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May 11, 2021
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH


When it comes to percent bleeding on probing, I challenge your team to see how low you can go. These strategies will help you develop and optimize treatment protocols.

If you haven’t integrated a zero percent Bleeding on Probing treatment goal for your practice, it’s time. We need to change the narrative with our patients by explaining that oral inflammation is the gateway to systemic inflammation and a plethora of associated diseases, so any bleeding is too much bleeding. The real question is, “Is zero percent bleeding a realistic expectation for our patients? And furthermore, is it possible to achieve?” Yes and yes! And here’s how we’ll do it.

HOW BADLY DO YOU WANT IT?
The literature tells us that we need to set “realistic” client-centered goals that are “measurable” in the treatment planning of our patients. I agree with the sentiment, but the word “realistic” is simply too subjective, particularly when you consider that clinicians in your practice have vastly different treatment philosophies, levels of experience, education, and training. We need a better way to define “realistic”.

In my years as a practising hygienist and consultant, I have found that “realistic” goals must be measurable, but just as important, they need to be formally integrated into your practice philosophy and treatment protocols. We can get to zero Bleeding on Probing, but you must decide as a practice team that it is a necessary endeavour and make the necessary shift in staff training, treatment protocols, and client education to affect change.

KEEPING SCORE
I’m a sucker for metrics, so it’s no surprise that I have always maintained a laser focus on Bleeding on Probing (BOP) scores. Scores don’t lie – they are undeniably measurable. And my practices have used these scores as a benchmark for treatment, slowly but surely moving many clients to zero percent BOP. Why do I encourage you and your team to wholeheartedly embrace this scoring system? Because it checks all the boxes for implementing “realistic” and “measurable” practice goals.

  • BOP scores are quantifiable, “objective and universally accep-ted as a reliable and accurate clinical measurement,” according to the 2018 Global AAP Periodontal Classification.1 Observable statements that we typically use to describe bleeding, like “generalized moderate bleeding,” leaves way too much room for interpretation among clinicians. How much bleeding is “moderate?” What treatment strategies are integrated for “moderate” bleeding? Are the treatment strategies aligned among clinicians when it is “moderate?”
  • Probing assessments are part of the comprehensive oral and annual examination in which BOP scores and percentage can easily be calculated at the same time.1 As a result, BOP requires minimal to no additional time.
  • BOP scores are a measurable evaluation tool for determining clinical efficacy of treatment strategies.1 Comparing BOP scores from pre-to-post treatment you can see at a glance which patients are making progress, which cases might need a more aggressive treatment plan or retreatment, and how the practice is performing as a whole.
  • A patient’s BOP score is an ideal topic of discussion. Think about how you can use this score to inform clients and motivate them to achieve a better health benchmark. Let’s do away with vague wording that minimizes periodontal disease like “you have a bit of inflammation,” and instead bring out our patient’s competitive streak. They should want to know their BOP score and improve on it with each subsequent visit.
  • BOP scores are an accurate way to differentiate between health, gingivitis, and or recurrent periodontitis, according to the new 2018 AAP Periodontal Health, Gingival Diseases and Conditions Category.2 See Table 2.
  • BOP scores are a reliable indicator of periodontal health, stability, remission and control, and prognosis, especially if repeated consistently over long periods of time.1 Again, this comes down to implementing the correct and accurate assessments plus, treatment protocols.

DON’T TAKE MY WORD FOR IT
What does the new global 2018 AAP Periodontal Classification have to say about BOP Scores?

Clinically you can detect gingivitis earlier with BOP scores vs. visual signs of inflammation (redness and swelling), allowing you to integrate treatment strategies sooner.1

In addition, we have moved past the “continuous progression theory” of the 80s where we believed that if you had bleeding, you were at risk for future clinical attachment loss, and or if you had gingivitis, it would inevitably progress to periodontitis. However, studies have shown that “sites with an incidence of BOP at 4 of 4 visits have a 30% chance of attachment loss.”3 So, at minimum, we should be spot probing those bleeding sites at every maintenance appointment rather than annually. As for progression, even though bleeding may not be an indicator, we do know that the absence of bleeding is a criterion for stability. Bleeding = Possible Progression. No Bleeding = No Progression, according to the literature. The bottom line: We want zero percent BOP.

