 3 months. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol . 1987;14:433-437.

19. Condition/treatment Recall visits Remark Only gingivitis Twice a year SRP Patients with chronic periodontitis 4 times a year; at intervals of: Intervals allow optimal gingival healing to occur 2 weeks 2-3 months 3-4 months 4-6 months Gingivectomy 1 week Removal of periodontal pack. If calculus has not been completely removed- curette. 4 weeks Complete epithelial repair occurs 7 weeks Complete connective tissue repair

20. Treatment Recall visit remark Resective osseous surgery 1 week Removal of pack 2 nd or 3 rd week Light debridement Every 2weeks until healing is complete (6 months) Oral prophylaxis Flap surgery 1 week Removal of pack Area corresponding to incision may bleed easily, hence, not probed. 1 month Implant procedure At intervals of : 1 day 1 month 3 months 6 months yearly

21. Gingival bleeding Gingival bleeding is one of the cardinal symptoms reflecting inflammation in periodontal tissues. It is related to the persistent presence of plaque on the teeth and is regarded as a sign of the associated inflammatory response. Bleeding may be detected from single periodontal site by provocation of tissues by periodontal probing, a blast of compressed air, or in advanced lesions- even spontaneously. Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.

22. Bleeding on probing Bleeding on probing represents an objective inflammatory parameter which has been incorporated into index systems for the evaluation of periodontal conditions- Loe and Silness ,1963 and Muhlemann & Son, 1971. It is used as an parameter by itself. Depending on the severity, BOP can vary from a tenuous red line along the gingival sulcus to profuse bleeding. Newmann , Takei, Klokkevold et al. Clinical diagnosis. In: Carranza’s Clinical Periodontology.10:Elsevier;2011:540-558.

23. Novaes AB, Lima FR, Novaes AB. Compliance with supportive periodontal therapy and its relation to the bleeding index. J Periodontol 1996;67:976-980.

24. Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.

25. As a single test, BOP is not a good predictor of progressive attachment loss; however the presence of bleeding on probing in a treated and maintained patient population is an important risk predictor for increased loss of attachment. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol . 1987;14:433-437.

26. Rationale of using bop as diagnostic aid Newmann , Takei, Klokkevold et al. Clinical diagnosis. In: Carranza’s Clinical Periodontology.10:Elsevier;2011:540-558.

27. Role of BOP can be discussed under following :- Histopathological Alteration: Inflamed tissues with associated histopathologic alterations are predisposed to a hemorrhagic response to even light probing. Probing may induce bleeding due to alteration or disruption of blood vessel walls, decrease of supporting perivascular collagen, decrease and weakening of crevicular epithelium, interaction between inflamed connective tissue and epithelium . Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

28. Bleeding is indicative of an inflammatory lesion in the connective tissue. As the severity of bleeding response increases, there is a concomitant increase in the size and the intensity of the inflammatory infiltrate. Periodontal disease activity has been linked to the type of infiltrate present, and the finding of plasma cells has been interpreted to be indicative of an active and progressive lesion . Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

29. Bacteria associated with BOP: Armitage et al.- examined the relationship between bleeding and the microflora and reported an increase in the number of motile forms, especially spirochetes. Tanner and Socransky - disease activity assessed radiographically can be predicted by Bacteroides gingivalis , Wolinella recta, Fusobacterium nucleatum . Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

30. Bleeding indices Sulcus bleeding index Gingival bleeding index Gingival bleeding index ( Ainamo and Bay) Papillary bleeding index Papillary bleeding score Modified papillary bleeding index Bleeding time index Eastman interdental bleeding index Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61

31. Index Author Year Instrument Score Time delay Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61

32. Index Author Year Instrument Score Time delay Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61

33. Sulcus bleeding index ( Muhlemann and Son, 1971) Score Interpretation Normal appearing gingiva , no bleeding upon probing 1 No colour or contour changes, but bleeding on probing 2 Bleeding on probing, colour change, no edema and contour changes 3 BOP, colour change, severe inflammatory edema 4 BOP, colour change, severe inflammatory edema 5 Spontaneous bleeding on probing, colour change, very severe inflammatory edema with or without ulceration Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61

34. Gingival Bleeding Index ( Ainamo & Bay, 1975) Performed through gentle probing of the orifice of the gingival crevice. If bleeding occurs within 10 seconds a positive finding is recorded and the number of positive sites is recorded and then expressed as a percentage of the number of sites examined. It has been show that the scores obtained with this index correlate significantly to GI ( Löe and Silness , 1963) and has been used in profile studies and short-term clinical trials. Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61

35. Subject risk assessment The patient’s risk assessment for recurrence of periodontitis may be evaluated on the basis of a number of clinical conditions, where the entire spectrum of risk factors and risk indicators can be evaluated simultaneously. For this purpose, a functional diagram had been constructed by Lang and Tonetti in 2003. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

36. Includes:

37. Low risk patients- Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

38. Medium-risk patient-

39. High-risk patient-

40. Percentage of sites with BOP Represents an objective inflammatory parameter used for evaluation of periodontal conditions. In assessing the patient's risk for disease progression, BOP percentages reflect a summary of patient’s ability to- Perform proper plaque control, Patient’s host response to the bacterial challenge, and Patient’s compliance. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

41. No established level for the prevalence of BOP above which a higher risk for disease recurrence has been established. However, a cut-off point of 25% has been an indicator between patients with maintained periodontal stability and patients with recurrent disease within the same time frame. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

42. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

43. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

44. According to study conducted by Karayiannis et al in 1991- Tissues were evaluated using bleeding on probing, at each maintenance visit, Probing attachment levels and probing depths were also determined Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.

