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PRESENTED BY :
SONAL GOYAL
1st YEAR POSTGRADUATE
DEPARTMENT OF PERIODONTOLOGY
A.E.C.S. MAARUTI COLLEGE OF DENTAL
SCIENCES
 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
 Site risk assessment
 Standardization of probing technique
 Reliability of BOP%
 Assessment of implants
 Limitation of BOP assessment
 Conclusion
 Reference
 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.
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development 2013;2:392-398.
 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.
 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.
 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 3rd 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.
 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.
 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)
 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
 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.
• Medical
• Oral pathologic examination
• Oral hygiene status
• Gingival changes
• Mobility changes
• Occlusal changes
• Dental caries
• Restorative prosthetic status
Part I
Examination
(approximately
17 minutes)
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development. 2013;2:392-398.
• Oral hygiene reinforcement
• Scaling and polishing
• Chemical irritation
Part II Treatment
(approximately 35
minutes)
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development. 2013;2:392-398.
• Schedule for next recall visit
• Schedule for further
periodontal treatment
• Schedule/refer for restorative
or
• Prosthetic treatment.
Part III Schedule
for next
appointment
(approximately 1
minute)
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development. 2013;2:392-398.
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
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}
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)
 Re-evaluation of the periodontal case should be made in no
less than 1-3 months, wherein
1. Re-probing of the entire mouth is done, and
2. 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.
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
Treatment Recall visit remark
Resective osseous
surgery
1 week Removal of pack
2nd or 3rd 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
 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.
 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.
Greenstein, referring to the importance of
bleeding upon probing, stated that "although
its presence may not be a conclusive
indication of a progressive inflammatory
process, there are specific clinical differences
between gingival tissues with and without
bleeding upon probing, and therefore this
seems to be a convincing argument for its use
in the monitoring of periodontal disease."
Novaes AB, Lima FR, Novaes AB. Compliance with supportive periodontal therapy and its
relation to the bleeding index. J Periodontol 1996;67:976-980.
BOP appears to address two different
levels of risk for disease progression:
1. The percentage sites within a dentition
which bleeds on probing may provide
information on the subject’s risk for disease
progression.
2. The dichotomous evaluation of whether
or not a single tooth site bleeds on probing
may provide information on the local risk
assessment at a given tooth site.
Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by
bleeding on probing.J Periodontol 2000 1996;12:44-48.
 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.
Use of the gingival
bleeding as an indicator of
inflammation has the
clinical advantage :
More objective – colour
changes require a
subjective estimation.
Good indicator of the
presence of an
inflammatory lesions in
the connective tissue at the
base of the sulcus.
Severity of bleeding
increases with an increase
in the size of the
inflammatory infiltrate.
Newmann, Takei, Klokkevold et al. Clinical diagnosis. In: Carranza’s Clinical
Periodontology.10:Elsevier;2011:540-558.
 Role of BOP can be discussed under following :-
1. 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.
 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.
2. 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.
1. Sulcus bleeding index
2. Gingival bleeding index
3. Gingival bleeding index (Ainamo and Bay)
4. Papillary bleeding index
5. Papillary bleeding score
6. Modified papillary bleeding index
7. Bleeding time index
8. Eastman interdental bleeding index
Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61
Index Author Year Instrument Score Time delay
Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61
Index Author Year Instrument Score Time delay
Newbrun E. Indices to Measure Gingival Bleeding. J Periodontol 1996;67:555-61
 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.
 Includes:
 Low risk patients-
Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant
 Medium-risk patient-
 High-risk patient-
 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.
 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.
According to Lang et
al. (1990) :-
Sites with residual periodontal pockets
>4 mm appear to bleed more
frequently on probing than sites with
probing depths of less than 4 mm.
This may indicate a higher risk
for deep pockets to lose further
attachment than shallow sites
and,
This would also suggest that pockets with
deep probing depth should be instrumented
at all recall visits in order to eliminate
gingival inflammation.
Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant
dentistry. 5:Backwell;2008:780-823.
Individuals with low mean BOP percentages- <10%
of the surfaces- regarded as low risk for recurrent
diseases.
Individuals with mean BOP percentages- >25% of
the surfaces- regarded as high risk for reinfection.
BOP had a high negative predictive value for disease
progression (98.1% frequent bleeding sites) - absence
of BOP is a good indicator for the maintenance of
periodontal stability.
Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant
dentistry. 5:Backwell;2008:780-823.
 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.
Progression of periodontal
disease
Loss of probing attachment of
2mm or more.
2/3rd of all sites that lost
attachment
mean BOP more than or equal to
30%
1/5th 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.
• 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.
 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.
Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant
dentistry. 5:Backwell;2008:780-823.
 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.
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.
 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.
 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.
 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.
BOP
Absence
Periodontal
stability
Presence
Increased
risk for
progression
Bleeding at
repeated
evaluations
When the sites are registered using BOP% in a
dichotomous way
Allows the
calculation of the
mean BOP for the
patients.
