Simplified basic periodontal examination (BPE) in children and adolescents: a guide for general dental practitioners

The Basic Periodontal Examination (BPE)

The BPE was introduced by the BSP in 1986 to act as a simple and rapid tool to help dentists to screen for periodontal diseases in adults. A study by Tugnait et al in 2004 found that its use had been adopted by the majority of GDPs during both new patient and recall examinations; reported use being 91% and 84% of the time, respectively.8 It is an important tool to help identify the early signs of periodontitis and prevent its sequelae and its use is recommended by some indemnity organizations to help clinicians to record periodontal health or disease.9 A lack of its use by a clinician may leave him/her vulnerable to a complaint or an allegation of negligence in failure to diagnose periodontal disease.

The new Basic Periodontal Examination

In 2011, the BSP introduced modifications to the use of the BPE. The asterisk code now only represents furcation involvement and not clinical attachment loss of 7 mm or greater as before (Figure 1, Table 1). This asterisk code also needs to be used in conjunction with a numerical code, eg if teeth in a sextant have pocketing of 6 mm and furcation involvement, the code would now be recorded as a 4*.

In addition to this, new guidelines have been introduced by the BSP and the BSPD7 which set out recommendations for the periodontal screening and management of children and adolescents under the age of 18 years in primary dental care. Unlike in adults, there was a lack of clear guidance for the assessment of periodontal diseases in children prior to this.

The aim of these new guidelines and the simplified BPE is to provide a quick, simple and acceptable method of screening patients for periodontal conditions that is sufficient to identify those who would benefit from a more detailed examination. The index teeth have been chosen as it is uncommon for periodontal breakdown to be found at other sites without these teeth being affected. Examination of these teeth allows the detection of both reversible and irreversible periodontal diseases.

Although this examination is appropriate for the majority of patients, for those with extreme dental anxiety or diminished understanding, it may not be appropriate.

How to use the BPE in children and adolescents

A simplified BPE is recommended for use in children (Figure 2). This involves assessing six index teeth UR6, UR1, UL6, LL6, LL1, LR6. The BPE should be performed using the WHO 621 probe with a light probing force of between 20 and 25 grams. The probe has a 0.5 mm sphere on its tip and a black band between 3.5 and 5.5mm. This is used to differentiate between a healthy sulcus depth (less than 3.5 mm) and a pathological periodontal pocket (3.5 mm or greater). The BPE codes shown in Table 1 apply to both child and adult patients.

The type of assessment required varies with the age of the patient. As for all adult patients, children should have a thorough extra-oral examination and an intra-oral assessment, to include examination of the soft and hard tissues in addition to an examination of the periodontal condition. This should include a description of the gingival colour, presence and location of swelling, inflammation, recession and suppuration (Figure 3). The oral hygiene should be assessed and any visible calculus deposits recorded.

Children under 7 years of age

A BPE is not necessary in this age group as periodontal problems are rare and index teeth are frequently unerupted. Children who demonstrate unexplained mobility or premature exfoliation of teeth or erythematous, swollen gingivae and/or suppuration for which no other dental cause can be found should be referred for specialist opinion. As in older children and adults, periodontal breakdown may be a manifestation of systemic diseases (Figures 4, 5)10 (Table 2).

Table 2. Systemic conditions that may be associated with periodontal breakdown

Neutropenia

Leukaemia

Down syndrome

Leukocyte adhesion deficiency syndromes

Ehlers-Danlos syndrome

Papillon-Lefèvre syndrome

Infantile Genetic Agranulocytosis

Chediak-Higashi

Histiocytosis syndromes

Glycogen Storage Disease

Cohen syndrome

Hypophosphatasia

Short-term management

Referral

Referral to a periodontist or paediatric dentist should be considered in the following instances:

BPE Codes 4 and * are detected, particularly if accompanied by bleeding, suppuration or mobility of teeth;

Chronic periodontitis not responding to treatment;

Aggressive periodontitis (Figure 6);

Systemic medical condition associated with periodontal destruction;

Genetic conditions predisposing to periodontal destruction;

A medical history that significantly affects periodontal treatment or requiring multidisciplinary care;

Drug-induced gingival overgrowth; Patients requiring diagnosis/management of rare/complex clinical pathology;

Root morphology adversely affecting prognosis.

Long-term management

The primary aim of the long-term management of affected young patients is to maintain periodontal stability and thus prevent irreversible bone loss and its sequelae, eg increased tooth mobility, ‘black triangle disease’ and potential tooth loss (Figures 7, 8).

If tooth loss does occur, young patients often seek prosthodontic replacement with or without prior orthodontic treatment. Orthodontics alone is rarely the treatment of choice if tooth loss has occurred, but is ideal for managing teeth that have migrated. However, the management of these patients is often difficult and, despite prolonged treatment, may still lead to a suboptimal functional and cosmetic result (Figures 9, 10). Thus optimal oral rehabilitation of patients who have suffered significant periodontal destruction at a young age often requires multidisciplinary care which always includes a primary care practitioner and may include experts in the fields of periodontics, prosthodontics, implantology, oral surgery, paediatric dentistry and orthodontics.

If orthodontics is indicated then the patient should be periodontally stable prior to treatment as orthodontic forces applied to teeth with ongoing periodontitis may act as a co-destructive factor and lead to increased bone loss.14 It is unclear as to the minimum time interval between active periodontal therapy and orthodontic treatment but the authors suggest a minimum of one year. If there is any doubt regarding the patient's stability or motivation to maintain excellent oral hygiene during orthodontics, then it should not be recommended.

