By Amy Nieves, RDH
Gingival bleeding, especially its presence or absence during periodontal probing, is often what many dental professionals focus on as the indicator of active periodontal disease. But bleeding upon probing alone is unreliable as a disease indicator.
I recently went on an interview and was surprised that the dentist determines periodontal therapy solely on bleeding upon probing. All patients in his practice who bleed are treated with the same protocol, despite differences in gingival inflammation, bone loss, or systemic factors. To rely on bleeding upon probing as the definitive indicator of periodontal disease is inadequately evaluating the patient for other factors that can cause capillary fragility. Several confounding factors should be taken into account: probing technique, smoking, hormonal changes in women, medications, blood disorders, alcoholism, depression, as well as other systemic factors. "As a predictor of periodontal progression, bleeding upon probing has low sensitivity owing to a high frequency of false-positive responses." (Newbrun, 1996, 1)
Bleeding upon probing should not be ruled out as a symptom of periodontal disease. Gingival bleeding is a clue to many systemic issues that a patient may be experiencing. Bleeding should not be ignored, but it should not be treated incorrectly. Periodontal therapy alone may not treat the definitive cause or systemic factor of the bleeding. The goal of periodontal therapy is to achieve a degree of periodontal health that is consistent with the patient's overall health.
A comprehensive evaluation of the patient should be performed. Bleeding should be recorded, and the reasons for the bleeding should be investigated. Assessments should include full-mouth radiographs; comprehensive medical histories; systemic and psychological factors; over-the-counter and prescription medications, including vitamins and herbal supplements; physical disabilities; and all oral signs and symptoms. The patient should be referred when needed to his/her medical doctor or other health-care professional for a complete physical, including necessary laboratory tests to determine any systemic diseases or deficiencies. The shortcoming of dentistry is that we treat symptoms, but we do not regularly treat or detect the causative factors.
Probing pressure, technique, and type of periodontal probe can influence gingival bleeding. Excessive pressure and improper technique can cause even healthy tissue to bleed. Bleeding tendency is higher if the gingival tissue is thinner compared to thicker tissue (Müller & Könönen, 2005). A study from the University of Berne School of Dental Medicine revealed a significant increase in percentage of bleeding upon probing when an increase of force is applied (Karayiannis, Lang, Joss, & Nyman, 1992). When a heavier force is applied, it is more likely that traumatization of clinically healthy tissue will occur. A controlled, forced probe will cause fewer traumas and less false-positive bleeding (Newbrun, 1996). "For years it was recommended to use a probe with a diameter of 0.40 to 0.50 mm to adequately reach the base of the pocket. Studies have shown that with a diameter that size, the probe usually penetrates beyond the base of the pocket and about 1 mm into the inflamed connective tissue" (Hassan, et al., 2005, p. 980-981). It is now recommended to use a probe with a diameter of 0.63 mm (Hassan, 2005).
Individuals who smoke may have a decrease in bleeding upon probing due to the depressed gingival inflammatory response. Dietrich, Bernimoulin, and Glynn (2004) stated that smoking showed a strong and consistent suppressive effect on gingival bleeding upon gentle probing. Despite the lower occurrence of gingival bleeding, disease progression over the years can be more severe in those who smoke compared to nonsmokers. The nicotine in cigarettes can cause acute vasoconstriction. Gingival blood flow was found to have increased during smoking (Dietrich, 2004). Cigarette smoke is known to contain numerous oxidants that can cause tissue damage (Nishida, et al., 2000). A history of smoking should be taken into account during any periodontal examination. The absence of bleeding upon probing may not indicate the severity of the periodontal condition. Smokers exhibit less reduction in pocket depth and less gain of attachment when compared to nonsmokers immediately following active periodontal therapy and maintenance (Biddle, Palmer, Wilson, & Watts, 2001). Once an individual ceases to smoke, gingival bleeding can increase (Nair, Sutherland, Palmer, Wilson, & Scott, 2003). The patient should be educated on the benefits of smoking cessation and the health of the periodontium.
