bleeding on probing

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.

 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.

 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:
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)

• Oral hygiene reinforcement
• Scaling and polishing
• Chemical irritation
Part II Treatment
(approximately 35
minutes)

• 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)

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.

 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.
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.

 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.

 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.

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.

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

 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.

 Low risk patients-

 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.

 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.

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.

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.

 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

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%

• 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

 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.

 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.

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.

 Absence of BOP – indicates periodontal stability with a
negative predictive value of 98-99%.
 Most reliable clinical parameter for monitoring patients
over time.

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.

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.

 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.

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.

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.

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

 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.

 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.

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%)
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.
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.
 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.

bleeding on probing

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