Yields
topographical
location for
bleeding site.
Repeated scores
during maintenance
will reveal the
surfaces at higher
risk for loss of
attachment.
Greenstein G. The Role of Bleeding upon Probing in the Diagnosis of Periodontal Disease- A
Literature Review. J. Periodontol 1984;55:684-688.
 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.
 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.
periodic supportive periodontal treatment visits allows for early
intervention to salvage an ailing implant.
Excessive plaque accumulation, bleeding on probing, increased
pocket depth, suppuration, radiographic bone loss, retrograde wear
and broken restoration may be early indicators of future implant
failure.
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development 2013;2:392-398.
Peri-implantitis can
create pockets
around implants, so
probing around the
implants becomes
part of the
examinaion and
diagnosis.
Plastic periodontal
probes are used to
prevent scratching.
A modified
ginigival bleeding
index has been
proposed by
Mombelli et al, to
define the
inflammatory
changes of
periimplant tissues.
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development 2013;2:392-398.
Score Criteria
0
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.
 Chayter et al:
In clinical practice, the reduction of the evaluation
of signs and symptoms of inflammation to bleeding
on gentle probing on implants may be reasonable
extrapolation from the clinical situation around the
teeth.
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of
Innovative Research and Development 2013;2:392-398.
 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.
Recurrence of periodontal
diseases can occur due to
inadequate oral hygiene and
therapy.
Clinical signs of breakdown :-
Periodontal pockets that
bleed or show exudate when
gently probed.
Periodontal pockets that get
progressively deeper.
Alveolar bone loss.
Increased tooth mobility.
Presence of plaque,
gingivitis and subgingival
calculus.
Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative
Research and Development 2013;2:392-398.
Surgery should not be undertaken unless the patient has
shown compliance.
Re-instrumented
More attention during maintenance visit
Higher risk for loss of attachment
Repeated scores during maintenance ( >25% BOP%)
Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by
bleeding on probing. J Periodontol 2000 1996;12:44-48.
If bleeding is from a furcation which has been proven inaccessible, it is
considered as unavoidable loss or left as long as it is asymptomatic.
The root surface in a pocket that bleeds during gentle probing should be
rescaled, and if bleeding continues, surgery should be done.
Retreatment in such cases may halt the progression of periodontitis, else
the breakdown may continue in spite of frequent recalls and good oral
hygiene.
BOP 2-3 weeks after the recall prophylaxis and instruction indicates root
surface irritants
Pockets that bleed on probing should be noted every recall visit.
Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol.
1987;14:433-437.
 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.
 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.
 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.

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bleeding on probing

  • 1. PRESENTED BY : SONAL GOYAL 1st YEAR POSTGRADUATE DEPARTMENT OF PERIODONTOLOGY A.E.C.S. MAARUTI COLLEGE OF DENTAL SCIENCES
  • 2.  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. 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.  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 3rd 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.  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. • Medical • Oral pathologic examination • Oral hygiene status • Gingival changes • Mobility changes • Occlusal changes • Dental caries • Restorative prosthetic status Part I Examination (approximately 17 minutes) Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development. 2013;2:392-398.
  • 13. • Oral hygiene reinforcement • Scaling and polishing • Chemical irritation Part II Treatment (approximately 35 minutes) Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development. 2013;2:392-398.
  • 14. • Schedule for next recall visit • Schedule for further periodontal treatment • Schedule/refer for restorative or • Prosthetic treatment. Part III Schedule for next appointment (approximately 1 minute) Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development. 2013;2:392-398.
  • 15. 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.  Re-evaluation of the periodontal case should be made in no less than 1-3 months, wherein 1. Re-probing of the entire mouth is done, and 2. 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 2nd or 3rd 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 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 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. Greenstein, referring to the importance of bleeding upon probing, stated that "although its presence may not be a conclusive indication of a progressive inflammatory process, there are specific clinical differences between gingival tissues with and without bleeding upon probing, and therefore this seems to be a convincing argument for its use in the monitoring of periodontal disease." 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. BOP appears to address two different levels of risk for disease progression: 1. The percentage sites within a dentition which bleeds on probing may provide information on the subject’s risk for disease progression. 2. The dichotomous evaluation of whether or not a single tooth site bleeds on probing may provide information on the local risk assessment at a given tooth site. 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. Use of the gingival bleeding as an indicator of inflammation has the clinical advantage : More objective – colour changes require a subjective estimation. Good indicator of the presence of an inflammatory lesions in the connective tissue at the base of the sulcus. Severity of bleeding increases with an increase in the size of the inflammatory infiltrate. 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 :- 1. 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. 2. 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. 1. Sulcus bleeding index 2. Gingival bleeding index 3. Gingival bleeding index (Ainamo and Bay) 4. Papillary bleeding index 5. Papillary bleeding score 6. Modified papillary bleeding index 7. Bleeding time index 8. 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.  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.
