The Periodontal Assessment

Sumamry
This lesson will guide you through how to carry out a thorough periodontal assessment.

NOTE – Please note this assessment and management criteria are indicated by the British
Society of Periodontology. If you are following this lesson from another region, please
check your national guidelines in regard to periodontal assessment and management.

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Keywords: ta
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Supracrestal attached The distance from the base of the gingival sulcus, to the alveolar
tissues (previously termed bone; it includes the connective tissue and the junctional epithelium
Biological width) attachment to the tooth.
Plaque which has calcified due to mineral deposits such as calcium
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Calculus
and phosphates from the saliva
The area where roots separate; this can be in a bifurcation (two
Furcation
roots), or trifurcation (three roots)
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The displacement of a tooth beyond its normal physiological

Mobility
boundaries in a horizontal or vertical plane
Periodontal Pocket A pathologically deepened gingival sulcus
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Is the distance between the free gingival margin and the bottom of
Pocket Depth
the pocket.
Clinical Attachment Loss
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CAL is the distance between the CEJ and the bottom of the pocket.
(CAL)
Instruments involved in the Periodontal Assessment

Basic Periodontal Exam Probe (also known as a WHO probe)

Williams probe
UNC 15 probe
Nabers probe

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BPE probe

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A BPE probe is the standard probe used in every initial dental assessment. This probe is used to give
a BPE score. ta
Its structure has a 0.5mm ball at the end; this is ball shaped to prevent trauma to the gingivae,
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but also this will pick up the tactile feel of calculus subgingivally.
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There are 4 sections to a BPE probe, with 2 black bands. The first black band is 3.5mm - 5.5mm.
The second black band is from 8.5mm – 11.5mm.
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BPE Probe
Williams Probe

A Williams probe can be used in a 6PPC to take more thorough and accurate measurements of the
pocket, and the gingival recession. The Williams probe has markings at; 1, 2, 3, 5, 7, 8, 9, 10

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Wiliams Probe
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UNC15 Probe
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A UNC15 probe can be used in a 6PPC also to take more thorough and accurate measurements of
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the pocket, and the gingival recession. This probe has black markings every 5mm. Therefore 5,
10 and 15! The UNC15 probe has markings at; 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15
UNC15

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Nabers Probe
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A Nabers probe is a probe which is used to measure the extent and the depth of a furcation. A
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furcation is the area where tooth roots meet, so can only be used in molar teeth. The markings on a
Nabers probe are; 3-6mm, 9-12mm both indicated through a black band
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Nabers Probe
The Initial Exam - Periodontal Stages

The periodontal exam is divided into multiple stages depending on findings. There are multiple parts

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to be considered;

Clinical Appearance

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BPE
Plaque Indices
Bleeding Indices
Radiographs
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If a person shows to have signs of periodontal disease, a further assessment is used called a 6-point
pocket chart (6PPC). This is divided into several further stages.
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Pocket depth
Gingival recession
Clinical Attachment Loss (CAL)
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Bleeding
Suppuration
Mobility
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Furcation
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This lesson will guide you through the way to carry out a periodontal assessment to gain the
appropriate information to make a diagnosis.
Clinical Appearance

When initially assessing a patient, it is important to not only take measurements, but to also evaluate
clinically the health of gums.

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Clinical Health can be determined by;

Colour - are they pink or erythematous?

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Contour – do they have the knife cut papilla or do they appear to have lost this contour?
Swelling – do they look slightly puffy indicating inflammation?
Recession – does the patient brush with a heavy hand or is there a history of gum disease?
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Plaque accumulation
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Following a clinical inspection of the gums to give you an idea of the health, it should be followed by
a Basic Periodontal Exam (BPE) as indicated by the British Society of Periodontology (BSP).
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Healthy Clinical Appearance
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Basic Periodontal Exam (BPE)

The BPE is the screening process for gum disease. This means exactly what it says in the name;
basic. It allows dentist to check in the least invasive and discomforting manner if there is gum
disease present, and also acts as a guide on where improved oral hygiene may be indicated.

A BPE is conducted using a BPE probe (sounds logical?). The BPE probe is walked around all 6
surfaces of the teeth with a light probing force estimated to be 20-25g. The clinician will be
watching the depth the probe goes to and always watching the black band, as well as gaining
information through tactile feedback for calculus or overhangs.

