Periodontal Screening and Recording: Its Use When Detecting

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Course Author(s): Tanya Villalpando Mitchell, RDH, MS

CE Credits: 1 hour

Intended Audience: Dentists, Dental Hygienists, Dental

Assistants, Dental Students, Dental Hygiene Students, Dental

Assistant Students

Date Course Online: 06/04/2020

Last Revision Date: N/A

Course Expiration Date: 06/03/2023

Cost: Free

Method: Self-instructional

AGD Subject Code(s): 490

Online Course: www.dentalcare.ca/en-ca/professional-education/ce-courses/ce617

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their

practice. Only sound evidence-based dentistry should be used in patient therapy.

Conflict of Interest Disclosure Statement

• The author reports no conflicts of interest associated with this course.

Introduction – Periodontal Screening and Recording

Periodontal Screening and Recording (PSR) is a rapid and inexpensive method of screening patients

to decide if a more comprehensive assessment is necessary. After taking Periodontal Screening and

Recording: Its Use When Detecting Periodontal Disease, the participant will be able to explain the

benefits of the PSR system, use the PSR system in a clinical setting, interpret a patient’s PSR score,

identify who should be assessed with a more comprehensive periodontal exam and discuss the PSR

system with patients.

Periodontal Screening and Recording:

Its Use When Detecting Periodontal Disease

Continuing Education

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Course Contents

• Overview

• Learning Objectives

• Introduction

• Objectives of Screening

• Interpretation of Codes

• Guidelines for Patient Management

• Advantages and Limitations

• Conclusion

• Course Test

• References

• About the Author

Overview

A complete periodontal assessment includes

a thorough review of the patient’s medical

and dental histories, as well as the recording

of gingival findings including probing depths,

clinical attachment levels, tooth mobility and

position, furcation involvement, bleeding on

probing, occlusal relationships, and bone levels.

It is important the dentist or dental hygienist

monitor and evaluate a patient’s periodontal

status on a regular basis. Periodontal diseases

are the leading cause of tooth loss in adults.

The Centers for Disease Control and Prevention

reports 47.2% of adults in the United States

have a form of periodontal disease. The rate

increases to 70.1% for those Americans age

65 and older.

A 2012 study by Eke et al. found

periodontal disease to be more common

in men than in women and in adults who

had not completed high school.

Every oral

examination should include an evaluation

of the periodontium. The ultimate goal of

the periodontal assessment is to identify

and classify periodontal disease.

Although

the Periodontal Screening and Recording

(PSR) is not intended to replace a full mouth

probing and recording of findings, it is a rapid

method of screening patients to decide if a

more comprehensive assessment is necessary.

The dentist or dental hygienist must decide,

upon completion and documentation of their

patient’s PSR scores, whether the patient should

receive a full periodontal examination. This

would result in the patient’s classification of

periodontal disease characterized by the staging

and grading system as recommended by the

American Academy of Periodontology (AAP).

Learning Objectives

Upon completion of this course, the dental

professional should be able to:

• Explain the benefits of the PSR system.

• Use the PSR system in a clinical setting.

• Interpret a patient’s PSR score.

• Identify who should be assessed with a

more comprehensive periodontal exam.

• Discuss the PSR system with patients.

Introduction

Gingivitis and periodontitis fall into the

category of periodontal diseases. Both are

microbial infections of the periodontium, where

the microorganisms operate in conjunction

with a person’s host response.

The dental

hygienist is most often the person in the

professional dental setting who screens

patients and assesses periodontal health or

disease. The most commonly used screening

method for the measurement of depth of the

gingival sulcus and the clinical attachment

level is periodontal probing.

The clinician,

by measuring probing depths, can make

assumptions of the state of health of the

periodontium. Early detection and diagnosis

are significant components in the prevention

of periodontal disease. The American Academy

of Periodontology (AAP) recommends every

dental patient should receive a comprehensive

periodontology evaluation annually.

The

Periodontal Screening and Recording

(PSR)

system is one example of a diagnostic aid used

to assess the periodontal health of patients.

The PSR system has been used to study the

relationship in overweight and obese patients

who smoke as well as a way to estimate the

periodontal health statuses of a representative

military population.

2,8

A study by Khocht et al

found the PSR to be an effective tool in the

screening of periodontal diseases.

The PSR has

been used to detect the periodontal status of

individuals with immunoglobulin A deficiency.

Overall, there are a limited number of studies

involving use of the PSR.

