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Application of Basic periodontal examination (BPE) in clinical practice

BPE is a valuable tool to assess the onset and stage of periodontal diseases. The scoring can be used to determine the severity and help determine the treatment options.

doctor and his patient

BPE: A screening tool

The 2017 World Workshop Classification system for periodontal and peri-implant diseases and conditions was developed to accommodate advances in knowledge derived from both biological and clinical Periodontal diagnosis. The aim was to create a system that captured and distinguished the severity and extent of periodontitis and assess the patient’s susceptibility for periodontitis. In addition, the system needed to accommodate the current periodontal status of a patient (probing pocket depth [PPD], and the percentage of bleeding on probing [BoP]).1

Careful assessment of the periodontal tissues is an essential component of patient management.1 The BPE is a clinical application of the epidemiological community periodontal index of treatment needs (community periodontal index) tool, developed by the British Society of Periodontology for rapidly screening for periodontal disease in patients with no overt signs of periodontal disease based on visual inspection alone. BPE is a screening tool employed to rapidly guide clinicians to arrive at a provisional diagnosis of periodontal health, gingivitis, or periodontitis, irrespective of historical attachment loss and bone loss.1

How to record the BPE

There are a series of steps involved in the measuring of BPE2

1. The dentition is divided into 6 sextants, and the highest score for each sextant is recorded:

  • Upper right (17 to 14)
  • Lower right (47 to 44)
  • Upper anterior (13 to 23)
  • Lower anterior (43 to 33)
  • Upper left (24 to 27)
  • Lower left (34 to 37)

2. All teeth in each sextant are examined (except for 3rd molars unless 1st and/or 2nd molars are missing).

3. For a sextant to qualify for recording, it must contain at least 2 teeth.

4. A WHO BPE probe is used. This has a ‘ball end’ 0.5mm in diameter and a black band from 3.5mm to 5.5mm. Light probing force should be used (20-25 grams).

5. The probe should be ‘walked around’ the teeth in each sextant. All sites should be examined to ensure that the highest score in the sextant is recorded before moving on to the next sextant. If a code 4 is identified in a sextant, continue to examine all sites in the sextant. This will help to gain a fuller understanding of the periodontal condition and will make sure that furcation involvements are not missed.

Scoring and interpretation of codes3

Score

Description of scores

Guidance on interpretation

of scores

0

< 3.5 mm, no bleeding

(black band entirely visible)

No need for treatment

1

< 3.5 mm, bleeding on probing

(black band entirely visible)

Oral hygiene instruction

2

< 3.5 mm, supra or subgingival calculus

(black band entirely visible)

As for 1, plus scaling

3

3.5–5.5 mm (black band partially visible)

As for 2, plus root surface debridement if required

4

> 5.5 mm (black band disappears)

As for 3, plus assess for complex treatment or referral

*

Furcation involvement

As per 0–4, plus assess for complex treatment or referral

 

The BPE score for each sextant gives an indication of the care required. In addition, individual factors unique to each patient may influence the treatment required.2

Interpretation of the BPE scores

Interpreting the BPE score depends on many factors that are unique to each patient. Each patient may present with a different clinical presentation, and therefore skill, knowledge and judgement should be used when interpreting BPE scores. The BPE scores should be considered together with other factors when making decisions about whether to refer.4

  • Assign a risk level, based on the patient’s medical history, an assessment of risk factors and the outcome of the BPE, to inform future treatment and recall. 4
  • For patients where the BPE score indicates periodontitis (BPE score of 3, 4 or *), it is necessary to carry out a full periodontal examinationand record the findings in the patient’s clinical notes. 4
  • An explorative study of the current practice and attitude towards the management of chronic periodontitis by general dental practitioners showed that a majority of dentists would recall patients after three months for BPE 3 and 4 (84% and 77%, respectively); most of the remaining dentists felt a shorter recall period was more suitable. 5

 

The right time for using BPE is during the diagnostic process

The BPE and its equivalent systems have been well established in the clinical community across Europe due to its relative simplicity and efficiency. BPE is of limited value in patients who have already been diagnosed with periodontitis as BPE is unable to identify patients with historical periodontitis, as it is based upon BoP and PPD, rather than recording attachment and bone loss.1

For example, using the BPE on a patient with a history of periodontitis and no BPE scores over 2 would wrongly result in a provisional classification of periodontal health (<10% sites with BoP), localised gingivitis (10–30% sites with BoP) or generalised gingivitis (>30% sites with BoP), rather than capture the fact that the patient is a periodontitis patient with a current status of health or gingival inflammation1

Therefore, in a new patient, complete history, examination (interproximal recession/attachment loss) or radiographs is vital. 1

Algorithm for clinical periodontal assessment of plaque-induced periodontal disease

Figure 1: Algorithm for clinical periodontal assessment of plaque-induced periodontal disease. 1

Treatment recommendations for patients with BPE 3 and 4*

An explorative study assessed the current practice and attitude towards the management of chronic periodontitis by general dental practitioners. For a patient with BPE 3 and 4, immediate intervention is required to delay the progression and severity of periodontal diseases.5

BPE score 35

  • For those patients with BPE 3, nearly all dentists indicated they would request radiographs (92%), perform oral hygiene instruction (OHI) (99%) and supragingival scaling (95%).
  • 34% of the dentist recommends performing root surface debridement (RSD).
  • 50% of GDPs recommends performing periodontal charting of sextants scoring 3 before initial nonsurgical treatment of Periodontitis (NSPT).

BPE score 45

  • For those patients with BPE 4*, almost all dentists recommend radiograph assessment (98%), assessing oral health index (97%) and performing supragingival scaling (91%).
  • The majority also recommends performing subgingival scaling (83%) and remove plaque retentive factors (85%).
  • 35% would advise the patients to quit smoking immediately.
  • 70% would perform full-mouth periodontal charting before initial NSPT

Summary

BPE is a valuable stressing tool to assess the onset and stage of periodontal diseases. The scoring can be used to determine the severity and helps to determine the treatment options.

Tips for counselling patients on oral health

Educating the patients on the need for maintaining oral health and the problems associated with it can help in changing their oral hygiene behaviour

  • Talk with the patient about the causes of periodontal disease and discuss any barriers to effective plaque removal;
  • Instruct the patient on the best ways to perform effective plaque removal including flossing;
  • Ask the patient to brush twice a day. Recommend  toothpastes with clinically proven benefits on gum health such as  Pepsodent GumCare with Zinc Citrate trihydrate
  • Encourage patients to visit the clinic for a follow up routine visit to check on their gum health.

 

References:

  1. Dietrich T, et al. Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions – implementation in clinical practice. British Dental Journal. 2019;226(1):16-22.
  2. BASIC PERIODONTAL EXAMINATION (BPE) [Internet]. Bsperio.org.uk. [cited 19 June 2020]. Available from: https://www.bsperio.org.uk/publications/downloads/107_084422_bpe-guidelines-2011.pdf
  3. British Society of Periodontology. Good Practitioners Guide. Available at: https://www.bsperio.org.uk/ publications/good_practitioners_guide_2016.pdf (accessed July 2020).
  4. Matthews D. Prevention and Treatment of Periodontal Diseases in Primary Care. Evidence-Based Dentistry. 2014;15(3):68-69.
  5. Bhandal S, et al. An explorative study of the current practice and attitude towards the management of chronic periodontitis by general dental practitioners in the West Midlands. British Dental Journal. 2020;228(7):537-545

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