Periodontal probing: Stop when you see red

During oral assessment, treatment and prevention visits, a periodontal probe is used to evaluate gingival health while patients are anesthetized. Depending on an animal's size, the veterinarian or dental assistant checks each tooth, probing the subgingival pockets for abnormal depths. During probing, little attention is usually given to bleeding because it's accepted as a common occurrence.

Consider your own oral hygiene. This morning when you brushed your teeth and looked at the brush, I hope you didn't see blood. But what would have happened if you had? An alarm would have gone off in your mind. A trip to the dentist certainly would have been in order.

Jan Bellows DVM, Dipl. AVDC, Dipl. ABVP

Let's bring this same knee-jerk reaction to dogs' and cats' mouths. Gingival bleeding on probing indicates an inflammatory lesion both in the epithelium and in the connective tissue. Gingival inflammation leads to engorgement of the capillaries and thinning of the sulcular epithelium, predisposing capillaries to rupture from usually innocuous stimuli. Thus, bleeding during pocket-depth probing should elicit an immediate reaction to stop, diagnose and treat. Bleeding doesn't occur in healthy tissue unless abnormally traumatized by the probe.

In simple terms, gingival bleeding is an objective, easily assessed sign of inflammation associated with periodontal diseases. Rare causes of gingival bleeding include hemophilia, leukemia, thrombocytopenia and liver and kidney disease. More commonly, though, bleeding comes from gingival inflammation due to inadequate plaque and tartar removal beneath the gum line.

Gingival bleeding assessment

Indices commonly used in human dentistry to assess gingival bleeding include the sulcus bleeding index, bleeding on probing and the gingival index.

Sulcus bleeding index (SBI) scores indicate:

• 0—Gingiva of normal texture and color, no bleeding on probing (Photo 1)

• 1—Gingiva clinically normal, but bleeding on probing (Photo 2)

• 2—Bleeding on probing, change in color, no edema (Photo 3)

• 3—Bleeding on probing, change in color, slight edema (Photo 4)

• 4—Bleeding on probing, obvious edema and/or obvious change in color (Photo 5)

• 5—Bleeding on probing and spontaneous bleeding, change in color, marked edema (Photo 6).

Bleeding on probing (BOP) is evaluated by noting bleeding after insertion of a probe into the base of the sulcus or pocket. Bleeding on probing is associated with inflammatory changes at the pocket's base and is a predictor of periodontal breakdown when present.

Gingival index (GI) scores of 0 to 1 indicate nonbleeding sites, despite clinical assessment of marginal inflammation (GI score of 1). GI scores of 2 and 3 indicate that bleeding is found spontaneously or after stimulation of the gingival margin with a probe. Specifically, GI scores signify:

• 0—Normal gingiva

• 1—Mild inflammation, slight change in color, slight edema, no bleeding on probing

• 2—Moderate inflammation, redness, edema, bleeding on probing

• 3—Severe inflammation, marked redness and edema, ulceration, spontaneous bleeding.

What to do when bleeding is noted

Determine the probing depth or attachment level (in cases of gingival recession). In midsized dogs, a depth > 3 mm is considered abnormal. In cats, a depth > 1 mm is consider abnormal.

Next, determine the stage of tooth mobility:

• 0 (M0)—Physiologic mobility is up to 0.2 mm.

• 1 (M1)—Mobility is increased in any direction other than axial over a distance of more than 0.2 mm and up to 0.5 mm.

• 2 (M2)—Mobility is increased in any direction other than axial over a distance of more than 0.5 mm and up to 1 mm.

• 3 (M3)—Mobility is increased in any direction than axial over a distance exceeding 1 mm, or any form of axial movement is noted.

Finally, determine the stage of periodontal disease (PD) present and treat accordingly:

• Stage 1 (PD 1) involves gingivitis only, without attachment loss. The height and architecture of the alveolar margin are normal. Probing depths will be normal. Treatment: Clean the teeth and apply a plaque prevention gel (Photos 7A and 7B).

• Stage 2 (PD 2) is considered early periodontitis. Less than 25 percent of attachment loss is present, or, at most, there's a stage 1 furcation involvement in multirooted teeth. Early radiologic signs of periodontitis are present. The loss of periodontal attachment is less than 25 percent as measured either by probing the clinical attachment level or by radiographically determining the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root. Treatment: After professional cleaning, apply a local antimicrobial agent.

• Stage 3 (PD 3) involves moderate periodontitis, which is noted when 25 to 50 percent of attachment loss is measured either by probing the clinical attachment level or by radiographically determining the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root. Alternatively, stage 2 furcation involvement may be noted in multirooted teeth. Treatment: If stage 2 or 3 tooth mobility is present and the owner cannot agree to an effective homecare regimen, consider extraction. Other options include gingival surgery to decrease pocket depth. Perform gingivectomy if sufficient attached gingiva remains (Photos 8A and 8B; 9A and 9B, p 8S). Open-flap root planning is indicated in cases in which clients are committed to home care and the teeth are not mobile (Photos 10A, 10B, 11A and 11B).

• Stage 4 (PD 4) is advanced periodontitis, which is noted when more than 50 percent of attachment loss is measured either by probing the clinical attachment level or by radiographically determining the distance of the alveolar margin from the cemento-enamel junction relative to the length of the root. Alternatively, stage 3 furcation involvement may be noted in multirooted teeth. Treatment: Extraction is the treatment of choice in cases of advanced periodontal disease (Photo 12).

Photo 12: Stage 4 periodontal disease that necessitates extraction.

Client communication

It's helpful to share with your client how many bleeding on probing areas are present and where they are in the patient's mouth. Explain that the goal is to get the bleeding down to zero (so the client goes home with a number to work toward) and that if these areas are neglected, damage may progress.

In addition to daily plaque control and the use of VOHC-approved plaque and tartar retardation products, tell the client that one or twice yearly professional oral evaluation visits under anesthesia are necessary for optimal care. Often in cases of excellent plaque control, bleeding will be resolved.

Suggested reading

• Lang NP, Adler R, et al. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol 1990;17(10):714-721.

• Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for monitoring periodontal conditions in clinical practice. J Clin Periodontol 1994;21(6):402-408.

• Chaves ES, Wood RC, Jones AA, et al. Relationship of "bleeding on probing" and "gingival index bleeding" as clinical parameters of gingival inflammation. J Clin Periodontol 1993;20(2):139-143.

Dr. Bellows owns ALL PETS DENTAL in Weston, Fla. He is a diplomate of the American Veterinary Dental College and the American Board of Veterinary Practitioners. He can be reached at (954) 349-5800; e-mail: dentalvet@aol.com.