Background

In 1982, the World Health Organization (WHO)

created the Community Periodontal Index

of Treatment Needs (CPITN). This method of

evaluation estimated the periodontal disease

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prevalence and severity based on the probing

depths and condition of the periodontium.

In 1992, the AAP modified the Simplified

Periodontal Examination (SPE), used in New

Zealand, and developed the PSR system for

use in North America (journal article). With the

corporate sponsorship of the Procter & Gamble

Company, the AAP and the American Dental

Association (ADA) adopted the PSR system.

The PSR system was designed to initiate the

promotion, prevention, and early treatment of

periodontal diseases by:

• Introducing a simplified screening method

that met legal dental recording requirements.

• Encouraging dentists to incorporate the PSR

system into every oral examination.

• Educating members of the public to

value periodontal health and to request a

periodontal screening from dentists (PSR

Training Program, 1992).

Objectives of Screening

The PSR system does not replace the need for

a comprehensive periodontal examination. It

acts as a time saving screening of periodontal

health to indicate when a partial or full-

mouth examination is required. When the

clinician becomes familiar with the PSR system

examination process, it should only take a few

minutes to conduct a screening.

Similar to a traditional comprehensive

periodontal examination, the PSR system

measures each tooth individually, with implants

examined the same way as natural teeth.

However, the mouth is divided into sextants

instead of quadrants (Figure 1).

Six measurements for each tooth are obtained,

utilizing a special ball-tipped probe. This probe

has a 0.5 mm ball at the tip and a color-coded

area 3.5 to 5.5 mm from the tip. The probe may

be plastic or metal. The ball at the end of the

probe is intended to enhance patient comfort

and assist in detecting overhanging margins and

subgingival calculus (Figure 2).

The probe is inserted into the sulcus or pocket

and walked around the circumference of each

tooth. This method is the same technique

Figure 1. Sextants of Mouth.

Figure 2. Special Ball-tipped Probe.

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method of more specifically defining individual

cases. This system will be discussed in further

depth under 5(b) Periodontitis.

Code 1:

The colored area of the probe remains

completely visible in the deepest probing

depth in the sextant; this indicates that probing

used as with a comprehensive periodontal

examination. However, the PSR system is

unique in the way the probe is read. The

clinician need only observe the position of the

color-coded band in relation to the gingival

margin. The color-coded band is commonly

known as a reference mark, which spans

between 3.5 mm to 5.5 mm. For each area

probed, the clinician will decide if the colored

band is either totally visible, partly visible, or

not at all visible.

The presence of furcation

involvement, mobility, mucogingival problems,

or recession should also be noted with an

asterisk. After each tooth in the sextant has

been examined, only the highest code obtained

is recorded and only one score is recorded

for each sextant. If a sextant is edentulous, an

“X” is placed. Measurements are recorded by

sextants as shown below (Figure 3).

Interpretation of Codes

Code 0:

The colored area of the probe remains

completely visible in the deepest crevice of

the sextant; this indicates that probing depths

in the sextant range between 1 mm to 3 mm.

There is no calculus or defective margins

detected. The gingival tissues are healthy with

no bleeding after gentle probing.

With this model in mind, the concept of

creating more individualized patient case

definitions came to fruition. Using the medical

model of staging and grading, the authors of

the new classification were able to combine

some of the factors typically used in disease

determination such as severity, extent, rate

of progression, risk factors, etc. to create a

Figure 3. Recording Scores.

Code 1

Code 2

Code 0

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The Symbol “*”:

The symbol “*” should be added to a sextant

score whenever the following is found: furcation

involvement, mobility, mucogingival problems,

or recession extending to the colored area of the

probe (indicating 3.5 mm or greater).

Guidelines for Patient Management

Code 0:

Appropriate preventive care should be given as

well as a review of daily plaque control habits.

Code 1:

Individualized oral hygiene instructions should be

reinforced with the patient. Appropriate therapy,

including subgingival plaque removal should be

performed.

Code 2:

Individualized oral hygiene instruction and

appropriate therapy, including subgingival plaque

removal, as well as the removal of calculus and

the correction of plaque-retentive margins and

restorations should be performed.

Code 3:

A comprehensive periodontal examination and

charting of the affected sextant are necessary

to determine an appropriate care plan. This

examination and documentation should include

the following: identification of probing depths,

clinical attachment levels (gingival recession),

bleeding on probing, mobility, mucogingival

problems, furcation involvement, and

radiographs. If one or more sextants score a

Code 3, a comprehensive full mouth examination

and charting are indicated.

