Clinical FAQs - practitioner top tips and helpful videos

We are often asked similar questions via our website, during lectures and on social media. Dr Viren Vithlani & Dr Ian Dunn have, therefore, collated the frequently asked questions with the BSP answers:

https://www.bsperio.org.uk/news/s3-treatment-guidelines-for-periodontitis

Q: I wonder if you can clarify for me regarding who does a BPE for patients at the recalls? In our practice, the hygienists like to do a BPE at the start of every scaling and OHI session. If this means that the BPE is done at least every 6 months then I, as the dentist, don't repeat it as it is pointless doing two in quick succession and can be very uncomfortable for patients with active perio. It also feels wrong to probe healing pockets more than necessary. My compliance company are saying the dentist must do the BPE even if the hygienist repeats it or has done it recently. Can you confirm if my system is reasonable? 

A: Ideally, the BPE would be carried out by whoever is taking responsibility for the diagnosis and treatment planning of that specific patient and this would usually be carried out at any routine examination. Under direct access, hygienists and therapists can diagnose within their scope and as such they are very capable of providing this aspect of care. That said, if they are not working under direct access arrangements then, ideally, the BPE would be done by the dentist, as it requires decisions to be made based on the codes identified and then ultimately a diagnosis.

You mention about the BPE being done too close together and being uncomfortable in active perio patients. Once periodontal disease is diagnosed, the BPE becomes obsolete, as we no longer need to screen for disease and we monitor treatment outcomes, disease activity, progression or stability with 6 point pocket charts. Usually, once a patient is in maintenance then the 6PPC and Bop charts would be done at least annually and certainly do not need to be done at every maintenance appointment.

Q: Many thanks for making the recent webinars available on the UK's implementation of the new EFP S3 guidelines. A clinician's meeting was held at my place of work to update fellow colleagues and discuss how we need to make the relevant changes.
During the meeting a few questions were raised, and I would be most grateful for clarification on the following:-
1. In Step 1, the flowchart indicates subgingival PMPR is undertaken. This created some confusion as when reading the papers, it was my understanding that the focus for Step 1 was Supragingival care and creating the correct conditions before going subgingivally?
2. If subgingival PMPR is undertaken at step 1, how does this differ to that undertaken in Step 2?
3. Will guidance be published on when to take a DPC and how often to repeat them? This was a source of significant discussion.

A: We have answered your queries in number order:

1. The subgingival PMPR that is undertaken in Step 1 is only for the clinical crown of the tooth if any elements of that are extending subgingivally. This is in order to allow for any elements of swelling and false pocketing that may be present at this stage in gingival tissues. I’m sorry if this is not completely clear in IV of step 1. What we are effectively saying as that we are not doing ant root surface management in this step until the patient engages and moves to Step 2. 

2. In Step 2 the patient has engaged and PMPR involves both crown and management of the root surfaces, but hopefully with the improvements in OH this will be accompanied by improved OH and resolution and you would be focussing solely on root surfaces again apologies if this is not clear perhaps we should have used a larger for this part in the title!

3. A 6 point probing chart would be undertaken after prior to starting treatment in advanced cases, 3 months post Step 2 and any repeated Step 2 phase., and generally annually thereafter if the patient is in maintenance care.

Q: I am a trainee dental nurse and at the moment I am very baffled about classification of periodontal disease.
I really do hope that you will be able to help and answer my simple question:
* A patient has a history of bone loss, however now his BPE scores are 1s and 2s with <10% BOP. What will you give him for his periodontal diagnosis? Is he coming into classification of having Clinical Gingival Health or something else?

A: In accordance with the current classification of periodontal disease this case would most likely have a diagnosis of gingival health on a reduced periodontium.

