By Eleanor Forshawand Jo-Anne Taylor

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©gehringj/E+/Getty Images Plus

Introduction

Periodontal disease (PD) is an oral inflammatory disease involving the periodontium, and is estimated to affect as many as half of the world's human population.1,2 With the initial stage being long since defined as 'gingivitis', periodontal disease generally begins as a reversible inflammatory response to the presence of accumulated plaque and biofilm.3,4,5

As the disease develops, the destruction of the teeth's supporting periodontal ligaments and alveolar bone becomes irreversible, and as such is defined as 'periodontitis'.6,7,8 As the 6th most prevalent global disease, periodontitis is the leading cause of tooth loss, and as a result is one of the ten most significant causes of years lived with disability.9

To halt the progression of periodontal disease, accurate diagnosis is essential. The Basic Periodontal Examination (BPE) is a quick, effective screening tool, and while it should not be used for diagnosis, is useful both in providing direction for treatment, and indicating whether additional investigation is appropriate. According to the British Society of Periodontology (BSP) Guidelines,10 the BPE should be carried out in sextants, with a ball ended WHO probe 'walked' around each tooth with a 20-25 gram force. Each sextant is given a score between 0-4, with a * given for those involving furcation. With the BPE being a vital initial step in the process of distinguishing between gingivitis and periodontitis, it is important that it is carried out both comprehensively and with precision.

Despite this, research into the current practice of BPEs, or discussing the competencies of qualified dental professionals in the UK, is hugely limited.

Older research suggests that there are shortcomings in the recording of BPEs amongst dentists in the UK11,12with recent findings in Scotland also indicating confusion amid practitioners surrounding the use of the BPE and the Community Periodontal Index of Treatment Needs.13 Diagnosis and treatment planning were further highlighted as areas for concern amongst clinicians.13

An unpublished study carried out at Portsmouth University in 2018 found a significant discrepancy between the BPEs carried out by dental students and hygiene/therapy students in their final year.14 The research identified a difference in 88% of the BPEs completed within the patient records audited, with 21% of those indicating the need for an alternative treatment plan as a result. Discrepancies were recorded on the same patient and within a certain time frame, therefore representing clinical variability, rather than a change in periodontal condition.

While this study confirmed a variability in the BPEs recorded amongst these two sets of students, the reasons for this were not explored.

The aims of the research were therefore:

To establish whether there was a difference in understanding of the BPE between dental students (DS) and hygiene/therapy students (HTS) in their final years

To establish whether specific factors may be contributing to the disparities in clinical recordings between these two groups.

Materials and methods

Ethical approval for this cross-sectional study was obtained on the 16/02/2020, and the research was carried out between February and March of the same year.

This 15-question survey was designed, piloted, and subsequently distributed to all final year DS (n = 80), and final year HTS (n = 28) undertaking clinical placement at the University of Portsmouth Dental Academy (UPDA). The questionnaire consisted of both open and closed questions, with some requiring short answers and others presenting as multiple choice. This was shared online via email on three separate occasions over the course of four weeks, and respondents were also given the opportunity to complete paper copies accessible on clinics, to increase availability. A response for each question was compulsory, and all data were automatically anonymised upon collection. The Mann-Whitney U test was utilised on SPSS to ascertain whether the theoretical knowledge difference between each year group was statistically significant (p<0.05).

Results

Completed questionnaires were returned by 59 of the total 108 students (55%) in their final years of both dentistry, and hygiene/therapy, undertaking placement at UPDA. Of these responses, 24 were from the HTS (86%), and the remaining 35 were from the DS (44%).

Overall, when looking at the available opportunities for each respondent to identify a correct answer in this questionnaire, with total marks given out of 13, the DS averaged a score of 62%, in comparison to the HTS' average of 77% (p = 0.004). Questions marked as 'correct' were done so in accordance with the BSP Guidelines.10

BPE in theory

The initial section of this questionnaire focused on the underpinning theory of carrying out an accurate BPE.

Respondents were first asked questions surrounding the use of probes, with responses shown in Table 1.

Table 1 Responses to questions surrounding probe use (n = 59)
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Respondents were asked to identify what a 'code 3' represented when recording a BPE.

Seventy-four percent of the DS answered this correctly, in comparison to 83% of the HTS' correct responses.