Code 4:

A comprehensive full mouth periodontal

examination and charting are necessary to

determine an appropriate care plan. This

examination and documentation should include

the following: identification of probing depths,

clinical attachment levels (gingival recession),

bleeding on probing, mobility, mucogingival

problems, furcation involvement, and

radiographs. It can be assumed that advanced

periodontal treatment will be required.

Symbol (*):

If an abnormality exists in the presence of Codes

0, 1, or 2, the clinician should make a specific

depths range between 1 mm to 3 mm. There

is no calculus or defective margins detected.

However, there is bleeding after probing.

Code 2:

The colored area of the probe remains

completely visible in the deepest probing depth

in the sextant; this indicates probing depths

range between 1 mm to 3 mm. Supragingival or

subgingival calculus and/or defective margins

are detected.

Code 3:

The colored area of the probe remains partly

visible in the deepest probing depth in the

sextant; this indicates that probing depths may

range between 4 mm to 5 mm.

Code 4:

The colored area of the probe completely

disappears indicating a probing depth of greater

than 5.5 mm.

Code 3

Code 4

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notation and/or treatment for that condition

as needed. If an abnormality exists in the

presence of Code 3 or 4, a comprehensive

periodontal examination and charting are

necessary to determine an appropriate care

plan.

Advantages and Limitations

The advantages of using the PSR system

include early detection, speed, simplicity,

cost-effectiveness, ease of recording, and risk

management.

• Early detection: Since all sites are

evaluated, the risk of periodontal disease

can be made early and appropriate

treatment can be performed.

• Speed: Once the technique of the PSR

system is learned, it should take only a

few minutes to perform the screening.

This saves time versus a comprehensive

examination.

• Simplicity: It is easy to do and understand

for patients.

• Cost-effectiveness: It is not necessary to

purchase expensive equipment since all that

is needed is a ball-tipped probe.

• Ease of recording: Only one number is

recorded for an entire sextant.

• Risk management: The dental team

is monitoring and recording a patient’s

periodontal status to stay compliant

with standards of care and for legal

requirements.

There are limitations when using the PSR

system. As stated earlier, it is not intended to

replace a full-mouth periodontal examination.

Those patients who have received treatment

for periodontal diseases and/or are in a

maintenance phase of care should receive

comprehensive periodontal examinations

routinely. There is also limited use of the

PSR system in children. It is necessary to

differentiate pseudo-pockets from true

periodontal pockets with these younger

patients. In any patient exhibiting enlarged

gingiva or recession, the PSR score may give

false results.

Landry and Jean reported that

since the PSR does not measure epithelial

attachment, the severity of periodontal

disease may be underestimated with its use.

While a study by Rams and Loesche found

a pretreatment PSR score of 4 or greater

in 110 adults to be a good predictor of

periodontal access surgery needs, this same

study concluded after performing non-surgical

periodontal therapy the score overestimated

surgical access needs.

Conclusion

The PSR system is a valuable tool in the early

detection of periodontal disease. This system

can indicate when a more comprehensive

periodontal examination should be performed.

The unique way the probe is read and

the limited amount of recordings needed

when performing an examination is easy to

incorporate into every patient’s appointment.

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Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please

go to: www.dentalcare.ca/en-ca/professional-education/ce-courses/ce617/test

1. What makes the PSR system unique?

A. The way the probe is read.

B. The way the probe is inserted into the sulcus.

C. Its adoption by the ADA and AAP.

D. Its intended use on patients.

2. A new patient presented to the dental office for an initial examination. The PSR would be

an appropriate method to comprehensively assess the patient’s periodontal status.

A. True

B. False

3. Which of the following describes a PSR Code 2?

A. Colored area of the probe remains partly visible; no calculus or defective margins detected;

gingival tissues healthy.

B. Colored area of the probe remains visible in deepest probing depth; no calculus or defective

margins detected; there is bleeding on probing.

C. Colored area of the probe completely disappears; probing depth > 5.5 mm.

D. Colored area of the probe is completely visible in deepest probing depth in sextant; supra-

or subgingival calculus detected or defective margins present.

