Bleeding on probing. Niklaus P.

Lang, Andreas Joss,

Thomas Orsanic, Francesco A.
Gusberti and Beatrice E. Siegrist

A predictor for the progression of University of Berne, School of Dental

Medicine, Berne, Switzerland

periodontal disease?
Lang NP, Joss A, Orsanic T, Gusberti FA and Siegrist BE: Bleeding on probing —
A predictor for the progression of periodontal disease? J Clin Periodontol 1986;
13: 590-596.

Abstract, Bleeding on probing (BOP) is a widely used criterion to diagnose

gingival inflammation. The purpose of the present retrospective study was to
evaluate its prognostic value in identifying sites at risk for periodontal breakdown
during the maintenance phase of periodontal therapy. 55 patients who had been
treated for advanced periodontitis participated in a recall system for at least 4
years, at regular intervals of 3-5 months. At the start of every appointment, BOP
to the bottom of the pocket was registered at 4 sites of every tooth. A random
selection of 1054 pockets was made and subdivided into 5 categories according
to the incidence of BOP during the last 4 recall appointments. All pockets with
a BOP incidence of 4/4 and 3/4 were selected, while only interproximal sites with
a BOP incidence of 2/4, 1/4 and 0/4 were chosen. Subsequently, these categories
were grouped according to whether or not the attachment level had been maintained
from the time prior to the last 4 recall visits. >2 mm was defined as loss of
clinical attachment. The results indicated that pockets with a probing depth of > 5
mm had a significantly higher incidence of BOP. Patients with 16% or more BOP
sites had a higher chance of loosing attachment. Pockets with an incidence of
BOP of 4/4 had a 30% chance of loosing attachment. This chance decreased to
14% with BOP of 3/4, 6% with BOP of 2/4, 3%, with BOP of 1/4 and 1.5%
with BOP of 0/4. Sensitivity and predictability calculations revealed that BOP is Key words: Bleeding on probing - periodontal
maintenance - attachment loss.
a limited but yet useful prognostic indicator in clinical diagnosis for patients in
periodontal maintenance phase. Accepted for publication 20 March 1985

It has been well documented in longi-
tudinal studies (Knowles et al. 1979,
Lindhe & Nyman 1984, Rosling et al.
1976, Philstrom et al. 1983, Lindhe et
al. 1982a) that reductions of pocket
probing depths and levels of probable
attachment can be maintained following
periodontal therapy irrespective of the
treatment modality cho.sen by the oper-
ator. However, one common feature of
all these well-controlled studies was the
rigid maintenance care program pro-
vided for all patients. Although the opti-
mal recall interval may vary from indivi-
dual to individual (Listgarten & Schifter
1982) most studies applied a 3-^ month
interval to assure the treatment success
for many years (Knowles et al. 1979,
Lindhe & Nyman 1984). On the other
hand, there is also evidence that success-
ful treatment results were not main-
tained if patients were not recalled for
maintenance care at regular intervals
(Kerr 1981, Axelsson & Lindhe 1981).
It is evident that a carefully operated
maintenance care program is an abso-
lute prerequisite to assure a good prog-
nosis in patients who were successfully
treated for advanced periodontitis. Al-
though various reports have elaborated
on the frequency of maintenance care
visits (Knowles et al. 1979, Lindhe et
al. 1982a, Listgarten & Schifter 1982,
Axelsson & Lindhe 1981, Westfelt et al.
1983), relatively little is known about
the practical and logistic aspects of peri-
odontal maintenance.
Since all the longitudinal studies
(Knowles et al. 1979, Rosling et al.
1976, Lindhe et al. 1982b, Philstrom et
al. 1983, Lindhe & Nyman 1984) have
documented a definite loss of probable
attachment in shallow pockets follow-
ing instrumentation with or without ad-
junctive surgical exposure, these
"healthy" sites should not be reinstru-
mented in the limited amount of time
available during recall visits. Hence, a
brief and simple clinical test to spot
areas of recurrent periodontitis would
represent a substantial improvement in
the efforts to diagnose the dentition
prior to instrumentation during peri-
odontai maintenance. So far, several au-
thors have recommended clinical par-
ameters, such as pocket probing depths,
bleeding on probing (BOP) and suppu-
ration (Badersten et al. 1985b) or micro-
biological parameters using dark-field
microscopy (Listgarten & Levin 1981,
Listgarten & Schifter 1982) with or
without adjunctive culturing techniques
(Rosling et al. 1984) as indicator tests
for disease "activity".
However, as of today, disease "ac-
tivity" in periodontitis patients can first

