I want to address a topic that is readily evident in clinical practice—patients who do not bleed upon probing yet hemorrhage in specific areas upon instrumentation. What is going on? Every practicing clinician has likely experienced this, yet the differences observed are often not documented in clinical notes. It runs the risk of patients perceiving that we are causing the bleeding with our “sharp instruments” if we identify it and discuss it following instrumentation. This is often considered the elephant in the room of dental hygiene visits, so I hope to shed some light on the topic.
‘The rest of the story’ and perfect tissue response
I want to share my experience first; then I’ll wrap up the article with a brief look at literature. Our dental practice invited the JP Institute to consult with our team about early recognition and treatment of periodontal diseases in 1991. What piqued my interest, but truthfully also made me suspicious, was their reference to achieving “perfect tissue response.”
My experience at that point in my career was that the vast majority of patients bled either upon probing or upon instrumentation. It was a rare occurrence to see a patient move from generalized bleeding to zero bleeding as I navigated every sulcus and pocket. However, what I learned from that in-office training changed the trajectory of my career, and most certainly the health of my patients.
I learned how to assess the true tissue response prior to instrumentation by assessing “bleeding upon tissue stimulation,” in addition to bleeding that was evident upon probing. I either used my probe to stimulate the interproximal nonkeratinized col where disease often begins or used a Stim-U-Dent to identify tissue response reflective of early inflammatory changes. Often these changes were not yet evident with probing to the bottom of the pocket, but readily seen with biofilm removal and instrumentation (stimulation of the tissue) in subgingival sites undergoing initial inflammatory changes.
I referred to these differences with my patients as Paul Harvey’s “the rest of the story.” (For those unfamiliar with Paul Harvey, he was a radio personality famous for leaving his audiences waiting for “the rest of the story,” leading in with a cliffhanger.) My clinical documentation reflected bleeding upon probing and bleeding upon tissue stimulation, and I began to discover and treat the earliest stages of periodontal diseases. And guess what? Perfect tissue response was not only achievable, but sustainable in patient after patient once I had a better understanding of diagnosis of disease during the earliest possible stage.
With technological advances, today I detect the true tissue response, or “the rest of the story,” with my Air-Flow technology using low-abrasive powder, such as glycine or erythritol, directed toward the gingival margin. What I love about assessing true tissue response with this technology is that I simply aim the nozzle and air polishing powder toward the sulcus to remove biofilm, but I don’t physically touch the tissue with any instrument. There’s no opportunity to blame the probe or sharp instruments as the cause of bleeding. Even tissue that does not bleed upon probing will bleed easily with stimulation if it is inflamed and if dysbiotic biofilm exists. What the patient and I see unfolding is that healthy tissue does not bleed upon probing or during removal of biofilm. Early inflammatory responses in the sulcus or pocket are always consistent with bleeding upon biofilm removal or tissue stimulation.
What about the science?
Because this is a column and not a novel, I will share only a bit of science that will help us wrap our brains around what’s happening clinically when we see these differences in detection of or in degrees of bleeding in our patients. Historically, there are publications that remind us that probing is one assessment to identify disease. But in early stages of inflammatory changes, histological changes are correlated to stimulation of the papilla and/or angulation of the probe.1
One study from the 1980s reminds us that papillary bleeding is indicative of early inflammatory changes. Histological changes were evident with regard to the intensity or degree of bleeding and most consistently correlated with the papillary bleeding index as opposed to bleeding upon probing.2
Various indices to assess the variation in bleeding were analyzed in a 1996 article that concluded that the angle of the probe makes a difference in bleeding scores, and indices that provide more tissue stimulation, such as a modified Sulcus Bleeding Index, are likely a better prognostic assessment than bleeding upon probing, albeit much more time consuming.3
The article states, “Angular probing (at ~60 degrees to the long axis of the tooth) of the gingival margin is a more sensitive indicator of gingival inflammation and less likely to elicit false-positive bleeding than probing to the bottom of the pocket.”3 Basically, while probing depth readings are important as part of a comprehensive assessment, increased tissue stimulation (whether with a probe, Stim-U-Dent, or Air Flow nozzle angled toward the gingival margin) helps detect early inflammatory changes, especially in shallow pocket depths where early tissue changes occur.
Call to action
Don’t put your foot in your mouth by saying “Congratulations!” to patients following a probing depth assessment without investigating further via additional tissue stimulation and assessment prior to instrumentation. We often tell patients, “Healthy tissue doesn’t bleed,” but that should encompass bleeding upon probing and bleeding during “the rest of the story.” In my opinion, clinicians who understand how to investigate and treat early inflammatory changes are true mavericks in the quest for optimal health.
1. Van der Weijden GA, Timmerman MF, Nijboer A, Reijerse E, Van der Velden U. Comparison of different approaches to assess bleeding upon probing as indicators of gingivitis. J Clin Periodontal. 1999;21(9):589-594.
2. Engelberger T, Hefti A, Kallenberger A, Rateitschak KH. Correlations among papilla bleeding index, other clinical indices and historically determined inflammation of gingival papilla. J Clin Periodontol. 1983;10(6):579-589.
3. Newbrun E. Indices to measure gingival bleeding. J Periodontol. 1996;67(6):555-561.
Karen Davis, BSDH, RDH, is the founder of Cutting Edge Concepts, an international continuing education company, and she practices dental hygiene in Dallas, Texas. She is an independent consultant to the Philips Corporation, Periosciences, and Hu-Friedy/EMS. She can be reached at [email protected].