You can find this information here:

Untitled-2 (bsperio.org.uk), which is located at Publications | BSP (bsperio.org.uk)

There is a video explaining this in more detail here https://www.bsperio.org.uk/assets/downloads/World_Workshop_1_-_Iain_Chapple.mp4 , which forms part of a series here:

BSP Webinars - 2017 World Workshop Classification System | BSP (bsperio.org.uk)

Q: I have had a read through the 'BSP UK CLINICAL PRACTICE GUIDELINES FOR THE TREATMENT OF PERIODONTAL DISEASES', and I am wanting to clarify one point which is a bit unclear to me. That is in step one, it states '+ /- Professional Mechanical Plaque Removal (PMPR) including supra and subgingival scaling of the clinical crown', and in step 2 which is conducted at a recall with an engaged patient 'Subgingival instrumentation, hand or powered (sonic / ultrasonic), either alone or in combination'.
Why is it that this part of step 2 would not be conducted in step one? Is that because you want to make sure the patient is engaged with good homecare/plaque control first, and if that is followed you should see a reduction in PPDs and BOP anyway without subgingival scaling? Ergo, perio prognosis following subgingival root surface debridement is going to be much improved?
What is subgingival scaling of the clinical crown? My understanding of the clinical crown is that is the portion of the tooth above the gingival margin - so how can this be subgingivally scaled?

A: You have effectively asked and answered the first question yourself. The main reason for not including sub gingival instrumentation or root surface management in step 1 is that we want the patient to take responsibility for their disease and its management. As you know, no amount of perio treatment will work in the absence of good home care and this approach ensures that we do not waste time and resources trying to treat this disease in a patient who is not engaged and where there will be little or no benefit. We have practiced like this for many years and the additional benefits that from this approach are:

•  Your patients sees the impact their changes have on their inflammation, they cannot attribute it to you. 
• Their superficial inflammation is controlled if they engage and this makes pocket charting more comfortable and, potentially, more accurate as there is less bleeding. 
• As the tissues are already less inflamed, treatment is often more comfortable. 

Regarding “scaling of the clinical crown”, in health a small amount of the clinical crown will be sub gingival in the periodontal pocket or sulcus. In early disease, especially with inflammation, it is possible that some of the crown (enamel) will be sub gingival and the supra and sub gingival scaling of the crown is essentially say that we are removing the calculus deposits off the crown to facilitate improved home care and we are not, at this step, providing root surface management. 

Q: I would like to ask for some guidance on how soon I can treat a periodontal patient after a hip replacement. However, I cannot find any guidance about it. I would really appreciate any scientific clearance about it or any guidance you have from Orthopaedic departments. Thank you.

A: There are no consistent UK guidelines in place suggesting that special measures are necessary  in these situations. You should write to the patient’s surgeon to confirm how  they wish to proceed.

Ideally, oral health should be achieved  before  this surgery is considered. It may be wise to then delay further interventions for some time, as many surgeons do worry about involvement of healing tissues as a consequence of bacteraemia (although this is controversial and not clearly proven).

Q: Just after some advice, I’m trying to set up a protocol for implants but dentists would like proof about recalls for maintenance, what is the time frame is it 3/12 or dependant on individual patients? Many thanks.

A: Obviously, we are not able to give precise advice on a patient by patient basis and this would be driven by your judgement or that of the practitioner prescribing care. Frequency for supportive/maintenance therapy is determined based on an individualised risk assessment for the patient taking into account local as well as systemic factors and of course a history of previous periodontitis. The papers below would tend to reflect the current consensus view that this would ideally be between 3 and 5 or 6 months to maintain peri-implant health, most likely influenced by the factors mentioned above, as well as the potential impact of peri-implant disease on the surrounding tissue, need for and consequences of treatment and outlook for any prostheses.

Implant Disease Risk Assessment IDRA–a tool for preventing peri-implant disease (Lisa J. A. Heitz-Mayfield | Fritz Heitz | Niklaus P. Lang)

Impact of Maintenance Therapy for the Prevention of Peri-implant Diseases: A Systematic Review and Meta-analysis (A. Monje, L. Aranda , K.T. Diaz , M.A. Alarcón , R.A. Bagramian , H.L. Wang , and A. Catena)

Q: I would like clarity and/or confirmation regarding recall periods following Initial Therapy of a new patient displaying BPE code 3. At University, we were informed 2/3 month recall. However, recently a colleague of mine has brought to my attention she was informed 1 month maximum.
Please could you advise the best recall that I should be advising my patients?

A: We would normally suggest that you would wish to reassess fully the patient’s response to treatment after a three month period, as this allows adequate time for good soft tissue responses and healing with resolution of inflammation. However, in addition to this, it is often helpful to contact a patient and/or see them after a month or so, in order to reinforce oral hygiene methods (which may need to change as tissues resolve) and other risk factors control, such as smoking cessation or diabetes control. Once in supportive/maintenance care, a three month review period is often suitable.