be evaluated in retrospect when ad-
ditional damage to the supporting struc-
tures, characterized by progressive loss
of connective tissue fiber attachment,
has occurred. The present study evalu-
ated retrospectively a four year period
of periodontal rnaintenance in patients
who were treated for advanced perio-
dontitis, Furthemiore, one of the main
goals was to challetige the emphasis
placed on bleeding on probing (BOP)
as a clinical prognostic indicator for the
identification of sites at risk for recur-
rent periodontal breakdown.
Material and Methods
The present investigation included 55
subjects who were referred to the Uni-
versity of Berne School of Dental Medi-
cine Department of Crown- and Bridge
Prosthetics and Comprehensive Dental
Care for the treattnent of periodontitis
and restoration of masticatory function.
Thirty female and 25 male patients in
the age range of 24-74 years presented
initially with advanced periodontitis
characterized by at least 50% loss of
alveolar bone and numerous missing
teeth lost due to periodontal disease.
Following an initial examination, all
patients were subjected to extensive in-
structions in oral hygiene and thorough
scaling and root planing procedures for
at least 4 h. One tnonth following cotn-
pletion of this hygienic phase a second
examination of the plaque status, gin-
gival health, periodontal probing depths
and attachment levels was performed to
decide on the necessity of surgical pock-
et therapy. Usually pockets yielding a
probing depth of 5 rnm or more were
subjected to a tnodified Widman fiap
procedure (Ramfjord & Nissle 1974),
One month following the last surgical
procedure the patient was reevaluated,
and reconstructive therapy was ini-
tiated. Already following completion of
the hygienic phase all patients were of-
fered a periodontal maintenance care
program irrespective of the event of fur-
ther periodontal or reconstructive
therapy.
The maintenance program included
regular recall visits with a dental hygien-
ist every 3-5 month. All these visits
were supervised by a dentist who also
decided on the following recall interval
depending on a brief evaluation of the
tissues at every visit. All patients were
maintained in such a prograrn for at
least 4 years during which time no fur-
ther periodontal or reconstructive
therapy had to be performed.
The present study presents an evalu-
ation of the last two years of this peri-
odontal maintenance program. During
this period, at least 4 recall visits had
been perforrned.
At the start of every recall visit, the
dental hygienist evaluated the gingival
and periodontal tissues using a gradu-
ated Michigan Ml periodontal probe
with a point diameter of 0,4 mm. Clini-
cal probing depths were measured to the
nearest mm, and bleeding on probing
according to the trtethod of Ainamo &
Bay (1975), however, to the bottom of
the pocket was recorded. This evalu-
ation took approxirnately 10 rninutes
following which the sites which bled on
probing were reinstrutnented with sharp
curettes, and the roots were planed. This
was concluded by a rubber cup pro-
cedure using polishing paste containing
fiuoride, Furthetmore, a solution of
concentrated amine fluoride (Elmex flu-
id®, Gaba, Basel) was applied to all root