  • 35.  Low risk patients- Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant
  • 38.  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.
  • 39.  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.
  • 40. According to Lang et al. (1990) :- Sites with residual periodontal pockets >4 mm appear to bleed more frequently on probing than sites with probing depths of less than 4 mm. This may indicate a higher risk for deep pockets to lose further attachment than shallow sites and, This would also suggest that pockets with deep probing depth should be instrumented at all recall visits in order to eliminate gingival inflammation. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.
  • 41. Individuals with low mean BOP percentages- <10% of the surfaces- regarded as low risk for recurrent diseases. Individuals with mean BOP percentages- >25% of the surfaces- regarded as high risk for reinfection. BOP had a high negative predictive value for disease progression (98.1% frequent bleeding sites) - absence of BOP is a good indicator for the maintenance of periodontal stability. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.
  • 42.  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.
  • 43. Progression of periodontal disease Loss of probing attachment of 2mm or more. 2/3rd of all sites that lost attachment mean BOP more than or equal to 30% 1/5th 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.
  • 44. • 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.
  • 45.  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.
  • 46. Lang NP, Lindhe J. Supportive periodontal treatment. In: Clinical periodontology and implant dentistry. 5:Backwell;2008:780-823.
  • 47.  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.
  • 48. 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.
  • 49.  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.
  • 50.  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.
  • 51.  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.
  • 53. When the sites are registered using BOP% in a dichotomous way Allows the calculation of the mean BOP for the patients. Yields topographical location for bleeding site. Repeated scores during maintenance will reveal the surfaces at higher risk for loss of attachment.
  • 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.  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. periodic supportive periodontal treatment visits allows for early intervention to salvage an ailing implant. Excessive plaque accumulation, bleeding on probing, increased pocket depth, suppuration, radiographic bone loss, retrograde wear and broken restoration may be early indicators of future implant failure. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.
  • 58. Peri-implantitis can create pockets around implants, so probing around the implants becomes part of the examinaion and diagnosis. Plastic periodontal probes are used to prevent scratching. A modified ginigival bleeding index has been proposed by Mombelli et al, to define the inflammatory changes of periimplant tissues. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.
  • 59. Score Criteria 0 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: In clinical practice, the reduction of the evaluation of signs and symptoms of inflammation to bleeding on gentle probing on implants may be reasonable extrapolation from the clinical situation around the teeth. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.
  • 61.  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 of periodontal diseases can occur due to inadequate oral hygiene and therapy. Clinical signs of breakdown :- Periodontal pockets that bleed or show exudate when gently probed. Periodontal pockets that get progressively deeper. Alveolar bone loss. Increased tooth mobility. Presence of plaque, gingivitis and subgingival calculus. Muthukumar S, Diviya M. Periodontal Maintenance-A Review. International Journal of Innovative Research and Development 2013;2:392-398.
  • 63. Surgery should not be undertaken unless the patient has shown compliance. Re-instrumented More attention during maintenance visit Higher risk for loss of attachment Repeated scores during maintenance ( >25% BOP%) Lang NP, Joss A, Tonetti MS. Monitoring disease during supportive periodontal treatment by bleeding on probing. J Periodontol 2000 1996;12:44-48.
  • 64. If bleeding is from a furcation which has been proven inaccessible, it is considered as unavoidable loss or left as long as it is asymptomatic. The root surface in a pocket that bleeds during gentle probing should be rescaled, and if bleeding continues, surgery should be done. Retreatment in such cases may halt the progression of periodontitis, else the breakdown may continue in spite of frequent recalls and good oral hygiene. BOP 2-3 weeks after the recall prophylaxis and instruction indicates root surface irritants Pockets that bleed on probing should be noted every recall visit. Ramfjord SP. Maintenance care for treated periodontitis patients. J Clin Periodontol. 1987;14:433-437.
  • 65.  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.  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.

Editor's Notes

  1. Percentage of bleeding on probing Prevalence of residual pockets greater than 4 mm Loss of teeth from a total of 28 teeth Loss of periodontal support in relation to patient’s age Systemic factors and genetic conditions Env factors such as cigarette smoking. Each patient has its own scale for minor, moderate and high risk A comprehensive evaluation , a func dia will provide and determine the frequencty of SPT patients
  2. Bop- 15% 4 residual pockets more than equal to 5 mm 2 teeth loss Bone factor in relation to age is 0.25 No sys factor No smoking
  3. Bop 9% 6 residual pockets more than equal to 5 mm 4 teeth have been lost Bone factor in relation to age is 0.75 Type I diabetic Non smoker
  4. Bop 32 % 10 residual pocket more than equal to 5mm 10 teeth have been lost Bone factor in relation to age is 1.25 No systemic factor Occasional smoker
  5. Positive predictive value for loss of probing attachment of > equal to 2mm in 2 years in sites which bled on probing 0,1,2,,3,4 times out of 4 SPT visits in total of 48 patients following active periodontal therapy