45. Progression of periodontal disease Loss of probing attachment of 2mm or more. 2/3 rd of all sites that lost attachment mean BOP more than or equal to 30% 1/5 th of all sites that loss attachment Mean BOP ≤20% Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.

46. Joss et al in 1994 , observed the patients for 4 years and sorted the distribution of “looser site” ( PD ≥4mm) dependent on BOP%. Patients with <20% of BOP have a significantly lower risk for disease recurrence Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

47. Site risk assessment Absence of bleeding on probing is a reliable parameter to indicate periodontal stability if the test procedure for assessing BOP has been standardized. If present, indicates presence of gingival inflammation. However, repeated BOP over time will predict the progression of a lesion is questionable. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

48. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

49. Standardization of probing technique Probing force- If probing force exceeds 0.25 N (25g) – tissues will be traumatized and bleeding will be provoked as a result of trauma, rather than alteration due to inflammation. Hence, a light probing force of 0.25 N is applied to assess true percentage of bleeding on probing. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

50. Probe: For many years, it has been recommended that probe tip diameters should be no more than 0.40 to 0.50 mm to allow an adequate determination of the depth of the periodontal pockets. Here, probe usually penetrates beyond the base of the periodontal pocket and about 1 mm into the inflamed connective tissue. Hassan MA, Bogle G, Quishenbery M, Stephens D, Riggs M, Egelberg J. Pain experienced by patients during periodontal recall examination using thinner versus thicker probes. J Periodontol 2005;76:980-4.

51. Frequent “ overprobing ” into the connective tissue at the base of the periodontal pockets with the 0.40 mm probes may be a primary cause of pain during probing. Using 0.63 mm probes, “ overprobing ” and pain experience may occur less often. Also, van der Velden evaluated the use of periodontal probes with tip diameters of 0.63 mm and observed that the base of periodontal pockets can be reached with these probes using a probing force of 0.50 to 0.75 N. Hassan MA, Bogle G, Quishenbery M, Stephens D, Riggs M, Egelberg J. Pain experienced by patients during periodontal recall examination using thinner versus thicker probes. J Periodontol 2005;76:980-4.

52. Probing technique : Probe is carefully introduced to the bottom of the pocket and gently moved laterally along the pocket wall. Sometimes, bleeding maybe delayed for a few seconds, hence, bleeding is checked 30-60 seconds after probing. Newmann , Takei, Klokkevold et al. Clinical diagnosis. In: Carranza’s Clinical Periodontology.10:Elsevier;2011:540-558.

53. Reliability of BOP% Absence of BOP – indicates periodontal stability with a negative predictive value of 98-99%. Most reliable clinical parameter for monitoring patients over time. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.

54. Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J. Periodontol 1984;55:684-688.

55. Studies- Proye et al.- Determined after one session of root planing and 3 weeks of oral hygiene, that bleeding upon probing was virtually eliminated. This corresponded with a gain of clinical attachment. Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J. Periodontol 1984;55:684-688.

56. Van der Veiden - found after resolution of clinically visual inflammation that many deep pockets still demonstrated bleeding upon probing thus indicating additional therapy was necessary. Furthermore, it indicated indices evaluating bleeding by running a probe along the soft tissue wall at the orifice of the crevices may not adequately diagnose inflammatory lesions in deeper pockets. Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J. Periodontol 1984;55:684-688.

57. Assessment of implants Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

58. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

59. Score Criteria No bleeding when a periodontal probe is passed along the gingival margins adjacent to the implant 1 Isolated bleeding spots visible 2 Blood forms a confluent red line 3 Heavy profuse bleeding Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

60. Chayter et al: Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

61. Limitations of BOP assessment Variables which can affect the response include width of the probe, angulation of insertion and application of force. Spray et al.- demonstrated that a probe can penetrate laterally as well as apically into the connective tissue. Therefore, it is possible that gentle probing may induce bleeding which would not be associated with histological alterations . Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

62. Recurrence & retreatment Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.

63. Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.

64. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol . 1987;14:433-437.

65. conclusion Despite limitations of bleeding assessments, studies have reported specific differences between gingival tissues which do, and do not, bleed after probing. While these differences may not conclusively indicate that the inflammatory process is progressing, they do demonstrate that a substantial deviation from health is present, and therefore form the basis for a cogent argument that bleeding upon probing is an objective parameter that may be used to monitor periodontal status . Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688.

66. references Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A Literature Review. J Periodontol 1984;55:684-688. Hassan MA, Bogle G, Quishenbery M, Stephens D, Riggs M, Egelberg J. Pain experienced by patients during periodontal recall examination using thinner versus thicker probes. J Periodontol 2005;76:980-4. Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. Periodontol 2000 1996;12:44-48.

67. Newbrun E. Indices to Measure Gingival Bleeding. J periodontol 1996;67:555-61. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol . 1987;14:433-437. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823. Newmann , Takei, Klokkevold et al. Clinical diagnosis. In: Carranza’s Clinical Periodontology.10:Elsevier;2011:540-558.