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Articulo 2 DX Periodontal
Articulo 2 DX Periodontal
Senn and
A. Joss
University of Berne, Sciiool of Dental
health
Lang NP, Nyman S, Senn C and Joss A: Bleeding on probing as it relates to probing
pressure and gingival health. J Clin Periodontol 1991; 18: 257-261.
Abstract. The present study was designed to determine the threshold pressure
value to be applied in provoking bleeding on probing (BOP) in clinically healthy
gingival units. 12 female dental hygiene students volunteered for the study. They
were selected on the basis of excellent oral hygiene standards, absence of probing
depths > 3 mm and absence of caries or dental restorations on smooth and
proximal tooth surfaces. Applying a probing force of 0.25, 0.5, 0.75 and 1.0 N
in one of the 4 jaw quadrants, respectively, on 2 different occasions with an
interval of 10 days, bleeding on probing was assessed. Oral hygiene and gingival
conditions were determined using the criteria of the plaque control record and
the gingival index. On the basis of the BOP values, obtained using the lowest
probing force (0.25 N), the subjects were divided into 2 groups: group 1 ("minimal
BOP" value) consisted of 6 subjects yielding practically no bleeding (mean BOP =
0.9%) at both examinations, while the subjects of group 2 ("low BOP" value) had
slightly higher BOP% (mean BOP =13.4%). Both groups showed significant
increase in mean BOP% with increasing probing force (0.9%-36.1% in group 1
and 13.4%-47.0% in group 2). Regression analysis revealed an almost linear
correlation and a high correlation coefficient between BOP% and probing force.
The comparison of the regression lines of the 2 groups showed almost identical
slope inclination. However, slight differences in slope inclination were found
for different sites: approximai sites clearly yielded steeper regression lines than
buccal/oral sites. The results of the study demonstrated that the BOP test using
uncontrolled forces may result in a proportion of false positive readings and that Key words: bleeding on probing; clinical tri-
a strong possibility exists for the traumatization of clinically healthy gingival als; gingival health; probing force.
tissues if a probing force exceeding 0.25N is applied.
Accepted for publication 8 May 1990
Inflammatory periodontal disease is ly objectivity, reproducibility and easy high negative predictive values. One rea-
clinically characterized by various clinical management. son for the discrepancy between the low
symptoms, including swelling and ac- Several studies have revealed corre- positive and high negative predictive
centuated redness of the gingiva, and lations beteen BOP and histopathology values may be that a high number of
an increased tendency for bleeding (Greenstein et al. 1981, Poison et al. false positive scorings are generated
(Schour & Massler 1947, Muhlemann & 1981, Davenport et al. 1982, Thilo et al. during probing. In other words, the pro-
Mazor 1958, Loe & Silness 1963). These 1986, Brecx et al. 1987), clinical (Loe & voked bleeding by probing could in sev-
symptoms have led to the development Silness 1963, Muhlemann & Son 1971, eral instances be the effect of mechan-
of clinical indices which have been Meitner et al. 1979) and microbiological ical trauma to healthy sites. To eliminate
adopted in clinical trials as well as in (e.g.. Slots et al. 1979, Armitage et al. the variability in the assessments, stan-
daily practice. Especially the symptom 1982) changes associated with perio- dardized probing pressures have been
of bleeding on probing (BOP) has been dontal diseases. More recent clinical tri- advocated to be used when determining
used in the creation of clinical indices als have attempted to define the diag- BOP (Van der Velden & De Vries 1978,
for the assessment of periodontal health nostic value of BOP (e.g., Badersten et Robinson & Vitek 1979, Poison et al.
or disease (Loe & Silness 1963, Miihle- al. 1985, Lang et al. 1986, Claffey & 1980). However, so far the appropriate
mann «fe Son 1971, Ainamo & Bay 1975, Shanley 1986, Lang et al. 1991). Using probing pressure to be applied to mini-
Saxer et al. 1977). The assessment of different sets of data, sensitivity, speci- mize false positives and, hence, to dis-
presence or absence of BOP appears to ficity and predictability of BOP for tinguish between health and disease in
fulfill the requirements for an ideal clini- periodontal stability or disease pro- the gingival tissues has not been deter-
cal parameter to verify presence or ab- gression were calculated. Generally, mined as yet.
sence of inflammatory processes in the BOP showed a modest sensitivity and The purpose of the present study was
periodontium (Greenstein 1984), name- specificity and rather low positive but therefore to determine the threshold
258 Lang et al.
Fig. 1. Outline ofthe study. PCR = plaque control record. Gl = gingival index. BOP = bleeding
on probing. Data analysis
n'R 1
• 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 r-1 n 0, 7, 14 are presented for each subject,
Subject Number 0,0
1 2 3 4
rirnnil 1
5 6 7 8 9 1 0 1 1 1 2
again ranked according to their mean
BOP % at 0.25 N. Both groups yielded
Fig. 2. Individual mean BOP % of days 2
and 12 using a probing force of 0.25 N. Ac- Subject Number a mean GI score of 0.06.
cording to this BOP %, 2 subject groups were Fig. 3. Individual mean GI scores of days 0, The mean % of surfaces exhibiting
7, 14. Same ranking of subjects as in Fig. 2. plaque in each subject during the experi-
Gingival bleeding and probing pressure 259
11
20- gingival indices at the start of the study
21,3%
n- 10 - 12,5%
which were even further improved
0,9%
1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 throughout. In addition, the absence of
Subject Number 0,25 0,5 0,75 1,00 caries cavities and fillings also docu-
Probing Force (N) mented an unusual state of dental
Fig. 4. Individual mean PCR of days 0, 7, 14.