In a BPE, the teeth are sectioned into sextants. All the teeth in that sextant, excluding wisdom teeth,
are included. The highest score is then taken as the recording for the sextant.

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Surfaces to Examine

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Disto-Lingual Lingual Mesio-Lingual
Disto-Buccally Buccally Mesio-Buccal
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Teeth to Check
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7,6,5,4 3,2,1,1,2,3 4,5,6,7

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7,6,5,4 3,2,1,1,2,3 4,5,6,7

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A full BPE should be conducted on all patients over the age of 18. A simple BPE should be
conducted on patients over the age of 7, when they have their first permanent molars, and their
permanent central incisors. More information regarding this can be found later in the lesson. The
meaning of the band height, and the BPE it is therefore scored can be found below.
 Pocket BPE
Band Meaning
Measurement score
No gingival bleeding
First black band completely
0 - 3.5mm 0 No calculus or plaque retentive
visible
factors
Gingival bleeding
First black band completely
0 - 3.5mm 1 No calculus or plaque retentive
visible
factors
First black band completely Presence of calculus or/and plaque
0 – 3.5mm 2
visible retentive factors
First black band is partially Indicates a pocket depth between
3.5mm - 5.5mm 3
visible 4-5mm
First black band is entirely Indicates a pocket depth above

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>5.5mm 4
in the pocket 6mm
This means a furcation can be felt.
- - * This is added onto the BPE
score eg 4*

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Image to show how the BPE probing depth screens Periodontal Disease
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Additional Information for the BPE:

For a sextant to qualify, there must be at least two teeth present

The score for the sextant is represented by the worst site
If there is only one tooth in the sextant, it should be added to the adjacent sextant
If no teeth are qualifying for the sextant, it should be marked with a X
The wisdom teeth (8's) aren't included in a BPE unless it allows for the sextant to be included,
for example only one other tooth is present in the sextant
Example:

UR6 disto-palatally the black band is completely within the pocket and furcation involvement
UR1 there is bleeding present
UL7 buccally there is partial coverage of the black band, and general calculus deposits
buccally
LL7 mesio-lingual there is partial coverage of the black band

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LL3-LR3 shows to have supragingival calculus lingually.
LR sextant only shows to have a LR5, therefore this is included in the BPE for the lower
anterior sextant.

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Therefore, the BPE for this patient would be:
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4* 1 3
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X 2 3
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Clinical Management Pathways based on the BPE scores

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BPE Management Additional Investigations

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No investigations required.
0 No further guidance required
Reassess BPE at next checkup.
Plaque and Bleeding Indices.
1 Oral Hygiene Instruction
Reassess BPE at next checkup.
Oral Hygiene Instruction, and removal of the plaque Plaque and Bleeding indices.
2
retentive factors eg. Supra/Subgingival calculus Reassess BPE at next checkup.
Plaque and Bleeding indices.
Radiographs should be
Oral Hygiene Instruction, removal of the plaque retentive considered.
3
factors, and Root Surface Debridement (RSD) if necessary 6PPC indicated in only the
sextants of 3 after initial
therapy.
 Plaque and Bleeding indices.
Radiographs taken to indicate
Oral Hygiene Instruction, and RSD. Consider referral to a
4 attachment loss.
specialist for more complex treatment.
6PPC before and after
treatment.
Treat based on the BPE code. Consider referral to a 6PPC before and after
*
specialist for more complex treatment. treatment.

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The Simplified BPE; for Children Only

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The BPE on a child can feel strange to do, especially as they are so young that having a probe in
their gums is going to feel very weird and can be uncomfortable. This means that an alteration to the
BPE is used, termed the simple BPE, until they are older and therefore more accustomed to the gum
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exams a dentist might do! A Simple BPE should be conducted on patients over the age of 7 when
their first permanent molars, and permanent central incisors have erupted.
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It is especially important to recognise the scoring and the teeth noted as it is very common for false
pocketing during the mixed dentition phase, which can falsely indicate the need for treatment.
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Differences:
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Only 6 teeth are checked in the BPE for a child

UR6, UR1, UL6, LL6, LL1 and LL6
A child between the ages of 7-12 should only be scored a BPE between 0-2
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A child between the age of 12-17 can be scored normally however using only the 6 teeth
Bleeding Indices

Bleeding on probing (BoP) helps to give dentists an idea of the gum health, as inflamed gums will
bleed. This means that active disease is occurring.