surfaces at the end of the recall hour.
The incidence of bleeding on probing
during the last four recall visits was cal-
culated for all sites of all teeth in the 55
patients. Out of 7704, a selection of
1054 pockets was made and subdivided
into five categories according to the
BOP incidence. Owing to the small
number of pockets with a BOP inci-
dence of 4 out of 4 times (4/4) or 3 out
of 4 times (3/4) all these pockets were
selected in the tnaterial. Pockets with a
BOP incidence of 2/4, 1/4 or 0/4 were
only chosen frotn interproximal sites of
the posterior teeth. The nutnber of
pockets in every category was held
above 150, if available, and litnited.
Care was taken that the whole tnaterial
contributed equally to the selection. As
the interest of the study was to evaluate
how the type of category behaved, the
numbers were extrapolated (4/4) or re-
duced (all other groups) to 100 in the
tables presented for easier under-
standing.
Subsequently, the 5 groups of pockets
with different BOP incidences were
grouped according to the presence or
absence of clinical attachment loss ex-
perienced. Attachment loss was con-
sidered to be significant if 2 mm or
greater had been lost during the last two
years. Pockets which had lost less than
2 mm or which had gained clinical at-
tachment (up to 4 mm) were defined as
"no change".
The BOP incidence was not only plot-
Bleeding on probing 591
ted against the probing attachment
changes but also against the pocket
probing depths at the final examination,
Chi-square analysis was used to deter-
mine statistical significance of the con-
tingency tables.
In order to validate the sensitivity
and predictability of the bleeding on
probing criterion to diagnose probing
attachtnent loss tnathematical ratios
were calculated as follows (Badersten et
al, 1985b):
Probing "No
attachment loss change"
bleeding a b
no bleeding c d
The diagnostic sensitivity of BOP is de-
fined as the ratio of a/(a-|-c) expressing
the proportion of sites with probing at-
tachment loss which show BOP, This
represents a true positive but retrospec-
tive ratio.
The diagnostic predictability of BOP
is defined as the ratio of a/{a + b) ex-
pressing the proportion of sites with
bleeding on probing which will loose
probing attachment.
If a clinical parameter is to be a re-
liable predictor for "active" disease
both ratios are expected to approach
100%,
Results
In the present patient material which
had been successfully treated for ad-
vanced periodontitis and maintained for
at least 4 years, only 196 sites out of a
total of 7704 in 55 patients bled on
probing 100% or 75% of the time. This
corresponds to 2,5% of the sites with
BOP of 4/4 or 3/4, Also, only 66 sites
yielding 2 mm or more of probable at-
tachment loss could be diagnosed corre-
sponding to a frequency of 0,85% or
0,21% per year.
Generally, the patients performed
high standards of oral hygiene pro-
cedures during the entire period of peri-
odontal maintenance. This was reflected
in the fact that the total patient group
Table I. % of bleeditig on probing (BOP) and
incidence of pockets with > 5 mm probing
depth at the titne of the last recall visit
Pocket probing
> 5 mm
BOP
20 17 r=4,99
4 14 /;<0,05
592 Lang et al.

