Dental Update - The simplified basic periodontal examination in children and adolescents: an update

Abstract

The ‘Guidelines for periodontal screening and management of children and adolescents under 18 years of age’ was updated by the British Society of Periodontology and Implant Dentistry and the British Society of Paediatric Dentistry in September 2021. The updated guidance acknowledged changes outlined in the 2017 World Workshop Classification of Periodontal Diseases and Conditions. The guideline outlines the use of the simplified BPE (sBPE) as a screening tool for periodontal disease in children, with treatment and management recommendations determined by sBPE codes 0–4*. It is an essential tool in primary dental care.

CPD/Clinical Relevance: The dental team should be aware of the recent changes in national guidance and carry out periodontal screening in children appropriately.

Article

The British Society of Periodontology and Implant Dentistry (BSP) developed the Basic Periodontal Examination (BPE) as a screening tool for adults in 1986. It was subsequently updated and in 2012, the BSP first published the ‘Guidelines for periodontal screening and management of children and adolescents under 18 years of age’ in 2012.^1,2 Updated guidelines were published in September 2021 and take into account the new 2017 World Workshop Classification system for periodontal and peri-implant diseases and conditions.

The primary dental care team should be aware of the recent updates and ensure periodontal screening is carried out appropriately in line with the latest evidence-based guidance. It is also important to have an understanding of when to treat in primary care and when to refer to specialist services to improve periodontal outcomes in children and adolescents. This article summarizes the key aspects of these updated guidelines.

Key aspects of the updated guidance

The 2021 guidelines recognize that the 2017 World Workshop Classification has reclassified the diagnosis of periodontal diseases and conditions.¹ Of particular relevance to children, the chronic/aggressive periodontitis diagnosis is no longer recognized owing to a lack of evidence supporting its continued use.³ The guidance reinforces the use of the simplified BPE (sBPE) as a screening tool for periodontal disease in children and outlines, in greater detail than before, the management and treatment recommendations determined by each sBPE code. The sBPE aims to reduce misdiagnosis of periodontal disease that may be caused by false pocketing in the developing dentition.¹

The Children's Dental Health Survey 2013 (UK)

The Children's Dental Health Survey (CDH) surveyed the oral health of children aged 5, 8, 12 and 15 years old in England, Wales and Northern Ireland in 2013.⁴ Three indicators were used to define good periodontal health. These were:

No more than one sextant with plaque;

No gum inflammation;

No calculus.

The CDH survey found that only one third of children met the criteria for good periodontal health. The prevalence of gingivitis was highest in 12 year olds. Pocketing was recorded in 15 year olds, of whom only a small percentage (5%) had shallow pockets of 4–5mm. Very few children with deep pockets were identified in the survey.⁴ As it is rare for children to have deep pockets, early recognition with appropriate screening is important, as is timely specialist referral.

The 2017 World Workshop Classification

The 2017 World Workshop reached consensus for a new classification of periodontal diseases and conditions.³ Three main agreed categories were:

Periodontal health, gingival diseases/conditions;

Periodontitis;

Other conditions affecting the periodontium.

Periodontal health, gingival diseases/conditions

In children with a healthy periodontium, the gingival margin is coronal to the cemento-enamel junction (CEJ), the gingival sulcus has a depth of 0.5–3 mm on a fully erupted tooth and, in teenagers, the alveolar crest is 0.4–1.9 mm apical to the CEJ.⁵

In children with dental plaque biofilm-induced gingivitis, false pocketing can arise owing to inflammatory infiltrate disturbing the junctional epithelium, which is still attached to the CEJ, and allowing apical migration of plaque.¹

Non-plaque-related conditions

There are a number of gingival diseases that do not correspond to the level of dental plaque biofilm. These can be divided into infective lesions (eg herpes simplex viruses), genetic conditions (eg hereditary gingival fibromatosis, coeliac disease), systemic diseases that manifest within the gingivae (eg myeloid leukaemia, B cell lymphoma, Hodgkin's lymphoma), trauma (eg thermal burns, ulceration) and drug induced (eg methotrexate, antimalarials)¹.

Periodontitis

Periodontitis in children is characterized by loss of attachment of the periodontal connective tissues, apical migration of the junctional epithelium beyond the CEJ and alveolar bone loss. Periodontal pathogens found in subgingival plaque are the same as those found in adults (Porphyromonas gingivalis, Prevotella intermedia, Aggregatibacter actinomycetemcomitans).¹

An important change in the updated guidance is that the chronic and aggressive periodontitis diagnosis has been removed from the 2017 classification.^3,6 There was limited evidence to support the continued use of this diagnosis, which had been included in the 1999 classification.^3,6 However, clinicians must be aware of its clinical presentation in children, which is well recognized and can be identified by the new staging and grading system (eg Stage II, III, IV Grade C).¹Figure 2 shows the British Society of Periodontology's flowchart implementing the new classification system.⁷ Localized first molar/incisor interproximal clinical attachment loss inconsistent with the level of plaque biofilm present, and an onset around puberty, should raise suspicion and warrants early specialist referral.