During the process of periodontal treatment, it is very important to repeat these bleeding indices as
it gives the patient a goal.

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For example, in their initial appt they have a score of 50%, but in their second appointment after
meticulous oral hygiene instruction it is 35%. This allows the patient to see their efforts to help
improve their oral health. It also can indicate where more help is required.

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If a patients BoP scores stay high, it means that there is active periodontal disease still occurring
indicating poor patient compliance or difficulty; this can influence the prognosis for future
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restorative and prosthodontic treatment.
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Image to show Bleeding Gums

Plaque Indices

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A Plaque index is a very helpful diagnostic and visual aid to help a patient understand what you are

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looking for! It works to test the amount of plaque present on the teeth. It typically
involves disclosing the plaque using food colouring which adheres to bacterial biofilms therefore
highlighting their presence.
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This is very good to show the patients as it makes them aware of how much plaque they are
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actually missing when they brush!
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Prior to beginning treatment, a plaque index should be taken. This allows the patient to understand
their oral health status to act as motivation for improvement, very similar to their bleeding index.
Throughout the treatment, these indices should be repeated, especially prior to carrying out
prosthodontic treatment as it is likely to have a poor prognosis if plaque levels are not controlled.
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There are several types of plaque indexes which can be used as described below;
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Silness & Loe

This method measures the plaque accumulation on certain teeth

UR6, UR2, UL4, LL6, LL2, and LR4

4 surfaces are examined – Buccal, Palatal/Lingual, Mesial and Distal
Plaque is not disclosed
Each surface is scored 0,1,2,3 depending on the amount of plaque present
Modified Turesky

This method measures the amount of plaque present on each tooth.

All teeth are assessed (excluding third molars)

2 surfaces are examined – Buccal and Lingual (these surfaces must be of unrestored teeth)
Teeth are disclosed
A tooth is assigned a score 0-5, depending on the amount of plaque present on the tooth
surface

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O'Leary

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This method measures the presence or absence of plaque on each surface of each tooth
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All teeth included
4 surfaces are examined – Buccal, Palatal/Lingual, Mesial and Distal
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Teeth are disclosed
Teeth are simply scored based on the presence, so either yes or no!
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Note: Prior to staining a patient’s teeth, ensure you offer them Vaseline to put on their lips. This will
prevent the staining from transferring to their lips and giving them an interesting lipstick!
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Image to show Plaque disclosing on the Left, and clean dentition on the Right
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Radiographs

Radiographs are used in dentistry to support a clinical observation. They are also highly important at
helping to determine the prognosis of teeth.

Radiographs are typically indicated after a clinical assessment, to either aid diagnosis or aid further
investigation. With relevance to periodontal assessments, radiographs can give valuable information
about the extent (generalised or localised), severity (mild, moderate, severe) and the pattern
(horizontal, vertical, furcation involvement bone loss) of bone loss. These are usually taken when
patients exhibit a BPE of 3, 4 or * or there is a clear clinical evidence of interdental recession

This is very important in the new BSP guidelines as the amount of bone loss will guide the
periodontal diagnosis!

Horizontal bitewings can be taken however in cases of severe bone loss, these are not as helpful.
Especially as they do not show additional pathoses which can be present in periodontally-involved
teeth; consequently, affecting their prognosis. Vertical bitewings usually show more of the bone
crest of periodontally involved teeth but still they cannot be used to assess the periapical status and

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the length of the root of the exposed teeth.

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Bitewing Radiograph shows details of the coronal Alveolar Bone

The gold standard for a periodontal assessment is a periapical (PA) radiograph. This is able to give a
full picture of the tooth; including assessing the association of the level of the bone crest relative to
the length of the root, furcation involvement, periapical and endodontic status of the teeth, and
bony defects – all of which need to be taken into account to determine prognosis at tooth and patient
level. In generalised periodontal disease, it is typically appropriate for full mouth PA's to be taken to
aid the diagnosis.
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Periapical (PA) Radiograph shows the most detail on the bone level

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OPGs can be helpful as they produce an overall picture of the dentition, including the height of the
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bone. However, they lack the detail and resolution for some teeth. Consequently, they may need to
be supplemented with additional periapical radiographs, especially in the anterior sextants, due to
superimposition of the image.
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This means that because the spine overlaps the OPG field in a 2D plane, it causes the image to
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distort in this region which is where the anterior teeth are found.
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OPG shows a general presentation of the Alveolar Bone health
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What should be noted in the Radiograph report?