Table 2, % of bleeding on probing (BOP) during the last four recall visits and incidence of LOSS OF ATTACHMENT J.2mm
pockets with > 5 mm probing depth %
40
Pocket probing > 5 mm
BOP <1,5% 1,6-6,0% >6.I%
<9,9% 14 5 2
10-15,9% , , ,,5 11 3 30 50
5 4 6 p<0,05

yielded a BOP score of 13.17% during the incidence of residual pockets with 20
the last 4 recall visits. 40 patients dis- > 5 mm probing depth was significantly
played mean bleeding %s of less than greater (p<0.01) for the patients with
16%. However, 27% of the patients (15) a mean bleeding percentage exceeding 14
regularly showed bleeding percentages 10% during the last 4 recall visits.
greater than 16% but never exceeding Out of a total of 7704 tooth sites in 10
37.8%. These patients showed a signifi- all patients, all 196 sites which bleed on
cantly (/><0.05) greater number of probing 100% or 75% of the time were
pockets with a probing depth of > 5 selected. In addition, 858 sites with a 1.5
mm (Table 1). lower BOP incidence (2/4, 1/4 or 0/4)
A similar observation was made, if were randomly selected from posterior 0/4 1/4 2/4 3/4 4/4
BLEEDING ON PROBING
only the last recall visit (Table 1) or if interproximal areas to garantee an
equal distribution for the five BOP inci- Fig, 1, Chances of loosing S 2 mm probing
the 4 last visits were analyzed (Table 2).
attachment for the 5 categories of sites with
If a cut-off point was chosen at 10% dence categories. The percentage distri-
bleeding on probing incidences (BOP) of 0/
sites with bleeding on probing (Table 3), bution of pocket probing depths with 4, 1/4, 2/4, 3/4 or 4/4.
the different BOP incidences is depicted
Die Wahrscheinlichkeit, dass die Zahnfldchen
in Table 4 and yields a highly significant der Kategorien mit Vorkommen von Sondie-
Table 3, % of bleeding on probing (BOP) (;;< 0.001) relationship between increas- rungsblutungen (BOP) - 0j4, ]J4, 2j4, 314
during the last four recall visits and incidence ing pocket probing depth and increasing und 4/4 — > 2 mm sondierbares Attachment
of pockets with > 5 mm probing depth bleeding incidencies, verlieren.
Pocket probing A highly significant (/;< 0,001) re- Chances de perdre >2 mm d'attache pour les
> 5 mm lation between an increasing incidence 5 categories de site avee incidence de saigtie-
of bleeding on probing and loss of prob- ment au sondage (BOP) de 014, 114. 2/4, 3/4
BOP <1.5% >1.6% ou 4/4,
ing attachment was found (Table 5) as
£9.9% 14 7 7^ = 7,33 well. If the percentages of sites loos-
> 10% 10 24
ing>2 mm probing attachment in 2
years and those which were considered
Table 4, % of 1054 tooth sites yielding differ- Table 6, % of pockets with loss of probing "normal", i.e. lost probing attachment
ent pocket probing depths and BOP inci- attachment ( > 2 mm) or "no change" in two
dence <2 mm, revealed unchanged probing
years in the categories with different inci-
dences of bleeding on probing (BOP) attachment levels or even gained prob-
(mm) ing attachment were calculated (Table
BOP BOP Loss > 2 mm No change Total 6) for all 5 categories with different BOP
AjA 33 30 12 25 4/4 30 70 100 incidence, an exponentially increasing
3/4 51 26 12 11 3/4 14 86 100 chance of loosing probable attachment
2/4 70 18 7 5 2/4 6 94 100 with a higher BOP incidence could be
1/4 71 21 3,5 4,5 1/4 3 97 100 established (Fig. 1).
0/4 11 19 3 I 0/4 1.5 98.5 100
Since in this retrospective study an
obvious association appeared between
the incidence of bleeding on probing
Table 5, Number of pockets with loss or gain of probing attachment («= 1054) with different and probing attachment loss the sensi-
incidences of bleeding on probing (BOP) tivity and predictability of this first
Loss Gain
BOP ^ 2 mm I 0 1 >2 mm I Table 7, Sensitivity and predictability values
4/4 13 4 14 5 7 43 in percent for bleeding on probing frequency
3/4 22 27 54 36 14 153
scores (BOP) of different magnitude
2/4 20 74 166 , 67, 23 350 BOP Sensi- Predict-
1/4 7 34 107 64 25 237 incidence ;; tivity ability
0/4 4 27 129 81 30 271
Si 783 97 13
no. of 66 166 470 253 99 ^2J, 546 M 17
pockets >:3 196 81 20
4 43 55 30
.;7< 0.001,