4. Which of the following patients would NOT be a good candidate for the PSR system?

1. Child patient

2. Periodontal maintenance patient

3. Recall patient with no bleeding upon probing

4. Patient screened at a health fair

A. 3

B. 3 and 4

C. 1

D. 1 and 2

5. For each sextant, only the lowest PSR score is recorded.

A. True

B. False

6. The patient management of a PSR Code 4 is _______________.

A. individualized oral hygiene instruction and removal of subgingival calculus; as well as

removal of calculus and correction of plaque-retentive margins and restorations

B. individualized oral hygiene instructions should be reinforced; subgingival plaque removal

C. comprehensive full mouth periodontal examination and charting

7. If one or more sextants score a Code 3, what is the appropriate protocol?

A. Removal of subgingival plaque

B. Full mouth exam and charting

C. Refer to a periodontist

D. Oral hygiene instruction

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8. All of the following are advantages to using the PSR except one. Which one is the

EXCEPTION?

A. Excessive cost

B. Simplicity

C. Risk management

D. Speed

9. The probe used with the PSR system has a 0.5 mm ball tip. Which of the following is

NOT a purpose for this tip?

A. Gives a more accurate reading.

B. Enhances patient comfort.

C. Detects subgingival calculus.

D. Detects overhanging margins.

10. In which of the following conditions could the scores of the PSR give a false reading?

A. Excessive plaque

B. Gingival health

C. Gingival bleeding

D. Gingival recession

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References

1. American Dental Association and The American Academy of Periodontology. June 1992.

2. Covington LL, Breault LG, Hokett SD. The application of Periodontal Screening and Recording

(PSR) in a military population. J Contemp Dent Pract. 2003;4(3):36-51. Published 2003 Aug 15.

3. Hodges KO. Concepts in nonsurgical periodontal therapy. Albany, NY. Delmar Publishers. 1998.

4. Khocht A, Zohn H, Deasy M, Chang KM. Screening for periodontal disease: radiographs vs. PSR.

J Am Dent Assoc. 1996;127(6):749-756. doi:10.14219/jada.archive.1996.0310.

5. Landry RG, Jean M. Periodontal Screening and Recording (PSR) Index: precursors, utility and

limitations in a clinical setting. Int Dent J. 2002;52(1):35-40. doi:10.1111/j.1875-595x.2002.

tb00595.x.

6. Weinberg MA. Comprehensive periodontics for the dental hygienist. Upper Saddle River, NJ.

Prentice Hall. 2001.

7. Weinberg MA, Fine JB. Comprehensive periodontics for the dental hygienist. Upper Saddle River,

NJ. Pearson Education. 2010.

8. Wood N, Johnson RB. The relationship between smoking history, periodontal screening and

recording (PSR) codes and overweight/obesity in a Mississippi dental school population. Oral

Health Prev Dent. 2008;6(1):67-74.

9. CDC. Oral Health Conditions. Periodontal Disease. Accessed June 1, 2020.

10. Eke PI, Dye BA, Wei L, Thornton-Evans GO, et al. Prevalence of periodontitis in

adults in the United States: 2009 and 2010. J Dent Res. 2012 Oct;91(10):914-920.

doi:10.1177/0022034512457373.

11. American Academy of Periodontology. Comprehensive periodontal therapy: a statement by

the American Academy of Periodontology*. J Periodontol. 2011;82(7):943-949. doi:10.1902/

jop.2011.117001.

12. Jorgensen GH, Arnlaugsson S, Theodors A, Ludviksson BR. Immunoglobulin A deficiency and

oral health status: a case-control study. J Clin Periodontol. 2010;37(1):1-8. doi:10.1111/j.1600-

051X.2009.01494.x.

13. Rams TE, Loesche WJ. Relationship Between Periodontal Screening and Recording Index Scores

and Need for Periodontal Access Surgery. J Periodontol. 2017;88(10):1042-1050. doi:10.1902/

jop.2017.170070.

14. Gehrig JS, Shin DE, Willmann DE. Foundations of periodontics for the dental hygienist.

Philadelphia, PA. Wolters Kluwer. 2019.

15. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-

implant diseases and conditions - Introduction and key changes from the 1999 classification.

J Periodontol. 2018;89 Suppl 1:S1-S8. doi:10.1002/JPER.18-0157.

Additional Resources

• No Additional Resources Available.

About the Author

Tanya Villalpando Mitchell, RDH, MS

Ms. Mitchell is Professor and Director, Graduate Studies at the University of

Missouri Kansas City School of Dentistry, Division of Dental Hygiene. She is a

member of the American Dental Hygienists’ Association and the American Dental

Education Association.

Email: [email protected]