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Degree of bone loss

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Type of bone loss – vertical or horizontal?

+/- Furcation defect
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+/- Presence of calculus

+/- Periapical pathoses, widening of the PDL, overhanging of restorations
Radiolucencies indicative of caries
Presence of root canal fillings and their quality
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6 Point Pocket Chart (6PPC)

These 6 positions are checked for every tooth in the sextant after initial therapy if there is a BPE of
3, however all teeth in the mouth are checked if there is a BPE of 4.

During a 6PPC, much more information regarding the periodontal health is noted.

Pocket depth – this is the reading from the base of the pocket, to the gingival margin. This is

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carried out using a Williams or UNC15 probe. Recession – this is the reading from the CEJ to
the level of the gingival margin. This is carried out using a Williams or UNC15 probe.
Mobility – the mobility is scored using its own separate scoring system. This is carried out
through gentle pressure, or through moving the teeth using the ends of two instruments.

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Furcation – furcation is graded using a separate grading system. This is carried out using a
Nabers probe.
Bleeding on Probing (BoP)
Suppuration: presence of pus exudate whilst probing
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Disto-Lingual Lingual Mesio-Lingual
Disto-Buccally Buccally Mesio-Buccal
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Above are the 6 positions which must be recorded for pocket depth and recession during a 6PPC.
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Note - For general dental practitioners, it is the minimum requirement to record pocket depths and
BoP in a 6PPC however this will not give you as much clinical data therefore the recommendation is
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to complete all sections!

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Clinical Attachment Loss (CAL)

CAL is a more accurate indicator of the periodontal destruction around a tooth than probing depth
alone. CAL defined as the distance between the CEJ and the bottom of the pocket. It aims to
calculate the degree of periodontal disease taking into account active disease (pocket depth) and
evidence of previous disease as shown through recession.
Where recession has occurred, CAL can be calculated as follows;

Pocket depth + Recession = Clinical Attachment Loss

In cases of gingival enlargement, to calculate the CAL we need to subtract the distance between the
gingival margin to the CEJ from the pocket depth (PD)

CAL = Pocket depth - distance from gingival margin to CEJ

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Based on the information provided, what is the recession?

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Recession

Recession of the gums is when the gums have started to cover less of the teeth; this can include the
loss of interdental papilla. There are a number of causes for recession including abrasive tooth
brushing, periodontal disease, periodontal therapy such as scaling, tooth positioning or a
combination of the above.

Patients showing recession will report their teeth look longer or are more sensitive.
Therefore, understanding the cause for the recession is essential to prevent its progression. Below
are some examples where recession can be avoided or indicators of another problem:

In patients who brush aggressively it is very common to show recession and abrasion cavities,
meaning recommendation of an electric toothbrush is advised. This is because they stop
moving (oscillating) if excessive force is applied.
Recession in younger patients is relatively uncommon, therefore is there a traumatic
malocclusion? This typically presents palatally in the upper anterior arch, or labially in the
lower anterior arch. It is a key justification for orthodontic appliances. Also chronic trauma,
such that caused by oral piercings have been shown to be implicated with gingival recession in
younger patients.

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If there is a history of periodontal disease, unfortunately recession is unavoidable. During
periodontal therapy, the inflamed gum will recede, therefore reducing the pocket depth. This is a

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positive outcome as the pocket becomes easier to clean, despite the gum recession.

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Once gums have receded, the tooth is more subject to problems. For example, root caries, dentine
hypersensitivity, and poor aesthetics. Communicating this information to patients is very important
prior to carrying out non-surgical/surgical periodontal treatment. This means that the patient isn't
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surprised if afterwards their gums recede.
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Remember – it's an excuse if you tell them after!

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Image of Gingival Recession
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Furcation
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Furcation involvement occurs when the bone loss has extended to the level of where the roots
separate in molars; this can be in a bifurcation (two roots), or trifurcation (three roots). Grading a
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furcation focuses on the horizontal measurements rather than the vertical, meaning
a specialised curved probe, called a Nabers probe is used to measure the amount of bone loss in the
horizontal plane.