clinical parameter were calculated for
its diagnostic reliability (Table 7),
The diagnostic sensitivity decreased
with increasing frequencies of BOP and
approached 100% for occasional bleed-
ing (incidence of 1/4 and 2/4), In con-
trast, the diagnostic predictability in-
creased with increasing BOP incidence.
However, it was rather low yielding
20-30% at 75% (3/4) or 100% (4/4)
bleeding on probing, respectively.
Discussion
Effect of periodontal maintenance
programs
In the last decade several well-con-
trolled longitudinal studies (Knowles et
al. 1979, Rosling et al. 1976, Philstrom
et al. 1983, Westfelt et al. 1983, Lin-
dhe & Nyman 1984) have documented
that irrespective of the periodontal
treatment performed, pocket probing
depth reductions and probable attach-
ment levels can be maintained over
several years provided that a high stan-
dard of oral hygiene and repeated scal-
ings and root planings are applied in a
regular maintenance care program.
Generally, recall intervals of 3 ^
months have been chosen to garantee
optimal periodontal maintenance
(Knowles et al. 1979, Philstrom et al.
1983) while other groups of authors
have preferred to apply some flexibility
to the frequency of recall visits (Westfelt
et al. 1983, Lindhe & Nyman 1984).
Similarly, the recall intervals in the pre-
sent study have been chosen between 2
and 6 months depending on the inci-
dence of bleeding on probing and the
status of the periodontal tissues as
judged by a dentist. Although the accu-
rate interval for optimal maintenance
visits is not known and most likely va-
ries with the individual, there is evidence
from a microbiological point of view
that recall visits should be scheduled
every 3rd or 4th month in order to alter
the subgingival microfiora in sites at
risk at optimal time intervals (Listgarten
et al. 1978, Mousques et al. 1980). Hen-
ce, in the present study the patients who
had been treated for advanced peri-
odontitis successfully, the recall interval
rarely exceeded 4 months.
The documented success of periodon-
tal maintenance in the longitudinal
studies mentioned is hampered by the
fact that all these studies reported indi-
vidual mean values of pocket probing
depths and probable attachment levels.
However, it is well known (Knowles et
al. 1979, Lindhe & Nyman 1984, Bader-
sten et al. 1985) that this kind of data
presentation may mask the occurrence
of individual sites in a patient yielding
recurrent periodontitis. These refrac-
tory sites may occur in a small pro-
portion of patients (Lindhe & Nyman
1984), but may account for the great
majority of teeth lost following success-
ful periodontal therapy. In a recently
published report on 14 years mainte-
nance of 61 patients with treated ad-
vanced periodontitis (Lindhe & Nyman
1984) this very well maintained group
displayed 0.8% sites with various am-
ounts of loss of probable attachment in
25% of the patients. In 11.5% of thetn
the refractory sites with recurrent pro-
gressive inflammatory periodontal dis-
ease caused the loss of 16 teeth out of
a total of 1330. However, if those teeth
lost were strategically important, even
such a low mortality may be detrimental
to a single individual.
In the present material, none of the
teeth was lost during a maintenance pe-
riod of at least four years corresponding
to the absence of tooth mortality in the
first 5-year observation period of Lin-
dhe & Nyman (1984). However, 66 sites
which lost 2 tnm or iriore of probable
attachment were identified. From these
in only 1 site a loss of 4/5 or 6 mm
respectively was noted. Thus 0.85% of
the sites in 23.6% of the present group
of patients were exposed to recurrent
periodontitis. This rate of 0.21% per
year is in the neighbourhood of the re-
port by Lindhe & Nyman (1984), It is
dramatically lower than the rate of pro-
gression of 1.9% sites per year in an
untreated Swedish or 3.2% sites per
year in an untreated American popu-
lation (Lindhe et al. 1983) documenting
the remarkable effect of such mainte-
nance programs. Lack of vigorously
controlled recall systems would inevi-
tably result in the recurrent progression
of periodontal disease at multiple sites
which will also be reflected in individual
mean scores (Kerr 1981, Axelsson &
Lindhe 1981). It is, therefore, necessary
to assure the optimal individual recall
interval for a_ particular patient.
In the present investigation, it was
revealed that significantly more residual
pockets with 5 mm or tnore probing
depth and significantly more sites loos-
ing 2 mm or more of probing attach-
ment in 2 years were identified when
mean bleeding on probing scores ex-
ceeded 16% (15 patients). This may sug-
gest that this mean value may be used
Bteeding on probing 593