Same ranking of subjects as in Fig. 2.
health.
Fig. 6. Mean BOP % for group 1 (minimal It is known that also in chnical
BOP) applying the 4 different probing forces.
Clearly, an almost linear increase from at the different tooth surfaces in groups 40
7.1% to 41.5% was noted with increas- 1 and 2, respectively. Generally, high
ing probing force applied. The differ- correlation coefficients were found in
ences of the mean % of bleeding units group 1, while group 2 yielded some-
between each of the different probing what lower but still highly significant
forces applied were statistically signifi- correlation coefficients between mean 0,00 0,25 0,50 0,75 1,00
cant (p<0.0\). In Figs. 6 and 7, the BOP % and the different probing
corresponding mean BOP percentages Probing Force (N)
forces. Also, different intercept values
are presented separately for each of the with the X-axis were found for groups 1 Approximaliy
BOP %
two subgroups (groups 1, 2). Almost and 2, confirming the difference in mean 80 •
identical linear relationships were ob- BOP % at 0.25 N between the 2 groups. 70
y = - 13,7+57,8x R = 0,86
served in both groups between the mean On the other hand, the inclination of 60
BOP % and the probing forces. It the regression line slopes were very simi- 50
should be noted, however, that the re- lar for all and also for the individual
gression line was at a lower level for 40
tooth sites when comparing the two
group 1 (0.9%-36.1%) (Fig. 6) com- subject groups, while the inclination of 30
pared to group 2 (13.4%^7.0%) (Fig. the slopes were somewhat different 20 -
7). The variation of the mean BOP % when comparing different tooth sur- 10 -
for each of the different probing forces faces (i.e., approximai with buccal/oral)
applied was of a similar magnitude in within the same subject group. 0,00 0.25 0.50 0,75 1,00
both groups. In the group with "mini-
Probing Force (N)
30 -
30,9%
41,5%
30 -
T
29,8%
40,4% 30
20
20 - 20 - 10
21,1%
10- 10 - 13,4%
0,00 0,25 0,50 0,75 1,00
7,1%
Probing Force (N)
0,25 0,50 0,75 1,00 0.25 0,5 0,75 1,00
Fig. 8. Regression analyses (group 1) of the
Probing Force (N) Probing Force (N)
mean BOP % and the varying probing forces
Fig. 5. Mean BOP % for all subjects applying Fig. 7. Mean BOP % for group 2 (low BOP) applied for all sites, and the approximai and
the 4 different probing forces. , ,. . applying the 4 different probing forces. , , buccal/oral sites respectively.
260 Lang et al.^''['""'h "••^-' •^^"'^^••:'^'•:^ .A-^
healthy gingival units, a minimal in- dard of periodontal health as evaluated It should be realized that the findings
fiammatory infiltrate may be identified by clinical means which would be diffi- of the present study refer to periodontal
histoiogicaily adjacent to the junctional cult to find in other population samples. tissues with normal anatomy and gin-
epithelium (e.g., Brecx et al. 1987). The results of this clinical experiment gival health in subjects with a history of
However, the parameter bleeding on demonstrate that the force applied to a excellent plaque controi. The question
probing (BOP) to the bottom of the gin- periodontal probe with a standardized arises, therefore, whether or not increas-
gival sulcus or pocket has been intro- point diameter of 0.4 mm must not ex- ing probing pressures will yield similar
duced into clinical diagnostics and ceed 0.25 N if traumatization of ciin- responses in healthy periodontal tissues
hence, it should preferably be compared icaiiy healthy tissues is to be avoided. but with reduced bone height, i.e., in
with other clinical, rather than histo- This is documented by the fact that in tissues which have been subjected to
logic parameters in the diagnosis of the subjects of group 1 ("minimal BOP" proper periodontai therapy and which
health or disease. In this respect, the group) practically no bleeding could be have heaied with altered morphology,
young dental hygienists volunteering for provoked by this threshold pressure at e.g., the presence of a long junctional
the present study certainly reflected a the two different examinations (days 2 epithelium. Before this question is
subject population of such a high stan- and 12). A few gingivai units bied for answered, the demand for standardizing
this pressure in the other subject group probing pressure and choosing the same
Group2 {low BOP group). Since the mean Gi probing pressure in periodontal tissues
score in both groups was extremely low with normal or reduced bone height in
(0.06), it might be that, on the histologi- order to distinguish between health and
BOP %
All Sites cai ievei, the latter group might have disease, remains questionable. How-