Representation of Probe
Clinical Observation Grade
through Furcation
No furcation present 0 -
Probe passes into the furcation however does not
extend more than 1/3rd of the bucco-lingual width of the 1
tooth

Probe passes into the furcation however does extend

more than 1/3rd of the width of the tooth, however does 2

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not extend completely through the furcation

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Probe extends completely through the furcation 3
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Furcation involvement must be noted as it can affect the prognosis for the tooth affected. Especially
as keeping this area clean is very difficult for the patient. However, various surgical and non-
surgical techniques can be used to ease the cleaning and improve the prognosis.
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Mobility

Tooth mobility is the amount a tooth can move. Teeth naturally have the ability to move within their
socket a minimal amount of around 0.2mm horizontally; this is facilitated by the PDL. However, it is
very common in the later stages of periodontal disease for a patient to become more aware of tooth
movement or 'looseness'.

The way to think about it, is like you have a post in the ground, surrounded by soil. If you dig up
some of the soil, it allows the post to wobble a bit more as it's not as well supported. However, if you
keep digging up the soil around the post, eventually the post will fall over.

Applying this to dental terms, the tooth is the post and the bone is the soil. Periodontal disease leads
to the loss of bone, meaning the tooth can move more, and can eventually fall out. It can also occur if
the tooth is subject to excessive occlusal loading.

Clinical Observation Score

Mobility is under 0.2mm (this is a healthy tooth's physiological mobility) 0
Mobility is between 0.2mm - 1mm in the horizontal plane 1

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Mobility is over 1mm in the horizontal plane 2
Mobility is in both the horizontal and vertical plane 3

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Violation of Supracrestal Tissue Attachment

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NOTE: this was previously termed Biological Width however has now been replaced by the term
Supracrestal Attached Tissue. (1)
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The supracrestal tissue attachment is a measurement which describes the distance from the base of
the gingival sulcus, to the alveolar bone. This is said to be approximately 2.04mm but it varies
amongst individuals (2). The importance of the supracrestal tissue attachment comes in when we
perform restorative work such as crown and bridgework, for example. The margins of our
restorations should be maintained ideally supragingival or at the same level of the gingival margin.
Sometimes it may be necessary to finish our preparations slightly subgingivally. This poses the risk
of violating the supracrestal tissue attachment (or more commonly known to clinicians, biological
width, although this term has now been replaced). An infringement of restorative margins within the
supracrestal connective-tissue attachment is associated with inflammation and loss of periodontal
supporting tissue.
The tissues may try to re-establish the desired amount between the margin of the restoration and
the bone crest either by a pocket formation and bone loss or by gingival recession. This is
considered to be dependent on the gingival biotype of the patient (thick or thin respectively).

Therefore, if there is an area of localised gingival recession, or bone loss with generalised good oral
hygiene, always consider if this is related to an overextended restoration which impinges
on supracrestal attached tissues. This means that the gingival sulcus and bone will adapt to
maintain a constant width. In the planning stages for restorative treatment this must be a
consideration to prevent avoidable damage.

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Conclusion
A basic periodontal assessment should always include information collected through;

Clinical Appearance
BPE
Plaque Indices
Bleeding Indices
Radiographs

For a more detailed periodontal assessment, a 6PPC should be used to gain more information.

Third Party Links

References
Specific References: (1) Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS,
Mealey BL, Papapanou PN, Sanz M, Tonetti MS. A new classification scheme for periodontal and
peri‐implant diseases and conditions–Introduction and key changes from the 1999 classification.
Journal of periodontology. 2018 Jun;89:S1-8. (2) Gargiulo AW, Wentz FM, Orban B. Dimensions and
relations of the dentogingival junction in humans. The Journal of Periodontology. 1961
Jul;32(3):261-7. General References: Bosshardt DD. The periodontal pocket: pathogenesis,
histopathology and consequences. Periodontology 2000. 2018 Feb;76(1):43-50. British Society of
Periodontology. Young Practitioners Guide to Periodontology. British Society of Periodontology;
2012. Clerehugh V, Tugnait A, Genco RJ. Periodontology at a Glance. John Wiley & Sons; 2013 May
31. Ziada H, Irwin C, Mullally B, Allen E, Byrne PJ. Periodontics: 1. Identification and diagnosis of

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periodontal diseases in general dental practice. Dental update. 2007 May 2;34(4):208-17.

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