as a clinical indicator for the selection
of the appropriate recall interval. If a
mean bleeding score exceeds 16%, the
recall interval should be shortened, and
if it lies below 10%, it may be prolonged
by 1 month. However, definite proof of
this suggestion still depends on further
prospective studies. - :;
Significance of bleeding on probing scores
(BOP)
In the present study, a maintenance pro-
gram was performed for at least four
years in patients treated for advanced
periodontitis. In this patient group time
for the evaluation of the periodontal
tissues was allowed at the beginning of
each recall visit. In this context, pocket
probing depths and the tendency of the
periodontal tissues to bleed following
probing (Ainamo & Bay 1975) was etn-
phasized to identify sites which had to
be instrumented following the examina-
tion. Thus, BOP served as a presump-
tive indicator of sites with recurrent "ac-
tive" periodontitis. The rationale for
not instrumenting all the tooth surfaces
of all teeth in every patient was not only
the lack of professional time available
at any particular recall visit, but the fact
that repeated scaling and root planing
in healthy sites of 1-3 mm probing
depth may, indeed, be detrimental for
the maintenance of probing attachment
levels (Knowles et al. 1979, Philstrom
et al. 1983, Lindhe et al. 1982a, b). In
agreement with recent studies (Lin-
dhe & Nyman 1984) very few single sites
deteriorated with this kind of regimen.
Since 196 (2.54%) of the sites bled on
probing with an incidence of 4/4 or 3/4
and since only 35 of these lost probing
attachment, the repeated instrumen-
tation of these sites may have contrib-
uted to the successful maintenance of
these pockets. Furthermore, the rela-
tionship between BOP incidence and
loss of probing attachment documented
in tables 5 and 6 justified the use of
BOP as a clinical prognostic indicator.
In order to further elucidate the diag-
nostic sensitivity and predictability (Ba-
dersten et al. 1985b) of BOP mathemat-
ical ratios were calculated for each inci-
dence (Table 7). The ratios calculated
show even slightly higher percentages
for predictability than similar cotnpu-
tations in a recently published report
(Badersten et al. 1985b). On the other
hand, the sensitivity calculations were
substantially higher than those reported
by Badersten et al. (1985b) probably
594 Lang et al.
owing to the difference in the size of the
material of the two studies.
Since the predictability of BOP never
exceeded 30% in this or other studies
(Badersten et al. 1985b) the diagnostic
value of this simple clinical parameter
must be questioned. However, it has to
be reahzed that sensitivity and predict-
ability calculations represent mathemat-
ical ratios rather than parameters based
on biological aspects. In this context
the criteria determining progression of
disease become crucial. In the present
study a probing attachment loss of 2
mm or more has been used to identify
recurrence of inflammatory periodontal
disease. Similar differences in attach-
ment levels such as > 1.5 mm (Bader-
sten et al. 1985b), >2 mm (Lindhe &
Nyman 1984) or in increased probing
depth of 3 mm (Listgarten & Levin
1981) were used by other authors to
identify "active" or refractory sites.
It is well-documented that the prob-
ing attachment level may not always
correspond to the histological level of
the connective tissue attachment (for re-
view, see Listgarten (1980)). Since the
tip of the probe identifies the apical ex-
tension of a cellular infiltrate in the peri-
odontal tissues rather than the most api-
cal cells of the dentogingival epithelium
(Armitage et al. 1977) the periodontal
probe may slightly overestimate loss of
histological connective tissue attach-
ment in refractory sites. On the other
hand, the tip of the probe may not pen-
etrate to the most apical cells of the
dentogingival epitheliutii in healed tis-
sues (Listgarten et al. 1976, Armitage et
al. 1977, Robinson & Vitek 1979, van
der Velden 1979, Caton et al. 1981). In
choosing a difference of 2 mm or more,
the inaccuracies in determining the his-
tological attachment levels should be
compensated for. However, it cannot be
excluded that true loss of connective tis-
sue attachment rnight have occurred
with a difference of probing attachment
levels of less than 2 mm. This is also the
reason why predictability calculations
should be interpreted with care.
Clinical implications
It has been postulated in recent years
that the progression of periodontitis in
untreated patients (Goodson et al. 1982)
as well as in refractory or recurrent peri-
odontitis sites (Haffajee et al. 1983b,
Badersten et al. 1985b) might not follow
a linear pattern but rather be character-