differed somewhat from the first. ever, the present study showed that too
With increasing probing forces by an high probing pressures must be avoided
increment of 0.25 N, applied for the in order to iimit the number of faise
BOP test, an almost linear increase of positive readings. Hence, a number of
bleeding sites with approximateiy 11% ciinicai studies which used probing
per increment was noted. The increase pressures with an obvious traumatic
in group 1 from around i% to 36% at component should be interpreted with
1.0 N paralleled the increase in group 2 care.
from around 13% to 47% with almost
identical inclination of the regression
0.00 0.25 0.50 0.75 1.00 line slopes. Since the regression iines of Acknowledgements
Probing Force (N) both groups yieided similar slopes but This study has been supported by the
different intercepts with the x-axis, it Clinical Research Foundation (CRF),
BOP % Approximally seems reasonable to assume that traum- University of Berne, Switzerland. The
atization of healthy gingival tissues is a secretarial help of Ms. Barbara Frutig
frequently encountered hazard which in is highly appreciated. Furthermore, the
turn may contribute to a number of authors wish to thank Dr. Herbert Hof-
false positive readings. This may at least stetter, DDS, Director of the Dental
in part explain why the specificity as Hygiene School, Berne, for his coliabor-
well as the predictive value for disease ation on the project.
progression of the BOP test have been
shown to be rather modest (Badersten
et al. 1985, Lang et al. 1986, Egelberg Zusammenfassung
1988, Lang et al. 1991). Zusammenhdnge zwischen gingivalem Gesund-
0.00 0.25 0.50 0.75 1.00
Probing Force (N) Another interesting finding of the heitszustand, Bluten auf Sondieren und Son-
present study was that around 60% of dierungskraft
Buccally & Orally all gingival units in fact did not bleed Ziel der vorliegenden Studie war es, den Zu-
BOP % even when a probing force of 1.0 N sammenhang zwischen Bluten beim Sondie-
was applied. In this respect, the separate ren (BOP) und angewandter Sondierungs-
analyses of the different tooth surfaces kraft bei Probanden mit klinisch gesunden
parodontalen Verhaltnissen zu untersuchen.
(Figs. 8, 9) revealed different slope incii- Als Probanden wurden 12 Schulerinnen der
nations for approximai and buccai/oral Dentalhygieneschule Bern ausgewahlt, die
sites, respectively. Approximately 70% hochstens okklusale Fiillungen und keine
of the buccal/oral sites, but only around Sondierungstiefen iiber 3 mm aufwiesen. Bei
50% fo the approximai sites did not alien Probandinnen wurde in zwei Unter-
bleed when a probing force of 1.0 N suchungen im Abstand von 10 Tagen mit den
was applied. This difference in response Kraften 0.25, 0.5, 0.75 und 1.0 N sondiert,
to different probing forces at different wo bei jeweils nur eine Kraftgrosse in je einem
0.00 0.25 0.50 0.75 1.00
tooth surfaces may reflect morpho- Quadranten zur Anwendung gelangte. Ent-
Probing Force (N)
logical differences of the soft tissues ziindungszustand und Mundhygiene wurden
Fig. 9. Regression analyses (group 2) of the mittels Gl (Loe & Siiness 1963) und PCR
mean BOP % and the varying probing forces
(Hock & Nuki 1971, Wennstrom et al.
kontrolliert. Aufgrund der BOP-Werte bei
applied for all sites, and the approximai and 1981) or of the tooth surface anatomy der tiefsten angewandten Kraft (0.25N) wur-
buccal/oral sites, respectively. • • involving different probe inclination. den die Probandinnen in 2 Gruppen geteilt:
Gingival bleeding and probing pressure 261
Die 6 Probandinnen von Gruppe 1 ("minima- faux-positif. De plus les tissus gingivaux chni- erity. Acta Odontological Scandinaviea 21,
ler" BOP Mittelwert) zeigten in beiden Unter- quement sains pourraient etre traumatises 533-551.
suchungen hochstens an einer Stelle Bluten lorsqu'une force superieure a 0.25 N est uti- Meitner, S. W., Zander, H., Iker, H. & Pol-
(x: BOP = 0,9%), wahrend die 6 Probandin- lisee. son, A. M. (1979) Identification of in-
nen von Gruppe 2 ("niedriger" BOP Mittel- flamed gingival surfaces. Journal of Clin-
wert) ausgepragt hohere Blutungswerte (x: ical Periodontology 6, 93-97.
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of periodontal diseases? Journal of Clinical
differences ont ete apergues quant aux sites Address:
Periodontology 13, 590-603.
differents: les sites interproximaux produi-
saient des hgnes de regression plus raides que Lang, N. P., Adler, R., Joss, A. & Nyman, S. Niklaus P. Lang
les sites vestibulaires et linguaux combines. (1991) Absence of bleeding on probing - School of Dental Medicine
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