Where responses were unclear, such as '3.5-5.5', a correct answer was determined on the basis of whether the clinical implementation would result in a recorded code 3.

When asked whether a BPE could be used to monitor the response to periodontal therapy, 66% of DS correctly selected 'FALSE', in comparison to 71% of HTS.

When asked to select which option radiographs should be available for, 77% of DS correctly identified the answer 'all sextants with a persistent code 3, or code 4', in comparison to 100% HTS. Those who answered incorrectly (14%) all selected 'sextants of codes 4 or 4* only'.

BPE in practice

The second section of the questionnaire focused on a short case study question, and paediatric guidelines. The questions in this section also had 'correct' answers. Across both cohorts, only 7% of respondents, DS (n = 1) and HTS (n = 3), recorded the BPE most appropriate for the available information. A wide variety of responses were given, as shown in Figure 1, and though the correct answer was 424*/32X, the most common answer given across both cohorts was 424*/42X (17%). With the BPE being recorded in sextants, giving each respondent the opportunity to correctly identify up to six scores, the DS' averaged accuracy was 3/6 in comparison to the HTS' averaged accuracy of 4/6. Table 2 displays the percentage of students able to correctly identify the scores of the individual sextants.

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Variation of BPE score responses

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Table 2 Responses to individual sextants (n = 59)
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Across both cohorts, 93% of respondents correctly identified the appropriate method of carrying out a BPE on a ten-year-old child. Of those who answered incorrectly, DS (n = 3) and HTS (n = 1), all respondents selected 'simplified BPE; measuring 6 index teeth, with the full range of codes' as their answer.

BPE in reality

The final section of the questionnaire focused on the experiences of students undertaking BPEs in the clinical environment. The answers for this section were not marked as correct or otherwise.

When asked to identify the BPE method that respondents most commonly carried out on adult patients, 14% of the DS, and 4% of the HTS, selected 'partial mouth' recording.

Despite this, after being asked to identify both how many teeth, and how many sites surrounding those teeth, that they measured on average (per adult patient), the responses suggest that it is actually 54% of students across both cohorts that are frequently carrying out partial mouth recording, as opposed to the 10% that selected this option (Table 3).

Table 3 Average number of teeth, and surrounding sites, measured per patient by respondents (n = 59)
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Finally, respondents were asked which barriers would prevent them from carrying out a full mouth BPE on an adult patient, with responses shown in Table 4. It is of note that respondents were able to select more than one option for this question. Of the respondents which selected 'Other', the responses commonly included 'patient sensitivity', and 'patient compliance'.

Table 4 Views of respondents on perceived barriers to carrying out a full mouth BPE (n = 59)
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Discussion

If left to progress untreated, periodontal disease can have serious effects on a patient's quality of life.15 With a rapidly growing body of evidence linking poor periodontal health to several systemic conditions,16,17,18,19 essential that this globally prevalent disease is managed effectively. Though non-reversible, the early identification of PD can significantly improve the prognosis when utilised in conjunction with timely periodontal therapy,20 and as such, makes the accuracy of the BPE screening process crucial.

The results of this study indicate a significant difference in the understanding of the clinical implementation of the BPE between dental students and hygiene/therapy students in their final months of education (p = 0.004). Retraining of skills in this area prior to qualification may be necessary across both clinical disciplines, to ensure the accurate diagnosis and treatment planning of those patients with poor periodontal health.

When requested to interpret a short case study and identify the most appropriate BPE score for the information given, the number of fully correct responses across both cohorts was surprisingly low (7%). With the vast majority of students able to accurately define a code 3 for a previous question, the data suggest that the inclusion of third molars in the recording is the likely cause of confusion in this case. When analysed further, the results indicate that only 27% across both cohorts (with little disparity between each group) seem to be aware that the third molar need not be included in a BPE score, should the rest of the molars in that sextant be present. While over 60% of the HTS were able to identify the correct codes for the remaining sextants, fewer DS achieved this, with only 54% of them recognising the code 4, or appropriately recording the furcation involvement. These inaccuracies lead to two clear issues: the presence of PD being potentially underdiagnosed, or over diagnosed.

