Board Certified Periodontist

6 – The Bleeding Index

This is the Perio Hygienist Podcast – a podcast centered on the intersection between the specialty of periodontics and the profession of dental hygiene. And the information being provided to you comes from a periodontist clinician, not an instructor. I think this is an important distinction for how best you might consider my advice. My name is Dr. Ben Young.

In this episode we continue talking about the periodontal probing examination.

Last time I gave you my ideas and opinions on how to accomplish the probing examination in ways that can help you clinically.

It’s a key  subject when it comes to supportive periodontal therapy – again, in my opinion – because the use of the periodontal probing measurements and the bleeding index in your session with the patient differentiate this particular visit from the adult prophylaxis appointment.

Without this step, your program simply becomes a cleaning appointment in the patient’s mind. And when it becomes a cleaning appointment you will be graded on your effectiveness at cleaning, which is a subjective thing as to what your patient may think a good cleaning – did you press hard enough? Did you take away all the stain?

The primary purpose of the Supportive Periodontal Therapy or SPT appointment is assessment, not cleaning. In fact, too much prophy-like cleaning of supragingival structures every three months can have some potentially destructive results long term. More on this in a future podcast.

Today, let’s talk about the bleeding index.

The bleeding index comes out of the probing examination because we are looking at pocket inflammation. And, unless you have explained this to patients, they will misunderstand what we are looking at and why.

I believe the bleeding index is more useful compared with the plaque index, so let me briefly say a word about the plaque index to get it off the table here.

The plaque index is a way of critiquing plaque control, but I find it a bit demeaning when used with adults. Also, for it to have any relevance at all, it would be necessary for the patient to go through their plaque control routine just before the dye is applied. These steps slow down appointments and do not put patients in particularly good moods.

Now back to the bleeding index.

It is not uncommon for patients to say that their gums no longer bleed. My response to this is that I am very glad to hear it, but the bleeding index is not looking at the area you are able to clean by brushing and flossing. It is looking at the area between the root and the gum – the periodontal pocket – and is an assessment of your body’s immune response to the bacteria that reside there.

As you look at areas in the mouth following gentle probing that bleed, try as much as possible to make this a yes or no question. Is the site bleeding? Yes or no? It isn’t a quantitative question – how much is the bleeding, it’s simply yes, it is bleeding or no, it is not. A little bleeding is yes, no bleeding is no.

Why is this important? Again, it’s like trying to determine between a 1 millimeter measurement and a 2 millimeter measurement. It is a lot of work to attempt to determine if a site is bleeding enough to count or not. Save the brain and make it yes or no.

But what if there is so much bleeding that it flows out of the pocket and surrounds other areas? Then count every area where you see blood as bleeding. This gives you the quantitative element to bleeding assessment.

But what about accuracy?

It’s inaccurate, I will give you that. I will also say it is quite arbitrary. After all you are deciding what is and is not bleeding. At this level, it is indeed your opinion. But it is an opinion based on findings that were observed, and then processed in a way that provides a number the patient can then absorb without embarrassment. Afterall, bleeding, by itself, is not a bad thing, it’s a good thing. It is an indicator of the body’s immune system. It is the first line of defense against bacterial attack subgingivally. We want some bleeding, but we want it at a low level.

When the bleeding index rises the body can become overwhelmed and the inflammatory response no longer represents an adequate defense. That’s where plaque control comes in.

(If you have your patient read my book, The Joy of Flossing, I explain it to them there).

Plaque control on a daily basis keeps the inflammation levels low and permits the body’s immune system to function.

Also, when the body is sending a lot of white blood cells and antibodies to the gums around teeth, it is not able to send those cells and proteins to other parts of the body that may need them. This is part of the link between the health of the mouth and the health of the body.  

My point about the bleeding index is that it is a very useful tool for providing patient’s feedback in a way that does not result in a defensive response.

When someone is backed against the wall by an accusation that they are not doing a good job at something, what is the natural response? It is to defend. It is to fight back.

But an assessment designed to give the patient important information in a way that helps them deal with the information is a very useful way at getting around the defensive reaction to what might be considered bad news.

So let me review how to take a bleeding index.

Again, it is arbitrary and its importance is in generating a number that is in the ballpark when it comes to accuracy.

The way I do it, and I have someone recording the measurements and bleeding sites for me, is to call out the pocket measurements for the facial sites around the upper teeth first. Then I go back and call out all sites that bleed.

Following this, I measure the pockets on the palatal aspect of the upper teeth, and when I have finished, I go back and call out all sites that are bleeding. If there is a lot of bleeding in an area, I don’t care where the bleeding is coming from specifically, I just call out all the sites where I see the bleeding.

Over time, especially following active therapy, the bleeding sites will become spots. I still call them out.

The bleeding index for me is calculated as the total number of sites that bled divided by the total number of sites probed – which for me is six sites around each tooth. Move the decimal point two positions to the right and you have the percentage of sites that bled. That’s the bleeding index.

I have a little calculator for making this calculation .

So anticipated pushback.

Why not four sites around teeth?

I don’t think four sites give me enough information from a pocket measurement standpoint – so that doesn’t work for me.

Finally, because I’m so picky, I set the bar at 20% as my cutoff between whether I am concerned it is too high or is reasonable.

And let me say, I have had pushback here. Some people would    like the set the acceptable bleeding index at 10% or something else.

My response: do what you want. Again, in my mind, it’s a communication tool. I try to find a cutoff that doesn’t clobber everyone I see.

If you set the bar too low, say at 10%, then you will encounter patients who clinically are doing well but are being hammered by the bleeding index. Also the bleeding index in women can run higher than men due to the monthly estrogen cycle. Too low an index will constantly be a challenge for many of them.

Again, this is a tool. It is to help you provide information to patients in a non-threatening way.

If the bleeding index is coming down, but is still higher than 20%, that in my book is a compliment waiting to happen. Good news patient, you bleeding index is coming down. We still would like to see it under 20%, but sometimes these things take time. Let’s check it again in three months.

That’s enough for now. Let’s pick this up next time by talking about treatment intervals and how we might consider adjusting them based on the numbers – what’s the bleeding index and what are the deepest probing sites?

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