Because periodontitis is a disease that is only managed and never cured, we know that periodontitis patients can have periods of inactivity and stability or enter periods of exacerbation and disease activity (some sites progressing more rapidly than others, random, and multiple burst patterns) throughout their lifetime. This puts stable periodontitis patient at higher risk for recurrent disease compared to a healthy or a gingivitis patient.2 Therefore, ongoing BOP evaluation and risk assessment management becomes imperative.

BOP scores can also help us with the vague nature of determining severity in a gingivitis diagnosis. Our textbooks describe extent and degree of gingivitis as acute or chronic or marginal, papillary, or diffused— again, terms that are too “subjective,” not quantifiable or objective among clinicians, and therefore difficult to align to a treatment strategy. The 2018 classification suggests there is merit in defining the severity of gingivitis using BOP parameters as a communication tool with your patients, and I would also suggest, to align treatment strategies among clinicians. However, there is no objective clinical criteria or evidence to clearly differentiate mild, moderate, and severe gingivitis so it remains a matter of professional opinion.2 The criterion we use to differentiate severity in the clinics I work with is listed in Table 1. Treatment strategies are set up accordingly. Of course, you are free to set up your own severity criterion in your practice. Be sure to develop and align to treatment strategies based on your criterion.

Table 1

YOUR AAP SCORECARD
The parameters of health and disease are defined very specifically in the new global 2018 AAP Periodontal Classification and Peri-Implant Diseases and Condition Classification using BOP Scores. These definitions provide measurable evaluation tools for the clinician and a clear communication tool for your patient in describing disease and setting treatment goals. Health and disease are described on three different periodontium types, which is new to the AAP’s Periodontal Health, Gingival Diseases and Conditions Category.2 The clinical features of Health and Gingival Disease are included in Table 2.

Table 2

REWRITING THE NARRATIVE
Considering that probing is part of the standard of care defined by our regulatory bodies, setting a “zero percent BOP” treatment goal is a great way to begin to align with the 2018 classification and provide a higher level of patient care.

When you begin to change your narrative from “you have a little bit of bleeding” to “your BOP score today is 15%. “Our practice goal is zero percent,” you will create a measurable and motivational goal for your patients and further develop your collaborative relationship toward achieving optimal oral and systemic health.

BOP Points to Remember

  • % BOP Calculation = (Number of Bleeding sites ÷ (6/sites per tooth x number of teeth)) x 100.
  • Although <10% BOP is considered a “spectrum of health”4 , it is referred to in the literature as “incipient gingivitis” which can rapidly become localized gingivitis if not treated immediately or left untreated.
  • Any % of BOP on a reduced periodontium in a successfully treated stable periodontitis patient puts them at an increased risk of recurrent progression of periodontitis. This risk is not as high for patients with reduced periodontium not due to periodontitis.2
  • BOP reliability drawbacks exist with smokers; suppressed bleeding and anticoagulant medication; increase bleeding response.1 May need to rely on other assessment to determine health vs. disease.

References

  1. Trombelli L, Farina R, Silva CO, Tatakis DN. Plaque-induced gingivitis: Case definition and diagnostic considerations. J Periodontol. 2018;89(Suppl 1):S46–S73. https://doi.org/10.1002/JPER.17-0576
  2. Chapple ILC, Mealey BL, et al. Periodontal health and gingival diseases and conditions on an intact and a reduced periodontium: Consensus report of workgroup 1 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S74–S84. https://doi.
  3. Lang NP, Bartold PM. Periodontal health. J Periodontol. 2018;89(Suppl 1): S9–S16. https://doi.org/10.1002/JPER.16-0517
  4. Murakami S, Mealey BL, Mariotti A, Chapple ILC. Dental plaque–induced gingival conditions. J Periodontol. 2018;89 (Suppl 1):S17–S27. https://doi.org/10.1002/JPER.17-009 org/10.1002/JPER.17-0719

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