Fluctuation in estrogen and progesterone levels in women is another confounding factor in gingival bleeding. Bleeding can vary in women due to the peaks in serum levels of estradiol during ovulation and then the drop during premenstruation. These fluctuations can have an effect on the immune system. Many women report an increase in gingival inflammation, bleeding, and discomfort associated with their menstrual cycle, most commonly around the menses period (Machtei, Mahler, Sanduri, & Peled, 2004). Studies have shown that: sex hormones have an effect on monocytes; increased sex hormones modulate the development of localized gingival inflammation; elevated progesterone levels might be responsible for the increase in GI scores; and a direct effect of sex hormones on organisms, such as increased level of Prevotella intermedia, promote gingival inflammation during the ovulation and premenstrual periods (Machtei, 2004).
During the medical history evaluation, ask the patient what medications, including anything over the counter, and the dosages that he/she has been taking. This is important in regard to aspirin and nonsteroidal anti-inflammatory drugs. Aspirin has anti-thrombolytic activity. "Taking aspirin is a nondisease factor that has the potential to alter the appearance of bleeding in various bleeding indices" (Schrodi, et al. 2002, p. 872). Schrodi, et al. concluded that those individuals who were taking a 325 mg dose of aspirin daily had a moderate, yet significant increase in bleeding on probing compared to the placebo group and the group that was taking only 81 mg of aspirin a day. Royzman, et al. (2004) concluded that daily intake of both 81 mg and 325 mg of aspirin significantly increased the percentage of bleeding upon probing.
Individuals with blood disorders can be more susceptible to gingival bleeding. Defective platelet function can also cause bleeding in congenital disorders such as von Willebrand's disease. von Willebrand's disease is "the most common hereditary clotting disease, and the most common inheritable cause of spontaneous intraoral hemorrhage" (Izumi, Taniguchi, Maruyama & Sueda, 1999, p. 548). This disease can affect normal blood clotting. If you have a patient who practices great oral home care but whose gingiva bleeds heavily on probing for prolonged periods, start asking questions. Ask the patient if he/she bleeds heavily for long periods when cut. Ask women if they have heavy and prolonged menstrual periods. If patients are experiencing heavy and prolonged bleeding, we should refer them to their medical doctor for necessary lab tests. Precautions should be taken for patients before any periodontal therapy or surgery.
Bleeding upon the slightest provocation is often seen in alcoholics. A study conducted by Tezal, Grossi, Ho, and Genco (2001) concluded that those who consume more than five drinks a week have higher gingival bleeding. Alcohol has an adverse effect on the host defense and is associated with complement deficiency. Prothrombin production, defective neutrophil function, Vitamin K activity, and clotting mechanism may be disrupted and hemorrhage may take place. Alcoholics also have higher rates of infections.
Psychosocial factors such as depression might play a role in increased gingival inflammation and bleeding. A higher incidence of bleeding can occur in those with a more severe bout of depression (Klages, Weber, & Wehrbein, 2005). Depression might suppress a patient's energy and affect oral home-care habits, resulting in higher incidences of bleeding and deterioration in periodontal status (Dolic, Bailer, Staehle, & Eickholz, 2005). If you notice that a patient is taking medications for depression, such as Zoloft or Prozac, positively reinforce oral home care and the importance of regular maintenance visits for periodontal health.
As dental hygienists, we need to use our education and critical thinking skills to properly assess a patient's periodontal or systemic condition. "The absence or presence of bleeding on probing is a sign of periodontal health or disease, but the presence of bleeding upon probing is not an accurate predictor of disease progression" (Shrodi, 2002, p. 871). Relying on bleeding upon probing as the definitive indicator of periodontal disease is not effectively treating the patient. Dental professionals need to evaluate a patient's total health — not just the visible sign of bleeding in their mouths.
Amy Nieves, RDH, practices clinically in a periodontal practice in Florida for four days a week. She spends her free time maintaining her websites at www.amyrdh.com and www.amysrdhlist.com and spending time with her husband and 3 teenage daughters. She has co-authored a book with Shirley Gutkowski, RDH, BSDH titled "The Purple Guide: Developing your Clinical Dental Hygiene Career," which is available at www.rdhpurpleguide.com. She welcomes all RDHs to become a lister at www.amysrdhlist.com.
References
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