Figure 2. BSP flowchart for implementing the 2017 classification.12

Periodontitis can also arise as a direct manifestation of systemic disease.^3,6 This may occur in children with type 1 diabetes mellitus, Down syndrome, Papillon–Lefèvre syndome, Chédiak–Higashi syndrome, Ehlers–Danlos syndrome, leukocyte adeshion deficiency syndromes, neutropenia and hypophosphatasia.^1,2,3,6

Necrotizing periodontal diseases are rare in children in developed countries, such as the UK. However, clinicians should be aware of the characteristic clinical presentation of painful, punched out, necrotic and ulcerated interdental papillae and pseudomembrane formation, which may be accompanied by lymphadenopathy and pyrexia.¹

Radiographs

The Faculty for General Dental Practice gives guidance for the use of radiographs in the diagnosis of periodontal disease.⁷ Bitewing radiographs showing a distance of greater than 2 mm between the cemento-enamel junction and the bone crest is evidence of bone loss.⁵ In children, bitewing radiographs taken for caries diagnosis provide additional information about bone levels, reducing the need for additional radiation. Panoramic radiographs taken for orthodontic reasons should be also be screened for bone levels.¹

Other conditions affecting the periodontium

The third agreed category in the 2017 classification includes systemic diseases or conditions affecting the periodontal supporting tissues, periodontal abscesses and endodontic–periodontal lesions, mucogingival deformities and conditions, traumatic occlusal forces and tooth- and prosthesis-related factors.^1–3,6 Periodontal lesions may present in children with dental anomalies. This can be seen in dens invaginatus, where the invagination extends apically through the root with a second foramen into periodontal tissues, leading to an inflammatory response and peri-invagination periodontitis.⁸

Simplified BPE (sBPE) in children

The Simplified BPE (sBPE) is a screening tool for periodontal disease in children and adolescents under the age of 18. It is an important tool to detect periodontal disease at the earliest opportunity and dictates the level of further assessment and management needed.^1,2,9 The sBPE:

Should be carried out on all co-operative children and adolescents aged 7 years and up;^1,2

The six index teeth are assessed with six sites per tooth: UR6, UR1, UL6, LR6, LL1 and LL6; disto-, mid- and mesio-buccal, disto-, mid- and mesio-lingual;^1,2

Use a WHO probe with a 0.5-mm ball-end and a black band between 3.5 and 5.5 mm.^1,2

Clinicians should be aware of the presence of false pocketing in the mixed dentition. Therefore, in children aged 7–11 years, only sBPE codes 0, 1, 2 should be used on index teeth. Children aged 12 years and above should be screened with sBPE codes 0, 1, 2, 3, 4, * on index teeth.^1,2 The sBPE screening tool is summarized in Figure 1.²

Management is dictated according to the sBPE code recorded (Table 1).²

Table 1. sBPE codes and periodontal management.1,2

sBPE code	Management
0	No periodontal treatment, screen again at routine recall or within 1 year, whichever sooner	7–11 years
1	OHI, screen again at routine recall or within 1 year, whichever sooner
2	OHI as for code 1. Supragingival/subgingival professional mechanical plaque removal (PMPR) Remove/manage plaque retention factors, screen again at routine recall or within 1 year, whichever sooner
3	OHI as for Codes 1 and 2. Supragingival/subgingival PMPR with particular emphasis on subgingival PMPR in shallow 4mm – 5mm pockets. Remove/manage plaque retention factors. After 3 months, do a full periodontal assessment, including a six-point probing depth (PPD) chart, in affected sextants	12–17 years
4 or *	Unusual in young patients. Do a full periodontal assessment, including a six-point PPD chart, throughout the entire dentition. Consider referral to a specialist, while do initial therapy as code 3	12–17 years

A comparison of sBPE code management between 2012 and 2021

The main change between the 2012 and 2012 sBPE guidelines is related to sBPE code 3. Previously, a code 3 required recording of full probing depths in the affected sextant, treatment with oral hygiene instruction and root surface debridement, with a review after 3 months. The 2021 sBPE takes into account the problem of false pocketing and if a code 3 is identified, the clinician should carry out OHI, supragingival/subgingival PMPR and review the patient after 3 months. The clinician should then carry out a six-point probing depth (PPD) chart in the affected sextants. In addition, the new guidelines specify that for a code 4, specialist referral should be considered while undertaking initial therapy as per code 3.

When to refer to specialist services

The decision to refer to specialist services is an important and time-sensitive decision that depends on many factors, including patient, dentist and case complexity. Early referral can significantly improve periodontal outcomes.^1,2Table 2 summarizes when referral should be considered. Additionally, in children, unexplained premature exfoliation of primary teeth warrants concern and could be due to a number of conditions, such as hypophosphataemia, Papillon–Lefèvre, Chédiak–Higashi syndrome, Langerhans cell histiocytosis, neutropenia and leukaemia.^3,6 Early exfoliation of primary teeth, in combination with other clinical signs, such as delayed growth, bone pain and lower limb abnormalities should raise suspicion of hypophosphataemia or rickets^10,11 and should be referred promptly for investigation.

Table 2. When to refer to specialist services.

1	Stage II, III periodontitis not responding to treatment
2	Grade C or Stage IV periodontitis
3	Periodontitis as a direct manifestation of systemic disease
4	Medical history that significantly affects periodontal treatment or requiring multidisciplinary care
5	Systemic/genetic diseases that can affect periodontal supporting tissues
6	Root morphology/furcation defects adversely affecting prognosis on key teeth
7	Non-plaque-induced conditions requiring diagnosis/management of rare or complex pathology, drug-induced gingival overgrowth and cases requiring evaluation for periodontal surgery

Conclusions

It is important for the dental team to be aware that the BSP and BSPD have updated their guidance for the use of the sBPE. The sBPE aims to combat misdiagnosis of periodontal disease caused by false pocketing in the developing dentition by recommending that six index teeth are assessed. Early diagnosis of periodontal disease and appropriate referral to specialist services is essential to improve periodontal outcomes and reduce periodontal morbidity. It is therefore prudent that children with unexplained early exfoliation of primary teeth and children with sBPE codes of 4 and * with associated bleeding, suppuration and mobility^1,5 are referred onwards to secondary care without delay.

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References

The simplified basic periodontal examination in children and adolescents: an update

Authors

Divya Pathak

Nabina Bhujel