Bleeding on punching in the nose ... Thoughts on bleeding on probing

Over the years, the idea of bleeding on probing has been a tightly held tenant in dental hygiene education and in practice. New studies on treatment benefits measure both bleeding and the decrease of bleeding on probing sites. Does anyone even know what that means?

Back in December 2014, we authors caucused in the beautiful snow/mud covered hills of the Wisconsin Dells to create our tentative editorial calendar. Written in pencil, the calendar illustrated which of our pet projects we’d highlight each month. Of course, BOP was one of those. The authors have both written previous articles on the fallacy of BOP as an indicator of disease, but the notion is so entrenched in the practice that fresh new dental hygienists are taught to regard BOP as an indicator of the severity of periodontal infections, and the idea is brought into the fold of nearly every dental office in the land.

Anyone remember how much pressure to exert on the probe? Ms. Ryan told us in 1985 to apply light pressure-so light that someone could pull the probe out of your hand as you’re holding it. In 2009, the Florida Probe taught us that probing requires about 15 grams of pressure. After speaking around the country and asking groups, large and small, how much pressure they put on a probe, I got more blank looks than a group of 4-year-olds being asked who ate the cookie. Super funny–all the studies measure the pressure in Newtons not grams. What’s a Newton?

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One Newton is the force needed to accelerate one kilogram of mass at the rate of one meter per second squared. It is based on Newton's second law of motion where F=ma. F is the force applied (the hand), m is the mass of the object receiving the force (the base of the pocket) and a is the acceleration of the object.

Alright, fun’s over. The seriousness of this problem comes into play when dental hygienists, who don’t trust their Newtons and therefore don’t trust the BOP indicator, allow what’s now commonly called a bloody prophy. Much like a punch in the nose elicits bleeding so does dental hygiene treatment. Since our first patient ever, our husband, boyfriend or mother, we know that bleeding is part of the patient’s prophy experience. Here’s where it gets to be super crazy: The difference in one study between bleeding on probing or not around dental implants was 0.15N. That’s 15 grams, the exact amount of pressure you’d use if you were applying the appropriate pressure as you were measuring pocket depths.

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Here is the study’s abstract:

Increasing the probing pressure by 0.1 N from 0.15 N resulted in an increase of BOP percentage by 13.7% and 6.6% for implants and contralateral teeth, respectively. There appeared to be a significant difference of the mean BOP percentage at implant and tooth sites when a probing pressure of 0.25 N was applied. A significantly deeper mean PPD at implant sites compared with tooth sites was found irrespective of the probing pressure applied.

The results of the present study demonstrated that 0.15 N might represent the threshold pressure to be applied to avoid false positive BOP readings around oral implants. Hence, probing around implants demonstrated a higher sensitivity compared with probing around teeth.

For the purposes of this article, I think this reference is a good one. There are tiny fractions in Newtons of pressure between bleeding and not bleeding in healthy tissue. Let’s get over it already. For the type of tissue at the base of the pocket, fractions of a Newton really is the difference between squeezing a pimple on the nose and getting punched in said nose. We would NEVER accept these kinds of lame diagnostics from our medical providers, and, if patients knew, and they do, what we were doing within some unmeasurable tolerances, they would clean their own teeth. Start demanding real diagnostic tools. Our profession demands it!

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