Q: DPC in BPE 3 patients

I understand a patient presents with bpe 3 in certain sextants, you do full mouth supra pmpr and then reassess their health by doing a dpc in the sextants that scored a bpe 3 initially. if this dpc shows pocket depths over 4mm in certain areas you would proceed with sub pmpr. 
This patient would then need a 6-8 week reassessment following this sub pmpr. At this reassessment, do you do the dpc in only the sextants you did the sub pmpr (i.e the initial bpe 3 areas) or would you do a dpc in all areas of the mouth, as the fact that the recorded a pocket depth of 4 means we now should be following the periodontitis pathway? but equally if you do a full mouth dpc post sub pmpr, you only have a pre treatment dpc in the sextants of 3 so you cannot compare in the other sextants. Also going forward at next maintenance appts, would you be doing a bpe of dpc on this patient?

A: The BPE is a screening tool so a patient who presents with a BPE code 3 in one or more sextant requires X-rays in the code 3 sextant that show crestal bone levels.  You would then provide OHI, risk factor modification and supra gingival PMPR of the clinical crown. You would then review the patient at a time period of your choosing but 6-12 weeks is not unreasonable to reassess engagement and resolution of superficial inflammation. At this stage it is prudent to do a 6PPC and BOP in the Code 3 sextant as a minimum requirement, if they are a periodontitis patient with bone loss, it may be prudent to have a base line pocket chart. With this information, X-rays, pocket charts and bleeding on probing score you can now confirm your diagnosis and that could be anything from gingivitis, periodontitis that is stable, periodontitis in remission or periodontitis unstable depending on the parameters.

If you have bone loss on your radiographs and residual pockets with inflammation AND they are engaged then they would move to step 2 of care and non-surgical periodontal therapy.

Moving forwards, whether you do a BPE or a 6PPC is depending on your diagnosis. If you had false pocketing and no bone loss then a BPE in the future would be adequate. However, if your diagnosis was periodontitis of any description, a 6PPC + BOP chart where you record pockets of 4mm or greater (as a minimum) should be recorded at least annually.

Q: I am enjoying the new series of webinars and have been implementing the new classification using the BSP flowchart since its inception. I am trying to develop some local treatment management protocols and I am just wondering whether the advice is still to use BPE codes to determine how you lead into the stepwise management of patients? 

A: Yes, the plan is to keep using BPE as a means to diagnosis and classification. The steps will fit into pathways accordingly. This will all hopefully become clearer once we release our new management flowchart in the next week or so, so it might be worth waiting until that is out before you go too far further.

Q: I am currently a GDP in practice and I have been following your latest series of webinars regarding the new S3 guidelines with interest. I have a couple of questions regarding the current BSP guidance that have cropped up through daily practice:

1. The current BSP Flowchart states that if BPE3 recorded then appropriate radiographs should be recorded then sites reviewed after 3/12 and following this if bone loss is evident then proceed to code 4 pathway. If bone loss is evident on radiographs should the clinician immediately proceed to code 4 pathway or still wait 3/12? I ask this as I am often taking bitewings on patients with posterior BPE3s for caries/restorative reasons and identify incidental loss of interdental crestal bone also. Should I be immediately taking PAs of sextants/ proceeding to 6ppc (ie code 4 pathway) or should I still be waiting 3/12 after OHE to carry out 6ppc and PAs as appropriate based off pocket chart measurements?

2. When encountering BPE3 should a differential diagnosis be made in the interim?

A: BPE guidelines state: “Radiographs should be available for all Code 3 and Code 4 sextants. The type of radiograph used is a matter of clinical judgement but crestal bone levels should be visible. Many clinicians would regard periapical views as essential for Code 4 sextants to allow assessment of bone loss as a percentage of root length and visualisation of the periapical tissues”.

We advise that if you already have bitewings showing the bone crests (even if reduced) you wait until completing the OHE as per the Step 1 of patient management, as was outlined in the webinar. The idea is that this then allows for resolution of inflammation and helps to determine better what is going on when you carry out your full assessment, as hopefully you will have eliminated some aspects of the false pocketing which may be present. Then your PAs are taken with more knowledge basis behind their selection, for instance if the tissues respond well and pockets are eliminated (eg by recession or other improvements), and the bone loss was not that great then there may be no justification for taking further radiographs to see root length involvement.