Unfortunately, the use of fixed orthodontic appliances has been found to increase plaque accumulation14 and orthodontic treatment in general causes a small but significant detrimental effect on periodontal health.15 Thus a patient who was previously stable for a significant period of time may find that he/she develops recurrent periodontitis as a result of this treatment. Even if the patient maintains good periodontal health during treatment, controlling orthodontic forces on teeth with reduced but healthy attachment apparatus is difficult and usually requires an experienced orthodontist.16

Prosthodontic replacement of lost anterior teeth is often required in addition to, or instead of, orthodontics. This also has notable difficulties as young patients are often averse to wearing a removable prosthesis. Even when a removable prosthodontic solution is acceptable to a patient, the evidence suggests that greater plaque accumulation may occur in both the restored and the opposing arches.17 This creates a downward spiral in which the patient becomes increasingly dependent on a prosthesis which is expediting the loss of the remaining teeth.

As the majority of young patients have a minimally restored anterior dentition, the prescription of conventional bridges is rarely warranted. Adhesive bridges are often suitable for the prosthodontic rehabilitation of affected young patients as long as the abutment teeth have sufficient remaining tooth structure and periodontal support. Using a healthy but periodontally compromised tooth as a bridge abutment may subject the tooth to secondary occlusal trauma and may cause the tooth to have increased long-term mobility.

Dental implants can provide an alternative fixed prosthodontic solution for patients with missing anterior teeth. For an implant fixture to osseo-integrate successfully, it ideally requires complete three-dimensional coverage with alveolar bone. The very nature of periodontitis, however, means that bone has been lost, especially at the most coronal aspects of the alveolar crest. Thus periodontally compromised sites often require bone and soft tissue augmentation which adds to the complexity, expense, time and expertise required to obtain a satisfactory result. Even when an implant-retained restoration is possible, the lack of crestal bone often means that recreation of the dental papillae is unpredictable (Figure 11). Another concern in implant rehabilitation in the aesthetic zone relates to the timing for the placement of any fixtures. It is well established that vertical alveolar growth in adolescents may continue long after maximum height has been established. Placement of an implant fixture prior to completion of vertical alveolar growth may lead to an unsightly discrepancy between the implant-retained crown and the remaining teeth (Figure 12). In a patient with a high smile line this is likely to be noticeable but is difficult or impossible to correct post-operatively.

Unfortunately, even if implants are optimally placed, they are known to have an increased rate of failure in patients who are susceptible to periodontitis.18 Indeed, implants suffer marginal soft tissue inflammation and peripheral bone loss which has a similar clinical presentation to the effects of gingivitis and periodontitis in teeth. The disease processes are termed peri-implant mucositis and peri-implantitis, respectively, and can be very difficult to manage once established.

If posterior teeth are lost due to periodontal disease then no prosthodontic replacement is often proposed. It is well recognized that patients can maintain oral function with a shortened dental arch and occluding units in the anterior and premolar teeth only.19^,20 If the patient desires prosthodontic replacement of teeth, the fixed or removable options outlined above may be indicated. If the patient is periodontally stable and has heavily restored teeth adjacent to the edentulous space, then a conventional bridge may be considered.

Finally, in addition to avoiding or mitigating the effects of tooth loss, it has been postulated that improving patients' periodontal health may have a beneficial effect on their systemic health. Recent high quality evidence indicates that improving a diabetic patient's periodontal health may improve his/her glycaemic control.21 It has also been hypothesized that improving periodontal health leads to a reduction in a patient's long-term risk of cardiovascular diseases,22 rheumatic disease23 and adverse pregnancy outcomes.24 At present, however, there is little conclusive evidence that elucidates the exact nature and causality of any links and how this may relate to periodontal diseases in younger patients.

A medico-legal perspective

It is well established that the number of complaints and legal claims made against dentists in the UK has risen steadily for several decades. Periodontology as a whole has been recognized as one of the higher risk areas in dentistry and the consequences of a failure to diagnose irreversible periodontal destruction can be severe for the patient and the dentist.25

For any plaintiff to be successful in proving that a defendant is negligent he/she must establish three broad facts. It needs to be shown, on the balance of probabilities, that the defendant:

A plaintiff usually has a time limit of three years in which to begin a claim in negligence under the Limitation Act. The earliest that this time bar begins for any claimant is from the time that he/she legally becomes an adult, which in the UK is 18 years of age. In addition, the time does not start to run from the date of the alleged breach of duty, ie failure to diagnose an irreversible periodontal disease. The time begins when the patient becomes aware of the problem, eg a periodontal assessment at a new dentist, or should have become aware of the problem, eg loose teeth.

Further to all of this, if the patient is seen under an independent contract, then instead of suing a dentist in negligence they can claim for a breach of contract. Under the Act, claims in breach of contract have a six year time bar rather than three years for claims in negligence. A patient cannot claim breach of contract if the patient is a registered NHS patient as no direct contract exists between the two parties.

Thus a dentist may find that a claim of failure to diagnose periodontitis may materialize many years or even decades after the alleged negligence.

Finally, if a dentist is found to have been negligent in failing to diagnose periodontitis in a child then the quantum of damages is also likely to be higher than for an older adult patient. This is because any damages that are awarded will have to take into account the cost of tooth replacement and subsequent maintenance and failure of those replacements over the remainder of the patient's life.

Conclusion

The BPE has now been modified for use in children. This should be used as described to identify children at risk of periodontal diseases, to act as a guide for appropriate management and to identify patients who may benefit from referral to a specialist in paediatric dentistry or periodontics.

This article provides a summary of the new guidelines released by the BSP and BSPD and explains the use of a modified BPE in children. This article also highlights the importance of providing appropriate clinical and radiographic examinations and outlines the difficulties in returning a patient to ideal function and cosmetics once irreversible damage has occurred.

Finally, failure to use the modified BPE in a young patient who is later diagnosed with periodontitis may leave a dentist vulnerable to a medico-legal complaint or claim.