ized by periods of quiescence and ex-
acerbations. These periods may com-
pletely be masked in longitudinal
studies since they may be of short dur-
ation. However, as a chnician it would
be of utmost importance to spot "ac-
tive" lesions at the time of activity in
order to institute new therapeutical
measures during periodontal mainte-
nance. So far, the diagnostic parameters
are either limited by the fact that overt
tissue pathology can first be recognized
after its occurrence or by the uncer-
tainty that inflammatory parameters re-
ally represent disease activity. Several
studies have questioned the validity of
clinical parameters to detect sites of "ac-
tive" disease (Haffajee et al. 1983a,
Listgarten & Levin 1981, Badersten et
al. 1985b). Since the predictabihty val-
ues of the present study appear to be
rather low as well, the results of this
patient material seem to agree with
these previously published reports.
However, the fact that the predictability
values for loss of probing attachment
increased exponentially from 1.5% in
absence of BOP to 30% with a BOP
incidence of 100% (Fig. I) substantiates
the claim that BOP still represents the
most useful clinical predictor for disease
"activity" during periodontal mainte-
nance. On the other hand, it has to be
realized that a site which bleeds on
probing at every recall visit still has a
70% chance of not loosing probing at-
tachment (Table 6). It is evident that
more reliable predictive tests have to
be developed in order to improve the
diagnosis of recurrent periodontitis or
refractory sites. Attempts have been
made to use dark field microscopy
(Listgarten & Levin 1981, Listgarten &
Schifter 1982) as well as this in combi-
nation with culturing techniques (Ros-
ling et al. 1984). However, the enum-
eration of spirochetes and motile rods
in dark field microscopy did not sub-
stantially improve the diagnostic pre-
dictabihty for site-specific probable at-
tachment loss in periodontal mainte-
nance patients (Listgarten & Schifter
1982, Roshng et al. 1984). Only cultu-
References
Ainamo, J. & Bay, I. (1975) Problems and proposals for reeording gingivitis and plaque.
Internaiiotial Dental Journal 25, 229-235.
Armitage, G. C , Svanberg, G. K. & Loe, H. (1977) Microscopic evaluation of clinical
measurements of tissue attachment levels. Journal of Clinieal Periodontoiogy 4, 173-190.
Axelsson, P. & Lindhe, J. (1981) The significance of maintenance care in the treatment of
periodontal disease in adults. Journal of Clinical Periodontoiogy 8, 281-294.
Badersten, A., Nilveus, R. & Egelberg, J. (1985a) Effect of nonsurgical periodontal therapy.
ring techniques seemed to improve the
diagnostic predictability (Rosling et al.
1984). It is most likely that these tech-
niques should be combined with clinical
parameters such as BOP and pocket
probing depth to diagnose recurrent
"active" periodontal lesions, while the
simple clinical criterion "absence of
bleeding on probing" showed an almost
100% predictabihty for health in the
present study. This suggests that sites
which do not bleed on probing at any
time should not be reinstrumented dur-
ing regular recall visits. However, a
word of caution might be appropriate
in this context. It should be realized that
in deep periodontal pockets, owing to a
time factor, bleeding might not be diag-
nosed by simply inserting a periodontal
probe to the bottom of the pocket. It is,
therefore, recorftmended to give special
attention to pockets with a probing
depth exceeding 5-6 mm during recall
visits. Reinstrumentation of such deep
sites may have a beneficial effect by sig-
nificantly altering the ecosystem, re-
ducing periodontopathic organisms
(Listgarten et al. 1978, Listgarten &
Schifter 1982, Syed et al. 1982).
Zusammenfassung
Bluien beim Sondieren. Fin Praediktor der
Progression parodotitaler Laesiotten
Die Blutungstendenz beim Sondieren (BOP)
ist ein oft angewendetes Kriterium zur Di-
agnose von Zahnfleischentzundungen. Mit
der hier zusammengefassten Studie wurde be-
absichtigt, den prognostischen Wert der BOP
zur Identifikation von Zahnfiachen zu unter-
suchen, bei denen wahrend der Betreuung das
Risiko eines Parodontitisrezidivs vorliegt. 55
Patienten, bei denen eine fortgeschrittene Pa-
rodontitis erfolgreich behandelt worden war,
wurden in ein Betreuungsprogramm einbezo-
gen, das wahrend mindestens 4 Jahren regel-
milssige Prophylaxebesuehe in Abstatiden
von 3-6 Monaten vorsah. Zu Beginn jeder
Prophylaxesitzung wurde das Vorkommen
von Bluten beim Sondieren des Taschenfun-
dus an 4 Zahnflaehen eines jeden Zahnes re-
gistriert. 1054 Taschen wurden zufallig ausge-
wahlt und je nach Vorkommen der Blutung-
stendenz nach dem Sondieren (BOP)