However, if your bitewings show bone loss and you are unable to see bone crests then it might be pragmatic to take PAs sooner, as you need to see where the bone levels and how long the roots are, and it’s likely that these areas may be less likely to respond well to OHE (although of course they are also more likely to be code 4 too).

Obviously, all of this is in the absence of any restorative issues… if there are restorative aspects then that might drive you to PAs sooner, especially for treatment planning where there are other problems.

Strictly speaking the pathway doesn’t have a diagnosis for this point…. However, you nee to use your judgement here, so if there is radiographic evidence of bone loss then it’s likely that there is active periodontitis, but if not then likely gingivitis. You can write that in the notes then make further notes at review. Obviously do not retrospectively change your records!

Q: I was wondering if you could clarify whether High Volume Aspiration is still required when carrying out a hand scale?  We have tried to search this information in Public Health Info as well as the updated NHS CDO but they have not specified.

A: BSP is not strictly in a position to issue formal guidance on these issues. People should be advised to refer to current guidance and make a risk-assessed decision.

The problem is that if one briefly reviews Sections 3.1, 3.2 and  4.1 and Table 3 of the SDCEP guidance (here Aerosol Generating Procedures in Dentistry - SDCEP), it (dated 25/09/20) is at odds with this High_Volume_suction_statement_NDNWPD_2020_7_14.pdf (bsperio.org.uk) dated 14/07/20 and the previous statement table from June...

“While the evidence supporting the use of high volume suction to reduce the risk associated with dental AGPs is very low certainty, the use of suction does have other benefits (e.g. saliva/debris removal, airway protection) and is standard practice in dentistry. ..... Therefore, an individual risk assessment to identify such patients may be necessary. High volume suction has a number of variables and is both equipment and operator sensitive. While suction is available in all dental practices, there may be practices where the existing ‘high volume suction’ does not meet the required standard and additional costs may be involved in upgrading facilities to meet these. There are also ongoing costs associated with assessing and calibrating the level of suction, and servicing of the suction equipment, although these costs are unlikely to be additional as use of suction is standard practice. Following consideration of these factors, the Working Group reached an agreed position:

The Working Group’s agreed position is that the use of high volume suction is recommended to reduce the potential risk of SARS-CoV-2 transmission associated with dental aerosol generating procedures. This agreed position is based on very low certainty, indirect evidence in favour of high volume suction, insignificant risk of harm, and as a standard current practice, high volume suction is known to be acceptable and feasible. “

However, this relates to AGPS, not to the issue in question, and reading in more detail and going to the Implementation points at the bottom of p13 you will find:

“Implementation Points

- Whenever possible, high volume suction should be used for dental procedures which will produce splatter, droplets or aerosol.

- High volume suction may not be suitable for certain dental procedures (e.g. biopsy) and some patients (e.g. those with a strong gag reflex).

- Use of high volume suction might contribute to a reduction in fallow time following a Group A dental procedure”.

And hand scaling can make splatter - therefore it is recommended, and this is in agreement with the BSP statement High_Volume_suction_statement_NDNWPD_2020_7_14.pdf (bsperio.org.uk):

“BSP would like to clarify that for non-surgical supra- and subgingival instrumentation, high

volume suction (HVS) should be used as and when needed during hand instrumentation to remove blood/debris/calculus and reduce the potential risk of splatter. According to risk assessment and the particular circumstances of each case/site, the clinician should judge if a wide or narrow tip can be used with HVS.”

There is also more information available here: COVID-19 latest guidance for England (gdc-uk.org)

Q: I am currently trying to get some firm guidance on the use of ETB intra-orally for OHI provided within our department. I am aware that the BSP guidance in the July 2020 classifies OHI given intra orally with Level 2 PPE is at moderate risk of aerosol. I assume this is with the use of high volume suction.
I have contacted our rep who states that the use of the ETB intra orally with high volume suction has been shown to only produce splatter. They appear to be a lot more reluctant to provide the research that supports this statement.
I wondered if there was anything on BSP’s stance/guidance on this point that I have missed?

