Clinical assessment and diagnosis

Take a history and examine the patient’s oral tissues.

Perform a BPE screen.

N.B. For a patient with an obvious history of periodontitis, as indicated by evidence of interdental recession, it is acceptable to omit the BPE screen and proceed directly to assessment of radiographs and full periodontal assessment. 

For a patient with BPE Code 0, 1 or 2 and no evidence of interproximal recession:

• assess the extent of bleeding on probing to inform the diagnosis (health, localised gingivitis or generalised gingivitis);
• assess modifiable risk factors (smoking status, sub-optimally controlled diabetes).

For a patient with BPE Code 3: 

• assess the extent of bleeding on probing;
• assess modifiable risk factors (smoking status, sub-optimally controlled diabetes);
• make a preliminary periodontal diagnosis based on patient presentation;
• at post-treatment review, carry out a full periodontal assessment including 6-point pocket chart at involved sextant(s) to determine if probing pocket depths have reduced and to confirm the periodontal diagnosis.

For patients with BPE Code 4 and those with a history of periodontitis: 

• carry out a full periodontal assessment including comprehensive 6-point pocket chart of the whole dentition (see Full periodontal examination);
• assess the extent of bleeding on probing;
• assess modifiable risk factors (smoking status, sub-optimally controlled diabetes).

For patients with a diagnosis of periodontitis:

• take or assess appropriate radiographs for evidence of bone loss; 
• determine the extent/distribution from radiographs, based on the number and site of teeth affected by bone loss;
• carry out staging and grading based on radiographic assessment of the site with the worst bone loss;
• assess current disease status based on probing pocket depth and the percentage of sites in the mouth which bleed on probing;
• assess modifiable risk factors (e.g. smoking status, uncontrolled diabetes).

For all patients, make a definitive diagnosis, document the diagnostic statement in the clinical notes and establish a treatment plan based on your diagnosis.

N.B. It is important to diagnose periodontal health and stable periodontitis and record this in the clinical notes.

Inform the patient of their diagnosis and emphasise the importance of long-term care (see Long-term periodontal care).

For a patient with evidence of historical periodontitis (i.e. evidence of interdental recession and radiographic evidence of bone loss), assess the stage and grade of their disease (based on the extent of bone loss at the worst site) and make a diagnosis on the basis of how the patient presents when seen at consultation.