In the case of overdiagnosis, the prescription of superfluous treatment is unlikely to cause harm to the patient. The use of further investigatory actions, however, such as full mouth pocket charting or periapical radiographs, may not only waste clinical time and resources, but could also result in avoidable radiation exposure.21 The underdiagnosis of PD may also lead to a host of problems, not least litigation under supervised neglect. With literature indicating rapidly increasing incidence rates of legal disputes within dentistry,22 and with much discussion surrounding the reasons behind this, particularly in regard to PD,23 it is more important than ever for clinicians to ensure that the safest standards of patient care are being met. As the results of this study support the previous literature indicating a need for improvement in diagnostic accuracy,11,12 further research into the effectiveness of dental training in this area, with subsequent revisions, may be required.

The accuracy of a BPE recording can also be affected by the number of teeth measured. Despite full mouth recording being widely considered more effective than partial mouth recording, with the latter underestimating both attachment loss and the prevalence of PD,24,25 the results indicated that 60% of DS, and 46% of HTS, are regularly carrying out partial mouth recordings on patients. The apparent difference in the number of students selecting 'full mouth recording' as the option they perceive themselves to most regularly carry out, in comparison to the number of teeth and surrounding sites that they report to actually measure, would suggest a lack of understanding of definition. The students therefore may not be aware that all teeth, and all surrounding sites, must be measured for a recording to constitute full mouth. This disparity could also be due to response bias, however, as although students may have answered honestly in the previous questions, the recognition that full mouth recording is best practice could have been reflected in the responses here.

As the results of this study support the previous literature indicating a need for improvement in diagnostic accuracy, further research into the effectiveness of dental training in this area, with subsequent revisions, may be required.

Interestingly, of those indicating the use of partial mouth recording, a comparable number of students in each cohort cited time constraints as the barrier most likely to prevent them from carrying out a full mouth BPE, a finding which is reflected in similar literature.11,13 With appointment lengths being significantly longer for clinicians in training than for those working in practice, it raises the important question of whether an increase would be seen in those utilising partial mouth recordings once qualified. Short appointment lengths have been an issue for a number of years, and with no evidence (anecdotal or otherwise) of a change in this trend, despite time pressures clearly leading to diagnostic errors,26 this may be a compelling subject for further investigation.

Regarding the theoretical knowledge of undertaking a BPE, for every question asked, a higher percentage (13% average) of HTS answered correctly when compared to the DS.

The average mark for each HTS was also 15% higher, a statistically significant difference (p = 0.004). These results suggest that the HTS have an overall better understanding of the BPE process than their peers studying dentistry, which in this case, is just prior to qualification. Though there is limited access to research comparing students of these two disciplines, where studies have previously compared the clinical skills of qualified dental hygiene/therapists and dentists in this area, the dentist has been the benchmark for accuracy.27,28 The current data would suggest, however, that this may not be the correct approach, as based on clinical understanding, the BPEs carried out by the hygiene/therapists are more likely to be accurate than those carried out by the dentists. As the literature indicates that only 28% of schools teaching dentistry revisit this area of training after the first year,29 it follows that there may well be a requirement for the reskilling of DS in subsequent years, to be added into the curriculum.

The limitations of this study must also be acknowledged. Firstly, the response rate of the DS was much lower than that of the HTS, giving a smaller sample size than anticipated. Though this response rate of around 40% is mirrored amongst health care professionals in wider research,30 when compared to the response rate of 86% amongst the HTS, it could be reflective of this cohort's attitude towards the importance of the BPE, or its perceived relevance in current research.

Beyond the educational environment, these results suggest that research into the prevalence of partial mouth recordings in general practice may also be valuable.

Secondly, the participants in these two groups each received training from a different university. While this may have impacted the discrepancy in knowledge, as all dental educational providers are expected to teach to a standardised level the results of this study could still reflect the wider population to an extent.

To rectify this limitation, repetition of this study across other UK universities would be required to determine whether these findings are consistent across the discipline. Beyond the educational environment, these results suggest that research into the prevalence of partial mouth recordings in general practice may also be valuable.

Conclusion

This survey supplements the limited body of evidence surrounding both the understanding and current practice of the BPE in an educational environment. There is a difference in theoretical knowledge between hygiene/therapy students and dental students. Both groups were confident in their competency in this area, despite high inaccuracy rates in BPE code identification. There is an indication that reskilling in this subject prior to qualification would be appropriate for both cohorts.