A: It Is splatter and hence is Level 2. Aerosols need a much higher rpm from the device in question. Therefore, you may need to consider use of high volume suction in this situation.

Reference section 3.2.1 of SDCEP guidance from September attached and here Mitigation of Aerosol Generating Procedures in Dentistry - A Rapid Review (sdcep.org.uk)

Also might want keep an eye on here Aerosol generating procedures and their mitigation in international guidance documents | Cochrane Oral Health

We have had a very positive response to the BSP implementation of the 2017 Classification and the flowchart to help practitioners has been an overwhelming success.

Many of us have been busy lecturing on the subject and answering questions on social media and we realised that the same questions were coming up time and time again. As such, we decided to collate the frequently asked questions with the BSP’s answers:

Q: When do we have to start using the new classification, can’t we just keep using the old system?

A: Whist the BSP have produced their implementation of the 2017 World Workshop, this is ultimately a global shift in the way we classify periodontal disease together with a change in the language we use when formulating a diagnostic statement. As such, using an out of date system and terminology is not appropriate once you understand the new system. Imagine if we still used the term pyorrhea!

The BSP accepts that it will take time for this to be adopted universally in the UK but practitioners should make the effort to familiarise themselves with the new system, attend courses to allow it to be explained further and practice using this over the coming years

Q: Do I have to do the staging and grading every time I see the patient for a new examination i.e. every 6 months?

A: No, Staging and grading and your diagnostic statement is based on the radiographs that you take when you first meet a patient. At your review, following treatment, the only thing that can realistically change is the element of the diagnostic statement that relates to disease activity i.e. stable, in remission, unstable, as you will not be taking more radiographs at this stage. You should reflect on this in your notes when you reassess your patient and are deciding on the need for more treatment or progressing to supportive care.

Should there be a need to re-X-ray a patient i.e. due to a relapse in the patients periodontal status, then you should produce a new diagnostic statement based on the new radiographs that you have taken.

Q: How can I produce this new diagnostic statement if I do not have any radiographs to work with?

A: Patients who have been identified as potential periodontal patients by their BPE scores, should have appropriate radiographs and special sets done to allow a diagnosis to be made prior to treatment. As the staging and grading requires knowledge of bone levels, it is not possible to produce an accurate diagnostic statement without radiographs and we should not treat patients without a formal diagnosis. In this situation, radiographs should be obtained.

Q: If one tooth has advanced bone loss and the rest of the mouth is affected to a lesser extent, doesn’t this new system skew how you feel about the case?  Should we stage and grade the worst tooth and the less affected teeth separately?

A: No, Staging and Grading is based on the worst affected tooth with periodontal disease. Whilst a diagnostic statement might give the feeling that a case is severe, but on examination it turns out to be based on one very badly affected tooth, as clinicians we interpret our clinical findings and treat accordingly. The new system, like the previous system, does not dictate treatment based on a specific diagnosis and it is for the clinician to decide on the most appropriate treatment for each case.

Q: If one tooth has advanced disease and the rest of the mouth is not too bad, do we re-stage and grade the case if we extract the worst affected tooth or teeth?

A: No, the diagnostic statement including the staging and grading reflect the severity of the case on presentation and the level of risk or susceptibility that the patient has.

Q: Now that we no longer have the diagnosis of Aggressive Periodontitis, when should we consider systemic antibiotics as an adjunct to our treatment?

A: The diagnosis of Aggressive Periodontitis alone did not automatically necessitate the use of systemic antibiotics as an adjunct to treatment. The use or timing of systemic antibiotics in the management of Aggressive Periodontitis was always a clinical judgement call and nothing has changed due to the new classification system.

Q: If the only bone loss is on the distal of lower second molars and we know there has previously been impacted third molars, do we need to stage and grade that patient?

A: No, in the case described where there is no other bone loss and the bone “loss” has a known aetiology i.e. the impacted third molars, a diagnosis of either gingival health on a reduced periodontium or gingivitis on a reduced periodontium would be applied. This is not Periodontitis.

Q: What do I do if a patient presents with BPE’s of 0’s but there is obvious historical bone loss?

A: What you are describing is a periodontitis patient that is “currently stable” and this should have the diagnostic statement produced to reflect the stage and grade and the fact that the case is “currently stable”.