wahrend der letzten 4 Nachuntersuchungen,
in 5 Gruppen eingeteilt. Alle Taschen mit
einem Vorkommen von 4/4 und 3/4 (4 x ge-
blutet bei 4 Nachuntersuchungen und 3 x bei
der gleichen Anzahl der Nachuntersuchun-
gen) wurden analysiert, Bei approximalen Ta-
schen wurde nur ein BOP-Vorkommen mit
der Haufigkeit von 2/4, 1/4 und 0/4 beruck-
sichtigt. Die Gruppen wurden dann noch
weiter unterteilt und zwar danach, ob das
Attachmentniveau vor den letzten 4 Prophy-
laxesitzungen beibehalten werden konnte
oder nicht. Eine Verringerung des Attach-
mentniveaus um 2 mm oder mehr wurde als
klinischer Attachmentverlust gedeutet. Die
Ergebnisse zeigten, dass bei Taschen mit einer
Sondierungstiefe von > 5 mm BOP signifi-
kant vermehrt vorkommt, Bei Patienten mit
BOP bei 16% der Zahnflachen oder mehr
lag eine grossere Wahrscheinlichkeit weiteren
Attachmentverlustes vor, Bei Taschen, bei de-
nen BOP mit einer Haufigkeit von 4/4
(4 X Sondierungsblutungen bei 4 Untersu-
chungen) registriert wurde, lag eine 30%ige
Wahrscheinlichkeit vor, dass Attachment ver-
loren ging, Diese verringerte sich bei Taschen
mit einer BOP-Haufigkeit von 3/4 auf 14%,
bei BOP von 2/4 auf 6% und bei BOP von
0/4 auf 1,5%, Genauigkeits- und Voraussage-
berechnungen zeigen, dass das Bluten beim
Sondieren ein begrenzter, aber trotzdem an-
wendbarer prognostischer Indikator bei der
klinischen Diagnose fiir Patienten in der pa-
rodontalen Betreuungsphase ist.
Resume
Saignement au sondage: un signe de la pro-
gression de la maladie parodontale?
Le saignement au sondage (BOP) est un crite-
re tres utilise dans le diagnostic de l'inflam-
mation gingivale, Le but de la presente etude
retrospective a ete d'evaluer sa valeur pro-
nostique a identifier des sites a risque de
destruction parodontale durant la phase de
maintien de la therapeutique parodontale, 55
patients qui avaient ete traite pour parodonti-
te avancee ont suivi un systeme de rappels
pendant au moins 4 ans, avec des intervalles
reguliers de 3 a 5 mois. Au debut de chaque
visite le BOP (Ainamo and Bay, 1975) au
fond de Ia poche a ete enregistre dans quatre
sites de chaque dent. Une selection randomi-
see de 1054 poches a ete faite et subdivisee
en 5 categories suivant l'incidence de BOP
pendant Ies 4 derniers rappels. Toutes les po-
ches avec une incidence de BOP de 4/4 et 3/
4 ont ete selectionnees tandis que seulement
les sites interproximaux avec une incidence
de BOP 2/4, 1/4 et 0/4 ont etc choisis, Ensuite
ces categories ont ete groupees suivant qu'el-
les avaient ou non un niveau d'attache stable
durant Ies 4 derniers rappels. > 2 mm a etc
defini comme une perte d'attache clinique,
Les resultats ont indique que les poches avec
une profondeur au sondage de > 5 mm
avaient significativement davantage de BOP.
Les patients avec 16% ou plus de sites BOP
avaient une plus grande chance de perdre de
I'attache, Les poches avec une incidence de
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596 Lang et at.

BOP dc 4/4 avaient 30% dc chance de pcrdrc

de l'attache. Cette chance diminuait a 14% Address:
avec un BOP de 3/4, 6% avec un BOP de 2/ Prof Dr. Niklaus P. Lang, MS
4, 3 % avec un BOP de 1/4 et 1,5% avec uti University of Berne
BOP de 0/4. Les calculs de setisibilite et de School of Dental Medicine
prediction ont revele que le BOP est un signe Freiburgstras.se 7
limitc mais utile dans les diagnostics cliniques DH-3010 Berne
lors de la phase de tnaintien. Switzerland